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The Management of ACL injury in a skeletally immature patient

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Summary

In this on-demand teaching session, medical professionals will focus on the topic of knee conditions, half on emergency cases, and half elective. The session will delve into the specifics of ACL injuries including in immature patients, and rehabilitation strategies for ACL as presented by a physiotherapy team. There will be discussions surrounding knee pain in a completely immature patient from both emergency and elective perspectives. An external speaker, Mr. A, convenes for a section focused on kidney-related topics. The session kick-starts with an interactive Q&A on ACL injuries in skeletally immature patients. Throughout, the discussion covers key topics such as ACL ruptures in children staging a sharp increase in recent years, the complications associated with conservative management of these injuries leading to an increased risk of long-term osteoarthritis, and the debates surrounding surgical intervention. This packed session is sure to equip medical professionals with vital knowledge and understanding of these pressing concerns within the field.

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Description

Infection

Pain

Alignment

Soft tissue Injuries

Learning objectives

  1. By the end of the session, participants will have a deeper understanding of the prevalence and causes of increased ACL injuries in pediatric populations.
  2. Participants will be able to discuss the complications associated with conservative management of ACL injuries in children and can illustrate the rise in early onset arthritis related to this approach.
  3. Participants will be able to critically analyze and discuss the range of scientific literature surrounding ACL surgery in pediatric patients, including potential complications and different methods used in the studies.
  4. Participants will gain an understanding of the potential hazards, such as growth plate damage and alternatives to surgery, in the surgical management of ACL injuries in children.
  5. Participants will be able to apply this knowledge to clinical scenarios involving pediatric ACL injuries, effectively answering higher order single best answer questions.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Welcome to the pe knee term. Well, for today and term for east of England is one of the senior registrars in the in the region. Um Today, we're gonna focus on kidney but half of it is emergency and half of it will be elective uh in the sense that they will be talking about ACL injuries including in mature patients. Um We have um, Hannah from Hannah and Hannah from the um uh a physiotherapy team to talk about the P MDT within the region and the role of rehabilitation in ACL, uh which are all very hot topics uh for both the Fr CS as well as nationally. You know, if you, if you've been paying attention to news about power up play, that's one of the most important things uh in around ACL, rehab, prehab and post surgery rehab, then we'll move on to um Mr Mitchell and LA I talking about um knee pain, uh especially in a completely immature patient, both from the emergency point of view or, and um, and an elective setting and I'll round it off with some fiber cases that are commonly, they commonly come up for that five, I have to advertise for our external speaker, Mr A uh who was one of the conveners for kidney conference this year at uh Sheffield. So two days six and seven. So if you're interested in kidneys, um feel free to join. Uh and my, our first speaker, it was a pleasure to invite an external speaker for Mr Ali. I met him at the Chesterfield Court. If you've been hiding under a rock, you will not know about this book. But if you're not hiding under a rock, you would definitely know this book. It was, is very important for your Frcs revision without further ado a thanks. Um I will not do that. OK. Welcome everyone. My task was to try to um to talk to you about uh ACL injuries in uh kids, basically Scully immature patients. Uh I will first um start this because I understand most people here are trainees. I'll first start this by, by um taking, taking you through some what I call uh level two single best answer questions. Now, II for my sins, II, probably I would be shocked for this. I was the um the lead uh question writer for the last 66 years uh before I um uh to took on another role at the ACI E. So um uh the, the, the, the, the trend of move from what we call level one questions to level two questions came up during my, my tenure. And what I, I'm I'm gonna show you some examples of what I mean by level two questions. Now, these are obviously things I II wrote to myself over the couple of days. They're not, they're not proofread by a panel of examiners which what happens to the questions that go into your papers. However, this is just for me, an example of level two questions uh concerning the topic that I'm, I'm going to teach you on, on. So uh it's all about kids knees and if you can just write your own answers and at the end of the talk, I'll give you the answers to, to, to the, to them. So the first one is this. So clinical scenario, fourteen-year-old girl playing