All-epiphyseal, all-inside ACL reconstruction yields high return-to-sport and minimal growth-related complications at mid- to long-term follow-up in skeletally immature patients.

PURPOSE: Paediatric anterior cruciate ligament (ACL) injuries are becoming increasingly frequent. Surgical management remains challenging due to the risk of growth plate disturbance. Physeal-sparing techniques aim to restore stability while minimizing this risk. The purpose of this study is to evaluate the clinical, functional and radiological outcomes of an all-inside, all-epiphyseal ACL reconstruction in skeletally immature patients, with particular attention to complications, return to sport (RTS) and the influence of associated injuries.

METHODS

Seventy-eight patients (48 males and 30 females; mean age 13.1 years, range: 9-16) underwent physeal-sparing ACL reconstruction between 2015 and 2024. All procedures were performed using hamstring autograft with all-epiphyseal sockets under fluoroscopic guidance. Pre- and postoperative assessments included plain radiographs, magnetic resonance imaging (MRI) and clinical evaluation. Outcome measures were Lysholm, Paediatric International Knee Documentation Committee (Pedi-IKDC) and visual analogue scale (VAS) scores, recorded preoperatively and at a mean follow-up of 48 months (range: 24-82). Return-to-play rates, complications and growth disturbances were documented. Subgroup analyses investigated the effect of meniscal/chondral lesions, gender and surgical delay.

RESULTS

Significant postoperative improvements were achieved in all clinical scores: Lysholm (53.4-94.6, p < 0.01), Pedi-IKDC (53.5-90.6, p < 0.01) and VAS (5.6-1.8, p < 0.01). No growth arrest, angular deformities, or leg length discrepancies were identified. Complications included one infection, two re-ruptures and one residual laxity. RTS was achieved in 94.8% of patients, with a mean recovery period of 11.1 months. Meniscal and chondral lesions were associated with inferior outcomes and delayed return-to-play. Delayed surgery significantly increased the risk of meniscal injury (odds ratio [OR]: 5.1, p = 0.001).

CONCLUSION

All-inside physeal-sparing ACL reconstruction demonstrates excellent mid- to long-term outcomes in skeletally immature patients. The technique offers high RTS rates and minimal growth-related complications. Early surgical intervention may reduce the risk of secondary meniscal and chondral damage.

LEVEL OF EVIDENCE: Level IV, retrospective case series.