Dr. Nirav Pandya presents "I Kneed Surgery: What’s New in Pediatric ACL?" at the UCSF Pediatric Musculoskeletal and Sports Medicine Conference 2023 in Berkeley, CA.
Um our first speaker today is Dr Pandia. Doctor Nara Pandia is a pediatric orthopedic surgeon and sports medicine specialist within the U CS F Department of orthopedic surgery, Vice Chair of pediatric Operations and Section chief of the division of pediatric orthopedics. Doctor Pandia received his undergraduate degree from the University of Chicago where he was elected to the Phi Beta Cappa Honor Society and then received his medical degree from the University of Chicago Pritzker School of Medicine. He completed his orthopedic surgery residency at the Hospital of the University of Pennsylvania in Philadelphia and then completed a fellowship in pediatric orthopedic surgery at Ray's Children Hospital in San Diego. Um Doctor Pandia currently can be found co hosts the 6 to 8 weeks perspectives in sports medicine and he is an amazing Twitter and I g follow if you haven't done that already. So I'd like to welcome on his birthday. Doctor Pandia. I was, I was hoping Tom wouldn't mention it was my birthday. I'm not a um So once again, thank you everyone for having me uh today to speak and I wanna thank um everyone for organizing a really wonderful course. Um I am unfortunately on call as well too. So after my talk, I'm gonna have to run to the hospital, but, um, feel free to, uh, send me any questions on my emails on there as well too. Um, so I'll be talking about pediatric AC L injuries. Um, I don't have any disclosures and I think it's important to understand where we've come in terms of treating pediatric AC L injuries. So, historically, if you look back 15, 20 years ago, many of you who, you know, played sports, you know, especially if you're in your thirties and forties, you don't remember anyone ever tearing their AC L when they're in junior high. Like kids may have sprained their knee. You know, you just didn't hear about, you know, a 12 year old coming in with a hinge and knee brace because it just underwent AC L reconstruction. And a lot of it has to do with the fact that for a long period of time, the traditional thought was that kids didn't tear their AC L because the ligaments were stronger than bone, the ligaments wouldn't dam get damaged and you have injury at the bone. So kids would break things in their knee, but they wouldn't necessarily tear their AC L. So a lot of times there are probably a lot of kids who tore their AC L and just never knew about it because they got x-rays. They are normal and they just kind of went on their way. And I think we all knew kids growing up who maybe just kind of dropped out of sport or just kind of had knee injuries or knee issues and just never really got, got back on the field. And a lot of those kids potentially did have AC L injuries because we just didn't know that those existed. But if you look at what's going on right now, we're seeing a tremendous increase in ac O reconstructions. And part of that has to do with the fact that we're identifying these injuries. But a large part of it also has to do with the fact that kids are playing sports in different ways. And a lot of that has to do with sport specialization as well as increased recognition of these injuries. And there are lots of different surgical techniques that have, have that have been reported. But really the root problem is that we're emphasizing skill development rather than fitness. So if you look around and obviously this changed a little bit during COVID, you just don't see kids just outside playing sports like you don't, you go to the park, you don't see kids just playing, pick up basketball, you don't see kids throwing a football around. Everyone is doing something specialized, they're trying to gain skill and a lot of those basic things. I know we all how many of you did the, the physical education tests when you're growing up and do sit ups, right? They don't do that anymore. Right. So, but a lot of those things we, you know, we hated, I hated that day. Um, but, you know, the, but like, the principles of like, flexibility, core strength, you know, like all these things that are really, really important, kids just don't get anymore because they're more concerned about how good they can hit a golf ball, how fast they can pitch as opposed to, like, let's just learn about just taking care of our bodies. And we, and as a result of this, we've seen a huge increase in injuries, particularly amongst youth soccer players. And there's been 100 and 11% increase in youth soccer injuries over the last 14 years. Um And you all know this, many of, you know, soccer players have kids who play soccer, I mean, just a setup for injury, particularly in the way that kids are playing soccer now, starting at age 56 or seven. Um and playing competitive soccer year round and there's been a 400% increase in youth ac L tears over the past decade. And this is funny because it's like several iterations of Tom Brady ago. But um there's, there's been a tremendous increase in how much we're seeing. And if you look at data nationally, um the under 18 age group is the number one group that's getting AC L reconstruction in the United States. And if you look at the 12 to 14 year old age group, which is super young. Um That's the second most, um you know, increase