construction techniques using a Ficeal Sparing Iliotibial Band Autograph, also known as the McKayley-Coker Technique. So why even consider using this technique? I will show you that it has, at least in the published literature, a 0% clinically relevant growth disturbance rate, a 7% failure rate, which for this age category is actually very, very low. It's technically simple. It's quick to do. I average trinicate times on this, 35 to 45 minutes. Does not require any radiation or fluoroscopy, unlike some of the other competitive techniques. It's been shown to have a quicker neuromuscular recovery because you're not messing with their hamstrings or their extensor mechanism. Does have in the lab the best biomechanics of any of the Ficeal Sparing Reconstruction Techniques, and it does, at long-term, restore normal in vivo kinematics. Well, who am I doing this on? Obviously, they have to have a complete ACL tear, and this is, in my practice, pretty much prepubescent athletes, which really means prepubescent males. I think I've done this once in a girl, and like 99% of the rest have been boys, so typically boys under 13, so meaning they have more than three years of growth remaining. I have, in occasional instances, done this in about a 13-year-old male. If the parents came in and said, we're going to sue you if our kid has a one-centimeter growth disturbance, we are so worried about growth disturbance, we will take any measures to not have a growth disturbance, I'll do it in that population. But I think that the failure rates are a little bit higher. In fact, the one that I pushed the age the most, he did re-tear it, and I think that's because proportionally the IT band graft you get is smaller compared to the athlete, and you don't get a big enough graft. And I've occasionally done this for smaller children with congenital ACL deficiency. Why that particular age? Well, if you look, 13 in a boy and 11 in a girl corresponds to basically right before they're going to have their maximum growth spurt. So if you do some other techniques where you violate the physis, they have a lot of growing left to do. In terms of preoperative planning, I'd credit Dr. Green, who's here, who developed this method with the HSS team. This makes it much easier to understand skeletal age in clinic. I get a PA of the left hand and wrist on any pediatric athlete I'm going to be considering an ACL on, and I have these laminated and put up in my clinic space, and it takes about 10 seconds to figure out what their skeletal age is. And so anytime I'm talking about an age cut off for an operation, it's skeletal age, not chronological age. I will always get baseline alignment films. Not everybody's limbs are equal in length, not everybody's limbs are straight, and you want to understand that before you do the operation so that if there's an issue after the operation, you know what their baseline is. In terms of the surgical technique, giving credit where credit is due, this is developed by Dr. Coker and Dr. McKaylee. First published, this is 2006 in JBJS, and this is sort of my evolution of the technique that they originally described. And so you can see here a clearly unstable knee. I position them just supine, I don't drop the foot of the bed, and what's really critical for this, since you're going to have to get access high up the thigh, is you have to have a post that's pretty high up. You can't put your standard arthroscopy post low, and you have to have your tourniquet really, really high. And so I show this picture just to say get that tourniquet as high as you can, because in rare instances you may have to make a little escape incision at the top of the thigh, and I'll show you that in a minute. And then just position them over a bump, plan out a lateral incision, and, oh, sorry, as well as your more standard medial incision that's fairly similar to where you would put, for example, a hamstring heart risk incision. Standard arthroscopy portals, this lateral incision, just for reference, if you look, it basically is going from in line with Gertie's tubercle towards the anterior aspect of the iliotibial band, so it's actually crossing the iliotibial band almost at a 45-degree angle. I find that to be important. If you make the incision in line with the IT band, it's actually harder to mobilize the skin all the way anterior-posterior, and this also ends up making it straight in extension. If you make this look straight when you have their knee flexed like this, when they are in extension, which they will be most of the time, it will look crooked, and they'll ask you about it. So the approach on this is actually remarkably easy. I should not have paused that, I apologize. Where all you have to do is cut the skin, okay? So there's basically nothing between the skin and the iliotibial band, so that's your approach. You cut the skin, and the iliotibial band is right there. The next thing you do is get the biggest cob elevator that they have at your hospital, and you basically give them a morel lavalier of the thigh by hubbing this thing all the way up, because you have to detach the iliotibial band from the subcutaneous tissues. You then harvest really about the central 80% of the iliotibial band. I usually use a 15 blade, I incise anteriorly first, posteriorly second. It's just a little bit easier logistically to do it that way, and you only leave about a centimeter of IT band on either side to get a graft that's big