We're a minute early on starting, but I figured we'd go ahead and get us started so we can get out of here, so we can start our night off. So welcome to the Neat Kids on the Block, Get the Right Stuff for Pediatric ACL session here, last session of the evening for us. We've got two papers, and then we've got four excellent kind of expert talks, and then we'll do a little Q&A at the end. But our first paper here is by Ian Holier, going to talk to us about tibial spine fracture fixation. Good afternoon, everyone. Thanks for coming to the most exciting session of the afternoon. My name's Ian, and today I'll be discussing several fixation strategies for displaced tibial spine avulsion fractures in pediatric cadaveric knees. And all disclosures can be found via the QR code. So tibial spine avulsion fractures represent about 2% to 5% of all pediatric knee injuries, and arthrofibrosis is consistently one of the most common complications postoperatively. Therefore early motion is key for these patients for preventing complications, and durable fixation is thus needed to start these patients on early motion protocols. Prior studies in adult or porcine models have found that in general suture fixation is stronger than screw fixation. However, last year we published a study in pediatric cadaveric knees demonstrating that suture fixation was equivalent to screw fixation in terms of ultimate failure strength, and that these loads in general were lower than those published in either adult or porcine models previously. When we reviewed our failure mechanisms, especially for the suture fixation group, we found that this most commonly occurred via cheese wiring of the high tensile suture through the anterior tibial cortex, as shown in the video. So the motivation for this study was to see if we could improve fixation strength with sutures by adding suture anchors. In the study we had three different comparative groups. The first was screws, the second sutures over a bone bridge, and then the third was sutures with suture anchor fixation. All specimens in the testing were pediatric cadaveric knees, age range 6 to 14, who had osteotome induced type 3 or completely displaced tibial spine avulsion fractures in the lab. In the screw group, we used two 35 millimeter by four millimeter cannulated screws with a washer that replaced all epiphyseal and then confirmed via fluoroscopy. For the sutures tied over a bone bridge, we used two number two fiber wire sutures that were passed through the ACL plus tibial spine avulsion stump and then brought through two 2.4 millimeter bone tunnels and tied over a one centimeter cortical bone bridge. And finally, in the suture anchor group, we again used two number two fiber wire sutures passed through the ACL stump and brought out through 2.4 millimeter bone tunnels, and these were secured into the distal metadiaphyseal bone with two 2.8 millimeter suture anchors. All specimens were then loaded onto our biomechanical testing platform and measured in terms of cyclic elongation, stiffness, and finally ultimate failure load. In each group, we had six cadaveric knee specimens. There was no statistical difference in the age ranges except for in the suture anchor group, there was a slightly higher median age, although not statistically different. The stiffness and the elongation measurements were all statistically similar between the fixation groups. However, we found that in the sutures plus suture anchors, there was a significantly higher failure load compared to both screws or sutures tied over a bone bridge. There are several limitations to the study, including it being a biomechanical model at time zero, does not account for changes in healing or changes over time. There was that slight age discrepancy, as I mentioned, the suture anchor group had a slightly higher median age, which may have imparted slightly higher bone density in these specimens, although this was not statistically different. And finally, our biomechanical testing protocol was simply axial traction and not rotational forces, which may be more common in later rehabilitation for these injuries. So in conclusion, in our pediatric cadaveric model, we found that sutures plus anchor fixation was significantly stronger with a higher failure load compared to both screws and sutures tied over an anterior bone bridge. This is important because it represents a more durable fixation strategy for these injuries and potentially earlier range of motion for patients. And finally, it highlights the importance of performing these types of studies in pediatric cadaveric models. As prior studies in adults or porcine bone had found that suture was significantly stronger than screws, we found that we had to add anchors to suture fixation in order to ultimately outperform screws. I'd like to thank Allosaurus, the donors, and their families, whose generosity made this study possible, and my co-authors and mentor, Dr. Shea. Excellent. Thank you. My co-moderator is actually not here. She had a family emergency, so we can't take any questions via the app. So we'll just do questions at the end to the mics at the end. But next is Sebastian Rilke, who's going to be talking to us about ACL repair. Good afternoon, everyone. I'm extremely excited to present our first five-year results, our first and initial 113 patients treated with ACL primary repair. My name is Dr. Sebastian Rilke. I'm currently a postdoc research fellow at the Hospital for Special Surgery. And these are our disclosures. In 2021, we published our first outcomes on this cohort. It's the first 113 patients at a minimum of two-year follow-up in arthroscopy and demonstrated excellent patient-reported outcome measurements, while failure rates for skeletally mature patients 21 years and younger were shown to be significantly increased at 37%. However, patients at age 21 and older, which were the majority of this cohort with 86 out of 113 patients, demonstrated low failure rates at 3.5%. This negative impact of younger age on failure rates has further been confirmed now by the Santee Study Group showing significant differences between repair and reconstruction when not considering age, however, no significant differences when only considering older patients. Additionally, the Bayer Group out of Boston showed that revision odds decreased by one-third for each year of increase in age. Additionally, we were not only also able to further prove these findings in a meta-analysis, which was just published in KESTA last week, and we again found that the revision risk is generally lower for reconstruction when not considering age. However, when performing an age-stratified revision risk analysis, we again were able to show that there's a significantly increased revision risk for repair versus reconstruction in younger patients. However, again, no significant differences in patients 21 and older. Nonetheless, it has to be mentioned at that point that increased re-injury risk among younger patients is not unique to repair, but in general the problem or concern of ACL surgery in general with two to six-fold increased re-injury rates in younger patients with studies using age cutoffs between 18 and 25 years, as shown here on the slide. So talking about the resurgence of interest in modern-day ACL repair, where are we actually at? So considering most recent literatures, I think it can be said that there's