in terms of the reconstructions that are being done. So that tells you where, where the trends and where the injuries are right now. Now, really, really briefly, in terms of AC L function, I think it's important to understand what the AC L does and why it's important for kids to, for kids to be able to get back to activities as well as for preventing long term issues in terms of knee arthritis and degeneration. So essentially what the AC L does is it prevents the femur and the tibia from basically moving more than they should, particularly in terms of activities that involve agility or rapid change of direction. Um This is a great kind of anatomical picture of the AC L and the AC L has two bundles. It has an anti media which you see there on the right in a poster lateral bundle. Um but you can kind of see there. I think the visual really drives home why it's important in terms of giving your your knee stability. But the important thing to understand for kids, which is unique compared to adults is that there's the growth plate, the phys and whenever you're doing a pediatric AC L reconstruction, that's something that you have to take into consideration as well too in the way the bones grow from, from this Feiss and most of the growth of the lower extremity comes from the tibia and the femur, um which you can see here in this diagram. So essentially the way you do an AC O reconstruction is that you have to drill holes across the bone and then you put a new graft in there and we'll go through that. And the issue is if you do that in a very young patient, there's a risk of causing a growth disturbance. So you can get leg lung discrepancies, you can get angular deformities, you can get issues in terms of which way the bone is growing. So it's that's unique consideration of of pediatric AC L reconstructions. Along with the fact that some studies show that there's about a 25% re injury rate amongst pediatric patients. So not only do you have this risk of growth disturbance, but you're basically doing a surgery on these kids where they will have a risk, a quarter of them may potentially re tear again. And we'll talk about the reasons for that. So really what this is is that basically balancing this risk of damaging the growth plates, the risk of potentially not damaging the growth plate by not doing surgery. But then with these kids having instability and then developing arthritis with an unstable knee. So traditionally, you know, when we started realizing that kids were getting these AC L reconstruction, so let's go back 15 years ago where we're like, ok, kids can get AC L Terra, what are we gonna do about it? A lot of people were hesitant to operate on them and what was basically the natural history of, of these kids who had basically were just treated with a brace or were told just don't play sports. Um, they all had instability, swelling, pain and meniscus injuries. So you can imagine if you have a 12 year old come in and they've torn their AC L and you're like, look, just don't play any sports, don't do any agility activity that lasts for about two days. Ok. Um, kids just don't do that. But at the same token, you know, you have to balance that risk of growth disturbance. And when I see patients that come in who are younger, a lot of parents will talk about how they want their kid to get AC L reconstruction because they want them to be able to get back to sports, which obviously is the short term thing that a lot of these parents are talking about. But from a long term standpoint, I tell parents that look, part of the reason to get ac L reconstructive surgery done if you meet the criteria is that you don't develop degenerative changes down the road. So for a lot of parents, they may say, look, we'll just hold our kids out of sports. But you can imagine the day to day life, even if you are one of those kids who cannot do agility activities they're gonna be instability events, you're crossing the street, you're, you know, you're going up the stairs. If you don't have a functioning AC L, you're gonna develop meniscus changes, you're gonna develop arthritic changes. So it's something that also prevents degeneration in your knee. Now, this is drastically different than if you're 45 where there are already some degree of instability that your body can tolerate because there's already some degree of arthritis already in that knee. So there when you're older, it's more an issue of, am I gonna be doing activities that involve agility, not necessarily to prevent you from having degenerative changes that have already set in. So a lot of adults sometimes elect not to get AC L surgery because their activity levels don't, don't demand that they do it, but it's very different when you're 10, 11 or 12. So we do know in this picture that you are very young, you have an AC L tear if you're under the age of 18 and you don't treat it. It's gonna lead to this pathology of getting arthritis down the road simply because you don't have stability in your knee and the cartilage and the meniscus is gonna take the hit. So then the second question that it comes. Ok, great. Well, let's do these AC L reconstruction surgeries on kids. What's the actual failure rate? Ok. So this is a study that was done at Children's Hospital of Philadelphia. Excuse me. Down in San Diego. Sorry, there's another study from Philadelphia and they found the failure