enough. I'll then get a clamp and free this off the lateralis, and the septum, and the capsule to make sure that that's free, and then these meniscotomes originally designed by Dr. McKaylee, you simply run them up the front, get alice clamps on the front to hold tension, and run it all the way up the back, and if you just hub it on the skin, you get the correct length. I then think it's very important to untether the bottom surface of the graft. So we've already used the cob on the front, well now you've got to use the cob or your finger on the backside, dissect any adhesions to the lateralis that might result in premature truncation of your graft. And then there's this curved meniscotome, once again, if you hub this meniscotome to the skin, and you truncate it at the top, truncate it at the bottom, you can get a graft of sufficient length. This graft has to be on average at least 15 centimeters in length, your average ruler in the OR is 15 centimeters, so if it's longer than that, you're good to go. I'll then just gently dissect this off the capsule distally to mobilize it a little bit better. Obviously you want to leave your capsule intact so your fluid doesn't extravasate during arthroscopy. This is a at-the-bed, not-on-the-back table prep because it's still attached to Gertie's tubercle. I use a simple locking whip stitch construct over the distal two to three centimeters of the graft, and this will allow me to have control of it and pass it through the knee. It's then important, you'll see, to tubularize this graft. So this graft is flat, and it's very thin, and you're trying to get a more tubular structure So I will typically mark out with a marking pen where I think the graft will actually enter the joint, and then I will tubularize the part that will be in the joint with a zero-vicryl so I don't have non-absorbable suture in the joint. This is very easy to do, and typically if you get a sizer on this, it's usually between a six-and-a-half to an eight-millimeter graft depending on the size of the kid. Unfortunately, you have no control over really what size it is, it's just depending on the size of their IT band. I'll then basically stuff it into the lateral thigh and then go ahead with arthroscopy. So, Davide, I don't think this was one that I could repair. There was not enough stump left there, so this one did need a reconstruction. And then you can proceed with sort of your standard diagnostic arthroscopy. I'll skip through that part because it's not... You can just see this kid had normal meniscus, normal cartilage. You have to preserve your intermeniscal ligament. It's sometimes easy as you're clearing out the fat pad to shave that out or damage it, and if you do that, that makes it much more difficult to do this operation. I do remove the ACL stump. I think particularly the tibia, if you leave too much there, it'll make your graft sit more anterior than you want, and you try to make a trough. You can use a burr, you can use a rasp, there's a lot of different ways, but you try to make a little trough in the epiphysis to get that graft to sit a little bit more posteriorly since you're not drilling a tunnel through the tibia. And then this is sort of the critical part of the operation. You get a clamp. This comes in the set, the McKaylee set, and it is the perfect size, the perfect shape, and you get it to that over-the-top position, and then you actually pass it all the way through the knee, and I'll show you in a second, but what I like to do is have my finger around the back of the femur so I can feel myself coming out and make sure I'm in the right spot. At that point, you simply pull the graft through the anterior portal. Obviously, you're not done at this point. You make your small medial tibial incision, and now you want to dissect down to but not through periosteum. I know when I do this in an adult ACL, I literally bovee the bone, and a kid, you don't want to do that. You want to preserve the periosteum to fix the graft. You also just have to be careful to not be too lateral so you don't get into the tubercle. You then pass a clamp underneath the intermeniscal ligament, and you pull the graft through the tibial tunnel. It is very easy for that graft to get stuck under the intermeniscal ligament, so you really have to kind of pull firmly and make sure your graft's all the way out to length so you don't under tension it, and if you had about a 15 to 17 centimeter graft, it'll be just the right length for fixation. You then fix this on the femur. This is done at 90 degrees with neutral rotation, and you simply sew it to the lateral periosteum of the femur. I use three high tensile strength sutures. It's remarkably easy to do. Then on the tibial side in full extension, I'll make a trough in the periosteum. So I incise the periosteum, and I take a cob elevator and elevate it on both sides. I always tell the residents or fellows I'm trying to make a taco, okay? So the graft's going to go inside the taco, and the periosteal flaps are your tortilla, and you're going to put it around there. This is not part of the originally described technique, but I found this very helpful. I take the lead sutures from the whip stitch, and I tension them into a knotless sort of lateral row anchor. What this allows is, one, me to sleep better at night, that this fixation is robust. It also allows me to then sew it into the periosteum, knowing that it's held out at the appropriate tension