This lad presented to me when he was ten, and I felt that his was an interesting story.
In Spring 2017 young William fell off a climbing frame and twisted his left knee, and he was in a fair amount of trouble for two weeks. Things settled as they so often do and he felt confident enough to try and play a game of rugby. But he was unfortunately tackled and his knee then caused him further issues with pain and significant instability.
They went for a local opinion, and it was picked up that he had torn his anterior cruciate ligament (ACL) and reconstruction was recommended. He was referred through to me because of my interest in ACL Repair and particularly because of the excellent results that we have had in children with our new repair procedure.
I met William with his parents and, looking at the MRI scan, I was hopeful that I would be able to repair the ACL. So in May I took William to the operating theatre and carried out a careful examination under anaesthesia and an arthroscopy. Sadly, however, I could not perform a repair - there wasn't sufficient tissue. I think another part of the reason why I couldn't repair his ACL was that there was quite a significant delay between William injuring the knee and presenting to me. We really do like to try and get these patients for repair into theatre in the first month or two following the injury.
Despite the clinical decision not to perform a repair, I met with William's parents and we talked about the options. I explained to them that there was an option of reconstructing (rather than repairing) and we could either use William's own tissue or indeed go for a parental donation - for which we have a special licence in Basingstoke.
What we know about paediatric knee injuries and the difficulties associated with surgery and the outcome is that children have a high failure rate. And one of the reasons why they fail is that their own tissue never widens - it just elongates - so it stretches like an elastic band.
But, we have a bone bank in Basingstoke (where we hold a licence to store femoral headswhich we take at the time of hip replacements), and because we have this licence it was relatively easy for me to get this extended such that we could offer parental donor transplantation in cases like this.
What we do in this surgery is we take a tendon from one of the parents -either the father or the mother for use in the child. I often say to the parents that the mother has usually done more than their fair share, so we frequently take from the father a single hamstring, which provides us with a very nice-sized tissue in terms of its length and diameter.
So in William, had we taken his hamstrings (which is the standard graft for reconstruction) and make a new ACL out of those hamstrings the diameter would have been anywhere between 4mm and 5.5mm, whereas with the parental paternal hamstring which we took from William's father we were able to get a very nice 7mm graft which will stand him in good stead as he grows.
So two months ago, William underwent the surgery. I first operated on the father, and through a 1.5cm incision found the semitendinosus hamstring and removed this in isolation. I then prepared this and placed it into an antibiotic-impregnated swab and two sealed containers and then it was placed on the back operating table in the operating theatre.
Once we had sown up the small wound and got William's father out of the operating theatre, William was then brought in through from the anaesthetic room and we implanted the donor tissue as the new ACL.
The procedure went extremely well and I am delighted to say that William is doing extremely well too. He is now two months down the line and he has done well from the start. He had very little pain after the surgery and was able to leave the following day with a good range of motion and minimal swelling.
The nice thing about this procedure is that you are not taking anything from the child's knee so the recover does tend to be fairly quick and fairly pain free - this is an operation that is well tolerated. Within a few weeks he was off his crutches and he walked in today with a completely normal gait without any pain and without any swelling, and his mother tells me that he is back on his bicycle and enjoying normal activities and is about to start his physiotherapy.
His knee felt beautifully stable and there is a full range of motion. I am delighted William has done so well.
A parental donor anterior cruciate ligament (ACL) reconstruction is a great operation to carry out in the appropriate paediatric patient. In the largest series from Leo Pincewski he has shown the failure rate dropping from 20% to 5% in the young patients that he has treated in this way - which now numbers several hundred.
Note from William's mum -
“We had no idea that this surgery is available – there must be so many children whose ligament damage goes unnoticed. We’d like other children to have access to this treatment so they can return to full activity. Whilst William’s injury has meant he can’t run or play contact sports at the moment, he fully intends to return to rugby at some point and plans to be playing cricket by next summer.”