of this technique from Neta Mandola that you just saw and was my mentor so as the person that taught me this type of surgeries. So this is how I changed a little bit his technique. So basically what is changing in my practice right now is that I'm not drilling a full transphysiol tunnel on the tibia but I am going with a 4.5 transphysiol and then I'm retro drilling just in the epiphysis so an all epiphyseal tunnel. And then I'm adding also modified Arnold-Cocker lateral tenodesis on the lateral side because I already have an incision there and so this is what changes. So our indications for this type of surgery are patients at mild risk of growth disturbance which means a growth potential of around two years. And this is the surgical technique and so the hamstrings are harvested according to the surgeon's favorite technique. They are brought to the back table and another difference is that we prepare it we prepare the graft in a six strand fashion so we increase a little bit the volume of the graft compared to the original technique. So both hands are armed. The proximal and distal ends are attached to an adjustable loop on both sides and then the graft is passed to have a six strand graft there. So as you can see it's a thicker graft compared to the original technique. We size it, pre-tension it, pre-soak it in vancomycin. This is the lateral approach which is as you can as you've seen before in Ned's video. The difference is that I harvested the iliotibial band, the iliotibial strip right away so that I have more space to get into the over-the-top position. This is armed with a number two vitreol. Then you incise the intramuscular septum and then you open this opening in a blunt fashion until you can palpate the posterior condyles. I prefer to go from proximal to distal with a suture passer and retrieve a passing suture from the antero-medial portal. At this point we leave the suture there. We pass to the tibial tunnel using a retro drill. So this is done trans-physio and then the retro drilling is done all epiphyseal. So the length of your tunnel is measured on the MRI pre-operatively and it's usually an 18 millimeter tunnel. Tunnel is retro drilled until the desired length. Then you can clean the aperture and you're looking inside the tunnel to see the cartilage status. If you see a white ring in your tunnel you have gone through the physis. You put another passing suture which will help you retrieve the other passing sutures through the tibial tunnel and this point you can use the suture to bring the graft in. This is done from proximal to distal and you want it to sit nicely into the tibial half socket. Then you fix it on the tibia first and then on the femur you put a screw and washer. Take the adjustable loop and loop it around the screw. Start tightening it a little bit and then you can put the screw down. You can use this arming sutures as an additional fixation. Then you go under the lateral collateral ligament with your suture passer. Pass the ITB strip under it and then you re-suture it to itself. So this is how it looks. The final check and this is the post-operative x-ray. So surgical tips. We need to measure the tibial half socket first on the MRI. Use a cancellous half threaded screw and washer. We don't like the washer with teeth, the soft tissue washer, because these can damage these adjustable loops. Do the tibial fixation first. You can use the arming sutures for additional fixation and when we do the lateral plasty we do this at 30 degrees of knee flexion and the foot in neutral rotation. The pitfalls. Be careful not to over tension the graft because you have two adjustable loops. If you pull too much that would be a very, very over tighten graft and might affect the growth plates. Pay of course attention to the neurovascular structures in the back of the knee while you're doing your over the top lateral approach. So why do I like this technique? Because there is no need of x-rays intraoperatively. There is no risk of graft tunnel mismatch. You can use a larger graft. It's actually, as Ned showed in his presentation, over the top can be considered anatomic. It's quite easy to adjust the tension and avoid over tensioning. The lateral tenodesis can be performed through the same incision so it's not extra surgery that you're doing to add this lateral tenodesis and you don't have too short graft issues. So postoperatively the patients are allowed to weight bear as tolerated. No brace for compliant patients. I usually ask the parents if I should trust the kids. ROM exercises are done as tolerated and we don't do open chain strengthening for five months. Return to sport not before one year and not before return to sports criteria are satisfied. This is a recommended reading list and I thank you for your attention.

surgery technique

modified technique

transphysiol tunnel

epiphyseal tunnel

Arnold-Cocker lateral tenodesis