I do want to open it up to the audience, if there's any questions for the panelists on those different topics, please come to a microphone or just yell out. We do have a little bit of time for that. If not, I have a little bit of a case with our 13 or 14 minutes left to share with the group that maybe can bring out some of those points. I see a question back there. Dave Lintner, how are you? Thank you, everybody. I've been around long enough to worry about training. ACL Reconstruction always had an LUT. Then it went away. Now it's back. The reasons that it went away, I wonder if the panel could discuss why it went away and have those issues actually resolved. Just hear her, why vigilance? Maybe Al, you want to take that on? Sure. No, it's been a long time, but it's been a long time. It's a great question, great comment. You know, I think that the devil's in the detail, really, in some of the studies that were done previously. And one of the papers that often gets quoted and probably was the key decision-making factor as to why LET disappeared in North America was a study by Steve O'Brien and HSS. They looked at a, essentially a comparative study of ACL reconstruction with patella tendon grafts. They took all comers, and then they compared the failure rates, and there were no difference in failure rates. And there were some patients that had some increased pain, and they really didn't feel that there was any additional advantage of having a lateral tenodesis. But, you know, I think what you hopefully take away from these discussions here is that all the patients that we're talking about, we're doing, so it's an individual risk assessment in terms of their risk of re-injury. So we're talking young patients, meniscal deficiency, high slope, generalized ligamentous laxity, high-grade rotatory laxity. And so when you start drilling down into that patient population, we know our failure rates are significantly higher. And then when we do a study that's adequately powered, then we can see the benefits of a lateral tenodesis. Will we see that with a patella tendon or a quadricep tendon? And Volkow's already expressed his thoughts on that one. We may not in the lower-risk individual, but in the higher-risk individual that Chris is talking about, which has got the high slope and the generalized ligamentous laxity, that may be the patient where we see a benefit of a lateral tenodesis with a patella tendon graft as an example. I think even in the high-risk, I think those are all great thoughts. Even in the high-risk patient, I think you can get away with just an anatomic ACL. But what we're not talking about so much, but we should, is that each patient deserves a particular graft for them. Hamstring can be very good in a small notch, but it's a huge ACL that has a huge footprint. You ought to put a big quadriceps in there, and you have to make sure that your tunnels are adequate. And I think why people like LET so much, in my mind, is because it's just really very easy to add on, and it sort of covers everything like a Band-Aid. And I think there is a role for LET, but I think it can also be overdone. And I think what you're alluding to is maybe what happened to the lateral compartment and the over-constrained and all this. We haven't seen it yet, and this modern LET has been around now for, I don't know, 15 years or so. But there's probably a certain subgroup that deserves it. Maybe, Chris, you have that subgroup you just told me about. Yeah, I mean, I would just say, in the study we looked at our, is this on? The study we looked at our hypermobile group, the majority of them had BTB autographs, and that was a 24% failure rate. So I think, again, it's looking at these subgroups and probably throw a tibial slope into that. And so I feel pretty strongly that they're gonna find, if they look at subgroups that include this generalized laxity and high tibial slope, I think the LET or an anterolateral complex procedure will make a difference. So that's what I've seen in my hands and my own patients, and I think they're gonna find that, but we'll see. Just remember that the key phrase that Volker used there was getting away with it. And if you look at our stability data, 89% of hamstring grafts on their own did fine, but it's what you do about that 11% that failed. And if we can do something that is very simple, that can reduce our failure rates, in your individual patient, that young kid that you're working with and you wanna try and reduce their failure rates, it's a very simple thing that you can add into your surgical treatment. Question here. Yes, good presentation, thank you. So my question is about ALET versus ALL. So I first started with an ALET reconstruction of our breast technique using the holographic and then I'll use angiograms to do tibial task twice, and then criminal task twice. It's not a two-thousand dollar procedure, we can call it that. It's not like the LETs, we've done a bunch of those. What I found was, if you check the isometry, the recommendation, I think, was a little higher, which is eight or 10 millimeter proximal, down to about one or two millimeter posterior, or something like that. And it was never isometric. So in other words, I tensioned it at 20 to 25 degrees of inflation. When you flex it, it's tight. And so therefore, we finish your LET at 20 degrees and you flex it eight, and you go back and check it, and just on the right, again, it's looser for us. And so then I started moving it more posteriorly. So my question is, one, for example, do you use a LET, obviously you do, or do you use an ALL anymore? Do you run it under the fibroclateral, or on top of it? And where do you fix it on the femur? Should I start? So, you know, remember, so I'll start with the LET. It's a tenodesis, so it has a tenodesis effect as you come into extension. So the impact of putting it under the fibroclateral