Declining Allograft Use in Young Females, Increasing Quadriceps Tendon Use, and Female-specific Adoption of...

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.