Review Article

Anterior Cruciate Ligament

Injuries in the Skeletally Immature
Athlete: Diagnosis and
Management

Abstract
Jeremy S. Frank, MD Intrasubstance anterior cruciate ligament (ACL) injuries in children
Peter L. Gambacorta, DO and adolescents were once considered rare occurrences, with tibial
eminence avulsion fractures generally regarded as the pediatric
ACL injury equivalent. However, with increased single-sport focus,
less free play, and year-round training at younger ages,
intrasubstance ACL injuries in children and adolescents are being
diagnosed with increased frequency. As in the adult, a knee devoid
of ligamentous stability predisposes the pediatric patient to
meniscal and chondral injuries and early degenerative changes.
Management of ACL injuries in skeletally immature patients
includes physeal-sparing, partial transphyseal, and complete
transphyseal ACL reconstruction. Complications include iatrogenic
growth disturbance resulting from physeal violation.

I n the past 20 years, sports injuries

From the Division of Pediatric
Orthopaedics and Spinal
Deformities, Joe DiMaggio
Children’s Hospital, Hollywood, FL
(Dr. Frank) and the Division of
Sports Medicine, Women and
Children’s Hospital of Buffalo, East
Amherst, NY (Dr. Gambacorta).
Neither of the following authors nor
any immediate family member has
received anything of value from or
has stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Frank and
Dr. Gambacorta.
J Am Acad Orthop Surg 2013;21:
78-87
http://dx.doi.org/10.5435/
JAAOS-21-02-78
Copyright 2013 by the American
Academy of Orthopaedic Surgeons.
in pediatric and adolescent athletes
have dramatically increased.1 Ap-
proximately 38 million young ath-
letes participate in organized sports
annually in the United States.2 Of
these, nearly 2 million high school
students and almost twice as many
athletes aged <14 years are treated
for a sports-related injury each year.
This new epidemic of sports-related
injuries can be partially attributed to
the dramatic surge in the number of
participants since the passage of Title
IX, along with increased emphasis
on year-round competition, single-
sport concentration, and more in-
tense training.
Injuries to the anterior cruciate liga-
ment (ACL) were once thought to be a
rare phenomenon in pediatric athletes.
Midsubstance tears were believed to
occur only in adults, and the tibial em-
inence fracture was considered to be
the pediatric equivalent of the ACL tear
in adults. The incidence of midsub-
stance tears in pediatric patients has
grown considerably, especially in sports
that involve cutting, pivoting, and col-
lision.
In a recent study of high school
athletes, female soccer players were
found to have the highest rate of
ACL injury, with an incidence of
14.08 per 100,000 exposures; male
football players had the second high-
est rate, with 13.87 injuries per
100,000 exposures.3 Stanitski et al4
noted that 47% of preadolescent and
65% of adolescent athletes present-
ing with an acute hemarthrosis of the
knee were ultimately diagnosed with
acute ACL rupture.
Management of ACL injuries in
the skeletally immature athlete is
challenging. In adults, the traditional
arthroscopically assisted placement
of osseous tunnels for ACL recon-

