Aylyarov Alexandr, Tretiakov Mikhail, Walker Sarah E, Scott Claude B, Hesham Khalid, Maheshwari Aditya V
Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY, USA.
Indian J Orthop. 2018 Sep-Oct;52(5):513-521. doi: 10.4103/ortho.IJOrtho_381_17.
Pediatric intrasubstance anterior cruciate ligament (ACL) tears have a significant epidemiologic impact as their numbers continue to grow globally. This review focuses on true pediatric intrasubstance ACL tears, which occur >400,000 times annually. Modifiable and non-modifiable risk factors include intercondylar notch width, ACL size, gender, landing mechanisms, and hormonal variations. The proposed mechanisms of injury include anterior tibial shear and dynamic valgus collapse. ACL tears can be associated with soft tissue and chondral defects. History and physical examination are the most important parts of evaluation, including the Lachman test, which is considered the most accurate physical examination maneuver. Imaging studies should begin with AP and lateral radiographs, but magnetic resonance imaging is very useful in confirming the diagnosis and preoperative planning. ACL injury prevention programs targeting high risk populations have been proven to reduce the risk of injury, but lack uniformity across programs. Pediatric ACL injuries were conventionally treated nonoperatively, but recent data suggest that early operative intervention produces best long term outcomes pertaining to knee stability, meniscal tear risk, and return to previous level of play. Current techniques in ACL reconstruction, including more vertically oriented tunnels and physeal sparing techniques, have been described to reduce the risk of physeal arrest and limb angulation or deformity. Data consistently show that autograft is superior to allograft regarding failure rate. Mean durations of postoperative therapy and return to sport were 7 ± 3 and 10 ± 3 months, respectively. These patients have good functional outcomes compared to the general population yet are at increased risk of additional ACL injury. Attempts at primary ACL repair using biological scaffolds are under investigation.
小儿实质性前交叉韧带（ACL）撕裂在全球范围内的发病率持续上升，对流行病学产生了重大影响。本综述聚焦于真正的小儿实质性ACL撕裂，其每年发生次数超过40万次。可改变和不可改变的风险因素包括髁间切迹宽度、ACL大小、性别、着地机制和激素变化。提出的损伤机制包括胫骨前剪切力和动态外翻塌陷。ACL撕裂可能与软组织和软骨缺损相关。病史和体格检查是评估的最重要部分，包括Lachman试验，该试验被认为是最准确的体格检查手法。影像学检查应首先进行前后位和侧位X线片，但磁共振成像在确诊和术前规划中非常有用。针对高危人群的ACL损伤预防计划已被证明可降低损伤风险，但各计划缺乏一致性。小儿ACL损伤传统上采用非手术治疗，但最近的数据表明，早期手术干预在膝关节稳定性、半月板撕裂风险和恢复到先前运动水平方面能产生最佳的长期效果。目前ACL重建技术，包括更垂直定向的隧道和保留骺板技术，已被描述以降低骺板停滞和肢体成角或畸形的风险。数据一致表明，在失败率方面自体移植物优于同种异体移植物。术后治疗的平均持续时间和恢复运动的时间分别为7±3个月和10±3个月。与普通人群相比，这些患者功能结局良好，但再次发生ACL损伤的风险增加。使用生物支架进行原发性ACL修复的尝试正在研究中。
