Which is about ACL repair. These are my disclosures. So ACL repair can be indicated in case of proximal avulsion of the ACL with a distal remnant of more than 90%. That would be a Sherman Type 1. And this is roughly what we encounter in the group of age between 11 and 13 in a third of the cases. Usually this should be done acutely, less than three weeks from injury, in isolated or multi-ligament knees. That doesn't matter. Theoretically, there is no age limit. Ideally, I prefer to do this procedure in prepubescent patients for the reasons that I will tell you. So the rationale of the technique is that pediatric population is at high risk of ACL repair or reconstruction failure. And prepubescent patients are at high risk of growth disturbance as well. And ACL repair can represent a minimally invasive procedure to stabilize that knee. In pubescent, post-pubescent, and competitive athletes, I still prefer a pediatric ACL reconstruction until a stronger evidence regarding ACL repair is available. So recently, the biological stimulation and the improved mechanical stability have improved the outcomes that in the past were described as unsatisfactory for ACL repair. So this is the surgical technique. You can see the ACL stamp is mostly preserved. What we do is to arm the stamp with two sutures in a luggage tag fashion. This will help you to pull on the suture and move the ACL stamp in front of the knee and improve the visualization of the notch back there. Then you can start cleaning the notch. And then you drill an olepiphyseal 4.5 tunnel, which is drilled out in. You put a passing suture through this tunnel, through the anteromedial portal. Then you drill a 4.5 millimeter tibial tunnel, transphysio. Another passing suture, which is used to retrieve the first one through the tibial tunnel. Then you need to add a second passing suture through the femoral tunnel. And this will help you retrieve the ACL stamp arming sutures through the femoral tunnel itself. Some biological stimulation with some microfracturing on the intercondylar notch. And then you can see here the extracortical fixation with a tape augmentation passing into the tibial and femoral tunnels. At this point, you tie all the suture up. And this is the final x-ray. As you can see, this patient also had a proximal bony avulsion of the MCL. And this is why he went to the operating room very, very soon. And we were able to repair his ACL. So surgical tips, use a cannula in the anteromedial portal. This will avoid entrapment of the soft tissues around the portal itself. Arm the ACL stamp first so that you can pull it in front of the knee and have a good visualization of the intercondylar notch. You need to use two passing sutures, one going through the femoral tunnel in the anteromedial portal. And you can use this passing suture to retrieve the ACL stamp arming sutures in the femoral tunnel. The second passing suture will go through both tunnels and will help you pull the extracortical fixation and the tape augmentation inside both tunnels. You need to be careful not to over-tension the tape because this should act like a seat belt. So post-operatively, weight-bearing is allowed as tolerated. We put these patients in a brace locked in extension for four weeks. Range of motion exercises are started after these four weeks. No open-chain strengthening for five months after surgery. This is a recommended reading list. And I thank you for your attention. So Jonathan, please come on the podium. I've got a question for you. I've queried using an internal brace type construct in a young person like that since it is a fixed rigid construct. Any concerns with tethering the visus with a rigid tape type suture or have you gotten away with it? I am actually not too worried about that. I think that you definitely don't need to over-tension that just a brace. So you just basically don't over-tighten it and you should be fine.

ACL repair

pediatric patients

minimally invasive procedure

surgical technique

postoperative care