Age and Sex-based Frequency of Graft and Technique Used in Pediatric Anterior Cruciate Ligament Reconstruction: A Multicenter Study

Objective: As the incidence of pediatric and adolescent anterior cruciate ligament (ACL) reconstruction rises, knowledge of contributing factors to decision-making regarding graft selection and technique is important. Variations in ACL reconstruction (ACLR) regarding graft choice, tunnel placement, and technique may depend on patient age, sex, and surgeon preference. The purpose of this study was to review technique and graft source of pediatric ACLR based on these factors. Methods: A prospective, surgeon-driven, multicenter quality/performance improvement registry was queried to evaluate graft selection and technique in primary ACLR. Data regarding ACLR in those 19 years or younger performed by 23 contributing surgeons was collected. Frequency of graft use and surgical technique were stratified by patient age and sex. Results: A total of 3968 ACLRs were included, with an average age of 15.1 years (range: 6 to 19 years), 53.7% males, with a majority using autograft (97.4%). Of ACLR, 82.9% of those under age 11 used iliotibial band (ITB) graft and extra-articular extraphyseal technique. ITB use was similar in females (80.0%) and males (83.5%). For ages 11 to 15, soft tissue quadriceps (STQT, 38.1%), hamstring (HS, 23.5%), and ITB (16.6%) were most frequently used. STQT use was 40.1% in females and 36.2% in males. ITB was used more in males than females (25.6% and 7.4%, respectively). After age 15, STQT (30.9%), bone patellar tendon bone (BTB, 27.8%), and HS (24.8%) were most common. STQT was the dominant graft in females (35.5%) in this group, while BTB (32.3%) was the most frequent in males. When comparing the early (2018 to 2020) to the late (2020 to 2022) portion of collection period, quadriceps tendon autograft use increased from 30.5% to 48.0%. Conclusions: Variation exists in graft selection and technique for pediatric and adolescent ACLR. ITB, extra-articular extraphyseal technique, is favored in patients under age 11. Quadriceps autograft use has increased in ACLR in this patient population in recent years. Level of Evidence: Level III—retrospective cohort study.