I know certainly a lot of people probably haven't done this in their training, and it may seem like a daunting operation, particularly because it's on young children, but I'm going to try to show you that this is actually very safe, very effective, and for perhaps the average person who's doing ACL surgery on young people, might be the easiest operation to choose from. Typically, for me, this is in a prepubescent athlete. I think all but one of these that I've ever done have been boys, just based on sort of skeletal maturity patterns. So typically, boys under the age of 13, and I have a handful of these that are for kids with congenital ACL deficiency. The rationale, and this is sort of both a combination of Dr. McKaylee and Coker's rationale as well as mine, is you have no tunnels in the tibia or the femur, minimizing your risk of growth disturbance. It doesn't eliminate it, but it minimizes it. You get a combined lateral extra-articular tenodesis in doing this technique by leaving the IT band attached to a GERDI tubercle and attaching it to the femur, and there is a good number of studies showing this can improve rotational stability and reduce re-rupture rates. It also helps you preserve all of their major autograft sources. So if they re-tear this when they're 14 or 15, we can very easily use a quad or a hamstring. And it also makes the revisions much easier because you don't have holes in the bone. And finally, we don't cause any change to the dynamic stabilizers of the knee. They lose less quad strength, and they still preserve all of their hamstring strength. So here's kind of the crux of this. Can we go back to that video? Is anybody back there? Nobody's back there? You can just click on that video. Check this like 10 times this morning and it works. Okay, well, I will talk you through what one would do. So for this operation, you're going to lay your patient supine, okay. The nice thing about this, I don't need fluoro, I don't need an intraoperative CT, I just need a scope and some open instruments. You will mark out their lateral epicondyle and their GERDI's tubercle, and you basically make a lateral incision directly over their iliotibial band. It's the easiest approach in the world. You could probably have a medical student do this approach because it's skin to IT band. There's nothing in between you. Once you get to the level of the IT band, you harvest a very long and relatively wide strip of it. So unlike in a LAMARE procedure where you take maybe a 10 millimeter strip, you're probably taking 80% of the width of the IT band. And you have to take it way up into the thigh. So you have to make sure you get your tourniquet proximal and your prepped out proximal. And there's special instrumentation that is developed originally by Dr. McKaylee, and they're basically these long meniscotomes. So after you've made small incisions in the IT band with a 15 blade, you basically just run them up the thigh, under the skin, and then there's a curved meniscotome that allows you to transect that proximally, and what you get is usually a 16 to 17 centimeter strip of iliotibial band that is still attached at GERDI's tubercle, and that becomes your graft. You can then whip stitch the free end of that, and I sort of shove it back into the thigh and I go and scope the knee. And the scope is actually very rapid because you want to leave a lot of the ACL tissue intact for vascularity purposes, and you don't really want to shave a lot around the over-the-top position because that is where your perichondral ring is, and you're actually more likely to cause growth disturbance if you start shaving or doing a notchplasty. So you just have to clear enough ACL so that you can see around the corner of the lateral notch. And at that point what you do is you take a long curved clamp, and it's a little scary at first, but you put it through the anterior portal, you kind of skirt right along the lateral wall, and you come to that over-the-top position, which our Italian friends have described very well, and you basically shove it through the posterior capsule of the knee, which once again seems scary. The incidence of neurovascular injury with this has largely never been reported. It's actually very safe. And what I do is through my defect in the IT band, I have a finger around the back of the femur, and your clamp just meets your finger, and then it's literally going all the way through their knee. At that point you can just grab the lead sutures where you've whipsed at your graft, and you just pull, and your graft goes around the back of the femur and through your AM portal. Obviously you can't leave it there. So then you make a standard, think a standard hamstring harvest incision, and you take a clamp, a little curved hemostat of any variety, and you ride over the front curve of the tibia. You come underneath the intermeniscal ligament. What that does, it helps keep your graft from bostering in towards the front, and you just, once again, pull it down. And now you have the graft coming out of your tibial incision. At that point you can make a little trough in the periosteum. I will typically use a knotless metathasial anchor, and I'll take those same whipsed at sutures and put them into a small anchor. They're probably five or six centimeters distal to the thysis at that point, so it's very safe to do that. Place it near full extension, and for the IT band tenodesis part of it, you bring the knee to 90 degrees, and you simply sew that IT band graft right around the lateral epicondyle. And so from an implant standpoint, I use suture and I use one metathasial anchor. There are no tunnels, a very, very safe technique. In terms of some tips, if one is going to try to do this, one, there is very good videos online. If you're watching this, you're watching mine right now because I think it's one of the better ones, but there are multiple videos online on how to do this. You