The Feasibility of Blinding Intraoperative Electro-Auricular Acupuncture Under Neuraxial Anesthesia.

Objective: Demand for complementary medicine, in particular, acupuncture, has increased over the past few years but widespread acceptance has been limited, in part, by the lack of high-quality studies, including lack of blinding. Acupuncture studies traditionally have difficulty with blinding as sham acupuncture can have up to a 40%-50% analgesic effect. This study randomized patients between Acupuncture and No Acupuncture (standard of care) without using sham needles. The primary outcome was adequate blinding of electro-auricular acupuncture in the intraoperative setting with secondary outcomes of pain/nausea control. Materials and Methods: Forty patients undergoing anterior cruciate ligament reconstruction were enrolled. Subjects were randomly assigned to receive acupuncture (Enhanced Electro-Auricular Trauma Protocol) or No Acupuncture during their surgeries. All patients received spinal anesthesia and intravenous midazolam, ketamine, and propofol for sedation. 1000 mg of intravenous (IV) acetaminophen and up to 30 mg of IV ketorolac were given at closure. No opioids or peripheral nerve blocks were administered intraoperatively. Results: Bang's Blinding indices were 0.2 (95% confidence interval [CI]: -0.02, 0.42) in the Acupuncture group, and 0.11 (95% CI: -0.10, 0.31) in the No Acupuncture group on postoperative day 1. Both groups had adequate blinding. There were no differences in pain scores, nausea/vomiting incidence, opioid consumption 0-24 hours, or patient satisfaction. Five patients in the No Acupuncture group received rescue blocks, while no patients in the Acupuncture group needed a rescue block (Fisher's exact test: p = 0.047). Conclusions: This study proved the primary hypothesis that adequate blinding of intraoperative acupuncture can be performed when patients are under sedation and neuraxial anesthesia. This research is registered at ClinicalTrials.gov as Clinical Trial Registration #: NCT03711734.

Surgical Treatment of Iatrogenic Nerve Injury Following Arthroscopic Capsulolabral Repair.

PURPOSE: Case reports of nerve injuries following arthroscopic capsulolabral repair emphasize the proximity of major nerves to the glenoid. This study describes preoperative localization using nerve-sensitive magnetic resonance imaging in a small cohort of patients with iatrogenic nerve injuries following arthroscopic capsulolabral repair and the outcomes of nerve repair in these patients. METHODS: Cases of iatrogenic nerve injury following arthroscopic capsulolabral repair referred to 2 surgeons from January 2017 to December 2019 were identified. Clinical charts, electrodiagnostic testing, magnetic resonance imaging studies, and operative reports were reviewed. RESULTS: Four cases of iatrogenic nerve injury were identified. The time to presentation to our institution ranged from 2 weeks to 8 years. The axillary nerves in 3 cases were tethered by a suture at the inferior glenoid, whereas 1 case had a suture tied around the radial and median nerves inferior to the glenohumeral joint capsule. One case underwent excision and nerve transfer, 1 underwent excision and nerve repair, and 2 underwent suture removal and neurolysis. Open and arthroscopic approaches, including a recently described approach to the axillary nerve in the "blind zone," were used. Three cases demonstrated good recovery of all affected motor and sensory functions after surgery. At the 10-month follow-up, 1 case had persistent weakness, but there was evidence of axonal regeneration on electrodiagnostic testing. CONCLUSIONS: Arthroscopic capsulolabral repair places regional nerves, particularly the axillary nerve, at risk owing to their proximity to the joint capsule and inferior glenoid. Patients with neuropathic pain in the distribution of affected nerves with corresponding sensorimotor loss following arthroscopic capsulolabral surgery should undergo focused magnetic resonance imaging with nerve-sensitive sequences and electrodiagnostic testing to localize the injury. The use of multiple surgical windows to the axillary nerve in the "blind zone" enables full visualization for neurolysis, suture removal, and nerve repair or transfer. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Surgical Games: A Simulation-Based Structured Assessment of Orthopedic Surgery Resident Technical Skill.