promising results at two-year follow-up currently, especially within the last two, three years. However, the question still remains, following poor mid- to long-term outcomes of historic open approaches, is history repeating itself or can short-term outcomes be sustained this time using modern-day techniques? And that was the reason for the objective for following up our initial 113 patients, and we wanted to evaluate age stratified survival rates of ACL primary repair at a minimum of five-year follow-up to determine if previously reported two-year rates are durable. All of our patients were skeletally mature patients and presented with complete ACL tears with a proximal type 1 or type 2 tear location and good to excellent tissue quality. And were treated with dual suture anchor ACL primary repair by the senior author of this paper. So after the analysis of a two-year follow-up with 113 patients, we're now able to recruit 107 patients at minimum five-year follow-up. So we lost 5% to follow-up. Now comparing baseline demographic and clinical characteristics, there were no significant differences noted, and the final mid-term follow-up was conducted at a mean of 6.6 years. So what are the failure rates now at five-year follow-up? Non-age differentiated failure rate of 15.9% is shown, while no additional failure rates, and we think this is really interesting, are reported for patients 21 and younger. And patients over the age of 21 now show a failure rate of 8.6%. So it is again shown here also at the five-year follow-up mark that these numbers again demonstrate the significant difference between these two age groups. And additionally, there were no significant differences between the five-year and the two-year follow-up mark. Yeah, also considering our reoperation rates, there were no significant differences detected. Similar for the patient-reported outcome measurements, here the Lyshom score, IQD-C score, ACL-RSI score, and lastly, the forgotten joint score. So what are we concluding from this cohort? We're concluding that analyzing the outcomes of the first 107 patients treated with ACL primary repair at minimum five-year follow-up, short-term outcomes for ACL primary repair can be maintained at mid-term follow-up with promising results, especially for patients over the age of 21. And patients 21 and younger have not demonstrated any additional failures after the two-year follow-up mark. However, high failure rates of 37% at short-term follow-up can definitely not be neglected. And therefore, we think that efforts to further refine and define risk factors are definitely needed to answer questions if poor outcomes in younger patients are due to technical approaches we used, or just pure indications given they were the initial 113 patients. And we're also posing the question if additional lateral extra-articular procedures are maybe the key to success in younger patients after observing great success in reconstruction and the first repair study by Edoardo Monaco from Rome, Italy, or if ACL repair should only be indicated in patients over the age of 21, given the promising results at mid-term follow-up. With this, I want to thank our entire research team, and want to thank you for your attention. Excellent, so we'll open the floor for questions here. We've got a couple minutes for questions. Just come to the mic if you have a question. While you're doing that, I'll ask a question of Dr. Hoyer. How strong does tibial spine fixation have to be in order to initiate early, just passive range of motion? I think that some of the biomechanical studies in adult, with adult referencing, has found that there can be up to 300 newtons of force during certain rehabilitation exercises, such as contralateral toe-off walking. So I think that that's not necessarily translatable to a smaller, like, you know, body habitus pediatric patient. So I don't know if there's a precise answer that's known, and I think it probably is more of a surgeon confidence factor that allows for when to start early range of motion. I know that our protocol can be around one to two weeks to start passive range of motion. Great. Any other questions? Oh, here we go. Jay Albright from here in Denver. My question about, Ian, about for you is thoughts about cost analysis, cost-benefit ratio of adding in two anchors versus just two tunnels and a couple sutures. I mean, I can tell you that I have, in the last 20 years, I haven't seen any failures of fixation from tibial spine with that technique. And so that's where I have a hard time, whether it's, is it cost effective enough to use it that way? Yeah, it's a great point. I think, you know, obviously in the era of trying to reduce healthcare costs, anchors are expensive. And so I think the ultimately would be a judgment call in terms of are we saving dollars, which may be a challenge to study on preventing cases of arthrofibrosis by earlier range of motion. Are we preventing fixation failure via early range of motion protocols? So I think it would be a challenging thing to study, but, you know, if you balance those costs, it may end up being ultimately better to have a stronger fixation with slightly higher cost of anchors. One last question. Hi, Mark Paterno from Cincinnati Children's. I have a question for Dr. Rourke. Great study, very interesting. I was curious, so essentially age is a risk factor in your group. We know age is probably a confounding variable, and it might really be activity that's driving folks to have that second injury. Did you guys track activity at all in your study? Yeah, good point. And that's what we're currently working on. We're currently working on like a, of our like cohort of 300 ACL repair patients, and really trying to like be more refined and really finding these risk factors as like brought up in the conclusion. And we definitely, definitely there's more to it maybe than just age. And like we said, we learned from the first 113 patients, we're more meticulous now in how we are approaching these. And repair is just definitely part of a whole algorithm. But yes, definitely, but results are awaited. Great, thank you. Good, 30 second question. Yeah, well, I can say it in less than 30 seconds. So same sort of thought process. I'm glad to know that I'm not the only one with high failure rates of ACL repairs in medical patients. But do you think that maybe augmenting with something like, you know, the what we're gonna hear about with the augmentation with the bear or for that adolescent population, or, and then the other question is from a, burning a bridges standpoint, do you think that you burn any bridges by doing repair first and having it fail, and then going on to do a reconstruction after that? Yeah, so first question concerning that the augment, like I said, it's part of like a big algorithm. And what we've learned, especially from the first patients, most of the younger patients now, younger active patients, they're being treated with like an augment, a single bundle of augmentation. So yes, definitely. And second question. Burning bridges. Burning bridges, yeah. So burning bridges is interesting. There's like no, no data on that, but just the experience what I've seen now spending two years with Dr. DeFelice in the OR. And it's really fascinating seeing these repair patients, if they fail, that they're being treated as a primary ACL. So not scientific answer, but no, I