Good morning, everyone. My name is Davide Bonazia from the University of Torino, Italy. And welcome to this instructional course regarding ACL reconstruction in pediatric patients. I would like to thank all the panel of these great experts that are on board for this. So thank you guys for being part of this IC. So the first talk would be about ACL repair. These are my disclosures. So the indications for ACL repair in pediatric patients, if there are any, this is a very controversial topic. Maybe we'll have some time to discuss it later in the discussion, would be proximal avulsions when more than 90% of the ACL stump is preserved, which represents almost one third of the patients in the age group between 11 and 13 years of age. Less than three weeks from injury, could be isolated or multiligament. Theoretically, there is no limit of age. Ideally, this is a technique to be performed in prepubescent patients. So the rationale of the technique is that the pediatric population is at high risk of ACL repair or ACL reconstruction failure. Prepubescent patients are also at high risk of growth disturbance. And ACL repair can represent a minimally invasive procedure and allow for a future ACL reconstruction like a primary procedure. In pubescent, post-pubescent, and competitive athletes, there are still some concerns regarding this technique, and stronger evidence is needed to support ACL repair in these groups. With biological stimulation and improved mechanical stability, we can have better outcomes for ACL repair than they were reported in the past as unsatisfactory. Let's see the surgical technique. So we start with the arthroscopy, and we need to evaluate the ACL stump and make sure that there is enough preservation of the stump. This is then armed with two sutures in a luggage tag fashion. And by pulling the sutures, we are actually removing the stump from in front of the camera and improve the visualization of the notch and prepare the notch better. Then an all-epiphyseal 4mm full tunnel is drilled on the anatomical femoral footprint. Then a first shuttle suture is passed through the femoral tunnel and retrieved through the anteromedial portal. Then a transphyseal or an all-epiphyseal 4mm tunnel is drilled on the tibia. And another suture is used to retrieve the previous suture in the tibial tunnel. A second suture is placed through the femoral tunnel, and this is used to retrieve the ACL stump arming sutures in the femoral tunnel. Some microfractures are done for biological stimulation. And then non-biological augmentation is passed through the tibial and femoral tunnel. You can see here the tape passing. And this is the final result of the repair. As you can see from this x-ray, this patient came to the operating room very early because he also had a proximal avulsion of the MCL with a bony fragment that was fixed with suture anchors and a headless screw. So, like surgical tips, we need to use a cannula in the anteromedial portal to avoid the entrapment of the soft tissues around the portal itself. We need to arm the ACL stump first in order to improve the visualization. We need to put two sutures through the femoral tunnel. One is going through the femoral and tibial tunnel and is for the non-biological augmentation. The other one is used to retrieve the ACL stump arming sutures in the femoral tunnel. We need to remember not to over-tension the biological augmentation because this needs to act as a seat belt. So post-operatively, the patients are allowed weight-bearing as tolerated. We usually put a brace in full extension for four weeks, mostly in very young patients. These patients have little risk of stiffness post-operatively. And we don't like to do open-chain strengthening for five months after surgery. These are some recommended reading lists. And thank you. So I will welcome now Professor Stefano Zaffagnini from the University of Bologna. And he will show us his technique. So, thank you for inviting me again in this session, and we will discuss about our technique. These are my disclosures. So, the indication, when you have a LACMA more positive, anterior drover positive, and PO shift positive, and you can have complete or partial ACRT on MRI, and use up to pubertal phase, so 13 for the female and 15 for the male. And open physis on the knee x-ray. So the aim is to obtain stable knee, guarantee return to play, and avoid meniscal injury, and maintain long-term knee health. So my technique is very simple. Hamstring tendon graft, interpessant serenus insertion on the tibia, fluoroscopic assessment of the growth cartilage, olepiphyseal tibial tunnel on top of the growth plate, non-femoral tunnel, we go over the top, and we add the lateral extraticular tenodesis. So the interpessant serenus insertion is a vital growing graft, and the physio-sparing ester physio, no cartilage disruption, low risk of growth arrest, lateral tenodesis, you have better control of rotation, and we did narrow tunnel, because six or seven millimeter to have a high graft press fit in the tunnel. So this is the technique, it's a simple video, you see this small lady, LACMA 3+, anterior drover 3+, and she has really gross pivot shift. So this is the ACL and the normal side of the other knee. She has also a medial side layer of the lesion, so we suture this type of suture with all inside the suturing device, in order to avoid a meniscectomy at this stage, and we will do a second stitches, and then we go to clean up the notch. We don't do too much cleaning, we do with fluoroscopy, under fluoroscopy, the position of the growth tunnel, so we will go a little bit up on this. So we do a small incision in order to be sure, and then we check again to be sure, and we arrive with a tunnel that is very oblique, and you will see that it will be in that way. So after this, we go laterally, and this is the tunnel with the fluoroscopy, then we drill the tunnel, and then we go over the top, and we go the fixation with two staples, simple staples on the femur, the first passage, and then with the remnant of the graft, we do a lateral tenodesis, it sounds like anterolateral reconstruction, that we fix with bony tunnel or with staples, depending on the, we need, this is a bony fixation on the, below the growth plate again, so we are all out of the growth plate in any way. And the tunnel, and the technique is finished, so this is the technique, it's very simple, and the surgical tip, you have to do associated lesion first, always fluoroscopy to check the physis, and to see that the tunnel is in the nice position, always drill above the physis on the tibia, and the too wide tunnel is risky of growth, that's why also we do a small tunnel, and if staple intolerance, you need to remove it, but it happens not so very frequently right now, and many say to me possible because, to avoid, many say to me because it's possible to create axial deviation. So our postoperative regimen, we do no heparin, first day full weight bearing, passive range of motion, isometric quadriceps, 15 days, they start rehab in the water, 3-4 months straight run, and the 6 months they start post-specific rehabilitation, and return to sport is not allowed before 12 months, and 18 higher risk of retear and contralateral injury in the young population, we know, so we need to look for the injury risk, like the steep tibia slope. So this series that we did in 2019, where we had our first 20 pediatric ACL, between age 18 to 13, follow up of 5 years, excellent results, we have no failure at that time, no major growth disorders, just 2 patients that has leg lengthening, but we didn't know if this was before or after the surgery, and just 3 minor axial deviation, but this was related to the many certainties that we need to perform in that case. And this is our PAMI, I know that Pluto is an American company for having a collection of the old pediatric ACL, this is, PAMI is the ESCA section for pediatric ACL, this is our series of 43 patients, mean age 16, 34 females and 9 females, 22 basketball, football, these are the sports that we're doing, and the injury list, and the results at the time of follow up, so PEDI-IKDC very good, and PEDI-FABS quite good. Just to show some cases, this is the surgery 14 years old, no contact injury, time to injury to surgery 6 months, no meniscal lesion, we were lucky, you see the tunnel and the position at 2-5 years of follow up, same competitive level, and the PEDI-IKDC. This is another case, surgery at 14 years old, no contact injury, time from injury to surgery 3 months, and the return to play, to training at 4.5 months, he wants to return to match easily because sometimes you cannot control this type of patient, so they come to you and they say, oh I already play many games, so this is what happens. So at 2 years, we have same competitive level and PEDI-IKDC 96. And this is the third case, I was very upset with this guy because he came to me in the office after 3 months and he said, I return to snowboarding, and I was really crazy about this, and he returned to football match 6 months and still playing at same competitive level. So now we have also some study about the return to play, because I think this is an important section especially in this pediatric ACL, and we have on the field running and training and sports as if he can plan the movements with ball and opponents, and we try to assess the risky pattern and functional limb asymmetry in this type of patient. And this is an ongoing study, and we have the PAMI cohort that we are doing versus match control and trying to see what is the difference between the normal leg and the operated one in order to see when is the time to let allow to return to play in a good way. So in conclusion, I think this type of surgery is, he has vital growing graft, we have no graft disturbance, we have let to control rotatory laxity, we have to save the meniscus as much as we