儿童骨骺前交叉韧带重建术中关节外外侧手术的隧道位置优化：基于三维模拟的骨骺损伤与安全区域识别研究
简介
该研究通过三维模拟，评估骨骺未闭患者前交叉韧带重建（ACLR）中增加关节外手术（LEAP）时的骨道安全区域。纳入52例10–17岁患者（平均13.1岁）的MRI数据，建立股骨远端及骨骺三维模型，模拟ACL骨道（前外侧AL与直接外侧DL方向）及ALL骨道（4 mm钻头，20 mm深度），量化骨骺损伤体积百分比。关键发现：AL方向ACL骨道面积更大（384 vs…
英文摘要
INTRODUCTION: Lateral extra-articular procedures (LEAP) are increasingly used in anterior cruciate ligament (ACL) reconstruction (ACLR) in patients with open growth plates, reducing graft failure in high-risk populations. This study aimed to determine safe tunnel orientations for epiphyseal ACLR, identify the anterolateral ligament (ALL) position relative to the physis, quantify physeal damage, and define safe zones for LEAP to prevent physeal injury and tunnel collision using three-dimensional (3D) simulation. METHODS: Magnetic resonance images of patients aged 10-17 were analyzed to create 3D models of the distal femur and distal femoral physis (DFP). ACL tunnels were simulated with 8-mm drills from the ACL-femoral insertion in anterolateral (AL) and direct lateral (DL) directions while avoiding lateral structures, the physis, and articular surface. ALL drillings used 4-mm drills with 20-mm depth from the ALL-femoral insertion across a 70° cone. Safe zones were defined as directions where neither the DFP nor ACL tunnel were breached. Physeal injury was quantified as a percentage of total physeal volume. STATISTICAL ANALYSES: Student's t-test, one-way ANOVA, and simple linear regression (p<0.05). RESULTS: 52 knees with open physis (mean age 13.1 years [SD 2], 44.2% female) were obtained. The AL epiphyseal ACL direction showed a larger area (384 vs 219 mm2) and greater drilling length (34 vs 26 mm) than the DL direction. ALL footprints were located between the DFP borders in 58% of cases, with a median distance of 1.74 mm [IQR 2.13] to the DFP center, decreasing with age (p<0.05). Maximum DFP damage with LEAP occurred with horizontal drilling (10°-cephalic, 5°-posterior), resulting in 1.67% [SD 0.78] physeal injury. Optimal safe zone directions for LEAP were 21° distal and 18° anterior for DL approaches and 18° distal and 17° posterior for AL approaches, with AL approaches providing a larger angular area (p<0.05). No other significant differences by age or sex were observed. CONCLUSIONS: This 3D-simulation quantifies physeal damage, establishes safe zones for epiphyseal ACLR, and defines optimal LEAP drilling and fixation orientations. The AL approach provides a wider safe zone and greater drilling length for the epiphyseal ACL tunnel, with the potential to minimize the risk of physeal injury and tunnel collisions during LEAP drilling or fixation. STUDY DESIGN AND LEVEL OF EVIDENCE: Descriptive Laboratory Study; Level V.