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 effect of the use of 3D intraoperative fluoroscopy 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 fluoroscopy used: a 2D group and a 3D group. Interrater reliability of radiographic measurements was evaluated using intraclass correlation coefficient (ICC).
Results
Seventy-two patients fit 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 difference in distance between the tibial socket and the PTP was significantly 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, significantly 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 significantly 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.
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References
Anderson AF (2003) Transepiphyseal replacement of the anterior cruciate ligament using quadruple hamstring grafts in skeletally immature patients surgical technique. J Bone Jt Surg Am 85:1255–1263
Anderson AF (2004) Transepiphyseal replacement of the anterior cruciate ligament using quadruple hamstring grafts in skeletally immature patients. J Bone Jt Surg Am 86(1):201–209
Beisemann N, Keil H, Swartman B, Schnetzke M, Franke J, Grützner PA, Vetter SY (2019) Intraoperative 3D imaging leads to substantial revision rate in management of tibial plateau fractures in 559 cases. J Orthop Surg Res 14:236
Calvo R, Figueroa D, Gili F, Vaisman A, Mocoçain P, Espinosa M, León A, Arellano S (2015) Transphyseal anterior cruciate ligament reconstruction in patients with open physes: 10-year follow-up study. Am J Sports Med 43:289–294
Cordasco FA, Mayer SW, Green DW (2017) All-inside, all-epiphyseal anterior cruciate ligament reconstruction in skeletally immature athletes: return to sport, incidence of second surgery, and 2-year clinical outcomes. Am J Sports Med 45:856–863
Cruz AI, Fabricant PD, McGraw M, Rozell JC, Ganley TJ, Wells L (2017) All-epiphyseal ACL reconstruction in children. J Pediatr Orthop 37:204–209
DeFrancesco CJ, Striano BM, Bram JT, Baldwin KD, Ganley TJ (2020) An in-depth analysis of graft rupture and contralateral anterior cruciate ligament rupture rates after pediatric anterior cruciate ligament reconstruction. Am J Sports Med 48:2395–2400
Dekker TJ, Godin JA, Dale KM, Garrett WE, Taylor DC, Riboh JC (2017) Return to sport after pediatric anterior cruciate ligament reconstruction and its effect on subsequent anterior cruciate ligament injury. J Bone Jt Surg Am 99:897–904
Dimeglio A (2001) Growth in pediatric orthopaedics. J Pediatr Orthop 21:549–555
Dodwell ER, Lamont LE, Green DW, Pan TJ, Marx RG, Lyman S (2014) 20 years of pediatric anterior cruciate ligament reconstruction in New York state. Am J Sports Med 42(3):675–680
Geerling J, Kendoff D, Citak M, Zech S, Gardner MJ, Hüfner T, Krettek C, Richter M (2009) Intraoperative 3D imaging in calcaneal fracture care—clinical implications and decision making. J Trauma Acute Care Surg 66:768–773
Gupta A, Tejpal T, Shanmugaraj A, Horner NS, Gohal C, Khan M (2020) All-epiphyseal anterior cruciate ligament reconstruction produces good functional outcomes and low complication rates in pediatric patients: a systematic review. Knee Surg Sport Traumatol Arthrosc 28:2444–2452
Guzzanti V, Falciglia F, Gigante A, Fabbriciani C (1994) The effect of intra-articular ACL reconstruction on the growth plates of rabbits. J Bone Jt Surg Br 76:960–963
Ho B, Edmonds EW, Chambers HG, Bastrom TP, Pennock AT (2018) Risk factors for early ACL reconstruction failure in pediatric and adolescent patients. J Pediatr Orthop 38:388–392
Hüfner T, Stübig T, Citak M, Gösling T, Krettek C, Kendoff D (2009) Utility of intraoperative three-dimensional imaging at the hip and knee joints with and without navigation. J Bone Jt Surg Am 91:33–42
Kercher J, Xerogeanes J, Tannenbaum A, Al-Hakim R, Black JC, Zhao J (2009) Anterior cruciate ligament reconstruction in the skeletally immature. J Pediatr Orthop 29:124–129
Koch PP, Fucentese SF, Blatter SC (2016) Complications after epiphyseal reconstruction of the anterior cruciate ligament in prepubescent children. Knee Surg Sports Traumatol Arthrosc 24:2736–2740
Kocher MS (2005) Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Jt Surg Am 87:2371
Kocher MS, Heyworth BE, Fabricant PD, Tepolt FA, Micheli LJ (2018) Outcomes of physeal-sparing ACL reconstruction with iliotibial band autograft in skeletally immature prepubescent children. J Bone Jt Surg Am 100:1087–1094
Ladenhauf HN, Jones KJ, Potter HG, Nguyen JT, Green DW (2020) Understanding the undulating pattern of the distal femoral growth plate: implications for surgical procedures involving the pediatric knee: a descriptive MRI study. Knee 27:315–323
Larson CM, Heikes CS, Ellingson CI, Wulf CA, Giveans MR, Stone RM, Bedi A (2016) Allograft and autograft transphyseal anterior cruciate ligament reconstruction in skeletally immature patients: outcomes and complications. Arthroscopy 32(5):860–867
