Precision anterior cruciate ligament (ACL) reconstruction in high-level athletes

Introduction

Anterior cruciate ligament (ACL) injuries are common knee injuries and are becoming increasingly prevalent, especially among high-level athletes (1-7). Pivoting sports such as football, basketball, soccer, gymnastics, and skiing have been associated with a higher incidence of ACL injuries than non-pivoting sports (8-13). An annual 1.3% increase in ACL injuries was noted in fifteen different National Collegiate Athletic Association sports (14). Notably, female athletes experience a disproportionately higher rate of ACL injuries, with rates ranging 2–8 times higher than male athletes (15-19). For elite athletes, in this review defined as athletes competing on the highest level of their sport, ACL reconstruction (ACLR) in case of an ACL tear is recommended (20). Reported return to sports (RTS) and return to play (RTP) rates are achieved by 83–93% of professional athletes (7,21). Besides surgical treatment, rehabilitation after ACLR plays a key role in successful RTS and RTP. High sports-specific knowledge is required to meet the unique demands of high-level athletes (22). Yet RTS does not guarantee full restoration of performance or RTP, and many athletes face persistent muscular deficits, altered biomechanics, or shortened careers even after successful surgery and rehabilitation (7,22-24). Given the rising incidence of ACL injuries and numerous factors influencing outcomes after ACLR in high-level athletes, treatment is constantly being improved. Optimizing clinical and functional outcomes requires technical surgical proficiency, an individualized strategy that integrates intrinsic anatomy, sport-specific biomechanics, injury history, and performance goals. This review synthesizes current evidence on ACLR in elite athletes and highlights key considerations for maximizing functional recovery and sustaining at a competitive high level.

Epidemiology and mechanisms of ACL injury in elite athletes

Optimizing ACL injury treatment strategies in elite athletes begins with understanding the specific context in which they occur, including risk factors and mechanisms of injury. While American football accounts for almost half of all ACL injuries at the National Collegiate Athletic Association (NCAA) level, women’s soccer, women’s gymnastics, and women’s basketball all demonstrate similar or higher rates of injury per exposure (14). This highlights female sex as an important risk factor at the elite level, with females experiencing 2-to-4 times higher injury rates than males playing the same sport (8). Along with anatomic differences, hormonal effects and ligamentous laxity have been proposed as drivers of these sex differences (25). As early research into the modulation of risk factors has not consistently demonstrated efficacy in decreasing risk, it is important to tailor surgical treatment strategies to mitigate reinjury risk in female athletes (26).

Pivoting, cutting, and landing movements have been consistently implicated in ACL injuries, which is displayed by the high rates of ACL injuries in American football, soccer, basketball, and gymnastics (14,27). Noncontact mechanisms account for nearly 75% of all ACL injuries (28). On the other hand, professional ice hockey, a contact sport with limited pivoting and jumping, has been associated with lower rates of ACL injury and highlights the relative importance of the type of movements rather than exposure to contact in injury risk. Understanding the sport and specific at-risk movements the athlete participates in is imperative when developing a treatment plan, especially in graft choice, which will be discussed later in this article. This individualized approach is also important when counseling the athlete on postoperative expectations. For example, National Football League (NFL) athletes RTS at a lower rate, with lower average performance, and with worse longevity than National Hockey League (NHL) athletes (23).

Considerations in the treatment of high-level athletes

The term precision ACLR has been outlined in previous works and refers to the personalization of surgical decision-making and technical approaches to the patient’s native anatomy, activity level, and their concomitant pathologies (29). This concept is critically important in the treatment of elite athletes who demand a higher level of function than the general athletic population and in whom small deviations may be altering their career (30).

The anatomy of the ACL is variable across the athletic population with considerable individual differences in femoral and tibial footprints, ligament size, and notch size (31,32). For example, larger ACL sizes are seen in males and athletes with higher body mass indices (BMIs) (9). The concept of anatomic ACLR with the goal of closely restoring the native ligament anatomy has been suggested to improve outcomes, including stability, patient-reported outcomes (PROs), and post-traumatic arthritis rates (33,34). Checklists have been developed to facilitate anatomic reconstruction, including the use of consistently identifiable landmarks, measuring notch width and footprint size, and the use of transportal femoral tunnel drilling (Figure 1) (34-36). For those with larger tibial footprints (>14 mm) and notch widths (>14–16 mm), the surgeon should consider a larger graft or even double-bundle reconstruction as the goal is to restore 50–80% of the tibial insertion while avoiding notch impingement (34,37).

Figure 1 Femoral insertion of the ACL. (A) Lateral radiograph of the knee. The anatomical femoral insertion point of the ACL is highlighted (blue circle). (B) The arthroscopic view of the left knee shows the anatomical footprint of the resected ACL, utilizing a tip aimer. ACL, anterior cruciate ligament.

ACL injuries are frequently associated with concomitant injuries, including meniscus, cartilage, and additional ligamentous injuries (38). Appropriate recognition and management of these injuries is a critical part of optimizing outcomes in the treatment of ACL injuries (3). Elite pivoting athletes have been shown to present with higher rates of concomitant meniscus and cartilage injuries, while high-impact sports like skiing or American football have been associated with high rates of multiligamentous injuries (39,40). Appropriate care for elite athletes with multiligamentous injuries must include a heightened index of suspicion during preoperative and intraoperative evaluation for concomitant pathologies.

