Good morning, Brett Owens from Brown here. I'm so sorry I could not join you in person, but I had an unplanned surgery a couple days ago and can't travel. I've been asked to discuss the bear ACL restoration with a focus on the technique. Is ACL repair a bear? Nah, you can do it. My disclosures are in your program. Of note, I do not have any current financial relationship with MEOC, the maker of the bear implant. My personal journey with ACL repair goes back to my fellowship days where I was fortunate to learn about the repair experience of the late John Fagan. I tried some primary repairs early in my practice on a few select patients with overall good outcomes, but primarily relied upon reconstruction. When I ended my Army career and came to Brown eight years ago, I was lucky to work with Braden Fleming and Martha Murray and perform bear surgeries in mini pigs. When the opportunity came to be part of the Bear 3 trial and be the first facility outside of Boston Children's to perform bears, I jumped at the chance. I was hopeful based upon the early clinical data, and then I saw a bear with my own eyes and hands. This is one of my first bears from five years ago. He was 14 at the time. He was able to return to baseball without issue and is now in his second year of college. This is what his ACL looked like nine months after a bear surgery. Building upon the results of the early bear studies, Chris Spillner has assembled the Bear Moon trial, a multi-center, single-blinded RCT comparing bear with patellar tendon autograph reconstruction. Despite being slowed by COVID, we have consented 100 and randomized 84 so far, and look forward to be able to sharing these results soon when they become available. So here's the bear technique in a few minutes. There are many steps that's currently performed utilizing an arthrotomy. Once we advance to an arthroscopic approach, this will be even easier. I do recommend having a printed checklist posted. I still use this in every case. Also having the rep present can also be helpful. If you can perform the suture management of a rotator cuff repair, you can do a bear. We start with a diagnostic arthroscopy. We need to ensure we have a quality stump that will be able to hold sutures. We next perform a notchplasty, as the quality of the repair tissue was more robust when a notchplasty was performed in the early bear experience. We next place our femoral tunnel anterior to the ACL footprint, and then ream with a 4-5 reamer to allow the button to pass. We then have to make a lateral incision over where the button will be so we can tie over it. Similarly, we place our tibial pin just anterior to the footprint, dissect down to the tibial pin so that you can then shuttle a passing stitch with a Hewson. You can whip stitch the stump with a vicral suture through the arthrotomy. This is how I watched Lyle McKellie do some of the first bears. But you can also shuttle between two portals as shown here, in order to produce a crossing pattern with control of the ligament stump. Or you can use a rotator cuff type shuttling device through a single cannula, if you feel more comfortable with this approach. Next comes the arthrotomy, extending your medial portal for a medial parapatella approach. It has to be big enough to get the implant through, past some army retractors. You must now manage your sutures and flip your femoral button. You need to communicate with anesthesia to draw whole blood while you pass the ethabond splint sutures through your implant. Now you're ready to prepare and pass the implant. You soften the sponge with whole blood, and as it begins to soften, you pass it up into the notch. You hold it in the notch with your thumb, and then gently extend the knee. We can't usually see what happens next, but here's a dry scope using a Sawbones model, where you can see the blood-soaked implant being inserted into the notch, followed by reduction of the ACL stump into the implant. Next, we pull the slack out of the ethabonds and tie the entire implant together. Next, we pull the slack out of the ethabonds and tie the internal splint over the tibial button. We then reduce the ACL stump into the implant and tie either directly over the femoral button as seen here, or also by using a knot pusher to ensure that the knot is directly on top of the button. So, is bare a bare? Well, there are a bunch of steps with a learning curve like any new procedure, but I do this in the same amount of time as I perform a reconstruction. It does require a slight shift of thinking, as you can't check a lock then at the end of the case and high-five your assistant, but so far the outcomes have been reliably excellent. The literature so far is strong, and hopefully we'll have more to report soon with the bare moon trial. Thank you so much for your time. I wish I could be there with you in D.C.

bear ACL restoration technique

ACL repair

bear surgeries in mini pigs

Bear 3 trial

Bear Moon trial