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While surgical techniques and fixation devices have undergone substantial refinement, the optimal choice of graft remains a subject of ongoing debate. Traditionally, emphasis has been placed on the biomechanical characteristics of grafts, including tensile strength, stiffness, and resistance to cyclic loading. However, increasing attention has been directed toward biological factors that influence graft incorporation and clinical outcomes. The aim of this narrative review is to summarize the currently available literature regarding graft selection in ACL reconstruction by integrating biomechanical properties, biological graft incorporation, fixation strategies, and clinical outcomes. Particular emphasis is placed on the relationship between biomechanical performance and biological healing, as well as postoperative outcomes, in order to facilitate individualized graft selection in contemporary orthopedic practice.<\/jats:p>","DOI":"10.3390\/medicina62091683","type":"journal-article","created":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T07:53:11Z","timestamp":1788335591000},"page":"1683","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Anterior Cruciate Ligament Reconstruction: Clinical Outcomes and Biomechanical Considerations of Graft Selection\u2014A Narrative Review"],"prefix":"10.3390","volume":"62","author":[{"given":"Bogdan","family":"Huzum","sequence":"first","affiliation":[{"name":"\u201cGrigore T. Popa\u201d University of Medicine and Pharmacy, University Street, No. 16, 700115 Iasi, Romania"},{"name":"\u201cSt. Spiridon\u201d County Clinical Emergency Hospital, 700111 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dan Viorel","family":"Cionca","sequence":"additional","affiliation":[{"name":"\u201cSt. Spiridon\u201d County Clinical Emergency Hospital, 700111 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Ciupilan","sequence":"additional","affiliation":[{"name":"\u201cSt. Spiridon\u201d County Clinical Emergency Hospital, 700111 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-4979-1057","authenticated-orcid":false,"given":"C\u01cet\u01celina","family":"Ionescu","sequence":"additional","affiliation":[{"name":"Doctoral School of Biology, Faculty of Biology, \u201cAlexandru Ioan Cuza\u201d University of Ia\u0219i, 700505 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-0891-1320","authenticated-orcid":false,"given":"Mihnea-Theodor","family":"S\u00eerbu","sequence":"additional","affiliation":[{"name":"\u201cGrigore T. 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