ACL injuries in the skeletally immature patient

Anterior cruciate ligament injuries are becoming increasingly prevalent in a younger, more athletic population. These injuries require aggressive management given the poor natural history with regard to progressive meniscal damage and advanced degenerative changes. In general, strict nonoperative management has been associated with failure in the individual committed to return to an active lifestyle. As a result a general algorithm can be expressed as follows: 1. Activity limitations and bracing are initially used for the asymptomatic skeletally immature patient with a complete ACL tear. 2. If the patient remains asymptomatic, formal reconstruction can be delayed until skeletal maturity. 3. For the symptomatic patient a precise delineation of their physical development or skeletal age is important. 4. In patients who have reached Tanner IV secondary sexual development or a skeletal age of 13-14 (F/M), a traditional transphyseal reconstruction with hamstring autografts is appropriate. 5. In the skeletally immature patient who has significant skeletal development ahead of them, the judicious use of physeal sparing procedures is an option for the surgeon comfortable with these techniques. In this case the goal is temporization until formal transphyseal reconstruction can be performed after the peak of skeletal growth.