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Anatomic, Transepiphyseal Anterior Cruciate Ligament Reconstruction

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Anatomic, Transepiphyseal Anterior Cruciate Ligament Reconstruction

Kyle E Hammond et al. JBJS Essent Surg Tech.

Abstract

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.

Figures

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Fig. 1
Fig. 1
Preoperative markings are made to delineate the fibular head, lateral epicondyle, popliteal insertion, axis of the femoral shaft, and a line perpendicular to the axis from the lateral epicondyle. The area proximal to the lateral epicondyle and anterior to the femoral axis is not safe for introduction of the femoral tunnel pin because of the likelihood that this trajectory will encroach on the femoral physis. Use of the area posterior to the femoral axis line will increase the likelihood of cartilage cap injury and/or creation of a very short femoral tunnel.
Fig. 2
Fig. 2
Illustration of the three described portals used with this technique. The far anteromedial portal is labeled as the accessory anteromedial portal.
Fig. 3
Fig. 3
An awl has been utilized to mark the central portion of the femoral footprint, which we utilize for a single-bundle anatomic reconstruction. The arthroscope is visualizing the lateral intercondylar wall from the anteromedial portal, while the awl is placed through the far anteromedial portal.
Fig. 4-A
Fig. 4-A
Photograph depicting the extra-articular placement of the FlipCutter at a point between the popliteal tendon’s insertion and the lateral epicondyle.
Fig. 4-B
Fig. 4-B
The intra-articular (arthroscopic) placement of the FlipCutter’s guide. This guide is placed into the previously created awl mark.
Fig. 5
Fig. 5
A single fluoroscopic view is obtained to ensure that the FlipCutter pin is placed in the correct, epiphyseal position prior to proceeding with the FlipCutter drill.
Fig. 6
Fig. 6
The FlipCutter drill has entered the knee joint at the predetermined femoral footprint. A probe is then used to flip the blade of the drill into position, thus allowing the device to drill in a retrograde manner.
Fig. 7
Fig. 7
When the femoral tunnel is drilled correctly there will be no evidence of the femoral physis or any signs of femoral tunnel blow-out.
Fig. 8
Fig. 8
The tibial footprint in addition to the posterior portion of the anterior horn of the lateral meniscus are both used to place the tibial tunnel guidepin in the central portion of the tibial footprint for a single-bundle ACL reconstruction.
Fig. 9-A
Fig. 9-A
Postoperative anteroposterior radiograph showing that, with our described technique, the femoral tunnel is transepiphyseal. The graft is suspended in the femoral tunnel, and the tibial side is tied over a screw and washer (to avoid placing an interference screw near the tibial physis).
Fig. 9-B
Fig. 9-B
Postoperative lateral radiograph.
Fig. 10-A
Fig. 10-A
Preoperative 3D MRI template, lateral view.
Fig. 10-B
Fig. 10-B
Preoperative 3D MRI template, posterior view.
Fig. 10-C
Fig. 10-C
Comparison of this lateral, sagittal CT image with the preoperative 3D MRI template shows a well-placed femoral tunnel that is transepiphyseal and does not encroach onto the femoral physis.
Fig. 10-D
Fig. 10-D
This intercondylar, sagittal CT image depicts accurate recreation of the femoral tunnel anatomy.
Fig. 10-E
Fig. 10-E
Posterior, coronal CT image.

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