Anterior cruciate ligament (ACL) repair continues to generate interest as a tissue-preserving alternative to reconstruction, but new evidence suggests caution may be warranted in high-risk populations. Recent findings indicate that patients with characteristics such as high activity demands, participation in pivoting sports, or other risk factors may experience higher rates of reinjury following ACL repair compared with traditional reconstruction. While repair offers potential advantages—including preservation of native tissue and avoidance of graft harvest—it may not provide the same durability in individuals exposed to greater mechanical stresses. These results emphasize the importance of careful patient selection and individualized treatment planning, reinforcing that reconstruction remains the benchmark procedure for many high-risk patients seeking reliable long-term knee stability.