Yeah, so if the speakers of the next session could come up and have a seat right here at the table. So, I'm Volker Muser, I'm here with Bonnie Gregory, and we're going to be hosting the session on ACL, the most important thing in the world, so it'll be fun. We have three papers this morning. Yeah, Bonnie. Yeah, first off, we have Dr. Bhargavi Maheshwar from Case Western talking to us a little bit about predictors of ACL ligament re-tear and return to sport in our adolescent athletes. Thank you. Good morning. My name is Bhargavi Maheshwar. I'm a resident at Case Western, and today I'll be talking about predictors of ACL re-injury and return to sport in our adolescent athletes. On myself, my co-authors have no disclosures relevant to this talk. So, ACL injuries are rapidly increasing in the adolescent population with a very high incidence in this age group, largely due to earlier participation in sports at a higher intensity as well as increased injury awareness. However, this can have a devastating impact on future athlete performance, as up to 14% of our young athletes with ACL tears do not return to sport. This is important because the demographics and variables associated with ACL injury remain largely unknown, and the risk for secondary ACL injury is often greatest in the early return to sport period. There's an overall lack of literature investigating the type of sport played as well as the mechanism of injury in primary and recurring ACL tears, as well as the surgical management amongst high school athletes. As such, the purpose of our study is to characterize the epidemiologic trends of ACL injuries and secondary tear rates in high school athletes, as well as to determine the variables associated with sustaining a secondary ACL injury, which we defined as a contralateral ACL tear or a primary ACL graft failure. So we took a prospective database over the course of five years and looked at various demographic variables, including age, fissile status, sex, race, body mass index, as well as school grade, and looked at various sport and surgical variables, including primary sport, mechanism of injury, and if patients did have a secondary ACL injury, graft type, time to return to sport, number of physical therapy visits, as well as duration of follow-up. So we took patients from the ages of 13 to 18 years with an ACL injury and had 431 patients who were participating in high school sporting activities. And with 344 patients not having a secondary ACL injury and 87 patients who did have a secondary ACL injury that was further broken down into graft failure and contralateral ACL injury. And when looking at the breakdown of the sports played by these athletes, we found that football, basketball, and soccer were the three most commonly played sports. And looking at our cohort as a whole, we found that patients with a secondary ACL injury were significantly younger in age. And patients with a primary graft failure had an overall less number of physical therapy visits, as well as a 14-month timeframe from their primary ACL reconstruction to their primary graft failure. And when looking at the contralateral ACL injury subgroup, we saw that there was 19 months from their index ACL reconstruction to their contralateral ACL injury. And when looking at graft failures in the contralateral ACL injury subgroups together, we saw that there was no significant difference in sex, BMI, sport played, time to return to sport, as well as the graft type used in their primary reconstruction. And most importantly, after adjusting for all variables, we found that age at the time of the primary ACL reconstruction, as well as the time to return to sport, were associated with an increased rate of primary ACL graft failure, as well as an increased rate of contralateral ACL injury. And as age at primary ACL reconstruction increased by one year, we saw that there was a rate of secondary ACL injuries decreasing by 29%. And for every one-month delay in return to sport, the rate of secondary ACL injury decreased by 17%. Thus, a younger age at the time of primary ACL reconstruction, as well as a shorter time to return to sport, were associated with an increased rate of secondary ACL injury. Some limitations of our study is that this is a single institution study, and our results may not be applicable to other institutions across the country. And there are differences in level of play in this patient population, which ultimately contribute to the heterogeneity of their makeup, with varsity and junior varsity and freshman play making up part of that. As well as the documentation of physical therapy did vary for patients, as some patients did complete their physical therapy at outside institutions that were not documented in our system. So in conclusion, younger age and decreased time to return to sport following index ACL injury were significantly associated with sustaining a secondary injury in the pediatric population. And this is important for the counseling of young adolescent athletes, as well as their parents and guardians, to allow for adequate rehabilitation and the time to return to sport. And for us, further steps included the needing to determine and optimize development of specific return to sport protocols and timelines applicable for this very unique patient population. Thank you. Very nice presentation. Very important topic. The next presentation is from the Santee Clinic, Bertrand Sanoicote, and he's going to talk about osteoarthritis after ACL and ALL, or not. Can you put the lectures? Thank you again for your kind invitation. Let me present the radiographic incidence of near osteoarthritis after combined ACL and ILL reconstruction. This is my disclosure. It is now more than 10 years that the articles of Stephen Kleiss was published in the Journal of Anatomy showing the controversial new ligaments, the anterolateral ligaments. We published the first clinical study in 2015 and there were a lot of controversy pro or cons these structures and the existence of these ligaments. When you look at the history, we can say that probably mostly in the U.S. the lateral extracellular reconstruction was abandoned in the U.S. following the Snowmass meeting in 1999. But since these last 10 years, I would say that the paper from the Stability Group and from the Santee Group clearly showed that when you had a lateral extra-articular reconstruction, ILL or LOMIR, you reduced the graft future rate by an average of 50%. However, there is a lot of question about the risk of over-constraint, which is for me mostly a cadaveric laboratory word, which doesn't mean osteoarthritis. But we have to assess the osteoarthritis and the risk of over-constraint lateral compartment due to this extra-articular reconstruction. So the objective of the study was to compare the prevalence of knee osteoarthritis 10 years after an ACL reconstruction. We compared two groups, combined ACL and ILL reconstruction versus isolated