ACL Reconstruction Using Epiphyseal Tunnels

Fig. 13.1

The femoral guide. The handle of the guide should be elevated approximately 35–40° to avoid damaging the lateral collateral ligament and popliteus tendon during reaming (Copyright 2013 OrthoPediatrics Corp., with permission)

Fig. 13.2

The tibial guide. The handle of the guide is positioned medial to the tibial tubercle to allow the guide wire to be advanced through the anteromedial epiphysis (Copyright 2013 OrthoPediatrics Corp., with permission)

Before proceeding, confirm that both guide wires are in the correct position. Measure the diameter of the quadruple hamstring graft using tendon sizers; these grafts typically range from 6 to 8 mm in diameter. Because a tight fit is essential, use the smallest reamer possible to ream over the guide wires. Chamfer the edge of the femoral hole intra-articularly. After drilling the tibial and femoral holes, it is necessary to insert the OrthoPediatrics ShieldLoc sleeve into the femoral hole. Insert the counterbore reamer into the femoral hole until it bottoms out on the lateral femoral cortex (Fig. 13.3). During this step, the counterbore is inserted to a depth of 8 mm and increases the diameter of the femoral hole by 2 mm. The small amount of bone removal occurs rapidly. Retract the iliotibial band and carefully remove the soft tissue immediately around the hole to allow for clear placement of the ShieldLoc sleeve. The appropriately sized ShieldLoc sleeve is screwed on to the insertion device (Fig. 13.4a) and then gently tapped into the femoral tunnel (Fig. 13.4b). The fluted fins on the outside of the ShieldLoc sleeve prevent the device from backing out of the femoral tunnel while removing the insertion device. The ShieldLoc sleeve is designed to protect the physis from radial pressure caused by the insertion of the interference screw. After the ShieldLoc sleeve has been inserted, place the Graft Passer from the Disposable Kit through the femoral tunnel, and with an arthroscopic grasper, pull the Graft Passer loop out of the tibial tunnel (Fig. 13.5). Place one end of each graft through the Graft Passer loop on the femoral side. Then pull the tibial end of the Graft Passer, bringing the graft through the femoral tunnel into the tibial tunnel. Gently pull 1–2 cm of the graft loop outside of the anterior tibial cortex to allow installation of the ArmorLink implant. With the use of hemostat, pass the ArmorLink around the tendons (Fig. 13.6a). Pull on the free strands of the graft coming out of the femoral tunnel in order to seat the ArmorLink on the tibial cortex (Fig. 13.6b).

Fig. 13.3

Fig. 13.4

Fig. 13.5

Fig. 13.6

(a) The ArmorLink device is grasped with a hemostat and passed around the loops formed from doubling both the semitendinosus and gracilis tendons. (b) The free strands of the graft exiting the femoral tunnel are then pulled laterally to seat the ArmorLink on the tibial cortex (Copyright 2013 OrthoPediatrics Corp., with permission)

The ArmorLink may be positioned in any orientation. Observe the ShieldLoc when pulling the free strands of the graft to make sure the ShieldLoc sleeve does not catch on the sutures in the free ends of the graft and become displaced. If the ShieldLoc sleeve moves when pulling the tendons through, then stabilize the ShieldLoc sleeve with a hemostat to prevent displacement. With the knee in approximately 20–30° of flexion, apply tension with the graft tensioner, and insert the screw of the ShieldLoc (Fig. 13.7). Evaluate the graft for intercondylar notch impingement (Fig. 13.8a, b), and then close the wound in a standard fashion. Postoperative X-rays of a 9-year-old male show the position of the femoral drill hole and the ArmorLink implant.

Fig. 13.7

The graft is then tensioned with the knee at 20–30° of flexion, and the interference screw is then inserted into the ShieldLoc sleeve. The free ends of the semitendinosus and gracilis are trimmed after satisfactory stability is confirmed (Copyright 2013 OrthoPediatrics Corp., with permission)

Fig. 13.8

Postoperative Rehabilitation for Transepiphyseal or All-Epiphyseal Anterior Cruciate Ligament Reconstruction

Postoperatively, the leg is placed in a long-leg hinged knee brace locked in extension. Rehabilitation following the transepiphyseal ACL reconstruction procedure has three phases. Phase I begins when the patient awakens from surgery. Encourage the patient to perform straight-leg raises and to contract the quadriceps muscles. Use cryotherapy for 5–10 min each hour. The day after surgery, the patient performs range-of-motion exercises and hamstring stretches in a prone position. Patients without meniscal repairs may ambulate with crutches and partial weight bearing for 4 weeks. For patients who required meniscal repair, only toe-touch weight bearing is allowed for the first 6 weeks. The 1-week postsurgical goal is to have a range of motion of 0° of extension to 90° of flexion (Fig. 13.9).