BACKGROUND: Simulation-based education and objective evaluation of surgical skill have been incorporated into many surgical training programs. We describe the development and implementation of a timed, multitask, station-based Surgical Games to evaluate orthopedic resident surgical skills. METHODS: Participants in the study were postgraduate-year 2 to 5 orthopedic surgery residents from a single institution. Residents completed 4-timed simulated tasks: cadaveric carpal tunnel release (CTR), Sawbones model of total knee arthroplasty (TKA), Sawbones model of ankle fracture open reduction internal fixation (ORIF), and knee arthroscopy simulator (KAS) of removal of loose body. Evaluations were performed using standardized score sheets by attending surgeons. Resident performance was analyzed by postgraduate-year and number of weeks of prior task-related residency training. RESULTS: A total of 32 residents were assessed at the 4 stations. Total scores were significantly different for CTR (p = 0.006), TKA (p = 0.05), and the KAS (p = 0.004) by year of training, but not for the ankle ORIF task. Residents with more task-specific experience performed significantly better on the KAS (p < 0.001), TKA (p = 0.002), and CTR (p = 0.02) tasks but not on the ankle ORIF task (p = 0.1). Overall, residents rated the exercise valuable to their education with mean scores of 3.9 ± 0.54 on a 5-point Likert Scale. CONCLUSIONS: This Surgical Games exercise provided an objective evaluation of surgical skill that correlated with year-in-training and prior experience in skill-specific rotations for the KAS, TKA, and CTR tasks. This surgical skills assessment provided an opportunity for effective structured feedback and identification of areas for improvement.

The Scaffold-Articular Cartilage Interface: A Combined In Vitro and In Silico Analysis Under Controlled Loading Conditions.

The optimal method to integrate scaffolds with articular cartilage has not yet been identified, in part because of our lack of understanding about the mechanobiological conditions at the interface. Our objective was to quantify the effect of mechanical loading on integration between a scaffold and articular cartilage. We hypothesized that increased number of loading cycles would have a detrimental effect on interface integrity. The following models were developed: (i) an in vitro scaffold-cartilage explant system in which compressive sinusoidal loading cycles were applied for 14 days at 1 Hz, 5 days per week, for either 900, 1800, 3600, or 7200 cycles per day and (ii) an in silico inhomogeneous, biphasic finite element model (bFEM) of the scaffold-cartilage construct that was used to characterize interface micromotion, stress, and fluid flow under the prescribed loading conditions. In accordance with our hypothesis, mechanical loading significantly decreased scaffold-cartilage interface strength compared to unloaded controls regardless of the number of loading cycles. The decrease in interfacial strength can be attributed to abrupt changes in vertical displacement, fluid pressure, and compressive stresses along the interface, which reach steady-state after only 150 cycles of loading. The interfacial mechanical conditions are further complicated by the mismatch between the homogeneous properties of the scaffold and the depth-dependent properties of the articular cartilage. Finally, we suggest that mechanical conditions at the interface can be more readily modulated by increasing pre-incubation time before the load is applied, as opposed to varying the number of loading cycles.

Tracking Cumulative Radiation Exposure in Orthopaedic Surgeons and Residents: What Dose Are We Getting?

BACKGROUND: The purpose of this study was to determine the amount of cumulative radiation exposure received by orthopaedic surgeons and residents in various subspecialties. We obtained dosimeter measures over 12 months on 24 residents and 16 attending surgeons. METHODS: Monthly radiation exposure was measured over a 12-month period for 24 orthopaedic residents and 16 orthopaedic attending surgeons. The participants wore a Landauer Luxel dosimeter on the breast pocket of their lead apron. The dosimeters were exchanged every rotation (5 to 7 weeks) for the resident participants and every month for the attending surgeon participants. Radiation exposure was compared by orthopaedic subspecialty, level of training, and type of fluoroscopy used (regular C-arm compared with mini C-arm). RESULTS: Orthopaedic residents participating in this study received monthly mean radiation exposures of 0.2 to 79 mrem/month, lower than the dose limits of 5,000 mrem/year recommended by the United States Nuclear Regulatory Commission (U.S. NRC). Senior residents rotating on trauma were exposed to the highest monthly radiation (79 mrem/month [range, 15 to 243 mrem/month]) compared with all other specialty rotations (p < 0.001). Similarly, attending orthopaedic surgeons who specialize in trauma or deformity surgery received the highest radiation exposure of their peers, and the mean exposure was 53 mrem/month (range, 0 to 355 mrem/month). CONCLUSIONS: Residents and attending surgeons performing trauma or deformity surgical procedures are exposed to significantly higher doses of radiation compared with all other subspecialties within orthopaedic surgery, but the doses are still within the recommended limits. CLINICAL RELEVANCE: The use of ionizing radiation in the operating room has become an indispensable part of orthopaedic surgery. Although all surgeons in our study received lower than the yearly recommended dose limit, it is important to be aware of how much radiation we are exposed to as surgeons and to take measures to further limit that exposure.