ligament, essentially you're using the FCL attachment as its fulcrum, and as long as you place your fixation point along that posterior cortex, you can carry on going more proximal, depending on the length of your graft, but as long as it's sitting posterior, there's been multiple studies that have shown that it's very safe to do that, and it's much more forgiving than an ALL reconstruction, in terms of, you know, with an ALL reconstruction, you have to be very careful of your positioning, because you can have an issue with over-constraint if you get it wrong. I think, you know, both techniques will work well. You mentioned that there's a cost differential. I think one thing to keep in mind, too, is, right, reconstructing an ACL is gonna be probably an anatomic procedure. The lateral side, by definition, what you're doing there is non-anatomic, which is not a disqualifier at all. A Latage is non-anatomic, but very useful. So, knowing this, I think there is a potential to make it too tight and make it difficult. So, an LET gets tensioned very little, just like Andrew Amos showed in his lab, with this isometric point, which is quite proximal, and more inflection. And one thing, I think, when I take an IT band for an LET, I always wonder, you know, do I rob Peter to pay Paul? The Kaplan fibers in the posterior part, so if you leave, if you don't leave the posterior IT band intact, you will disrupt those fibers, and they do control rotatory laxity, so you gotta be really careful. And if you do a free graft, I mean, maybe Chris, you can talk about it, but free grafts, of course, are quite big. Tibialis anterior is pretty thick. Yeah, and I also think with an LET, if you're taking out the central part of the IT band and then suturing it back, you may even be tensioning Kaplan's fibers to some degree, so maybe that's actually an advantage if there's a slight injury there. So I don't think there's enough data to support one versus the other. I just think you need to know the pearls and pitfalls of each. So I would just say with an ALL, I go over the top of the FCL, just because that's how I've done it, but you do need to make sure you're accurate, and what does that mean? I don't know that we know 100%. For me, I'm always posterior and proximal to the FCL, and I like to use intraoperative floral because I want to be as careful as I can about that point, because that point is critical to make sure you have the degree of isometry that you want. And then I go a little bit more anterior to the midpoint of Goethe's tubercle and the anterior aspect of the fibular head, and for me, I found that that gives me more of an isometric graft through range of motion. So some of it's gonna be kind of you testing things as you do your technique, but that's what works for me. But I'll use an LET too if somebody doesn't want an allograft, or if somebody has open growth plates, I'll use an LET because I don't want to drill a tunnel near the tibial fices. Yeah, for me, it's all LET, no ALL. I use the central slip of the IT band. I think there's two reasons not to use the distal extent. One, you already heard of. The second is if you're gonna pass the graft under the fibular collateral ligament, you've set yourself up for a very challenging and very oblique turn if you take the bottom of the IT band and then try to get under the fibular collateral and proximal to it. So I think technically, it makes a lot of sense to take the central slip, and then also from the Kaplan Fiber Stability perspective, it makes a lot of sense to take the central slip. I take about an eight to 10 centimeter length graft. I put it under the fibular collateral ligament, and I go just proximal and posterior to the fibular collateral ligament attachment site. And I first started with a staple, which I thought was very painful for the patient, but cheap and effective. I then switched to interference fixation, but that required you to drill across the femur, which I didn't love. And now I use a very small all suture anchor that's knotless, and I can take a little less graft, and I use almost like a noose technique. So I create the knotless loop. I slide the graft into it, and about 40 degrees of knee flexion, I tension the graft in that position by just sliding the noose down onto the graft to tighten it. And what I see in those patients is that when I bring the leg into extension, it tightens, and when I bring the leg into flexion, it loosens. And that's what you wanna see, is you want that to protect the knee when they're gonna be testing their ACL, which will be zero to 30 degrees of extension. What position do we secure the femoral side in? What position of knee flexion or extension? So the IT band and antilateral capsule structures are most taught in flexion. So I always struggle with the idea of fixing it near extension. I do understand that with an ALL reconstruction, you want to reduce the pivot shift, which happens near extension, 20 to 35 degrees. So, but my fixation is at about 60 degrees with the foot neutral and very little tension. So I use an O-Vicro, so I can't really over-tension it for the staple. Yeah, 60 degrees, sure that was safe in the lab, and it's shown to work clinically, so haven't changed. Yeah, I think Alan has a good paper on that, right? Looking at different flexion angles. And, you know, I do it about 40 degrees, but I think it's set anywhere from like 30 to 60. I actually do it more at 20 to 30 degrees. I don't know if we're completely anatomic, so what we're securing is exactly the same as the anterolateral complex. So I do 20 to 30 degrees, but what I do is basically just pull the graft up before completing the suture and run it through a range of motion to make sure the tension is okay. So I'll always kind of run through a range of motion before I secure it, but for me, it's 20 to 30 degrees with neutral rotation of the foot. Ashish? I'm also 