Anatomic, Transepiphyseal Anterior Cruciate Ligament Reconstruction

[Introduction][1] 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][2] 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][3] 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. ![Figure][4] ![Figure][4] [Step 3: Prepare ACL Footprint and Establish Far Anteromedial Portal][5] Maintain soft-tissue remnants at both the femoral and the tibial footprint in order to individualize the anatomy. ![Figure][4] [Step 4: Identify Extra-Articular Landmarks and Prepare Femoral Tunnel][6] 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. ![Figure][4] ![Figure][4] ![Figure][4] ![Figure][4] [Step 5: Prepare Tibial Tunnel][7] The tibial tunnel can be safely drilled in a transphyseal manner in skeletally immature patients. ![Figure][4] [Step 6: Fix Graft][8] Use the Arthrex ACL TightRope RT for femoral fixation. ![Figure][4] [Step 7: Postoperative Care][9] As a skeletally immature athlete differs from a more mature athlete in several important ways, alter the postoperative protocol accordingly. [Results][10] Our clinical experience has corresponded to our MRI-based findings from our original study[14][11], and we have not observed any physeal or chondral injuries leading to growth disturbances from our femoral tunnels. ![Figure][4] [What to Watch For][12] [Indications][13] [Contraindications][14] [Pitfalls & Challenges][15] [Introduction][1] 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][2] 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][3] 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. ![Figure][4] ![Figure][4] [Step 3: Prepare ACL Footprint and Establish Far Anteromedial Portal][5] Maintain soft-tissue remnants at both the femoral and the tibial footprint in order to individualize the anatomy. ![Figure][4] [Step 4: Identify Extra-Articular Landmarks and Prepare Femoral Tunnel][6] 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. ![Figure][4] ![Figure][4] ![Figure][4] ![Figure][4] [Step 5: Prepare Tibial Tunnel][7] The tibial tunnel can be safely drilled in a transphyseal manner in skeletally immature patients. ![Figure][4] [Step 6: Fix Graft][8] Use the Arthrex ACL TightRope RT for femoral fixation. ![Figure][4] [Step 7: Postoperative Care][9] As a skeletally immature athlete differs from a more mature athlete in several important ways, alter the postoperative protocol accordingly. [Results][10] Our clinical experience has corresponded to our MRI-based findings from our original study[14][11], and we have not observed any physeal or chondral injuries leading to growth disturbances from our femoral tunnels. ![Figure][4] [What to Watch For][12] [Indications][13] [Contraindications][14] [Pitfalls & Challenges][15] [1]: #sec-11 [2]: #sec-12 [3]: #sec-13 [4]: pending:yes [5]: #sec-14 [6]: #sec-15 [7]: #sec-16 [8]: #sec-17 [9]: #sec-18 [10]: #sec-19 [11]: #ref-14 [12]: #sec-20 [13]: #sec-21 [14]: #sec-22 [15]: #sec-23