football for her club Intrasubstance ACL rupture three months ago, but no meniscal tear, occasional instability symptoms. What would be your preferred treatment option for this patient? OK. Question two is um now we don't like writing lists in, in our exam but sometimes some ques some, some, some um some questions. It is the best question to put the word list. But so have you given an example of one where list is used? So, um which of the following graft choices would you expect to be least likely used in a 12 year old boy with a intrasubstance ACL rupture? OK. You're planning surgical management of an ACL reconstruction in a child, which of the following methods would you use to assess maturity? Uh Which of the following methods. Do you find most useful when, as assessing maturity? Yeah. OK. Following an ACL reconstruction in 12 year old girl, when would be the earliest, would you advise return to sport? And the last one is this one when performing the ACL reconstruction for an intersubstance rupture uh of the ACL which of the following scenarios are most likely to add a lateral, extra articulate ades? OK. So we'll, we'll um some of the, some of the answers will be in the talk and, and some of the answers we'll, we'll go through at the end. It uh if, if um I gives me time. So let, let, let, let, let, let, let's, let's, let's talk a little bit about um ACL injuries in, in kids now, about 20 years ago, 2020 30 years ago, it was thought that the incidence of ACL ruptures was less than 1%. Most of these injuries were thought to be uh tibial spine fractures but not intrasubstance ACL tears. Now, it is thought that the, that ACL ruptures in kids account for 5% of all ACL injuries as much as 5%. Why is that? So it's maybe because our kids now are big in size, they're more involved in competitive sport. They have pressures by their clubs and pressures by their parents on their sporting career and more females are participating in, in sport at a younger age. And we know that uh females are more genetically, uh anatomically and even neuromuscular pre predisposed to ACL rupture. Now, when you're bigger, a great force goes through your knee if you have a fall, and therefore you get an ACL injury on top of all of that, we are more aware of ACL injuries in kids. So we are looking for ACL injuries in kids. So our history is geared towards that. Our clinical examination is geared to, towards uh picking up ACL ruptures and our radiologists are getting better at reading MRI scans about 20 years ago. You'll find that the, that the sensitivity was only about 75% of picking up uh AAA an ACL rupture on a kid's MRI. Whereas now it's regarded as 95% still not as good as in adults, but uh the radiologists are getting more experience in reading them and therefore we're getting our diagnosis uh uh a bit more accurately. So is it really portrayed as a, as an increase in incidence? And I'm gonna take you through a co a couple of papers which show that there is a definite increase in incidence. This is looking at all the new, all the um the the insurance data in New York State uh over a 20 year period. And you can see that in all age groups, especially the 15 to 18 year age group, the rise in ACL reconstruction has is almost is almost vertical uh in, in those groups. So in all age groups, there is an increase in, in, in ACL reconstruction over the last 10 to 15 years in New York State. If you look at the finish uh registry, you can see again that rise is upwards. Now, look at this paper just published two years, two years ago, a couple of years ago out of Oxford, what they're showing in the UK that we have had, we have had a 29 fold increase in ACL reconstructions in, in, in uh in kids average age 16.9 over a 20 year period. So 29 fold increase in ACL reconstructions. Now you can extrapolate that as increased number of surgeries. But there is definite inference that there is a increased number of ACL ruptures in this group of patients. But what happens? What's the natural history? What should we do? We know uh in a situation where we have ACL rupture increasing in our kids? Do we know what happens if we do nothing? Do we know what happens if we don't operate on them? Well, let's look at a natural history of what happens with the, with the knee. Uh If you don't do anything, don't do anything means there's no paper that will tell you that nothing was done there. These are, these are, these are studies which show conservative treatment was tried. And if you look at the conservative management of patients for, for ACL ruptures, you will see that up to 65% of Children eventually develop meniscal tears who had ACL ruptures 65%. A more recent studies shows that if you, if you, if you, if you look at this even more closely that every week, the, the, the incidence of getting an a a medial meniscal tear increases is is 3%. So you add 3% for every week that you wait between ACL rupture and operate. So your risk of getting medial meniscal tear becomes e every week that goes by increases by 3%. So this is this is this, this is not the only thing that, that we recently um realized about meniscus. We realized that uh that ramp lesions are also increasing. And in fact, the incidence of ramp lesions in kids is double that, that there is in adults. So if