rate was about 10%. Ok. Now, if you think about adult AC L reconstruction, the failure rate is usually right around 2 to 3%. Ok. So keep that in mind that this study looking at the surgeries they did down, there was 10%. This is another study done at Duke, same, same kind of pediatric and adolescent population. They found a failure rate of 2, 19 to 20%. Ok. So once again, another high failure rate, this was the one done out of Philadelphia and you have a 10% failure rate, ok. So much higher than the than the adult population. And the probably the longest term study, this was done at a mayo clinic where they looked at um a very long, long term follow up on some pediatric ac R reconstructions and they found repeat surgery in nearly 28% of patients. Ok. So the reason why that's important is that when we're counseling kids for the surgery, it's not necessarily get your surgery done and you return to the same level as a professional athlete, there are risks in terms of monitoring for growth disturbance as well as the risk of a retear. And we'll talk about where that retail risk comes from. Ok. So if we look at kids who are basically are getting this surgery done, you know, 12 to 18 is a large age group, there's a lot of different kind of standards and where they are in terms of physiology, you know, some 12 year olds come to my clinic with a beard, some look like they're seven. Um, so, you know, like there's a great variety of kids, you know, in terms of where they are. So it's not just necessarily age, it's also where they are physiologically. So this was a study that basically looked at pediatric patients as a whole. So you're looking at patients who are under age 20 in which age group actually had the highest retail rate. And we look at it a little bit more specifically and they basically found that the kids who were in that 14 year old age group, basically the the eighth graders, the the freshmen coming in had the highest rear rate as compared to the super, super young kids who get ac O reconstruction who had more similar to an adult adult kind of failure rate. And then the college age kids. Now, why do we think this occurs? Why suddenly are 14 year olds, you know, getting tearing more than say those younger kids? Because you assume that probably the younger and the older kids are the ones that are gonna, aren't gonna listen as much. And it has to do with a lot of in terms of skeletal development. Ok. So in that age group, the 12, 13, 14 year old patients, they're the ones who are undergoing maturation, their neuromuscular control is changing. And also you have to think about where they are in terms of sport. So that's where a lot of kids are making that transition to trying to play competitively or make it, uh you know, on that next level team or have that path to play in high school. And you can imagine a kid gets an AC L surgery when they're 12, they've basically been out for a year and then they're trying to catch up with all these other kids who may have gone through skeletal maturity, they've gone through puberty and they're trying to catch up and play with them and then they place their knee at risk when you have kids who are 89, 10 11 or who tear their AC L. A lot of times those parents make the decision not to have their kids do cutting and pivoting in sport. So they're not at risk. And then you get the 16, 17 or 18 year old kids who tear their AC L and tearing their AC L basically is the end of their competitive athletic career because it's so hard for them, uh to get back if you're 17 and you're junior and something you're trying to hop into something in your senior year is very, very difficult. So a lot of this has to do about where they are in their sporting development as opposed to like something about their, um physiology in terms of how the reconstruction is done. So we think about failure rate, there are lots of different things that are being studied right now. Some think it's a graph something it's sport, some think of it's, you know, compliance with physical therapy, surgical techniques, skeletal development, there are multiple factors. But you know, the analogy I like to use with my, you know, pa parents and patients and clinic is that it's kind of like crossing the street. So the more uh more times you cross the street, the more likely you're gonna get hit by a car, get in an accident. Ok. So if you have an AC L reconstruction and you're going back to playing sports, that's where your risk risk comes from. So if you're age 14 and you're getting back into playing, you're, you're placing that graph into more at risk situations. So that's where the difference comes also from adults versus kids is that the more sports you play, the more cutting and pivot you do, you're more likely gonna re tear that. So that's where the higher failure rate comes. It's really about activity level. If you take an adult patient, a pediatric patient and you control for their activity, then they're gonna have the same retear rate. So it's not necessarily the surgical reconstruction that we're doing. It's what they're exposing their need to. So I think that's important to, to let parents know because sometimes when you tell parents that your risk, your risk of getting the surgery done and failing is 20%. They look at you like you're some sort of horrible surgeon. Uh, but in fact, it's that you're, you're placing