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Objectives and questions: To analyze how patient and injury characteristics influence the initial treatment decision (operative vs conservative) in skeletally immature patients with ACL injuries.

Material and methods: Between 2018 and 2024, 330 patients with MRI-confirmed ACL injuries were included in the PAMI registry. Of these, 178 were initially scheduled for operative treatment and 152 for conservative management. Group comparisons were performed using χ² or Fisher’s exact test for categorical variables and Mann–Whitney U test for continuous variables. A p-value <0.05 was considered statistically significant.

Results: Operative patients were (1) older (12.8 ± 2.0 vs. 12.1 ± 2.1 years, p = 0.0008), (2) more skeletally mature (13.6 ± 2.1 vs. 12.8 ± 2.1 years, p = 0.0068), and (3) had a higher BMI (20.1 ± 3.0 vs. 18.7 ± 2.7 kg/m², p = 0.0017), indicating greater physical maturity. Conservative treatment tended to be chosen more often for younger male patients, although sex distribution did not differ significantly (71% vs. 80% male, p = 0.08). Non-contact injuries predominated in both groups (78.7% vs. 68.1%). The median time to treatment decision was shorter in the operative group (59 vs. 122 days, p < 0.001). A trend toward surgical treatment was observed with higher grades of clinical instability (Pivot Shift >2°, Lachman 2-3°), though this was not statistically significant in the full cohort.

Discussion and conclusions: The PAMI registry highlights key demographic and clinical factors—age, skeletal maturity, BMI, and instability—that influence treatment decisions in pediatric ACL injuries. Recognizing these patterns may help clinicians develop more personalized and scientifically grounded decision-making strategies for skeletally immature patients.