Improved epiphyseal socket placement with intraoperative 3D fluoroscopy: a consecutive series of pediatric all-epiphyseal anterior cruciate ligament reconstruction

Abstract

Purpose Disturbance of the growth plate during all-epiphyseal anterior cruciate ligament reconstruction (ACLR) socket placement is possible due to the undulation of the distal femoral physis and proximal tibial physis. Therefore, it is important to obtain intraoperative imaging of the guide wire prior to reaming the socket. The purpose of this study was to investigate the efect of the use of 3D intraoperative luoroscopy on socket placement in patients undergoing all-epiphyseal ACLR. It was hypothesized that 3D imaging would allow for more accurate intraoperative visualization of the growth plate and hence a lower incidence of growth plate violation compared to 2D imaging. Methods Patients under the age of 18 who underwent a primary all-epiphyseal ACL reconstruction by the senior authors and had an available postoperative MRI were retrospectively reviewed. Demographic data, surgical details, and the distances between the femoral socket and distal femoral physis (DFP) and tibial socket and proximal tibial physis (PTP) were recorded. Patients were split into two groups based on type of intraoperative luoroscopy used: a 2D group and a 3D group. Interrater reliability of radiographic measurements was evaluated using intraclass correlation coeicient (ICC). Results Seventy-two patients it the inclusion criteria and were retrospectively reviewed. 54 patients had 2D imaging and 18 patients had 3D imaging. The mean age at time of surgery was 12.3 ± 1.5 years, 79% of patients were male, and 54% tore their left ACL. The mean time from surgery to postoperative MRI was 2.0 ± 1.1 years. The ICC was 0.92 (95% CI 0.35-0.98), indicating almost perfect interrater reliability. The mean diference in distance between the tibial socket and the PTP was signiicantly less in the 2D imaging group than the 3D imaging group (1.2 ± 1.7 mm vs 2.5 ± 2.2 mm, p = 0.03). The femoral and tibial sockets touched or extended beyond the DFP or PTP, respectively, signiicantly less in the 3D group than in the 2D group (11% vs 43%, p < 0.000, 17% vs 65%, p < 0.000). Conclusion There was a signiicantly increased distance from the PTP and decreased incidence of DFP violation with use of 3D intraoperative imaging for all-epiphyseal ACLR socket placement. Surgeons should consider utilizing 3D imaging prior to creating femoral and tibial sockets to potentially decrease the risk of physis violation in these patients. Level of evidence III.

Pediatric Anterior Cruciate Ligament Reconstruction With Over-the-Top Femoral Position and All-Epiphyseal Tibial Tunnel

“…In pubescent patients, both all-inside all-epiphyseal and partial transphyseal techniques can be safely performed, but these procedures are not without shortcomings. The shortcomings of all-inside all-epiphyseal pediatric ACL reconstruction include (1) the need for fluoroscopy to correctly place the tunnels and, in some cases, this is not even enough to avoid physeal damage 4 ; (2) graft-tunnel mismatch can be a complication (a too-long graft can result in a lax ligament and a too-short graft might not seat properly in the sockets, with poor tendon-bone integration); (3) in small knees, the all-epiphyseal tibial tunnel is very horizontal, with the risk of creating a large oval intra-articular aperture during retrograde drilling. 6 The drawbacks of partial transphyseal technique include (1) a small vertical tunnel is created through the tibial physis and (2) to minimize the physeal damage, a small graft (usually a 2-strand semitendinosus autograft) is generally used.…”

“…These include (1) physeal-sparing techniques (intra-articular, extra-articular, and combined intra-/extra-articular), (2) partial transphyseal, and (3) physeal respecting or complete transphyseal techniques. Based on the patients’ age and growth potential, the most commonly used techniques include: 1) Kocher-Micheli, 3 2) all-inside, all-epiphyseal, 4 (3) partial transphyseal (transphyseal on the tibial side and physeal sparing on the femur), 1 and (4) transphyseal. 5 …”

Surgical techniques in the management of pediatric anterior cruciate ligament tears: Current concepts

“… 38 Three-dimensional intra-operative imaging may help reduce the risk of violation of the growth plate. 39 It is also essential to pre-operatively assess the size of the physis in order to ensure adequate size for drilling of bony tunnels. This is more important in the younger child.…”