78 Journal of the American Academy of Orthopaedic Surgeons


Figure 1
Sagittal T2-weighted magnetic
resonance image of a Tanner stage
2 patient with a complete anterior
cruciate ligament rupture (arrow).
struction is highly effective in pre-
venting instability. This technique is
usually avoided in younger patients
with significant growth remaining
because drilling across the growth
plate carries a potential risk of
growth disturbance and angular de-
formity. Historically, the approach
for managing ACL tear in a young
patient consisted of activity modifi-
cation and bracing until the onset of
skeletally maturity, at which point a
traditional transphyseal ACL recon-
struction could safely be performed.
However, nonsurgical management
commonly leads to recurrent insta-
bility, resulting in secondary injuries
to the surrounding articular cartilage
and menisci. Several physeal-sparing
ACL reconstruction techniques have
been developed to stabilize the knee
and minimize the risk of physeal dis-
ruption.
History
A focused history is required before
proceeding to physical examination.
Chronicity, mechanism of injury (ie,
February 2013, Vol 21, No 2
Jeremy S. Frank, MD, and Peter L. Gambacorta, DO
contact versus noncontact), and re-
sulting symptoms are critical pieces
of information. For the young child,
most of these questions are directed
toward the parent or guardian, but it
is important to engage the child, as
well, to develop rapport. Any history
of swelling or effusion in the knee re-
quires further investigation. The pre-
senting signs and symptoms of an
ACL tear in pediatric patients are
similar to those experienced by
adults. The athlete may experience a
pop at the time of injury. Nearly half
of all ACL injuries are associated
with a hemarthrosis, which ensues
between 6 and 12 hours after the in-
jury.3 Up to 70% of these injuries oc-
cur through a noncontact mechan-
ism, and instability may recur if the
young athlete continues to play on a
ruptured ACL.5
Physical Examination
Proper physical evaluation is para-
mount in diagnosing pediatric knee
injuries. Performance of the physical
examination can be a challenge be-
cause pediatric patients are often
anxious and guarded. Examination
of the uninjured knee can be helpful
for demonstrating clinical maneuvers
and determining normal joint laxity.
Visualization and gentle palpation
are used to detect any underlying ef-
fusion. Palpatory evaluation of the
knee should include the distal femo-
ral and proximal tibial physes, me-
dial and lateral joint lines, patella,
patellar retinaculum, and tibial tu-
bercle apophysis. When normal
range of motion (ROM) is compro-
mised, a concomitant injury to the
meniscus and/or cartilage should be
considered. The collateral ligaments
should be evaluated at zero degrees
and 30°. A proper Lachman test is
critical to assess anterior tibial trans-
lation and end point firmness. The
pivot shift test is beneficial in repro-
ducing the sense of instability; how-
ever, it may not be well tolerated fol-
lowing acute injury.
Imaging
Imaging of the injured knee is essen-
tial in devising a treatment plan. Ini-
tial AP, lateral, notch, and sunrise ra-
diographs of the injured knee are
helpful in assessing osseous struc-
tures and skeletal maturity. MRI is
indicated to evaluate for partial ver-
sus complete ACL injuries, define as-
sociated ligamentous pathology, and
assess for suspected meniscal de-
rangement. MRI is not absolutely
indicated for the patient with a de-
finitively positive and asymmetric
Lachman and pivot shift examina-
tion, no additional ligamentous lax-
ity, and full knee ROM. With proper
sequencing, MRI has 95% sensitivity
for detecting ACL tears in pediatric
patients6 (Figure 1).
Maturity Assessment
Surgical management is guided by
the patient’s skeletal, physiologic,
and chronologic maturity. Chrono-
logic age serves as a rough estimate;
the skeletal and physiologic age may
be quite different. The Tanner stag-
ing system is best utilized to classify
a patient’s physiologic maturity (Ta-
ble 1). Assessment of secondary sex
characteristics and questions con-
cerning menarche are useful in deter-
mining physiologic age. Skeletal ma-
turity can be determined by a variety
of methods. Our preference is to ob-
tain a PA radiograph of the left hand
and wrist for comparison with the
Greulich and Pyle atlas.
Child athletes who are being con-
sidered for ACL reconstruction can
be classified as either prepubescent
or pubescent. The prepubescent pa-
tient has physiologic findings consis-
tent with Tanner stages 1 and 2 and
79
Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete: Diagnosis and Management

Table 1
Tanner Stages of Physiologic Maturity
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

