Injuries to the anterior cruciate ligament (ACL) are increasing in frequency among children and adolescents as a result of earlier and more active participation in highrisk sporting activities.1,2 The treatment of ACL injuries in skeletally immature patients remains very controversial. The primary concern is injury to the growth plate during surgery, which may result in limb-length discrepancies and/or angular deformities.

When approaching the pediatric patient with an ACL injury, options available to the treating surgeon include nonoperative management, primary ligament repair, extra-articular tenodesis procedures, partial transphyseal procedures, transphyseal reconstructions, physeal sparing all-epiphyseal procedures, or delayed reconstruction at skeletal maturity. Several recent studies have shown that transphyseal surgery has minimal risk of growth arrest.11–18 However, many of these studies included patients with minimal growth remaining and therefore a lower likelihood of a resulting disturbance. 11,12,15 One study looked specifically at Tanner stage I and II patients, but in many cases patients were not followed to skeletal maturity.

There is considerable literature regarding growth disturbances in animal models.19–25 Moreover, a recent case report by Lawrence et al26 described a skeletally immature patient with a transphyseal tibial and all-epiphyseal femoral ACL reconstruction who developed femoral valgus angulation postoperatively. Recent and ongoing research has thus been dedicated to understanding growth arrest following ACL reconstruction and possible methods of preventing it.17,18,27–31 In our case series, we report the clinical outcomes of 4 patients who underwent transphyseal ACL reconstruction and subsequently developed either growth retardation or premature growth plate closure resulting in deformity.

ROBERT G. MARX, MD

KNEE SURGEON

Scientific Articles

Selected Articles:

Graft choices for paediatric anterior cruciate ligament reconstruction: State of the art

Return to Play after Posterior Cruciate Ligament Injuries

Posterolateral Corner Reconstruction Using Double Femoral Fixation With Adjustable Loop Cortical Suspension and Interference Screw

Obesity and sex influence fatty infiltration of the rotator cuff: the Rotator Cuff Outcomes Workgroup (ROW) and Multicenter Orthopaedic Outcomes Network (MOON) cohorts

Factors Associated With an Intra-articular Infection After Anterior Cruciate Ligament Reconstruction: A Large Single-Institution Cohort Study

MOON's Strategy for Obtaining Over Eighty Percent Follow-up at 10 Years Following ACL Reconstruction

Chronic Popliteus Tendon Avulsion Fracture with Chronic Knee Pain and Locking: A Case Report

Coach Education Improves Adherence to Anterior Cruciate Ligament Injury Prevention Programs: A Cluster-Randomized Controlled Trial.

Complications Associated with Posterior CruciateLigament Reconstruction and Avoiding Them

Feedback Cues Improve the Alignment and Technique of Children Performing ACL Injury Prevention Exercises

The Incidence of Kaplan Fiber Injury Associated With Acute Anterior Cruciate Ligament Tear Based on Magnetic Resonance Imaging

Graft Selection in Anterior Cruciate Ligament Reconstruction

ACL Reconstruction in the Multiple Ligament Injured Knee

Knee Arthroscopy: How Fast Is Too Fast? How Slow Is Too Slow?

Osteotomies in the Multiple Ligament Injured Knee – When is it Necessary?

Current Concepts and Controversies in Rehabilitation After Surgery for Multiple Ligament Knee Injury

Outcomes of Surgical Treatment of Posterolateral Instability of the Knee

Subsequent Surgery After Revision Anterior Cruciate Ligament Reconstruction: Rates and Risk Factors From a Multicenter Cohort

2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears

Characteristics of Orthopedic Publications in High-Impact General Medical Journals

Quality of Life Following ACL Reconstruction: Baseline Predictors of Patient-Reported Outcomes

Do Surgeon Expectations Predict Clinically Important Improvements in WOMAC Scores After THA and TKA?

Patients Undergoing Shoulder Stabilization Surgery Have Elevated Shoulder Activity Compared With Sex- and Age-Matched Healthy Controls

Patients Undergoing Shoulder Stabilization Surgery Have Elevated Shoulder Activity Compared With Sex- and Age-Matched Healthy Controls

Does the Chronicity of Anterior Cruciate Ligament Ruptures Influence PatientReported Outcomes Before Surgery?

Graft Selection and Preparation in Anterior Cruciate Ligament Reconstruction

Predictors and Outcomes of Crossover to Surgery from Physical Therapy for Meniscal Tear and Osteoarthritis

Comparison of Revision Rates of Non-modular Constrained VersusPosterior Stabilized Total Knee Arthroplasty: a Propensity ScoreMatched Cohort Study

Editorial Commentary: Is Medial-Side Repair Indicated in the Treatment of Multiligament Knee Injuries?

