Volumetric Injury of the Physis During Single-Bundle Anterior Cruciate Ligament Reconstruction in Children: A 3-Dimensional Study Using Magnetic Resonance Imaging

Purpose

To determine the volume of injury to the physis during anterior cruciate ligament (ACL) reconstruction in pediatric patients.

Methods

Magnetic resonance imaging scans of 10 pediatric knees were converted into 3-dimensional models. Computer-aided design/computer-aided manufacturing software placed drill holes (6, 7, 8, and 9 mm in diameter) in these models, simulating tunnels used for ACL reconstruction. The software was used to calculate total physeal volume and volume of physis removed by the tunnel. The ratio of physeal volume removed to the total physeal volume was determined.

Results

For 6-, 7-, 8-, and 9-mm-diameter drill holes, the mean percent of physeal volume removed/total physeal volume was 1.6%, 2.2%, 2.9%, and 3.8%, respectively, for the tibia and 2.4%, 3.2%, 4.2%, and 5.4%, respectively, for the femur. For all subjects, the volume removed was less than 7.0% for the tibia and 9.0% for the femur by use of drill holes from 6 to 9 mm. The tibial drill hole was centrally placed in all cases compared with a more peripheral drill hole placement of the femur.

Conclusions

Drill hole placement during ACL reconstruction produces a zone of physeal injury. The overall volume of injury is relatively low, which reduces the risk of physeal arrest. With careful drill hole placement, the region of injury is central on the tibia, and the total volume of injury can be less than 5.0% of the physeal volume. For the femur, the total volume can be less than 5.0% as well. However, the region of injury is peripheral, which carries a higher risk of physeal arrest.

Clinical Relevance

A better understanding of the relation between the ACL and physis may guide the placement of drill holes, which have a lower risk of producing physeal arrest.

Key Words: Anterior cruciate ligament, Anatomy, Pediatric, Adolescent, Physis, Knee injury, Skeletally immature