Evaluating the Statistical Fragility of Comparative Studies on Autografts for Pediatric ACL Reconstruction

The literature presents conflicting findings regarding outcomes after pediatric anterior cruciate ligament reconstruction (ACLR) with various autograft options, reflecting a lack of consensus on the standard of practice. Fragility analyses may assist in evaluating the statistical robustness of these studies.

To evaluate the statistical fragility of comparative studies in pediatric ACLR through the fragility index (FI) and fragility quotient (FQ), as well as qualitative factors such as outcome type, outcome significance, and patients lost to follow-up.

Systematic review; Level of evidence, 4.

A systematic review conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines identified 1139 studies in the PubMed and Embase databases that met the search criteria; ultimately, 6 studies were selected for inclusion. A total of 32 comparative outcomes were assessed for fragility across the 6 studies. Descriptive statistics were employed to summarize the fragility data and generate subgroup comparisons.

The mean FI was 1.5, and the mean reverse FI was 3.19 (P < .01); the mean FQ was 0.0064, and the mean reverse FQ was 0.028 (P≤ .0001). No significant difference was found in the FIs between objective outcomes and patient-reported outcomes (P = .418). These findings suggested that a comparable number of patients would need to transition from a nonevent to an event to alter a statistically significant result to a nonsignificant one. The FI was lower than the estimated number of patients lost to follow-up for 30 of the 32 outcomes (93.7%).

Comparative studies on pediatric ACLR autograft outcomes displayed vulnerability when assessed using fragility metrics, indicating a lack of statistically robust data. The findings revealed that many reported outcomes are fragile and may require further investigation. Future research should incorporate fragility analyses-especially in studies with long-term follow-ups-to enhance the reliability of conclusions regarding optimal graft selection in pediatric ACLR.