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ACL reconstruction in the professional or elite athlete: state of the art
  1. Rafael A Buerba1,
  2. Stefano Zaffagnini2,
  3. Ryosuke Kuroda3,
  4. Volker Musahl4
  1. 1 Orthopaedic Surgery, Banner Health, Peoria, Arizona, USA
  2. 2 2nd Orthopaedic Surgery and Traumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
  3. 3 Orthopaedic, Kobe University Graduate School of Medicine, Kobe, Japan
  4. 4 Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  1. Correspondence to Dr Rafael A Buerba, Orthopaedic Surgery, Banner Health, Peoria, AZ 85374, USA;{at}


Anterior cruciate ligament (ACL) injuries are on the rise at all levels of sport, including elite athletics. ACL injury can have implications on the athlete’s sport longevity, as well as other long-term consequences, such as the development of future knee osteoarthritis. In the elite athlete, ACL injury can also have ramifications in terms of contract/scholastic obligations, sponsorships and revenue-generating potential. Although the goal of anterior cruciate ligament reconstruction (ACLR) is to return any athlete to the same preinjury level of sport, management of ACL injuries in the elite athlete come with the additional challenge of returning him or her to an extremely high level of physical performance. Despite outcome studies after ACLR in elite athletes showing a high return-to-sport rate, these studies also show that very few athletes are able to return to sport at the same level of performance. They also show that those athletes who undergo ACLR have careers that are more short-lived in comparison to those without injury. Thus, returning an elite athlete to ‘near peak’ performance may not be good enough for the athletic demands of elite-level sports. A possible explanation for the variability in outcomes is the great diversity seen in the management of ACL injuries in the elite athlete in terms of rehabilitation, graft choices, portal drilling and reconstruction techniques. Recently, the advent of anatomical, individualised ACLR has shown improved results in ACLR outcomes. However, larger-scale studies with long-term follow-ups are needed to better understand the outcomes of modern ACLR techniques—particularly with the rise of quadriceps tendon as an autograft choice and the addition of lateral extra-articular tenodesis procedures. The purpose of this article was thus to provide an up-to-date state-of-the-art review in the management of ACL injuries in the elite athlete.

  • anterior cruciate ligament
  • athletic injuries
  • autografts
  • knee injuries
  • sports medicine research

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  • Twitter @rafabuerba

  • Contributors RAB and VM: manuscript writing and conception, editing, figures, literature review, final manuscript approval. SZ: manuscript writing (rehab and rotatory instability), editing, literature review and final manuscript approval. RK: manuscript writing (international perspectives), editing, literature review and final manuscript approval.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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