Hello, this is Jeff Nepple from Washington University in St. Louis presenting all epiphyseal ACL reconstruction. Here are my disclosures. So typical patient we're talking about here is an 11-year-old male with a knee injury on a trampoline. You can see the immature growth plates here and an ACL tear on MRI. The treatment of pediatric ACLs has really changed over time. If you look back to Mencocher's Heredicus Society 20 years ago, most people were thinking about leaving these patients alone in an 8-year-old or even in a 13-year-old. And nowadays I think the approach has really flipped because we realize the consequences of continued instability in this young active group. We've got a lot of options out there for treatment in the youngest patients, certainly some people crossing the growth plates. I think a lot of people preferring physio-sparing approaches, and then it comes down to choosing all epiphyseal approaches as advocated by Alan Anderson, or intra-articular, extra-articular IT band approaches, the Coker-McAlee approach, which both have pretty good results in the literature. So we've got lots of options out there. Approaching these patients, we really want to understand their true sort of maturation. Bone age can help here as well as tanner staging. This patient is 11 but 9 by skeletal age, so even younger with a lot of growth remaining because that's going to put you on different stages for growth remaining. So for me, we can clearly cross the growth plates when we're a few years of growth remaining. For me, that's about four years. If they're more than four years, I'm thinking about physio-sparing approaches with my preference being for all epiphyseal in most of these patients. So these physio-sparing approaches are pretty safe in the literature, certainly case reports of problems, but the series generally support about a 1% risk, and I think with improvements in the technique have become more and more standard. So why choose all epiphyseal ACL reconstruction over an IT band? So for me, it's a more anatomic ACL, similar to what I'm putting in older age groups, and you'll see in the technique it's actually not that different. Low retear rates in the literature supported that are very similar to what we see with patellar tendon grafts. For me, I've never had a retear of an all epiphyseal graft. Low rates of growth disturbance, similarly, if you do this right, very low rates of growth disturbance, and then we avoid some of the cosmetic concerns associated with IT band that can be a little hard to predict. I do use IT band in the youngest population, but that can be a concern in some of these patients. If we look in the literature, low retear rates, Dan Green at HSS, this nice study comparing different techniques, 6% retear rate with all epiphyseal, which was identical to our gold standard. So I think this can be a very good option. The IT band autograft certainly is a good option as well, however, this does require harvest of most of the IT band in these younger kids, and there can be cosmetic concerns that are a little hard to predict. If we look back at the McIntosh procedure, a publication by Johnston 20 years ago said you could think about this in situations where cosmesis wasn't an issue because they certainly saw it in the older patients. Coker's series showed 17% with cosmetic concerns, 44% with thigh asymmetry. So these issues can happen. Often I think they are mild, but it's a little hard to predict. So for me, in many cases, I prefer this all epiphyseal reconstruction. So on the top, you see for hip surgery, sometimes we'll take the IT band, but we're taking a small little strip. For knee surgery, we're taking the majority of the IT band up the thigh for some of these procedures. So anatomic all epiphyseal reconstruction, we can put these tunnels in the right spot. Proportional graft sizes, these are generally going to be 7.5 to 8.5 millimeter grafts in these smaller knees. I tend to use hamstring autograft, the five-strand graft tripling over each MIT gives you a little additional size. You can certainly go with quadriceps autograft, but you have to be careful to not overstuff these smaller knees. Many of the harvest systems only go down to nine millimeters, which often by the time you put sutures in as a 10 millimeter graft is not what you need in these small knees. There are knees that get too small to do this. For me, often that's getting under the eight year of age where I'd really prefer the IT band to have a larger margin for space. Alan Anderson is the pioneer here 20 years ago in JBGS, his publication of a small series with this approach. Fluoroscopic guidance is really critical to putting these tunnels properly within the epiphysis to avoid issues with growth disturbance. Here are his original florals from that study where he was drilling a full tunnel at that point and his technique article. Different variations of this have then been put out using sockets and then even going all inside. I'll show you how I like to do it here. Technically, it's really important to have good fluoroscopic access. If you don't do this right and confirm with fluoro, you certainly could do more harm to these patients, but with fluoro, this is actually pretty routine. We need to be precise with femoral and tibial tunnels. We have small tunnels that are proportionate to their size and avoiding excessive heat adjacent to the growth plate. The femoral tunnel, this is very close to the LCL. We want to be careful here, C in the