1、未成年人交叉韧带重建 Cruciate Ligament Reconstruction in Skeletally Immature Patients,广东省中医院二沙岛分院骨科 许树柴 黄泽鑫,为什么要重建未成年人完全断裂的前交叉？循证医学证据,1.半月板损伤 meniscus injury 2.软骨损伤 cartilage damage 3.保守治疗是无赖之举4.儿童/少年制动是一件难事,All-Epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Surgical T
2、echnique Using a Split Tibial Tunnel,Many techniques have been described for anterior cruciate ligament (ACL) reconstruction in skeletally immature patients including physeal-sparing techniques（骨骺保护技术） , And extra-articular（关节外技术）, complete or partial transphyseal（通过骨骺技术）,Marios G.Lykissas, M.D., Ph
3、.D., Address correspondence to Eric J. Wall, M.D., Division of Orthopaedic Surgery, Cincinnati Childrens Hospital Medical Center, 3333 Burnet Ave, MLC 2017, Cincinnati, OH 45229, U.S.A.,An all-epiphyseal quadruple-hamstring ACL reconstruction using a split tibial tunnel. 全骨骺内，股薄肌/半腱肌分开通过胫骨隧道,The spl
4、it tibial tunnels drop the tunnel size down to 4.5 to 5.5 mm because only half the total graft diameter passes through each of the split tunnels. This increases the safety margin for keeping the tunnel within the tibial epiphysis, in addition to avoiding damage into the growth plate.,Modified all-ep
5、iphyseal ACL reconstruction. (A) A femoral tunnel and a split tibial tunnel are placed entirely within the distal femoral and proximal tibial epiphysis, respectively. (B) A biocomposite interference screw (Matryx) is used to fix the graft into the femoral tunnel. A 1-cm bone bridge between the 2 tib
6、ial tunnels is maintained. (C) 中间1CM的骨桥保护Lateral illustration of the all-epiphyseal technique showing the correct position of the femoral tunnel in the lateral plane, as well as the looped end of the graft around the anteromedial tibial epiphysis.,Graft preparation in all-epiphyseal ACL reconstructi
7、on with split tibial tunnel. The proximal end of the gracilis is sewn to the thin distal end of the semitendinosus with a whipstitch and vice versa by use of No. 2 FiberLoop sutures. (两端缝合，中央不缝) The central 12 cm of the doubled graft is left free of suture. The doubled tendons are folded over, and V
8、icryl suture is looped around the midpoint of the graft. The tendons are then placed under 10 lb of tension for 20 minutes on the back table with the use of the GraftMaster device. 中央12CM不缝合。,Tibial tunnel preparation in all-epiphyseal ACL reconstruction with split tibial tunnel. (A) . The first tib
9、ial guidewire is drilled into the epiphysis under fluoroscopic guidance while the probe is used for triangulation（三角）. (B) Arthroscopic view of the same knee through the anterolateral portal. One should note that the tip of the probe is placed at the desired exit point of the guidewire. (C) Arthrosc
10、opic view of the same knee through the anterolateral portal. The tip of the guidewire is visualized arthroscopically while entering the knee joint at the medial aspect of the ACL footprint at the level of the free edge of the lateral meniscus.,Tibial tunnel preparation in all-epiphyseal ACL reconstr
11、uction with split tibial tunnel: lateral radiograph (A) and arthroscopic view through the anterolateral portal (B). It should be noted that the second tibial guidewire is placed in a convergent（趋集于一点） way to the first tibial pin.,Tibial tunnel preparation in all-epiphyseal ACL reconstruction with sp
12、lit tibial tunnel: lateral radiograph of the left knee of a 9-year-old boy with a complete midsubstance ACL tear. 胫骨隧道准备，9岁的男孩，ACL体部全断裂，术中X机透视 Tibial tunnel drilling begins with the lateral tibial tunnel after the medial guidewire has been pulled back.,Femoral tunnel preparation in all-epiphyseal AC
