Graft Failure in Pediatric Patients After Bone-Patellar Tendon-Bone, Hamstring Tendon, or Quadriceps Tendon Autograft ACLR: A Systematic Review and Meta-analysis.

Background: Anterior cruciate ligament (ACL) reinjury risk is high in young athletes, with graft failure rates as high as 23%. The optimal autograft choice to minimize reinjury risk in this population is unclear.

Purpose: To compare graft failure rates between bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT) autografts in patients aged ≤18 years with a minimum follow-up (FU) of 24 months.

Study design: Systematic review; Level of evidence, 4.

Methods: A systematic review of the literature between database inception and March 2022 encompassed PubMed/MEDLINE, Cochrane CENTRAL, Embase, and Web of Science Core Collection databases. Studies on autograft ACL reconstruction (ACLR) using HT, QT, or BPTB autograft in patients ≤18 years old with a minimum FU of 2 years were included. Graft failure rates were pooled and estimated using random-effects models via the inverse variance method and logit transformations. Meta-analyses were used to estimate failure rates and pairwise comparisons were conducted by autograft type when appropriate.

Results: A total of 24 studies comprising 2299 patients (HT: n = 1237, 44.8% female, 59.1-month mean FU; BPTB: n = 913, 67.3% female, 79.9-month mean FU; QT: n = 149, 36.4% female, 35.3-month mean FU) were included. HT exhibited the highest failure rate at 11.8% (95% CI, 9.0%-15.4%); failure rates for BPTB and QT were 7.9% (95% CI, 6.2%-10.0%) and 2.7% (95% CI, 1.0%-7.5%), respectively. HT had a significantly higher failure rate than both BPTB (Q = 5.01; P = .025) and QT (Q = 7.70; P = .006); BPTB had a significantly higher failure rate than QT (Q = 4.01; P = .045). Male patients were less likely than their female counterparts to experience graft failure after HT ACLR (odds ratio, 0.48; 95% CI, 0.25-0.95).

Conclusion: While the HT remains a common choice for ACLR, the current aggregate data indicate that BPTB and QT demonstrated significantly lower failure rates than HT ACLR in adolescent athletes ≤18 years old. The QT demonstrated the lowest failure rate in adolescents but also the lowest proportion of patients represented due to a paucity of published QT data, indicating a need for future studies with larger sample sizes that include QT autografts, reduced risk of bias, and consistent reporting on skeletal maturity and surgical technique to better determine the ideal autograft for active athletic populations ≤18 years old.