hamstrings is that if you do what has been described by my co-panelists here, and Stefano has a phenomenal technique where he uses a hamstring but combines it with an ITB tenodesis essentially, and the modified MAC is an extra-articular and intra-articular tenodesis reconstruction as well. So the answer to your question is complete transphysials are great in that population, you just have to decide whether it's a BTB or an all-soft-tissue autograph. I think that's a super-reasonable approach. I would agree with Frank that for most people who don't specialize in pediatric sports, the majority of who you're going to see are these 14-, 15-, 16-year-olds, and so most of what you're going to do is transphysial. Just a little plug, and maybe I'm biased, but you'll notice that just about everybody on this panel is doing lateral augmentation for someone of that age. For me, if you're in that age group, it almost matters less what graft you use. I think you really have to add lateral augmentation. Would you guys, would the panel agree with that? Yes. It is. There's probably nothing more powerful in the last 30 years of ACL techniques than a lateral tenodesis. In fairness, our European colleagues figured this out 30 years ago. We were a little bit behind the ball. But I think that's critical. So worry less about a minor growth disturbance. Worry about, they're at really high risk of failure if I don't add a lateral tenodesis. Yeah, probably it doesn't matter if you decide one graft or the others, but probably it's much more important to protect the periphery. So lateral extraticular tenodesis. And just on that note, if anyone in the panel had any downsides to having some anecdotal age groups, your recovery age groups, or how you see patients progress, extension block, anything like that, that you've seen in the lateral extratumoris period versus not? I have no range of motion limitation in my patient. So really, actually, they are easier than the normal population. One of the biggest... I agree, Stefano. I think one of the biggest concerns historically has been over-constraint. And if you heard Jonathan describe avoiding external rotation, which is the way Michele originally described it. But a lot of the recent data from Julian Feller and others using best evidence analysis has suggested that osteoarthritis is not likely to occur using 10- to 15-year follow-up. Obviously, that's not enough. But I would say that it's more of a back-to-the-future situation. So if you think back to the 60s and 70s and publications from people like Slocum and others, they were using extraticular reconstructions before we ever got to intraticular ACL reconstructions. And then in North America, we sort of... It fell into disfavor predominantly because of a paper out of my institution where Steve O'Brien was the lead author. And he reviewed all of Russ Warren and Tom Witwitz's cases, and they decided to do a prospective study comparing BTB alone to BTB with LET, and they found no difference. The mean age was 36 in that study. So the problem we're dealing with right now is this cohort of under-20-year-olds, and what you've seen is the pendulum has swung back. We like intraticular reconstructions, but we want to add something extraticularly on the lateral side. So the bulk of my case is, as Jonathan just told you, under the age of 20. If they're high-level competitive athletes, as high as you could be as a high school athlete or a young college athlete, I'm adding a lateral reconstruction. And at the professional level, if you think about Andy Williams with the Premier League soccer players, everyone's getting a lateral reconstruction. And that's what I've been doing in NFL athletes as well. I think everything goes in cycles. You know, the COCR technique, you know, the technique that you presented, the men COCR technique in Toronto, when I was training, you know, they were doing the Marshall-McIntosh, which was a big lateral incision, taking a big strip of IT band and doing basically the same surgery, but through a tibial tunnel over the top on the femur. But they were immobilizing all their patients in external rotation for six weeks, the leg. So I saw a bunch of patients when I started my practice come in with very tight knees, but they even had an external rotation contracture. But I want to ask you, Jonathan, some of those patients had lateral herniation. Do you see any lateral herniation from the graphs? Yes, that's a real thing. So you make a big enough defect in the IT band that you can't close it. I mean, it's physically impossible to close the defect. And I think actually one of the mistakes you can make is to try to partially close it, because what that will do is it will sort of force their lateralis to go through sort of this more narrow channel. You want a big, broad area for it to essentially