Question for the auditory, yes. Regarding the return to the spot, does the dominant kicking lead to the same difference in the time of the return? What I mean is, whether it's a kick, because some players they try to kick to the right leg and they pivot to the left, some players they move both, some players they go one side, does that make the difference in the return to the spot? Yes, it's very important because in my experience I think the leg that has more injury is the leg that doesn't kick, is the other leg, because there you make the movement, you know, the valgus, flexion and external rotation. I don't know if someone wants to say something about that. Thank you for your talks, they're all very good. In relation to the indication for adding an inlet, obviously a lot of it depends on the graft you use. From the stability study we're aware that it has to be an inlet, we're not sure which, but if you're using BTB or more recently quads tend to, especially if you know the collagen the quads has and the outcomes that we're currently seeing, what's the indication for adding an inlet if you're using BTB or quads? I appreciate the stability 2 study, but that could take some years. So based on your experience, your providing experience and based on your guidelines, what would you say to us if you're using quads or BTB? That's a very good question. Yeah, that's a very good point, but I think it's not depending on the graft that you use. For us it's the same. Some group of surgeons use, like from Italy Stefano Safanini and Rizzoli, use only hamstrings and long hamstrings and go back to use the anterolateral reconstruction. So they perform in 100% of the cases. But you have, if you use BTB you can do that, so you have to take two grafts. If you do with iliotibial band or you use allograft or you use hamstrings more. So in our hands, to ask your question, I think you have to add anterolateral, it does not depend on the graft. I disagree because in some patients, for example, a woman of 33 years that plays soccer, recreational and then in that lady I think, I don't know, it's BTB only or hamstring tendon plus lead. In this case, I think that I perform hamstring tendon plus lead instead of BTB for the post-op. You know, lady, 32, two children, recreational soccer, and for that reason I think you can manage the extracellular reconstruction. Do you think it's the same in the table? Yes, for quad tendon I use lead augmentation in under 25, pivot shift sports, hyperlaxity, and I agree with Dr. Maisto, in ladies more than 25, 30 years, I prefer hamstring plus lead than quad tendon. Yes, Guillermo. I think the reconstruction, the ACL reconstruction procedure is a biologic procedure. Then I try to explain it's anatomic and functional. For this reason, the graft is only part of this process. I think it's most important to understand the biomechanic function of this knee. I think it's most important the size of the tunnels, the age of the patient, and if it's a patient with a high demand of the sport, I think it's a good option, tenodesis extraticular. Yes, of course, it's very important to discuss the case with the patient, of course. We discuss about the graft, the extraticular, tenodesis, the post-op, the scar in ladies, and everything. But it's a very good question. Another question? Yes. Do you perform your technique in every patient? The trans-tibial technique that you described? No, I use quads, I use BTV too. Always trans-tibial? Trans-tibial, yes. Because I understand that the biomechanical position is most important to get better resistance of the graft. For this reason, I try to conserve this technique. What you do is you modify your entrance point? Yes, yes. Yes, I use trans-tibial modified with 55 degrees. You said you use retro-screw? Yes, we use retro-screw for the quad reconstruction. When we use hamstrings, we use normal retro-screw. We go from the articular, from outside, yes. Inside out? Inside out. For you, Guillermo, because when I saw your talk, for me it's more easy to go for the anterior medial portal to perform a femoral tunnel. Why do you go to tibia? We found it more difficult. I understand this is more difficult, but the biomechanical is most important for us. I think we must try to reach the best for the patient. If we try to conserve this linear design, it's better for the patient.

ACL reconstruction surgery

dominant kicking

grafts

anterolateral reconstruction

tunnel placement