come on out. All right, well, we're excited to get this kicked off for AOSSM. Thanks to John Allison for inviting us to do this and a wonderful start by Bruce. Volker, any words? No, thanks. I mean, it's a great start to a session when Bruce Reiter is singing the national anthem, amazing. So let's get started. We're going to invite up Walt Lowe to talk about slow producing osteotomies in conjunction with ACL reconstruction. Perhaps we won't. Or we won't. Maybe if Walt isn't here, can we start with a second presentation by Bertrand Sonnery-Coté? Is Bertrand here? There, I see you over there. Why don't we do this and then add Walt's talk after. So Bertrand, 1,100 patients, it only should take about a year to recruit, right? On that note, please. Thank you. Thank you very much. It's a great pleasure for me to be here and to introduce this nice session. So my presentation is Combined ACL and Lateral Extrarticular Procedure Reduce Graphic Treatment in Patients Over the Age of 30 Years Old. It's a match study of over 1,000 patients. This is my disclosure. So the question is always, once again, why to talk on lateral extrarticular in 2024? From, I will say, at least 10 years now, the stability group and the Santee group show better joint stability, better rotational stability, better clinical and functional outcomes with an extrarticular reconstruction. But moreover, because I think it's the most important expectation for our patient, we all demonstrate a low graft-future rate and reoperation rate. It was already proven by this very nice literature review based on a primary and revision ACL, where both the conclusion are clear. Anterolateral reconstruction or lateral extrarticular tendinitis type lumere reduce the graft failure rate in primary and in revision surgery. But the question is always, when is the indication for this extrarticular reconstruction? Our indication, I will say, because in France we have the culture from the beginning to do this extrarticular reconstruction, so it was dedicated for high graft instability, for revision ACL, for pivoting sports, for chronic ACL tears, but also for young patients. However, the exact indication for combined ACL and extrarticular reconstruction has not been clearly defined, especially with regard to patient age. In fact, I analyzed in my huge database with almost 10,000 ACLs now, the distribution by age, and we discover, which is very funny, that the over 30 years old represent more than 30% of the population that you treat. So we propose this study, which was to compare the outcome of isolated ACL reconstruction using either Amstring or BTB compared to Amstring plus lateral extrarticular reconstruction using lumere or ILL in a population over 30 years old. It's a retrospective randomized match study with a comparative group. It's a population operated from 2003 to 2020, and is only patient over 30 years old. At this time, the indication for extrarticular reconstruction was important pivot shift, high demanding sports, pivoting activity, and chronic ACL. We matched two groups of over 500 patients with a mean follow-up of 97 months. The mean age of this population was 37 years old, and I told you they were BTB and Amstring versus BTB-lumere or Amstring-ILL. In terms of graft uptake rate, we found 2.7% failure rate in the isolated ACL reconstruction group versus 0.7% for the ACL combined with lateral extrarticular tendonitis, which means a hazard ratio of 3.3%. The same in terms of secondary meniscectomy with this long follow-up. We observed 5.6% meniscectomy in the isolated group versus 2.2% in the combined ACL and lateral extrarticular reconstruction group. In terms of multivariate analysis, the only risk factor for failure was the type of surgery and the age. We discovered that the population just under 35, the group between 30 to 35 years, has also a high risk of failure. So the conclusion of our study showed that the patient older than 30 years old did not have undergone a lateral extrarticular tendonitis, has threefold higher risk of graft failure. The patient has between 30 to 35 years has fourfold more risk to have a graft failure regardless to the presence of lateral extrarticular tendonitis. And moreover, the patient who underwent the combined ACL and lateral extrarticular tendonitis experienced a lower reoperation rate for secondary meniscectomy. So once again, whatever the population we treat, we must definitely consider to think outside the notch. Let me invite all of you for this fantastic next Journée Lyonnaise in October in Lyon, where the subject would be ACL. Thank you for your attention. All right, next we're going to introduce Costas Economopoulos to talk about their results looking at isolated lateral extrarticular tendonitis in the setting of instability after an ACL reconstruction. Thank you. I appreciate that. It was the same for allowing us to present our data today. I also want to thank my co-author, Alex Hoffer, our current fellow now, who's done a great job and really kind of did the majority of the work on this study. As we all know, ACL reconstruction is a common procedure performed, but even though we do hundreds of thousands a year, I don't think we've perfected the procedure at all. Despite the re-tear rate being relatively low, residual rotational instability continues to be a significant issue following primary ACL reconstruction. Several studies have shown that rotational instability is a common factor after primary ACL reconstruction. It can be found up to almost 40% of patients. Rotational instability following ACL reconstruction can not only make the patient feel unstable in their knee, but can also be a risk factor for developing cartilage and meniscal pathology following primary ACL reconstruction. I've gone through an evolution in treating these patients. In my practice, I started with performing revision ACL reconstructions on patients with residual rotational instability. Once I understood the LAT a little bit better, I started using an LAT in addition to the revision ACL reconstruction. Once I really understood the pivot shift and started understanding things a lot better, I began using LAT in isolation for this patient population. So the question began, what is the best treatment for treating patients with residual rotational instability, an intact graft, and a new meniscal tear? To answer this question, we performed a retrospective study of patients with previous ACL reconstructions who presented with a pivot shift of a two plus or more, an intact graft, and a new meniscal tear. We compared the patients who underwent revision ACL reconstruction, revision ACL reconstruction plus LAT, and isolation. We had two-year IKDC, lysome, and Tegner scores on these patients. Clinically, we looked at recurrent meniscal and ACL tearing. We also looked at residual rotational pivot