herniate through. The majority of patients will notice mainly a sunken appearance to their distal lateral thighs. So actually, if you think about it, your femoral metathesis flare is kind of what bony-wise defines your distal femur. But from a soft tissue standpoint, your IT band is not right along the femur. So the definition of your contour is from your IT band. And so they'll have this very sort of sunken appearance just around the metathasial flare. I've only had one patient who had, I'd say, noticeable herniation with contraction. And actually, it's interesting. I did this at age seven. He was probably 11. He came back and found me five years later when he was 16, he tore his other side. And I told him he needed a BTB, and he said, I'm really hoping you can do the same things on the other side, because look at this. And he flexes his leg, and he gets this huge-looking quad. He's like, I look jacked. This is great. And so it was pain-free. It was a cosmetic difference. But it's important to educate patients that it's going to look different than the other side. So you're trading a cosmetic abnormality for a growth abnormality. I think, Ned, that's an important point, because that largest series of modified Macintoshes that's been published was published out of Boston Children's. Peter Fabrikant was the lead, and they reported close to a 50% complaint from the patient. Now they asked specifically, what do you think of the appearance of your thigh in 50% of the patients felt that there was an asymmetry that they were uncomfortable with? And it was probably slightly geared on a gender-specific level. The females were a little bit more concerned about it than the males. But there are more males in that population, by definition. So it is something to be aware of. All right. Well, I had a couple of cases, if you guys want, or we can keep going. But this is a case of an acute injury in a 14-year-old male. Anyways, I got the impression that there's really no reason to delay surgery, right? So we're talking about surgery in all these cases. So basically, wanted to ask the panel what they would just go down the panel, what they would do for this case, 14-year-old, complete mid-substance rupture of the ACL, no significant meniscal injury. So what would you guys recommend? If we start on this side, so if we look at his growth plates, you guys will notice tubal tubercle apophysis still quite open, distal femoral and proximal tibial fices open. But assuming that his skeletal age and chronologic age are congruent, I would do a transficial operation, so a complete transficial operation, biasing your tibial tunnel slightly vertically. I use a hybrid transcivial technique on the femur. We could talk about that later if you want. But it's anatomic, but slightly more vertical in trajectory. I would use an all-soft-tissue quad graft with suspensory fixation on both sides away from the growth plate. And I would add a lateral extraticular tenodesis. Roberto? Well, probably in this case, we do over-the-top technique for the femur. And for the tibia, we can use house tunnel, like David described, and for sure, lateral extraticular tenodesis. Stefano? I normally do my technique easily, and I just use the tibial tunnel over the growth plate because for me, still, growth plate are still open, and so I don't want to avoid the — I want to avoid any growth disturbance. Can you show us the coronal views again, Ned, just to look at those for a moment? Back one slide. Okay, so no MR. I would do what Jonathan suggested. I'd be a little concerned about the lateral, the distal lateral femoral fysis. So I would be a little bit more vertical. I'd use an all-soft-tissue graft, quadriceps. I would use a trans-tibial approach as opposed to an all-in side. By trans-tibial, I mean a full tunnel on the tibia as opposed to a socket. But I'd be a little concerned about the lateral side from the standpoint of an augmentation, so I would do an LAT as well. So I would add that in the SAGE group in a 14-year-old. I would probably investigate a little more about the growth potential, so parents, height, and also spurt of growth, a lot of data, shoes, number of shoes changing. This is all questions that I ask, but probably I would go either with a quad adult-type technique or with an over-the-top on the femur and the technique that I described. So nobody would do a repair of the ACL? I cannot say if it's repairable from... And then in addition to that, some would augment it in his age group with a lateral extra-articular tenodesis. Okay, how about his slope? Tibial slope measures about 15, 16 degrees. Is that any concern? You know, we've been hearing a lot more about this lately. There were several publications, you know, with a huge failure rate in children with a high slope greater than 12 degrees. Davide, would