don't think we're burning bridges. Bummer for the patient, but makes it easier for the surgeon. Great, all right. So thanks for those papers. Let's have our four kind of panel experts giving our talks coming up for us. First, we have Dr. Chang talking to us about Bayer. All right, I want to thank ASSM for inviting me and giving me the opportunity to speak. I think the important disclosure on this slide is that we are a site for the Bayer 3 clinical trial. And this is a multi-center study evaluating age as a risk factor for outcomes following Bayer. Currently the study recruitment is closed, but we'll be collecting PROs, radiographs, x-rays, MRIs over the next 10 years. So we know that a lot of basic science research has been done to develop the Bayer implant. And this has then translated to animal studies, including this one published in 2009, where they looked at 27 knees that underwent ACL transection and suture repair, with half of them receiving the collagen implant. And at three months, they found that the enhanced repair demonstrated increased ligament biomechanical properties, as well as increased cellular density. And then in 2015, the first Bayer procedure was performed on a 25-year-old male who sustained an acute ACL tear from a skin injury. And he became one of the first of many patients to undergo the Bayer procedure in the clinical trials. And in December 2020, the Bayer procedure obtained FDA approval and was indicated for patients over the age of 14 with a complete tear demonstrated by MRI. And since then, the popularity has increased. And as of today, more than 2,500 patients have been treated commercially with the Bayer procedure, with many of them being less than 18 years old. And so these are the eligibility criteria for Bayer 1, 2, and 3 clinical trials. As I mentioned earlier, the Bayer 3 is still ongoing, but the recruitment is now closed. And so the Bayer 1 trial was conducted in 2015. This was a non-randomized study with 10 patients receiving the Bayer implant and 10 patients undergoing ACL reconstruction with hamstring autograft. And this is more of a safety study where they want to make sure and demonstrate that there were no deep infections or significant joint inflammations in the first three months after the surgery. And secondarily, they wanted to compare their postoperative outcomes to ACL reconstruction. And what they found in both groups that there were no signs of infection or deep joint inflammation. Blocking examination were similar in both groups. And MRI imaging obtained at three months demonstrated that all patients in both groups had an intact graft or ACL repair. These patients were then followed out 12 to 24 months. Again, demonstrated no graft or repair failures. IKDC scores improved significantly in both groups. And they found no significant difference in anterior translation, functional hop testing. One patient in each group did undergo a partial immunosectomy within the first 12 months. And the authors concluded that these results warranted a larger randomized control study, which was the Bayer 2 study. Which was the Bayer 2 study that was conducted between 2016 and 2017. They had 100 patients, randomized control trial, as many of you know. 65 underwent Bayer, 35 underwent ACL reconstruction, with the majority of them getting a hamstring autograft. The medium age was younger than the first trial at 17 years old. And their primary goal was to compare IKDC as well as anterior-posterior laxity. And what they found was that the non-inferior criteria was met for both IKDC score and AP laxity. In the Bayer group, there was an increase in ipsilateral ACL surgery, but this was not statistically significant. And these results paved the way for FDA clearance and commercial use. And so this study in 2021 looked at those Bayer 2 patients and wanted to compare PRO and functional outcomes at multiple time points. And it also looked at timing of return back to sports. And what they found was that the Bayer patients at six months had higher or improved IKDC scores and CU scores compared to reconstruction group. But at two years, there's no significant difference. They also found no significant difference with return to sport timing as well. And when they looked at psychological readiness, they evaluated ACL RSI scores and found that at six months, the Bayer group had a higher RSI score than the ACL reconstruction groups. But at 12 and 24 months, there were no significant differences. The six-month IKDC score was found to be the strongest predictor of having a higher RSI score at six months. And the baseline predictors of having higher RSI scores were included Bayer procedure, younger age, and participating in level one sports, which is defined as cutting and pivoting sports, such as soccer, basketball, or football. And they also found that patients that had a six-month RSI score greater than 65 returned back to sports or were cleared back to sports about 50 days earlier than patients that had an ACL RSI score less than 65, and that was in both groups. And this last clinical study identified preoperative risk factors for revision surgery after Bayer. This is the first study that includes some of the Bayer three patients. The median age still was lower at 17.6 years, and they found that the independent predictors for revision surgery included younger age, and you can see on the graph to the right that the majority of patients that re-injured were under the age of 22, or all the patients that were re-injured were under the age of 22, as well as increased medial tibial slope. There's been a few radiographic studies published as well, and this one in 2019 looked at the Bayer one clinical trial, and they had MRIs performed at multiple time points and found that the hamstring autograft had a higher cross-sectional area compared to the native contralateral ACL at all time points, whereas the Bayer repair group had a larger cross-sectional area at three and six months, but then at 12 to 24 months, it was more similar to its native ACL. And this is again validated in the Bayer two clinical trial, and they found the same things with hamstring autograft being larger at all time points, and then the Bayer had a larger cross-sectional area in the first year after surgery. And as this procedure has been now being performed commercially, there has been some evolving techniques and modifications of the original Bayer technique. This study here was published in 2024, where the authors utilized a non-absorbable high-strength suture to suture the stump compared to the number two Vicryl, and they utilized a screw and anchor for knotless fixation on the femoral side, and then used the free suture limbs from that anchor to actually shuttle the Bayer implant in. So looking forward, I think there are a lack of clinical studies from other institutions, and that's why I'm excited to see what the Bayer three results will show, because this is a multi-center study. And I also want to acknowledge the Bayer MOON study, which is a multi-site randomized control trial comparing Bayer ACL repair compared to ACL reconstruction with patella tendon autograft. So in conclusion, the Bayer procedure has been shown to restore the torn ACL to its previous cross-sectional area. The Bayer two randomized control trial demonstrated non-inferiority to ACL reconstruction. We've seen that younger patients and patients with