You do the technique that I was talking about, or you're doing what Frank does with a quad in an IT band, or you're using a hamstring in an IT band. I think all around the world we've converged to very similar techniques. And so what I have found the more that I do these operations is I tell patients, actually, our surgical techniques perhaps matter a little bit less, actually, than what we're going to talk about right now, which is how do you safely return somebody to sport? Because we're going to assume that everybody who's doing these knows how to do it well, and there's little variations in technique. But the hard part is safely returning these patients back to sport. And here's the problem. And these are the real numbers. If you are a child or an adolescent, and you tear your ACL, one in three is going to have another ACL tear during their active years. Now, that includes both the ipsilaterony and the contralaterony, but that is a shocking number, and patients really do not actually know this. Well, why does that happen? For starters, if you look at the studies, more than 90% of young patients go back to playing sports. So they put themselves in the exact same risky situation that caused the problem in the first place. If I tore my ACL skiing, guess what? I'm probably not going to ski anymore. But when you're 14 years old, you're darn well going to go play soccer or lacrosse or whatever it is that happened to you. And these are just a couple of references, if anybody wants to talk, showing these very, very high return to sport rates in this cohort. So they're exposing themselves to the same risk. And when you break it down, once again, the number's about 18% chance, if you look at the whole literature, of tearing your ACL graft, 18% chance of your contralaterony adding up to somewhere in the 35%, 36% range of having another ACL event. And there's probably not many other procedures in orthopedics where we have a quote, unquote, 35% failure rate, and we accept that. And while I always feel better when I have an ACL patient, and it's been a couple years, and their name pops up on my schedule, I immediately call the patient. I'm like, which knee was it? Because I feel better when it's their contralateral knee, but the patient doesn't necessarily feel better. I still think it's a failure of our treatment when they go on and then they have another preventable ACL injury. So how do we do better? We're going to make a couple of assumptions. One is that you choose an appropriate ACL graft. That can be an appropriately sized hamstring. That can be a quadriceps. That can be a BTB if they're old enough. Let's assume you do a technically sound ACL reconstruction, and all of the techniques presented today are fantastic options. And let's assume that your patient has received good physical therapy, and they're six to nine months out. Well, now what do we do? The last thing that you have control over is how and when they return to sport. And I think this is something we have to own as surgeons. So the secret sauce of doing this for a decade and thinking about this for a decade, this is kind of what I'll distill it down to, is seven steps. Number one, set expectations preoperatively. And I'll expound on all of these. Number two, wait a minimum of nine months before ever letting any kid go back to full sports participation. Three, use an objective panel of tests to guide your decision. I'll tell you which tests may have some value. Utilize patient-reported outcomes as part of your decision tree to go back to sport. That should include number five, which is psychological metrics of readiness to return to sport. The other thing is you have to have a return to play program after you've cleared the athlete. So how many of you guys have had this where it's a nine-month appointment and the patient comes in with their cleats in their bag and they're like, I have a tournament at 5 PM today after you clear me? That's not the reality. It should be a transition. And finally, you have to think about ongoing rehab and ACL prevention programs. I tell people, it's like changing the oil in your car. You've got to take care of the investment that you made in your new ACL. So let's expound on all those things. Number one, and this is maybe the most important one, set expectations pre-operatively. So I do somewhere around 200 ACLs a year. So I give the talk 200 times a year to the point that it's very refined. And sometimes I feel like I'm a broken record saying the same thing. But it's so important to talk to families about this. The first is you have to say this is a one-year process. Stephanie Mayer, who Frank knows well, did a study at Colorado Children's where they asked patients coming into clinic with ACL tears how long they thought it was going to take them to recover. This is before they had their encounter. And the average answer was three months. So there is a massive discrepancy with between what children think, even parents think, is going to be their recovery and what we know to be the reality of recovery. I tell every patient that rehab is probably more important than the surgery. And I tell people, you went through great lengths to find me because I'm a pediatric sports specialist. You have to spend just as much time finding the right therapist and investing in your therapy. You have to tell them that going back to sport carries risk. A lot of people think this is like Tommy John surgery. It makes you stronger. It makes you throw faster. Oh, you're putting in a brand new ACL? Oh, that must be bulletproof. I can never tear that thing. Have to educate them about the risks. The younger the athlete, the higher the risk. Frank has shown this better than anybody, particularly these tweener athletes, these 12 to 14-year-olds are particularly vulnerable. You tell them ahead of time, under no circumstances will I ever let you go back to sports before nine months. That's not negotiable. And you have to pass your functional testing before I let you go back. Well, why this number of nine months? It's not necessarily that time is the driving factor, OK? So it's not that at eight months and 28 days you're at a really high risk, and nine months and one day all of a sudden that risk is gone. It's that on average, it takes nine months to achieve the objective metrics of return to sport, to have enough quad strength, to have enough neuromuscular control, to have enough functional control to be able to safely return to sport. And there's some really good studies out there, including one in the middle that Dr. Amendola and I had done at Duke. And look at these numbers. So in Scandinavia, if you go back to sports before nine months, this is all the way on the left, you have a seven-fold increased risk of tearing your ACL again. The numbers are staggering, 40% failure rate before nine months, about 5% failure rate after nine months. The middle one is a study I did when I first got to Duke. We modeled it a little bit differently, but for every month you wait to go back to sport, you reduce your risk of re-injury by 13%. And once again, this is sort of like compound interest on your credit