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Clinical outcomes of different autografts used for all-epiphyseal, partial epiphyseal or transphyseal anterior cruciate ligament reconstruction in skeletally immature patients – a systematic review

BMC Musculoskeletal Disorders volume 24, Article number: 630 (2023) Cite this article

Abstract

Background

Different types of grafts can be used for anterior cruciate ligament reconstruction (ACLR). There is little published data regarding skeletally immature patients. The purpose of this systematic review was to assess the clinical outcomes and complications for different autograft types used in all-epiphyseal, transphyseal and partial epiphyseal/hybrid ACLR in skeletally immature children and adolescents.

Methods

PubMed, Embase and Cochrane databases were systematically searched for literature regarding ACLR using hamstrings, quadriceps or bone-patellar-tendon-bone (BPTB) autografts in skeletally immature patients. Studies were included if they examined at least one of the following outcomes: graft failure, return to sport(s), growth disturbance, arthrofibrosis or patient reported outcomes and had a minimum follow-up of 1 year. Case reports, conference abstracts and studies examining allografts and extra-articular or over-the-top ACL reconstruction techniques were excluded. Graft failure rates were pooled for each graft type using the quality effects model of MetaXL. A qualitative synthesis of secondary outcomes was performed.

Results

The database search identified 242 studies. In total 31 studies were included in this review, comprising of 1358 patients. Most patients (81%) were treated using hamstring autograft. The most common used surgical technique was transphyseal. The weighted, pooled failure rate for each graft type was 12% for hamstring tendon autografts, 8% for quadriceps tendon autografts and 6% for BPTB autografts. Confidence intervals were overlapping. The variability in time to graft failure was high. The qualitative analysis of the secondary outcomes showed similar results with good clinical outcomes and low complication rates across all graft types.

Conclusions

Based on this review it is not possible to determine a superior graft type for ACLR in skeletally immature. Of the included studies, the most common graft type used was the hamstring tendon. Overall, graft failure rates are low, and most studies show good clinical outcomes with high return to sports rates.

Peer Review reports

Background

The incidence of anterior cruciate ligament (ACL) ruptures in children is increasing, as well as the number of ACL reconstructions (ACLR) and graft failures in this age group [11, 19,20,21, 67, 69]. Different types of grafts can be used for ACL reconstruction, which can be divided in autograft and allograft. Graft choice for ACL reconstruction in skeletally immature patients are influenced by the surgeon’s preference, surgical technique, patient size and the remaining skeletal growth [11, 12, 49, 65].

The most commonly used autograft types are hamstring, quadriceps and patellar tendon grafts [5, 70]. Previous research comparing the different graft types in adults or adolescents with closed physes showed contrasting results [52, 54, 56, 64]. Some studies showed a lower graft failure rate in bone-patellar tendon-bone autografts (BPTB) compared to hamstring autografts [52, 54]. Contrasting, a cohort study by Snaebjörnsson et al. (2019) including 18,425 patients from the Swedish and Norwegian National Knee Ligament Registries showed no significant different revision rate due to graft failure between hamstring and patellar tendon autografts [64].

There is little published data on clinical outcomes of different graft types in children and adolescents with open physes [17]. Common techniques used for ACL reconstruction in children with open physes are transphyseal, all-epiphyseal and partial epiphyseal (hybrid) [3]. Another common technique is the over-the-top procedure, which is a combined intra- and extra-articular reconstruction with an iliotibial band autograft or hamstring tendon autograft [28, 69]. It has been previously observed that the use of autograft instead of allograft decreases the rate of graft failure in pediatric patients [11]. Given this outcome, the use of allograft has widely been discouraged and will not be investigated in this review. Whilst several studies describe clinical outcomes after pediatric ACL reconstruction, the available literature has not yet been systematically reviewed to determine which specific autograft type provides the best results regarding stability, return to sports (RTS) and complications such as graft failure, arthrofibrosis and growth disturbances, in skeletally immature children and adolescents undergoing transphyseal, all-epiphyseal or partial epiphyseal ACL reconstruction.

The aim of this systematic review is to assess the clinical outcomes and complications for different autograft types used in all-epiphyseal, transphyseal and partial epiphyseal/hybrid anterior cruciate ligament reconstructions in skeletally immature children and adolescents, in order to provide the surgeon with sufficient information when choosing a graft type and to stimulate personalized medicine. In line with findings in the adult population [27, 53, 54], we expect that the hamstrings tendon autograft will be most frequently used for ACLR in children and adolescents. Furthermore we hypothesize that the quadriceps tendon and BPTB autograft do not show inferior clinical outcomes as compared to hamstrings tendon autograft.

Methods

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [60] and registered with Prospective register of systematic reviews (PROSPERO) (CRD42022307073).

Literature search

Pubmed, Embase and Cochrane were searched from inception to December 20, 2021. The specific search strategy was created by a consultant with expertise in systematic review searching. A literature search using medical subject headings (MeSH) and text words related to ACL graft reconstruction in children/adolescents with open physes was used. Key search terms included skeletally immature children/adolescents, open growth plates, open physes, anterior cruciate ligament reconstruction, transphyseal, all-epiphyseal, partial epiphyseal/hybrid, physeal sparing technique, quadriceps, patellar tendon, bone patellar bone, graft type, autograft, hamstring, re-ruptures, graft failure, return to sport(s), growth disturbances, arthrofibrosis. The full search is described in Appendix 1. After the study selection, the reference lists of included studies were scanned to ensure literature saturation.

Study selection

All studies were screened by title and abstract and in a second phase using full text by two independent reviewers using the Rayyan software program [47]. Disagreements were settled by a third reviewer. Only original research studies related to ACL reconstructions (all-epiphyseal, partial epiphyseal or transphyseal technique) in skeletally immature children and adolescents (with open physes) with use of autografts (for example hamstring, quadriceps or BPTB) were included if they studied at least one of the following outcomes: graft failure, return to sport(s), growth disturbance, arthrofibrosis or patient reported outcomes and had a minimum follow-up of 1 year. Studies addressing both data of patients with open and closed physes were included if data on the result of treatment were reported separately for each patient group. If results were not reported separately, the authors were contacted and requested to provide the separate data. Only studies written in the English or Dutch language were included. Case reports, conference abstracts and studies examining allografts were excluded. Studies examining extra-articular tenodesis or over-the-top ACL reconstruction techniques were excluded due to the extra-articular nature of the procedure, which differs from the purely intra-articular ACLR techniques and can therefore not be rightfully compared to each other.