Graft selection

A crucial element of precision ACLR is appropriate graft choice tailored specifically to the athlete’s sport and anatomical conditions. The type of graft healing and timeline to integration, the overall failure rates, and donor side morbidity are all considerable variables of graft choice. The unique complication profile for each graft type must be considered in the context of sport-specific demands (41). Although bone-patellar tendon-bone autograft (BPTB) autograft is often considered the gold standard in elite athletes in American professional leagues, a majority of surveyed European and Asian surgeons prefer using a hamstring (HS) autograft in athletes (42-44). Quadriceps tendon (QT) autograft is becoming an increasingly popular graft choice, although long-term outcomes data are limited compared to BPTB and HS grafts. Regarding sports-specific differences in graft selection, BPTB grafts are favored for young athletes in pivoting and cutting sports like soccer and basketball, offering superior stability and lower re-rupture risk, but with higher rates of anterior knee pain (45,46). Hamstring tendon (HT) autografts are more preferable to use in older or less active patients, and in sports relying heavily on knee extension, though they carry a greater failure risk in young, high-demand athletes (45,47). QT grafts are emerging as a strong option for pivoting and cutting athletes, showing outcomes like BPTB while reducing donor site issues and potentially enabling a faster RTP (48). The potential for prolonged extensor muscle weakness over the first 6 months should be considered when choosing this graft (49). Graft selection is not a one-size-fits-all approach, and a thorough understanding of the advantages and disadvantages of each option is essential for educating the athlete in the shared decision-making process. A detailed overview of the most used autografts in ACLR is provided in the following section.

BPTB

Seventy percent of surveyed team orthopedic surgeons covering NHL, Major League Soccer (MLS) and Olympic teams reported they prefer the use of BPTB autograft in their elite athletes, with 86% preferring BPTB in college and NFL football (50-52). The current data displays an overall low failure rate from 5–8% in ACLR with BPTB autograft compared to HS autograft in a comparable follow-up time (53,54). The tendon to bone insertion on the proximal and distal portions of the graft remains intact, and the bone graft incorporates in the tibial and femoral tunnels within 6 weeks, whereas soft tissue grafts may take up to 8–12 weeks (55). Although the time of graft incorporation of BPTB autografts into bone tunnels is shorter, the literature does not consistently show better rates of athletes returning to their previous performance when using HS grafts (48,56,57).

The major drawback of BPTB use is the potential for donor site morbidity (58). Devastating complications, including patellar tendon rupture or patella fracture, were related to the harvest technique, and care must be taken to limit the size of the graft harvest to what is necessary for the patient’s anatomy (58,59). Anterior knee pain and difficulty kneeling are more common with BPTB autograft and can present in up to 20% of patients, which is twice as much as when using a HS autograft (60,61). Although less long-term data is available, QT autograft also appears to have lower rates of anterior knee pain (62). This potential complication must be disclosed to all athletes and is an important consideration in athletes who frequently go to a kneeling position.

HS autograft

HS autograft is a popular graft choice in an international context and remains a reasonable graft option for patients at high risk for complications with other graft options (53,54). Notably, multiple series report excellent RTP and low failure rates in professional athletes with HS grafts (63,64). Along with lower rates of anterior knee pain, proponents of the graft point to the potential for a larger cross-sectional area and higher tensile strength of the quadrupled HS graft (65-67).

The HS graft is an excellent graft choice for skeletally immature athletes when open physes must be respected and modified techniques, sparing the physes, are used for ACLR (66,68). The comparatively higher failure rates of HT autografts are frequently mentioned as a potential downside. The literature indicates that HS grafts have a higher failure rate in ACLR, with reported rates ranging from 5% to 29% (48,69). Risk factors such as young patient age, high activity level, graft diameter <8 mm, and female sex were identified by multiple studies and should be considered in graft decision making (70). In cases with present risk factors, adding a lateral extra-articular procedure (LEAP) significantly reduces the failure rate (47). Furthermore, slower return of knee flexion strength, tunnel widening, and prolonged healing times have been cited as drawbacks of using HS autograft (71,72). Overall, the HT autograft remains a reasonable graft choice for a low-risk population, but must be carefully evaluated when chosen in professional athletes.

QT autograft

The QT autograft can be harvested with a bone block or as an all-soft tissue graft (Figures 2,3). In biomechanical studies, the QT grafts demonstrated a thicker diameter and higher tensile strength than the BPTB autograft (73,74). Along with lower rates of anterior knee pain compared to BPTB autografts, the QT grafts show a similar anteroposterior laxity of the knee joint, PROs, and failure rate when compared to BPTB autografts in ACLR (62,75,76). Good clinical and functional outcomes have been reported with QT autografts in high-level young athletes with RTS rates of 80% at a mean time of 9.7 months and revision rates of 10% at a midterm follow-up 10% (77).

Figure 2 Examples of the three most used autografts in ACLR. (A) Four-strand hamstring autograft (semitendinosus and gracilis tendons). (B) Bone patellar tendon bone autograft and (C) all soft tissue quadriceps tendon autograft. ACLR, anterior cruciate ligament reconstruction.

Figure 3 Intraoperative arthroscopic images of ACL grafts. (A) Hamstring tendon; (B) bone patellar tendon bone; (C) quadriceps tendon autograft after arthroscopic ACL reconstruction. ACL, anterior cruciate ligament.

Despite potential advantages of the QT graft in ACLR, only 1 of the 32 NFL team physicians reported preferring the QT autograft for primary ACLR in their NFL athletes (78,79). Higher rates of extensor mechanism and quadriceps weakness postoperatively compared to HS and BPTB autografts have been reported, and this may be especially prominent in female athletes (49,80,81). About 35% of patients experience a temporary weakness of the quadriceps muscle after ACLR (49). Therefore, this should be discussed with the athlete, especially in athletes participating in jumping sports. Other described, although less common, complications include rectus femoris retraction and patella fracture in graft harvesting with a bone block (58,75,82).

