Individualized graft selection in anterior cruciate ligament reconstruction: a literature review

Rodrigo Álvarez de la Reguera-Babb, Servicio de Ortopedia y Traumatología, Hospital Christus Muguerza Alta Especialidad, Monterrey, Nuevo Leon, Mexico
Francisco J. Arrambide-Garza, Servicio de Ortopedia y Traumatología, Hospital Christus Muguerza Alta Especialidad, Monterrey, Nuevo Leon, Mexico
Carlos E. Godoy-Ponce, Servicio de Ortopedia y Traumatología, Hospital Christus Muguerza Alta Especialidad, Monterrey, Nuevo Leon, Mexico
Carlos Godoy-Salinas, Servicio de Ortopedia y Traumatología, Hospital Christus Muguerza Alta Especialidad, Monterrey, Nuevo Leon, Mexico

Anterior cruciate ligament (ACL) reconstruction (ACLR) is one of the most performed orthopaedic procedures, yet graft selection remains controversial because it directly influences graft failure, return to sport (RTS), donor-site morbidity, and long-term outcomes. This review summarizes the current evidence to provide an evidence-based framework for individualized graft selection in ACLR according to patient characteristics and sporting demands. A narrative literature review synthesized recent high-level evidence, including systematic reviews, meta-analyses, randomized controlled trials, and national registry studies, on bone-patellar tendon-bone (BPTB), quadriceps tendon (QT), hamstring tendon (HT), and allografts for anterior cruciate ligament reconstruction. Evidence on graft augmentation procedures and emerging reconstructive strategies was also reviewed. No single graft is ideal for all patients. Bone-patellar tendon-bone (BPTB) provides the lowest failure rates in young pivoting athletes but is associated with greater anterior knee morbidity. Quadriceps tendon (QT) offers comparable outcomes with lower donor-site morbidity, although registry studies suggest a higher early revision risk. Hamstring tendon (HT) remains widely used but is associated with increased revision risk in young patients and grafts < 8 mm. Allografts should generally be reserved for older, multiligament, or revision cases. Adjunctive lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR) reduce graft failure in high-risk athletes. Graft selection should be individualized using age, sex, sport-specific kinematic demand, occupational kneeling exposure, prior surgery, and patient preference, refined by surgeon experience and shared decision-making.

Keywords: ACL reconstruction. Graft selection. Bone-patellar tendon-bone. Quadriceps tendon. Hamstring tendon.