elevated medial tibial slope are at risk for revision surgery, and that future studies are going to be needed, and there are a couple good ones currently ongoing. Thank you for your time. Thank you. So next, we have Dan Green, right, going to be talking to us about the LAT. Thank you. Thanks for the opportunity to speak, and it's good to see a full room. So today I'm talking on the LET in pediatric, or young patients undergoing primary ACL. So we really fell in love with the LET ID after reading this article from Sonia Cotet in 2017, and talking with our French friends. Recall that in this article in 2017, with 502 patients, the BTB failure rate was 2.5 times less with lateral-sided augmentation, and three times less with hamstrings. And this was a high-risk group of mostly soccer players in France. Everybody in this room, I think, is aware of the Get Good Stability Study with 618 patients, the average age of 18, with an 11% failure rate in the ACL alone group, and 4% in the ACL LET group. So our first cases were around 2017. We published our modification of the modified LAMARE, just to take into account, simply to take into account, of the growth plate. So the all there that you see on the screen is below the physis, and the all represents the placement of the epiphyseal anchor, just below the growth plate. When we first started, we were always getting x-rayed to make sure we weren't violating the growth plate. But now we no longer do, because we know that just posterior to the lateral epicondyle, it's a safe area. We just angle the all away from the growth plate. Just a quick study. I think most of you guys have, most everybody here has seen this. It's a pretty small incision. Overall it takes, it adds about 7 to 10 minutes to the case. Also moving the video fast helps too. But here we are just exposing the ITB, a center slip, or a posterior center slip of about a 10 millimeters, about 6 centimeters proximal. And then we're going to amputate it here and control the free limb. Once we've got the lib, then we're going to control it with the suture. And just bear with this for a second. And the next step is we're going to really isolate the LCL. And if you haven't done this yet, that's kind of the first scary thing, because we don't expose it that often. But it could be easily palpated. A bovie just on each side of it helps develop the plane. And then you can pass your graph underneath. And then we put in the anchor just proximal and at the level of the lateral epicondyle. This area is below the growth plate. We're angling our implant away from the growth plate. And then we're going to secure it with a neoneutral rotation and a bit of flexion. And then, unlike the modified McIntosh pediatric ACL reconstruction, with just a 10 millimeter defect, it's easy to close the ITV band with vicals. So we just reported our first 50 consecutive patients. So these are patients kind of pre from 2017 to 2020. A couple of them were revisions. The majority were trans-ficeal reconstructions that were some all-epiphyseal. And in this cohort, they were all quad tendon soft tissue autographs. And the rate of graft rupture was really low. The return to sports was really good. This was our indications that we included in the publication. In reality, in 2017, the first two were revisions. And now at the end of our practice, it's really including all adolescents with an ACL tear that we assume they're going back to a pivoting sport. So this study kind of proved it could be done safely. The outcome, there was no growth arrest. Our outcomes at three years were excellent, and our revision rate was excellent. So the fear was perhaps adding this lateral-sided surgery to this young age group would lead to some short-term complications, and that wasn't our finding. So thank you very much. Thank you. And next we have Kevin Shea, talking to us about tibial spine fracture techniques. All right, it's a pleasure to be here. It's great to see so many people in the audience. All disclosures are up to date. And you've heard some of this from Ian, who did a great job presenting earlier. But as we all know, these are fairly common in kids, these tibial spine fractures. And failure is not the problem with these. It's arthrofibrosis, which unfortunately may affect 20% or even more in some studies. Early motion, we think, may be key to prevent this complication. But obviously, you have to have confidence that the strength of your fixation is going to allow that early motion. In the adult literature, and this literature is a little bit vague, but it says that early accelerated rehab probably subjects the graft to 300 to 400 newtons. Now, that's in adult-sized patients. If we downsize that by 25% or 30%, it might get us a 300 newton range. So just something to think about. One thing we have learned, in recent years, we've been able to get access to pediatric tissue for a number of biomechanical studies. And adult human bone fixation strength for sutures and anchors and other things is remarkably, sometimes two to four times greater than kids, so something to keep in mind and one of the reasons we decided to do this study. As we know that sutures and screws have been compared, human pediatric bone, as we mentioned, much lower bone density. In our lab, we've shown significantly lower pullout in some settings for suture anchors and for screws. So we thought we needed a little bit more information, and that study was published about a year ago looking at the first phase in which we showed sutures and screws weren't quite as strong as we had hoped. And if the 300 or 400 newtons is that range of loading, we have to be cognizant of that if we start early motion. So that brought the issue up, if we try to do early motion to prevent arthrofibrosis, are we gonna get ourselves into trouble? So that's what was behind this study that Ian presented today, and then Tom Johnson presented last year here. As we think about reducing these technically, we're gonna be talking about some of the technical aspects and challenges, is the transverse meniscal ligament is something that you gotta keep your eye on, both surgically with a scope, but you can usually see it very well in the MRI. You can almost always see this on these images. In many cases, it's below the fragment. So keep that in mind when you're doing the procedure. I find technically in the OR, that mini C-arm fits very nicely into the surgical field. You don't have to have a big C-arm, it's a 1 20th radiation dose, and it's very easy, I think, to get the perfect lateral view by yourself. And you can see both the thysis as well as assess your reduction. So just some steps arthroscopically, I think first taking a close look and identifying that fragment, look at its mobility. I think probing the ACL, looking at integrity is also really helpful. And then as you come down more distal, you can look for the anterior horns of the menisci, or here's the transverse meniscal ligament being elevated. Keep those in mind, because you'd want to try and get those out during the procedure. These are blocks to reduction, both the anterior horn of the meniscus and a bigger bone fragment, as well as the transverse meniscal ligament can get in the way and prevent you from seeing things. Here's the tibial spine. Not sure what's going on here, but meniscus. and transverse meniscal ligament. Let's hope that was just one slide. Okay, so