Welcome to the American Journal of Sports Medicine's webinar in conjunction with the American Orthopedic Society for Sports Medicine and the European Society for Sports Traumatology, Knee Surgery, and Arthroscopy. Thank you for joining us. I am Donna Tilton, Editorial and Production Manager for the American Journal of Sports Medicine, and I will be the operator for the webinar today. Before we get started, I would like to take a moment to acquaint you with a few features. There are options for how you can listen to this webinar. If you have any technical difficulties hearing the audio properly, please try clicking the phone call option and calling in for the audio or switching the speakers that are being utilized. At any time, you may adjust your audio using your computer volume settings. To ask a question, click in the text box and type your question. When finished, click the Send button. Questions you submit are seen by today's presenters and will be addressed throughout the presentation. So please send your questions as you watch rather than waiting until the end. There is CME available for this online activity. There are learning objectives and disclosures. At the conclusion of today's program, we will ask you to complete a brief evaluation by going to education.sportsmed.org and logging in. Please take a moment to complete this if you wish to collect CME for this activity. At this time, I would like to introduce our moderator, Dr. Ivand Inderhog. Dr. Inderhog is an Associate Professor of Orthopedic Surgery at the University of Bergen and the Chair of Sports Medicine Traumatology Orthroscopy Research Group. He is a Consultant Orthopedic Surgeon at Hockland University. Dr. Inderhog is a member of the AJSM Electronic Media Editorial Board and will be moderating our webinar. And with that, I'll turn the microphone over. Thank you, Dr. Inderhog. Thank you, Donna, for the kind introduction and for facilitating this exciting event. As a member of the AJSM Electronic Media Editorial Board, I have greatly anticipated today's webinar. And I am excited to have with me this extraordinary panel who will give talks and discuss the role of lateral extra-articular tenodesis in ACL reconstruction. From Rome, we have with us Professor Andrea Ferretti, Chairman of the Department of Surgery at San Andrea University Hospital, La Sapienza University. Now, Dr. Ferretti is the Chief Doctor of the Italian National Soccer Team and a member of the Medical Committee of the UFL. From London, Ontario in Canada, we are joined by Alan Getgood, Associate Professor at the University of Western Ontario and Orthopedic Surgeon specializing in Complex Knee Reconstruction at the Fowler Kennedy Sports Medicine Clinic. From Lyon in the South of France, we have Beaute Solnery-Cotet, Orthopedic Surgeon at the Centre Orthopédique Saint-Denis, FIFA Medical Centre of Excellence. Dr. Solnery-Cotet is the Vice President of the French Orthoposcopic Society and the founder of the Santee Study Group. And finally, from London, UK, Mr. Andy Williams, Knee Surgeon and the founder of the Fortress Clinic London. Now, Williams is known for his extensive work with many Premier League soccer players and with English Premiership rugby players. He holds a position as Reader at Imperial College London and Honorary Senior Research Fellow at the University of Oxford. And without further ado, we would like to give the word to tonight's first speaker, Andrea Ferretti. Okay, dear friends and colleagues, good afternoon and good night, according to your country. The beginning of the modern ACL surgery can be pinpointed in the 60s, where rotator instability and pivot shift phenomenon were clearly described. Among the researchers that should be credited for their brilliant intuitions, Marcel Lemaire and Ronald Losey take a special place. I never met Lemaire, who in 1967 described in the Journal de Chirurgie a new and revolutionary concept of lateral tenodesis. However, I had the great privilege to meet Dr. Losey in Seattle in 2014, when after my speech at the house meeting, he approached me and complimented me with his book, where he tells the story on how he had rediscovered the subluxation of the lateral tibial plateau, and got the idea to perform a lateral sling and actually did it using rough instruments made up by his mechanic in the back of a Texaco garage in Ennis, Montana. Probably no one could imagine that an old brand of beer, very popular in Northwest, and its can opener would become precious surgical instruments playing an important role in the development of lateral tenodesis, performed with the aim to reduce the pivot shift in ACL deficient knees. As a result of the brilliant intuitions of Lemaire, Losey, McIntosh, and other surgeons, let's soon spread, and many surgeons developed personal techniques to control rotational instabilities to be used alone or in association with intra-articular reconstructions. Initially, extra-articular reconstructions were classified in active and passive, as they were addressed towards muscles and tendons or ligaments and capsule. Since the 70s in Howard Hospital, several techniques have been used, such as the advancement of a biceps tendon and the semi-membranosus, as suggested by Jack Houston, Andrew's technique, McIntosh, original Lemaire using a PDS band instead of a nylon string, until we discovered a simple, cheap, safe, and very effective Cochrane modification of the McIntosh procedure. And since the beginning, I've been using extra-articular reconstruction along with intra-articular reconstruction with no interruption to date. Let's, where based on solid biomechanical principles, the longer and more efficient lever arm as compared with a central pivot, the protective effect on the reconstructed ACM and the repair or reinforcement of secondary strains. What's the role in controlling tibial rotation and pivot shift is well recognized. And those injuries seem to occur in up to 90% of all apparently isolated ACL tears. However, let's, which were very popular in the 80s, were almost completely given up as a result of a consensus conference organized by Haussmann Snowmass in Colorado, where