want to make sure you dissect any adhesions of your IT band. Where people get into trouble harvesting this is that they haven't freed it up from the lateralis, and when you try to pull it out, it won't come out because it's still attached to tissues. When you're passing your graft, like we talked about, having a finger around the back of the femur can be very helpful in terms of making sure your clamp's going to come out in the right spot. And in order to pass your graft well, when that clamp is through there, you want to crank it open so the graft will pass easily. Finally, if you read the original descriptions of this technique, they would externally rotate the foot when sewing the IT band to the femur. That tends to over-constrain the knee, so you just leave the foot in 90 degrees with neutral rotation. And then the, I guess, rebo modification is using that knotless anchor. The traditional technique, you simply sew it to the periosteum on the tibia, but that can be a little bit weak at times. I have fortunately never run into this particular problem, but this is something that should give you a little bit of anxiety, is truncating your graft. I always tell people that if you're new to doing this, there's no shame in making a small escape incision towards the top of the thigh, and just take a 15 blade and cut the graft approximately that way, rather than truncating it. Some of the things that I have seen over the years in learning to do this better, if you put your hole in the capsule in the wrong spot, the graft can actually subluxate into the lateral compartment, and you'll look at them, and it's literally in their lateral joint space. If that's the case, you can actually sort of just make a new capsular hole, and you can actually use a spinal needle using an outside-in technique to figure out exactly where you want to put it. And that's, I think, more like what our Italian friends do. Why do I prefer this technique? It's difficult to show these slides in front of Dr. Kordasko here, but one, basically no published clinically meaningful growth disturbance in the largest series of these, which is 240 patients, which is good. In fairness, they did not get limb alignment films. Those were based on a clinical examination, so it might be underreported. A 7% failure rate in a very high-risk cohort over a long period of time. It is technically simple. It's very quick to do. So I can do this in about half to a third of the time that it would take to do an all-pith seal. There's no radiation or fluoroscopy, which is good for me and good for the patient. There are some studies out of Boston showing quicker neuromuscular recovery, since you don't touch the extensor mechanism or the hamstrings. And interestingly, has, if not the best biomechanics, at least equivalent biomechanics to an all-pith seal with an IT band tenodesis. And so I think there's no techniques that are better biomechanically. And finally, there are some studies showing that it can restore normal in vivo kinematics. From a rehab standpoint, I follow to the letter the McKaylee-Coker Rehab Protocol. I don't know that you have to. But if it's not broken, why fix it? So this does require six weeks of toe-touch weight-bearing and a brace for six weeks. The main reason for this is that these young children are very unreliable and they have two speeds, 0 and 100 miles an hour. And if you give them a little bit, saying, oh, you might not have to wear your brace during the day or around the house, next thing you know they're shooting hoops in the yard or snowboarding at three months like Stefano's patient. And typically, we'll talk about this later, but criterion-based return to sport at a minimum of nine months after surgery. Thank you very much. This is not—yep, thank you. So now I will talk to you about the evolution that we had with a partial transphysiol technique where the femoral part was done over the top and then a transphysiol tunnel was done on the tibia. So my mentor, Neda Mendola, who is here, who learned this technique from Peter Fowler, published this paper, and this is one of the paper—not a lot of patients, but probably one of the youngest cohort. So as you can see from the x-rays shown, so these are patients with a lot of growth potential. And so the results were quite safe and with minimal growth disturbance in very, very young patients. So this is Dr. Romandola performing the surgery. I was doing the video while I was a fellow at Iowa, and so this is the harvesting of the hamstrings. Actually, just the semitendinosus is harvested with an open tendon stripper, then released from the pes sensorinos, and then the tendon is prepared. So it's just a two-strand tendon, two-strand graft, which is tubularized. The ends are armed with non-absorbable stitches, and then all the graft is sized. It's usually a six to seven millimeter in diameter, and then all these absorbable stitches are put around the graft to tubularize it. Then the graft is tensioned and pre-soaked in vancomycin. This is the evaluation of the stump, which was not repairable in this case. So this is the lateral approach with an incision of the ilotibial band just above the septum. Then you release the muscle from the septum, and then you create a blunt, in a blunt fashion, a hole in the septum itself. And you should be able to reach and to palpate the posterior condyles with your finger. And with a gaff hook, this can be done from distal to proximal or proximal to distal. You punch a hole in the posterior capsule, and you put a shuttle suture there. This is the tibial tunnel that is drilled. As you can see, as much of the stump is preserved for a nice environment, a nice healing of the stump, of the graft itself. And then this is drilled transphysio. It's usually a vertical, small tunnel of six to seven millimeters. Then the suture is retrieved from the tibial tunnel. And then the graft is passed. In this case, a non-adjustable