your meniscus is tearing, then you should infer that the, the risk of osteoarthritis is going to be greater. And it, it's without doubt that if you look at kids who are, are in the eighties and nineties and, and early two thousands treated conservatively, they are all presenting with a, with early osteoarthritis in, in, in their knee at present. So this epidemic of young arthritics, uh knee arthritics is because a la lot of them have had ACL ruptures that were treated conservatively. So the answer to the to the question is what should we do? Should not be, uh uh should, should only in my view be considered for surgical care. But surgery. If we're gonna do surgery on these patients, then we have to think what are we doing, gonna do surgery? So, what are the results of these surgery? Are we gonna make them better? And are we on, are, are we going to or are they going to be a high complication rate? And in particular, when we're talking about complications, does this affect the growth plate by doing operations on these patients? And that's what we need to look at. If you, if you, if you look at the literature with regards to um the results or the the complication rate of, of, of ACL ruptures in kids, you can see it's a hetero heterogeneous um uh group, none of the papers rarely um would use 11 method. Uh They would use a variety of methods and they did you and there are different type of studies. So there, so there's nothing that is that stands out fully clear in the literature. What we can see by looking at these papers that if you look at, for example, at Kumar's paper, which is the longest follow up of any paper, the complication rate is very low. And even in even in prices, uh paper out of Oxford a couple of years ago, he showed that the complication rate following Oper operating in the sally immature patient is also low. The only other point to take from from this is that if you look at the third, this paper that realized that the highest complication rate was seen in, in, in, in the study where they had, they, they, they used the most difficult operative technique which is the all E ACL reconstruction. Mhm. But is there growth plate damage? And we all were we all worry about if you're gonna operate on a kid with, with um with uh ACL injury, are we gonna cause growth plate damage? When we drill through the growth plate, it is the reserve or the um germinal layer of the growth plate that becomes damaged that causes the growth that causes the the rotational or the the alignment problems related to damaging the growth plate. MRI studies show that if you, if you did an MRI six months after an ACL reconstruction kit, you can see you will see cortical organization in 100% of, of, of, of um MRI S indicating that that, that um a almost certainly there is some damage uh happening to the growth plate. And Peter Fo from Denmark looked at it and said that in every single postoperative film that you can look at uh where the there was a uh breach of devices, then there was some ra radiological damage to the growth plate. However, this is just radiological and this is not clinical uh clinically apparent damage to the growth plate. So, in essence, when you look at clinically apparent damage to the growth plate following ACL reconstruction, it is very rare to see a picture like this. And if you look at all the studies and you look at the the growth plate damage in any of these studies, you will see how rare grow growth plate damage is uh in following ACL reconstruction. So it's reassuring to know that by doing an ACL reconstruction in a kid that although it's theoretically possible that the actual uh clinical growth plate damage that occurs is very rare. So what surgeries can we do? Uh oo on a kid with ACL and we can divide them into the trans into 33 groups, transfill the physeal sparing and the partial transfix uh or the hybrid group of, of operations. The transfix is essentially that your normally a cell reconstruction. Uh You do it basically the exact same way that you will do your adult ACL reconstruction. You make a little few changes you can consider using x-rays so that your screws, you make sure that your screw is not uh going across your vices can consider using va sob screws, you ream at a lower rate to prevent damage to, to uh by heat to the growth plate and you orientate your, your drills, your holes through your vices more vertical. And this picture shows that by going more vertical, you can see what, what, how, how less a percentage of the growth plate you, you, you will damage by going more vertical. And that's why we, in theory, we go, we tend to go a little bit more vertical in, in, in doing your transvaal A ACL reconstruction. What about your physeal sparing ones? The ones where you have to spare the piss. There are two types, the extraarticular and they're all epiphyseal physeal sparing procedures. The extraarticular one is basically a modified marketing tosh where you take a bit of the iliotibial band, a strip of it, you go uh pass it around the lateral femoral condyle in the over the top position and you bring it out through the intermeniscal on deep to the intermeniscal ligament and you tie it on or, or attach it on to the front of the tibia. It avoids the DEF devices, it's non isometric, but it is a