experts concluded that even biomechanically justified, they were unable to provide any evidence that biomechanically justified, they were unable to provide any substantial benefit with the higher rate of complications, leading surgeons to focus only on ACL. However, in few centers, especially in Europe, role of secondary strains and lets continue to be seriously considered. I remember a bottle with my friends, I remember a bottle with my friends, friend, the Freddy Fu, where we argue about the role of lets as opposed to double bundle, where I claim that the double bundle is less effective than lets in controlling tibial rotation. In 2014 in Seattle, 25 years after the Snowmass meeting, I presented our long lasting experience in lets, knowing that even if they are used in more risky patients, they resulted in a lower rate of failure, better stability with no complications. This was probably due to the change, to do changes occur in the ACL surgery since the 1989 conference. Today, lets seem to have regained a well-recognized role in ACL surgery and discussion has switched towards indications and surgical techniques. New classification include the repair and reconstruction, either anatomic or non-anatomic. Repair is suggested in acute cases according to the site and the extent of tear of the anterolateral complex, with the results comparing well with the reconstructions. Decision on whether perform anatomic or non-anatomic techniques seem to rely on surgeon's preference, being the selection of patients probably the most hot topic today. In conclusion, before leaving to the following speakers, this task to more deeply go inside this intriguing matter, let me remember what I've learned by some of the most distinguished surgeons of the past, which along with Lemaire and Losey, led me to state that we will never fully understand rotatory instability, as long as you look only at ACL. At the end of my presentation, let me invite all of you to the next Congress of ESCA to be held in the wonderful Paris next month, where this and many other aspects of sports medicine and knee surgery will be argued by the most internationally renowned experts. Thank you very much indeed. Thank you, Andrea, for giving us this really nice backdrop on the history of lateral extraticular procedures. I do have one question for you before we proceed. Looking back at that SNOMAS meeting after the use of lateral tenodesis declined, what do you think today and in recent years is the main reason why we now see this total increasing use of extraticular procedures in ACL reconstruction? My opinion is that the increased use of hamstrings is probably the main reason, because the use of patellar tendon often results in a mild loss of range of motion, so a more stiff knee rather than a more stable knee. So adding extraticular reconstruction to a bone patellar tendon bone can increase the morbidity of the procedure, resulting in an unacceptable loss of range of motion. Use of hamstrings is less risky for range of motion, but probably it needs a supplemental stability procedure stabilisation procedure. So I think that the use of hamstrings and accelerated rehabilitation has switched the indication towards an extensive use of extraticular reconstruction. Thank you so much. Thank you so much. And with that, I think we will give the word to the next speaker, who is Alan Getgood from London, Ontario. Thank you, Ivan. And thank you to AJSM for inviting me to join for this great webinar. And I thought it was a fantastic overview by Andrea regarding the past, and it's really important that we understand that before we move forward into the future. So I'm going to be speaking about what we have learned specifically from the stability study. I do have some research support for this particular study from ISACOS, but there is no industry funding associated with it. So just as a reminder, I mean, stability was a randomised clinical trial that was sponsored by ISACOS back in 2014, involved nine centres across Canada and Europe. And we had the hypothesis that the addition of a lateral tenodesis to ACL reconstruction would reduce graft failure in patients deemed to be at high risk of failure. And this paper was published in 2020 at AJSM, and we're grateful to AOSM for awarding the Donoghue Sports Injury Award. So we randomised 618 patients under the age of 25 to either a hamstring tendon, ACL reconstruction, with or without a lateral tenodesis. All patients had to be under the age of 25. They had to have two or more criteria that included competitive pivoting sport, a 2 plus or greater pivot shift, or a hyperextension recurvatum or a generalised ligamentous laxity. And that really was what we thought would put them into a high risk group. And then they had a standard randomisation. Our primary outcome was clinical failure. So this was a composite of both rotatory laxity as well as graft rupture. And our sample size gave us 300 in each group to recognise a 40% reduction in that clinical failure rate. We had standard secondary outcome measures right out to 24 months. In terms of the intervention, it was a hamstring tendon autograft. This was the most popular graft that was being utilised across the study centres. But we did try and maintain graft diameter with tripling grafts, tripling semitendinosus if the four-strand graft was less than 8mm. The tenodesis that was used was a modified Lemaire. This technique can be found on JBJS techniques, but essentially it's a strip of the IT band. And I'm sure Andy Williams will talk more about this in terms of surgical technique. But it was essentially rooted underneath the lateral collateral ligament and then reattached to the distal femur with a staple. We screened over 1,000 patients, 618, and we had less than 5% loss to follow up at the two-year mark. Importantly, the mean age involved in the study was 19. So it's a young, high-risk population, the majority of whom were playing sports, particularly of a pivoting nature. And then as an overview of results, we found a 40% relative risk reduction in rotatory laxity. So that was our primary endpoint. This was clinically and statistically