January 2026

Pediatric ACL Reconstruction: Where Are We Now?

By: Nirav K. Pandya, M.D.

Member, AANA Communications and Technology Committee

 

Historically, the pediatric patient with an anterior cruciate ligament (ACL) tear was treated nonoperatively due to the concern for growth disturbance with surgical reconstruction. Yet, the risk of degeneration with a chronically ACL deficient knee1,2 combined with the development of multiple surgical techniques that provide stability while minimizing growth disturbance has changed the approach to these injuries. Furthermore, the potential psychosocial implications of not being able to play sports for a young athlete while awaiting skeletal maturity has increased the desire for reconstruction.

 

As a result, the number of pediatric ACL reconstructions performed continues to increase3. The reasons are multi-factorial including increased injury recognition, changing patterns of youth sports participation (i.e., single sport specialization), ease of MRI imaging, prevention of meniscus/chondral damage and engagement in cutting/pivoting sports. Yet, compared to the adult population, the failure rates after ACL reconstruction are higher4,5. As the risk of growth disturbance requiring surgical intervention has been noted to be low6, much of the recent research in this population has shifted to strategies to decrease the risk of second injury.

 

The type of surgical reconstruction performed varies based on surgeon comfort/experience, degree of skeletal maturity, type/volume of sports participation and patient anatomy. From a global perspective these include transphyseal, partial transphyseal, physeal sparing all-epiphyseal and physeal-sparing extra-articular reconstructions. Although debate continues to exist as to which surgical technique to utilize for the immature patient, a consistent method that assesses skeletal maturity is important7.

 

Many of the recent advances in pediatric ACL reconstruction have centered around graft choice. Although allograft continues to be the least viable option due to failure rates of ~ 25%4, and bone-tendon-bone autograft is reserved for patients nearing skeletal maturity, there is research that has helped to differentiate the utilization of iliotibial (IT), hamstring and quadriceps autografts.

 

Using a physeal-sparing extra-articular reconstruction with IT band, Kocher et al. found a graft rupture of 6.6% in their series of 240 knees8. In their systematic review comparing quadriceps tendon versus hamstring tendon autografts in the pediatric population, Rangasamy et al. found that quadriceps tendon autografts had a significantly less graft re-rupture rate (3.5%) compared to hamstring tendon (12.4%)9. This was also shown by the systematic review of Petit et al. which demonstrated a failure rate of 2.7% for quadriceps tendon versus 11.8% for hamstring tendon autografts5.  As a result, there is an increasing trend towards the utilization of quadriceps tendon autograft in this skeletally immature population; particularly when non-extra-articular techniques are chosen.

 

Of note, recent attention has focused on the Bridge Enhanced ACL Repair (BEAR) technique. Although this has been shown to have promise in the adult population, there is limited data in the pediatric population with one recent study citing a revision surgery rate of 27.3% in patients under age 1610.  Further research is needed in the skeletally immature population that examines the utilization of this implant for the ACL-deficient knee.

 

The addition of lateral extra-articular procedures (LEAP’s) has also gained increasing attention in this active cohort of patients11; particularly with the high rate of re-injury. The indications for LEAP procedures continue to evolve but for the primary setting include but are not limited to greater than 10 degrees of recurvatum, ligamentous laxity, involvement in high-risk contact/pivoting sports and rotational instability even after graft placement. Knowledge of pediatric anatomy is critical when utilizing these procedures12. There are limited long-term studies in this young cohort of patients, but what has been published shows promise13-15.

 

Finally, evolving rehabilitation strategies including injury prevention are critical in the return to play process for the young patient. These strategies must take into account changing neuromuscular control, knee kinematics, knee kinetics and psychological readiness to return to sport. Simple time-based strategies no longer can be utilized, particularly for the significant amount of heterogeneity in this population due to varying degrees of maturity. In addition, the impact of injury and surgery on mental health must be considered as well16.

 

In conclusion, pediatric ACL reconstruction continues to be a procedure which is performed with increasing frequency in this active population. Recent literature has demonstrated that surgery can be performed safely but there remains a higher failure rate than the adult population. The utilization of quadriceps tendon autograft with lateral-sided procedures may help to mitigate this risk. Further research is needed to elucidate the ideal surgical technique and graft choice given the wide range of options in this population.

 

