Thanks, Ashish. So these are my disclosures that are in the program. So generalized joint hypermobility, it's a spectrum that can range from hypermobility of synovial joints to global extreme connective tissue disorders such as EDS. It's more common in our younger patients and in females. The most objective criteria is Baten's criteria, but there might be some knee-specific measures that are less cumbersome and more relevant to this topic. So if we're looking at Baten's criteria, I think it's fine to use it as a nine-point scale. You're looking at hyperextension to the fifth digit, thumb to forearm apposition, elbow hyperextension, knee hyperextension, and then palms to the floor. And basically, if you have a score between four and nine, you're considered to be hyperlaxed. We did do a study where we looked at outcomes after ACL reconstruction in patients with generalized hypermobility, and we did use Baten's criteria and compared these to a control group without. The hypermobile group has significantly higher ACL graft failure and combined graft failure contralateral ACL injury rates. But what we found is that the independent predictors for ACL graft failure were, interestingly, fifth digit hyperextension, but not surprisingly, heel height. And so basically measuring the heel height off the table with hyperextension greater than five centimeters. And so that's really my current test when I'm evaluating these ACL-deficient patients. So what about studies out there looking at ACL injury, re-injury rates, and the presence of joint hyperlaxity? So if we look at ACL injury, this study looked at 24 ACL injuries in 1198 West Point cadets, and what they found is that generalized hypermobility was a significant independent predictor. This study looking at patients with ACL injury found they were more likely to have joint hypermobility compared to a control group with an odds ratio of 4.46. And then this study looked at 169 patients with an ACL injury, and then 169 age and gender match controls. Generalized hypermobility was present in 43% of the ACL injured group versus 22% in the control group. What about ACL and graft failure rates in the presence of hyperlaxity? So this study looked at 139 ACL reconstructions, 44 ACL revisions, and then had a control group of 70 who had no knee issues. They found that primary and revision ACL reconstruction had a higher prevalence of joint hyperlaxity, and they found also that the revision ACL group had a higher prevalence of joint hyperlaxity compared to the primary ACL group. This study, 163 ACL reconstructions divided into generalized joint laxity or not, they had a higher rate of ACL re-injury and contralateral ACL injury in the laxity group, poor stability and functional outcomes at five to eight years in the generalized joint laxity group as well. And this study looked at joint hypermobility and ACL reconstruction, and they had a graft failure rate of 21.7%, so that's obviously much higher than our published rates in most of our studies. So this was my early experience. I was interested in this group looking at patients that were hypermobile, had high-grade pivot shifts. So basically I look at a consecutive group of patients, 182 ACL reconstructions, used Baton's criteria, and 41 of them were hypermobile based on that criteria. I had a mean six-year follow-up in this group, and our graft failure rate was higher in the hypermobile group. So 24% graft failure rate in the hypermobile group compared to 7.7%, and this included KT1000 greater than five millimeters side-to-side difference, so you have some of these biologic failures or stretching out in this hyperlaxed group. And then if you combine that with contralateral ACL injury, it was 34 versus 12%. And again, as I stated previously, a heel height greater than five centimeters was predictive of failure. So this is really my criteria looking at this laxity group. So is there an optimal graft choice in these hypermobile patients? So this is a study looking at 237 patients with ACL reconstruction. They looked at two things, generalized joint hypermobility versus non-hypermobile, and they looked at BTB autograft versus hamstring tendon autograft. And what they found is that the patients with generalized joint hypermobility had poor results at two and five years for stability and functional patient-related outcome measures. And they also found those patients with hypermobility had better stability and functional outcomes after a BTB autograft compared to a hamstring graft. So maybe the BTB autograft should be considered for these patients with hyperlaxity. Here's just a systematic review that was done several years back, and their conclusions were that there's an increased risk of primary ACL injury and hyperlaxity, increased post-op laxity at five and eight years with generalized