Shea Kevin G, Apel Peter J, Pfeiffer Ronald P, Traughber Paul D
Intermountain Orthopaedics, 600 N. Robbins Road, Ste. 401, Boise, ID 83702, USA.
Knee Surg Sports Traumatol Arthrosc. 2007 Apr;15(4):320-7. doi: 10.1007/s00167-006-0171-1. Epub 2006 Aug 15.
Although the treatment of anterior cruciate ligament (ACL) tears in skeletally immature patients is still controversial, several studies have advocated ACL reconstruction in selected patients to prevent secondary injury. The proximal tibial physis is a structure at risk during ACL reconstruction in young patients, and physeal growth complications have been reported after surgery in this area. The relationship between the ACL and the proximal tibial physeal/apophyseal regions is poorly understood. This study examined the MRI anatomy of the ACL and the proximal tibia apophysis and epiphysis. MRIs of 59 skeletally immature knees were reviewed (Average age = 12.75 years, range 6-15) to define the anatomy of the epiphyseal and apophyseal regions. Measurements were recorded in three parasagittal planes: (1) at the lateral border of the patellar tendon, (2) the lateral edge of the ACL insertion, and (3) the medial edge of the ACL insertion. A single three-dimensional (3D) computed tomography (CT) scan was used to evaluate the position of standard drill holes used in ACL reconstruction to assess for potential degree of injury to the epiphyseal and apophyseal growth plates. In the parasagittal planes, the average height of the epiphysis was 19.6, 20.7, and 21.5 mm at the lateral border of the patellar tendon, the lateral border of the ACL, and the medial border of the ACL, respectively. At the level of the same landmarks, the apophysis extended below the physis at an average of 20.2, 16.8, and 7.0 mm, respectively. Expressed as a percentage of epiphysis height this was an average of 104, 82, and 33%, respectively. Examination of 3D CT images revealed that variations in drill hole placement had effects on the volume of injury to the proximal tibial physis and apophysis. Drill holes that started more medial, distal, and with a steeper angle of inclination reduced the amount of physis and apophysis violated when compared with holes placed more lateral, proximal, and with a shallow angle of inclination. The proximal tibial physis and apophysis is vulnerable to injury by drill hole placement during ACL reconstruction in skeletally immature patients. This paper defines the anatomic relationship of the apophyseal and epiphyseal regions of the physis in the proximal tibia. The volume of injury to the physis can be reduced by avoiding tunnel placement that is too lateral or too proximal on the tibia. A better understanding of these relationships may guide the placement of tibial drill holes, which have a lower risk of producing significant physeal damage.
尽管在骨骼未成熟患者中前交叉韧带（ACL）撕裂的治疗仍存在争议，但多项研究主张对部分患者进行ACL重建以预防继发性损伤。在年轻患者的ACL重建过程中，胫骨近端骨骺是一个有风险的结构，该区域手术后已报告有骨骺生长并发症。ACL与胫骨近端骨骺/骺板区域之间的关系尚不清楚。本研究检查了ACL以及胫骨近端骨骺和干骺端的MRI解剖结构。回顾了59例骨骼未成熟膝关节的MRI（平均年龄 = 12.75岁，范围6 - 15岁）以确定骨骺和干骺端区域的解剖结构。在三个矢状旁平面进行测量：（1）在髌腱外侧缘，（2）ACL插入点外侧缘，以及（3）ACL插入点内侧缘。使用单次三维（3D）计算机断层扫描（CT）来评估ACL重建中使用的标准钻孔位置，以评估骨骺和干骺端生长板的潜在损伤程度。在矢状旁平面中，在髌腱外侧缘、ACL外侧缘和ACL内侧缘处，骨骺的平均高度分别为19.6、20.7和21.5毫米。在相同标志水平处，干骺端分别平均在骨骺下方延伸至其下方20.2、16.8和7.0毫米。以骨骺高度的百分比表示，分别平均为104%、82%和33%。对3D CT图像的检查显示，钻孔位置的变化对胫骨近端骨骺和干骺端的损伤体积有影响。与更外侧、近端且倾斜角度较浅的钻孔相比，起始位置更内侧、远端且倾斜角度更陡的钻孔对骨骺和干骺端的侵犯量减少。在骨骼未成熟患者的ACL重建过程中，胫骨近端骨骺和干骺端容易受到钻孔位置的损伤。本文定义了胫骨近端骨骺的干骺端和骨骺区域的解剖关系。通过避免在胫骨上过于外侧或过于近端的隧道放置，可以减少对骨骺的损伤体积。对这些关系的更好理解可能会指导胫骨钻孔的放置，从而降低产生显著骨骺损伤的风险。
