A Narrative Review of Anterior Cruciate Ligament Reconstruction Graft Choice and Its Influence on Return to Sport

Purpose of Review Anterior cruciate ligament (ACL) rupture is among the most common knee injuries in active individuals and can lead to persistent instability, secondary intra-articular damage, and an elevated risk of osteoarthritis. Because return to sport (RTS) is a major goal for most active patients and graft selection remains one of the most debated aspects of ACL reconstruction, this narrative review summarizes the contemporary evidence on how graft choice influences RTS, focusing on the four most common grafts: bone–patellar tendon–bone (BTB), hamstring tendon (HT), quadriceps tendon (QT), and allograft. Recent Findings RTS rates range from ~ 65% to 73% at three years and are higher (83–90%) in elite and high-school athletes. In young, active patients, autografts are associated with higher RTS and lower revision rates than allografts, and high-level evidence—including randomized-trial meta-analyses—has not established the superiority of any single autograft. BTB offers reliable bone-to-bone healing and low revision rates; HT reduces donor-site morbidity and anterior knee pain but has variable diameter and possible flexion weakness; and QT is a versatile option with favorable biomechanics, low donor-site morbidity, and encouraging RTS data, including in skeletally immature athletes. Summary RTS is one of several important outcomes after ACL reconstruction, alongside long-term joint health and reinjury prevention. For RTS, the literature supports autograft over allograft in young, active patients while identifying no universally superior autograft. Graft selection should be individualized to patient age, sport, activity level, anatomy, and reinjury risk; the senior author favors QT or BTB autografts for high-demand athletes.