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Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology logoLink to Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology
. 2026 Aug 19;46:7–23. doi: 10.1016/j.asmart.2026.07.001

Knee proprioception following anterior cruciate ligament repair and reconstruction: A systematic review and network meta-analysis

Jiayan Cheng a,b,d, Tian Xia a,d, Yilin Wu c,d, Yushi Chen a, Le Yu a, Tsz Yuen Frank Wang a, Jian Zhang a,⁎,e, Xiao'ao Xue a,⁎⁎,e, Yinghui Hua a,⁎⁎⁎,e
PMCID: PMC13522239  PMID: 42666376

Abstract

Background

Proprioception dysfunction, including deficits in joint position sense (JPS) and kinesthesia, is a common sequela following anterior cruciate ligament (ACL) injury. While previous studies have compared proprioceptive outcomes in ACL-injured patients undergoing different types of surgical reconstruction or repair, their findings have been inconsistent, and a systematic review is lacking.

Objective

To summarize and evaluate proprioceptive deficits (in JPS and kinesthesia) across different postoperative time points and joint angles in patients undergoing different types of ACL reconstruction or repair, compared to healthy controls.

Literature survey

A comprehensive literature search was conducted across PubMed, Embase, the Cochrane Library, CINAHL, Scopus, Web of Science, and SPORTDiscus databases using terms related to ACL injury, reconstruction or repair, and proprioception, covering all records through November 2025.

Method

ology: The following information was extracted from the included articles: demographic data, sample size, selection criteria, methodology, test indicators (e.g., time points and joint angles), proprioceptive test results, and other relevant variables. Network meta-analyses were conducted to synthesize proprioceptive outcomes.

Results

Nineteen studies were included in the network meta-analysis. No statistically significant differences were found in intermediate-angle JPS or kinesthesia among various ACL reconstruction and repair techniques when assessed beyond six months postoperatively. Notably, our analysis revealed that hamstring tendon autografts (SMD = 1.9, 95% CI = 0.3, 3.5) and tibialis anterior allografts (SMD = 1.7, 95% CI = 0.1, 3.5) were associated with inferior small-angle position perception outcomes at the six-month follow-up compared to control.

Conclusion

The results indicate that, in small-angle position at six-month follow-up, ACL repair may yield similar or even better proprioceptive recovery compared to hamstring tendon autografts and tibialis anterior allografts. However, different types of reconstructive grafts or repairs do not show significant differences in proprioceptive recovery from most angles. These findings suggest that ACL repair demonstrates proprioceptive outcomes similar to those of ACL reconstruction, and different graft selections for ACL reconstruction may produce similar proprioceptive outcomes, allowing graft choice to be guided by specific clinical needs.

Keywords: Anterior cruciate ligament reconstruction, Anterior cruciate ligament repair, Joint position sense, Knee, Network meta-analysis, Threshold to detection passive motion

1. Introduction

Anterior cruciate ligament (ACL) rupture is one of the most prevalent sports injuries encountered in daily life, with approximately 120,000 cases reported annually in the United States.1 The persistent instability of the knee after ACL injury can not only lead to reduced athletic performance, but also can contribute to long-term joint degeneration and the development of osteoarthritis.2 ACL reconstruction (ACLR) is the current gold standard for treating ACL rupture and is widely used to restore knee function and stability. According to previous evidence, ACLR significantly improves the mechanical stability of the injured knee, enabling approximately 65% of athletes to return to their pre-injury level of sport.3,4 However, ACLR has been associated with various postoperative functional deficits and sensorimotor impairments, which suggests that surgical reconstruction alone may not fully address the neural and sensory disruptions caused by ACL injury.5 Despite advances in surgery and rehabilitation, restoration of sensorimotor function remains challenging.

One of the key mysteries lies in the incomplete recovery of proprioception—the body's ability to sense joint position and movement—which is critical for dynamic neuromuscular stability control and sports performance.6 Even worse, the impaired proprioceptive acuity can also lead to an increased risk of re-injury and failure in return to physical activity after ACLR, with nearly a third of patients who have undergone ACLR unable to successfully return to exercise.3,6 Several studies have found that even after successful ACLR, patients often exhibit persistent deficits in joint position sense (JPS) and kinesthesia, when compared to uninjured healthy controls7, 8, 9, 10, 11. These technique-related differences in postoperative proprioception may be clinically relevant. For example, primary ACL repair, which preserves the native ligament tissue, may offer potential proprioceptive advantages in well-selected patients,12 while postoperative proprioceptive deficits should be addressed early in rehabilitation, ideally within the first six weeks after surgery, to minimize reliance on the visual-motor system.13 Despite its clinical importance, evidence on proprioceptive recovery after ACLR remains fragmented, with most studies focusing on small samples and isolated outcomes. A comprehensive synthesis is therefore clinically important.2

Previously, several reviews have been performed on the proprioception deficits after ACLR by simply comparing the proprioception on the injured side and the non-injured side of the ACLR subjects.14,15 However, these studies overlooked several critical factors that may have introduced bias into their pooled outcomes. Several important factors may influence these findings, including postoperative follow-up duration, testing angle and movement direction, and surgical technique. Also, the recent re-emerged ACL repair technique may offer improved proprioceptive prognosis in the subacute phase due to better preservation of mechanoreceptors within the native ligament tissue.12 A network meta-analysis (NMA) is uniquely suited to address these questions, as it allows for the simultaneous comparison of multiple interventions while preserving within-study randomization and incorporating both direct and indirect evidence.

