Assessment of Skeletal Maturity and Postoperative Growth Disturbance After Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Systematic Review

Abstract

Background: Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients. Purpose: To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance. Study Design: Systematic review; Level of evidence, 4. Methods: This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted. Results: A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity. Conclusion: This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment. Registration: CRD42019136059 (PROSPERO)

Leg-Length and Alignment Changes in Children and Adolescents After Transphyseal Anterior Cruciate Ligament Reconstruction With Soft Tissue Graft: Results at 1-Year Follow-up

“…Although alignment after transphyseal ACLR has been previously evaluated postoperatively in pediatric patients, these studies have been limited by sample size, radiographic field of view (ie, short-leg radiographs only) and/or by referencing postoperative imaging to typical data rather than the patient's presurgical status. 3,5,9,11 This study prospectively compared preoperative with postoperative longleg radiographs and showed that there were no statistically significant changes in mean alignment or longitudinal growth after transphyseal ACLR. However, caution regarding the possibility of growth disturbance should persist given that 7 out of 104 postsurgical patients demonstrated a change in mechanical axis of >10 mm (five patients) or a change in LLD of >10 mm (two patients).…”

Anterior Cruciate Ligament Reconstruction With Iliotibial Band Autograft in Skeletally Immature Prepubescent Children: A Physeal-Sparing Technique

“…The awareness of physeal injury related to the operative treatment of ACL tears in the pediatric population has resulted in several physeal-sparing and physeal-respecting techniques of reconstruction. 6,11 Although some authors criticize these techniques because of its usual ''nonanatomic'' configuration, biomechanical studies have shown otherwise, with a good restoration of kinematic constraint. 7,12 This ITB physeal-sparing technique described by Micheli and Kocher can reduce the risk of physeal damage, maintaining stability and providing excellent functional outcomes, with low revision rates: at a mean follow-up of 5.3 years, from 44 patients, 41 returned to sports involving cutting or pivoting, and the revision rate was at 4.5%.…”

Postoperative complications following ACL reconstruction: Prevention and management

“…Additionally, it is a deficiency that can be reduced by using practical strength training and neuromuscular rehabilitation methods. Bilateral landing knee joint loading patterns are significantly impacted by isometric quadriceps femoris strength deficiencies of more than 15% [22,23] . In a recent study, Schmitt and colleagues discovered that people with quadriceps femoris strength impairments had altered landing patterns.…”