Good morning, everyone. Thanks so much for being here at 7 a.m. on the first day of AOSSM, we appreciate it. I am Mary Mulcahy, I'm excited to moderate this and have really excellent faculty. So we're just gonna start by introducing everyone, but before we do that, so the focus of this, of course, is optimizing outcomes following ACL reconstruction in 2024. So let's, oops, sorry. I have to use this clicker. Oh, there we go, okay, so now maybe we're advancing. So first we have Dr. Cassandra Lee, who's Chief of Sports at UC Davis. She's Professor in the Department of Orthopedic Surgery, and she is Official Team Physician for the Sacramento Republic FC Professional Men's Soccer Team. Her talk is gonna focus on BTV as the gold standard for ACL reconstruction. Myself, I'm Chief of Sports at Loyola and Team Physician for the Loyola Ramblers. I'm Professor in the Department of Orthopedic Surgery, past President of RJOS and Team Physician, as I mentioned. I'm gonna talk about how quad autograft is a reliable and reproducible option for ACL reconstruction. Clay Nolley, unfortunately, couldn't make it because of flight-related issues. So Dr. Simon Gertz from Brigham and Women's in Boston has very kindly offered to step in and give Clay's talk about ACL reconstruction in a female volleyball player. These patients always need some type of augmentation, so talking about internal brace and LAT. And then Dr. Adnan Saithna, who's an Associate Professor of Orthopedic Surgery at the University of Arizona. He's also Honorary Professor in the School of Science and Technology in Nottingham Trent University. His talk is going to focus on male collegiate basketball player with a re-tear of prior ACL reconstruction, and actually I think he's talking about a re-revision. And then last, but certainly not least, I also want to acknowledge my colleague, Dr. Berthe Ver, who is a sports medicine surgeon at Oslo University Hospital in Oslo, Norway, who's up here as faculty, too, to help contribute to the discussion. So thank you guys so much for being here, and actually we're gonna kick off with Dr. Lee. Sorry, sorry, sorry. All right, so we're going to start off the first case with a 20-year-old football player, and I'm going to talk about why BTP is still the gold standard. It's a good way to start the morning, so all right. like I said, video. So all right, so let's introduce our case. So 20-year-old male football player, Division I, running back, had a non-contact injury during a game. Exam-wise, you see him right there on the sidelines. And you see exam, still full range of motion, 0 to 130, no hyperextension. Effusion is increasing. Lockman is 2B, and you do get a pivot shift of about 2 plus. So MRI-wise, this is what we see. Yeah, this is where we crash it. So what's it playing? OK, so it's super duper fast. I'm sorry. I want to try to slow it down, but it's not letting me slow it down. And all right, so what you can see here, I think on the kernels, is I just want to show you that standard ACL tear, bone bruising that we expect, and an anterior horn lateral meniscus tear. OK. So when we look at our patients, what is our decision-making process? So starting out, which is a little bit beyond the scope of this ICL, but we think about where are they in terms of season, when are the realistic expectations to get our player back to play, how many years of eligibility, and what other plans do they have in terms of the future. When we talk about treatment options for the ACL reconstruction, we can talk autograft versus allograft, quad tendon, BTP, hamstring. And then the panel will talk about all the different options like in terms of suture augmentation, histologic augmentations, or extra-articular augmentation. And then different treatment options for the meniscus tear, what to consider in terms of weight bearing, non-weight bearing, do you trim it out, do you repair that and keep it in place. So in terms of graft choice characteristics, requirements in general, we want a graft that's about seven centimeters in length, cross-section area ideally should be something close to the ACL. And so we've seen these biomechanical and histologic studies looking at what exactly the characteristics are of all our tendons. Overall, all our graft options are stronger than the ACL. Our stiffness is very similar and stronger. And cross-sectional area, the only thing is BTP might be a little bit smaller than our ACL, just in that ribbon-like central portion. But the healing biologic incorporation is fastest and superior with patellar tendon. So just as a quick summary, BTP autografts, high load to failure, it's faster graft incorporation. Within six weeks, you have then intrasubstance failures of the graft. So we know that bone-to-bone healing occurs reliably and quickly. In general, all the literature will show us that there's a higher proportion of return to play, especially to pre-injury level of activity and a potentially lower risk of graft rupture. However, the flip side of it is that there's always a risk of patellofemoral pain, loss of range of motion, patellar fracture, and even patellar tendonitis. Hamstring autograft, just for completeness and discussion, it's soft tissue-to-bone healing. But again, the failure occurs at mid-substance at roughly three months. So slower than the BTP, but certainly does incorporate fairly fast. It has a lower donor site morbidity compared to patellar tendon, lower anterior knee pain, lower risk of patellofemoral arthritis. However, there's a risk of damage to flexor strength. There's variability in hamstring size in terms of morphology for the patients, anywhere from a single strand to eight strands to try to create that fat enough graft. And there's always issues of fixation of hardware limitations and delayed incorporation. Quad tendon, I'm going to skip over because Dr. McCahey will be talking about that. But I think one of the big things is quad tendon definitely has a lot more collagen than patellar tendon in cross-section. So in this literature, if you asked for team physicians, at least in the United States, if we were to have two scenarios, where you have a 20-year-old Division I football player running back versus a 25-year-old recreational player, overwhelmingly, team physicians in this country choose patellar tendon autograft as a gold standard. You can see when you get to the recreational athlete, not necessarily the high-demand, high-cutting, twisting, pivoting athlete, that that number can be a little bit more divided in terms of hamstring versus patellar tendon versus others. We know that allograft is not a great option. So just putting it out there to start, that allograft is not a great option in this patient population, right? The young, the active, high risk, and high return to play. Allograft is four times higher risk than autograft, and odds of re-tear. But we know that BTP versus hamstring, overall, maybe no difference. There have been multiple studies looking at cohort studies, as well as systematic reviews in comparing patellar tendon to hamstring, when we're now looking at autograft. Overall, looking at the Scandinavian registry, we know that BTP has less risk for revision, but slightly more pronounced. Sorry, this is not clear in terms of how I wrote it. But it's definitely better in terms of patients who are in cutting, twisting, activity sports. That risk is much lower compared to hamstring tendon. And these next three studies are meta-analyses that have gone on since from 2011 to 2014 to 2019, looking at all the different trials that have been within the literature, looking at functional scores, IKDC scores, and even OA. Overall, patellar tendon always performs better in terms of Lachman, pivoted instrument laxity. And there's definitely a trend towards a little bit less strength in terms of extension. And hamstring always shows a little bit more risk of loss of knee flexion strength. This meta-analysis shows that, again, patellar tendon is better at pivot shift, and able to return patients to pre-injury activity level. And then this meta-analysis looks at both grafts are viable options, but there's a slightly higher failure rate for hamstring tendon. So overall, I think the literature does show us that both are great options. Autograft definitely more superior than all allograft. But patellar tendon probably a little, just a hint, better than the other soft tissue grafts when it comes to high activity patients with cutting, twisting, and pivoting. So the MOON study shows us that odds revision is two and a half times higher for hamstring compared to patellar tendon. So certainly there is much more of a bias towards patellar tendon as being the gold standard. Now the question is, how do we look at quad tendon versus hamstring and BTP, right? How do we look at the new kid on the block that's not really that new anymore, right? We do have longer outcome studies showing that quad tendon has less donor site morbidity. And functional outcome scores are very similar to that of patellar tendon, as well as hamstring tendon. In the long-term, we know that patellar tendon in 20-year outcome reviews, so it's certainly very long-term outcome. Graft-free tear rate overall is about 11.5, contralateral is about 12.5%. Arthroplasty is about 5%. Overall, there is some arthritis that is present in about a quarter of patients. These are typically associated with meniscectomies, and overall. So overall, this is what we did with this patient. So I did ACL reconstruction, patellar tendon autograft, and then I went ahead and repaired the lateral meniscus and made him touchdown weight-bearing for about six weeks. So it did slow down his rehab a little bit, trying to preserve that joint to prevent that risk of arthritis down the road. So in conclusion, patellar tendon is the gold standard for young, cutting, twisting, pivoting athletes who are at high risk. We know that overall in the literature, this is about 81% return to play, with about 70%, compared to 70% for hamstring tendon. Graft incorporation is faster, about six weeks with bone-to-bone healing. Overall, patients will have less laxity, less of a pivot shift, and lower re-tear