Editorial Commentary: The All-Epiphyseal Anterior Cruciate Ligament Distal Femoral Approach: Sockets or Tunnels?

Abstract

I believe that the distal femoral approach for anterior cruciate ligament reconstruction in the skeletally immature athlete with 3 to 6 years of remaining growth is best performed with an all-inside, all-epiphyseal technique using sockets rather than an outside-in approach creating tunnels. A shorter socket rather than a longer tunnel exposes a smaller surface area of the lateral distal femoral physis to potential compromise and resultant valgus malalignment. In addition, exiting the lateral femoral aspect of the epiphysis with a full-diameter tunnel as compared with a smaller diameter drill hole used to prepare a socket places the posterior articular cartilage, the lateral collateral ligament and anterolateral ligament footprints, and the popliteus tendon insertion at risk. My preference for sockets is also related to my belief that they provide a superior biologic milieu for graft incorporation compared with a full-length tunnel with the attendant violation of the lateral femoral cortex of the epiphysis.

Return to Sport and Reoperation Rates in Patients Under the Age of 20 After Primary Anterior Cruciate Ligament Reconstruction: Risk Profile Comparing 3 Patient Groups Predicated Upon Skeletal Age

“…15 The Greulich and Pyle method has traditionally been used to assess skeletal age, and more recently the Shorthand Bone Age Assessment has been introduced to simplify this determination; the current series of athletes were evaluated with the Shorthand Bone Age Assessment. 20 The menu of surgical options include the modified MacIntosh popularized by Kocher et al 26 and the transepiphyseal reconstruction originally described by Anderson 2,3 and more recently modified and referred to as the AE reconstruction, 10,11,31,33 the PTP reconstruction, 32 and the CT reconstruction. 6,27 A recent review of current concepts provided a proposed treatment guideline for selecting 1 of these options predicated upon skeletal age.…”

“…Based on the skeletal age and growth remaining, these techniques can be broken down into 3 categories: physeal sparing with a combined intra-articular and extra-articular reconstruction (modified MacIntosh) 26,44 and all-epiphyseal reconstruction 2,3,10-12,31,33 for prepubescent patients with significant growth remaining, partial or complete transphyseal reconstruction for young adolescents, 6,27,32 and adult reconstruction techniques such as bone-tendon-bone autograft for older adolescents at or near skeletal maturity. 13,15,23…”

“…This information is then used to determine which reconstruction technique is most appropriate to diminish the potential for growth disturbances, including leg-length discrepancy and angular deformity. 15 Based on the skeletal age and growth remaining, these techniques can be broken down into 3 categories: physeal sparing with a combined intra-articular and extra-articular reconstruction (modified MacIntosh) 26,44 and all-epiphyseal reconstruction 2,3,[10][11][12]31,33 for prepubescent patients with significant growth remaining, partial or complete transphyseal reconstruction for young adolescents, 6,27,32 and adult reconstruction techniques such as bone-tendon-bone autograft for older adolescents at or near skeletal maturity. 13,15,23 ACLR techniques for the skeletally immature population have shown reasonable outcomes with minimal complications, 2,7,[11][12][13]26,27,35 although second-surgery rates are highest and RTS rates are lowest among these young athletes.…”