Abstract

The early surgical management of the anterior cruciate ligament (ACL) tears in children remains controversial. The argument for nonoperative treatment is driven by concerns about the risk of growth arrest caused by a transphyseal procedure. On the other hand, early surgical reconstruction is favoured because of poor compliance with conservative treatment and increased risk of secondary damage due to instability. This paper reports a series of 39 very young children who had an ACL reconstruction using a transphyseal procedure with a hamstring graft. Patients were followed to skeletal maturity or for a minimum of three years. Only those patients with either a chronological age less than 14 years or with a Tanner stage of 1 and 2 of puberty were included in the study. Thirty children were Tanner 1 or 2 and nine were Tanner 3-4 but were younger than 14. The mean age at operation was 12.2 years (Range 9.5-14.2, Median 12.4). The mean follow up was 60.7 months (range 36-129, median: 51) months. Thirty four patients had attained skeletal maturity at the last follow up. The mean Lysholm score improved from 72.4 pre-operatively to 95.86 postoperatively (p<0.0001). The mean Tegner activity scale was 4.23 after injury and it improved to 7.52 after operation (p<0.0001)) which was a reasonable comparison to the pre- injury score of 8.0. One patient had a mild valgus deformity with no functional disturbance. No other growth related abnormalities including limb length discrepancy were noted. There has been one re-rupture but all others had good or excellent outcome. This is one of the largest series reporting the long term results of ACL reconstruction in very young children. Most other studies include children up to the age of 16. Based on our results we can conclude that transphyseal ACL reconstruction modified for very young patients is a safe procedure

Most problems encountered in complex revision total knee arthroplasty can be managed with the wide range of implant systems currently available. Modular metaphyseal sleeves, metallic augments and cones provide stability even with significant bone loss. Hinged designs substitute for significant ligamentous deficiencies. Catastrophic failure that precludes successful reconstruction can be encountered. The alternatives to arthroplasty in such drastic situations include knee arthrodesis, resection arthroplasty and amputation. The relative indications for the selection of these alternatives are recurrent deep infection, immunocompromised host, and extensive non-reconstructible bone or soft-tissue defects.

Fixed flexion deformities are common in osteoarthritic knees that are indicated for total knee arthroplasty. The lack of full extension at the knee results in a greater force of quadriceps contracture and energy expenditure. It also results in slower walking velocity and abnormal gait mechanics, overloading the contralateral limb. Residual flexion contractures after TKA have been associated with poorer functional scores and outcomes.

Although some flexion contractures may resolve with time after surgery, a substantial percentage will become permanent. Therefore, it is essential to correct fixed flexion deformities at the time of TKA, and be vigilant in the post-operative course to maintain the correction.

Surgical techniques to address pre-operative flexion contractures include: adequate bone resection, ligament releases, removal of posterior osteophytes, and posterior capsular releases. Post-operatively, extension can be maintained with focused physiotherapy, a specially modified continuous passive motion machine, a contralateral heel lift, and splinting.