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Physeal-respecting anterior cruciate ligament reconstruction in adolescents: Our surgical experience and clinical outcomes
, Prabhakar R1, Dhurvas Ramlal Ramprasath1, Kannaiyan Mohankumar1, Loganathan Balasurya1
*Corresponding author: H. Dhariwal Varrdhaman, Department of Orthopaedics, Government Stanley Medical College, Chennai, Tamil Nadu, India. varrdh@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Varrdhaman HD, Prabhakar R, Ramprasath DR, Mohankumar K, Balasurya L. Physeal-respecting anterior cruciate ligament reconstruction in adolescents: Our surgical experience and clinical outcomes. J Arthrosc Surg Sports Med. doi: 10.25259/JASSM_35_2026
Abstract
Objectives:
Anterior cruciate ligament (ACL) injuries in adolescents are increasing with sports participation, and management in open physes is challenging due to the risk of growth disturbances. This study aims to assess long-term outcomes of physeal-respecting ACL reconstruction using the Micheli–Kocher IT band autograft technique.
Materials and Methods:
This retrospective case series included 17 skeletally immature adolescents with open physes who underwent Micheli–Kocher physeal-sparing ACL reconstruction between 2015 and 2024. Functional outcomes at 6, 12, and 24 months were assessed using Tegner-Lysholm and subjective International Knee Documentation Committee (IKDC) scores with repeated measures analysis of variance and Tukey’s post hoc analysis.
Results:
The cohort included 15 males and 2 females (mean age: 12.8 ± 0.90 years). Tegner–Lysholm scores improved significantly from 48.5 ± 5.33 preoperatively to 63.7 ± 3.44 at 6 months, 80.6 ± 3.32 at 1 year, and 91.1 ± 2.63 at 2 years (p < 0.001). Subjective IKDC scores also rose significantly from 54.1 ± 3.13 preoperatively to 64.0 ± 2.78 at 6 months, 73.8 ± 3.11 at 1 year, and 86.5 ± 3.06 at 2 years (p < 0.001). All consecutive pairwise comparisons were significant (p < 0.001). No growth disturbances (arrest, deformity, or limb-length discrepancy), graft failures, or revisions occurred.
Conclusion:
The physeal-respecting Micheli–Kocher technique using an iliotibial band autograft is a safe and effective option for pediatric and adolescent ACL tears, providing excellent knee stability and functional recovery without risking growth plate arrest.
Keywords
Iliotibial band autograft
Micheli–Kocher technique
Physeal-respecting anterior cruciate ligament reconstruction
Subjective International Knee Documentation Committee
Tegner-Lysholm
INTRODUCTION
Anterior cruciate ligament (ACL) tears were historically considered a rare clinical entity within the pediatric and adolescent populations. However, over the past two decades, the incidence of adolescent ACL ruptures has experienced a substantial escalation. This macroeconomic epidemiological shift is primarily driven by the increasing intensity of youth participation in competitive, organized sports, year-round specialized athletic training, and a heightened clinical awareness coupled with advanced diagnostic magnetic resonance imaging (MRI) accessibility.[1,2]
Managing an ACL rupture in a skeletally immature athlete presents an intricate surgical and therapeutic dilemma. The pediatric and adolescent knee possesses open physes that are highly sensitive to mechanical and thermal insults. The distal femoral physis and the proximal tibial physis contribute significantly to longitudinal limb length; the lower femoral physis accounts for approximately 70% of growth of the femur and 37–40% of total lower limb growth at a rate of 9 mm/year, while the upper tibial physis contributes approximately 6 mm/year. Consequently, conventional adult transphyseal ACL reconstruction techniques, which rely on drilling large-diameter intraosseous tunnels directly across these active growth plates, carry a severe, well-documented risk of causing premature physeal arrest, bone bridge formation, limb-length discrepancy (LLD), and progressive angular deformities such as genu valgum or varum.[3]
To avoid these catastrophic growth disturbances, various physeal-sparing and physeal-respecting techniques have been pioneered, classified generally into all-epiphyseal, transphyseal, and physeal-sparing extra-articular/intraarticular non-tunnel approaches.[3,4] The Micheli–Kocher technique, originally conceptualized in 1976, represents a combined intra-articular and extra-articular physeal-respecting reconstruction that completely avoids intraosseous tunnel drilling across active growth plates.[5] By utilizing a continuous autologous iliotibial (IT) band graft that remains anchored distally at Gerdy’s tubercle, this approach replicates the anatomy of the native ACL using an over-the-top femoral pathway and an intra-articular tibial routing above the proximal tibial physis.[5]
While multi-center studies from Western nations have validated this procedure, there remains a paucity of structured clinical data characterizing its efficacy within South Asian athletic cohorts. Therefore, the specific objective of this retrospective study is to present our clinical experience, outline precise surgical pearls and pitfalls, and report the consecutive 2-year functional outcomes and growth safety profiles following physeal-respecting Micheli– Kocher ACL reconstruction in adolescents executed at a specialized Indian tertiary care center.
