All-Epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Surgical Technique Using a Split Tibial Tunnel Marios G.

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All-Epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Surgical Technique Using a Split Tibial Tunnel Marios G. Lykissas, M.D., Ph.D., Senthil T. Nathan, M.D., Eric J. Wall, M.D. Arthroscopy Techniques Volume 1, Issue 1, Pages e133-e139 (September 2012) DOI: 10.1016/j.eats.2012.05.005 Copyright © 2012 Arthroscopy Association of North America Terms and Conditions

Figure 1 Modified all-epiphyseal ACL reconstruction. (A) A femoral tunnel and a split tibial tunnel are placed entirely within the distal femoral and proximal tibial epiphysis, respectively. (B) A biocomposite interference screw (Matryx) is used to fix the graft into the femoral tunnel. A 1-cm bone bridge between the 2 tibial tunnels is maintained. (C) Lateral illustration of the all-epiphyseal technique showing the correct position of the femoral tunnel in the lateral plane, as well as the looped end of the graft around the anteromedial tibial epiphysis. Arthroscopy Techniques 2012 1, e133-e139DOI: (10.1016/j.eats.2012.05.005) Copyright © 2012 Arthroscopy Association of North America Terms and Conditions

Figure 2 Graft preparation in all-epiphyseal ACL reconstruction with split tibial tunnel. The proximal end of the gracilis is sewn to the thin distal end of the semitendinosus with a whipstitch and vice versa by use of No. 2 FiberLoop sutures. The central 12 cm of the doubled graft is left free of suture. The doubled tendons are folded over, and Vicryl suture is looped around the midpoint of the graft. The tendons are then placed under 10 lb of tension for 20 minutes on the back table with the use of the GraftMaster device. Arthroscopy Techniques 2012 1, e133-e139DOI: (10.1016/j.eats.2012.05.005) Copyright © 2012 Arthroscopy Association of North America Terms and Conditions

Figure 3 Tibial tunnel preparation in all-epiphyseal ACL reconstruction with split tibial tunnel. (A) Lateral radiograph of the left knee of a 9-year-old boy with a complete midsubstance ACL tear. The first tibial guidewire is drilled into the epiphysis under fluoroscopic guidance while the probe is used for triangulation. (B) Arthroscopic view of the same knee through the anterolateral portal. One should note that the tip of the probe is placed at the desired exit point of the guidewire. (C) Arthroscopic view of the same knee through the anterolateral portal. The tip of the guidewire is visualized arthroscopically while entering the knee joint at the medial aspect of the ACL footprint at the level of the free edge of the lateral meniscus. Arthroscopy Techniques 2012 1, e133-e139DOI: (10.1016/j.eats.2012.05.005) Copyright © 2012 Arthroscopy Association of North America Terms and Conditions

Figure 4 Tibial tunnel preparation in all-epiphyseal ACL reconstruction with split tibial tunnel: lateral radiograph (A) and arthroscopic view through the anterolateral portal (B) of the left knee of a 9-year-old boy with a complete midsubstance ACL tear. It should be noted that the second tibial guidewire is placed in a convergent way to the first tibial pin. Arthroscopy Techniques 2012 1, e133-e139DOI: (10.1016/j.eats.2012.05.005) Copyright © 2012 Arthroscopy Association of North America Terms and Conditions

Figure 5 Tibial tunnel preparation in all-epiphyseal ACL reconstruction with split tibial tunnel: lateral radiograph of the left knee of a 9-year-old boy with a complete midsubstance ACL tear. Tibial tunnel drilling begins with the lateral tibial tunnel after the medial guidewire has been pulled back. Arthroscopy Techniques 2012 1, e133-e139DOI: (10.1016/j.eats.2012.05.005) Copyright © 2012 Arthroscopy Association of North America Terms and Conditions

Figure 6 Femoral tunnel preparation in all-epiphyseal ACL reconstruction with split tibial tunnel: lateral radiograph of the left knee of a 9-year-old boy with a complete midsubstance ACL tear after drilling of the femoral tunnel. Arthroscopy Techniques 2012 1, e133-e139DOI: (10.1016/j.eats.2012.05.005) Copyright © 2012 Arthroscopy Association of North America Terms and Conditions

Figure 7 Graft retrieval in all-epiphyseal ACL reconstruction with split tibial tunnel: arthroscopic view of the left knee of a 9-year-old boy with a complete midsubstance ACL tear through the anterolateral portal. One should note the 2 graft limbs lying at the intra-articular end of the femoral tunnel just before their simultaneous advancement into the femur. The 2 tibial tunnels share a common exit point at the articular surface of the tibia. In young children the space available for drilling is limited because of the presence of the growth plate. Thus this is a split–tibial tunnel technique without being a double-bundle ACL reconstruction at the same time. Arthroscopy Techniques 2012 1, e133-e139DOI: (10.1016/j.eats.2012.05.005) Copyright © 2012 Arthroscopy Association of North America Terms and Conditions