can, and the return to play is time and criteria based, and probably we need further study about this, and we are doing this type of study right now, and so far we have excellent results and mid-term follow-up. Thank you very much. Okay, now I'd like to welcome Jonathan Rebo from Ortho Carolina. He will describe the Cochrane-McKinley technique. Perfect, and David do you thank you for the invitation. I am going to be presenting primarily a technique-based description of this McKaylee-Coker technique. This, I cannot claim credit for creating this technique, but rather it is one that I've adopted and found very helpful in my pediatric practice. So specifically, who do you want to consider this operation on? This is for the really young kids. Okay, so these are typically athletes that are prepubescent. If you look at both the literature and in my own experience, almost all of these are males, and typically the people I'm considering this are people with more than three years of growth remaining. So that would be a male 13 or under, or a female 11 or under. And why consider this technique? There's a lot of things that are out there. The, I think, main competitor is, at least in the United States, is the all-epiphyseal technique, and not to speak ill of it in front of the people who sort of developed this technique right here, but my personal reasons to prefer the McKaylee-Coker are listed here. So if you look at the literature, which by the way is fairly limited, there's only two outcome studies on the McKaylee-Coker. One from the Boston group, which is this first one I talked about here in 240 knees, and one from a group in Atlanta that had about 30 patients. So not a huge amount of literature, but in the studies that are out there, absolutely no clinically relevant gross disturbances. And that's really important in this very young population, right? So it's safe from a growth standpoint. It does have a low reported failure rate, 7% in the Boston series. It was about 10% in the Atlanta series. It's simple. So compared to a lot of the other operations that are out there, this is very easy to do. This is easy for me to teach to fellows and residents. It is quick. It only takes about half an hour to do, and it's very cheap. There's no implants, or you can use at most one anchor. There's no radiation or fluoroscopy, which is I think better for the surgeon and better for the young patient. And there are some studies showing quicker neuromuscular recovery than any other autograft source. So there's less effect on their strength and their functional performance than taking a hamstring, a quad, or a patellar tendon. Not that you would in this group, but it's a very low sort of morbidity graph when it comes to neuromuscular function. This also has the best biomechanics of any of these fissile sparing techniques that are out there, and it does restore normal in vivo kinematics on biplanar fluoroscopy. So honing in on the technique, a lot of people have not either done or seen this. Your setup is very much like a standard ACL. I prefer sort of a large bump here. It allows me access to the whole lateral thigh. You have to prep them really high and put your tourniquet really high because you need to access the iliotibial band about 15 or 16 centimeters above the epicondyle. You make a lateral-based approach. It's essentially like an extended LET approach. The dissection is very easy. It's skin-to-IT band. You then use the largest cob you can find, and you will give them a morale lavalier lesion of the thigh. That's important so that the graph will become dissociated when you free it up. Unlike an LET, which many of you may have done, you have to harvest actually the majority of the IT band. So I typically leave one centimeter anterior, one centimeter posterior, but you're taking 80 to 90 percent of the IT band, or you're going to get a graph that's just far too small. You then dissect your graft. It's important, as you see here, to spread the plane now underneath the graft, in between the graft and the vastus lateralis. You can then use these menisca tomes that are commercially available. They're very easy, and their length is such that if you just hub them to your skin incision, you're going to get the right length graft every single time. I then, again, will spend a lot of time dissecting the undersurface of the graft. Here I'm using a cob. You can use a Metzenbaum. If you don't do this, when you try to dissociate your graft through this small incision, it just won't come out. And that's when you find yourself having to make an escape incision higher up. You can then use this curved menisca tome to cut the anterior half, cut the posterior half, and if you free it up, it just pops right out. And it really is sort of that straightforward if you've done your dissection well. You want this graft to have at least 16 or 17 centimeters in length. Your standard OR ruler is 15 centimeters, so I pull it out. If it's longer than the ruler, I know I'm going to be fine. You can then dissect this off the lateral capsule to enhance mobility, and then you actually prep your graft. Obviously this happens up at the patient level, not on the back table, because it's remaining atastic or it's tubercle. I'll typically whip stitch the free end over the course of three to four centimeters. This will be the portion that ends up overlaying the tibia, okay? And whip stitching this and tubularizing it will help with passage of your graft. The next thing I do is I tubularize the interarticular portion. You can see I made a little purple mark on the graft where it's going to sort of pass around the back of the femur and go into the joint. And then I will tubularize the graft with an absorbable suture. This is just a visceral suture because I don't want anything permanent in the joint. This helps with graft passage. It also makes your graft a little bit more cylindrical, kind of more like what we're used to in terms of hamstring grafts, for example. You can then put this in a vancomycin soaked sponge and temporarily park this in your lateral incision and initiate your arthroscopy. You can see here a very clear ACL tear. My femoral prep is minimal because you do not want to disturb the perichondral ring that's right there. But on the tibial side, I do try to get some exposed bone. This is very safe to do. You're well above the physis and this will hopefully give you a little bit of a spot weld for biologic healing. The ones of mine that I've done that have failed always fail right at that location. They fail at the passage underneath the intermeniscal ligament. Next, we will get a long curved clamp. The same set that has those nice meniscotomes has this clamp, but you can use any large curved clamp. And you have to pass this from the overtop position through the knee. It's a little scary the first time you do this, but as long as you're aiming laterally, it is actually quite safe. You can see we then pass the graft over the top. It's currently parked out of my anteromedial portal where obviously it cannot stay. So we then make a standard tibial incision, just like any tibial ACL incision. We dice it down carefully in this case because we want to preserve the periosteum for fixation. So when I do this in a standard ACL, it's knife to bone. I don't even look, you know. But in this, you want to preserve the periosteum. You then get a clamp underneath the intermeniscal ligament, which is a little trickier than it sounds, but with some practice you can do. And then you shuttle the graft underneath the intermeniscal ligament, which will prevent it from sort of bowstringing off the tibia as you come into extension. It actually takes, you can see, a fair amount of force to get that out. And you want to put your scope back in the knee and make sure that your graft is not bunched up. Make sure it's all the way out to length. Just like a standard ACL, we will fix this on the femur first. This is done at 90 degrees of flexion with neutral rotation in three figure-of-eight sutures with a non-absorbable high tensile strength suture. You can sew this to the periosteum or to the intermuscular septum. It's very easy. We then come into full extension. We make a trough in the tibial periosteum. As long as you're below the tip of the tubercle, all of this is below the physis. The physis is always at the level of the tip of the tubercle. So you can use floor if you would like, but you don't really need to. I make a little bed for the graft. This here is essentially the Reba modification of the McKinley-Coker technique. I personally prefer to use an anchor to supplement fixation on the tibia. So I put this just distal to where the graft would attach. This also allows me to then not need an assistant to hold the graft out to length while I suture it to the periosteum. And that, by the way, is essentially the only cost for this operation is that one anchor. Then you can make sort of a little burrito or taco out of your graft. You fold the periosteum over top of it, which makes for very robust healing, and that is it. This is a quite straightforward operation. These are my references and hope to entertain any questions. Thank you, Jonathan. Okay, welcome now Daniel Green from HSS, and he will talk about their all-epiphyseal ACL reconstruction. Good morning everybody. So let's move, we're going to talk now about all epiphyseal ACL. Focus obviously, and I'm Dan Green from New York, thank you so much for the invitation. Try to get the next slide working. This with a mouse, it was a mouse. Okay, thank you. Disclosures. You know, we're here at the AOSSM meeting and it's really this this technique was developed by Dr. Alan Anderson as the president of this society in 2015 and 2016 and he passed away unfortunately right after his presidential year. I remember meeting him the year before his presidential year, I think it was in May, and he