Editorial Commentary: Mild Limb Asymmetry and Pediatric Anterior Cruciate Ligament Reconstruction-A Classic "Chicken and Egg" Scenario?

Growth disturbance from a physeal injury is considered by many surgeons to be the most feared iatrogenic surgical complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients, typically resulting in valgus, recurvatum, and/or a short limb. These deformities also predispose children to an ACL injury in the first instance, and therefore, a firm understanding of the contributions of both preoperative deformity and iatrogenic injury to postoperative limb asymmetry is critical. Preoperative and postoperative imaging (until 2 years postoperatively or skeletal maturity) should include standing hip-to-ankle alignment radiographs when the patient is able to straighten the knee and fully bear weight, as well as a lateral projection of the knee to quantify tibial slope. This should be the standard of care for children with open physes undergoing ACL reconstruction.