loop was put on the proximal part of the graft for fixation. Okay, so you can see the loop there. And at this point, a screw is placed on the lateral side of the femur above the growth plate. This is the screw. It's important to make sure to have enough length also for the tibial fixation. Sometimes this graft can be a little too short. Pre-tension, then you screw the screw all the way down. Make sure it's tensioned enough, pre-tension again, and fixation distal to the physis with a staple, soft tissue staple. And this is the result. So we changed a little bit this technique because we felt that the graft was a little too small, but of course it was small also because it was transphysio on the tibia. So we changed the way of drilling the tibial tunnel. So we did a retro-drilling while keeping the over-the-top position on the femur. So the indications for this type of surgery are patient at mild risk of growth disturbance with this tenor growth potential of two years. and this is how we modified this technique. So both gracilis and semitendinosus are harvested, and they are prepared in a six-strand fashion, so increasing the diameter of the graft itself. This also shortens a little bit the graft, so also the fixation device, the suspension devices had to be changed, moving to adjustable devices. So the ends of the grafts are armed in this way, and the two suspension devices are used on both sides, tibial and femoral. The graft is looped around and prepared in this six-strand fashion. Then the graft is pre-sized, pre-tensioned, and pre-soaked in glycomycin. So this is the lateral approach. Since we have it there, the iliotibial band is there, we take an ITB strip for lateral tenodesis, which is done right now, and then through that approach, we go over the top as seen before. So you start this section, until you can palpate the posterior condyles, and then in this case, as you can see, we went from proximal to distal, puncture the capsule, retrieve the shuttle suture from the antero-medial portal. And you leave it there, and you move to the tibial tunnel. So the tibial tunnel is retro-drilled, and the largest part of the drilling is all epiphyseal. So this is measured on the MRI, preoperatively. It's usually an 18, 15 to 18 millimeter half socket, while the 4.5 drill goes through the physis. So this is the sizing of the half socket. Then you can look inside the tunnel and make sure you don't see a white ring, which means that you went exactly through the physis. This point, you can put another shuttle suture, which will help you with pulling the graft inside the joint. So the graft is pulled from proximal to distal. Sit in the tibia first, because it's the shortest tunnel. Suspension on the tibia, and then, as you've seen before, fixed with a screw and washer on the femur. In this case, you have two adjustable loops devices, so you need to make sure you do not over-tension this graft, and mostly do it in extension, maximum 20 degrees of flexion. Otherwise, you might have a stiffening. And at this point, you can go under the lateral collateral ligament for your lateral exarticular tenodesis with the tibial bandstrip you had harvested before, suture it to itself with a modified Arnold-Cocker technique. And that's the final result. So I like this technique because it's quite easy. It's important to measure on the MRI preoperatively the length of the half-socket you need to drill. Use cancellous screws, but without teeth on the washer, because these can damage these adjustable loops, which are a little thinner compared to the other loops. Do the tibial fixation first. You can also leave the arming sutures of the tendon for additional fixation, and perform your lateralplasty at 30 degrees of knee flexion and foot in neutral rotation. It's important not to over-tension the graft and to pay attention to the neurovascular structures on the back of the knee. So I like this technique because we don't need intraoperative x-rays. There is no risk for graft tunnel mismatch as the only sidewall epiphyseal. The graft is large enough compared to the original over-the-top partial transphysio. It's theoretically anatomical. When you go back and do a second look on the over-the-top patient's position, either in the adult population or the pediatric population, you're really, really happy on the position on the femur of your graft. And it's easy to adjust the ligament tension. Lateral tenodesis can easily be done through the same incision, and you don't have issues of a too short issue. So the postoperative regimen is basically what was described until now. It's usually no support for one year. And basically, the patient has to fulfill the criteria for returning to sports. Thank you. Okay. We are ready. So we are moving to the last presentation about surgical technique. We are talking about adult-type reconstruction. These are my disclosures, but nothing related to this talk. So the rationale of the technique, we are talking about closed physis, so no risk for growth disturbance. But we're talking about young patients, especially they are athletes, they increase risk of rupture, of course infection, and the majority, they are involved in pivoting sports. So what we are doing is standard adult-type reconstruction, femoral tunnel through the AM portal, anatomical single bundle. In some cases, we use lateral exoskeletal tenodesis, and I think it's very important also the graft choice, and in this case, we use BTB or quadriceps tendon. Lateral exoskeletal tenodesis is used when we have a huge pivoting test positive or when we have important rotatory instability. These are the indication, tunnel 4-5, bone age 16 years old in males, 14 years old in female with closed physis, and this is for BTB standard incision. First of all, we prepare the bone block on the tibia that will go inside the tibia because it's the longest bone block, and then we have the patella bone block that is