Risk Factors for Revision Surgery After Superior Labral Anterior-Posterior Repair: A National Perspective.

BACKGROUND: Data regarding risk factors for revision surgery after superior labral anterior-posterior (SLAP) repair are limited to institutional series. PURPOSE: To define risk factors for revision surgery after SLAP repair among patients in a large national database. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A national insurance database was queried for patients undergoing arthroscopic SLAP repair (Current Procedural Terminology [CPT] code 29807) for the diagnosis of a SLAP tear. Patients without a CPT modifier for laterality were excluded. Revision surgery was defined as (1) subsequent ipsilateral SLAP repair (CPT 29807), (2) ipsilateral arthroscopic debridement for the diagnosis of a SLAP tear (CPT 29822 or 29823, with diagnosis code 840.7), (3) subsequent ipsilateral arthroscopic biceps tenodesis (CPT 29828), (4) subsequent ipsilateral open biceps tenodesis (CPT 23430), and (5) subsequent biceps tenotomy (CPT 23405). Multivariable binomial logistic regression analysis was performed to identify risk factors for revision surgery after SLAP repair, including patient demographics/comorbidities, concomitant diagnoses, and concomitant procedures performed. Odds ratios (ORs), 95% CIs, and P values were calculated. The estimated financial impact of revision surgery was also calculated. RESULTS: There were 4751 patients who met inclusion and exclusion criteria. Overall, 121 patients (2.5%) required revision surgery after SLAP repair. Regression analysis identified numerous risk factors for revision surgery, including age >40 years (OR, 1.5; 95% CI, 1.2-1.8; P = .045), female sex (OR, 1.5; 95% CI, 1.3-1.8; P = .010), obesity (OR, 1.8; 95% CI, 1.5-2.2; P = .001), smoking (OR, 2.0; 95% CI, 1.6-2.4; P < .0001), and diagnosis of biceps tendinitis (OR, 3.5; 95% CI, 3.0-4.2; P < .0001) or long head of the biceps tearing (OR, 5.1; 95% CI, 4.1-6.3; P < .0001) at or before the time of surgery. Concomitant rotator cuff repair and distal clavicle excision were not significant risk factors for revision surgery. The cost of revision surgery averaged almost $9000. CONCLUSION: Risk factors for revision surgery after SLAP repair include age >40 years, female sex, obesity, smoking, and diagnosis of biceps tendinitis or long head of the biceps tearing. The diagnosis of biceps tendinitis (OR, 3.5) or long head of the biceps tearing (OR, 5.1) at or before the time of surgery was an especially significant risk factor for revision surgery. The high cost of revision surgery highlights the importance of appropriate indications to avoid the need for subsequent procedures.

Subscapularis tendon loading during activities of daily living.

BACKGROUND: The purpose of this study was to determine the relative amount of load that is transmitted through the superior portion of the subscapularis during activities of daily living as compared with the load that is transmitted through the middle and inferior portions in a normal shoulder and in a shoulder with a supraspinatus tear. METHODS: By use of the Newcastle shoulder model, the subscapularis was modeled with 3 lines of action encircling the humeral head. The load was measured in the entire subscapularis, and the percentage of this load in each of the 3 tendinous bands was calculated. Subsequently, a supraspinatus tear was simulated, and the forces generated by the subscapularis and glenohumeral joint contact forces were measured. RESULTS: The maximum force produced by the entire subscapularis muscle for the various activities ranged from 3 to 43 N. Load sharing between the 3 subscapularis bands showed that the superior band bore the largest percentage of the total load of the muscle (95% ± 2%). The load in the subscapularis, particularly in the superior band, increased significantly when a supraspinatus tear was simulated (P < .0001). CONCLUSION: The superior band of the subscapularis tendon bears the highest percentage of load compared with the middle or inferior band. The load in the subscapularis increased significantly in the presence of a simulated supraspinatus tear. Because a disproportionate amount of force is transmitted through the superior subscapularis, more clinical research is warranted to determine whether tears in this region should be routinely repaired.

Increased Lateral Tibial Slope Is a Risk Factor for Pediatric Anterior Cruciate Ligament Injury: An MRI-Based Case-Control Study of 152 Patients.