Therefore, the aim of this NMA was to compare postoperative knee proprioception across different ACL surgical techniques while accounting for follow-up duration and test angle. We hypothesized that ACL repair would result in better proprioceptive recovery than other ACLR techniques at different times points and across various proprioceptive modalities, with no significant differences among ACLR types.

2. Method

2.1. Registration

We proceeded this systematic review and NMA in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement Guidelines for Network Meta-Analysis (PRISMA-NMA). The study protocol was registered on the international prospective register of systematic reviews.

2.2. Search strategy

We conducted systematic literature searches of seven electronic databases (i.e., PubMed, Embase, Web of Science, Cochrane Library, Scopus, CINAHL, and SPORTDiscus) from inception to November 14, 2025. The search strategy was constructed by combining the following thematic categories using “AND”: (1) ACL-related terms; (2) injury and reconstruction or repair-related; and (3) Proprioception-related terms. Within each thematic group, keywords were linked using “OR”. The detailed search strategy is provided in Supplementary Appendix 1. Two authors (J.C. and T.X.) independently selected the articles with the following inclusion criteria:

Population: Humans of any age with an anterior cruciate ligament (ACL) injury who underwent either ACL repair or ACL reconstruction (ACLR) and in whom knee proprioception was assessed in the injured limb.

Intervention: Surgical treatment consisting of ACL repair or ACL reconstruction with explicit reporting of the repair technique or graft type utilized.

Comparator: Either (1) alternative surgical approaches (e.g., different graft types or ACL repair versus ACLR) or (2) healthy control participants without a history of ACL injury.

Outcome: Quantitative assessment of knee proprioception in the surgically treated knee. (Knee proprioception: JPS assesses the ability to reproduce a target joint angle, and is typically quantified as the error between the reproduced angle and the target angle. TTDPM assesses kinesthesia by determining the smallest passive movement that a participant can detect, usually during very slow passive joint motion.)

Studies were excluded if they: (1) were non-human or cadaveric studies; (2) were not published in English; (3) were reviews, conference abstracts, editorials, letters, case reports, or study protocols and trial registries; (4) did not assess knee proprioception as an outcome; (5) did not clearly report the repair technique or graft type; or (6) included mixed or inadequately defined comparison groups that introduced confounding and prevented extraction of relevant data. The reference lists of the selected articles were manually reviewed, and the authors of any articles that were not accessible online were reached out to.

2.3. Data extraction

Two authors (J.C. and T.X.) independently reviewed the searched studies. Any disagreements during study screening were resolved through discussion and, if necessary, consultation with the corresponding author. The primary outcomes extracted included: (1) mean difference in JPS or kinesthesia method between participants with ACLR or ACL repair and those without such interventions; (2) available follow-up time; (3) joint angle at which proprioception was assessed; and (4) movement direction (i.e., flexion or extension). When multiple follow-up time points were reported, outcomes were extracted according to the predefined follow-up categories of this review, namely within 6 months and beyond 6 months after surgery, and each cohort was included only once within a given pooled comparison.16 For all eligible studies, full-text articles were retrieved, and the following data were systematically extracted: Demographic characteristics (e.g., age, sex), sample size, time from injury or surgery to trial, graft type used for reconstruction or repair, trial details (e.g., instrument, duration, number of repetitions, target angle), whether rehabilitation was performed, and mean and standard deviation of JPS and TTDPM for the primary outcome. No restrictions were applied regarding study design, publication date, or participant age. Studies reporting medians and interquartile ranges were converted to means and standard deviations when feasible. For studies reporting medians and interquartile ranges, standard deviations were estimated as IQR/1.35, assuming an approximately normal distribution, in accordance with the Cochrane Handbook and the method described by Wan et al.17 Otherwise, they were excluded from meta-analysis and summarized qualitatively. For studies reporting TTDPM as a composite score of flexion and extension, combined values were used to generate a unified kinesthetic index. The authors were contacted if numerical data were unclear or not reported.

Because JPS was the most commonly reported proprioceptive outcome in the included studies, it was used for subgroup-based synthesis where appropriate. In addition, because JPS may vary according to the angle and direction of knee movement, JPS measurements were further classified into three angle-based categories—small (0°–30°), medium (30°–60°), and large (60°–90°)—in both flexion and extension directions.

2.4. Quality and risk of bias assessment

The quality and risk of bias of the included studies were independently evaluated by two authors (J.C. and T.X.) to ensure objectivity. Discrepancies were resolved through discussion with a third author until consensus was reached. Methodological quality was evaluated using the Epidemiological Appraisal Instrument (EAI), a validated and reliable tool for epidemiological research. The original EAI comprises 43 items; however, 10 items were not applicable because the included studies were limited to cross-sectional and case-control designs. Study quality was assessed using a standardized epidemiological evaluation tool comprising 33 items, each rated as “yes” (1 point), “partly” (0.5 points), or “no or uncertain” (0 points). An average score was computed to determine the overall methodological quality of each study.18

Risk of bias was assessed using validated tools tailored for non-randomized cross-sectional and case-control studies designs. Bias was evaluated across five key domains: selection, performance, detection, attrition, and reporting bias. However, reporting bias was excluded from the final analysis due to challenges in quantification. Each domain was rated dichotomously as “yes” (indicating adequate methodological safeguards) or “no” (indicating insufficient or unclear measures).19

As no universally accepted cut-off values for the modified 33-item version were identified, studies were classified using proportionally adapted thresholds based on a previous EAI-based review.18 Studies were classified as high quality (≥24/33), moderate quality (18–23.9/33), or low quality (<18/33) according to their overall methodological quality score. Risk-of-bias assessments were used to inform the interpretation of the findings, but were not incorporated into formal sensitivity analysis because of the limited number of studies and the substantial heterogeneity in study design and outcome assessment.