that knee at risk. Ok. And then the next question, a lot of parents will ask, well, what are the, what are the risk of complications? So, what are the risks of growth disturbance? Ok. So we know that you're basically going into a surgery with a potentially 15 to 20% failure rate. And then you're also telling them that there may actually be a risk of growth disturbance. Ok. So this is a, a study that we did um a couple of years ago with our adult sports medicine group looking at all the studies that were out there for pediatric and adolescent ac O reconstructions. And obviously there are more than 1400 pediatric and adolescent ac O reconstructions being done, but this is what was reported on. So interestingly enough, if you look at the retail rate in our, in in this kind of analysis, we found that it was about 9%. Um and all that 9% you know, the ones who did retail got a second surgery, but there actually was only a 4.1% rate of growth disturbance. Ok. So it is really interesting. So a lot of parents are concerned about growth disturbance and only about a quarter of them actually needed uh correction. So in general, I think the key thing in terms of treating these kids is if you use the right surgical technique, you're not gonna get issues in terms of growth. And really, it's how do we prevent kids from retiring when they get this surgery done? And how do we keep them healthy and happy? Because the end of the day, for me, it's not about them playing competitive sports or, you know, getting going on to get a scholarship. Um, it's about making sure that they're healthy and active into their adulthood. And a lot of times kids see their athletic participation as what, what am I gonna do for the next four years? Not, can I place my knee in a position so I can be healthy and active for the next 70 years? Ok. So I think that's really important and in terms of growth disturbances that we look at, um, you know, a lot of individuals think it's gonna be an issue in terms of you're gonna stop the growth on one leg. Um Honestly, what ends up happening with AC L reconstruction? We'll go through some diagrams that you're more worried about the leg getting a vagus deformity. So you're getting knock need. Um, and, well, I'll show you some pictures about why that's more of a concern and as opposed to one leg that's gonna be one ft shorter than the other one if you get an AC L surgery done. Ok. So really our overall goal and this is where a lot of the new surgical techniques are developed are balancing the risk of growth disturbance versus how do we put the AC L in the right spot? Ok. And it's a totally reasonable question that parents will ask and they'll say that's great. You're gonna do the surgery and you're gonna make sure that my kid doesn't get a growth disturbance. But is this AC L gonna be the same AC L that can hold up for them for the next 40 50 years of the life? Assuming that they don't have a re tear? And the answer is it's really based on the surgical technique. There's some surgical techniques that give the knee stability that basically don't put the AC L in the same spot as it would in an adult. And there are other techniques that basically give you stability can avoid growth disturbance. They're a little bit more technically challenging, but that can be the same AC L you have for the next, you know, the whole next several decades of your life. Ok. Now, when these kids come into clinic, ok, I'm sorry for this picture. Everyone doesn't like looking at this picture. Um But there are multiple things that these kids will complain about. Ok. Um A lot of kids in adults, it's usually a contact injury, but kids can come in with various different complaints. Ok? So you know, they can have an acute painful, swollen knee, they can hear a pop, they can lots of different factors that can come in, in the adult population. A lot of times people will have a very similar type of story. I was skiing, I was playing soccer. I felt a pop and my knee swallow for a lot of kids. What will happen is that besides the swollen knee that will, they'll sometimes give a history of some may not hear a pop. Some will continue to play for two weeks with the torn AC L. Some kids will say they've had instability for 2 to 3 years. So I think it's important to understand that unlike an adult, we think of this one huge traumatic event, kids will come in with multiple complaints. So if you do feel instability on your exam and they do have a history of swelling, I think it's important to work them up for it. And so in terms of kids coming in with a swollen knee, I think that should raise your red flag in terms of that, this might be an AC L tear or some sort of intraarticular injury. Kids don't get swollen knees like adults do who get it just for degenerative changes. They might have gout, they have, you know, other kind of early forms of arthritis, but a swollen knee kid uh warrants a work up. So, pre adolescence with a swollen knee, um you have a pretty even distribution of AC L injuries and miniscule tears in terms of adolescence, it's a much higher pop uh excuse me, proportion of AC L injuries. So kid comes in your clinic, they've got a swollen knee, definitely make sure you're working them up for an AC L injury. Examine them as such and get imaging if you need it in terms of the best test, in terms of physical exam. I do get a lot of