shifts, and we looked at complications associated with the surgery. In athletes, we also looked at return to play. I used a modified lamera procedure where I took a sliver of the IT band, passed it under the LCL, and attached it to the lateral femur using various methods including interference screws and all suture anchors. Our demographics and our patient population were relatively the same throughout all three groups, including age, sex, BMI, and also presence of a generalized ligament dyslaxia. We did find that between 40 and 50 percent of our patients had generalized ligament dyslaxia identified with a Batten score of four or higher. Looking at the use of grafts between all three groups, the use of bone patella tendon and hamstring autografts were similar between all three groups. Quadriceps autograft is a pretty uncommon used graft with this group. We also found that medial meniscal repair occurred in between 15 and 25 percent of the patients in their primary surgery. There was no real difference between the pivot shift and Lachman exam between the three groups of patients. We did find that partial tearing did occur between 60 and 75 percent of patients who were part of this study. Looking at the results, we found that at one and two years, IKDC scores were significantly higher in patients who underwent either ACL revision with LET or LET in isolation compared to those patients who underwent simply revision ACL reconstruction. This held true also for the lysome scores with higher scores being found in patients who had LET rather than just revision ACL reconstruction. Clinically, we found that there was a much higher rate of meniscal re-tearing and residual pivot shift in patients who underwent simply revision ACL reconstruction as compared to those patients who had an LET in addition. I found no difference between patients who underwent revision ACL plus LET versus isolated LET with regards to recurrent meniscal tearing or residual pivot shift. In the athletic population, I found that there was a trend towards a higher return to sport and higher return to sport at a higher level in patients who had isolated LETs, but this did not reach clinical or statistical significance. We did find that the Tegna scores were significantly higher in patients who underwent an isolated LET. Complications were similar between the groups. Arthrofibrosis actually was similar between all three groups. We did find that there was a higher rate of hematoma formation in patients undergoing LETs. There was no patient in the study who required removal of hardware secondary to pain. In conclusion, an LET, whether it's in isolation or in association with an ACL reconstruction, can decrease the rotational instability following surgery. We also found that meniscal re-tearing was also less when we associated an isolated LET. We also found that complication rates were also about the same, so adding an LET really didn't add too much to the complication rate in these patients. Now, mind you, this is a very small population of patients. I think it's just sort of the starting point to really look into this difficult issue and get an idea of how to treat this complicated set of patients. Thank you. Thank you, Costas. Next is Laura Houston, and we'll hear from the MARS study group about 10-year outcome. Laura. First, we're going to talk about long-term outcomes of ACL injuries. I'm presenting this today on behalf of the MARS group. Whose members and support staff are listed here. And our disclosures can be found on the AOSSM website. As this group is well aware, revision ACL reconstructions remain a challenging clinical issue. Studies have shown that revisions fare worse clinically compared to primaries, but the long-term outcomes remain unknown. This was the impetus of the formation of the multi-center ACL reconstruction revision study, or MARS group. Nearly 20 years ago, the group of over 80 surgeons, both academic and private practice, enrolled over 1,200 ACL patients at the time of their revision surgery and followed them for over 10 years. Purpose of this study was to assess the long-term outcomes, including the incidence of graft failure and both the signs and symptoms of Neo-A in this revision group. Our hypothesis was to characterize the 10-year natural history of an ACL revision cohort, quantified by physical exam measures, radiographs, and patient reported outcomes. All eligible subjects were asked to participate. Patients were brought back into one of seven regional sites for an on-site assessment. Research personnel traveled to each of these sites for study consistency, and a blinded physician who was not involved in the patient care was asked to do a comprehensive Neo-A exam. KT-1000, range of motion, radiographs, and patient reported outcome measures were also obtained. We define the radiologic or structural OA as anyone with a Kellgren and Lawrence grade 3 or 4 on their bilateral standing x-rays. We define symptomatic OA as anyone who scored 70 points or lower on the Koos pain subscale. We used regression modeling to determine the predictors of both structural and symptomatic OA, controlling for a host of baseline measures that could potentially influence these outcomes. 205 subjects, representing 42 of the 83 surgeons, returned an average of 12 and a half years follow-up. The mean age of this cohort at the time of their on-site eval was 40 years. 16% were bilaterals. In terms of the physical exam, 58% experienced a loss of extension compared to their opposite knee. 41% had a knee extension less than zero. 10 to 20% had either a soft endpoint, Lachman, or KT difference greater than 5 millimeters. And 18% had a non-functional graft as deemed by the blinded physician. In terms of the radiograph results, the table on the left depicts the KL grades at the time of the revision or baseline. The table on the right are the KL grades at the time of the 10-year onsite assessment. By the time of the revision, approximately 2% of the cohort had KL grades 3 or 4 in their involved knee, but by 10 years, that jumped to 54%. To illustrate this point, I'd like to show you a couple examples. Example one, the radiograph on the left is at the time of the patient's revision surgery. Radiograph on the right is at the time of their assessment, in this case, 13 years later. This next follow-up is a 15-year follow-up of a now 51-year-old female and a 12-year-old follow-up on a now 47-year-old female. Our study wants to know what makes this person different than the other two. The significant drivers of a higher KL grade at 10 years are found to be older age, higher baseline BMI, having a medial meniscectomy performed prior to or at the time of revision surgery, having a lateral meniscectomy prior to revision, or having a subsequent surgery. Patient-reported outcomes of this onsite group depicting in