without having an extra assist and having to hold the graft the entire time. And here I simply close the taco over top of the graft so it's completely surrounded by periosteum and should heal very robustly in a child. And that's the operation. That usually renders them very stable, and you can, I think, do your standard closure at that point. Some pearls and pitfalls of this technique, when you're harvesting the IT band, like I said, you want to dissect all adhesions on the sort of front surface and the back surface of the graft. If you are having a hard time truncating the graft with the curved meniscotome, the last thing you want to do is kind of blindly be shoving it around and not sure what you're doing. You can make a small incision at the top of the thigh and just take a 15 blade and cut it. It comes out. It's very safe to do. You just have to remember to close it because it's way up here. And always take more IT band width than you think. If you take the standard width that you would do, for example, for a lateral X reticulatina adhesus, a 10 millimeter strip, you end up with this puny little 4 millimeter graft that I don't think is strong enough. From a graft passage standpoint, when you're passing that clamp, I have the clamp in one hand and I have my finger around the back of the femur on the other side. You want to be able to feel yourself coming out. If you push that thing too posteriorly, you could certainly end up in a bad position. And so that allows you to guide the clamp out very easily. And you have to dilate the hole in the capsule because you have to pass the IT band there. So you really want to kind of work that clamp open to get the graft through. Fixing it on the femur, if you read the original technique paper, they talked about doing this in external rotation. They have later come to find that that over constrains the knee. So do not externally rotate the foot when you're fixing on the femur. And I found that using a knotless fixation on the metaphysis on the tibia is very, very easy and very helpful. If you were to prematurely truncate your graft, which thankfully I have not done, it has been reported sewing an allograft into this. Quite frankly, I don't know that I would do this. At that point, I would probably convert to an all epiphyseal type technique with a soft tissue graft rather than put an allograft in a young child. One of the hardest things, and my fellows who I've trained on this always call me, and the first one they do, they say, I did this, but when I did it, the graft would subluxate into the lateral joint space. And what that is, is you basically pierce the capsule too laterally with your clamp. And if that's the case, don't accept that because that patient, every time they walk, are going to have a graft going into their lateral compartment. They're not going to like that. And so you have to do a separate passage through the capsule. It's always more central than you think. It's a little bit scary because you're basically shoving a clamp, it seems like, right towards the neurovascular bundle. But it is safer than you think. You're using a blunt instrument. And there have never been reported cases of neurovascular injury from this operation. Make sure your graft doesn't get stuck under the intermeniscal ligament. And then those are kind of my tips. Relatively straightforward operation. From a rehab standpoint, I have not modified the original rehab protocol described by the Boston Children's Group. It is fairly conservative, okay? It's a toe-touch weight-bearing for six weeks, no range of motion past 90 degrees for six weeks, and a hinged knee brace locked in extension for ambulation for six weeks. So this is not your standard ACL reconstruction rehab. At week six, pretty much it becomes standard rehab. I do return to sport testing at six months for a baseline, nine months to actually decide if they're ready to go back to sport. I never clear a pediatric athlete before nine months. Some rehab considerations with this. Send your protocol to the therapist. Most of them have never seen this operation. They have no idea what to do with these kids. And by default, they're usually going to do an adult-style ACL rehab, which is not what you're shooting for. So you have to communicate with them. I have learned that children are extremely kinesiophobic. I should say there's sort of two kinds. Ones that are really kinesiophobic, ones that do totally fine. But the ones that are fearful of motion, don't talk about manipulating them or license of adhesions early on. They pretty much always get their motion back. And so you just be patient with them, and I promise you they'll get their motion back. Remember that there's very little neuromuscular impact of harvesting the IT band. So these kids at like two months feel awesome, and it's really hard to slow them down. And prepubescent boys, as you can imagine, really only have two speeds, off and 100%. And so you have to be careful in what you say, like, oh, you can jog, and you can play with your friends. Just don't do any organized sports. Well, that's probably just as high risk as putting them back into sports, right? Make sure to engage the parents to motivate the child to do therapy. I don't know how many of you guys have children. I have a nine-year-old and a seven-year-old at home. The thought of my seven-year-old doing like physical therapy is hard to imagine, but yet that's what we ask of these children