The Impact of Transphyseal Anterior Cruciate Ligament Reconstruction on Lower Extremity Growth and Alignment

Arthroscopy. 2019 Mar;35(3):940-949. doi: 10.1016/j.arthro.2018.10.132. Epub 2019 Feb 4.


Purpose: To evaluate the effect of transphyseal anterior cruciate ligament (ACL) reconstruction on lower extremity radiographic growth and alignment.

Methods: We retrospectively reviewed patients who underwent transphyseal ACL reconstruction and were followed to skeletal maturity or at least 2 years, with the nonoperative limb used as an internal control. Changes in coronal plane alignments and tibial slope of the operative limb were compared with a Wilcoxon test. Associations among sex, tunnel, and graft characteristics and failure; changes in coronal plane measures and tunnel size; and tunnel angles and the development of deformity were examined by χ-square and correlation coefficients.

Results: Fifty-nine patients (41 boys and 18 girls) underwent surgery at a mean age of 12.5 years (range, 6.8-16.0 years). There were differences in changes in the mechanical lateral distal femoral angle comparing operative and nonoperative limbs (decreased 1.1° in girls and 1.9° in boys ≤13 years of age, P = .0008 and .025, respectively) and in changes in tibial slope of the operative limb (decreased 2.1° in male patients >13 years, P = .012). No patient developed a new limb length difference >1 cm. Two boys were treated for deformities. Eight additional patients developed >5° difference in alignment for a rate of radiologic deformity of 10 of 59 or 17%. Neither graft failure nor the presence of deformity was associated with sex, tunnel size, mode of femoral tunnel positioning, inclination of tunnels, or the use of allograft.

Conclusions: Radiographically evident limb deformities following transphyseal ACL reconstruction occurred at a rate of 17%, although these deformities were clinically evident in only 5% of patients. Tunnels intersecting physes near cortical margins may increase the risk of developing deformity. Regular follow-up should include alignment radiographs to detect deformities despite the clinical appearance of neutral limb alignment.

Level of evidence: Level III, case-control study.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Anterior Cruciate Ligament / surgery*
  • Anterior Cruciate Ligament Injuries / surgery*
  • Anterior Cruciate Ligament Reconstruction / adverse effects*
  • Bone Malalignment / etiology*
  • Case-Control Studies
  • Child
  • Female
  • Femur / abnormalities*
  • Growth Plate / surgery
  • Humans
  • Lower Extremity / pathology
  • Male
  • Postoperative Complications / pathology
  • Retrospective Studies
  • Tibia / abnormalities*