Anterior cruciate ligament (ACL) injuries in skeletally immature patients present a major clinical challenge due to the risk of growth plate (physeal) damage during reconstruction. To mitigate this risk, femoral extra-physeal techniques aim to preserve growth plate integrity while restoring knee stability. A systematic review evaluated the safety, growth disturbance rates, and graft survivorship associated with these extra-physeal approaches in young athletes with open physes.

Analyzing 21 studies encompassing 579 pediatric patients with a mean age of 11.8 years, the review examined three primary surgical procedures: the Over-The-Top technique (176 patients), the Kocher–Micheli procedure (327 patients), and the Clocheville technique (76 patients). Postoperative growth disturbances were reported in 4.5% of patients (26 cases), with the majority classified as minor (3.8%), predominantly presenting as mild overgrowth. Major deformities occurred in only 0.7% of patients (4 cases), and notably, no patient required surgical corrective procedures. Furthermore, the overall graft failure rate remained low at 5.2%.

Subgroup analysis indicated that combining the reconstruction with a lateral extra-articular tenodesis (LET) helped protect against graft failure without increasing the risk of major growth disturbances. Overall, these findings support femoral extra-physeal reconstruction as a safe and effective option in growing knees, though the authors emphasize that results should be interpreted cautiously given study heterogeneity and a frequent lack of routine preoperative radiographic baselines.