Abstract
Anterior cruciate ligament (ACL) injuries in skeletally immature patients pose unique clinical and surgical challenges due to the presence of open physes and ongoing growth. In recent years, multiple surgical strategies have been developed to restore knee stability while minimizing the risk of growth disturbances. However, clinical decision-making remains complex due to the lack of consensus regarding the optimal timing, technique, and graft selection for this population. This narrative review outlines the current clinical and radiological tools used to assess skeletal maturity and explores how maturity status informs surgical approach, with particular emphasis on physeal-sparing, hybrid, and transphyseal techniques. We summarize postoperative complications-including growth disturbances and graft failure-while highlighting current guideline recommendations and ongoing controversies. Lastly, we propose a multimodal model for skeletal maturity assessment to support individualized treatment strategies and emphasize the need for standardized protocols and high-quality research to improve long-term outcomes in pediatric ACL reconstruction.