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All-Inside, All-Epiphyseal Autograft Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete
Peter D. Fabricant, MD, MPH1; Moira M. McCarthy, MD1; Frank A. Cordasco, MD, MS1; Daniel W. Green, MD, MS1
1 Sports Medicine and Shoulder Service (F.A.C.), Department of Orthopaedic Surgery (P.D.F. and M.M.M.), and Section of Pediatric Orthopaedic Surgery (D.W.G.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for P.D. Fabricant: fabricantp@hss.edu. E-mail address for M.M. McCarthy: mccarthymo@hss.edu. E-mail address for F.A. Cordasco: cordascof@hss.edu. E-mail address for D.W. Green: greendw@hss.edu
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Based on an original article J Bone Joint Surg Am. 2013 Mar 6;95(5):e28.

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.
JBJS Essential Surgical Techniques, 2013 May 08;3(2):e9 1-13. doi: 10.2106/JBJS.ST.M.00017
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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.

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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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