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

Abstract 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. (Systematic Review Abstract).