Growth Disturbance in Physeal Sparing ACL Reconstruction: A Comparison of 3 ACLR Techniques in Skeletally Immature Patients

Background: In pediatric anterior cruciate ligament reconstruction (ACLR), there exists a potential to injure the open physis in skeletally immature patients and cause growth disturbance. Thus, there is a need to determine the optimal ACLR technique for this population. Purpose: To evaluate the functional outcomes and rates of physeal disturbance, graft failure, and reoperation after transphyseal and physeal-protecting techniques—including extraphyseal intra-articular and partial epiphyseal ACLR—within the skeletally immature population. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent primary ACLR from June 2018 to April 2023 at a tertiary pediatric hospital were identified. The exclusion criteria included skeletal maturity based on preoperative magnetic resonance imaging, concomitant multi-ligamentous injury, excluding medial collateral ligament sprain that did not require surgical intervention, and <6 months of follow-up. Descriptive, injury, and surgical data; clinical outcomes; and complications were analyzed using the chi-square and Kruskal-Wallis tests. Growth disturbance was assessed using pre- and postoperative standing hip-to-ankle films. Results: A total of 87 patients met the study inclusion criteria. A total of 41 (47.1%) patients underwent transphyseal (mean age, 15.2 ± 0.9), 34 (39.1%) underwent extraphyseal intra-articular (12.9 ± 1.7), and 12 (13.8%) underwent partial epiphyseal (14.6 ± 1.2) ACLR. The transphyseal group was significantly older in chronological and skeletal age ( P < .001). Autograft types varied significantly across cohorts ( P < .001). The partial epiphyseal technique had the highest rate of complications (50%; P = .009), most commonly stiffness (n = 2) and ACL retear (n = 2). Four (4.6%) patients experienced unilateral growth disturbance, with 1 in the extraphyseal intra-articular group. Angular growth disturbance ranged from 3° to 5º of valgus. There were no cases of leg length discrepancy or growth arrest. Conclusion: Comparable angular growth disturbance and retear rates were observed across all 3 ACLR techniques in skeletally immature patients, suggesting acceptable outcomes with appropriate surgical technique.