just diagrammatically, here's that transverse meniscal ligament, which can be tied to the anterior horns. You can use a suture around this, a probe. You can take a K-wire and put a little hook on the end. Occasionally, I'll take a K-wire and just pin it to the tibia to get it out of the way if it tends to hop back into the place that I don't want it to be. So, next here is you want to identify that fracture pain really clearly. There are frequently small bone fragments or even some healing bone cows below this that they can prevent and you can get a good reduction. And once again, you want to keep your eye on that transverse meniscal ligament and the anterior horns and menisci to preserve them while you're doing this procedure. Now, frequently, especially if you get these cases three weeks, four weeks later, kids heal very quickly and you'll be surprised how much healing bone cows is in there already. And that, in many cases, is going to prevent you from getting that spine down to where you want to really restore that proper tension in the ACL. So, that fragment may sit proud and you might have to actually do a little work down here with your shaver, curette, or other things or sometimes a freer elevator will help get tissue out to really get that down. I would think you want to be careful. I only take it on the bottom side. I don't take it on the top side because that tibial bones piece, I want it to be as large as possible to hold fixation. So, I try not to take anything off, superiorly just inferiorly to get a reduction. And here's just that view assessing that fracture bed. And once again, that curette can be a really helpful tool to get some of that cows out of the way to get you a nice low reduction to restore the tension. So, you can use these drill guides. The drill guides actually are nice. They're like the perfectly designed reduction tools. So, here's the drill guide. I'm using it to reduce and I see a nice reduction there. If it doesn't come down with the drill guide, go back to the curette or the shaver, take a little more tissue out of there to get that reduction just the way you want it. You might have to keep going back to get tissue out. Sometimes it takes longer than you think, but it's definitely worth the work because there's nothing worse than trying to pull that down when your sutures are in place and you can't get it down when you want and then you worry about cutting your sutures if you remove it. So, this animation is not working, but normally you would put your drill hole in there and then pass a little metal snare. Here's a pictorial setting on that. There's your snare for passing suture. This suture passer has already passed the posterior one-third through the ACL. And now here, I think, let's see if this video will work. And here's that second suture passer through the anterior one-third of the ACL. The tibial spine tends to tip up a little bit on the anterior edge, and so if you put an anterior one-third suture, it'll help you pull that front edge down to kind of prevent that from being elevated. And then you just shuttle these sutures, and we'll show that on the next animation here. This lateral suture has been shuttled, and here you can see you're pulling down, you're assessing your reduction there. You can see it's pulling down nicely to the bone. And then here's the demonstration of placing the medial drill hole. You want to be just off to the side a little bit so you don't hit your lateral drill hole or your sutures. And you'll once again shuttle another wire snare through here, and then pass your sutures through the snare, and you'll shuttle these. And then next, you just see yourself, you're going to shuttle the sutures through the medial hole. So you've already shuttled the lateral sutures, so you've got a lateral limb of two sutures. Now you've got a medial limb of two sutures, and you can pull this down. And now you've got a nice hold of this, and you can look down at your reduction, and you can assess that fragment coming all the way down. The next step is, what do you do to secure sutures on the tibia, suture across a bone bridge? And I did that for years. And I know Jay has talked about there's some cost value considerations, but I feel that 135 newtons is a blower that I'm really comfortable with if I'm going to start early aggressive rehab. And so I've tried to do something that gives me a little more strength than that. Tibial fixation, I think there's lots of good suture anchors out there. You probably need a smaller one rather than a larger one. And whether you use one versus two, I typically use one, put both sutures in one hole, but two probably could be used as well. Typically, I have a little 15-millimeter incision for both for my drill holes, a vertical incision, and for the anchor there as well. One thing to keep in mind is the metaphyseal bone is quite a bit softer than the cortical bone. You get too far cortical, it gets hard to put the suture anchors in. But if you go a little more distal, the bone purchase is going to be better. We've shown, as Ian presented earlier, this gets us up from about 130, 140 to about 225 newtons of fixation in that 7- to 11-year-old age group. A couple of tips. Kind of like using two rubber portals, that way you avoid any sutures, soft tissue bridges when you're shuttling sutures. Spend a lot of time. Get these obstacles to reduction out of your way, bone fragments, healing calves, transverse meniscal ligament, and sometimes meniscus. And once again, that mini C-arm is really easy to use. I think you can do it faster than you can with an x-ray tech. One concern we've learned about cheese wire, initially cheese wire lower through the tibia. Now we've shown in those subsequent studies it's cheese wiring through the upper part of the tibial spine fragment. And so what this video doesn't show is that I now am using luggage tags. I'll place two luggage tags, one medial and one lateral, to see if we can maybe lower the risk of cutting through that tibial spine fragment. This research shows that meniscus tears are present in at least 40% of these kids, so be ready to repair the meniscus and look very carefully when you're doing these procedures. Once again, we talked about that arthrofibrosis concern, and particularly flexion contractures. Flexion may allow for early motion, and it really costs you about immobilizing them too long. Maybe a short period and full extension as opposed to 20 or 30 degrees of flexion might help with that. What I do for rehab is early PT, and typically I start them at 7 to 10 days post-op, and I let them start riding exercise bike with light loads at about two weeks just to get them moving. I don't know if they need crutches, but kids, if you've ever taken care of like a vet, if you've ever been a vet and taken care of animals, they put the cone of shame on animals so they don't chew their sutures out. Well, kids are kind of the same thing. And so I try to make them non-weight-bearing for a month, knowing they probably don't want to pay attention all the time, but they just get too active too quick. There's a great static stretching knee device for flexion contracture you can get for $65 on Amazon. I've had to use that a few times. And most of these kids have complete healing pretty early, and they get back to sport by four to five months. I think there's still a lot of questions. One key question