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Volumetric Injury of the Distal Femoral Physis During Double-Bundle ACL Reconstruction in ChildrenA Three-Dimensional Study with Use of Magnetic Resonance Imaging
Kevin G. Shea, MD1; Nathan L. Grimm, MD(s)1; Jennifer S. Belzer, MD1
1 Intermountain Orthopaedics, 600 North Robbins Road, Suite 401, Boise, ID 83702. E-mail address for N.L. Grimm: ngrimm@intermountainortho.com
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at Intermountain Orthopaedics, Boise, Idaho

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Jun 01;93(11):1033-1038. doi: 10.2106/JBJS.J.01047
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Double-bundle anterior cruciate ligament (ACL) reconstruction was developed to produce a more "anatomic" reproduction of the anteromedial and posterolateral bundles of the ACL. The purpose of this study was to determine the volume of injury to the physis during double-bundle ACL reconstruction in children with open physes.


Magnetic resonance images (MRIs) of ten knees of children were converted into three-dimensional models. Computer-aided design/computer-aided manufacturing software placed drill-holes of 6, 7, 8, and 9 mm in diameter in these models, simulating tunnels in the femur used for anatomic double-bundle ACL reconstruction. Computer-aided design/computer-aided manufacturing software was used to calculate the total physeal volume and the volume of physis that was removed by creation of the tunnels. The ratio of the physeal volume that had been removed to the total physeal volume was subsequently determined.


With use of 6, 7, 8, and 9-mm-diameter drill-holes in the femur, the average physeal volume removed, as a percentage of the total physeal volume, was 1.5%, 2.0%, 2.5%, and 2.9%, respectively, for the anteromedial tunnels; 2.2%, 2.9%, 3.6%, and 4.2% for the posterolateral tunnels; and 3.7%, 4.8%, 5.7%, and 6.5% for the anteromedial and posterolateral tunnels combined. The volume of physeal damage caused by the posterolateral drill-holes was greater than that produced by the anteromedial drill-holes in all subjects.


Drill-hole placement during ACL reconstruction produces a zone of physeal injury. Double-bundle techniques substantially increase the volume of injury to the physis, which appears to increase the risk of abnormal growth in the distal femoral physis following this surgical procedure.

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    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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