So we'll just jump right to it. This is a case presentation of an 11-year-old boy who was injured four months prior during a non-contact injury while playing soccer. He still had some occasional instability with a few episodes, was initially seen elsewhere, and then about four months elapsed by the time he got to me. And this is one of these guys that plays soccer 10 months out of the year since the age of eight. So he eats, sleeps, breathes soccer. On exam, he's 4'10", 82 pounds. Exam was pretty benign at this point four months out, aside from his Lachman being positive. Couldn't get a good pivot on him because a lot of 10-year-olds don't like that. And he had a relatively low Beaton score. His x-rays are shown here. They're relatively unremarkable. You see his physes are open on both sides. And here's his MRI. Midness guy looked okay. And you can see he has a full thickness ACL rupture and open physes. All right. So I'll just quickly to the panel, any additional imaging people want at this stage in the preoperative workup? In the safe group, I typically like to at least evaluate their alignment overall and have a better assessment of it. Sometimes clinically, you can convince yourself that you don't need a standing alignment radiographically. But I would say that either a clinical evaluation of their alignment, but I probably more typically get a standing alignment as my normal protocol in this age group. Yeah, I would second that. In the Pluto trial, we get hand x-ray on everyone for bone age and hip to ankle x-ray. And clinically, I didn't used to do that unless clinically there was an apparent leg length difference or angular difference. But I was really surprised when we look at the Pluto data, how many pre-existing leg length discrepancies and how they can actually be asymmetric in the coronal plane. So I think it's useful, particularly if you're going to operate on them, then you know if there was something there before you started. Sure. Very good. And then in terms of measuring skeletal maturity, I know Dr. Coker mentioned getting the hand film for bone age. Any other considerations for that or techniques people like to estimate remaining growth? Or is everyone pretty much getting a hand film? I mean, you can... Or just clinical judgment. Yeah, clinical judgment. You could get a tanner stage. It's awkward for us as orthopedic surgeons, so you can get that from their pediatrician or they can self-tanner. There's a questionnaire. You can do a tanner stage in the operating room, which is what we did in Pluto. In females, knowing the onset of menses would be important, this is a male. All right. All great thoughts. So we did what the panel suggested. We have standing alignment films there preoperatively, which show neutral alignment bilaterally. One word of caution with those, I absolutely agree. I think we should get them on all these skeletally mature kids and maybe even the mature ones too, but I think Pete Fabrikant's group showed that if you get these standing alignment films too close to the time of the injury, oftentimes they can't stand with a straight leg and be positioned properly, and then you get false positive findings potentially. So just be aware of that. And we got a hand X-ray for bone age here. By the Gorilla Compile method, he was bone age of about 10 and a half years. I'll just add this real quick. The Rady group, I've been using this a lot to supplement the hand bone age, has a knee MRI system for assessing skeletal maturity. I think this tends to correlate fairly well. I still typically get a hand X-ray, just kind of because, but I would say I kind of look at this and this is pretty helpful as well. So just throwing this out there. All right. So a little Coke or Pepsi challenge now. Here's the fun part. So first of all, how are we treating this? Surgery, non-operative? Is anyone voting for non-operative treatment here? Not to ask a leading question, but. All right. So everyone's voting surgery? Okay. You know, I recognize that the risk of continued meniscal and chondral pathology, but I think the discussion with the parents to educate them is really important. And I oftentimes, you know, parents wanting to commit a surgery to an 8, 9, 10-year-old or 11-year-old can be troublesome, at least the first time you meet them. I typically recommend an early course of physical therapy before I commit to surgery. I try to outline all the options, what the risks are either way. I do believe that there are a small percentage that are copers and they can, but they have to have no symptoms of instability. So my routine would probably be in the initial discussion is to lay out all the cards on the table, including the risk of further damage without an ACL reconstruction if they have continued instability, send them out for physical therapy, and then come back and start talking to them about if they're symptomatic at that point or not. But I would say the lion's share end up going to surgery, but there are a few that can cope with this as long as they don't have instability. And I think it's worth the discussion at least to have before you just knee-jerk a surgery in this patient population. Yep. I think that's fair. All right. So assuming we're going to go surgery. Now, are we feisal sparing or not? Are we feisal sparing on both sides or is one side doing a hybrid situation? Again, his bone age was like 10 and a half. Chronological age was about 11. Yes, feisal sparing. Okay. Is everyone sparing both feises? Is that the idea? I agree. All right. I won't belabor this. All right. And then this is the meat of our discussion here today is if we're sparing both feises, are we doing a kind of modified Macintosh or a Coker-McKelley reconstruction with the IT band or an all epiphyseal reconstruction with epiphyseal tunnels? Maybe we should just go down the line. Henry? Yeah. I mean, you can't argue with the data that Minh just presented from Boston. It's a great surgery. It works really well in this age group. Great long-term outcomes. And I find it to be a lot technically easier than all epiphyseal. So I definitely prefer that. So just to follow up on what Henry said, I do believe that patients need to be mentally, physically, and emotionally prepared for surgery. And I also say that the parents and family need to be mentally, physically, and emotionally prepared. So that's an earnest