I want to thank the AOSSM for inviting me to speak here today. I'm going to switch gears a little bit and talk about ACL reconstruction, what are we getting right and wrong, and a little bit in between as well. Here are my disclosures. So just to take a bird's eye view of ACL reconstruction, first ACL reconstruction was reported in 1912, so we certainly have come a long way since then. Up to 200,000 ACL injuries occur each year and estimated over 250,000 and 200,000 ACL reconstructions occur per year in the United States alone. Again, we pride ourselves with our success rates of 75% to 97%. Our goals are to create a stable knee, to really return our athletes and our patients to sport or activity, to prevent further injuries of the knee joint, particularly meniscus injuries and post-traumatic arthritis, as well as prevent re-injury and failure of our grafts. Our patients have high expectations as you've seen before in the talk earlier. They want to return to the same level of sport. They want a nearly normal or normal knee and they want no pain. But we don't always meet those expectations. So despite our best efforts, we still have high failure rates. There is no consensus in the literature about what failure means. We can all agree that recurrent instability is one of the criteria, but certainly arthritis and loss of motion and recurrent pain are also criterias for failure. We do a lot of ACL revisions in the United States, but we need to do better. We need to be more honest with our patients regarding our re-tear rates, especially in our young athletes and our young female athletes. We also have high rates of post-traumatic osteoarthritis. Again, recent studies showing 37% osteophyte formation in 10 years. Earlier studies, again, show higher than 50% arthritis rates. So certainly we need to work on our post-traumatic arthritis. So where can we intervene? Certainly this is a busy slide, so I apologize for that. But again, there are many, many areas that we can intervene from prevention to a return to sport. And I'll be mentioning a few of those as well as the graphs that we just talked about. So in prevention, I would, it behooves all of you to take a look at this, the HUNT report that was done by Edie Griffith and co-authored by many of you in the room here today to look at what were the strategies for prevention as well as the risk factors for ACL reconstruction. And just to see how far we've come, again, we can all agree that prevention programs involve stretching and strengthening, aerobic conditioning, plyometrics, agility training, as well as risk awareness. Again, recent studies with the 11 plus and the FIFA 11 plus have shown reduction of ACL tears. But again, in specific populations, other prevention programs have shown the same. But again, despite all the strategies to decrease ACL injuries, we still have many, many injuries that occur in our general population. And certainly, none of us are doing less ACL reconstructions than we did 10 years ago. So what are we doing right? Again, difficult question. We have a better understanding of anatomy of the ACL. We're really using individualized considerations for our patients, looking at the anterior medial bundle and posterior lateral bundles, recognizing the anatomic landmarks of the notch and the ACL certainly have been very important, as well as notch size and shape. We have some good outcomes looking at the anatomic ACL, at least in reducing arthritis in our patients. Again, we've come from the isometric ACL studies done in Keith Markoff's office or his lab with myself as a fellow, looking at the o'clock position, certainly found 11 o'clock and 10 o'clock were good positions. But now, we've really, really advanced to using the anatomic positions on our ACL reconstruction, particularly in the femoral side, again, also in the tibial side. Again, what are we doing right? We have new techniques and specialized equipment. We have better visualization. We have independent tunnel drilling, although there is a group who still does trans-tibial modified type of technique that gets us to that point. Again, use of the anterior medial portal, as well as accessory portal, 70-degree arthroscope, and drill guides and special equipment that we can do all inside, outside in techniques. Again, but when we look back at how successful we are, even a study from Canada showing that even our best surgeons, most experienced surgeons have difficulty placing the tunnel in the right position. Graph choices, as you just heard three talks regarding that. The only thing that I will mention regarding that is really that individualization. You know, using certain graphs for certain populations, and we're seeing more studies on that as well. Again, one of the most important points we didn't talk about were allografts, and I think it's an important point. One of the things that we're doing right is not using them in our young, active patients because we've seen high failure rates. Posterior tibial slope, again, something else that you should look at when you're looking at your patients who are undergoing anterior cruciate ligament reconstruction. We know that increased posterior tibial slope leads to increased risk of ACL and ACL graft failure. Again, these tibial slope reducing osteotomies have decreased graft forces and decreased anterior tibial translation. So again, we're using this technique and HTOs mostly in our revision ACLs, but again, is this something that we should be correcting in our primary ACLs? Again, research will tell us if this is the case. Looking outside the notch, again, is this right or wrong? Anterior ligament reconstruction and LETs, again, indications for these, high-grade pivot shifts in your patient, meniscal deficiency, sagon fractures perhaps, chronic tears, revision tears, and primaries with a high posterior tibial slope. Again, how do we identify our patients? I think that's something that we're continuing to learn, and what are the consequences of these actions that we do? Are we increasing stress in portions of the knee that we don't want to? These are something that we certainly need to look at. The role in this meniscus has become more and more important, so I think this is a thing that we're doing right. We're looking at the posterior horn of the medial meniscus more clearly. Ramp lesions is what I want to highlight here today. Peripheral tears of the posterior horn of the medial meniscus, again, occurring in over 24% of our cases, so the thing that we're doing wrong is not looking for them. The thing that we're doing right is really repairing them, particularly if they're unstable. So again, I would encourage you to look for these lesions, particularly using either a posterior medial portal or using a 70-degree arthroscope to look in the back of the knee. Preventing failure, again, our young, active patients, they're at increased risk for a second ACL injury. Greatest risk, the re-tear is in their first two years, and this has been shown in many, many, many studies in the literature, so again, we have to really worry about these, and so what are we doing wrong with these patients? We talked about return to sport a little bit in some of the talks earlier. Again, we've all prided ourselves in getting our patients back faster and faster, but that may not be the right thing to do. We really have to take into account graft maturation and ligamentization and biological healing, which may take up to two years, as most of us know. And again, Timothy Hewitt's group asked a good question. Should we return to sport or delay return to sport for two years on our patients? Again, there are other factors to be included in that, including psychological readiness and physical preparedness in our patients. Again, and we should also consider secondary prevention programs, so again, basing our return to sport solely on time, a no-no, basing it, at least in part, by biology is going to be an important move forward for us. Post-traumatic arthritis, again, coming back to that, I think an important concept in ACL reconstruction. I would be remiss if I didn't mention the work, over 20-year work of Dr. Constance Chu, who has spearheaded the work on post-traumatic osteoarthritis in ACLs. Again, multifactorial, we have to remember that there are two insults to the knee, one at the time of injury and one at the time of surgery. We need to look at our collagen degradation markers, inflammatory markers, and consider treatment of our patients at the time of their injury, including injection of potentially cortisone or other marker inhibitors, including inflammatory markers like interleukin-1. So again, what are we doing right and wrong? I think that's up to debate, and many of us up here, we still have so many unanswered questions regarding ACL reconstruction, and particularly when to use graphs and how they fail. We have a long way to go to create the perfect ACL reconstruction, the one that has no instability, really reproduces the exact kinematics of the knee, and prevents arthritis. Thank you.

ACL reconstruction

graft failure

prevention programs

posterior tibial slope

meniscus injuries