red reflected the PROMs of the overall cohort depicted in black. All PROMs except for the marks activity level significantly improved from baseline and remained steady over time, however, activity level shown on the right steadily declined over time. 20% of the subjects reported symptomatic pain, while 44% of our cohort reported no pain. The significant drivers of symptomatic OA at 10 years were found to be grades 3 or 4 pathology in the lateral compartment at the time of revision, having a medial meniscectomy performed prior to the time of revision, or having a subsequent surgery. Conversely, having a hamstring autograft or any kind of allograft compared to a BTB autograft at the time of revision predicted less symptomatic pain at 10 years. In conclusion, this is the first report of an ACL revision cohort with minimum 10-year onsite follow-up, a study which demonstrates worrisome outcomes for patients who are still relatively young. The study demonstrates a loss of range of motion in 41 to 58% of the cohort, an 18% graft failure rate, 56% who exhibited KL grades 3 or 4, and 20% who reported COUS pain scores less than 70 points, which collectively all emphasize the challenge of managing the ACL revision reconstructed patient. Thank you. All right. So we got Walt Lowe. So we're going to have Dr. Lowe come up and talk about slope-reducing osteotomies in patients with concomitant ACL reconstructions. Great. Thanks for putting up with me getting lost. So this morning, I'm going to talk about—I was at the wrong hotel—this is about clinical outcomes following ACL reconstruction with slope-reducing high-tibial osteotomies, which is a matched control study. So if you look at this group and you guys don't need a lecture about how the slope forces that are transmitted to the ACL go up as the slope goes up. Basically, this is a matched control group of, I think, our first 24. We're now up to about 60 of these. We looked at them with all the basic demographics, all the outcome measures, and then all the way through return-to-play testing, and this is sort of our usual battery of return-to-play testing. So when we look at the patient demographics, you can see through this they're a very well-matched group, and there was really no differences other than a little higher BMI in our slope group. When we looked at the surgical demographics, the graph choice is all over the board because most of these were revisions, I think, of this entire cohort. Only three were primaries, and so the graph choice tended to depend on what had been done also, but really no significant difference other than more quad tendons in the slope group. And the primary reason that was is all of these were, all the osteotomies were done down low through the infratubicle region, and we were scared to take a patellar tendon graph primarily because of that. When we looked at the return-to-sport outcomes, you know, there were two that were very concerning, and so, you know, the time to return was significantly longer in the slope group, and then the ACLRSI was significantly longer in the slope group, and this didn't really match what I was seeing, so I asked Lane and our PhDs to sort of break it down a little bit, you know, and what it showed is that when we dissected it out to those that we could do in a single stage versus those we had to do in two stages, then that's where we could start to see the differences, and so when we did that, the return-to-play was actually very similar to the primary ACLs in the single stage, but obviously significantly longer in the group that had to be staged, and the ASL, I mean, the ACLRSI showed us kind of the same progression, that a double stage was really a pretty big whammy to them, and it really didn't return to the level we wanted it. But the single stage ones, again, very much mirrored the primary ACLs that we compared them to, and so you can see in the follow-up assessment, really, there was no differences in return-to-sport, graft failure, or other complications when we looked at the matched control group. So I think the discussion and the conclusion for this, being short, is that a slow-producing osteotomy is not the end of an athletic career. A single stage slow-producing osteotomy can get these active patients through return-to-play testing at very, very similar times to just a primary ACL group. The last part of this is that I just wanted to be focused on was that these were infratubicle. We chose infratubicle because we thought that would maintain the patellofemoral joint mechanics and let them be athletic again. So these are just some videos, if they'll play. Let's see. So the top one is obviously a made-for-TV video of a young guy that was a primary ACL at University of Houston that had a slope of 22 when we came in. He got in the transfer portal a year out, went up the street here to see you, to Coach Prime, and then this year is transferred again, will be the starting running back at Arizona State University. The bottom video is Texas A&M soccer girl had a revision ACL slope of 20. Nothing else known to man done to after failed BTB. This is her at 12 months out. She's now playing on the Canadian national team, and obviously anecdotal deals, but the main thing of this study to get out there is this operation can, I think, and will need longer data to prove it protect from future tears of the ACL, and they can regain their athletic ability. Thank you. Great, great first session. Thanks so much for all four speakers. We have a short time for Q&A here, so if you have burning questions, come on up. Bertrand, I think I know the answer to this, but is there a patient that you would not do an LET on? Does everyone get LET? Microphone is not on. You have to shout really loud. I say that I don't do extraterritorial reconstruction for the patient that I treat conservatively. Yeah. There you go. I said, I think I knew the answer, so. So I have a question for Costas. Well, I guess it's in two parts. The first one is, who are the no-no patients to do an isolated LET on? You know, I really base mine not on so much who not to do it on, but to who to do it on. So anyone with ligament dyslaxia, but if you have someone who does not have a pivot shift of two or greater, beating scores of four or less, then I'm really not performing the LETs on these patients. So I'm being very selective on who gets a LET and who does not get an LET. So low-grade rotational instability that's symptomatic. Correct. I think there's a Scott there. Yes. Hi. For Laura. That's nice. Nice work. You found a high rate of post-traumatic OA. I was curious, the high rate of patients that lacked full extension, was there any relationship between the flexion contracture or extension loss and your PTOA, the arthritis group? Repeat the question. It's the lack of extension due to- Was your flexion contracture