Boys
Growth 5–6 cm/y 5–6 cm/y 7–8 cm/y 10 cm/y None
Testes, penis Testes: <4 mL or Testes: 4 mL or 2.5– Testes: 12 mL or 3.6 cm; Testes: 4.1–4.5 cm; Testes fully mature in
<2.5 cm 3.5 cm; penis usu- enlargement, lengthen- increased size and shape and size
ally not yet en- ing of penis breadth of penis
larged
Pubic hair None Sparse, at base of Pubic hair over pubis; Adult-like, but over a Fully mature in type
penis darker, coarser, and smaller area and quantity, extend-
more curled ing to the thighs
Girls
Growth 5–6 cm/y 7–8 cm/y 8 cm/y 7 cm/y None
Breasts No development Buds Elevation and areolar Areolae and papillae Mature
enlargement form secondary
mound
Pubic hair None Sparse, on labia; On mons pubis; darker, Adult-like, but over a Fully mature in type
slightly pigmented coarser, and more smaller area and quantity, extend-
curled ing to the thighs

a bone age of <12 years in boys and
<11 years in girls. The pubescent pa-
tient has physiologic findings consis-
tent with Tanner stages 3 and 4 and
a bone age of 13 to 16 years in boys
and 12 to 14 years in girls.
Nonsurgical Management
Historically, nonsurgical treatment op-
tions for skeletally immature patients
with ACL tears consisted of activity
modification, functional bracing, and
physical rehabilitation. The rationale
for this approach was to allow the pa-
tient to mature skeletally before per-
forming transphyseal ACL reconstruc-
tion, thereby minimizing the risk of
physeal violation and potential growth
deformity. This nonsurgical approach
is best used in the highly compliant,
low-demand patient who has no addi-
tional intra-articular pathologies or
who has a partial ACL tear. Partial
tears have been found to occur in 61%
of adolescents with ACL injuries.7
Diagnosis of a partial tear based on
physical examination alone is diffi-
cult. Instability maneuvers (eg, Lach-
man test, pivot shift test) may be
negative initially even when 75% of
the ligament is torn.8 MRI in the
oblique coronal plane is useful in
quantifying the percentage of intact
fibers.
To date, Kocher et al7 have per-
formed the only study on partial
ACL tears in the adolescent patient.
The study included 45 patients aged
<18 years. The diagnosis was made
using physical examination, MRI,
and arthroscopic evidence consistent
with partial tear of the ACL. At a
minimum 2-year follow-up, 31% of
patients underwent subsequent ACL
reconstruction. Risk factors associ-
ated with failed nonsurgical manage-
ment included tears involving >50%
of the midsubstance ligament width,
tears predominantly involving the
posterolateral bundle, a mildly posi-
tive pivot shift test, and older chron-
ologic and skeletal age. The authors
of that study concluded that partial
ACL tears in children and adoles-
cents aged ≤14 years with near nor-
mal Lachman and pivot shift tests
may be managed nonsurgically.
Conservative management of skele-
tally immature patients with com-
plete ACL injuries has been less suc-
cessful. The high noncompliance rate
is associated with secondary damage
of the menisci and/or articular carti-
lage, and a large percentage of pa-
tients eventually require surgical
reconstruction.9,10 In a recent system-
atic literature review, Vavken and
Murray9 compared 47 studies that
reported the clinical outcomes of sur-
gical and nonsurgical management
of skeletally immature patients with
complete ACL tears (minimum
follow-up, 6 months). The authors
concluded that in the skeletally im-
mature patient with a complete ACL
rupture, surgical intervention pro-
duces superior clinical outcomes
with regard to future stability and
secondary injury prevention. More-
over, the specific procedure chosen
for surgical stabilization appears to
have less clinical impact than does
the selection of surgical treatment in
itself. In a cohort study, Lawrence
et al10 found that delaying manage-
ment of a complete ACL injury with
subjective knee instability for >12
weeks correlated with a significant
increase in the amount of irreparable