MATERIALS AND METHODS
Study design and compliance
This study was conducted as a retrospective case series (Level IV Evidence) at a major multi-specialty tertiary care referral center in South India. The investigation received formal protocol approval from the institutional ethics committee. Written informed consent was meticulously obtained from the parents or legal guardians of all participants, and formal assent was gathered from all participants aged over 7 years.
Participant selection and screening criteria
Our study reviewed the clinical, operative, and radiographic registries of all pediatric and adolescent patients who sustained a complete ACL rupture and were managed operatively using the physeal-respecting Micheli–Kocher technique between January 2015 and January 2024. The strict inclusion criteria were defined as follows: (1) Clinically and radiographically confirmed complete ACL tear via manual laxity tests and 1.5-Tesla MRI; (2) Clear evidence of gross skeletal immaturity, defined by open distal femoral and proximal tibial physes on bilateral knee anteroposterior and lateral long-leg radiographs; and (3) A minimum postoperative follow-up period of 24 months with complete records.
Patients were excluded if they presented with: (1) Concurrent multiligamentous knee injuries, such as posterior cruciate ligament (PCL) or posterolateral corner (PLC) disruptions; (2) Associated treatable displaced meniscal tears requiring extensive simultaneous repair that could confound early functional outcomes; (3) Prior knee surgery or congenital musculoskeletal anomalies; or (4) Absolute skeletal maturity. Over the study timeframe, a total of 22 consecutive patients underwent this specific procedure. Following the strict application of the criteria, 5 patients were excluded: 2 patients were lost to follow-up before completing the mandatory 24-month assessment, and 3 patients were excluded due to intraoperatively confirmed multi-ligamentous injuries (1 combined PCL tear and 2 complex PLC unstable injuries). This resulted in a final highly consistent cohort of 17 patients.
Surgical technique
The patient was placed in the supine position, and adequate knee flexion to 90° was verified. A skin incision was made over the lateral aspect of the distal thigh. Following clearance of the subcutaneous tissue, the IT band was exposed. Using a measuring device, a 1.5–2 cm wide strip was marked along the central portion of the IT band. Proximally, the soft tissue was cleared off the IT band using blunt dissection or a Cobb elevator. A minimum 15 cm strip of the IT band was then harvested using a meniscus knife [Figure 1], carefully preserving its distal insertion at Gerdy’s tubercle.
The proximal end of the harvested IT band graft was prepared, typically using a non-absorbable suture. This proximal end was then passed around the lateral femoral condyle using an “over-the-top” technique, facilitated by a feeder instrument such as a Kocher forceps [Figure 2]. With the knee maintained at 90° of flexion, the graft was anchored to the soft tissue surrounding the lateral femoral condyle [Figure 3].
Concurrently, a second Kocher forceps was advanced through the standard anteromedial knee portal to grasp the passed graft. The graft was then withdrawn, routed through the intercondylar eminence, and anchored to the periosteum of the proximal tibia distal to the proximal tibial epiphysis [Figure 4]. This final fixation was performed with the knee at approximately 30° of flexion to eliminate any anterior drawer. Graphical representation is given in Figure 5.
Surgical pearls
(1) Ensure a minimum graft harvest length of 15 cm; insufficient graft length prevents adequate, tension-free distal tibial fixation. (2) Maintain meticulous blunt dissection when navigating the over-the-top space to avoid any mechanical or thermal violation of the perichondral ring of the lateral femoral condyle.
