A narrative review of anterior cruciate ligament reconstruction in skeletally immature patients

Anterior cruciate ligament injuries in children and adolescents have steadily increased in prevalence over the past 20 years. This high number of pediatric patients suffering from ACL injuries has contributed to the development of anterior cruciate ligament reconstruction (ACL-R) into a pediatric surgical procedure, and thus also increased rate of intervention in children and adolescents. The possible consequences related to growth abnormalities require professionals to carefully evaluate patients’ skeletal age. Three methods are generally utilized for such evaluation and include the Greulich-Pyle method, the Tanner Whitehouse method, and the Fels18 method, no gold-standard has been accepted in literature. Using these tests surgeons can determine the years of growth remaining which facilitates the selection of a specific pediatric surgical approach for ACL-R. Surgical interventions include the transphyseal, partial transphyseal, and physeal sparing techniques. These techniques attempt to work around the level of remaining open physes to avoid possible growth deformities and other complications. Unfortunately, these procedures tend to have higher rates of re-injury and re-operation as compared to adult ACL-Rs, and always carry the risk of growth abnormalities. Overall, the complexity of ACL-R in the context of skeletally immature patients begins at preoperative evaluation, permeates treatment selection, and reaches postoperative outcomes, which must reach an adequate level that allows patients an almost unrestricted return to sports.