rates. However, you do have to advise, patients will have some anterior kneeling pain or anterior knee pain, and potentially higher risk of patellofemoral arthritis. So, thank you. All right. Fantastic talk. We will try to pull this up and see. Perfect. Okay, I will, let's see, it's gonna flip up. I'll flip through the intro slides again, real quick. If it cooperates. Okay. So, I'm gonna go ahead and get started. Okay. Okay, perfect. So, switching gears just a little bit, I'm gonna talk about a 14-year-old male soccer player, and why quad autograft is reliable and reproducible. These are my disclosures, none of which are directly relevant to this talk. So, for this case, this patient's a 14-year-old male. He presented after injuring his left knee while playing soccer. He had a misstep, felt a pop. He had immediate pain and swelling, and he was unable to continue playing. On exam, he did have some mild swelling in his knee. He was able to straight leg raise, and at this point, his knee range of motion was actually quite normal, but he had a little bit of pain at the extreme of flexion. He had some tenderness over the lateral joint line, and did have pain with McMurray test, and an obvious positive, obviously positive Lachman. These were his x-rays in clinic, which were totally normal, and then a few cuts from his MRI. So, seeing the typical bone bruising pattern, the lateral meniscus tear, and in case you didn't see that clearly, there's the nice green arrow sign, his ACL tear, and then the medial meniscus actually looked fine. So, we will get back to that just a little bit. Dr. Lee touched on some of these things, too, but there are a lot of factors that influence what graft we choose. Certainly, surgeon experience, preference, and comfort level are among the most significant that contribute to graft selection, but we also take into account, of course, patient age and activity level, their sport or occupation, and their desire to get back to work and play. We also need to consider their comorbidities and BMI, and then evaluate for high-grade pre-op knee laxity, any history of previous surgery, of course, a prior ACL reconstruction, and then have a good understanding of the patient's preference and expectations, and then any rehab concerns. So, quad autograft, there are so many advantages. It can be used with or without a bone block. It's a very strong graft. It's large diameter. It's robust and reliable. It can be used in a primary or revision setting, and it really causes minimal donor site morbidity in terms of anterior knee pain and anterior numbness. We do have to acknowledge some of the disadvantages. There's an increased risk of proximal patella fracture if you use a bone block, and there's a lack of bone-to-bone healing if you use an all-soft-tissue graft. There is a risk of injury to the rectus femoris if the harvest goes up into the muscle belly, but as Dr. Lee was talking about, too, if you harvest, really, about a seven-centimeter graft, that risk is really low, and then risk of loss of extension and quad weakness, which is similar to what we see with BTB. A little bit about the anatomy of the quad. It's classically described as trilaminar, where there's a superficial middle and deep layer. There's also a thin, fatty layer that separates the rectus femoris and vastus intermedius, and for any of you that have either harvested this yourself or seen it or seen it presented at meetings, there is a very clear fat layer, and then, based on MRI, most of the time, the quad is three layers, so 56% of cases. The length ranges anywhere from about seven to eight-and-a-half centimeters from the myotendinous junction to the superior pole of the patella, so that means you could harvest an all-soft tissue graft, which is what I tend to do, or you could use a bone plug from the proximal patella if you wanted to do that, and the width ranges anywhere from about two-and-a-half to three centimeters. The vascular anatomy is very important. There are contributions from three arcades, the medial, lateral, and peripatellar. The medial arcade, it's anastomosis of the femoral artery and then several other branches, and it's between the muscular portion of the vastus medialis and the medial portion of the rectus femoris and vastus intermedius. The lateral arcade also is really important to consider, and these medial and lateral arcades anastomose within and below the rectus femoris, so what's important to take away from this is harvesting the graft in the central third of the quad tendon is really important because it spares the lateral perforating vessels, it avoids violating the quad muscle, and decreases the risk of developing a post-op hematoma. Very briefly about biomechanics, there are several studies demonstrating that quad is superior to BTV in terms of load-to-failure, strain-at-failure, and Young's modulus of elasticity. It has a significantly larger cross-sectional area and a significantly greater ultimate load-to-failure. Dr. Lee highlighted this study, but this is a very good study in AJSM, and if you guys haven't seen it, I encourage you to look at it because it's comparing quad and hamstring and BTV. So when looking at quad and BTV head-to-head, they were very similar in several parameters, but quad had less donor site pain. And then quad versus hamstring, again, similar in several parameters, but quad showed improved mean Leishman scores. So the main takeaway from this was that quad autograft has comparable clinical and functional outcomes and graft survival rate compared with BTV and hamstring autograft. It is a fantastic option, and it shows significantly less harvest site pain compared with BTV and better functional outcome scores compared with hamstring autograft. So getting back to our case, our 14-year-old male soccer player. So I included these pictures. These are not from this specific patient, but I just included them to show you how I position my patients for this case. That's on the far left. So I put the affected leg in the leg holder and the contralateral leg. I actually used a lithotomy boot, which works fantastic to get the leg out of the way, abducted and flexed a little bit. That central picture is drawn out the incision, which actually I make probably it's about half that length. Now this picture is from about a year ago. And then I mark out the VMO. And then on the far right, you can just see the quad tendon exposed. And I will use a plastic ruler that I cut at about two centimeters. And I just fit that into the incision and I mark out the central third. So it's about 10 millimeters that I mark out just at the distal end as I harvested off the patella. And you can see the graft just after that has been harvested and the right is starting to prepare the graft. So there are several companies now that are making types of instrumentation and the sutures to prepare this. So this is not meant to highlight any one particular company, but you can just show this. This is really important as you're learning how to prepare the graft. Take time and be careful with this because obviously the fixation depends on that suture being secured. And then let's see if we can get this. There is a video here, but there we go. Okay, so this is just a very short video showing how to prepare the graft. I find it helpful to have someone help me. So like I have someone holding on both ends. You can sometimes rig it up to like connect to the graft master, but this is just what's worked well for me. So this is just to show you briefly, like you secure that tip to the end of the graft. And I always start with the femoral. What's gonna go into the femoral tunnel is the end that is harvested off of the patella. That central picture is after the graft has been prepared. And then on the far right is after I've taken those two cards off. And then you can just see how the sutures are laid out. So there's a cortical button up at the top. That's gonna be suspensory fixation on the femur. And then the sutures at the bottom are gonna come out the tibial tunnel. So I will drill a full tibial tunnel. And then I fix on the tibia with a small metal ABS button. And you'll see what that looks like. This is just the graft efforts prepared on the back table. And then I wrap a damp lap pad around that. I don't tend to soak it in Vanco. I mean, we can talk about this, but that's just how I have that prepped. So I actually do all of that before I do anything intra-articular. Then these are some of his intraoperative pictures too. So medial meniscus was fine. On that far right picture, you can see the ACL tear. Here's his lateral meniscus tear. And so we repaired that. I brought in a rasp first and then used an all-inside meniscal repair device. And then on the far right is his final repair. And then I drill the femoral tunnel from inside out. So this is just the femoral guide. And then on the right-hand side, you can see, see if we can get this to play. This is just after I've drilled and taking out the drill and then we'll come down this tunnel with the suture. We want to see that donut, of course, right? That tells us that the lateral femoral cortex is still intact. And this is just what that looks like. And then on the right is just our tibial guide. So again, I drill a full tibial tunnel. You could do this all inside though too, of course. Here we have the cortical button coming up into the joint. And then the video on the right is just showing that actually advancing. So I will actually typically watch the button advance up into the femoral tunnel by viewing from the anteromedial portal. And it gives you really a fantastic view to watch that button so you can see it as it's passing up and as it gets to kind of the aperture on the lateral femoral cortex. Let's get this one to play. So the button has already flipped and now we're advancing the graft. So again, I'm still watching this by viewing from the anteromedial portal. And I always check the cortical button with a mini C-arm. So however you want to do it is fine, but I think that it's really important to check that and make sure that it is positioned appropriately on the lateral femoral cortex and that it's not over the