All-inside, physeal-sparing anterior cruciate ligament reconstruction does not significantly compromise the physis in skeletally immature athletes: a postoperative physeal magnetic resonance imaging analysis

Am J Sports Med. 2014 Dec;42(12):2933-40. doi: 10.1177/0363546514552994. Epub 2014 Oct 16.


Background: Anterior cruciate ligament (ACL) reconstruction in skeletally immature patients can result in growth disturbance due to iatrogenic physeal injury. Multiple physeal-sparing ACL reconstruction techniques have been described; however, few combine the benefits of anatomic reconstruction using sockets without violation of the femoral or tibial physis.

Purpose: To utilize physeal-specific magnetic resonance imaging (MRI) to quantify the zone of physeal injury after all-inside ACL reconstruction in skeletally immature athletes.

Study design: Case series; Level of evidence, 4.

Methods: Twenty-three skeletally immature patients (mean chronologic age 12.6 years; range, 10-15 years) were prospectively evaluated after all-inside ACL reconstruction. The mean bone age was 13.2 years. There were 8 females and 15 males. Fifteen patients underwent an all-epiphyseal (AE) ACL reconstruction and 8 patients had a partial transphyseal (PTP) ACL reconstruction, which spared the femoral physis but crossed the tibial physis. At 6 and 12 months postoperatively, MRI using 3-dimensional fat-suppressed spoiled gradient recalled echo sequences and full-length standing radiographs were performed to assess graft survival, growth arrest, physeal violation, angular deformity, and leg length discrepancy.

Results: The mean follow-up for this cohort was 18.5 months (range, 12-39 months). Minimal tibial physeal violation was seen in 10 of 15 patients in the AE group and, by definition, all patients in the PTP group. The mean area of tibial physeal disturbance (±SD) was 57.8 ± 52.2 mm(2) (mean 2.1% of total physeal area) in the AE group compared with 145.1 ± 100.6 mm(2) (mean 5.4% of total physeal area) in the PTP group (P = .003). Minimal compromise of the femoral physis (1.5%) was observed in 1 case in the PTP group and no cases in the AE group. No cases of growth arrest, articular surface violation, or avascular necrosis were noted on MRI. No postoperative angular deformities or significant leg length discrepancies were observed.

Conclusion: The study data suggest that all-inside ACL reconstruction is a safe technique for skeletally immature athletes at short-term follow-up. Physeal-specific MRI reveals minimal growth plate compromise that is significantly lower than published thresholds for growth arrest.

Keywords: ACL reconstruction; MRI; all-inside; physis; skeletally immature.

MeSH terms

  • Adolescent
  • Anterior Cruciate Ligament / surgery*
  • Anterior Cruciate Ligament Injuries
  • Anterior Cruciate Ligament Reconstruction*
  • Athletic Injuries / surgery
  • Child
  • Epiphyses / anatomy & histology
  • Female
  • Femur / anatomy & histology*
  • Femur / surgery
  • Follow-Up Studies
  • Humans
  • Imaging, Three-Dimensional
  • Magnetic Resonance Imaging*
  • Male
  • Prospective Studies
  • Tendons / transplantation
  • Tibia / anatomy & histology*
  • Tibia / surgery