Concomitant injuries

Concomitant injuries occur in the majority of ACL tears among athletes, with rates ranging from 60% to over 89% depending on the population and study design. The most frequent associated injuries are meniscal tears (35–70%), chondral lesions (20–49%), and medial collateral ligament lesions (3–57%) (83-86). Current evidence strongly favors meniscal repair over meniscectomy in athletes with ACL injuries. Meniscal repair is especially indicated for tear patterns such as bucket handle, ramp lesions, root tears, and tears in the vascularized (red-red or red-white) zones. The literature suggests an early rather than a delayed repair due to inferior outcomes and higher meniscus re-tear rates with delayed meniscal surgery with concomitant ACLR (87,88). There is an overall trend of using all inside repair techniques for the lateral and medial meniscus (89,90). The inside-out technique may provide a more robust construct for athletes, as in this case, the suture knot can be tightened under visual control against the joint capsule (91,92).

LEAP

Competitive athletes in pivoting sports are at high risk for ACL graft failure after ACLR (93,94). International consensus stated that a LEAP should be considered in active patients ≤25 years undergoing HS-autograft ACLR, in the presence of high-grade pivot shift, knee hyperextension, or in patients who want to return to pivoting sports, in revision surgery, or multiple combined risk factors may reduce the ACL graft failure rate (47,95). Long-term follow-up studies corroborate the findings and report superior graft survival (96.5% vs. 82.6%) and fewer reoperations with comparing isolated ACLR with HS autograft versus combined with a LEAP (93,94,96,97). Systematic reviews and meta-analyses showed reduced graft failure and improved pivot-shift outcomes without increased complication rates for combined procedures in ACLR with HS autograft (98,99).

The literature is not conclusive on whether adding a LEAP in ACLR using QT or BPTB autografts reduces failure rates (70,100). On the other hand, clinical and functional outcomes have not been altered by adding a LEAP to an HS, QT, or BPTB autograft (101,102). The complication rate following LEAP procedures has been low (103-105).

In summary, for high-performance athletes, lateral extraarticular tenodesis (LET, Figure 4) offers a robust adjunct in primary ACLR with HS autograft, as there is substantial evidence that adding LET to an HS autograft reduces the risk of ACL graft failure. There is a strong consensus amongst international experts that a LEAP to high-demanding athletes, high-grade pivot shift, or patients aged 25 years and younger, when considering primary ACLR, may be added (95,107). However, randomized controlled trials will need to further investigate the effectiveness of LEAP in ACLR with QT and BPTB autografts.

Figure 4 The sequence of a lateral extra-articular tenodesis is one option for a LEAP procedure involving the iliotibial band. (A) A strip of the iliotibial band is cut and released proximally. (B) The iliotibial band, armed with sutures, is then shuttled beneath the lateral collateral ligament (*) before fixation is performed on the lateral femoral condyle (106). LEAP, lateral extraarticular procedure.

Rehabilitation and RTS protocols

High-level athletes seek to return to RTSs and RTP at the same level, or a higher level, compared to pre-injury. A comeback to an “almost similar” level may not be enough, so a closely monitored rehabilitation process is mandatory for a successful RTS and RTP. The terms RTS and RTP are often used interchangeably, but research highlights important distinctions. RTS is a broader, multi-stage process, while RTP is a specific milestone within that process, typically marking full, unrestricted participation in competition or training (108,109). The RTS rates after ACLR in athletes are overall high and were reported between 78% and 85% (7). There is a significant variation in the time to RTS across different sports, with reported time to RTS ranging between 6–13 months (7,50,51,63,110). The variation in time to RTS displays that, rather than time-based criteria, functional criteria should be used for a successful comeback to reduce the reinjury rate after ACLR (111).

The Functional tests, such as the limb symmetry in quadriceps strength (≥90% compared to contralateral), hop tests, and sports-specific RTSs criteria, significantly reduce reinjury risk after ACLR and reduce contralateral ACL tear, and may be indicative of the timing of RTP (111,112). Besides functional testing, neuromuscular training may help athletes to optimize kinematics, improve knee stability, and prevent contralateral ACL injury (110). Neuromuscular training may be even more essential, for example, in view of the quadriceps weakness that can occur after a QT autograft, since reduced corticospinal excitability has been demonstrated in this context (113).

The successful comeback of an athlete is not only determined by physical factors but also influenced by the psychological readiness to RTS (114). The Anterior Cruciate Ligament Return to Sport after Injury Calculator (ACL-RSI) was developed to measure athletes’ emotion, confidence, fear of reinjury, and risk appraisal when returning from ACL injury or ACLR (114,115). The ACL-RSI strongly correlates with successful RTP (114,116). This goes in line with further studies that linked the psychological readiness to physical parameters and showed a direct positive correlation between single-leg hop testing, ACL-RSI, and a successful RTS (115).

Conclusions

Treatment of ACL injuries in elite athletes remains challenging, with unique demands placed on both surgical reconstruction and rehabilitation. The most used graft in ACLR in elite athletes is the BPTB autograft, followed by the HT autograft. The QT has become more commonly used in recent years. Graft selection depends on a combination of each graft’s different characteristics and the athlete’s demands. Concomitant meniscus injuries are most frequent and should be repaired with an all-inside or inside-out technique if reasonable. To reduce failure rates in HT grafts in the high-risk population, LEAP should be considered for ACLR. Data on QT and BPTB autografts combined with an LAEP remains scarce. Rehabilitation concepts should focus on improving the range of motion, quadriceps strength, neuromuscular and sports-specific exercises, and psychological aspects for a successful comeback of the athlete.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Jeremy Burnham, Brian Godshaw and Patrick Cook) for the series “Evaluation and Treatment of ACL Injuries in High Level Athletes: The Continuum of Care” published in Annals of Joint. The article has undergone external peer review.

