Unlocking Surgical Decision Dilemma Between Physeal-sparing And Transphyseal Technique in Anterior Cruciate Ligament Reconstruction for Skeletally Immature Patients: A Systematic Review

Objectives: This study aims to compare the functional outcomes and complications between physeal-sparing (PS) and transphyseal (TP) of anterior cruciate ligament reconstruction (ACLR) in skeletally immature patient by recent studies. Methods: This systematic review followed the Cochrane Handbook and PRISMA guidelines. We systematically searched PubMed, Embase Ovid, Cochrane Library, and Web of Science from 2019 to July 2024. Our protocol is registered with PROSPERO (CRD42024565859). Risk of bias was evaluated using ROBINS-I tools and JBI critical appraisal tool. The evidence was appraised using the GRADE approach. Results: Six studies (3 retrospective cohorts and 3 case series) involving 1,489 patients met the inclusion criteria. The studies had high to moderate risk of bias. Cohort studies compared PS and TP, while case series focused on TP. Range of motion (149.6°±3.6°vs148.8° ±3.2°), KT-1000 (0.6±0.9vs0.4±0.8mm), muscle strength, KOOS (97.3±4.1vs94.2±8.5), and overall complications showed no significant differences between PS and TP. PS had a higher return-to-sport (RTS) rate (100%) and RTS at the same level (92%), but higher angular deformity (>3°). TP had more meniscal injuries and revision ACLR. Case series reported growth disturbances in TP with a mean leg length discrepancy (LLD) of 3.0 ± 6.1 mm, high IKDC and Lysholm scores, time to RTS (7.4±2.7mo), and complications such as reoperation, graft failure, and patella dislocation. One study reported no LLD > 1 cm. Conclusion: The PS achieved satisfactory clinical outcomes and muscle strength recovery, though with higher angular deformity and inferior postoperative knee stability. The TP showed good midterm results with minimal growth disturbances and comparable graft rupture rates. Complications such as graft failure and new meniscus tears were similar across techniques, indicating other factors play a role. Surgical choice should consider skeletal maturity, growth potential, and surgeon expertise. Higher evidence studies are needed to refine guidelines and optimize outcomes in paediatric ACLR.