Thank you. My disclosures are listed on the Academy website, but pretty much everything I do is volunteer and is listed here. These are our goals and objectives for this talk. We'll start with a case, a nine-year-old male, pivot, pop, and pain. You can see wide open growth plates. You've done an exam. We'll call this your office. They have a complete ACL tear. It's isolated, and they're nine, and they're skeletally immature, pre-adolescent, and you elect to rehab and restrict activities. One year later, they're unstable. They have a bucket handle meniscus tear and no ACL, so you're considering surgical options. In terms of surgical delay, even without a meniscus tear, what are the consequences? Todd touched base on the issue of odds ratio, four to 11-fold increased risk of irreversible meniscal changes and grade three and four chondral changes. This patient on the left is a 14-year-old patient of mine with a two-year following and ACL deficiency who did not restrict his activities. So we have a patient with greater than two years of growth remaining, and we're considering operative treatment. These images are from a clinic in sports medicine text. We're going to focus on those with wide open fices, which can be the all-epiphyseal or the hybrid that Todd described. So all-epiphyseal can include all-epiphyseal femoral tunnel, which is a growth plate avoiding procedure on the femoral side. It can include this hybrid case, which is transficial growth rate respecting on the tibial side, but for the purposes of this talk, we'll focus on all-epiphyseal femoral and tibial tunnels. This was emergently described by Alan Anderson. I reviewed that for JBGS in 2003. He showed with KT1000 scanograms and return to sport favorable outcomes with no limb length discrepancy or growth arrest. So therefore, we developed a variation of that with all-epiphyseal tunnels and fixation. And I'll discuss the treatment philosophy behind this treatment technique. So we'll note here an ACL footprint represented with the blue dots, and we'll call that our anatomic footprint. And we'll have a standard adult type ACL drilling angles as shown. For the all-epiphyseal ACL, we'll have the same footprint, we'll simply vary the drilling angles. Well, how do you know you have reached that native ACL footprint? Well, the principles are described here from the AJSM article of this footprint. And this is a patient of mine from our article on that technique. It's not a perfect lateral, but it shows you can get to that location. Freddy Fu described for adult ACL surgery the need for 3D CT to confirm that they've reached that appropriate location. Can we do that when developing a new technique? So what was done was we used intraoperative 3D CT to confirm that we can get to that location in all three planes, the coronal, axial, and sagittal images as shown here. You'll note the undulating nature of that distal femoral physis on these images. This was further confirmed by other MR studies by Dr. X from Atlanta, and in vitro studies as well. In terms of the technique, we'll have the black rectangle representing your femur, and the green showing it as your standard femoral incision. We'll say our drill guide is approximately 115 degrees for those cases. For an all-epiphyseal, I show the red circle showing your all-epiphyseal drilling site. Your drill guide will be at approximately 90 degrees. And I will show here one-way short form after having done these different techniques to get your correct location. A short version of that is to draw out the distal femur epiphysis, and then you complete that circle with an artificial dotted line, make a bisector from that, and I'll start my incision just above the equator of that. Keep in mind this all-epiphyseal surgery has less margin for error, so precision is more critical. You do want to check that. You can check that with the C-arm evaluation as well. Standard drilling for the tibia, if you use between 50 and 60 degrees, the all-epiphyseal drilling angle will be about 25 degrees. You can either bring your hand up with an adult guide, but you have to work pretty hard at that. There are now some pediatric guides for that to help you get that more easily. There are a variety of different fixation of ice. Alan Anderson described button techniques in a post. Again, screws can be used as well as button fixation. We'll currently use button fixation in a docking technique. This is a presentation from 2012, and Frank elegantly described that in print as well. All-epiphyseal surgery, however, does not need to be mine or Frank's or Todd's, but can be your techniques as long as you follow the following principles, that your tunnel addresses the native footprint and avoids the growth plates. Your fixation does not cross the growth plates, and your graft, we recommend autograft, which is any form which is stronger than your native ACL, and Frank elegantly described the use of quad tendon. I'd like to emphasize the importance of dedicated teams. We'll consider a dedicated team an expert group that frequently works together, whereas a casual team we'll describe as not regular or permanent in particular. And why is that? Well, it's important to, these surgeries have reports of instability, meniscal recurrent surgery. You can see a listing of superficial infection, arthrofibrosis, and contralateral ACL injuries, and that's for both the ITB and the all-epiphyseal technique. Limb length discrepancy has been described as well more recently in the past two years, but the contralateral aspect of that is that we have to balance that with the risk of chondral and meniscal damage. This dedicated teams can also help your efficiency. You can be more efficient in terms of your surgical time, ancillary service time, turnover time, and OR work time efficiency. In terms of rehab protocols, we recommend targeted rehab for these patients, including prehab, proprioceptive and balanced training, and keep in mind that these can, full return can take longer in this unique patient population. We believe in setting expectations for these patients, have a systematic review and meta-analysis for these patients, and keep in mind that male athletes, high school athletes, one season of football can be a little under 1% of injury. A full season of football, baseball, and basketball can be just over 1%. But one season of high school adolescent female soccer can be 1% per season, or 4.4% per year. So I'll give that to the patients and make them circle the sports they want to get back to. So therefore, we believe over and versus under age 25 is apples and oranges. Case in point is this is a patient who I fixed her olepipseal ACL, and six years later she had this injury to her contralateral, previously unaffected knee. In conclusion, therefore, we have literature to support this technique. We have review articles for you. There's an International Olympic Committee Delphi consensus. I credit Alan Anderson for the development of this technique. God rest his soul. There are risks with this, but there are risks with surgical delay as well. Hopefully we've addressed your goals and objectives, and thank you for your time.

ACL tear

case study

rehab

surgical options

all-epiphyseal technique