for the great topic that we are doing. So I'm talking about adult-type reconstruction. These are my disclosures, but nothing related to this talk. So we are talking about close physis. So we have no risk of growth disturbance, of course. But we are talking about young patient. Usually, they are really active. And the risk of increase of re-raptor is quite high. It goes up to 34%. And we have an increased risk of infection, depending also of the graft, and often is involved in a pivoting spore. So the goal, and we know that we have a high rate for revision ACR. So our surgical technique is AM portal on the femur to perform the femoral tunnel, single bundle. And we would like to reduce the rear tear. So I think it's very important, the graft choice. And usually, we use BTB, but we are increasing a lot the number of quadriceps tendon. And we associate it with lateral exerticular tenodesis. We use modified lemur with suture anchor if we are using BTB. So we have no problem for femoral tunnel and suture anchor interface. And we use modified cochlear arno if we're using quadriceps tendon. So the indication, of course, is postpubescent patient, tunnel four and five. Bony age is 16 years old for male, and 40 years old for female with closed physis. So this is a surgical technique where we use BTB. So the first part is to prepare the bone block on the tibia. And we see that it's very easy, because while we prepare, we can see very well. And we can prepare the bone block on the patella. It usually is 20 millimeters maximum length, because we don't want to create any kind of fractures on the patella. Then, of course, we remove the remnant part of the bone in the bone block. We create two holes in the patella block and in the tibia block. And then I think it's important to protect the first centimeters of the tendon that goes inside the joint. Once we put the screws, it avoids damage of the tendon. Then we color the cancellous part of the patella bone block. And then we cover with vancomyces. The remnant part of bone we can fix in the bony part of the patella. Then we prepare through antero-medial portal, the femoral tunnel. We can use also accessory portal. It's very important to check with your scope through the antero-medial portal the position. I think this is a very important step to understand the good position. And then, of course, we finish the femoral tunnel with drill. Usually the bone block is about 9 to 10 millimeters on the femoral side and 10 to 11 on the tibial side. I think that this is a very tricky point, because the length of the tibial tunnel is very important. We can use the plus 7 rule. That means that we have the millimeters of the tendon plus 7. It tells you the inclination of our tibial guide. So we measure with another key wire just to understand the correct length. So we prepare, of course, the hosting part on the tunnel. Then we use a suture passing. So we prepare also the hosting part where we put the screws on the femur. And then we pass the graft. And you can see that we can see the blue marking part. That is the consenus bone of the patellar bone plug. And we want to put exactly the screw between that area. So we prepare the place for the screw. And usually we use non-absorbable screws. And then we fix it. I think that the weakest part is the tibia. So once we put the screws, if we are in doubt, or if we are not happy about the stability, we use non-absorbable sutures. And we can fix with staples in fully extension, I think is very important. Then we do lateral exarticular tenodesis. David already mentioned about that. I think it's very important. We need to leave a touch, of course, close to the girdle tubercle. So we prepare the graft. Usually it's one centimeter and six of length. We need to identify the lateral collateral ligament, of course, two small incision. Be very careful to not create a damage of lateral collateral ligament. Then we pass the graft under the lateral collateral ligament. And we need to identify, in this case, it's a BTB. We can use anchor sutures. And usually it's proximal and posterior to the lateral femoral epicondyle. And then we can close and fix the graft in 30 degrees of flexion, neutral position, I think is very important at this point. We don't want to over-constrain too much. And this is the X-ray results. For what concerns quadriceps tendon, the surgical technique is quite the same. I think it's very important. The harvesting of the quadriceps tendon, we use full thickness. We are not happy just to. It depends, of course, of the dimension of the guy. Usually the length is from 6 to 7.5 centimeters. I think it's very important to prepare very well the graft. This is with a marking pen. We mark the middle, in the middle part, and the part, the remnant part that stays inside a femoral tunnel and inside a tibial tunnel. We are using two extra articular suspensory fixation. This is for the femur. And then we create a tension on the tibia. And usually we fix in a fully extension, in this case with a button. And again, the exarticular tenodesis is quite the same. But we use a modified Cochrane Arnold. So we have some surgical tips for BTB. The tibia bone plug first is very helpful because we can see better the remnant part of the patella. So patella plug harvesting is easier. So patella plug no more than 20 millimeters, just to avoid a fracture of the