Anterior cruciate ligament reconstruction: TRANSEPIPHYSEAL, PHYSEAL-SPARING

Transepiphyseal replacement of anterior cruciate ligament using quadruple hamstring grafts

The transepiphyseal reconstruction of the anterior cruciate ligament using quadruple hamstring grafts procedure described by Anderson is indicated in patients in Tanner stage III of development. The procedure is not indicated in patients in Tanner stage IV of development, who can have conventional anterior cruciate ligament reconstruction. Preteens and patients with Tanner I or II stages should have an over-the-top iliotibial band graft (i.e., Kocher, Garg, and Micheli described later). Pitfalls of this procedure include suboptimal graft placement, incorrect diameter of transepiphyseal drill holes, failure of fixation, and graft slippage with suture post fixation ( Box 15.1 ).

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  Place the injured lower limb in an arthroscopic leg holder with the hip flexed to 20 degrees to facilitate C-arm fluoroscopic viewing of the knee in the lateral plane.

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  Position the C-arm on the side of the table opposite the injured knee and place the monitor at the head of the table. View the tibial and femoral physes in the anteroposterior and lateral planes before the limb is prepared and draped. When the distal part of the femur is viewed, adjust the C-arm so that the medial and lateral femoral condyles line up perfectly with the lateral plane. Rotate the C-arm to see the extension of the tibial physis into the tibial tubercle on the lateral view of the tibia.

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  Make an oblique 4-cm incision over the semitendinosus and gracilis tendons. Dissect these tendons free and transect at the musculotendinous junction with use of a standard tendon stripper, and detach distally.

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  Double the tendons, and place a no. 5 FiberWire suture (Arthrex, Naples, FL) in the ends of the tendons with a whipstitch.

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  Place the doubled tendons under 4.5 kg (10 lb) of tension on the back table with the use of the Graftmaster device (Acufex-Smith & Nephew, Andover, MA).

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  Insert the arthroscope into the anterolateral portal and insert a probe through the anteromedial portal.

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  Perform intraarticular examination in the usual manner.

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  Remove debris in the intercondylar notch and perform a notchplasty to see the anatomical footprint of the anterior cruciate ligament on the femur.

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  Repair any substantial meniscal tears found.

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  With the C-arm in the lateral position, adjust the limb to show a perfect lateral view.

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  Place the point of the guidewire over the lateral femoral condyle, corresponding with the location of the footprint of the anterior cruciate ligament on the femur. This point is approximately one-fourth of the distance from posterior to anterior along the Blumensaat line and one-fourth of the distance down from the Blumensaat line. Make a 2-cm lateral incision at this point ( Fig. 15.1 ).

  

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  Incise the iliotibial tract longitudinally and strip the periosteum from a small area of the lateral femoral condyle.

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  Use the C-arm to view the entry point of the guidewire in the anteroposterior and the lateral planes. With the C-arm in the lateral plane and with the use of a free-hand technique, introduce the point of the guidewire 2 to 3 mm into the femoral epiphysis. Do not angulate the pin anteriorly or posteriorly, but rather keep it perpendicular to the femur in the coronal plane. Rotate the C-arm to the anteroposterior plane to ensure that the guidewire is not angulated superiorly or inferiorly.

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  Drive the guidewire across the femoral epiphysis, perpendicular to the femur and distal to the physis. Through the arthroscope, view the entrance of the guidewire into the intercondylar notch. The guidewire should enter the joint 1 mm posterior and superior to the center of the anatomical footprint of the anterior cruciate ligament on the femur.

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  Leave the femoral guidewire in place and insert a second guidewire into the anteromedial aspect of the tibia, through the epiphysis, with the aid of a tibial drill guide. From the direct lateral position, rotate the C-arm externally approximately 30 degrees to show the physis clearly extending into the tibial tubercle. Drill the guidewire into the tibial epiphysis under real-time fluoroscopic imaging. The handle of the drill guide must be lifted for the wire to clear the anterior part of the tibial physis. The wire should enter the joint at the level of the free edge of the lateral meniscus and in the posterior footprint of the anterior cruciate ligament on the tibia ( Fig. 15.2 ).

  

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  Arthroscopically confirm the appropriate position of both guidewires at this point.

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  Use tendon sizers to measure the diameter of the quadruple tendon graft (which typically is 6–8 mm). A tight fit is important; consequently, use the smallest appropriate drill to ream over both guidewires.

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  Chamfer the edge of the femoral hole intraarticularly and measure the width of the lateral femoral condyle. Choose the appropriate EndoButton continuous loop (Acufex-Smith & Nephew, Memphis, TN) (2–3 cm), so that approximately 2 cm of the quadruple hamstring tendon graft remains within the lateral femoral condyle.

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  Pass the EndoButton continuous loop around the middle of the double tendons and loop the inside of itself to secure the tendons proximally ( Fig. 15.3 ). Alternatively, the tendons can be placed through the continuous loop before the tendon ends are sutured together. However, this requires drilling and measuring the length of the femoral hole before graft preparation. Otherwise, it is difficult to determine the appropriate length of the EndoButton continuous loop necessary to leave 2 cm of the tendon graft within the lateral femoral condyle.

  

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  Place a no. 5 FiberWire suture in one end of the EndoButton and pass a suture passer from anterior to posterior through the tibia and out of the lateral femoral condyle. Pull the EndoButton and tendons up through the tibia and out of the femoral hole with the use of the no. 5 suture ( Fig. 15.4 ).

  

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  Place an EndoButton washer (Smith & Nephew, Memphis, TN), 3 to 4 mm larger than the femoral hole, over the EndoButton. Apply tension to the tendons distally, pulling the EndoButton and washer to the surface of the lateral femoral condyle. The washer is necessary to anchor the graft proximally because the hole in the femoral condyle is larger than the EndoButton ( Fig. 15.5 ).

  

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  Place the graft under tension and extend the knee to determine arthroscopically if there is impingement of the graft on the intercondylar notch.

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  An anterior notchplasty is usually unnecessary when this technique is used; however, if the anterior outlet of the intercondylar notch touches or indents the graft in terminal extension, remove a small portion of the anterior outlet.

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  With the knee in 10 degrees of flexion, secure the quadruple hamstring graft distally by tying the no. 5 FiberWire sutures over a tibial screw and post that is placed medial to the tibial tubercle apophysis and distal to the proximal tibial physis ( Fig. 15.6 ).

  

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  If the tendon graft extends through the tibial drill hole, secure it to the periosteum of the anterior tibia with multiple no. 1 Ethibond sutures (Ethicon, Johnson & Johnson, Somerville, NJ) with use of figure-of-eight stitches. Close the subcutaneous tissue and skin in a routine fashion and apply a hinged brace.