Copyright
Knee BY
THOMAS
0.
CLANTON,
years
old
ARVO
repair,
all
associated anterior
nine
patients
demonstrated
concomitantly
with
C.
M.D.*,
intercondylar patients, four
ligament
degree
less
to the ligaments
than
fourteen
of the knee
of avulsion of injury is em-
years
old
in children
is unusual,
children with A review injuries
revealed
1 ,749
fourteen years were discussed
cases.
Nine
patients
of in any
Isolated reports have been presented.
1978.
were
whom
,
The
of
M.D.*,
Center,
San
Antonio
there
were
nine
children
whom
had
open
physes.
average
age
of
these
under
children
.
was
follow-up erage
evaluation
follow-up
was
was
two
injuries on a
obtained
4.3
years
repair within ten series who were roentgenographic
years
in all patients.
(range,
eight
The
months
av-
to 7.3
years).
trauma
nine patients. while riding patient
was
was
hurt
The vehicle
the
severity
of the
had
other
major
injuries: patients
A thorough
had
ligaments was
two One
another,
in a
one
knee
pain,
patient
patient
(Case
and
4)
a cerebral
hemarthrosis, unable
(Case
evaluation
in falls De-
9) had
was
and
to bear
weight
an obvious
attempted
in
the
it was frequently not possible to deof the lesion because of the child’s
.
Routine roentgenograms were six avulsion fractures four eminence and two involving Examination
performed
under in
three
for stress
roentgenograms arthroscopy
fifteen
and symptoms of significant lesions at the knee but whose diagnosis is unclear on completion of the standard history, physical examination, and roentgenograms. Opening at the joint line on stress roentgenograms of eight millimeters
years. Materials
Clinical Nine
hundred
were
ence
Center
ence
VOL.
in San
Division
7703
NO.
Floyd
requests
thirty-two
at the
Curl
to Dr.
8. DECEMBER
patients
University
Antonio
of Orthopaedic
reprint
61-A,
and
treated
Center,
address
Methods
Material
juries
*
and
of
between Surgery,
Drive,
DeLee.
1979
San
with Texas
June
University Antonio,
knee Health
1971 ofTexas Texas
and
inSci-
our
Please
than
that
in the
stressed
criterion for operative treatment. As already noted, arthroscopy
patients. whom could
.
in six patients; It has become
to perform an examination under stress roentgenograms in patients
or greater
May
Health Sci78284.
policy make
1-B) were made in three patients
anesthesia patients;
four-year-old boy with a medial ligament injury. Hyndman and Brown 17, in 1978, reported to the Canadian Orthopaedic Association on fifteen cases of acute kneeligament injuries in children between the ages of nine and
was
(Fig. done
and
spleen
and were
One knee
alone
only
a ruptured
pain and apprehension. made in all cases, revealing involving the intercondylar the collateral
accident
trauma,
of motion, side.
in all
final two injuries occurred and from a merry-go-round.
spite
range
of injury
were hit by automobiles: and three as pedestrians.
in a motorcycle
go-cart accident. from a moving
diagnosis
the mechanism
Five children their bicycles
emergency room, but termine the full extent
than
10.4
of
.
of injury, and all underwent operative days. There were no patients in our treated non-operatively Clinical and
on the injured knee dislocation.
less
the age
(range 6 . 2 to 1 3 5 years) There were seven boys and two girls. The right knee was involved in five patients and the left knee, in four. All patients but one were seen on the day
are our in
only
reported
all
decreased
ligament
knee-ligament
Science
Of these,
fourteen,
SANDERS,
TEXAS
Health
be-
detail32. of children’s Joseph and
ANTONIO,
of Texas
concussion. All nine
presumably
open physes has been published. of the literature in English on knee
BILL
are
who
cause the resiliency and strength of the ligaments greater than those of the physis and bone37’39. To knowledge, no previous series of knee ligament injuries
M.D.*,
Significant
phasized. Injury
in Children
SAN
Although
at the time of arthritis in the injury must be of the child suf-
association ligament
Incorporated
.
of
increased been per-
repair.
none of the children were symptomatic writing, development of degenerative future must be considered. Ligament considered in the differential diagnosis fering from knee trauma. The the tibial spine and collateral
injuries surgical
was had
Surgery.
DELEE,
University
an initial evaluation, only at op-
some
postoperative ligament instability. This in those patients in whom meniscectomy formed
JESSE
who were less than fourphyses and ligament in-
collateral ligament drawer sign. Despite
and Join:
Injuries
Surgery,
in seven of the nine patients. The of the tibia was avulsed in five
of whom had and a positive
of Bone
NEIDRE,
juries of the knee were studied. Despite thorough physical and roentgenographic the full extent of the lesion was determined eration eminence
The Journal
M.D.*,
of Orthopaedic
Nine children and had open
ABSTRACT:
teen
Division
by
Ligament AND
the
Front
979
This
was
of no value
anesthesia and to who have signs
normal was
in one
poor visualization was due to not be removed by suction-irrigation.
and our
knee
has
performed patient large
been
in three (Case
8),
in
clots which In the second 1195
1196
0.
T.
CLANTON,
J.
C.
DELEE,
BILL TABLE
SANDERS,
AND
ARVO
NEIDRE
I
Findings Case
Age. Sex (Yrs.)