significant. We had a reduction in graft failure. This is a 66% relative risk reduction in graft failure, again, clinically and statistically significant. And this is, again, with the addition of the lateral tenodesis. In terms of overall complications, there were some patients that needed to have a staple removed. But in terms of when you compared the overall complications compared to the ACL alone versus the ACL-LET, there was no difference across the two groups. We looked at a range of functional outcomes, including strength and limb symmetry index hop testing. We found there was no significant difference at 12 and 24 months. At earlier time points, there was a slower recovery of quadricep strength with the addition of a lateral tenodesis. But this washed out by the 12 and 24-month time frame. And then when we looked at return to sport, we're still in the process of just working on this. But whilst there were no difference in return to sport rates, we did find that no matter what procedure was performed, the rotationally stable knees returned to a higher level of return to play. Now, we did do a recent systematic review just to look to see whether or not these results are in keeping with other comparative studies that have been done since 2012. And sure enough, when we look at failure rates, we find that when this cumulative data and this meta-analysis, again, we see a 50% reduction in failure rate in a number of studies using anterolateral reconstructions or procedures. In terms of the predictors of outcome, this is something first that we really all want to know. What can we modify? What can we do ahead of time to see what patients would maybe benefit most from adding an LET? So we did this multivariable logistic reduction model. We found that, of course, the lateral tenodesis reduced the odds of graft rupture by 60%. Age was a major predictor in re-injury with each one-year increase in age reducing the odds of rotational laxity. Return to sport time also reduces the odds of graft rupture. Rehabilitation and delaying return to sport is important. Preoperative high-grade knee laxity was associated with just over three times the higher odds of graft rupture. So these are things that you can pick up in your clinic, in the OR, examination under anesthetic, and can be predictive of a re-injury. And when we actually then looked at some of the baseline characteristics of what makes a high-grade pivot, certainly knee hyperextension and generalized ligamentous laxity was a major predictor of that. So that was a major peak failure. And then we have this issue of posterior tibial slope. This has been shown in multiple studies of being an issue. And when we actually plot slope versus age, we see this maybe a 10-degree cutoff whereby actually the risk really increases in these younger individuals rather than what's 12 degrees that's maybe been promoted in other studies. So with slope and age, 10 degree is maybe an option. So taking this information forward, these are my indications. In the primary ACL, if I'm using a hamstring graft, young patients, they get an LET. And then looking at these other characteristics, so young age, generalized ligamentous laxity or knee hyperextension, going back to pivoting sports, tibial slope greater than 10 degrees or chronic lateral notch greater than five millimeters. This wasn't specifically studied in stability, but certainly has been picked up in numerous other studies. One question I often get asked is, how does this compare? So we tried to do an indirect comparison with the MOON data using their risk calculator. And we basically plugged in some of the stability data into this. And what we did find is that both teletendon and a lateral tenodesis to a hamstring tendon seems to be protective of graft rupture versus a hamstring tendon alone. But when we do an indirect comparison, maybe the LET provides even more protection. What it certainly does support is not using isolated hamstring tendon grafts for young active patients with high grade knee laxity. And this is really the subject now of stability too, because we want to understand whether or not a patella tendon or a quadricep tendon is adequate to be done in isolation without a tenodesis. This is a large NIH and CIHR study with 1,200 patients across this multi-centered group in North America and Europe, really trying to understand whether or not these grafts actually can manage on their own. With that, I'd like to thank my colleagues, Diane Bryant in particular, the Stability Study Group, Kurt Spindler from MOON, and then my colleagues for Stability 2, and Andrew Firth and Hannah Mamura, my PhD students who've done a lot of this post-hoc analysis. Thanks very much for your attention. Thank you, Al, for that brilliant talk and for summarising some of the important findings from Stability 1. Just one of the things you showed us was that we probably slowed down our patients somewhat in the rehab by adding something on the lateral side. And you also showed that by delaying return to sports, you decrease the risk of repeat laxity. So, should we go slower in the rehab? Should we keep these patients longer before we allow them to go back to their sports? Yeah, I mean, I think we have to be very cognisant of the impact of an early return. And I think time is important, but also a readiness to return. And so it's a mixture of looking at time, but also having some measures of sports-specific training and then strength and functional indices to try and help you with that decision making. But there's no question, there's some athletes maybe ready functionally to be able to go back to play, to return to sport, but unfortunately, the graft may not be mature enough. And maybe a lateral tenodesis is helpful in that regard, as it may protect the graft a little bit longer. But I think those are things that we just need to further study and clarify going forward. Thank you again for a good talk and for good answers. And I would like to give the audience the chance to ask questions that we can, I'm sure there's a lot of things that you wonder about for these good studies, so that we can take these