Outcomes of surgical treatment of posterolateral instability of the knee

Patient demographics and surgical characteristics in ACL revision

Complete rupture of the pectoralis major tendon- Comparison of MRI and intraoperative images

The fate of meniscus tears left in situ at the time of ACLR

Postoperative rehab after PCLR and combined PCLR-PLC surgery

Postoperative rehab after PCLR and combined PCLR-PLC surgery

Closing versus opening wedge HTO—An evidence-based review

Update on the Methodological Quality of Research Published in The American Journal of Sports Medicine : Comparing 2011-2013 to 10 and 20 Years Prior

Defining the Value of Future Research to Identify the Preferred Treatment of Meniscal Tear in the Presence of Knee Osteoarthritis

Updating the Assignment of Levels of Evidence

The Potential Influence of Regionalization Strategies on Delivery of Care for Elective Total Joint Arthroplasty

Association of Meniscal Status, Lower Extremity Alignment, and Body Mass Index With Chondrosis at Revision Anterior Cruciate Ligament Reconstruction

Baseline Predictors of Health-Related Quality of Life After Anterior Cruciate Ligament Reconstruction

Growth Arrest Following ACL Reconstruction With Hamstring Autograft in Skeletally Immature Patients: A Review of 4 Cases

KOOS pain as a marker for significant knee pain two and six years after primary ACL reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) prospective longitudinal cohort study

Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACL Reconstruction

Outcomes for Surgical Treatment of Posterolateral Instability of the Knee

Factors Associated with Infection Following Anterior Cruciate Ligament Reconstruction

Transtibial ACL Femoral Tunnel Preparation Increases Odds of Repeat Ipsilateral Knee Surgery

Accuracy and reliability of determining the isometric point of the knee for multiligament knee reconstruction

The Rate of Subsequent Surgery and Predictors After Anterior Cruciate Ligament Reconstruction: Two- and 6-Year Follow-up Results From a Multicenter Cohort

Differences in Mechanisms of Failure, Intraoperative Findings, and Surgical Characteristics Between Single- and Multiple-Revision ACL Reconstructions: A MARS Cohort Study

Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete: A Review of Current Concepts

Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study

CORR Insights: Risk of thromboembolism in shoulder arthroplasty: Effect of implant type and traumatic indication

Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis

Anterior cruciate ligament prevention strategies: are they effective in young athletes – current concepts and review of literature

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Was Superior to Conventional Single-Bundle Reconstruction

The effect of lateral opening wedge distal femoral osteotomy on medial knee opening: clinical and biomechanical factors

CORR Faceoff: Single- Versus Double-bundle Anterior Cruciate Ligament Reconstruction

Arthroscopic Agreement Among Surgeons on Anterior Cruciate Ligament Tunnel Placement

The MeTeOR Trial (Meniscal Tear in Osteoarthritis Research): Rationale and design features

Outcomes of Treatment of Multiple Ligament Knee Injuries

Return to High School− and College-Level Football After Anterior Cruciate Ligament Reconstruction: A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study

Prognosis and Predictors of ACL Reconstructions using the MOON Cohort: A Model for Comparative Effectiveness Studies

Nonoperative treatment for anterior cruciate ligament injury in recreational alpine skiers

Discordance in TKA Expectations Between Patients and Surgeons

Reliability of Early Postoperative Radiographic Assessment of Tunnel Placement After Anterior Cruciate Ligament Reconstruction

Return to Athletic Activity After Osteochondral Allograft Transplantation in the Knee

Femoral Tunnel Malposition in ACL Revision Reconstruction

Surgical Decision Making for Arthroscopic Partial Meniscectomy in Patients Aged Over 40 Years

Association Between Previous Meniscal Surgery and the Incidence of Chondral Lesions at Revision Anterior Cruciate Ligament Reconstruction

The Epidemiology of Reoperation After Flexor Tendon Repair

Indications and Reoperation Rates for Total Elbow Arthroplasty: An Analysis of Trends in New York State

Complex Knee Ligament Surgery

Preoperative Patient Expectations of Total Shoulder Arthroplasty

Complications Associated with Posterior Cruciate
Ligament Reconstruction and Avoiding Them

Comparison of Revision Rates of Non-modular Constrained Versus
Posterior Stabilized Total Knee Arthroplasty: a Propensity Score
Matched Cohort Study