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-58/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-58/coif). The series “Evaluation and Treatment of ACL Injuries in High Level Athletes: The Continuum of Care” was commissioned by the editorial office without any funding or sponsorship. V.M. declares receiving educational grants from National Center for Advancing Translational Sciences of the NIH [No. TL1TR001858 (Training support for Poploski KM)] and Department of Defense (No. W81XWH-17-2-07), and receiving consulting fees and speaking fees from Newclip and Smith & Nephew, stock or stock options from Ostesys. None of the funding was related to this article. He is a board member of the ACL Study Group, and has a patent, U.S. Patent No. 9,949,684, issued on April 24, 2018, to the University of Pittsburgh. Also, he is a board member of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS), and deputy editor-in-chief of Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Gianotti SM, Marshall SW, Hume PA, et al. Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study. J Sci Med Sport 2009;12:622-7. [Crossref] [PubMed]
2. Memmel C, Krutsch W, Weber J, et al. Increased rate of injuries to the anterior cruciate ligament in amateur soccer players after the COVID-19 pandemic lockdown. Arch Orthop Trauma Surg 2024;144:4319-24. [Crossref] [PubMed]
3. Musahl V, Engler ID, Nazzal EM, et al. Current trends in the anterior cruciate ligament part II: evaluation, surgical technique, prevention, and rehabilitation. Knee Surg Sports Traumatol Arthrosc 2022;30:34-51. [Crossref] [PubMed]
4. Sanders TL, Maradit Kremers H, Bryan AJ, et al. Incidence of Anterior Cruciate Ligament Tears and Reconstruction: A 21-Year Population-Based Study. Am J Sports Med 2016;44:1502-7. [Crossref] [PubMed]
5. Werner BC, Yang S, Looney AM, et al. Trends in Pediatric and Adolescent Anterior Cruciate Ligament Injury and Reconstruction. J Pediatr Orthop 2016;36:447-52. [Crossref] [PubMed]
6. Sutton KM, Bullock JM. Anterior cruciate ligament rupture: differences between males and females. J Am Acad Orthop Surg 2013;21:41-50. [Crossref] [PubMed]
7. Lai CCH, Ardern CL, Feller JA, et al. Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Br J Sports Med 2018;52:128-38. [Crossref] [PubMed]
8. Arendt E, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med 1995;23:694-701. [Crossref] [PubMed]
9. Barnett SC, Murray MM, Flannery SW, et al. ACL Size, but Not Signal Intensity, Is Influenced by Sex, Body Size, and Knee Anatomy. Orthop J Sports Med 2021;9:23259671211063836. [Crossref] [PubMed]
10. Bradley JP, Klimkiewicz JJ, Rytel MJ, et al. Anterior cruciate ligament injuries in the National Football League: epidemiology and current treatment trends among team physicians. Arthroscopy 2002;18:502-9. [Crossref] [PubMed]
11. Charpy S, Billard P, Dandrieux PE, et al. Epidemiology of injuries in elite Women's Artistic Gymnastics: a retrospective analysis of six seasons. BMJ Open Sport Exerc Med 2023;9:e001721. [Crossref] [PubMed]
12. Lian J, Sewani F, Dayan I, et al. Systematic Review of Injuries in the Men's and Women's National Basketball Association. Am J Sports Med 2022;50:1416-29. [Crossref] [PubMed]
13. Shimokochi Y, Shultz SJ. Mechanisms of noncontact anterior cruciate ligament injury. J Athl Train 2008;43:396-408. [Crossref] [PubMed]
14. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train 2007;42:311-9.
15. Branche K, Bradsell HL, Lencioni A, et al. Sex-Based Differences in Adult ACL Reconstruction Outcomes. Curr Rev Musculoskelet Med 2022;15:645-50. [Crossref] [PubMed]
16. Gupta AS, Pierpoint LA, Comstock RD, et al. Sex-Based Differences in Anterior Cruciate Ligament Injuries Among United States High School Soccer Players: An Epidemiological Study. Orthop J Sports Med 2020;8:2325967120919178. [Crossref] [PubMed]
17. Hewett TE, Myer GD, Ford KR. Anterior cruciate ligament injuries in female athletes: Part 1, mechanisms and risk factors. Am J Sports Med 2006;34:299-311. [Crossref] [PubMed]
18. Lin CY, Casey E, Herman DC, et al. Sex Differences in Common Sports Injuries. PM R 2018;10:1073-82. [Crossref] [PubMed]
19. Cerciello S, Corona K, Morris BJ, et al. Hybrid coracoclavicular and acromioclavicular reconstruction in chronic acromioclavicular joint dislocations yields good functional and radiographic results. Knee Surg Sports Traumatol Arthrosc 2022;30:2084-91. [Crossref] [PubMed]
20. Musahl V, Karlsson J. Anterior Cruciate Ligament Tear. N Engl J Med 2019;380:2341-8. [Crossref] [PubMed]
21. Barth KA, Lawton CD, Touhey DC, et al. The negative impact of anterior cruciate ligament reconstruction in professional male footballers. Knee 2019;26:142-8. [Crossref] [PubMed]
22. Waldron K, Brown M, Calderon A, et al. Anterior Cruciate Ligament Rehabilitation and Return to Sport: How Fast Is Too Fast? Arthrosc Sports Med Rehabil 2022;4:e175-9. [Crossref] [PubMed]
23. Mai HT, Chun DS, Schneider AD, et al. Performance-Based Outcomes After Anterior Cruciate Ligament Reconstruction in Professional Athletes Differ Between Sports. Am J Sports Med 2017;45:2226-32. [Crossref] [PubMed]
