Graft Selection for Pediatric ACL Reconstruction

For prepubertal children undergoing extraphyseal reconstruction, the ITB autograft is the most commonly used and best-studied graft. It requires minimal surgical insult to harvest, does not cross the physis, and provides excellent biomechanical outcomes. Long-term motion analysis data confirm that ITB reconstruction restores symmetric, physiologically normal kinetics and kinematics in the growing knee — a finding not yet replicated for other graft types in this age group. Thigh asymmetry at the harvest site is reported in up to 48% of patients but is rarely functionally problematic.

Hamstring tendon autograft (typically quadrupled semitendinosus) is the most frequently used graft for all-epiphyseal, partial transphyseal, and transphyseal techniques. Advantages include ease of harvest, no risk to the physis, and no risk of patellar fracture. Disadvantages include a higher re-rupture rate compared to bone-patellar tendon-bone graft in some series, variations in graft diameter (which can be a limiting factor in smaller patients), and slightly longer graft-bone integration times. Recent evidence highlights gender-specific considerations: young female athletes have a higher quadriceps-to-hamstring activation imbalance, which may have implications for reinjury rates when hamstring autograft is used.

Quadriceps tendon autograft is rising in popularity as an alternative graft source, particularly in adolescent patients. Its advantages include availability of large graft diameters in most pediatric patients (>8 mm achievable in the vast majority), lower risk of patellar fracture compared to bone-patellar tendon-bone harvest, and comparable graft survival and return-to-sport rates in published series. A recent systematic review found that quadriceps tendon autograft for pediatric ACL reconstruction yielded promising postoperative function and return-to-sport rates. Graft dimensions can be estimated preoperatively on MRI. Evidence in the strictly pediatric population remains limited, but early results are encouraging.

BTB autograft offers advantages in adolescents near skeletal maturity (Tanner Stage 3–4), including faster graft-to-bone integration and potentially lower re-rupture rates. However, traditional BTB harvest techniques are contraindicated in skeletally immature patients because the harvest site crosses the tibial apophysis, risking growth disturbance. BTB should not be used in patients with open growth plates.

Irradiated allografts carry unacceptable failure rates in high-demand young athletes and are not recommended as a primary graft choice. Living donor allografts — where a parent donates their own hamstring tendon for use in the child’s reconstruction — represent an emerging technique with early positive results but significant practical, financial, and ethical considerations that require further investigation. This approach is not currently part of routine clinical practice.