2.5. Statistical analysis

A meta-analysis was performed using R software, and figures were generated with the netmeta package (netmeta: An R Package for NMA Using Frequentist Methods). A network meta-analysis was conducted using a frequentist effects model to evaluate the efficacy of multiple treatment options. Unlike traditional pairwise meta-analyses, this approach allows for the simultaneous assessment of various interventions and facilitates indirect comparisons among different outcomes, even in the absence of direct head-to-head comparisons. Extracted data were summarized as standardized mean differences (SMD) with 95% confidence interval (CI), comparing ACL-injured groups to healthy controls. Lower SMD values indicated better proprioceptive recovery after surgery. A random-effects model was utilized to address the heterogeneity in ACLR criteria and testing methodologies among the included studies, thus rendering the pooled results more conservative. Heterogeneity was evaluated using the Q and I2 statistics, with p < 0.05 considered significant and I2 ≥ 75% indicating high heterogeneity.

3. Result

3.1. Study selection

The literature search identified 42,991 potentially eligible studies. Of these, 24,818 duplicates were removed. Ultimately, 19 full-text studies met the inclusion criteria and were incorporated into the systematic review and used for the quantitative synthesis. The detailed process is illustrated in Fig. 1. Additional study characteristics, including the background of participants, gender, comparison type, sample size, study design, test methodologies, and outcomes, are presented in Table 1.

Fig. 1.

Fig. 1

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Flow chart of the systematic review selection process.

Table 1.

Characteristics of studies included in the systematic review.

