Graft selection in ACL reconstruction: Clinical and functional outcomes based on level I–II evidence

PURPOSE: This systematic review aimed to evaluate the clinical and functional outcomes of anterior cruciate ligament reconstruction (ACLR) using various graft types, based exclusively on studies with Level I-II evidence published in Q1-Q2 journals. The goal was to synthesise high-confidence data that can guide graft selection in orthopedic practice. METHODS: A comprehensive literature search of PubMed and Embase was conducted in accordance with PRISMA guidelines. Inclusion criteria were: (1) Level I-II study design, (2) publication in Q1-Q2 journals, (3) comparison of graft types (e.g., BPTB, HT, QT and allografts), and (4) reporting of outcomes including graft failure (GF), return to sport (RTS), anterior knee laxity, and patient-reported outcome measures (PROMs). Eighteen studies met all inclusion criteria. RESULTS: BPTB autografts demonstrated the lowest failure rates (2%-6%) and highest RTS (~81%) but were associated with higher anterior knee pain. Hamstring autografts showed higher failure rates (11%-17%) and lower RTS (~52%) but favourable PROMs. QT autografts had low failure rates (2%-3%), good stability, and reduced donor-site morbidity, with RTS ~ 64% based on limited data. Allograft results were variable: BPTB allografts demonstrated good function in selected populations, while hamstring and tibialis posterior allografts showed higher failure rates (6.2%-13.8%), particularly in younger patients. CONCLUSIONS: BPTB and QT autografts appear to offer the best combination of Failure rate and functional outcomes for high-demand patients. Hamstring autografts remain a practical option but may be less suitable for younger athletes. Allografts-particularly tibialis posterior-should be used cautiously due to elevated failure risk. LEVEL OF EVIDENCE: N/A.