My disclosures are in the program. There's really no specific conflicts of interest with this talk other than research funding. So we know pediatric ACL injuries have received increased attention. This is the front page of the New York Times, front page of the Chicago Tribune, career-ending injury at age 11. This was a patient of ours who, at eight, tore his ACL, had surgery, got to meet Tom Brady. This was good for us when Tom Brady was in Boston. And we see these numbers nationally with the Dodwell data from New York State Insurance. We looked at United States Children's Hospitals. And we see this internationally from the Australian Registry and the Scandinavian Registry. There is controversy. There's controversy about initial management, what the technique should be with respect to the FICEs, and what the risk is of growth disturbance. And we had a consensus meeting 2017. And like many consensus meetings, we concluded that we need more and higher-level evidence. This is our algorithm for treatment. And this is the patient population. So the prepubescent patient, 10 or stage one or two, typically males, skeletal age 12 or younger, females 11 or younger. What are the options in this group? So non-operative treatment is an option, but the results tend to be poor. Transficile reconstruction has certainly been described, but when there's a growth disturbance, it can be significant. All epiphyseal reconstruction by Alan Anderson, Ted Ganley. We use this technique, which is a modification of the McIntosh-2 with the iliotibial band, extra-articular and intra-articular, and the trade-off being less anatomic for fiseal sparing. So this is a technique video of the IT band technique. Again, fiseal sparing using the IT band extra-articular and intra-articular. We have a lateral knee incision, and we're elevating the subcutaneous tissue from the IT band to facilitate harvesting. The IT band is very flat and not necessarily very thick, and so you need a large width to get volume, particularly in your larger prepubescent or the early adolescent patients that you may be doing this in. We use these meniscal knives to make incisions towards the anterior and posterior border of the IT band and carry this proximally under the skin. We then harvest approximately with this longer meniscal knife, or you can make a counter-incision. A regular stripper won't work because the tendon is tendinous all the way to the ilium. So we then harvest our IT band. We're looking for a length of 15 centimeters for it to go extra-articular and then intra-articular through the knee and the tibia. So that ruler is 15 centimeters. We whip stitch the end. We then dissect it distally towards Gertie's tubercle, leaving the tendon intact. And then below the IT band, we leave the capsule intact, and that way you don't leak during arthroscopy. We're bringing it through the knee in the over-the-top position. We use a full-length clamp, or you can use a different passer. This is the sutures coming through the knee in the over-the-top position. We like to leave some soft tissue there as a hinge. So this is our extra-articular component of the reconstruction. We then bring it underneath the intermeniscal ligament within the base of the ACL. We use a rasp to make a groove, almost like a shallow epiphyseal tunnel in the tibia. This puts the graft anatomic, helps with healing into the footprint of the tibial ACL, and prevents impingement and hyperextension. So we grasp these sutures, and we're bringing it through the tibial stump. We bring it under the intermeniscal ligament, and then into our tibial incision. So we're seeing that here with the external video. So this is the intra-articular component of the reconstruction, showing the graft in its position. We extend the knee to make sure we are not hyperextending, which again, if you make the epiphyseal groove, you tend to not hyperextend. We fix the lateral extra-articular component not adding in any external rotation with tension on the graft, and then we fix the tibial side in extension. We've made an incision in the periosteum of the tibia, and we suture from the periosteum through the graft in a Mason-Allen fashion with tension on the graft. We like to fix it this way. We roughen the cortex of the tibia. You have to be careful about the tibial tubercle apophysis. We should be medial to that. We like to fix it this way so it heals really biologically and can grow as the knee grows, as it often does in these very young patients. We reported on our results with this. Originally 2005, 44 patients. Mean age was 10.3. We had average 5.3-year follow-up, a low 4.5% revision rate, good patient-reported outcome measures, and no cases of growth disturbance. We followed up in 2018 now with 240 knees. Interestingly, 86% of these patients were male. Average age was 11.2, 50% had concomitant injuries. At mean 6.2-year follow-up, we had a 7% revision rate. Interestingly, we had a 10% contralateral knee injury rate, 2% arthrofibrosis, 6% had subsequent meniscal surgery. Patient-reported outcome measures were high. Return to sports was 97%. At the same level was 84%, and we had no cases of growth disturbance. When we look at this technique biomechanically, this has been looked at in Brian Feeley's lab with different pediatric ACL reconstruction techniques. This technique best restored the normal anatomics, and certainly there's been a lot of attention on ALL reconstruction and lateral extra-articular tenodesis, and that may be a benefit of this procedure that we've been doing for the last 30 years. We've also looked at post-op recovery in terms of strength, hop, and balance tests. We find that there's not a strength deficit such as we see in our hamstring ACL patients, and we don't see an extensor mechanism deficit as we do in our BTB patients. We've looked in longer-term follow-up at their kinematic performance compared to the non-injured knee, and we found no differences in terms of their knee moment, ground reaction force, and vertical jump height. Growth disturbance certainly has been described in the animal models, and we've seen clinically with all techniques. In this technique, the ESCA group, Frank Chodol, Romaine Sell, reported two cases of growth disturbance. One was a progressive tibial valgus deformity that went on to spontaneous correction, and one was a 15-millimeter leg-length discrepancy, actually an overgrowth, and that was treated with percutaneous epiphysiodesis. We do need better data. That's why we started the Pluto study, multi-center prospective cohort study. We're following 780 patients forward for 10 years, and we just are reporting on our two-year minimum outcome data, and we find that between the techniques, we see similar patient-reported outcome scores. The re-tear rate for this technique was 3%. For all epiphyseal was also 3%. Interestingly, as we go to the adolescent patients with transfacial and partial transfacial, we start to see higher re-tear rates, 8% and 10%. Thank you for the Pluto team, and thank you very much for your attention. Thank you.

pediatric ACL injuries

controversy

iliotibial band technique

graft positioning

revision rates