So, essentially, the gist of our study was to look at the paradigm of does type 2 tibial spine fractures, does it reliably reduce if you bring them out into an extended position? And we used an MRI protocol to do this. These are my conflicts. So, the classic paradigm for type 2 tibial spine avulsions is to attempt a reduction with extension. The papers quote anywhere between 3 to 5 millimeters within the position of normal. And if your fragment reduces, then you immobilize. If you get an inadequate reduction, then you treat them surgically. Personal observations is I've had some individuals in clinic where we've gotten multiple views on the lateral view where the fragment, depending on the amount of rotation and obliquity through the radiograph, has changed how it looks. Also, if you look at the arthroscopic evaluation of tibial spines when you're doing the surgery, you know, I was surprised at how little the fragments moved. And sometimes, like the video here, that some of the type 2s even get worse with their position when you bring them out into extension. So, we took type 2 tibial spine avulsions and compared two different MR images. And we had them in a resting knee flexion position, and then we brought them out into extension. And our hypothesis was that it was an inconsistent reduction with extension. So, we had a prospective case series. Our inclusion criteria was looking at patients that were less than 18 years of age. They had to have a type 2 tibial spine. Our exclusion criteria really limited us because we had to have individuals and children that were able to fully extend their knee in order to include them in the study. And then we also had to obtain an MRI within 10 days just because we didn't want to have individuals that were enrolled in the study that had an MR and already had maybe potentially some healing that caused our fragments to not move. And then they couldn't have any other injuries. So, we had three different distinct images that we looked at. We used the lateral radiograph to look at the fragment to make our diagnosis. And then we got the two different MRI protocols for looking at flexion and then extension. In the flexion position, we did 2 millimeter thick cuts, and we looked at the position on a 20 millimeter, or I'm sorry, 20 degree foam. And in the extended position, we used thigh and tibial straps to bring them out and make sure that they're in a neutral position. And then we kept their foot in a neutral position as well. And this was performed without anesthesia. We measured knee flexion angles, extension angles, and then we looked at the max displacement of the fragment on the flexion and the extension MRI films. And then we did statistical analysis, PRT test. So we had 10 patients, 7 males and 3 females. The mean age was 10 years of age. Our mean flexion angles were quite consistent with a mean of 28, and the extension was right around 1. Despite being significant, the displacement only reduced by a mean of less than a millimeter in the extended position. So I know this is a busy slide, but I think when you have a small number of individuals, it's good to look at the actual raw data. I think the area where I would want you to concentrate on is this area of the MRI in the extended position. If you look at all 10 of our patients, we weren't able to get any of them to reduce less than 4 millimeters on the sagittal views. The other issue that I would bring up is that if you look at intermeniscal ligament entrapment, which is considered a reason for the blockage to the reduction, our numbers were about the same as what's quoted out there in the literature. We had 4 of the 10, but it didn't matter whether the intermeniscal ligament was what was blocking or not. The inability to get reduction was similar between those with IML entrapment and those that did not have it. So the limitations of our study, it's a small study, it was a really difficult patient collection as you can imagine with kids. You have to be able to get them out into full extension, and some of them just couldn't do that. And then we had to make sure that we got MRIs within 10 days so that we weren't having any early healing that inhibited our ability to move that fragment. And really the study is only evaluating whether extension reduces the fragment. It doesn't address whether we actually have to fix those or not. And so from a conclusion, none of our reductions went down below 4 millimeters. The amount of reduction didn't correlate with IML entrapment. And then obviously it would be nice to have a little bit of a larger study, and then we certainly have to answer the question in the future of how much displacement is too much. Thank you. Thank you, Steven. Next study is all inside anterior cruciate ligament reconstruction with hamstring autograft. Consistently yields grafts with 8 millimeter diameter or larger, Dr. Looney. Thank you. So the reason for undertaking this study was that the attending sports medicine physician at our institution five years back switched from a technique using interference screw fixation to an all inside suspensory technique for his hamstring graft ACLs. No disclosures. So we know from previous studies that have looked at hamstring grafts for ACLs that patients that have a larger graft diameter do better, and specifically a minimum graft size of 8 millimeters has been associated with a lower risk of failure in revision surgery. And additionally using conventional interference screw fixation requires a sufficient amount of graft length to extend into the tunnel to achieve appropriate fixation with that technique so that can sometimes result in some of the graft diameter or potential diameter being sacrificed in order to have enough length in the tunnel. And then finally higher rates of failure have been reported with allograft augmentation. It's especially the case for younger patients. So we wanted to establish a very easy to follow intraoperative algorithm that would allow surgeons to consistently get grafts of the minimum of 8 millimeters without having to use allograft tissue. So we used the all inside technique for reconstruction and then hamstring autograft. We would harvest the semitendinosus tendon and then size that and if the size was deemed insufficient we would then go back and harvest the gracilis as well and incorporate that into the graft. And we believe that following this simple algorithm would allow us to consistently create these grafts without having to use allograft. So several methods have been described for combining these tendons. It's not necessarily a novel technique. We wanted to follow a very simple method though and where other authors have previously suggested the creation of five-string or six-string graft constructs. When harvesting the gracilis we just preferred to trim them both to the same length and then wrap the ends around each other in opposing directions and then use that as a thicker tendon to then create the typical four-stranded graft construct while maintaining equal tension on all limbs of the graft as seen here. And then both the tibial and femur sockets are retro drilled and the graft is suspended at both ends with suspensory cortical fixation. So we reviewed all consecutive cases of ACL reconstruction over a four-year period and then reviewed the operative dictations to determine the technique and then also the graft size. We included all primary cases of ACL reconstruction in which hamstring grafts were used and we did exclude cases of revision and then other graft types like bone tendon bone or quad tendon. So we identified 113 eligible cases including 70 males, 43 females. All patients that we identified as being eligible did receive a graft of at least 8 millimeters and in fact 93% of them had a graft of 8.5 or larger. And our mean graft diameter in this study was 9.3, the median was 9.5. We did find that overall males had a significantly larger graft than females but even with a smaller graft size no females had a graft below the 8 millimeter ideal minimum. And then just this graphic just depicts the distribution of graft sizes which is you would expect is a little larger with more patients having larger grafts with the combined tendons. So in conclusion we did find that using this technique we were able to consistently achieve grafts of the ideal minimum of 8 millimeters or larger and we did find that females had significantly smaller grafts but these still met the ideal size characteristics. We felt that this technique allows surgeons to consistently achieve the ideal graft minimum and following a very simple technique without having to form different kinds of grafts and different stranded graft constructs. And this was the largest series that we had found in the literature where graft size was reported. Thank you.

type 2 tibial spine fractures

extended position

MRI images

reduction of fragments

graft size