Data extraction

Data extraction was performed by two independent reviewers and recorded into a spreadsheet. After comparison and discussion of both spreadsheets, a database containing the final extracted data was formed. Study characteristics recorded included authors, publication year, design, inclusion and exclusion criteria, bone age analysis or tanner staging, outcome measurements, number of study subjects, graft type, ACLR technique and rehabilitation program. Specific patient characteristics concerning mean age of study subjects, sex, body mass index (BMI) and timing of surgery were also recorded.

Risk of bias assessment

Risk of bias was assessed with the Methodological Index for Non-Randomized Studies (MINORS) score [62]. Each methodological item was scored as 0 (not reported), 1 (reported but inadequate) or 2 (reported and adequate). Non-comparative studies could earn a maximum score of 16 and comparative studies of 24, respectively, with a higher score indicating a higher study quality and lower risk of bias.

Outcomes

The primary outcome was graft failure, determined by Magnetic Resonance Imaging (MRI), arthroscopy and/or clinical diagnosis. Secondary outcomes were clinical outcomes and growth disturbances. The following clinical outcome measurements were included in the review: Knee stability, arthrofibrosis, growth disturbances, patient reported outcome measures (PROMs) and return to sports (RTS). The definition of arthrofibrosis varied per study and was usually measured through physical examination [46]. Previous studies have reported RTS as a percentage of how many patients returned to their prior level of sports activity. Commonly used PROMs for subjective functional knee outcomes were the Lysholm score or (pedi-) International Knee Documentation Committee (IKDC) [10, 57]. All types of measurements were taken into account. Only growth disturbances that are measured radiologically in mm or cm (shortening or overgrowth) or degrees (valgus, varus or recurvatum) were evaluated.

Statistical analysis

Graft failure rates (primary outcome) were pooled for each graft type using the quality effects model of MetaXL [18]. This model gives lower weights to studies of lower quality. The first 8 items -applicable to all included studies- of the MINORS score were used to determine the study quality. Only studies presenting similar definitions of re-rupture or graft failure were included in this pooling. In addition, a qualitative synthesis of secondary outcomes was performed. Secondary outcomes evaluated in a similar manner regarding definition or method were included in this synthesis. Outcomes across four or more studies were reported as ranges, and outcomes assessed in three or fewer studies were reported individually.

Results

The database search identified 242 studies. After the removal of duplicates, screening of abstracts and full texts, 31 studies were included in this review (Fig. 1). These studies evaluated in total 1358 patients. The average age of the participants ranged from 11 to 15 years and the individual study populations consisted in 0–61% of female patients. The average duration of follow-up ranged from 21 months to 10 years (Table 1).

Fig. 1
figure 1

Flowchart which shows the study screening and inclusion process

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Table 1 Study characteristics and study bias scores of the included studies
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The majority of the included studies (n = 26) investigated ACLR using hamstring tendon autograft (n = 1042 patients, 81%). BPTB and quadriceps tendon autografts were used in respectively, 5 and 5 studies covering 141 and 103 patients. Although not specified in all studies, across all three graft types most studies used a transphyseal surgical technique. To a lesser extent a partial epiphyseal/hybrid or all-epiphyseal technique was applied (Table 1).

Risk of bias

The mean MINORS score for non-comparative studies and comparative studies were 9.1 ± 1.4 and 14.7 ± 3.6, respectively (Table 1). The full MINORS assessment is shown in appendix 2. The most common flaw was an unbiased (blinded) assessment of the study endpoints and all studies, except one, did not prospectively calculate a sample size.

Primary outcome

In the meta-analysis, respectively 12 studies on ACLR with hamstring, 5 with quadriceps and 2 BPTB-grafts with comparable definitions of graft failure were included. The overall pooled failure rate was 12% for hamstring tendon autografts, 8% for quadriceps tendon autografts and 6% for BPTB autografts (Fig. 2). The overlapping 95% confidence intervals, suggest that the rates did not significantly differ between graft types. Sensitivity analyses indicated a relatively large contribution of the study by Astur. However, excluding this study would not change the interpretation of the pooled results (failure rate hamstring tendon autografts 10% [95% CI 6–14%].

Fig. 2
figure 2

Pooled graft failure rates per graft type using the quality effects model. CI; confidence interval

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Pennock et al. [48] was the only study that directly compared hamstring (n = 56) to quadriceps (n = 27) tendon autograft and found a statistically significant lower graft failure rate in favor of quadriceps tendon (p = 0.037).

Two studies [2, 44] were excluded from the analysis, mainly because they did not specify if the numbers provided were specifically regarding ipsilateral re-rupture or graft failure. The excluded studies reported similar failure rates though. The exact graft failure rates and used definitions are presented in Table 2.

Table 2 Graft failure rates, time to graft failure and definition of graft failure per graft type
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Secondary outcomes

Knee stability

In the hamstring group, the KT-1000 was reported by 13 studies, ranging from 0.29 ± 1.07 mm to 2.58 (-2,7–7) mm side to side difference. In the BPTB group, two studies reported KT-1000 scores of 2.1 ± 1.2 mm and 3.3 ± 1.6 mm. McCarroll et al. (1994) reported a < 3.5 mm side to side difference in 51 patients, whereas 6 patients had a 4–5 mm difference (Table 3). In the quadriceps group, only Gebhard et al. (2006) reported a 2.0 mm difference (range 0–4 mm) (Table 3).

Table 3 Clinical examination per graft type
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Concerning stability tests, the Lachman and the Pivot shift at follow up were tests of interest. In the hamstring group, the Lachman test was reported by 9 studies and was negative in 80 to 100% of the cases. Five studies reported a positive Lachman ranging from 6 to 97% of the cases. The Pivot shift test was determined in 9 studies and was negative in 78–100% of the cases and positive in 2–22% of the cases. Two studies using quadriceps grafts reported a negative Lachman in 100% of the cases, one study also reported a negative Pivot shift in 100% of the cases (Table 3).

