Declining Allograft Use in Young Females, Increasing Quadriceps Tendon Use, and Female-Specific Adoption of Suspensory Fixation and Suture Augmentation During Anterior Cruciate Ligament Reconstruction

Contemporary anterior cruciate ligament reconstruction (ACLR) techniques have evolved, but whether these changes differ by sex remains unclear. This study evaluated sex-based temporal trends in graft selection, fixation strategy, and suture augmentation after primary ACLR. Following Institutional Review Board approval, a retrospective cohort study was performed within a large multicenter health system which evaluated all primary ACLR procedures performed between 2014 and 2022 and were identified using Current Procedural Terminology code 29888. Adult patients (≥18 years) were included, while those with multiligamentous injuries or revision ACLR were excluded. Demographic and operative variables were analyzed by sex, and temporal trends were assessed using correlation and categorical analyses. A two-sided p value < 0.05 was considered statistically significant. Of 2,695 primary ACLR procedures identified, 1,781 met inclusion criteria, including 583 female patients (32.7%) and 1,198 male patients (67.3%), with a mean age of 31.2 ± 10.6 years. Autograft was used in 1,162 cases (65.2%). Autograft utilization was lower in females than males (58.5% vs 68.5%, p < 0.001). Among females ≤25 years, allograft use declined from 26.3% in 2014 to 0.0% by 2022 (r = -0.722, p = 0.015). Overall quadriceps tendon graft utilization, including both autograft and allograft sources, increased in both sexes, reaching 20.5% in females and 16.7% in males by 2022. In temporal analyses, quadriceps tendon allograft utilization increased among females (r = 0.719, p = 0.029), while quadriceps tendon autograft utilization increased among males (r = 0.772, p = 0.015). Suspensory fixation (r = 0.703, p = 0.034) and suture augmentation (r = 0.765, p = 0.016) increased significantly among female patients over time, while pin fixation declined in both females (r = -0.692, p = 0.039) and males (r = -0.765, p = 0.016). These findings demonstrated that contemporary ACLR technique selection evolved in a sex-specific manner, with distinct patterns in graft adoption and fixation strategy consistent with changing operative preferences over time.