joint laxity, and again, this high rate of biologic failures where the graft's intact but it's loose and it's non-functional. In the presence of joint hyperlaxity, hamstring autograft had increased laxity and inferior outcome scores compared to BTB autograft, and maybe we can consider that our graft of choice in these hypermobile patients. So what if we take it a step further? Should we consider adding concomitant procedures in addition to maybe using a BTB autograft? Should we consider an anterolateral complex procedure? And I know Al Getgood's going to go into that in more detail. So we've described anterolateral reconstruction techniques using soft tissue allograft and autografts, described lateral extra-articular tenodesis. I don't think I would argue that one's going to be better than the other. If we look at our indications in the literature and just look at reviews that are out there, expert consensus, you know, these are our primary indications, maybe these are our secondary indications. But if you look at three of the main indications, it's really this group. It's the high-grade pivot shift, it's hyperlaxity in our young athlete. So this is one of the main things we're thinking about with anterolateral complex procedures. And Al Getgood was part of this study as well, the systematic review in 2021, six studies looking at ALL reconstruction and five studies looking at lateral extra-articular tenodesis. In the end, significant reduction in graft rupture when you add a lateral augmentation. Rotational laxity was higher in the isolated ACL reconstruction group. Lysolome scoring was better with the lateral augmentation and maybe a slightly higher return to sports when you add a lateral augmentation. So is there data to support this in your ACL injured patients with underlying hyperlaxity and adding an ALL complex procedure? So this study looked at 90 patients, they used Bayton scale, and they had historical controls without an ALL reconstruction and more recent patients who had an ALL reconstruction, so consecutive groups. And in the ALL reconstruction group, they had better KT-1000 stability, better rotational control based on the pivot shift, a lower ACL failure rate, again, similar to our study, 21% versus 3%, and then no difference in patient-related outcome measures if the patients did well. So what's my experience? I haven't done as much of this as some people in terms of lateral complex procedures, but basically I've performed about 160 anterolateral complex procedures. I do about 200 ACLs a year, and about 15% of the time I'm going to add a lateral complex procedure. So we had 205 knees for an ALL. We used a free tendon reconstruction. I like to use a Tibialis anterior allograft, and for an LET, obviously, it's your IT band allograft. So what are our patient-related outcome measures? This is the primary group at a mean follow-up of 19 months, and you can see a significant improvement in the IKDC, Cincinnati, and Leisholm scoring, 101 knees. And in our revision group, 104 knees, we had a mean follow-up of 22 months, and again, a significant improvement in the overall outcome measures, which I think are acceptable. If we're looking at our ACL reconstruction failures, this is probably the most significant finding looking at this primary group. This is really hyperlaxity, high-grade pivot-shift patients. With an ALL, we had two graft failures, this is an earlier follow-up, but it's only a 2% failure rate. So we compare that to 24% failure rate in our previous study looking at hyperlaxed patients, and a 22% failure rate in that Halita et al. study looking at hypermobile patients. So this was kind of a revelation for me looking at my own patients and seeing that I think this is working. And in the revision group, we've only had one graft failure. Again, only a 22-month follow-up, but that's still pretty good. And if we look at our patient-related outcome measures and our failure rates, this is really equal to or better than the pooled high- and low-risk ACL revision studies reported by the MARS group at Anand et al. So surgical technique pearls, you know, there's not a lot of data on this, but just I have a lot of experience in hypermobile patients. I would say if you see a patient with a high-grade pivot-shift as seen here, if they have heel height greater than 5 centimeters and you see both of these, you really may want to consider a specific graft choice and a concomitant procedure, in my opinion. So when you have ACL deficiency with hyperlaxity, I would use a BTV autograft. That's my graft of choice. I would strongly consider an anterolateral complex procedure in these patients as well. I think you need to have accurate tunnel placement. You need to avoid potential impingement. They have a lot of hyperextension. It's a volatile environment. It's