2012年北美31屆AANA關節鏡年會就是在這家酒店（11.8-12）舉行的。（地址：美國ARIZONA州的鳳凰城萬豪沙漠邊酒店，在這裡上不著天，下不著地，丘陵地帶，想偷懶學分又拿不到，只有呆呆的學習，聽美國關節鏡方面的大師輪潘轟炸，期間一對一的屍體操練。）廣東省中醫院骨科許樹柴
Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients
為什麼要重建未成年人完全斷裂的前交叉？循證醫學證據支持。如果不做重建，會有如下結果：
• 1.半月板損傷meniscal damage
• 2.軟骨損傷and cartilage destruction
• 3.保守治療是無賴之舉(a last resort)
目前的治療方法：
Many techniques have been described for anterior cruciate ligament (ACL) reconstruction in skeletally immature patients.
including extra-articular{關節外非解剖替代方法};
complete or partial transphyseal<完全或部分通過骨骺技術>;
and physeal-sparing techniques《骨骺保護技術》.
An all-epiphyseal technique places the tendon and its tunnels and fixation all within the child's epiphysis, leaving the growth plates untouched.
未成年狗各種手術方法的模型結果：動物實驗結果Canines(From：Vol 23 (12):1309-1319,2007,The Journal of arthroscopic and related surgery.)
美國HSS醫院資金支持；
方法：25周的狗，分三組，股骨側骺內，過頂，及通過骺板。16周後處死動物做。
研究內容：MRI，大體形態，對照側肢體形態，旋轉，韌帶成功，骨骺損傷，軟骨損傷等
結果： 任何方法都不特別推薦。
未成年人膝關節前交叉韌帶重建的治療建議:
We advocate a treatment algorithm for anterior cruciate ligament insufficiency in skeletally immature patients based on the amount of growth remaining, which can be evaluated most accurately with an assessment of physiological age, skeletal age, growth velocity, and the growth of other family members. Chronological age alone may be a poor guide to the amount of growth remaining because of large variations in skeletal and physiological maturity.
In older adolescents approaching skeletal maturity with minimal growth remaining (Tanner stage 4), adult-type reconstruction of the anterior cruciate ligament with a variety of grafts (autogenous hamstrings, autogenous patellar tendon, or allograft) and a variety of fixation methods (interference screws, transfixation pins, or cortical fixation) are likely acceptable, since, with minimal growth remaining, the consequences of an iatrogenic growth disturbance are minimal.
In prepubescent children with a large amount of growth remaining (Tanner stage 1 or 2), we perform a previously described physeal-sparing combined intra-articular and extra-articular reconstruction with an autogenous iliotibial band, since this minimizes the risk of an iatrogenic growth disturbance, which would have major consequences in these very young children.
In pubescent adolescents with growth remaining (Tanner stage 3), we perform the technique described in this study.
未成年人膝關節韌帶重建的治療Conclusion:
We advocate a treatment algorithm for skeletally immature patients with anterior cruciate ligament insufficiency based on the amount of growth remaining, as determined according to three categories: prepubescent children with substantial growth remaining, pubescent adolescents with a variable amount of growth remaining, and older adolescents approaching skeletal maturity with minimal growth remaining. 應該根據不同的年齡（不僅僅是年齡），生長潛力，家庭其他成員，個體情況等制定不同的手術方式。充分考慮各種手術的潛在優點與可能傷害。
On the basis of our findings, Transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft with metaphyseal fixation is a reasonable treatment option for skeletally immature pubescent patients with a variable degree of growth remaining. （如圖所示可見一點點）
（圖片FROM：Sports Med Arthrosc Rehabil Ther Technol. 2011; 3: 7.
Published online 2011 April 8. doi: 10.1186/1758-2555-3-7）
最近的另一篇報道：
From:Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients With Transphyseal Tunnels .
Lauren H. Redler, Rebecca T. Brafman, Natasha Trentacosta, Christopher S. Ahmad
The Journal of Arthroscopic and Related Surgery Vol. 28, Issue 11, Pages 1710-1717 。November 2012 。
Purpose
Our purpose was to evaluate the results of transphyseal anterior cruciate ligament (ACL) reconstruction with hamstring autograft in skeletally immature patients.