1
13.5, M
Exam. under Anesthesia
Stress Roentgenogram
Not recorded
Arthroscopy*
Not performed
At Operation*
Not performed
ACL reattached with suture through drill holes; medial ligaments repaired;
Ant.
tibialspine avulsion; medial ligaments
torn
from
tibia; medial meniscus detached 7.7,
2
M
3+
Ant. sublux. of tibia: medial opening at joint line of 2 1 mm (normal, 13 mm)
medial laxity at 3O flexion; 3 +
ant. drawer in neutral and ext. rotation and 1 + in rotation
Complete periph. detachment of medial meniscus from meniscofemoral and meniscotibial ligaments; tear of TCL;
nt.
stretching
Follow-up (Mos.)
Treatment*
medial
AU.. attenuated; medial ligaments torn in mid-substance; medial meniscus
ACL
Results*
1+ ant. drawer; 2+ medial laxity
87
meniscect. with
reefed
9
1+
TCL stapled back to tibia; deep MCL repaired; POL reefed; medial and lat. meniscect.
57
2+
MCL
81
suture;
MCL
repaired
TCL
medial
laxity
and and
reefed; medial meniscus re-
detached
attached; reefed
and hem-
POL
orrhage in substance of ACL over entire length 1 I .8, F
3
Not recorded
Medial
opening
at
Not performed
AG. attenuated; ant. tibial spine avulsion; PCL attenu-
joint line of 22 mm (normal, 14 mm)
ated; medial ligaments torn from tibia; both menisci
ant. drawer; pivot shift, anterolat. instabili+
ty; 2+ medial laxity
detached
I 2.0, M
4
Not recorded
Medial
opening
at
jointlineof2l
(normal, 5
1 2.9.
M
Not
recorded
Medial
Not performed
Medial ligaments torn from tibia; medial meniscus detached
mm
12 mm)
opening
at
Hemorrhage
joint line of 24 mm (normal, 14 mm)
in mid-
and TCL repaired; POL reefed; medial meniscect.
ligaments torn in substance; medial meniscus detached
8
MCL and TCL re-
Medial
capsule noted outside synov.; tear at meniscofemoral junction; ACL un-
paired medial
1+
medial
laxity
1+ medial
laxity
and reefed; meniscus
reattached
involved 1 2.3
6
Not
F
.
recorded
Lateral
opening
at
Not
Ant.
performed
joint line of 22 mm (normal, 9 mm)
7
Not
M
8.0,
recorded
Not
tibial
performed
Not
performed
spine avul-
ant. drawer; 2+ lat. laxity
ACL reattached with suture through drill holes; lat. ligament reattached with staple
72
1+
Lat. meniscus and ACL reattached with suture through drill holes
68
1+ ant. drawer
from cartilage
PCL reattached with suture through drill
26
ROM
avulsed from tibia with cartilage; PCL avulsed from femur with cartilage; LU. and arcuate ligament torn; medial
AG. and PCL reattached with sutures
sion; from
LCL avulsed femur
ant.
attenuated;
ACL
tibial spine and anterior horn of lateral meniscus
avulsion M
6.2,
8
9
3+ post.
M
9.0,
18 mm post.
sublux. of tibia on femur
drawer
3 + post. drawer, 3+ at. laxity
Not performed
Unable to visualize due to large clots of blood
PCL
Not performed
ACL
avulsion
femur
with
*
= =posterior TCL
tibial
collateral
oblique
ligament;
ligament;
patient cofemoral
(Case and
ligament,
torn
marked cruciate
hemorrhage ligament.
copy and
showed
ROM
= = range
anterior
fibers
of
the
tibial
no
injury
injury
to the
This
seven of the nine patients termined only at operation who
had
PCL
demonstrated in the medial collateral
was
of the
anterior
= posterior
meniscapsular
ligament,
successful
medial
cruciate
important
operative approach in this patient. Despite the aforementioned evaluation
patients
ligament;
and
through
1+
52
ant. 1+
drawer; lat. laxity
drill holes;
post. capsule, LU., and arcuate corn-
plex all reefed; medial meniscect.
detached
cruciate
ligament;
LCL
of the
injury
was
lateral
=
in five
collateral
ligament;
= medial
MCL
collateral
ligament;
planning
or
the
procedures,
in
the full extent of injury was de(Table I). It was only in the two arthroscopy
that
the
severity
jury sign ments
preoperatively.
Findings
patients.
the anterior
ligament ligament
in
Surgical
known
The intercondylar
and stretching of fibers of the anterior In the third patient (Case 5), arthrosa suspected
structures.
cruciate
130#{176};
drawer
of motion.
2), arthroscopy meniscotibial tears
confirmed
other
ACL
and
post.
holes
meniscus
POL
= 5 to
1+
Of
cruciate
eminence these
five,
ligament
of the collateral ligament. was present in the latter Both the tibial collateral were
disrupted
of the all
while
had
tibia
four
had
A positive four patients. and medial
in five patients.
was
associated
avulsed injury
of
associated anterior
Ofthese
indrawer
capsular
liga-
five,
the tib-
ial collateral ligament was avulsed from the tibia in three, from the femur in one, and torn in its substance in the fifth patient.
