Anterior Cruciate Ligament Reconstruction With Open Physis and Closed Physis



Anterior Cruciate Ligament Reconstruction With Open Physis and Closed Physis


Mininder S. Kocher



Physeal-Sparing Combined Intra-articular and Extra-articular Technique With IT Band


Operative Indications



  • Anterior cruciate ligament (ACL) reconstruction is indicated in full-thickness intrasubstance ruptures regardless of physeal status



    • It is preferable to perform ACL reconstruction in patients with open physes rather than waiting for skeletal maturity as this approach has been associated with an unacceptably high rate of meniscal and chondral injury


  • ACL reconstruction is also indicated in patients that have failed conservative treatment of ACL injuries due to either recurrent instability or the presence of other intra-articular injury such as meniscal tears or cartilage injuries


  • The combined extra-articular and intra-articular ACL reconstruction described below is indicated in patients at Tanner stage 1 or 2 and those with skeletal bone age ≤11 in females or ≤12 in males (Figure 31.1)



    • Transphyseal, all-epiphyseal, or hybrid reconstruction techniques are acceptable in older patients



Examination Under Anesthesia



  • Flexion and extension range of motion


  • Lachman examination


  • Pivot shift maneuver


  • Varus/valgus stress, posterior drawer, and dial test to rule out other injuries








Positioning



  • Position the patient supine on the operating room table with all bony prominences well padded


  • A nonsterile tourniquet is placed as high as possible on the thigh to allow enough room to harvest a 15-cm iliotibial band (ITB) graft


  • An arthroscopic leg holder or lateral post can be used to allow access to the medial compartment based on surgeon preference


Technique


ITB Graft Harvest



  • Make a 6-cm incision obliquely from the lateral joint line to the anterior border of ITB (Figure 31.2)


  • Use a Cobb elevator to separate the ITB from the superficial soft tissues


  • Incise the ITB in line with its fibers a few millimeters posterior to the anterior border of the ITB


  • Repeat this process just anterior to the posterior border of the ITB


  • Extend both ITB incisions proximally for 15 cm with the use of meniscotomes



    • Ensure the splits stay parallel to the fibers of the ITB so the graft is not prematurely transected


  • Use a curved, end-cutting, meniscotome to release the graft as proximally as possible



    • A cutting tendon stripper can be used if the graft is small enough to fit in the device


    • A counter incision can also be made proximally to release the graft under direct visualization


  • Distally, use scissors to continue the anterior and posterior incisions in the ITB to Gerdy tubercle (Figure 31.3)


  • Tubularize and whip stitch the proximal free end of the graft with heavy nonabsorbable suture


  • Place the graft under skin to prevent desiccation while performing the intra-articular portion of the procedure


Diagnostic Knee Arthroscopy



  • Standard anterolateral and anteromedial portals are created



    • The anteromedial portal, which will facilitate graft passage, can be created slightly distal and medial to the typical position to provide a better trajectory for passing the clamp around the “over-the-top” position


  • A complete diagnostic arthroscopy should be completed


  • Any intra-articular injuries such as meniscal or cartilage injuries should be addressed at this point













Femoral Graft Passage



  • Insert the tips of a full-length clamp through the anteromedial portal


  • The tips of the clamp are passed posterior and cranial to the ACL footprint around the lateral femoral condyle in the “over-the-top” position (Figure 31.4)



    • A portion of the soft tissues at the ACL femoral footprint should be preserved to act as a sling to prevent inferior subluxation of the graft


  • The tips of the clamp should be identified through the lateral open incision within the anterior and posterior borders of the ITB (Figure 31.5)


  • The clamp is then used to withdraw the ITB graft into the knee joint (Figure 31.6)


Tibial Bed Preparation



  • A 3 to 4 cm incision is made over the proximal tibia medial to the tibial tubercle and distal to the proximal tibial physis


  • Carry the dissection down to the periosteal layer and incise the periosteum in line with the incision























  • Use a periosteal elevator to create flaps medial and lateral to the periosteal incision



    • Take care laterally not to violate the tibial tubercle apophysis


  • A burr or rasp can be used to decorticate the proximal tibial bed to facilitate tendon to bone healing


Tibial Graft Passage

Jun 9, 2022 | Posted by in Reconstructive surgery | Comments Off on Anterior Cruciate Ligament Reconstruction With Open Physis and Closed Physis
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