80 Journal of the American Academy of Orthopaedic Surgeons


medial meniscal tears and lateral
compartment chondral injuries.
Surgical Management
Historical Review
Traditional surgical techniques for
adult ACL reconstruction include the
creation of transphyseal tunnels fol-
lowed by graft tensioning and fixa-
tion. In the skeletally immature pa-
tient, conventional tunnel placement
and graft tensioning risks iatrogenic
growth disturbance caused by phys-
eal violation. Multiple animal11-13
and human clinical series14-16 have
documented such growth distur-
bances. More recent animal studies
have investigated the effect of small
tunnels and soft-tissue grafts on
physeal bar formation and subse-
quent growth arrest.17-20
Stadelmaier et al17 compared phys-
eal defects with and without the use
of soft-tissue interposition grafts in
eight skeletally immature dogs. The
authors concluded that the presence
of soft-tissue grafts in the transphys-
eal tunnels prevented physeal bar
formation. These results have been
verified in subsequent animal stud-
ies, which also noted that transphys-
eal tunnels that occupy <5% of the
physeal cross-sectional area do not
appear to cause growth distur-
bance.18 However, when >7% to 9%
of the cross-sectional area of the
physis is violated, growth distur-
bance is possible even in the presence
of a soft-tissue graft.18
Clinical reports of growth distur-
bance are rare. Lipscomb and Ander-
son14 reported one case of growth
disturbance following transphyseal
hamstring ACL reconstruction out of
a total of 24 patients aged 12 to 15
years. Koman and Sanders15 published
a case report on one 14-year-old boy
who experienced growth disturbance
following transphyseal hamstring ACL
reconstruction. Kocher et al16 sur-
February 2013, Vol 21, No 2
Jeremy S. Frank, MD, and Peter L. Gambacorta, DO
veyed members of the Herodicus So-
ciety regarding growth disturbance
after skeletally immature ACL recon-
struction and noted 15 additional
cases of growth disturbance. Those
authors concluded that associated
risk factors for growth disturbance
included fixation hardware across
the physis, large tunnels (≥12 mm),
lateral extra-articular tenodesis, dis-
section in proximity to the perichon-
drial ring of LaCroix, and suturing
near the tibial tubercle.
More recent clinical studies have
examined the use of MRI to charac-
terize physeal injury after transphys-
eal ACL reconstruction in skeletally
immature patients. Kercher et al19 re-
viewed 31 patients aged 10 to 15 years
with MRI and custom three-dimen-
sional modeling following transphyseal
ACL reconstruction. The authors con-
cluded that, with 8-mm tunnels, <3%
of the cross-sectional area of the physis
was violated. Moreover, using a custom
computerized model of the physis, they
documented that tunnel diameter was
potentially more offensive to the physis
than was drill angle.
Anatomic positioning of the femo-
ral tunnel with the use of single- or
double-bundle techniques is becom-
ing the standard in adult ACL recon-
struction. The anatomic placement
of the femoral tunnel is drilled at a
more oblique angle that, if per-
formed in a skeletally immature pa-
tient, places the lateral physis at an
increased risk of injury. Shea et al20
used a computer-aided three-dimen-
sional model to incorporate the drill-
ing of an anatomic double-bundle
ACL femoral tunnel in 10 pediatric
knees using a variety of drill-hole di-
ameters. They demonstrated that, by
using this technique, the average
physeal volume removed—as a per-
centage of the total physeal vol-
ume—was between 3.7% and 6.5%.
The authors concluded that ana-
tomic double-bundle drill-hole place-
ment during ACL reconstruction
produces a zone of physeal injury
that appears to increase the risk of
abnormal growth in the distal femo-
ral physis postoperatively.
Yoo et al21 reviewed the postopera-
tive magnetic resonance images of 43
skeletally immature patients who un-
derwent transphyseal ACL recon-
struction (mean age, 14.8 years;
range, 12.4 to 16.5 years). The aver-
age bone tunnel–to–growth plate
cross-sectional area ratio was <3%.
Five patients developed MRI-
documented focal physeal disruption
without a perceived clinical growth
disturbance (11.6%). The authors of
the study noted that, although trans-
physeal reconstruction of the ACL
may not be a benign procedure in
younger children with substantial
growth potential, they were able to
safely perform this procedure in ado-
lescents with limited growth remain-
ing in this series.
Surgical Techniques
The great majority of ACL tears in
skeletally immature athletes occur in
adolescents with limited growth re-
maining. Treatment traditionally in-
cludes transphyseal ACL reconstruc-
tion with minimal risk of growth
disturbance.9 Surgical management
of these injuries in the preadolescent
patient is the subject of much debate,
given the substantial growth remain-
ing, the poor prognosis of nonsurgi-
cal management, and the conse-
quences of potential growth arrest.
Graft Selection
There has been considerable contro-
versy regarding the use of autograft
