The Current State of Anterior Cruciate Ligament Reconstruction: Graft Selection, Lateral Augmentation, Rehabilitation, and Return-to-Play

PURPOSE OF REVIEW: Anterior cruciate ligament reconstruction (ACLR) reliably restores anteroposterior stability; however, the rate of return to prior level of play and incidence of recurrent ACL injury have improved little over the past two decades. The purpose of this review is to describe the current state of ACLR with respect to graft selection, lateral extra-articular augmentation, rehabilitation and return to play, including the role of psychological readiness, and the specific rehabilitation protocol utilized by the senior author. RECENT FINDINGS: Graft utilization has shifted substantially. Quadriceps tendon autograft accounted for less than 5% of primary reconstructions prior to 2014 and approximately 20% by 2023. Contemporary registry data demonstrate smaller differences in revision risk between autograft types than previously reported. Randomized and comparative data support lateral extra-articular tenodesis in selected high-risk knees, with the largest effect reported in the revision setting. Return-to-play practice has shifted from fixed timelines toward criteria-based clearance. However, a subset of athletes do not pass a full clearance battery, and some athletes who do pass and observe recommended timeframes still sustain reinjury. Limb symmetry index may overestimate functional recovery, while test batteries and thresholds vary considerably between institutions. Psychological readiness is independently associated with both return to sport and second ACL injury. Graft selection should be matched to the patient profile, and lateral augmentation should be reserved for high-risk knees. Return to play should be determined by a combination of time from surgery, functional criteria, and psychological readiness. Future study should focus on validating return-to-play criteria against reinjury endpoints and on standardizing how these criteria are defined and reported.