blue dot is an LCL. If you imagine in a pediatric knee, it's probably an even bigger relative footprint that we got to be careful to not compromise this. There's not a lot of space posterior to the LCL. The original images and another image out there from a reconstruction here shows sneaking that tunnel behind the LCL, I think is fine, but you have to be careful. For me, given how close some of those appear to the LCL, I prefer to go in front of the LCL with an anterior to posterior trajectory of my tunnel. This is what this looks like on fluoro. You can see I'm angled 30 degrees posteriorly when you look at the clinical image of the knee. We can start in front of the LCL to give us a bigger safeguard from getting into that with our tunnel, I think even improves the safety of this technique. This is a typical, we'll get a guide pin. If that's a little too close to the growth plate, we can then move it down to get into the right spot. Then we're going to use a flip cutter to drill the actual tunnel you'll see in the video in a second. The tibial tunnel similarly is maybe the bigger risk for problems. If we look at the HSS study showing in general, growth disturbances were very small. If they got into issues, it tended to be this anterior portion of the tibial tunnel, which was the most common situation. Why does that happen? I think we want a short horizontal tunnel here. The tibial tubercle apophysis gives you a false sense of security. The tubercle apophysis is a laterally based structure that we're typically medial to that. You don't want to think you can go so far distal that you're overlapping the tubercle apophysis. Here's some images from the literature. It's wishful thinking that we're getting this within the apophysis. If we go there, it's actually much thinner. As you go distal, it's not that broad. Even some of the original images, you're getting very close here. If you do an all inside approach, you can see this button down here is actually across the growth plate to some degree that I prefer to get that tunnel more anteriorly. The risk there would be blowing out into the joint. If you think about the IT band, they even put a trough in that area that I'd rather go out that side. There's actually usually a lot more cartilage than you realize. Despite moving that more and more anterior, I've never felt like that actually occurred. If it did, a little bit of a blowout probably is not an issue. That tunnel should look like this on AP and lateral images. Very horizontal compared to what you're used to looking at with your older patients. We can end up with a situation like this or suspensory fixation on the femur. I use a full tunnel on the tibia and we'll tie this over a screw. Let's look at what this looks like. This is a video. There's the ACL footprint in a young patient. We've shot a guide pin in first and then we like that. We'll do our pounding guide and use a flip cutter. We get that in place and flip. We want to start the flip cutter full speed off of bone before making the socket. This looks like this probably a seven and a half millimeter flip cutter. We're going to drill that socket. Often it's going to be about 20 millimeters. Again, there's a slight anterior to posterior trajectory you can see there. We're going to undeploy the flip cutter and then save that tunnel by placing a passing suture. We'll grasp that and pull that out the portal, saving that for later passage. Then if we look up that tunnel compared to a transficial reconstruction, you can see we don't see any cartilage ring. Here's the horizontal tunnel for the tibial tunnel. Once we like that, I drill a complete tunnel, which makes graft passage pretty easy. We're going to shuttle that suture down. Then here comes our suspensory fixation, a button on the femur. We'll confirm with x-ray that that's adequately deployed and then bring our five strand graft up there. We've marked about 20 millimeters to ensure we're adequately in our tunnel. It looks very anatomic and oblique, similar to what we would do in an adult. We tie that in full extension with a posterior drawer stress around that screw in post, which makes for nice fixation there without too many technical issues. This is our goal here. This is a patient now one year post-op. The leg lengths are symmetric and no growth disturbance. You can see over time that tibial screw will grow away from the joint. This doesn't seem to cause an issue. The graft is spanning the front of the joint there with this approach, but has never been shown to be an issue. Growth in general probably adds some tightening effect that the results of this approach seem to be better than transficial hamstrings for some reason. These are often these that feel very stable when we're done. If you draw out what your tunnels look like here, again, a slight anterior to posterior trajectory to keep us away from the LCL seems to give us a bigger margin for error. Then this very short oblique tunnel, this person's now a little bit down the road. You can see that tibial screw growing away so that they tend to not be bothered by that too much. That's all epiphyseal ACL reconstruction. I think it's a very good option with low re-tear rates, fairly anatomic graft position. I've been very happy with this approach to minimize growth disturbance and to maximize stability of the knee without too many negatives. Thank you.

epiphyseal ACL reconstruction

pediatric ACL injuries

treatment options

all epiphyseal reconstruction

maturation stage