The
medial
capsular THE
JOURNAL
ligament OF
BONE
was AND
torn JOINT
in SURGERY
the
KNEE
meniscotibial
portion
cofemoral dial
patients
and
INJURIES
in the
menis-
portion in two. Three of the patients with meinjuries had associated lesions of the anterior
ligament
cruciate severely cruciate All five
in three
LIGAMENT
two avulsed from the tibia and one attenuated. One also had an attenuated posterior ligament and detachment of the lateral meniscus. patients had peripheral detachment of the medial ligament
There was collateral
avulsion
and
of
one patient (Case 6) with ligament from the femur
the
anterior
no meniscal One patient
substance sion
tear
cruciate
injury. (Case of
fracture
the
7)
the tibial
of
ligament
sustained
anterior
avulsion associated
spine,
from
a 75
cruciate
of the with the
per
cent
ligament,
and
tibia
an
avulsion
inavul-
of the lateral
meniscus.
One posterior The
in the repairs
patient (Case 8) had an isolated avulsion of the cruciate ligament from the femur. final patient (Case 9) sustained a posterolateral
dislocation of the knee with injury to the anterior tenor cruciate ligaments, peripheral detachment medial meniscus, cuate ligaments.
and
tears
of the lateral
and posof the
collateral
and
ar-
All nine lowing
gree
of residual
degree graded
cluded
suture
from
bone
tients
and
and
of
imbricated
the
alone
avulsions
were
drill-holes
in the bone
of the
cross
the
fractures
proximal Two
patients
were
treated
with
No cruciate
using
was
attempted
cruciate ligaments
were
not
anterior
case
The
two
to
casts inbe-
cruciate
of attenuation avulsed
with
of
posterior
sutures
through
drill-holes through the medial femoral condyle. Five meniscectomies were performed four medial and one lateral. Peripherally detached medial menisci were repaired in two children and a detached lateral meniscus was
replaced in another. Postoperative immobilization,
cast
with
was
the
knee
maintained
pin
through
VOL.
61-A,
consisting to take
for six weeks the
NO.
positioned
proximal
end
5. DECEMBER
979
stress
off
in all patients. of the
tibia
of
a long
the
repair,
A Steinmann was
incorporated
ligament
in the knee had
fol-
no effect
level of activity. No locking, or instability.
patient Two
on
comof the
of chondromalacia patellae aspect of the knee, accenof the children subsequently sports including football,
ligament
laxity
related
or less ofjoint
separation;
millimeters millimeters
of separation; of separation
and
3
injury.
The
by stress testing of 1 + indicated
to the
was five
2+
meant
indicated
+
five to ten
more
than
ten
Of the two patients with injury to the medial collateral anterior cruciate ligaments, one (Case 1) had a 1 + an-
tenor
drawer
sign
(Case
2) had
no anterior
Case
1 the medial was
and
2+
medial drawer
meniscus
reattached
in Case
laxity,
while
1+
medial
removed,
and
and
was
cruciate She had
2+
ligament medial
and anterolateral shift. Both boys (Cases
tibial
collateral medial laxity.
the
other
laxity.
In
the menis-
2.
One girl (Case 3) had avulsion medial collateral ligaments
posterior menisci. sign, pivot
and
of the anterior with attenuation
and laxity,
rotatory
detachment a 2+ anterior
instability
4 and 5) with
cruciate of the
with
isolated
and medial capsular In Case 4 the medial
of
both drawer
a positive
injuries
ligaments meniscus
of the had was
1+ re-
moved.
avulsion
in long other ligament subsequently
in one replaced
as-
this
.
tied
care
non-displaced
of their avulsions
ligament.
dis-
sutures
taking
In Case 2, an attenuated reefed using sutures.
repair
pa-
three
of the anterior
tibia,
with
in-
in four The
immobilization
positioned with consideration juries. Neither of these two
the posterior
9).
epiphysis
of the
physis.
came displaced. ligament was
(Case
reattached
end
ligament
eminence
in one
through
patient.
cruciate
the intercondylar
cartilage
placed pect
in one
anterior
or
pain
although
millimeters
cus
avulsions
occasional
of instability determined from 1 + to 3 + Instability
tion in one.
with
cruciate
On follow-up clinical examination, eight of the nine patients had a full range of motion from zero to 135 degrees. One patient (Case 8) lost 5 degrees of flexion and 5 degrees ofextension, but this could not be correlated with the extent of his injury or its repair. All patients had some de-
sutured
The
had
activity,
nine patients had symptoms with mild pain in the anterior tuated by stair-climbing. Four participated in high-school track, and swimming.
and
in four patients and was stapled to the tibial inserThe avulsion of the lateral collateral ligament stapled to its origin and the torn lateral collateral was
children
vigorous
their performance plained of effusion,
All of these nine patients had surgical repair of their ligament injuries. All five of the medial ligament injuries were reconstituted by primary repair of the medial capsular ligament with sutures. The tibial collateral ligament was
repaired
cast to support the two posterior by holding the tibia anteriorly. Results
Treatment
was
1 197
CHILDREN
-
meniscus.
lateral
IN
The child (Case 6) with avulsion of the anterior cruciate and lateral collateral ligaments had 2+ lateral laxity and a 1 + anterior drawer sign. The patient (Case 7) with the anterior cruciate injury and associated detachment of the lateral meniscus had 1 + anterior laxity. The isolated (Case 8) produced of motion The
posterior 1 + posterior
cruciate laxity
ligament and
avulsion
a 5-degree
in both flexion and extension. last patient (Case 9), with posterolateral
loss
disloca-
tion,
had 1 + anterior laxity and 1 + lateral laxity. Roentgenographic evaluation at follow- up showed mild hypertrophic bone formation in the intercondylar notch of both patients with cruciate ligament and similar spine in three of five patients spine.
