Physeal-sparing ACL reconstruction has equivalent survivorship and functional outcomes as transphyseal reconstruction but does not prevent growth disturbance: a systematic review of clinical and radiological outcomes

BACKGROUND: ACL reconstruction in the paediatric population presents unique challenges, owing to the ongoing skeletal growth. This systematic review aimed to compare the functional and radiological outcomes of transphyseal(TP), partial transphyseal(pTP) and physeal-sparing(PS) techniques. METHODS: A systematic search of the MEDLINE and EMBASE databases was performed in accordance with the PRISMA guidelines to identify studies reporting growth disturbances and/or functional outcomes. Pooled incidence of growth disturbance and graft rupture was calculated from available raw data using an inverse-variance random-effects model. RESULTS: The search identified 37 studies reporting on TP (n = 1389), 11 on PS (n = 867), 5 on pTP (n = 91), and 6 comparing both techniques [TP (n = 1668), pTP (n = 8), PS (n = 445)], with mean follow up ranging from 1.25 to 8 years. Mean age in TP studies ranged between 12-16.4, pTP; 10.7-13.6, and PS; 10.5-14.3 years. Pooled proportional incidence of leg length discrepancy was 1.3% in TP, 5.7% in pTP and 3.4% in the PS studies. Incidence of angular deformities was 1.5% in TP, 2.8% in pTP and 1.8% in the PS studies. Graft rupture rate was 6% in the TP studies, 9.8% in pTP, and 8.1% in the PS studies. Five comparative studies reported no differences in rates of graft rupture or growth disturbance. CONCLUSION: TP, pTP and PS ACL reconstruction techniques result in similar patient reported outcomes and graft rupture rates. Patients who undergo pTP and PS reconstruction are generally younger, thus more susceptible to growth-related complications post-surgery. Larger comparative studies with age-matched cohorts are required to investigate this association further.