Okay, thanks Ashish, and thanks everyone for turning up this morning for this session. Okay, so I'm going to give you a little bit of an insight into what we've been doing with regards to lateral tenodesis, and where it fits into your ACL reconstruction algorithm. I have a lot of research support regarding this particular topic, no real specific disclosures from an industry point of view. If we focus on a case example, this is a 21-year-old female, she's a criminology student, has a skiing injury, classic injury where the binding hasn't released on her ski, and basically ends up with an ACL injury because of recurrent instability, lack of trust. Examination, just as Chris has been talking about, we've looked at her generalized ligamentous laxity, she's a Beighton score of 7 out of 9, she's got symmetrical hyperextension, high grid anterior laxity as well as rotatory laxity, but stable collateral and PCL. If we look at her radiographs, we can see that these look pretty unremarkable, but when we actually really drill down and look at her tibial slope, and depending on how you measure that, you can often get some slightly different values, but certainly her posterior tibial slope is elevated. MRI scan confirms an ACL injury, she has an increased bone bruise, the poster medial aspect of her tibia, suggestive of a ramp lesion, and of course the characteristic bone bruise pattern in the lateral compartment. This is her examination under anesthesia, you can see that high grid Lachman, stable collaterals, and then we see that she has a really quite significant pivot shift. So the big question is, would you add an LET into this young patient's need in this scenario? And if we look at the data from stability study, we would say yes. So this was a randomized clinical trial sponsored by Issacos, it was the winner of the Donahue Award in 2019, sorry 2020, and this was nine centers across Canada and Europe, and we essentially randomized ACL reconstruction with hamstring tendon autograft, with or without atenoidesis, we randomized over 600 patients. All the patients were young, they were less than 25 years old, and they had high grid laxity as well as some of them had generalized ligaments laxity based on a Baten score, so we really focused on high risk individuals, and then randomized in a standard manner, looked at a number of different outcomes, with our primary outcome being clinical failure, but also looking at graft rupture, and a number of secondary outcome measures. The intervention, as mentioned, was a hamstring tendon autograft, I'm sure we can get into talking about that later on. And then the intervention was a modified Lemaire IT band tenoidesis, and I'm going to show a video of this at the end of the presentation. So this is just the concert flowchart when we see patients coming through, so over 600 patients randomized, with less than 5% follow-up, and really just high-level review of the results, we saw a 40% reduction in rotatory laxity, we saw a 66% reduction in graft failure, with no increase in overall complications, no difference in functional outcomes, and no real difference in return to support, but what we do see is that patients that have got a more stable knee actually reach a higher level of support, and we're looking at trying to publish this at the moment. We then did a multivariable logistic regression model, looking at predictors, and this is really trying to tease out what are the indications for us in our clinical practice, and so we've already mentioned that the addition of an LET reduced our failure rates by 60%, the younger the patient, the worse outcome, or at least the higher risk of re-injury. Each month that a return to support time was delayed reduces the odds of graft rupture, so again it speaks to our rehab, and making sure that we're not letting our patients go back to support too soon. Pre-operative high-grade knee laxity had 3.27 times higher odds of graft failure, so that's something you can see in clinic, in the office, you're going to measure those particular individuals, and we know that they have a worse outcome, as well as patients with high tibial slope, and when we looked at tibial slope against age, our data would suggest that the real risk factor really starts to kick in around about 10 degrees, so if you're seeing tibial slopes greater than 10 degrees, have in the back of your mind thinking about adding a lateral augmentation. Chris has already mentioned about ALL reconstruction, and I think it's fantastic that essentially they're shadowing some of the results that we're seeing as well, so greater than 50% reductions in ACL reconstruction failure, and this systematic review confirmed that across multiple studies with multiple techniques, so really speaking to the generalizability of this particular procedure in terms of reducing failure rates. So I put it to you to have a think about this morning, is what other technical evolutions in ACL reconstruction, and whilst lateral tenodesis isn't exactly an evolution that's been around for a long time, but what other techniques have you seen in the last 20 years that have resulted in a 50% reduction in our failure rates in ACL reconstruction? Double bundle? Probably not, probably increased our failure rates. Anatomic mid-bundle reconstruction, again, number of reports suggesting higher failure rates, all inside ACL reconstruction, that would maybe show equivalence to our standard techniques. Quad tendon, quad is the big thing at the moment, but we really haven't seen data that would suggest that the quad can reduce failure rates, maybe equivalent to hamstring, but we really don't know how it stacks up against patella tendon. The internal brace, well the internal brace maybe in one study has shown equivalence with the patella tendon, but certainly hasn't reduced our failure rates, ACL repair definitely hasn't reduced our failure rates, and the bare procedure, whilst it looks attractive and there's lots of really good evidence surrounding this procedure, we're also seeing studies with four times higher risk of failure, so lateral tenodesis it is. Now the question I always get asked is, what if I use a patella tendon, your study was all really involved hamstring tendons, what if we use a BTB autograft, and I think it's a very relevant question, and so we did look at the MOON data, looked at their risk calculator with the data from stability, and used a hamstring tendon plus an LET