OK, I put the case, it's a professional soccer player, 20 years old, girl, boy, it's the same. What's your time from lesion to surgery? On Sunday, the soccer player has the lesion. And we'll wait to indicate the surgery. Hernan? I wait that I have a complete room of motion, no fusion and no pain. Especially I take a very important extension, it's very important to recover the extension. And in your experience, what's the time? One week, one month, two weeks. No, one week. In some cases, if I hurry to make the reconstruction, I drain the veneer. Perfect. Sebastian, something different? No, the same criteria, so it's very difficult to achieve those criteria in less than one week, so normally it's average two weeks. Something different? Different? No. Audience, some question? What's the insurance safety? It's probably two weeks. Yeah, I think it depends. If you go to the rehab, you inject a corticoid, you know, perhaps two or three weeks. But it's very important to indicate the surgery when the whole movement is okay, no fusion, no pain. For that reason, it's more easy to post-op. Graf, I know what you use. In this space, you use hamstring tendon, Guillermo? Yes, I like. Yeah. We use BTV plus anterolateral. Perfect. Sebastian? Yeah, BTV and any anterolateral procedure, it depends on the other factors. But it has at least professional, 20 years old, but it's the first episode. So I'm not absolutely sure about anterolateral augmentation, but BTV. Okay. I know you. The audience, what do you go to BTV, Graf? I think the majority. Hamstring tendon? I have a question. You're alone, Guillermo. Yes. But I have a question. If we use the graft of the quads or the patellar tendon, we are less on the extensor musculature. Then the future of the rehabilitation of this patient will be more slowly. Yes, of course. But the paper said that no problem in the future and have less injuries. Quad? Quad. Good. I'm not alone. Okay. But there are no big differences about Graf, of course, no? Return to sport. Very nice talk of Sebastian. In the table, you take a time, you take movement, you use some tests. What's your return to sport? In my case, I use time, no less than eight months. We evaluated the strength of the knee with the isokinetic machine and then functional hop test, triple hop test, and crossover hop test. Yes. Sebastian, your talk is? Yes, the same, but we're also using some scores related with psychological kinesophobia. The TAMPA kinesophobic scale, we use it before return to sport. Yes. To add, in my personal opinion, I had an MRI, also in professional soccer players, because it's very important for us and for the player if you have a good image post-off also. But I think it's a good point to perform an MRI, so you can control the incorporation and biologic incorporation of the MRI. You think that? I order an MRI too, but I order my MRI for the patient and to see some other thing as meniscus, cartilage, etc. I don't think that I can see the maturity in the MRI. Yes, if you see a graph, all homogeneous, point-to-point continuous, and black one, it's a very good point. But it's very difficult at eight months. We perform a study and in perhaps 70% of the patients, you can arrive at that, but in another patients, you are heterogeneous and all of these parameters that they describe, and it's one point more. It's not definitely the MRI, I say, but for us, for me, it's a very good alternative. Guillermo, something different? I use the TAMPA criteria, the clinical criteria. I use too the MRI to control, but it's more for psychological reason for the patient. He feel more comfortable with this. Okay. Then, I have this paper from Italy that said it's very, very, very important, the preventive programs, it's very important, and some other thing that is not so important. In this other paper, it said that no differences in ACL graph choice in female and male soccer player, it's very important. You can choose BTB, quad, but the papers don't push a lot on this indication. But I think the very important thing that only half of patients return to pre-injury level of sport, as Sebastian showed us. And it's very, very important sport psychology therapy in this, to return to sport. In another paper from Europe, Norway and UK, said, of course, that soccer as a sport with ACL injuries, of course, is very dangerous for the incidence. In this other paper, it's in Spanish, sorry, from Chile, and said that only 57 return to pre-injury level. It's very important to discuss with the patient in the OR before the surgery. Sebastian showed this consensus that we part, and they had 34 experts, and the surgeon with more than 20 years of practice, at least 50 ACL recursion per year, and more than 1,000. And in patient with a high level of intensity