Background: Most studies examining the safety and efficacy of transphyseal anterior cruciate ligament (ACL) reconstruction for skeletally immature patients utilize transtibial drilling. Independent femoral tunnel drilling may impart a different pattern of distal femoral physeal involvement.
Purpose: To radiographically assess differences in distal femoral physeal disruption between transtibial and independent femoral tunnel drilling. We hypothesized that more oblique tunnels associated with independent drilling involve a significantly larger area of physeal disruption compared with vertically oriented tunnels.
Study design: Cross-sectional study; Level of evidence, 3.
Methods: We analyzed skeletally immature patients aged between 10 and 15 years who underwent transphyseal ACL reconstruction utilizing an independent femoral tunnel drilling technique between January 1, 2008, and March 31, 2011. These patients were matched with a transtibial technique cohort based on age and sex. Radiographic measurements were recorded from preoperative magnetic resonance imaging and postoperative radiographs.
Results: Ten patients in each group were analyzed. There were significant differences between independent drilling and transtibial drilling cohorts in the estimated area of physeal disruption (1.64 vs 0.74 cm(2); P < .001), femoral tunnel angles (32.1° vs 72.8°; P < .001), and medial/lateral location of the femoral tunnel (24.2 vs 36.1 mm from lateral cortex; P = .001), respectively. There was a significant inverse correlation between femoral tunnel angle and estimated area of distal femoral physeal disruption (r = -0.8255, P = .003).
Conclusion: Femoral tunnels created with an independent tunnel drilling technique disrupt a larger area of the distal femoral physis and create more eccentric tunnels compared with a transtibial technique.
Clinical relevance: As most studies noting the safety of transphyseal ACL reconstruction have utilized a central, vertical femoral tunnel, surgeons should be aware that if an independent femoral tunnel technique is utilized during transphyseal ACL reconstruction, more physeal tissue is at risk and tunnels are more eccentrically placed across the physis when drilling at more horizontal angles. Prior studies have shown that greater physeal involvement and eccentric tunnels may increase the risk of growth disturbance.
Keywords: anterior cruciate ligament; athlete; knee; pediatric sports medicine; physis.
Conflict of interest statement
The authors reported that they have no conflicts of interest in the authorship and publication of this contribution.
Anterior Cruciate Ligament Reconstruction in the Skeletally Immature: An Anatomical Study Utilizing 3-dimensional Magnetic Resonance Imaging ReconstructionsJ Kercher et al. J Pediatr Orthop 29 (2), 124-9. PMID 19352236.Average volume of the tibial and femoral physis was 12,683.1 microL and 14,708.3 microL, respectively. The volume increased linearly with age. Average volume removed from …
Transtibial Versus Anteromedial Portal Drilling for Anterior Cruciate Ligament Reconstruction: A Cadaveric Study of Femoral Tunnel Length and ObliquityA Bedi et al. Arthroscopy 26 (3), 342-50. PMID 20206044.The anteromedial portal technique allows for slightly greater femoral tunnel obliquity compared with transtibial drilling. However, there is a substantially increased ris …
The Effects of Extra-Articular Starting Point and Transtibial Femoral Drilling on the Intra-Articular Aperture of the Tibial Tunnel in ACL ReconstructionMD Miller et al. Am J Sports Med 38 (4), 707-12. PMID 20164306.We observed significantly increased tibial aperture size and shape after transtibial femoral drilling with a medial tibial starting point. Medial tibial tunnels, compared …
Anterior Cruciate Ligament Injuries in the Skeletally Immature PatientIK Lo et al. Instr Course Lect 47, 351-9. PMID 9571437. - ReviewAnterior cruciate ligament injury in the skeletally immature is becoming increasingly recognized and reported. History taking and physical examination based on the princi …
Medial Portal Drilling: Effects on the Femoral Tunnel Aperture Morphology During Anterior Cruciate Ligament ReconstructionD Hensler et al. J Bone Joint Surg Am 93 (22), 2063-71. PMID 22262377. - ReviewThe drill-bit diameter, transverse drill angle, and knee flexion angle can all affect femoral tunnel aperture morphology in medial portal drilling during ACL reconstructi …
Cited by 3 PubMed Central articles
Paediatric Anterior Cruciate Ligament Tears: Management and Growth Disturbances. A Survey of EPOS and POSNA MembershipF Accadbled et al. J Child Orthop 13 (5), 522-528. PMID 31695820.Current practice patterns across the Atlantic remain varied and controversial. Consensus remains elusive; as such, research collaboration among societies will be importan …
Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Early Results Using a Hybrid Physeal-Sparing TechniqueRG Willson et al. Orthop J Sports Med 6 (2), 2325967118755330. PMID 29497620.The femoral physeal-sparing with transphyseal tibial drilling "hybrid" technique in skeletally maturing patients appears to have a high rate of success with low morbidity …
Anterior Cruciate Ligament Reconstruction in Skeletally Immature PatientsA Pennock et al. Curr Rev Musculoskelet Med 9 (4), 445-453. PMID 27586663. - ReviewThe management of pediatric patients with an anterior cruciate ligament (ACL) tear can be a challenging endeavor for physicians, athletic trainers, coaches, and parents a …
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