Okay, thanks very much, Jorge. So current indications for adding LET. So these are my disclosures. A lot of the research that we've done has been supported by ISACOS, and now Canadian Institute of Health Research, as well as the National Institute of Health. So if we look at our patient population, what are we going to do with this 17-year-old female soccer player? She's an acute non-contact plant and pivot. So classic ACL injury, wants reconstruction, wants to go back to playing sport, and wants to go back to playing soccer. What makes her at high risk of an ACL reconstruction graft failure? So lots of data in terms of the different predictors of re-injury. Age is a significant risk, and that's been shown in multiple studies, I think some of the data that's come out of the MOON study, really showing the age and activity level as a significant predictor of both ipsilateral and contralateral ACL injury. High grade knee laxity, again, some data from MOON showing that high grade either rotatory knee laxity or anterior translation, again, is a predictor of rates of re-injury. Generalized ligamentous laxity, it's a nice study from Chris Larson showing asymmetric hyperextension is a predictor of poor outcome. With hypermobile patients with failures up to 24%, non-hypermobile of 8%, and certainly when we looked at our stability cohort, we did clearly show that generalized ligamentous laxity, in particular knee hyperextension, as being a predictor of increased rotatory knee laxity as judged by a pivot shift. Meniscus injury is important, we know the issues regarding meniscus preservation, so we want to be able to try and preserve the meniscus, and some data that I was involved in when I worked with Tim Spaulding in the UK, showing that meniscus deficiency is correlated with reduced graft survivorship. Bony morphology, we've already seen the demonstration from Volker, and we understand that 12 degrees of increased posterior slope is associated with ACL injury and graft injury, and if you add in age, so adolescence with increased posterior tibial slope, it really has catastrophic outcomes in terms of graft survivorship. And as an MRI study, again looking at both medial and lateral slope, as well as lateral femoral condyle offset, and all of these factors do play a significant role, as well as our lateral femoral condyle notch as a result of the pivot shift mechanism, these are all associated with high grade rotation, as well as increased risk of re-injury. We got to understand the associated patholaxities, the posterolateral corner, we know is a problem because of the shift of graft forces into the central pivot, if we lose the lateral side, and the medial side is becoming more and more topical, understanding antramedial rotatory laxity and the effect that that may have on ACL re-injury rates. And then that brings us really to the antralateral complex, and I'm not going to give a talk about the biomechanics and the anatomy of the antralateral complex, because I think that is really very well understood, that we really appreciate that the antralateral complex has a role in controlling rotation. So here's this young girl, she's got a high grade pivot shift, if we look at her imaging, she's got a lot of the issues that we've mentioned, so increased posterior tibial slope, her MRI scan confirms she's got a bone bruising pattern on the lateral side, issues with the soft tissue complex on the lateral side, as well as a posterior root tear of the lateral meniscus. So she really ticks a lot of the boxes, she's young, she's got high grade knee laxity, generalized ligamentous laxity she doesn't have, but meniscus injury, bony morphology, and associated patholaxities. So the big question is, should we add an LET into this patient? And so stability one, this is a randomized clinical trial that looked at this very question as to whether or not a lateral tenodesis would reduce the risk of graft failure, and in summary, we find that the addition of a lateral tenodesis reduced relative risk reduction by 40% in controlling rotational laxity, a 66% reduction in graft failure, we had no increase in overall complication rates, so yes there were some patients that needed hardware removal, but when you compare that to the number of re-operations because of failure, then there was no difference. Our clinical outcomes in terms of functional testing were no difference between the groups of 12 and 24 months, and this is some data that we're now just looking at in terms of return to sport, and the level of return to sport, and it would suggest that the patients that had better rotational stability resulted in a better return to play. So when we look then at predictors of outcome within stability, again using a logistic regression, adding LET reduced the odds of graft rupture by 60%, each one year of increase in age reduces the odds of rotational laxity by 38%, so the younger patients are at higher risk. Return to sport time is important, if you delay return to sport, we have a reduction by approximately 14% each month of delay, pre-operative high-grid knee laxity associated with over three times the higher odds of graft rupture, and each one degree increase in posterior tibial slope increases the odds of graft rupture by 15%, and if we actually look at age, similar to the Pinchefsky study, if we look at age as well as increased posterior tibial slope, we see that LET actually