First Authors (Year) Sample Size (Sex, Age) Device Design Graft species Target angle injured limb injury rehabilitation Duration of Target angle Times of Repetitions time from:1)injury-test; 2)injury-surgery; 3)surgery-test Measured Outcomes
Skinner (1991) bone-patellar tendon-bone graft patients: 10 (5m+5f, average 27 years) NR Cross-sectional comparative study 1. Autograft (bone-patellar tendon-bone) 5°—25°range of flexion NR NR 2∼4s 5 2): average 10.4 months JPS
controls: 11 (NR, average 24.9 years) 3): average 31.6 months
Peter B. MacDonald (1996) hamstring tendons-LAD ACLR patients: 8 (5m+3f, 25.8 ± 3.5 years) NR Cross-sectional comparative study 1. Autograft (bone-patellar tendon-bone) 30° to 40° range of flexion NR yes / 5 3): hamstring tendons-LAD: 24 ± 3.25m bone-patellar tendon-bone: 31±8months TPPM
bone-patellar tendon-bone graft patients: 8 (5m+3f, 26.4 ± 4.5 years) 2. Hamstring tendons-LAD ACLR
controls: 6 (NR, 30 ± 4 years)
M. A. Risberg (1999) bone-patellar tendon-bone graft patients: 20 (8m + 12f, 35 ± 6.25 years) NR Randomized controlled trial 1. Autograft (bone-patellar tendon-bone) 15° of flexion NR yes between 5 and 45 s 3 2): 4.6 ± 2.88 months TDPM
controls: 10 (5m+5f, 33 ± 4.75 years) 3): 24 ± 5.25 months
David Roberts (2000) ACLR patients: 20 (15m+5f, 27 ± 4.75 years) a platform placed on the floor Cross-sectional comparative study 1. Autograft (bone-patellar tendon-bone) starting positions of 20.40 of knee-joint flexion NR yes TTDPM: 5-15s 3 3): average 24 months TTDPM/JPS
controls: 19 (14m+5f, 25 ± 4.25 years) JPS: NR
A. Merter Ozenci (2007) Autograft group: 20 (20m, 29.5 ± 6.9 years) Cybex Norm dynamometer (CSMI, Stoughton, MA, USA) Cross-sectional comparative study 1. Autograft (bone-patellar tendon-bone) TDPM: 15° of flexion NR No NR 10 3): Autograft group: 16.5 ± 5.5months TDPM/JPS
Allograft group: 20 (16m±4f, 30.2 ± 4.6 years) 2. Allograft (bone-patellar tendon-bone) JPS: NR Allograft group: 25.6 ± 13months
controls: 20 (17m+3f, 27.6 ± 2.6 years)
A.G. Angoules (2011) hamstring patients: 20 (16m+4f, NR) isokinetic dynamometer Prospective cohort study 1. Hamstring tendon autograft JPS: 15°, 45° and 75° from extension to flexion NR yes NR JPS: 3 1): 6 months (2-24 months) JPS/TTDPM
BTB patients: 20 (18m+2f, NR) Con-Trex MJ (Con-Trex, Zyrich, Switzerland) 2. Bone–patellar tendon–bone autograft TTDPM: starting angles of 15° and 45° TTDPM: 6 3): 3/6/12 months
Takashi Nagai (2012) ACLR patients: 11 (7m+4f, 23.1 ± 4.8 years) Biodex System Cross-sectional comparative study 1. Hamstring tendon autograft 15° of knee flexion and either moved into flexion or extension direction NR yes / 5 3): 12.5–15 months TTDPM
controls: 11 (7m+4f, 22.5 ± 3.2 years) 3 Multi-Joint Testing and Rehabilitation System (Biodex Medical Inc., Shirley, NY, USA)
Enes Büyükafşar (2019) ACLR patients: 34 (34m, 33 ± 7.78 years) digital inclinometer (Dualer IQ, J Tech Medikal) Cross-sectional comparative study 1.tibialis anterior tendon allograft Three angles (15°、30° and 60°) from full extension (0°) to flexion NR yes 10s 3 3): 4.35 ± 2.23 years JPS
controls: 34 (34m,32.44 ± 4.44 years)
Hande Guney-Deniz (2020) QTA group: 22 (17m+5f, 27.8 ± 2.8 years) Cybex II dynamometer (CYBEX Division of Lumex Inc, Ronkonkoma, NY) cross-sectional comparative study 1. Quadriceps tendon autograft seated with 85° hip flexion and 0° knee flexion to target angle (15°, 45° and 75° knee flexion) NR yes 10s 6 3): QTA group: 13.3 ± 2.1months JPS
HTA group: 24 (18m+4f, 26.7 ± 4.6 years) 2. Hamstring tendon autograft HTA group: 13.3 ± 1.8months
TAA group: 21 (17m+4f, 26.4 ± 5.5 years) controls: 20 (NR, 28.7 ± 3.1 years) 3. Tibialis anterior tendon allograft TAA group: 13.1 ± 1.9months
Suner Keklik (2021) ACLR patients: 34 (NR, 29.18 ± 8.16 years) controls: 31 (NR, 23.5 ± 3.4 years) Dualer IQ Digital Inclinometer (J-Tech Medical, Midvale, UT, USA) Cross-sectional comparative study 1. Hamstring tendon autograft 30°from full extension (0°) to flexion ACLR patients:
12 L+15 R		 21yes 13no 5s 3 3): 23.97 ± 15.04 months JPS
Adam Grinberg (2022) ACLR patients: 34 (9m + 25f, 23.6 ± 4.6 years) controls: 23 (3m + 20f, 23.5 ± 3.4 years) NR Cross-sectional comparative study 1. Hamstring tendon autograft two angles (40° and 65°) from full extension (0°) to flexion NR yes 2s 5 3): 12.8 ± 17.43months JPS
Changli Xu (2022) Autograft group patients: 20 (14m+6f, 37 ± 12 years) (CMV AG, Dübendorf, Switzerland) Randomized controlled trial 1. Hamstring tendon autograft two angles (45° and 75°) from full extension (0°) to flexion NR yes 5s 3 2) Autograft group patients: 18.4 ± 8.5months JPS
LARS group patients: 20 (17m+3f, 36 ± 10 years) 2. ACLR using artificial LARS LARS group patients: 10.8 ± 6.1months
Linda Bühl (2023) Repair patients: 29 (13m + 16f, 36.8 ± 10.6 years) dynamometer (Biodex System 4 Pro, Biodex Medical Systems, Shirley, MA, USA) Non-randomized comparative study 1. Primary repair 90° knee flexion and 70° hip flexion to 60°and 30° knee flexion Repair patients: 13 L+16 R NR NR 3 2) Repair patients: 20 ± 7.41 days JPS
ACLR patients: 27 (13m + 14f, 37 ± 10.7 years) 2. Hamstring tendon autograft ACLR patients: 12 L+15 R ACLR patients: 28 ± 31.11 days
controls: 29 (13m + 16f, 37 ± 10.7 years) 3) Repair patients: 24.4 ± 2.67months
ACLR patients: 24.2 ± 0.96months
Zhao Yixuan (2023) 1.5-6m ACLR patients: 14 (3m + 11f, 28.20 ± 7.25 years) Biodex Medical System 4 (Biodex Medical System, New York, NY, USA) Prospective cohort study 1. Hamstring tendon autograft 90° flexion to each of 30° and 60° 1.5-6m ACLR patients:10 L+4 R yes 10s 3 3) 1.5-6months&6month+ JPS
6m + ACLR patients: 14 (4m + 10f, 29.35 ± 7.52 years) 6m + ACLR patients:6 L+8 R
controls: 14 (8m+6f, 22.62 ± 1.29 years)
Murat Ciceklidag (2024) ACLR patients: 34 (30m+4f, 28.2 ± 6.4 years) digital inclinometer (Dualer IQ; J Tech Medikal) Cross-sectional comparative study 1.hamstring tendon autograft flexion angles of 15°,30°, and 60° ACLR:25 R+9 L
Repair:21 R+8 L		 yes 10s 3 1)ACLR: 27 ± 5.5m Repair: 29±6months JPS
Repair patients: 29 (25m+4f, 27.3 ± 8.3 years) 2. Primary Repair 2)ACLR:47.5 ± 11.8 days Repair: 30 ± 10 days
controls: 33 (29m+4f, 27.6 ± 5.9 years) 3)46.56 ± 28.08 months
Adrian Góralczyk (2024) ACLR patients: 28 (18m + 10f, 21.8 ± 4.8 years) the BIODEX System 4 Pro (Biodex Medical Sys-tems) Retrospective comparative study 1.hamstring tendon autograft 95° of hip and 90° of knee flexion in 30° and 60° knee flexion NR yes 10s 3 3) ACLR patients: 30 ± 18months JPS
Repair patients: 20 (12m+8f, 25 ± 10.5 years) 2. Primary Repair Repair patients: 28 ± 15months
Sophie A. Gommers (2024) Repair patients: 45 (26m + 19f, 32.5 ± 9.3 years) NR Case-matched comparative study 1. Primary repair 50° of knee flexion NR yes 3s 3 3) Repair patients: 31±3months JPS
controls: 45 (26m + 19f, 30.4 ± 8.9 years)
Aglaja Busch (2024) ACLR patients: 20 (12m+8f, 26.9 ± 6 years) Potentiometer RP20, Megatron Prospective cohort study quadriceps tendon graft starting position of 90°knee flexion and target angle of 50° knee flexion NR yes 3s 2 3) average 6months JPS
controls: 20 (12m+8f, 28.4 ± 7.6 years) Elektronik GmbH & Co.KG, Munich, Germany
Adam Grinberg (2024) ACLR: 22 (12f+10m,24.6 ± 4.7 years) NR Prospective cohort study 1. Hamstring tendon autograft 40° and 65°from full extension (0°) to flexion NR yes 3s 3 2)5 ± 8.07months JPS
controls: 22 (18f+4m,21.4 ± 3 years) 3)13.4 ± 3.5months
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NR, not reported; m, male; f, female; ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; QTA, Quadriceps tendon autograft; HTA, hamstring tendons autograft; TAA, tibialis anterior allograft; CoP, center of pressure.