ACL using Armstrong or BTB graft. We matched the two groups based on seven different criteria, age, meniscal statute, cartilage, time between injury to surgery, bio-MRI, pre-aplexity, and type of sports. We evaluated this population with three different methods for the assessment of the osteoarthritis. The surface fit method, the EKDC radiological graft, and the Kehlgren-Lawrence. And for all the population, we compared the operated versus the L-C knee. And we compared the tibiofemoral joint, but also the paterofemoral joint for both populations. The mean follow-up was almost nine years with 42 patients with combined ACL and ILL, and 68 patients with Armstrong and BTB. We found no difference in terms of problems, and we had a rate of secondary meniscectomy similar in both groups. We finally found no difference in terms of osteoarthritis regarding the tibiofemoral joint. It means that we don't observe any lateral narrowing in the group of ILL reconstruction. However, we found that when you have lateral meniscus injury, whatever the repair or the meniscectomy you have done, you have almost five times more risk of narrowing on the lateral side. So lateral meniscus injury is a high risk of narrowing your space in 10 years. Also, and it was a strange discovery for us, we also discovered that there is a risk of paterofemoral narrowing in the BTB group with an average of five. We observed 66% of paterofemoral narrowing in the BTB group compared to 12% in the Armstrong group. In conclusion, the ILL does not increase the risk of osteoarthritis, which is good news. The lateral meniscal lesion increased the risk of narrowing by an average of five, but also the BTB graph increased the risk of paterofemoral joints narrowing, and probably we could extend and we have to be really careful with the use of quad tendon because it could be one of the issues in the future as well. So in conclusion, once again, it's important for the SONCTI group to think outside the notch. Thank you. Thank you, Bertrand. Nice presentation. The next presentation will be given by Leith Basravi from NYU, and we're going to be talking about the posterior tibial slope, period. Thanks, Volker. Thanks to Dr. Sharif, who's really the driving force behind this project. No relevant disclosures. We know that an increased posterior tibial slope is a risk factor for primary anterior cruciate ligament tear and graft failure. PTS can be measured on different imaging modalities, including knee x-ray, CT scan, and MRI. And typically on knee x-rays, the posterior tibial slope greater than 12 degrees has been associated with around a five-fold increase for ACL injury. On MRI, there are also measurements, and the posterior tibial slope cutoff value for an increase of ACL injury typically reported is between about five and seven degrees. Posterior tibial slope, unfortunately, has not been well-defined in those who have experienced bilateral ACL tears. And so the purpose of this current study was to compare posterior tibial slope between patients who have undergone bilateral ACL reconstructions versus unilateral ACL reconstructions. We also looked at whether there was an association between x-ray and MRI slope measurements. We did a retrospective review from our institution between 2012 and 2020. We were able to match 53 patients with bilateral ACL reconstructions with 53 patients with unilateral ones. And these were matched based on age, sex, and BMI. Patients who had undergone a unilateral ACL reconstruction within less than five-year follow-up were excluded to make certain that they didn't tear their contralateral ACL. We had three blinded reviewers who measured the posterior tibial slope on lateral radiographs and also the medial posterior tibial slope and lateral posterior tibial slope on MRI. We used the classic measurement described in the literature with the circle technique on the lateral knee radiograph. And then for MRI, we used the notch shot where we used the circle technique and then translated over to both the medial and lateral compartments to measure the slope there. Here are the demographics. Very similar for both patients. No significant differences in terms of sex, age, and BMI. We also did an inter-rater reliability amongst the three people who measured the radiographs and the MRIs. And we did an inter-class correlation coefficient and it indicated good inter-rater agreement for MRI measurements and lateral radiograph measurements with all the readers. So when you break down the data, the two things that came out that were statistically significant with patients with posterior tibial slope greater than 12 degrees, that there were many more in the bilateral ACL group, about two and a half times more compared to the unilateral ACL group. And while the average MRI results were small, there was also a statistically significant difference with an increase in the average for bilateral compared to unilateral. When you look at it broken down in a chart, again, posterior tibial slope greater than 12 degree frequency, 41% in the bilateral ACL reconstructed group versus about 13% in the unilateral group. And then when you looked at those measurements on MRI with the slope greater than 7 degrees, again, for the lateral slope, it was significant in terms of more in the about 53% in the bilateral group versus about 32% in the unilateral group. And while this trend was there for the medial slope on the MRIs, it didn't reach statistical significance between the two groups. And again, these are just the way when we looked at comparing MRI versus the radiographs, what we found that when you're utilizing these two modalities, there's really weak to negligible correlation between radiographs and MRI measurements. So the bottom line, if you're going to pick one method, you got to use one and not both because there's poor correlation. In the literature, it's challenging when you look at posterior tibial slope measurements. A lot of studies in LePrad's study doing a meta and systematic review showed numerous studies looking at MRI as the main measurement, then radiographs, and even then CT. And some of the studies also combined all these measurements to get an average, which is, you know, challenging to interpret. The limitations of our study was retrospective, small cohort, relatively, but still large enough to get statistical significance. And we didn't control for other obvious ACL risk factors like femoral notch width, coronal and coronal malalignment. So in conclusion, patients with bilateral ACL tears have about a two and a half time greater rate of posterior tibial slope, greater than 12 degrees compared to unilateral ACL reconstructive patients. PTS measurements on radiographs demonstrated a weak to negligible correlation with posterior tibial slope measurements on MRI. The lack of standardization among posterior tibial slope measurements will continue to complicate the PTS-ACL association and other associated