questions into the discussion at the end of this webinar. Okay, thank you very much. Thank you, Evin. And thank you for my previous colleagues who present fantastic data. I really enjoy when you present clinical outcomes, because for me, it's definitely the most important for our community. So, let me present our last ICSM publication, which is based on ACL revision. These are my disclosures. Many recent publications have shown that lateral extra-articular tenodesis improved clinical outcomes in ACL reconstruction and reduced failure rate. The purpose of our study was to compare the main lateral extra-articular procedure in revision ACL. The objective of this study were to compare the two most common used lateral tenodesis techniques, ILL reconstruction versus modified Lumaire, in terms of clinical result, mobility, complication, and efficacy. Our hypothesis was that ACL revision using Armstrong-Pulse ILL was at least equivalent to the gold standard represented by BTB-Lumaire. We performed a retrospective analysis of prospective data, including all patients who had a revision ACL with a minimum follow-up of two years. Patients with underwent revision ACL reconstruction with BTB-Lumaire were matched with a patient with received Armstrong-ILL. The matching process was based on seven different criteria. We collect the classic prompts and assess knee stability at the last follow-up. Complication and reparation rate were also recalled. Today, we match 36 per patient in each group, BTB plus modified Lumaire versus Armstrong-ILL. Due to the small number of patients, no significant difference were found in terms of curvature on reparation rate between the two groups. However, when you look in detail, we found 11% failure rate in the BTB group compared to zero in the ILL group, and 22 reparation rate in the BTB group compared to 8% in the ILL group. However, the post-op technique score was significantly higher in the BTB group. Also, we discovered that combined ACL and ILL reconstruction was also associated with a significantly shorter surgical time, 41 minutes versus 59. A previous study from Korea have confirmed this excellent clinical outcome with combined ACL and ILL reconstruction in ACL revision. However, the main question tonight is why are we talking on lateral extra-articular procedure? First of all, we must discover and understand that our clinical results following ACL reconstruction, whatever the graph used, are still unacceptable in 2022 in terms of graphic rate, reparation, but also return to sport. Also, we must understand and consider that an isolated ACL ruptures is uncommon. Professor Ferretti team show in 2017 that concomitant lesions of the anterolateral structure of the knee were present in 90% of acute ACL ruptures. We have all forgotten this very important lesion. In France, hopefully, we grow up with a lemaire and we know perfectly its limits, mainly in terms of complication. It is why we gradually evolve toward a more anatomical reconstruction based on this ILL reconstruction. Modified lemaire require harvesting a strip of IT band, whereas the ILL reconstruction is a percutaneous reconstruction. From a literature point of view, the stability group have shown very good clinical outcomes, as recently presented by Allan, with modified lemaire technique. In particular, a graph rupture rate in primary ACL reconstruction, which is our aim. Our result within the SANTI group show a similar finding with a very low complication rate using the ILL reconstruction, less than 1%. In fact, our combined ACL and ILL reconstruction is a real concept of a bell effect around the lateral side. We leave the hamstring attached to the tibia and we turn around the lateral condyle, which allow a better control of the anterior subluxation of the lateral tibial plateau during rotatory movement. This all-should concept was described by Terry and Hughston in 1993. There is nothing new. Clinically, we demonstrate that in elite skiing, which is probably the highest risk sport in terms of ACL graph ruptures, that the combined ACL and lateral extracellular procedure is associated with a significant five-fold less reduction in terms of graph ruptures. 34% failure rate in the isolated group versus 6.5% in the combined groups. Moreover, in a long-term study with a mean 100-month follow-up, we demonstrate a five-fold less graph rupture rate with the combined ACL and ILL reconstruction compared to an isolated ACL reconstruction, including hamstring or BTP. In a future article, we will also demonstrate the importance of the anterolateral reconstruction in meniscal preservation. Patheon, in the suture hook group, undergoing additional ILL reconstruction, demonstrate a three-fold higher medial meniscal repair survival rate compared to all other groups. It seems that the ILL protects your medial meniscus repair. So the question for most of the surgeons is when to perform a lateral extracellular procedure. Indeed, it appears mandatory to consider the extracellular alternatives in all primary ACL reconstruction. We will demonstrate with this paper a higher prevalence of meniscal and chondral lesion in Patheon undergoing subsequent revision ACL when compared to primary ACL. So doing an extracellular tenodesis for your revision, it's already too late. In conclusion, all studies evaluating lateral extracellular procedure demonstrate better clinical outcome, in particular, a lower graph rupture rate and a longer survival rate of medial meniscus repair. Therefore, lateral extracellular procedure appear mandatory in 2002 for primary ACL reconstruction. Both modified LEMER and ILL reconstruction provide good clinical result. However, for us, combined ACL and ILL reconstruction is the LEMER 2.0. However, I still use the LEMER in 20% of my practice. Don't forget that definitively the lateral extracellular procedure must be considered for the primary ACL reconstruction, not only for revision. Thank you for your attention. Thank you Bertrand for this nice talk and for providing us with the good knowledge of these really nice clinical studies that you are performing. I have one question for you and that is