24. Read CR, Aune KT, Cain EL Jr, et al. Return to Play and Decreased Performance After Anterior Cruciate Ligament Reconstruction in National Football League Defensive Players. Am J Sports Med 2017;45:1815-21. [Crossref] [PubMed]
25. Slauterbeck JR, Fuzie SF, Smith MP, et al. The Menstrual Cycle, Sex Hormones, and Anterior Cruciate Ligament Injury. J Athl Train 2002;37:275-8.
26. Bram JT, Magee LC, Mehta NN, et al. Anterior Cruciate Ligament Injury Incidence in Adolescent Athletes: A Systematic Review and Meta-analysis. Am J Sports Med 2021;49:1962-72. [Crossref] [PubMed]
27. Arendt EA, Agel J, Dick R. Anterior cruciate ligament injury patterns among collegiate men and women. J Athl Train 1999;34:86-92.
28. Boden BP, Dean GS, Feagin JA Jr, et al. Mechanisms of anterior cruciate ligament injury. Orthopedics 2000;23:573-8. [Crossref] [PubMed]
29. Herman ZJ, Kaarre J, Getgood AMJ, et al. Precision Anterior Cruciate Ligament Reconstruction. Clin Sports Med 2024;43:535-46. [Crossref] [PubMed]
30. Longstaffe R, Leiter J, Gurney-Dunlop T, et al. Return to Play and Career Length After Anterior Cruciate Ligament Reconstruction Among Canadian Professional Football Players. Am J Sports Med 2020;48:1682-8. [Crossref] [PubMed]
31. Kopf S, Pombo MW, Szczodry M, et al. Size variability of the human anterior cruciate ligament insertion sites. Am J Sports Med 2011;39:108-13. [Crossref] [PubMed]
32. Hussein M, van Eck CF, Cretnik A, et al. Individualized anterior cruciate ligament surgery: a prospective study comparing anatomic single- and double-bundle reconstruction. Am J Sports Med 2012;40:1781-8. [Crossref] [PubMed]
33. van Eck CF, Widhalm H, Murawski C, et al. Individualized anatomic anterior cruciate ligament reconstruction. Phys Sportsmed 2015;43:87-92. [Crossref] [PubMed]
34. Fox MA, Engler ID, Zsidai BT, et al. Anatomic anterior cruciate ligament reconstruction: Freddie Fu's paradigm. J ISAKOS 2023;8:15-22. [Crossref] [PubMed]
35. van Eck CF, Morse KR, Lesniak BP, et al. Does the lateral intercondylar ridge disappear in ACL deficient patients? Knee Surg Sports Traumatol Arthrosc 2010;18:1184-8. [Crossref] [PubMed]
36. van Eck CF, Gravare-Silbernagel K, Samuelsson K, et al. Evidence to support the interpretation and use of the Anatomic Anterior Cruciate Ligament Reconstruction Checklist. J Bone Joint Surg Am 2013;95:e153. [Crossref] [PubMed]
37. van Eck CF, Martins CA, Vyas SM, et al. Femoral intercondylar notch shape and dimensions in ACL-injured patients. Knee Surg Sports Traumatol Arthrosc 2010;18:1257-62. [Crossref] [PubMed]
38. Pruneski JA, Heyworth BE, Kocher MS, et al. Prevalence and Predictors of Concomitant Meniscal and Ligamentous Injuries Associated With ACL Surgery: An Analysis of 20 Years of ACL Reconstruction at a Tertiary Care Children's Hospital. Am J Sports Med 2024;52:77-86. [Crossref] [PubMed]
39. Granan LP, Inacio MC, Maletis GB, et al. Sport-specific injury pattern recorded during anterior cruciate ligament reconstruction. Am J Sports Med 2013;41:2814-8. [Crossref] [PubMed]
40. Farinelli L, Csapo R, Meena A, et al. Concomitant Injuries Associated With ACL Rupture in Elite Professional Alpine Ski Racers and Soccer Players: A Comparative Study With Propensity Score Matching Analysis. Orthop J Sports Med 2023;11:23259671231192127. [Crossref] [PubMed]
41. Buerba RA, Zaffagnini S, Kuroda R, et al. ACL reconstruction in the professional or elite athlete: state of the art. J ISAKOS 2021;6:226-36. [Crossref] [PubMed]
42. Chechik O, Amar E, Khashan M, et al. An international survey on anterior cruciate ligament reconstruction practices. Int Orthop 2013;37:201-6. [Crossref] [PubMed]
43. Farber J, Harris JD, Kolstad K, et al. Treatment of Anterior Cruciate Ligament Injuries by Major League Soccer Team Physicians. Orthop J Sports Med 2014;2:2325967114559892. [Crossref] [PubMed]
44. McCarty EC, Kraeutler MJ, Langner P, et al. Historical Patterns and Variation in Treatment of Injuries in NFL (National Football League) Players and NCAA (National Collegiate Athletic Association) Division I Football Players. Am J Orthop (Belle Mead NJ) 2016;45:E319-27.
45. Reinerink JM, Vendrig T, Keizer MNJ, et al. One type of graft for reconstruction of the ACL does not suit all patients based on their characteristics and sports: a scoping review. Musculoskelet Surg 2025;109:115-25. [Crossref] [PubMed]
46. Ostojic M, Indelli PF, Lovrekovic B, et al. Graft Selection in Anterior Cruciate Ligament Reconstruction: A Comprehensive Review of Current Trends. Medicina (Kaunas) 2024;60:2090. [Crossref] [PubMed]
47. Getgood AMJ, Bryant DM, Litchfield R, et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med 2020;48:285-97. [Crossref] [PubMed]
48. Connors JP, Cusano A, Saleet J, et al. Return to Sport and Graft Failure Rates After Primary Anterior Cruciate Ligament Reconstruction With a Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autograft: A Systematic Review and Meta-analysis. Am J Sports Med 2025;53:1996-2006. [Crossref] [PubMed]