20 to 30 in neutral rotation. There's a question here, I think. Thanks so much, that was really great. Thank you to the panel so much. I'm wondering how the panel will approach unilateral valve-guests, if you want to name them, physical febrile valve-guests. It must be something in the water in San Francisco. I'm just curious about, they were already hired at SCL, primarily SCL teenagers, kind of relaxing, playing soccer with physical febrile valve-guests, but in your film, you're not very SCL, I'm wondering how you approach that. I just have a, I have a girl, I almost included in my talk, I have a girl in that exact situation who, you know, you obviously know with soccer parents, they can be quite stressed about their daughters. She was just barely still skeletally mature. She looked like this radiograph you can see. The dad was so hyper-focused on this, he called Jimmy Andrews twice on his cell phone. The second time, Jimmy Andrews said, you don't need to call me anymore. I think you can find a surgeon in LA. So, super aggressive parents, and we just had a conversation about osteotomy versus a primary ACL reconstruction, and I think when you have, you disclose all the information and the data available, I think you let the family make an informed decision. In this case, they decided to just have an ACL reconstruction, and she's done very well. And we, because of her open growth plates, we've watched her alignment over a year, and it hasn't changed. We used an all-soft-tissue quad in an adult-style fashion because of her growth plates, but I think you just need to have that conversation with the parents. I think it's really hard to take a primary 15-year-old, 16-year-old soccer player and say, listen, you're gonna get a distal femoral osteotomy and an ACL reconstruction, but there's probably some parents who will say, yeah, that's what I want for my child. I'd do them together. If I was to do them, I'd do it together. And I think you just have to be careful, too, to make sure it's a purely coronal valgus problem and not a femoral and tibial torsional problem, because I've seen some people with asymmetric femoral and tibial torsional issues, and if you just do a purely coronal correction, that may not actually be addressing the problem that's there. I'll maybe take that as a little bit of a segue that we didn't get to this case, but maybe just a quick question for the panel. I don't know that we know the answers to this. This happens to be a patient who looks like they fell on a hardware store, but it had like three prior ACLs and then has a re-revision and an anterolateral ligament reconstruction, and I went back and looked at these final x-rays, and it points out exactly the point that you had just made. She was in unilateral valgus from day one. She has this increased tibial slope, but now there's some literature that talks about the lateral femoral condyle depth to height ratio, and could that predispose the patient, and so how much of these underlying osseous factors are there in these patients, and we treat them as a primary ACL just the same, but is this not really about whether it was a quad tendon graft or a patellar tendon or a hamstring, but that we had left these osseous factors that were predisposed to failure, and then eventually we just exhaust them by doing three or four ACLs, but maybe there were factors that are there. I guess a question, Volker, for you. You've published on this, Ben Ma and Drew Lansdowne have, and there's a great paper out of Turkey in the recent journal. If you see these kind of factors, was this a miss the first time? Should some of this have been corrected before the fourth ACL? So there's no way that in this case I wouldn't get a 3D CT scan, so I understand it better, but the slide that I showed about the statistical shape modeling, all the parameters that are off in an ACL injured patient are in this particular case. Now, I would not act on this on a case zero. I would look at it, and I'd probably be pretty upset about it, and I'd point it out to them and say you have a high slope, you have these things, but I currently have not acted on these slope issues. Probably would do an LAT, things like that, but yeah, in this scenario now, after the hardware store there on the femur, I would make sure that the ACL is actually anatomic. I wouldn't just accept that based on an x-ray. It doesn't look terrible. Would get a 3D CT scan and probably work on the distal femur. Would it be fair to say, Volker, if you had multiple of these factors at the primary setting that this may be one of the cases that you would do a primary LAT? Yeah, for sure. The question is would you do a primary slope-changing osteotomy and distal femur varizating osteotomy, which would probably correct all this, and she would never have four failures, but do you know that when you meet that patient for the first time? So right now, I would say no. I would not act on this. We need a little more data. I think one thing to think about, Shisho, as well, is I totally agree with what Volker's saying, but your preoperative lateral weight-bearing view and stance phase, right? If you see that anterior tibial translation, and we see a lot of that in the Middle East. We see these really huge translations even in the primary scenario, so then you've got this very lax soft tissue envelope. Those are very, very challenging to control just with a graft and an LAT, so there may be some indications to do a slope-production osteotomy in the primary scenario, but it's pretty rare, and certainly pretty rare in North America. And to add on to it, in this case, she was a hyperextender of 10 degrees, so I don't know where you factor that in, but we're over time, so thank you all for joining the ICL, and thanks to the panel. Thank you.

ACL reconstruction

lateral extra-articular tenodesis

LET

graft options

post-operative fixation