We're going to discuss intercruciate ligament reconstruction for patients with open FICEs. Okay, thanks very much. Disclosures are in the program. So, for the last decade and a half or so, we've been using the same algorithmic approach at Boston Children's and really throughout the PEEDSports community to this issue. In the prepubescent patient who's 12 or 13 or younger in males or 11 to 12 or younger in females, we'll use a FICEL sparing technique. In Boston, we favor the IT band, but other techniques exist. We'll discuss that. Rehabilitation, activity modification, and functional bracing is a historic approach to this problem in pediatrics, but we've sort of seen a whole body of literature suggesting that patients will suffer recurrent instability, meniscus tears, and chondral injuries at really unsettling degrees or rates, and so we've really sort of done away with this as a standard. In the middle age group, these are pubescent adolescents who still have growth remaining, so it's one to two years of growth remaining, open growth plates. This tend to be males 14 to 15, females 12 to 13. We'll use trans-FICEL sockets or tunnels with FICEL respecting techniques, so generally metaphyseal fixation, classically it's been the hamstring, but the quad has clearly come on as a good option here, and then for older adolescents with closing FICES, this is Tanner Stage 5, males 16 to 17, females 14 to 15. We can really use any adult ACL-type reconstruction technique, so we'll see the FICES still partially open but really closing at the front and at different places here, so this patient can get a patellar tendon graft with bone plugs across the FICES or implants across the FICES as shown here with any of our techniques that you may favor. We'll see how long the hamstring is still kind of a code gold standard in the coming years with some of the literature coming out at this meeting and others. The quad has obviously come on as an alternative to hamstring and this can be a BQT or an all-soft-tissue quad tendon option for this age group. So it's really the two younger age groups that we're more focused on here with our considerations. So the adolescents with growth remaining one or two years, wide open growth plates, we tend to favor use of the shorthand bone age method, although some knee MRI-based bone age considerations are coming out. So until those are more well-established and validated, we tend to use this derivation of the Gulick and Pyle Atlas, which is a little bit simpler, and I credit my mentors at HSS. I was lucky enough to help them validate this and use it almost weekly in the clinic. So these are wide open growth plates, but one to two years of growth remaining, and Dr. Coker and Michele have published on this. The historic kind of approach was more vertical tunnels in the sort of trans-tibial age and then metaphyseal fixation, for example, a shorter biocomposite screw in this case, and it was shown to have no issues with growth disturbances. But I think we've come a long way with the anatomic techniques and different drilling approaches. So our tunnels have become much more oblique. This is a very typical look into the femoral tunnel now, seeing that pinkish bone of the metaphysis and the yellow bone of the epiphysis. So our tunnel tends to run more closely along the growth plate rather than more vertical sockets. We have not seen issues with growth disturbance, but look forward to presenting on that in a large-scale way from the Pluto cohort, where we have hundreds of trans-ficeals with these considerations. Here's a case of a quad with suspensory fixation on both sides. You can see the sockets are trans-ficeal, but the femoral socket is very much running along the physis, and we have not seen issues with growth disturbance on the short term. So then this youngest age group, the prepubescent. So these are patients with two or more years of growth remaining. So these are ficeal sparing techniques. The first, sort of earliest popularized, was the modified McIntosh in the upper left corner there, developed by Dr. Lyle McAley. And then Alan Anderson, a couple years later, presented on his all-epiphyseal technique with a lateral distal femoral epiphyseal socket, or a tunnel, and a proximal tibial epiphyseal socket, in this case with a screw-in-post fixation in the metaphysis. High-volume surgeons like Ganley and Kordasco and Green and others have modified this technique to largely be all-epiphyseal without metaphyseal fixation, but rather suspensory fixation or screw fixation techniques in the epiphysis. Here's a case of a partial trans-ficeal. So that's epiphyseal on the femoral side, but trans-ficeal on the tibial side, because it's more central and has less effect on growth. This is a good option for some kids without real issues with growth disturbance. So in terms of the different ficeal sparing techniques, the IT band technique has intra- and extra-articular stabilization component inherent in it. And we are all hearing more about the ALL and LET and the benefits of improved stability and lower retail rates. There are no reamed tunnels with this technique, so there's a proximal tibial epiphyseal trough that's two to four millimeters deep, but fixation is really with sutures within the trough on the tibial metaphysis and at the posterolateral femoral periosteum. So there