patella. Place some sutures on the proximal part of the graft to protect it when we put the screws on the tibial side, if you're using the screws, of course. Bone plug for the femoral tunnel must be rounded and tapered so it's easy to put it inside. And use non-absorbable suture on the tibia bone tendon junction because if you are not happy about the stability of the screw, we can put staples and we can fix it. Use unabsorbable screws to make possible revision easy. Create a hosing for femoral screws because sometimes the quality of bone is very hard. So we had some cases where we had a rupture of the screw. Unabsorbable screw can break, as I mentioned, so tap at screws eight millimeters or bigger. And tibial tunnel length adjusted to avoid graft tunnel mismatch. So remember the plus seven rules. And tibial fixation, of course, in fully extension. Do not always trust in tibial fixation. I think that the weakest part of this technique every time is tibia. And then lateral extraticular tenodesis fixed at 30 degrees of flexion and foot neutrally rotated. So some tips for quadriceps tendon. The length goes from six to 7.5 based on patient aid, of course. With some extraticular fixation devices, you lose some graft lengths while arming, so be careful about it. Quadriceps tendon can be difficult to pass in the tunnel, so we need to prepare very well. No tight fit, round up the graft, and clean tunnel apertures. And quadriceps tendon can be a thick graft, so make sure there is no roof or wall impingement. So we really like this technique for several reasons. BTB and quad grafts are strong grafts with lower risk of re-raptor and infection. BTB makes revision easier and can partially reproduce the ribbon anatomy. Quad tendon graft can use extraticular fixation on both femoral and tibial sides with a lower donor site mobility compared to BTB. And of course, less lateral extraticular tenodesis seems to reduce risk of revision in this type of patient. So when is the return to sport? I think it's no less than one year, so we have to wait and we have to talk with this type of athletes or young active patient. Difference in rehabilitation, nothing compared to adult patients, so full weight-bearing is tolerated, no brace, no open-chance exercise for five months. So remember, return to sports close to one year. These are recommended reader lists and thank you very much for your attention. Quick question as we're transitioning, or a point. You made it clear that you don't use an anchor on the femur for your LAT if you're using a quad. Just for, if you guys end up trying this, because I do a lot of quads, anatomic studies show that your tunnel position for an LAT on the femur and your ACL tunnel femur have a 75 to 85% chance of collision. Yeah. And so when you have a BTB, technically if you put a little anchor into the plug, it's not a big deal. It's just a ball in the end. But if you already have, for example, your tightrope in for a femur on a quad and then you drill right through it, you blow your entire contract. So what I've gone to do is before I drill my femoral ACL tunnel and I put my scope in the anterior portal, I'm looking up the tunnel while I drill the path for a small anchor on the femur and then I put that anchor in before I even pass my graft because there will be times where you drill and it goes right into your ACL tunnel and then you have to adjust your positions. That's an important technical point that you made. Yeah, the percentage is quite high, as you mentioned. With BTBs, not a problem because you can have screws or you have the bone plug. But with cut sets or hamstrings first, you're at risk to create some damage. So in this case, we would prefer also modify a hook around on that. I think it's a very easy procedure. But again, it's a very good point. I mean, you can check before you put your anchor suture and if you don't see anything, you can go on and finish your surgical procedure. What we're using a lot when we do this suspensory fixation and we don't want to put the suture anchor or staple or whatever hardware. We've been doing it for over a year now and we're starting the position. We're using the sutures, the RP, the sutures of the suspensory fixation. Usually, when you drill a natural medial portal, a femoral tunnel, that's usually anterior and proximal to so the position is. And if you use a retro reamer, like a flip cutter, you can mark where you want your angle to go. Use that as the starting point for your flip cutter and you're exactly right, tie it down and attach it to the button. Everything you need to make simple. This is the most important part. Yeah, and cheap, of course. I try to put the LAT anchor point just distal to the groin plate, just right behind the LCL insertions. Maybe I'm a little more distal than you guys. Yeah, when I do a transfacial, I always get x-ray and I'm always amazed, the physis is right where you would actually want to go. So, when I do it in a trans, an LAT in a transfacial setting it's always a little bit more distal. It's almost like on the upslope of the epicondyle. Would you agree with that? I don't know that I've had issues with it, but if you put it in the true anatomic position it'll be right through the physis. Just kind of take the angle of your insertion. Right.

ACL reconstruction

young patients

graft choice

BTB graft

quadriceps tendon graft