So I'm presenting allepiphysial femoral-sided ACL reconstruction with soft tissue quad autograft. This is for that intermediate group. I don't think it's advancing. Do I have to play? Okay. Thanks. Is that working? I think so, yes. Graft harvest is performed with the knee flexed over a bump about 30 degrees to place the quad under tension. A tourniquet is used during this portion of the case. A vertical midline incision is made. And previously, I had marked out the epiphysis. You can see that X mark on the lateral knee. The dissection is carried down to the quad tendon. Overlying fat is excised and blunt dissection is performed subcutaneously. More proximally, I'll push a Raytec up with a key elevator and then insert the arthroscope. I'll identify the vastus lateralis and medialis and follow the tendon proximally, then transluminate the skin at the proximal extent and make a dot. You can see that dot on the thigh. And then I'll mark out the tendon with the quad graft harvester and make full thickness incisions on either side. Release the quad distally from the patella. I'll carry that dissection proximally using metzenbaum scissors to dissect it off the capsule. And then place a traction stitch at the distal extent of the graft. I use a cylinder harvester for this. You wiggle it past the suture so you don't cut it. And then full rotations going proximally. I'll pull tension with my hand and use the back of my knuckles against the harvester to maintain a constant forward pressure during this. My assistant does the cut and I catch the graft. And then this is the quad defect and my assistant will do the repair while I'm at the back table. I usually aim for about a 55 to 60 millimeter graft. I use adjustable suspensory fixation on both sides, which allows for a shorter graft and poses less risk of injury to the rectus femoris. And that's the graft. And then intra-articularly, I prep the notch. I clean the back wall with a curette and do a minimal notchplasty. Then I mark the tibial tunnel site at the native footprint. I'll identify the lateral meniscus and the medial and lateral tibial spine. This patient also had a pretty complex poster horn medial meniscus tear with vertical and horizontal components. So I did a gentle debridement and then did an all-inside repair, capsular-based, with a cerclage type of configuration to incorporate both tear patterns. And I placed four sutures in this manner. And then for femoral tunnel drilling, outside-in drilling is performed so you have better control of the position of the tunnel. As you can see, that lands right at the X mark. This is the pediatric femoral guide. And intra-articularly, I'll place the guide at the native footprint on the lateral wall. Beware of getting too posterior or proximal with this, as it can endanger the distal femoral epiphysis or physis. And then an A-to-P tunnel trajectory is good at providing a longer tunnel and protecting the lateral structures. I start off with a 2.4K wire, which is more easily adjustable if you need to, and also has a pilot tunnel, which then makes the reamer entry more easy and accurate. And then you can open up your reamer to the desired size. As another double-check, you can sort of manually rotate it along the lateral wall to make sure you like the position. And then I'll usually ream about 5 millimeters short of whatever I measure. Keep the reamer in the tunnel to remove any bone shavings. And then you can exchange that for the passing suture. I'll bring this out through the medial portal for ease. And then dock it outside of the lateral portal. This brings it up against the lateral femoral condyle and out of the way for the tibial side. Tibial side, I do standard transphyseal drilling outside in, again, passing the 2.4K wire first, which makes the reamer passage much easier. And then ream the tunnel. Oh, I think this is the old version of the video. And then you can pulse the reamer back up to avoid widening that tunnel. Exchange it for the passing suture again. Bring it out medially. And then dock the suture on the lateral side. Now I'm extending the medial portal in preparation for graft passage. This is an important step to avoid soft tissue bridges. You can also use a cannula here, although I haven't found it to be necessary, as long as you're careful to bring both loops out together through that enlarged anterior medial portal. And then secure those passing sutures and go back to the back table. And I'll lengthen the femoral side of the adjustable suspensory fixation. This helps with button flipping to keep the graft out of the way while you're flipping the button. We'll bring the button into the knee. And then change to a medial viewing portal to watch the button go up the tunnel. Once the button is flipped, you can see the graft is still largely outside of the knee joint. So now we'll bring the femoral side of the graft into the femoral tunnel partially. This will allow for some final tensioning on the femoral side at the end and avoid premature shorting out of the graft. And then we'll dunk the tibial side in. If there's any difficulty with this, you can use a blunt trocar or a grasper to help with that. And then for the tibial side of tensioning, we'll bend the knee over a bump, leaving the tibia hanging free for the natural posterior drawer. So the suspensory fixation button tightened, and then final tightening is done on the femoral side, still in 30 degrees of flexion. That's the final graft. Thank you very much.

surgical technique

allepiphysial femoral-sided ACL reconstruction

soft tissue quad autograft

graft harvesting

suspensory fixation