and building a little bit on Brett's great demonstration of ACL repair, we have a brief panel here to talk a little bit about repair versus reconstruction and how can we decide. And we're very fortunate to have this group, Latul, Seth obviously from Stanford, Darren from Kentucky, and Craig from LifeBridge who are key opinion leaders in this space and hopefully are gonna teach us some things. In preparing for this talk, I obviously can't share all the literature, but I pulled out a few things in this repair versus reconstruction stage that we're in and these are some of the early articles that have come out about primary reconstruction and I highlight in the methods that the focus at least initially seems on quote unquote good to excellent tissue quality and quote unquote proximal tears. And these are oftentimes what those images look like in those kind of studies that report those outcomes. As the literature has gone on and we now have more studies to hang our hat on, there are systematic reviews like this comparing at least early or near term outcomes of repair versus reconstruction. And while we don't have structural outcome data, if you look across the board by IKDC, Lysholm, VAS scores, there doesn't appear to be a significant difference between repair and recon which of course gives some early optimism for the potential of repair in the appropriate cases. And then as Brad has just shared from the great work from Martha Murray and Braden and others, we now have scaffolds and the bare construct and what you notice here by contrast is in the methods, the ability to not just address the quote unquote proximal tear, but as is highlighted here in situations where even 50% of the length of the ACL is attached on the tibial side. So maybe to engage the panel a little bit and seeing this evolution, I feel like we started maybe here with the type one Sherman tear and then now maybe which one of this group is it? Maybe I'll start with you Latul. Thoughts on that. How do we indicate these in the face of the current literature? So right now what we're looking at, when you look at certainly the technique as it was described, you need stump on both sides. This is really a bridge. And so it's not necessarily intended for these type one tears. So you have to have tissue that you're essentially bridging. And so more than five millimeters of stump on the femur and obviously a tibial stump, all things remaining equal is kind of the ones that we're doing now as part of the study, the multicenter bare moon study. Yeah, great. And Seth, do you think, as Latul just pointed out for the type one or the proximal tear is still a role for repair? And is that maybe one that's without a scaffold versus with a scaffold? Yeah, I'll just comment that I have not yet done a bare clinically. I am going to be part of the registry. I've done these in the lab and obviously I've followed the space closely. So for me, I've kind of kept things very close to the classic indications for primary repair, which typically for my patients would be those older patients, those type ones off the wall. They typically will be patients with less hyper laxity, maybe that low grade MCL, repairable meniscus, maybe a 2A Lachman, a pivot glide. So I mean, I'm really keeping my indications extraordinarily narrow still and have not moved to those tear patterns that are in the two or three and four bridging techniques to date. But I do think that there is, of course, great promise with these techniques and technologies. Yeah, great points and transition. And maybe before I share just a few MRIs, Darren, all the points that Seth just brought out, when you look at this kind of list and I threw this together, the pattern, the chronicity of the tear, the level of sport, as Seth just mentioned, may be different in a high athlete versus maybe somebody more recreational. And then as we just heard in the prior session, no two ACLs are alike and there seem to be cases where high grade pivots or high slope or retro bottom increase our concern. How do you factor this into whether you're selecting a repair or recon or do we not know yet? Yeah, a lot of that stuff we don't know. I think we're trying to learn about that. I think all those things you mentioned, tear pattern, level of sport, activity level, risk factors, those are all things to think about. I think you also have to know what's your personal failure rate of doing a good ACL reconstruction, right? So probably if I take your patellar tendon and you're 14, I think your failure rate's about 8% in my hands. So you have to know your own personal failure rate. And then by doing this on that young person, high pivot sport athlete, what can I walk in the room and say? Am I gonna lower that number? Is that number gonna be higher? I think those are things you need to think about as we learn more and we need to get more information. I think that's just where I am with understanding. I realize there's a lot of excitement about this. It's new. We've looked at it a long time. Dick Steadman used to do the picking of the proximal ACL tear, had some pretty good results a long time ago in skiers. But we just need more information. Yeah, I think those are very thoughtful and important points. And you do have to compare it to your current standard of reconstruction. And that's different for each of us. Craig, you have some real practical and real world experience with this. I thought maybe to take a deeper dive, I'll just share some real kind of pictures and MRIs that we sometimes get. And at least with the initial data you have in the clinic, assuming not a high grade pivot, maybe click through a few of these and say, how do you indicate this? And how do you have that discussion? If you see an MRI like this in a 19 year old skier, it's three weeks out, what would you say? Is repair on your differential every time? Is it an intraoperative decision? Or are there some MRIs where you're just ruling this out? There are some MRIs where I'm much less inclined to consider a repair. Like most of us have said, I've done this particularly with the Sherman One type tear. But there are MRIs where if there's no quality mid substance tissue, particularly on a high level person, I'm not considering repair at this time. One caveat I'll make is that for me, some of my repairs that I've been very, very pleased with have been patients who've had an absence of a classic bone bruise pattern on the MRI. So I'm looking to see how much injury there is isolated to just the ACL area. And