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.