Changes in gait patterns after anterior cruciate ligament reconstruction in children.

PURPOSE: Anterior cruciate ligament reconstruction (ACLR) in children is indicated to reduce recurrent knee instability and further damage to the joint. Postoperative modified gait pattern was reported in the adult population after ACLR. The aim of this study was to analyse gait abnormalities, and especially knee and ankle adaptations during gait in children after ACLR. METHODS: A prospective study was performed between 2018 and 2022 on 50 children, aged nine to 15 years with unilateral ACL deficiency. Changes in gait pattern were evaluated by gait analysis before surgery and at the latest follow-up of 24 months. Kinematic data of ACL-deficient limb were compared to contralateral limb and to those of a matched control group of healthy children. RESULTS: Compared to control group, knee flexion was decreased for both ACL-deficient and contralateral knee before surgery. Decreased knee flexion during gait cycle persisted at latest follow-up. Ankle kinematics showed decreased dorsal flexion for both ACL-deficient and contralateral limb before surgery. At latest follow-up, ankle kinematics were modified for ACL-reconstructed limbs only at initial contact and showed no significant difference for contralateral limb compared to the control group. CONCLUSION: In children with ACL injury, abnormal gait patterns persist two years after ligament reconstruction, in spite of extensive rehabilitation and no clinical complaints. These findings might guide neuromuscular training to improve clinical outcomes and reduce the rerupture rate.

Foot and ankle compensation for anterior cruciate ligament deficiency during gait in children.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are common in adults and cause knee instability, pain, and an increased risk of osteoarthritis. Previous studies demonstrated changed gait patterns in adult patients with ACL deficiency. In paediatric patients, ACL injuries were once thought to be rare but are being increasingly diagnosed due to greater involvement of children in contact sports and to the introduction of more effective diagnostic tools such as magnetic resonance imaging (MRI). However, little is known about gait adaptation in children with ACL deficiency. The objective of this study was to look for compensatory foot and ankle behaviours during gait in paediatric patients with symptomatic ACL deficiency. HYPOTHESIS: Compensation for ACL deficiency during gait occurs at the foot and ankle in children, because compensation at the hip and pelvis would require greater energy expenditure. MATERIAL AND METHODS: We included 47 patients, 33 males and 14 females, ranging in age from 9 to 17 years (mean, 14.1 years). The patients had a history of unilateral ACL injury documented by MRI and initially treated by immobilisation and physical therapy. They were allowed to walk with full weight-bearing on the affected limb and were not taking medications at the time of the study. All patients had pain, knee instability, or functional limitation. The physical examination showed joint laxity indicating surgical ACL reconstruction. None had neurological conditions, congenital musculoskeletal abnormalities, or a history of knee surgery. Gait analysis (GA) was performed using a Vicon 460 system. Kinematic data for the ankle and foot were compared to those in a control group of 37 healthy children. Ankle angular positions were calculated for each group at the following stance time points: initial contact (0% of gait cycle [GC]), mid-stance (25% GC), terminal stance (60% GC), and swing (83% GC). Foot progression data were recorded at mid-stance (25% GC) and swing (70% GC). Student's t test was applied to compare the results to reference values obtained at our laboratory and to data from the control group. RESULTS: Compared to the reference values, the ankle was in plantar flexion at initial contact in 41 patients, and ankle dorsiflexion during the stance phase was diminished in 39 patients. The external foot progression angle was increased in 23 patients during the stance phase and 38 patients during the swing phase. Compared to the control group (mean age, 9.1 years), the patients had plantar flexion of the ankle at initial contact (3.43°±3.5° vs. 0.74°±3.6°, p<0.05) and decreased dorsiflexion during the stance phase (3.43°±3.5° vs. 0.74°±3.6°, p<0.05). No significant differences were found for any of the other parameters. DISCUSSION: Children with ACL deficiency developed compensatory foot and ankle behaviours during gait that improved knee stability. Understanding these compensations may guide treatment optimisation. LEVEL OF EVIDENCE: III, retrospective comparative study.

Ewing sarcoma of the acetabulum in children: a "growth plate-based" surgical strategy.

BACKGROUND: Surgical strategy for Ewing sarcoma (ES) of the pelvis relies on Enneking classification. In adults, in case the acetabulum is involved, excision of the entire acetabulum is needed and often leads to loss of function. In children, the surgeon may adopt a strategy, such as in metaphyseal tumors of long bones where an unaffected growth plate allows a transepiphyseal resection, therefore sparing the joint. METHODS: We present a "triradiate cartilage strategy" for the excision of ES of the pubic component of the acetabulum, which allows a wide resection while preserving most of the socket. The approach is ilioinguinal. Osteotomies of the iliopubic and ischio pubicrami are performed, followed by hip arthrotomy and anterior dislocation. Transacetabular resection is achieved using osteotomes, under image intensifier guidance, with no further reconstruction. Cases are presented for 2 boys aged 6.5 and 9.5 years, treated with chemotherapy and transacetabular resection. RESULTS: Resections were all rated R0. Patient #1 remained asymptomatic, including during sport activities, and had normal hip range of motion at 12-year follow-up. Radiograph demonstrated mild protrusio acetabuli. Patient #2 had no complain at 3-year follow-up with normal hip range of motion, although he presented with an equinus gait. Radiographs demonstrated a well-covered femoral head without medial shift. CONCLUSIONS: A "growth plate-based" surgical strategy can be adapted to malignant pelvic tumors in skeletally immature children. This technique leaves intact the ilio ischiatic component of the triradiate cartilage, which, according to Ponseti, contributes the most to the growth of the acetabulum. Joint sparing improves the functional result and decreases the risk of complication. LEVEL OF EVIDENCE: IV.