or loss of extension related to the rate or risk of post-traumatic OA? Not yet. If I could ask this quickly. Walt, what was your threshold for your osteotomy, over 12 for Walt? That number changes daily and goes down daily, Scott. So for this study, our threshold for the osteotomy to make the decision, since this includes the initial group we did it on, was over 16. And I think when you looked at the numbers, the average slope, I think, was 17, if I remember right, in that group. Yeah. It's a high number. So in the interest of time, we're going to move on to the next. But thanks very much to all four speakers. Great session. Thanks, Scott. Yeah. We're going to stay to introduce these folks. Okay. Do it. All right. So we're going to have Bertrand stay on stage. We're going to go to his video technique of slope-reducing high tibial osteotomy. So take it away. Once again, thank you very much for the invitation. My message will be a little bit strange, but I will be very careful. I will say that in the hand of Walt, maybe in the hand of David Dejour and you, Volker, tibial slope osteotomy is very easy. For me, it's still the worst surgery that you can provide in sport medicine for a patient. This is my disclosure. I will recommend all of you to read the fantastic editorial by Bruce Rader, Sleeply Slope, where he explains his first experience showing people from New York doing a slope osteotomy. Biomechanically, we all know that this PTS reduction osteotomy significantly decreased the ACL force and reduced the anterior tibial translation for knee loads. That's one of the reasons why a lot of surgeons are taking care of this strange surgery. In fact, the model is coming from the vet. They do it for a small dog. My partner, Michel Bonin, which is one of the important people in the Lyon eSchool, did his MD thesis on this subject. What you see in the literature is funny because most of the clinical studies are done by people from Lyon, Professor Lerat, David Dejour, my groups. So it's a typical Lyon knee school surgery. The aim of this surgery, there is a lot of debate about that, is at least to be under eight or nine degrees, and there is different technique that you can use to do this osteotomy. However, and once again, for me, the most important is to answer to the patient expectation, nothing else. What is a patient expectation? Platoon 2 sport at the same level, no graft failure, no re-operation. So whatever you do, you must answer to this question. I love the series of the moon groups. You see the rate and the result of the revision is a disaster. So whatever you do, we must avoid to all our patients to get a graft failure. In this recent publication this year, the author showed that the anatomic primary reconstriction in case of increased medial patellar tibial slope was not associated with a higher risk of graft failure. So we must pay attention. These series I already showed, these two meta-analyses on extra-articular reconstriction and primary revision show a low graft future rate when you had an extra-articular reconstruction to your ACL. When I analyze my own database based on 700 revision, it's understanding is funny to observe that when I revise my patient with a primary in isolated ACL revision, sorry, my failure rate is 3.7. When I revise those patients with an extra-articular reconstruction, my failure rate is 1.1%. So doing an extra-articular reconstruction show a very low failure rate in case of revision. In 2023, I will perform almost 600 ACL reconstruction with almost 100 revision, but only five slope osteotomy, which means less than 1% of my practice. Let me show this supratubercle osteotomy. The video demonstrates an anterior closing wedge osteotomy for slope correction that preservates the anterior tibial tuberosity, keeping the extensor apparatus intact. The approach begins with a midline incision centered in the anterior tibial tubercle exposing the patellar tendon insertion. Lateral extensor muscles are detached from the intended osteotomy site, creating a superior and inferior flap with the periosteum. Medial dissection is carried the same way as before. Both these flaps should be used in the end for adequate closure. We should detach the MCL up to the posterior part of the tibia. Next, we perform the first vertical cut, preserving the patellar tendon attachment. This allows the osteotomy to be carried at the desired level regarding the extensor apparatus. First, we insert the two distal parallel K wires under fluoroscopy control on both sides of the patellar tendon until the posterior tibial cortex, aiming at the insertion of the posterior cruciate ligament. Perfect parallel positioning is the main goal. Next, we position the two proximal parallel K wires, similar to the first ones. The starting point is achieved after measuring the desired correction. Usually one degree corresponds to one millimeter cut. Posterior cortex should not be violated. Osteotomy should be finished with an osteotome. Again, gentle and precise hammering is needed in order to keep the posterior cortex intact. Bony bridge is critical to protect the popliteal structures and limits the risk of secondary displacement or pseudoarthrosis. Then, we remove both medial and lateral bone wedges. After removal of all osteotomy bone, reduction of resected surfaces is achieved by gentle knee extension. With the osteotomy site closed, fixation is completed with two staples positioned medially and laterally with respect to the tibial tubercle. Post-operative x-rays show the degree of the correction and the preservation of posterior cortex. One of the questions we had with this supra-tubercular osteotomy is the influence of the patellar height. I can't answer because it really depends on the index that you use, but it's not clear. In conclusion, for the slow post-operative osteotomy, we propose this amortisseur for the patient, but we do it only in case of revision. When we have graft ruptures, we first analyze the tunnel position, which is the classic one that we can easily correct. If the tunnel position is correct, then we observe and we note if the primary ACL was with or without lateral extra-articular tenodesis. If not, we revise just with an extra-articular reconstruction. If you have a primary ACL with an extra-articular reconstruction, then we can discuss with the patient, depending on the x-ray, if we have to do a slow post-operative osteotomy or not. In conclusion, ACL reconstruction with anterior closing wedge osteotomy for patients requiring ACL revision with pathological slope over 12% is a procedure that is efficient. The influence of the patellar height must be assessed because it's really one of the concerns for long-term follow-up, and I will recommend to have a caution indication as lateral extra-articular reconstruction is already highly effective. Thank you