Special considerations. Anterior cruciate ligament reconstruction in the skeletally immature.

ACL injury in children is being recognized with greater frequency because of improved diagnostic techniques as well as heightened awareness of the condition. Unfortunately, the diagnosis is still missed because the attitude persists that children do not suffer ligament injuries. Hemarthrosis must be considered an indication of a significant intra-articular injury. During the past decade, ACL reconstruction has evolved to a reproducible technique with low morbidity. Aggressive rehabilitation programs allow accelerated return to activity while allowing the biology of graft maturation to progress. The basic principle of diagnosis and the treatment goals in the skeletally immature patient are the same as those in the adult patient. The diagnosis approach to ACL injury in the scholastic-age patient, however, must also include evaluation of the patient's skeletal maturity because it plays a major role in treatment decisions. Maturity is evaluated on the basis of the patient's chronologic age; various physiologic factors, such as family height, patient's projected height, and estimation of sexual development; and radiographic findings in the knee, pelvis (Risser sign), or hand and wrist (bone-age study). Because of the special characteristics of the skeletally immature patient, the orthopedic surgeon must act as "knee counselor" by attempting to identify at-risk patients, particularly those who abuse their knees for any of a variety of reasons. The nonoperative treatment principles are the same as those in an adult. Consideration of surgical treatment must take into account assessment of skeletal maturity. If questions remain about the status of the femoral and tibial physes, polytomography or MRI is used to assess the extent of physeal closure. The surgical reconstruction used reflects the patient's skeletal maturity. As the skeletal maturity threshold is reached, transphyseal reconstructions may be done with diminished reservation about causing sequelae of physeal arrest.