Pediatric patients undergoing anterior cruciate ligament reconstruction (ACLR) generally show higher graft failure rates and slower graft maturation (ligamentization) compared to adults, despite having greater biological healing potential. Ligamentization reflects graft strength, vascularization, and biomechanical integrity, and is closely related to safe return-to-sport decisions, as premature return is a major risk factor for graft failure in children.

Graft maturation in pediatric patients is highly variable, ranging from 6 months to 3 years, and may be influenced by graft type and surgical technique. Hamstring tendon (HT) autografts have been associated with delayed maturation, while techniques such as lateral extra-articular tenodesis (LET) and preservation of the tibial insertion have been reported to improve graft maturation, knee stability, and reduce re-injury risk.

Aim of the study:
This study evaluated short-term graft maturity in skeletally immature patients undergoing ACLR and compared the results with adult patients treated with the Over-The-Top (OTT) technique using HT autografts with preserved tibial insertion. It was hypothesized that satisfactory early graft maturation could be achieved in children and that outcomes would be comparable to those observed in adults.