Surgical decision making is based on several patient related factors, including (1) clinical stability of the knee, (2) associated
intra-articular pathology, (3) patient activity level and goals, and (4) skeletal age. As previously discussed, current literature suggests both nonoperative and delayed surgical treatment are associated with progressive meniscal and chondral injury.⁶,⁷,⁸,⁹,¹⁰,¹¹ Thus, it is important to have a detailed conversation with both the child and parent to determine optimal treatment. A trial of nonoperative management consisting of activity modification, functional bracing, and an accelerated rehabilitation protocol is a reasonable treatment alternative. This approach may be best in a compliant, low-demand child who does not plan on participating in athletic activity. Additionally, some pediatric patients with partial ACL tears may benefit from a trial of nonoperative treatment.⁵ Overall, any pediatric patient who demonstrates recurrent instability after a focused rehabilitation program should strongly consider operative intervention. Patients with concomitant meniscus tears or chondral injury should also consider early surgical treatment to prevent progressive injury.

In our experience, partial transphyseal (hybrid) ACL reconstruction is indicated in young adolescents with less than 2 to 3 years of skeletal growth remaining. In general, this typically includes Tanner stage 3 or 4 patients, with boys typically ranging from 13 to 16 years and girls ranging from 12 to 14 years in bone age. The Tanner staging system can be used to classify a patient’s physiologic maturity. Assessment of secondary sex characteristics and specific information related to menarche can help determine physiologic age. Skeletal growth (bone age) is routinely determined using a posteroanterior (PA) radiograph of the left hand and wrist for comparison with the Greulich and Pyle atlas. This method relies on a predictable pattern of ossification to estimate skeletal age. Recently, we have transitioned to using the Hospital for Special Surgery Shorthand Bone Age Measurement Scale (see Table 5.2). This method facilitates prediction of bone age without the use of an atlas for comparison, as it relies on the recognition of a few standard radiographic findings to reliably predict bone age with accuracy that has been shown to be equivalent to use of the Greulich and Pyle atlas.¹² We routinely obtain a 51-in anteroposterior (AP) hip-to-ankle radiograph for accurate preoperative assessment of subtle limb length discrepancy and angular deformity. Preoperatively, a growth chart can be used to predict any limb length discrepancy at skeletal maturity with the use of the aforementioned radiographs.