Undefeated

Recovery from rare knee injury

For a 10-year-old, Pares Cuffee has particularly long legs, but they suit him well on the diamond. They give him a steady stance in the batter’s box; the quickness he needs to reach for difficult catches; and power to push off the pitcher’s mound with force.

But Pares’ strong and agile movements on the field are a stark contrast to his form four years ago, when a serious injury destroyed parts of his knee and left him unable to use his right leg at all.

“I was playing on our exercise bench and the heavy weight bar fell on my leg,” Pares says. His mother, Paris Clark, immediately knew that this was not a minor injury. Her son was crying. He couldn’t put any weight on his right leg, and his knee seemed to be stuck in a half-bent position. “Pares is very strong and rarely cries,” says mom. “So I was instantly concerned.”

“Going to CHKD was the only option I even considered,” she says. “That’s where my mother took me and where I always take Pares. The entire place is set up just for kids, and they know how to care for them better than anyone.”

At CHKD’s emergency department, images of Pares’ knee revealed an injury called a tibial spine avulsion fracture – pieces of his tibia, or shin, had broken away from the rest of the bone at the precise spot where the anterior cruciate ligament (ACL) is normally attached. The ACL – one of the four major ligaments in the knee – is located inside the knee joint and connects the bones of the upper and lower leg, providing stability during movement of the leg. “When they showed me the X-ray, it looked like pieces scattered everywhere,” says mom. “It did not look like a puzzle that would fit neatly back together.”

Dr. Allison Tenfelde, a pediatric orthopedic surgeon at CHKD, met with the family to explain that Pares would need an operation to reattach the ligament and repair his broken bone. He went home on crutches, with surgery scheduled for 10 days later.

During surgery, Dr. Tenfelde discovered that Pares’ injury was far more severe than any of the scans had indicated. His ACL was not only detached from his tibia but also torn away from his femur, the large bone of his upper leg. “It was shocking,” says Dr. Tenfelde. “His ACL was completely detached and free-floating. It’s an injury so exceptionally rare that I still have not found another orthopedic surgeon who has ever seen it in a child.”

Instead of a single surgery, Pares’ recovery became a multi-year process that would take more than 100 hours of therapy and multiple surgeries to complete. The process included intensive physical therapy to re-establish range of motion in his knee, and a preliminary surgery to clean out scar tissue that had formed in the joint.

It would take nearly a year for Pares to make enough progress to undergo the reconstruction procedure. Dr. Tenfelde enlisted Dr. Allison Crepeau, a fellow orthopedic surgeon at CHKD, to assist in the complicated repair. Dr. Crepeau and Dr. Tenfelde are among a small number of orthopedic surgeons who are dual fellowship-trained in both pediatric orthopedic surgery and orthopedic sports medicine.

The surgeons created a new ACL for Pares using a portion of his ileotibial (IT) band – a ligament that stretches from the outside of the hip to the knee. They meticulously attached the harvested ligament to the upper and lower bones of his leg, taking great care not to affect the growth area of his femur. At age 7, Pares still had a lot of growing to do, and damage to that area could result in one leg being shorter than the other.

Dr. Mark Polak, a pediatric anesthesiologist and medical director of anesthesiology at CHKD, also played an important role in the complex surgery. He is one of a handful of CHKD anesthesiologists who perform nerve blocks – a special way of numbing an area of the body to reduce discomfort after surgery. These nerve blocks can last up to three days and reduce the amount of strong pain medication, like narcotics, children need after an operation.

“As a pediatric anesthesiologist, it’s my job to keep kids safe during a procedure, help them with anxiety before the operation, and ease their pain afterward,” says Dr. Polak. “These families are trusting me with their children. I take that very seriously.”

“Working with a pediatric anesthesiologist is an incredible benefit,” says Dr. Tenfelde. “They are so comfortable working with kids and incredibly knowledgeable about their special needs. It’s one of the main reasons I choose to work at CHKD.”

After surgery, Pares began his recovery in CHKD’s pediatric inpatient rehabilitation unit – the only one of its kind in Virginia – where physical, occupational, and speech therapists help children regain skills and abilities lost after injuries or illnesses.

“Pares was not a typical patient. Most children that come to us are injured in more than one area,” says Dr. Rianna Leazer, medical director of inpatient rehabilitation at CHKD. “But the severity of his injury made it vital for him to start rehabilitation right away. Kids with intensive rehabilitation needs make a much quicker recovery in a hospital setting.”

Pares’ inpatient physical therapy schedule included as many as three hours per day, six days a week. His treatment focused on improving his range of motion and mobility and was supplemented with occupational therapy to practice basic tasks that would be challenging as he healed, like bathing and putting on his pants and shoes. Completing inpatient rehabilitation was only the beginning of Pares’ recovery process. After discharge from the hospital, he continued physical therapy as an outpatient at the sports medicine gym in CHKD’s Health Center at Oakbrooke in Chesapeake.

“Pares needed so much physical therapy. The convenience of being able to go to a health center near our home was a big help,” says Paris. “And the fact that he could work with his favorite therapist at that location made things even better.”

For most of his three-year rehabilitation journey, Pares worked with Ashley Koto, a pediatric sports medicine physical therapist at CHKD. “When I first met Pares, he had trouble straightening and bending his knee due to the injury,” says Ashley. “He went through a lot of fear and pain to get that range of motion back, but he always showed up laughing, smiling, and raving about his newest Lego creation.”

CHKD’s sports medicine physical therapists are specially trained to care for growing bodies, and they work closely with CHKD’s orthopedic surgeons to ensure successful rehabilitation for kids with injuries of all kinds.

“Ashley was amazing,” says Paris. “She really pushed Pares. Sometimes it was emotional, but he made significant progress when he worked with her.”

Throughout the more than 100 outpatient physical therapy visits Pares completed, he challenged himself to reach a goal of playing basketball, football, and baseball. With his love of sports, Ashley incorporated functional activities, like basketball drills, into his therapy to keep him motivated and inspired about his progress.

“At the beginning, I wasn’t sure it would be possible, but he’s playing baseball now. It’s amazing that he’s come this far,” says Ashley. “After all the ups and downs together, we really developed a relationship, and I think he finally understands why I had to push him so hard.”

“Now, Pares runs around like the injury never even happened. But it has been a long journey,” says mom. “Dr. Tenfelde is so wonderful – we were lucky to have such an amazing surgeon. If it hadn’t been for Dr. Tenfelde, Ashley, and everyone else at CHKD, there’s no way Pares would be where he is today.”

This story was featured in the summer 2018 edition of Kidstuff magazine, a quarterly publication from CHKD that features inspiring stories about patients, physicians and friends of CHKD.