13、L reconstruction with split tibial tunnel: lateral radiograph of the left knee of a 9-year-old boy with a complete midsubstance ACL tear after drilling of the femoral tunnel. 一个9岁的前交叉韧带全断裂的男孩，C臂机证实股骨定位点及隧道未损伤生长板,Graft retrieval in all-epiphyseal ACL reconstruction with split tibial tunnel: arthrosco
14、pic view through the anterolateral portal. One should note the 2 graft limbs lying at the intra-articular end of the femoral tunnel just before their simultaneous advancement into the femur. The 2 tibial tunnels share a common exit point at the articular surface of the tibia. In young children the s
15、pace available for drilling is limited because of the presence of the growth plate. Thus this is a splittibial tunnel technique without being a double-bundle ACL reconstruction at the same time. 这是一个胫骨隧道分开技术，但并不是一个双束双隧道技术,Advantages, Risks/Limitations, Tips, and Pearls of All-Epiphyseal ACL Reconstr
16、uction Using Split Tibial Tunnel,栓系,Table 2. Indications and Contraindications of All-Epiphyseal ACL Reconstruction Using Split Tibial Tunnel,全骨骺内分叉技术的适宜症与反指征,Video 1. The all-epiphyseal ACL reconstruction begins with the insertion of a 2.4-mm guide pin percutaneously through the lateral femoral con
17、dyle from outside in with the Arthrex femoral cobra RetroDrill guide. The accurate position of the guide pin is confirmed fluoroscopically in both anteroposterior and lateral planes. The femoral tunnel is reamed over the guide pin with an appropriate-size drill. The first tibial guide pin is drilled
18、 into the epiphysis under fluoroscopic guidance while the probe is used for triangulation. A second guide pin is placed about 1.5 cm more medially in the proximal tibial epiphysis and directed so that it converges with the first guide pin. The second guide pin is also drilled within the epiphysis. T
19、he accurate position of both guide pins is confirmed fluoroscopically, and the tibial tunnels are reamed. By use of 2 looped 22-gauge wires that are placed through the femoral tunnel and retrieved through the tibial tunnels, the individual doubled graft limbs are advanced independently through the t
20、ibial tunnels to the intra-articular end of the femoral tunnel. Then, the graft limbs are pulled up through the femoral tunnel simultaneously, and the graft is fixed with a Matryx biocomposite interference screw while the knee is positioned in approximately 30 of flexion.,手术操作视频,All-Epiphyseal Anter
21、ior Cruciate Ligament Reconstruction,All-Epiphyseal, All-Inside Anterior Cruciate Ligament Reconstruction Technique for Skeletally Immature Patients,The graft is a quadrupled semitendinosus autograft secured with 2 TightRope RT devices in the GraftLink technique. Graft length is between 50 and 55 mm
22、, with a diameter between 7 and 8 mm. The graft is tensioned at 20 lb for 5 minutes.,Moira M.McCarthy, M.D. Address correspondence to Moira M. McCarthy, M.D., Hospital for Special Surgery, 535 E 71st St, New York, NY 10021, U.S.A.,The femoral footprint 股骨韧带足迹is debrided while the surgeon is viewing
23、with arthroscopes using both 70 and 30 lenses from the anterolateral portal. This is a view using the 70 lens. The tunnel is planned for the center of the femoral footprint, approximately 2 to 3 mm from the back wall. (B) The tunnel is drilled by first placing the outside-in femoral guide through th
24、e anterolateral portal. Once the appropriate position is verified by fluoroscopy, the FlipCutter is opened and the tunnel is drilled retrograde while the surgeon is viewing with either a 30 or 70 arthroscope from the anteromedial portal. (C) The tunnel, viewed from the anterolateral portal, with a b
25、one bridge to the lateral cortex of at least 7 mm, is tagged with a FiberStick for later graft passage.,特殊的操作工具，从关节内向关节外钻隧道，保证皮质7MM厚度。,The tibial footprint, as viewed through the anterolateral portal with a 70 arthroscope, is debrided. The tunnel is planned for the center of the tibial footprint. Ag