versus allograft tissue in ACL recon-
struction. In a recent study, the Mul-
ticenter Orthopaedic Outcomes Net-
work patient database was analyzed
to evaluate graft choice and the risks
associated with failure and graft rup-
ture.22 Patients between ages 10 and
19 years were found to have the
81
Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete: Diagnosis and Management
Figure 2
Illustration of the physeal-sparing
all-intraepiphyseal anterior cruciate
ligament reconstruction as
described by Anderson.29
highest percentage of graft failures
regardless of graft type. Moreover,
the odds of graft rupture were four
times higher with allograft recon-
struction than with autograft recon-
struction.
Physeal-sparing Techniques
As previously noted, current evi-
dence suggests that surgical stabiliza-
tion is the preferred management for
ACL rupture in skeletally immature
patients, with physeal-sparing tech-
niques used in preadolescent patients
and transphyseal techniques used in
adolescent patients.9 Both techniques
carry a beneficial safety profile and
minimal risk of growth disturbance.
Poor results have been reported fol-
lowing early extra-articular reconstruc-
tion in preadolescent patients.23-26
Similar reports of ACL repair during
that time noted considerable clinical
laxity and functional instability.24
More recent studies investigating
ACL repair in large animal models
have indicated promising results
82
with the use of a bioactive and bio-
compatible scaffold in the form of a
clot that could be placed in the
wound site to enhance cellular prolif-
eration and biosynthesis at the torn
ACL edges.27 Human clinical studies
are necessary prior to implementing
widespread clinical applications.
A variety of physeal-sparing tech-
niques has been reported. In 2003,
Guzzanti et al28 reported the results
of a new technique described to
manage five Tanner stage 1 ACL
tears (mean chronologic age, 11.15
years; mean bone age, 10.9 years). In
this technique, the hamstring ten-
dons were kept intact at their distal
attachment, passed through a trans-
epiphyseal tibial tunnel, looped over
a staple at the femoral ACL origin,
brought back through the tibial tun-
nel, and sutured onto themselves.
The authors reported no functional
instability, 1.8 mm of graft laxity,
and no cases of growth disturbance.
Anderson29 described an all-intra-
epiphyseal technique in patients with
a mean age of 13.3 years, in which
autograft hamstring tendon was
passed through the distal femoral
epiphysis and fixed with an En-
doButton (Smith & Nephew) over
the lateral femoral condyle. The re-
maining portion of the graft was
then passed through an all-
epiphyseal tibial tunnel and fixed
with a post distal to the proximal
tibial physis. The author reported no
functional instability, no evidence of
growth disturbance or limb-length
discrepancy, and 1.5 mm of clinical
laxity at 2- to 8-year follow-up (Fig-
ure 2). Finally, Kocher et al30 de-
scribed a physeal-sparing combined
intra- and extra-articular reconstruc-
tion technique in 44 prepubescent
patients using autogenous iliotibial
band graft (mean chronologic age,
10.3 years). This procedure is a mod-
ification of the combined intra- and
extra-articular reconstruction de-
scribed by MacIntosh and Darby in
Journal of the American Academy of Orthopaedic Surgeons
1976.30 Although it was initially
thought to be a temporizing proce-
dure until adult-type reconstruction
could be performed after skeletal
maturity, the data of Kocher et al30
demonstrated a low revision rate
(4.5%) and clinical laxity rate as
well as a high rate of functional sta-
bility and return to prior levels of
sport (Figures 3 and 4).
Three distinct physeal-sparing
techniques have been described, all
with excellent clinical results and no
reported evidence of growth distur-
bance. Kennedy et al31 performed a
biomechanical evaluation of each
technique to determine which most
closely restored native knee kinemat-
ics. In a controlled laboratory set-
ting, six cadaver knees were sub-
jected to static AP, varus, and
internal rotation forces at zero de-
grees, 15°, 30°, 45°, 60°, and 90° of
knee flexion. Displacement and rota-
tion of the tibia with respect to the
femur were measured in the intact
knee after ACL disruption and after
ACL reconstruction using all-
epiphyseal, transtibial over-the-top,
and iliotibial band physeal-sparing
techniques. The authors concluded
that, although all physeal-sparing re-
construction techniques restored
some stability to the knee, the iliotib-
ial band reconstruction best restored
AP stability and rotation control;
however, it appeared to slightly over-
constrain the knee to rotational
forces at some flexion angles.
Partial Transphyseal
Technique
The partial transphyseal technique is
a hybrid of physeal-sparing recon-
struction and traditional transphys-
eal procedures performed in adults.
Traditionally, hamstring or bone–pa-
tellar tendon–bone grafts are used.
Either the distal femoral or the prox-
imal tibial physis is left undisturbed,
thereby minimizing the risk of