3.2. Characteristics of the included studies

A total of 982 subjects were included, of which male subjects were more than female subjects. TTDPM was tested on 213 participants, including 147 participants who underwent ACLR and 66 healthy controls. JPS was measured in 908 individuals, comprising 587 patients and 321 healthy controls.

3.3. Quality and risk of bias assessment

The methodological quality scores, as assessed by the Experimental Appraisal Instrument, ranged from 0.59 to 0.70, with a median score of 0.62 (see Supplementary Appendix 2 for details). While the majority of studies clearly articulated their research objectives or hypotheses, study design, and outcome measures, several methodological limitations were identified. Notably, nearly all studies failed to adequately account for potential covariates and confounders, and the use of blinded assessors during testing procedures was inconsistently reported. Risk of bias assessment revealed significant concerns regarding detection bias, primarily due to insufficient blinding protocols. Nevertheless, all included studies appropriately described their statistical analyses, reported essential characteristics of both ACL repair or ACLR and control groups, and employed validated devices for measuring JPS and TTDPM. Comprehensive results of the quality assessment and risk of bias evaluation are presented in Supplementary Appendix 2.

3.4. Network meta-analysis (NMA)

This NMA included two primary proprioceptive outcome measures: JPS and TTDPM. The network structure adhered to coherence, transitivity and consistency. JPS data within six months postoperatively, particularly at smaller flexion angles, were excluded due to insufficient reporting and limited study availability. Fig. 2 shows NMA maps from studies examining the comparison of graft species to JPS and TTDPM. Nodes indicate the number of patients in that graft type, and the numbers on the lines between grafts relate to the number of studies in that comparison. Fig. 3 presents a comparative analysis of JPS ranges across multiple groups over a six-month period. Given the limited number of comparable studies reported in the literature, the data cannot be meaningfully represented as a league table. Instead, we have employed a forest plot to visualize inter-group comparisons (Fig. 4).

Fig. 2.

Fig. 2

Fig. 2

Fig. 2

Fig. 2

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Network meta-analysis maps of the studies for different group.

Fig. 3.

Fig. 3

Fig. 3

Fig. 3

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Network meta-analysis matrix of results in flexion JPS after 6 months.

Fig. 4.

Fig. 4

Fig. 4

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Forest plots comparisons of JPS and TTDPM in different groups.

3.4.1. Joint position sense

A total of 15 studies involving 908 participants and seven types of grafts contributed to this NMA evaluating JPS8, 9, 10,12,20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31. The hamstring tendon grafts accounted the most of the data, followed by autologous BTB grafts, ACL repairs, and allograft anterior tibialis muscle grafts, quadriceps tendon grafts, and both LARS and allograft BTB grafts. The control group constituted the remaining part.

3.4.1.1. Over 6 months

In this NMA, JPS was evaluated at flexion angles, small-range angles, and medium-range angles over a follow-up period of more than six months. These measurements reflect the recovery of proprioception at various time points following different graft types. For small-range movements in the direction of knee flexion, patients with hamstring tendon grafts (SMD = 1.9, 95% CI = 0.3, 3.5) and tibialis anterior allografts (SMD = 1.7, 95% CI = 0.1, 3.5) demonstrated poorer proprioceptive outcomes compared to control, however, there were no differences between the groups in terms of ACL repair, quadriceps tendon grafts, and autologous or allogeneic BTB. (SMD ranged from 0.53 to 2.2). In contrast, no significant differences in proprioceptive recovery were observed among graft types during medium-range movements.

Additionally, we compared the proprioceptive outcomes of hamstring tendon reconstruction, BTB grafts, and small-angle repair with healthy controls. These comparisons focused on position sense during small-angle movements (from 90° flexion to 0° extension) and medium-angle movements. No significant differences were observed between the results of small-angle and medium-angle movements. However, ACL repair demonstrated a slight probabilistic advantage over hamstring tendon reconstruction in proprioceptive recovery.

