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Anatomic, Transepiphyseal Anterior Cruciate Ligament Reconstruction
Kyle E. Hammond, MD1; John W. Xerogeanes, MD2; Dane C. Todd, MD2
1 Emory Orthopaedics, 704 North Superior Avenue, Decatur, GA 30033. E-mail address: kehammond6@gmail.com
2 Emory Orthopaedic and Spine Center, 59 Executive Park South, Suite 1000, Atlanta, GA 30329. E-mail address for J.W. Xerogeanes: john.xerogeanes@emory.edu. E-mail address for D.C. Todd: dctodd@emory.edu
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Based on an original article: J Bone Joint Surg Am. 2012 Feb 1;94(3):268-76.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
JBJS Essential Surgical Techniques, 2013 Feb 13;3(1):1-11. doi: 10.2106/JBJS.ST.L.00019
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Our technique for physeal-sparing, anatomic anterior cruciate ligament (ACL) reconstruction reliably produces femoral tunnels that are of adequate length and that safely avoid the femoral physis without the addition of time-consuming surgical methods or substantial utilization of fluoroscopy.

Step 1: Preoperative Planning

Obtain radiographs and MRI of the knee as well as an anteroposterior radiograph of the hand (to obtain a bone age).

Step 2: Patient Setup, Portal Placement, and Graft Harvest

The affected knee must be able to flex at least 90° with the end of the operative table lowered, in order to properly visualize the anatomy of the ACL femoral footprint.

Step 3: Prepare ACL Footprint and Establish Far Anteromedial Portal

Maintain soft-tissue remnants at both the femoral and the tibial footprint in order to individualize the anatomy.

Step 4: Identify Extra-Articular Landmarks and Prepare Femoral Tunnel

Visualize and palpate your previously marked popliteal sulcus and lateral epicondyle; these landmarks are the crucial extra-articular points for establishing a safe femoral tunnel.

Step 5: Prepare Tibial Tunnel

The tibial tunnel can be safely drilled in a transphyseal manner in skeletally immature patients.

Step 6: Fix Graft

Use the Arthrex ACL TightRope RT for femoral fixation.

Step 7: Postoperative Care

As a skeletally immature athlete differs from a more mature athlete in several important ways, alter the postoperative protocol accordingly.


Our clinical experience has corresponded to our MRI-based findings from our original study14, and we have not observed any physeal or chondral injuries leading to growth disturbances from our femoral tunnels.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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