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Modified Macintosh Extra-Articular Anterior Cruciate Ligament Reconstruction in a 6-Year-Old Patient
Diego Costa Astur1,2, José Ricardo Dantas Moura Costa1, Joicemar Tarouco Amaro1
1Hospital Israelita Albert Einstein, São Paulo, Brazil.
Insights
This study presents an extra-articular anterior cruciate ligament (ACL) reconstruction technique using the iliotibial band for skeletally immature patients. The technique successfully restored knee function and allowed a return to sports, avoiding growth plate disruption.
Area of Science:
- Orthopedic Surgery
- Pediatric Sports Medicine
- Biomedical Engineering
Background:
- Anterior cruciate ligament (ACL) injuries are increasingly common in children.
- Surgical reconstruction is becoming more indicated due to a better understanding of immature skeletal anatomy.
- Historically, non-surgical management was preferred for pediatric ACL injuries.
Purpose of the Study:
- To describe an extra-articular ACL reconstruction technique for skeletally immature patients.
- To evaluate the efficacy of this technique in restoring knee function and enabling return to sports.
- To highlight the advantages of avoiding growth plate disruption in pediatric ACL surgery.
Main Methods:
- An extra-articular technique using the iliotibial band was performed for ACL reconstruction.
- The graft was positioned 'over-the-top' of the lateral femoral condyle and fixed to the anterior tibial cortex.
- The procedure preserved the tibial physis to avoid growth plate injury.
Main Results:
- The patient was asymptomatic and able to perform daily activities and return to sports six months post-surgery.
- Clinical evaluation showed functional knee parameters comparable to the uninjured knee.
- Radiographic and MRI studies confirmed good graft positioning and no bone abnormalities.
Conclusions:
- Extra-articular ACL reconstruction with the iliotibial band is a viable option for skeletally immature patients.
- This technique effectively restores knee function and allows for a safe return to athletic activities.
- The decision for surgical technique in pediatric ACL reconstruction should consider patient-specific factors.
Background:
Anterior cruciate ligament (ACL) injury in children is an increasingly common occurrence. Historically, nonsurgical treatment has been the main treatment option; however, the indication for surgical reconstruction is increasing, as the histological characteristics of the immature skeleton are better known.
Indications:
The extra-articular surgical technique for ACL reconstruction is a good option for Tanner I patients, aged up to 8 years, with knee instability and recurrent pain. Its advantage in skeletally immature patients is due to the fact that it avoids the bone growth plates.
Technique Description:
After skin incision and subcutaneous dissection, we isolated the iliotibial band and released the proximal portion of the band. We proceeded with the tubularization of the graft, suturing its edges, and with the aid of radioscopy we marked the top of the lateral femoral condyle. Thus, we transported the graft, in an over-the-top position, to the intercondylar portion of the femur. Femoral fixation is performed by placing the graft close to the lateral femoral condyle. For fixation on the tibia, a second incision is made, preserving the physis, and the graft is fixed to the tibia using an absorbable Swivelock anchor.
Results:
Six months after the surgery, when his physical rehabilitation was completed, the patient was asymptomatic and able to perform his daily activities, and also returned to sports. Clinical evaluation showed a knee with almost the same functional parameters as the uninjured one. Furthermore, radiographic studies showed no bone abnormalities and magnetic resonance image showed a newly reconstructed ligament with good positioning.
Discussion/Conclusion:
According to the literature, surgical treatment seems to be better than conservative treatment in skeletally immature patients. However, there is a continuous discussion about the most appropriate surgical technique. The decision is relative to many specific characteristics for these patients: age, bone age, graft choice, sports modality, and surgeon expertise. In this case, we decide to do an ACL extra-articular reconstruction technique with the iliotibial band over the top in the femoral condyle and fixed in the anterior cortical bone of the tibia.
Patient Consent Disclosure Statement:
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.