good o operation for, for um if DEF is if devices needs to be spared. The other surgical procedure you can do is one called or epiphyseal. The probably the most technically challenging of all the ACL reconstructions uh where you have to use anatomical uh points to enter and e exit the joint. However, it traverses horizontally across the, the, the, the physeal part of the, of the, of the bone. The problem here, it, it's an operation like this. But the problem here is that if you look and see on the picture on the right there where where the drill holes are going in the pus, you see how close it is to the to the growth plate. Now, if you look at the growth plate, on the distal femur, on the growth plate, on the proximal tibia, you can see the germinal zone or the, or the reserve zones are closest to the point where you're drilling. So the point that causes the, the, the, the, the, the damage to the uh to the growth plate is closest to where you're drilling on both sides of the uh of on both sides of the arm of, of the knee joint. This is why when you're trying to decide between, are you going to do a of all epiphyseal or you're gonna do an extra articular, you will look to see how wide this V is before you, you make your, before you decide on your final option. Because if you're too close to the growth plate heat or, or mechanical factors will cause damage to the reserve or germinal zone of the growth plate. Then comes the third group, which is called the hybrid group, which is a partial transvaal. And that's based on the theory that 70% of growth occurs around the knee in the lower limb. 40% of that 40 of that is from the distal femur and 30 of that is from the proximal tibia. So if you're gonna drill through one, then you will drill through the proximal tibia and you will spare the, you will spare the um distal femur. So, so you go standard, you, you, you go transversely through the distal femur and your, you and, and, and, and you go through your standard uh transvaal position in your tibia. So how can we now come up with a surgical strategy for um choosing which operation we need to do for our ACL reconstruction? For, for the four, the five factors. I think that you have to bear in mind when choosing which operation or age of the patient and therefore calculate growths remaining. Does this patient have? What symptoms of instability? Does this patient have? What levels of activity do they want to get back to? And their goals of your treatment? And do they have any associated injuries such as meniscal injuries? You'll need to use all those factors into coming up with your decision. Oo On what treatment when we talk about age, we talk, there are different types of age. They are chronological age, physiological age and skeletal age, chronological age is not really uh not really an accurate way of doing it physiologically age is like, for example, Tanner stage is what's chosen in the literature. Uh but it's a difficult one for to, to do because Tanana staging involves looking at the kids, uh genitalia, looking at the kids uh um uh uh breasts, pubic hair and, and, and this is usually done in theater. So it's not something in the UK we find um that is that uh it's more for research purposes. But, but practically speaking, we don't use um kind of staging for, for making uh these decisions. What we use is skeletal age. And the way to use skeletal age is the best way is to use a hand X ray or hand radiographs and using the G and Atlas. Then, then calculating the skeletal age and with the skeletal age, then you can use the Anderson green chart to calculate growth remaining and growth remaining is what we use to, to actually uh make a decision on what surgical procedure that you are going is best for this patient. So it's growth remaining. And this is a strategy we use at uh in our hospital in Sheffield Children's Hospital that, that, that we published and II want to take you through it. It uses, it uses the same five parameters. I just talked about SCLE age growth remaining symptoms of instability, activity levels and goals and associated injuries. Now look at the associated injuries on the right there. If you had a complete ACL rupture and you have any meniscal theory, it is, it is imperative that you operate on this patient. So any ACL rupture with a meniscal tear needs ACL surgery, that's specific for, for that age. Now, if there's no meniscal tear and that's on the left side, uh there are on the left side, then what you do depends on the skeletal age of the patient. If there's 1 to 2 years of growth remaining, you do a transvaal standard transvaal operation. If you have between two and five years of growth remaining, you do a partial Pfizer sparing uh operation and if you have more than five years growth remaining, then you have to use one of your five year sparing operations. Ok. But in general, that's only if the child cannot manage what we try to do with more than five years growth remaining is at first see if they can, they can just hold on, they can just hold on with conservative treatment and manage until we can do a partial five sparing procedure. However, these days, we find less and less kids and less and less families are, if they, especially if they are involved in sport, are willing to wait to see whether