Due to insufficient data on wide-range movements, this comparison could not be included in the network meta-analysis. The complete comparison matrix is presented in Fig. 3.

3.4.1.2. Less than 6 months

The literature review revealed a lack of studies with healthy controls for JPS measurements within less than 6 months postoperatively. Therefore, this NMA focused on comparing three commonly used reconstruction techniques: hamstring tendon reconstruction, BTB reconstruction, and artificial ligament reconstruction. Proprioceptive outcomes were evaluated at medium-range and wide-range angles in the flexion direction.

The statistical results indicated no significant differences in JPS outcomes among the three reconstruction techniques at either angle range. These findings suggest that, within the first 6 months postoperatively, the choice of graft type (hamstring tendon graft, BTB, or artificial ligament) does not significantly influence proprioceptive recovery as measured by JPS.

3.4.2. Threshold to detection of passive motion

Over the past decade, kinesthetic testing following ACLR has been infrequently reported in the literature, with all included studies featuring follow-up durations exceeding 6 months. These studies assessed kinesthesia by integrating movement data in both flexion and extension directions. To facilitate analysis, this NMA categorized postoperative kinesthetic assessments into two angle-based groups on the initial joint angle: small (<45°) and large (>45°) angles.

A total of 6 studies involving 193 participants and four graft types were included in this NMA20, 21, 22,32, 33, 34. The distribution of graft types was as follows: hamstring tendon-ligament augmentation device (LAD) grafts (4%), autologous BTB grafts (35.23%), allograft BTB grafts (10.36%), and hamstring tendon grafts (16.06%). The remaining 34.2% of the data were derived from control groups.

In terms of statistical analysis, no significant differences were observed in kinesthetic performance between graft types when considering both small and large starting angles. However, probabilistic ranking analysis revealed nuanced differences. For small-angle kinesthetic measurements, allografts demonstrated slightly superior performance compared to hamstring tendon grafts, and both outperformed autologous BTB grafts. In contrast, for large-angle kinesthetic measurements, hamstring tendon grafts showed better outcomes than both hamstring tendon-LAD grafts and autologous BTB grafts (Fig. 2).

3.5. Heterogeneity assessment

Heterogeneity statistics for the direct comparisons are presented in Supplementary Appendix 4. Because several comparisons were informed by only one study estimate, heterogeneity statistics were not estimable for these comparisons. Among comparisons with at least two study estimates, heterogeneity was generally low or absent for several comparisons, although substantial heterogeneity was observed in selected comparisons, including tibialis allograft versus control for JPS flexion after 6 months in the small-range analysis (I2 ≈ 92.0%, τ2 ≈ 3.37, p = 0.0004), hamstring tendon versus control for JPS flexion after 6 months in the large-range analysis (I2 ≈ 79.1%, τ2 ≈ 0.354, p = 0.008), and hamstring tendon versus control for JPS extension after 6 months in the medium-range analysis (I2 ≈ 86.5%, τ2 ≈ 3.38, p = 0.0065). Therefore, these direct pairwise estimates should be interpreted cautiously.

4. Discussion

The main finding of this study is that in the non-acute phase, compared with uninjured healthy controls, ACL repair is not inferior to other reconstructed grafts in terms of positional sensation at all angles. When the flexion angle is relatively small, it can outperform hamstring tendon and allogeneic anterior tibial tendon grafts. However, at other angles, there is no difference in position perception and motion perception between the repair and each reconstructed graft.

4.1. The proprioception between patients and healthy controls

As previously mentioned, the proprioception consisted of the body's ability to detect JPS and movement, also referred to as kinesthesia. In this review, most kinesthetic tests employed TTDPM uniformly, whereas earlier studies often used the angle of perceived motion.33 Data standardization was carried out in this study to ensure the accuracy of the study. The comparison of kinesthetic perception between reconstructed grafts and healthy controls in this study did not reveal any significant differences, suggesting that the reconstructed grafts may have achieved a level of kinesthetic function to levels comparable to those of uninjured individuals.35 However, the low sensitivity of current kinesthesia assessment methods may partially account for this observation. The active/passive joint reproduction test used for JPS frequently revealed variation. Some graft types failed to restore JPS to the level of healthy controls, while others achieved similar results to healthy controls in the non-acute recovery stage. This finding aligned with the primary goal of ACLR: to restore both structural integrity and functional proprioceptive capabilities of the injured joint. Possible explanations for this result may include differential injury to proprioceptive receptors—kinesthetic receptors may be less affected than position receptors—and variability in rehabilitation protocols across studies. Additionally, more studies reported JPS than kinesthetic, and JPS studies often include larger sample sizes, leading to higher statistical power. More articles on TTDPM direct measurement of kinesthesia and JPS may be needed in the future to verify the conclusions.

From the perspective of position perception, the test performed at the small-angle of flexion yielded poorer results than those of healthy controls. Movements within the small-to medium-angle ranges are believed to better reflect the angle range of ACL afferent loss.36 In addition to factors such as graft tension and the recovery of surrounding muscles (e.g., quadriceps and hamstrings), proprioceptive outcomes may also be influenced by differences in rehabilitation training intensity and the angles emphasized during therapy. Despite these findings, no statistically differences were observed in kinesthetic perspection, which could be considered that the number of relevant articles on kinesthetic testing is insufficient. In short, more article was needed to refine the classification of proprioceptive deficits and to provide stronger evidence regarding postoperative proprioceptive outcomes.