for your attention. Thank you, Bertrand. I'll get you next. Show us your technique, revision ACL and osteotomy. Thank you. Okay, thanks very much, Volker. So, this is going to be relatively similar to Bertrand's technique, but a little bit of repetition is never that bad, certainly when you're dealing with really complex procedures. I don't have any significant disclosures in relation to this specific talk. So, what I thought I'd do is present a case and then go through the technique that it utilizes. This is actually a 19-year-old male. He had an ACL reconstruction about six years previous. This was a hamstring tendon autograph. No lateral tenodesis was performed at that time. He subsequently had an injury just about a year before I actually saw him in clinic, but it sounds like he had multiple injuries, so he's really been dealing with a chronically deficient ACL for about two to three years. His physical exam really was consistent with high-grade anterior, as well as rotatory laxity with neutral limb alignment. His radiographs, and you can see here, a really significant posterior tibial slope of 18 degrees. It was measured off as medial plateau. What's more concerning for me is the amount of anterior tibial translation, and I think we talk a lot about increased posterior tibial slope. If I see this amount of anterior tibial translation, this is not a knee that you're going to be able to control with an ACL reconstruction or certainly with the addition of a lateral tenodesis, and his coronal plane was neutral. MRI scan, you can already see that anterior translation of his tibia on his MRI, but he's also got a medial meniscus tear with posterior third deficiency, which is accentuating the issues that he has with his anterior translation. We did a CT scan. The CT scan showed that the femoral tunnel essentially had a posterior wall blowout of his primary reconstruction, so a very easy tunnel to manage in the revision, so this can be done as a one-stage. And his tibial tunnel diameter was slightly anterior, quite shallow, but again, not too big, so again, this could be done in a single-stage fashion. So the surgical plan was to do a one-stage revision ACL reconstruction using a quadricep tendon autograft. I was planning for a transportal femoral tunnel drilling that would create a new tunnel, essentially, and then use the same tibial tunnel with sequential drilling, which I'll show. I'm going to do a supertubicle anterior closing wedge proximal tibial osteotomy. The calculation was an eight-millimeter closing wedge and then add in a lateral tenodesis. Now, some of the surgical pearls, in terms of graft choice, a quad tendon is nice because it's a little bit shorter, so if you're dealing with a short tibial tunnel in the primary, I've got no concerns regarding a graft tunnel mismatch. But of course, if you want to use a patella tendon, you can do, just as shown here, you can do outside-in drilling, which allows going through the same incision as your LET. So you need to have a number of different tools in your tool bag to be able to deal with some of these cases. The supertubicle osteotomy, I like it because I can go early weight-bearing, it doesn't affect the extensor mechanism. It's in the metaphyseal bone, so I get good healing. And then easy staple fixation, so I don't have to have really rigid hardware if I go infratubicle and using a bit of an old-school calculation of one millimeter for every degree of correction. This is not a very accurate osteotomy. I'm really trying to gauge how much hyperextension that I want to avoid, essentially. So, here's the technique. So you can see he's got a high-grade anterior laxative lockman, significant pivot, really not reducing very easily. He's got that old anterior skin incision, so the plan is to do an ellipse and then we've got a lateral tenodesis incision as well. I started with the quad tendon harvest. If there's any concerns about the tunnels, then you can always do that later. Arthroscopic work is then commenced, doing meniscal work, as well as then after that doing the femoral tunnel. So this is a transportal medial portal technique. We then come to medial, so an antemedial skin incision, using the previous incision that was used and then doing a subperiosteal dissection medially, just like Bertrand showed. We're going subperiosteal underneath the MCL. You can then go to the lateral side. We're going to take off tibialis anterior and then placing blunt retractors both medially and laterally, giving us good exposure. And we can see here then, just underneath the patella tendon as well. The key here is having a perfect lateral fluoroscopy set up and you want to have a perfect lateral of your tibia, making sure that your plateaus are level as well as your condyles are aligned. We're then going to place two pins. These are proximal pins rather than the two distal pins. I don't think it really matters. My insertion is a little bit more distal than what Bertrand would have shown and that gives me more real estate for my tibial tunnel. And then we can measure the distal pins. So for this was an 8mm correction and I just cut a little 8mm part of the plastic ruler that you get with your marker pen and I can put those two pins in. So now we've got four pins that are proximal and distal and parallel. Then the osteotomy is performed with an oscillating saw. So we start medially, then go laterally. It's really important that you get as far posterior lateral and as far posterior medial as you can so you don't have a cortical block to be able to reduce that down. And you can see where my tibial tunnel is placed, just how far distal that osteotomy is to allow you to have real estate. The key then is that you have to complete the osteotomy with osteotomes but then also create this back cut, this super-tubicle cut that Bertrand showed to allow you to drop the level of your osteotomy distal to your tibial tunnel so that you can do all this in one go. I can then take the bone out and so you can see here in the fluoroscopy we've got the resected bone as well as that super-tubicle cut and you've got to take a little wafer of bone away so that the tubicle doesn't then buttress against the metathesis as it closes down. I did a controlled osteoclasis of the posterior hinge with a 2.4 pin and then gently bring the knee up into extension making sure it's nice and flexible and then fixed with a couple of staples. In this scenario I used a step staple on the lateral side and then a standard staple on the medial side and I actually added a third staple just to give me a little bit of extra stability. So here we've got the slope correction with the fixation in situ with no significant change in the coronal plane which is important. We can then go to do the tibial tunnel drilling so I've got a nice stable platform so I'm going to drill this