IT band. Perfect, so these are this patient's final graft in place. And then this is the ABS button. So the sutures are coming out the tibial tunnel and then you just fit that button on there. And then it's just, it literally, as you shimmy those sutures back and forth, the button advances and it seats right in the aperture of the tibial tunnel. And then I tend to back this up with an anchor. I don't think you absolutely have to, but I was previously using an interference screw, a biocomposite interference screw and backing up with an anchor. So that has just sort of become habit. And then these are the patient's final x-rays. So in summary, quad autograft is really a fantastic option for primary or revision ACL reconstruction. Patients have great functional outcomes, minimum morbidity compared to some of the other graft options. So I would encourage all of you, use it now, use it often. It is really a fantastic graft. So thank you so much for your attention. Next up, we are gonna have Dr. Simon Gertz talking about augmentation options. Oh. Maybe not. I was under the impression that Clay's talk was uploaded. No? Okay. Okay, well, maybe not. Okay, little twist in the plot. We will talk, we will have plenty of time to talk about that. I'm very sorry. I really thought that Dr. Nully's slides were uploaded. So that's okay. He had last minute flight issues yesterday, but we will cover all that stuff. So plenty of time to talk about LET and internal brace. Sorry, Simon. Okay, let's go back to this. All right, so then, I guess we will round it out with Dr. Stathna talking about re-revision ECL. Good morning, everyone. So I'm talking about, let's get this working. All right, so my case is a 35-year-old female. She's an ex-collegiate volleyball player. It differs a little bit from the brief Mary gave me, but the principle of tackling a revision ACL reconstruction is what we're really interested in here. So this patient was referred to me by her physical therapist. She had undergone a revision ACL reconstruction six months prior with another surgeon, but her physical therapist referred her because they were concerned about her lack of progress, pain, and swelling. When I saw the patient, she relayed a history of five previous failed ipsilateral surgeries. So the first was in adolescence. She had an ACL injury, which was deemed to be partial in 2002, and she underwent a thermal shrinkage and partial medial meniscectomy, and that really sets the tone for what happens next. So the following year, she underwent a trans-tibial BTB autograft ACL reconstruction, and then in 2005, she hadn't really got back to a high level of sports, and she underwent a thermal shrinkage for what was described as a partial ACL tear, and she also underwent partial medial and lateral meniscectomy. That's really not surprising to some extent because obviously if she has persistent instability, we know that that leads to progression of meniscus and cartilage injuries. By 2012, she was continuing to have instability symptoms, and again, she was determined to have a partial tear. She underwent a debridement, and this time, instead of thermal shrinkage, PRP was attempted, and further medial and lateral meniscectomy and chondroplasty. Again, progression of those meniscus and cartilage lesions. In 2023, she saw another surgeon and underwent a revision ACL reconstruction, this time with allograft. It was found pre-operatively that she had a grade two pivot shift and lachman. She also was determined to have a proud femoral screw from the previous trans-tibial surgery, which was close to the articular cartilage that was left in situ because it was non-anatomic, and an antramedial portal drilling technique was used for a new femoral tunnel. The tibial tunnel was reused, and allograft was used, but after the surgery, the patient told the, or rather, the surgeon told the patient that maybe we should have grafted the tunnels. So the patient's perspective was that she had increasing pain and swelling at six months post-operatively. She had increasing knee stiffness despite physical therapy. She couldn't do any sports. She didn't trust her knee. It felt unstable. However, after the revision, it did feel more stable than any of the previous four surgeries, but she still had persistent instability that stopped her from doing any recreational activity. She drastically changed her expectations, and all she wanted to do was easy hikes, no pivoting or twisting expectations. So my workup for a failed revision ACL reconstruction is a battery of x-rays, including AP, a true lateral so we can assess tibial slope, sunrise, PA30, long leg alignment x-rays. I always get an MRI. I get a CT only if I'm unsure about tunnel positioning or widening or planning an osteotomy. Obviously, physical examination is a cornerstone, and then I also like to obtain labs to do a check for any sort of infection parameters. So this is the patient's imaging. So on the left-hand side, you can see a simple AP view of the knee. You can see that non-anatomical femoral tunnel from the original trans-tibial surgery, which might explain why she had persistent instability from the very outset. However, you can also see that there's some widening around the femoral and tibial tunnels. The middle image is the true lateral of the knee. One of the discussion points we can have is about how you measure tibial slope. I prefer to use the posterior cortex as my landmark for measuring that slope, and in this case, it was 13 degrees. There was no abnormality of coronal plane alignment. I won't play a video of the MRI because they're often difficult to interpret, but here are some key images, and the key findings are that the radiologist felt that they had an intact ACL graft, which I didn't really agree with. There was cystic change along unincorporated tibial tunnels, which is something that we could really see from the X-rays. There was extensive metal artifact in the synovium, which had increased significantly since the revision surgery. Thankfully, there was no high-grade cartilage lesion, but there was some small grade II lesions in the trochlear and medial femoral condyle. There was a persistent central patellar tendon defect, which was asymptomatic clinically, 50% loss of the medial meniscus, no new tear, and an attenuated lateral meniscus, but also no new tear. When I look at these images, although the radiologist reports it as an intact ACL graft, I see redundancy, curvy linear fibers rather than straight fibers, high signal within the graft, widening of tunnel cystic formation, especially around that tibial tunnel, so I didn't really feel that this was a great-looking graft. I did get a CT in this case. I was concerned about that cystic change, and you can see that there's large tunnels, both on the femoral side and the tibial side. In terms of the physical exam, that matched up with the long-leg alignment. There was no coronal plane abnormality. She had a normal gait. She did have a large effusion in synovitis, generalized joint-line tenderness, negative McMurray's. Range of motion was a little bit restricted, particularly in extension, but that was something that I was actually able to resolve fully at her first appointment with me. She had arthrogenic muscle inhibition, probably due to the fact that she had a large effusion, and we can talk about how we managed that in the discussion. But anyway, I was able to restore her full extension at that first appointment. I was able to thoroughly examine her knee. She had a grade three Lachman, grade two pivot shift. The rest of the knee ligaments were intact. So my treatment plan was a two-stage revision ACL reconstruction. The first stage was a synovectomy, removal of hardware, slope change osteotomy, and bone grafting of tunnels, and the second stage was a revision ACL reconstruction. However, the patient was not in agreement with this plan. She did not want another ACL surgery. She felt that she'd already had five previous ACL surgeries which had not been successful. She also was very apprehensive when I discussed a slope change osteotomy, and I'd be grateful for my colleagues on the panel to give me their advice on that, and also from the audience, if you have any tips, how to better explain osteotomy to patients so that they're more accepting of this as an option. I tend to find that they tend to be pretty apprehensive when we first raise that topic. Anyway, the patient requested removal of the metallic screws. She was very worried about the metallic synovitis and the metal debris, so that's what I offered her, and you can see that there's a torn internal brace there on the left, or I should call that suture augmentation, torn suture augmentation, and the graft is pretty shredded. Yes, there are some fibers intact. We can tell that from the MRI, but really it's not functional, both in terms of her knee laxity parameters and on probing. So anyway, she was very happy for about six months, and then she came back with worsening instability, and so I planned to do the original surgery that I'd recommended to her, which was two-stage revision ACL reconstruction. So I did a slope change osteotomy. I like to plan these out carefully. I think if you're doing a big number, then maybe this isn't necessary to do, but I find these 3D CT images and planification very helpful. So the key findings here are that her posterior slope was 13 degrees. My plan correction was to eight degrees. I found the CT particularly helpful to help me better understand exactly where I'm gonna position that plate, but one of the other key features here is, I don't know how easy it is to see, but we can actually see where the original tibial tunnel was, how close it is to the plate, and also we can see where it's gonna lie here in relation to the screws and a planned trajectory if you were gonna do this as a single stage, but in this situation, I'm not doing it as a single stage, so it wasn't that useful to have that information here, but it can be. So here are my pre- and post-operative x-rays. On the left, 13-degree slope. Post-operatively, eight-degree slope. So I found that pre-operative planning very helpful to