shorter, usually is 20 millimeters, that usually goes in the femur. We prepare the graft, we decide the size, usually in the tibia is bigger compared to the femur. Two holes, they are very important, and you see that the first one centimeter of the graft that stays inside the joint, so in the femoral tunnel, we prepare with a Vicryl because we want to avoid any damage when we use the screws. We color the bone plug with marking pen, and I think it's very important the length of the graft. We cover with Vicomycin, and then the remnant piece of bone are put in the patella side. We perform femoral tunnel through the antero-medial portal. We do a double check. We want to be sure that the position is, for us, the majority of isometric position, so usually you see that you bend the knee close to 120 degrees of flexion, and then we ream. Usually the length of the reamer is close from 20 to 25 millimeters. We have a look about the position of femoral tunnel, and then I think that the tibial length of the tunnel is very important, so we usually measure the Q wire with another standard Q wire to understand the total length of the graft, and it's important to avoid any mismatch at the end of the surgery. In some cases we have part of the bone plug that is outside the tunnel, so we have to be very careful. We clean very well inside the joint and outside in the tibial part of the cortex. And then we create, let's say, a small hole area for the screw just to avoid that the screws can go posteriorly when we fix it. Then we pass the graft inside the tibial tunnel, and then we help with the Kelly to go inside the femoral tunnel so we can see very well that all the bone plug is inside. We use non-absorbable suture, but also because it's quite easy if, unfortunately, we need to do a revision. And then in some cases, if the screw in the tibia is not enough, we use a staple, and for that reason we use every time a non-absorbable suture to protect it. As I mentioned, in some cases we do lateral extraticotone tenodesis. Davide showed the Cochrane-Arnold modified. We are talking about Lemaire modified. It's quite the same, so the graft is prepared in exactly the same situation. We identify the lateral collateral ligament. We pass under the lateral collateral ligament, and then we identify the point that usually is posterior and proximal to the lateral epicondyle, and you can fix it with different type of devices, a screw or other systems. Quad tendon, it's something that we are using more and more because we like it. It seems to be very strong structures, depending also if you're using two layers or full thicknesses or three layers. You see that the difference between the BTB is the graft inside the joint that is bigger comparing to BTB. It's very important. It's more technical demanding, so it's very important to measure exactly with a marking pen the middle of the graft and two centimeter just to avoid malposition of our femoral tunnel in terms of proximal or to distal. And then we fix with two double suspensory fixation. It's very important to fix the last part, so in the tibia, in fully extension and not flex at 30 degrees. Otherwise we create too much tension and we have difficulties to hyperextend the knee. In this case, we can use another, let's say, solution. It's all inside technique. For the femur, exactly the same. For the tibia, we just use a retrodrill. Of course the graft must pass through the anteromedial portal, of course, and then is pushed inside the tibial tunnel and we do again the same fixation. So, tips and tricks about BTB, tibia bone plug first, then it's easy to remove the patella bone plug. Patella bone plug no more than 20 millimeters. We don't need it. Place some sutures on the proximal part of the graft to protect it to the screw. Bone plug from femoral tunnel must be rounded and tapered and use non-absorbable suture at the tibial bone tendon junction. Non-absorbable screws to make possible revision easier. We need to create a housing for femoral screw. Absorbable screw can break, so we need to create, let's say, a tap for the hosting new screw. And tibial tunnel length must be measured just to avoid a mismatch with our graft. Tibial fixation and full extension also with a staple. Don't always trust in tibial fixation. This is the weakest part for BTB. Quad tendon, we already mentioned about the length from 6 to 7.5 centimeters, depending on the age of the patient. With some extra cortical fixation devices, we lose some graft length, so be careful. Quad can be difficult to pass in the tunnel, so we need to clean very well the extremity of the quad tendon. And remember that it's a bigger graft inside the joint, so be very careful about possible impingement. So why we like this type of technique? We love both these grafts because they are strong grafts with lower risk of rupture and infection. BTB makes revision easier because we have, of course, the tunnel that they are covered with the bone block. Quad tendon graft can use extracortical fixation in both femoral and tibial sites with lower donor-side morbidity compared to BTB. And lateral extracortical tenobisis can reduce risk of revision in this type of patient. These are my recommended reading lists, and thank you very much for your attention. Okay, now Dr. Rebo will talk about the return to sports and risk of re-injury. And if you need to run it directly off the USB, it's just called when to return to sport. As he's loading that up, a couple themes that you see going through all these talks is one, a focus on a reasonable size of graft in the joint. I think there's increasing data that you have to have something of a reasonable size. So Davide has modified his technique. People are using quads. So I think graft size does end up mattering. Perfect.

surgical technique

anterior cruciate ligament reconstruction

young athletes

prepubescent athletes

iliotibial band graft

screws or staples fixation