Anterior cruciate ligament reconstruction in elite and professional athletes: does graft choice influence return to sport and failure rate? A systematic review and meta-analysis

Background: Different grafts are used for anterior cruciate ligament (ACL) reconstruction, but their impact on return to sport (RTS) in elite and professional athletes remains unclear. Most evidence derives from nonprofessional cohorts, with limited data comparing graft-specific outcomes in high-demand populations. Purpose: The purpose of the present systematic review and meta-analysis was to compare the return to play and percentage of re-rupture between different grafts in elite and professional athletes from different sports. Study design: Systematic review and meta-analysis of level 3 and 4 studies. Methods: A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines (PROSPERO Registry - CRD42025637410). MEDLINE, Embase, and the Cochrane Library were searched up to January 2025 for studies reporting RTS and re-rupture after primary ACL reconstruction in skeletally mature elite and professional athletes. Eligible designs included randomized controlled trials, cohort studies, case-control studies, and case series. Pooled proportions and odds ratios (ORs) were calculated using random- and mixed-effects models, with patellar tendon grafts as the reference group. Subgroup analyses were performed for concomitant meniscal injuries, multiligament injuries, and high-impact sports. Results: Ten studies comprising 824 elite athletes were included. Overall, 81.7% (95% CI, 75.4-86.7) returned to sport, while the re-rupture rate was 7.1% (95% CI, 4.3-11.7). Use of hamstring/peroneus plus lateral extra-articular procedures (LEAPs) was associated with significantly higher RTS rates compared with the reference graft, both overall [94.0% (95% CI, 85.5-97.6); OR, 3.52; 95% CI, 1.20-10.34] and in high-impact sports [98.9% (95% CI, 94.2-100.0); OR, 23.16; 95% CI, 2.51-213.98]. No significant differences were observed between grafts in re-rupture rates (range 6.2-11.2%; all P > 0.05), although hamstring/peroneus plus LEAP showed a trend toward lower odds of re-rupture (OR, 0.32-0.45). Subgroup analyses of athletes with concomitant meniscal or multiligament injuries yielded similar findings, with no significant between-graft differences. Conclusions: Approximately 80% of elite athletes RTS after ACL reconstruction, with an overall re-rupture rate of 7%. Hamstring/peroneus combined with a LEAP demonstrated superior RTS outcomes compared with other grafts, while re-rupture risk remained comparable. These findings suggest that while graft choice may influence RTS outcomes in elite athletes, the addition of a LEAP appears to further enhance RTS rates, particularly in high-demand sports.