Growth disturbance in paediatric anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) reconstruction in skeletally immature patients represents a significant challenge due to the risk of growth disturbance, including limb length discrepancy (LLD) and angular deformity (AD). Although rare, the consequences of such complications can be substantial. Contributing factors include inadequate clinical and radiological preoperative assessment and insufficient postoperative monitoring. Methods: This review synthesizes the current understanding of growth disturbances after paediatric ACL reconstruction, examining their incidence, pathophysiology, and technical considerations. Growth anomalies, categorized as arrest (type A), overgrowth (type B), or tethering effect (type C), arise from physeal damage, periosteal disruption, or tunnel malposition, during autograft harvesting, bone tunnels placement or graft fixation. Results: Surgical technique is crucial, with disturbances reported across transphyseal, all-epiphyseal, and extraosseous reconstructions, regardless of whether bone or soft tissue grafts are used. Meta-analyses indicate low overall rates of LLD and AD; however, reporting is complicated by heterogeneous definitions and follow up protocols. Conclusions. No single technique has demonstrated superiority in preventing growth disturbances, and most complications correlate with technical errors rather than the approach itself. Accurate assessment of growth potential – utilizing bone age, clinical markers, and radiographic tools – is paramount for surgical planning. Postoperative surveillance with clinical and full-length standing radiographs of the lower limbs is strongly recommended until skeletal maturity. While most growth disturbances are subclinical or self-limiting, significant anomalies may necessitate observation, guided growth procedures, or corrective osteotomy. Until high-level comparative studies are available, meticulous surgical technique and vigilant follow up are essential to minimize complications in this vulnerable population.