Intraoperative arthroscopic images of the proposed transphyseal surgical ACL reconstruction technique using quadriceps tendon autograft in patients with open physes. A The intercondylar notch and femoral attachment areas were cleaned using a shaver blade. A burr was used to create a groove in the very posterior aspect of the lateral side wall of the notch from 2:30 o'clock for a left and from 9:30 for a right knee respectively in order to stay distally to the physis. B The femoral position is found under standard arthroscopic view with the knee in 70 degrees of flexion using the high anterolateral portal. A groove is established just posterior to the resident ridge in the 2:30 or 9:30 o'clock position, a posterior wall of at least 3 mm should remain. in adults we go 1-2 mm furthermore posterior. After verification of the correct tunnel position via the medial portal the groove was gradually deepened using 6-8 mm wide surgical spoons. The 8 mm spoon should completely fit into the groove simulating the future position of the bone block. During preparation of the groove it was mandatory to meticulously control the posterior cortical wall to prevent iatrogenic posterior wall break out. C Tibial intra-tunnel view demonstrating its small diameter. The starting point of the tibial tunnel was medially and distally compared to the standard adult technique to pass the physis in an steep angle and as far central as possible to harm as less as possible of the physis and to spare the tibial apophysis. D Retrograde introduction of the graft in the femoral bone groove. E Image after insertion of the quadriceps tendon autograft at the end of surgery.