you be concerned about this or do anything different than what you planned? Okay, so this is, going back to your question, this is the patient where I would not probably repair because it's probably the highest risk patient. So I would not do a repair. Regarding the slope, I have no experience in addressing a slope before an ACL surgery. I don't think there is any evidence for doing that. I probably would not do it. I would probably even more do a reconstruction more than a repair. Even in Europe, you know, you guys are the slope masters. Roberto? No, I agree with Davide. So probably we will move directly to an ACL reconstruction. Stefano? We just finished a paper that we showed that adding a lateral plastic to your reconstruction reduces the risk of slope disturbance. So you are more effective, especially if you have maybe 12 degrees of slope, you are more effective in using a lateral tenodesis than doing a tibial osteotomy. Yes? Well, can I answer? So you mean the small plates and correct? Okay. I don't really, there are some people from my institution that evaluated all these patients and actually the tibia is not growing right. Sometimes it grows like in a roof, in a roof way. It doesn't, it doesn't grow perfect. It's a perfectly aligned patient, but it's, it's done like this. It's like a roof. So this concerns me a little bit with this type of surgeries. Yeah. So I think Ned is, is, you know, prompting us to come up with the reasons to do coronal, not osteotomies, but managing the coronal slope in a way in a primary situation, not a revision situation. And I think historically we've all been concerned about doing that on the, to segue to a different type of case with valve disalignment. Again, I mentioned earlier, I operate with my colleague Dan Green and we routinely do implant mediated guided growth to correct valgus. And we'll do that bilaterally if it's a bilateral injury, a bilateral situation, which it often is. And we're very comfortable with that. It doesn't add much to the operation. It's really easy to evaluate over the course of the 12 to 24 to 36 months subsequently and the plates can be removed. We haven't done that for coronal corrections, which is what Ned is really describing here. And the question is, why shouldn't we in a case like this? And I think it's predominantly because we haven't really felt comfortable doing it, but it may be something that we should do moving forward. That's a good question. I'd say when it gets beyond 15 degrees of valgus bilaterally in a growing young person. Or if they have lateral symptoms. Right. Have you studied those patients that have done that bilaterally? And I guess my first question is, when you do that bilaterally, is it more for cosmetics? Or is it, do you think that it might reduce the risk of injury on that non-injured side? And have you studied that to show that there is a decreased risk of injury on the non-injured side? So on the first question, for bilateral purposes, it's both. Cosmetic and the potential for preventative action. For the study side of the question, we don't have enough cases. I mean, there are probably 25 cases over the last 10 years. So it's not a large N. Right, it's difficult to answer that question. It's a great question, but we don't have the data to really answer the question. I think these are good things to consider. But in this case, underwent repair. You can see the sutures going through. This was a bare technique repair. And you can see the technique and tunnels that were done. And after this, he was not clear to go back to play, but re-injured himself, basically about three or four months following the surgery. So now he has a recurrent injury. Recurrent ACL tear. You can see the effusion. Not really much of any ACL tissue there. And this guy seemed to be intact. So would you recommend anything different than you recommended the first time? If it's a redo surgery, were you more likely to do an L.E.T.? I would have done it in the first place. Yeah, you heard that. I think the other question that comes up with this is, you know, you often hear, well, you don't burn any bridges if you do a repair and it fails. And I think, you know, we've been down that road with multiple parts of the body, multiple pathologies. And I think you do potentially burn bridges, and we should be very cognizant of that. Now, in this case, he was lucky. He didn't sustain irreparable meniscus tears, but he may have, or even repairable meniscus tears. So I think we really need to go cautiously down that road. Do the best operation the first time, especially in this cohort. There was a guy in Fayetteville. I forget his name. He was doing a huge number of ACL repairs. This was before the barrier. And somehow he got my name. And, like, every one of his failed repairs he sent to me. And it's actually