is there a concomitant injury as well as we've discussed at length? So for me, Sherman One isolated, and in particular one where you don't have as significant a bone bruise pattern is where I'm gonna consider a repair. In this particular case, I'm leaning more towards classic reconstruction given the quality or lack of quality of proximal tissue. Yeah, great points. And obviously limited time, but I put some of these images in to share the true heterogeneity where sometimes as we're looking and being more thoughtful about repair, we're paying a little more attention. Latul, how about one like this? Is this maybe more a bare type of approach versus just a proximal repair to bone? Yeah, I think given that the age activity level, the acuity of the injury, and what this sort of stump looks like on MRI, but certainly you have to go into surgery with a backup plan. You can't only say we're gonna do a repair, say we're gonna back this up with, or we're gonna do a ACL reconstruction if we can't repair this tissue if it's not reparable. But I don't find that my MRI images highly correlate with what I find in the operating room, which is I think is the point to get across here. So certainly we can talk about it, but certainly have a backup plan. Yeah, you made that transition easy for me in a bit, Latul. How about along those same line sets, sometimes you see situations like this where tissue is in continuity, but it appears stretched, it appears damaged, there's some plastic deformation. How's that factor into it if it's repairable, and are you at that point thinking about either augmentation with a scaffold or a protective suture or tape? I think this is a potential candidate, right? So I'll go to the operating room with a plan that will include evaluation of the tissue and it'll include potential for reconstruction. So I think that that's critically important. Just thinking this through, certainly you could do proximal repair in this, but for the last one that you showed as well, I think you'd have more confidence if you're going in with a bear mentality that you don't need as much of that tissue near or close to the wall. So you'd be more apt to pivot, I guess, with the proximal peel-offs that I might repair versus doing a bear based on the classic indication. Yeah, all great points and just more images showing that same concern of what's repairable, but I think, Latul, you summarized it better than I can, which is oftentimes the poor correlation between what's here and still having to need intraoperative data. So along those lines, maybe, Darren, once you do decide you're going to the OR, can you provide some insights if you're contemplating repair, what is it that you're looking for at the time of surgery that is your decision point? Tissue quality, the location of the tear, reducibility, how do we make that call now that you're there? Yeah, I think this picture's a great picture, right? I mean, I think the tissue quality is very important. Probably, I would assume most of us would agree if we're going to do some type of repair, bear implant, we're going to want to be in that knee relatively soon as opposed to later. How does that tissue look? That view you have there where you could say, you know, is this like almost a peel-off lesion, if you will? Is there an avulsion of the footprint that I could maybe get back and then in some way, shape, or form, protect that environment with a bear implant or whatever else you have? But I think you'd make that decision after, as Seth said, you got to get in the knee and see what the tissue looks like. As you pass sutures through it and grab, does it hold the tissues, right? And I think, you know, you need to get it back to the footprint of where Mother Nature had it. So maybe I need this view. Maybe I need to clean off a little bit of the front of the notch because I got to see all the way back there. All those things I think are really important. Yeah, great points. And this is one where that approach was taken and without a scaffold, a lower demand patient. So Seth, I elected to do that and use even some time zero protection, maybe protecting myself, but in some ways offering some protection to that interface. Craig, you have taught me about this and I think it's something we're learning about. Sometimes you have situations like this one where the ACL is there, it seems scarred to the PCL and out to length. And then as I mobilize it, I'm able to kind of reduce it over. So is this part of your equation as well? How do you decide how much is too much tension and how much of a reduction is acceptable? What if it's just a single bundle that's reducible there? So for those of us who still try to implement the two bundle concept upon occasion, this is a scenario where it looks like you have enough length of that tissue, particularly go more horizontal on the native tissue. So as we've talked about, I'll take that tissue and I'll repair that down to the three o'clock position. And then I'll put a graft in at the one o'clock position, a soft tissue graft. So I know the numbers of those are small. We have a small series that we've written up in terms of that technique. But to answer your specific question about assessment of it, you don't wanna try to over tension the tissue. So in that particular scenario, it looks like you've got one bundle that's able to be repaired and I would use soft tissue to reconstruct the other bundle. Yeah, I think great points and we have limited time, but just showing the variations of these and I think you highlighted it, which is sometimes you can be reducible, but if you're under tension and you notice, obviously a difference in tension as you go through range of motion, be cautious about that being the same as a primary acute repair of tissue. Given limited time, maybe a little bit of questions on technical side of things. Latul, you talked about using the scaffold. Even with primary repair without a scaffold, if you look at the literature, some have talked about anchors in the wall. Others have talked about a socket and using suspensory fixation. Is this a single luggage tag type stitches or is it running crack out stitches? And as we talked about, are we protecting this with a bioinductive scaffold or a tape? Can you give some pearls as you started to do this about do we know enough or are all of these acceptable? So I think all of them can be acceptable. I think in my own practice, I think about my extra articular ligament repairs. And so like if you repair an MCL and