Great, great work from both the speakers there. I guess we just have one point of clarification, because I think we have the argument against all epiphyseal, but Volker's doing this hybrid technique, so there's probably a point of discussion there. But just for the audience, for this case, it was a 13-year-old boy with open phyces, wide open phyces. Who would do transphyseal? Anybody doing all epiphyseal? Anybody doing a hybrid technique? Okay, so a reasonable spread, but probably more transphyseal than followed by hybrid. Can I ask both speakers, and please feel free to come to the mic if you have any questions. Both speakers, do you vary your technique depending on the age? So if you've got a nine-year-old versus a 13-year-old versus a 16-year-old, how do you choose your technique? Volker, you go first. Yeah, absolutely. On a nine-year-old, I would definitely do the technique that I just showed you. On this 13-year-old case, it depends. I think it's important for you to get a preoperative long cassette radiograph so you can track the alignment. You can get a bone age, and I would probably choose a slightly smaller graft if I go across the physes, so maybe eight is the maximum for me there. Yes. Yeah, so I think a couple things. If the patient doesn't have a full knee range of motion, then your long leg X-rays are less useful. So it's important to remember that. I think in the very young patients, I would do the sort of modified McKaylee technique over the top with an all-epiphyseal trough. And then in the sort of usually the 11- or 12-year-olds, I will do all-epiphyseal on both sides. And then sort of 12 usually is that hybrid physeal sparing, and then for, again, depends on the physiologic age more than chronologic age. But I think for some of those patients, again, they're in the transition zone between the hybrid physeal sparing or transphyseal. But honestly, after doing some more prep for this talk, I think there's much actually, I'm a lot more comfortable going transphyseal in almost every 13-year-old patient. And Harris, do you have any tips for the audience about how compared to your adult technique, how you modify your technique when you're doing transphyseal in kids? Yeah, so people talk about trying to place the tibial tunnel a little bit more posterior and trying to increase your angle so that you're drilling a little bit more vertical. And I think all those things are fine, but you don't wanna sacrifice an anatomic ACL. And in the slide that I showed, changing your tunnel angle does not really change, changing your tunnel from 50 degrees to 60 degrees doesn't actually change the volumetric disruption on the tibial physes very much. So you definitely wanna avoid the perichondral ring, maybe start a little higher on the femur or try and exit a little higher on the femur depending on your drilling technique. The short answer is for a 13-year-old, I'm not really changing too much. So your anatomical aperture location is still the same? Yes. But you're changing your angle slightly? I want an anatomic graft. Volker? Yeah, no, I wanna just reiterate, you cannot go more posterior on the tibial footprint than it's just a vertical graft, you may as well leave it alone. So I think the only change really is that you go slightly smaller. And if you wanna change that angle a bit, I don't know that that matters very much. The key is you're gonna stay anatomic. David. Yes, I have a question regarding the use of a LET procedure associated to the reconstruction because there are many arguments for doing it in patients less than 20 years old. So the question is, would you add it to these patients? I mean, Volker, yours is sort of built in to your technique. Yes, but so if you do hamstring, I think the data is so overwhelming, you probably do a LET in 100% of the cases. Now, I don't do a lot of hamstring, I just showed this case in this particular population. But yes, I would add the LET. And even if it's only for the fact that in the very beginning, they're a little more painful, a little slower to recover their muscle strength. And anything you can do to slow people down at that age is good. And that is probably why your quadriceps tendon is going to work very well, only because the quad recovery is gonna be harder. And so the return to sport on average is closer to 10 months. And so now you bought them two extra month or four extra month compared to the six months return. And that may be the difference maker, because the longer you can keep away from sport, the better. And Harrison, you're adding LET to your transvascular reconstruction? I have done it a couple of times. There's good data from HSS and Dr. Kordasko that shows actually really good outcomes with LET in these groups. And so I think it's totally reasonable if there are non-modifiable risk factors, there are very generalized ligamentous lax. I think it's a reasonable thing to add. I don't do it for all cutting or pivoting athletes, but if there was reasons to, I'd have no problems doing it. Volker, do you have any concerns about your fixation being above the thyrsus and having a tether on that lateral side? Have you seen any problems with that? No. No, thank you. Nick. Question for both. Volker, what do you do if your graft is smaller than the ideal graft you would like to use in that patient? And- More mean thicker. If it's, no, not unnecessary. Smaller. Smaller. Smaller for you and probably bigger for- It's okay. If you're asking me if I would go hybrid and add an allograft, I really haven't done that very much. I don't know that that makes a lot of sense. Look, we talk about this number eight way too much. One little retrospective study not telling us where the tunnel position is only saying that eight is the key number. I just don't believe it. I'm very sorry. If you have a small notch and many of these tiny athletes, as you know, notch size is a risk factor, have a 13 millimeter notch. You don't need a nine graft in there. Absolutely not. Six is fine. Yeah, so I think there are some studies that show that some bigger grafts can have better functional outcomes. You can certainly oversize the notch and that's a huge problem. So I think scoping the knee first, assessing their notch size, trying to kind of match what their normal anatomy would be or should be. And with a quad graft, that's what I love about it is you can match the graft to what you want it to be. Okay. Now I think that I'd love to hear Volker saying, get rid of the dogma about this eight millimeter thing that everybody talks about. I think individuality in the graft is obviously very important. So we're out of time on the first debate. Can we get the debate up on the screen so everybody can vote? Calm down, Volker. Oh, it's tight. You just want to make friends in Charleston. I know. Don't worry about it. Pittsburgh is a nice place. You're all invited to come to Pittsburgh anytime. It's an international place. Beer's on me tonight, guys. All right, I think we can see where that result's going. I'd like to thank both speakers. Excellent debate. And we'll hand it over to Nick to chair the next debate. Terrific.

ACL reconstruction techniques

transphyseal method

hybrid method

all-epiphyseal method

individualizing graft size