Dr. Garcia demonstrates his technique for adolescent (pediatric) ACL reconstruction using quad tendon autograft

This video details Dr. Grant H. Garcia’s specialized surgical technique for an Adolescent Anterior Cruciate Ligament (ACL) Reconstruction using a Quadriceps Tendon Autograft.

When treating young, skeletally immature athletes, protecting their open growth plates (physeal plates) is the most critical priority. Standard adult ACL reconstructions drill wide tunnels right through these zones, which can cause premature growth plate fusion, leg length differences, or angular deformities. Dr. Garcia’s technique utilizes a thick, robust quadriceps tendon graft paired with an all-inside, physeal-sparing approach to safely reconstruct the ligament without disrupting the child's natural growth.

Surgical Process Breakdown

• Minimally Invasive Graft Harvest: The surgeon makes a small vertical incision just above the kneecap to access the quadriceps tendon. Using specialized cutting guides, he harvests a precise, partial-thickness strip of the quadriceps tendon. Unlike the adult BTB graft, this adolescent harvest is strictly soft-tissue (no bone block is taken from the patella) to avoid disrupting the growth zones of the kneecap.
• Back-Table Preparation and Sizing: The harvested quadriceps tendon is taken to the sterile back table. The graft is folded and whipstitched on both ends using high-strength suture tapes. The resulting graft is remarkably thick and strong—frequently matching or exceeding the diameter of a standard hamstring graft—making it excellent for reducing the high re-tear rates seen in young athletes.
• Arthroscopic Clearance: The arthroscope is introduced into the knee joint to carefully clear out the torn, scarred remnants of the native ACL, establishing a clear visual window of the anatomical landmarks.
• Physeal-Sparing Tunnel Construction: This is the most crucial mechanical phase of the adolescent surgery. Using high-precision retrograde drill guides (such as the FlipCutter system), Dr. Garcia creates sockets inside the bone from the inside out. He maps out the trajectories to ensure the sockets are entirely epiphyseal or intraphyeal—meaning they are positioned safely away from, or drill right through the absolute center of, the delicate growth plates at a minimal angle to keep the perimeter of the growth plate completely intact.
• Graft Passing and Next-Generation Suspension Fixation: The prepared quadriceps graft is shuttled up through the knee and seated perfectly into the bone sockets. To avoid using traditional heavy metal screws that could compress or damage growing tissue, Dr. Garcia uses low-profile suspensory cortical buttons. These buttons flip open flat against the outside wall of the bone, acting like a pulley system to tightly wedge and lock the soft-tissue graft inside the sockets.