Thanks, Davide, for inviting me to this course. So these are my disclosures. So the indication for ACL in open physis, Lachman plus 3+, anterior drover 3+, and PIVO-SHIFT 3+, complete partial or ACL tear on MRI, and up to pubertal phase. Open physis on the knee, like this. So the aim of the surgical training in pediatrics is to obtain a stable knee, guarantee return to play, reestablish sport performance, avoid a second injury, and maintain long-term knee health. This is the goal. And my preference in pediatric ACL, I use hamstring tendon graft. I maintain interdependent serinus insertion. I do a fluoroscopic assessment of the growth cartilage while I'm doing my tibial tunnel. And I do all epiphyseal tibial tunnel drilling. I don't do any femoral tunnel, and I go over the top. And I normally add a lead for rotational stability. So in this way, I have no cartilage disruption, and I have low risk of growth arrest, while the transfusional has cartilage damage and fissure damage, even if it's more anatomic. And why do I prefer this technique? The lateral tendon adhesives allow me to have a better control of rotations. A narrow tunnel allows to have a high graft press fit on the tibial tunnel, and maintain the intact hamstring insertion, maintain a vital growth of our graft, and maintain intact fissures. Why it doesn't work? There was a video of the technique. I don't know why it doesn't work. Before it was working. Can you go back and check if there is a representation? Because, okay, so I will check another time, because, okay. As you can see, or not. No. Let's go ahead. So the associated lesion first, so we normally treat meniscus lesion if there is one. Always fluoroscopy to check the physis, so this is the images that you can get. And you have a little bit more oblique tibial tunnel, and always drill above the physis. And the two-way tunnel is allowed to have a growth arrest, and the staple intolerance, you need to remove it, and the meniscectomy, you have immediate axial deviation. So we avoid, you should avoid to have a meniscectomy in this type of patient, and treat as much as you can, try to save the meniscus, because this include and deteriorate your results. So my post-operative is no heparin, one-day full-weight bearing, passive range of motion, 15 days water rehabilitation, active range of motion, and three, four months, months straight run, and six months, they start the sports specific rehabilitation, following FIFA 11+. Return to play is not before 12 months, 18% year old have higher risk of retire, and contralateral injury retire. So you have to look for associated injury risk, like, let's see, the steep tibial slope that in some cases you can see in this type of patient. So my experience, this is a paper that we published in 2019, 20 pediatric ACL, age 8 to 13, with more than almost five years follow-up, excellent subjective clinical score, no failure so far. So KTE 1000, side-to-side difference was one millimeter, and just two patients have a leg lengthening, so zero, one, zero, five, and three minor axial deviation, and this is related to the meniscectomy that we did in this case. So we participate with the PAMI core, that is the Pluto for the European part, and these group of patients, we collect 26 patients so far, and so far we have excellent post-operative clinical outcome, and you see the sports, and we have only two patients that was not doing sport. And this I just saw some cases, this is the first case, surgery at 14 years old, no contact injury mechanism, time from injury to surgery six months, no meniscal lesion, current follow-up is 2.5 years, still playing at the same competitive level, and the pedi-KDC is 98, pedi-FAPS 19. Then this is a case two, again, surgery at 14 years old, no contact injury, time injury to surgery three months, no meniscal lesion, return to training 4.5 months, return to match six months, because these patients sometimes don't follow your advice, current follow-up time is two years, still playing at the same competitive level, pedi-KDC 96, pedi-FAPS 23. And this, there was a video here that he's playing, he's sloping down with the snowboard, at three months he showed me a video with doing a snowboard, I scream on it, so return to snowboard in three months, return to football match six months, current follow-up one year, still playing at the same competitive level, 97 and 20. And we started doing an innovative biomechanical testing motion capture with wearable inertial sensors on the field during training, and sport-specific unplanned movements, and investigating risky patterns and functional limb asymmetries. And we are really ready for a tour to play on this type of patient, and this is a PAMI cohort versus CELSI match control, this is an ongoing study that we are doing on the field, really, and so my surgical take-home message, surgical treatment for pediatrics should be recommended, few evidence regarding best management, it's essential to knowledge the injury mechanism, you have to have an adequate surgical technique, save the meniscus as much as you can, and you should have criteria for base return to play, and correction of movement patterns in this type of patient. Thank you very much, and I invite everybody to Milano, ESCADRO 24, and to jail.

pediatric ACL reconstruction

hamstring tendon graft

growth cartilage

meniscus lesions

post-operative protocol