All right, if anyone wants to come up to the microphones to ask any questions. I don't see any on the app, so the floor is open. I guess I'll get it started for Dr. Shi. Looking at your paper, I was just wondering, for the skeletally immature patients, what type of graft were you using? Were you using all hamstrings or bone quad tendons for those also? We've done some preliminary analysis. We have more patients now, and the skeletally immature, they're getting bone quad tendon and hamstring grafts. We excluded all IT band because they were significantly younger and didn't really represent the similar type of patient cohort. Can you go over briefly how you selected each patient for the different types of grafts that they received, whether they were participating in level one sports or was surgeon dependent? If you think that influenced your outcomes in terms of whether they were to return to sport at a year or not? Our study included two main surgeons. I know one of them, there is some surgeon selection bias. Only one of them does the BQT ACL reconstruction. In terms of the conversation, it's a decision between the surgeon, the family, and the patient. And all are offered, and I think they just kind of come to a consensus based on what the patient desires. There's not really a decision based on what sport they're going back to. That's another limitation of the paper, and something that we would like to add is the specific sport that the patient's going back to. Thanks. For Dr. Featherall, for your Schottles point, you found that half of your patients on radiographs were proximal to the physis, kind of on the digitally reconstructed images, and half at the physis. But yet, on the CT renderings on 3D, you then found that all of them were distal to physis. So in the operating room, most of us are using lateral knee fluoroscopy. So how do you apply these principles clinically? Do you trust your lateral radiograph Schottles point, or are you adjusting that based on the findings of your study? I think you can trust the lateral radiograph, or I should say, I would trust the findings of the study, and I think that when you're looking at that lateral radiograph, you're seeing a tangency point to the physis that is often distant from the physis on the medial cortex. So I think you can be confident that that medial physis is further proximal than Schottles point, and I think that the work that's been done previously looking at a tunnel that's slightly anteriorly and distally aligned will allow you to follow sort of the downslope of the physis and stay in a safe trajectory. There were, in terms of the number of cases within our study that had a small distance to the physis, say of around less than four millimeters, there were, I think, two or three of those. So I think you may need to compensate for a reamer using those, and you can always check on the AP to see where you are relative to that downsloping portion of the physis. We've got a question over here. Yes. So I have a question for Dr. Shiga on that last paper regarding graft type. I think it was really interesting to see the return to sport rates by graft type, being that hamstring actually had the lowest rate, I think, because actually I think that's contrary to a lot of the adult literature where we see the hamstring grafts going back sooner, likely because they're doing better with quad strength and probably have less anterior knee pain. So I was curious, thinking about which factors limited individual patients' ability to get back to sport. Do you have a sense for which one of your return to sport criteria were limiting the hamstring grafts, or was it more a factor of that's a younger population and maybe a little different group of patients? From our data, I think it's pretty clear the primary reason that they're not meeting the clearance goals is their hamstring weakness. Specifically, I mean, we didn't report the quad to hamstring ratio, but that was something as well. But with the goal of having an LSI of 90%, they weren't meeting that with that specific hamstring isometric strength testing. Great. Thank you. We got a question from the app from Shannon, and one that I was thinking about also. Was there a difference in the fixation for your tibial spine fractures? Because you showed that that screw can be prominent, and if you're using suture fixation, it's probably not as important to get that screw recessed so it's not prominent. So we didn't differentiate between screw and suture on this one, but it's definitely something to look at in the future just because it was a very large cohort. We had like 570 patients, so it would be interesting to look at suture versus screw, but we focused more on non-op and op for arthrofibrosis for this. And one last question for Dr. Serban. Although you mentioned your paper wasn't necessarily done for the purposes of looking at these final outcomes in these patients aside from reoperation, did you notice what were the key findings on patients who had revision surgery? Were they things like adhesions, residual impingement, labral pathology? And then kind of secondly is what was routine capsular management, and did you find any differences related to that? Sure. So I think that about a third of the patients underwent a repeat scope. A third had some labral procedure done, and a third underwent PAO. So in terms of intraoperative findings on whether or not what pathology was seen, I'm not sure. I wasn't necessarily there. We didn't really look into that or review that, but definitely something to consider. But I think the big takeaway is that we were just looking at, you know, capsular placation is probably with micro instability and an additional procedure that probably could be done whether or not, you know, we recommend that in the future or not, so, yeah. All right. Thanks for the questions. We will now move on to our Pediatric NPFL video.

pediatric orthopedics

grafts

consensus

return to sport rates

revision surgeries