pathologies, and future research should focus on determining the most accurate measurement for posterior tibial slope. Thank you. So we have a few minutes for questions. And Bertrand, you know, years ago, we had the ALL consensus meeting in London, a quite heated debate. We talked a lot about the term over-constrained. And then last week, we were at the ACL study group, and Andy Williams, also a few years ago, asked that we please put to bed the word over-constrained. So your data showing that really there isn't an increased OA rate after ALL and ACL reconstruction, is this discussion over with over-constrained? What's your perspective? For me, yes, definitely. I mean, it was a little bit confused for me. I don't understand how you can link the over-constrained in cadaveric study to osteoarthritis. And I think we demonstrate that it's wrong. I mean, what he was demonstrating in robotic study is not clearly validated in a long-term clinical study, which is good. Very nice. Kurt Spindler? Right there. No. Over here? Thank you. For the first author on the adolescent ACL, a point of clarification, you mentioned younger patients having a higher risk of re-tear, but I was confused if you were referencing the time of the reconstruction versus just the age of the patient. And I was also curious, when you talked about the older patients not having as many re-tears, was there a correlation? Or did you see in your study a correlation between those older patients and a decrease in their return to the same level of sporting activity? In other words, maybe the younger ones are more likely to want to continue to try to play their sport at 14 versus an 18-year-old. Thank you. Thank you. For the first part of the question, so it's younger age at the time of their primary ACL is associated kind of with the increased rate of a secondary ACL injury. And then looking at our older patient cohort, that is something that really does contribute to the heterogeneity of this group, that at that age of 17, 18, there's a small subset that are going on to collegiate sports and even more competitive sports, but a large majority do not kind of go on and continue to that same level of competitive play, which does play a part in that. Okay. Next question. Kurt Spindler, please. I enjoyed the talk on posterior slope, and I actually enjoyed very much your iterator agreement and your struggles in trying to measure that. So we've also had the same issues when we've looked at it ourselves trying to get, do you have recommendations about how going forward, how we could standardize it and what we should use? Yeah. I think the, going through these measurements, the easiest way to measure it is probably on a long leg lateral tibial graph. So we're going to, our next study that's coming out, it's going to be published, showed that the more tibia you get on the lateral radiographs with the circle technique is probably the most accurate way. Now with that being said, I think a lot of us are doing CAT scans now, especially with these PSI instrumentation for osteotomies. And to me, that's probably, CAT scan is probably going to be the most accurate way to determine posterior tibial slope. Thank you. One more question. Andy Williams. Bertrand, as you know, I'm a big fan of lateral surgery with ACL and do it in almost every case. Going back to your previous talk, my brain does work slowly. How do you think that an anterolateral procedure protects the ramp repair because it controls anterior translation of a lateral compartment, not necessarily the medial? I really don't know. We were surprised when we observed that. I think it's probably rotational control. I don't know if it's the translation, but mostly we said the rotation. But all the study we have done on ramp, it's very significant when you had a lateral extratertial reconstruction to protect your medial meniscus repair. Very interesting. Thanks. All right. Thank you very much. Thank the three speakers. It's my pleasure now to introduce my chair, boss, and mentor, Dr. Walter Lowe, to talk to us a little bit more about his experience with slope-leveling osteotomy in both the primary and the revision setting. Great. Thanks, Bonnie. I hope I can figure out how this thing works here. So this is pretty straightforward. Just our clinical outcomes following ACL reconstruction with the slope-reducing osteotomy in a highly athletic population. The reason we took this on was sort of the dogma out there that once we started addressing slope operatively, it was the end stage of an athletic career. I really wanted to ask that question. I think the talks today have been great. How does this go forward? So you've heard a bunch of good talks this morning. We know that slope negatively affects our ACL reconstructions. And certainly, like you heard in the previous talk, a slope above 12 has about a 5.7% incidence of increasing re-injury to it. So the purpose here, like I said, was just to compare the functional performance and the graft re-injury rates in a mass control study between patients undergoing ACL reconstruction surgery basically with and without a slope-reducing osteotomy. Our outcome measures were your typical return-to-play measurements, just like we would return any primary ACL in both groups of these patients. So if we look at the demographics, they were matched for age, gender, height, weight, BMI, pre-injury activity level from a MARCS. So when we looked at the surgical demographics of it, almost all of these were revision ACLs, but not all of them. The pre-optibial slope in the ACL group was average 17 degrees, while it was 10 in the isolated ACL group. Our post-op change was fairly significant, where we measured about a 7 in the slope-reducing osteotomy group and obviously stayed the same. The osteotomies, for the most part, were uniplanar, but, you know, several or almost half were biplanar osteotomies, which definitely changed a lot of things about this. The graft choice, as you can see, varied based on, since most were revision on their previous graft choice, and the fact that I was nervous early on because all of these osteotomies we did were infratubrical osteotomies and harvesting a patellar tendon graft and doing an infratubrical slope-producing osteotomy at the same time. In the slope-producing osteotomy group, over half were staged procedures. So when we look at the initial return-to-sport outcomes, they were a little scary to me, and the point of this is they didn't match what I was seeing in follow-up and clinic. And so the two things that were statistically significant in these was the time to return-to-sport was significantly longer in the osteotomy group versus the isolated group, and the ACLS-RSI was pretty significantly worse in that same group. The problem for me is that really didn't match what I was seeing, so I asked our researchers to dig a little deeper, and indeed where the difference was found between these two groups, if