Concomitant Intra-articular Injuries in 37,423 Primary and Revision ACL Reconstructions: A Systematic Review and Meta-analysis of Comparative Studies

BACKGROUND: Intra-articular lesions of menisci and cartilage are common in anterior cruciate ligament reconstruction (ACLR) and may differ between primary and revision procedures. Clarifying their prevalence, morphology, and risk factors is important for prognosis and surgical planning. PURPOSE: To perform a systematic review and meta-analysis comparing the prevalence and risk factors for intra-articular injuries in primary versus revision ACLR. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the PubMed, MEDLINE, and Embase databases were searched, supplemented by citation review and author contact. Comparative studies reporting intraoperative meniscal and/or chondral findings in both primary and revision ACLRs were included. Pooled odds ratios with 95% confidence intervals were calculated using random- or fixed-effects models. RESULTS: = 61%). High-grade lesions (Outerbridge/International Cartilage Regeneration & Joint Preservation Society grades 3 and 4) were consistently more common in revisions, with progression observed in up to 26% of intrapatient comparisons. Risk factors reported for intra-articular injuries on revision ACLR included older age, male sex, tunnel malposition, malalignment, increased tibial slope, longer time to revision, and prior meniscectomy. CONCLUSION: In this review of >37,000 ACLRs, revision status was associated with 1.6-fold higher odds of meniscal tears and 3.5-fold higher odds of chondral lesions compared with primary reconstruction. Chondral injury at revision was more prevalent across all compartments and consistently more severe, with the greatest risk observed in the trochlea and medial compartment. These findings demonstrate a substantially greater intra-articular disease burden at the time of revision surgery.