they can, they can um hold on for a partial Pfizer sparing. They are, they are, they are sort of uh more or less insisting that we, we operate on the child when they're younger and therefore we have to do a Pfizer sparing procedure, but we're doing surgery on these patients. And we, we have to know that uh all we know that the complication rate with regards to, to, to growth plate disturbance is low. But the one complication that we can't get away from is what's called rupture rate. Now, all the studies are showing to us that the re rupture rate in a kid is three times greater than that than that of an adult. Uh When you look at the, the all registry data, all studies that three times a lot higher rupture rate uh uh in that kid compared to the adult counterpart. In fact, this meta analysis actually shows that if you have a child who has an ACL rupture, they have a one in four chance that they'll either rupture that ipsilateral leg ACL or contralateral ACL when they return to sport one in four channel. In fact, some studies actually show that uh on the in on day 18, you have seven times chance oo of of it being contralateral knee uh falling uh return to sport. So returning to sport is a big problem. So now we're in a situation where we have such a high rupture rate. Then what do we do? How can we prevent, how can we prevent this rerupture rate? There are three step strategies to look at in preventing uh this high complication of rerupture rate and I can subdivide them into surgical strategies, rehabilitation and injury prevention programs. This is the surgical strategy that we talking about the use of the lateral extra articulate tenodesis in your operation. Now, everyone going for an exam has to know about the stability trial. So the stability trial is, is not, not only involves kids, it involves all all groups of ACL reconstructions, but you can subdivide kids out of it. And what the stability trial shows that in in all groups, use of a lateral extra articulating ades, reduces the failure rate of your ACL reconstruction So this has to be co this has to be considered in all kids. The second concept we said we talked about was rehabilitation after surgery. Now, this is not general ACL rehab that we have to send our kids for. This is all individualized. This is all bespoke uh physiotherapy for our kids. It has to be related to, to their age and it has to be related to their maturity level. You have to be using things like goal based treatment rather than a time based treatment. Uh uh when you're rehabbing these patients in general, if you look at these uh uh uh kids, this is the uh see the picture on the right. This is how a kid, especially a young woman tends to land with their legs and valgus. And because they land in this position, their rupture rate is higher when they, when you jump and you land. And that's why jumping and landing sports, it gives you the highest amount of ACL ruptures and ruptures. So your rehab has to be co uh concentrated on this. And this involves building core stability, building, balance, building stabilization, eccentric hamstring exercises and essentially teaching them them to land in the knee over toe position rather than so that they land like that to prevent ACL. And this is the, this is in theory, the basis of what we call injury prevention programs. Now does injury prevention program work? If we look at the only three studies that are available in the literature which looked at injury prevention programs uh in kids, we can see that up to 88% reduction in, in, in, in, in um rupture of your ACL if you are part of an injury prevention program, the downside of all of that is that all of these studies do not arise from the UK. And we have a very, our injury prevention program in our country is at its infancy. And that's why we have to give a lot of credit to the, to the people on the, the surgeons and the teams that are starting up power and, and, and you mentioned it earlier, power power up to play, which is an injury prevention program and helping you to prevent ACL ruptures and helping to prevent ACL ruptures. So, in summary, we're dealing with a group of patients where the diagnosis is difficult, they are growing growth, plate damage is a possibility. There are multiple techniques, complication rates are high contralateral rupture rates are high. So in, in essence, what I'm trying to say that doing an ACL reconstruction and dealing with a kid with ACL rupture is not the same as it is in adult. It's a totally different ball game to help summarize it. I want you to be aware of the vascu guidance on the treatment of um uh on the management of ACL rupture in kids and, and um and I was privileged to be part of this group that, that, that set it up. And now, now it's the best guidance uh which if you're going for an exam, you have to know all, all, all, you know, you have to know all the best guidances. And this is one of those that, that you will have to be aware of. And in summary, if you look at it, I've highlighted a few things, but if I have a few minutes, II, would I would like to take you through all all aspects of it, what it's saying that any. So I'll tell uh this is part of the summary. But basically what I'm saying is that we use the literature to come up with all these