Surgical pitfalls
Over-tensioning the graft at 90° of flexion can induce graft over-constraint, leading to restricted terminal extension and early graft failure. The graft must be tensioned strictly at 20°– 30° of flexion while checking for full, unobstructed passive range of motion.
Postoperative rehabilitation protocol
Rehabilitation followed a specialized, conservative, phased protocol that was deliberately slowed down compared to adult ACL timelines to safeguard the non-tunnel periosteal fixations. Patients were maintained in a locked long-knee brace in full extension for the first 4 weeks. On postoperative day 1, isometric static quadriceps exercises and straight leg raises were initiated. For the first 2 weeks, only passive and active-assisted closed-chain exercises were permitted, strictly capping knee flexion between 0° and 90°.
Touch-down, partial weight-bearing was enforced with crutches during weeks 3 to 6, progressing gradually to full weight-bearing by the end of the 6th week. At 12 weeks post-surgery, open-chain exercises were introduced, the knee range of motion was safely advanced beyond 120°, and straight-line jogging was authorized. Return to non-contact recreational sports or light agility drilling was permitted at 6 months, provided the patient demonstrated symmetric quadriceps strength. Full clearance for unrestricted competitive contact sports was strictly withheld until 9 months postoperatively, contingent on regular clinical monitoring, a negative shift test, and a >90% limb symmetry index on functional hop testing.
Statistical analysis
Statistical Package for the Social Sciences software (IBM Version 21.0) was used for data administration and statistical computations. The mean ± standard deviation, median, and range were used to express continuous demographic and structural characteristics. Metrics for categorical distribution were displayed as percentages (%) and absolute frequencies (n). Repeated measures analysis of variance (RM-ANOVA) was used to thoroughly assess functional recovery characteristics over the four longitudinal clinical intervals (pre-operative baseline, 6 months, 1 year, and 2 years postoperatively). Mauchly’s test of sphericity was used to confirm the statistical assumptions of RM-ANOVA. The Greenhouse-Geisser correction was used to modify the degrees of freedom for parameters that did not show the sphericity assumption, guaranteeing reliable and non-inflated F-statistics. Tukey’s honestly significant difference (HSD) test was used in post hoc pairwise comparisons to identify particular changes between time intervals after a statistically significant main effect. The cutoff point for statistical significance was established as a two-tailed p < 0.05.
RESULTS
Baseline cohort characteristics
The demographic and pre-injury baseline profiles of the 17 study participants are compiled comprehensively in Table 1. The mean age was 12.8 ± 0.90 years, with a median age of 13 years (range: 11–14 years). Stratification by age demonstrated that injuries occurred predominantly in patients aged 12 and 13 years (35.3% each). A distinct male predominance was observed, with 15 male patients (88.2%) compared to only 2 female patients (11.8%). All 17 participants (100%) were actively enrolled students. In terms of pre-injury physical performance levels, 41.2% (n = 7) were classified as highly competitive club-level athletes, 29.4% (n = 5) engaged regularly in recreational contact sports, and 29.4% (n = 5) led a predominantly sedentary lifestyle before injury.
| Variable | Category | Frequency (n) | Percentage(%) |
|---|---|---|---|
| Age (years) | Mean±SD | 12.8±0.90 | — |
| Median (Range) | 13 (11–14) | — | |
| Age distribution | 11 years | 1 | 5.9 |
| 12 years | 6 | 35.3 | |
| 13 years | 6 | 35.3 | |
| 14 years | 4 | 23.5 | |
| Sex | Male | 15 | 88.2 |
| Female | 2 | 11.8 | |
| Occupation | Student | 17 | 100 |
| Activity level | Athlete | 7 | 41.2 |
| Recreational sports | 5 | 29.4 | |
| Sedentary | 5 | 29.4 |
SD: Standard deviation
Pre-operative clinical mechanical instability
The preoperative mechanical profile demonstrated severe, multi-planar structural knee instability across all study subjects [Table 2 and Figure 6]. On objective manual Anterior Drawer testing, 58.8% (n = 10) of patients exhibited gross Grade 3 laxity, while 41.2% (n = 7) had Grade 2 laxity. The Lachman test demonstrated severe anterior translation in 82.4% (n = 14) presenting with Grade 3 laxity, and 17.6% (n = 3) with Grade 2. Rotational instability was similarly pronounced, with the Pivot Shift test demonstrating Grade 3 subluxation in 88.2% (n = 15) of patients and Grade 2 in 11.8% (n = 2), emphasizing significant functional compromise before surgical stabilization.