Of the 9 studies that described the range of motion (ROM) in the hamstring group, 7 studies reported no ROM deficit. Anderson et al. (2003) reported a flexion deficit with a mean of 3° in 5 patients (42%), but no greater than 8°. Koch et al. (2014) reported a slightly reduced flexion of 5°–10° in 4 patients (33%). In the quadriceps group, only Gebhard et al. (2006) reported a loss in ROM in 2 patients (5%) (Table 3).

Arthrofibrosis

Only 4 studies described the occurrence of arthrofibrosis. In the hamstring group, Kocher et al. (2007) reported 3 cases (5% of the study population) of arthrofibrosis 11 to 16 weeks postoperative. Nelson et al. (2016) reported 4 cases (1%) and Redler et al. (2012) confirmed there were no cases of arthrofibrosis. The definition of arthrofibrosis in all three studies was unclear. Additionally, in the BPTB group, McCarroll et al. (1994) reported 2 cases of arthrofibrosis (3%) and defined arthrofibrosis as > 5° extension loss compared with the non-operated knee.

Growth disturbances

In total 20 studies in the hamstring group, 4 in the quadriceps group and 2 in the BPTB group identified growth disturbances as an outcome measurement using radiographs. Two studies (Gicquel [26], Kopf [36]) were excluded from the analysis since only studies using radiographs were included.

In the hamstrings group, 8 studies reported no occurrence of length discrepancy, 13 studies no valgus, and 16 no varus or recurvatum deformity. Length discrepancy occurred in 10 studies ranging from a 1.2 to 22 mm difference compared to the other leg in 124 patients in total. Valgus deformity was reported by 6 studies, ranging from 0.46° to 4.5° in 64 patients in total. Varus deformity was reported by only 2 studies. Koch et al. (2014) reported one patient with a 1.5° varus deformity and Faunø et al. (2016) reported 23 patients with a varus deformity ≥ 2° on the operated knee, which was statistically significant compared to the non-operated knee (p = < 0.01). None of the studies reported the occurrence of a recurvatum deformity (Table 4).

Table 4 Growth disturbances per graft type
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In the quadriceps group, Mauch et al. (2011) reported one patient with valgus deformity, Gebhard et al. (2006) reported no length discrepancies and Pennock et al. (2019) reported no length discrepancies as well as no angular deformities. Kohl et al. (2014) reported a mean length discrepancy of − 2.9 ± 8.6 mm (99.7 ± 0.9%) over all 15 patients compared to the other side with 2 patients > 10 mm and one patient with valgus deformity. Both Memeo et al. (2012) and Shelbourne et al. (2004) reported no growth disturbances in the BPTB group (Table 4).

PROMs

In the hamstring group, the (Pedi-)IKDC was reported by 16 studies, average scores ranged from 85.6 to 96.5. The Lysholm score was reported by 14 studies, ranging from 58.8 to 97.9. Nine studies used the Tegner score, showing results ranging from 4.9 to 8.6. Faunø et al. (2016) and Razi et al. (2019) reported a mean KOOS of 76.8 ± 15.1 and 75 ± 7.4, respectively. Cordasco et al. (2016) and Graziano et al. (2017) both reported the Marx Activity Rating Scale with mean values of 13.4 ± 3.6 and 23.2 ± 8.3, respectively (Table 5).

Table 5 PROMs per graft type, mean
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In the quadriceps group, the Lysholm score was reported by three studies. Gebhard et al. (2006), Kohl et al. (2014) and Pennock et al. (2019) reported a mean Lysholm score of 94.3 (range 53–100), 94.0 (range 68–100) and 96 ± 8, respectively. Gebhard et al. (2006) and Pennock et al. (2019) also reported a mean Tegner score of 5.9 and 6.6, respectively (Table 5).

Pennock et al. (2019) also compared the Lysholm and Tegner scores of the quadriceps group directly to the hamstring group, showing no statistically significant differences (p = 0.095, p = 0.229, respectively).

In the BPTB group, only Shelbourne et al. (2004) reported a mean IKDC score of 95.4 ± 6.9 (Table 5).

Return to sports

In total 19 studies described return to sports (RTS) as an outcome measurement. Most studies recorded the percentage of patients who returned to the same level or higher level of sports or activity as before the operation ranged. These percentages ranged from 63 to 100% in the hamstrings group (n = 15) and 92–100% in the BPTB group. No studies in the quadriceps group identified RTS as an outcome measurement. Five studies in the hamstring group reported the time to RTS, with means ranging from 7 to 13.5 months. In the BPTB group, only McCarroll et al. (1994) reported a time to RTS ranging from 1 to 9 seasons of competition (Table 6).

Table 6 Return to sports per graft type
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Discussion

The most important finding of this systematic review was that no specific autograft type seems superior regarding graft failure rates in skeletally immature children after transphyseal, all-epiphyseal or partial epiphyseal ACL reconstruction. Due to the lack of studies evaluating quadriceps or BPTB autografts, quantitative comparison of other outcomes than graft failure was not possible. Hamstring tendon autograft was evaluated most frequently. Graft failure rates of hamstring tendon autografts were 12% (95%-CI: 7-18%), quadriceps tendon 8% (95%-CI: 2-18%) and BPTB 6% (95%-CI: 1-13%). There were no statistically significant differences in graft failure rates between the three graft types based on comparison of the 95%-confidence intervals. The variability in time to graft failure was high. According to the available literature in this systematic review, no graft seems therefore to be evidently superior in graft failure rates in transphyseal, all-epiphyseal or hybrid ACL reconstruction techniques. Overall, there are no large differences in graft failure rates, however there is a tendency towards higher failure rates in hamstring tendon autografts. This tendency is supported by the only study in this review that directly compared hamstring autografts to quadriceps autografts, showing a statistically significant lower graft failure rate when using a quadriceps tendon autograft [48]. A systematic review on graft types in the population under 19 years of age that included both skeletally immature and mature patients also supports these findings [11].

