Global Variations in Surgical Techniques for Primary Anterior Cruciate Ligament Reconstruction at Minimum 2-Year Follow-up: A Systematic Review of Randomized Clinical Trials

Background: Regional differences in primary anterior cruciate ligament (ACL) reconstruction (ACLR) remain largely unknown. Purpose: To systematically review the literature examining Level 1 and Level 2 studies to identify global differences in surgical techniques associated with primary ACLR. Study Design: Scoping review; Level of evidence, 1. Methods: A literature search was conducted following the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using keywords and Boolean phrases in Embase, Cochrane, and PubMed on October 25, 2024. A total of 741 articles were identified. The inclusion criteria were as follows: Level 1 and Level 2 human studies reporting on primary ACLR, with a minimum 2-year follow-up. Studies were categorized into 3 regions (Europe, Asia, and North America), and patient characteristics, surgical details, and graft failure/revision rates were compared between regions using parametric/nonparametric tests. Results: In the 141 studies (n = 11,048 patients) identified, the mean patient age of 28.9 years (range, 13–79 years) and the follow-up of 53.8 months (range, 24–252 months) did not differ by region. Hamstring tendon (HT) autograft use was associated with Asian studies, while bone-patellar tendon-bone (BPTB) and quadriceps tendon (QT) autograft use were associated with European and North American studies. Suspensory fixation was the most common femoral fixation method (n/N = 4605/10,403 patients; 44%), associated with use in Asian studies and with HT autografts, whereas bioabsorbable screws were the most common overall method of tibial fixation (n/N = 4470/10,235 patients; 44%). Graft failure (n/N = 399/8314; 4.8%) was reported less often in Asian than in North American studies. Revision surgery (n/N = 222/6065; 3.7%) was reported less often in Asian than European and North American studies. Conclusion: Our study demonstrated that European and North American studies were associated with BPTB and QT autografts, whereas studies from Asia were associated with HT autografts. Femoral suspensory fixation and tibial bioabsorbable screw were most commonly reported. Graft failure and revision rates were broadly similar between regions. These findings suggest potential cultural and training differences worldwide to improve patient treatment outcomes.