regarding the use of extracellular procedures in revision cases. Is there anything that you consider doing differently when you add these to a revision case as compared to a primary case? So, do you do anything technically differently or are there any technical considerations that you take into account when you do these in a revision case versus a primary case? Thank you. I mean, it's a very good question. In fact, I changed nothing. I mean, it meant that if most of the patients with revision, I would say that they have no extraticular tenodesis. So, if it's a primary BTB, I will revise with my technique. I mean, ACL and ILL reconstruction. If it's a previous BTB graph, sorry, hamstring graph, then I will use a BTB with LEMER. So, I really don't care. What is sure that we have strongly to consider that extraticular tenodesis is more important than the graph itself. So, I mean, I would say that I will do, I used to do extraticular tenodesis in 90% of my patients, but in 100 patients for revision, definitely, and whatever the technique. I think the technique really doesn't matter. Thank you again, Bertrand. And we will move on to the last speaker tonight from London, UK. We have Mr. Andy Williams. Thank you very much indeed, Ivan. It's my great pleasure to be here and thank, must thank the organizers for inviting me. Hello to everybody, wherever you may be in the world. As you can see, the technique involves a lateral incision. I've got my index finger on the GERDES tubercle. I'm going to make an incision of around six to eight centimetres. I deepen that down to the IT band, and then I'm going to make an incision around the I'm going to make an incision of around six to eight centimetres. I deepen that down to the IT band, leaving a retractor on the right on the GERDES tubercle, and I create two parallel incisions along the fibres of the IT band in its mid portion, about a centimetre wide. If the tissue is thicker, I tend to be less wide. If the tissue is thin, I make a wider graft. Next question is, how long does the graft need to be? Basically, two to three centimetres proximal to the LCL. So, I palpate the LCL through the wound, as you can see, and then I'll add another couple of centimetres proximal to that, so I've got enough graft, because once the graft has been passed deep to the LCL, I then wrap it back upon itself, as you'll see later on. So, there's my graft, and it's very, very important that the graft is placed deep to the LCL. Ivan was involved in a lot of research at Imperial College, supervised by Andremis and myself, and it was very clear that a graft was taken superficial to the LCL. Its performance was compromised, so you have to go deep to it. It forms, effectively, a pulley, and you can see on this MRI scan how the graft goes up and then curves away as it forms a pulley from the LCL. This seems to aid the isometry of the graft. Now, people say it's very non-anatomic, but the reality is, if you look at the posterior portion of the IT band, which I, amongst others, think is the most important restraint to internal rotation, it's a curvilinear structure, as you can see, and the only way of producing that with a straight graft is to use a pulley system, hence the LCL. So, perhaps, although not anatomic, it's the best anatomic compromise. So, having got my graft, I've then got to find the LCL, I palpate it. If you can't find it, then, obviously, you can put the knee in the figure four position and feel it tense up. I take the tissue off the superficial aspect of the LCL, which I'm sure will offend some people because it must involve some of the ALL tissue. Having found the LCL, I then take my scissors close to its posterior surface, sorry, medial surface, and create a tunnel for my graft. So, the next question is, where do you place the graft? And, again, Ivan's work in the lab showed that if you placed it at position three, four, or five, as you can see here, three is a Lemaire, crack off number four, and then Macintosh position, taking the graft deep to the LCL, which is represented in the blue line, then your graft will perform well. So, you need to be on that line, if you like, on the lateral femur. Now, that's very important because if you put your graft too posteriorly, then you have a real problem as the knee extends, it'll cause tightening, you may get fixed flexion deformity, or if it doesn't cause fixed flexion, then you'll be excessively slack. So, you really want to get a pretty isometric graft, hence those three positions. So, here I'm making a position for Lemaire's procedure, and that point where I've used the periosteal elevator to create bleeding bone is 10 millimetres proximal and five millimetres posterior to the lateral collateral ligament. So, having got down to bleeding bone, I then place a suture anchor. I prefer a suture anchor here, it's only 15 millimetres long, and therefore I've got no risk of hitting the femoral tunnel of the ACL. If you drill tunnels, that can be problematic. And in kids, you can place a suture anchor distal to the growth plate. You wouldn't want to go proximal because that would create a tethering, and therefore increase the risk of growth arrest. Baxter-Willis published on this effect in dogs. So, you need x-ray to put your suture anchor distal to the growth plate. I then take the graft, pass it through that tunnel and the soft tissue deep to the LCL, and that is effectively the construct there. So, the next thing is, what about over-constraint? When people use the phrase over-constraint, they usually use it to attack lateral extraarticular platenodesis because it implies too much tension and therefore osteoarthritis. But they rarely say what it really means. Do they mean you lose a degree or two of terminal internal rotation? Well, if that happens, that's probably not a big deal because we rarely internally rotate our knees, even when strikers shoot the ball. If I had a problem with that, I'm sure they would tell me amongst my football clientele. But of course, if we have an operation that causes loss of flexion, or increased articular contact pressures, or a fixed external rotational deformity, that is bad