Pediatric Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction With Hybrid Over-the-Top Femoral Fixation, Transphyseal Tibial Fixation, and Tibial All-Epiphyseal Anterolateral Ligament Fixation Using Attached Hamstring Autograft

The rise in high-intensity sports among children and adolescents has led to more anterior cruciate ligament (ACL) reconstructions. Techniques have evolved to minimize growth plate damage and decrease failure rates. This article describes a surgical technique for combined ACL and anterolateral ligament (ALL) reconstruction in skeletally immature patients. The procedure uses a hamstring graft with preserved tibial attachment, creates a transphyseal tibial tunnel for the ACL, and routes the graft “over the top” on the femoral side―passing over the posterior aspect of the lateral femoral condyle and emerging extra-articularly on its lateral surface. The graft is then fixed at the anatomic ALL insertion point on the lateral femoral condyle. The remaining portion of the graft is passed deep to the iliotibial band and fixed to the tibia in an all-epiphyseal fashion at the anatomic ALL insertion point.