of pivoting sport practice, BTB should be the favorite graph as an earlier graph recommendation in the 70% agree of the faculties. Of course, psychological readiness for return to sport is essential, 100% agree. And in young patient, less than 25 years old, hyperlaxity, high rotatory laxity, and revision cases, we may consider adding an extra-articular lateral genodesic to the ACL reconstruction for a better return to sport, 100% agree. In this paper, it was the UEFA of the Europe soccer player, said that the return to playing time for soccer is 200, more or less, 100 days. It is different. In this paper, you have the time is now the indication for a return to sport, no? Of course. Thank you very much. I don't know if you have some questions in the auditor. We have one. Yes, Guillermo. Does anybody of you preserve any type of remaining tissue as a remaining bundle when you reconstruct an ACL in professional athletes? Very good question. Guillermo, it's a very good point. We love to retain some fibers of the ACL. It's easier when you use hamstrings, and it's more difficult when you use BTB. But we try to do that because we think that have more vascularization and proprioception after that. We try to do that. I think that you must differ if the band is functionally or it's not functionally. It's functionally the band, you must return that band, and then you perform an augmentation of that ACL reconstruction. Of course, it's very difficult with BTB and quad. It's more easy with hamstring tendon or autograft or whatever. On the other hand, if the band is not functionally, you can keep again because I think it's more easy for the surgery because you don't remove the band. If it's not in the place where you will go to perform your channel, I think it's better. I remember 10, 20 years ago that we clean all the notch, the knee. We saw the bone, and now it's not that. We only clean to show the anatomical mass to perform our acute channels. If you have some tissue that don't bother you in your channel, keep that tissue. Okay. I am relieved. Sorry. No, I am relieved. Another question? Yes. So, a tool for our cleaning clinic. Who is doing formal ALLs versus doing just a modified lumbar LET? What's your reasoning for doing one technique versus the other? We prefer modified lumbar. In our hands, we don't always have an allograft. So, this is our first choice. We prefer the lumbar modified with a fascia lata. Idiot lumbar band. Huh? Yeah, idiot lumbar band. Idiot lumbar band. Sorry. And put it in the LCL. Fixed with a screw in the young patient with the ankle, whatever. And I have, in revision, I put the anterolateral reconstruction with allograft if my lumbar fails. Another? Yes. We use LET augmentation, and in young patients with feces open, we use anal cocker without implant. Okay. Yes. I also use modified lumbar or anal cocker. I prefer more than ALL reconstruction, extraticular tenodesis, because there's some discussion about the overconstriction of the lateral femorotibial compartment. There's no, like, long-term studies that can show how much overconstruction are we having with ALL reconstruction. So, with the evidence that we have now, I prefer, like, extraticular tenodesis more than ALL reconstruction. Guillermo? I have the same criterion. I think it is, we have a high risk of high constriction, for the reason I use lumbar modified with tenodesis. I think that there are some papers that say that the extraticular tenodesis have overconstriction of the knee, but this is all papers, because in the past, never diagnosis a root of the meniscus. The reconstruction is no anatomic, and perhaps in the patient have meniscectomy, but the papers, the actual paper now say that no overconstriction if you perform the extraticular technique with in 30 or 10 degrees of extension, and in the neural rotation, no internal and external. It's very important to not constrain the lateral compartment. Sonny Cotet, that performed 94% of all his ACL reconstruction with extraticular tenodesis, said that he fixed in extension, 5 or 10 degrees of extension, not in 30 degrees, that is the papers told us. Okay, some more questions? How do you perform open site with double buttons? You show that you use a screw. No, the hamstring with two buttons, the quad, no, with interference screw in the femur, and yes, cortical fixation in the tibia. No, no. No, sometimes for revision, sometimes for revision, because we can make the tunnel from inside to outside. Of course, with a patient with open physis, of course, you would double endobotony under the physis. Okay, thank you very much for this Sunday, the last talk. Thank you very much for being here.

ACL surgery

professional soccer players

graft options

returning to sport

preventive programs