news. And Ivan's work in our lab did show that you can over-constraint with atenodesis, and you would do so if you had excessive tension on the graft, you found 40 newtons was too much, and if the tibia was allowed to be fixed in external rotation. And that really is not good for the knee, it increases contact pressures in the telephragmal and tibia femoral joints. So you need to think of the atenodesis as a check ring, rather like an MPFL reconstruction. You don't need to put great tension, 20 newtons be enough, just make it taut and no more. And also ensure that when you fix the graft, the knee is in neutral axial rotation. And so we walk with about a 10 degree external rotation circle progression angle, and that's where I place the foot and therefore the tibia. We don't want any more external rotation than that. And just to show the point, with rotation, you see the graft move, and so you do need to fix it with the knee in neutral rotation. I fix it with number two sutures, non-absorbable. You can see one of them going in there, and then the remaining graft proximal to the LCL, I fold back upon itself and suture itself over the LCL to augment the fixation. The question about closing the defect, well, we found no effect on stabilisation by closing the defect. But if you have a bigger incision and muscle is exposed proximally, then you really do need to close the IT band defect, otherwise the patient will have a hernia. So that's my talk on the technique. The reason I use it is it's effective. We just published a series of 232 professional footballers of mine, and we've got the re-rupture rate down to 2% in this very high demand group if I use a patellar tendon intra-articular graft plus a lameo type tenodesis. I must thank all of those involved in the work at Imperial College who are listed here under the guidance of Andrew Amos. And in keeping with Andrea Ferretti, why would you not want to come to Paris in springtime? This is going to be the big one. There's no question. I had a first face-to-face conference last week, and it was fantastic. And where better to come than ESCA in Paris? These are my disclosures, and I thank you very much indeed for your attention. Thank you so much, Andy, for a clear and very good presentation. So I'd just like to pick up on one of the things that you said in your talk, Andy. You commented on your use of suture anchors as the fixation on the femoral side. I know that some people would like to use a screw instead, and therefore put in a tunnel. And as always, when doing combined intra and extraticular procedures, there is a risk of tunnel confluence. Now, is there anything you can do to reduce or eliminate this risk of tunnel confluence? Yeah, so I do use a suture anchor for that reason. I accept that it may compromise fixation, but I've got data to prove it works, as I just said. Work was done in Singapore by Dave Lee, a friend of mine, and he kindly involved me in the paper we published in the OGSM last year. And we looked at the distance to hitting the femoral tunnel. And if you want no risk, then you need an implant that's 15 mm neu llai, a dyna pam rydw i'n defnyddio'r deunydd hwnnw. Os ydych chi eisiau defnyddio tunnel dros y gne, yna mewn gwirionedd, os ydych chi'n dod â'ch cefndir ac yn ymlaen ymlaen, 30 o gradd, o fewn y deunydd hwnnw a'r ddeunydd hwnnw, byddwch chi'n mynd i ddod â'r tunnel ffermwl. Ond hyd yn oed, rydw i wedi darganfod fy mod i'n mynd i ddod â'r tunnel, yn enwedig os ydych chi'n defnyddio'r botwm cenedlaethol i'r hamstring, mae hynny'n bwysig iawn. Mae'r tendon gyda'r sgrw metal yn mwyaf bwysig iawn. Y unig broblem gyda'r sutran yw fy mod i'n teimlo fel y byddai angen i mi ddod â'r graff yn ôl, felly rydw i'n cael ystafell lateral sy'n eithaf cyffredinol, sydd yn amlwg nid yw'n boblogaeth cosmetigol. Mae'n mynd i lawr gyda'r amser, ond rydw i'n teimlo â gwneud ymddangosfa mwy cyffredinol, fel y dywedodd Alan gyda'i stapel yn y rhan yma o'r metafysydd distyl, dim ond ar gael ar y condal, oherwydd mae hynny'n cael ei gofio ac dydych chi ddim yn cael unrhyw broblemau o ddefnyddio, ac rydych chi'n iawn ar gael ar y tunnel ffermwl o'r ACL, ond rydw i'n meddwl ein bod ni'n rhaid ystyried hynny'n dda. Diolch. Felly, os ydy'r rest o'r panelwyr yn mynd i ddefnyddio eu ficroffonau a'u camerau, byddwn i'n cael fwy o gwestiynau. Yn gyntaf, rydw i'n meddwl y byddwn i'n hoffi fynd yn ôl i Al. Mae'r astudiaeth gysylltiedig wedi gwneud ei fod yn astudiaeth sylfaenol, ac rydyn ni wedi dysgu llawer o hynny. Mae'r astudiaeth hwnnw wedi'i ymddangos â phobl sy'n risg fawr. Nawr, a oes unrhyw grwpiau neu phobl y byddwn i'n ddweud ei fod yn rhaid i ni ddefnyddio'r tenedesis fel ysbrydoliaeth i'r adeiladu'r ACL? Waw, gofyn dda. Iawn, rydw i'n meddwl, efallai, rydych chi'n gwybod, mae'n rhaid i ni ddefnyddio'r tenedesis fel ysbrydoliaeth i'r adeiladu'r ACL. Rwy'n meddwl bod eu rhesg o adeiladu'n dda iawn. Rwy'n mynd i ddweud bod llawer o'r pobl hynny, yn amlwg, yn gallu bod yn candidataethau da i ddefnyddio sylfaenol gyda'r adeiladu'r ACL. Felly rwy'n meddwl bod gwneud ysbrydoliaeth ysbrydoliaethol yn y poblogaeth pobl sy'n debyg i'r adeiladu. Rydyn ni wedi edrych ar yr oed yn 25, ond mae hynny'n eithaf arbennig. Rwy'n meddwl, ar ddiwedd y dydd, mae'r oed yn ymddangos i fod yn adeiladu o lefel gweithredu. Felly os ydych chi unrhyw un sy'n gweithredu cyhoeddus, yn gwneud sportau ar risg, yn cael eu gadael, neu fel y dywedodd Bertrand, chi'n gwybod, chi'n gwybod, sgyrwyr lefel elit. Mae'r rhain yn sportau ar risg cyhoeddus, ac rydyn ni'n eithaf angen ceisio gwneud yr holl beth sy'n gallu ei wneud i ceisio gweithredu eich graff intrawartigol. Rwy'n meddwl mai dyna pam y gall ymddygiad adeiladuol fod yn ddefnyddiol iawn. Felly byddwn i eisiau gofyn y cwestiwn hwnnw i Bertrand. A oes gennych unrhyw gefnogaeth ar hynny? A oes unrhyw grŵp o bobl sy'n rhaid eu gwneud ymwneud â hyn? Mae'r cwestiwn yn unrhyw fath. Rydyn ni'n tyfu gyda BTV Lomair, felly mae'n ddefnyddiol gwych a'n opsiwn dda iawn, ond creu fy mod i pan fyddwch chi'n mynd i'r ILL Amsring, mae'n ymwneud â gweithredu yn ddiogelach that that paper is so worth reading. It's relevant