ACL injuries in the skeletally immature patient

Anterior cruciate ligament injuries in the pediatric and adolescent population are becoming more common with the trends of increased participation in competitive athletics in younger children. The natural history of this injury is similar to that of the adult and results in frequent reinjury, instability, and debilitation. Delayed reconstruction has proven to be a clinically effective treatment method but requires a prolonged restriction of competitive athletics. Reconstruction in the acute and subacute period has been shown by many authors to be a successful, reproducible treatment regimen. Nonetheless, the unique pitfalls of ACL reconstruction in a skeletally immature patient must not be overlooked. A thorough preoperative evaluation for leg-length discrepancy or subtle angular deformity is essential to identify the presence of an entity that might otherwise be attributed to surgical complication. For the patient nearing skeletal maturity with little growth remaining, we recommend the standard tunnel positioning and the use of soft-tissue graft. For younger patients who have significant growth remaining, alternative physeal "safe" procedures should be considered. No prospective, randomized studies compare the clinical success of graft type, graft placement, or graft fixation in this age group. Further follow-up of existing study groups and prospective research is warranted to fine-tune the result-based decision making for treatment of this injury.