to do. The youngest person I've done this on is six. And so you really have to engage the parents on those. And find somebody who can make the rehab fun. Just breezing through the literature, there's actually not a ton of it. There's one large study out of Boston, 240 knees, no growth disturbance, 6.6 failure rate, and a 50% cosmetic thigh abnormality. I'll get to that in a second. And then another study out of Atlanta showing equally no growth disturbances and a 14% graft rupture rate. A couple meta-analyses showing lower failure rates in the allopifacil technique, lower incidence of growth disturbance, and higher return to sport rates, so Dr. Green might debate this data. And then looking in the lab, it best re-approximates the mechanics of the knee. And at 20 years, they did a gait lab study showing, and this is at Boston Children's, showing that these patients did have full recovery of normal knee kinematics. And then I put this in there. This actually, this is hot off the press. This is a kid who I did his IT band on the right side five years ago when he was 10. He's now 15. He tore his other ACL, so he got a BTB on the other side. And he had never mentioned it in his seniors. And then last week in clinic, when I saw him for his left side, he said, hey, my thigh does this weird thing. I was wondering, was that related to the surgery that I had? And then he contracts his quad and basically gets herniation of his lateralis through the defect in his IT band. And at first, I sort of vomited in my mouth, right? And then after that, he goes, can you do that on my other side, because it looks sweet, right? He's like, he thought it was the greatest thing, because it looked like he had this huge quad. But people don't talk about this enough. And this happens in all of these kids, because you're taking the majority of their IT band. Now, it doesn't always manifest this much. Sometimes it looks like a concavity distally, because they don't have the IT band to kind of create the normal contour of the knee. You have to tell patients, the price that you're paying to not get a growth abnormality is some cosmetic abnormality of the thigh. And some people are OK with that, and some people might not be. But if you don't tell them, and then this happens, they will be concerned. Failures do occur. I've been doing these for eight years. I've had two failures. And they both failed, interestingly, in the exact same way, right at the junction with the tibia. So the extra-articular portion's intact. The inter-articular portion's intact, but it tears right as it goes over the lip of the tibia. This is what it looked like intraoperatively. And this is somebody I revised to a partial transphysiol soft tissue quadriceps graft. He was 12 at the time, and he's done very well with that. I'm certainly happy to entertain any questions. And if not, we can move on to the next presentation. John, I have a question for you. So they're telling us that the ACL is a ribbon. They want us to do a ribbon-type reconstruction. Have you considered not tubularizing your graft and try to keep it a little flatter? That's the first question. That's a great question. So actually, I unintentionally did that once, where I simply was just, we were going, I was with the resident, and they were prepping the graft, and forgot to tubularize it. And I was like, all right, let's go. Let's pull it through. And it's actually very hard to pass the graft when it is not tubularized through the capsule. And so after struggling with that particular patient to get the graft passed, I have always tubularized it. Second question. When you puncture the capsule too lateral, and you have the graft falling into the lateral joint space, what do you do? Do you use a suture anchor to have it hang up there on the other part of the femur? That's a good question. So there's sort of three approaches. One is get your clamp back in, like start over again, pull the graft out, get your clamp back in, and really try to get a new passage through the capsule more centrally. The other thing you can do is you can actually do an outside-in type technique, where you get a spinal needle through your lateral incision, and localize it, and make sure it's much more central than where you previously passed it, and then you can make a little nick outside-in, get a clamp in outside-in, and then, you know, retrieve a passing suture, for example. The only danger with that is you're sort of stabbing a needle into the back of the knee, and if your triangulation skills are not ideal, you could potentially hit something you don't want to hit. And the last thing that you can do if you're subluxating a little bit but it's pretty close, you can either put a suture anchor, or simply when I tie it to the periosteum, I sort of pull it up. So I take a bite much more anterior through the periosteum, and it basically pulls the graft up, but there's only so much that you can move it, maybe about a centimeter. And so those are the three techniques that I've found if you pierce the capsule too laterally. Okay, thank you. I have another question. If I understood it, you leave the IT band, so you don't close the IT band at the end of the surgery. That's correct. You can't. It's such a big gap. I've tried. I've never been able to successfully close the IT band. Thank you.

Ficeal Sparing Iliotibial Band Autograph

McKayley-Coker Technique

ACL reconstruction

prepubescent athletes

low failure rate