to medial and for medial and for lateral instability. Those two authors sorted out rotation. They almost got it completely right. No MRI is available. It's purely clinical and observational. Truly landmark paper and I read it for the first time two years ago and I was absolutely stunned. And so we need to get a control rotational instability for symptomatic control but also to protect the knee in the long term and it's better on said if you get condor damage, it's too late or minuscule damage. So I the people I would avoid it on people you're worried may not have been a deal with pain or trauma. Knees that are very angry or add extra. And these patients who have a stiff knee on the other side may not need it. And of course we had great results from single bundle ACLs in the past, but maybe those needs long term get osteoarthritis. So when it's done properly, all these techniques work very, very well. And what's wonderful is that we spent 10 years arguing about the procedures whether you do ALL or whether you do it in a decent. But both sides of that argument now publishing clinical data. So we closed the audit loop. It's stunning. The last two years I mean Spectrum series Allen series except we've just published it's it's stunning. Actually, how we've converted quite unacceptable as better said failure rates to really do a good job of getting really low levels even in high demand people. Uh. Thank you, thank you. Would you like to comment as well? Yes, about the risk of osteoarthritis. In actual fact, in the last paper we publish. Long term follow up radiological follow up. Of two groups created by ACL reconstruction, one with another without. X extractive reconstruction. And we found that in case of lateral minisectomy, in case of lateral minisectomy. The addition of the latter reconstruction reduces the risk of osteoarthritis. This is is quite surprising probably, but in our experience, the better stability. Is it protective against the? The generative osteoarthritis. Therefore, if the question was at the beginning, if there is a contraindication. For a lot of reconstruction. In my experience, I don't find any contraindication. Probably there are some cases that you could. Avoid that there is not necessary to do it, but this is not a contraindication. Some people worry about moving. Yeah, yeah, some people worry about its use if there's a post lateral corner injury. And of course if you pull the foot into external rotation, then that would not be good. But as long as you fix it in neutral, often I'll do an ACL plus post excess extra rotation and I'll add a tinnitus as well. So they've got anterolateral stability and they've got post lateral as well. Great picking up from there. You're doing a great job guys answering some of the questions that that we have from the audience actually already so but I just like to move on from there and talk about the thesis and complications there is. There is one question from the audience related to that. Either either Maramonteiro is asking what are the main complications of LAT? Al would you like to answer that one? And yes, I mean the the most frequent complication that we had was hardware irritation, but you know, but that's associated with the fact that we were using the particular hardware that we use now. That being said, there's only 10 staples that were removed out of 300 patients, so still very low risk. What you know, I think Andy brought up the point as well is that sometimes you just get more of a fullness on the lateral side of the knee. I personally don't think it's the staple that's causing the problem. It's just the fact that we've operated on the lateral side of the knee through the IT band and that causes but you know if you're concerned about that for sure you can use a different implant for fixation but then you run the risk of some of the potential complications that we've already talked about and I think one thing you've got to be very aware of if using a tunnel and screw particularly if you go more proximal getting at the cortical bone. There's a really high risk of actually amputating your graft as you put your screw in so you know there there are. There's always risks and benefits with everything that we do and you just have to be aware of those. And then the other thing is a risk of hematoma and there's a lot there's a leash of vessels, the super lateral geniculate so again really after I do the dissection I let if you're using a tourniquet I let the tourniquet down and make sure that I've got good control of bleeding before closing up. Great, so another question is. Staple versus screw versus suture anchor and we've covered some of the effects. Does anyone want to say anything more about that or? So using a screw probably and also suture anchor you eliminate that risk of hardware removal and we've talked about tunnel confluence and the in in tunnels versus suture anchors. I haven't got the case so I would just to think to think about is cost as well. You know one of the reasons that we opted for a staple from a generalizability point of view after stability is we wanted this this procedure if it worked to be potentially adopted across the world and you know a staple is a simple cheap piece of material compared to maybe a suture anchor. I agree with Alan, we are now using a as said by Andy, anchor which is a fiber loop not less without without I mean it's a short implant is less than 15 millimeters and with that you avoid all the the tunnel collision with the so it's a very good option. Another technical question guys so you tension at 60 degrees I think this is for Andy again and you tension at 60 degrees why do some people go to 30 degrees when they tension? Well it's a nice lead in to quote one of your papers Ivan but Ivan looked at the flexion angle of fixation of the tenodesis graft and found it made no difference whether it's fixed at 0, 30 or 60 degrees and so I'm very happy to do placement in that range the critical thing is axial rotation. The ALL as Bertrand will tell you is non-isometric and therefore it must be fixed with the knee completely straight and it's there are pros and cons and we