Hamstring Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient

Summary: Intrasubstance anterior cruciate ligament (ACL) tears in children and adolescents are being reported with increasing frequency. For behavioral, or other reasons, the natural history of ACL tears in children and adolescents is poor. The consequences of nonoperative treatment are often recurrent instability, meniscal damage, and sports-related disability. The risks of surgery include iatrogenic leg length discrepancy or angular deformity. There is a deficiency in the orthopaedic literature regarding basic science on the effects of physeal injury and clinical studies documenting safety and efficacy of transphyseal drill holes for ACL replacement in children and adolescents. Consequently, the methods of surgical treatment are controversial. Even so, it is widely accepted that the surgical technique is influenced by the patient’s skeletal maturity. Therefore, the treating physician must know the patient’s skeletal age, risk factors for iatrogenic growth disturbance, and treatment options. Anatomic intraarticular ACL replacements are biomechanically superior to extraarticular and modified physeal-sparing procedures. High-risk prepubescent patients may be treated with efficacy and relative safety using a transepiphyseal ACL replacement. Low-risk pubescent Tanner stage IV patients, nearing skeletal maturity, may be treated with transphyseal reconstruction with small, centrally placed, perpendicular drill holes and quadruple hamstring grafts. Postpubescent Tanner stage V patients may be treated as adults.