and children with open growth plates. I'm going to be speaking mainly about this technique that utilizes the over-the-top position on the femoral side. Indications are pretty straightforward, mid-substance ACL tear in anybody with open physis wanting to return to a previous activity level. The rationale for this technique really comes from Peter Fowler, whom I learned from. And this was a paper that was published by Dr. Fowler and his group, looking at a series of kids that had ACL reconstructions and were folded for a long period of time, demonstrating that there were no abnormalities to the physis. In addition, you can see the growth that happened over time. In addition, MRIs were performed, showing that the graft and the ACL reconstruction grew with the child as they grew. Questions come up about the over-the-top technique and the anatomic accuracy for the ACL. As you can see on this catabaric dissection, the attachment of the femoral side of the ACL is very close to the over-the-top position. In addition, we did a number of dissections and ACL reconstructions using various techniques in this other paper published by the Moon Group, basically showing that the femoral position, irregardless of the technique used, is very close to the over-the-top position. So I don't feel that the over-the-top position is really that far from anatomic location of the ACL. In addition, this technique minimizes the risk to the physis by using a very small vertical tibial tunnel, soft tissue graft, again over-the-top on the femur, leaving the posterior aspect of the femoral roof alone, avoids the growth plate completely. The fixation is proximal and distal to the growth plates. And in addition, if you want to utilize the stump like a tomato steak technique, you can with this technique. There are some pitfalls in terms of using the hamstrings. Sometimes graft size is limited and especially if you are dealing with a bigger patient, you have to harvest the hamstring and sometimes that can be a problem. And then the length of the graft overall needs to be long enough to span both the femoral side and tibial side, proximal and distal to the growth plate. I still prefer this technique. I think it's very reproducible. I have not had any physio complications. The hamstring harvest is fairly straightforward and you can make sure the length of the graft is optimized by using this synthetic loop on one side for the femoral fixation and it can be variable if necessary if there's a shorter hamstring graft that's been harvested. So here's an example, a 12-year-old. You can see the ACL injury and you can see the tibial stump. There's the graft with the synthetic loop on the femoral side. Here's the tibial tunnel right through the stump and the graft has passed through and you can see the stump is overlying the graft which I feel is very biologic and may help heal the graft in a better healing environment. And then here's the femoral incision and fixation, tibial incision and fixation with two staples and here's what the knee looks like with this approach. This is surgical video on this technique. The tibial incision is made about two finger breasts medial to the tibial tubercle. The two tendons can be palpated through the sartorial fascia. You can make an incision over the lower tendon and harvest the semitendinosus and make sure you harvest the periosteum as well to optimize the length of the graft. Here's how we get the graft prepared through the loop. Again that can be an adjustable loop depending on what you need and again preparing basically a double bundled hamstring graft that's usually about six to seven millimeters in diameter. We pre-tension the graft until we insert it into the knee joint. So here's the arthroscopic view, here's the tibial stump. Again I usually try to preserve these if possible. I think in children these end up healing very well and help with healing of the graft. The over the top incision is made proximal to the lateral femoral condyle, incise the IT band in line with the incision, elevate the vastus lateralis as you see here, go along the intermuscular septum, make an opening in the intermuscular septum and then we insert this large gaff up under direct vision along the lateral femoral condyle with a finger posteriorly to make sure that we are staying along the bone and we are not damaging any other soft tissues that you don't want to be near. There's a passing suture. Now we prepare the tibial side right through the tibial stump and from here on it's fairly straight forward and we pass the graft with the tibial stump in place as you can see. So again, the graft is passed without difficulty. Make sure that you don't pull the graft completely through so holding it on both ends, removing any slack in the graft and once you have the graft passed and you have the end of the graft, you figure out where you can put in a ligament screw and washer. So just drilling a 3.2mm hole, we put in the screw and before you tighten it down, put the loop around the screw and washer, tension the graft down to remove any laxity particularly around the screw, tighten down the screw and washer. You can see the graft nicely there and then pre-tension the knee and then fix the tibial graft usually with one small ligament staple as shown here. Here's an example of a 9-year-old. We use staples on both sides. Here's an example of a 14-year-old and we used screws on both sides. Post-operative rehabilitation is similar to the adult in terms of a progressive rehabilitation program. We use a hinged knee brace for the first 6 weeks, do some general physical therapy, range of motion and mild strengthening exercises. The next 6 weeks, focusing more on strength, gain and joint control and then once you get to the 3-month mark, you can do more progressive sport-specific exercises and with a plan of returning back to sport around the 1-year mark. I think that is one difference compared to adults is the return to sport is not as aggressive and I think the longer you can wait and rehab and make sure the knee and the muscular control is back to normal before returning to sport. Thank you for your attention.

surgical technique

ACL reconstruction

children

open growth plates

over-the-top position