ACL surgery, we all know the options, the allograft, BTB, hamstring, and Achilles, autograft, BTB, hamstring, quads, and then the others, these internal braces, the LETs and the ALLs, and then the Bayer technique. So my clinical experience, I'm 33 years out, 31 years as a team physician, I do about 125 to 150 ACLs a year, 70% of them are BTB, 15% are quads, autografts, 10% are Achilles allografts, and 5% are hamstrings autografts, but I only use the graft length. So my BTB overall failure rate is less than 4%. I've done over 60 ACLs in the NFL, with or without medial clad or ligament repairs, and with or without an internal brace. So my preference, and I'll try to back it up for you, is a BTB autograft with screw fixation, and the most important thing is obviously in the right place. So why would I choose a BTB autograft? It's easy to harvest, multiple fixation options, reliable, predictable graft size, autogenous bone-to-bone healing for each tunnel, there's no risk of disease transmission, the ultimate tensile strength is actually greater than the native ACL, and when we go through the literature, you can see that there's proven outcomes in the literature for knee instability, low re-rupture rate, return to sport, return to sport at the same level, or very predictable, decreased revisions, and basically it's the gold standard in the NFL. So I initially did the NFL study back in 2010, 86% of the doctors were using primarily BTB for their primary graft choice. Dan Cooper then did it again with 27 teams in 2013, 82% of the people were using it at that time, and the other two were ipsilateral hamstring and Achilles allografts on the coast. I redid the study this year, primary graft, 97% of the teams, 31 of 32 teams, used BTB autograft in the NFL, ipsilateral quad was only one at 3%. The revision setting, surprisingly, which we do a lot of, is a contralateral BTB, 75% of the teams use that, five of the teams use an ipsilateral quad, one used a BTB allograft, and one used a contralateral quad. Well, for internal braces, primarily, only one team used a primary internal brace. Revision, most of the time, only one team used them in revisions, but surprisingly, LETs and ALLs, only 6% always used them, but they always used them in revisions, the others did not. Five others in the league had done at least one ALL. Here's the big problem, or big change, in my old study, everybody thought about six months was the time to return to sport, this year, when I did the study, it was not, the average return to sport in the NFL, the doctors thought it was approximately nine months. 97% of them did some kind of performance functional testing before they let the athlete return to sport. So if you look at the literature, started in 2014, when Brian Cole and his group surveyed 267 NFL and NCAA Division I orthopedic physicians, autograft was 99.3%, and BTB was 86%, and one guy did a double bundle. Then in 15, the same group, with Nick Verma starting it, this time, a survey of 94 orthopedic docs in the NHL, Major League Soccer, and the World Cup snowboarding and skiing, the graft preference, autograft was 89.4%, BTB was 70, hamstrings 14, and quads was 4.3%, they all did single bundle repairs. 2018, McCarty came out with his, where he looked at the evolving patterns of NFL players, or NFL players and by orthopedic team physicians over the past decade. In 2008, he had 31 of the 32 teams respond, and in 2016, he had 91% respond. The graft choice in 2008 was 87% BTB auto. By the time 2016 came around, it was 97% autograft BTB. Return to sport at the time, in 2006, was less than they thought, somewhere around six months, but by the time 2016 came, that was only 14%, so people were keeping them longer out of the sport. If you look at allograft versus autograft, what if I told you it's not even close, especially in young athletes? So if you look at the literature, the most recent studies in the literature, there's a higher re-rupture rate in allograft, anywhere from 2.7% to 7.7% using allograft in this group. What about BTB versus hamstring autograft? That's kind of what this picture shows. In the early studies, BTB had decreased laxity, re-injury rates, and decreased revisions, and increased return to sport in these studies. Les Beeson, who takes care of Buffalo, he did his systematic summary of systematic reviews on the topic. They did 1,031 articles, of which 240 were pertinent, and what he basically found was there was greater improvement in stability using BTBs versus hamstrings. And BTB was more likely to return to sport at the same level and had greater stability. Aaron Critch then looked at almost 40,000 BTBs versus almost 8,000 hamstrings, and what he basically found out was the BTB ruptures at a less rate than hamstrings. Thus, for every 285 BTBs, that prevents one hamstring rupture. What about