There
were
no
cases
avulsion of the posterior changes around the tibial with avulsion of the tibial of
growth
disturbance
of
the
1 198
0.
T.
epiphyseal were no follow-up
CI.ANTON,
growth plate from the injury roentgenographic signs of in any of the nine patients.
J.
or its
C.
BILL
DELEE,
repair.
There
produces
than
at
fractures
ligament
or
most
applied
often
to the
dissipated
lower
by
fracture
suggested by the relative tients with these fractures suggesting
a lesion
direct
trauma,
inacular
i:t
knee.
spine
that cause
injuries
knee
symptoms
much
rarer
‘
similar
and
injuries
in
were
teen.
operated
and
Brown’7
one medial
noted
associated
with
with
seven medial
that should be suspected. The anterior cruciate spine
case
no
spine
in patients
of seven
of tibial
spine
collateral cases
1-A: 1-B:
spine
was
and
ligament.
of
avulsion
ligament
and
tibia,
of
the
disruption. an
tibial
Our
avulsion injury
ex-
and colcomplex
but
does
rather
anterior
Anteroposterior Anteroposterior
not
insert and
directly lateral
I-A
roentgenogram roentgenogram
Type
tibial
fractures
one-third
ofthe thirteen
type cases
during
(2+
there tion
have
was
no significant
a portion
of the
remained
the tibial
anterior
attached
injury and spine
involving
anteroposterior No by
instability
Zaricznyj
.
drawer
sign was not In four of our five
‘
eminence
anterior
under
anterior
is completely
offracture.
or greater)
examination
of the frag-
cases
presented
of the intercondylar
a significant
Type
to one-half
avulsion
presence
of the
I , non-displaced:
by Hyndman with
noted
classified
into
of an anterior and Brown
the
FIG. made made
ligament. McKeever2 2
regardless
Jones to
and
of the
to sixty years old, with eleven of ten. They found a positive an-
of only
in the
comitant ligament
Garcia fractures
drawer
anesthesia.
these patients had an associated collateral In the fifth patient with an avulsion of
Hyndman
of the an-
tibiatttt7t5124t.
Type III, in which the fragment from its bed. In their thirty-five they reported finding only minor
mentioned
patients and
a rupture
seven
age
eminence
noted
avulsions
four-
cause
adult most often results in ligament in a child, with a
of forty-two
from
intercondylar ment;
liga-
the
a series
of a collateral Meyers and
displaced children, instability,
are
fracture
from
the
might
in an cruciate
tenor drawer sign in six patients who had a concomitant tear of a collateral ligament, but the ages of these six patients were not mentioned. We agree with their statement that a positive anterior drawer sign in the presence of an avulsion of the tibial spine is indicative of an associated
and
but
associated
the ages
Fi. Fig. Fig.
reported
ret-
ligament
knee
anterior
with four cases of anterior spine ligament injury confirms this as
tibial
fragment
Neer
that
ligament of the anterior
II, displacement
in chil-
Knee the
noted
children
had
and
the
with
injuries
at
of
from
tubercle
signs.
symptoms
on between
of the associated
into
patella
tibial
bone
tear
occur,
sustained
the
the
cruciate
proximal
2 per cent
common
McKeever2 -2”
tear
perience lateral
do
NEIDRE
Trauma
tenor avulsion
Similarly,
ten
Zaricznyj
spine
symptoms or
patella of
as Pa-
2.:t:t.:37.4:t
Meyers ment
have
femoral
of
is
injuries.
approximately
avulsion
relatively
produce
distal
child
or tibia,
these
symptoms
ofthe
other
the
femur
of
dislocation and
are
the
Such
Fractures
traumatic
disruption,
tibial dren
who
injuries
of
do not ordinarily
however, with injury to the tibial physes, which constitute all physeal
of
frequency
the
at
extremity
ARVO
of them under
disrup-
tionst7t.
Force
AND
t.:t.2u.24.27.
osteoarthropathy
Discussion
Trauma to the knee in children physeal injuries more conimonly
SANDERS,
drawer cruciate
All ligament
the sign,
ligament
to the tibia,
and
there
of the sign
tibial but was
was
was
four
of
injury.
spine, at operaseen
to
no con-
to the collateral ligament. Smith ‘ pointed out that not all fractures of are the result of cruciate ligament avulsion,
I-B
without stress. The physes are open. with valgus stress, demonstrating damage
THE
to the medial
JOURNAL
OF
ligament.