questions for that. Uh a pivot shift test which some of you may know it's great for ruling in an ac R rupture, but it's almost impossible to do in a clinic. You're basically taking the leg, rotating it and shifting their leg around. No, 11 year old in clinic is gonna let you do that and then the parents are gonna look at you like you're crazy. OK? So it's something that, that's really hard to do the Lockman test, which is something pretty easy to do in clinic, um is best for ruling out in ac L rupture, ok. Um In the test which a lot of us learned in medical school where you flex the knee to 90 and kind of pull the leg forward. It's really not the best test in terms of telling whether there's a tear or not. If you have a meniscus tear, it can block it. Um You can also be just simply be blocked by your anatomy of your knee. So really the Lockman test, um which uh you know, you've basically taken the knee at 30 degrees and, and kind of trying to translate the tibia forward, um is the best test. Uh that's easiest to do in, in clinic. The next thing you wanna do when you have a pediatric and adolescent patient is assess their skeletal maturity. Ok. Chronological age is not reliable. So you really wanna look for physiologic age. So you're looking for markers of maturity. Um You wanna look on their x-rays if their growth plates are open. Um If you're comfortable doing Tanner staging, that's something you can do as well too. Um If haven't uh started their periods yet, that's another sign of skeletal and maturity. Um If they've had their growth spurt and if they're at least 10 centimeters less than their parent, then we consider that something that is a degree of skeletal maturity and if they haven't had a shoe size increase. So those are all various things that we use to get a sense of where they are to choose the appropriate surgical reconstructive technique. We always want to get x-rays because even though we're still kind of locked in on this being an AC L injury, kids can still fracture things. Ok? And MRI is really used to both confirm the diagnosis and look to see if there are any other meniscus tears or other kind of self tissue injuries. Now, the reason why I say this is that even though we're concentrating a lot on AC L tears, kids can still have injuries that mimic AC L tears that involve the bone. So this is called a tibial spine fracture. So a lot of kids will give the same exact uh injury kind of history I felt to pop and it was swollen. Um And you're like, oh, it's, this must be an AC L injury. Let's order an MRI. It takes a couple of weeks to get the MRI. And actually they, if you would have gotten an x-ray, you can see that actually, they pulled off the bone where the AC L attaches and that's something you want to get to relatively urgently. So, um that's part of the reason why we'll get x-rays and there's a classification system for that where it just based on how much the piece of bone has pulled off and we treat this by fixing the piece of bone back down, which is a much different surgery than an AC L surgery. You also wanna make sure that patients don't have Dyty Femur fractures. So this is a kid that actually came into my clinic, I think five years ago who was referred in for a quote, an AC L injury. No one got an x-ray on him. He came in into my clinic, got an x-ray and oh, he's got a Dyty Femur fracture, ok. Um So it can look like a big swollen knee and the kid was definitely very unstable because his bones were moving around. Um So once again, like get an x-ray first, you know, uh just to rule out fractures because it's important to do that, ok? Um And then obviously this kid didn't need AC L surgery. Um So all that being said and done, there's all the signs behind it, but this, this families will come to your clinic, ok? If you order an MRI and then that you get the results back and they're coming back to you for results or um you're helping to take care of them. I think the most important thing to understand for a lot of these families that this is a traumatic injury and it has severe social and emotional consequences for the patient and the family. OK? Um We talk about rehab protocols, we talk about surgical techniques, but for a lot of kids, unfortunately, the way sports culture is right now is that their life revolves around sports and even if they're not specializing, that's their social group, both for the parents and the kids as well too. Ok? And suddenly we're talking to them about basically extracting them from this, from this basically social environment. They're gonna be rehabbing for 9 to 12 months. It's hard. OK? And then you take in the fact that a lot of these kids are trying to play sports or have goals for that as well too. So I think more so than uh more than I spend time counseling about the surgical technique we're gonna use. It's about what does this mean for them and how can we socially and emotionally support them as well too. It's a big deal for a lot of these kids and their identity comes from playing sports or, and even for parents, that's their social group, you know, who's on their team, who they're seen every weekend. So, I think it's important to understand that and recognize that and then you have to assess their emotional maturity. So the worst thing I could do as a surgeon is operate on someone who's 11 years of age, who is not gonna listen to what we do. Ok? And