Factors Influencing Consultant Knee Surgeons’ Decision Making in Anterior Cruciate Ligament (ACL) Injury Management in Athletes: An International Delphi Study

BACKGROUND: Prolonged surgical waiting lists and changing healthcare systems have raised questions about the best approach to anterior cruciate ligament (ACL) injury management in athletes, highlighting the need for consultant knee surgeon consensus. OBJECTIVE: The aim was to establish consultant knee surgeon consensus on ACL injury management for athletes. METHODS: Twenty-two male consultant knee surgeons from the United Kingdom (UK) (n = 18), Australia (n = 2), and Canada (n = 2) completed all three rounds of a Delphi survey between April and September 2024, responding to statements developed from the existing literature and clinical expertise. RESULTS: Median responses ranged from strong agreement to strong disagreement, indicating diverse views, with narrower interquartile ranges in later rounds suggesting increasing consensus. Agreement was observed for rehabilitation‑focused approaches, patient involvement in shared decision making, and clinical factors such as knee stability and concomitant injury, while patient age and level of sport were less consistently prioritised. Disagreement persisted regarding surgical risk, including whether surgery would be required, and graft preferences (autologous versus synthetic). Some items reached full agreement (100%) or showed clustered responses (interquartile range = 0). Most items were stable between rounds (Wilcoxon: p = 0.16-1.00), although variability was observed for first-choice management, inclusion of lateral extra-articular procedures, and preferred lateral extra-articular procedure type, despite minimal median change (Wilcoxon: p = 0.02-0.09). Kendall's W indicated strong agreement in round 2 (W = 0.532, p < 0.001) and round 3 (W = 0.672, p < 0.001). CONCLUSIONS: These findings may support clinicians and athletes in navigating complex treatment decisions, particularly where public healthcare delays challenge conventional surgical pathways.