Complete midsubstance tears of the anterior cruciate ligament (ACL) in skeletally-immature adolescents are being diagnosed and reported with increasing frequency. Conservative treatment of such ACL tears in junior high schools, subsequent meniscal tears, and very early osteoarthritis. Results of primary repair of the torn ACL and extra-articular reconstructive procedures have been disappointing. Intra-articular ACL reconstruction in young athletes approaching skeletal maturity using the autogenous patellar tendon graft gives excellent knee stability, and decreases the risk of meniscal tears. Athletes are able to return to competitive sports at their preinjury level. Here, the existing literature on the subject of midsubstance ACL tears in young athletes is reviewed, and guidelines for the management of ACL-deficient knee in this population are provided.