get a precise correction, and then moved on to, in the same setting, doing bone grafting of the widened tunnels. I used bone dowel allografts. On the femur, it was a 16-millimeter, and 18 on the tibial side, which you can see in the lower picture. And then my plan now is to proceed to the second stage revision, ACL reconstruction in six months. Hopefully, those tunnels will have incorporated, but some questions I have is, how long to leave it before going ahead? Obviously, those are some pretty big allograft dowels, so do we leave it a bit longer than normal? Do we obtain a CT scan to check for incorporation? Graft choice, we've had lots of good presentations on that, and we can discuss that in more detail. Just to remind you, they had a previous BTP autograft, and then some unknown allograft for the revision. We've already heard that allografts are not a great option, much higher risk of refailure, so that's not really something I'm considering. My current thinking is that I'm gonna proceed with a revision ACL with ipsilateral quads. I am concerned, however, about the fact that she does have patellofemoral degenerative change already and has a persistent patellar tendon defect from the prior harvest. And I'd also definitely add in a lateral extra-articular tenodesis here. We published in Arthroscopy Journal last year a systematic review demonstrating that in the revision setting, a lateral extra-articular procedure significantly increases or rather improves knee stability and reduces graft failure risk, whether that's a modified Lemaire, which in this situation is my preferred choice since I'm doing a quads-tendon autograft or an anterolateral ligament reconstruction. Thank you. So I think, actually, before we transition to just general discussion, Adnan, a few questions maybe to clarify about that case. You probably said this, but can you remind us how old the patient was or is, when you're taking care of her? She's currently 35. She's 35. So how old was she at her initial procedure? I think it was 14 or 15. Okay. And the thermal shrinkage, so was she cared for the entire time within the United States or did she have some care outside the country? No, all her care was in the United States. Interesting, okay. Yeah, I was just curious. And any other questions about, or any other questions from the audience, too, just about that particular case before we just transition to general questions? I did, and it was negative. But yeah, I did that for any revision ACL. Great question. Yes, please. Did she play for the volleyball team? Yes, she did. Well, I mean, I don't know. Obviously, I'm basing it on the history that was relayed to me. I didn't examine any at the time. I didn't have medical records from then, but she did play collegiate basketball with what seems to be some symptoms of persistent instability. That's a great question. I think that we don't have a definitive answer on where we should correct to. 12 degrees is my threshold for doing a slope change osteotomy and what we need to be mindful of is that the more aggressive that correction is the more we stress the PCL and for sure you can have a PCL rupture as a result of an over correction. So I basically took a survey of people who do lots of slope change osteotomy and came up with that figure of 8 degrees. I think that's what most people are aiming for but it's not really robustly scientifically demonstrated that that's the correct figure. Yeah if you look in the literature what is out there in terms of how much to correct and what degree what is a critical critical number you want to correct at. I think DeJure's group is one who had the kind of largest case series that looked at placing 12 degrees is kind of like your critical threshold but really that case series is only you know 50 some odd patients if you look at their outcomes and then I think the Santee group is kind of where they looked at correcting that towards eight nine degrees but I think the French group the digital I'm sorry they're both French. My bad. So but the DeJure's group looked at correcting that down to four to five degrees. So I think it's not clear as to what that threshold should be and I guess my question to you know just my thought process is that you know so when you see these patients who have that primary ACL secondary ACL tertiary ACL like now they've had three revisions into that should that threshold be different at different degrees of revision right like so if you're the first if you're at your first revision you know would you correct if there are like 15 degrees or would you correct at 10 degrees you know and then move that downward so that's not hashed out yet. Right but I think maybe the point of this ACL is that let's get it right the first time around so we don't have to see that 35 year old patient you know for her fifth time. I mean she actually had two ACL surgeries but you know if if you count some thermal shrinkage or debridement NPRP she had five surgeries on her ACL but only two actual ACL reconstructions. Yeah I don't know if we have a good handle on what percentage of surgeons within the U.S. or outside of the U.S. would do this type of osteotomy in a primary ACL like I I don't know I mean obviously it's kind of scary you know to for that to be done at the primary ACL but anyway it's something to think about because yeah I don't think we know at what point should we doing this like at the first revision or just at the re-revision like I don't know. Any other questions about that case before we transition just a little bit? Okay Simon would you mind I'm very sorry again about the slides but I did want to give Dr. Girtz the opportunity just to talk give us your general thoughts about augmenting ACL reconstruction whether we're talking about suture augmentation or lateral sided augmentation and what some of your key indications are so I guess let's start with lateral sided augmentation what are your thoughts if you do it when you do it and what procedure do you tend to use most often? Yeah thank you so I use this very sparingly to be honest with you and as you're finding out I got you know as to be up here availability being the most important ability okay. And expertise don't let him sell it he can't sell himself short. I'm a fairly active ACL surgeon but in my hands as I said I use this very sparingly. We don't put grafts in my in my practice of any origin that are less than nine millimeters and then obviously I'm very fanatic about my tunnel position. Usually when I hear oh we added at the end of the case when there's still some laxity that confuses me because normally you know if you plan your surgery carefully there shouldn't be any residual laxity. With people who hyperextend and generally on the opposite knee for high-risk young patients that go back to high-risk activity and for soft tissue grafts I will augment with an LET. I use the modified Lamer as well. I use an anchor I don't use staples anymore even though the stability trial data is always staples so always a little bit conflicted of going away from that. In general I would caution that this is not a completely low risk add-on. Wound healing issues if you do enough of them are not zero. Particularly in complex cases when you use a brace that brace strap is going to be right on your LET incision and can lead to some issues. So hemostasis and meticulous wound closure there and surveillance in my mind are important. I'm always also a little bit conflicted because when you look at it the LET builds for almost as many RVUs as the ACL itself. So when I see these numbers that people added to every single ACL I'm a little bit I question that I don't think it's necessary in my hands to be honest with you and I do a lot of ACL surgery. I don't routinely perform in turn bracing of my ACL. I know that that comes with the button but I usually take that tightrope out. So I don't have any particular experience with that. I want to add a comment so when we talk about adding suture intra-articulately I guess to Dr. Seitz and I would say with that I mean there's a lot of kind of a disaster dumpster fire disaster going on in that patient's knee but looking at that suture that was just shredded inside that knee how much of that do you think is actually contributing to that synovitis? Because I've had a couple patients come through young patients who've had that augmented intra-articular augmented ACL from a soft tissue autograph so like a hamstring and unexplained synovitis within the joint. Again biopsy to look for infection parameters can't really figure it out but can't help but feel that that suture might be adding to something at least in some patients. I know data is trying to come out of as to how safe it is. Yeah for sure I think that's definitely a potential cause of synovitis. You saw from those images that the ACL was also kind of shredded so that probably can cause synovitis and there was also unexplained metallic debris in the joint. I'm not really sure why that was worse after the revision. That screw from the previous trans-tibial surgery was well away from the new tunnels so I don't really have a good explanation for that but for sure all of those things can contribute. But I'd like to make a comment about the role of lateral extra-articular procedures going back to the previous discussion. I respectfully disagree with my friend here. So from my perspective there's a few things to think about. The first is do we need to improve the results of ACL reconstruction and all of us who are doing ACL reconstruction will be well aware that there's certain high-risk categories. A really good example of that is our local young female soccer team. We know from the literature that the rate of graft rupture in this population is 30%. So for sure we need to improve the results of our ACL reconstruction and there's lots of other high-risk groups which I won't go into but that's the basic premise for this. The second basic premise for this is that when an ACL injury occurs and an ACL reconstruction is performed we can't restore normal knee kinematics unless we address all the secondary restraint lesions. There's multiple MRI studies and also