when I was, when I first started in practice like, oh awesome, 11 year old coming in with an AC L. Let's let's go ahead and do this. I learned all these great techniques and the kid decided to play basketball three weeks after his surgery and re to his graft. Ok? And I, you know, learning early on that, looking at the family didn't seem to be someone who could kind of support that this kid going through this and the kid was not ready for it. So at that point, you're gonna will be have to be willing to take the risk of there being potentially some arthritic changes if you're gonna hold up on reconstruction, because the worst thing you do is have these kids go down the route of needing a revision surgery. Ok. So I think it's important that even though we can do it, it might not necessarily be the best decision uh simply because kids need to adhere with the protocol. And as many of the physical train, uh physical therapists here can, can attest to it's a very intense rehab that needs really buy in from the family, um as well as the patient to be very successful. Ok, so what are the treatment options? And this is where we're kind of going into some of the signs of what we're doing right now. Um We can avoid the growth plate completely. We can kind of tunnel things around the growth plate or we can go across the growth plate. And this is where there's been tons of uh kind of explosion in terms of what, you know, pediatric AC L treatment in terms of all these various surgical techniques. The one thing I always tell individuals is that a lot of these kids, even though they're involved in sporting activities, particularly for the 89 and 10 year olds, it's important to look at what could have caused them to tear their AC L. Ok. Now, 13, 14, 15 year olds, it does make sense, you know, they're just playing sports or doing more things. But if you get a seven or eight year old and you're like, oh, do they, are they more knock need? Do they have risk factors from an alignment standpoint? So I think it's important to look at the bony issues that may be causing them of AC L tears and correct them as well. Um, particularly if they're young or if there's some sort of kind of congenital issue that's going on. And there's one thing that if you want to take home from this talk is that when we're doing AC L surgery, you can either use your own tissue or you can use cadaver tissue in pediatric and adolescent patients. The risk of failure is four times higher, using solely cadaver tissue. Ok. So if you have patients who come in and say, hey, what, what graph do you think we should get, avoid cadaver tissue at all costs in and of itself, it's just gonna fail because it's not gonna hold up to the stress of what they're gonna do in their reconstruction. OK? So if you're skele immature and will tell you why this is important, you basically don't want to put bone or anything that has bone across the growth plate. So we can use hamstrings and we can use quad steps tendon and quad tendon is a relatively new graph that's being used. It was used 40 50 years ago. And now it's really greening a lot more um interest now is simply because it's a bigger graft. If your skele, I mature, you can still use those soft graphs. But you can also use graphs that have bone attached to it as well too. But really more and more what's what the trend is for a lot of these patients is getting a quad seps tendon graft. That's a graph where you're basically taking a portion of your tendon. It's very thick, it's very predictable and has good mechanical properties. So that's really becoming the gold standard, particularly for female adolescents in terms of how you're gonna be basically doing a CL reconstruction, but sometimes it can be hamstring, it can be a patella tendon just based on their actual activity level. But quad seps tendon is really gaining a lot of popularity uh based on various patient factors. There are other things we can do as well too to help prevent uh patients from re tearing their AC L. Um some of you who kind of look a lot of x-rays. So many of you heard of a sago fracture when people hear what that is? Ok. So that's basically a little fracture you'll see on x-ray kind of on the lateral part of the, of the knee um that you'll see sometimes with AC L AC L injuries. And the thought is that there's this ligament called the anti lateral ligament that gets injured. Um So now what we've started to do a lot is particularly in high risk populations is reconstruct or repair that at the same time as an AC L surgery. And that has been shown to help decrease rete rates. And part of that is that you can imagine that when the knee rotates, um that's gonna stress the AC L as well too. But if that ligament on the outside is also damaged, um that can also lead you to have some instability rete rate. So there's a huge push now to potentially reconstruct or repair that ligament as well too at the same time as an AC L. So you may see more and more patients coming in and saying, look, I got my AC L done and I got my A L L and you're like, what's the A L L? I haven't heard of that before. Um That's that ligament that basically attaches kind of on the outside part of the knee that can help give you more stability to your knee. Uh at the same time that you do an AC L reconstruction and there are multiple studies that have shown that, ok. And probably the newest