uh a all these points uh in, in terms of the management of these kids. So basically, if a child presents to you with he arthrosis following an injury, uh it must come through an acute, you must have an acute knee management pathway for these Children. If you're not able to make the diagnosis straight away, an MRI scan should be available within, must be available within two weeks. You must have radiologists who are reading these MRI scans, who are used uh used to reading uh kids MRI S in these. And if you're gonna operate on them, you must have the ability to calculate gross remaining. It must be uh this kid, this kid must be managed by surgeons either who by themselves are used to managing kids with knee injuries or in combination with their colleagues as part of an MDT uh able to uh manage kids, kids with ACL injuries. The technique you choose, it must be techniques that you're familiar to use. And at present, ACL repair is not recommended as a as a treatment method unless it's part of a research uh setting. When you're rehabbing these patients, the rehab must follow a dedicated pathway by, by, by um uh therapists who are used to looking after kids with ACL injuries. And these kids must be followed up until skeletal maturity by, by someone looking for uh complications of uh ACL surgery. And unless you're following all this, then you should not be looking after patients with, with a uh a ACL uh injuries in kids before we answer our questions for M CQ again. Uh uh He has plugged our, our confidence but it, it really is uh we got the best speakers he uh in, in, in the world who could be there, not only surgeons, but, but there are lots of physiotherapists coming from Australia, New Zealand and, and um or, or it's truly international both in faculty and, and, and in delegates uh for so I look forward to seeing many of you there. So, question one and now the answer to this is uh B uh this is a trans vasal ACL reconstruction. So, so uh this is a 14 year old uh uh playing football for a club. So this is a high level, reasonably high level, wanting, obviously wanting to get back to sport, not wanting con conservative treatment. So, three months ago. So it's a bit too long for if you even going to think of repair and you, you wouldn't have done a repair uh but no meniscal tear, occasional instability symptoms. So, uh if I, if I take you to the algorithm and that's uh so 14 will be one or two years growth remaining. So you'll use a tra a trans vasal uh procedure here. OK. So that, that's the answer for number one question, number two. which, which of these uh which of these would you least likely use it? It will be allograft um of, of these. And I'll explain why all of these are use. You can use all of these. Uh you can use all of these graphs in, in, in a, in a kid. But probably uh so allograft will be the one that you, you, you won't use. Now, allograft hires a much higher rup rupture rate than, than uh any of the autographs in uh in all the studies. So it's one that has the worst me Biomedic mechanical. One of the, you wouldn't be wrong to think the BTB was 11 that you won't use because of the bone bone on either side. And that's why I put 12 years and not nine years. If it was nine years, I would think that that definitely I wouldn't use AAA BTB in, in this kid. But, but uh for 12 year old, um the the studies show that the the failure rate is low for BTB. But the worry about using BTB in a kid is if you're putting the bone blocks on it very close to devices on either side, you can get uh premature arrest. So quads graft is used, parental graft is also used as it is very popular in, in Australia to, to use parental graft for, for some of these younger kids. Question three. And um that's the one that we, we talked about just uh just now as part of the talk, we saw that. Um So the answer will be the Anderson and Green chart cause to where, where you need to calculate growth remaining. The TAA one is what I describe R 10 Rs stage is 10 to be used for scoliosis and looks at diarrhea crest. The, the uh ruin pile is from using the hand and then you use the skeletal age to calculate the um the growth remaining, which is an an Anderson green chart. Now, question for um calling ACL reconstruction in a 12 year old. When would the earliest that you would advise them to return to sport? Uh Oh no. Again, one year is the answer if you were an adult in general. Uh We say nine months, nine months is the earliest you can get back to sport in, in, in, in, in, in a, um, in a, in a adult now it's not nine months in a kid and let's not wait until skeletal maturity. Uh, because you, these kids want to get the, especially as I said, um, these kids want want to get back to sport so you can't really wait, they want to have their operation. So the reason why it's not, not nine months is that studies show that at nine months, um the, the, the, the movement pattern is not safe enough to go back to um to, to sport as yet. And therefore, you should wait a bit longer than nine months. So in, as a, as a, as a ballpark figure, we use one year before a kid goes back to the minimum of one year before they go back to sport. And then question number five, the last question forming an ACL reconstruction for intrasubstance rupture. Uh Which of these