Compared to previous systematic reviews on outcomes after ACLR in skeletally immatures, graft failure rates were somewhat higher in the current study [23, 38, 70]. Compared to systematic reviews including patients under 19 years of age, the graft failure rates were lower in the current review [11, 32]. Although these systematic reviews show no statistically significant difference between the techniques in terms of graft failure or growth disturbances, they did use different in- and exclusion criteria and included multiple graft types, making it difficult to compare the results directly [17, 23, 38, 70].

One of the secondary outcomes of interest were growth disturbances. After ACL reconstruction, growth disturbances can occur in about 2.6–24% of the cases [22, 38]. In contrast to the systematic review by Collins et al. [9], the current systematic review found that length discrepancies, although in many cases very limited, were more common than valgus angular deformities [9]. In the systematic review by Frosch et al. [23], hamstring autografts were associated with a slightly lower risk of the occurrence of leg-length differences or axis deviations compared to BPTB grafts [23]. Regarding recurvatum deformities, the International Olympic Committee (IOC) statement discourages the use of BPTB grafts due to damage to the tibial tubercle apophysis when harvesting the graft. Frosch et al. [23] did not state this, but hypothesized that the apophysis of the tibia could be damaged due to the position of the tibial drill tunnel in physeal-sparing techniques or that the transplant blocks the tibial growth plate when it’s fixated on the ventral side [3, 23]. No recurvatum deformities were reported in the included studies that used BPTB in this systematic review. In both studies the follow-up did however not include a long leg radiograph, which is a limitation in diagnosing growth disturbances after ACLR [42, 61].

Another secondary outcome of interest was return to sports. The RTS percentages were high in most studies, with only two studies scoring lower than 80% [41, 45]. Interestingly both these studies reported a discrepancy between RTS percentages and return to previous levels of activity according to the Tegner score, which was above 80% in both studies [41, 45]. The lack of a clear and comparable definition of RTS in the different studies makes interpretation challenging. Overall, it seems that RTS percentages in skeletally immature patients after ACLR are high and independent of graft type [25, 30]. However, not all patients return to the exact same type of sports, but most patients are able to return to a similar level of sport [13, 32].

The other secondary outcomes of interest could also not be quantitatively compared between different graft types, due to limited number of studies evaluating a specific outcome or due to the use of different outcome measures. In all graft groups, clinical evaluation showed limited residual loss of range of motion and instability in the KT-1000 arthrometer or during Lachman or Pivot shift test. Different knee-specific and physical activity PROMs were analyzed in the included studies, which showed similar outcomes in the graft groups. Mostly adult versions of PROMS were used, while these are often not appropriate for a pediatric population [15].

A limitation of this systematic review is that it focused only on clinical outcomes of graft types in ACL reconstruction techniques in skeletally immature patients. Other outcomes, such as incorporation, ligamentalization and mechanical properties of the different graft types were not included. These processes are relevant in relation to the structural properties of a graft [1]. As such they might be important to determine which graft type is best suited to act as an ACL surrogate in terms of stability and mechanical durability. A stronger graft may be able to resists loads that caused the native ACL to fail. However, if a surrogate tissue is too stiff, it could potentially lead to joint overstraint and increased risk of osteoarthritis or early graft failure. Additionally, the mechanical properties of the ACLR grafts have been demonstrated to decrease during the postoperative ligamentalization process and never recover. A stronger graft may remain sufficient as surrogate after this process, while a graft similar to a native ACL may remain insufficient [14]. There have been studies in the past investigating these processes. Aitchinson et al. [1] showed that quadriceps autografts have an improved graft maturation, remodeling and structural integrity compared to hamstring autografts at one year postoperatively [1]. The clinical relevance remains unclear since more graft failures seem to occur after 12 months postoperatively [4, 16, 44]. Schmidt et al. [58] conducted a cadaveric cohort study on mechanical properties and microstructures of ACLs and grafts in skeletally immature specimens. The study shows that patellar tendons were most similar to native ACLs mechanical properties, which corresponds to the findings in adults in a cadaveric study by Schilaty et al. [14, 56]. Semitendinosus and iliotibial bands (ITBs) were significantly stronger but less compliant than quadriceps or patellar tendons [14]. ITBs were the most similar to ACLs regarding microstructure [14].

Another limitation is the methodological quality of the included studies. Since almost all studies are cohort studies or case series, the level of evidence is low. The MINORS tool used to determine the quality of the studies also showed moderate quality. The most common factors which increased the risk of bias were an unbiased (blinded) assessment of the study endpoints and failing to prospectively calculate a sample size. The different graft types could not be compared directly due to variations in outcomes and surgical techniques and due to the small sample sizes of the quadriceps and BPTB groups. The strength of this systematic review is however that it provides a current overview of the outcomes of different graft types used in skeletally immature patients. The investigated groups in the individual studies were grossly comparable regarding surgical indications, study designs and follow-up duration.

Future research should focus on the clinical outcomes and complications of using a quadriceps or BPTB autograft directly compared to a hamstring autograft. Another field of interest might be extra-articular surgical techniques such as the ‘’over-the-top ACL reconstruction or additional lateral extra-articular tenodesis (LET). ACLR in immature patients following these techniques also showed promising functional results in terms of return to sports and graft survival rate [e.g., 51]. The use of a registry such as the ESSKA Paediatric Anterior Cruciate Ligament Initiative (PAMI) registry might provide an opportunity to investigate a large number of patients [43]. Additionally, future research should also focus on graft characteristics including ligamentalization and mechanical properties, this might be insightful when choosing a specific graft type in skeletally immature children.