looking at the meta-analysis? McCarty used this meta-analysis of BTB versus hamstring autografts, and basically found the current best evidence, this was 2017, proves there's superior static stability in the BTBs, but there were decreased post-op complications in the hamstring autografts. Cristiani then looked at his Europeans. BTB had increased outcomes in terms of decreased post-op laxity, decreased likely to experience a surgical failure, and secondary instability of the graft. What about OA? So no one talks about OA, but actually, with the medial meniscectomy, you have increased OA with hamstrings of 43.5%, that's moderate to severe, versus OA with BTBs, which is only 18.3%. What about hamstring, this always bothered me, why are you taking hamstrings in runners? And this is kind of the seminal paper that basically said that the results show significant weakness versus the other knee with hamstring, when you take the hamstrings for an ACL. Then I looked at, if you look through the literature, every one of these papers shows significant isometric and isokinetic hamstring weakness if you use hamstrings. What about anterior knee pain? Well, everybody said it's like 12%. Well, actually, we finished our study, we used this thing called Osferon. Ours was 4%, so we just published this, and our number is 4% with anterior knee pain when you use Osferon, or if you use some sort of bone grafting to the patella. What about revision subsequent surgery? The Moon Group showed us quite clearly that hamstring or allograft are increased risk factors for subsequent meniscal and cartilage damage. What about infection? So no one really talks about that, but really, if you look at that, if you use a BTB, you have a 77% decreased risk of infection versus hamstring. If you use a BTB versus all the other grafts, it's 66% decreased rate of infection. What about the big registry studies, like thousands of them, 45,000, 13,000, 17,000? Most of those show BTB has decreased revision rates. Only one back in 2009 showed that it was the same, was Swedish study. So they're equal revision rates in the Swedish study. So quad tendon autograft, it has potential. There's a new one coming out. There's no loss of flexion strength. There's less kneeling pain. Similar outcomes, John X shows us. Increased cross-sectional area versus BTB. Patients with quad showed similar short-term quad recovery and post-op outcomes. So the quads are now gaining popularity. Here's the issues, though. Is it ready for prime time? So if you look at the most recent studies on this, there's increased risk of cyclops and arthrofibrosis. Cyclops is 7.2% and greater than five degree flexion contracture in 20% of the patients. The big problem is there's no large study in young high-risk population or NFL yet to say this is the graft we should do. There is papers out there by John X of 100 revision ACLs with the quad, and he felt that it had improved IKDC and equal knee laxity versus other grafts. What about, same thing, soft tissue quad grafts in athletes only, level three study, single surgeon. Quad grafts revision in athletes had similar outcomes as BTB for this. This is what really bothers me. Knee muscle strength after quad. If you look at these 18 studies in the systematic review and meta-analysis, knee extensor strength recovery with a quad graft appears not to be restored before 24 months, which is a problem for me. The future may be ACL with internal brace. The internal brace protects the graft early. The tension, you can tension the internal brace fully in full extension. In the tunnel, first you fix the brace, and then you fix the BTB. Secondly, Pat Smith and I did that study. We looked at the internal brace group, 31% better cyclic displacement. Ultimate load was 17% better, and the construct stiffness was 21% better. So it's something that we may wanna consider as a backup. So conclusions. The BTB grafts, impressive track record at all levels. Auto graft heals quicker. Bone-to-bone healing is predictable. Predictable timetable for rehab. Improved knee stability in multiple studies out there. Excellent return to sport, return to sport at the same level, which is predictable. Anterior knee pain, kneeling pain, and risk of patellar fracture all decreased with bone graft neurosphere on plugs. There's decreased revisions in the literature, and there's dogma and there's data. And I'm trying to present the data that's out there right now. So as my good friend John Bergfeld said, pay attention to what the orthopedic surgeon does for the athlete on his or her team. As they know the results, good, bad, it will be with them on a daily basis, and in the newspaper. So for me, I'm sorry, the gold standard right now, at least in the NFL, is a BTB auto graft. Thank you very much. Thank you.

ACL surgery

BTB autograft

knee stability

graft types

NFL