Schumacher Felipe C, Galvão Pedro H S A F, Mameri Enzo S, Credidio Marcos V, Franciozi Carlos E, Kubota Marcelo S
Department of Orthopedics and Traumatology, EPM/UNIFESP, São Paulo, Brazil.
Department of Surgery, Universidade Estadual de Londrina (UEL), Londrina, Brazil.
Video J Sports Med. 2023 Nov 16;3(6):26350254231200591. doi: 10.1177/26350254231200591. eCollection 2023 Nov-Dec.
As there has been an increasing incidence of anterior cruciate ligament (ACL) tears in children and adolescents in the past few decades, nonoperative management is seen to result in less favorable clinical outcomes, resulting in meniscal and cartilage damage, and arthritic changes. Despite the risk of iatrogenic physeal injuries with operative approach, several reconstruction options, such as physeal-sparing techniques for skeletally immature patients, are described to restore joint stability.
We bring a combined extra-articular and intra-articular ACL reconstruction technique using autogenous iliotibial band (ITB), which is indicated for prepubescent patients (Tanner stages 1 or 2) with open physes, significant growth potential (≤11 years for girls and ≤12 years for boys) and smaller knees, where an all-epiphyseal ACL reconstruction would lack epiphyseal space.
The technique consists of a modified MacIntosh intra-articular and extra-articular ITB reconstruction, described by Micheli and further characterized by Kocher. The central portion of the ITB is harvested proximally (at least 15 cm) and left attached to Gerdy's tubercle distally. The harvested graft is brought from over-the-top posteriorly and passed under the intermeniscal ligament anteriorly through an epiphyseal groove on the tibia.
The outcomes shown for the Kocher ITB ACL reconstruction technique are favorable at a mean follow-up of 5.3 years: from 44 patients, 41 returned to sports involving cutting or pivoting, and the revision rate was low at 4.5%.
DISCUSSION/CONCLUSION: The awareness of physeal injury related to the operative treatment of ACL tears in the pediatric population has resulted in several physeal-sparing and physeal-respecting techniques of reconstruction. Some of these have shown to reduce the risk of physeal damage, maintaining stability and providing excellent functional outcomes, with low revision rates in long-term follow-up and minimal risk of growth disturbance.
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
在过去几十年中，儿童和青少年前交叉韧带（ACL）撕裂的发生率不断上升，非手术治疗的临床效果较差，会导致半月板和软骨损伤以及关节炎改变。尽管手术方法存在医源性骨骺损伤的风险，但仍有几种重建选择，如针对骨骼未成熟患者的保留骨骺技术，可恢复关节稳定性。
我们采用一种自体髂胫束（ITB）联合关节外和关节内ACL重建技术，该技术适用于青春期前（坦纳分期1或2）、骨骺未闭、有显著生长潜力（女孩≤11岁，男孩≤12岁）且膝关节较小的患者，在这些患者中，全骨骺ACL重建会缺乏骨骺空间。
该技术包括改良的MacIntosh关节内和关节外ITB重建，由Micheli描述，Kocher进一步阐述其特点。ITB的中央部分在近端采集（至少15厘米），远端仍附着于Gerdy结节。采集的移植物从后上方经“过顶”位置引出，向前穿过胫骨上的骨骺沟，从半月板间韧带下方通过。
Kocher ITB ACL重建技术在平均5.3年的随访中显示出良好的效果：44例患者中，41例恢复了涉及急停或变向的运动，翻修率低至4.5%。
讨论/结论：对儿童人群ACL撕裂手术治疗相关骨骺损伤的认识促使了几种保留骨骺和尊重骨骺的重建技术的出现。其中一些技术已显示出可降低骨骺损伤风险，维持稳定性并提供良好的功能结果，长期随访中翻修率低，生长障碍风险最小。
作者证明已获得本出版物中出现的任何患者的同意。如果个体可能被识别，作者已随本投稿附上患者的豁免声明或其他书面批准形式以供发表。
