pleasure to be here. I think John Kelly deserves a great deal of credit with his committee for putting together a fantastic program. So I've been charged to talk a little bit about graph choice. And I will attempt to advance the slide here. Left side. Got it. Those are my disclosures, which are available on the Academy website. So much as you just heard from Todd, we developed this guideline, which was published in 2013. And it begins with the HSS shorthand bone age measurement scale. Once you've identified the skeletal age, then you can plug it into this menu of operations and select it based upon the amount of growth remaining. So moving to graph choices, I think I'll start by saying allografts in this population really has unacceptably high failure rates. And this has been documented across multiple countries, as well as thought leaders around this country and the world. So for the purpose of this talk, we're not going to be talking about allografts in the pediatric and young adolescent group. Of the autograft choices, you have iliotibial band, which is really part of the modified McIntosh, as was just discussed. Bone patellar tendon bone is limited to those young athletes who have less than a year of growth remaining or approximately a year. So essentially we're talking about hamstring and quadriceps autografts as your two choices for pediatrics and young adolescent athletes. And historically, it's fair to say the hamstring has been the workhorse in this area. I think more recently, and even in the adult population, the quadriceps graft has become much more popular. When people in my age group were training in orthopedics, the quad was basically reserved for revisions or for PCLs, as we heard from Chris Horner earlier this afternoon. So I'll move to outcomes, and I'm going to use a paper that we just published as an example of why the quadriceps graft has become more popular. So this was published in the March issue of AGSM. Dan Green and I and our group put together this perspective analysis of 324 athletes under the age of 20. The surgical technique was predicated upon skeletal age, and we had three groups essentially. Group 1 was this group of all epiphyseal reconstructions. They had three to six years of remaining growth. They were basically 7th grade and younger. They had hamstring autografts with suspensory fixation and adjustable loop constructs. Group 2 was a young adolescent group with two to three years of remaining growth, and these were basically 8th and 9th graders on the bubble between middle and high school, and they had partial or hybrid reconstructions or complete transfusial reconstructions, again with the same graft and the same surgical reconstruction. So hamstrings with suspensory fixation and an adjustable loop construct. Sorry. Group 3 was a skeletally mature adolescent group. These were 10th grade through first year in college, and they had patellar tendon autografts. If you look at the results of these 324 athletes in the breakdown, you can see that the all epiphyseal group had 49, the partial or complete transfusial group had 66, and the patellar tendon group had 209. The ages were obviously statistically different by design of the study, so there were 12, 14, and 16. The median grades, as you can see, were 6th, 9th, and 11th grades, and females were in the minority in Group 1 and the majority in Group 3. Sports participation at injury, 100%. All of them were involved in travel club or school levels of competition, and 75% or 243 played soccer, lacrosse, basketball, or football. When we look at the results, you can see that the revision rate in Groups 1 and 3 were equal, 6%, whereas the revision rate in Group 2, this is, again, this 8th and 9th grade group, was unacceptably high, 20% overall, and 24%, nearly 1 in 4 males retore their graft within 2 years of reconstruction. And that's despite the fact that the hamstring autograft diameter was larger in Group 2 than it was in Group 1. Similarly, the return to sport rates were lower in the Group 2 athletes. So we concluded from this study that while we had decent results in Groups 1 and 3 with a 6% revision rate and it compared favorably with the literature, it confirmed as well that the all-epiphyseal is not simply a bridge to an adult reconstruction, and we may hear more from Ted on this in a few minutes. The clear issue here was the etiology for poor outcomes in Group 2 was probably multifactorial. We do believe that level of competition may be a factor as they return to sport with a skeletally mature high school cohort that has not lost a year of physical development and sports-specific experience. But we also believe that the hamstring autograft, while it appears suitable for the 7th grade and underpopulation, it may not be up to the task for the Group 2 athlete. So what changes did we make at our institution? Well, since 2015, we've transitioned to an all-soft-tissue quadriceps autograft for this cohort, and we add an ITV tenodesis for select indications, which we might get to in the panel in a few minutes. The quad graft is robust. We choose to use a full-thickness graft. It's usually 10-11 millimeters in diameter. It's important to avoid injury to the muscle-tendon junction. And in general, this graft is, for the all-epiphyseal group, 60-65 millimeters, and the complete transphysial group, 70-75 millimeters in length, in that range. Thus far, within two years, we've had 35 athletes under the age of 16 approaching this two-year follow-up, 24 are complete transphysials, 11 are all epiphyseals. We have no revisions. Return to sport is 93%, and we have not had significant donor site morbidity, but this is preliminary data thus far. What does the literature tell us about the quadriceps autograft? Well, this paper from Innsbruck, Fink, and colleagues in Austria compared quads and hamstrings. This is in an adult population. They found the hamstring-quadriceps ratio was significantly higher in the quad group, and the flexor muscle strength was higher in the quad group as well. There have been three systematic reviews published in the last 18 months on graft options, including the quad, and this one, in essence, was a meta-analysis, 27 studies, nearly 3,000 patients. When quad was placed head-to-head with hamstring, they had better outcomes and better stability scores, and quad head-to-head with bone-tendon bone had less donor site pain. This is a paper recently published by Jay Albright in which he looked at 157 quad-tendon patellar bone grafts. This is not a soft-tissue-only graft. He does use the superior pole of the patella, and as you can see in his series with two-year follow-up, his revision rate is under 5%. So benefits of the quad autograft. I think we know that there are suboptimal options if a hamstring graft is insufficient. You can prep the contralateral side and harvest it. However, in this young cohort, there's already a high incidence of contralateral injuries. We can augment with allograft. Multiple papers suggest poor outcomes, but the literature is somewhat mixed in this. We know we can get more consistent size with a quad. Higher failure rates are demonstrated with a hamstring, and as I've mentioned, hamstring-quadriceps ratios are a concern with hamstrings, and this is particularly an issue with females. And then there's, of course, persistent hamstring weakness, even out to three years, and that can have an impact on knee kinematics. So in conclusion, choose the quad for this young population over hamstrings. Thank you for your attention.

graph choice

pediatric athletes

young adolescent athletes

reconstruction surgery

autograft choices