Conclusions

Based on this review it is not possible to determine a superior graft type for ACLR in skeletally immature. Of the included studies, the most common graft type used was the hamstring tendon. Overall, graft failure rates are low, and most studies show good clinical outcomes with high return to sports rates.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Abbreviations

ACL:

Anterior Cruciate Ligament

ACLR:

Anterior Cruciate Ligament Reconstruction

ACL-RSI:

Anterior Cruciate Ligament Return to Sport after Injury score

BMI:

Body Mass Index

BPTB:

Bone-patellar-tendon-bone

IOC:

International Olympic Committee

ITB:

Iliotibial band

KOOS:

Knee injury and Osteoarthritis Outcome Score

MAD:

Mechanical Axis Deviation

MeSH:

Medical subject headings

MINORS:

Methodological Index for Non-Randomized Studies

MRI:

Magnetic Resonance Imaging

PAMI:

Paediatric Anterior Cruciate Ligament Initiative

(pedi-)IKDC:

(Pediatric) International Knee Documentation Committee

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

PROMs:

Patient reported outcome measures

PROSPERO:

Prospective register of systematic reviews

ROM:

Range of motion

RTS:

Return to sports

SD:

Standard deviation

QMA:

Quality of movement assessment

References

  1. Aitchison AH, Alcoloumbre D, Mintz DN, Hidalgo Perea S, Nguyen JT, Cordasco FA, Green DW. MRI Signal Intensity of Quadriceps Tendon Autograft and Hamstring Tendon Autograft 1 Year after Anterior Cruciate Ligament Reconstruction in adolescent athletes. Am J Sports Med. 2021;49(13):3502–7.

    PubMed  Google Scholar 

  2. Anderson AF. Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients. A preliminary report. J Bone Joint Surg Am. 2003;85(7):1255–63.

    PubMed  Google Scholar 

  3. Ardern CL, Ekås G, Grindem H, Moksnes H, Anderson A, Chotel F, Cohen M, Forssblad M, Ganley TJ, Feller JA, Karlsson J, Kocher MS, LaPrade RF, McNamee M, Mandelbaum B, Micheli L, Mohtadi N, Reider B, Roe J, Seil R, Siebold R, Silvers-Granelli HJ, Soligard T, Witvrouw E, Engebretsen L. International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries. Knee Surg Sports Traumatol Arthrosc. 2018;26(4):989–1010.

    PubMed  Google Scholar 

  4. Astur DC, Novaretti JV, Cavalcante ELB, Goes A Jr, Kaleka CC, Debieux P, Krob JJ, de Freitas EV, Cohen M. Pediatric Anterior Cruciate Ligament Reruptures are related to Lower Functional Scores at the time of return to activity: a prospective, Midterm follow-up study. Orthop J Sports Med. 2019. https://doi.org/10.1177/2325967119888888.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Barber-Westin S, Noyes FR. One in 5 athletes sustain Reinjury upon Return to High-Risk Sports after ACL Reconstruction: a systematic review in 1239 athletes younger than 20 years. Sports Health. 2020;12(6):587–97.

    PubMed  PubMed Central  Google Scholar 

  6. Calvo R, Figueroa D, Gili F, Vaisman A, Mocoçain P, Espinosa M, León A, Arellano S. Transphyseal anterior cruciate ligament reconstruction in patients with open physes: 10-year follow-up study. Am J Sports Med. 2015;43(2):289–94.

    PubMed  Google Scholar 

  7. Chambers CC, Monroe EJ, Allen CR, Pandya NK. Partial Transphyseal Anterior Cruciate Ligament Reconstruction: clinical, functional, and Radiographic Outcomes. Am J Sports Med. 2019;47(6):1353–60.

    PubMed  Google Scholar 

  8. Cohen M, Ferretti M, Quarteiro M, Marcondes FB, de Hollanda JP, Amaro JT, Abdalla RJ. Transphyseal anterior cruciate ligament reconstruction in patients with open physes. Arthroscopy. 2009;25(8):831–8.

    PubMed  Google Scholar 

  9. Collins MJ, Arns TA, Leroux T, Black A, Mascarenhas R, Bach BR Jr. Growth abnormalities following anterior Cruciate Ligament Reconstruction in the skeletally immature patient: a systematic review. Arthroscopy. 2016;32(8):1714–23.

    PubMed  Google Scholar 

  10. Cordasco FA, Mayer SW, Green DW, All-Inside. All-Epiphyseal Anterior Cruciate Ligament Reconstruction in skeletally immature athletes: return to Sport, incidence of second surgery, and 2-Year clinical outcomes. Am J Sports Med. 2017;45(4):856–63.

    PubMed  Google Scholar 

  11. Cruz AI Jr, Beck JJ, Ellington MD, Mayer SW, Pennock AT, Stinson ZS, VandenBerg CD, Barrow B, Gao B, Ellis HB Jr. Failure rates of Autograft and Allograft ACL Reconstruction in Patients 19 years of age and younger: a systematic review and Meta-analysis. JB JS Open Access. 2020. https://doi.org/10.2106/JBJS.OA.20.00106.

    Article  PubMed  PubMed Central  Google Scholar 

  12. DeFrancesco CJ, Storey EP, Shea KG, Kocher MS, Ganley TJ. Challenges in the management of Anterior Cruciate Ligament Ruptures in skeletally immature patients. J Am Acad Orthop Surg. 2018;26(3):e50–e61. https://doi.org/10.5435/JAAOS-D-17-00294.

    Article  PubMed  Google Scholar 

  13. Dekker TJ, Godin JA, Dale KM, Garrett WE, Taylor DC, Riboh JC. Return to Sport after Pediatric Anterior Cruciate Ligament Reconstruction and its effect on subsequent anterior cruciate ligament Injury. J Bone Joint Surg Am. 2017;99(11):897–904.

    PubMed  Google Scholar 

  14. di Roberti T, Macchiarola L, Signorelli C, Grassi A, Raggi F, Marcheggiani Muccioli GM, Zaffagnini S. Anterior cruciate ligament reconstruction with an all-epiphyseal “over-the-top” technique is safe and shows low rate of failure in skeletally immature athletes. Knee Surg Sports Traumatol Arthrosc. 2019;27(2):498–506. https://doi.org/10.1007/s00167-018-5132-y.

    Article  Google Scholar 

  15. Dietvorst M, Reijman M, van Groningen B, van der Steen MC, Janssen RPA. PROMs in paediatric knee ligament injury: use the Pedi-IKDC and avoid using adult PROMs. Knee Surg Sports Traumatol Arthrosc. 2019;27(6):1965–73.