spent days dissecting pediatric knees with Dr. Ganley and Dr. Shea and was just filled with energy and mentorship and skill. So we're really inspired by him. We wanted to, to my partner Dr. Kardashian and I were really excited about this technique and with Dr. Eric Wall was at Cincinnati, was also whispering in the back hall about his great successes of the technique and then with Dr. Leibowitz and my partner Dr. Kornasko, we worked at cadaver labs and basically just did a slight modification of the Anderson technique to an all inside, all epiphyseal technique with reverse sockets and not tunnels with suspensory fixation. Our first case was in 2010. So again, sockets not tunnel, soft tissue autograph. We began with the hamstring but transitioned to the quad, tensioning suspensory buttons and by design there's no fixation on either side of the physis. All the fixation is epiphyseal. We had a few technique articles. This is a 2013 JBJS, 2012 arthroscopy techniques. Just, you know, these are very young kids. This is a 12 year old boy who just to show, I think it's essential to get pre-op standing x-rays and to monitor these kids for leg length as time goes on, but also we're aggressive using our pediatric mind of, in this case, this kid had isolated pathologic genu-valgum worse on one side of the other. So during our epiphyseal ACL, we added a tension plate and then took the plate out a year later after the deformity of the valgus improved. And these are sockets. So the graft is fairly short. Usually we shoot for about a 65 millimeter graft of 9 to 10 millimeters. And in the femur, you want to have a 20 millimeter socket and in the tibia, it's hard to usually get a full 20 millimeter socket, but you could usually get a 15 millimeter socket. There's special guides that help you with the epiphyseal approach. This step off cannula is very handy when you reverse ream. It keeps you from going out through the cortex. Dr. X has described kind of the anatomic approach, the safe zone for this technique. I think you can see my big hand on this little knee. I'm always kind of feeling the posterior condyle. I don't want to blow out the back, but I don't want to be at the LCL level or papateous level either. So first with a guide wire, once the x-ray demonstrates a good safe area, then with the reverse reamer and then reverse reaming the femoral socket, the tibia socket's kind of fun because you can feel the growth plate. And so with our standard incision, how do you feel the growth plate? Essentially the epiphysis is a little bit convex and then it transitions to a concave metaphysis. So you can feel it with your finger if you rub over the periosteum. So you want to get your guide wire just in the epiphysis away from that growth plate. And then it's just passing the graft using the all inside technique. In our first 20 patients or 25 patients, we had no growth arrests. Then we did have a couple of growth arrests with regular x-rays. So we transitioned to using 3D fluoro. So I put the reamers in the femur and the tibia and run a check with 3D fluoro. And many times we made adjustments based on those images. When we studied our post-operative MRIs, when I was just using regular a C-arm or mini C-arm, the sockets were touching the growth plates a large amount of time in the femur, 40% with just the regular C-arm and 60% on the tibia. But even with my 3D fluoro, I was touching the growth plate with my socket was touching the growth plate 11% on the femur and 16% on the tibia. Here's a case of a 10-year-old rising sixth grader, isolated ACL tear. I think it's essential to get your hand for bone age or scotal age. And I'd really like to get a standing x-ray pre-op whenever the kid has full range of motion. And six months later, you can see the sockets really just nestling up to the growth plate there in the femur. Here's a second case that has a good, you can see a 10-year-old boy, you can see how immature he is with the lack of full ossification of the tibial tubercle. And you can see the tibial socket right coming up to that non-ossified epiphysis as well as the growth plate. And here's his post-op x-rays. Our outcomes are surprisingly good. In our first 49 patients, when I say we're surprisingly good, our revision rate was 6%, which matched our older adolescent kids with the BDB. And this was an older study from 2019. But you can see the all-epiphysial hamstring had a 6% revision rated over two years. And the transphysio hamstring group in the older kids had a 20% revision. So this analysis kind of led us away from hamstring and excited about the quad tendon graft and then also more LETs. Dr. Ganley and the CHOP group had a, as a publication of over 100 patients with the all-epiphysial group, they had about a 10% re-rupture rate and one case of limb-leg discrepancy. So as Josh said, you know, the pros and the cons. You know, the pros are it's inside the knee, it's an anatomic reconstruction, you could use it with a hamstring or quad. It appears to have a very low revision rate in that 6% to 10% range. And there's multiple centers of excellence. Excellence, Dr. Anderson was the pioneer, our friends at CHOP, Cincinnati Children's, San Diego, Sheffield, here in Denver, Jay Albright are all advocates, strong advocates of epiphyseal. But what are the negatives? It's technically demanding. In terms of the all-inside technique, there's a lot of suture management and important graft preparation. There's definitely a risk of growth disturbance. We've had a few cases and there's a poster in the lobby about it. It requires a lot of x-ray and what really is kind of drifted us away from the technique in our institution is it was taking so much time to do the 3D imaging and the changing. So here's one of my growth arrests. So it's a 12-year-old male and over a year and a half, two years later, it started to see valgus. It went on to develop a limb length discrepancy and more valgus and required a limb lengthening procedure and corrective osteotomy. So my old, this is my disclaimer, my old algorithm just a few years ago was a modified MAC for the very young kids, the McKayley-Coker technique, all epiphyseal with more than two years of growth remaining, and then transphyseal. And this is kind of where I am now. I'm doing less all epiphyseals. I'm back in love with the modified MAC and I'm doing transphyseals a little bit on a little slightly younger age group than I used to. If we look at our friends at Pluto with over 700 cases enrolled by skeletal age, look at the technique variation and that's probably why everybody's in this room like what to do in that 12-year-old. If we just go to the skeletally, if we just go to the 12-year-old, there's a huge number of patients in this group that were transphyseal. There's a second and second was physeal sparing with the ITB, the McKayley-Coker, and third was all epiphyseal. And so we're all here trying to figure out what's best. So we'll, I don't, I think we'll, so it's a little bit of a journey and thanks for letting me share it with you. Thank you. Okay, so we have seen now all the fissile sparing techniques, but sometimes we can use partial trans-fissile techniques. And this is actually the history of a technique that I learned from Neta Mandola, who is my mentor. He learned it from Peter Fowler. And actually, this was an old paper with reporting excellent results of this technique. And even in very young patients, you can see the growth remaining and the migration of the staples. So this technique involves an over-the-top position on the femur of the graft and a trans-fissile small vertical tunnel on the tibia with a soft tissue graft. So this is the surgery. This is Dr. Mandola operating. And a semi-T autograft is harvested according to the surgeon's favorite technique. In this case, only the semi-T is harvested with an open tendon stripper. And then the graft is released from the pessence arenas. Then the graft is brought to the back table, is prepared in a two-strand fashion after looping it around a loop with no button. The distal ends of the graft are armed. And then the graft is sized and then tubularized with absorbable sutures like you see in the video. And then the graft is pre-tensioned and pre-soaked in vancomycin. So this is the ultrascopic evaluation. The stump is not big enough for, long enough for a repair. So the notch is cleaned, not in a super careful way because we are going over the top on the femur. Then we move to the lateral side and size the IT band and the intermuscular septum. This is done being in contact with the posterior femoral cortex. We need to enlarge this opening until we can actually palpate the posterior capsule and posterior lateral condyle. And then a gaff hook is used to puncture the capsule being attached to the posterior femoral cortex in order to avoid neurovascular injuries back there, and is guided outside the lateral incision. And this is used to bring into the joint a shuttle suture which is left in place. Then the tibial tunnel is performed. As I said, this is a transfusional tunnel done in a vertical position and a small size, usually a six millimeters tunnel. This is done in a pretty standard fashion. Sometimes the good part of the stump is preserved for biological healing and integration. And then through the tibial tunnel, we retrieve the suture that we previously placed over the top. Then the graft is brought into the joint from the tibial tunnel and then outside the lateral incision. Sometimes it's a little hard to pull it through the posterior capsule. At this point, we can see the loop holding the graft. And this is fixed on the lateral femoral cortex suspended there with a 6.5 millimeter screw, cancellous screw, with a washer. In this case, it's a soft tissue washer with little teeth holding the loop very nicely. Then the loop is placed around the screw. The graft is pre-tensioned, and then the