Remnant-preserving anterior cruciate ligament reconstruction using hamstring autograft yields the lowest re-rupture...

Remnant-preserving anterior cruciate ligament reconstruction (RP-ACLR) has garnered interest due to its potential biological benefits. This study aimed to compare graft survival, complication and reoperation rates between RP-ACLR and standard remnant-sacrificing techniques (non-remnant-preserving ACLR [NP-ACLR]), with subgroup analysis by graft type.

A systematic literature search was conducted in PubMed, Embase and Cochrane Library up to June 2025. Study selection, data extraction and risk-of-bias assessment (using Risk of Bias In Non-randomized Studies of Interventions [ROBINS-I]) were performed independently by two reviewers, with discrepancies resolved by a third. Inclusion criteria comprised clinical studies (Levels I-III) reporting complications or reoperations after RP-ACLR. Pooled rates were calculated using random-effects meta-analysis where appropriate.

Across 34 studies (n = 4368 patients), the RP group comprised 2759 patients and the NP group 1609 patients. Graft re-rupture was significantly lower in the RP group (risk ratio [RR] = 0.58, 95% confidence interval [CI] 0.41-0.83), while reoperation rates did not differ significantly (RR = 1.12, 95% CI 0.56-2.22). Patient-reported outcomes favoured RP-ACLR, with a significant improvement in Lysholm scores. Subgroup analysis revealed the lowest re-rupture rate with hamstring autograft and remnant preservation (2.8%). Second-look arthroscopy demonstrated superior graft synovial coverage in RP patients (~85% vs. ~59%) and a lower incidence of cyclops lesions (pooled rate 9.4%).

RP-ACLR is a safe and clinically beneficial technique that demonstrates significantly lower rates of graft failure and comparable complication and reoperation rates versus standard ACLR. These findings support remnant preservation in appropriately selected patients to enhance graft survival.

Level IV.