would you most likely uh add a lateral extra articulate in the A I didn't give you the answer here immediately because I wanted to tell you a few things because this is an important topic. Now, if you're considering in present day orthopedics and uh an ACL reconstruction and you want to do a, I want to know whether you should do a lateral tenodesis on this patient or not. These tend to be the general indications for Tenodesis that is a patient with the grade three pivot a hyper lax patient. Or if you're doing a revision ACL, then you do if the patient wants to go back to a high, high impact or high risk sport such as uh pivoting sport than you do in uh uh uh Tenodesis and any young patient, uh especially adolescents uh in adolescence, you will do uh um uh Tenodesis. So those tend to be the general indications. And remember the stability trial shows that, that, that um there is general benefit or and decrease in rupture rate with by doing aosis. However, 11 of the problems of doing aosis is always constrained of the knee. And therefore we, although the, it's not exactly clear yet, there are signs saying that by over constraining the knee that you might increase the, the risk long term osteoarthritis in some of these patients uh who you do a TES for. So it's not a magic answer to, to, to, to the question of whether to use it or not. If you look at uh the, the, the both the, the, the, the guidance that we wrote based on the literature, you will see that this is what the guidance, the BO guidance actually states in particular relation to L ETS that if you had a young child with two or more of these, that's high grade pivot generalized laxity recurva greater than 10 degrees and participation in pivoting sports, then you will do uh Tenodesis and on these patients routine use. However, outside these indications is not yet evidence based. The other point to make is that if you and these are the only Cadaveric work that is done. If you look at cadaveric studies on kids around average age six, you see that very few of them have an uh A LL in them. And if you do Cadaveric studies in slightly older Children, a bit more of them have anterolateral ligaments which makes us uh uh postulate that anterolateral ligament is not present at birth but evolves with the stresses of the knee over time and evolves. So the A LL is not, is, is not there early on but comes with time. And hence why when you look at the answers to the question that I just wrote, then I would say that uh AAA is wrong because a seven year old is unlikely to have an anterolateral ligament. So doing a tenodesis is not really helping the situation there c is wrong because um uh it's not the one that you would want to do it, but because this patient has early osteoarthritis, if you over constrain the knee, then, then you, you will pro provide more problems. BM I doesn't have an indication for whether you do a tenodesis or not. And as I, as we said, uh there are some limitations to it. Therefore, it cut should not be indicated in all ACL reconstructions. So to the answer to that is B so I hope some of you got five out of five if you didn't. But that's just my, uh, my, my, my, um, attempt to, uh, show you, um, to show you how a level two question and is written and what you should, how you should prepare for your exams if you're going for your exams. Thank you very much. Thank you. Um, have you got any questions so far? Exactly. Any tips, the passing part one. Oh, no. Yeah, I mean, the, the, the hard, it's, you know, it's, it used to be said that part one was all over in the books. But it, now, now because there are level two questions, it's not all about the books. It's, it's, it's, it's being on the, on, on the floor floor too. Um, just, just, um, just because it, every question is so clinically orientated. These things you pick up in trauma meetings is things that you pick up in MDT discussions and so on because the single best answer is not, it's not, is, it is single best answers given from a panel of examiners who say that that's the right answer. It isn't necessarily something that's written in the book. Mm. It's, it's quite a complex, well, there's a lot of level two, level, even, level three questions now. So definitely, um, I wanted to ask if, when you're, when you're counseling a patient, um, and if they're, they're not high performance, uh, athletes, uh, um, and they would rather, er, wait, would, would anyone, you, would you wait for anyone to get to sleep for maturity before you start doing an ACL? So II, because, I mean, I, II, not these days, you know, um, it, it, because I, even if they're not high level, they want to get back to sport and 3% per week, if you saw read that paper, 3% chance of medium meniscal tear per week. You wait between ACL rupture and operation. When you, when you, when you, if you, if you think of that, then you think that, that, that, that, you know, you, if you want, you really have to save the meniscus and it's all about saving the meniscus rather than more than anything else in these kids. Great. Thank you very much. It is such a big problem. Mm ok. Thank you very much. Um ok. Thank you very much. No problem. Thanks for joining. Uh I think we've got our second speaker who's just having some technical issues. So I'm gonna stop.