much more easy to have impingement on your graft. You may want to consider intraoperative lateral fluoro as well to make sure that your tunnel placement is as perfect as it can be. And I actually like to perform fixation at zero degrees of extension. I worry if you hyperextend them too much when they have excessive hyperextension, you're going to get some anterior translation of the tibia, and if you fix it there, you may end up with some graft laxity at time zero. So if you're going to hyperextend them, I would use intraoperative fluoro to make sure you've restored the relationship between the femur and the tibia. So just a quick case example, 22-year-old college soccer player, grade 2V Lachman, high grade pivot shift, 14 degrees hyperextension, and the heel height of 8 centimeters, generalized hypermobility. So this is really this patient young athlete we're talking about. Typical ACL tear, kind of a mild lateral femoral notch sign, and posterior tibial slope, which you'll hear about later as well, was elevated. So all of these things leading us down this potential lateral augmentation procedure. So this is just the procedure, this is the way I initially did these. So you find the Gertie's tubercle you can see is outlined there, you see the fibular head outlined. I used to make two incisions, so I'd make one for the tibia, one for the femur, now I just make an incision between those two. There's the FCL that I've outlined, you can put a little varus stress so you can feel the FCL. Make a second incision here, just proximal and posterior to the FCL. I'm going to use a BTB in this case, that's going to again be my go-to for somebody who has hyperlaxity, we're all familiar with that. I use a two incision ACL technique, but I would argue it's okay, go ahead and drill your femoral and your tibial tunnels first, but don't place your graft. I would go ahead and drill your tibial tunnel for the ALL and do that before you place your graft so you're not having convergence or disrupting your graft. So here you can see I'm one centimeter below the joint line, you can see I'm using intraoperative floral to make sure that I have appropriate position as well as palpation. This is a semi-tendinosis graft, so early on in my first view I used a semi-tendinosis graft. I actually like a tibialis anterior graft, I think it's flatter and it just reproduces more of a thickening in the capsule for me, so that's my preference. So now I'm going to pass the graft into the tunnel, it's just going to be a line-to-line fit, so usually a six millimeter, six and a half millimeter graft, and then a six and a half millimeter tunnel, and then I'll either use a six or a seven millimeter biocomposite screw depending on how dense the bone is, softer bone I'll use a bigger screw. So then I fix the tibial side, in this case here now I'm fixing the ACL. What I would actually do currently is I would go ahead and I would either drill my tunnel or place a suture anchor for the femoral side before I pass my graft, and that way you can look up the femoral tunnel or down the femoral tunnel and make sure there's no convergence when you're placing this. If you use a low anterior medial portal, make sure you place that tunnel anterior and proximal to stay away from that femoral tunnel. So what you do is you make your incision, split the IT band, I like to put a little varustress on the knee so that you can palpate the FCL. Again using intraoperative floral, Kennedy and LaPrage showed kind of our floral landmarks for the anterolateral ligaments, so I'll use that just to better define in addition to palpation where the femoral site is. I use a double-armed number two suture anchor, all suture anchor, but you can drill a tunnel if you want to. And then I'm just passing the graft up into the femoral incision, and then the other point is at what, and we can all talk about this, at what degree of flexion or extension do we fix the ALL. I personally prefer somewhere around 20 to 30 degrees, and we can all talk about why we do that. And you want to make sure the foot is in a neutral position, not too internally rotated or externally rotated. And then you just secure the ALL, which I do after the ACL reconstruction, and there's no post-op restrictions based on the anterolateral complex procedure. So generalized joint hypermobility, they're at increased risk for ACL injury and re-injury. I think a BTB autograft might have improved outcomes compared to a hamstring graft. Anterolateral complex procedures might further reduce ACL re-injury rates in these patients, and I think an anatomic and impingement-free graft placement might be even more important in this patient population. Thank you very much.

generalized joint hypermobility

ACL injuries

hypermobility

BTB autograft

anterolateral complex procedure