Methods
Eighteen knees in 18 skeletally immature pubescent patients with a mean chronologic age of 14.2 years underwent transphyseal ACL reconstruction with hamstring autograft between 2002 and 2007. Concurrent meniscal surgery was performed in 9 knees. The final patient evaluation occurred at a mean of 43.4 months (range, 24.0 to 86.6 months) and included physical examination, KT-1000 arthrometry testing (MEDmetric, San Diego, CA), and functional outcome instruments, including the International Knee Documentation Committee subjective knee form, the Lysholm knee score, and the Tegner knee activity scale.
Results
At the latest follow-up, the mean International Knee Documentation Committee subjective knee score was 92.4 ± 10, the mean Lysholm knee score was 94.3 ± 8.8, and the mean Tegner activity scale score was 8.5 ± 1.4. Lachman and pivot-shift testing were negative in all knees. No restriction in knee range of motion of 5° or greater when compared with the contralateral knee was observed in any patient. The mean manual maximum side-to-side difference with KT-1000 testing was 0.29 ± 1.07 mm, and no patients had a difference greater than 3 mm. No angular deformities were noted, and all leg-length measurements were symmetric bilaterally on clinical examination. No patients had traumatic graft disruption or underwent revision ACL reconstruction, whereas 3 patients sustained an ACL injury in the contralateral leg while participating in sports.
Conclusions
Transphyseal ACL reconstruction with autogenous quadrupled hamstring graft with metaphyseal fixation in skeletally immature pubescent patients（千萬注意平均年齡14.2歲呀） yielded excellent functional outcomes in a high percentage of patients without perceived clinical growth disturbance.（千萬不能照本宣科）。
結論：
不少文獻報告了在決定未成年人前交叉韌帶修復的手術方式前，Tanner分期（Tanner stage）在臨床的參照價值。Tanner分期是根據未成年人的外貌特徵用於評估未成年人生長發育狀態的一項標準。醫生制定修復計劃及術式時應考慮兒童發育分期，不能僅僅通過年齡去評估患者所處的生長和發展的階段。最重要是評定患者的骨骼生長空間，如生理年齡、骨骼年齡、生長速率和家庭其他成員的骨骼生長情況等。單一的用某一項指標去評定都可能造成不正確的指引，醫生需要結合以上多種因素，綜合評定後選擇術式。
Christopher C.Kaeding等搜索了1966年到2009年7月中的文獻進行統計，結果表明無論經骨骺型或是骨骺保護型手術都可以在Tanner 2-3期的患者降低骨骺生長併發症的發病率。而Tanner 1期的患者在接受骨骺保護型重建術（關節內/外）後同樣取得很好的臨床效果。相反，在Tanner 1期接受經骨骺型重建術的臨床效果並沒有足夠的文獻支持。對於Tanner 4期的患者，更多傾向於採用經過骨骺型重建術的適應症。對於年齡更大的青少年，骨骼生長已接近成熟，具有很小的生長空間，則可以用接近成年人的重建術去治療。
綜上所述，對於Tanner 1-2期的未成年患者，為了更好的保護患者的骨骺，預防生長抑制和成角畸形的併發症，推薦使用骨骺保護型（關節內/外結合技術）的重建技術進行前交叉韌帶的重建。對於Tanner 3、4期的未成年患者，趨向於使用經骨骺型的重建技術，並且使脛骨隧道儘量中央化，手術的細節也極為重要，術中及固定時注意保護骨骺。對於Tanner 5期的患者，骨骺接近閉合，則使用更接近於成年人的重建技術。
（如果要展開此兒童交叉韌帶重建手術必須要了解tanner stage 的概念，不然必然要犯錯誤的，如骨骺損傷，膝關節內外翻畸形，身高不等，再次手術矯形等等。）
（待我真正的文章發表後，我會及時更新，全面更新，給大家一個完整版）
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