we could address this in a single-stage procedure, then our outcomes in return to sport actually weren't much different from an isolated ACL alone, and that's what I was seeing in the clinic. The MARC scores definitely were much higher in a single-stage procedure versus a staged procedure, and the RSI the same. A two-stage procedure essentially crushed their confidence on return to sport, so I really think that's probably the most important part of this talk right here. When we looked at all of the other assessment outcomes, these two groups were pretty much equal and certainly not statistically different. So in summary, there was lower psychological readiness, longer time to return to sport, no real difference in objective functional performance or in graft failure rates or complication rates, but this, you know, I think we just need to look closer at how we have to accomplish this. Does this video play? I don't believe, yeah, it does. So this was our first patient, both a Canadian national team player and a Division I soccer player, and this is after her two-time failed ACL slope of almost 20, giant lateral meniscus tear, and this is about 10 months out from her procedure, but when you watch her functionally, you really can't even tell which leg, you know, she had. And so, you know, I think what I took away from this is that a slope-reducing osteotomy to help reduce the risk of a secondary failure in a revision setting, and we can discuss more a primary setting, is not the end to an athletic career. And looking at the functional performance of these athletes from sports metrics data, which there wasn't time to do in this talk, they're virtually identical, especially in the college players where we have all that data ahead of time. Their return to sport, their functional performance, all of those things are basically identical once you've been through the recovery period around that nine months. So I want to thank you. Thank you for this really great presentation. And while we get up the next video for Brian Lau, can you, Walt, just give us an idea on your primary ACL patients, like going forward, you can't unsee the slope once you see these numbers, 18 degrees, like how many, like you see doing this in primary cases quite commonly? Well, the more interested I become in slope, the less I know about it, for sure, you know. And I think we, you know, we have to embrace the reality of what we do. And it's easy to ignore slope for the primary because we have a lot of people who've had primary ACLs with bad slope that probably survived over the long haul. And we really don't know. There's a, you know, a plethora of papers here already starting to dissect out what's there. But I have a slope-reducing osteotomy discussion, if we're giving a simple answer, if I see 16 or 17 degrees in a primary patient. And now we have about seven of those out that I don't know if I'm glad we did it or not, but, you know, so far so good is the most scientific thing you can say. Great. It will be fun to hear in the next couple of years how they do. Thank you. So the next speaker is Brian Lau from Duke, and he's going to show us the technique. Brian. Thanks. Thanks, everyone, for being here. Thanks to the committee for letting us speak about this. And so this is posterior slope-reducing osteotomy. It's our technique. It's, you know, to give credit where credit is due is Dr. Amendola's technique, which we've adopted at Duke and has been using. So we'll highlight that. So as we all know, ACLs are very, very common. We do a lot of them, as everyone in this room probably does many, many of these a year. But there are still a fair amount that fail, and I was trying to understand why those fail. And there's many reasons why they fail. And today we're going to focus on one thing, which is the alignment. So you still make sure when someone fails, you're considering all these different factors, but make sure you're considering this as well. And we speak of alignment, as we've been highlighting the last couple of talks here, is that we're looking at the sagittal as well as the coronal alignment, too. So there's two parts to that. Where does this slope-reducing, so the origin is actually from the canine population and our veterinarian population, but they called it tibial plateau leveling osteotomy, or TPLO, and it's still used today in our canine population. For Dr. Amendola, where he first learned about this, you talk to him, he'll say he learned this on his traveling fellowship when he was in Europe, in Lyon, this is where he first saw it, and where he's modified that technique. And it's been highlighted again by multiple talks here, you know, posterior slope is becoming increasingly understood as a risk factor for failure. In this study here, looking at age as well as slope together being a highest risk factor. And on the right here, the biomechanical data showing that reducing the slope can reduce the forces that your graft will feel as well. And then more recently even, more data, and then, you know, as was highlighted with the last couple of talks, too, more data showing the risk factors for tibial slope. There are many techniques and, you know, fixation is the main ones, you have dual plating, you have H-plating and adding TTO, and you have plate and staples, which is what we've been using and we're going to show here. So here's our case presentation, it's a 36-year-old male, active military, failed revisions, left knee in persistent pain, primary ACL in 2017 with a hamstring autograft, 2018 had a revision, autograft with a concurrent HTO for coronal alignment, and then full range of motion, grade two lock-man pivot, no collateral laxity. These are his radiographs here. We don't have full-length lateral, but this is what we have and what we've been using, he's a standard lateral measurement, he's going to have 16 degrees of sagittal slope, and then, you know, his coronal alignment kind of right at the lateral tibial spine there. I also want to highlight, if you look at his lateral there in the middle, you can see that his anterior tibia is translated anteriorly, just there on the radiograph there. So our plan was a revision ACL with allografts, we tend to prefer allografts, especially in this triple revision kind of case to decrease morbidity to the knee with the idea that the posterior slope is going to help protect that graft. Plan for diastatomy, so our approximation is one millimeter bone wedge per one degree of correction, and then we'll consider TTOs if there are larger corrections, but in this case it was about 11 degrees, and so we opted to leave the tubercle in place. So there's audio to this as well, so I'm going to play this if we can get the audio as well. Diagnostic arthroscopy is first performed on the prior ACL graft, demonstrating it to be incompetent. The previous graft tunnels are inspected and found to be somewhat shallow and high. A revised femoral tunnel is then created