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IC 105-2023: Surgical Techniques for ACL Reconstru ...
IC 105 - Surgical Techniques for ACL Reconstructio ...
IC 105 - Surgical Techniques for ACL Reconstruction in Patients with Open Physes (1/6)
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Video Transcription
Welcome to this instructional course. This course is about surgical techniques for ACL reconstruction in patients with open physis. It's a great honor to be with this amazing panel. We have Frank Ordasco from HSS New York, Roberto Rossi, University of Torino, Stefano Zaffagnini from the Rizzoli Institute in Bologna, Italy, Jonathan Rebo from North Carolina, and Ned Amendola from Duke University. My name is Davide Bonesia and I work for the University of Torino. So the first talk is ACL repair. So these are my disclosures. ACL repair is a little bit controversial in patients with open physis because these patients are at very high risk of re-rupture and a lot of people doing ACL repairs are moving away from younger children. But there could be some indications and these are when there is a proximal avulsion, there is a good remnant, a Sherman type 1 or 2, according to the classification, which represents probably most of the tears in this age group. It should be an acute tear. It can be isolated or in the multi-ligament knees. Theoretically, there is no age limit. Ideally, this should be done in prepubescent patients. So the rationale of repairing an ACL in these patients is that it's actually a very minimally invasive surgery. And so in patients with high risk of growth disturbance, this can be an option. And even if they re-rupture, revising that patient is not really a revision ACL. It would be starting from fresh. So this is something that we can take in mind and mostly in the youngest population. So in pubescent, post-pubescent and competitive athletes, however, the indications for the results of ACL repair are still controversial and I still prefer to do an ACL reconstruction. So this is a case of ACL repair. As you can see, the evaluation of the remnant, this tear is amenable to repair. There are two stitches, non-absorbable stitches that are put through the ACL in a luggage tag fashion. This is done first so that by pulling through the stitches, you can remove the stump and have a better visualization of the notch back there. At that point, you can clean it. You can do a 4.5 all epiphyseal tunnel where the femoral footprint is. And at this point, you can pass a shuttle suture. You will see we will pass two shuttle sutures, but this is the first one. Then we drill a 4.5 tunnel at the level of the tibial footprint. We retrieve the previous shuttle suture from that tunnel, as you can see in the video. And then we pass a second shuttle suture. This is used to retrieve the sutures arming the stump, the ACL stump that we did before. We can do some biological stimulation. And then you can see here the suspension fixation passing together with tape, non-biological augmentation. And that's the final result. As you can see, this patient also had an avulsion of the MCL, which is why he came to the operating room so early and so we had time to do an acute ACL repair. So some surgical tips. It's very important to use a cannula in the antiremedial portal to avoid entrapment of the soft tissues. Arming the stump first will allow to move the stump away from the notch and have a better visualization of the notch itself. You need two shuttle sutures. One is going through the femoral tunnel and the tibial tunnel. This will help pull up the non-biological augmentation. The second shuttle suture is used to retrieve the arming sutures from the femoral tunnel. It's very important not to over-tension the biological augmentation, which should act as a seat belt. So usually the patients are left with bearing as tolerated. They keep a brace and full extension for four weeks. A range of motion exercises as tolerated are started after four weeks and no open chain strengthening for five months after surgery. These are some recommended readings and I thank you.
Video Summary
In this instructional course, the speaker discusses ACL repair techniques in patients with open physis. The speaker mentions that ACL repair in younger patients is controversial due to the risk of re-rupture, but there are some indications for its use. The speaker explains the procedure of ACL repair, including evaluation of the remnant, suturing techniques, tunnel drilling, and fixation. They also provide surgical tips and post-operative recommendations. The speaker concludes by recommending further reading on the topic. The speaker in the video is Davide Bonasia from the University of Torino.
Asset Caption
Davide Bonasia, MD
Keywords
ACL repair techniques
open physis
younger patients
surgical tips
Davide Bonasia
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