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The distance between the hamstring grafts and the physis and apophysis of the proximal tibia - implications for pediatric ACL reconstruction and physeal arrest
  1. Connor G Richmond1,
  2. Daniel W Green2,
  3. Peter C Cannamela3,
  4. Duncan Martinson4,
  5. Kevin G Shea5
  1. 1 University of New England College of Osteopathic Medicine, Biddeford, Maine, USA
  2. 2 Department of Orthopaedics, Hospital for Special Surgery, New York, USA
  3. 3 University of Utah School of Medicine, Salt Lake City, Utah, USA
  4. 4 Brown University, Providence, Rhode Island, USA
  5. 5 Department of Orthopaedics, Stanford University, Palo Alto, California, USA
  1. Correspondence to Dr Kevin G Shea; kevingshea{at}


Objectives To evaluate the relationship of the gracilis and semitendinosus tendon and the proximal tibial physis and apophysis regions on human paediatric knee specimens.

Methods Metallic markers were placed at the proximal and distal extents of the anterior margin of the pes anserine in 24 paediatric knee specimens (ages 2 to 11 years). CT scans from each specimen were analysed using OsiriX. The distance from the proximal and distal tibial epiphysis and pes anserine insertion (proximal and distal extent) was measured in the sagittal plane. The medial–lateral distance from the centre of the apophysis to the pes anserine insertion was measured in the axial plane.

Results In the sagittal plane, the anteroproximal pes anserine insertions were found to be distal to the proximal tibia physis by a mean of 21.4 mm (range 13.1–30.5 mm). In the axial plane, the mean distance from the anteroproximal extent of the pes anserine to the tibial apophysis was 6.6 mm (range 3.1–12.3 mm). No clear trend was observed based on age.

Conclusions The distance from the pes anserine insertions to the physis apophyseal region of the tibia is relatively small. Dissections in this area should consider the intimate relationships of the physeal/apophyseal structures. Techniques that strip the tendons and surrounding periosteum from the insertions may damage the peripheral regions of physeal/apophyseal regions. Graft harvest from the pes anserine (gracilis and semitendinosus) should consider modifications of the surgical technique that avoid direct injury to the vulnerable physeal/apophyseal regions.

Level of evidence Level IV.

  • Semitendinosis
  • Gracilis
  • Pes Anserine
  • Pediatric ACL
  • ACL Reconstruction
  • ACL Graft
  • Physis
  • Physeal Injury
  • Physeal Arrest
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  • Contributors All authors contributed to study design, data collection and manuscript preparation. All authors gave final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests KGS and DWG are members of the ROCK (Research in OsteoChondritis of the Knee) study group, which receives unrestricted educational grants from Vericel and AlloSource.

  • Patient consent Not required.

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

  • Data sharing statement Please contact Dr Kevin Shea at to gain the rights to use any and all images in this manuscript.

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