BONE
AND
JOINT
SURGERY
KNEE
MEDIAL TIBIAL
CAPSULAR
COLLATERAL
TIBIAL
LIGAMENT
INJURIES
LIGAMENT
EPIPHYSEAL
FIG.
as
Their
proposed
by
( 1) avulsion
Pringle’ .
of
the
tibial
and their
relationship
classification
spine
or
tubercle’ ; (2) fracture of the ‘external spine; and (3) injury of the spine combined ‘
its
‘
the tuberosity of the tibia. The first type was thought to be caused by tension on the cruciate ligaments. Three cases of were
presented,
being
shorn
which off
by
they
the
inner
thought
were
margin
of the
lateral femoral condyle with either forced anterior motion of the femur or posterior motion of the tibia. While it is our impression that the tibial spine can be fractured by other mechanisms,
such
lesions
must
injury.
Nine
of
the
be extremely
sixteen
rare.
ligament
bone,
and growth of strain has
the site and position
of
the
of application knee
at
the
of force time
in our
the growth Since
plate
ligament
may
influence
ruptures
one must be aware of their child with knee complaints
when
related
are
the
strain
uncommon
is
(Fig.
in children,
when examining trauma. After
bear
a the
VOL.
61-A,
NO.
5.
DECEMBER
1979
Occasionally
stress
PLATE
epiphyseal
can
plates
be obtained
in children
has
from conclude fare
this
better out.
not
favor
at this
been
experience that knee than
epiphyseal
point.
disruption
Should
this
defined.
If one
were
in adults
primary
.
surgical
Our
study
repair
immobilization, in our patients.
Seven of our nine of these menisci
ofjoint thors
stability
that
not by
injuries healing reported.
in in
detachment; results might
better with surgical reattachment, stability to the knee. The concept
preservation
I.3.5,I4.fl.22.23,31
does
followed
some degree of This suggests that
patients had meniscal were removed. The
been some
to ex-
with children’s fractures, one ligament injuries in children
those
Despite
and
to be gaining acceptance subsequent degenerative
partial
meniscectomy
seems
due to the decreased incidence joint disease and the maintenance have
been
reported
by a number
of
of au-
,34.31i.44
Although some degree of objective knee-ligament laxity persisted in all of our patients, this did not result in subjective symptoms of instability. Even in adults, ligament laxity is not always associated with symptoms of instability. Nevertheless, long-term follow-up of these surgically treated patients is needed to determine if instability will eventually lead to arthritic changes.
signs
instilled.
and femoral
of meniscal
local
is
LIGAMENT
such injuries are analogous to adult ligament this respect. Documented studies of ligament children compared with adults have not been
jury
agent
EPIPHYSEAL
six weeks of plaster-cast ligament laxity persisted
standard history, physical examination, and roentgenograms, several other diagnostic alternatives are available to fully delineate the lesion. Aspiration of the knee may allow a more thorough examination, especially when a anesthetic
FIBULAR
conceivably have thus contributing
to the
the site of injury
existence following
COLLATERAL
,
five
applied72t. The relationship of the attachment of the collateral ligaments and joint capsule to the epiphyseal growth plate and the fact that the ligaments are stronger than
. FIBULAR
LIGAMENT
of the knee is another useful tool offering much potential for definition of the location and extent of the lesion while adding little to the morbidity. The best method of treatment of knee ligament in-
would
plate as related to age7 at 2M4b47. The been shown to be important, as well as
direction
CAPSULAR
fail to provide a thorough assessment, examination under anesthesia and stress roentgenograms in the operating room can be diagnostic (Figs. 1-A and 1-B). Arthroscopy
might
All five
injuries
to the tibial
trapolate
series were avulsions of cartilage or bone, six being visible on the initial roentgenograms. Numerous factors are involved in determining the site of ligament disruption, including the structure of ligament, rate
. LATERAL
PLATE
2
juries
such fractures in our patients apparently were the result of traction on the anterior cruciate ligament causing avulsion of a variable amount of its bone insertion. Kennedy and co-workers2#{176} found only two cases of bone avulsion in fifty patients with anterior cruciate ligament
EPIPHYSEAL
roentgenograms
in-
internal
‘ ‘
tubercle’ of the with fracture of
‘
the second type due to the spine
. FEMORAL
PLATE
of the knee
initially
1199
CHILDREN
LIGAMENT
The origin and insertion of the ligaments rather than damage to the ligaments.
cluded:
IN
Conclusions One
must
in the child in the
knee
be aware with
open
secondary
of the possibility physes
who
to trauma.
of ligament has
symptoms
inand
1200
T.
A
child’s
complete not reveal under
pain
anesthesia
tibial
CLANTON,
L
apprehension
C.
often
DELEE,
BILL
preclude
SANDERS,
a
together
should should
with
stress
roentgenograms
be considered.
be
sought
in patients
with
tients similar
and
Concomitant
ARVO
this
of the
repaired
in adults
experience,
knee-ligament
knee
favors
plus
detachments,
spine.
NEIDRE
injuries
in the
pa-
in our series did not appear to fare any better than injuries in adults. Experience with such ligament
disruptions
ligament
avulsion
AND
Surgically
physical examination and roentgenograms may the extent of the lesion. Therefore, examination
arthroscopy injuries
and
0.
leads
ligament
surgical
repair.
the possibility us to recommend
injuries
Nevertheless,
of reparable surgical
meniscal treatment
for
in children.
References I
.
Treatment has been Removed.
AARSTRAND,
the Meniscus 2.
L. C.;
ABBOTT,
Surg.,
3. 4. 5.
