Background

ACL reconstruction in the paediatric population presents unique challenges, owing to the ongoing skeletal growth. This systematic review aimed to compare the functional and radiological outcomes of transphyseal(TP), partial transphyseal(pTP) and physeal-sparing(PS) techniques.

Methods

A systematic search of the MEDLINE and EMBASE databases was performed in accordance with the PRISMA guidelines to identify studies reporting growth disturbances and/or functional outcomes. Studies reporting on combined or hybrid/partial TP techniques were excluded. Leg length discrepancy (LLD) was defined as >10mm and angular deformity (AD) as >5° difference. Pooled incidence of growth disturbance and graft rupture was calculated from available raw data using an inverse-variance random-effects model. Studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) checklist with a maximum score of 16 for non-comparative studies and 24 for comparative studies.

Results

The search identified 37 studies reporting on TP (n=1384), 12 on PS (n=882), and 5 comparing both techniques (n=2098), with mean follow up ranging from 1.25 to 8 years. Mean age in the TP studies ranged from 12-16.4 years and in PS studies from 10.5-14.3 years. Pooled proportional incidence of leg length discrepancy was 1.3% in the TP and 3.4% in the PS studies. Incidence of angular deformities was 1.5% in TP studies and 1.8% in the PS studies. Graft rupture rate was 6% in the TP studies, compared to 8.1% in the PS studies. Mean Lysholm scores ranged from 84.6 - 98.8 in the TP and 93 - 100 in the PS studies. Mean IKDC scores ranged from 83.3 - 95.4 in the TP and 94 - 96.5 in the PS studies. Five comparative studies reported no differences in rates of graft rupture or growth disturbance. MINORS scores ranged from 8-12 for non-comparative and 16-20 for comparative studies.

Conclusion

Transphyseal and physeal-sparing ACL reconstruction techniques result in similar patient reported outcomes and graft rupture rates. Patients who undergo physeal-sparing reconstruction are generally younger, thus more susceptible to growth-related complications post-surgery. Larger comparative studies with age-matched cohorts are required to investigate this association further.