using an outside-in technique. A shuttle suture is then passed to the anterior medial portal. An anterior midline incision is then made over the proximal tibia. Electrocardi is used to maintain hemostasis. Next dissection is made down to the patellar tendon where the lateral, medial, and proximal borders are carefully defined. Next the intended osteotomy sites are better exposed over the medial and lateral proximal tibia with subperiosteal dissection. The intended osteotomy site is then marked, and according to preoperative templating, this case there will be a 10 degree osteotomy correction. Under fluoroscopic guidance, a medial and lateral pin are placed at the osteotomy sites. They're in line with the native tibial slope. A sagittal saw is used for medial and lateral cuts at the distal osteotomy site at the intended corrective angle to create a closing wedge osteotomy. Care is taken to preserve the native patellar tendon insertion. Osteotomes are then used to remove anterior cortical bone at the closing wedge osteotomy. Here, rongers are then used to remove any remaining anterior metapseal bone at the anterior osteotomy site. A sagittal saw is then used to remove the most anterior cortex directly behind the patellar tendon. Here fluoroscopy is used to confirm the intended closing wedge osteotomy site. Curettes and rongers are used to remove metapseal bone to the posterior cortex of the proximal tibia. The intended osteotomy is confirmed using fluoroscopy and ruler measurement. The posterior cortex of the proximal tibia is perforated gently using an osteotome to facilitate closing of the wedge osteotomy. The closing wedge osteotomy is then confirmed under fluoroscopy. Fixation of the lateral aspect of the osteotomy is achieved using a staple that is impacted in gently. The medial aspect of the osteotomy is secured using plate and screw fixation. Layers take in reserved space from the intended tibial tunnel drilling site for the ACL reconstruction. For this particular plate, the most proximal and central screw hole is left empty until the tibial tunnel is created. This screw can later be placed if there is adequate space to protect the tibial tunnel and graft. Arthroscopy is then performed and the tibial guide pin is then placed. It is over reamed to create the tibial tunnel for intended ACL reconstruction. A shaver is then used to ream remaining soft tissue restricting graft passage. The previously placed shuttling suture is then passed through the tibial tunnel. The ACL graft is then passed in a retrograde fashion into its proper position. Femoral fixation is then achieved with a cortical button and adjustable loop. After cycling in the knee and tensioning the graft, an interference screw is used to achieve tibial fixation. A staple is used to augment the fixation as a backup. Post-operative radiographs reveal interval reduction in posterior tibial slope. When a closing wedge osteotomy is planned for greater than 1 to 1.2 centimeters, one may consider tibial tubercle osteotomy with distalization after completion of slope correction osteotomy. Here, two parallel guide pins are placed across the tibial tubercle. An oscillating saw is used to create the osteotomy from a medial to lateral fashion, followed by an anterior to posterior cut. The shingle is then freed with the use of an osteotome. This allows improved visualization of the anterior tibia that may improve accuracy when creating the closing wedge osteotomy. Once the slope is corrected, the tibial tubercle shingle can be distalized and fixed using compression screws as shown here. Post-operative rehabilitation protocol includes bracing, limited weight bearing, and an initial range of motion restriction from 0 to 90 degrees during therapy. Gradual progression to functional activity occurs over the course of 16 weeks. Outcomes for similar procedures in the literature show positive clinical and functional scores with adequate reduction in the posterior slope and no need for additional ACL revision surgery. This will conclude our presentation on the technique of posterior slope-reducing osteotomy with concurrent revision anterior cruciate ligament reconstruction. Thank you. So that video, if you guys want to review on your own, it's published in VJSM, that technique. So if you want to review that. In the few minutes we have, I want to highlight a little bit about planar correction. That's a question we get a lot. This is the biomechanical data showing that correcting both varus and slope, as you might predict, is better. So how do you do that? I mean, you're going to do, this is a 34-year-old female. This is a triple revision as well, quad, hamstring, previously, autografts, wants to get back to flag football. And you can see it has a sagittal slope as well as a coronal defect of 15 degrees of slope and varus alignment. So you make your measurements as you would for a standard for HTL and what that degree would be. And then you kind of do an asymmetric correction. You're able to do that here. And I think in the future, as we get more used to the PSI, that would be a better role for that. But you can do this as well. And similar technique of that asymmetric cut here, and you can see that you can still get a correction. The difference in this one, we use a distal tibial plate. We find it has a little bit more flexibility, so we've kind of evolved a little bit since that last video. The screw's a little bit smaller, but gives you a little more flexibility in order to pass your graft at the same time. And this is just showing the corrections of that. And then so just this is kind of unpublished data, but of our Duke group here, of all of our knee surgeons, we've had about 22 since 2018, showing that correction in 15 to 6 degrees. We've had one re-tear and a couple symptomatic hardware, but overall good results, again still early though. VES scores are improved as well as their PRO scores. So in summary, it's necessary for you to look at slope. It's been highlighted here. I think that's very well. That's the last couple of talks. Slope greater than 12 in a revision setting may be a need for correction of this. Opening wedge can be a possibility if you want to incorporate for HTL with smaller corrections, but closing wedge is really going to be a bigger one for the biplanar correction and bigger corrections. Thanks. Thanks, Brian. While the rest of our panel's coming up, you mentioned with the case you presented that they had had a prior HTL. Do you think that contributed to their increased tibial slope? It's possible. So I think as everyone who does a lot of our studies, you have to be very careful of not changing that slope, and so it's a possibility, definitely. We have another minute or so, so if there are burning questions, please come up. It was brought up in the last session. We talked about posterior tibial slope. We also talked about lateral extra-articular tenodesis. Do you think there's a role in