26:
July
Late
Results
Supplementum
B1.OUNT,
W.
P.:
Fractures
CARGII.1.,
A.
O’R.,
and
248-251,
Joint. A Follow-up 146-157, 1954.
Examination
C. E.: Injuries
ANDERSON,
of Material
to the Ligaments
Where
ofthe
Only
the Ruptured
Knee Joint.
Part of
J. Bone and Joint
1944.
dinavica, 58-A:
Rupture of the Knee Scandinavica, 107:
J. B. DEC. M.; BosT, F. C.; and
SAUNDERS,
503-521,
HEI.GE:
APPEI.,
of Meniscal Acta Chir.
T0RLEIv:
after
Meniscectomy
the
in
Knee
Joint.
A Clinical
and
Roentgenologic
Follow-up
Investigation.
Acta
Orthop.
Scan-
133, 1970. in Children,
March
pp.
171-182.
Baltimore,
J. P.: Bucket-Handle
JACKSON,
Williams
Tearofthe
and
Medial
Wilkins,
Meniscus.
1954.
A Case for Conservative
Surgery.
J. Bone and Joint Surg.,
1976.
6. CRAWFORD, A. H.: Fractures About the Knee in Children. Orthop. Clin. North America, 7: 639-656, 1976. 7. CROWNINSHIELD, R. D., and POPE, M. H.: The Strength and Failure Characteristics ofRat Medial Collateral Ligaments. J. Trauma, 16: 99- 105, I 976. 8. EHRLICH, M. G., and STRAIN, R. E., JR.: Epiphyseal Injuries About the Knee. Orthop. Clin. North America, 10: 91-103, 1979. 9. FETTO, J. F., and MARSHALl., J. L.: Medial Collateral Ligament Injuries of the Knee: A Rationale for Treatment. Clin. Orthop., 132: 206-218, 1978. 10. GARCIA, ALEXANDER, and NEER, C. S., II: Isolated Fractures ofthe Intercondylar Eminence ofthe Tibia. Am. J. Surg., 95: 593-598, 1958. 11. GIRGI5, F. G.; MARSHALL, J. L.; and AL MONAJEM, A. R. S.: The Cruciate Ligaments ofthe Kneeioint. Anatomical, Functional and Experimental 12. 13.
Analysis.
HORNE,
214-220,
14.
Clin.
Orthop.,
106:
216-231,
1975.
J. 1.: Fracture Management; A Practical Approach, pp. 279-284. Philadelphia, Lea and Febiger, 1978. J. G., and PARSONS, C. J.: The Anterior Cruciate Ligament: Its Anatomy and a New Method of Reconstruction.
HARTMAN,
Canadian
J. Surg.,
20:
87-93,
Jan.
1977.
H. H., and
HSIEH,
P. 5.: Stabilizing
WALKER,
Mechanisms
ofthe
Loaded
and Unloaded
Knee Joint. J. Bone and Joint Surg.,
58-A:
1976. 15.
HUGHSTON,
16.
HUGHSTON,
J. C.: A Simple J. C.; ANDREWS,
Compartment 17.
and
Cruciate
J. C., and
HYNDMAN,
thopaedic 18.
Association, JONES, ROBERT, and 1: 70-89 1913.
19.
JoSEPH,
of
J. C.;
KENNEDY,
and
Clinical
Vancouver, SMITH, S. A.:
WEINBERG,
and
Disruption
W. R.;
KRAUSE,
23.
Surg. , 58-A: 599-604, MCGINTY, J. B.; GEUSS, 763-766, Sept. 1977.
24.
MARSHALE.,
J. L.;
152-158,
July-Aug.
MEYERS,
M.
25.
Ligament
British Columbia, On Rupture ofthe
R. J.;
HAWKINS,
22.
July-Aug.
58-A:
1975.
Classification
ARNALDO:
Injuries
June Crucial
159-172,
L.
F.;
and
ofthe
Knee,
J. B.;
WANG,
Ligaments.
F. G.; and
GIRGIS,
J. Bone
Instabilities.
Read at the Annual
of the
ofthe
Knee
Part
Meeting
Spineofthe
I.
The
Medial
of the Canadian Tibia.
in a Four-Year-Old
of the Anterior 1974.
Changes
Meniscectomy.
British
Boy.
Surg.
,
Ligament.
Or-
J. Surg.,
Case As
Knee Ligaments.
58-A:
350-355,
Yield
April
Report
and
Determined
by
A Comparative
Analysis.
Drawer
Point,
Ultimate
1976.
in the Knee after Meniscectomy.
R.: The Anterior
WARREN,
Cruciate
Studies of Human
and Joint
D. G.: Mechanical
WILDER,
R. A.: Partial or Total W.;
Ligament
and on Fractures
K. D.: Tension
DANYLCHUK,
Collateral
R. J.; and
FURMAN,
Knee
1976.
of the Knee in Children.
1978. Ligaments
Rupture
and Tibial
MARVIN,
of
March
, 60-A:
R. B.; and
WILLIS,
of the Cruciate M. H.; JoHNSoN, July 1976.
