Sex-Specific Outcomes in Adolescent ACL Reconstruction: A Propensity-Matched Cohort Study

Background: Sex-related differences in outcomes after adolescent anterior cruciate ligament reconstruction (ACLR) remain inadequately characterized in the literature. Preliminary studies suggest potential sex-based differences in postoperative complications, although findings regarding specific adverse outcomes remain inconsistent. Purpose: To evaluate sex-specific differences in postoperative complications after adolescent ACLR in a multicenter cohort with propensity matching and 2-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Data were retrospectively extracted from the TriNetX Research Network. Adolescents aged between 12 and 19 years who underwent ACLR were identified using Current Procedural Terminology codes. Male and female cohorts were propensity score-matched (1:1) for age, obesity, and concomitant meniscal repair. Outcomes at 3, 6, 12 months, and 2 years included subsequent ACLR revision, subsequent meniscal surgery, and other postoperative complications. Odds ratios with 95% CIs were calculated. Results: A total of 7793 adolescents per sex were propensity-matched. At 3 months, male adolescents had greater rehabilitation utilization (33.7% vs 31.1%; P = .003). At 6 months, female adolescents had higher manipulation under anesthesia (MUA), and lysis of adhesions (all, P < .001), whereas rehabilitation use remained higher in male adolescents ( P = .02). At 1- and 2-year follow-up, female patients experienced higher rates of MUA and lysis of adhesions (all, P < .001). No differences were observed in subsequent ACLR, meniscal surgery, or any knee reoperation. Conclusion: Distinct postoperative complication profiles were observed between male and female adolescents after ACLR. Female patients consistently demonstrated a higher likelihood of postoperative stiffness requiring secondary procedures. In contrast, no sex-based differences were identified in subsequent meniscal surgery or revision ACLR. These findings highlight postoperative stiffness as a sex-specific complication in adolescents and underscore the importance of incorporating sex-based considerations into postoperative monitoring and future outcome-focused research.