Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient

Anterior cruciate ligament (ACL) injuries in skeletally immature patients are being seen with increased frequency. The management of these injuries is controversial. Nonreconstructive treatment of complete tears typically results in recurrent functional instability with risk of injury to meniscal and articular cartilage. A variety of reconstructive techniques have been utilized, including physeal sparing, partial transphyseal, and transphyseal methods using various grafts. Conventional adult ACL reconstruction techniques risk potential iatrogenic growth disturbance due to physeal violation. Growth disturbances after ACL reconstruction in skeletally immature patients have been reported. In this review, we discuss our approach to ACL reconstruction in the skeletally immature patient based on physiological age. In prepubescent patients, we perform a physeal-sparing, combined intra-articular and extra-articular reconstruction using autogenous iliotibial band. In adolescent patients with significant growth remaining, we perform transphyseal ACL reconstruction with autogenous hamstrings tendons with fixation away from the physes. In older adolescent patients approaching skeletal maturity, we perform conventional adult ACL reconstruction with interference screw fixation using either autogenous central third patellar tendon or autogenous hamstrings.