Figure 3
A, Intraoperative photograph demonstrating harvest of the iliotibial band with proximal detachment. The distal insertion
onto the Gerdy tubercle is preserved. B, Intraoperative photograph after iliotibial band harvest and whipstitch suture
placement into the proximal portion. The distal attachment to the Gerdy tubercle is intact.
growth arrest. Smaller bone tunnels
(6 to 8 mm) and more vertical tun-
nels are used to limit to <5% the
overall cross-sectional area of physis
that is interrupted.
Lipscomb and Anderson14 detailed
their experience with partial trans-
physeal reconstruction techniques
using transtibial physeal drilling only
and autogenous semitendinosus and
gracilis tendons in 24 skeletally im-
mature patients (mean age, 13 years;
range, 11 to 15 years). At an average
35-month follow-up, 20 of 24 pa-
tients had returned to similar activity
and sporting levels. Clinical laxity of
1.8 mm was noted, and one patient
suffered a 2-cm limb-length discrep-
ancy.
Andrews et al32 reported on eight
patients with open physes who un-
derwent partial transphyseal ACL re-
construction using either fascia lata
or Achilles allograft (mean age, 13.5
years; range, 10 to 15 years). Tibial
tunnels were drilled through the
proximal tibial physis, and the graft
material was secured in the over-the-
top position and affixed on the fem-
February 2013, Vol 21, No 2
Jeremy S. Frank, MD, and Peter L. Gambacorta, DO
oral side. At a follow-up of 58
months, 38% of patients had >3 mm
of clinical laxity, and 13% reported
poor results. No clinically significant
limb-length discrepancies were
noted.
Lo et al33 described five skeletally
immature patients (mean age, 12.9
years; range, 8 to 14 years) who un-
derwent partial transphyseal recon-
struction using transtibial physeal
drilling only and soft-tissue au-
tografts. At a mean 7.4-year follow-
up, no patient had >3 mm of clinical
laxity, one patient reported a poor
result, and no evidence of limb-
length discrepancy was noted.
Complete Transphyseal
Reconstruction
Complete transphyseal reconstruc-
tion strongly resembles adult-type
ACL reconstruction, with some dif-
ferences, including smaller, more ver-
tical tunnels; no hardware or bone
blocks at the level of the closing
physis; and metaphyseal fixation.
This procedure is typically per-
formed on adolescents with little to
no growth remaining. Some authors
advocate its use in even younger,
more skeletally immature patients.34
Earlier work by Lipscomb and An-
derson14 and Matava and Siegel35
touted the success of complete trans-
physeal ACL reconstruction using
autograft hamstring tendons. Lip-
scomb and Anderson14 reported one
case of limb-length discrepancy,
which measured 2 cm. More re-
cently, other authors have reported
success with complete transphyseal
reconstruction using autograft mate-
rial. McCarroll et al36 reported 92%
return to sport with no growth dis-
turbances in 60 patients treated with
autograft bone–patellar tendon–bone
reconstruction. Aronowitz et al37 re-
ported similar postoperative out-
comes in 19 patients aged 11 to 15
years who were treated with Achilles
allograft.
In 2007, Kocher et al38 reported on
their results of 61 knees in 59 skele-
tally immature pubescent adolescents
(Tanner stage 3) (mean chronologic
age, 14.7 years) who were managed
83
Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete: Diagnosis and Management

