Advances in anterior cruciate ligament reconstruction: Risk stratification, graft choices, and functional recovery in 2026

Purpose: To synthesize recent developments in anterior cruciate ligament reconstruction (ACLR), highlighting emerging evidence, evolving surgical strategies, and persistent controversies in risk stratification, graft selection, surgical planning and rehabilitation. Methods: A narrative review of the recent literature (2023-2026) was conducted, incorporating randomized controlled trials, systematic reviews, large registry analyses and emerging studies. The review focused on evolving concepts in graft selection, imaging-guided surgical planning, biomechanical risk factors, neuromuscular recovery and long-term outcomes following ACL reconstruction. Results: Quadriceps tendon autografts have gained prominence for their robust dimensions and low donor-site morbidity, with bone-block variants potentially enhancing rotational stability. Imaging innovations-3D mapping, navigation and individualized morphometrics-improve tunnel precision. New studies reinforce posterior tibial slope, notch shape and hyperextension as critical anatomical risk factors. Neuromuscular training techniques such as VR-based rehabilitation, blood flow restriction, and individualized strength timelines improve functional symmetry and readiness. Registry data show rising ACLR rates, especially among young females, and link failure to younger age, high activity, delayed surgery and septic arthritis. PROMs correlate poorly with objective performance, underscoring the need for integrated assessment. Long-term outcomes remain favourable across graft types, with no consistent differences in osteoarthritis progression. Conclusion: ACLR is transitioning toward a precision-based, individualized model. This paradigm shift integrates anatomical risk profiling, tailored graft selection, and multimodal rehabilitation to optimize both biological and functional outcomes. Yet, unresolved questions, around pediatric predictors, repair techniques, and real-world adherence, highlight the need for ongoing refinement. The field is evolving from reconstruction toward comprehensive restoration, grounded in anatomy, technology and behavioural science. Level of Evidence: Level V, narrative review.