can argue about the detail but I think for tenodesis it's relatively isometric construct and therefore as long as you go in that line of those points Lemaire, Krakow and McIntosh if you if you go to posterior then that's a problem you can't if you go to anterior then you simply have a tighter pulley. I've never seen a case of attritional rupture of the LCL just proximal to its femoral attachment but you just you do wonder if that if you went hard anterior you might get that so you do need to come that line and understand where that is but it's if you're in a rush and went too posterior I think that could be a bad thing. I can add a word I'm totally agree with Andy I mean the ILH is an isometric so it has to be fixed in extension for the Lemaire is isometric so whatever the position is not a trouble however I saw in the past with my patient that the tendency to be fixed in external rotation so now I'm cleaning for the Lemaire to avoid that I try to fix it close to the extension. Great Andrea how do you tension your guards? In actual fact we use a sort of a self-adjusting technique we do not fix to the bone but just to the lateral collateral ligament as suggested by Coker and Arnold this is a very very simple safe and effective technique is so is a self-adjusting we fix at about 60 degrees of flexion but you can fix like you want there is no risk of over constraint and is a very effective technique is unbelievable how is effective as simple and effective in the same time and we don't need to to find any point of isometry don't don't care about it this and it's very simple and effective however there are a lot of techniques and the the short the choice of the of the the thing is related to the surgeon preference and if you want to get familiar with the harvesting of a fascia lata the stripper the the Coker Arnold is a very simple and for starting with the extraterritorial construction is a very very advisable technique then you can proceed to more complicated or precise technique but for as a starting point I think is a is a very very is a good choice for starting great thank you so I think we have time for two last questions first one is regarding skeletally immature patients Dr. Getgert will stability to include include the feisal sparing let procedures you could perhaps elaborate a little bit so all patients that were involved in stability and stability too are skeletally mature and so patients that have got an open face is my approach with them is to use a soft tissue graft my preference at the moment is a quadricep tendon in that in that patient population and then I will do a lateral tenodesis now in some some individuals particularly the really young ones which I have to say is very rare in my practice I'll do a more catchy type technique with a hamstring over the top and then back down onto the lateral side and I think that's a very effective technique in that patient population right anyone else so we do the final question do you change your rehab protocol when you add in a lateral tenodesis let's start with Andy Williams no I don't at all I as always unless there's a reason not to they fully weight bear I have full extension immediately there's no restriction on flexion I'll alter that if there's a root repair or ramp lesion etc and so the meniscal pathology is the main thing but if it's a if there's no other reason for it then I've got no restriction I don't brace them either maybe again that's one of the reasons things have improved this is a this isn't new it's an old technique but I would hope we fine tuned it but I can remember in the late 80s working at the Royal National Orthopaedic Hospital Stanmore putting people in plaster with their knee at 90 degrees and with maximum external rotation after McIntosh tenodesis and they did take a year to get their knee straight and bending they never play sport again and so they never gave way again but they didn't do very well so movement is life as I suppose would say do you change your protocol oh exactly like Andy, full weight bearing no brace, extension first and routine procedure and routine rehabilitation nothing nothing particular no restriction at all thank you, Andrea the difference is between acute and chronic cases in acute cases we go faster we accelerate a little bit the rehabilitation as compared with the chronic ones but about the cast the femoral and the casting in external rotation if you have the chance to see a documentary about the life of Dr Losey there is an internet the title is Sodam Glad you see the Losey with the plaster in external rotation with the foot in full external rotation I suggest you to see this documentary in internet you can find Sodam Glad I recommend you thank you for that recommendation and finally Al do you change your rehab when adding a lateral tenosynosis no exactly the same as other guys the meniscus drives the rehab okay great thank you so much for your valuable presentations and for your inputs in this very good discussion and thank you to to the audience for all the good questions that we've had to discuss over so I wish you all good luck with the ACL surgery with or without lateral extracurricular procedures thank you Ivan thank you thank you very much bye-bye see you in Paris you Thank you to all our panelists and presenters for their work tonight on tonight's webinar and thank you attendees for your participation. If you're interested in CME or would like to view the recording of this webinar, please go to education.sportsmed.org and log in and click on my resources and then the course title. You can complete the evaluation for CME or view the recording which will be available by Friday. The information will be emailed to you in 24 hours so please don't worry about remembering it all. We thank you again for your participation and have a great rest of your night and we hope to see you all in Colorado for the AOSSM 50th Annual Meeting in July. Thank you.

webinar

American Journal of Sports Medicine

lateral extra-articular tenodesis

ACL reconstruction

Andrea Ferretti

extra-articular reconstruction

Alan Getgood

Stability Study

Beaute Solnery-Cotet

Andy Williams