BACKGROUND: Increased posterior tibial slope is associated with increased risk of anterior cruciate ligament (ACL) injury in adults. A similar association has not been rigorously examined in children and adolescents. PURPOSE: To determine whether alterations in posterior tibial slope are associated with ACL tears in pediatric and adolescent patients and to quantify changes in tibial slope by age. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Magnetic resonance imaging (MRI) studies of the knee were reviewed by 3 raters blinded to each other in a 1:1 sample of cases and age- and sex-matched controls. A total of 76 skeletally immature ACL-injured knees were compared with 76 knees without ACL injury; the mean age of the study population was 14.8 ± 1.3 years. The posterior slope of the articular surface of the medial tibial plateau and lateral tibial plateau was measured by use of a method similar to that used in previous studies in adult populations. The current study technique differed in that the slope was measured on the cartilage surface, not the subchondral bone. Comparisons between knees were made with t tests, and Spearman correlation analysis was used to assess changes in tibial slope with advancing age. RESULTS: Increased slope of the lateral tibial plateau (LTS) was significantly increased in ACL-injured patients compared with controls (5.7° ± 2.4° vs 3.4° ± 1.7°; P < .001). There was no statistically significant difference in the slope of the medial tibial plateau (MTS) in the ACL-injured and control knees (5.4° ± 2.2° vs 5.1° ± 2.3°; P = .42). There was no difference in LTS between male and female patients (4.46° vs 4.58°; P = .75). Receiver operating characteristic (ROC) analysis of the LTS revealed that a posterior tibial slope cutoff of >4° resulted in a sensitivity of 76% and a specificity of 75% for predicting ACL tears in this cohort. Spearman correlation analysis revealed that MTS and LTS decreased, or flattened, by 0.31° (P = .028, correlation coefficient r = -0.18) and 0.37° (P = .009, correlation coefficient r = -0.21) per year, respectively, as adolescents age. CONCLUSION: The LTS was significantly associated with an increased risk of ACL injury in pediatric and adolescent patients. The MTS was not associated with risk of injury. Posterior slope was found to decrease, or flatten, with age. A cutoff of >4° for the posterior slope of the lateral compartment is 76% sensitive and 75% specific for predicting ACL injury in this cohort. The LTS did not influence the incidence of ACL injury differently between sexes.

The mature athlete: aging tendon and ligament.

CONTEXT: Aging changes the biology, healing capacity, and biomechanical function of tendons and ligaments and results in common clinical pathologies that present to orthopedic surgeons, primary care physicians, physical therapists, and athletic trainers. A better understanding of the age-related changes in these connective tissues will allow better patient care. EVIDENCE ACQUISITION: The PubMed database was searched in December 2012 for English-language articles pertaining to age-related changes in tendons and ligaments. LEVEL OF EVIDENCE: Level 5. RESULTS: The mature athlete faces challenges associated with age-dependent changes in the rotator cuff, Achilles tendon, lateral humeral epicondylar tendons, quadriceps tendon, and patellar tendon. The anterior cruciate ligament and the medial collateral ligament are the most studied intra-articular and extra-articular ligaments, and both are associated with age-dependent changes. CONCLUSION: Tendons and ligaments are highly arranged connective tissue structures that maintain joint motion and joint stability. These structures are subject to vascular and compositional changes with increasing age that alter their mechanotransduction, biology, healing capacity, and biomechanical function. Emerging research into the etiology of age-dependent changes will provide further information to help combat the age-related clinical complications associated with the injuries that occur to tendons and ligaments.

All-Inside, All-Epiphyseal Autograft Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete.

