ACL Repair in a 5 year old girl

A young girl - aged 5 - suffered an acute ACL injury and fitted our criteria for an ACL 'repair'. (FOLLOW-UP April 2016 - She is now 2 years post op and has a superb knee. Fully stable. No pain and full function with no growth disturbance.)

This young girl suffered a trampoline injury and presented with a swollen painful knee. She was unable to bear weight. She was unstable on clinical examination, and Lachmann and Pivot Shift test showed that she was ACL deficient.​

The MRI did not get ideal slices, but was suggestive of ACL rupture and lateral meniscal tear.

ACL Repair Technique

A standard arthroscopy was performed, and demonstrated the so­-called 'empty notch sign' as well as a partial thickness tear of the meniscus. The joint surfaces were good.

In these cases, if the remnant is of sufficient quality, its proximal end is lassoed with a locking suture, and this is what we did here. So is the FibreLink suture being loaded it onto the special device which will then get passed around the ACL remnant to create the lasso.

The femoral socket position is identified with minimal tissue debridement and a 2.4 mm tunnel is made through the lateral wall. ​A further 2.4 mm tibial tunnel is made exiting in the ACL tibial footprint, which allows internal bracing using a 2.0mm FibreTape​. The sutures holding the remnant are tied onto the suspensory fixation tightrope button which sits against the lateral femoral cortex. The FibreTape is secured and tensioned at the tibial end with a 4.75mm SwiveLock anchor​.

We used X-­ray to stay underneath the growth plate with the drill using the special guides that has been designed for children.

Here we show the guide pin and the drill coming into the knee.

Here we show the vertical position we took for the 3mm drill through the growth plate.

These two pictures show before and after the internal brace has been passed. The before picture on the left just has the ACL nicely pulled up back into its normal position reduced against the original origin where it tore away on the femur, and then the internal brace can be seen in the next picture alongside the native ACL. Obviously we did not want to leave this hardware in such a small child so at 12 weeks she came back to have the hardware removed.

A final examination of the knee shows it is entirely normal in terms of the anterior drawer, Lachmann and pivot shift.

At a 'second-look' procedure at 3 months, the fixation on the tibia is removed and the tape pulled out.

There was no synovitis, the joint surfaces were normal and the ACL healed.

I think a really nice thing that I got from her Dad was the text message he sent through, because we communicate a lot, he was talking about how well she was doing at a year in terms of running in and out of the waves.

Recent paper of relevance

Accepted for publication May 2016: Paediatric ACL repair reinforced with temporary internal bracing. JournalKnee Surgery, Sports Traumatology, Arthroscopy, 24(6), 1845-1851DOI10.1007/s00167-016-4150-x

There is a recent resurgence in interest for ACL repair due to advances in imaging, techniques and rehabilitation. Patient selection is key - the idea patient has:

  • acute injury <6 weeks
  • good quality ACL remnant
  • detachment from the femoral insertion

The procedure is especially useful in paediatric cases to avoid significant violation of the physis​.

It’s amazing that we were -
a) referred her and,
b) one of my colleagues was able to make the diagnosis or know enough to send her through to me, because often these children are just told, you know, because they are young and have such great healing potential not to worry about things, and things will settle, and often parents just hope time will settle these things down, and many of these severe injuries go undetected.

Our technique involved using cortical suspensory fixation tightropes and FibreTape via 2.4mm tunnels to minimise growth plate disturbance. The ​FibreTape and buttons were removed at 3 months. She was reviewed at one year follow up and found to have a stable knee with normal anterior drawer, Lachmanns and negative pivot shift. Her activity levels were normal and she was pain free.

At one-year follow-up

Her long leg X-­rays at 1 year show how well she was doing.

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