Prepubescent skeletally immature patient with anterior cruciate ligament (ACL) tear who is Tanner stage 1 or 2 who has failed nonoperative treatment (Fig. 1)

 Prepubescent skeletally immature patient with ACL tear and other injuries, such as meniscal tears or chondral injury and functional instability

 Prepubescent skeletally immature patient with congenital ACL insufficiency with symptomatic instability recalcitrant to bracing

 An examination under anesthesia is performed.

 Range of motion is checked.

 Varus/valgus stress test

 Lachman’s test

 Pivot shift test

 Tanner stage (Fig. 2)

 Plain radiographs

 Magnetic resonance imaging (MRI)

 Iliotibial band (ITB)

 Intermeniscal ligament

 Figure 5 shows pediatric ACL anatomy. Note the proximity of the over-the-top position to the perichondrial ring of the distal femoral physis.

 The patient is placed in the supine position.

 The extremities are padded.

 The tourniquet is placed on the operative leg as proximal as possible and the leg is prepped circumferentially from foot to tourniquet.

 A leg holder not used, but a retractable post can be placed on the side of the operative leg to aid with valgus stressing when having difficulty evaluating the medial compartment.