Thank you for coming to my talk. I'm Dr. Jennifer Beck, and I'm going to be talking about Don't Cross the Line, Options for Fisale-Sparing ACL Reconstruction. I have no disclosures for this talk, but I did train at Boston Children's under Minn-Coker and Lyle McKaylee. When considering ACL reconstruction in a skeletally immature patient, this is an algorithm that you should have in your back pocket, understanding the three main types of skeletally immature patients. You have patients that are greater than two years of growth remaining, ones that are less than two years of growth remaining, and those, then, that are skeletally mature. This audience is well-versed in the skeletally mature patient population, where it's trans-fisale, and it's really a dealer's choice based on how you train to do your ACL reconstruction. This middle group of less than two years of growth remaining is a highly controversial group about techniques and indications. That would be for a separate talk, but making sure that you know your Tanner staging, as well as being able to classify the patients into this group versus the greater than two years of growth remaining is of crucial importance. The focus of this talk is really on this greater than two years of growth remaining subgroup, and really, there's two main surgical procedures and techniques that most people are trained in one or the other, and I'll talk about the main training that I have in the Coker-McKaylee IT Band to ACL reconstruction, some of the benefits of this. So, making sure you understand skeletal growth and maturity of pediatric patients is of importance when dealing with these young patients. You need to make sure that you can put them in the one of the two buckets of, does this need a Fisial Sparing Procedure or a Fisial Respecting Procedure? Here are some things that you can look at when you're trying to assess skeletal growth and maturity. You can compare their skeletal height to adult family members, use Tanner staging, and often we rely on pediatrics notes for this. Look at their skeletal age based on their hand or a knee MRI, which I'll show you later, and then understanding girls' growth spurts and when they complete their growth, as well as boys, and knowing that these are approximately two years separate from each other. Especially in young females, menarche can be delayed in athletes, especially high-endurance athletes, so understanding this is of importance, as well. When I'm evaluating these patients, this is my typical workup, is they do get four views of the knee. They get a bone age, they get a standing lower extremity alignment, and they do get an MRI. I think the standing lower extremity alignment is really important to understand their preoperative varus or valgus so that you can monitor for any complications postoperatively. Typically, we're getting standing lower extremity alignment x-rays at six-month intervals after ACL reconstruction in this young population to make sure we've not introduced any iatrogenic valgus. Your imaging that you obtain is going to help rule out any fracture, particularly a tibial spine fracture, which can be subtle in these patients at times. It's going to help you assess for skeletal maturity, as well as lower extremity alignment. Your MRI is going to be looking for concomitant injuries, such as other ligament injuries, chondral injuries, meniscus tears, and especially can help you evaluate the physis and what their skeletal maturity is and the hydration of that physis. Two important points that you really should look at for any developmental staging of a skeletally immature patient when considering an ACL reconstruction is both their Tanner staging as well as the classic pile atlas. Tanner staging, as I mentioned, is often relied upon the pediatrician's notes. Pile atlases can be found around. They're getting harder and harder to get, but if you are seeing a lot of these patients, it's a book that you should have in clinic. Understanding that the pile atlas is getting harder and harder to obtain, Andy Pendick and his research group down in San Diego did create and validate a knee bone age atlas utilizing MRI. If you're seeing a lot of these patients, that is a paper that you should have handy so that you can help determine if your patient is indicated for a FICL sparing or FICL respecting ACL reconstruction. The good news is a systematic review looked at trans-FICL and FICL sparing ACL reconstruction techniques and showed a very low rate of leg length discrepancy or angular deformity. There's two main techniques of how to do FICL sparing, an allopiphysial technique seen on the left and the Cochrane-McKaylee iliotibial band reconstruction seen on the right. As I mentioned, my Boston focus means that I'm much more in favor of the iliotibial band reconstruction, and I'll show a couple studies indicating why. There's two papers that have shown the biomechanics of IT band reconstructions in comparison to intact ACLs. This one coming from UCSF, and this is a study that was done in the United States of IT band reconstructions in comparison to intact ACLs. This one coming from UCSF shows that the IT band reconstruction had actual decreased translation in comparison to an intact ACL, and some people have criticized that that's actually over-constraining the joint. But the second paper out of Los Angeles comparing IT band and allopiphyseal to native ACLs has shown that the IT band is closer biomechanics to an intact ACL in comparison to the allopiphyseal technique. Biomechanically, we think this makes sense because the IT band ACL is not only reconstructing the ACL, but it's also reconstructing the ALL at the same time, and we know from the adult population that