Graft Choice for Adolescent Athletes Returning to High-Risk Sports: A Matched Cohort Analysis of Patellar Tendon and Hamstring Autografts

OBJECTIVES: Graft selection for skeletally mature adolescents undergoing anterior cruciate ligament (ACL) reconstruction is guided by surgeon and patient preference. In young patients returning to high-risk cutting and pivoting sports, graft rupture is the most feared complication of ACL reconstruction. Some studies have demonstrated slightly lower rates of graft failure and decreased laxity in the short term associated with patellar tendon (BTB) autografts as compared to hamstring (HS) autografts, but these studies are limited by their heterogeneity of ages and activity level. The purpose of this study is to compare the rates of graft failure between BTB and HS ACL reconstruction cohorts matched by age, sex, and sport. METHODS: A single-institution retrospective review was performed of consecutive patients less than 19 years of age treated with ACL reconstructions using either patellar tendon (BTB) or hamstring (HS) autograft performed by a single surgeon. Skeletally mature or nearly mature patients in “high-risk” ACL injury sports (basketball, football, soccer, lacrosse, and gymnastics) were initially treated with hamstring autografts but the graft preference transitioned to BTB autografts as the preferred graft choice during the study period. This transition in graft preference for adolescents participating in “high risk” sports allows for a comparison of outcomes based on graft types. Inclusion criteria were ages 13 – 18 years, participation in a “high risk” sport, and minimum 24-month follow-up. The two cohorts of patients were matched by age, gender, and sport. The primary outcome measure was graft rupture. RESULTS: One hundred twenty-six patients with an average age of 15.8 years (range 13 – 18 years) met inclusion criteria. There were 60 BTB reconstructions and 66 HS reconstructions. There were 55 females and 71 males. There was no difference in age, sex, BMI, or laterality between groups. There were more patients who played soccer in the BTB cohort (44%) vs HS cohort (22%) and fewer who played basketball in the BTB cohort (24%) vs HS cohort (38%), p = 0.005. There were no differences between the BTB and HS cohorts in terms of meniscus tears (60% v 68%, p = 0.34), meniscus repair (20% v 30%, p = 0.19), or partial meniscectomy (33% v 39%, p = 0.48). Mean duration of follow-up was 41 months (range 24-78 months). There was a difference in follow-up between cohorts (BTB 36 months and HS 50 months, p < 0.05). There were 16 graft ruptures (12.6%). There was no difference in the rate of graft rupture between cohorts (BTB 10.0% vs HS 15.2%, p = 0.45). Mean time to graft rupture was 21 months (range 8 – 35 months) and Kaplan-Meier survival curves demonstrated no difference between cohorts. The mean age of graft failures within the BTB cohort was 15.5 years as compared to 16.1 years for those that did not have a graft failure (p=0.268). The mean age of graft failures within the HS cohort was 14.9 years as compared to 15.9 years for those that did not have a graft failure (p<0.05). CONCLUSION: ACL reconstruction in adolescents returning to high-risk sports can be performed utilizing BTB or HS autografts with similar rates of graft rupture. Patients under the age of 15 years have a greater risk of failure associated with HS autograft as compared to patients 16 years of age and older with the same graft. In contrast, BTB grafts have similar failure rates regardless of age. There is a trend toward lower rates of graft rupture associated with BTB autografts, but additional patients will be necessary to determine if this trend will become a statistically significant difference.