screw is tightened down to the bone. And pre-tensioning again the graft. These grafts do not need to be over-tensioned. And then the fixation is below the physis with a staple. And this is the postoperative X-ray. So over the years, we changed a little bit this technique, trying to improve what we thought were a little bit the weak points of this surgery, which were basically a graft that was quite small. And the fact that the transphysial tunnel was a full tunnel through the physis. So we kept the over-the-top position, and we decided to modify the tibial tunnel so that a 4.5 millimeter was drilled through the physis, but then a half socket was retro-drilled just in the epiphysis. So it's basically a smaller damage to the physis. And then with the increased evidence of the lateral tenodesis reducing the retail rate in this population, we added also a modified Arnold-Cocker tenodesis. So the indications for this surgery are patients with mild risk of growth disturbance, so basically 10 or 2 or 3, and the growth potential of 2 or 3 years. So this is the surgery. In this case, we harvest both the gracilis and the semite. This is done with an open tendon stripper. Then the graft is brought to the back table and is prepared in a six-strand fashion. So we lose a little bit of length, but we increase the size of the graft. So both ends are armed with non-absorbable sutures. And then the graft is prepared with two adjustable loops, both on the femoral and the tibial side. This is loop number one. Then the graft is passed through loop number two, inside loop number one again, and then fixed to loop number two. So in this fashion, you have a six-strand graft which is then sized, pre-tensioned, pre-soaked in vancomycin, and then we move to the lateral incision. Only difference compared to the technique you've seen before is that we harvest a strip of the iliotibial band right at the level of the lateral femoral epicondyle. The strip is then armed with absorbable sutures. And then we try to achieve the same thing that I mentioned before. So inside the intramuscular septum, be able to palpate the posterior capsule. In this case, we achieved the over-the-top position from proximal to distal with the suture passer that is then visualized into the joint with a suture on it. It's retrieved from the antromedial portal and then left in place. And then we move to the tibia. This is the retro-drilling of the tibial socket. So we go transphysio with the retro-drill. And then we retro-drill a half socket, all epiphyseal. So this is measured on the MRI before. So the length of the tunnel is usually 18 to 20 millimeters. So we decided preoperatively on the MRI. When we achieved the length desired, go back, remove the retro-drill, check the tunnel. If we see a little white circle in our tunnel, means that we damaged the physis. In this case, we did not. So then we use another shuttle suture, which is used to retrieve the previous one through the tibial tunnel. Then the graft is passed from proximal to distal, seated into the tibial tunnel, and then fixed on the tibia with an extracortical suspension device. Then the femoral fixation is very similar to the one you have seen before. The washer is without teeth because with adjustable loops, the teeth can damage a little bit the loop. With two adjustable loops, it's quite easy to over-tension this graft. So we recommend doing the fixation to no more than 10, maximum 20 degrees of flexion of the knee. And this is the final part, which is the lateral tenodesis, small incision, anterior and posterior to lateral collateral ligament. And the graft is passed under, and then it's sutured to itself with a modified Arnold-Cocker technique. And this is the final result. And this is the final x-ray. So the first thing to know when we do this technique is to measure how long we need to retro-drill this tibial half socket. And this is done on the MRI. We prefer to use a screw and a washer with no teeth in order not to damage the loop. You need to do the tibial fixation first, which is a little different compared to what we are used to. Lateral plast is important in this patient. It can be done through the same incision and should be done with the knee at 30 degrees of flexion and the foot neutrally rotated. We need to be careful not to over-tension the graft. Over-tensioning in pediatric patients is always not good. We need to pay attention to the neurovascular structures during the over-the-top lateral approach. This is the most scary complication that we can have. And why do I like this technique? Because we don't need intraoperative x-rays. This makes the technique really easy. There is no graft tunnel mismatch because we can put the screw on the femur to our desired position. The graft in the joint is quite large. So we are overcoming small grafts in this population. It can be considered anatomical because over-the-top is considered anatomical by many. And when you go back in knees where you did an over-the-top position, you're really very happy about the position on the femur of your graft. And the two-adjustable loop can allow fine-tuning of the tension of your graft. Lateral tenodesis can be performed through the same lateral incision, so no additional incisions. And we don't have issues with too short grafts. So postoperatively, weight-bearing is tolerated. No brace for compliant patients. A range of motion exercises right away. No open chain for five months after surgery. Usually no sports for one year, nine months to one year. And then the criteria to return supports are very important. We'll talk about them with Jonathan Rebo later on. This is recommended reading list. And thank you. Okay, now I welcome Federica Rosso. Federica will talk to us about the adult-type reconstruction in these patients. Thank you, Davide. Good morning, everyone. Okay, it's a pleasure to be part of this instructional course. Here are my disclosures. So we usually perform an adult-type reconstruction in patients with closed physis, but they are still young patients, so they have an increased risk for a rupture, for infection, and they are often involved in pivoting support. For all these reasons, there is a high rate for revision ACL in this population, and so we should do everything we can to reduce that risk. So first of all, we perform a standard adult-type reconstruction with transportal femoral drilling. We use a very strong graft, either a BTB graft or a quad tendon graft. And we usually add lateral tenodesis, which can be a modified LMR fixed with suture anchoring in case the BTB graft is used, or a modified Arnold-Cocker if an old soft-tissue quad tendon graft is used. This technique is indicated in patients with no risk of growth disturbance, which means standard four and five, bone age, 16 years for male, 14 years for female, and basically closed physis. So I will show first our technique for the BTB graft, starting from the harvesting. The middle third of the patellar tendon is harvested in a standard manner. Then we usually harvest the tibial plaque first, because it will be easier to harvest the patellar one. The patellar plaque should not exceed 20 millimeters to avoid any patellar fracture. Then we go on the bake table with our graft. We make the plaque round, around 9 to 10 millimeters, and we make two holes in each plaque for a number two absorbable suture for some traction. We also apply some more suture at the patellar bone tendon junction to protect it from the interference cue, and also a number two non-absorbable suture at the tibial bone tendon junction for some more strong traction. Then we mark the cancellous part of the patellar plaque for a better orientation in the joint. We measure the plaques and the tendon portion, and we pre-socket the graft in vancomycin. As I told you before, the femoral tunnel is performed in a standard manner. We use a transportal technique. We usually perform a stamp before, and then we check the position from the intermediate portal to be sure it's anatomical. Then if we like it, we put the wire and we drill a socket that should be a maximum 25 millimeters of the desired diameter. The tibial tunnel is a little bit more tricky. We usually apply the plus seven rule to avoid any graft tunnel mismatch, which means that the inclination of the tibial guide should be the length of the tendon portion of the graft plus seven. So we put our wire and we check the position, both anterior and medial lateral, and we check for any roof impingement to avoid any loss of extension post-operatively. If we like the position, again, we measure the length of the tunnel to avoid any graft tunnel mismatch, and then we fully drill the tibial tunnel of the desired diameter. At this point, we retrieve our shuttle suture, and then we start working for the fixation. We usually use an absorbable screw on both sides, no less than eight millimeters to avoid any breakage, but we create a housing on the femoral house for the better fixation, as you can see here. Then we pull the graft into the joint. It can be a little bit tricky to pull the patella plug on the femoral side, so we use a curved callic clamp, also to orientate the plug, having the cancellous part in front of us for a better fixation. And then we tap for the interference screw on the femoral side, and we put the interference screw. On the tibial side, we fix the graft in full extension. And if you don't trust our tibial fixation, we also add the staple for a stronger fixation in full extension, both of them. And then we go to the lateral tenodesis, very similar to the one we saw before. So a lateral approach is performed, a six to eight centimeter ITB strip is made, and we prepare with some stitches for traction. Then we go in a figure four position, and we palpate the lateral collateral ligament. Two small stub incisions are performed, anterior and posterior. And we use a curved