26、ain, the FlipCutter is drilled from outside in completely within the epiphysis. Once appropriate position is confirmed by fluoroscopy on the anteroposterior and lateral views, the FlipCutter is opened and the tunnel is drilled antegrade. (B) Views of the tibial tunnel from the anterolateral portal u
27、sing a 70 arthroscope. The guide is malleted 球棍through the cortex to ensure a bone bridge of at least 7 mm between the graft and the suture button.,特殊的操作工具，从关节内向关节外钻隧道，保证皮质7MM厚度。,Views of intra-articular portion of all-epiphyseal ACL reconstruction from anterolateral portal.,Radiographs of all-epiph
28、yseal ACL reconstruction and fixation with GraftLink RT.,Sports Med Arthrosc Rehabil Ther Technol.2011;3: 7.Published online 2011 April 8.Anterior cruciate ligament reconstruction using quadriceps tendon autograft for adolescents with open physes- a technical note Christian Mauch,1 Markus P,骨骺保护技术,B
29、ackgroundOne major concern in the treatment of ACL lesions in children and adolescents with open physes is the risk of iatrogenic damage to the physes and a possibly resulting growth disturbance.PurposeThe primary purpose of this article is to describe our technique of a transphyseal ACL reconstruct
30、ion using quadriceps tendon-bone autograft in children and adolescents with open growth plates. The secondary aim is to report our early results in terms of postoperative growth disturbances which are considered to be a major concern in this challenging group of patients. It was our hypothesis that
31、with our proposed technique no significant growth disturbances would occur.ConclusionsThe described ACL reconstruction technique represents a promising alternative to previously described procedures in the treatment of children and adolescents with open growth plates. Using quadriceps tendon future
32、graft availability is not compromised, as the most frequently used autograft-source, ipsilateral hamstring tendons, remains untouched.,Schematic drawing of an example of a physeal sparing ACL reconstruction technique in patients with open physes. 骨骺开放的骨骺保护技术，隧道重建技术 Transphyseal techniques, establish
33、 their tibial and/or femoral tunnels by transphyseal drilling, and are either named as partial (only tibial) or complete (tibial and femoral) dependent whether all or only one physes is drilled through Chotel described a partial transphyseal technique using quadriceps tendon autograft being placed e
34、xtraarticular under the lateral femoral condyle and attached intraarticular through a transphyseal tibial tunnel which leaves the femoral physis untouched,At least 7 cm long quadriceps tendon autograft is harvested, shaped and then armed with two non resorbable sutures on the bone and tendon end.,In
35、traoperative arthroscopic images of the proposed transphyseal surgical ACL reconstruction technique using quadriceps tendon autograft in patients with open physes. A The intercondylar notch and femoral attachment areas were cleaned using a shaver blade.,Illustration showing the described transphysea
36、l surgical ACL reconstruction technique using quadriceps tendon autograft in patients with open physes.,Postoperative treatment An early functional rehabilitation program with passive range of motion training, electrical muscle stimulation and closed chain quadriceps and hamstring exercises was init
37、iated. For a maximum of two weeks ambulation with full weight bearing was only allowed in full extension. Passive range of motion on a continuous passive motion machine was initiated on day one after surgery. During 8 weeks the patient was mobilised in an extension brace. Sports activity was initiat