Figure 4 noted, and there were no growth ab-

normalities. Liddle et al40 noted simi-
lar results using a similar technique
in 17 patients with a mean age of
12.1 years (range, 9.5 to 14 years).
In this study, one patient had 5° val-
gus deformity compared with the
contralateral limb at a mean 44-
month follow-up.

Postoperative
Management
Proper rehabilitation after ACL re-
construction in the skeletally imma-
ture patient is paramount to ensure
an excellent outcome and a success-
ful and timely return to sports. Child
and adolescent athletes can pose a
challenge to traditional physical ther-
apists who specialize in working
with adult patients. Thus, it is impor-
tant to work with a therapist who
has experience with young patients
and who can make therapy sessions
both engaging and beneficial. Activ-
ity restrictions and compliance with
Illustration of physeal-sparing combined extra- and intra-articular anterior graduated activity levels are critical
cruciate ligament reconstruction using autogenous iliotibial band. A, The to successful outcomes. Compliance
iliotibial band is harvested free proximally and left attached distally to the can be problematic in this age group,
Gerdy tubercle. B, The graft is brought through the knee in the over-the-top
position. C, The graft is brought through the notch and under the
and patients must be carefully moni-
intermeniscal ligament anteriorly. D, The final intra- and extra-articular tored at school and home by teach-
reconstruction construct after the graft is sutured to the lateral femoral ers, parents, and caretakers.
condyle and proximal tibia.
Wright and Fetzer41 published a
systematic review of 12 randomized
with a transphyseal reconstruction immature pubescent patient, with a controlled trials on bracing after
technique involving autogenous qua- low revision rate and minimal risk of ACL reconstruction (predominantly
drupled hamstrings tendon and growth disturbance (Figure 5). in adults) and reported that there
metaphyseal fixation. Two patients Two recent studies tout the success was no conclusive evidence that use
(3%) underwent revision ACL recon- of complete transphyseal ACL recon- of a brace had any effect on pain,
struction because of late graft failure. struction. Cohen et al39 performed ROM, graft stability, or protection
No cases of angular deformities were complete transphyseal ACL recon- from subsequent injury. However,
noted radiographically, and no limb- structions on 26 skeletally immature these authors strongly encouraged
length discrepancy was noted clini- patients with autogenous hamstring bracing following ACL reconstruc-
cally. The authors concluded that tendons using metaphyseal fixation tion in children and adolescents,
transphyseal reconstruction of the away from both the distal femoral whose risk taking and behavior are
ACL with use of autogenous quadru- and proximal tibial physis (mean markedly more haphazard than that
pled hamstring tendons and meta- age, 13.3 years; range, 11 to 15 of adult patients. The duration and
physeal fixation provides excellent years). At a mean follow-up of 45 type of bracing method used is at the
functional outcome in the skeletally months, good clinical outcomes were surgeon’s discretion because there

84 Journal of the American Academy of Orthopaedic Surgeons

 Jeremy S. Frank, MD, and Peter L. Gambacorta, DO

Figure 5 are no true evidence-based guide-

lines.

