We present an all-inside, all-epiphyseal anterior cruciate ligament (ACL) reconstruction technique with use of a hamstring autograft for skeletally immature athletes.
Step 1: Identify Subcutaneous Landmarks
Identify and mark subcutaneous landmarks to aid with anatomic orientation throughout the operation and to assist with socket placement.
Step 2: Harvest the Hamstring Graft
Harvest a hamstring autograft to create a four-strand autograft in the standard fashion or, if you prefer, perform a posterior hamstring harvest.
Step 3: Prepare the Graft
Prepare a four-strand hamstring autograft using suspensory cortical fixation devices—a reverse-tensioning button (ACL TightRope RT; Arthrex, Naples, Florida) on the femoral side and an attachable button system (ACL TightRope ABS, Arthrex) on the tibial side.
Step 4: Prepare the Femoral and Tibial Sockets
Create blind-ended intra-articular sockets in the femur and tibia using the center-center footprint positions while avoiding the physeal plates.
Step 5: Pass and Secure the Graft
Pass the hamstring autograft through the anteromedial portal and dock it in the femoral and tibial sockets; engage the cortical button on the femur, dock the graft, and then perform final fixation on the tibial side.
Step 6: Postoperative Rehabilitation
The patient’s age and maturity level dictate the progression of rehabilitation, and parents and caregivers are encouraged to regularly participate in the child’s rehabilitation regimen.
Research is ongoing to evaluate the clinical and radiographic outcomes following ACL reconstruction in skeletally immature athletes with use of this technique19.
What to Watch For
Pitfalls & Challenges