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To perform a systematic review of the literature to answer whether early ACL reconstruction for a skeletally immature individuals result in improved outcome compared with nonsurgical treatment or delaying the reconstruction until skeletal maturity in the pediatric athlete.Articles were restricted to the English language, and 6 databases were searched (MEDLINE, CINAHL, EMBASE, ACP Journal Club, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews). The following keywords were used: anterior cruciate ligament, ACL, child, immature, pediatric, pediatric, and young.All studies examining the ACL reconstruction in skeletally immature individuals, including citations describing complications. Excluded were articles looking at ACL repairs and ACL avulsion injuries. All types of study design, including review articles, were included. Comparative studies were reviewed in detail and analyzed qualitatively.A total of 615 articles were identified. Sixty-six articles met the inclusion and exclusion criteria. There were no articles with levels of evidence better than level III. The majority of the articles represented case series and reviews with expert opinion.There were 7 articles that provided comparisons between surgical and nonsurgical treatment in order to answer the question.The study designs are inadequate to answer the question of whether early or delayed ACL reconstruction results in the best possible outcome in skeletally immature individuals. Future prospective studies are required to answer the question adequately. A proposed algorithm was described to deal with the question.