Introduction. Patellofemoral instability is one of the most common presentations to a children's orthopaedic clinic. Recurrent patellar dislocations and instability episodes are painful, disabling and increase the risk of irreversible chondral damage. The medial patellofemoral ligament is the primary static stabiliser to prevent lateral dislocation of the patella and is almost always torn or attenuated in these cases. Reconstruction of this ligament is commonly performed using autologous hamstring tendon however there has been some interest recently in use of quadriceps tendon as a graft. Children with patellar instability also present unique challenges due to the small size of the patella and the presence of open growth plates which may require adaptations to the common techniques. Methods. Patients undergoing medial patellofemoral ligament reconstruction using quadriceps tendon autograft were identified using electronic theatre records. Prospectively collected clinical records and imaging findings were reviewed and underlying pathology, additional procedures at time of MPFL reconstruction, current function and need for further revision surgery determined. Results. Between January 2019 and August 2023, 50 MPFL reconstructions were performed in 37 children using partial thickness quadriceps autograft. Patient age at time of surgery ranged from 5 to 17 years (median age 13 years). The technique was utilised for a variety of indications including recurrent traumatic and habitual patellofemoral instability, fixed dislocations, and revision MPFL reconstruction. Conclusion. Partial thickness quadriceps tendon autograft can be used safely to primarily reconstruct the medial patellofemoral ligament in paediatric population, including those children with open growth plates. It also has utility in revision cases following previous failed hamstring MPFL reconstruction. We have noted that the younger the child, the more distal to the physis lies the femoral point of isometricity, rendering this a safe and reproducible treatment in this age group. Use of this technique has increased in our unit as we have observed that patients seem to be satisfied with their clinical and functional outcomes with a low incidence of short- and medium-term complications

Introduction. Anterior Cruciate ligament reconstruction is a common operation in orthopaedics surgery. A common complication of whilst havesting the hamstring tendon is injury to the infra-patellar branch of the saphenous nerve (IPBSN), resulting in altered sensation to the anterior and lateral aspects of the knee and leg. Aim. The aim of this study was to further understand the course of this nerve in relation to surgical approach to anterior cruciate ligament reconstruction. Material and method. The nerve was traced and dissected in 25 knees from 14 different cadavers. Four paths of IPBSN in relation to the Sartorius muscle were identified: (1) a posterior path which ran round the inferior posterior border of the muscle, (2) a transmuscular path that penetrated through the muscle, (3) an anterior path that ran from the anterior border of the muscle and (4) posterior patellar path that ran round the posterior of the muscle at the same level as the patellar. Dissections were carried out with further 14 knees in a standard manner using both type of incision techniques, vertical incision or horizontal, in ten pair of knees. Using a tendon stripper, the hamstrings tendon were harvested in a standard fashion in different angles of the knee ie full extension and flexion at 90 degrees. Results. Of these paths the posterior was the most common featuring in 57% of specimens and the nerve was at higher risk of being injured due to the proximity of that pathway and the gracilis and semintendinosus muscle tendons. Horizontal incision has a higher chance of damage to the saphenous nerve and the infra-patellar branch. The saphenous nerve was injured on every occasion by this incision. Vertical incision, 1.5cm from the midline, avoided the infra-patellar branch and the saphenous nerve. Harvesting of the tendon in full extension was difficult, and it made the incision sites both horizontal and vertical at greater risk injuring the tendons. When the knee was flexed at 90 degrees these problems were overcome. Conclusions. A vertical incision with a flexed knee gave the best method to harvest the tendon with minimal risk to damaging the infra-patellar branch and the saphenous nerve when using the tendon stripper

Introduction. ACL reconstruction using hamstring tendons has gained general acceptance. However, it has been recommended to seek a tight fit of the tendon in the bone canal in order to provide circumferential contact and healing of the graft, and to prevent secondary tunnel widening. Recent findings show, that the graft dynamically adapts to pressure in the canal resulting in a potentially loose graft-bone contact. It was the goal of this study to understand the viscoelastic behaviour of hamstring grafts under pressure and to develop a new method for tendon pre-conditioning to reduce the graft volume before implantation, in order to reduce the necessary bone canal diameter to accommodate the same graft. Material and Methods. Flexor digitorum tendons of calf and extensor digitorum tendons of adult sheep were identified to be suitable as ACL grafts substitutes for human hamstring tendons in vitro. The effect of different compression forces on dimensions and weight of the grafts were determined. Further, different strain rates (1mm/min vs 10mm/min), compression methods (steady compression vs. creep) and different compression durations(1, 5, 10min) were tested to identify the most effective combination to reduce graft size by preserving its macroscopic structure. Results. The effect of compression on volume reduction (25% of initial volume) reached a plateau at 6000N. Both, steady compression and creeping were able to reduce dimensions of the graft, however, creeping was more effective. There was no difference in effect with different durations for compression (p>0.05) in both methods. With a strain rate of 1mm/min no macroscopic destruction was documented, however with 10mm/min some parts were ruptured. During all pressure tests, considerable amounts of liquid were pressed out from the tendons, and if the graft was submersed in saline solution overnight, the volume reduction was mostly reversible. Conclusion. Compression reduces the dimensions of the ACL graft reversibly, to the greatest part by squeezing out of interstitial water. It is reasonable to assume that this effect also occurs if tendons are under constant pressure in the body, such as at the bend where entering a bone tunnel or under the pressure of interference screws. This in vitro experiment suggests that preconditioning of a 8mm hamstring graft is achieved best by creeping compression with 6kN at a strain rate of 1mm/min. By using this technique, indeed a canal of approximately 10–15% less diameter (i.e. 7 instead of 8mm) may be drilled for the same tendon, resulting in a tight fit of the graft in the bone

We retrospectively analysed the clinical results of 30 patients with injuries of the sternoclavicular joint at a minimum of 12 months’ follow-up. A closed reduction was attempted in 14 cases. It was successful in only five of ten dislocations, and failed in all four epiphyseal disruptions. A total of 25 patients underwent surgical reduction, in 18 cases in conjunction with a stabilisation procedure.

At a mean follow-up of 60 months, four patients were lost to follow-up. The functional results in the remainder were satisfactory, and 18 patients were able to resume their usual sports activity at the same level. There was no statistically significant difference between epiphyseal disruption and sternoclavicular dislocation (p > 0.05), but the functional scores (Simple Shoulder Test, Disability of Arm, Shoulder, Hand, and Constant scores) were better when an associated stabilisation procedure had been performed rather than reduction alone (p = 0.05, p = 0.04 and p = 0.07, respectively).

We recommend meticulous pre-operative clinical assessment with CT scans. In sternoclavicular dislocation managed within the first 48 hours and with no sign of mediastinal complication, a closed reduction can be attempted, although this was unsuccessful in half of our cases. A control CT scan is mandatory. In all other cases, and particularly if epiphyseal disruption is suspected, we recommend open reduction with a stabilisation procedure by costaclavicular cerclage or tenodesis. The use of a Kirschner wire should be avoided.