Anterior cruciate ligament reconstruction in the modern era: A patient-centered approach

Anterior cruciate ligament (ACL) injuries are among the most frequent knee pathologies, with athletes-particularly females and those in pivot-heavy sports such as soccer, basketball, volleyball, and skiing-at increased risk. The success of ACL reconstruction is multifactorial, relying on individualized graft selection, surgical precision, patient-specific characteristics, and optimized rehabilitation. Despite the availability of various graft options-hamstring tendon, bone-patellar tendon-bone, and quadriceps tendon-no single type has demonstrated clear superiority, reinforcing the need for patient-tailored approaches based on anatomical, functional, and age-related factors. Surgical techniques continue to evolve, with adaptations such as physeal-sparing methods for skeletally immature patients and minimally invasive procedures aimed at reducing morbidity and improving recovery. Rehabilitation is a critical determinant of functional outcomes. Current evidence supports immediate mobilization, early weight-bearing, and initiation of neuromuscular and strength training, while routine use of continuous passive motion and bracing is discouraged, except in multi-ligament injuries. Prehabilitation is recommended, though accelerated rehabilitation remains controversial. Implant choice and fixation strategy are also essential to long-term success. The use of materials that reduce the risk of chronic complications and support biological integration is increasingly favored. Nevertheless, rare mechanical failures emphasize the need for accurate tunnel placement, appropriate implant selection, and vigilant postoperative monitoring. Outcomes are further influenced by patient-specific variables, including bone quality, metabolic status, and physical activity levels. Optimal ACL reconstruction results from a comprehensive, patient-centered strategy that integrates surgical accuracy, individualized rehabilitation, and continuous follow-up to minimize complications and enhance recovery.