Pediatric anterior cruciate ligament reconstruction

An increasing number of anterior cruciate ligament (ACL) injuries are seen in children now than in the past due to increased sports participation. The natural history of ACL deficient knees in active individuals, particularly in children is poor. Surgical management of ACL deficiency in children is complex due to the potential risk of injury to the physis and growth disturbance. Delaying ACL reconstruction until maturity is possible but risks instability episodes and intra-articular damage. Surgical options include physeal-sparing, partial transphyseal and complete transphyseal procedures. This article reviews the management of ACL injured skeletally immature patients including the functional outcome and complications of contemporary surgical techniques.     

Epiphyseal preservation and an intercalary vascularized fibular graft with hydroxyapatite composites. Reconstruction in metaphyseal osteosarcoma of the proximal tibia: a case report

Background data and objectives We present here a case report of a patient with metaphyseal osteosarcoma with a preserved epiphysis and reconstructed by a vascularized fibular graft and hydroxyapatite composites. Methods The case was a 14-year-old boy, who had osteosarcoma in the proximal tibia. After the diagnosis was confirmed by biopsy, the patient immediately received preoperative chemotherapy including high-dose Methotrexate, Cisplatin and Doxrubicin. Imagings after preoperative chemotherapy including MRI and contrasted enhanced CT confirmed no tumor penetration into the physis. Subsequently, we performed transepiphyseal resection of the proximal tibia to reserve the joint surface. The intercalary twin-barreled vascularized fibular graft was placed with hydroxyapatite composites. The patella tendon was reattached to the grafted fibular to biologically reconstruct the knee extensor mechanism. Postoperative chemotherapy was completed with the same regime as preoperative chemotherapy. Outcomes The bony union was completed at 10 months after the operation. The Enneking’s functional evaluation score was 28 out of 30 points (93%). There was no evidence of local recurrence and no metastatic disease during the 42 months follow-up after initial diagnosis. Conclusion An accurate evaluation of MRI and CT can give a reliable assessment of intraphyseal penetration of metaphyseal osteosarcoma. In case of no involvement of the tumor in the physis, transepiphyseal osteotomy is the optimal procedure to preserve the joint surface and superior function of the joint, especially in the proximal tibia.