callic clamp to pass the ITB strip under the LCL, as you can see here in the video. Since we use a BTB graft in this case, we fixed our tenodesis with a suture anchor, which is normally placed slight proximal and posterior to the lateral epicondyle. And then we fix the tenodesis at 30 degree of flexion with the foot neutrally rotated, as you can see in a few seconds. In the last here, we move a little bit from the BTB graft to the quad tendon graft, because it's easier to harvest, and we can use a couple of adjustable loops. So we usually harvest six to 70.5 centimeter long graft, depending of patient height. And we try to harvest just two layers out of three. Then we go on the bake table and prepare it with two adjustable loops. In this case, we fully drilled the tibial tunnel. So we are using an adjustable loop with the button on the femoral side, and one without a button on the tibial one. We make a little bit rounded the femoral portion, because the graft is very thick. The passage can be difficult. And we mark half of the graft and the two sockets to be sure that the positioning will be good after pulling in the joints. And then we press hooking again with mancomycin. The tunnels are performed in a standard manner, as I showed you before. The tibial one has to be pretty long for the fixation. So the guide is usually set at a 65 degree. And then the graft is pulled inside the joint. We usually adjust the femoral loop first, as you can see here. It's very important to check any roof impingement, because the quad tendon is very thick. And then we go on the tibial side in full extension. And we are the 20 millimeter rounded extra cortical fixation, again, in full extension, as you can see here. And also here, we will add a lateral tinnitus, as the same technique I showed you before. I'm sorry. There is another. OK. The same technique can also be used with an all-in-side technique. In this case, the tibial tunnel, obviously, is retrograde. Why would you prefer this technique? Because the BTB and quad tendon graft are really strong. They have a low risk for revision and infection. And it pretty good reproduce the ribbon concept anatomy. If you're using some plugs, if you have to revise the ACL revision, maybe easier. We now like the quad tendon graft, because the harvest is really easy. You can use a couple of adjustable loop. And it has a little lower donor side morbidity compared to the BDP graft. If you harvest it properly. Adding a lateral tinnitus reduce the risk of revision. And this is the reasons why we always started in this type of population. The post-op regimen doesn't change compared to the other type, the other reconstruction. So weight bear depends from the associated procedure. We use no brace and no open chain exercises before five months. Return to sports is usually all within this population between nine and month and one year. The criteria have to be fulfilled, but we will see something more about return to sport in the next presentation. Here there is a list of recommended reading. And thank you for your attention. Jonathan, can they go back to sport and when? All right, well you guys already know me. So here's the problem. These techniques are all great, right? And you're gonna leave here, you're gonna go home, you're like, I'm gonna do Dan's technique, I'm gonna do Stefano's technique, I'm gonna do Davidia's technique. But these are the numbers, okay? 20% of these kids are gonna tear their graft. This is, this is the literature, this is from CHOP, this is long-term outcomes, five-year-plus outcomes. 20% of kids are gonna tear their ACL graft. To make it worse, about 15% of them are gonna tear their other knee, tear their other ACL. So you add it together and one in three kids that you operate on is gonna have another ACL tear. There's basically no other operation that we do in orthopedics with this high of a failure rate. It's crazy. And so it's a little bit good from a practice building standpoint because you get a lot of like repeat customers in a way, but it's really hard on these kids and really hard on these families. And I would portend that any of the surgical techniques that you've seen today are good, acceptable, and sort of ready for prime time in your practice. But personally, I believe that a huge part of how we get better and taking care of these kids is with return-to-play testing and objective criteria before people go back to sports. So if you look at the literature that's out there, and I will, I'll portend to you that it's not as extensive as it maybe should be, but the studies that are out there show that if you look at patients that meet objective criteria to return to sport versus patients who did not but went back to sport anyways, the people that met criteria have about a 60 to 80 percent lower chance of re-tear. So I always put this in the numbers for my patients and I look at them, I look at the mom and the dad, I say it's not the kid, I say if they go back before they meet criteria, they have a 40% chance of tearing their ACL. 40%, right? That's terrible. If they wait until they have passed, that number is about 5%. That's what both of these studies have shown. This is actually a really interesting study where this was a group that looked at those studies said, okay, let's just implement a return-to-play program and let's look at our failure rate before and after we implemented that program. And their graft failure rate went down 36% after implementing a return-to-play testing program. So this is the simple easiest thing you can do in your practice. It's not learning a new surgical technique, it's not positioning your tunnel one or two millimeters different, it's return-to-play testing is the easiest thing you can do to reduce your failure rates, particularly in this high-risk population. Well, what are the challenges? Well, the first is implementation, right? Because a lot of people come to talks like this, they hear this and they go home like, yeah, I'm not going to do that. So recent studies show that only, this is in the United States, 23% of patients who go back to sports would have actually met criteria. Okay, so that means that 75% of surgeons are either unable to convince their patients not to go back or they're not testing them and not making sure they're ready. Those are pretty bad numbers. The other problem is that it takes a long time to actually meet objective criteria and kids don't want to hear this and parents don't want to hear this, but if you look at the data, only about a quarter of patients meet objective criteria at 12 months. 12 months, right? When I was in fellowship, I'm not that old, when I was in fellowship at six months we told every kid to have a nice life and you have a good Lachman, see you later, right? Times have changed. The other thing, if you go back to, this is a study from Scandinavia, but on young patients, okay, if you go back to sport before nine months you have a seven-fold higher risk of re-injury. And again, the numbers in this study, it's about 40% versus like four or five percent. Seven times the risk of re-rupture if you go back to sports before nine months. So in my mind, there's never a situation in which the kids should go back before nine months and oftentimes it's longer than that. This is a study that I did at Duke years ago and then another study by Lynn Snyder-Mackler. So for every single month that you wait to go back to sport, you reduce your risk by somewhere between 17, which was our number, and 50% which was their number. But the point is, I'll tell people, imagine a credit card with a 50% interest rate, right? That's what this is. Every single month that you kind of push up your return to sport, you're dramatically and exponentially increasing your risk of a re-tear. The other challenge is that the data is not perfect and this is coming from Tim Hewitt, who's one of the smartest people on this topic. This is on a sort of big position statement paper he put out a couple years ago and he said, there are equivocal findings in terms of the current return to sport literature in whether it reduces the risk of graft rupture and contralateral injuries. And that's true. So for the studies that I've shown you, there are other ones out there that are a little bit less conclusive. The other challenge is that testing in kids is more complicated. So this is some of the work that I did when I was at Duke. Kids at baseline have asymmetries. So we took a hundred healthy kids and we put them through our return to sport testing protocol. And you guys probably know when we do return to sport testing, we often use limb symmetry as kind of our metric of success. Well, this is the percentage of kids for all the different tests we did that would have met return to sport symmetry criteria, meaning more than 90%, but these are healthy uninjured kids. So like, for example, single leg squats on a BOSU, less than half of kids are symmetric because people have limb preferences and limb dominances. So limb symmetry in and of itself in a child is a flawed metric. Another thing we did, this is another study we did on this same cohort, we basically built growth curves. So essentially, what is a normal performance on these different tests based on your age and your sex. So this is readily available, this is published, you guys can look this up. But it's helpful because now you can benchmark children against sort of their peers because you may say, well, what's a good single hop distance for an 11-year-old, right? It's not the same as it is for an 18-year-old. Well, now we have data on how we can do that. Another problem is that your healthy limb also deconditions. These kids are not working out. So again, not hard on limb symmetry, but if you're using limb symmetry as your only metric, well, your reference point can be up to 50% below what it should be nine months after ACL reconstruction. So