those patients somewhere, tibial slope between 12 and 15 they present to you primarily, and where you would do an extra-articular tenodesis to kind of take some stress off the graft? Yeah. I'd say that's... Both of you. Both of you. Go ahead. I'd say for me, I would probably do a lateral articulation for that. I think Dr. Lo was talking about doing some primary slope reductions, but for me, I'd probably add an LAT. So you know, the question is, does a lateral procedure change the forces in the ACL graft? There's been some pretty good presentations here that say yes, maybe to some degree. The published paper last year right after the Colorado Springs meeting said not much at all, slope angle. So I really think it's a question we need to answer. Philosophically, if you want to change high slope forces, you should change slope, right? I mean, that just makes sense. If you have big rotational issues, you know, all the interlateral rotatory stuff, the hyperextension stuff, the high Baton score people, well, you know, the lateral procedures definitely protect from that rotation. So I think that we have to consider them independently in the menu that we're doing. And so the answer is, I don't think we should be afraid to do both. Thanks. Walt, can I ask you a quick question? I enjoyed your talk, but as you're going through, in the beginning, I saw 1,900 ACL reconstructions and 23 you had done in slope osteotomy. Can we assume that that's the frequency of doing it so we have an idea of what we see in practice or not? No. I think it's the, you know, I don't think the frequency is high. I think it is a recognition of not being afraid to address slopes starting three years ago. And so those 1,900 were more than that. You know, I think if I had to throw out a number, and I hate to throw out numbers to you because you'll prove me wrong down the line, but, you know, to me, a discussion of slope-reducing osteotomy probably happens in my practice almost half the time. And the actuality of doing a slope-reducing osteotomy is probably 2 or 3 percent of the people I see. Half the time in revisions? In revisions? Yes. Yeah. Good. Well, I just want to get perspective from the folks there. And you have as much experience as anyone. Thank you. Yeah. Yeah. Great. Now, that's a great discussion. And I think this topic is here to stay for a little while longer. Who in the room, for a show of hands, is doing slope-reducing osteotomies in revisions? There's a few people. Every year, the number gets a little higher. So very good. So now I have the distinct pleasure to run a panel discussion with a really superstar crew. So we have Brian Lau from Duke. We have Bonnie Gregory from UT Houston. We have Aaron Critch from Mayo Clinic, Walt Lowe from UT Houston, and then Mr. Andy Williams from London in England. You're the only European here. I hope you're okay with that. What about you, Volker? I can be both, whichever you want me to. Swinging both ways. So I have three cases picked out for you guys. So let's take a look. So this is a very typical case. So this is a 60-year-old woman. She's in her mid-20s. She's in her mid-30s. She's in her mid-40s. three cases picked out for you guys. So let's let's take a look. So this is a very typical case. So this is a 16-year-old high school football player. Andy, this is quarterback. So okay, number 10. Okay, I'm struggling now. So he sees you six days after non-contact pivoting injury. He was the ball carrier. Dangerous thing to do. Presents a pain and instability. The range of motion is still decreased because it's only six days old. But there's a positive. Lahman cannot get a pivot shift. He does have a 2 plus valgus at 30 degrees and a 1 plus valgus at zero. He has slight varus standing alignment, as you saw in the photo. And his MRI shows on the right that he has a tibial-sided grade 3 MCL, though not completely torn, but high grade injury. And then on the left you can see there's a lot of awkward anterior translation, maybe rotation, hard to say. And a lateral meniscus root tear that Aaron likes very much and showed us great technique on. So my first question to the panel is the good old question of timing of surgery. And I put just a few studies up there. On top is new school. Go now. On the bottom is old school. Shelburne and Harner, wait. So define immediate. Immediate, meaning, you know, so he's six days out and you're going, you know, this coming Monday, like you're going now. Okay. So Barney, just keep it brief. Yeah, I'm A, immediate, especially with the meniscal tear and the MCL. I want to fix those. We'll deal with some of the stiffness as it arises. Of course, I want their quad going first and we'll try and get them doing quad sets and some heel slides right away, but that's not going to allow me. Walt? Agreed. Okay, you're from the same place, you're better. Brian? I think I would have a discussion with the family, but I would be, because of the meniscus, probably lean toward more immediate or early. Okay. Aaron? I think you have dealer's choice here. I think that's an MCL that will heal with six weeks of bracing, but it's really a discussion with the patient where the timeline is in the season. Are you trying to get them back next season? If you're anticipating six weeks of non-weight bearing because of the meniscus repair, then maybe better to go early and do it all in one. Yeah, I'm really not sure that MCL is going to heal. Andy? High demand patient, I go B, and low demand, I brace and reevaluate three months. Okay, very good. So, I mean, this discussion could go on forever, but we're going to go through six questions here. Graph choice, so the current trends are listed there. This is worldwide. Hamstring is number one. There's also a practice guideline of recent. So, for a show of hands on the panel, who's doing semitendinosus? Very good. Who's doing BTB? And who's doing quadriceps? All right, we're very clear. Everybody clear with that? Very good. All right, BTB. The lateral root, so you have this type of lateral root that Aaron really beautifully showed earlier, and there's also a recent heated debate that Aaron and I and many others, Bob LaPrade and others, are part of. So, leave it alone is what we did, I think, in the past, or maybe even resect it. I've seen it many times. Repair. Everyone on the panel repairs this? Yeah, so really nobody leaves it alone. We're repairing this every time. Next question, the bigger question is, what do you do with this old MCL, right? So, again, so first question is healing response, or do you do any further eval? So, I'm just going to lay it out here. In your hands, looking at this MRI, having had the exam in the office, are you all set? Do you need your EOA, or do you even use stress images? Bonnie? I think probably for the more aggressive ones in this side of the table, I think with that distal injury and your exam, I think I'm leaning towards fixing anyway, unless I see something clearly