Thank you, Lee, and thank you to the program committee for inviting us to speak today. These are our disclosures. So we're going to talk a little bit about the advantages of the BTB autograft. Certainly, we can debate some of these topics, but I would say that improved stability, increased return to sports rates, lower re-tear rates, better graft maturation, bone-to-bone healing. It's a reliable graft tissue, and it has a long history of success, particularly here in North America. So we'll talk a little bit about some of the studies that really back this up. This is a study at a KSSTA in February of 2019, looking at a national registry of over 5,000 patients. And what they found was that there was a decreased laxity in the BTB group compared to hamstring group. And most of the studies we'll talk about early on will be comparison to hamstring, because obviously that's where the history mostly resides. Another study looking at return to sports, BTB versus hamstring, a systematic and meta-analysis looking at over 2,000 patients published in AJSM. I'm sorry, OJSM in 2020. Overall return to sports rates were 73%. However, if you look at the BTB graft, it was 81% compared to hamstring, which was 70%. And the re-rupture rates were slightly less in the BTB versus hamstring. And return to pre-injury levels, again, slightly better in the BTB group. How about returning just to pre-injury activity level? This is the New Zealand registry published last year in AJSM, looking at return rates at one year and two year. The overall return rates you can see are fairly low with regard to pre-injury levels at one year. However, if you look at the BTB group was higher at 17% at one year versus 9% in the hamstring group. And at two years, it was 23% versus 13%. So certainly improved rates and a better history of return to activity. This is the HSS registry published last year in OJSM looking at high school athletes. What they found was that at just under four years that 83% of patients reported back to return to sports at this young population at a mean of 10 and a half months. And so certainly return rates at six, seven months, particularly in this group, put you at higher risk. Overall satisfaction in this group was 91%. The MOON registry looked specifically in 2020 in AJSM looking at BTB versus hamstring. And I'll debate my close friend, Jeff, that the incidence of revision rates were 2.1 times higher in the hamstring autograph than the BTB group. And I think Jeff will acknowledge that these are mostly these young high school and college athletes that he would do BTBs on as well. How about graft maturation? So Fukuda published a study last year in KSSTA looking at 75 MRI or second look arthroscopies, 30 BTB and 45 hamstring. What they found was the laxity was decreased significantly less than the BTB group versus hamstring. And that the maturation was superior of that of double bundle hamstring autograph in both MRI and arthroscopic second look. How about graft harvest? Jeff really showed a great job of his hamstring. So we'll show some of our steps. So the midline incision, expose the paratenon. Split and maintain the paratenon for later closure. I think that's really important. Measure the width of your tendon. Take a centralized graft, whether it's 10 or 11, whatever you choose. Really the important thing is to stay in line with your inferior pole, the patella and the tibial tubercle. So if you have somebody with a really elevated Q angle, you really need to be wary of where your inferior pole is compared to your tubercle. Incise the tendon and mark the superior aspect of the patella tendon and inferior aspect where the bone insertion is. Measure your bone plug lengths. I typically try to measure 22 millimeter bone plug lengths. That way, if I'm two millimeters off on either side, I know I'm okay. Trapezoidal cut on the patella and rectangular cut on the tibia. Use an eight to 10 millimeter wide saw blade and do a 10 millimeter depth marking. Osteotome to remove the plugs. I use a straight osteotome and I remove the patella first. I really want to get to that inferior aspect of the patella to try to avoid any articular cartilage damage and we'll show that in the video. On the tibia, you really want to make an angle cut at the very top part of your bone plug to prevent overhang of your bone plug. Prepare the graft. You want to bullet the plugs for easier passage. I do two perpendicular sutures in the bone plug, but I add a third suture at the tendon bone interface of my tibial plug just to avoid and decrease risk of any suture cutout when you're putting your screw in. Save bone graft. Soak the graft, as Jeff said, in vancomycin irrigation. Place the bone graft into the harvest site at the end. Add some DBX or chips if you feel like you need additional. Loosely close the patella tendon with a few inverted absorbable sutures. Run enclosure of the paratenon and then I postoperatively brace to protect our quad muscle and our patella tendon. A few other graft tips. You want to do a, I do a separate tibial tunnel incision as you'll see in a second so that I