card, that adds up very quickly. And the final study, this is by the Delaware-Oslo cohort, 50% risk reduction for every month that you wait to go back to sport. So time is powerful. But once again, time's not enough. You have to have objective panels to return kids to sport. The same Delaware-Oslo group did a study where they looked at patients that had passed versus not passed testing at the time of return to sport. And the numbers were, again, staggering, 40% failure rate if you did not pass testing, 5% failure rate if you passed testing. And these things are multiplicative. So once again, if you didn't pass testing, and it's before nine months, and you're under the age of 16 years, in our Duke cohort, if you met those criteria, there's 100% failure rate. 100% failure rate. So the days of saying, oh, you have a great lockman in the office at six months, have a nice life, those days are over. Well, what should your panel look like? The truth is, we probably all have different panels. And I don't think the exact makeup of your panel matters, but it has to include these components. One, their knee has to be stable. That can be your physical exam. That can be stress radiographs. That can be a KT-1000. However you want to just document that their knee is stable. Additionally, you have to measure their strength. That should include their quad, their hamstrings, and their glutes, ideally. Not everybody has isokinetic machines like a Biodex, but you can use a handheld dynamometer. There's this device called a Tendec that costs 200 bucks. It's a rock climbing device to measure your grip strength. We've now rigged this in our PT offices. We get very reproducible tests. We've actually validated this against a Biodex, and it's just as good, and it's $200. You have to have some assessment of balance and proprioception. What I make people do is I make them do 30 single leg squats on a BOSU ball, and look how long it takes them to do that. It's actually really hard to do. Hop testing in some variety or form. That can be a single hop, a triple hop, a crossover hop. It doesn't so much matter, but it measures how much strength you have to propel yourself, how you land, because you have to stick the landing, and how much you trust your knee, because if you don't trust it, you're not going to launch yourself very far. Some measurement of movement quality. I happen to use the landing error scoring system, but some measure of movement quality, and finally, some composite movement testing. I always tell my athletes, this is the NFL combine test. How high can you jump? How fast can you do a shuttle run? How far can you broad jump? Things of that nature. When we do these tests, we sort of get numbers back, and those numbers come back as twofold. One is just their absolute performance. If you do a hop test, did I jump to Davide? Did I jump to Frank? Did I jump all the way to Stefano? That's the raw number, and then you get a limb symmetry. How did you do on your surgical limb versus your non-surgical limb? And we're very, very used to looking at limb symmetry as our metric. There's a problem with limb symmetry, though. In fact, there's a couple of problems with limb symmetry. This is a study I did at Duke a few years ago where we took 100 healthy kids. These kids had never been hurt. They had never had surgery. They were mainly our children, basically, and our physical therapist children, and we put them through return-to-sport testing, and this table shows, for the different tests that are in our battery, one percentage of normal, healthy kids met the return-to-sport criteria of 90%, and it was about half, right? So kids have limb dominance at baseline, and so limb symmetry in isolation is not enough. That led me to do a follow-up study where we took an even larger cohort of kids, and for all the different tests that we did, we developed these growth curves. So now, all of a sudden, we know what should a 12-year-old girl be able to do on a single-leg hop, and you can then plot them here, and you get a percentile score, and so I always tell people, you have to be 90% symmetric, but you also have to be at least at about the 50th percentile for your age and your gender before we consider you as recovered. The other problem, and Lynn Snyder-Mackler from Delaware has shown this well, is that your contralateral limb deconditions during recovery, right? These are athletes who haven't been doing their sport for some time, and so if we're measuring the normal leg as our metric, we're probably underestimating what level of performance they need because that contralateral limb has also deconditioned. One final thought, if you do use patellar tendons, know that it takes them, on average, this is crazy, three months longer than soft tissue grafts to recover full strength and ability to pass return-to-sport testing. Utilize your patient-reported outcomes. Typically, I use some measure of general health, some measure of knee-specific health, and these, really, for a kid, should probably be in the 90s before you're talking about return-to-sport. For psychological readiness, there's something called an ACLRSI. This is very easy to administer. It is publicly available, and it's basically a score of zero to 100, how much do you trust your knee for athletic endeavors, and there's a little bit of this Goldilocks effect where if your score is below 65, your brain is telling you that you're just not ready to play sports, but conversely, if you are too confident, and this is a great paper by Mark Paterno, if you are too confident, and this tends to be the boys, they'll say 100, like, I'm so confident. They actually have a higher reinjury rate because they don't sort of respect the fact that they've recently had surgery. So I ideally want this score sort of 65 to 85 is, in my mind, the sweet spot. One of the challenges, and there's not great literature on this, maybe over the time I'll be able to help develop this, but you have to develop a return-to-play program for your athlete. This is athlete-specific, this is sports-specific, this is sort of situation-specific, it's time-of-year-specific, depending on their season, but you can't just say, hey, it's been nine months, you're cleared, go. You have to say, all right, you can go, but you should be looking at your load, and we wanna linearly increase your load in terms of, that's minutes played, amount of practices you do per week, intensity that you put into it, and you have to progressively go through individual drills and team drills and then scrimmages and then match play. And finally, I think it's very important to have secondary prevention programs, so I ask all my ACL patients to check in with their physical therapist once every six months. I tell them, basically, go back and do your testing, see what you've sort of regressed back to your baseline on, tune up those things, and that should keep you out of my office. Once again, just a summary of the seven points of success I think are important for returning a pediatric athlete to sport, and happy to entertain any questions. Thank you.

ACL tear

return to sport

children

adolescents

re-tear rate