lateral exploration study demonstrating that when you have an acute ACL injury the rate of injury to the anterolateral structures is 70 to 90%. We've also demonstrated that these typically do not heal. The healing rate is very low and so if you're only doing an ACL reconstruction and you're not assessing or rather evaluating and dealing with all the secondary restraints then there's a high chance of persistent instability. Now you might not be able to detect that clinically but in the in the laboratory we can certainly detect that and these things add stress and abnormal kinematics affect the graft healing and abnormally load the graft and that's one of the reasons that we have these high rates of graft ruptures in select populations. We also know that doing an extraarticular procedure is very effective. There's numerous studies we have the stability study for the modified lamar and Bertrand who's sitting right there with the Santee study group has numerous comparative studies demonstrating that when we add a lateral extraarticular tenodesis we significantly reduce graft rupture rates. Now that brings me on to Cass's talk about BTB graft being the gold standard. Last year we published with the Santee group a study of 2,000 ACL reconstructions isolated BTB versus ACL reconstruction performed with hamstring tendons and a lateral extraarticular procedure which was ALL reconstruction. We demonstrated that if you have an isolated BTB ACL reconstruction theoretically the gold standard that the graft rupture rate is threefold higher than if you have a combined procedure. So I think that what we need to do is move away from the idea that any of the three main graft choices are superior to the other that hasn't really been demonstrated very clearly in the literature. They're all good options but what we need to do is think more globally and to address thoroughly the secondary restraint lesions including the lateral extraarticular structures. Thanks for sharing all that yeah and definitely I want to hear Bertha's perspective from Norway and Europe about what you guys are doing from with LAT and suture augmentation. Yes I do agree that we should use LAT more than we do maybe not in every case like Bertrand and his team is doing. I also use it more and more and definitely in revision cases. What I wanted to comment now was I would be careful to use an MRI finding to decide what I'm doing with my patients because we know that from many many other issues that MRI is overestimating the injury. So I would never like say to my patients that I will do your MCL because you have a finding in MRI. I will always do the clinical examination and for me that's the same with the lateral structures. So you cannot base your decision and diagnosis on the MRI. That was my comment to that. But anyway then I agree a lot with Cassandra that BTP is also my primary choice. That's for Norway. For you guys I guess Scandinavia is all the same but in Sweden they do like a 98 percent hamstrings but in Norway it's 70 percent BTP. So we are not totally similar and yes I like the BTP for many of the same reasons as Cassandra said. The results for quad in the Scandinavian registries have a little bit higher revision rate than BTP. But we think that is because of our experience because we don't use it so much so we don't have the same routine for the quad. And Martin Lin and his group has proven that the revision rates are higher for those who are not doing it as often. So high volume quad has the same results as BTP in the registries. Thank you for sharing all that. Berta before you pass the microphone off can you just summarize for us what are your indications for doing an LAT or lateral sided procedure and then do you ever use suture augmentation or internal brace type construct? I never use internal brace in my ICLs. I've been working with Lars Engelbretsen who will never let me do that because they have bad experience with internal bracing. And also my concern if you use internal bracing in addition to a hamstring graft I think that internal bracing will take some of the load from the graft so the graft might be weaker. That's a thought. Yes so if you have a hamstring graft you have to make sure that it's thick enough. I would accept 8 though. You said minimum 9 but I would have accepted 8 for hamstring but I would never compromise and say that I could use internal bracing and then a 7 graft is OK. I would never go lower than 8. So that's internal bracing I never use it. For the LAT we are including to the stability study. So for many of the patients I would have to say that I randomize because that's all the athletes below 25 years old. We try to include them in the stability study where we randomize to do a LAT or not. For the other patients I would probably add it if I had an athlete who was not going in the study. And for revisions I think I would do it in every case. Thank you. Cassandra were you going to add something? I just want maybe a clarification with so with the athletes less than 25 if you weren't part of the study you would add an LAT with the patellar tendon graft? Yes. OK. I'd just like to respond to the comments about the role of MRI for evaluating the lateral extraticular structures. I have a different perspective and the first thing to say is that we've definitely validated MRI and the percentage agreement with lateral exploration. So what that specifically means is and this is based on a study with Professor Ferretti from Rome. We looked at patients having 1.5 Tesla MRI scan of the knee and we also performed a lateral exploration of their anterolateral structures in all cases. And what we demonstrated was that MRI abnormalities seen corresponded with 90% agreement with lateral exploration. So we actually feel that MRI is very accurate in evaluating the lateral extraticular structures. In terms of whether that should be an indication or not I think that remains to be defined. So I agree with you on that. I'm not typically using that as an indication. My indication for doing a lateral extraticular structure is someone who's at high risk of graft rupture. However having said that Camillo Helito has published a study where he looked at patients who've got an MRI abnormality of their anterolateral ligament and they all had an ACL reconstruction but without a lateral extraticular procedure and those who did have an ALL injury had worse outcomes in terms of problems and graft rupture rates. So I think we definitely have emerging evidence firstly that MRI is actually a very good modality for evaluating the anterolateral structures and secondly that it can be potentially used as an indication to do a surgery. But again that my disclaimer is that I'm not currently using that as an indication. My indication is to reduce the risk of graft rupture in high-risk patients. Yes made the decision before going to the OR. Yeah I think that's a great point. I think for most of us probably that decision is made before the case. But Adnan just to summarize so your primary indications are an athlete at high risk of re-rupture right that's one main indication and then revision I imagine? Correct. Okay yeah for me I'm doing it in any revision setting and then like following the literature I think it's very you know there's there's definitely good support coming out for doing LET in a primary setting in a very high-risk athlete hyper hyperlaxed female etc but in a revision for sure I'm doing it. Anybody else want to comment on yeah please question from the back great. I don't know the data for that very narrow specific population. I think there are numerous studies in the literature looking at quad autograft and comparing to BTB and hamstring autograft and and then you've heard comments from several of the faculty I think the data is very convincing that the grafts like patients can do well with any of these grafts. So for me at this point too and I've heard like several of my sports colleagues over the past couple of years who maybe previously were 90% BTB transitioning to using primarily quad I just feel like there's not really an indication where I don't think quad would be an appropriate graft. So I think even in elite athletes they do very well. Please go ahead. Auto autograft for sure autograft yeah I mean allograft I don't think so either no I haven't seen any and interestingly and I mean that maybe this is a good just general question for the panel in the past six years I think I've done one allograft ACL reconstruction and I think patients are wanting more and more to have autograft like I've done autograft in a 52 year old patient so it's a lot of what they want I think when we were most of us were in training around the same time we were told you know over the age of 40 just use allograft and I think patients over the age of 40 like they still want autograft so I think it's becoming more and more common to use autograft for the majority of our ACLs and of course most of the patients are young but I have absolutely done an autograft ACL reconstruction in a 50 or 52 year old the one allograft I did in the past actually was like 14 months ago was a 60 year old patient who like was super active and had an acute injury and had instability in his knee allograft ACL reconstruction and he has done phenomenally so I don't I guess just general question for the panel age or whatnot with regards to autograft yeah I just want to say something real quickly about that in my mind there's not a allograft we have to be careful working with the tissue banks to understand where that graft is coming from we have aseptically prepared grafts and we have sterilized grafts that has to do with the circumstances of the recovery if that's a fresh donor usually you can use aseptic techniques which basically is just freezing the graft there's a lot of proprietary mechanisms including shooting high jet you know hydroperoxide lavage to the graft to sterilize it and then irradiating it and then freezing it and I think that that does something different to the tissues so understanding a little bit more about the graft cycle where it's recovered and how it's treated after is important when we're looking at