can actually tailor my tibial tunnel length exactly to my graft. You want to clear that distal tibial tunnel of any soft tissue so that your graft passes easily. Medial portal drilling, very similar to what Jeff described. I use a probe as a fulcrum to help guide the femoral plug in. And when you're tapping your tibial tunnel for your screw, I use a seven followed by a nine millimeter tap so I don't push the plug in. These are the incisions. Again, I do use a separate incision over that anterior medial site. Obviously, typical incision over our midline to expose our patella tendon. We're going to, once we expose the tendon and incise the paratenon, we're going to measure our width. You know, we always want to make sure that we get the size of the graft that we want, so 10 or 11. After we do that, we'll go ahead and start to make, we went blank here, so, make our patella cut. As you come up to higher up on the patella, you really want to mimic the curve of the patella by bringing your hand up and around so that you create a 10 millimeter depth all the way around, and this is what it should look like afterwards. So, as we, after we made our cuts, we used the osteotome to free it up, and you can see on this picture on the right here, we take the osteotome from the inferior aspect of the patella and try to just create an area so that way, when you're removing your bone plug, you're not doing any damage to the articular surface, particularly if you do happen to be a little bit deeper. After we get our patella plug out, we put it back in place, and then we'll go ahead and do our tibial side, so we'll measure our length of our tibial graft, then we'll make our cut on our tibial graft, tibial side, our plug. Again, same thing, you want to really try to do a rectangular plug on the tibia. Here's our transverse cut at the inferior aspect, and we've created our depth all the way around. And after we've made our cuts, we're going to remove our tibial plug. Again, I try to use an 8-millimeter osteotome so I don't lengthen our tunnel, so we'll see, we'll start to remove it, remove any of the soft tissue attachments, and then we can go ahead and remove the entire graft. We'll take it to the back table, we'll measure it where the tendon and bone interface is with the marking pen, measure the length of our graft, we'll then tailor the length of our femoral and tibial grafts based on the length of our graft. If you like to use a crimper, you can certainly do that. The main thing is really bulleting your plug so that the passage is easier, and then making sure that you have a real easy passage through whatever size, whether it's 10 or 11, that you opt to go with. So it should be a really easy fit. Now we're ready to pass the graft. So similar to what Jeff did, I don't show you the medial portal drilling, but very, very similar to that. We'll pass our graft, pull it through our femoral side. Then we have our probe here, which is kind of helping direct the plugs. I think it's really important, you can see that the hands of my fellow are right here and here, and he's controlling the graft on both sides, he or she. That way, when they're pulling, they're not pulling against somebody else who may not know exactly what's going on. So they're controlling it. We're pushing our plug in. Once we get the plug seated, we can go ahead and direct our plug in and make sure we have the right angle. If you're struggling a little bit, you can hyperflex the knee and make your tunnel a little bit more anterior to get you there. Once we have our plug seated in place, we'll go ahead and tap our femoral side. We'll bring the tap in. Then we go ahead and put our screw in. Again, all through the accessory medial portal. After we've seated our screw, we'll check our length of our tibial graft. Go ahead and cycle the knee and make sure that we've taken some creep out and get our length all the way down. Once we've done this, we'll go ahead and put our tibial screw in. I do it in full extension. So here we are tapping it again. I use a 7-millimeter, if I'm using a 10-millimeter graft, it's a 7-millimeter tap first, so that way, we don't push the plug in and really hold good tension on it. Then we'll go ahead and put our, tap it again with a 9 and then put a 9 screw in. And then once we have our graft seated, fixed, we check it and everybody's pretty happy. So afterwards, we'll go ahead and put the bone graft in our patella harvest site, loosely close the patella tendon and then close the paratenon. So in summary, BTB to me is still the gold standard. I think we have, I think we've proven better stability in return to sports rates, lower re-tear and revision rates. Hamstring graft size variability, as Jeff mentioned, certainly can be an issue for a high-level athlete. I use a BTB graft unless there's a reason against it. And would you really trust this guy when he's putting in your ACL? I wouldn't. I still think this is the best mascot in sports. So thank you very much for your attention.

BTB autograft

ACL reconstruction

bone-patellar tendon-bone

surgical technique

gold standard