Johnston Tyler Robert, Hu Jessica, Gregory Bonnie, Liles Jordan, Riboh Jonathan
Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A.
Arthrosc Tech. 2020 Aug 7;9(8):e1121-e1131. doi: 10.1016/j.eats.2020.04.012. eCollection 2020 Aug.
Significant controversy exists regarding the optimal surgical technique for anterior cruciate ligament (ACL) reconstruction in adolescents with 1 to 3 years of skeletal growth remaining. Graft choice and physeal injury remain primary concerns given significantly elevated rates of failure of hamstring autograft reconstructions in this population, as well as risks of leg-length discrepancy and growth axis deviation. Traditional (more vertical) transtibial drilling of the femoral tunnel can reduce risks of physeal injury but has been shown to have less accuracy restoring the native femoral ACL footprint and associated incomplete knee stabilization. On the other hand, anteromedial and outside-in drilling yields improvements in the tunnel location and biomechanics but at the cost of a more oblique trajectory and greater risk of physeal injury. A hybrid transtibial pin technique using a Pathfinder guide facilitates femoral drilling with the "best of both worlds," allowing for reproduction of the native ACL footprint and a more physeal-respecting femoral tunnel. When combined with an all-soft tissue quadriceps tendon autograft and suspensory fixation, the hybrid transtibial method yields a reliable, safe, and robust construct with promising results for the young athlete. We describe our preferred graft harvest, tunnel drilling, and fixation techniques to minimize physeal risks and optimize outcomes.
对于骨骼生长还剩1至3年的青少年，前交叉韧带（ACL）重建的最佳手术技术存在重大争议。鉴于该人群中腘绳肌自体移植重建失败率显著升高，以及腿长差异和生长轴偏差的风险，移植物选择和骨骺损伤仍是主要关注点。传统的（更垂直的）经胫骨股骨隧道钻孔可降低骨骺损伤风险，但已证明在恢复天然股骨ACL足迹方面准确性较低，且膝关节稳定不完全。另一方面，前内侧和由外向内钻孔在隧道位置和生物力学方面有所改善，但代价是轨迹更倾斜，骨骺损伤风险更大。使用Pathfinder导向器的混合经胫骨销技术有助于股骨钻孔，兼具两者优点，可重现天然ACL足迹并形成更尊重骨骺的股骨隧道。当与全软组织股四头肌肌腱自体移植和悬吊固定相结合时，混合经胫骨方法可产生可靠、安全且稳固的结构，为年轻运动员带来有前景的结果。我们描述了我们首选的移植物获取、隧道钻孔和固定技术，以尽量减少骨骺风险并优化结果。
