Sex-stratified analyses of femoral intercondylar notch morphology and ACL injury risk: a systematic review and meta-analysis

Background Anterior cruciate ligament (ACL) injury is more common in females. Although ACL injury risk is multifactorial, involving neuromuscular, hormonal, and biomechanical factors, femoral intercondylar notch morphology is a proposed non-modifiable anatomical contributor that may help explain this disparity. This review synthesizes evidence on its association with ACL injury risk, analyses stratified by male and female sex. Methods A literature search of PubMed, Web of Science, and Scopus was conducted through January 2026. After duplicate removal, 527 unique records were screened and 134 full texts assessed for eligibility. Twenty-four studies met inclusion criteria, with 22 providing quantitative data. Data were extracted on ACL-injured (ACLi) and control (ACLc) knees, stratified by sex. Results ACLi knees had narrower notch widths than ACLc knees in both females (MD −1.74 mm, 95% CI −2.54 to −0.95) and males (MD −1.31 mm, 95% CI −1.94 to −0.68), with substantial heterogeneity (I 2 81–95%). NWI differences were significant in males (MD −0.01, 95% CI −0.02 to 0.00) but not females. Limited notch shape data suggested higher ACL injury odds with A-shaped notches in females (OR 2.85, 95% CI 0.07–110.66) and males (OR 1.67, 95% CI 0.00–3.98 × 10 5 ). Conclusion Narrower femoral intercondylar notch width was consistently associated with ACL injury in both sexes, whereas findings for NWI and notch shape were limited by heterogeneity and sparse data. These results provide a structured synthesis of sex-specific anatomical risk factors and support femoral notch narrowing as a shared contributor, while highlighting the need for prospective, standardized studies in the future.