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Review
. 2024 Nov 21;12(11):23259671241289140.
doi: 10.1177/23259671241289140. eCollection 2024 Nov.

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

Camryn B Petit  1   2   3   4 , Zaamin B Hussain  3 , April McPherson  1   2   3   5 , Erich J Petushek  6 , Alicia M Montalvo  1   7 , Mia S White  8 , Harris S Slone  9 , Joseph D Lamplot  1   10 , John W Xerogeanes  1   2   3 , Gregory D Myer  1   2   3   11   12   13   14
Affiliations
Review

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

Camryn B Petit et al. Orthop J Sports Med. .

Abstract

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.

Keywords: ACL; adolescent; athlete; graft failure; knee.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: H.H.S. has received education payments from Evolution Surgical and Peerless Surgical and hospitality payments from Arthrex. J.D.L. has received hospitality payments from Arthrex and Smith & Nephew, education payments from United Orthopedics and Smith & Nephew; and consulting fees from DePuy Synthes Products. J.W.X. has received royalties from Arthrex, consulting fees from Arthrex and Trice Medical, nonconsulting fees from Arthrex, and education payments from United Orthopedics. G.D.M has current and ongoing research funding to his institution from Arthrex Inc. to evaluate ACL surgical treatment strategies. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart for inclusion and exclusion of articles.
Figure 2.
Figure 2.
Risk-of-bias assessments for included studies using the Risk of Bias in Non-Randomized Studies of Interventions tool, with green representing low risk for a given criteria, yellow representing moderate risk, and red representing serious risk.
Figure 3.
Figure 3.
Pooled risk of graft failure by graft type for all included studies. BTB, bone–patellar tendon–bone; HT, hamstring tendon; QT, quadriceps tendon. A/B/C designations were added to author groups that included more than one autograft type in ther study in order to distinguish between graft type groups when performing statistical analysis.
Figure 4.
Figure 4.
Risk of graft failure by sex for each graft type. BTB, bone patellar tendon bone; HT, hamstring tendon; QT, quadriceps tendon.
See this image and copyright information in PMC

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