that several groups are looking at is early versus delayed surgery. Does this impact arthrofibrosis? Should we be waiting three, four, five weeks, get the motion back like we do with an adult ACL, and then fix the tibial spines? I don't know if we know the answer to that yet, but the PRISM group, the Sarasteroid group, and Henry Ellis has got some data on this, a score. So that's a question I think we'll have to consider in the future. I'd love to see my fixation strength above 300 newtons. Maybe we get more fixation in distal bone or maybe using luggage tags. We're currently, we've got seven cadavers we're going to study this summer, looking at luggage tags and see if that makes a difference. The challenge with pediatric tissue, in a good year I get 10 specimens to study. In many years I get two or three. So tissue studies in kids is really hard to come by. But I think the differences in bone density in kids is going to change the way we think about some of these fixation problems in the future. Thank you. Excellent. And so to finish us off here, we've got Jonathan Rebo talking to us about the AKA McKaylee Coker technique, IT band, ACL reconstruction. Perfect. Well, thank you for the opportunity to chat here. This will be primarily a technique-focused talk, but who do we do a McKaylee Coker operation on? For those of you who aren't familiar with this operation, this is really designed for the prepubescent athlete. So typically we're thinking of that as somebody who's got more than three years of growth remaining. It's predominantly, almost always males. I think I've done one or two females in 10 years. So it's usually males under 13, females under the age of 11. That's based on the skeletal age. And why might I do this? A lot of times when like residents or fellows come on service with me, they say, hey, why aren't we going to do an all epithelial? And this is not, speaking ill of that technique, but this is why I personally have preferred the McKaylee Coker technique. Well, at least in the published literature, 0% clinically relevant growth disturbances. That's what families care about the most. That's really important. There's only about a 7% failure rate, which for this young active cohort is actually really quite good. I find this is a technically simple operation. You can teach this very quickly to residents and fellows. It's quick to do. It takes about 30 minutes. It's cheap. You can actually do this with no implants. You'll see in my technique, I use a singular anchor, but it's much cheaper than using buttons and all other things. There's no radiation to yourself or to the child with fluoroscopy. There are some studies out of Boston that have shown quicker neuromuscular recovery than using any other autograft source. It actually has some of the best biomechanics of all of the thiaceal sparing techniques. That works that Lee Pace here did back when he was in LA, and then it does restore normal in vivo kinematics. So if we look at the actual technique, the setup is quite simple here. You can use a supine position. I usually use a large bump just to have the ability to get the knee at 90 degrees. The primary work is done through lateral incision. Think of this as like a slightly bigger LAT incision. We've seen a lot of talk about LAT at the meeting today. The approach is the easiest approach in the world. You've cut the skin and you're at the IT band. There's no neurovascular structures at risk in this plane. I then ask for the largest cob that they have at the hospital or the surgery center, and you essentially want to give them a morel lavalier of the thigh. It's really important to dissociate the skin from the IT band. Your graft will not come loose. Unlike an LAT, you want to take about 80% of the width of the IT band. I'll typically make my anterior cut first with a 15 blade. I'll make the posterior cut next. I'm a little bit more careful here because the LCL is close distally. You want to make sure not to cut that by cutting too deep. I then really think it's important to create a plane between your IT band and the deeper tissues. This can be adherent to the intermuscular membrane. It can be adherent to the lateralis, so you want to create a plane. These menisca tomes, they're old instruments. They work better than anything else I have tried, and basically you just hub it. You put it all the way as far as you can, and that's always going to give you enough length. Once you do that, again, I spend a lot of time clearing the undersurface. So we've cleared off the skin. On the lateral surface, you want to clear off the undersurface to make sure that your graft will actually come free. The next thing you're going to do is you're going to get a curved menisca tome. You'll see I put my finger underneath the graft. You have some tension on it, and you hub the menisca tome. You cut it anteriorly and posteriorly, and without having to make an exit incision more proximally, you can get your graft to come out. I'll typically then get a ruler. The standard rules in the operating room are 15 centimeters. You want this to be 16 to 17, so as long as it's longer than your ruler, you're going to have enough length. You can then dissect this carefully off the capsule, and this just gives you good mobility. You will then want to whip stitch the free end of this graft, and typically I try to guesstimate how much of that is going to be on the tibial side. The part that you're whip stitching now is what's going to end up on the tibial metathesis. You can do this with any kind of suture. A loop suture is a relatively efficient way of doing this, and then one thing that I do think is important is then tubularizing the portion of the graft that's going to be in the joint. I think this makes for easier passage through your capsular defect posterolaterally, and the one time I forgot to do this actually was very difficult to pass the graft, and it can be quite frustrating. So I use an absorbable suture so there's no permanent suture in the joint, and you can simply tubularize your flat graft and now make it into the more typical cylindrical graft. At this point, I'll cover this in a vancomycin-soaked sponge. I will sort of shove it into the morel lavalier that we've created, and we're going to start with the scope portion of the operation. This is standard arthroscopy. You can see this person had a complete femoral-sided ACL tear. I tend to do little to no preparation on the femoral side for fear of violating the pericondal ring. On the tibial side, I actually try to roughen the bone right at the insertion point because I want to create sort of a biologic spot weld where that graft can heal since we're not going to drill a tunnel in the tibia. Then comes the scariest part of the operation, which is taking a clamp and literally shoving it through the knee. This sounds actually relatively dangerous. It is safer than you would think. A couple keys here. You have to put this a lot more central than you think. We always try to cheat it lateral because we're scared of the neurovascular structures, but if you go too lateral, your graft will subluxate into the lateral compartment. Once you've done that, you see you can very easily pass your graft over the top of the femur, and now it's sticking out of your anterior portal. We obviously cannot leave it there, so we make a tibial metaphyseal incision, very much like if you were