| Clinical test | Grade | Frequency (n) | Percentage (%) |
|---|---|---|---|
| Anterior drawer test | Grade 2 | 7 | 41.2 |
| Grade 3 | 10 | 58.8 | |
| Lachman test | Grade 2 | 3 | 17.6 |
| Grade 3 | 14 | 82.4 | |
| Pivot shift test | Grade 2 | 2 | 11.8 |
| Grade 3 | 15 | 88.2 |
Functional outcomes and statistical significance
The Tegner–Lysholm functional scores demonstrated a highly significant, progressive linear expansion throughout the postoperative tracking period [Table 3]. The mean score expanded from a deficient baseline of 48.5 ± 5.33 to 63.7 ± 3.44 at 6 months, reflecting initial structural consolidation. It continued to climb sharply to 80.6 ± 3.32 at 1 year, and ultimately converged at an excellent functional ceiling of 91.1 ± 2.63 by the 2-year mark. RM-ANOVA demonstrated a highly statistically robust main effect across time (F = 677, p < 0.001).
| Time point | Mean±SD | Median | Range | F value | p-value |
|---|---|---|---|---|---|
| Pre-op | 48.5±5.33 | 49 | 40–59 | 677 | <0.001 |
| 6 months | 63.7±3.44 | 63 | 59–69 | ||
| 1 year | 80.6±3.32 | 80 | 75–88 | ||
| 2 years | 91.1±2.63 | 90 | 88–96 |
SD: Standard deviation, ANOVA: Analysis of variance. p value <0.001 is significant
The patient-reported subjective International Knee Documentation Committee (IKDC) scores strongly mirrored this positive trajectory [Table 4]. The mean IKDC score increased from a restricted preoperative level of 54.1 ± 3.13 to 64.0 ± 2.78 at 6 months, advanced to 73.8 ± 3.11 at 1 year, and reached a near-normal functional capacity of 86.5 ± 3.06 at 2 years. RM-ANOVA confirmed that these differences were highly significant (F = 510, p < 0.001), confirming steady, uniform patient satisfaction and functional optimization across the study subjects. Figure 7 graphical representation of pre op and post op clinical outcomes by international knee documentation committee score and Tegner Lysholm score till 2 years.
| Time point | Mean±SD | Median | Range | Fvalue | p-value |
|---|---|---|---|---|---|
| Pre-operative | 54.1±3.13 | 54 | 50–59 | 510 | <0.001 |
| 6 months | 64.0±2.78 | 64 | 59–68 | ||
| 1 year | 73.8±3.11 | 72 | 70–79 | ||
| 2 years | 86.5±3.06 | 86 | 81–91 |
IKDC: International knee documentation committee -subjective. p value <0.001 is significant, ANOVA: Analysis of variance, SD: Standard deviation.
Post hoc pairwise multi-comparison diagnostics
To rigorously isolate functional progression between discrete surgical follow-up phases, an exhaustive post hoc pairwise multi-comparison analysis was performed utilizing Tukey’s HSD test [Table 5]. For the Tegner–Lysholm score, the increase from preoperative baseline to an early postoperative milestone (3 months intermediate proxy check) was highly significant (mean difference: −15.2, p < 0.001). This recovery trend was maintained into the mid-term phase, with a mean difference of −32.1 between preoperative and 6-month states (p < 0.001), expanding to −42.5 at 1 year (p < 0.001). Critically, comparisons between sequential periods, such as 3 months versus 6 months (mean difference: −16.9) and 6 months versus 1 year (mean difference: −10.4) retained complete statistical significance (p < 0.001), demonstrating continuous, ongoing functional adaptation.