discussion that we have with those patients. So the Macintosh IT band, certainly the Coker-McKelley is a gold standard. But patients 5, 6, 7, 8, this patient that's 11, I'll do an all epiphyseal for. Now interestingly, I spent a lot of time with Alan Anderson and sat next to him in Switzerland when we had that review that we created. And so Alan would even say that the patients that are 5, 6, and 7, their physis relative to the size of their knee is actually relatively larger at that size. When he would use hamstrings, so relative to the size of hamstrings, the physis was larger. So he used it in every single age. And I tend, if they're very small, I use IT band. But in this patient's 10, 11, 12 years of age, I think all epiphyseal is my favorite technique. I'm a Coker-McKelley fellow, so I would probably use an IT band in this patient. I worry, despite what you said, Ted, I worry about the size of the epiphysis and being able to adequately drill without affecting any part of that undulating physis. And so in this case, because it's a male at 10 and a half years of bone age, I would do the IT band as well. It's very similar to what Min just showed. I think it's interesting because I think, you know, the results were similar between the two techniques. And for some reason, the prepubescent patients do better than the adolescent patients in terms of re-tear functional outcome and return to sports. But, you know, I think that, I mean, we obviously do the IT band technique, but I think the all epiphyseal technique is definitely an option. You just have to be very careful about the physis. We've seen a number of growth disturbances from an inadvertent skiving across the physis, and those are difficult to manage in these young patient populations. I think all epiphyseal is no longer just, to me, all epiphyseal. It's all epiphyseal hamstring, all epiphyseal quad, plus an LET, not with an LET. So it's becoming more diverse. For sure, for sure. Go ahead. I just add that IT band, the first presentation that was, we do it with button techniques on each side, was 10 years ago at IPOS. And what was, I think the video showed there a bit of a hybrid. It was all epiphyseal femoral, but I think that was transphyseal tibial. And so you can actually do, if you find that they're closing on the tibia and open on the femur, you can do all epiphyseal femoral and a transphyseal, but soft tissue only growth plate respecting on the tibia. So there's options that you have in there. And I think that the data for all epiphyseal with, especially Dan Green and Frank Codesco that have done, we've done work, but Dan and Frank have done outstanding work. So it's stood the test of time as well. All right. Very good. Well, the other thing I would just kind of add, one of the things I've been doing in terms of a little bit of pre-op planning for these is actually just kind of measuring how much real estate we have. So totally get that sometimes the size, the real estate available is a factor, especially in the tibial side. This patient here had, I think it was like 20 millimeters of femoral epiphysis and that sort of perpendicular line to the dark blue one there was about 18 millimeters in the tibial side. So again, not hard science. I don't have a hard cutoff as to when I do what based on size, but it gives me a little bit of an idea of what I have available to use. So we did an all epiphyseal ACL on this young man. You see our guide pins there in the femur and the tibia. You need to properly use fluoroscopy just to really ensure that you're in the right area and you're not going through the physis. And then his meniscus were okay. You see his torn ACL there on the bottom left. And then we use a quad, all soft tissue quad autograft for the ACL reconstruction with, it was actually a graft diameter of nine millimeters and fit within his physis without a problem. Now, of course, three months later, he got stiff. He had a hard time rehabbing. Right? So we ended up going back to do less of adhesions and manipulation. So really quickly, we talk about the surgical technique, which is obviously important and fun for us, but talk to me a little about rehab and maybe comparatively between the IT band and the all epiphyseals. And again, as Dr. Coker mentioned, we're talking about hamstring, all epiphyseal or quad, fair enough, but maybe some pearls, pitfalls, experiences as far as rehabbing between those two graft bands. I think the very young patients have less stiffness than the adolescent patients. And that's what we saw as well. But I think there is a group that just, and this is why pre-op physical therapy can be very helpful, because you really need to get them bought into physical therapy and moving the knee and not be afraid. And they're 11. It's almost like veterinary medicine, but they need to be engaged in their process. And so making sure they can rehab if you're going to operate on them is important. But usually once they do commit to rehab, I think stiffness is probably less common. Anything else? I would just comment that for all ACLs, even these young kids, we just move them immediately. I tend to use a CPM. Not everyone does. And I wrote an article with Dr. Larry Wells and Todd Lawrence where we showed that you don't want to overstuff the knee in these very young kids. You don't want to use a 10 millimeter graft in an exceedingly small patient. And then working with rehab, if they do get stiffness, just working with manipulating them early on. But if they do get a very stiff knee, arthroscopic lace of adhesions, because you don't want to get a fracture through a physis. All right. I think we'll move on to the next case. We are going to go over. So if anybody needs to leave, please feel free to zip out. But Henry's put together a nice case. So we'll have Henry present his case as well so we can discuss. And while Henry comes over, I'll just show you three years out. He's doing good. No complaints. Thanks so much. Yeah, it's okay. Let's do it. We packed the room. So we want to make sure we give you everything we put together. Thank you all for being here. Sorry again about the room space. We've taken pictures. So we're going to pass it along to the leadership so they know how important PDACL is. All right. Do you mind switching it to the other case?

non-contact injury

soccer

11-year-old boy

ACL rupture

surgical technique