Modified Macintosh (Micheli-Kocher) Technique: Pediatric Physeal Sparing Anterior Cruciate Ligament Reconstruction With an ITB Autograft
Daniel W. Green, Gyözö Lehoczky, Sarah Lu, Ariana I. Matarangas, Marco TuratiBackground:
Anterior cruciate ligament (ACL) injuries in skeletally immature patients present a unique challenge, as traditional transphyseal reconstruction techniques risk growth disturbance. Physeal-sparing approaches, including the modified Macintosh (Micheli-Kocher) technique using an iliotibial band (ITB) autograft, aim to restore stability while preserving open physes.
Indications:
This technique is indicated for skeletally immature patients with wide-open physes and at least 3 years of growth remaining, typically corresponding to girls <12 years and boys <14 years. It is particularly suited for patients at high risk of growth disturbance or when transphyseal techniques are undesirable.
Technique Description:
The modified Macintosh (Micheli-Kocher) technique utilizes an extra-articular ITB autograft harvested while preserving its distal attachment at Gerdy tubercle. The graft is passed in an “over-the-top” position around the lateral femoral condyle without violating the distal femoral physis and secured at the lateral femoral metaphysis. It is then directed intra-articularly beneath the intermeniscal ligament and fixed to the proximal tibial metaphysis using periosteal sutures or suture anchors, avoiding the proximal tibial physis. This approach restores anterior and rotational stability without transphyseal drilling.
Results:
Biomechanical and clinical studies demonstrate restoration of anterior-posterior stability comparable to the native ACL, with favorable kinematics and low graft failure rates. Large clinical series report minimal risk of growth disturbance or limb-length discrepancy and excellent functional outcomes, including high rates of return to sport.
Discussion/Conclusion:
The modified Macintosh (Micheli-Kocher) ITB autograft technique is a reliable, reproducible, physeal-sparing option for ACL reconstruction in skeletally immature patients. Its avoidance of transphyseal drilling, combined with strong clinical outcomes and low complication rates, supports its continued use in this high-risk population.
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.