different than my EOA. So, I think Aaron's right on the first view of that. You would say it's not out from under the PES. It has a pretty good chance of healing, and so for me, at the diagnostic arthroscopy part of this, if the tibia moves away, if the MCL moves, if the medial meniscus moves away from the tibia, then I'm going to fix not only the deep, but repair the superficial distal injury. Brian? Yeah, I agree with that. I do do stress radiographs on any kind of multi-leg to come into my clinic, but I'm still doing it EOA and checking it, just what Dr. Lowe mentioned, seeing how the meniscus is moving when you do that stress. Aaron, you do anything different? Yeah, I mean, I would use stress x-rays liberally if there's ever a question, and then we have to also think about rotational instability with the MCL as well. Maybe I'll let Andy comment on that. Yeah, so in soccer, very different animal because the MCL is holding everything up when you kick. Andy? Absolutely. So, I think in soccer, you have to have a normal MCL laxity. Otherwise, you really run a high risk of re-rupturing your ACL. Unlike the lateral side, where you may argue about the indications for atenodesis or ALL, I think immediately it's very clear-cut. If you've got opening of the medial compartment with valgus stress and full extension, if you've got a grade two or more at 30 degrees, or if you've got a positive dial test for antramedial rotation, you need to do surgery. And I think the principle really is anatomic restoration with suturing, be it acute or chronic, and then protect that suturing with a reconstruction. Yeah. So, I mean, Rob LaPrade has showed us a lot of good data on the stress images. Now, 3.2 is the number for complete rupture. You can see also here, like Walt just mentioned, so there's a little bit of funny rotation going on. You're not very happy when you see that. And so, now here we are. There's about a two-millimeter opening, so it's not that 3.2 number, but here we are. So, NONOP, repair, reconstruction, augmentation. You kind of all alluded to it a little bit, that there's some repair going on. Now, any of you in this particular scenario, 16-year-old, mobile, you know, quarterback guy, leave this alone, like NONOP? And that's probably a different answer 10 years ago also. So, we're getting a little more aggressive here. So, I just show real quick what we did. So, this is what you see. There's the root that we did an all-inside type of repair. This patient received a BTB graft. I'm really glad now that I did this, that you were 100% on this. Oh my god. Because we're randomizing also into studies anyway. And then, with respect to the MCL, yes, we did a repair with suture anchors. And I don't know if a synthetic augment is needed or not, or if it's even bad. You know, there's old literature that says it's bad. Do any of you use any of these synthetics? You stay away from it? You're happy with it? What's going on there? I've been using synthetics to augment a repair. And I find, you know, it gives me confidence. I got them moving earlier and everything. But I'm not sure if it's absolutely necessary, but it makes me feel better. Yeah. I mean, the conversation about a synthetic is a pretty toxic one. But I've had a long history of using polyester prosthesis, and it absolutely changed my life. Soft tissue reconstructions medially often stretch out. And I think the reason for that is during stance phase of gait, there's valgus external rotational torque on the knee. And until you've got normal neuromuscular control, you're at risk of stretching out. And I've not seen the problems associated with the intra-articular use of synthetics when they're used medially. We've got a series of 76 cases and haven't seen the biological problems. Yeah. Last question to the panel. In this scenario, you did an ACL, a root repair, you did an MCL. Are you adding an LAT, hands up? Even on top of that? Absolutely. Okay. All right. So here's the next case, maybe a little bit shorter. This is a very emotional and sad story type of case. 18 year old female field hockey player, very, very active and powerful. Had an ACL reconstruction done with quad tendon, very, very complex retracted lateral meniscus repair that was repaired. Then a cyclops, not the topic of this particular panel right now, but that happened too. And then 10 months later, the typical ipsilateral graft re-rupture. So first question when you see this type of case is, should always be graft, but then tunnel position. So everybody okay with this particular tunnel position? Any argued on this? Hard to see. Here's the outline and the quadrant. Probably all right, right? And there are some interoperative images as well. So that probably is not the reason for failure. So the next question is graft choice. So they had a quadriceps tendon, you like it or don't like it, but so now what do you do? So you're going to the semi T that you a hundred percent disagreed on earlier, or you're going to the second time of the extensor mechanism. So Barney, where do you go? No allograft, right? I think for an 18 year old, I'm going BTB or considering contralateral too. I think contralateral is really important, but I think ipsilateral, I wouldn't worry too much about. Yeah, we've actually published using either quad tendon after BTB graft or BTB after quad tendon graft. And I don't think there's any issue whatsoever in taking another graft from the same side. So I would go to a BTB ipsilateral. Yeah. I would talk about either doing ipsilateral, BTB or a contralateral quad if she prefers that, but I let the patient decide between those two. Good choice too. Yep. Yeah. A hundred percent agree with Walt. Okay. Okay. So autograft for sure. I think we're all clear on that. And, and Rick Wright and the Maas group showed that. And then we also have the study on the double hit, which didn't seem to matter. So that's where we're going. One versus two stage. So we were recently at the ACL study group and we talked about this a lot. There's the ACL study group right there for you to see. So where are you going? One or two stage? Do you bone graft anything? You use the same tunnel? What do you do Barney? Yeah, I think, you know, it didn't seem like there was much tunnel expansion. I think if you were at all concerned, you could get a CT scan preoperatively as well to, to make sure that the tunnels are really where you think they are and that you don't have more expansion than you can tell based on your MRI radiographs. And if so, one stage. Yes. Anyone do two stage? Not really. Try not to do two stage. I don't think that's all the time necessary. Next question is, will you add the lateral procedure? ALL, Lemire, Ellison, McIntosh. So now that it's a revision, all of you? A hundred percent. There you go. I mean, there's a lot of data for the primary. There really isn't a lot on revision and whether it works. We all think it works. We just published this a few days