All-Inside, All-Epiphyseal Autograft Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete.

[Introduction][1] 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][2] Identify and mark subcutaneous landmarks to aid with anatomic orientation throughout the operation and to assist with socket placement. ![Figure][3] [Step 2: Harvest the Hamstring Graft][4] 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][5] 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. ![Figure][3] [Step 4: Prepare the Femoral and Tibial Sockets][6] Create blind-ended intra-articular sockets in the femur and tibia using the center-center footprint positions while avoiding the physeal plates. ![Figure][3] ![Figure][3] [Step 5: Pass and Secure the Graft][7] 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. ![Figure][3] ![Figure][3] [Step 6: Postoperative Rehabilitation][8] 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. [Results][9] Research is ongoing to evaluate the clinical and radiographic outcomes following ACL reconstruction in skeletally immature athletes with use of this technique[19][10]. [What to Watch For][11] [Indications][12] [Contraindications][13] [Pitfalls & Challenges][14] [Introduction][1] 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][2] Identify and mark subcutaneous landmarks to aid with anatomic orientation throughout the operation and to assist with socket placement. ![Figure][3] [Step 2: Harvest the Hamstring Graft][4] 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][5] 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. ![Figure][3] [Step 4: Prepare the Femoral and Tibial Sockets][6] Create blind-ended intra-articular sockets in the femur and tibia using the center-center footprint positions while avoiding the physeal plates. ![Figure][3] ![Figure][3] [Step 5: Pass and Secure the Graft][7] 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. ![Figure][3] ![Figure][3] [Step 6: Postoperative Rehabilitation][8] 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. [Results][9] Research is ongoing to evaluate the clinical and radiographic outcomes following ACL reconstruction in skeletally immature athletes with use of this technique[19][10]. [What to Watch For][11] [Indications][12] [Contraindications][13] [Pitfalls & Challenges][14] [1]: #sec-10 [2]: #sec-11 [3]: pending:yes [4]: #sec-12 [5]: #sec-13 [6]: #sec-14 [7]: #sec-15 [8]: #sec-16 [9]: #sec-17 [10]: #ref-19 [11]: #sec-18 [12]: #sec-19 [13]: #sec-20 [14]: #sec-21