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Background: Graft choice for ACL reconstruction in patients under 18 years old remains controversial. BTB autograft has long been considered for young athletes who are at or near skeletal maturity. Quadriceps autograft has emerged as an alternative graft choice in the young patient population. However, there remains a paucity of comparative outcomes. Hypothesis/Purpose: Our purpose is to compare subjective outcomes and complications of ACL reconstruction in patients under 18 years old using either BTB or quadriceps autograft. Our hypothesis is that there will be no difference in subjective outcome or complication between groups. Methods: Following IRB approval, retrospective review of prospectively collected data identified consecutive cohorts of patients under 18 years old undergoing ACL reconstruction with either BTB or quadriceps autograft. Surgery was performed by a single sports fellowship trained surgeon between 2011-2019. Patients undergoing concomitant osteotomies, cartilage restoration, and other ligament reconstruction procedures were excluded. Pre- and post-surgical patient reported outcomes (PROs) including IKDC, KOOS, PROMIS, SANE, Tegner, and Marx were compared between groups. Complications requiring re-operation (i.e., infection, stiffness, reconstruction failure) were recorded. Results were analyzed statistically. Results: 71 patients met inclusion criteria. There were 41 BTB and 30 quadriceps autografts. Mean age was 16.5 years in the BTB group and 14.5 in the quadriceps group (p=0.6). 27 of 41 (66%) BTB and 13 of 30 (43%) quadriceps were female. There were no significant differences in PROs between groups. At minimum 6-month follow-up (range 6-25.7 months), patients in both quadriceps and BTB autograft cohorts reported statistically significant improvements in IKDC scores (31.10%, p=0.0009; 34.25%, p=0.8), all KOOS domains, SANE (41.80%, p=0.6; 42.42%, p=0.2), and Tegner scores (2.99%, p=0.0002; 3.35%, p=0.4). Post-operative PROs were not significantly different between groups (p>0.05). Complications were low and not significant between groups. Both quadriceps and BTB autograft cohorts required 3 post-operative re-operations (10% and 7%, p=0.7), each group including 2 revision reconstructions (7% and 5%, p=0.8) and 1 procedure for stiffness (3% and 2%, p=0.8). Conclusion: For ACL reconstruction in patients under 18 years old, both BTB and quadriceps autografts demonstrated significant subjective improvements and low rates of complications requiring re-operation. Quadriceps autograft appears to be a safe and effective alternative to BTB autograft in this challenging patient population. Table 1. Pre-Operative PROs KOOS Sub-scale Graft Pre-op N P-value Mean SD 95% CI Lower Bound Upper Bound ADL Quadriceps 75.13 16.13 72.43 77.83 17 0.425 BTB 79.16 15.77 77.00 81.32 25 Pain Quadriceps 66.99 19.50 63.73 70.26 17 0.065 BTB 77.20 14.99 75.11 79.30 24 Sport Quadriceps 38.82 23.29 34.93 42.72 17 0.806 BTB 40.60 22.47 37.52 43.68 25 Symptoms Quadriceps 63.43 19.91 60.10 66.76 17 0.713 BTB 65.53 16.65 63.25 67.81 25 QOL Quadriceps 28.69 20.50 25.26 32.13 17 0.229 BTB 36.02 18.07 33.54 38.49 25 PROMIS Sub-scale Graft Pre-op N P-value Mean SD 95% CI Lower Bound Upper Bound Physical Health Quadriceps 49.15 6.53 48.05 50.24 17 0.332 BTB 51.24 6.05 50.26 52.22 18 Mental Health Quadriceps 57.59 7.54 56.33 58.85 17 0.418 BTB 59.54 6.51 58.48 60.60 18 Physical Function Quadriceps 39.52 5.73 38.56 40.48 17 0.183 BTB 42.60 7.49 41.38 43.81 18 Pain Interference Quadriceps 57.93 6.33 56.87 58.99 17 0.892 BTB 58.27 8.29 56.92 59.62 18 MobilityT-Score Quadriceps 40.91 6.52 39.46 42.36 10 0.372 BTB 43.69 7.87 42.23 45.14 14 Variable Graft Pre-op N P-value Mean SD 95% CI Lower Bound Upper Bound Marx Quadriceps 14.18 4.14 13.48 14.87 17 0.964 BTB 14.20 3.24 13.76 14.64 25 SANE Quadriceps 45.65 26.51 41.21 50.08 17 0.968 BTB 46.00 24.84 41.84 50.16 17 Tegner Quadriceps 2.47 1.42 2.23 2.71 17 0.158 BTB 3.21 1.74 2.96 3.45 24 IKDC Quadriceps 44.83 15.07 41.92 47.74 13 0.313 BTB 50.63 16.37 48.12 53.15 20 Other Table 2. Post-Operative PROs KOOS Sub-scale Graft >6 Months Post-op N P-value Mean SD 95% CI Lower Bound Upper Bound ADL Quadriceps 98.88 1.67 98.63 99.13 21 0.326 BTB 97.86 4.48 97.33 98.40 33 Pain Quadriceps 94.57 6.71 93.57 95.58 21 0.637 BTB 93.43 9.64 92.29 24.57 33 Sport Quadriceps 92.20 9.87 90.73 93.68 21 0.108 BTB 83.64 22.61 80.95 86.32 33 Symptoms Quadriceps 91.43 8.93 90.09 92.77 21 0.563 BTB 89.59 12.59 88.10 91.09 33 QOL Quadriceps 70.54 19.68 67.59 73.49 21 0.251 BTB 77.04 20.46 74.64 79.43 34 PROMIS Sub-scale Graft >6 Months Post-op N P-value Mean SD 95% CI Lower Bound Upper Bound Physical Health Quadriceps 58.30 7.98 57.07 59.53 20 0.651 BTB 59.24 6.52 58.42 60.05 30 Mental Health Quadriceps 58.24 8.33 56.92 59.55 19 0.131 BTB 61.83 7.74 60.87 62.80 30 Physical Function Quadriceps 51.79 7.99 50.57 53.02 20 0.205 BTB 55.32 10.49 54.04 56.61 31 Pain Interference Quadriceps 47.16 7.04 46.10 48.21 21 0.589 BTB 46.00 7.81 45.04 46.96 31 MobilityT-Score Quadriceps 53.98 7.55 52.58 55.38 14 0.456 BTB 55.72 6.34 54.81 56.63 23 Variable Graft >6 Months Post-op N P-value Mean SD 95% CI Lower Bound Upper Bound Marx Quadriceps 11.17 5.02 10.16 12.18 12 0.572 BTB 12.22 5.24 11.47 12.97 23 SANE Quadriceps 87.44 10.60 85.72 89.17 18 0.805 BTB 88.42 14.58 86.63 90.21 31 Tegner Quadriceps 5.46 2.40 5.00 5.92 13 0.221 BTB 6.56 2.66 6.20 6.92 25 IKDC Quadriceps 75.93 26.33 71.38 80.47 16 0.219 BTB 84.88 16.38 82.37 87.40 20 Other

COMPARISON OF BONE-PATELLA TENDON-BONE (BTB) AND QUADRICEPS AUTOGRAFT FOR ACL RECONSTRUCTION IN PATIENTS UNDER 18 YEARS OF AGE