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Avoiding tibia physeal injury during double-bundle posterior cruciate ligament reconstruction
  1. Stockton Troyer1,
  2. Nicolas G Anchustegui2,
  3. Connor G Richmond3,
  4. Peter C Cannamela4,
  5. Aleksei Dingel3,
  6. Tyler J Stavinoha5,
  7. Theodore J Ganley6,
  8. Allen F Anderson7,
  9. Kevin G Shea3
  1. 1 Department of Biology, Williams College, Williamstown, Massachusetts, USA
  2. 2 Department of Biology, George Washington University, Washington, District of Columbia, USA
  3. 3 Department of Orthopaedics, St. Luke’s Health System, Boise, Idaho, USA
  4. 4 University of Utah School of Medicine, Salt Lake, Utah, USA
  5. 5 Department of Orthopaedics, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
  6. 6 Department of Orthopaedics, Children’s Hospital of Pennsylvania, Philadelphia, Pennsylvania, USA
  7. 7 Department of Orthopaedics, Tennessee Orthopedic Alliance, Nashville, Tennessee, USA
  1. Correspondence to Dr Kevin G Shea, Department of Orthopaedics, St. Luke’s Health System, Boise, ID 83702, USA; kevingshea{at}gmail.com
  • Dr Allen F Anderson died on 12 Nov 2017.

Abstract

Background Anatomic studies of the paediatric posterior cruciate ligament (PCL) demonstrate that the tibial attachment spans the epiphysis, physis and metaphysis. To better reproduce the anatomy of the PCL and avoid direct physeal injury, a double-bundle PCL reconstruction technique that includes both an all-epiphysial and an all-metaphyseal tibial tunnel has been proposed. The purpose of this study was to evaluate tibial tunnel placement in a paediatric double-bundle PCL reconstruction technique that avoids direct physeal injury using a 3-D computer model.

Methods Ten skeletally immature cadaveric knee specimens (ages 5–11) were used to create 3-D model reconstructions from CT scans. All-metaphyseal and all-epiphysial tibial tunnels were simulated with the goal of maintaining adequate spacing (≥2 mm) between the tibial physis and tunnels to avoid injury. The all-metaphyseal tunnel, simulated at sizes of 5, 6 and 7 mm, entered anteriorly, below the tibial tubercle (apophysis) and exited posteriorly in the metaphyseal PCL footprint, distal to the proximal tibial physis. Four-millimetre all-epiphysial proximal tibial tunnels were simulated to enter the epiphysis anteromedially and exit posteriorly at the central epiphysial region of the PCL footprint, proximal to the physis. The distance was measured from the all-metaphyseal tunnels to the physis posteriorly and from the all-epiphysial tunnels to the physis, both anteriorly and posteriorly.

Results In all specimens, the 4 mm all-epiphysial tunnel and the 5, 6 and 7 mm all-metaphyseal tunnels maintained adequate spacing, ≥2 mm from the physis. In the specimens aged 5–7 years, the 5, 6 and 7 mm all-metaphyseal tunnels measured a mean distance of 3.5, 2.8 and 2.5 mm from the physis, respectively. In the specimens aged 8–11 years, the 5, 6 and 7 mm all-metaphyseal tunnels measured a mean distance of 3.4, 2.9 and 2.6 mm from the physis. In the specimens aged 5–7 years, the all-epiphysial tunnel measured a mean of 2.1 mm to the physis anteriorly and a mean of 2.8 mm posteriorly. In the specimens aged 8–11 years, the all-epiphysial tunnel measured a mean of 2.2 mm to the physis anteriorly and 2.4 mm posteriorly.

Conclusion These computer-aided 3-D models of paediatric knees illustrate that 5, 6 and 7 mm all-metaphyseal tunnels as well as 4 mm all-epiphysial tunnels can be placed without direct injury to the proximal tibial physis. The margin of error for direct physeal injury is small, especially for the all-epiphysial tunnel. Further, the all-epiphysial tunnel, while reproducing the anatomy of the PCL epiphysial attachment, may also produce a more extreme ‘killer turn’ of the graft. Modifications to the all-epiphysial tunnel may be considered to reduce the impact of the high ‘killer turn’ angle on the tibia.

Level of evidence IV.

  • all-metaphyseal
  • all-epiphyseal
  • posterior cruciate ligament
  • reconstruction
  • tibial tunnel
  • pediatrics

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Footnotes

  • Competing interests KGS, AFA, and TJG are members of the ROCK (Research in OsteoChondritis of the Knee) study group which receives unrestricted educational grants from Vericel and AlloSource. AFA holds a patent and receives royalties from OrthoPediatrics for an ACL reconstruction device, acts as a consultant for DePuy Mitek, Ceterix, Flexion Therapeutics, Orthopediatrics and Cotera and received payment for educational presentations from OSET and ETO.

  • Ethics approval This study was determined by our local IRB to be IRB exempt because it was performed on cadaveric specimens, with no contact with donor families.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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