to give us a demonstration on his technique. And I think he's going to talk a little bit about his tips on both an all epiphyseal, avoiding the physis altogether, and then a trans-physial technique. Jeff, are you there? Can you hear us? Yeah, sounds great. Thanks, guys. All right, Jeff. Okay, so we've got this a little bit prepped, ready to go. Back this pin up up just a little bit. So we're going to show all epiphyseal. I think it's this one here. So all epiphyseal ACL reconstruction is, for me, an option that I use a lot. I usually am going trans-physial up to about three to four years of growth remaining. So for a boy, this is kind of maybe 12 and under. For a girl, 10 and under. Eventually, kids get too small, so the space becomes sort of not quite safe to do this. But those needs, I think, are like, for me, once or twice a year, that this is a much more common situation. So we can really put these tunnels in the same place we do trans-physially. So you guys can see the scope image here. So we've put in an all epiphyseal pin and a trans-physio pin for sort of demonstration. So drive our trans-physio pin here in. So if we were doing a trans-physio reconstruction, sort of that is our pin there. So now pull that back. And then let's go in, let's see our guide. So I'll put the guide on and we can kind of simulate. So this is a pediatric-specific guide that gives us better angles to go at this all epiphyseal. So this guide's set to 85 millimeters. And similarly with my scope in the medial portal, I've got a nice, hold on, loosen once, it's a little tight. I've got a nice view to look at this. Maybe just leave it free, it's fine. Undo it from the guide. So I can get this to a similar location and then go ahead and drive through our all epiphyseal pin. And we're really getting to the exact same spot with just a much different trajectory. So on the side of the knee here, I don't know if you can see from the lateral side a little bit. So with this all epiphyseal femur, I really like an anterior to posterior trajectory. As Kevin showed earlier today, that protects you from blowing out any of those posterior structures. So this is about a 45 degree angle A to P to keep me in front of any of that trouble. I'll usually draw out the surface of the femur pre-op and kind of mark where I wanna be. So I'll shoot a pin in without checking x-ray and then confirm on fluoro. So we checked this on fluoro. You can maybe show the monitor here. So this obviously isn't a pediatric cadaver, but we'll say we're proximal to growth plate there with that transverse pin. So once we're happy with that, we're gonna get ready to drill a socket. So let's get the pound and guide. So we're gonna, the guide pins there are two four. We're gonna put our drilling system, which is more a three five drill. So we're gonna pound this centering sleeve in seven millimeters into the bone to have a stable construct so that it doesn't move. And typically might check this on floor, but that feels pretty good. Go a little bit more maybe. And then, okay, good. And then we're gonna change this pin out now and put in our, and make sure he's ready. He's ready. Okay, I'm gonna hold this when you come out to make sure we don't lose it. And then go nice and slow and kind of find the same channel with a slightly bigger pin. Yep, slow and steady. And you'll see a little bit of a cylinder of bone coming through here. Okay, perfect. And there is your line. So that's perfect. So you are adequately in. This system lets you kind of dial in the size. So we have prepared a hamstring. For me, this is typically a hamstring all epiphyseal. We'd want a proportional graph that typically quads can get pretty big. You could do this with a quad, but it seems like the rates of issues down the road are really good with hamstring already. So we sized our graph. This is a adult knee. So we use four strands to get to an eight. In a pediatric knee, you might end up tripling that semi T to get a adequate size so that this is typically a seven to eight graph for me. So we're gonna drill a eight socket here. So go ahead. So I've got Magda from Boston, one of the Boston fellows with me helping me here. Okay, and we're gonna go, what's your depth there? So probably 20 issue. Yeah, you're probably hitting the, that's probably 25. You're hitting our guide, which is fine. So come back in and then let's undeploy. And then we got our passing suture ready. Yeah. So we're in a pretty anatomic position there, similar to what we do transphysio. There's our transphysio pin. And then we're gonna put a passing suture. We don't wanna lose this because that can be a hard hole to find. So here comes our passing suture and then hold the guide there. You got a crab claw? I think there was one there. And we'll pull this out and keep it out of our way. Or any kind of grasper. There we go. Okay, so I'm gonna pull that through and then you can take that guide out and we'll just keep, yeah, oops, hold on. Get it one more time, it's shuttling. Yeah, let me grab it. Okay, good. Okay, pull the guide out now. So now we've got our suture ready and our femur. So I think the femur is probably the easier part of this. That with, as long as you can get good fluoro, I only check an AP view of my fluoro because I know my anterior posterior trajectory is gonna protect me from issues. And then we're gonna need to check a lateral view on our tibia. Let me get a little bit of the bone debris out of here. There's the root repair from earlier. Okay, perfect. So now we've got our suture ready to go. I got the scope back in the lateral portal. So let's show the incision here. So our incision here compared to your typical hamstring harvest is gonna extend proximally because we really need to get up to that all epiphyseal location. And then we're gonna eventually fix this with a screw and post distal. So that's just