this data as well when you're looking at registry data you don't get that stratification of the donor and when I first started at the Brigham you know the the youngest donor that I pulled out of the freezer there was 56 and you know cause of death was MI and this is kind of what clearly you know I talked to them to the equipment to the manager and I said you know what's going on in there what's your problem with this and I asked him I said this is a little anecdote and I said how old are you he said I'm 56 and said it's perfect how you know how are you feeling he said well I'm doing great well except my knees my knees are bothering me I said well if I told you that I was gonna put this graft from your 56 year old self into your 36 year old body would you have been happy with that and then he was like well clearly there's a problem right so I think that I'm talking to your tissue banks and I mean full disclosure I'm a consultant for JFS I have a really good relationship with that tissue bank but just understanding how your grafts are recovered how they are treated now they're stored now they get to you I think that that's really important also to relate to the to the patient if you leave it to the people at the hospital they're gonna buy the cheapest graft and that's routine you're gonna be something that's old close to expiration and that's been treated cheaply also to come back to the LET we do not have a disagreement about it as I said in young high-risk patients and people with hyperlexia I would absolutely add it you know with the MRI findings I agree with somewhat with both of you I do recognize that enter a lateral injury routinely to Kaplan's fibers on the femur but without prehab and our time from injury to surgery that we have I don't know how that would look at time of surgery you certainly do an exam on anesthesia that's very thorough and thoughtful and you know if there's additional rotatory instability as I said I think that that's a good indication but I still would not go as far as going every time I see it on MRI and that's why I agree with you same with MCL same with other structures that I would just treat that based on MRI I mean I think it adds something to the complexity of the the case and the rehab and in my mind you know for the average first-time index ACL that's going a little bit too far other questions see some some some agreement there but I won't go back over the issues we've already discussed but one additional point to raise is about the rehabilitation actually we published in asthma a couple years ago that when we do a natural actual ligament reconstruction there's no delay in rehabilitation in terms of isochronic strength testing pain return to sport rates and I think there's some other similar studies that demonstrate that there's no change in the rehabilitation I think an extra articular procedure doesn't change the rehabilitation it doesn't delay the rehabilitation with yeah questions in the back standing So the question was, degree of rotation and flexion of the leg when performing an LAT. And then I'm also going to add a little bit more to it. Can you over-tighten the lower compartment? Well, it all depends on what technique you're doing. So for an anterolateral ligament reconstruction, we're trying to replicate the normal anatomy and therefore the normal biomechanics, which is that the anterolateral structures are tight in extension and slack in flexion. So we fix it in full extension and neutral rotation. For the modified Lemaire, maybe Berta can answer since she's part of the stability study. Yes, neutral rotation and in between 30 and 60 degrees of flexion is okay. That's what we do. There's another question in the back. Oh, sorry. Go ahead. Yeah. I can comment on the allograft. Or was there a question? Do you want to take a question? No, no. If you have another comment, go ahead. Yeah, because we don't use much allografts in Scandinavia. But I can also comment on the quality because there's no doubt there's a big difference. More than three years ago, we used to buy grafts from the States. They were radiated. And sometimes, if I had to use it, I felt very bad putting this into a young person. So now, the last three years, we are harvesting our own grafts. It's young donors. If we have a limit on 55 years, we will not take the graft if the donor is older. And also, if there's some kind of issue with the donor like rheumatoid disease or something, we will not take them. And it's very enjoyable to take these grafts out of the freezer now because the quality is like if you are next door taking the tendon out. So it's a big difference. So this would lower my threshold to use the allografts now. But we never use it for primary cases. The only primary cases we use it for if it's a multiligament injury. Thank you. Yeah, go ahead. Yeah, so just a question for the group so everybody heard. It's just what we're all doing for fixation of our grafts. So I do quad autograft in the vast majority of my cases, and I'll do suspensory fixation on the femur. So I always check that button with a mini C-arm intraoperatively. And then on the tibia, I was using a biocomposite interference screw and backing up with an anchor. And then probably like four months ago, transitioned to using the small metal ABS button, which I really like. And I still back that up with the anchor. For patellar tendon, I use a bioabsorbable screws that have the little flutes in it for bony ingrowth. For soft tissue, I tend to use a suspensory. I don't C-arm it, but when you cycle it, you can see how much it dimples the lateral compartment. So I make sure to, before I fix it on the tibial side, I make sure to cycle and make sure I'm not anywhere near the IT band or below it. And then I do it all inside, so it's double bundle, sorry, double button fix, suspensory. For B-tibia, I use metal screws, both in femur and tibia. For quad, I use metal screw in femur because I use a bone block. And for tibia, I don't trust the soft tissue fixation with my interference screw. So I use interference screw, but also an anchor. One of the principles that I like to follow is remnant preservation. And so I'm always trying to preserve that tibial stump. And for that reason, I'm drilling a full tibial tunnel. So that lends itself to an interference screw fixation, although you could use a large button. So I'm using a hybrid technique of suspensory femoral fixation and interference screw on the tibia. When we do a combined ACL and ALL reconstruction, then there's a single femoral tunnel, and so it's two interference screws for the ACL graft fixation. I do metal screws on the bonobone, both in the femur and the tibia. Soft tissue grafts, I use suspensory fixation. I'm with Mary on this one. I always use a minicium during the case, single shot, to confirm that that is on the cortex. I've revised multiple grafts where that button was either in the femur or was sitting on the IT band. And that's something that's easily avoidable. You mean during the case? You don't leave the OR until it's perfect. It's surprisingly high. Oftentimes it's some soft tissue interposition. In younger patients, when they have thicker periosteum, it can be misled a little bit. But I always also take post-op x-rays at the first post-op appointment, and I confirm that everything is where we left it. And the best way to do that is knowing where you left it. On the tibial side, I normally use interference screw fixation for either graft. So yeah, a few things to try to prevent it from happening in the first place. One is when we make that incision in the skin, and then the IT band, really opening up the IT band too with a hemostat to try to make sure it's easy, that if inadvertently that button does pass through the IT band, that it's not hard to get it back through. So that's one thing. And then the other thing is, I work with residents a lot, and usually a PGY-2 or 4, but I tell them to be very slow and methodical about this. And as the button is going up into the tunnel to actually wrap the sutures around their hand and literally roll their hand on the patient's thigh, roll it, and that helps bring the button up just gradually, and that really decreases the risk of the button inadvertently pulling out through the IT band. But I check every time, and it does not add a lot of time. It's not a labor-intensive thing. It's very easy to have the mini C-arm in there. So it's not going to take away a lot from the case for anyone who is hesitant because of that. Up here, please. Yeah, I'm happy to start with that because in my fellowship, we did a ton of hamstring autographed I did my fellowship in San Diego and that was just a predominant graph that we used So for my first few years of practice, I was doing almost entirely hamstrings And it's just sort of the unpredictability of the size of the hamstrings that makes you a little bit worried and then also taking away like that medial restraint especially in like young female athletes and then when I When I transitioned, I was at Tulane for six years when I started working there and was doing some cases with one of my partners early on And I saw a quad autograph like just getting the exposure and seeing like how big that graft is How reliable it is like it is very predictable that you can get a really robust graft And so once I started doing that like it was a very easy transition to like wow This is a great graft and I can always rely on this and I have like tweaked my technique Definitely over the past seven years in terms of length of graft and the size that I harvest and the fixation But that's how I personally made that transition. I Think for me my first case was a revision patellar tendon like I'm a young CrossFitter He was like 20 and then so I just didn't think about take I didn't really want to contralateral him because actually had bilateral a sales with patellar tendon that both failed So that was kind of my first foray into it and how quickly he recovered from it without any deficit was kind of what? kind of sold me Yeah, we we didn't use it very often, but then we Agreed to to be a part of the stability study So and I knew that if you didn't