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Distance to the Neurovascular Bundle for Iliotibial Band Graft Passage During Anterior Cruciate Ligament
Nicholas D Thomas1, Salvador Ayala1, Matthew Rohde1
1Investigation performed at Stanford University School of Medicine, Stanford, California, USA.
Insights
The Micheli technique for pediatric anterior cruciate ligament reconstruction (ACLR) shows neurovascular structures are close to graft passage. Surgeons must consider these small distances to avoid injury during iliotibial band (ITB) graft placement.
Area of Science:
- Orthopedic Surgery
- Pediatric Orthopedics
- Sports Medicine
Background:
- The Micheli technique for anterior cruciate ligament reconstruction (ACLR) is a reliable method for skeletally immature patients, with minimal risk of growth disturbance.
- Increasing incidence of anterior cruciate ligament tears in pediatric population necessitates more ACLR procedures.
Purpose of the Study:
- To evaluate the Micheli technique for iliotibial band (ITB) graft passage in ACLR using cadaveric knee models.
- To measure the proximity of the surgical instrument tip to the peroneal nerve, tibial nerve, and popliteal artery in the posterior knee.
Main Methods:
- Descriptive laboratory study involving gross dissection of 17 pediatric cadaveric knees (ages 4-12).
- Simulated ITB graft passage using a curved-tip hemostat clamp with the knee flexed at 90°-100°.
- Digital imaging software used to measure distances from the clamp tip to posterior neurovascular structures.
Main Results:
- Mean distances from the clamp tip to the tibial nerve, popliteal artery, and peroneal nerve were 0.875 cm, 0.968 cm, and 1.149 cm, respectively.
- Neurovascular structures were found in close proximity (<1 cm in many specimens).
- A statistically significant increase in distance to the peroneal nerve was observed in older pediatric specimens (11-12 years) compared to younger ones (≤8 years).
Conclusions:
- Posterior neurovascular structures are in close proximity to the ITB graft passage path during ACLR using the Micheli technique.
- Surgeons must be cognizant of these small distances to critical neurovascular structures when performing graft passage.
- This study highlights potential risks and emphasizes careful technique during pediatric ACLR.
Background:
The Micheli technique for anterior cruciate ligament (ACL) reconstruction (ACLR) has proven to be a reliable method with a minimal risk for growth disturbance among skeletally immature patients.
Purposes:
To evaluate the Micheli technique of iliotibial band (ITB) graft passage for ACLR using cadaveric knee models and to measure the distance between the surgical instrument tip and the neurovascular bundle in the posterior knee joint: specifically, the peroneal nerve, tibial nerve, and popliteal artery.
Study Design:
Descriptive laboratory study.
Methods:
Gross dissection was performed on 17 pediatric cadaveric knees (12 male and 5 female) aged between 4 and 12 years. To simulate ITB graft passage, we passed a curved-tip hemostat clamp through the posterior capsule, with the knee flexed from 90° to 100°. Next, clinical photographs were taken, and digital imaging software was used to measure the distance in centimeters from the clamp tip to each respective neurovascular structure.
Results:
The mean distances from the clamp tip to the tibial nerve, popliteal artery, and peroneal nerve were 0.875 cm (range, 0.468-1.737 cm), 0.968 cm (range, 0.312-1.819 cm), and 1.149 cm (range, 0.202-2.409 cm), respectively. Mean values were further calculated for age groups of ≤8, 9-10, and 11-12 years. The mean distance from the clamp tip to the peroneal nerve was 1.400 cm larger for 11- to 12-year-old specimens than for ≤8-year-old specimens (95% CI, 0.6-2.2 cm; P = .005).
Conclusion:
The neurovascular structures in the posterior knee were in close proximity to the path of graft passage, with distances <1 cm in many specimens in this study. When passing the graft through the knee for an over-the-top position, surgeons should consider these small distances between the path of graft passage and critical neurovascular structures.
Clinical Relevance:
As the incidence of ACL tears is continuously increasing within the pediatric population, there are a larger number of ACLR procedures being performed. Although neurovascular injuries during ACLR are rare, this study clarifies the close proximity of neurovascular structures during ITB graft passage using the Micheli technique of ACLR.
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