is somewhat protective right the way across that spectrum, but when we're getting close to 10 degrees, maybe that's the patient that we really should be adding LET into our primary ACL reconstruction. It'd be remiss of me not to mention ALL reconstruction, and you know, it's not, I think the discussion of ALL versus LET, I think we've gone beyond that now, we look at lateral reconstructions, and this study again showing upwards of 50% reduction in failure, we know these procedures work and have an impact. We did this, we've just done a systematic review of the most recent comparative studies, these are the old papers that have been done since 2012, it's just been accepted for publication in the Journal of Experimental Orthopaedics, and we see that we have a significant reduction in graft failure with the addition of some form of lateral procedure, whether that's a lateral tenodesis or an ALL reconstruction. What about graft choice? Well this always comes up, if we hadn't used a hamstring, what if we'd used a BTB? That might be more appropriate and result in a better outcome. So we looked at the Moon Risk Calculator and validated the Moon Risk Calculator with our stability dataset, and what we found is that both patella tendon as well as lateral tenodesis appear to be protective for graft rupture versus hamstring tendon alone, so in these young patients, young patients going back to pivoting sport, BTB clearly is more effective than a hamstring tendon, and that's been shown in multiple studies. We also then did an indirect comparison of hamstring plus LET versus the BTB, and it would suggest maybe that the LET might provide even more protection, but we don't really know that for sure, we need better data, and that's why we started the Stability 2 study along with Volker Musall and Jay Ergang at the University of Pittsburgh, comparing quad tendon and patella tendon with or without tenodesis. This is a large multi-center trial, I look forward to being able to present the results maybe in five to seven years' time when we finally get this thing finished. So revisions, we've got to be aware of this as well, and certainly in our practice Volker and I looked at our revisions over the past 10 years, and our utilization of LET is certainly increasing, and that has been shown in a number of studies really showing that LET is effective in reducing post-operative rotatory laxity and failure rates with the addition of a lateral tenodesis. So this really is an effective treatment in both the primary and revision scenario. So in terms of my indications as things stand, revisions, I'll use the LET more and more often, particularly where I'm not addressing any other pathology. And then in the primary ACLs, if I'm going to use a hamstring tendon for some reason, they pretty much all get a lateral tenodesis. If I'm using a patella tendon or a quadricep tendon and they're not involved in our RCT, then I'm looking for other risk factors, and those would be young age, generalized ligamentous laxity in particular, knee hyperextension, going back to pivoting sports, and then this issue of tibial slope. Patients that have tibial slope over greater than 10 degrees, then we'll add in a lateral tenodesis. So in terms of our technique, this is available, both JBJS techniques as well as VUMEDI. It's a very simple procedure. It adds an extra 5-10 minutes onto your procedure. It's essentially a small incision based over the lateral epicondyle. We take a 1-centimeter-wide, 8-centimeter-long strip of the posterior half of the IT band. It's left attached at GERDI's tubercle and disconnected. And essentially what I've found over the years of doing this is that once you get to the muscle belly of vastus lateralis, it's usually long enough. So we cut that. We essentially cut it proximally and then whip stitch that with a number one vascular suture. It's important that you don't go too posterior in the IT band because you want to preserve that layer, which is the capsule wassius layer, and that's going to help in terms of controlling rotation. We're going to take that strip. We'll do a small couple of throws of a whip stitch on there, see if we can speed this up a little bit for time. And then what I'm going to do is go into a figure four position, identify the fibular collateral ligament. The other option is you can put the leg over the side of the bed and push it into VERUS. And again, find the FCL. Then tunnel under the FCL with a metz and bump scissor and then a clamp, a Kelly clamp, and then pass your graft. And then it's going to be fixated onto the metaphyseal flare of the lateral femoral condyle. Important to use cautery here. There is the superior lateral geniculate vessel that you want to make sure that you get a good hemostasis. And if you do use a tourniquet, release the tourniquet to avoid hematoma formation postoperatively. Importantly, the fixation is done at approximately 60 degrees of flexion, neutral tibial rotation, minimal tension applied to the graft. It is a tenosynovitis after all. You do not need to tension this to avoid significant over-constraint. And with that, I'd just like to finish up and thank my co-authors and my colleagues both at Western as well as University of Pittsburgh and the whole stability study group. Thank you very much for your attention.

lateral extra-articular tenodesis

ACL graft failure

patholaxities

Stability One

graft choice