49. Greiner JJ, Drain NP, Setliff JC, et al. Factors Associated With Knee Extension Strength Symmetry After Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft. Orthop J Sports Med 2024;12:23259671241239692. [Crossref] [PubMed]
50. Erickson BJ, Harris JD, Cole BJ, et al. Performance and Return to Sport After Anterior Cruciate Ligament Reconstruction in National Hockey League Players. Orthop J Sports Med 2014;2:2325967114548831. [Crossref] [PubMed]
51. Erickson BJ, Harris JD, Cvetanovich GL, et al. Performance and Return to Sport After Anterior Cruciate Ligament Reconstruction in Male Major League Soccer Players. Orthop J Sports Med 2013;1:2325967113497189. [Crossref] [PubMed]
52. Erickson BJ, Chalmers PN, D'Angelo J, et al. Performance and Return to Sport After Anterior Cruciate Ligament Reconstruction in Professional Baseball Players. Orthop J Sports Med 2019;7:2325967119878431. [Crossref] [PubMed]
53. Gifstad T, Foss OA, Engebretsen L, et al. Lower risk of revision with patellar tendon autografts compared with hamstring autografts: a registry study based on 45,998 primary ACL reconstructions in Scandinavia. Am J Sports Med 2014;42:2319-28. [Crossref] [PubMed]
54. Samuelsen BT, Webster KE, Johnson NR, et al. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? A Meta-analysis of 47,613 Patients. Clin Orthop Relat Res 2017;475:2459-68. [Crossref] [PubMed]
55. Rodeo SA, Arnoczky SP, Torzilli PA, et al. Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am 1993;75:1795-803. [Crossref] [PubMed]
56. DeFazio MW, Curry EJ, Gustin MJ, et al. Return to Sport After ACL Reconstruction With a BTB Versus Hamstring Tendon Autograft: A Systematic Review and Meta-analysis. Orthop J Sports Med 2020;8:2325967120964919. [Crossref] [PubMed]
57. Brinkman JC, Hassebrock JD, Tummala SV, et al. Association Between Autograft Choice and Psychological Readiness to Return to Sport After ACL Reconstruction. Orthop J Sports Med 2025;13:23259671241291926. [Crossref] [PubMed]
58. Trasolini NA, Lan R, Bolia IK, et al. Knee Extensor Mechanism Complications After Autograft Harvest in ACL Reconstruction: A Systematic Review and Meta-analysis. Orthop J Sports Med 2023;11:23259671231177665. [Crossref] [PubMed]
59. Almekinders LC, Moore T, Freedman D, et al. Post-operative problems following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 1995;3:78-82. [Crossref] [PubMed]
60. Rahardja R, Love H, Clatworthy MG, et al. Comparison of Knee Pain and Difficulty With Kneeling Between Patellar Tendon and Hamstring Tendon Autografts After Anterior Cruciate Ligament Reconstruction: A Study From the New Zealand ACL Registry. Am J Sports Med 2023;51:3464-72. [Crossref] [PubMed]
61. Freedman KB, D'Amato MJ, Nedeff DD, et al. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med 2003;31:2-11. [Crossref] [PubMed]
62. Kunze KN, Moran J, Polce EM, et al. Lower donor site morbidity with hamstring and quadriceps tendon autograft compared with bone-patellar tendon-bone autograft after anterior cruciate ligament reconstruction: a systematic review and network meta-analysis of randomized controlled trials. Knee Surg Sports Traumatol Arthrosc 2023;31:3339-52. [Crossref] [PubMed]
63. Zaffagnini S, Grassi A, Marcheggiani Muccioli GM, et al. Return to sport after anterior cruciate ligament reconstruction in professional soccer players. Knee 2014;21:731-5. [Crossref] [PubMed]
64. Bonanzinga T, Grassi A, Altomare D, et al. High return to sport rate and few re-ruptures at long term in professional footballers after anterior cruciate ligament reconstruction with hamstrings. Knee Surg Sports Traumatol Arthrosc 2022;30:3681-8. [Crossref] [PubMed]
65. Brown CH Jr, Steiner ME, Carson EW. The use of hamstring tendons for anterior cruciate ligament reconstruction. Technique and results. Clin Sports Med 1993;12:723-56.
66. Cerulli G, Placella G, Sebastiani E, et al. ACL Reconstruction: Choosing the Graft. Joints 2013;1:18-24.
67. Malige A, Baghdadi S, Hast MW, et al. Biomechanical properties of common graft choices for anterior cruciate ligament reconstruction: A systematic review. Clin Biomech (Bristol) 2022;95:105636. [Crossref] [PubMed]
68. Marx RG, Hsu J, Fink C, et al. Graft choices for paediatric anterior cruciate ligament reconstruction: State of the art. J ISAKOS 2023;8:145-52. [Crossref] [PubMed]
69. Petit CB, Hussain ZB, McPherson A, et al. Graft Failure in Pediatric Patients After Bone-Patellar Tendon-Bone, Hamstring Tendon, or Quadriceps Tendon Autograft ACLR: A Systematic Review and Meta-analysis. Orthop J Sports Med 2024;12:23259671241289140. [Crossref] [PubMed]
70. Parmar R, Tummala SV, Brinkman JC, et al. Lateral Extra-Articular Tenodesis With Iliotibial Band in Anterior Cruciate Ligament Autograft Reconstruction for Female Soccer Athletes With Generalized Ligamentous Laxity Yields Graft Failure and Return-to-Sport Rates Comparable With Athletes Without Generalized Laxity. Arthroscopy 2025;41:4136-44. [Crossref] [PubMed]
71. Mohtadi NG, Chan DS, Dainty KN, et al. Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev 2011;2011:CD005960. [Crossref] [PubMed]
