Precision anterior cruciate ligament (ACL) reconstruction in high-level athletes

Anterior cruciate ligament (ACL) tear is a common injury in high-level athletes and has a significant impact on a professional career. Precision management is necessary for successful return to sports (RTS) and return to a competitive level, referred to as return to play (RTP). ACL reconstruction (ACLR) is considered the gold standard and restores anteroposterior and rotatory knee stability to facilitate a successful comeback in the elite athlete's sport. Despite an overall high RTS and RTP rate in elite athletes, performance and career longevity can be significantly impacted. Management of ACL injury in an elite athlete should be individualized to address the demands of the sport and the athlete's expectations. Optimal treatment includes the proper graft choice, detailed sport-specific rehabilitation, and metrics for psychological readiness to RTS and RTP. Hamstring tendon (HT), quadriceps tendon (QT), and bone-patellar tendon-bone (BPTB) autograft for ACLR are the most widely used grafts in athletes. Each graft has a specific profile of characteristics, with BPTB and QT autografts showing the lowest failure rates compared to HT autografts. Graft-specific complications represent anterior knee pain in BPTB, functional weakness of the extensor mechanism of the knee when using QT autografts, and a higher failure rate in HT autografts. Concomitant injuries are common, with meniscus, chondral, and medial collateral ligament lesions being most frequent. Meniscus injuries should be repaired, and early timing plays a crucial role, considering good outcomes after meniscus repair in combined ACLR. Rehabilitation in high-level athletes is recommended to be based on functional criteria rather than purely on a timeline. Successful rehabilitation with the goal of RTP should include prevention of re-injury, progressive muscle strengthening, neuromuscular training, and sport-specific functional exercises.