In terms of follow-up time, it was generally accepted that 6 months is the period of return to exercise.37,38 At 6 months, the graft began to undergo ligamentization and reach initial healing,39 and the receptor was slowly reborn. In addition, muscle strength could usually recover to 85%-90% of the healthy side at 6-9 months, reducing the risk of re-tearing and meeting the standard of return to exercise.40 It was also possible that the effects of targeted rehabilitation protocols may vary across studies, and the number of high-quality articles addressing these factors remains limited. Therefore, more prospective longitudinal studies were warranted to clarify the role of rehabilitation and its timing in proprioceptive recovery.

In general, compared with healthy people after ACL injury, patients' oceptive acuity is still relatively poor in different categories, angles and times, and more targeted methods of proprioceptive rehabilitation need to be explored.

4.2. Repair or reconstruction graft type

The prognosis of ACLR is significantly influenced by the type of graft used. Autografts, including hamstring tendon, BTB, and quadriceps tendon, each presented unique advantages and limitations. BTB grafts, while historically popular, were often associated with increased prepatellar pain and had seen a decline in their use in recent years. In contrast, quadriceps tendon grafts, while technically more demanding for surgeons, had demonstrated excellent functional outcomes and were increasingly favored in clinical practice. In this study, the slightly inferior performance of hamstring tendon grafts compared to healthy controls may be attributed to the absence of major knee flexor tendons, which could impair proprioceptive function during knee flexion.41 Allografts, while avoiding donor site morbidity, had been associated with higher reinjury rates in prior studies.42 This may be due to the inconsistent recovery of proprioceptive function, as the distribution and integration of mechanoreceptors in allografts differ from those in native tissues. Additionally, the biomechanical properties of allografts, particularly in the context of ankle flexor tendons used for knee reconstruction, may not fully replicate the sensory feedback required for optimal knee joint stability. It should also be considered that iatrogenic factors may be related to the processing process during allograft preparation, which may remove donor cells as much as possible, resulting in affecting the proprioception after integration.43,44

Emerging evidence indicates that in small-angle position sense, anterior cruciate ligament repair yields proprioceptive outcomes comparable to those of most reconstructions, or even superior to some grafts, potentially due to the preservation of native mechanoreceptors within the repaired ligament. This advantage is attributed to the preservation of native mechanoreceptors in the repaired ligament.12 However, this conclusion remains contentious, as some studies have reported no significant proprioceptive advantages associated with repair relative to hamstring tendon reconstruction.28 Another potential source of heterogeneity is that the included ACL reconstruction studies did not consistently report whether remnant-preserving techniques were used, which may have influenced proprioceptive outcomes. Furthermore, the clinical application of repair surgery is restricted—primarily in patients with Sherman type I tears—a factor that may contribute to the observed recovery of proprioception to levels similar to those of healthy controls.45,46 When the indications of repair expand in the future, the postoperative recovery of proprioception may decline as the location of injury approaches the middle part of the ligament, has restricted the availability of long-term data on proprioceptive outcomes.47 Recent studies have begun to explore the proprioceptive prognosis of repair surgery in comparison to ACLR and healthy controls. The findings of this meta-analysis suggest that ACL repair is not inferior to reconstruction in terms of proprioceptive recovery, providing a theoretical rationale for considering repair surgery in clinical decision-making for ACL injuries.

In conclusion, the choice of surgical intervention should be determined based on the specific needs and circumstances of the patient. Potential differences in postoperative proprioception across surgical techniques may have implications for both surgical decision-making and rehabilitation planning, particularly with respect to individualized proprioceptive and neuromuscular training. The surgical technique determines the initial tension, position sense and mechanical environment of the new ACL, which may directly affect the transmission of neural signals and central integration. The choice of surgical intervention should be determined based on the specific needs and circumstances of the patient. ACL repair techniques can help reduce ACL injury and accelerate the inflammatory response of PTOA after surgery.48 For patients with less activity requirements, repair surgery may be a feasible option. However, when repair is not feasible, using grafts that meet the patient's anatomical structure and lifestyle requirements for reconstruction remains a reliable option. This is the author's initial speculation, and more clinical studies are needed to confirm our conclusion.

4.3. Research implication

Current evidence on postoperative proprioception after ACL surgery remains limited by small sample sizes, predominantly single-center studies, and substantial heterogeneity in follow-up duration, testing protocols, and surgical techniques. The present review further suggests that proprioceptive outcomes may vary according to postoperative time point, test angle, and procedure type, highlighting the need for better-designed comparative studies in this field. In particular, longer-term studies are needed to determine whether the absence of a clear proprioceptive disadvantage for ACL repair in the present analysis is maintained over time.

Future research should prioritize prospective, adequately powered, and preferably multicenter studies that directly compare ACL repair with different reconstruction graft types using standardized proprioceptive assessment protocols. More consistent reporting of baseline characteristics, including preoperative proprioceptive status, patient selection criteria, and time from injury to surgery, is also needed to improve comparability across studies.

In addition, because proprioceptive assessments varied substantially across the included studies, future work should aim to develop more standardized and clinically relevant evaluation methods. This may help clarify postoperative proprioceptive recovery more accurately and provide a stronger basis for future evidence synthesis.

