Anterior cruciate ligament (ACL) reconstructions in skeletally immature patients present unique difficulties, one major concern being reconstruction-induced growth disturbances. Another issue is the failure of adolescent patients to comply with the treatment programs. Initially, activity limitations and bracing can be recommended for isolated ACL tears in young skeletally immature adolescents who are at stages I, II, and III according to the modified Tanner classification, and for whom reconstruction can be delayed until completion of skeletal maturity provided that any joint instability or meniscal injury do not develop. For symptomatic patients, partial or complete transphyseal techniques or complete transphyseal reconstruction with doubled or quadrupled hamstring tendon grafts can be applied, with special care being afforded to keep clear distance between fixation materials and the physeal plates. In patients who are at pubertal stages of IV or V or with skeletal ages above 13 (F) or 14 (M) years, a transphyseal reconstruction with hamstring autografts seems to be the best solution. It should be kept in mind that functional outcomes of ACL reconstructions in skeletally immature patients are inferior to those obtained in adults even after a prudent surgical approach without associated growth disturbances.