as a surrogate for a patella tendon graft within their risk calculator, and what you see is that, basically both the BTB and the LET appear to be protective versus the hamstring tendon alone. By doing an indirect comparison in this manner, it may suggest that the LET may offer additional protection, but we obviously can't make any firm conclusions based on the methodology of this study, but what it does support is that we probably should not be using isolated hamstring tendon autografts in young athletes going back to contact pivoting sports where we've got high grade laxity. But it is a question that we need to consider as to whether or not there's additional advantages of an LET over a patella tendon, and that's why we're now doing a current study along with Volker Mosel, JR Gang, and my colleague Diane Bryant, co-PIs at Stability2, where we're comparing BTB versus quadricep tendon, with or without tenodesis. We're actually about 240 patients into this study, but we've got a long way to go. So what about the revision scenarios? This is a 25-year-old with a failed BTB ACL reconstruction, so unfortunately BTBs can't fail as well. Pretty good tunnel placement from his original surgery, graft ruptured, so we did a quad tendon revision ACL reconstruction plus an LET. Why did we do that? Well, the data suggests that the addition of a tenodesis to ACL revision reconstruction has an impact on reducing rotatory laxity, but also can reduce our failure rates in the revision scenario. So if we pull all of that data together and we look at our indications for a lateral extra-articular tenodesis, for me, pretty much the majority of my revisions, I will add an LET, and then in the primaries, if for any reason the patient wants to have a hamstring tendon graft, they all get an LET. And then in patients who are high-risk individuals, so with high-grade rotatory laxity, young patients, generalised ligamentous laxity, in particular, knee hyperextension, recurvatum, pivoting sports, and then of course the tibial slope greater than 10 degrees, then an additional LET is performed. So this is the technique that I use. This is a modified Lemaire technique. There are a number of techniques that have been developed, but essentially it's a small incision just posterior to the lateral epicondyle. It's usually an incision of about 5 centimetres, and essentially we can just use sharp dissection right down onto the IT band. I take a 1 centimetre wide, 8 centimetre long strip of the IT band from the posterior half of the IT band. I really want to make sure that the most posterior fibres are left intact, that is the capsulo-osseus layer, and actually was the original description of the anterolateral ligament, backed by Glenn Terry and even by Kaplan. So that is a very robust structure in the posterior aspect of the IT band. So then basically I can then dissect distally, you don't really have to go that too far distally, approximately it's about 8 centimetres. In reality, once you hit the vastus lateralis muscle belly, it's usually long enough. Then add an absorbable suture, just as a simple whip stitch, just so this facilitates passage of the graft underneath the fibroclateral ligament. So it's just a couple of throws on the graft. You can identify the FCL in a number of different ways, you can put it in a figure 4 position or you can even drop the leg under the table and go into various positions, obviously it depends on your set-up. And then once the FCL is identified, we'll do two capsular incisions, one anterior, one posterior. I'm going to take my medicine balm scissors and pass and make a soft tissue window underneath the lateral collateral, and then using some sort of angled clamp, this is a mixture of angled clamp passed from posterior to anterior, that is placed and then the graft is shuttled through. And then once we've shuttled that through, then we're going to fix it on the femur. Now there are a number of different options here. If you harvest a longer graft, you can take it a little bit more approximately and that keeps you really well away from your femoral tunnel. If you do that, you've got to be very careful and make sure you use lots of cautery to achieve haemostasis. And then the other thing is you want to make sure that that fixation point is right at the posterior cortex of the distal femur. Once that's placed, so I'm using a staple there, I'm going to talk about that in a second, I just basically double the graft back onto itself and then suture it. If you do use the tourniquet, make sure you release the tourniquet and make sure you do have haemostasis. Just as we're seeing here, there can be quite a significant amount of bleeding from the lateral genicular vessels, and so you want to make sure you've got good haemostasis and then you can re-approximate the IT band. So in terms of fixation point, there's been a number of studies looking into this. This is some work from Ivan Inderhoog in London, UK and Andy Williams and Andrew Amos's lab. And really these two points, one and two, as long as you're hugging that posterior femoral cortex, then you don't end up with issues regarding over-tensioning. And in terms of tensioning, placing the graft at less than 20 newtons of tension with the foot held in a neutral tibial rotation. Fixation devices, I do use a staple. It's inexpensive, it's easy to use and of course that's what we used in the stability so I haven't felt the need to change that, but it can have some irritation and instability with 10 patients out of the 300 that had to have the staple removed. Suture anchors may be a great option, they are more expensive and sometimes it's difficult just to be able to set your length, tension of your graft. And of course an interference screw, again more expensive but there's a significant increased risk of potential tunnel coalition, and so in which case then you need to go much more proximal. So if you've got to go more proximal, it's still a great option but just be aware you're into hard cortical bone, you've got an increased risk of cutting your graft, so make sure you've got a good whip stitch along your graft. So these are all options and they can all be utilized. So in summary, LET reduces rotational laxity, reduces graft failure, we get improved outcomes in revision ACL reconstruction. Thank you very much for your attention.

lateral tenodesis

ACL reconstruction

randomized clinical trial

rotatory laxity

graft failure