INTRODUCTION: We present an all-inside, all-epiphyseal anterior cruciate ligament (ACL) reconstruction technique with use of a hamstring autograft for skeletally immature athletes. STEP 1 IDENTIFY SUBCUTANEOUS LANDMARKS: Identify and mark subcutaneous landmarks to aid with anatomic orientation throughout the operation and to assist with socket placement. STEP 2 HARVEST THE HAMSTRING GRAFT: Harvest a hamstring autograft to create a four-strand autograft in the standard fashion or, if you prefer, perform a posterior hamstring harvest. STEP 3 PREPARE THE GRAFT: Prepare a four-strand hamstring autograft using suspensory cortical fixation devices-a reverse-tensioning button (ACL TightRope RT; Arthrex, Naples, Florida) on the femoral side and an attachable button system (ACL TightRope ABS, Arthrex) on the tibial side. STEP 4 PREPARE THE FEMORAL AND TIBIAL SOCKETS: Create blind-ended intra-articular sockets in the femur and tibia using the center-center footprint positions while avoiding the physeal plates. STEP 5 PASS AND SECURE THE GRAFT: Pass the hamstring autograft through the anteromedial portal and dock it in the femoral and tibial sockets; engage the cortical button on the femur, dock the graft, and then perform final fixation on the tibial side. STEP 6 POSTOPERATIVE REHABILITATION: The patient's age and maturity level dictate the progression of rehabilitation, and parents and caregivers are encouraged to regularly participate in the child's rehabilitation regimen. RESULTS: Research is ongoing to evaluate the clinical and radiographic outcomes following ACL reconstruction in skeletally immature athletes with use of this technique19. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Contact stress and kinematic analysis of all-epiphyseal and over-the-top pediatric reconstruction techniques for the anterior cruciate ligament.

BACKGROUND: Adult anterior cruciate ligament (ACL) reconstruction techniques may be inappropriate to treat skeletally immature patients because of the risk of physeal complications. "Physeal-sparing" reconstruction techniques exist, but their ability to restore knee stability and contact mechanics is not well understood. PURPOSE: (1) To assess the ability of the all-epiphyseal (AE) and over-the-top (OT) reconstruction techniques to restore knee kinematics, (2) to assess whether these reconstruction techniques decrease the high posterior contact stresses seen with ACL deficiency, and (3) to determine whether the AE or OT technique produces abnormal tibiofemoral contact stresses. STUDY DESIGN: Controlled laboratory study. METHODS: Ten fresh-frozen human cadaveric knees were tested using a robotic manipulator. Tibiofemoral motions were recorded with the ACL intact, after sectioning the ACL, and after both reconstructions in each of the 10 specimens. The AE technique consisted of tunnels exclusively within the epiphysis and was fixed with suspensory cortical fixation devices. The OT procedure consisted of a central and vertical tibial tunnel with an over-the-top femoral position and was fixed with staples and posts on both ends. Anterior stability was assessed with 134-N anterior force at 0°, 15°, 30°, 60°, and 90° of knee flexion. Rotational stability was assessed with combined 8 N·m and 4 N·m of abduction and internal rotation, respectively, at 5°, 15°, and 30° of knee flexion. RESULTS: Both reconstruction techniques off-loaded the posterior aspect of the tibial plateau compared with the ACL-deficient knee in response to both anterior loads and combined moments as demonstrated by reduced contact stresses in this region at all flexion angles. Compared with the ACL-intact condition, both the AE and OT procedures had increased posteromedial contact stresses in response to anterior load at some flexion angles, and the OT technique had increased peripheral posterolateral contact stresses at 15° in response to combined moments. Neither reconstruction technique completely restored the midjoint contact stresses. Both techniques restored anterior stability at flexion angles ≤30°; however, neither restored anterior stability at 60° and 90° of flexion. Both reconstruction techniques restored coupled anterior translation under combined moments. Additionally, the AE procedure overconstrained internal rotation in response to combined moments by 12% at 15° of flexion. CONCLUSION: Both reconstruction techniques provide anterior and rotational stability and decrease posterior joint contact stresses compared with the ACL-deficient knee. However, neither restored the contact mechanics and kinematics of the ACL-intact knee. CLINICAL RELEVANCE: Because the AE reconstruction technique has clinical advantages over the OT procedure, the results support this technique as a potential candidate for use in the skeletally immature athlete.

Patellofemoral pain: an update on diagnostic and treatment options.

Patellofemoral pain is a frequent and often challenging clinical problem. It affects females more than males and includes many different pathologic entities that result in pain in the anterior aspect of the knee. Diagnosis of the specific cause of pain can be difficult and requires assessment of lower extremity strength, alignment, and range of motion, as well as specific patella alignment, tracking, and mobility. The treatment for patellofemoral pain is usually conservative with anti-inflammatory medications, activity modification, and a specific physical therapy program focusing on strengthening and flexibility. Infrequently, surgical treatment may be indicated after a non-operative program fails. The outcomes of surgical management may include debridement, lateral release, and realignment of the extensor mechanism to unload the patellofemoral articulation are favorable.