trend in AC L reconstruction is something called the bear implant. Have some of you heard about this in the news or in the New York Times? No. So what the bear implant is there is a um uh orthopedic surgeon at Boston children's named Martha Murray, who's basically spent her whole life, basically trying to figure out how we can get ligaments to repair. Ok. Now, extraarticular ligaments like the MC LLC L, they have very good blood supply so they can heal a lot on their own. But AC L tears don't heal on their own. And part of that is due to the fact that it's intraarticular and there's not good blood supply to that. So, what Martha Murray developed was basically this something called this bear implant, which is this collagen sponge that you can basically implant into the knee when you have a torn AC L and the AC L primarily repairs itself. Ok. So this is very different from an AC L reconstruction where you're basically taking a piece of tissue and putting a brand new tissue piece of tissue inside the knee. This is basically allowing you to heal your AC L. Um it's been shown to be very successful, ok. The AC L does repair itself. Um They've done MRI studies and, and they're now starting to kind of bring this implant out across the country. Um in terms of re tear rates and some of the early studies um in pediatric and adolescent patients, the re tear rates are still the same. So it's still kind of right around 10 to 15%. But what they are seeing is that when they go back in to do this, the second surgery after they've pre torn, they don't have as many arthritic or degenerative changes in their knee. So the thought is that even though it may not be preventing re tear, it can, can prevent potentially arthritic changes at the time of a re injury. Um And there are very specific indications for this there, you know, you have to have a clean tear where it's right in the middle. Um You have to have no other uh kind of arthritic changes in the knee. You have to get to these patients relatively early. Um But this is something you'll hear more and more about um in terms of repairing the AC L using this kind of uh uh this kind of device as opposed to doing a full on reconstruction. So we're still within the first 2 to 3 years of this being kind of um kind of done more nationally. But this probably is the, the biggest thing that may change how we we treat AC L S where we don't necessarily have to take piece pieces of tissue from other parts of the body. Um Instead, we can just repair it um utilizing this device. So a lot of great science behind this and they give you a nice teddy bear when you get the surgery done too, you know. Um and then finally here in the last couple of minutes. So if you, if you, if you don't have access to this kind of new technology, which we're still learning more about basically A L reconstruction involves drilling holes to basically get this new graft in. OK. And there are various ways you can do that, OK. So things we do to avoid damage to the growth plate, drill small holes. So we don't holes. So we don't basically make uh damage in terms of growth disturbances. You want to put soft things across the growth plate. OK. So that means quads tendons, hamstring tendons, you make drill holes in different ways so that the cross sectional area of the growth plate damage is much smaller. OK. So kind of the traditional technique that had been used for a long period of time is called the I T band technique. It was developed out of Boston where you basically take part of the I T band and loop it around. The need to basically simulate the AC L. The AC L is not in the anatomical location, but it gives you stability. Um And you're basically just taking the I T band and looping it around and kind of attaching it to the leg. And that kind of mimics an AC L. The advantage of this is that you're not making any holes. It's the one technique that doesn't involve any holes across the growth plate. It basically kind of stabilizes the need, but it's not in an an atomic position. So that's the reason why some of us don't do this technique. The technique that I utilize and a lot of people across the country do is basically drilling holes just like you would in an adult surgery, but you're avoiding the growth plate. So you're basically putting the graft in the knee where it normally would go, but then where it's exiting out, um avoids growth plate damage. You can sometimes modify this a little bit and just kind of avoid the growth plate on the, on the femur, OK? And just basically grow across the tibia. Um So that's a technique that we utilize a lot. And then sometimes if kids are old enough, you can just go right across the growth plate. OK? But what you're doing is not putting any pieces of bone across, across the growth plate because putting bone across it will essentially lead it to stop growing. So these you typically do in 14, 15 and 16 year old. So a lot of it has to do with the fact that you number one, look at where they are in terms of their skeletal maturity, what their activity level is. Um And then have a decision with the parents about what they feel the best technique is. Um And basically based on that age where they are, you have all the various different techniques. So it's assessment of what they look like an X ray, what they look like physically what the parents want, what the best graph choice