Anterior cruciate ligament injury in the skeletally immature patient

Anterior cruciate ligament instability (ACL) injuries are being diagnosed with increasing frequency in the pediatric and adolescent population. Controversy exists regarding treatment of the skeletally immature, ACL injured athlete. Nonoperative management is challenging due to relatively poor compliance with activity restrictions in this age group, which in turn can lead to persistent instability, meniscal tears, and chondral damage. Concerns with respect to operative management include the possibility of physeal arrest, injury or overgrowth with subsequent risk of leg length inequality and angular or rotational deformities. The purpose of this review will be to discuss the natural history of ACL tears in the pediatric and adolescent population and to review surgical anatomy, treatment strategies, technical considerations, results and complications of treatment, as well as the prevention of ACL injuries. ACL reconstruction should be considered to maximize ability to return to sport, and minimize risk for meniscal and articular cartilage damage. In prepubescent patients, an initial trial of rehabilitation with functional bracing and activity modification may be considered due to the possibility of iatrogenic growth disturbances with surgical management. For those patients that are unable to comply with activity restrictions, and or experience recurrent instability episodes, operative management should be considered. ACL reconstruction is recommended provided there is preoperative planning, attention to detail, and close postoperative follow-up. Satisfactory functional results have been reported for both transphyseal and physeal sparing techniques with acceptable rates of revision and minimal risk of growth disturbance.