If you believe that tunnel is, that graft is eight millimeters, you should see Dr. Kelly for his Brooklyn Bridge for sale. So no relevant financial disclosures. I do want to disclose Volcker's way smarter than me, but he got this one wrong. Many patients do need Fiseal sparing surgery, just not a 13 year old, or at least a physiologic and chronologically 13 year old. So there's no one-size-fits-all solution. There was a patient who I was doing, planning to do a trans-fiseal ACL on a couple of weeks ago, got in there. His Tanner score was really low, so we actually converted and pivoted. So the one on the left is a 14 and a half year old who got a Fiseal sparing. The one on the right is a 13 year old who got a trans-fiseal, and these were both done within a couple of weeks of each other. So you can't ignore the Fises, you got to respect it. So I think on any skeletally immature patient, you need to do a thorough workup, ask about their parents height, you know, preoperatively assess Tanner stage. You might need to change your decisions intraoperatively. So why do we care? Fiseal sparing is less familiar for most of us. It's technically demanding. Traditionally we think kind of high risk, high reward, but I'm going to present some data that it's really not as high reward as we think. Why do we care? We want to avoid this. This is not what you want with a lot of distal femoral valgus, complete obliteration of lateral Fises. This surgery started or ended right at the perichondral ring, so not exactly what we're looking for. Let's get back to the basics. There's a lot of animal data that would suggest that you need more than 7% of volumetric Fiseal disruption on the femur and more than 4% on the tibia to lead to a growth arrest, and we know that the most important factor that's going to lead to a change in the volume is the diameter of the graft. This is a really nice study done out of Georgia Tech and Emory, and basically if you've got a 9 millimeter graft drilling at a reasonable tunnel angle, you're going to be way below those thresholds that were shown biomechanically. Changing the angle of your tunnel actually does not change the amount of volumetric disruption very much within reason, but changing the diameter of the graft very much does. And we know that Fiseal damage decreases linearly with age, and so patients who only have a couple of years left of growth probably are not going to have a problem. But let's look at the outcomes data. So kind of bigger data set, systematic review, over 300 patients. In this study, overgrowth was more common than growth arrest, and of the eight people with femoral base deformities, three of them had epiphyseal tunnels. Another study looking at all epiphyseal femoral technique, of the 12 patients in this group, 50% of them had overgrowth, and two of them had what was called significant overgrowth, more than 20 millimeters. Again, another systematic review comparing trans-fiseal versus fiseal sparing. So over 700, almost 800 patients in the trans-fiseal group versus 160 in the fiseal sparing group. A little bit difference in age as you would expect, right, and more patients who are closer to that 13 or 14 are going to get trans-fiseal, but again, no difference in growth disturbance or graft survivorship between the two groups. Does it matter if we drill trans-tibial? Should we, you know, try and place it more centrally? This is a systematic review that says you can do an independent femoral tunnel drilling technique or a trans-tibial drilling technique with no difference with re-rupture or growth disturbance. But don't take it from me, take it from Volker. So these were two of his recent studies that he published, very low incidence of growth disturbance with soft tissue graft across the visus, and study of ACL, ACL study group survey looking at a 13 year old male athlete, majority of surgeons recommended trans-fiseal ACL reconstruction. So takeaways, growth disturbance can be seen with all techniques, you got to respect the physis, there's no one-size-fits-all approach, you got to do good surgery, use a soft tissue graft, for me that's a quad tendon, anatomic reconstruction, pick the right size graft, don't oversize it because that will, that will increase your risk of fiseal damage, avoid the perichondral ring, and follow your patients closely post-op. Don't sweat it. Thanks.

individualized decision-making

ACL surgeries

adolescents

growth disturbances

soft tissue grafts