Authors’ Recommended
Management
A recent systematic review clearly
demonstrated the benefit and safety
profile of ACL reconstruction in the
skeletally immature patient.9 Our
current treatment algorithm is predi-
cated on the patient’s skeletal, chron-
ologic, and physiologic age, as well
as on the extent of the ACL tear
(Figure 6).
Patients with partial tears involv-
ing <50% of the entire ACL diame-
ter are treated nonsurgically with ac-
tivity modification, physical therapy,
and bracing. The patient with a clini-
cally stable knee on examination and
AP (A) and lateral (B) radiographs demonstrating complete transphyseal stress maneuvers typically can return
autogenous quadrupled hamstring anterior cruciate ligament reconstruction in
a 13-year-old patient (Tanner stage 3). Tunnels are placed more vertically to sport approximately 3 to 6
with metaphyseal fixation (arrows). months following the initial injury.
Complete ACL ruptures are man-

Figure 6

Authors’ preferred treatment algorithm for anterior cruciate ligament (ACL) reconstruction in the skeletally immature
patient. All ages referenced are bone ages.

February 2013, Vol 21, No 2 85

Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete: Diagnosis and Management
aged surgically even in the very
young patient. In prepubescent pa-
tients (ie, Tanner stages 1 and 2)
(bone age: boys, ≤12 years; girls, ≤11
years), we prefer a physeal-sparing
combined intra- and extra-articular
reconstruction using autogenous ilio-
tibial band. Adolescent patients with
growth remaining (ie, Tanner stages
3 or 4) (bone age: boys, 13 to 16
years; girls, 12 to 14 years) are
treated with complete transphyseal
reconstruction using autogenous
quadrupled hamstring tendons with
smaller, more vertical tunnels and
metaphyseal fixation. In older ado-
lescent patients with closing physes
(ie, Tanner stage 5) (bone age: males,
>16 years; females, >14 years), we
prefer to perform an anatomic adult-
type ACL reconstruction with autog-
enous quadrupled hamstring or
bone–patellar tendon graft and inter-
ference screw or aperture fixation.
Patients are placed in a ROM
brace for 6 weeks postoperatively.
Patients treated with iliotibial band
ACL reconstruction are restricted to
toe-touch weight bearing for 6
weeks, whereas patients treated with
a transphyseal technique are re-
stricted to toe-touch weight bearing
for only 2 weeks. Progressive reha-
bilitation consisting of ROM, closed-
chain quadriceps and hamstring
strengthening, patellar mobilization,
and modalities are used for the first
3 months postoperatively. Initiation
of straight-line jogging and plyomet-
rics begins at 3 months after recon-
struction. A full return to cutting and
pivoting activities and sports is al-
lowed at approximately 6 months
postoperatively. An ACL brace is ad-
vised during sports activities for the
first 2 years postoperatively.
Summary
ACL ruptures in skeletally immature
patients are becoming more common
86
with increased single-sport concen-
tration, year-round participation,
and less time spent in free play. It is
the role of pediatric sports medicine
providers to properly diagnose and
manage these injuries. Nonsurgical
management, including activity mod-
ification, bracing, and physical ther-
apy, is best used for patients with
partial tears involving <50% of the
ACL diameter. In patients with com-
plete ruptures, chronologic, physio-
logic, and skeletal maturity must be
assessed to appropriately address the
injury. Treatment options are predi-
cated on assessment of the patient’s
maturity and include physeal-
sparing, partial and complete trans-
physeal, and adult-type anatomic
ACL reconstruction. Postoperative
management includes weight-bearing
and activity modifications, bracing,
and a progressive physical therapy
protocol emphasizing ROM, closed-
chain strengthening, and a gradual
and measured return to sport-specific
maneuvers. Surgical complications
are rare.
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