Lynn Snyder Mackler is really credited with what's called the concept of EPIC, estimated pre-injury capacity. What should this person be able to perform at? And they advocate actually testing the uninjured limb before you do surgery. It's a little bit complicated to do in a kid that's hurt and their other knees in a, you know, a brace and parents are like, why are you testing my kid who's injured? This doesn't make a lot of sense, but the concept is there. So anyways, if you go home and you decide you want to implement return-to-play testing, what do I think you should be doing? Well, the hard thing is there's no silver bullet. There's not one battery of tests that everybody agrees is perfect, but these are the guiding principles, okay? You have to check that the graft is working and that's just as easy as a Lachman or a KT or whatever you want to do, but the graft has to be intact. You have to check their strength. This is predominantly quad strength, hamstring strength, their quad to ham ratio, and usually their hip abductor strength, which is usually pretty poor. You need to integrate some form of functional hop testing, single hop, a triple hop, but some form of hop testing. You want to measure their balance and proprioception. Why balance tests? We do a lot of stuff on the BOSU ball, which creates a lot of instability. It's really good at kind of assessing proprioception. You want to look at their motion quality. This can be a landing test. It can be any kind of motion quality test. You want to look at their vertical force generation, and you want to assess their psychological readiness. If you do these seven things in some shape or form, you're going to do a great service to your patients. So I'm at a sort of privedemic group in Charlotte, and we had sort of requirements that were a little bit different than what I had at Duke. So not only did we have to meet all the guiding principles I just talked about, but this had to be cost-effective in a private practice setting, right, because our group was not going to do something that was going to lose money. It had to be time effective. We have one-hour slots, and the physical therapist said we can't go over one-hour slots. It had to be contained within an hour. It had to be evidence-based, and we had to be able to reproduce this at a lot of different clinical sites, so it had to be easy to teach. So this is what we've come up with. I don't know if this is right. If this is wrong, this is just what we've come up with, and what I've been doing routinely for the last five years. So at six months, I do a first round of testing. You may ask why. I tell every patient, no matter how well you do on this test, there's a 0% chance you're going back to sport in six months. This is not a pass-fail test. This is just a benchmark. Where are you at? I tell them it's like the PSAT. Figure out what you're not good at, so when you take the real thing, you can do a better job, and there's actually a study at ASM last year showing that if you tested at six months, you had a higher likelihood, regardless of your performance, you had a higher likelihood of passing your testing at nine months, right? So that's why I like doing a six-month test. So at six months, we do something called a landing error scoring system. I'll show you what all these look like. We do a single leg BOSU squat for reps. We do a single hop for distance, and we do not have a Biodex machine because they're too expensive for a private group, so we do use an estimated one rep max single leg press as a metric of strength. So this is the landing error scoring system. They stand on a box, they jump, they land, and they jump again, okay? So our physical therapist is filming them. There's five ways you can mess this up, like knees are too straight, hips are too straight, landing in valgus, loud impact, and valgus as you push back up. So a score of zero out of five would mean you did it perfectly. A score of five out of five means you did everything wrong, and that is helpful from a motion quality standpoint. Single leg BOSU squats, I encourage if you want to feel old and out of shape, try to do this. It's exceptionally hard, but they have to do max reps in 30 seconds. Okay, so this requires strength, it requires them not to have anterior knee pain, it requires a lot of proprioception. We then do a single hop for distance. This is fairly self-explanatory, but single hop, and importantly they have to stick the landing, right? If they put their other foot down or they trip or they fall, doesn't count. And the last thing we do, we get them on sort of a shuttle press, and we do, at their body weight, the number of reps that they can accomplish before they sort of fatigue out. You can then use simple online calculator to figure out what their estimated one rep max is, and that is sort of our crude metric of quad strength. At nine months, this is what we do. So this is a harder test, as you would expect. We do a triple crossover hop. We do a vertical hop. You can measure this vertical hop with a very cheap force plate, like these things cost like two or three hundred bucks. They're very easy to have in your physical therapy office. We do something called a T-drill hop, which I will show you. We actually use a handheld dynamometer. We actually got these, these are from, their rock climbers use these to measure their grip strength. They cost a hundred bucks, and you can rig them up on a chair and test isometric quad strength very easily, and we measure their psychological readiness with an ACL RSI. So the triple crossover hop, they have to do three hops alternating on either side of a line, and it's measured for total distance. The vertical hop, you can see here, this is this cheap force plate. You don't need a motion lab to do this, and it actually measures essentially their time off the ground, and based on their height, it can then calculate the actual vertical distance that they jumped. The T-drill hop is basically hopping in a drill pattern. This is tested for time, so there are population-based metrics for this. They're gender-specific, so women, it's under eight seconds. Men, it's under seven seconds that you should be able to do this, so we can calculate a symmetry as well as how they perform compared to norms, and what I get from my physical therapist when the patient comes in at nine months is something that looks like this, and so this is rich with information, and this makes for a really good sort of discussion point for a patient, and it's really easy. I tell them this is your report card, and if you come home with a report card with three F's, we got a little bit of a problem, right, so this kid clearly was not going to be returning to sport. Some illustrious quotes from me. Always look at their raw performance, not just their limb symmetry index, right, because there's a lot of patients that are symmetrically bad, so if you look back at this patient, look back at item number three, the T-drill hop, right, so this kid was actually very symmetric, 96% symmetry, but we didn't pass him because he actually was almost a second and a half slower than what's considered to be the slowest acceptable speed for a male, or same thing. I'll have people that come in for, say, a single hop, and they're 100% symmetric, but they hop 30 centimeters, which is like the size of your foot, like it's nothing, so it's not good enough to be symmetric. You have to be symmetrically good, and if you look back at our growth curves, you have to be, I think, at least at the 50th percentile for your age for me to consider that you've passed return-to-sport testing. The other thing I have noticed very, very strong gender differences in this, where the males tend to overestimate their readiness on an ACL RSI, and they tend to underperform on the objective testing, so they'll have scores in the 70s or 80s in their LSIs, but their ACL RSI score is 99, right, like I'm perfect, I'm confident, I'm ready to go. That kid is at a really high risk of reinjury. Mark Paterno has looked at this excessive confidence results in higher reinjury rates, so you have to protect these kids from themselves, and then the final problem is that the work is only half done once you clear them, so once I pass them on their testing, and I say, okay, you can go back and play soccer, well, what does that actually look like? This is, I think, a huge void in the literature, and there's a handful of things that are out there, actually primarily in soccer, but they're pretty vague. It's like, oh, well, you should probably do non-contact practice, maybe do a small contact practice, then maybe do full practice, and maybe then go back to competition, but not at full minutes, but what does this actually mean? The parents are like, how many minutes can he play? Can he do this drill? Can he do that drill? Can he touch the ball? There's a lot of unanswered questions, and all of it is sport-specific, so there's this massive area for research that we need to look into. The way I solve this problem is I surround myself by people that are better and smarter than me at doing this, so I'm lucky to work with this team at the MLS Club in Charlotte, and they are fantastic with our professional soccer athletes, and returning these people to sports, and the level of testing that they do, and the thoughtfulness of the drills that they put these people through is incredible, and I think we need to learn from our professional athletic trainers, because they are functioning at such a high level, and translate that back to the high school kids, the middle school kids that we're taking care of, who don't have these resources. So, if this seems overwhelming, it is, but what I'd say is just stay calm and test people. It doesn't matter what you do, just do something. As long as you are testing your patients, you're doing them a service. Thanks