ago and I'm sure Bertrand is going to write a nice commentary on it. But, but anyway, this is just what the data showed. So it didn't really seem to make a difference in failure rate, admittingly still very high failure rate. So who knows if the slope is where we should go after all. But anyway, this is the case. This is a BTB autograph revision, ipsilateral, and then the staple there for the LET and so far so good. All right. One more case for you. This is a 24 year old now banker, but very, very high level gymnast way back when. So 10 years ago they had a BTB autographed ACL, a medial meniscus repair, a partial lateral meniscectomy. So she comes in, there's some effusion. There is really no joint line tenderness, excuse me. Range of motion is okay, but if you really look closely, she lost hyper extension and that's been there for years. Lachmann is 2B. There's a positive anterior jaw and a two plus pivot shift. So you're looking at a first revision type of scenario. So any other studies other than the x-ray that you see where the joint line is not much compromised and of course the MRI showing the graft is gone? Well, I get some good long leg x-rays to start with. So you get a long tibia x-ray. You alluded to it earlier, but is it a standing, a weight bearing? Yes. How do you do that? A long tibia on a weight bearing is not long enough. Well, it's a stitched right now, I think is the best way to say it. And really, I think the new weight bearing CTs are going to be the best way. That'd be nice. My people can do it. I asked them to do a weight bearing lateral full length, can't do it. So it's either weight bearing or full length. How about you, Brian? Yeah, I mean, I would agree with other alignment films. We've talked about trying to do the long length like lateral as well. Our techs right now, we're still trying to figure that out. So that's why we've been still using this standard lateral. Any other studies, Aaron? I mean, just a comment on the, I mean, you have to get a weight bearing full lateral tibia and you have to have your techs turn that cassette diagonally in order to get the entire tibia. When you look at, again, the School of Lyon, I learned 2010-2012 from Philippe Nere, it's very important that you get a monopodal weight bearing stance because it's not only tibial slope, it's also anterior tibial translation. Now, if you see anterior tibial translation on non-weight bearing x-ray, certainly you wouldn't use weight bearing, but you have to have a weight bearing x-ray. I'm a little worried that we might be overdoing slope on some of these patients that don't have the tibial translation. Andy, do you get a CT scan? Yeah, to plan the reconstruction, as we said, alignment films, long lateral, I always get a CT and that previous lateral is classic. They've lined it nicely so the joint line is horizontal, but if you actually spin it around, you realize that the slope is massive. So that's the combination I'd use. Good, so we're lining out here, the coronal alignment is okay, the slope all of a sudden looks crazy, where on the last lateral you thought you're going to get away with an LAT, which you may still, and then the CT scan, none of you mentioned it, but I really like a 3D CT scan. You already saw, if I go back one, that the tunnel, everything's bad now, sorry for this, here we go, that the tunnel is no good, but how no good is it? Is it a two-stage? I just told you not to do that, so the CT scan will convince you that in the first stage you can sneak behind that any old day. So anyway, so here we are, 17 degrees, I think graft choice, I'm just going to jump over because, but actually no, so Brian, you said you use allograft in revisions, you feel comfortable with that? Allograft in the setting, if we're correcting slope and if like a triple, this was like a, you know, one time there's still good graft choices to use on the lateral side, so I think I'd probably still lean for auto, depending on her, what her goals are, I don't know if she's going back to gymnastics or not, or if she's just going to be biking or something, but depending on her, what her goals are, I'd have that conversation. Okay, okay, I mean, I do agree that allograft sometimes is a nice choice, we have a long Achilles and it's so versatile, but there's all this data from Mars, so. It's a nice choice for the surgeon, I'm not sure it's nice for the patient. Yes, so a quick comment, Volker, on what Aaron said, because I think this slope is a slippery slope right now, and you know, there's a tendency for all of us to get very myopic on one thing, and it's not just one thing, I think Aaron's comments, great, you have to look at translation, you have to look at all the rotational stuff, it is, the one thing that slope, I hope, makes us do is see a much better, big, complete picture of what we're dealing with, and I don't think we've had that focus in the past, and I, but I don't want us to just focus on slope. Yeah, agree, so probably autographed in this case now, for a show of hands, who's going with L.E.T. here? Two, three, plus slope, and then how about the slope? Three of you, so you would do a slope and an L.E.T., can you explain the rationale? Just the same thing I did before, it's, she's pretty loose, she comes a little forward, she's had a failure, I think the, her slope's significant, and I don't think you can really change the forces without changing it, probably, and she has a big pivot, she has other things on exam, and I think we have to do the things that address the individual problems we see, so that's how I'd approach it. And also, I think she had a fixed flexion deformity, so it'd be a perfect way of correcting that. Yes, so the fixed flexion deformity, you will only correct with a slope correction. Yeah, that'll fix her lack of extension. Right, sure, so anyway, the data keeps piling up, those are all small studies, and obviously Brian just told us he's going to add 22 patients to that, but so there is more and more data, so as a way of thank you to the AOSSM, we just received this Stephen Arnalski Young Investigator Grant Award, so this is the patient that I just presented to you, she was on the treadmill before slope surgery, her kinematics are obtained, and then after slope surgery, hopefully we'll come back to you next year and show you what the kinematics now do. Look on the upper left, you see that ugly N-tier tunnel, so you can sneak on the lower left an anatomic tunnel behind it, there's a quad tendon in the middle of it, and then we did a slope correction above the tubercle, dealer's choice where you go, but just like Brian showed, and use a locking plate construct. So anyway, thanks to the panel, I thought there was a lot of fun, and thank you so much for inviting us to do this. Thank you.

ACL injuries

treatment options

panel of experts

ACL tear

MCL injury

surgery recommendation

BTB autograft

ACL reconstruction

re-rupture

rotational instability