Lower ACLR Failure Rates in Bone–Soft Tissue Versus Soft Tissue–Only Allografts in Adults: A Systematic Review and Meta-analysis

Background: While allografts are commonly used for anterior cruciate ligament reconstruction (ACLR), evidence to guide specific allograft selection is lacking. Purpose: To compare clinical and graft failure rates after ACLR using soft tissue–only allografts and bone–soft tissue allografts in adults. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: English-language studies with clinical outcome data on primary and revision ACLR in adults with nonirradiated soft tissue–only and bone–soft tissue grafts were identified in the search. Data extracted included allograft type, patient characteristics, follow-up time, and failure rates. The cumulative failure rate was defined as International Knee Documentation Committee grade C/D, graft retear, grade ≥2+ Lachman, grade ≥2+ pivot shift, and/or side-to-side KT-1000 laxity of >5 mm. The graft rupture rate was defined solely by the proportion of patients who had a graft rupture. Meta-analyses using the inverse variance method were used to estimate the pooled rates with 95% CIs. Subgroup analysis was conducted to compare allograft types and determine whether age, sex, and follow-up time influenced the estimates. Results: A total of 14 studies met the inclusion criteria: 7 investigated bone–soft tissue allografts, 6 investigated soft tissue–only allografts, and 1 investigated both. The comparative study showed a difference in the cumulative failure rate between bone–patellar tendon–bone and soft tissue–only allografts. The pooled cumulative failure rates for bone–soft tissue and soft tissue–only allografts were 11% (95% CI, 7-17) and 20% (95% CI, 14-29), respectively ( P = .05). The pooled graft rupture rates for bone–soft tissue and soft tissue–only allografts were 6% (95% CI, 4-9) and 13% (95% CI, 7-23), respectively ( P = .07). Conclusion: The meta-analysis results showed that bone–soft tissue allografts have lower cumulative failure rates than soft tissue–only allografts. Bone–soft tissue allografts may be the preferred allograft choices for ACLR.