    CAS  PubMed  Google Scholar 

  16. Dietvorst M, Verhagen S, van der Steen MCM, Faunø P, Janssen RPA. Lateral tibiofemoral morphometry does not identify risk of re-ruptures after ACL reconstruction in children and adolescents. J Exp Orthop doi: https://doi.org/10.1186/s40634-021-00403-5.

  17. Diwakar M. (2018) Management of ACL tear in paediatric age group: A review of literature. Journal of Arthroscopy and Joint Surgery. 2021; doi: https://doi.org/10.1016/j.jajs.2018.01.005.

  18. Doi SA, Barendregt JJ, Khan S, Thalib L, Williams GM. Advances in the meta-analysis of heterogeneous clinical trials II: the quality effects model. Contemp Clin Trials. 2015;45(Pt A):123–9.

    PubMed  Google Scholar 

  19. Duart J, Rigamonti L, Bigoni M, Kocher MS. Pediatric anterior cruciate ligament tears and associated lesions: Epidemiology, diagnostic process, and imaging. J Child Orthop. 2023;17(1):4–11. https://doi.org/10.1177/18632521231153277.

    Article  PubMed  Google Scholar 

  20. Fabricant PD, Kocher MS. Anterior cruciate ligament injuries in children and adolescents. Orthop Clin North Am. 2016;47(4):777–88. https://doi.org/10.1016/j.ocl.2016.05.004.

    Article  PubMed  Google Scholar 

  21. Faunø P, Rahr-Wagner L, Lind M. Risk for Revision after Anterior Cruciate Ligament Reconstruction is higher among adolescents: results from the danish Registry of knee Ligament Reconstruction. Orthop J Sports Med. 2014. https://doi.org/10.1177/2325967114552405.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Faunø P, Rømer L, Nielsen T, Lind M. The risk of Transphyseal Drilling in skeletally immature patients with Anterior Cruciate Ligament Injury. Orthop J Sports Med. 2016. https://doi.org/10.1177/2325967116664685.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Frosch KH, Stengel D, Brodhun T, Stietencron I, Holsten D, Jung C, Reister D, Voigt C, Niemeyer P, Maier M, Hertel P, Jagodzinski M, Lill H. Outcomes and risks of operative treatment of rupture of the anterior cruciate ligament in children and adolescents. Arthroscopy. 2010;26(11):1539–50.

    PubMed  Google Scholar 

  24. Gebhard F, Ellermann A, Hoffmann F, Jaeger JH, Friederich NF. Multicenter-study of operative treatment of intraligamentous tears of the anterior cruciate ligament in children and adolescents: comparison of four different techniques. Knee Surg Sports Traumatol Arthrosc. 2006;14(9):797–803.

    CAS  PubMed  Google Scholar 

  25. Geffroy L, Lefevre N, Thevenin-Lemoine C, et al. Return to sport and re-tears after anterior cruciate ligament reconstruction in children and adolescents. Volume 104. Orthopaedics & Traumatology, Surgery & Research; 2018. pp. 183–S188. 8S.

  26. Gicquel P, Geffroy L, Robert H, Sanchez M, Curado J, Chotel F, Lefevre N. French arthroscopic society. MRI assessment of growth disturbances after ACL reconstruction in children with open growth plates-prospective multicenter study of 100 patients. Orthop Traumatol Surg Res. 2018;104(8S):175–S181.

    Google Scholar 

  27. Gifstad T, Foss OA, Engebretsen L, Lind M, Forssblad M, Albrektsen G, Drogset JO. Lower risk of revision with patellar tendon autografts compared with hamstring autografts: a registry study based on 45,998 primary ACL reconstructions in Scandinavia. Am J Sports Med. 2014;42(10):2319–28. https://doi.org/10.1177/0363546514548164.

    Article  PubMed  Google Scholar 

  28. Grassi A, Pizza N, Macchiarola L, et al. Over-the-top anterior cruciate ligament (ACL) reconstruction plus lateral plasty with hamstrings in high-school athletes: results at 10 years. Knee. 2021;33:226–33.

    PubMed  Google Scholar 

  29. Graziano J, Chiaia T, de Mille P, Nawabi DH, Green DW, Cordasco FA. Return to Sport for skeletally immature athletes after ACL Reconstruction: preventing a second Injury using a quality of Movement Assessment and quantitative measures to address modifiable risk factors. Orthop J Sports Med. 2017. https://doi.org/10.1177/2325967117700599.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Gupta A, Tejpal T, Shanmugaraj A, Horner NS, Gohal C, Khan M. All-epiphyseal anterior cruciate ligament reconstruction produces good functional outcomes and low complication rates in pediatric patients: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2020;28(8):2444–52.

    PubMed  Google Scholar 

  31. Guzzanti V, Falciglia F, Stanitski CL. Preoperative evaluation and anterior cruciate ligament reconstruction technique for skeletally immature patients in Tanner stages 2 and 3. Am J Sports Med. 2003;31(6):941–8.

    PubMed  Google Scholar 

  32. Kay J, Memon M, Marx RG, Peterson D, Simunovic N, Ayeni OR. Over 90% of children and adolescents return to sport after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2018;26(4):1019–36.

    PubMed  Google Scholar 

  33. Koch PP, Fucentese SF, Blatter SC. Complications after epiphyseal reconstruction of the anterior cruciate ligament in prepubescent children. Knee Surg Sports Traumatol Arthrosc. 2016;24(9):2736–40.

    PubMed  Google Scholar 

  34. Kocher MS, Smith JT, Zoric BJ, Lee B, Micheli LJ. Transphyseal anterior cruciate ligament reconstruction in skeletally immature pubescent adolescents. J Bone Joint Surg Am. 2007;89(12):2632–9.

    PubMed  Google Scholar 

  35. Kohl S, Stutz C, Decker S, Ziebarth K, Slongo T, Ahmad SS, Kohlhof H, Eggli S, Zumstein M, Evangelopoulos DS. Mid-term results of transphyseal anterior cruciate ligament reconstruction in children and adolescents. Knee. 2014;21(1):80–5.

