Personalized graft selection and reinforcement strategies in anterior cruciate ligament reconstruction: A state-of-the-art review

Anterior cruciate ligament reconstruction (ACLR) is a standard treatment for restoring knee stability. However, graft failure persists as a clinically relevant problem, influenced by patient age, sport profile, graft diameter, and inadequate reinforcement strategies. To provide a state-of-the-art synthesis of graft options and reinforcement techniques in ACLR, integrating biomechanical and clinical evidence, and to propose a structured, risk-adapted decision algorithm for individualized graft selection. State-of-the-art review. A comprehensive literature review was performed using PubMed, MEDLINE, EMBASE, and Cochrane databases (2000–2025). Studies evaluating biomechanical performance, biological incorporation, clinical outcomes, and complication rates of autografts, allografts, synthetic constructs, and reinforcement techniques were included. Risk factors for graft failure were identified and incorporated into a multi-variable stratification model, which informed a stepwise clinical decision algorithm. Autografts remain the gold standard, with quadriceps tendon (QT) and peroneus longus tendon (PLT) validated as reliable alternatives, and rectus femoris tendon (RFT) emerging in complex cases. Allografts provide acceptable outcomes in older or low-demand patients but are associated with higher failure rates in young athletes. Internal bracing with suture tape significantly reduces elongation and early failure in high-risk scenarios, whereas hybrid constructs are currently limited to salvage cases. The proposed algorithm integrates patient age, sport type, ligamentous laxity, and predicted graft diameter, providing a reproducible framework for graft selection and reinforcement. Risk-adapted graft selection and selective reinforcement strategies enhance graft durability, reduce complications, and improve return-to-sport outcomes. Incorporating new autografts (PLT, RFT), internal bracing, and structured algorithms represents a paradigm shift toward precision ACL surgery. Level V, expert opinion.