Anterior Cruciate Ligament Injury In The Skeletally Immature

ACL injury in the skeletally immature patient represents another set of complex issues in ACL reconstruction. Intrasub-stance tears of the ACL have been reported with increasing frequency as more children participate in high-level athletic activities.23 As many as 65% of acute pediatric knee injuries (children ages 13 to 18 years) accompanied by hemarthrosis involve injury to the ACL.24 The predicament presented by pediatric ACL injury is a difficult one. On the one hand, neglect of a complete tear of the ACL can, as in adults, lead to repeated episodes of instability, meniscal injury, and accelerated arthrosis.25-27 On the other hand, ACL reconstruction carries the theoretical risk of limb shortening or angular deformity resulting either from direct mechanical disruption of the physis or according to the Hueter-Volkmann principle from increased mechanical loads across the physis.28,29 With the distal femoral and proximal tibial physes together accounting for approximately

Figure 52-11 A, Medial meniscal allograft prepared for transplantation using double bone plug technique. B, Passage of medial meniscal allograft into medial compartment. A Henning retractor has been placed adjacent to the posteromedial joint capsule through a standard posteromedial approach for retrieval of inside-out meniscal sutures.

/WBL = 33% With or without medial compartment narrowing

Lateral compartment opening

Lateral compartment opening

Hyperextension and external tibial rotation

Primary varus • Tibiofemoral geometry

Triple varus

• Tibiofemoral geometry

• Separation of lateral compartment

• Varus recurvatum

Figure 52-12 Illustration of the concept of Noyes et al of single, double, and triple varus knee deformity.

Double varus

• Tibiofemoral geometry

• Separation of lateral compartment

/WBL = 33% With or without medial compartment narrowing

Hyperextension and external tibial rotation

65% of total leg length, there exists the potential for significant deformity.

This scenario plays itself out most commonly in an adolescent population. Retrospective reviews of large numbers of pedi-atric patients suggest that intrasubstance tears of the ACL are extremely rare in young children (younger than 12 years old).30,31 More than 80% of ligament injuries involve tibial spine avulsion rather than intrasubstance tear in children younger than 12 years of age.30 Tibial spine avulsions invoke an algorithm different than that of intrasubstance tears, with consensus dictating that displaced fractures should be reduced and fixed anatomically. Complete tear of the ACL without concomitant meniscal or chondral injury in a slightly older, adolescent population represents perhaps the most difficult scenario with respect to decision making. These patients are often 24 to 36 months away from skeletal maturity, at which time definitive, transphyseal reconstruction of the ACL could be performed without concern for iatrogenic injury to the growth plate. This also, however, tends to be a very active population that may not easily accept the necessity of stringent activity modification for these 2 to 3 years, followed by another 3 to 6 months of postoperative rehabilitation prior to returning to preinjury level of competition.

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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