is. OK. The one thing we want to avoid is this revision surgery. OK. The reason why revision surgery is bad is it's another surgery you can imagine going through 9 to 12 months of rehab, you retear again and you're doing it again. OK? And the outcomes are really bad when you look at in terms of revision surgery, in terms of people getting back to high level sports activities, you basically this was a study looking at 90 revision AC L surgeries. And you can see that even with the revision, they retour about 20 to 25% of the time. And you know, there's very poor patient reported outcomes and, and this has been shown in this study as well too. So, the only time I tell kids and we'll talk about prevention in the last couple of minutes here. The only time I tell patients and families that they can't go back to sports, um, is not after the first AC L surgery, but if they have a second AC L tear and need to go through surgery again, then I say it's time to reconsider what sports you're gonna be doing. You can still be healthy, you can still be active, you can run, you can swim, you can play things like tennis, but playing competitive sports after a second AC L surgery can be very different, difficult. Um, some families will want to take that risk and there's a higher risk of re injury. Um, but that's where I begin to counsel. Maybe it's about time that you, you think about playing something differently. Ok. And finally, I think the most important thing is even though I love doing these surgeries, if you never tear your AC L, that's the best thing. Ok. Um, you know, if we can prevent it. Um, and there are multiple risk factors I've identified that lead to you to tear your AC L and a lot of it has to do with landing mechanics and landing with your knee in which we call kind of valgus collapse, ok? That will place a lot of stress on your AC L, ok? So some of the risk factors that we see and these are things that we'll assess when kids come to our clinic for just knee pain or come in for an ankle sprain. And let's let's look at your risk factors for having an AC L injury. So a lot of individuals who tear their AC L will very quad dominant. Um they'll have asymmetric leg strength. Um They'll have less core strength and a lot of times they'll have these massive quads, but they don't have any core strength and they drop into August and I'll show you a picture of that and the bones and ligaments absorb the force rather than the entire muscle contraction. The risk factor is obviously high demand sports, um an atomic variations in terms of how big your notch is inside your knee. Um Females are at a higher risk 3 to 1 in terms of tearing AC L s. Um And a lot of that has to do with kind of bony anatomy. Um in terms of in some degree of ligament is laxity. Uh how many of, you know who Robert Griffin the third is in football? Ok. So phenomenal athlete obviously had a uh lots of issues with his knee and you can see massive quads, great athlete. We look at how he's landing at the NFL combine. Ok. All right. So, and obviously his career was derailed by various knee injuries. And you know how, um, his coach, the coach, part of it was the coach who is here with the 49 Ers now used his, uh, used him when he was with the, uh, with the Washington football team. So you can see how, um you know, no matter how good and strong you are dynamically, how you're moving places, you at risk for your AC L. So I think that's really, really important what we do in, in terms of physical therapy as well too, there's a static component to it, but dynamically how you move um is really what's important. So in summary, now that you can all do AC L reconstruction after this talk, um AC L injuries are tremendously increasing. A lot of it has to do with just the way kids are playing as well as the fact that we're, we're recognizing a lot more you really are in terms of these patients balancing the risk of growth disturbance that if using the right technique is relatively small um versus the risk of delaying reconstruction and them having arthritis. Um and then also balancing this risk of growth disturbance versus the rate of, of them failing and needing a second surgery. We do know that if you don't treat these kids, there's a higher risk of arthritis. But they do have a high, much, much, much higher failure rate than the adult population. The most important thing is assess the family and patient for if they're emotionally ready and socially ready to undergo the surgery because it's a lot of buying, it's a lot of time. In order to achieve success, there are various ways to assess skeletal maturity and how you assess it and making sure you have a consistent way of assessing. It leads to the surgical technique that use um always get rays on these kids because you want to make sure you're not missing a fracture. Um and be consistent, have a consistent age based treatment algorithm. I think that's really, really key for treating these kids and try to prevent them from having tears in the first place. There are a lot of modifiable risk factors that AC L prevention type programs it can do to make sure kids aren't dropping their knee in when they're running, making sure they have appropriate core strength, the FIFA AC L prevention exercises that are great. There are multiple things that you can do. So. Thank you very much and I appreciate you all listening. Thanks.