REFERENCES

  1. Kay, J., Memon, M., Shah, A., Yen, Y.M., Samuelsson, K., Peterson, D., Simunovic, N., Flageole, H., Ayeni, O.R. Earlier Anterior Cruciate Ligament Reconstruction Is Associated With a Decreased Risk of Medial Meniscal and Articular Cartilage Damage in Children and Adolescents: A Systematic Review and Meta-Analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2018;26(12):3738–3753.
  2. Kolin, D.A., Dawkins, B., Park, J., Fabricant, P.D., Gilmore, A., Seeley, M., Mistovich, R.J. ACL Reconstruction Delay in Pediatric and Adolescent Patients Is Associated With a Progressive Increased Risk of Medial Meniscal Tears. The Journal of Bone and Joint Surgery – American Volume. 2021;103(15):1368–1373.
  3. Campbell, R.J., An, V., Molnar, R., St George, J., Sivakumar, B.S., Symes, M. Trends in Pediatric Anterior Cruciate Ligament Reconstruction in Australia: An Analysis of Australian Medicare Benefits Schedule Database From 2001 to 2020. Journal of Pediatric Orthopaedics. 2024;44(5):347–352.
  4. Cruz, A.I. Jr., Beck, J.J., Ellington, M.D., Mayer, S.W., Pennock, A.T., Stinson, Z.S., VandenBerg, C.D., Barrow, B., Gao, B., Ellis, H.B. Jr. Failure Rates of Autograft and Allograft ACL Reconstruction in Patients 19 Years of Age and Younger: A Systematic Review and Meta-Analysis. JBJS Open Access. 2020;5(4):e20.00106.
  5. Petit, C.B., Hussain, Z.B., McPherson, A., Petushek, E.J., Montalvo, A.M., White, M.S., Slone, H.S., Lamplot, J.D., Xerogeanes, J.W., Myer, G.D. Graft Failure in Pediatric Patients After Bone–Patellar Tendon–Bone, Hamstring Tendon, or Quadriceps Tendon Autograft ACLR: A Systematic Review and Meta-Analysis. Orthopaedic Journal of Sports Medicine. 2024;12(11):23259671241289140.
  6. Wong, S.E., Feeley, B.T., Pandya, N.K. Complications After Pediatric ACL Reconstruction: A Meta-Analysis. Journal of Pediatric Orthopaedics. 2019;39(8):e566–e571.
  7. Longo, U.G., Villa Corta, M., Valente, F., Ruzzini, L., D’Hooghe, P., Samuelsson, K., Cordasco, F.A., Nicholls, A.S. Skeletal Maturity Assessment in Pediatric ACL-Reconstruction. 2025;12(9):1186.
  8. Kocher, M.S., Heyworth, B.E., Fabricant, P.D., Tepolt, F.A., Micheli, L.J. Outcomes of Physeal-Sparing ACL Reconstruction With Iliotibial Band Autograft in Skeletally Immature Prepubescent Children. The Journal of Bone and Joint Surgery – American Volume. 2018;100(13):1087–1094.
  9. Rangasamy, K., Baburaj, V., Gopinathan, N.R., Dhillon, M.S., Parikh, S.N. Quadriceps Tendon Autograft Is Promising With Lower Graft Rupture Rates and Better Functional Lysholm Scores Than Hamstring Tendon Autograft in Pediatric ACL Reconstruction: A Systematic Review and Meta-Analysis. Journal of Orthopaedics. 2023;49:156–166.
  10. Sanborn, R.M., Badger, G.J., Fleming, B.C., Kiapour, A.M.; BEAR Trial Team; Fadale, P.D., Hulstyn, M.J., Owens, B.D., Proffen, B., Sant, N., Portilla, G., Freiberger, C., Henderson, R., Barnett, S., Costa, M., Chrostek, C., Ecklund, K., Micheli, L.J., Murray, M.M., Yen, Y.M., Kramer, D.E. Preoperative Risk Factors for Subsequent Ipsilateral ACL Revision Surgery After an ACL Restoration Procedure. American Journal of Sports Medicine. 2023;51(1):49–57.
  11. Madhan, A.S., Ganley, T.J., McKay, S.D., Pandya, N.K., Patel, N.M. Trends in Anterolateral Ligament Reconstruction and Lateral Extra-Articular Tenodesis With ACL Reconstruction in Children and Adolescents. Orthopaedic Journal of Sports Medicine. 2022;10(4):23259671221088049.
  12. Randhawa, S., Stavinoha, T.J., Trivedi, S., Ganley, T.J., Tompkins, M., Ellis, H., Wilson, P., Green, D.W., Fabricant, P.D., Musahl, V., Shea, K.G. Paediatric Reference Anatomy for ACL Reconstruction and Secondary Anterolateral Ligament or Lateral Extra-Articular Tenodesis Procedures. Journal of ISAKOS. 2022;7(6):206–213.
  13. Carrozzo, A., Monaco, E., Saithna, A., Annibaldi, A., Guy, S., Ferreira, A., Vieira, T.D., Ferretti, A., Sonnery-Cottet, B. Clinical Outcomes of Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Tenodesis Procedures in Skeletally Immature Patients: A Systematic Review From the SANTI Study Group. Journal of Pediatric Orthopaedics. 2023;43(1):24–30.
  14. Green, D.W., Hidalgo Perea, S., Brusalis, C.M., Chipman, D.E., Asaro, L.A., Cordasco, F.A. A Modified Lemaire Lateral Extra-Articular Tenodesis in High-Risk Adolescents Undergoing Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft: 2-Year Clinical Outcomes. The American Journal of Sports Medicine. 2023;51(6):1441–1446.
  15. Moreno Mateo, F., Perea, S.H., Green, D.W. Lateral-Extra Articular Tenodesis vs. Anterolateral Ligament Reconstruction in Skeletally Immature Patients Undergoing Anterior Cruciate Ligament Reconstruction. Current Opinion in Pediatrics. 2022;34(1):71–75.
  16. Hinton, J.B., Sefcik, R., Burdyny, M., Raina, R., Riley, P. Jr. Impact of Depression on Rehabilitation Outcomes in Pediatric Patients Undergoing ACL Reconstruction: A Retrospective Study. Journal of Pediatric Orthopaedics. 2025;45(10):e984–e989.
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