up sequentially starting with a small drill then drilling up to a larger drill I've now drilled my tunnels I can place my graft, cycle the knee fix the graft in situ in full extension perform a modified lamar lateral tenodesis and then at the end we've got a stable knee with a good range of motion without significant hyperextension recurvatum. In terms of the rehabilitation with flat foot touch weight bring for the first two weeks I can get early range of motion early quadricep activation I haven't done a TTO if you go in for tubicle you go with a much stiffer construct because there is a risk of non-union with those, you're down into cortical bone whereas with the metaphyseal bone the whole quadricep mechanism is essentially compressing your osteotomy site and then after we partial weight bear for four weeks and then at six weeks weight bear is tolerated I use a brace until we've got good quadricontrol and then continue with the standard ACL rehabilitation after that and this is the patient two weeks post-op and here is post-operative radiographs so just a couple of things just to highlight Dr. Stoker and Mark Hurd and Banff we collated our patients these were mostly second and third revision ACL reconstructions with slope reducing osteotomy the procedure is very effective at reducing slope and also we're controlling anterior tibial translation but if we look at our outcome scores they're not that special our IKDC scores are pretty low now if you compare this to a German series where they were doing slope reduction in the first revision adding in an LET much better in terms of the KUHS scores at this point in time I think that maybe we should be a little bit more aggressive if an osteotomy is indicated do it sooner rather than later try and avoid having multiple surgeries as Bertrand has always said and I would suggest one of the worst things you can do in sport medicine to your athletes if they need an osteotomy is to ignore it and not do the appropriate operation because they will run into problems so in terms of take-home message obviously clinical examination is of paramount importance in terms of hyperextension and then 12 degrees think about 12 degrees as a nice sort of thought of cut-off but I also think anterior tibial translation much more important add an LET and maybe do it sooner rather than later thank you very much for your attention all right thank you Al next we're going to have Rachel Frank come up and talk about her technique for lateral extraticular tenodesis well thank you very much I want to thank the program chairs Dr. Toth, Dr. Dickens as well as our moderators and the entire program committee for having me here it's truly an honor to be on the stage especially with these incredible world-renowned surgeons I was asked to talk about the video technique for lateral extraticular tenodesis and I will share my approach for that I have no relevant disclosures to this presentation however all of my disclosures are available online the ACL surgery outcomes are not perfect we have a lot of room for improvement and so is there a way to improve our outcomes both in the primary and revision setting what can we do better? all the things that you see here some things are in our control as surgeons some things are out of our control as surgeons particularly those patient specific risk factors but as surgeons we have an ability to impact change and one of those opportunities to impact change is adding something to your ACL and lateral extraticular tenodesis options so let's get right to the video surgical technique when I know I'm doing an LET I actually do my exposure immediately after I harvest my graft I do this so for two reasons one there's no fluid extravasation in the IT band from the pin from the femoral tunnel and number two I can't bail on my decision the decision to do an LET is a pre-surgical decision not after you fixed your ACL and you decide oh is it tight enough or not tight enough so your LET is a pre-surgical decision we make an incision over the lateral aspect of the knee in line with the IT band centered over the lateral epicondyle aiming toward Gertie's tubercle I actually make my incision smaller and I'll show you that on another slide but this patient was very generous in letting me make a bigger incision for specifically video demonstration of how to do this technique we harvest a strip of the IT band I cheat a little posterior leaving it attached at Gertie's tubercle we then whip stitch the proximal end and I wrap it in a vancomycin soaked sponge while I identify my next landmarks you can really feel the LCL quite nicely but if you can't you can put the knee in a little bit of figure 4 varus and then once you do that you can slide a hemostat clamp underneath the LCL and pass the graft I actually won't pass the graft this minute I'll pass it after I've drilled my femoral tunnel but here we're going and drilling in just a second you'll see that I have my scope up and you'll be able to see your landmarks here the landmark for the anchor that I use is going to be proximal and posterior to that lateral epicondyle and when I'm putting my anchor in if I'm in the right spot you shouldn't converge with your femoral tunnel but I'll put my scope up the femoral tunnel just to make sure. Here I'm using an all suture suture anchor and it has its unique guide and many companies offer different types of fixation devices you could use a staple you could use a screw I like to use an all suture suture anchor and we'll go ahead and place this again posterior and proximal to that lateral epicondyle and we really want to pull on it and make sure that that's going to set in the bone and even with an all suture suture anchor you can see that this is quite robust fixation. We've then passed our graft from distal to proximal underneath the LCL for the tenodesis effect and then we'll go ahead and fix it using our fixation device of choice again in this case for me it's a double loaded knotless suture anchor but you can use a variety of different techniques here. Here we're passing the graft through both loops of this suture anchor and then we can go ahead and cinch the suture anchor limbs down for a low profile knotless configuration. We can fold the graft back over through one of these loops we can suture the graft back to itself which I do routinely just for belt and suspenders fixation and you do this at a variety of different in a variety of different fixation angles. I like to do this with the knee at 60 degrees neutral rotation. I have not seen problems with respect to over tightening or over constraint of the lateral compartment. You do want to make sure your patient can achieve full range of motion after the fact. I do close my IT band with vicryl sutures at the end loosely re-approximating it and then a standard closure. I just wanted to show