| Outcome score 1 (Tegner-Lysholm) | ||||
| Comparison | Mean difference | SE | t | p-value |
| Pre-op vs 3 months | -15.2 | 1.037 | -14.6 | <0.001 |
| Pre-op vs 6 months | -32.1 | 1.221 | -26.3 | <0.001 |
| Pre-op vs 1 year | -42.5 | 1.252 | -34.0 | <0.001 |
| 3 vs 6 months | -16.9 | 0.897 | -18.9 | <0.001 |
| 3 vs 1 year | -27.4 | 0.985 | -27.8 | <0.001 |
| 6 vs 1 year | -10.4 | 0.563 | -18.5 | <0.001 |
| Outcome score 2 (IKDC) | ||||
| Comparison | Mean difference | SE | t | p-value |
| Pre-op vs 3 months | -9.94 | 0.979 | -10.1 | <0.001 |
| Pre-op vs 6 months | -19.76 | 0.922 | -21.4 | <0.001 |
| Pre-op vs 1 year | -32.47 | 0.944 | -34.4 | <0.001 |
| 3 vs 6 months | -9.82 | 0.744 | -13.2 | <0.001 |
| 3 vs 1 year | -22.53 | 0.892 | -25.3 | <0.001 |
| 6 vs 1 year | -12.71 | 0.695 | -18.3 | <0.001 |
p <0.001 value is statistically significant, SE: Standard error.
An identical, highly integrated trend was observed for subjective IKDC parameters. The functional gain from preoperative baseline to the early post-acute phase was notable (mean difference:−9.94, p < 0.001). This expanded further at 6 months (mean difference: −19.76, p < 0.001) and reached its peak at 1 year (mean difference: −32.47, p < 0.001). Incremental improvements between consecutive intervals—3 and 6 months (mean difference: −9.82, p < 0.001) and 6 months to 1 year (mean difference: −12.71, p < 0.001) were confirmed as statistically robust, supporting the long-term effectiveness of this non-tunnel approach.
Growth safety and complications profile
Serial orthopaedic examinations and standardized scanograms performed at final follow-up revealed no cases of premature growth plate arrest, structural physeal bar formation, or architectural changes. The mean LLD measured at 2 years was negligible (0.12 ± 0.08 cm), with no patient exhibiting structural discrepancies exceeding 0.5 cm. Furthermore, coronal and sagittal alignment checkups revealed no signs of induced genu valgum, genu varum, or fixed flexion deformities. Importantly, there were no cases of graft elongation, structural graft rupture, arthrofibrosis, deep joint space infection, or secondary revision interventions within the study cohort. Figure 8 the clinical photo of a girl child after 1 year follow up.
DISCUSSION
The incidence of ACL injuries in athletic adolescents is increasing day by day. The demand of the individual to outperform the peer group in any form of sports is already a physical and mental stress, and an ACL injury will only add to it. Treating these patients is technically more challenging due to an intact physis, iatrogenic injury of which will lead to early arthritis, significant deformities, limb length discrepancy, and can further affect his/her sporting abilities.
Though studies have shown less donor site morbidities with grafts like the peroneus longus tendon,[6] moreover, IT band, being considered weaker than other conventional grafts such as hamstring, quadriceps, and patella tendon, when harvested by maintaining its attachment to Gerdy’s tubercle, IT band retains its native vascularization, which promotes faster healing and biological viability.
Randomised control trials have shown considerable graft failure rates when the thickness is <8 mm.[7] Since IT band provides the freedom of harvesting about 15–20 mm the threshold of 8 mm is conveniently surpassed. Gupta et al.,[8] in their study have stated that the graft selection should be based on patient demands such as sports involvement, occupational status, and skeletal maturity. Samuelsen et al.,[9] in their study stated that the Asian and Middle Eastern population has very low graft failure rates, which was favourable for our study.
The optimal management of ACL injuries in pediatric and adolescent athletes remains a subject of active debate in orthopaedic sports medicine. Historically, non-operative management consisting of activity modification, structural bracing, and rehabilitation was widely favored due to fears of growth plate injury from surgery. However, contemporary literature has conclusively shown that delaying surgery in active adolescents is associated with poor outcomes.[1,2]
Chronic mechanical instability in an ACL-deficient knee frequently leads to recurrent subluxation episodes, which cause secondary irreversible injuries to the menisci and articular cartilage. This significantly accelerates the onset of early osteoarthritic changes, transforming a manageable ligamentous tear into a complex, long-term joint problem.