Injury profile in elite female basketball athletes at the Women's National Basketball Association combine.

BACKGROUND: Anterior cruciate ligament (ACL) and meniscus injuries are common in female athletes participating in cutting and pivoting sports such as basketball. The epidemiological characteristics of injury in athletes seen at the Women's National Basketball Association (WNBA) combine and the effect of ACL reconstruction and meniscus surgery on longevity in the WNBA are unknown. PURPOSE: To evaluate the details and spectrum of injuries in athletes entering the WNBA combine and to assess the potential effect of specific injuries on the round drafted into the WNBA and career length. STUDY DESIGN: Descriptive epidemiology study. METHODS: Demographic data and the documented collegiate injury profile were reviewed from the WNBA database for all players entering the WNBA combine in 2000-2008. The study included injury data on 506 athletes. Complete demographic data were available for 496 players. RESULTS: Of the athletes taking part in the combine, 45.2% were guards, 33.7% were forwards, and 21.1% were centers. Ankle sprain (47.8% of players), hand injury (20.8%), patellar tendinitis (17.0%), ACL injury (15.0%), meniscus injury (10.5%), stress fracture (7.3%), and concussion (7.1%) were the most common injuries reported. Seventy-three athletes (14.4%) reported ACL reconstruction before entering the WNBA combine, and meniscus surgery was the next most common surgery (n = 50 players; 9.9%). There were no differences in ACL or meniscus surgery when analyzed by player position or round drafted. History of ACL or meniscus surgery did not affect career length in the WNBA. Excluding ACL and meniscus surgery, other reported surgical procedures were knee arthroscopic surgery (11.7%), ankle reconstruction (2.6%), and shoulder stabilization (2.0%). CONCLUSION: The ankle is the most common site of injury and ACL reconstruction is the most common surgery in elite female athletes participating in the WNBA combine. A history of injury or surgery did not affect the round drafted or career length.

Does the quality, accuracy, and readability of information about lateral epicondylitis on the internet vary with the search term used?

BACKGROUND: Concern exists over the quality, accuracy, and accessibility of online information about health care conditions. The goal of this study is to evaluate the quality, accuracy, and readability of information available on the internet about lateral epicondylitis. METHODS: We used three different search terms ("tennis elbow," "lateral epicondylitis," and "elbow pain") in three search engines (Google, Bing, and Yahoo) to generate a list of 75 unique websites. Three orthopedic surgeons reviewed the content of each website and assessed the quality and accuracy of information. We assessed each website's readability using the Flesch-Kincaid method. Statistical comparisons were made using ANOVA with post hoc pairwise comparisons. RESULTS: The mean reading grade level was 11.1. None of the sites were under the recommended sixth grade reading level for the general public. Higher quality information was found when using the terms "tennis elbow" and "lateral epicondylitis" compared to "elbow pain" (p < 0.001). Specialty society websites had higher quality than all other websites (p < 0.001). The information was more accurate if the website was authored by a health care provider when compared to non-health care providers (p = 0.003). Websites seeking commercial gain and those found after the first five search results had lower quality information. CONCLUSIONS: Reliable information about lateral epicondylitis is available online, especially from specialty societies. However, the quality and accuracy of information vary significantly with the search term, website author, and order of search results. This leaves less educated patients at a disadvantage, particularly because the information we encountered is above the reading level recommended for the general public.

All-epiphyseal, all-inside anterior cruciate ligament reconstruction technique for skeletally immature patients.

Anterior cruciate ligament (ACL) injuries are an increasingly recognized problem in the juvenile population. Unfortunately, outcomes with conservative treatment are extremely poor. Adult reconstruction techniques are inappropriate to treat skeletally immature patients because of the risk of physeal complications, including limb-length discrepancy and angular deformities. "Physeal-sparing" reconstruction techniques exist, but their ability to restore knee stability is not well understood. We describe an all-epiphyseal ACL reconstruction for use in skeletally immature patients. This is an all-inside technique with the femoral tunnel drilled retrograde and the tibial tunnel drilled retrograde; both tunnels are entirely within the epiphysis. Fixation of the hamstring autograft is achieved with soft-tissue buttons on both the femur and tibia. We present case examples for 2 patients who underwent the all-inside, all-epiphyseal reconstruction and our postoperative rehabilitation protocol. We present a novel surgical technique for an all-inside, all-epiphyseal ACL reconstruction in skeletally immature patients.