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Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete: A Review of Current ConceptsAAOS Exhibit Selection
Peter D. Fabricant, MD1; Kristofer J. Jones, MD1; Demetris Delos, MD1; Frank A. Cordasco, MD, MS1; Robert G. Marx, MD, MSc1; Andrew D. Pearle, MD1; Russell F. Warren, MD1; Daniel W. Green, MD, MS1
1 Sports Medicine and Shoulder Service (F.A.C., R.G.M., A.D.P., R.F.W.) and Section of Pediatric Orthopaedic Surgery (D.W.G.), Department of Orthopaedic Surgery (P.D.F., K.J.J, D.D.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for P.D. Fabricant: fabricantp@hss.edu
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Investigation performed at the Hospital for Special Surgery, New York, NY

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Mar 06;95(5):e28 1-13. doi: 10.2106/JBJS.L.00772
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This article was updated on August 7, 2013, because of a previous error. On page e28(10), the study by Hui et al. had been listed as both a “physeal-sparing” technique and a “complete transphyseal” technique. The text now refers to it only as a “complete transphyseal” technique, and Table IV has also been updated with that and additional information.

An erratum has been published: J Bone Joint Surg Am. 2013;95(16):e117.


Intrasubstance tears of the anterior cruciate ligament (ACL) were once considered a rare injury in skeletally immature athletes but are now observed with increasing frequency. Treatment strategies have evolved as recent studies have identified unique considerations specific to the skeletally immature patient. The current literature now supports the trend toward early operative treatment to restore knee stability and prevent progressive meniscal and/or articular cartilage damage, but the optimal approach to ACL reconstruction in this age group remains controversial. Despite the reported clinical success of transphyseal reconstruction, iatrogenic growth disturbance secondary to physeal damage remains a genuine concern. The reluctance to place drill-holes across open physes has led to the development of numerous “physeal-sparing” reconstruction techniques using anatomic femoral and tibial footprints that have adequately restored anteroposterior and rotational knee stability in biomechanical studies but have demonstrated mixed results in the clinical setting. The intent of this review is to (1) highlight the unique anatomic considerations pertaining to ACL reconstruction in the skeletally immature athlete, (2) discuss preoperative clinical and radiographic assessment of the pediatric patient with a suspected ACL injury, (3) review transphyseal and physeal-sparing reconstruction techniques and highlight surgical technical considerations, (4) present clinical outcomes according to patient and technique-specific factors, and (5) review age-specific injury prevention treatment strategies and a novel treatment algorithm based on skeletal maturity. ACL reconstruction in the skeletally immature athlete typically results in a successful clinical outcome, yet the optimal surgical technique is still controversial. This review will help guide the management of ACL injuries in the pediatric athlete.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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