without any augmentation whatsoever, you know, those things loosen up and maybe not a big deal for the MCL, but inside the knee, if you loosen up one, two, three millimeters for an ACL, that's a huge deal. So I think if you are gonna repair, you need to back that up with some kind of augmentation. So the tape that you showed, if you use anchors, I would avoid absorbable anchors because those things can cause osteolysis. And when revised, I've had cases that I've had to go back and bone graft, the same as like with a bad tunnel. So I prefer to do trans-osteosutery if I'm gonna do this technique and tie over the lateral cortex things. Yeah, I think those are great points. And while sometimes it's perceived that these procedures are relatively benign, at the end of the day, you do have to still be prepared for the potential conversion. Along those lines, Seth, if you see a stump that sometimes looks like this, and then there's the question of stump retention and remnant sparing, do we know that facet of things, right? There's certainly been a body of literature that that preserves proprioception, it favors healing. Can you do a hybrid as Craig mentioned? What's your thought on remnant sparing situations if you can't necessarily do a primary repair? I think I'm more apt to spare the remnant tissue on the tibia versus the femur, just for visualization sake. I mean, I use bony anatomy in most cases. And so I wanna get it right with my tunnel positions and I won't get it wrong at the expense of not being able to see. That said, I've been to France and visited Bertrand and watched his technique with Sama. And I've also, when I do have cases where I have some preserved femoral bundle, like one that you showed, I think you can get that position right, even with a recon, keeping some of the tissue as a bridge. And I use an over the top guide so that I make sure that I'm in the correct position in cases like that. If I don't have a perfect bony reference to visualize. You know, Darren, sometimes one of my worries is, and sometimes it's out there in the literature, that ACL repair also sometimes becomes synonymous with expedited recovery. And obviously the question for the panel here was recon versus repair, but it often gets misunderstood that repair means return to play sooner. With all your experience in ACL reconstruction and returning athletes to play, can you give us some insights on your thoughts on that and maybe my bias, the dangers of that? You know, I think if you do a repair, I think probably people are gonna think, well, it's gonna heal quicker and I'll be back quicker. That's probably not a place you wanna go. I wouldn't recommend that necessarily. It's really how's the patient doing functionally. But I think going back to talk about the saving the stump and stuff like that, I think that's very important. I just returned from Asia as the AOSSM traveling godfather. So I went to Korea, Hong Kong, Japan, Thailand, and remnant preserving knee ligament surgery is a big deal to them, doing ACL and PCL surgery. And I think there are tremendous benefits. Just gotta be careful on the tibial side, you don't overstuff the notch, and then you get a cyclops or lose extension or whatever. You just gotta be careful on that tibial side with your graft. If you are gonna do a repair, if the patient's family says to me, well, Darren, you could just do the repair and I'll be back in two months, right? I'm not sure I'd go down that road. So be careful if you are doing repairs because they will assume you're gonna get them back quicker and then when they fail, it's your fault. Yeah, great points. And sometimes because it's less painful, there's a perception that you're further along the recovery curve. Along those lines, Craig, this is always a question for me, especially when we're pushing towards a change in paradigm for repair. As you saw in that systematic review, if we hold ourselves to the standard of IKDCs and Lyshomes and VASs, well, gosh, things look equivalent. And so when you're assessing outcomes, when you're pushing in your practice, how should we do that? Is it functional? Is it just your Lachman and your pivot and those scores? Or should we be thinking about MRIs like this to assess the maturity of a repair? And what's your threshold in terms of deciding when something's looking right or whether it's not looking the right direction to convert to a recon? Well, it's everything. So as we've chatted about, everything on this list is critical in terms of, to piggyback to Darren's comment and your question with the time for recovery, with a repair, what I will say is that, like most of us who do them, the quad does tend to recover more quickly. And so I'm still looking at the same outcome measures, but generally speaking, it's gonna be a lot longer than a lot of the athletes will want in regards to repair before they're actually functionally completely ready despite the low level of pain. So every factor on here is important. I will also add that with my repairs, any athletes who are trying to come back in that five, six month timeframe, particularly with pivoting sports, I'll add an LET as well. I feel more comfortable with the relatively quick recovery with that as opposed to an isolated repair alone. The examination of the knee is more important than the MRI. I don't routinely get an MRI on my ACL reconstructions, but I will get an MRI on the ACL repairs when I can insurance-wise in order to assess the quality of the tissue. But it's everything. Yeah, you make a great point, Craig. It's not just the ligament, it's the muscle recovery as well. I think we're almost out of time. Seth, I'll give you the last word here. Yeah, I think all of those assessments are critically important. I would get MRIs to assess these repairs for sure. And I think the Holy Grail is mitigation of osteoarthritis in the longterm. And that, I think, is what might eventually get me to shift more of my patient population if we have safe return to sport and mitigation of OA because we have not solved that problem in 2023. And just remember, an ACL reconstruction done appropriately is not that bad of an operation. It's pretty good. We have pretty good results. Do some fail? Yes, some fail for all of us, but let's just remember doing that surgery correctly with the right graft, right patient, everything goes well. They do okay. All great points, and thanks to the panelists. Thank you.

ACL repair

ACL reconstruction

tissue quality

proximal tears

scaffolds

bare constructs