Anterior cruciate ligament reconstruction in a patient with Athetoid cerebral palsy: a case report
© Tajima et al.; licensee BioMed Central Ltd. 2012
Received: 17 August 2011
Accepted: 28 September 2012
Published: 2 October 2012
Recent years have seen ACL reconstruction performed in a broad range of patients, regardless of age, sex or occupation, thanks to great advances in surgical techniques, instrumentation and the basic research. Favorable results have been reported; however, we have not been able to locate any reports describing ACL reconstruction in patients with athetoid cerebral palsy.
We present herein a previously unreported anterior cruciate ligament (ACL) reconstruction performed in a patient with athetoid cerebral palsy. The patient was a 25-year-old woman with level II athetoid cerebral palsy according to the Gross Motor Function Classification System. She initially injured her right knee after falling off a bicycle. Two years later, she again experienced right-knee pain and a feeling of instability. A right-knee ACL tear and avulsion fracture was diagnosed upon physical examination and confirmed with magnetic resonance imaging (MRI) and X-ray examination at that time. An ACL reconstruction using an autologous hamstring double-bundle graft was performed for recurrent instability nine years after the initial injury. Cast immobilization was provided for 3 weeks following surgery and knee extension was restricted for 3 months with the functional ACL brace to prevent hyperextension due to involuntary movement. Partial weight-bearing was started 1 week postoperatively, with full weight-bearing after 4 weeks. The anterior drawer stress radiography showed a 63% anterior displacement of the involved tibia on the femur six months following the surgery, while the contralateral knee demonstrated a 60% anterior displacement of the tibia. The functional ACL functional brace was then removed. A second-look arthroscopy was performed 13 months after the ACL reconstruction, and both the anteromedial and posterolateral bundles were in excellent position as per Kondo’s criteria. The Lachman and pivot shift test performed under anesthesia were also negative. An anterior drawer stress radiography of the involved knee at 36 months following surgery showed a 61% anterior translation of the tibia. The preoperative symptoms of instability resolved and the patient expressed a high degree of satisfaction with the result of her surgery.
KeywordsAthetoid cerebral palsy Anterior cruciate ligament reconstruction Involuntary movement Stress radiography
Anterior cruciate ligament (ACL) injury is common with sporting activity. ACL laxity sometimes causes knee joint instability in activities such as cutting or pivoting, which can lead to articular cartilage degradation and/or meniscus injury [1–3].
Recent years have seen ACL reconstruction performed in a broad range of patients, regardless of age, sex or occupation, thanks to great advances in surgical techniques, instrumentation and the basic research. Favorable results have been reported for many [4–8]. We have been unable to identify any reports describing ACL reconstruction in patients with athetoid cerebral palsy in the literature. We are presenting our experience with ACL reconstruction in such a patient. The patient and her family were informed that data concerning the case would be submitted for publication, and gave their consent. With the patient`s agreement, we are reporting on the case with its clinical features and the treatment.
Examination of the patient 1 year after surgery revealed a Lysholm score of 72 points and an IKDC score of 64.4. The patient continued to feel no knee pain or instability with activities of daily living or when walking quickly. VAS evaluation was scored at 0 mm, with absolutely no pain or sense of discomfort. She did have tenderness upon palpation of the tibial fixation devices.
The pattern and strength of the involuntary movement associated with athetoid cerebral palsy is variable rather than regular, and becomes more intense at times when the subject is active.Maintaining a constant posture is difficult for this type of patient, and sudden joint movement may occur. Rehabilitation after surgery such as ACL reconstruction can thus be difficult. To date, no reports have described ACL reconstruction in a patient with athetoid cerebral palsy, and appropriate rehabilitation programs for such patients have not been defined. Our patient exhibited pronounced involuntary movement, so we employed cast immobilization for 3 weeks after the ACL reconstruction to inhibit sudden joint movements and stress on the reconstructed ligament. We also slightly restricted extension of the knee by having the patient wear the functional ACL brace thereafter. Full extension of the joint was possible by 6 months after surgery.
Ordinarily, ACL function is evaluated by manual examination or using instruments such as the KT2000 arthrometer and Kneelax. However, in patients with athetoid cerebral palsy, accurate evaluation of knee stability is difficult due to the involuntary movements. Moreover, MRI requires sedation, and cannot be readily repeated due to cost. The patient underwent evaluation by stress radiography, because this technique can be repeated and it is useful as a simple, low-cost modality requiring no special measures.
With the stress radiography technique used, a finding of greater than 70% tibial translation indicates ACL failure . The results of this case demonstrated six month and 36 month postoperative evaluations of 63% and 61% anterior tibial translation, respectively.
If the examiner felt muscle spasticity, he or she repeated the evaluation. The graft was in good condition regarding synovial covering, thickness and tension at the time of the second-look arthroscopy. The stress radiography at this time revealed a 63% translation of the tibia indicating no stretch of the graft. Furthermore, under general anesthesia, the Lachman and pivot shift tests remained negative. These results indicated that the ACL reconstruction was successful in this case.
This is the first reported case of ACL reconstruction in a patient with athetoid cerebral palsy, with good short-term results. Accurate evaluation of ACL function in such patients is difficult due to the involuntary movements, but stress radiography was useful for evaluating our patient. Anatomical double-bundle autologous hamstring graft ACL reconstruction was performed, and evaluation of the reconstructed ligament revealed good results.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Assistant professor of Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki.
Member of Japanese Orthopaedics Society.
Member of Japanese Orthopaedics Society for Sports Medicine.
Member of Japanese Society of Clinical Sports Medicine.
Member of Japanese Orthopaedics Society Knee, Arthroscopy and Sports Medicine.
Anterior cruciate ligament
Magnetic resonance imaging
Gross Motor Function Classification System
International Knee Documentation Committee
Visual analog scale.
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