Lawrence JTR, West RL, Garrett WE (2011) Growth disturbance following ACL reconstruction with use of an epiphyseal femoral tunnel. J Bone Jt Surg Am 93:39
Lawrence TJR, Bowers AL, Belding J, Cody SR, Ganley TJ (2010) All-epiphyseal anterior cruciate ligament reconstruction in skeletally immature patients. Clin Orthop Relat Res 468:1971–1977
Leyes-Vence M, Roca-Sanchez T, Flores-Lozano C, Villarreal-Villareal G (2019) All-inside partial epiphyseal anterior cruciate ligament reconstruction plus an associated modified lemaire procedure sutured to the femoral button. Arthrosc Tech 8:e473–e480
Makela EA, Vainionpaa S, Vihtonen K, Mero M, Rokkanen P (1988) The effect of trauma to the lower femoral epiphyseal plate. An expermimental study in rabbits. J Bone Jt Surg Br 70(2):187–191
Malham GM, Wells-Quinn T (2019) What should my hospital buy next?—Guidelines for the acquisition and application of imaging, navigation, and robotics for spine surgery. J Spine Surg 5:155–165
McCarthy MM, Graziano J, Green DW, Cordasco FA (2012) All-epiphyseal, all-inside anterior cruciate ligament reconstruction technique for skeletally immature patients. Arthrosc Tech 1:e231–e239
Mencio GA, Swiontkowski MF (2015) Green’s skeletal trauma in children. Green’s skelet trauma child, 5th edn. Elsevier, Amsterdam
Nathan ST, Lykissas MG, Wall EJ (2013) Growth stimulation following an all-epiphyseal anterior cruciate ligament reconstruction in a child. JBJS Case Connect 3:e14
Nawabi DH, Jones KJ, Lurie B, Potter HG, Green DW, Cordasco FA (2014) All-inside, physeal-sparing anterior cruciate ligament reconstruction does not significantly compromise the physis in skeletally immature athletes. Am J Sports Med 42:2933–2940
Nguyen CV, Greene JD, Cooperman DR, Liu RW (2015) A radiographic study of the distal femoral epiphysis. J Child Orthop 9:235–241
Patel NM, DeFrancesco CJ, Talathi NS, Bram JT, Ganley TJ (2019) All-epiphyseal anterior cruciate ligament reconstruction does not increase the risk of complications compared with pediatric transphyseal reconstruction. J Am Acad Orthop Surg 27:e752–e757
Pennock AT, Chambers HG, Turk RD, Parvanta KM, Dennis MM, Edmonds EW (2018) Use of a modified all-epiphyseal technique for anterior cruciate ligament reconstruction in the skeletally immature patient. Orthop J Sport Med 6:232596711878176
Pierce TP, Issa K, Festa A, Scillia AJ, McInerney VK (2017) Pediatric anterior cruciate ligament reconstruction: a systematic review of transphyseal versus physeal-sparing techniques. Am J Sports Med 45:488–494
Roberti di Sarsina T, Macchiarola L, Signorelli C, Grassi A, Raggi F, Marcheggiani Muccioli GM, Zaffagnini S (2019) Anterior cruciate ligament reconstruction with an all-epiphyseal “over-the-top” technique is safe and shows low rate of failure in skeletally immature athletes. Knee Surg Sport Traumatol Arthrosc 27:498–506
Schnetzke M, Fuchs J, Vetter SY, Beisemann N, Keil H, Grützner P-A, Franke J (2016) Intraoperative 3D imaging in the treatment of elbow fractures—a retrospective analysis of indications, intraoperative revision rates, and implications in 36 cases. BMC Med Imaging 16:24
Shifflett GD, Green DW, Widmann RF, Marx RG (2016) Growth arrest following ACL reconstruction with hamstring autograft in skeletally immature patients: a review of 4 cases. J Pediatr Orthop 36:355–361
Thorolfsson B, Svantesson E, Snaebjornsson T, Sansone M, Karlsson J, Samuelsson K, Senorski EH (2021) Adolescents have twice the revision rate of young adults after ACL reconstruction with hamstring tendon autograft: a study from the Swedish national knee ligament registry. Orthop J Sport Med 9:232596712110388
Wall EJ, Ghattas PJ, Eismann EA, Myer GD, Carr P (2017) Outcomes and complications after all-epiphyseal anterior cruciate ligament reconstruction in skeletally immature patients. Orthop J Sport Med 5:232596711769360
Wong SE, Feeley BT, Pandya NK (2019) Comparing outcomes between the over-the-top and all-epiphyseal techniques for physeal-sparing ACL reconstruction: a narrative review. Orthop J Sport Med 7:232596711983368
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AHA and SHP have no conflicts of interest to disclose. FAC is a consultant and receives royalties from Arthrex Inc. DWG is a consultant for Arthrex Inc and receives royalties for Arthrex Inc and Pega Medical.
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This study was approved by the HSS IRB (Study # 2015-366).
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Aitchison, A.H., Perea, S.H., Cordasco, F.A. et al. Improved epiphyseal socket placement with intraoperative 3D fluoroscopy: a consecutive series of pediatric all-epiphyseal anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 30, 1858–1864 (2022). https://doi.org/10.1007/s00167-021-06809-z
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DOI: https://doi.org/10.1007/s00167-021-06809-z