do it very often the results were inferior So that was one of the reason that I'm doing it also outside the study sometimes now to get some more experience with the graft harvesting But I think still I do 70% b2b I think it's a good graft option But I also think that we need to be familiar with all three of the main autographed options I'm gonna preface this by saying I've revised more quad tendons from the community that I've put in primarily. Okay in my primary ACLs the quad tendon solves a problem that I don't have Meaning it's not like we can't figure out where to get a graft and get a good result on a primary ACL I think if you're getting into the revision setting then yes, I mean, it's it's good to be facile with that The reason I really haven't made the jump is because I'm concerned about Revisiting that whole learning curve in the meantime because it would take in surgery that Currently without sounding arrogant works fairly well in my hands with good outcomes and and it's always Unless a patient requests this and this is happening more and more because it's also an industry and and social media driven thing then I will disclose what my numbers are what I'm using and If they still want to go with a quad with me happy to do it if they want to go with a quad with One of my partners who's a higher volume quad surgeon. I will absolutely refer him for it Thank you, yeah question over here I don't know, I mean, that's a great question. I can say anecdotally that at least a couple of my sports colleagues, our sports colleagues, and I touched on this briefly, but who were far and away predominantly BTB surgeons have transitioned to using quad. So there are some BTB surgeons who are doing that, definitely, and these are just a couple that I know. I'm sure there are many more. But I think for a lot of us, it comes down to what do you do most often and what are you most comfortable with, right? That's what Simon's just saying. We're being honest about it. That is a huge factor that influences what graft we use is what are we most comfortable with, for sure. But I don't know, any other comments just about that kind of evolution of? Yeah, we could look at global trends. So if we look at the ACL study group survey, they recently presented that historically they were very BTB dominant, but now they've moved away from BTB and soft tissue grafts are predominantly preferred by members of the ACL study group. And also, there was, I think last year, a systematic review of national registry data, which also demonstrated that there's been a move away from BTB grafts towards more soft tissue grafts. Excellent, was there another? Sorry, over here, please. Great question. I harvest down to the capsule. So I don't just go straight down and just harvest and have this big gaping hole. I try to preserve that capsule. But if you create a rent, not a big deal, you just have to close it. And I always, I will close the capsule, but I'll close the harvest site. So even if I don't get into the capsule, I'm closing the harvest site completely. But the width, the depth, I guess, ends up being typically like the depth of a 10 blade. Like I use a 10 blade to harvest, just a standard 10 blade. I don't use a dual blade. I use a standard 10 blade to just harvest off the distal, or sorry, off the proximal pole of the patella. I probably about the distal, I don't know, two centimeters maybe I'm using, like elevating that with the scalpel. And I actually, I put an Ethabond in the distal end of the graft to just use for traction. And then once I get that distal end, I actually use Mets. And that's something that I've transitioned to in the past, I don't know, probably over the past year. And it makes it a lot faster harvesting the graft. I mean, graft harvest, it can take about five minutes. But using the Mets has made an enormous difference to harvest the medial and lateral sides, superior and inferior surface. And then your incision, your actually skin incision, doesn't have to be that big because you can still elevate proximally. And then we have, you use the cigar cutter or whatever type of instrument that allows you to go proximal to harvest the graft without actually seeing, you don't have to see the full proximal extent of the graft. I hope that answers the question. I think there's a definite learning curve to that. Oh, for sure there is. In my initial experience, I for sure harvested some grafts that proximally were maybe a little bit thinner than I wanted to because I tried to do it through a small incision and not getting the plane precisely right. So right now I just do a full thickness graft if I'm using quads. I think it's easier, more reliable. And also even in that situation, sometimes that proximal part can be a little bit thinner than you want. It's often in the tibial tunnel, so it's not necessarily a big deal, but it's something to be aware of. I agree with that completely. And definitely not meaning to make it sound like it's easy. Anything that we've done more times, obviously it becomes easier. But for sure, when you're just learning this, take your time, make the incision bigger. Patient does not care. Make it so that you can actually see the graft. I do make that vertical incision just like I showed, but for that, it's a little bit shorter than that now. It's not the one centimeter horizontal incision that you'll sometimes see if you're watching videos or whatnot. No, I make a vertical incision and it's probably at least a few centimeters long. So I don't know what you guys do, how you harvest your graft if you're doing quad. When I started to do quad, I made a longer incision because I wanted to be safe that the graft was thick enough. I also tend to do full thickness or I go down to the capsule. And of course, in the beginning, sometimes it was holes of fluid coming out because I did this arthroscopy before. But that's not bad for the patient. So better be safe and make the incision bigger in the beginning. Yes, exactly. I prefer a vertical incision. I hate cruciate incisions. So if they're gonna need another surgery that needs a longitudinal incision in the future, it doesn't make sense to me to do something transverse. And also, one of the other issues I've encountered is that if you have an obese patient and they have a lot of padding anterior to the patella, getting the trajectory right can be difficult. And so just having the option to extend that to see better is always helpful. Yeah, that is an excellent point. Because there sometimes is a lot of fat there. You say like, how can there be this much fat till you get to the quad tendon? But sometimes there is. Yeah, so full thickness, I would use the scope to help augment your vision. Just be very careful. It's very easy to overstuff the joint with a quad tendon graft. So I definitely wouldn't go higher than a nine on it personally. I think that when you try to get to a 10, 11, you might have some issues, particularly if you're trying to do an all inside technique. Yeah, that's a very, very, very important point. Size of the graft matters. And John Zerogin, he's out of Emory. I'm sure all of you have seen some of the literature that he's published. A relatively recent study was talking about arthrofibrosis and that the risk is higher in grafts over like 9.25 millimeters or something. So yeah, I think aiming for around nine. My graft is usually somewhere between nine and 10. I mark out the central 10 millimeters, but ultimately the harvest ends up being, it's probably between nine and 10. I definitely don't go bigger than that. No, that's good, I appreciate the questions. So the question is about notchplasty and who's doing it and how often. I don't routinely use it. I use flip cutter instrumentation from Arthrex. It sometimes has a hard time sitting down if you have a little bit of a prominent notch, which time I will take it down to make sure that we can get that tunnel where we like it. But I don't do a routine, at least bony notchplasty. I do a very thorough soft tissue notchplasty though. I think there's some concern that notchplasty can reduce the, or rather impair the biomechanics of the stability of the graft. So I always try and avoid it. It's very rare that I do it. I think the most common time I do it is in the older patient who has some notch osteophytes and you need that access, but otherwise I don't really see a role for it. No, I hardly ever do it. Must be a case if you, when you extend a knee that you are concerned that your graft is touching the wall or something, but then it's probably something wrong with your tunnels as well. So I hardly ever do notchplasting. Yeah, I agree. I mean, like Simon was saying, I will obviously clear off all the soft tissue and I wanna make sure I can see the wall from superior to inferior and anterior to posterior. And then I will often just smooth out the very, very anterior most aspect of the medial wall of the lateral femoral condyle just to help with visualization, but it's a tiny amount. So minimal. Other questions? I'm just gonna pose a couple of quick questions to the panel. So first, bracing patients after ACL, just in the immediate post-op period. Do you use a brace at all? If you do, do you do it all the time? Is it only with certain patients? I don't brace my ACL patients, no. We say that brace is for the brain, not for the knee. But there might be some cases if I have a meniscal root tear and I don't trust the patients that I put a brace on them to make them not flex the knee more than 30 degrees for the first two weeks and then not more than 90 degrees until six weeks. Okay, Adnan or Simon? I didn't use any bracing after ACL surgery. Yeah, I don't use braces after index ACL. I don't think there's any data for it. I will use a brace routine to protect the meniscus repair. Usually I set the brace to minus 10 to allow for some hyperextension because there's always the lack of terminal extension that gets people and restrictive deflection to 90 degrees. With quad and extensor mechanism grafts, if there's any issue getting their motion back, again, full disclosure, I'm invested in that company as well. It's Icarus Medical with a dynamic brace