POPE,
3: 179-187,
of the Medial Ligament 402-403, April 1978. H. W.; and WIlSON, A. S.: The Anatomy and Function Studies. J. Bone and Joint Surg. , 56-A: 223-235, March
Morphological
J. C.;
Failure,
D. C. S.: Major
BROWN,
POGRUND, HYMAN: Traumatic Literature. J. Bone and Joint Surg.
the
21 . KENNEDY,
J. Sports Med.,
M. J.; and MoscHI, J. Bone and Joint Surg.,
Ligaments.
K. N., and
Review 20.
Meniscectomy. J. R.; CROSS,
J. Bone and Joint
J. Bone and Joint Surg.,
Sign: What Is It? J. Sports
59-A:
Med.,
3:
1975.
H.,
and
MCKEEVER,
F. M.:
Fracture
ofthe
Intercondylar
Eminence
ofthe
Tibia.
M. H., and
MCKEEVER,
F. M.: Fracture
ofthe
Intercondylar
Eminence
ofthe
Tibia.
J. Bone
and Joint
41-A:
Surg.,
209-222,
March
1959. 26.
MEYERS,
J. Bone and Joint Surg.,
52-A:
1677-1684,
Dec.
Am. J. Sports Med.,
5: 171-176,
July-
1970.
L. A.,
27.
N0RW00D,
28.
Aug. 1977. N0YE5, F. R.,
Related 29.
and
O’DONOGHUE,
37-A:
l-l3,Jan.
3 1 . ORETORP, PALMER,
35.
PRINGLE,
POLLEN, PRICE,
E. S.:
The
Strength
J. Bone and Joint Surg., DELUCAS, J . L .; and T0RvIK, of Failure
in Primates.
D. H.: An Analysis 1955.
NILS;
Tensile 32. 33. 34.
GR00D,
M. J.: The Intercondylar
CROSS,
Changes.
NOYES, F. R .; and Mechanisms
30.
and
JR.,
ALM,
ANDERS;
IvAR:
On
the
to the
Cruciate
and Joint
and
HANS;
Ligaments
Knee
Cruciate
Ligament
in Humans
Ligament. and
Rhesus
Monkeys.
Age-Related
and
Species-
of Anterior Cruciate Ligament Failure: 56-A: 236-253, March 1974.
An Analysis
of Strain-Rate
Sensitivity
,
GILLQUIST,
of the
the Anterior 1976.
Treatment
in Dogs. Acta Orthop.
and Dislocations W. C.: Ligament
Dec.
Surg.
Results ofSurgical
EKSTR#{246}M,
Injuries
G.: Fractures C. T., and ALLEN, A.
Anterior
58-A: 1074-1082, P . J .: Biomechanics
J. Bone
ofEnd
Load on Knee Joint Ligaments
of the
Shelfand
JAN:
ofMajorlnjuries Immediate
Scandinavica, Joint.
A
to the Ligaments Effects
of Meniscectomy
49:
Clinical
in Children, pp. 170-178. Baltimore, Repair in the Knee with Preservation
ofthe
407-414, Study. Acta
1978. Chir.
Knee. J. Bone and Joint Surg.,
on the Knee
Scandinavica,
Joint.
The
Effects
53,
1938.
Supplementum
Williams and Wilkins, 1973. ofthe Meniscus. J. Bone and Joint Surg.,
60-A:
61-65,
of
Jan.
I 978.
J. H.: Avulsion E. L.:
Our
of the Spine of the Tibia.
Current
Understanding
RADIN,
37. 38.
RANG,
MERCER:
ROTH,
39.
SALTER,
40.
SHELTON,
P. B.: Fracture of the Spine of the Tibia. R. B.: Textbook ofDisorders and Injuries M. L.; NEER, C. S., II; and GRANTHAM,
Surgeons;
Symposium
Children’s
on
Fractures,
Surg.,
46: 169-178,
1907.
of Normal
36.
Orthopaedic
Ann.
Reconstructive
pp.
181-188.
Knee Mechanics and Implications for Successful Knee Surgery. In American Academy of Surgery of the Knee, pp. 37-46. St. Louis, C. V. Mosby, 1978. Philadelphia, J. B. Lippincott, 1974. J. Bone and Joint Surg. , 10: 509-518, July 1928. ofthe Musculo-skeletal System, pp. 416, 446-449. Baltimore, Williams and Wilkins, 1970.
S. A.: Occult
Knee Ligament
Ruptures
Associated
with Fractures.
J. Trauma,
11: 853-856,
I971.
41
.
SHIELDS,
tal.
LAURENCE;
J. Trauma,
MITAL,
9: 192-215,
MOHINDER;
and CAVE,
E. F.: Complete
Dislocation
ofthe
Knee:
Experience
at the Massachusetts
General
Hospi-
1969.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
KNEE
42. 43.
TACHDJIAN,
I. S.:
44.
TAPPER,
E.
45.
TAYloR,
A.
SMILLIE,
Rats. 47.
J. Bone
49.
J. Bone
Joint.
and
R. D.; and
MATTHES,
and
C. M.;
TIPTON,
Jan. 48.
Treatment.
C. M.;
TIPTON,
of the Knee
Ed.
0.: Pediatric Orthopedics, M., and HOOVER, N. W.: Late R.; ARDEN, G. P.; and RAINEY,
Conservative 46.
Injuries
M.
Joint
Surg.
SCHILD,
,
60-A:
J.; and
R.
LIGAMENT
4, pp.
