At one time, anterior cruciate ligament (ACL) tears in skeletally immature patients were considered rare. The recommended treatment option for skeletally immature patients with ACL tears was to modify activities until skeletal maturity, at which point definitive ACL reconstruction could be safely performed. The management of ACL tears in skeletally immature patients has evolved as a result of the increased frequency of ACL tears in younger patients and an increased awareness for the potential development or worsening of meniscal tears, chondral lesions, and degenerative changes that occur with the "wait-and-fix-later" approach. The surgical options for ACL reconstruction in skeletally immature patients include physeal-sparing, partial transphyseal, and complete transphyseal techniques. The timing and ideal technique for ACL reconstruction in skeletally immature patients are controversial. Accurate assessment of skeletal growth remaining and concerns for iatrogenic growth disturbances continually challenge treating physicians. Similar controversies with regard to the treatment of skeletally immature patients who have partial ACL tears or congenital absence of the ACL also exist.