Concurrently, various physeal-modifying techniques have evolved to secure stability while respecting skeletal anatomy. Standard transphyseal reconstruction techniques, which involve drilling intraosseous bone tunnels across active physes, are frequently performed in older adolescents approaching skeletal maturity.[4] However, in younger children with significant remaining growth potential, drilling tunnels through growth plates carries a clear risk of thermal necrosis or mechanical compression, which can lead to premature physeal arrest and subsequent bone bridge formation.[3,4] While advanced all-epiphyseal techniques avoid transphyseal drilling by placing intraosseous tunnels entirely within the distal femoral and proximal tibial epiphyses, these procedures are technically demanding.[4,10-13] They require precise, intraoperative fluoroscopic guidance and carry an inherent risk of thermal damage to the adjacent physis or intra-articular penetration during drilling.[4,10-13]
The Micheli–Kocher technique offers a reliable compromise, eliminating the need for intraosseous tunnels across active growth plates.[5] By routing a continuous autologous IT band graft over the top of the lateral femoral condyle and flat over the proximal tibial epiphysis, the procedure preserves the stock of the bone.[5,14] This leaves the bone entirely uninjured, keeping future options open for anatomical transphyseal reconstruction once skeletal maturity is achieved.[5,14] Our excellent functional results are consistent with landmark multi-center series published by pioneers of this technique. Kocher et al.,[5] in an analysis of prepubescent children managed with an IT band autograft, reported excellent long-term knee stability, a low graft failure rate, and minimal growth complications. Similarly, a systematic review comparing procedural choices confirmed robust functional outcomes and high safety profiles across multi-center evaluations.[15,16] Further retrospective series by Willimon et al.[17] and Kocher et al.[6] involving pediatric athletes confirmed robust functional outcomes and high return-to-sport rates at a mean follow-up of 3 years.
Our study also provides important insights regarding post-injury athletic performance. A key finding was that the majority of participants returned safely to their pre-injury baseline physical activities, excluding high-impact contact sports, and were completely pain-free as early as 10– 12 weeks postoperatively. However, it is critical to interpret this quick early recovery within the context of our protocol. This early activity refers strictly to non-contact recreational movements, static cycling, and straight-line jogging under supervised conditions, not an immediate return to pivoting competitive sports.
Unrestricted clearance for competitive contact sports was strictly delayed until 9 months post-surgery, allowing time for adequate graft ligamentization and the restoration of objective neuromuscular control.
Despite these encouraging results, we acknowledge several limitations inherent to this technique. First, the Micheli–Kocher approach is fundamentally non-anatomical. By utilizing an over-the-top femoral pathway, it does not perfectly replicate the spatial footprint of the native ACL, which can theoretically result in altered knee kinematics under extreme rotational loads. Second, the procedure requires harvesting a minimum of 15–20 cm of the central IT band. Insufficient graft length poses a significant intraoperative challenge, risking suboptimal or insecure distal tibial fixation. Furthermore, aggressive soft-tissue dissection near the posterolateral femoral condyle risks damaging the perichondral ring, which could inadvertently cause a localized growth disturbance. Finally, this study is limited by its retrospective design, a small sample size (n = 17), and the lack of a direct comparative control group. Nonetheless, the high consistency of our data and the complete absence of growth-related complications provide valuable evidence supporting the safety and efficacy of this technique in South Asian populations.
CONCLUSION
Physeal-respecting ACL reconstruction using the Micheli– Kocher technique is an exceptionally safe, reliable, and functionally effective operative approach for managing complete ACL tears in skeletally immature pediatric and adolescent patients. When executed with precise attention to surgical technique, this non-tunnel method provides excellent restoration of multi-planar knee stability, high patient satisfaction, and a safe return to recreational and competitive sports. Crucially, it completely avoids the risk of premature growth plate arrest, limb-length discrepancies, and progressive angular deformities. While small-volume case series are valuable, further large-scale, multi-center prospective studies are warranted to fully validate these findings and analyze long-term knee kinematics into adulthood.
Author contributions: HDV and RP: Conceptualization, methodology, validation, investigation, resources, data curation, writing – original draft, writing – review and editing, supervision, visualization, project administration; DRR: Resources, writing – review and editing, project administration; KM: Conceptualization, methodology, resources, supervision; LB: writing – original draft, writing – review and editing.
Declarations
Ethical approval:
The research/study was approved by the Institutional Review Board at the Government Stanley Medical College and Hospital, Chennai 600001, number 20260102, dated February 04, 2026.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for their images and other clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.
Availability of data and materials:
Data and materials are available.
Financial support and sponsorship: Nil.
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