Assessment of Skeletal Maturity
The first step in surgical treatment of ACL injuries in pediatric individuals is determining the skeletal maturity and growth potential of the patient. In determining these factors, the relative risk and potential consequences of iatrogenic physeal injury can be estimated. Subsequently, the appropriate surgical technique can be selected to minimize the chance of leg-length discrepancy or angular deformity.
The most common method for assessing skeletal maturity is comparing hand and wrist radiographs to the Greulich and Pyle atlas. When using this reference, emphasis should be placed on the phalanges and metacarpals, as the maturity of carpal bones vary significantly and often demonstrate a lower bone age than is actually present.
Tanner staging can be used to determine the physiological age of the patient. While this system provides an excellent assessment of physiologic maturity, there is a fairly wide variation in bone age compared to pubertal stage. Furthermore, preoperative Tanner staging performed by orthopaedic surgeons has been shown to be unreliable, with significant intraobserver and interobserver variability.