doing a tibial tunnel for any kind of ACL technique or a hamstring incision. You want to just leave the periosteum intact. This is not a knife-to-bone situation. You need that periosteum later for fixation. You can then pass a clamp underneath the intermeniscal ligament, which will prevent bowstringing of your graft and extension, and you can pass that graft carefully underneath the intermeniscal ligament. Typically, you have to get a probe to pull that suture all the way out. It's important to, you'll see I put a lot of force on this thing because it'll often get kind of stuck. You want to make sure you get that thing all the way out to tension and that you look back in the joint to make sure that the graft is actually taut. Just like a standard ACL, we will fix this on the femur first. This is done at 90 degrees of flexion and neutral rotation. Three sutures into the lateral periosteum is all you need. On the tibial side, we make a small trough in the periosteum. You do not want to excise a rectangular portion, rather you want to make a linear incision and then use an elevator kind of front and back to create a healing bony bed for your graft. So I'll roughen it with a rasp or a curette. You can see there's a landing zone for the graft. I personally like to augment fixation with a knotless anchor. This can be any anchor of your choice, and you're going to place this just distal to where your graft would end. I find this is a little bit more robust than just suturing it to the periosteum. It also obviates the need for an assistant to hold the graft out to length while I'm sewing it to the periosteum. And here I always say this is sort of a graft taco. You're taking both limbs of the periosteum, you're putting them over top of the graft, and that will give you very, very robust healing of that tissue within a couple of weeks. And that's your final product. Happy to entertain other questions, but in the interest of time, I'll stop here. So that was excellent. We're going to bring up two more people, Jay Albright and Mark Tompkins, to join our panel. And we'll have a little roundtable discussion here. But if anybody has any questions, I guess we could start with a couple of questions from the audience if anybody has any. If not, I really just have one case to provoke a lot of discussion. I wonder, can I ask Kevin a question? Sure. Kevin, back to the tibial spine, do you have any concern when you're doing your suture fixation through the epiphysis, through the physis, and in the metaphysis about growth of disturbance? What are your thoughts on that? Yeah, it's a great question, Dan, because early on in my career, I tried to make the sutures all metaphyseal, but to get the angle right to pull the graft down is really hard to do. And so I went to, I'm sorry, first all epiphyseal, but the angle wasn't good for pulling the graft down. So then I went to metaphyseal fixation. It's a much better anchor. And early on in my career, I would actually tag the sutures with a nonzero suture that I could find, make incision, three months later, pull that suture up, cut the suture so there was no tether across the anchor. And maybe I was doing that unnecessarily. Ben Hayworth told me four or five years ago that the growth plate is stronger than any number two suture that you have, and so don't worry about it. So for the last four years, five years or so, I've not been cutting those sutures out or maybe a little longer than that, and I've not seen any growth disturbance, but it's a legitimate concern. And I guess if I get the fixation too strong or the sutures too strong, you might eventually cause a growth disturbance. So there may be a balance there. Let's take a poll of the panel and maybe of the audience. Has anybody ever seen a growth disturbance that they feel like they can attribute to suture fixation across the physis in a tibial spine fracture case? No. No. You want to tell us about your case? Interesting, so that was recurvotum in a 13-year-old with transfisal sutures. Any thoughts about whether you were maybe a little bit too close to the tibial-tubercle hypothesis? I don't know, that's only one of my considerations as I'm drilling those transfisal sutures. How about in the tibial spine repair group at PRISM, any note of that? I think it's a pretty low risk thing there, yeah, so perfect. All right, so we're supposed to kind of discuss maybe a little bit of Bayer, a little bit of LET. So I kind of put together this case, nothing crazy here, nothing trying to trick anybody up, but basically a 12-year-old female soccer player, knee pain and swelling after cutting injury, playing soccer, non-contact injuries. She's got an effusion, positive Lachman's, tender at the lateral joint line, got decent range of motion, Bighton's 4 out of 9, pretty standard. MRI shows an ACL tear, lateral meniscus tear. Maybe they're far peripheral kind of lateral meniscus-type tear there. Got your standard pivot shift contusions and effusion. Her bone age is 12 1⁄2. She's six months postmenarchal but not having regular periods, no leg length discrepancy, and neutral alignment. So let's just take, since we talked about Bayer, we talked about some of the indications, contraindications, FDA approval. Anybody doing an ACL repair? Maybe she's got a tibial stump, decent tibial stump there. Anybody considering doing an ACL repair in this patient or talking to your adolescent patients about Bayer? Up and down the panel. I see a lot of heads shaking, no, no, no. Anybody want to, like, give me some real words on an age range that they would consider doing Bayer in an adolescent patient? What if I said this was a 14-year-old patient? She would meet FDA criteria. I personally would be very cautious knowing that the Bayer 2 under the age of 18, the rates of tear are much higher than the overall rate. So the overall rate was, what, 14% in Bayer 2? And the under 18, if you just isolate those, are higher than that. So I'm very cautious about any Bayer under the age of 16 at least. But if it was a proximal ACL tear, I would definitely consider it. But for where Bayer was studied on in a mid-substance, I don't talk about it with patients at that age. It's like coming to you asking, hey, Dr. Oliver, will you do a Bayer? I've read about this new thing. I think it sounds cool. Would you please do it? So I will talk to them, and I'll talk to them about the pluses and minuses of that versus what my standard would be, which would be a quad with patellar bone, which we've shown for a female is about a 2.5% failure rate and no growth arrests in this age population or younger, actually. And so I would talk to them about the pluses and minuses of a higher failure rate with potentially, especially if you're a pig, you have a decreased rate of arthritis with a successful repair versus more predictability likely with a quad patellar bone autograft. Yeah, Bertrand Center a good day this morning was talking about how the one thing that patients hate the most is reoperations. And particularly, I think if you're trying to build and sustain a pediatric and adolescent ACL practice, your re-tears are the ones that haunt you and the ones that really, really hurt. And particularly for someone at this age, lots of times if they have a re-tear and they go through two and a half or three years of rehab, that's often the end of their athletic career. And so to me, taking any chance of