again. Okay, now I would like to welcome all the panelists on the on the chairs here, and Dr. Amendola for some case discussion. Okay. Thank you, David. Congratulations. Those are excellent presentations, like outstanding surgical techniques, all of you. Stefano Zaffagnini had another instructional course, that's why he's not here at the conflict. But anyways, I wanted to congratulate all of you, and I was quite impressed. I would like to do all those techniques. And it was really good to see that there's evolution along the way. Daniel, you mentioned that you've moved away from the all-epiphyseal technique. What are you doing now? I've lowered the indication for transphysio, maybe by a year, and then upped my indication for modified MAC as well. So I'm just, it's either transphysio or modified MAC. And mostly it was just timing in the OR. I've got, you know, because there was a few cases of growth arrest, I wanted to do it safer with that 3D fluoro, and it was just taking too much time in the OR. I was done with my first case at 1231, but just took too much time. But when I use 3D fluoro, all those patients are in the Pluto study group, and none of those have growth arrest, and their revision rate's really low, so it's successful, but it was just taking too much time. And so just from the rest of the panel, so that, you know, we can get an idea. So what's your armamentarium for ACLs in children, Davide? Do you do the same technique in every one, or do you have? No. No, I think that you need to know them quite all. I actually do a modified Arnold Cocker, so for very young patients. So I use the hamstrings, leave them attached on the tibia, pass under the intermeniscal ligament, and then go over the top, so I do, yeah, which is actually described, I think, by Eduardo Monaco recently on arthroscopy techniques. Then with pubescent patients, the technique that I showed with six strand over the top anolepithelial, and for patients with little or no growth arrest risk, classic transphysiol with quad. Quad tendon. Yeah. And Jonathan? Yeah, you know, I've largely evolved similar to Dan to, for me, it's really, it's a, I'd say two and a half or three options. So in the prepubescent, I'm always doing the Michaeli in what I'll call the tweeners, so they're post-pubescent, usually 11 and older in females, 13 and older in males, but they're not skeletally mature yet. I will do a transphysiol soft tissue quadriceps with an LET, and I've had tremendous success with that that I think matches that of the HSS group. And then in skeletally mature patients, I still have a preference for a BTB autograft, but I routinely add an LET in that population as well if they are still in high school or, you know, early college, I feel strongly they need a lot of augmentation. Federica, do you? Yeah, it's easy for me because I work with Davide, so we basically have the same indication. So for prepubescent patient, the technique he described, and then we usually in the over the top of the femur and partial transphysiol on the tibia in the prepubescent patient and adult patients, and now we are using more quad tendon, almost never BTB. And Daniel? No, no, just as I said before, you know, one thing we didn't talk about is, you know, some of our Scandinavian colleagues and folks from New Zealand and Australia are using small, a 10-11-year-old transphysiol with a very small graft. I went to Germany and where I watched the case, it was a 5-millimeter graft transphysiol, you know, so there's a lot of different approaches in this tough HP. And then even before the last couple of years, it just seems like the techniques incorporated, you know, a lateral tenodesis. Now it's really, does everybody use a lateral tenodesis in children with open physes in most cases? Just to sleep at night. It's probably because of that. I don't think there is such a strong evidence. Mostly you need to evaluate the knee, like the knee that Stefano was showing before with a gross PIVO shift. I think in that patient, you need to add a lateral tenodesis. Some patients do not have a strong PIVO shift. So maybe in those patients, you don't need it. You know, Ned, I've looked at my data. We're actually about to publish our quad LAT numbers, but when I was at Duke, before I left, I looked at all the A-cells I had done. My failure rate with an isolated hamstring in an adolescent was 20%, which perfectly matches what you guys said. I then transitioned to doing quads, but I wasn't doing a lot of LAT at the time. My failure rate with that was 4% to 5%, which matches what they were getting in San Diego and other places. And then when I moved to Charlotte, I sort of made the, I made the jump and I started doing LATs on all these kids. My failure rate in four years has been doing probably 70 to 80 a year of these has been 0%, which matches again the experience in New York. And so to me, in these high-risk patients, given an operation with, it's probably not zero, but it's really very close. I don't see a reason not to do the lateral tenodesis. I do think there's an increased chance of stiffness. I've noticed that in my patients where I'm doing one or two manipulations a year, but I'd rather do one or two manipulations than five or six revisions. Okay, that's great. So just another question about the Michaeli-Coker technique. You know, I trained in Canada, London, Ontario, two hours from Toronto, where the Marshall-McIntosh operation was really taking the whole IT band and using that for ACL reconstructions. And I would see, you know, two or three patients come from Toronto with complaining of fascial hernia laterally. Do you see that in kids? The short answer is yes. If you look at the literature, it's buried in the Boston Children's Paper, but 50% of their patients in that series had a cosmetic deformity. They sort of glossed over that. But I think that's actually an underestimate. I tell patients that there's a 100% chance you're going to have some kind of cosmetic difference in your thigh. The contour of your lateral thigh right over the metaphyseal flare is defined by your IT band. If you lose that, you get sort of a concavity, so they get this scalloping of the thigh. Not everybody gets herniation. It's probably 10% to 15% get true herniation. I've not had to be painful, but it is sort of cosmetically shocking when it happens. So I have interest in sort of the reverse Michaeli-Coker like you do with the hamstrings. I've never done it, but it'd be interesting to sort of compare those in a study and see how they perform. Well, that's good. Now, a couple weeks ago, I did a surgery on a young woman who Allen Anderson had done the all-epiphyseal technique on one side, and she came with an ACL tear on the other side. She's a softball player. I saw her for follow-up because the family lived in North Carolina, and Allen had recommended that she not go back to sports. I've never done that in children, so it's interesting. Then she comes back and tears her other side, and her parents said, oh, we should have followed Dr. Anderson's advice and not let her go back to sport. Now, after all the data you just presented, return to sport, do you guys ever recommend to children not to return to competitive sport? Yes is a short answer, but to me, it's in the repeat offender. So I will see kids in my practice that are 15 years old and they've had three ACL tears. They've had one on one side, two on the other side. I don't know that I have a hard cutoff if it's two, if it's three, if it's four ACL tears, but if they're a repeat offender, particularly if there's a family history, if they've started to have meniscal damage, chondral damage, I will have conversations, not necessarily about sport cessation, but sport modification, meaning like, hey, swimming is a really great sport. Golf is a really great sport. There's a lot of ways you can take out your competitive itch, and maybe soccer is not the answer. I've never said that to someone after a singular ACL tear. No, same. It's a great discussion there. Great thought. These are really, really high rate of recurrence. And another thing is what is return to sport? So you have a senior in high school. They're not playing in college. They're probably not returning to sport. If you've got an eighth grader, is there going to do four years of high school sports, pivoting And then which sport is it? Like you said, because in my practice in New York, 90% of the tears are soccer, lacrosse, basketball, football, skiing. If you're in Europe, it's probably soccer, soccer, soccer. So it's multifactorial. I love to get these kids at nine months. I said, please just join the track team and do long distance running before you get on a soccer field. Usually not. I think the patients I'm worried the most are the patients that maybe re-tear and mostly those with a significant laxity. So those with a 15 to 20 degrees of recurvatum, those are maybe with a normal slope and they're very difficult to treat and very difficult to keep away from the operating room if they go back to sports. That's a great point. Those severe laxity patients, not the biting fours, the biting eights, nines. That's a good thought. Okay. We show some cases unless anybody have any questions at the back. that allows you to capture a flexible pin that's coming through the tibia or the guide that's coming through the intramural portal. So you have full freedom on where you put the guide, you can put it in on a partition, but your pin is literally coming through the tibia. So you can never hyperflex any enough to get that vertical trajectory. I have a paper in OGSM probably four or five years ago that looked at the angle of approach to the physis with that technique compared to AM and trans-tibial and the estimated surface area of disruption. And basically you get an anatomic aperture, but you get a trans-tibial zone of injury. So that's how I have done all of my