Femoral extra-physeal ACL reconstruction in skeletally immature patients shows a low rate of clinically relevant growth disturbances: A systematic review.

Purpose: Physeal-sparing techniques aim to reduce growth disturbances after anterior cruciate ligament reconstruction (ACLR) in skeletally immature patients, but evidence on femoral extra-physeal approaches remains limited. The aim of this study was to systematically review the literature on femoral extra-physeal ACLR in patients with open physes and to evaluate the reported incidence and severity of growth disturbances, including potential influencing factors, such as surgical technique and lateral extra-articular tenodesis. Methods: A systematic search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies including skeletally immature patients undergoing ACL reconstruction with femoral extra-physeal techniques were included. Growth disturbances were defined as limb length discrepancy or angular deformity. Graft failure was defined as graft rupture, revision surgery or recurrent instability. Results: A total of 579 patients were included with a mean age of 12 years. The over-the-top technique was used in 176 patients, the Kocher-Micheli technique in 327 and the Clocheville technique in 76. Growth disturbances were reported in 26 patients (4.5%); overgrowth was the most frequent pattern. Most of the growth disturbances were minor (3.8%). No patient required surgical correction. Graft failure occurred in 30 patients (5.2%). Conclusion: Paediatric ACL reconstruction using femoral extra-physeal techniques was associated with a low rate of clinically relevant growth disturbances. Most deformities were mild, and no corrective procedure was required. The graft failure rate was also low. These findings should be interpreted with caution given the heterogeneity of the included studies. Level of Evidence: Level IV.