a, what did the numbers say, 22, 24% failure rate, I don't think is acceptable in this age group. One small addition I would add to on at least the imaging we have, that stump is pretty small. So in the bare moon trial, we've looked at our stump data and the ones that have, I mean, we have to decide once we're in there, right? But the ones that we have ultimately decided were not candidates for surgery, their stumps often look like this. So it'd be one I'd be worried about not having adequate tissue to work with anyway. Interesting. All right. So how about any sort of lateral extra-articular tenodesis? We saw a great technique there from Dan, but does anybody else do anything differently, I guess, first off for your LETs if you're doing it? Does anybody build in an ALL? I would 100% add lateral augmentation in this patient personally. I use the technique that Dan described. I have found, at least in Charlotte, I always get a fluoro of where I am anticipating to put an anchor laterally. And just like Kevin's study in pediatric specimens, I think, what was it, 70% of the attachments of the ALL were kind of below the physis and about 30 were above. That's kind of what I found is if I put an ALL or a pin just proximal and posterior to the epicondyle, 70% to 80% of the time it's fine and it's distal to the physis and I'll put an anchor. If that's not the case and it's either at the physis or proximal, I'll typically just do an Arnold-Coker variation where I just pass it around or underneath the FCL. I can sew it to the periosteum and then sew it to itself with no anchors. The one thing I would do differently would be I use my ACL, ALT-FCL-ACL femoral button that I'm using for suspensory fixation as my anchor point for my modified lumere that he showed. And I get a little bit shorter graft and it ends right at that button. It works really, really nicely for not worrying about convergence of tunnels when you're doing an ACL and an ALL or modified lumere at the same time. So you're going to run it under the LCL, then slightly anterior, slightly proximal. Under the LCL and then bring it anterior to the ACL button. And are you doing any sort of periosteal type of sutures along the graft as it exits underneath the LCL? I have not, not routinely, but I've been looking at the ease of doing that and I haven't found it necessary, but I'm also open for influence from other people. It's kind of getting in the weeds a little bit, but on the ALL epiphyseal ACL, I was always worried about getting too low close to the LCL. So I didn't do the Dr. X direct lateral epiphyseal tunnel. I always did more of an anterior direction as you went laterally. So it was, so I couldn't, we always needed a second anchor. So we just do a quick down the panel, yes, no on recommending an LAT slash ALL for this 12-year-old patient. What's going to be our graft choice for the patient? Because that might influence people. We could answer that question first. You want to take that? What would your preferred technique then be for ACL reconstruction in this 12-year-old? This patient maybe is kind of on the borderline of a Michaeli-Coker, which is, I think, a really great procedure for all the reasons outlined earlier. But it's also, I think, a quad tendon is a good option as well. And I think the data on whether or not you need a quad tendon and an LAT to reduce range of rates may not be clear. The stability secondary trial is looking at that right now. BTB isn't an option, and we know, sorry, hamstring is an option. And that is probably best treated with an LAT. But BTB we don't know yet. But BTB is probably not an option for this patient. So I think the three choices for this one would be all epithelial technique and graft choice, either hamstring or quad tendon or Michaeli-Coker. And what would you do? Put you on the spot. I have a discussion with the family, but I would maybe lean towards a quad tendon and not necessarily with an LAT unless the family feels strongly about that. If you do a Michaeli-Coker, you're essentially doing an LAT at the same time. Great. How about you, John? Yeah, so I have gone in what I call the tweener group, which I think is what you're trying to get at here. They're not prepubertal, but they're not skeletally mature. I have typically done a transficial quadriceps with soft tissue only and an LAT. Now, this person, while you say she's 12 1⁄2 skeletally, her x-rays look younger than that. And so she might be one that you would talk to the family. And if the family is much more concerned about growth than they are re-tear, I might consider a Michaeli-Coker. If they're much more concerned about re-tear than they are growth disturbance, I've had, knock on wood, no clinically relevant growth disturbance using a hybrid trans-tibial approach to making the femoral tunnel. We could get in the weeds on why I do that, but it's a vertical trajectory through the physis, but an anatomic aperture on the femur. And we're about to write up our series on that, very similar to the New Yorker, 50 consecutive patients to your follow-up 0% failure. So my practice is more adult-based, and so I don't see a lot of patients that have a fair amount of growth remaining. But I would, from an LAT perspective, I've been a little bit more aggressive about performing in LAT primarily, especially in these higher-risk patients, especially female, that want to get back to cutting pivoting and maybe have some laxity or a large pivot shift. Interesting. Dan? Yeah, I agree with all the comments. My choice would be if it was truly a 12-year-old on the bone age, and I saw nice capping of the epiphysis over the metaphysis on the bone age film, then I would probably do trans-fisial quads off tissue with the LAT. But here I feel just a tiny bit less on the bone age, I'd probably go modified MAC. I think I'm going to be the outlier here. In the last 18 years of doing quad with color bone, this patient, and actually even younger, we can have a great discussion about pre-puberty. This patient, again, all epiphyseal femoral with bone in the femur from the quad. Quad trans-fisial most likely, but we have a technique that Dr. Pierce back there and I wrote up about doing a fisial respecting that Ted Ganley gave me the term for, with regard to crossing the physis with just a suture. Hence the discussion. I've been doing that for 10 years, have zero growth plate arrests, and have a 2% to 3% failure rate for the ACL. So I'm very comfortable using a quad in even younger patients. So it would be a quad with bone and an LAT. Great. Mark? I appreciate the tweener here, but I would say because female soccer player, so wanting to get back to significant cutting and pivoting sports, I would say it's easy to accomplish all the stuff we're talking about, and as Jonathan nicely highlighted, low implant burden, low cost. McKaylee, go ahead. Yeah, great. We are officially at 5.01. I think that's a great way to end it. And thank you all for your attention. Thank you.

Pediatric ACL

Tibial spine fracture

Suture fixation

ACL primary repair

Bioenhanced ACL Repair

Lateral extra-articular tenodesis

McKaylee Coker technique

Arthrofibrosis

Growth disturbance

Surgical approaches

John T. Lawrence, MD, PhD

Stephanie W. Mayer, MD

Ian Hollyer, MD

Sebastian S. Rilk, MD

Edward S. Chang, MD

Daniel Green, MD

Kevin G. Shea, MD

Jonathan Riboh, MD

Jay C. Albright, MD

Marc Tompkins, MD