ACL injuries in skeletally immature athletes

Anterior cruciate ligament (ACL) injuries in skeletally immature patients are becoming increasingly prevalent. These injuries present a unique set of challenges because of the presence of open physes and the associated risk of inducing a growth disturbance with traditional ACL surgical management. This review highlights the relevant anatomy, biomechanics, epidemiology, and risk factors associated with ACL injuries in the skeletally immature population and outlines a thorough evaluation process to determine the appropriate treatment strategy for each individual patient. Although non-operative management may be appropriate in select patients, operative intervention may be best for complete ACL injuries to prevent the risk of secondary injury to associated intra-articular structures. Both physeal-sparing and physeal-respecting approaches may be considered, and the most appropriate treatment option can be determined through assessment of remaining growth. Surgical management of these injuries with the correct approach can result in low complication rates [including retear rates (6%-11%) and low growth abnormalities (1%-2%)], as well as high rates of return to sport and patient satisfaction.