are no implants. It's low cost. It's really technically pretty simple, tends to take under an hour, and has excellent outcomes based on a variety of studies now, with return to sports usually nearing six months rather than the kind of new standard of nine months, as our patients have not seen issues with the early re-tears and tend to pass our return to sports test earlier than with other graft types. So there have been minimal to no growth disturbances in our series, and it has a low graft rupture rate at 6.6% in our study of 248 knees. The disadvantages of the IT band, it's been criticized as being non-anatomic in terms of its graft position. We'll talk a little bit more about that in a moment. As well, you can see this MRI. We feel the graft does grow into the epiphysis over time and become potentially more anatomic. And then the lateral thigh fullness phenomenon. When I arrived at Boston, I asked Drs. Michele and Coker about this, and they said it wasn't an issue, so we tried to dig a little deeper as part of our 2018 study and asked every patient as part of our original questionnaire. Found less than half reported noticed any difference, but pain in less than 2% and an effect on sports performance in 5%. To address this non-anatomic criticism, we did a study published last year bringing back 40 patients for functional outcome measure surveys, 3D kinematic analysis, and these were at different time points after surgery. Ten were 1-2 years, another group 2-5 years, another 5-10 years, and another 10-20 years. We found no differences between their operated and non-operated leg in terms of knee moment, ground reaction forces, and vertical jump height, and it was no difference between the time to surgery. So this non-anatomic concept doesn't appear to affect the biomechanics or function. In terms of the all epiphyseal technique, the advantages are it's a little bit more familiar technical principles to those who perform adult ACLs, so may have a shorter learning curve, though those unfamiliar with the epiphyseal drilling may have more issues with it. It's hypothetically more anatomic in terms of position of graft, but maybe less so in the younger kids. One can get a larger graft diameter, particularly with the quad tendon and modern hamstring doubling techniques, and has also had excellent outcomes returned to sports and relatively low growth disturbances, though it has been higher than the IT band in terms of reports in the literature. It does not have an inherent extra articular component, though many AE enthusiasts are adding the LAT or ALL to this. And then reports in the literature have had variable graft rupture rates at 6% from one large series comparable to the IT band, but another, the largest series in the literature from CHOP suggesting 18.2% at four-year follow-up. Most importantly, it appears to have a limited age group of applicability, so it's great for the 10- to 13-year-olds, but most AE surgeons will say there is a threshold below which they will not do an all-epiphyseal due to the increasingly small proximal tibial physis and the real room for actually putting a tunnel between the cartilage and the growth plate. So most people have a fourth limb of their algorithm with the IT band if they use AE. So to follow the incredible work of the MOON group, the MARS group, the STABILITY group, and the SANTI group, Minn-Coker, it's all the credit for formulating and forming the PLUTO group, which is a multicenter group of 10 centers, 23 surgeons, trying to look at these physio-sparing and trans-physio techniques. All patients are open growth plates, and systematic reviews have been performed of the world PEDS-ACL literature, suggesting that there are low rates of reported growth disturbances and that nonoperative treatment is associated with high rates of persistent instability and low rates of return to sport, as well as increased risk of meniscal tear with delays even as little as 12 weeks following injury. And the third systematic review suggested that the outcome measures used have not been validated for kids in most of the previous literature. So working on that. The final systematic review we're completing is the data is in, it's not yet published, but looking at the physio-sparing versus trans-physio techniques. Similar ACL retear rates, not statistically significant. When we look at all epiphyseal, this is the worldwide literature, 10% retear for AE, 7% for IT band, 7.5% for partial trans-physio. No statistical differences there, but complications statistically significantly higher in the other techniques compared to IT band. When we looked at the trans-physio literature, hamstring versus quad, there was no difference between the graph techniques. So our enrollment data, we have 748 patients after five years, which we ceased last year in the midst of the pandemic. So I think we're in like a good time with the huge numbers and we'll be comparing the different techniques in the coming years and look forward to reporting those. You can see the different uses at different ages. Some people pushing the indications of trans-physio low, some people pushing the indications of physio-sparing high in the age group, but a lot to report. Thank you.

intercruciate ligament reconstruction

open growth plates

pediatric populations

ficeal sparing techniques

trans-ficeal sockets