more and more attention has been brought to this ALL ligament and its reconstruction and contributions to AP translation in ACL reconstruction patients. Thanks to the stability study and the Santee study group, we know that there's a subset of patients that would benefit from an ALL reconstruction. It does seem to be these high-risk patients, which basically anybody who's scaly immature is in that high-risk group. The IT band ACL reconstruction takes advantage of this being, as I mentioned, not only an ACL reconstruction, but also an ALL reconstruction. I'd like to take a moment to go through some of the technique of an IT band ACL reconstruction. I'd like to thank Minn-Coker for these slides. So first of all, we'll talk about the grass harvest. There's about a six-centimeter incision over the lateral thigh in the IT band in this oblique nature, and you want to make sure and clear the adhesions, both superficial and deep to the iliotibial band, using a cob or free elevator. The posterior IT band incision goes along the length of the posterior IT band, and this is a meniscitome using this, but other techniques such as curved MAOs can be utilized as well. Similarly, you're going to make an incision in the anterior iliotibial band, and really you take the entire width of the iliotibial band. Given its thin nature, you want enough bulk of collagen tissue across your joint to have a thick enough ACL reconstruction. This curved meniscitome can be used to free the proximal aspects of the IT band. Opposite, you can do a counter, a small counter incision in the proximal aspect to release it if you don't have a tool long enough in order to get this. Your ideal graft length is about 15 centimeters from Gertie's tubercle. You can see here the iliotibial band graft that's been taken outside the knee and a whip stitch is passed in the very proximal aspect, making sure to tubularize the graft for easy graft passage. Distal dissection of the graft is completed, making sure to stay extra capsular as there is a thin attachment between the iliotibial band and the lateral capsule at this area. A long curved COCR can be used to retrieve those sutures intra-articulately in an over-the-top position, especially in a cadaver lab. You should take advantage of this time to trial putting this COCR across the posterior aspects of the knee joint because it does go rather close to the posterior neurovascular bundle. Through a small tibial incision over the pes anserine, you're going to introduce a clamp underneath the inner meniscal ligament, making a track that you'll be using for passing your graft as well as passing a rasp. A rasp is then introduced into the same pass as you're creating a trough in the anterior tibia as well as in the bed of the ACL to allow for graft healing as well as posteriorization of the graft. A clamp is then passed under the inner meniscal ligament and grafts the sutures that were previously brought out intra-articulately or from the over-the-top position. The graft is then passed under the inner meniscal ligament and out the tibial incision. As you can see here, the 15 centimeter graft provides you just enough graft passage into the tibial incision for your suture fixation. This technique relies on entire suture fixation. So first, you're going to attach the graft to the lateral aspect of the femur. You're going to have the knee bent over the side of the bed approximately 80 or to 90 degrees with the foot in a neutral position, passing a suture through the lateral femur periosteum and around the graft, securing the lateral aspect of the graft to the distal lateral femur. This is essentially your ALL reconstruction. A slit in the periosteum is made so this graft can be sutured then subperiosteally to allow the graft to heal adjacent to the bone. These sutures are placed with the knee at approximately 30 degrees of flexion with the foot in a neutral position. As there's been no outcome studies really comparing all epiphyseal and IT band reconstructions in this pediatric population, we need to consider other things we need to do to try and minimize failure in this population. And I think time to return to sport is one of those things that really is of critical importance. I often cite this study to my patients about NFL quarterbacks return to sport after ACL reconstruction. I quote them that in this study, the average quarterback went back at 13 plus or minus 4 months, and these are patients who have nothing to do and have their entire life dependent on rehab, so we can understand how this is critically important for their recovery this time frame. This time frame is especially important in context of scalably immature patients because we know that half of failures of grafts occur within the first year postoperatively, so it's really our duty to help protect these patients in this first year of recovery. That is why I'm very up front with my patients, and I tell them that on average, most patients are going to return to their contact pivoting sport somewhere at or about a year, and it's very rare before nine months that I'll return any contact athlete that's scalably immature to a cutting pivoting sport. I hope you've learned something about the Cochemichaeli iliotibial band ACL reconstruction for scalably immature patients. I focused on this not only based on my bias, but that this seems to be the less familiar technique for typical sports surgeons with a very different concept of not having any sort of bone tunnel. So if there's any questions, please feel free to reach out any time. Thank you.

fisale-sparing ACL reconstruction

skeletally immature patients

surgical techniques

Coker-McKaylee IT Band reconstruction

skeletal growth and maturity