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

Abstract 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.