    PubMed  Google Scholar 

  36. Kopf S, Schenkengel JP, Wieners G, Stärke C, Becker R. No bone tunnel enlargement in patients with open growth plates after transphyseal ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010;18(11):1445–51.

    CAS  PubMed  Google Scholar 

  37. Lemaitre G, Salle de Chou E, Pineau V, Rochcongar G, Delforge S, Bronfen C, Haumont T, Hulet C. ACL reconstruction in children: a transphyseal technique. Orthop Traumatol Surg Res. 2014;100(4 Suppl):261–5.

    Google Scholar 

  38. Longo UG, Ciuffreda M, Casciaro C, Mannering N, Candela V, Salvatore G, Denaro V. Anterior cruciate ligament reconstruction in skeletally immature patients: a systematic review. Bone Joint J. 2017;99–B(8):1053–60.

    PubMed  Google Scholar 

  39. Mauch C, Arnold MP, Wirries A, Mayer RR, Friederich NF, Hirschmann MT. Anterior cruciate ligament reconstruction using quadriceps tendon autograft for adolescents with open physes- a technical note. Sports Med Arthrosc Rehabil Ther Technol. 2011;3(1):7.

    PubMed  PubMed Central  Google Scholar 

  40. McCarroll JR, Shelbourne KD, Porter DA, Rettig AC, Murray S. Patellar tendon graft reconstruction for midsubstance anterior cruciate ligament rupture in junior high school athletes. An algorithm for management. Am J Sports Med. 1994;22(4):478–84.

    CAS  PubMed  Google Scholar 

  41. McIntosh AL, Dahm DL, Stuart MJ. Anterior cruciate ligament reconstruction in the skeletally immature patient. Arthroscopy. 2006;(12):1325–30.

  42. Memeo A, Pedretti L, Miola F, Albisetti W. Anterior cruciate ligament recostruction with bone-patellar tendon-bone autograft in Tanner 3 stage patients with open physes. J Pediatr Orthop B. 2012;21(5):415–20.

    PubMed  Google Scholar 

  43. Mouton C, Moksnes H, Janssen R, Fink C, Zaffagnini S, Monllau JC, et al. Preliminary experience of an international orthopaedic registry: the ESSKA Paediatric Anterior Cruciate Ligament Initiative (PAMI) registry. J Experimental Orthop. 2021. https://doi.org/10.1186/s40634-021-00366-7.

    Article  Google Scholar 

  44. Nelson IR, Chen J, Love R, Davis BR, Maletis GB, Funahashi TT. A comparison of revision and rerupture rates of ACL reconstruction between autografts and allografts in the skeletally immature. Knee Surg Sports Traumatol Arthrosc. 2016;24(3):773–9.

    PubMed  Google Scholar 

  45. Nikolaou P, Kalliakmanis A, Bousgas D, Zourntos S. Intraarticular stabilization following anterior cruciate ligament injury in children and adolescents. Knee Surg Sports Traumatol Arthrosc. 2011;19(5):801–5.

    PubMed  Google Scholar 

  46. Ouweleen AJ, Hall TB, Finlayson CJ, Patel NM. Predictors of Arthrofibrosis after Pediatric Anterior Cruciate Ligament Reconstruction: what is the impact of Quadriceps Autograft? J Pediatr Orthop. 2021. https://doi.org/10.1097/BPO.0000000000001860.

    Article  PubMed  Google Scholar 

  47. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan — a web and mobile app for systematic reviews. Syst Reviews. 2016;5:210.

    Google Scholar 

  48. Pennock AT, Johnson KP, Turk RD, Bastrom TP, Chambers HG, Boutelle KE, Edmonds EW. Transphyseal Anterior Cruciate Ligament Reconstruction in the skeletally immature: quadriceps Tendon Autograft Versus Hamstring Tendon Autograft. Orthop J Sports Med. 2019. https://doi.org/10.1177/2325967119872450.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Perkins CA, Willimon SC. Pediatric Anterior Cruciate Ligament Reconstruction. Orthop Clin North Am. 2020;51(1):55–63.

    PubMed  Google Scholar 

  50. Razi M, Moradi A, Safarcherati A, Askari A, Arasteh P, Ziabari EZ, Dadgostar H. Allograft or autograft in skeletally immature anterior cruciate ligament reconstruction: a prospective evaluation using both partial and complete transphyseal techniques. J Orthop Surg Res. 2019;14(1):85.

    PubMed  PubMed Central  Google Scholar 

  51. Redler LH, Brafman RT, Trentacosta N, Ahmad CS. Anterior cruciate ligament reconstruction in skeletally immature patients with transphyseal tunnels. Arthroscopy. 2012;28(11):1710–7.

    PubMed  Google Scholar 

  52. Rousseau R, Labruyere C, Kajetanek C, Deschamps O, Makridis KG, Djian P. Complications after Anterior Cruciate Ligament Reconstruction and their relation to the type of graft: a prospective study of 958 cases. Am J Sports Med. 2019;47(11):2543–9.

    PubMed  Google Scholar 

  53. Runer A, Suter A, Roberti di Sarsina T, Jucho L, Gföller P, Csapo R, Hoser C, Fink C. Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction show comparable clinical, functional, and patient-reported outcome measures, but lower donor-site morbidity compared with hamstring tendon autograft: a matched-pairs study with a mean follow-up of 6.5 ​years. J ISAKOS. 2023;8(2):60–7. https://doi.org/10.1016/j.jisako.2022.08.008.

    Article  PubMed  Google Scholar 

  54. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: is there a difference in graft failure rate? A Meta-analysis of 47,613 patients. Clin Orthop Relat Res. 2017;475(10):2459–68.

    PubMed  PubMed Central  Google Scholar 

  55. Sasaki S, Sasaki E, Kimura Y, Yamamoto Y, Tsuda E, Ishibashi Y. Clinical outcomes and postoperative complications after All-Epiphyseal double-bundle ACL Reconstruction for skeletally immature patients. Orthop J Sports Med. 2021. https://doi.org/10.1177/23259671211051308.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Schilaty ND, Martin RK, Ueno R, Rigamonti L, Bates NA. Mechanics of cadaveric anterior cruciate ligament reconstructions during simulated jump landing tasks: Lessons learned from a pilot investigation. Clin Biomech. 2021;86:105372. https://doi.org/10.1016/j.clinbiomech.2021.105372.

