We've got about 12 minutes to go through some cases. Can we get the cases up? And we've also lost a couple of our panelists, so I'm going to just get, use captain's prerogative here, I'm gonna get Laurie to come up. And Julian, can you come up on the stage? On the panel? You've been called off the bench. We lost a couple of our panelists. So there should be some case presentations, if we can have those loaded, please. Laurie comes to the next team. Hey, how you doing? So thanks to all the speakers for keeping on time to allow us to do some case presentations. You know, while they're loading it up, could I ask down the panel, what's your number one graft, just for the audience? All comers, if you had to pick today to do an ACL, what would you do? I choose according to the patient. So I've got no favorite, but I use autograft because allograft is the work of the devil. That's not an answer. Keep going, keep going. Under 25 pivoting athletes, quads, tendons, soft tissue. Other ones, hamstring. Hamstring, okay. Quadriceps and patella tendon, both sometimes hamstring, but only with LAT. VTB. Quad auto. Can I ask a follow-up after we get our last answer? 60% hamstring, 40% quads. If it's your knee, what graft do you want? I don't need one, I'm too old. Nowadays, I'd have hamstring, I think. Hamstring. I'd probably have hamstring. In my old age, yeah. But patella tendon's the best graft. I mean, it's obvious. I mean, it's two bone blocks, it's got natural soft tissue attached to the bone. Why would you want anything else? Except maybe it comes at a price. Volker, what about you? I'm a Julian, I'm a swimmer, I'm a cyclist. I don't think I need it. If I do need it, it's an allograft, clearly, because I'm old. Summer? Well, back in my college soccer playing days, VTB. But now, I try to avoid it or allograft, yeah. Okay. Okay. Well, that's a good little warmup for this discussion. You may have answered some of the questions already. So, these are our panelists, expert group that's going to tell us everything they know about ACL reconstruction in the next 10 minutes. So, I've got a couple of primary cases, and Rachel's got a revision case. So, we'll go through them fairly quickly for the purposes of getting through them. So, and I also want to take this opportunity, being Issacoss AOSSM combined, to introduce some additional sports that you may not be so familiar with. So, this is rugby league, which is sort of somewhere between rugby and NFL. Sort of like NFL without the pads. So, this is a player. These are my patients. He's running with the ball now, and he's just torn his ACL. And as they often do, they clutch the lateral side of their knee. And we'll get a video of that. So, he's a 21-year-old. He's never had any problems with his knee before. This is his injury here. So, it's when he finally steps off that leg, and then it goes. So, he's turned up with a big swollen knee. It's stiff. He's got a positive lock. His other ligaments are stable, and his alignment is neutral. This is his ACL rupture. He's got quite a large lesion on his lateral femoral condyle from the impaction. You can just see he's pretty much destroyed the posterior horn of his lateral meniscus, and he's got chondral lesions on the medial femoral condyle. So, as a treating surgeon and a professional athlete, these are the worst ones, because you're sort of hoping for an isolated ACL, and you've got about four or five problems in each. So, the discussion points, and we can go from Andy across. How do you time your surgery, Andy? And if everybody else, feel free to say the same, unless you've got a different answer. So, as soon as the knee is quiet, that means to me swelling is going down. He's got full active, as well as passive extension, and he's flexing to at least 90 degrees off of surgery, and obviously my practice is largely pro sport, and there's a lot of pressure to get on with it, quote, unquote, but you have to be strong, and if the knee isn't coming straight, do not agree to do surgery. Any disagreement? Anybody gonna rush in and do it tomorrow, because the coach is telling you to do it? I think the worst case scenario is the athlete that imposes on you. We all know that, but if somebody comes in, and they want it done the next day, and you think they're not ready, you need to be strong. Okay, so we've got a consensus on that one. Okay, so we're gonna go. Dave, I like to say to the patient, when they're sitting there in the holding bay, they should feel like they don't need the operation. You know, they're walking, they're off crutches, they can ride a stationary bike, this sort of guy, and I think with professional athletes, we all have that same sort of experience, but if