Children are evaluated clinically and radiographically for ACL tears and concomitant injury as outlined previously throughout this text. A thorough evaluation of bony alignment, skeletal maturity, and Tanner staging is performed. A course of pre-reconstruction physical therapy is prescribed focusing on reducing pain, swelling, and effusion, regaining normal gait mechanics, and maximizing quadriceps and hamstring strength preoperatively. This delay of approximately 4 weeks helps to minimize postoperative arthrofibrosis [15]. In the event of an urgent meniscal (e.g., locked bucket-handle tear) or osteochondral injury with loose body, the reconstructive surgery can either be staged or performed earlier after appropriate counseling of the risks, benefits, and requirements involved in either approach.

A combined general anesthetic with regional blockade is performed after consultation with the anesthesiologist, which consists of either a fascia iliaca block or a combination of femoral and lateral femoral cutaneous nerve block. Depending on surgeon, anesthesiologist, and family preference, an indwelling catheter may be left in place overnight to provide sustained analgesia.

After an examination under anesthesia, a nonsterile tourniquet may be placed high on the thigh, but is not inflated until after graft harvest to facilitate iliotibial (IT) band access. Surgery begins with IT band harvest through a longitudinal-oblique 4.5 cm incision from the lateral joint line (a point equidistant from Gerdy’s tubercle and the lateral epicondyle) to the superior border of the IT band. A long, broad Cobb elevator is used to elevate the subcutaneous tissue off the superficial surface of the IT band a minimum of 15 cm up the thigh. The anterior and posterior borders of the IT band are identified. Anteriorly, the IT band is confluent with the fascia of the vastus lateralis. The transition point is noted where the dense and opaque IT band tissue transitions to a more transparent vastus fascia. Posteriorly, the IT band blends into the posterior intermuscular septum. Once these borders are identified, the IT band is incised near either border leaving a few millimeters of intact IT band on either side. The cuts are continued proximally with curved meniscotomes for a distance of at least 15 cm. The graft is truncated proximally with a curved meniscotome or an open-ended tendon harvester with cutting mechanism. If similar instruments are unavailable, a counter incision may be made proximally to detach the graft. After harvest, the free end is tubularized with a nonabsorbable suture. The graft is further freed distally from the lateral joint capsule but leaving it attached to Gerdy’s tubercle (Fig. 12.2a, b). The graft is then placed back in the wound to prevent desiccation during arthroscopy.

Diagnostic arthroscopy is performed through standard anterolateral and anteromedial portals, and any meniscal or chondral work is performed at this point. The medial portal is widened, and a large curved clamp is introduced through the medial portal and into the over-the-top position. Widening the medial portal allows for easier clamp spreading and minimizes the chances of traumatic and irregular enlargement of the portal. The clamp is placed through the soft tissue remnants at the posterior aspect of the over-the-top position to allow for a sling, pushed through the posterolateral capsule of the knee and into the IT band defect on the lateral knee. The clamp is opened and closed several times to dilate the passageway and allow for easy graft passage. The suture attached to the free end of the graft is placed in the clamps and brought back into the knee. The graft is typically parked in the over-the-top position, and the sutures are brought out the medial portal (Fig. 12.3a, b).

Next, a longitudinal incision is made medial to the tibial tubercle and distal to the tibial epiphysis near the superior border of the pes anserinus tendon insertion. Dissection is carried down to but not through the periosteum, and then blunt dissection is directly proximal with a curved clamp up into the knee underneath the intermeniscal ligament. This passageway is then dilated to aid with tibial preparation and graft passage. A curved “rat-tail” rasp is used to create a groove in the tibial ACL footprint in order to create an exposed bony bed to facilitate intra-articular healing of the graft as well as to posteriorize the tibial footprint to a more anatomic position that minimizes the chance of impingement in extension. The clamp is then reintroduced in the knee, and the intra-articular sutures are grasped and brought out through the tibial incision, advancing the graft to its final intra-articular position (Fig. 12.4a–d). With tension on the graft, the knee is flexed and extended to confirm impingement-free range of motion.