Great. I will just kind of speed through this and hit some key points perhaps. This is a 12-year-old, 12-and-a-half-year-old female, high-level soccer, non-contact injury, heart pop, mid-substance ACL tear, small longitudinal lateral meniscus tear. Pretty classic case. Many of us see this in clinic, moderate effusion. She's got signs consistent with ACL deficiency. She's got a little bit of hyperextension, a little bit of hyperlaxity, a little bit of gray area everywhere intentionally. Here are her radiographic images. You can see nothing really stands out on these images here. I like to use what I call stop sign bone age. I still like it. I think Andy's done a great job, but for some reason I haven't quite completely gone over to the MRI bone age. I like doing the stop sign because I can see both the hand as well as the elbow. The elbow, to me, is a really important indicator of peak growth velocity. And again, a standing you can see here. She's got just a hair of valgus. I'm going to call it mild to moderate valgus, zone two. You got to be very, very careful to be sure that she fully weight bears and her leg's fully straight because pseudovalgus can trick you in these early kids that have an effusion. So be sure you talk to your radiologist to ensure that they get adequate images and you're not seeing pseudovalgus. So just straight to the punchline of discussion here, you've got a 12-and-a-half-year-old soccer, year, year-and-a-half, 18 months of growth left, mild valgus. And I'm just going to go on the line. I'll start with men, particularly focusing on this particular case, technique, graft options, and whether you use an LET. Yeah. So here I think you have an adolescent patient now, not prepubescent. So I would typically go transfisial with a soft tissue graft. I think you could do hamstring or quadriceps. I tend to do hamstrings and add an LET now. And I think you can do that and spare the physis. I think the interesting thing in this patient is, would you add a guided growth hemipiphyseidesis actually to both knees given that she is actually significantly valgus? I don't know the answer to that. That was my next bullet point. I'm sorry. I take that back. That's okay. No, no, I appreciate it. Speaking of, so I don't get to that bullet point, but well, would you do a guided growth? I would. I talked to the family about it and I think she would be actually great for both knees because we know valgus is a risk factor for repeat injury to her other side. Perfect. Mark, would you do anything different? And specifically, are you LETing everyone in this age group? Transfisial tibia, all epiphyseal femur, just because there is still some growth. I would do guided growth. And LET is a conversation with the family and indicating that I think she's a high risk and that she potentially would benefit from that, but that I'm not totally sure in this population we know yet. So I would leave it up to the family. So I like the concept of shared decision-making, but then the family is going to look at you and say, well, what would you do, Dr. Tompkins? I would probably do an LET. So you're LET, soft tissue, quad, or hamstring? It doesn't matter. I do both. Which one are you going to do? Oh, in this case? I'm not going to let you walk the fence. I do more hamstring than quad in this case. So hamstring, LET, guided growth. Dr. New. This patient is almost exactly like the case I presented, actually. So the technique I would use is the soft tissue quad with all epiphyseal on the femoral side. So a hybrid technique. I worry about going transphyseal across the lateral distal femoral physis if there's already valgus. I would probably add guided growth to it just with a hemipiphyseal adhesive screw, which I did on the other case. And then as far as LET, I'm not doing that on all patients yet, but I would probably check her BITEN score and then also just check for anterolateral rotatory instability and check her PIVOT. Great. So high grade PIVOT and perhaps more hyperlax. I try to make it pretty gray. So three out of nine BITEN went forward on me. That was like a special extra. So you're doing guided growth. You're doing all epiphyseal femur hybrid with a quad. Dr. Ganley. So I just would add that I think setting expectations for these families is important. I would say to the family, laxity, female, valgus, year-round sports, soccer, tibial slope, which I think is the next slide. All of those things, if I was giving you a report card, I'd give you a low grade. I'd give you a high grade for your quad strength, your motivation, your family support, all those things. But I try to give them a balance. But I need to set the stage for challenges. That sets the stage for an LET. And then historically, since the late 1970s, bone age, 13 females, 14 males, all get growth plate respecting. ACL said probably study this. I could do a trans-fisle respecting or possibly all epiphyseal. But yeah, I think that discussion is important. And then also, I believe guided growth would be excellent option as well. Raj, specifically graft options, graft options in this particular patient, and again, LET or no LET. And maybe not this patient, but maybe this age group, what's your rationale for an LET? Sure. And I would go quad as well for my LET would be IT band. Yeah. So graft-wise, I'm a big quad person. I don't like to do things as a blanket statement, one size fits all. But quad has been pretty good to us the last six years that we've been doing in our place with our data. So I'd go soft tissue quad. As far as the LET goes, I would randomize her in our ongoing multi-center randomized control trial. Pallet, if anyone's interested in joining us, please let me know. I'm a little annoyed that Ted is not going to include her in our trial. But anyway, outside of the trial, I would say things I look at are things that we mentioned. So generalized ligament dyslaxia, so Baten score for above, knee hyperextension 10 or more degrees, high-grade pivot shift. If they have a Sagan fracture, sometimes I'll consider that a little bit. And certainly age, sex, and activity level. And the presence of valgus. So depending on how many of those boxes you check outside of our trial, those are things that would potentially clue me into doing an LET or an ALL with the ACL. Real quick on the guided growth and all that, I'd like to have a better idea of what her bone age actually is, either from a grueling compile thing or the radium or eye thing through the knee, just because I'm not totally convinced that I need to worry much about her feces at 12 and a half years old. You know, tibial-sided, I'm really not worried. And the femur, even, I'm a little on the borderline, to be honest with you. And because of that, I'd say guided growth, I'm not sure how impactful it would be at this age. You might eke out a couple degrees, I guess. But maybe that's good enough for this purpose. But I'm really, you know, I'd want to have a little more information on how much growth is really left. Got it. So just to summarize the panel, everyone will do soft tissue, 50-50 quad or hamstring. Much about everyone, it sounds like they would do an LAT here, but maybe variable based on the risk factors, and a 50-50 split between a allopiv seal femur versus a transficial, but everyone would do transficial on the tibia. Just since we're short on time, hands from the panel or maybe even in the room, would you consider guided growth in this setting? This is actually a different patient, but would you consider guided growth in this setting? Yes. To address the posture slope? Yes. Since you answered so quickly, can you tell us how you do that? I was trying to be direct so everybody else could go. I have one case that we had a patient with a lax ACL, but overall intact ACL with growth remaining, and we put guided growth plates on either side of the tibial tubercle, and that patient is corrected. And of one, we had good results, and so I would think strongly in this case. Thank you guys. Sorry we went a little bit over. I did a transficial technique. I think it works really well. I like to use a quad. I like to use the socket technique with the buttons on both ends, especially fixation, and she underwent bilateral guided growth as well. LAT? Oh, with an LAT, yes, with an LAT, thank you. Thanks so much, everybody. Appreciate it. Thanks so much for being here. Have a great evening.

ACL tear

soft tissue graft

guided growth

LET procedure

combination of treatments