distal to our hamstring harvest. So we've taken our hamstrings and we're in that position. So let's drive these pins through and show intra-articularly. So this is our all epiphyseal pin. You can see it's very flat, which is typical. You probably have to pull it back just a little. Good. And then our transphyseal pin, you'll see is ending up in the same spot, just getting there with a much different location. There we go, perfect. So it's a little lateral there, but okay, come out with that. So now let's put our tibia back in. I'll take a curette, put it back in a little bit. And then we're gonna drill a full tunnel on our tibia. So let's pull up image number three now. So we started, let's show the fluoro there. We started two anterior there, where it was skiving along and then go to four. We've moved it down. So I think the issues tend to be with growth disturbance getting too close to the tubercle. So you really got to ignore the shadow of the tubercle and stay proximal. I haven't had anywhere, I've felt like I've actually blown out into the joint. If you just blew a little bit of the bone out and the soft tissues are protected, I don't think that's an issue as well. We'll look up this tunnel after we drill it to see what our tunnel looks like. So let's drill a full tunnel here. You're gonna come all the way in, yep. A little more. So this is a very kind of oblong hole, which was pointed out earlier this morning too. A little bit more, that's fine. Good, and then come on out. You can take everything with you. We'll clear that out just a little bit. And then we can get a passer ready to grab that suture. Okay, put a finger over that. We're losing some of the flow. So inter-articularly, this doesn't look that much different than you might have an appearance with a transficial or even a BTB. I do my BTBs also with this very similar technique using a flip cutter guide and a small two incision tunnel. So for me, this is kind of the same case, just the angles are different. So let's pull that suture through. Hold on one second, I'm gonna unloop you here. Okay, so let's get that suture. Turn the water off, usually helps. Perfect, so now we've got this through both of our tunnels ready to go. And then let's show our graft there. So we've got a four-strand hamstring. I think we did about 80 in this adult. Often you're gonna be a little shorter, maybe 70 in a pediatric setting. We've marked 20 millimeters, so we wanna see that get into the bone. We've pre-tensioned it at 20 pounds for five minutes or so, and typically I soak it in some bank solution as well. So let's peek up our tunnel here. So as we pull back, so you can see we've got bone all the way up until the oblong entry. So that's the anterior part of our tunnel. That's the posterior part of our tunnel. The other thing when you do these, you can look in these tunnels and verify you don't see any cartilage. So I think we're just fine here and ready to go. So now this turns into a transficial reconstruction. So we've made a small incision laterally and have incised the IT band distally. When you're doing an all-epiphyseal, the IT band's a little more adherent, so I like to make sure we look under direct view to make sure we aren't pushing the IT band under that. So flip that through. Good, and you wanna come up lateral now. Okay, and then, yeah, pull sutures, and then I'll put the scope back in. Okay, perfect. So now we've shuttled that up through both tunnels, and we can see our view here. So let's start coming up. You'll see our button at some point here. Just pull everything. So Jeff, you mentioned on the femoral tunnel, taking a look up and looking for the physis, just to be sure. Yeah. Have you ever actually changed your tunnel based on seeing that? No, I think you've. Just a double check. Yeah, I think, I mean, if you had worries, I guess you could ream a little bit and then check, but I haven't, but it generally is reassuring. I've never felt like I've seen cartilage in that view. Yeah, get that through. So there's our button coming through. So you're gonna pull that all the way out the skin, and then we're gonna let this deploy under direct view. So grab a snap or something where you can control that. You'd like to keep this proximal distal rather than anterior posterior. So you're gonna hold that, help it get under the IT band, and then I've pulled it back. Good. Typically, we'd check x-ray at this point again to make sure that looks fine and deployed. Now we can sometimes look up the tunnel to see, there's our old pin. We can't quite see the button up there, which is a good sign. Okay, so now we can bring this up into the joint. So I'll keep a little backwards tension here and then walk those two sutures to get our graft up into the joint. There it comes, and there's our 20 mark, which should be, yeah, you can go as far as you want. Okay, yeah, so I think at this point, you can't inter-articulate often. You can't tell the difference between the trajectory of your tunnels. The list looks like a standard transphysiol reconstruction. So that's good, and then we're ready to fix this. So typically, I fix this with a screw-in post on the tibia. So we're gonna tie the sutures around a screw-in post. I don't know if we can start to look straight down on the cadaver here. So we've pre-drilled this. We can kind of show them where we're at here. So our tibial tunnel, again, was very close to the patellar tendon, trying to maximize our safe zone, and then we're coming down. We don't wanna put this into the tubercle apophysis, so we have a small hole here that we're gonna use. So let's put that screw-in, and then we'll demonstrate tensioning here. I guess we could take that out. Keep your hand, I think it's kind of there, yep. So we'll put this screw-in. It measured 30 millimeters. This is four or five with a soft tissue washer. So we're gonna get