Anterior cruciate ligament reconstruction in the skeletally immature: an anatomical study utilizing 3-dimensional magnetic resonance imaging reconstructions.
BACKGROUND
Anatomic anterior cruciate ligament (ACL) reconstruction has proven to be a reliable method to restore knee stability. However, the risk of physeal arrest with transphyseal tunnel placement in skeletally immature patients has raised concern regarding this technique. Conservative nonoperative management also has its limitations resulting in meniscal and chondral damage that may lead to degenerative joint disease and poor return to sport. Researchers have used animal models to study the threshold of physeal damage producing growth deformity. The purpose of this study was to examine the distal femoral and proximal tibial physes and determine the damage produced by drilling transphyseal tunnels. In addition, we attempted to find a reproducible angle at which to drill the tibial tunnel for safe interference screw placement. To do this, we used a custom software module.


METHODS
A custom software package designed by our team was used: Module for Adolescent ACL Reconstructive Surgery (MAARS). This module created a 3-dimensional model of the distal femur and proximal tibia. The data required for MAARS were sagittal and coronal T1 magnetic resonance imagings of at least 1.5 T. Thirty-one knee magnetic resonance imaging studies from patients aged 10 to 15 years old were used. The physes were segmented out to obtain volumetric measurements. Transphyseal tunnels were simulated based on the anatomic trajectory of the native ACL. The module calculated volume of physis was removed with the use of an 8-mm tunnel and the optimum angle for trajectory.


RESULTS
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 the tibial and femoral physis was 318.4 microL and 306.29 microL, respectively. This represented 2.4% of the distal femoral physis and 2.5% of the proximal tibial physis. The volume percent removed decreased linearly with age.Manipulation of the variables demonstrates graft radius is the most critical parameter affecting the volume of physeal injury. Variation of graft diameter from 6 mm to 11 mm will increase volume percent removed from 2.3% to 7.8%, which averages 1.1% for every 1 mm increase. Increasing tunnel drill angle from 45 degrees to 70 degrees will decrease volume percent removed from 4.1% to 3.1% which averages 0.2% removed for each 5 degrees increase in drill angle. The average angle to maintain a distance of 20 mm from the proximal tibial physis was 65 degrees with a range of 40 degrees to 85 degrees.


CONCLUSIONS
Less than 3% injury occurs when drilling an 8-mm tunnel across the physis. A vertical tunnel has minimal effect, but the tunnel diameter is critical. Interference screws can be placed safely to avoid the physis but requires careful planning. The MAARS module may be helpful in preoperative planning.


METHODS
Diagnostic, level IV.
Emory University Department of Orthopaedics, Atlanta, GA 30318, USA. jimkercher@gmail.com
Jim
J
Kercher
John
J
Xerogeanes
Allen
A
Tannenbaum
Ramsey
R
Al-Hakim
James C
JC
Black
John
J
Zhao
D000293:Adolescent; D000365:Age Determination by Skeleton; D000367:Age Factors; D016118:Anterior Cruciate Ligament / Q000033:anatomy & histology / Q000601:surgery*; D002648:Child; D004838:Epiphyses / Q000601:surgery; D005260:Female; D005269:Femur / Q000033:anatomy & histology / Q000601:surgery; D006801:Humans; D007091:Image Processing, Computer-Assisted / Q000379:methods; D021621:Imaging, Three-Dimensional / Q000379:methods*; D007718:Knee Injuries / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D008297:Male; D019637:Orthopedic Procedures / Q000379:methods*; D012189:Retrospective Studies; D012984:Software; D013977:Tibia / Q000033:anatomy & histology / Q000601:surgery; D016896:Treatment Outcome