you can get them out of the media for the first week or so, then they've been forgotten, there's another story that's come by. So waiting is good. Yeah, okay. So which graft are you gonna use, and how are you gonna fix it? Maybe we'll come backwards from Julian this time. Well, certainly in my own practice, that patient's gonna come in and say, I want a quads tendon, I want that thing on the lateral side as well. That'll be quads and lateral tenodasis. Okay, Geronimo Fashimi, you're doing quads? Yeah, I do quad, and there may be a next question, but I would give it LAT, big sulcus on the femur, big pivot, maybe some meniscal loss, high-level athlete. Okay, Summer? Yeah, I think either BTB auto or quad plus the LAT. The thing I was gonna mention is on that sagittal MRI, and I was gonna ask Andy what he thought. There's ever so slightly some anterior tibial subluxation, and I wonder if that, you know, by you much smarter people would study it and think, you know, on the first time, you know, injury, if that's a reason that you should consider adding an LAT. Okay, that's the next question. Okay. Volker? I think the key is that you fix that posterior horn of the lateral meniscus, you may get some stiffness, but you gotta fix that meniscus, otherwise the joint just go on haywire. Now, I have two indications currently to do LAT. If you wanna take your pens out, it's number one indication is stability two trial, and it's really, really, really hard to randomize a patient into any type of study, so that's indication number one. Indication number two is the resident in the room has never seen it. Laurie? Quick answer, which graft are you using? Quad's tendon. Quad's tendon, Andy? Patellar tendon is the best graft, and the tenodesis. Okay, so he's getting a BTB for it? Inert repair of the lateral meniscus. I wouldn't touch the chondral damage. Now, I was going to get a laser pointer and get you all to point where you're gonna put your tunnels, but maybe I'll get Andy. Just on the theme and the TV, where are you gonna put your tunnel? So, we've published on this, and when I moved from the AM bundle position to the center, the so-called anatomic position, I had more than doubled my re-rupture rate, and with hamstrings and professional athletes, went up to nearly 20%. It was a disaster, whereas nowadays, if I do a patellar tendon in the AM bundle position and add a tenodesis in pro soccer, I got a 2% re-rupture rate, so it's gotta be AM bundle, and you gotta choose the right graft, and you gotta add a tenodesis as well. So, we haven't got much time, so if everybody could tell us where they're gonna put it, it'd be a little less verbose than Andy, please. That's impossible. Where are you gonna put it, Laurie? Just in front of where Andy did, so I sort of split the difference between the middle and the AM bundle. Is everybody going AM? Anybody not going AM? The reason you should go AM is this, and so please follow this. If you're going down too far low, you automatically also are going to anterior. If you're going to anterior, it's gonna be tight inflection and either rupture or be forever stiff. Okay, so the answer to the question is yes, Volker's going AM as well. Everybody's going AM, okay. And I think we've already talked about supplementary procedures, so for whatever graft you, is everybody doing an LET here? Professional athlete, doesn't wanna have a re-injury. Is anybody not doing LET? No. Okay, good. So, this is what you got. B-T-B with screws, tenodesis, where he did repair his lateral meniscus and he had those nasty chondral lesions as well. So, I'm gonna quickly do this one. The only difference with this one is a 20-year-old female, so another professional athlete, she's about to tear ACL landing from a jump in a sport known as Australian Rules Football. So, in order to save time, she presents pretty much the same isolated ACL. So, she doesn't have the additional pathology that this other guy had. So, what I wanna know is, is anybody doing anything different because we have a female athlete here? Answers all the same? So, I've got a lot of experience with this patient group. Australian Rules Football, the home of the sport is Melbourne, which is where I'm from. AFLW has become an enormous sport. It's taken over from a lot of the other traditional sports played by young women. And when you ask why, they just say because it's fun. But they have a very high rate of ACL rupture. And I started off using the same logic, quads tendon plus lateral tenodesis. I'm not sure. I've got a feeling that, for some reason, this group may be better suited to hamstring plus lateral tenodesis. And it's just very much embryonic in my thinking, but we need to go back