Thank you, John. We have two minutes for any questions, so if the panel come up here, please. I'm going to start with a short question from Todd. I like your algorithm, but after that topic, do you think there is a place for the repair in that population, and if it is a place, in which percentage you perform a repair? Microphone please from Todd. Yes you have three, you have three now. There we go. So yeah I think that I think that Dr. Murray's work is is incredibly exciting. I think we're potentially right on the cusp of a change and I hope that that some of the data that that she and her group are able to put together will help define that, define that for us. Obviously, a repair in a skeletally immature kid would take a lot of the issues we have with drilling tunnels across the phisis away. Okay. Frank? Oh, sorry. Dr. Harner. Tess? Thank you. This is for Ted and Frank. I was trying to catch the size of the grafts. I didn't hear what size your tunnels were for your all-epiphyseal. Were they 8, 10 millimeters? And you were using hamstring, correct? Yes. For all-epiphyseal, using an all-cell tissue graft. Hamstrings. Right. You don't use quad tendon? I have been using quad tendon. So based upon recent data, I've been using quad tendon, but it's in the past few years. So I don't have publications on that yet. And the size of your tunnels? So that sometimes depends on the amount of tissue you get from your hamstrings. Right. So you drill your tunnels after you get your hamstring? So yeah, drill the tunnels after getting the graft. So I will actually... I think that's an important point. Yeah. So we'll probably get a quadrupled semi tendinosis and gracilis, because some of their hamstrings are smaller. We will also put those under tension and then put them in progressively smaller sizers to compress down the graft to put those in place. Frequently we'll get either an 8, 9, or 10 graft doing that technique. So Chris, your question's a very good one for a number of reasons. So first off, from the adult literature, when I was using hamstrings, we were concerned about having a diameter that was too small. So smaller than 8 or 8 and a half. Does it matter the size of the child? Well, that's what I was going to get to. So in our algorithm, we do use the modified McIntosh, popularized by Lyle McHaley, if the epiphyses are just so small that you can't fit a socket. And that's... That's a great point. That's typically under 80 pounds in our experience. I mean, I'd be interested to hear what Ted and Todd have to say about that. So generally, if the child is less than 80 pounds, we'll use the modified McIntosh. If they're older than 80 pounds and we're using an all-epiphyseal, historically it was based upon the diameter of the hamstring that we harvested, which was typically 8 and a half to 10. The other point on this is, there is this issue now of stuffing the notch, and the group at Pittsburgh and Volcker have looked at that. So that is a concern. You don't want a graft that's too big for the child. But my pediatric colleagues here have done a lot of great work analyzing the size of the notch after the age of 11, and it doesn't change much. And I'll let them elaborate on that, because they've done some fine work in that area. And completing the question, I was thinking about a small patient that sometimes you said, yes, diameter is always important, talking about the graft, but maybe 10 millimeters is too big for that tibia. So in that case, is what you prefer, to perform an eight with more compression, or you have another tip? So that seems to work itself out. So much smaller children tend to have smaller diameter hamstring grafts. And so that hasn't been an issue. It's not like you get a seven-year-old with a 12 millimeter diameter graft, it's just not going to happen. So now if you're harvesting quad, you can harvest any size that you want. So you have to take that into consideration. The other question I had was just on, when you do all epithelial, it's a smaller graft, it's shorter. And the graft tunnel mismatch is real. How do you calculate so you don't have graft tunnel mismatch for length? Because it's very easy to be too long at that technique. And also, the button on the tibial side bothers me. I don't think that's great fixation. So you've got to do a little math, you've got to be precise with that. And if you happen to find that you've bottomed out, you can take a little curette to the tibial tunnel, you can pull that through, and you can fix it just like Alan Anderson did with a screw and washer or an anchor or something like that. So there are options. For the panel, why not just do a regular tunnel? Because on the tibial side, we don't have as much trouble with the growth injury because it's central. And then you wouldn't have to worry about graft tunnel mismatch. You're describing the hybrid and that's an option. Okay, last question. Yes, my question. For the panel, what do you think about the... We have two questions. Dr. Lorraine, sorry, I don't see you. What do you think about the graft for the mother or father tunnel? Parent tunnel. What do you think? That Australian group published. Did you recommend that? For the younger children, about 80 years old, that they have very difficult to give a good size of the graft. Okay, that's a good question. As you know, Leo Pinchefsky from Australia has published on that. At least in North America, and certainly not in New York, we haven't chosen to use that. And as Ted mentioned, the graft diameters haven't really been an issue, whether it's hamstring or quad. And in the very young child, we would be using the ITB over the top combined intranextroarticular. My question goes to the panel. If we have a pediatric ACL torn in a nine years old with a genovalgal, okay, what are the end lines? When do I do an associated procedure? And if this will affect any of my technique or a graft choice or a fixation technique? How does an ACL tear in a young people? We always get a standing alignment films in all these kids to follow growth and alignment. I have to tell you, in 10 years of practice, I've not found one that's been in a ridiculous amount of algaes that I've considered a guided growth. I don't know if anybody else has ever done a combined guided growth and ACL. I've done an osteotomy with somebody with a deformity and an ACL concurrently, but it's rare. We've, my partner Dan Green and I have done a handful of combined ACL reconstructions and bilateral implant mediated guided growth. Usually it's more than 10 degrees of fixed valvus. And so it's in that setting, that's what we've opted to do. Even if it's equal on both sides, he has a bilateral and the same degree almost. Do I address it while doing the ACL or I proceed with the ACL? Again, what we have done, if it's more than 10 degrees, and there's no data to support this that I'm aware of, but this is what we've done because we believe that they're at high risk with, there are two components to this dynamic valgus, which is really neuromuscular and then fixed valgus. And so in the fixed valgus population, more than 10 degrees, if they're really playing at a high level, a competitive level, our feeling has been to do both at the same sitting and in that way, avoid the potential for recurrence. And the implant mediated guided growth piece is not a big part of the rehabilitation process. So it's a relatively, and again, my colleagues who do this every day can speak to that more effectively. Dr. DiFelici has the last question. If the great talks, by the way, if the panel could address, it's interesting with the kids, we talk about reconstruction of all the different types. And then some talk is given about conservative, which doesn't really fly well. But the repair argument is very compelling in the kids. And although there's a lot of concern since Albright's paper came out, you can look at his paper and say, well, heck, we have 50% failure rate, and that is totally unacceptable. Or you can look at that paper and say, well, that's 50% of children, very young children, average age 14, who had a very small surgery that's a hell of a lot easier to get over than a reconstruction. And so I'm just wondering where it all fits. Does repair end up being conservative plus and not considered a big surgical insult given the low morbidity of the modern procedure? If you guys would just kick that around, that'd be great. Yeah, I think that's great. I think your work and Jay's work is pioneering and is a great addition. It will be one more tool in the toolbox that we'll have. Jay's philosophy has evolved from the mid-subjects to the more proximal, like you've discussed as well. I think there's certainly a role in that. We're a bit conservative to have that learning curve develop before we do too much in that regard at this point. OK. John, you have the last thought. You have to close the symposium. Certainly, I think the idea of fixing ACLs is very compelling, but I would still regard it as experimental. These results have to be followed, not just for two years, but for five years. But I would be very hopeful that if it works, it's going to be a game changer for what we do in ACL surgery going forward. OK. Well, thank you very much. And if you want an update...

ACL repair

pediatric patients

grafts

hybrid procedure

less invasive