it down. Yeah, maybe there's fine. Okay, and then hold the knee here, and then we're gonna separate out the four limbs of our graft so that we have two going around each side. So I've got one of my semites, one of my gracilis, and then I'm gonna flip it around my button. Good. So I flip it all the way, and I'm gonna tie on the proximal aspect, and then we're gonna do the same thing here, tie on the proximal aspect. And then now we can go do a little bit, but then we'll tie it. Do that, okay, good. And then we do full extension with a poster drawer at this point, and I'm gonna tie the same hamstring to the same hamstring here. And then we always have the opportunity to re-tension back at the end if needed. So these two look like they go together, and then those two. Okay, perfect. So we'll just tie, tie that. And if you loop them this way, it's much easier to tie it than if you try to tie it straight on the distal end of the graft. Sort of a little help with the screw-in post to not feel like you have trouble tensioning this. And then we'll do the same thing up here. These two. All right, so we've got both of those tied, and then we'll finish our final seating of the screw. Sort of compresses everything, and usually you can really feel the tension on these sutures when we're all done. Let's see a scissors. We've got, or maybe a knife would work too. We'll just cut them to get them out of the way. Okay, so you can really feel these sutures are super tight, sort of guitar strings here. And now we can go back and double check that we got adequate tension. And then come to this side, you may tension the final tensioning of that even a little bit more. Yeah, so walk that up another millimeter or two. Okay, good. Yeah, so that looks great. So end of the day, we're back to sort of as anatomic as we can get for reconstructing the ACL here without too many issues. If you can be careful with fluoro, I think is the critical. Be prepared to augment your graft with that fifth limb if needed. It'll often get you a full millimeter of extra size that you wanna end up with something that looks proportional to the knee. So I think you really nicely showed how important the fluoro shots are to show that you're clear of the physis, especially on the femur and then on that lateral. And any particular points about setup of your room or your fluoro? Yeah, that's a good point. Invariably, I have the student x-ray tech who's coming up on the day when I'm in. So you can do it with mini C-arm or big C-arm. I like big C-arm. I will often check those shots pre-op to make sure the bed's not getting in the way, especially as you get into shorter knees, sometimes even taking the distal extension of the bed off so it doesn't hit it as you go proximal is a good move. But check those x-rays because if you have trouble getting those x-rays, you're gonna cause problems that you need to be able to get a good lateral, get a good AP without too much struggle to make sure you put this exactly where you want. Great point. How about your technique of using the screw in post as opposed to say an ENSOR going all the way through on the epiphysis of the tibia versus say trying to do a flip cut or like... Is it just that we've got such limited real estate there that this obviates having to be concerned about that? Yeah, I don't like the thought of putting a screw up there. The screw's gonna widen the tunnel and create a less margin for error. And then I think the issue with the button is often that button's gonna sit right at the edge of the growth plate and who knows if that's an issue or not. But I think the screw in post, you can hide these screws, seat them down nicely. I know this is super tight and not going anywhere. So I've really liked that. And it tends to, as they grow, it grows away from the joint too. So tends not to bother them down the road. And I wonder, it's a little bit difficult with the overhead camera looking just from the lateral side, but I wonder if it's worthwhile if we rotate them out so that we can really see the way you marked out on the distal femur before you even made your incision or put in your pins. Does that really seem to be key to, as you were saying before, you're using fluoro really more to prove that you're in the right spot as opposed to just guide it. Can you come flat now? Do you have ability to come from like eye level with anything? There we go, okay. So I've drawn out the, I can palpate the edges of the lateral femoral condyle. So you can kind of see the circle here. I don't wanna be back here because I think that you risk blowing out your LCL or popliteus. So I wanna be up here and then I've incised the IT band there to make sure I got a little window to sneak under. So I wanna be in the front half of that circle. Is it possible to show that first AP x-ray again up there? Just to kind of highlight where Jeff has gone. Yeah, and so I guess it's the direct feed. So I can't overlay there. But again, you can see the transvisial pin. It's hard to see. We don't really have a growth plate there. If you're ever not sure that you're too close, you can put a reamer up there, the size you're gonna cut your socket to simulate how big is an eight millimeter. Because it's not uncommon that you might have to move that pin even a little more distal to start to make sure. Last thing you wanna do is ream out the entire lateral physis on your way in. So sometimes you are cheating it a little bit more distal and it's just a little hard to simulate in a adult need. Great. Thanks, Jeff and Sasha for monitoring the session. Really appreciate you comparing the transvisial with all-epiphyseal and really demonstrates the similarities in your inter-articular apertures. If you rest this morning is working on the ACL. This afternoon.

surgeon

ACL reconstruction

all-epiphyseal technique

fluoroscopy imaging

hamstring graft