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Anatomic all-epiphysial tibial tunnels for anterior cruciate ligament reconstruction in skeletally immature knees may be placed without damaging the anterior meniscus root
  1. Kevin G Shea1,
  2. Peter C Cannamela2,
  3. Peter D Fabricant3,
  4. Allen F Anderson4,
  5. John D Polousky5,
  6. Elizabeth B Terhune6,
  7. Matthew D Milewski7,
  8. Theodore J Ganley8
  1. 1 St Luke’s Health System, Boise, Idaho, USA
  2. 2 University of Utah School of Medicine, Salt Lake, Utah, USA
  3. 3 Hospital for Special Surgery, New York City, New York, USA
  4. 4 Tennessee Orthopaedic Alliance, Nashville, Tennessee, USA
  5. 5 Children’s Health Andrews Institute, Plano, Texas, USA
  6. 6 Georgetown University School of Medicine, Washington, District of Columbia, USA
  7. 7 Connecticut Children’s Medical Center, Farmington, Connecticut, USA
  8. 8 Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  1. Correspondence to Peter C Cannamela, University of Utah School of Medicine, Salt Lake City, UT 84108, USA; pcannamela{at}
  • Dr Allen F Anderson died on 12 November 2017


Objectives The purpose of this study was to evaluate the spatial relationship of the anterior horns of the menisci and the tibial tunnel during all-epiphysial drilling of skeletally immature specimens and identify any iatrogenic damage or destabilisation to the meniscus and meniscal root.

Methods Four skeletally immature cadaveric knee specimens (aged 9–11 years) were used to create three-dimensional models from CT images. All-epiphysial anterior cruciate ligament (ACL) tibial tunnel drilling was performed in 14 specimens (aged 7–11 years), entering the joint surface at the ACL footprint and avoided the proximal tibial physis. The anterior meniscal roots and horns were closely inspected visually and probed for stability, prior to drilling. After drilling, the meniscus and attachment points were re-evaluated for damage to the meniscus, meniscus root and probed to evaluate for destabilisation.

Results All-epiphysial tunnels entered the joint at the anatomic ACL tibial footprint. Direct visual inspection of the menisci demonstrated an absence of damage to either meniscus or anterior horn regions in all specimens. Probing and traction of the medial and lateral meniscal tissue did not demonstrate evidence of instability or destabilisation of the anterior horn or meniscus root before or after drilling. All tunnels were circumferentially intact at the joint surface, with no evidence of superior tunnel perforation due to shallow tunnel angle.

Conclusion In this study, tunnel placement did not produce damage to either meniscus, nor noticeably destabilise the meniscal roots. This study also demonstrated that drill holes can be placed within the ACL footprint without entering the joint on the proximal tibia surface anterior to the ACL attachment, although the ‘safe zone’ for drill hole placement is limited. All-epiphysial ACL tibial tunnels can create a large aperture at the tibial joint surface, but these tunnels can be placed at the anatomic footprint of the ACL, without causing gross anterior medial or lateral meniscus horn or root injury.

  • knee
  • basic science
  • Acl / Pcl

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  • Contributors All authors contributed to the drafting and editing of this manuscript. KGS, PDF, JDP, MDM, AFA, JDP and TJG performed the dissections, and placed markers. Manuscript images were created by PCC and revised by all authors. KGS, EBT, PCC and PDF performed radiographic measurements and data analysis.

  • Competing interests KGS, PDF, AFA, JDP, MDM 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. JDP serves as a consultant to AlloSource. MDM receives royalties from Elsevier for editorial work and his institution receives a research grant from the Pediatric Orthopaedic Society of North America.

  • Ethics approval Our Institutional Review Board was consulted prior to the initiation of this study. As this study included access to cadaveric specimens without any patient identifiers or contact with the family, IRB approval was not deemed necessary. The specimens were provided by an allograft harvesting facility, which had received family consent for use of tissue for research purposes (AlloSource, Centennial, CO).

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

  • Data sharing statement AlloSource donated the cadaveric specimens and provided nonfinancial research support. The authors thank Tom Cycyota and Todd Huft (AlloSource) for their assistance, organisation and support of the dissections.

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