Introduction: Our technique for physeal-sparing, anatomic anterior cruciate ligament (ACL) reconstruction reliably produces femoral tunnels that are of adequate length and that safely avoid the femoral physis without the addition of time-consuming surgical methods or substantial utilization of fluoroscopy.
Step 1 preoperative planning: Obtain radiographs and MRI of the knee as well as an anteroposterior radiograph of the hand (to obtain a bone age).
Step 2 patient setup portal placement and graft harvest: The affected knee must be able to flex at least 90° with the end of the operative table lowered, in order to properly visualize the anatomy of the ACL femoral footprint.
Step 3 prepare acl footprint and establish far anteromedial portal: Maintain soft-tissue remnants at both the femoral and the tibial footprint in order to individualize the anatomy.
Step 4 identify extra-articular landmarks and prepare femoral tunnel: Visualize and palpate your previously marked popliteal sulcus and lateral epicondyle; these landmarks are the crucial extra-articular points for establishing a safe femoral tunnel.
Step 5 prepare tibial tunnel: The tibial tunnel can be safely drilled in a transphyseal manner in skeletally immature patients.
Step 6 fix graft: Use the Arthrex ACL TightRope RT for femoral fixation.
Step 7 postoperative care: As a skeletally immature athlete differs from a more mature athlete in several important ways, alter the postoperative protocol accordingly.
Results: Our clinical experience has corresponded to our MRI-based findings from our original study14, and we have not observed any physeal or chondral injuries leading to growth disturbances from our femoral tunnels.
What to watch for: IndicationsContraindicationsPitfalls & Challenges.
Anatomic Landmarks Utilized for Physeal-Sparing, Anatomic Anterior Cruciate Ligament Reconstruction: An MRI-based StudyJW Xerogeanes et al. J Bone Joint Surg Am 94 (3), 268-76. PMID 22298060.Drilling from the center of the ACL femoral footprint to the insertion of the popliteus tendon would have resulted in a mean tunnel length of 27 to 30 mm, and it would ha …
All-Inside, All-Epiphyseal Autograft Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature AthletePD Fabricant et al. JBJS Essent Surg Tech 3 (2), e9. PMID 30881740.Research is ongoing to evaluate the clinical and radiographic outcomes following ACL reconstruction in skeletally immature athletes with use of this technique19 …
Effect of Reamer Design on Posteriorization of the Tibial Tunnel During Endoscopic Transtibial Anterior Cruciate Ligament ReconstructionS Bhatia et al. Am J Sports Med 41 (6), 1282-9. PMID 23585487.Half-fluted reamers may be more advantageous for femoral tunnel reaming with a more oblique transtibial approach, as they result in less posterior tibial tunnel expansion …
Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete: A Review of Current Concepts: AAOS Exhibit SelectionPD Fabricant et al. J Bone Joint Surg Am 95 (5), e28. PMID 23467876. - ReviewIntrasubstance tears of the anterior cruciate ligament (ACL) were once considered a rare injury in skeletally immature athletes but are now observed with increasing frequ …
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 …