Improved epiphyseal socket placement with intraoperative 3D fluoroscopy: a consecutive series of pediatric all-epiphyseal anterior cruciate ligament reconstruction.

ABSTRACT

PURPOSE: Disturbance of the growth plate during all-epiphyseal anterior cruciate ligament reconstruction (ACLR) socket placement is possible due to the undulation of the distal femoral physis and proximal tibial physis. Therefore, it is important to obtain intraoperative imaging of the guide wire prior to reaming the socket. The purpose of this study was to investigate the effect of the use of 3D intraoperative fluoroscopy on socket placement in patients undergoing all-epiphyseal ACLR. It was hypothesized that 3D imaging would allow for more accurate intraoperative visualization of the growth plate and hence a lower incidence of growth plate violation compared to 2D imaging. METHODS: Patients under the age of 18 who underwent a primary all-epiphyseal ACL reconstruction by the senior authors and had an available postoperative MRI were retrospectively reviewed. Demographic data, surgical details, and the distances between the femoral socket and distal femoral physis (DFP) and tibial socket and proximal tibial physis (PTP) were recorded. Patients were split into two groups based on type of intraoperative fluoroscopy used a 2D group and a 3D group. Interrater reliability of radiographic measurements was evaluated using intraclass correlation coefficient (ICC). RESULTS: Seventy-two patients fit the inclusion criteria and were retrospectively reviewed. 54 patients had 2D imaging and 18 patients had 3D imaging. The mean age at time of surgery was 12.3 ± 1.5 years, 79% of patients were male, and 54% tore their left ACL. The mean time from surgery to postoperative MRI was 2.0 ± 1.1 years. The ICC was 0.92 (95% CI 0.35-0.98), indicating almost perfect interrater reliability. The mean difference in distance between the tibial socket and the PTP was significantly less in the 2D imaging group than the 3D imaging group (1.2 ± 1.7 mm vs 2.5 ± 2.2 mm, p = 0.03). The femoral and tibial sockets touched or extended beyond the DFP or PTP, respectively, significantly less in the 3D group than in the 2D group (11% vs 43%, p < 0.000, 17% vs 65%, p < 0.000). CONCLUSION: There was a significantly increased distance from the PTP and decreased incidence of DFP violation with use of 3D intraoperative imaging for all-epiphyseal ACLR socket placement. Surgeons should consider utilizing 3D imaging prior to creating femoral and tibial sockets to potentially decrease the risk of physis violation in these patients. LEVEL OF EVIDENCE III.