    Article  Google Scholar 

  57. Schmale GA, Kweon C, Larson RV, Bompadre V. High satisfaction yet decreased activity 4 years after transphyseal ACL reconstruction. Clin Orthop Relat Res. 2014;472(7):2168–74.

    PubMed  PubMed Central  Google Scholar 

  58. Schmidt EC, Chin M, Aoyama JT, Ganley TJ, Shea KG, Hast MW. Mechanical and Microstructural Properties of Pediatric Anterior Cruciate ligaments and autograft tendons used for Reconstruction. Orthop J Sports Med. 2019. https://doi.org/10.1177/2325967118821667.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Seon JK, Song EK, Yoon TR, Park SJ. Transphyseal reconstruction of the anterior cruciate ligament using hamstring autograft in skeletally immature adolescents. J Korean Med Sci. 2005;20(6):1034–8.

    PubMed  PubMed Central  Google Scholar 

  60. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart L, PRISMA-P Group. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;349(jan02 1):g7647.

    Google Scholar 

  61. Shelbourne KD, Gray T, Wiley BV. Results of transphyseal anterior cruciate ligament reconstruction using patellar tendon autograft in tanner stage 3 or 4 adolescents with clearly open growth plates. Am J Sports Med. 2004;32(5):1218–22.

    PubMed  Google Scholar 

  62. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological Index for Non-Randomized Studies (MINORS): development and validation of a new instrument. ANZ J Surg. 2003;73:712–6.

    PubMed  Google Scholar 

  63. Smoak JB, Macfarlane A, Kluczynski MA, Ferrick MR, Doak JP, Bisson LJ, Marzo JM. Postoperative radiographic observations following transphyseal anterior cruciate ligament reconstruction in skeletally immature patients. Skeletal Radiol. 2020;49(6):861–8.

    PubMed  Google Scholar 

  64. Snaebjörnsson T, Hamrin-Senorski E, Svantesson E, Karlsson L, Engebretsen L, Karlsson J, Samuelsson K. Graft diameter and graft type as predictors of anterior cruciate ligament revision: a cohort study including 18,425 patients from the swedish and norwegian national knee ligament registries. J Bone Joint Surg Am. 2019;101(20):1812–20.

    PubMed  Google Scholar 

  65. Turati M, Rigamonti L, Giulivi A, Gaddi D, Accadbled F, Zanchi N, Bremond N, Catalano M, Gorla M, Omeljaniuk RJ, Zatti G, Piatti M, Bigoni M. Management of anterior cruciate ligament tears in Tanner stage 1 and 2 children: a narrative review and treatment algorithm guided by ACL tear location. J Sports Med Phys Fitness. 2021. https://doi.org/10.23736/S0022-4707.21.12783-5.

    Article  PubMed  Google Scholar 

  66. Wall EJ, Ghattas PJ, Eismann EA, Myer GD, Carr P. Outcomes and complications after All-Epiphyseal Anterior Cruciate Ligament Reconstruction in skeletally immature patients. Orthop J Sports Med. 2017. https://doi.org/10.1177/2325967117693604.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Werner BC, Yang S, Looney AM, Gwathmey FW Jr. Trends in Pediatric and Adolescent Anterior Cruciate Ligament Injury and Reconstruction. J Pediatr Orthop. 2016;36(5):447–52.

    PubMed  Google Scholar 

  68. Willson RG, Kostyun RO, Milewski MD, Nissen CW. Anterior Cruciate Ligament Reconstruction in skeletally immature patients: early results using a hybrid physeal-sparing technique. Orthop J Sports Med. 2018. https://doi.org/10.1177/2325967118755330.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Wong SE, Feeley BT, Pandya NK. Comparing outcomes between the over-the-top and all-epiphyseal techniques for Physeal-Sparing ACL Reconstruction: a narrative review. Orthop J Sports Med. 2019. https://doi.org/10.1177/2325967119833689.

    Article  PubMed  PubMed Central  Google Scholar 

  70. Wong SE, Feeley BT, Pandya NK. Complications after Pediatric ACL Reconstruction: a Meta-analysis. J Pediatr Orthop. 2019;39(8):e566–71.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedic Surgery & Trauma, PO box, Máxima, Eindhoven, 5600 PD, MC, The Netherlands

    S Verhagen, M Dietvorst, MC van der Steen & RPA Janssen

  2. MMC Academy, Máxima, Veldhoven, MC, The Netherlands

    EJLG Delvaux

  3. Department of Orthopaedic Surgery & Trauma, Catharina Hospital Eindhoven, PO box 1350, Eindhoven, 5602 ZA, The Netherlands

    MC van der Steen

  4. Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands

    RPA Janssen

  5. Chair Value‑Based Health Care, Department of Paramedical Sciences, Fontys University of Applied Sciences, Eindhoven, The Netherlands

    RPA Janssen

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SV is the guarantor. SV, MD, MS and RJ drafted the manuscript. SV, MD, ED and MS contributed to the development of the selection criteria, the risk of bias assessment strategy and data extraction criteria. ED developed the search strategy. SV and MD performed the study selection, data extraction and interpretation of the results. MS provided statistical advise. RJ provided expertise on Anterior Cruciate Ligament (ACL) reconstruction. All authors read, provided feedback and approved the final manuscript.

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Appendix 1

: Draft Pubmed search. Appendix 2. Study quality and study bias scoring of the 30 included studies using the MINORS score for nonrandomized studies

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Verhagen, S., Dietvorst, M., Delvaux, E. et al. Clinical outcomes of different autografts used for all-epiphyseal, partial epiphyseal or transphyseal anterior cruciate ligament reconstruction in skeletally immature patients – a systematic review. BMC Musculoskelet Disord 24, 630 (2023). https://doi.org/10.1186/s12891-023-06749-4

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BMC Musculoskeletal Disorders

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