72. Ageberg E, Roos HP, Silbernagel KG, et al. Knee extension and flexion muscle power after anterior cruciate ligament reconstruction with patellar tendon graft or hamstring tendons graft: a cross-sectional comparison 3 years post surgery. Knee Surg Sports Traumatol Arthrosc 2009;17:162-9. [Crossref] [PubMed]
73. Diermeier T, Rothrauff BB, Engebretsen L, et al. Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group. Orthop J Sports Med 2020;8:2325967120931097.
74. Shani RH, Umpierez E, Nasert M, et al. Biomechanical Comparison of Quadriceps and Patellar Tendon Grafts in Anterior Cruciate Ligament Reconstruction. Arthroscopy 2016;32:71-5. [Crossref] [PubMed]
75. Slone HS, Romine SE, Premkumar A, et al. Quadriceps tendon autograft for anterior cruciate ligament reconstruction: a comprehensive review of current literature and systematic review of clinical results. Arthroscopy 2015;31:541-54. [Crossref] [PubMed]
76. Yang JS, Prentice HA, Reyes CE, et al. Risk of Revision and Reoperation After Quadriceps Tendon Autograft ACL Reconstruction Compared With Patellar Tendon and Hamstring Autografts in a US Cohort of 21,973 Patients. Am J Sports Med 2024;52:670-81. [Crossref] [PubMed]
77. Dadoo S, Herman ZJ, Nazzal EM, et al. Outcomes After Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon in Adolescent Athletes at Mean Follow-up of 4 Years. Orthop J Sports Med 2024;12:23259671241254795. [Crossref] [PubMed]
78. Arner JW, Bradley JP. Practice Patterns and Return-to-Sports Timing of National Football League Head Team Physicians for ACL Reconstruction. Orthop J Sports Med 2024;12:23259671241274139. [Crossref] [PubMed]
79. Fulkerson JP, Langeland R. An alternative cruciate reconstruction graft: the central quadriceps tendon. Arthroscopy 1995;11:252-4. [Crossref] [PubMed]
80. Holmgren D, Noory S, Moström E, et al. Weaker Quadriceps Muscle Strength With a Quadriceps Tendon Graft Compared With a Patellar or Hamstring Tendon Graft at 7 Months After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2024;52:69-76. [Crossref] [PubMed]
81. Hunnicutt JL, Xerogeanes JW, Tsai LC, et al. Terminal knee extension deficit and female sex predict poorer quadriceps strength following ACL reconstruction using all-soft tissue quadriceps tendon autografts. Knee Surg Sports Traumatol Arthrosc 2021;29:3085-95. [Crossref] [PubMed]
82. Lund B, Nielsen T, Faunø P, et al. Is quadriceps tendon a better graft choice than patellar tendon? a prospective randomized study. Arthroscopy 2014;30:593-8. [Crossref] [PubMed]
83. Brophy RH, Baker JC, Crain JM, et al. MRI Findings Associated With Anterior Cruciate Ligament Tears in National Football League Athletes. Orthop J Sports Med 2023;11:23259671231169190. [Crossref] [PubMed]
84. Kushwaha S, Khan FA. Meniscal and Chondral Injury Patterns in Athletes With Anterior Cruciate Ligament Tear. Cureus 2023;15:e49282. [Crossref] [PubMed]
85. Reist H, Vacek PM, Endres N, et al. Risk Factors for Concomitant Meniscal Injury With Sport-Related Anterior Cruciate Ligament Injury. Orthop J Sports Med 2023;11:23259671231196492. [Crossref] [PubMed]
86. Willinger L, Balendra G, Pai V, et al. High incidence of superficial and deep medial collateral ligament injuries in 'isolated' anterior cruciate ligament ruptures: a long overlooked injury. Knee Surg Sports Traumatol Arthrosc 2022;30:167-75. [Crossref] [PubMed]
87. Sorey W, Hagen MS, Mand S, et al. Effect of Delayed Anterior Cruciate Ligament Reconstruction on Repair of Concomitant Medial Meniscus Tears in Young Athletes. Am J Sports Med 2023;51:398-403. [Crossref] [PubMed]
88. James EW, Dawkins BJ, Schachne JM, et al. Early Operative Versus Delayed Operative Versus Nonoperative Treatment of Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Systematic Review and Meta-analysis. Am J Sports Med 2021;49:4008-17. [Crossref] [PubMed]
89. Zsidai B, Dadoo S, Fox MA, et al. Arthroscopic all-inside repair of challenging meniscus tears. J ISAKOS 2023;8:210-2. [Crossref] [PubMed]
90. Pioger C, Ayata M, Pettinari F, et al. Secondary Meniscectomy Rates and Risk Factors for Failed Repair of Ramp Lesions Performed at the Time of Primary ACL Reconstruction: An Analysis of 1037 Patients From the SANTI Study Group. Am J Sports Med 2024;52:1944-51. [Crossref] [PubMed]
91. Borque KA, Jones M, Cohen M, et al. Evidence-based rationale for treatment of meniscal lesions in athletes. Knee Surg Sports Traumatol Arthrosc 2022;30:1511-9. [Crossref] [PubMed]
92. Borque KA, Laughlin MS, Webster E, et al. A Comparison of All-inside and Inside-out Meniscal Repair in Elite Athletes. Am J Sports Med 2023;51:579-84. [Crossref] [PubMed]
93. Borque KA, Jones M, Laughlin MS, et al. Effect of Lateral Extra-articular Tenodesis on the Rate of Revision Anterior Cruciate Ligament Reconstruction in Elite Athletes. Am J Sports Med 2022;50:3487-92. [Crossref] [PubMed]
94. Hopper GP, Pioger C, Philippe C, et al. Risk Factors for Anterior Cruciate Ligament Graft Failure in Professional Athletes: An Analysis of 342 Patients With a Mean Follow-up of 100 Months From the SANTI Study Group. Am J Sports Med 2022;50:3218-27. [Crossref] [PubMed]
