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

Background: Anterior cruciate ligament (ACL) tears are becoming more common in the skeletally immature population as participation in high-risk sports continues to grow. This presents a challenge for the treating surgeon as ACL reconstruction in this patient set has the added aim of preservation of the growth plate anatomy. The purpose of this investigation is to report on 4 patients who developed growth arrest following ACL reconstruction and offer a review of the available literature. Methods: Four skeletally immature patients (2 male and 2 female) were identified who underwent ACL reconstruction at mean age of 14.2 years (range, 13.5 to 14.8 y) and developed growth arrests. Bone ages at the time of reconstruction were 14 and 16 years for the boys and 13 years 6 months and 14 years for the girls. All patients had a transphyseal reconstruction with a hamstring autograft. Standard postoperative care was provided including clinical and radiographic follow-up at regular intervals. Clinically significant postoperative physeal arrest was confirmed on MRI or CT scan. Detailed chart review examined demographics, operative variables, and postoperative subjective and objective clinical measures. Results: Two patients developed tibial recurvatum; 2 patients developed genu valgum. Three patients required further surgery. One patient underwent distal femoral-guided growth procedure, 2 underwent proximal tibial epiphysiodesis, and 1 patient was skeletally mature at presentation and did not require deformity correction. Conclusions: This report of 4 patients demonstrates that growth arrest following ACL reconstruction in skeletally immature patients is a real concern and highlights the importance of careful preoperative evaluation and discussion with patients and family members. We routinely obtain long-leg AP and lateral hip-to-ankle films on skeletally immature patients before performing an ACL reconstruction and then at 6 and 12 months postoperatively or every 6 months until the growth plates are closed to assess leg lengths and lower extremity alignment. Level of Evidence: Level IV-therapeutic study, case series.