By addressing these research gaps, this study aims to contribute to the development of more effective, evidence-based strategies for ACL injury management and rehabilitation, ultimately improving patient care and long-term outcomes.

4.4. Clinical implication

From a clinical perspective, the present findings suggest that ACL repair does not appear to show a clear proprioceptive disadvantage compared with commonly used reconstruction techniques. However, the current evidence remains insufficient to support definitive recommendations regarding procedure selection based on proprioceptive outcomes alone.

Postoperative proprioceptive recovery should be considered as one component of overall recovery after ACL surgery, alongside other established clinical factors. The present findings also support the potential value of individualized postoperative rehabilitation, particularly with respect to proprioceptive and neuromuscular training. Nevertheless, these implications should be interpreted cautiously, given the limited number of studies, methodological heterogeneity, and inconsistent reporting across the included literature.

While proprioception is a vital component of postoperative recovery, it is not the sole determinant of surgical success. The choice of surgical method should also account for patient-specific factors, including muscle strength, athletic demands, age, and activity level. Clinical decision-making must be individualized, balancing the restoration of proprioception with other functional and anatomical considerations to optimize patient outcomes.

4.5. Limitation

This study has several limitations that should be acknowledged. First, the analysis was primarily based on indirect comparisons using NMA, due to a lack of high-quality RCTs directly comparing different surgical modalities or graft types. Indirect comparisons may be susceptible to confounding factors, potentially introducing bias into the results.

Second, most included studies were cross-sectional in design, limiting causal inference and increasing susceptibility to selection and recall bias. Preoperative condition should also be considered when interpreting the findings, particularly in comparisons between ACL repair and ACL reconstruction, because baseline proprioceptive status, patient selection, and time from injury to surgery may differ across procedures. However, these data were inconsistently reported and could not be synthesized reliably. Future studies should prioritize prospective cohort studies or randomized controlled trials and report baseline clinical characteristics more comprehensively.

Third, the limited number of studies included in this analysis may have led to publication bias, potentially resulting in either overestimation or underestimation of the true effects. Future studies should aim to include a broader range of literature, encompassing both positive and negative results, to mitigate this issue.

Fourth, the extended time span across the included studies introduced heterogeneity in measurement methods and surgical techniques, which may have contributed to inconsistent findings. Future research should adopt standardized measurement protocols and surgical techniques to minimize heterogeneity and improve the comparability of results. The wide range of publication years among the included studies may also have introduced temporal heterogeneity, as older studies may not fully reflect contemporary surgical and rehabilitation practice.

Fifth, although the methodological quality of all included studies was systematically appraised using the EAI and categorized using predefined thresholds, we did not perform sensitivity analyses excluding studies of lower quality or stratifying estimates by quality tier. As a result, the potential influence of studies with heightened risk of bias or methodological limitations on the pooled effect sizes cannot be fully ruled out. Future updates of this meta-analysis should incorporate quality-based sensitivity analyses to evaluate the stability of the findings.

Finally, this study did not fully account for the impact of postoperative rehabilitation programs. Most included studies lacked detailed descriptions of postoperative rehabilitation, which may have led to incomplete conclusions. Future research should investigate the effects of specific rehabilitation strategies, such as neuromuscular training or functional exercises, on proprioceptive recovery and long-term functional outcomes.

5. Conclusion

In conclusion, in small-angle position at six-month follow-up, ACL repair may yield similar or even better proprioceptive recovery compared to hamstring tendon autografts and tibialis anterior allografts. However, different types of reconstructive grafts or repairs do not show significant differences in proprioceptive recovery from most angles. These findings suggest that ACL repair demonstrates proprioceptive outcomes similar to those of ACL reconstruction, and different graft selections for ACL reconstruction may produce similar proprioceptive outcomes, allowing graft choice to be guided by specific clinical needs. However, the current evidence remains insufficient to conclude that anterior cruciate ligament repair should be preferred, and its potential role may be limited to selected patients in specific circumstances.

Submission statement

The work described has not been published previously (except in the form of an abstract or as part of a published lecture or academic thesis), that it is not under consideration for publication elsewhere, that its publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published elsewhere including electronically in the same form, in English or any other language, without the written consent of the copyright-holder.

Funding

2026 Shanghai Sports Technology Projects (grant number 26J003) and Medical Innovation Research Project of the Shanghai Municipal Science and Technology Commission (grant number 25Y42800400)

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.asmart.2026.07.001.

Contributor Information

Jian Zhang, Email: zhangjian@huashan.org.cn.

Xiao'ao Xue, Email: xaxue16@fudan.edu.cn.

Yinghui Hua, Email: hua_cosm@aliyun.com.

Appendices

Supplementary Appendix 1. pdf.

Supplementary Appendix 2-Quality assessment and Risk of bias assessment. pdf.

Supplementary Appendix 3-Prisma checklist. pdf.

Supplementary Appendix 4- Heterogeneity assessment.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

Multimedia component 1
mmc1.pdf (118KB, pdf)
Multimedia component 2
mmc2.pdf (1.8MB, pdf)
Multimedia component 3
mmc3.docx (270KB, docx)
Multimedia component 4
mmc4.pdf (183.1KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Multimedia component 1
mmc1.pdf (118KB, pdf)
Multimedia component 2
mmc2.pdf (1.8MB, pdf)
Multimedia component 3
mmc3.docx (270KB, docx)
Multimedia component 4
mmc4.pdf (183.1KB, pdf)

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