and look at some of our results because I've seen problems with them regaining their extension when they have the combination of quads and lateral tenodesis. And if I could just add one other point about indications for lateral tenodesis, we haven't really heard much mention of family history of ACL injury. A positive family history is a significant risk factor. It increases your graft rupture rate by two times, 2.5 times, so pretty significant. Okay, we'll zip through this last case. So this is a revision. Professional soccer player. So for the non-American physicians in the room, soccer is football. Football is soccer. He sustained an acute non-contact injury. He's in the preseason. And he's had a history of, on that same knee, an ACL with BTB auto performed in another country. And he's had a medial meniscus repair. He comes in with an ACL knee and some medial joint line pain. These are his x-rays. We can all agree that there are some things we might change about these x-rays if we could. But what I'm hoping you notice is his slope in addition to his tunnel position on the femur, tunnel position on the tibia. So diagnostic imaging, again, for the sake of time, he's got a bucket handle medial. He's got a complex posterior horn lateral, pivot shift bone bruise pattern, no ACL graft left. And so this is our problem list. Recurrent ACL tear with elevated slope, somewhat dilated tibial tunnel, recurrent bucket handle medial meniscus tear, complex posterior horn lateral meniscus tear. And he's a professional soccer player in a contract year. So considerations. We're gonna do revision. Let's go down the panel. Let's start with Andy. Single stage or two stage? And what's your graft choice? Almost always single stage. We published on it. And the need for two stage is a reflex for many people. And it's just not necessary. Graft choice, I'd use patella tendon. From the other knee? Yeah. What if he says no thanks? If that case, I would go to a quad tendon. I'd measure up the length and make sure the length was compatible. Otherwise, hamstrings, but likely quad tendon with the tenodesis. Okay. Does anyone on the panel have a different choice? I'm gonna start with quad tendon, not go to his other knee. And then is anyone pulling the trigger on an HTO? Volker, 14.2 is what I measured on that AP or lateral of the knee. Only if he says I'm done with my career and just go ahead and fix me and I wanna be a dad to a family and all this. But I think there's so many things wrong with this case that you have a very, very good chance in helping this guy out. Is everyone adding a lateral augmentation procedure? If you're putting in an LET, can you put your hand up? LET. LET. Is anyone doing an ALL? Audience, LET. What's that? Is anyone doing an ALL? Okay, very interesting. So we went for a single stage. Here's his knee pathology. You can see the bucket handle medial. You'll see that. You can see some ACL unhappy graft. And then you can see this lateral meniscus tear that actually had a horizontal component as well behind. We reduced the bucket. We go ahead and fix the medial meniscus with a hybrid technique using mostly inside-out sutures in vertical mattress fashion, both above and below the meniscus. And then we place an all-inside suture fixation device in the most posterior aspect. This is actually a little bit more difficult than I had hoped for because it was a revision scenario. So the tissue wasn't quite as strong as we'd like. We fixed the lateral side as well. And then we go ahead and remove his screw. I'm neurotic, so I put in a bone dowel after removing the screw, just so I had safe circumferential bone to drill my new tunnel. I like to go low, but not create a killer turn. We drill our new low tunnel. We go through an intermedial portal with the knee hyperflexed, and we do a quad ACL all soft tissue revision on the same knee. And then I like to do a modified Lemaire as well using the technique that was described by Andy, just a different anchor. But we go ahead and pass that through. And again, I think the key here is this is the suspenders. The ACL is the belt. The ACL is holding the pants up. This is the suspenders. Don't over-constrain, don't over-tighten, but you could use an anchor, proximal and posterior, and you can aim that away from your ACL tunnel. Variety of different options here, but I've gone to using a suture anchor to avoid any potential convergence with the ACL femoral tunnel. Any comments from the panel as we close up this session? Nice job. Okay, thank you all very much. I'd like to thank all the speakers. We'll move on to the next session. Thank you.

ACL reconstruction

surgery timing

graft choice

patient readiness

case scenarios