Yeah, Seth. I have a question. Two questions for you. Number one, do you ever use an IT band instead of a free draft? And what is your protocol for knee flexion angle and knee flexion angle? Yeah. So I think we'd be all over the board with the second part of the question. So for me, because I really don't know, to be honest, I don't have any, none of us have any scientific evidence right now based on clinical studies to say this is the best knee flexion angle. I use 30 degrees with neutral rotation of the foot. I mean, you definitely don't want to externally rotate the foot. So neutral rotation, I think some people have argued 60 degrees because that's where it's supposed to really come into play maximally. I'm always a little worried because I don't think we're all as familiar with the anatomy or variable anatomy from one patient to the next, that if it does tighten up for some reason in extension, I don't want to lose that. So I just like to be a little closer to extension. So I use 30 degrees. How about you? Yeah. 20 or 30. Yeah. Patrick, do you have any thoughts on that? Same. I don't think you know yet, but I can put 20 to 30. 20 to 30. I think it's just sort of a safe range of motion where we're not worried about over constraining an extension. But I think I'm a little concerned tightening things up at 60 degrees at this point in time until we get more data. And then what was the first? Oh, yeah. So for me, I mean, I think if you only use an LET, I mean, the advantage of the LET, if you use the technique where you go deep to the FCL, is that you can fix it proximally pretty much anywhere. So you really don't have to worry about that femoral fixation site because it's a sling. So it's really probably your safest technique with regards to isometry of that. With an ALL, if you're going above the FCL, I think you have to be more accurate with regards to your femoral fixation site. And again, there's some question as to where it is or if there's variability between one patient and the next. And there is some data out there that suggests that patients who tear their ACL have a little bit different anatomy than those patients that don't into some control patients. So we need more information there. So when I typically will use an LET is when somebody says they don't want to use allograft tissue. So then I'll always do an LET, and I think that's perfectly fine. The other scenario, and we published an arthroscopy techniques on this, where I think it's great if you do predominantly ALL reconstructions is with your skeletally immature patients. And why I think that's a great scenario is because with your open growth plate patients, you're typically going to use a soft tissue graft. There is some data right now that suggests maybe the soft tissue grafts have a higher failure rate in some of our higher level athletes who are doing cutting and pivoting. Again, that's not concrete evidence, but we're starting to see a little bit of that. And the use of an LET means you don't have to do anything on the tibial side close to the tibial fysis. So really all you have to do is find your fixation point, and you can either place an anchor distal to the fysis, or you can fix it proximal to the fysis. So I think with an open growth plate, it's an ideal scenario. There is some limited real estate over there. So people ask, have you ever done an ALL or an LET in conjunction with like a posterolateral corner? Well, sometimes it's off, like it's a sleeve off the tibia, so it's just part of your repair, but you do start running out of real estate. So generally not. Yes. Yeah. For your monoclonal marrows, what do you do to prevent the effect of closing the tibia door? Yeah, so what I do is I start closing it proximally, and then I just go distal until I feel like the tension's too much. And usually you're going to end up leaving a couple centimeters open distally, but you can close most of it proximally. Have you had any kind of a public subtraction issue with your tibia? Yeah, that's a great question. I have not. So I'll present a case later at the end as well. But number one, I don't modify the rehab after this at all. There's no weight-bearing restrictions. I really don't restrict them with regards to their range of motion. I would treat this more like an MPFL, where it's an extra-articular reconstruction, so it doesn't have to be highly constrained. So even if you fix it with a suture anchor, I think it's fine. Allograft tissue is fine. So from my standpoint, I haven't seen problems with pain laterally. There were lots of things I was worried about when I started doing this, but I think most people, other than, I think Al just had a couple patients where he had a staple that was prominent proximally, and they had to remove the hardware. But I haven't really seen issues with patients having more pain or issues with this. Maybe the therapists are a little slower rehabbing them, or you think about it, these are your hypermobile high-risk patients, so they tend to rehab a little slower. They tend to get their neuromuscular firing pattern slower. So I think by saying patients who have this procedure done come back a month later, it may be a group of people that kind of recover later anyway because of the way they're put together. Yeah. Do you use the Baton score in any of your indications? Yeah. So in that first study we did, we used a modification of Baton score because they had an ACL injury on one side, so touching their palms to the floor is kind of hard. Measuring knee hyperextension in an ACL-injured knee is probably not all that reliable, but I do use Baton scores when I'm measuring it. But what I will say is when we looked at all of our data, if you just looked at knee hyperextension based on heel height, that was the most predictive thing of somebody who was going to have a problem. So if somebody has a ton of knee hyperextension, those are the ones that I worry about the most. I still don't know. I mean, posterior tibial slope is something I think we all think about, but I don't know exactly what to do with that yet, but I still, if it's more than 12, then I start thinking more about it. Yes. Yeah, I mean, so the question is, you know, typically when we've looked at procedures we do, when we restore anatomy, we do better than when we try to work around it and come up with something. So in other words, an LAT is not anatomic from what we're, you know, seeing with the anatomy, whereas an ALL reconstruction is technically anatomic if we think we really understand the anatomy. So maybe part of it is that we don't really understand the anatomy, you know, and maybe it's different for one group versus another. I think that all of us are still trying to figure out how to technically do these procedures best and try to figure out the right patients that require them. So I think we're still trying to figure out the right group to operate on. But I will say the difference here is that, again, the sling procedure where you go under the FCL is a pretty forgiving procedure. And if you watch that IT band as you go through range of motion, it does control internal rotation and, you know, it seems to, maybe this is just one of those scenarios where we're not going to see a big difference. But I've always been somebody who liked anatomy, which is why I kind of went down the ALL reconstruction road rather than doing all LATs. But there's not a right answer yet with what we have. Anybody else? So again, what we'll plan to do is, it looks like our break was set for 2.20. So we're about five minutes early. So why don't we plan to come back at 3? We have a couple of really good talks to come back to. And then, again, we're not going to break out again at that time. We're going to go through some case presentations that are relevant for these topics. So you guys can see maybe more how do we manage these in our practice, what are your technical pearls that you have for performing these procedures. I'll present an ALL reconstruction. And we have a number of different things that we can show you guys just on a case-based format that can be freely interactive, you know, feel free to interrupt at any time. So again, take a break, go to the bathroom, go check out what Smith & Nephew has back there. And at the very end, if there's still some other things you want to check out with them, I know they're going to stick around. But we'll cut 45 minutes out of this for you guys and just finish things up. Again, resuming here, reconvening at 3 o'clock. Thank you.

IT band

knee flexion angle

LET

skeletally immature patients

Baton score