Background: Anterior cruciate ligament reconstruction (ACLR) remains one of the most commonly performed orthopaedic procedures worldwide. Despite decades of technical refinement, surgical success is still frequently evaluated through isolated comparisons of single variables such as graft type, fixation method, or drilling technique. This reductionist approach may obscure the complex biomechanical and biological interactions that ultimately determine long-term outcomes.
Objective: To critically examine the four principal surgical pillars of ACLR graft selection, fixation strategy, tunnel angle (including graft bending angle), and instrumentation and to highlight the need for an integrated, multi-factorial decision framework.
Key Insights: Current evidence demonstrates relative equivalence among commonly used grafts and fixation devices in short- to mid-term outcomes, while robotic and navigation systems improve tunnel placement accuracy. However, most studies evaluate these variables in isolation, rarely accounting for their biomechanical interdependence. Emerging data suggest that graft–fixation compatibility, graft bending angle, and tunnel positioning interact in ways that may influence tunnel widening, graft integrity, and long-term stability. Yet, no high-level clinical trials have systematically investigated these interactions. This fragmentation of evidence limits the development of patient-specific surgical strategies.
Conclusion: Surgical success in ACLR is unlikely to be determined by a single superior technique. Rather, it emerges from complex, and potentially non-linear, interactions among graft type, fixation construct, tunnel geometry, and technological assistance. Future research must move beyond single-variable superiority trials toward multi-factorial, patient-centered models incorporating biomechanical parameters and long-term clinical outcomes. Only through such integrated approaches can the true determinants of ACLR success be defined.