INJURIES
154-158.
pp. 1706-1719. Results
after
New
54-B:
Dislocation
96-102,
R. K.: Influence
230-234,
March
1201
CHILDREN
Churchill
Livingstone,
1970.
W. B. Saunders, 1972. J. Bone and Joint Surg., 51-A: 517-526, April 1969. ofthe Knee. A Report ofForty-three Cases with Special
Meniscectomy.
H. A.: Traumatic
Feb.
Reference
to
1972.
of Age and Sex on the Strength
of Bone-Ligament
Junctions
in Knee Joints of
1978.
E.: Measurement
A.
York,
Philadelphia,
Joint Surg., MARTIN,
FLATT,
IN
ofLigamentous
Strength
in Rat Knees.
J. Bone and Joint Surg.,
49-A:
63-72,
1967.
YOUMANS,
W. T.: The So-Called
with
Observation
Some
B.: Avulsion
ZARICZNYJ,
I 1 15, Dec.
“Isolated”
on Treatment
Anterior
and
Fracture
its Effect
of the Tibial
Cruciate
Ligament
on Results.
Eminence:
Am.
Treatment
Tear or Anterior Cruciate Ligament Syndrome: A Report of 32 Cases Med. , 6: 26-30, 1978. by Open Reduction and Pinning. J. Bone and Joint Surg. , 59-A: 1 1 1 1-
J. Sports
1977.
Copyrighl
979 by The- J;urna!
of
and
BOfli
Joint
Surger
. In orpora -d
Editorial Mutagenesis
versus
Carcinogenesis
Plastic The
following
monomeric
study
on the
Implants
mutagenic properties by Poss and associates
methylmethacrylate
of is
of great general interest. Its special thopaedists, neurosurgeons, and dentists this editorial. The investigation of Poss
concern to orhas stimulated and co-workers
has
Ames
used
ogy,
a variation
in which
be assayed tant
for
strains
sidered
of the
chemical their
well
ability
persons
‘
cause
for concern.
In this
instance
at
could and the
authors
test
can con-
have
known
carcinogens
are not
mutagenic
dem-
test
is
raises
determining
stance assess human
the
carcinogenicity.
of the
current
technology
Are
megadoses
of
any
for
in humans
there
61-A,
NO.
8.
in addition is no DECEMBER
to solid better 1979
way
epidemiologic at this
time
make
a
such
carcinogenesis
in
the utilization of by a toxic chemical
question
as proof
such methods the enormous
a
of its car-
as the Ames test number of poten-
carcinogenic chemicals and their testing. It is obvious that accepted
of animal professional
‘
provides
tumorigenesis
are too consum-
and
resources,
technical
time,
,
an opportunity as
on are jump
to do this,
it is inappropriate
careful
tients
sub-
evidence to
without
methods
‘good
this
for
for
science’ but a hasty judgmental action, even based on good science, may not reflect good sense. Rational decision-making based on good science needs to be examined in detail. The study of Poss and colleagues ‘
repeatedly administered to mice a reasonable way to risk to humans, irrespective of the exposure a may receive! The consensus response to this ques-
tion is yes,
VOL.
problem
reason
and money to cope with the enormous number of chemicals requiring evaluation. At the moment, the method used in this study is
table
This
of chemical
Nonetheless, to screen
of skilled
methacrylate
for cancer.
change
bioassay ing
salient
in humans, and in bacteria induced
tially mutagenic and metabolites for further
though
risk
a more
promotion or
be accepted
methylmethacrylate may be at more risk than was expected. It is essential, however, to avoid the facile (and erroneous) extrapolation that any such mutagenic material is a carcinogen and that patients with polymeric methylare at special
and
cinogenicity. are invaluable
system.
potentially alarming central issue of any such study those exposed to repeated doses of monomeric
implants
However,
models
cannot
tested in accepted aniabout 10 per cent of in this
animal
mutagenic
that in the Ames test all mutagens are not necessarily carcinogens, although a very significant number of mutagens
The that
potential. Are the bacteria, such as the
conclusion on the role of these procedures is that do not as yet understand the molecular events in
the initiation is
that
do prove to be carcinogenic when mal bioassay systems. Conversely,
systems.
a tenuous we clearly
currently
be at hazard is a reasonable
carcinogenic using
technique employed by Poss and associates, relto determine carcinogenicity in humans? The answer to this is a qualified no or, at best, a perhaps. Significant false negatives and false positives occur in these microbial
a metabolic product of methylmethacrylate, not the monomer itself - nor, indeed, the polymeric form is the mutagen. It is crucial to understand, however, onstrated
on a chemical’s current methodologies
several evant
in mu-
The authors’ exposed
judgment Ames
methodol-
metabolites
mutagenesis
typhimurium. that
‘safe’ levels of methylmethacrylate the real burden of their investigation ‘
or their
to induce
ofSalmonella conclusion
accepted
substances
of
with
study’s
various
results
prostheses,
that will
as it is almost careless
suggest
dentures,
as inevi-
interpretation that
implants,
destined to have cancer. It is equally to the hasty conclusion that thousands
of
countless
pa-
and
so
erroneous of profession-
to
als and industrial workers methacrylate is greater than
whose exposure to methylthat of patients are even more
at risk
of cancer.
of the
development
The
authors
quite