trans-ficeals because I think it marries the best of all worlds, and it's very technically simple to do. I think we've gone away from, in the trans-ficeal cases, we've gone away from a really vertical alignment, but using the intermedial portal, there's some awareness of where the physis is and not trying to be right horizontal across the physis. I think Henry Ellis and Phil Wilson had 100 plus cases, I think, in AJSM going and looking at their trans-ficeals for an intermedial tunnel, and they didn't have any growth arrests over 100 cases. Having said that, there are growth arrests with trans-ficeal, and it can be two, three years later. So I think you still got to follow those trans-ficeal patients until they're done growing. I don't know, is the rate 1%? Is it less than 1%? But it's not zero. One of the little technical things, if you're doing an AM guide, like a curved AM guide, or plexigram, or something, you want to supinate your hand, your guide hand. It's when you get these really sort of shallow, highly-lit tunnels. One of my classmates from fellowship had texted me All right, so here's a case, you know, typical pivoting mechanism and complete mid-substance ACL tear, 14-year-old male. So we went through the, yeah, we went through the discussion already. The reason I put this up was that his slope is significant. And so I was wondering now with all the interest in tibial slope over the last few years, you know, and, you know, there's been a lot of sessions here as well, there's another session this afternoon talking about tibial slope and ACLs, correcting slope, you saw yesterday the different techniques. So you know, now we're waiting basically for failure of ACL reconstruction to consider changing the slope. Some people are talking about primary ACLs and changing the slope. So in children, when you have an opportunity to change the slope, do you guys ever consider that? Yeah, I think we will do it in the future, we should do it now. Some people that are already doing it in primary, in adults, slope reducing osteotomy is in primary ACL when the slope is excessive. And this is a kid, 14 year old, so high risk with a high slope, the risk of injury is too high, you should do it. And it's simple surgery now. It's a big jump, Daniel? No, I think there would probably be a series here using guided growth to correct the posterior tibial slope if we didn't have an LAT. So the LAT, I think it's protecting some of these kids from failure. But it's really super important. One of my favorite papers I ever wrote was a couple years ago. I found that Osgood-Schlatter's is linked to an increased posterior tibial slope. If you think about these, a JSM article a couple years ago. And if you think about these kids that are 12 years old playing soccer, these terrible Osgood-Schlatter's start looking at their x-rays, they have an increased posterior tibial slope. So is Osgood-Schlatter's a risk for ACL tear? It's never been proven from a population standpoint, but I think there's an argument that it is. Well, I think if you think about ACL tears and the mechanism, you know, being quad driven mechanism, it's probably the same people get Osgood-Schlatter's or very high quad, you know, active patients, you know, probably excessive. That angle, you know, of the tendon, I'm sure it's related. But you can see here, this is, you know, It's at 16 degrees or something. Yeah, but he's got, it looks like he's got Osgood-Schlatter's, you know. I think that is so great that you bring this up, because I think for everybody in the audience. So it's even worse. So this patient was referred because he had a ACL repair, isolated ACL repair, and you know, through a transphysiol technique, and you know, came back and failed, you know, after went back to play. So, you know, I think you're right. I think you need to be, you know, aggressive and really protect these knees. So I wanted to, again, just go through some of these cases. Daniel, you showed one of your cases that you did a femoral osteotomy. This is a bone tendon bone that had a valgus deformity. You did an intramedullary nail. Yeah, well, I didn't, but you know, obviously there's, there's tools now in the limb lengthening field. One of my goal to follow carefully is if you notice something at one year, you could do an outpatient closing of the growth plate of both distal femurs, and the kid will be fine. But if you don't diagnose at a year, you'll end up like this. And then you have to do corrective osteotomies, many times, even a limb lengthening procedure. So I think close follow up is super important. And I've seen, and Dr. Marks has published too, like severe cases of transphysiol in a 14 year old boy. So, you know, so it happens. And there are some, you know, folks in the New York City area that are doing VTBs in 14 year old boys. I'm like, the growth plates are open. I don't think we should do that. And so what what technique would you guys use just for this correction of deformity? Well, the deformity looks femoral, I would say. Yeah, it's all femoral, it looks like. So I would either do a medial closing on the femur. So generally, you're favored doing a medial closing wedge if you do a femoral osteotomy rather than a lateral opening wedge? When I'm doing, it depends on the amount of correction. So if it's a small correction, opening is fine, it's easier to achieve. But the problem with the opening wedge osteotomies is that they have a higher risk of complications in terms of medial hinge collapse, and in terms of not having strong fixation devices right now. So you should use a big femoral plate for fracture more than the osteotomy plates. So this is my concern, loss of correction. Well, Jonathan, you know, you did a lot of osteotomies. What do you favor doing here? Any other comments on…anyways, we just did a lateral opening wedge on this, and I agree with you. I think, you know, doing a medial closing wedge is fine, you know, lateral opening wedge is satisfactory, but I just had to put in a complication of a…but I did want to just show one last case before…we're almost out of time. And this patient had ACL tear and underwent ACL surgery, you see the transphysio…or the…all the epiphyseal technique, and patient went back to activities, returned to full activities 11 months, 12 months doing well, returned to playing football. Again, this is another patient that was referred and re-ruptured their ACL, and here's the subsequent. And this is what I just wanted to show, you know, he's got genu valga bilaterally, and there's a suggestion that he has a little bit more valgus on the operated side, you know. So again, Daniel, you've talked about it in your talk, you know, the proximity to the growth plate. So at this point, when you do a revision ACL surgery, what should be the algorithm in taking care of this patient? Do you investigate for a physio closure, do you just plan for correcting the deformity, or you just do a revision ACL? Yeah, definitely reduce scotal age, and just…and if there's significant growth remaining, close to 2 years, I would do implant-mated guided growth on both femurs, and it definitely can have asymmetry in this situation, but you've also got to make sure…that would only be the case if the growth plate was not damaged. So if there was a MRI showed a bar, then implant-mated guided growth wouldn't work. So you could close the growth plates and go down on each side. So there's a lot of things you've got to figure out, but if the growth plate was healthy, and there was growth remaining, I'd love implant-mated guided growth for this. On some of the standing x-rays we get in the injured kids, the injured leg will look a little more valgus because they don't have full extensions. You've got to make sure they've got full extension as well. Now this brings up a question that I've always had, and I'll kind of ask Dan. I think one of the hardest clinical situations is having to revise an all-epiphyseal reconstruction in a kid who's not yet skeletally mature, because you really don't want to drill a…particularly if they have a little hint of a growth disturbance, because if you drill another tunnel, those people I think are at very high risk of having a growth disturbance. And sometimes using that same sort of acute horizontal tunnel, if you're going to try to use a quad graft or it can be hard to pass, you may be really close to the…to the physis in the first place. That's part of why I really like the McKeely-Coker is because if they re-tear that, they have no bone tunnels, and it's really easy to revise the primary cell. But can you talk to us a little bit about revising an all-epiphyseal? Like how do you just use the same sockets? What's your approach? You can go over the top. I know. I think it's case-by-case. It's case-by-case. So, if you had great epiphyseal sockets and a lot of growth remaining, then maybe you could use those. I love the modified…McKeely is another option. And if the kid's a little older, 15, 16, you can…you can go just right to the transvasal tunnels. I wonder what… Well, this…this again was a referral. This underwent revision with an allograft, and then re-ruptured again, and then showed up again with increasing valgus deformity. So, at this point, you know, we did investigate. I don't have the pictures, but you did have a…a lateral femoral growth arrest, you know. So, at this point, you know, anyways, we're good. I think we're just a little bit over time, but any other questions from the…from the audience? And I thought the speakers did a great job. Great illustrations, great surgery, nice…nice work.

ACL reconstruction

pediatric patients

University of Torino

Davide Bonazia

surgical techniques

growth considerations

Bonazia's method

Zaffagnini's technique

Rebo's Coker-MacKinley technique

Green's all-epiphyseal method

return to sport testing

growth disturbances

individualized protocols