this slide. My technique now with this particular suture anchor is identical but through a tiny incision two to three centimeters centered over that lateral epicondyle so you can do this in a quite minimally invasive fashion. It adds about 10 minutes to your surgical time with minimal to no morbidity and we've all seen the excellent results published by the author sitting to my right here as well as many of you in the audience that L.E.T. really does add a lot to our primary and revision ACLs. When we look at the data I won't harp on this too much but the data is there it's very supportive and in 2024 we really can get a good result with L.E.T. with our ACLs. When you talk about L.E.T. versus A.L.L. there's still no consensus on this so I think do what works best in your hands. Thank you all very much. We're running a little bit short on time we're going to have our speakers exit stage left and we're going to introduce Armando Vidal who's going to take over our gold medal debate. Good morning everybody so it's it's time to crown a winner here so I invite up Dr. Robin West and Dr. Volker Bussall, good friends of mine, who are going to give our first gold medal debate. So our clinical vignette is a 16 year old female with a failed hamstring ACL, a borderline slope of around 13 to 14 degrees and a high-grade pivot shift and a high-grade laxity. So I invite them both up. Volker will start and Robin will respond and then we'll have time for a couple questions. Okay thanks Armando and thanks for having me debate finally not for the slope so I'm looking forward to debating my good friend Robin West but make no mistake this is a debate all right if I can get the slides then we get started the first slide will say that I have a disclosure I'm co-PI of the stability to trial that's my only disclosure and on my next slide I will say that in a 16 year old patient who's all nervous that now just the ACL tore again and the parents are crazy nervous too I'm not gonna do a slope osteotomy okay we're gonna do an let and the let works and here are the reasons not my slides I'll do yours but I take the winner my next slide I'm just gonna keep going and then rush through the slides is about biomechanics nobody is interested in the biomechanics yet they play a role now you have to do a failure analysis right and again something nobody wants to hear is that the most common reason for the failure even if it's your own my own ACL is tunnel malplacement so do dare to get a 3d CT scan on your own ACL tunnel and so you can make sure that is not the reason this patient needs a revision the other reason is the graft and the biomechanics clearly show that if you have a huge instability case which the revision cases unfortunately usually do that the let does significantly add to reducing the interior translation then my next slide says kudos to Armando for doing a great study with his partner go down at so here we go now at Vail and in that particular study so my clicker doesn't work anyways so in I can't read this anyway in in in your study you kind of nicely showed that the let does have a strong effect and reducing the force in the ACL reducing the anterior translation and also reducing reducing internal rotation more than anything so that is a nice study so here we go here we go here we go here we go there you go and this is slope and here is Armando study and then there are some outcome studies now we can add to that the outcome studies that were just presented very elegantly but there's a systematic review from from the Bologna group and they showed that the failure rate is much reduced by adding an let here two more systematic reviews one is from Leon and one is from Bologna again showing that the failure rate is much much reduced and this is polling about six seven hundred patients and then Camilo did a retrospective study very nicely on about 170 patients and in that study also showed that the failure rate again is reduced using the let so let is a quite powerful thing now what about the femur though we're talking about the tibial slope that is not the only risk factor that this patient has now there are many many studies pointing at the femur and I'm not telling you to do a femur osteotomy I'm just telling you that when you do a slope osteotomy you're only correcting part of the morphologic problem in this study we showed that the odds ratio is 8.0 for failed ACL if that posterior condyle is elongated like this this is Shelburne's data and also some data from Freddy Fu of course talking about the narrow notch and the volume of the notch and then there's also femur studies that we did at HSS with Tom Wikiewicz and then more recently published at KSSTA that if the femur is very narrow and you have like a small intermeniscal distance you also have a higher risk so I think you need to put all this into perspective now what are my arguments then at the end so the deformity is not just in the tibia the hyperextension you need to consider when you do a slope osteotomy because this young 16 year old probably has some hyperextension which is a contraindication LAT is faster much cheaper to do and has good outcome and also as Bertrand and also Andy Williams showed good predictable outcome now my indications currently are in the stability to trial and I do it for some revisions when nothing else needs to be done so don't perform the slope osteotomy in this particular patient Robin because it's unpredictable for the return to sport unless you're walled low there's a non-union risk there's hardware irritation risk there's hyperextension risk and for me it's a last resort surgery so and this is my final thought and I really like Robert Salter's cycle of research we have much more to do here to figure out exactly what to do with these high-risk patients and in this particular patient we're going to do a quadriceps autograft with an LAT we fix the meniscus that she probably tore as well and we probably save the slope osteotomy for later when we put the hammer down here we go thank you nice work Volker amazing and amazing that you're able to give that talk without slides Robin your response all right great well we have a 16 year old athlete high school athlete who has a failed ACL and so I think we've got to do the right thing but you know the second time around give her the best option possible so here's my disclosures so nothing pertinent here and I'm talking about the slope reducing osteotomy so as we know that since title 9 in 1972 there's really been an increasing trend in ACL tears in female athletes females have an eight times risk of an ACL tear when compared to their male counterparts and there's been shown of a 22 to 30 percent risk of a second ACL after an ACL injury in a high school and collegiate soccer player so again we have to look at this now this patient's already failed one