95. Sonnery-Cottet B, Carrozzo A, Saithna A, et al. Indications for Lateral Extra-articular Procedures in the Anterior Cruciate Ligament-Reconstructed Knee: Part I of an International Consensus Statement. Arthroscopy 2025;41:3303-12. [Crossref] [PubMed]
96. Nebelung W, Wuschech H. Thirty-five years of follow-up of anterior cruciate ligament-deficient knees in high-level athletes. Arthroscopy 2005;21:696-702. [Crossref] [PubMed]
97. Grassi A, Macchiarola L, Lucidi GA, et al. Ten-Year Survivorship, Patient-Reported Outcome Measures, and Patient Acceptable Symptom State After Over-the-Top Hamstring Anterior Cruciate Ligament Reconstruction With a Lateral Extra-articular Reconstruction: Analysis of 267 Consecutive Cases. Am J Sports Med 2021;49:374-83. [Crossref] [PubMed]
98. Grassi A, Macchiarola L, Lucidi GA, et al. Anterior Cruciate Ligament Reconstruction and Lateral Plasty in High-Risk Young Adolescents: Revisions, Subjective Evaluation, and the Role of Surgical Timing on Meniscal Preservation. Sports Health 2022;14:188-96. [Crossref] [PubMed]
99. Devitt BM, Bell SW, Ardern CL, et al. The Role of Lateral Extra-articular Tenodesis in Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis and Best-Evidence Synthesis. Orthop J Sports Med 2017;5:2325967117731767. [Crossref] [PubMed]
100. Vivacqua TA, Winkler PW, Lucidi GA, et al. Lateral Extra-articular Tenodesis Does Not Decrease Graft Failure in Revision Anterior Cruciate Ligament Reconstruction When Combined With Quadriceps or Patellar Tendon Grafts. Arthroscopy 2024;40:2601-9. [Crossref] [PubMed]
101. Getgood A, Hewison C, Bryant D, et al. No Difference in Functional Outcomes When Lateral Extra-Articular Tenodesis Is Added to Anterior Cruciate Ligament Reconstruction in Young Active Patients: The Stability Study. Arthroscopy 2020;36:1690-701. [Crossref] [PubMed]
102. LaPrade CM, Carey EG, Gachigi KK, et al. The addition of lateral extra-articular augmentation procedures to bone-tendon-bone or quadriceps autograft anterior cruciate ligament reconstruction does not negatively affect physical or psychological readiness for return to sport at 6 and 9 months. Knee Surg Sports Traumatol Arthrosc 2025;1.
103. Sheean AJ, Lian J, Tisherman R, et al. Augmentation of Anatomic Anterior Cruciate Ligament Reconstruction With Lateral Extra-articular Tenodesis Does Not Significantly Affect Rotatory Knee Laxity: A Time Zero, In Vivo Kinematic Analysis. Am J Sports Med 2020;48:3495-502. [Crossref] [PubMed]
104. Chiba D, Gale T, Nishida K, et al. Lateral Extra-articular Tenodesis Contributes Little to Change In Vivo Kinematics After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial. Am J Sports Med 2021;49:1803-12. [Crossref] [PubMed]
105. Devitt BM, Bouguennec N, Barfod KW, et al. Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: a systematic review and best evidence synthesis. Knee Surg Sports Traumatol Arthrosc 2017;25:1149-60. [Crossref] [PubMed]
106. Lemaire M. Ruptures anciennes du ligament croise anterieur du genou. J Chir 1967;93:311-20.
107. Sonnery-Cottet B, Carrozzo A, Saithna A, et al. Surgical Treatment and Complications of Lateral Extra-articular Procedures in the Anterior Cruciate Ligament-Reconstructed Knee: Part II of an International Consensus Statement. Arthroscopy 2025;41:3313-21. [Crossref] [PubMed]
108. Meredith SJ, Rauer T, Chmielewski TL, et al. Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group. Knee Surg Sports Traumatol Arthrosc 2020;28:2403-14. [Crossref] [PubMed]
109. Bisciotti GN, Volpi P, Alberti G, et al. Italian consensus statement (2020) on return to play after lower limb muscle injury in football (soccer). BMJ Open Sport Exerc Med 2019;5:e000505. [Crossref] [PubMed]
110. Nagelli CV, Wordeman SC, Di Stasi S, et al. Neuromuscular Training Improves Biomechanical Deficits at the Knee in Anterior Cruciate Ligament-Reconstructed Athletes. Clin J Sport Med 2021;31:113-9. [Crossref] [PubMed]
111. Tischer T, Karlsson J, Seil R. Sport-specific differences in ACL injury, treatment and return to sports. Knee Surg Sports Traumatol Arthrosc 2024;32:1359-62. [Crossref] [PubMed]
112. Grindem H, Snyder-Mackler L, Moksnes H, et al. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med 2016;50:804-8. [Crossref] [PubMed]
113. Canino MC, Arvin N, Nachazel Z, et al. Relating cortical morphology, corticospinal excitability, corticomotor representation, and quadriceps strength after anterior cruciate ligament injury. Exp Brain Res 2025;243:105. [Crossref] [PubMed]
114. Webster KE, Feller JA, Lambros C. Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport 2008;9:9-15. [Crossref] [PubMed]
115. Kitaguchi T, Tanaka Y, Takeshita S, et al. Importance of functional performance and psychological readiness for return to preinjury level of sports 1 year after ACL reconstruction in competitive athletes. Knee Surg Sports Traumatol Arthrosc 2020;28:2203-12. [Crossref] [PubMed]
116. Sadeqi M, Klouche S, Bohu Y, et al. Progression of the Psychological ACL-RSI Score and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Prospective 2-Year Follow-up Study From the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST). Orthop J Sports Med 2018;6:2325967118812819. [Crossref] [PubMed]