Over‐the‐Top Anterior Cruciate Ligament Reconstruction With Lateral Extra‐articular Tenodesis in Pediatric Athletes Provides Excellent Functional Outcomes and Preserves Growth Plate Symmetry

Purpose To assess clinical and radiological outcomes of pediatric anterior cruciate ligament (ACL) reconstruction using the over‐the‐top technique (OTT) combined with the lateral extra‐articular tenodesis (LET) technique in skeletally immature patients, providing insights into its safety, efficacy, and effects on the growing knee. Methods A retrospective study was conducted on skeletally immature soccer players undergoing ACL reconstruction with OTT + LET between 2019 and 2023 with a minimum follow‐up of 2 years. Functional assessment included Lysholm, Knee Injury and Osteoarthritis Outcome Score, as well as KT‐1000 testing. Radiological parameters included mechanical axis deviation, mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, anterior superior iliac spine‐medial malleolus distance, femoral/tibial lengths, and limb alignment. Paired t ‐tests/Wilcoxon tests were used, with P < .05 considered significant. Results Nineteen skeletally immature soccer players (mean age 12.8 ± 0.9 years) underwent ACL reconstruction with OTT + LET. At a mean follow‐up of 43.6 ± 15.9 months [28‐75], patients showed excellent functional outcomes (Lysholm 96.7 ± 10.9; Knee Injury and Osteoarthritis Outcome Score 94.6 ± 9.4). Clinical stability was restored in 94.4% of cases, with only 1 rerupture (5.6%). Radiological comparisons showed symmetrical alignment and bone lengths. A statistically significant reduction in mechanical medial proximal tibial angle was observed in operated knees compared with contralateral knees (85.0° vs 86.5°, P = .003). Conclusions ACL reconstruction using the OTT physeal‐sparing technique combined with LET provided excellent clinical outcomes in our small sample of skeletally immature athletes. At a minimum of 2 years of follow‐up, functional results were favorable, stability was restored, and radiological findings showed overall limb symmetry. The only significant radiological difference was a reduction of 1.5° in the mechanical medial proximal tibial angle. Level of Evidence Level IV, retrospective therapeutic case series.