surgery we've got to do the right thing this time around we've got to look at all the risk factors so we have to we have non modifiable and modifiable risk factors we all know these the you know the non modifiable ones are the hormonal developmental and biological ones and there are some non modifiable anatomical ones a shallow medial plateau convexity the increased curvature the medial and the femoral condyles and the modifiable ones are the neuromuscular ones like the quad dominance and the anatomic ones is a increased posterior tibial slope of greater than 12 degrees so we know failed ACLs are multifactorial and again we have to look at modifiable factors when we're revising somebody's ACL we have to figure out why did they fail the first time we can look at technical error tunnel position we can look at the graft type that was used poor rehabilitation are they lacking extension do they have persistent weakness was a graft maturation well did they did they get back too early to return to play and then finally bony anatomy and the tibial slope so we look at an LAT so LAT you can can show an improved by using an LAT lateral reticular tenodesis we can improve the high-grade pivot shift reduce the ACL graft force decrease the anterior tibial translation and improve rotational laxity but when we look at LAT in conjunction with an ACL in isolation and not doing a slope reducing osteotomy there's a there there's still an increased force and so the addition of an LAT to an ACL can decrease the ACL graft force but a slow producing osteotomy significantly reduces the force so an LAT and an ACL also results in a decreased anterior tibial translation versus an intact in extension versus an intact knee so there is concern now that we can over constrain the knee as well and that's been shown in several studies the tibial slope there's obviously and we know this there's significantly highly positive correlation between slope and graft force so as a as a slope increases a posterior tibial slope increases so does the graft force and there's a catastrophic effect between age and increasing posterior slope and out of the study in Australia it was a case series there was a 20-year follow-up and they looked at 20-year ACL graft survivorship and it was only 22% in patients and adolescent patients who had a posterior tibial slope of greater than 12 degrees we know that greater than 12 degree posterior tibial slope has an odds ratio of 11.6 for a repeated ACL graft failure posterior tibial slope of over 14 degrees has an 18.7 increased risk for an ACL revision graft failure we don't want we don't want to take this girl back to a third surgery so slow producing osteotomy results in significantly decreased graft force and anterior tibial translation so we don't want to end up like this we don't want her being one of these patients who's coming back again for her third ACL so in conclusion ACL graft tears and ACL primary tears are multifactorial we have to mitigate the risk and look at all all confining factors or variables so again patients with an increased posterior tibial slope of greater than 12 degrees are at high risk for early and repeated graft failure after an ACL reconstruction there's an 11-fold increased risk of a graft failure with a patient of a posterior tibial slope especially in young athletic population so LAT as we know can reduce the the risk of a increased graft graft failure and also anterior tibial translation so let's do our patient right this first time around I would do a revision ACL reconstruction using a BTB and a slope reducing osteotomy thanks it's pretty pretty compelling arguments in both directions it wouldn't be a debate without challenging you guys a little bit so Volker Al just talked about anterior tibial translation right so same patient with anterior tibial translation does that change your perspective or is that also a soft tissue operation yes but this is a 16 year old patient who just failed right so she probably has not developed yet that much anterior station of her tibia and I would go back to the graft choice and say why do girls get hamstrings and boys get BTBs why so she should get a BTB or quadriceps to begin with okay and again I reiterate that the tunnel position is important and for me a scenario where I would maybe consider the osteotomy in this particular patient is when mom sits there with her three failed ACLs her contralateral the 16 year old contralateral ACL has also already torn and then I would say yeah she needs that slope osteotomy otherwise it's the LAT with quadriceps all right can we put the QR code in the meantime so that people start pulling up the voting so Robin borderline slope we have challenges measuring slope right what's the best way to do it which slope are you measuring same patient with a lot of different factors for why they failed right they had an allograft at 16 their tunnels are malpositioned maybe they have a collateral ligament issue or a root tear does that change how aggressive you're going to be about recommending a slope osteotomy it certainly does I mean I think that it's multifactorial we talked about right so we're looking at technical biological issues and so if we can try and mitigate as many risks as we can so if somebody comes in and they've had an allograft they have poor tunnel placement or they've had poor rehab and they have an increased you know borderline posterior tibial slope then that's probably not going to be what I'm going to what I would recommend yeah it's nuanced right it's complicated so the QR code should be up or was up a second ago I'll give everybody a time you could just pull it up on your camera or in the app that should allow you to vote if they can pull that back up I think it's under my name there to the left you can also pull it up in the app under this session we'll give everybody a little bit of time do you guys have a QR code up there it doesn't work it's pretty clear anyway so it's not yeah I have a metal I've got to give this is burning a hole in my pocket here all right we'll just do by a show of hands we're gonna go low-tech by a show of hands who thought that Volker won with let alone that's pretty good pretty good all right low-tech Robin West with the slope reducing osteotomy I think I'm gonna have to award this to Volker I'm sorry Robin but I think I think the let has it thank you guys for a great session

Michael J. Alaia, MD

Volker Musahl, MD

Walter R. Lowe, MD

Bertrand Sonnery-Cottet, MD, PhD

Kostas Economopoulos, MD

Laura J. Huston, MS

Alan M. Getgood, MD, FRCS

Rachel M. Frank, MD

Armando F. Vidal, MD

Robin V. West, MD

ACL reconstruction

Lateral Extra-Articular Tenodesis

tibial osteotomies

graft failure

rotational stability

post-traumatic osteoarthritis

patient outcomes

surgical techniques

clinical session

complex ACL cases