not people say, oh, it's just an easy revision. It's not easy at all. There's suture in the joint, non-absorbable suture also in the joint that you're trying to get out. There are actually tunnels that you have to manage with. And the risk of growth disturbance is sort of additive. If you were close to the physis with that one and then you kind of go back and you hit the physis again, it can be sort of like a double crush type phenomenon. And I think, you know, saying we're not doing any harm is incorrect. So there's meniscal problems with re-injury, conval problems with re-injury. It is technically more difficult. And there's this additive risk of growth disturbance. And even if you add some artificial ligament inside, even worse. Right. So this is the arthroscopic pictures at the revision. You can see the sutures, as you mentioned, Jonathan. So would you use the same tunnels or do anything different than what was done here? Those are epiphyseal sockets. I would probably just steer clear and make a transfacial tunnel, epiphyseal tunnel, have good fresh bone on the femur. Tibia, you can use the same tunnel. All right. I think we're getting to the end of our time allotment. But this was just through this quick case here. This was a case that I received after a few years after this young man had an ACL reconstruction with hamstring autograft and developed a valgus deformity after two or three years following the surgery. I mean, I'm sure you all have seen this complication and soft tissue reconstruction. So what would you do for this? It's pretty simple. Just a question. He had also lateral meniscectomy or not? At the time of the surgery? Yeah. No. Okay. What techniques are there? I would do a distal femoral osteotomy straight forward. Yeah. No, I think this is pretty straightforward. We did a distal femoral osteotomy. What techniques would you use for those? The same type of technique or medial closing wedge? I normally use closing wedge. I prefer. Because I don't like to use weight on the lateral side because he has difficulty in pain. They have pain on this side. Yeah. Any other comments? I like that. That looks great. Okay. Yes. Anyways, thanks. That was really amazing. A lot of surgery. really thorough and covered all the topics, appreciate all your presentation. I guess one last question. Do not fix it in 20 degrees, particularly if you're doing a lateral tenodesis. You asked about complications of tenodesis. If you use a quad and you do an LET and you kind of tension things in anything but full extension, they will lose full extension. Yeah, definitely. And one last point about quad. Ben Hayworth at Boston Children's has done some work looking at fibroblast composition. And the quad has a lot of fibroblastic components. So there's a greater potential, I think, for arthrofibrosis for quad tendons. So one of the things that I think we've found is if your graft is too large, what's too large? More than 10 millimeters in diameter, you're probably more at risk for stuffing the joint. Volker Musall has done some work on this as well from Pittsburgh. So I'd be careful about getting too large a graft for the quad. It's a great graft. It has robust healing, but too much healing inside the joint is not great. Yeah, we dramatically increased the number of psychopath lesions that we had to remove since. But it's, I don't, I'm not really sure it's graft dependent, it's size dependent. So since we are doing six strands, four hamstrings, we are doing full thickness quad. Now we're not doing all of them full thickness, but the size of the graft significantly and the type of graft significantly increases the number of cyclope lesions. So this is, I don't know if you guys have seen more than in the past. For quad, yes. You know, I would say that's true. I think it's multifactorial. I think some of it may be biologic and some of it may be diameter. And the last comment I'd like to make, Ned, if permitted, is, you know, when I sort of bludgeoned hamstring graft in my talk, I didn't mean to suggest that it's not a great graft overall. I do think that it's important. We found this, we learned this in stability one, and we've learned this from our colleagues in Italy who add an ITB tenodesis effectively by using Stefano's technique. If you're using an isolated hamstring in this cohort, you're likely to find a higher failure rate. If you add either an LET or you add, you use a technique like Stefano's or Sonori Cote's, you'll find that the revision rate will be much lower. So it's a good graft, but I think you have to add something. It's a hamstring plus, if you will. All right. Well, thank you guys. You did a great job. If anybody has time and wants to...

ACL reconstruction surgery

graft options

lateral extra-articular tenodesis

complications

revision surgeries

recommendations