Anatomic, Transepiphyseal Anterior Cruciate Ligament Reconstruction.

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.