38、ed 6 months postoperatively, cutting and pivoting sport nine months postoperatively.,术后康复计划,Patrick N.Siparsky和Mininder S.Kocher教授认为，由于未成年人较差的依从性，对于未成年人的手术治疗，康复计划的完善化尤为重要对于术后康复计划Christian Mauch教授的做法是，早期的机能康复治疗方案包括被动型的运动训练、肌肉电刺激以及股四头肌和腘绳腱的闭链运动。最多两个星期内，关节在完全伸展的情况下开始进行全负重的主动活动，如下蹲和站立。手术后的第一天就要求开始在持续的被动
39、运动机上进行被动康复运动，8周内动员病人用支撑架进行活动，手术后六个月开始开展运动，手术后九个月开始剧烈运动和旋转运动。,Progressive valgus and flexion deformity of a patient after QT ACL reconstruction and after distal femoral varisation osteotomy. 儿童膝关节韧带重建后发生外翻及屈曲畸形，髁上截骨矫形。,The early localized growth stop was attributed to a malplacement of the autograft
40、bone block within the femoral posterolateral epiphyseal plate. The femoral bone block was placed to high in the notch damaging the femoral growth plate.,并发症,未成年人的前交叉韧带重建术主要的并发症在于半月板及骨骺的损伤，从而造成的生长抑制和成角畸形。 并发症主要包括，移植物的固定装置过于靠近或穿过骨骺，隧道没有被移植物充分的填充而形成骨桥，隧道位置不正等。 P.Vavken和M.M.Murray统计了47篇符合要求的文献，共585位前交叉韧
41、带重建术后的未成年患者得到至少6个月的随访，其中479位患者采用了至少1个跨骨骺型隧道的方法，有3位患者出现了成角畸形，2位患者出现双下肢不等长。另外106名患者采用了骨骺保护型重建术，并没有发现有生长障碍。,1.0骨骺保护技术,Investigation performed at the Division of Sports Medicine, Department of Orthopaedic Surgery, Childrens Hospital, Harvard Medical School, Boston, Massachusetts The original scientific
42、article in which the surgical technique was presented was published in JBJS Vol. 87-A, pp. 2371?379, November 2005Mininder S. Kocher, MD, MPHmininder.kocherchildrens.harvard.eduSumeet Garg, MDDepartment of Orthopaedic Surgery, Washington University Orthopaedic Residency Program, One Barnes Hospital
43、Plaza, St. Louis, MO 63110,J Bone Joint Surg Am 2006; 88-A; 283-93,2.0关节外技术,BACKGROUND: The management of anterior cruciate ligament injuries in skeletally immature patients is controversial. Conventional adult reconstruction techniques risk potential iatrogenic growth disturbance due to physeal dam
44、age. The purpose of this study was to evaluate the results of a physeal sparing, combined intra-articular and extra-articular reconstruction technique in prepubescent skeletally immature children. METHODS: Between 1980 and 2002, forty-four skeletally immature prepubescent children and adolescents wh
45、o were in Tanner stage 1 or 2 (with a mean chronological age of 10.3 years) underwent physeal sparing, combined intra-articular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft. Twenty-seven patients had additional meniscal surgery.
46、 Functional outcome, graft survival, radiographic outcome, and growth disturbance were evaluated at a mean of 5.3 years after surgery. CONCLUSIONS: Physeal sparing, combined intra-articular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band
47、 graft in skeletally immature prepubescent children and adolescents provides excellent functional outcome with a low revision rate and a minimal risk of growth disturbance.,2.0关节外技术,INDICATIONS: A complete midsubstance tear of the anterior cruciate ligament in a prepubescent child (Tanner stage 1 or
48、 2) for whom nonoperative treatment consisting of rehabilitation, bracing, and activity restriction has failed (). These patients have symptoms related to knee pivoting or further meniscal or chondral injury related to instability. CONTRAINDICATIONS: Pubescent adolescents (Tanner stage 3). Such pati
49、ents should be treated with transphyseal reconstruction with autogenous hamstring tendons and fixation away from the growth plate (). Proximal tears of the anterior cruciate ligament, which are amenable to primary repair, and distal tibial spine fractures, which are treated with arthroscopic reduction and internal fixation. child who will not cooperate with postoperative rehabilitation.,
