Functional and Return-to-Sport Outcomes After Biologic Augmentation in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.

Background: The clinical value of biologic augmentation during anterior cruciate ligament reconstruction remains uncertain, particularly regarding functional recovery and return to sport. Existing evidence has yielded inconsistent results, and prior syntheses have often emphasized radiologic outcomes rather than patient-centered functional measures. Methods: A systematic review and random-effects meta-analysis of comparative clinical studies evaluating biologic augmentation during anterior cruciate ligament reconstruction was conducted. PubMed, the Cochrane Library, and Google Scholar were searched without date restrictions. Tegner activity score, Lysholm knee score, International Knee Documentation Committee score, and return-to-sport outcomes were analyzed when available. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool and the MINORS criteria. Results: Ten studies were included. Biologic augmentation was associated with higher Tegner activity scores compared with standard reconstruction, with a pooled mean difference of 0.52 (95% confidence interval 0.14 to 0.91) and no observed heterogeneity. Lysholm knee scores were also higher in the biologic augmentation group (mean difference 3.32, 95% confidence interval 0.65 to 6.00), although substantial heterogeneity persisted across studies. No significant difference was observed in pooled International Knee Documentation Committee scores. Return-to-sport outcomes were reported inconsistently in only two studies and were not suitable for quantitative synthesis. Most randomized studies demonstrated some concerns regarding risk of bias, while non-randomized studies showed moderate methodological limitations. Conclusion: Biologic augmentation during anterior cruciate ligament reconstruction is associated with modest improvements in selected functional outcomes but does not result in consistent gains in global knee function or return-to-sport outcomes. Current evidence does not support routine use of biologic augmentation in primary anterior cruciate ligament reconstruction.