to help offload that patella femoral joint and get that extension faster. I'll just add to it too. So I absolutely, of course, will use the brace in any type of meniscus repair. I have been using a brace in the immediate post-op period after ACL just in the first couple of weeks while the quads are kind of waking up to help with the knee. But I think this is, I really feel like this has been a big transition over the past couple of years, transitioning away in general from using a brace in the post-op period at all. I don't get custom ACL braces. I don't do any of that prolonged ACL brace by any stretch, but I use it sort of in the first couple of weeks. I don't know, just a show of hands, I guess, in the room. Who's using a brace at all like in the immediate post-op period after ACL? Still quite a few. Okay, good. So exactly, good. Thank you for making me not feel alone up here. All right, back in the room, back in the room, please. Yeah, that's a very good point, yeah, I tend to do like adductor canal and IPAC, but it's very important, the nerve block in general, keeping that in mind. Please. Well, we block all of them, I tell them that like their pain will be so much better with the block. I mean, I can't recall a patient in my, in the sense I've been in practice that refuses to get the block. But I don't know, for you guys, have you had, have you come up, has that been an issue, a point of discussion? Yeah, so first of all, I think a femoral nerve block is really not indicated because it knocks out your motor and it's really going to slow down your rehab. If anything, it would be an adductor canal block. I've gone away from blocks completely since I started at the Brigham, we use pericapsular block now. IPAC, right? It's the same, I guess. Yeah, I guess. IPAC. Yeah. I mean, it's REC. So it's something that I inject subcutaneously during the case, it's made a phenomenal difference in terms of opium sparing. Never use, and you don't have to wait for any more blocks with the anesthesiologist, it's pretty perfect. So it's something that comes in a 15 milliliter pre-mixed syringe. You just can't use Toradol with those patients because it does include Toradol already. But as I said, for our post-op pain regimen, it's made a huge difference. So I usually don't send people with more narcotics than they need for two to three days. So normally they go with like 10 oxy, and a lot of them don't even use that. But I would never, for that exact reason about the quad inhibition, would not recommend using a femoral nerve block because the fall risk and the slowness of rehab is a real thing. And then I would definitely, if I use that type of block, definitely recommend being in a dynamic brace for that. Adnan. I agree with what's been said. I don't use femoral nerve blocks, but I also don't necessarily present it in a way that there's a choice about the block. I guess there is a choice, but we don't present it as an option. We just say this is a standard part of the care. You have a block to make sure you're comfortable after surgery. In addition to what's been said, I also typically will administrate some local anesthetic subcutaneously at the donor site, whatever that is. That's great. Yeah, I also present to patients, I just tell them in clinic, I tell them a little bit about what to expect, including that they're going to get a nerve block. And most patients just don't even question it. It helps so much with pain control. I just, I really encourage them. Please, standing back there. I'm probably the one who's working in public hospital here so I don't have to think about the cost. Anyway I use metal screws so they never ask me about the cost. I can use whatever I want, still use the metal screw. The reason I'm using an anchor when I do the quad is because that it's been shown that soft tissue fixation in tibia is not so good so I like to have the backup. I'm aware of the cost. I think it's a little bit of a slippery slope though when you look at it depending on what environment you practice in you make about 1% of what the surgery is built for. Okay and I think it's always a lot of pressure on us as the net revenue generators in a practice to be more cost-efficient and to be faster and to see more patients and do all that stuff. But when you look at it you take home 1% of what your hospital or whoever makes on that. Okay so I'm gonna do whatever I need to do to leave the oil with a good result and if there's equipoise between two things and I'll use the cheaper thing. I use metal screws on my bone-to-bone grafts. When I started in Boston you know I used normally through the intramedial portal with hyperflexion with a low-profile reamer. Didn't want to get low-profile reamers even though they're cheaper overall you know with the screw than it would be to use a suspensory fixation. But that's then not you know a battle I'd stand on the on the table for you know I mean and I just accept that we're gonna use something more expensive. But as I said I mean I understand that there's always economic pressure on us as the surgeon but I also think it's okay to stand up for your patients and your outcomes and tell patient and tell people to save money somewhere else. You know there's a lot of redundancy in every system and it's always nice to tell you to be faster and cheaper and more efficient. But you have to advocate for your patients and you can say it's your preference but you always have to say that it's a patient based decision and it's really hard to argue with that. Excellent thanks. I'm gonna pose before we go over there I appreciate that. I just want to ask one more question of the panel. Tourniquet. Are you guys using a tourniquet for your ACLs all the time sometimes never? I feel like this has been a little bit of a transition too so Berte. When I was learning many years ago I used a tourniquet and now I very seldom use it but it's always there in case I need it but not routinely. I always use a tourniquet. I've never tried to do an ACL surgery without a tourniquet. So I always use I like to see what I'm doing. I always use tourniquet and I always use TXA. I use a gram of TXA before tourniquet goes up and I put a second gram of TXA in at the end of a case. It's made a huge difference with one I mean visibility during the case and definitely with bleeding issues after. Speaking of cost a gram of TXA is 10 bucks. I think it's a completely reasonable you know thing to add even if there's not great data but in terms of patient outcomes and their happiness and the lack of any sort of incision based complications. I mean it's really sold me. It made a big difference. I use TXA on all my cases all scopes. Single gram of TXA. Two grams on bigger cases including ACL and I always use tourniquet. Okay thank you guys. I love the pearls being dropped left and right. So I use a tourniquet too for my ACLs and piggybacking off of what Simon was saying. I won't hesitate to use TXA. I don't use it all the time in for my ACLs but if I feel like there's more bleeding than I expect whatever I wouldn't hesitate to use it. I use TXA probably more commonly in shoulder scopes or cuff repairs but it's just like if I need to. I don't do it preemptively but I think there's very very good evidence in literature to show the benefits of TXA in shoulder and knee arthroscopy. And there was a question over there in the corner. So I personally drill a full tibial tunnel, so I'm not worried about it bottoming out. I think that is a potential risk for sure if you're doing all inside. But yeah, so I don't worry about that. But I don't know, for any of you guys, any other comments about the graft potentially bottoming out whether it's quad or another all soft tissue? Yeah, I'm gonna also loop back to a question that was asked earlier about the button fixation. Where's the button sitting? I think that when you use, I'm just gonna say flip cutter, but there might be other things out there. Every company has their own type of retrograde drill. Again, I'm not, actually, I'm one of the only people that doesn't get money for math checks, anyway. So you can look at your intraosseous distance, and I would be sure to note that and mark that on your fixation device to know where you're expected to flip the button. So you're not just yanking it through and pulling it out. Marking your graft with your, I guess, intraosseous portion that you want. I think that planning this and measuring your graft and doing this preoperatively, looking at imaging, and then doing the case to have multiple check reins there, I think is really important. I think that there's no harm in making a tubular tunnel if you're gonna go on all inside, which I don't do, a little bit longer to avoid having to take the graft in and out. Other comments, Adnan or Bertin? I'm like you, Mary, I drill a full tubular tunnel, so it's not an issue I encounter. If I'm doing quad, I harvest seven centimeters. I think if you're doing all inside, you could probably go as short as six and a half, but I always aim for seven centimeters, and that has not been a problem in terms of injuring the rectus femoris. It's all just tendon, but I think seven centimeters is a good length. For the patella tendon, you get the graft that you get, so if the tendon part is long, I try to make the tunnel longer, of course, but it's not always possible to make the tunnel as long as you want according to the tendon, so sometimes the bone block will be outside tibia. So then I do a soft tissue fixation in the tunnel, and I also use a staple to do a fixation of the bone outside the tunnel if it's too long. I always look at the patella tendon length on MRI pre-op, very simple to look at, so there's no surprises during the case. If you have a patient with a very long patella tendon, that might be part of your pre-op discussion about graft choices if you're concerned about it. I think it's still possible to play with your, I mean, you can read off of your bullet and the angle. You can certainly drop your hand more, and you can, I guess, calculate out what your graft length would be, how much is gonna go in your femoral tunnel, 25 millimeters in the joint, and then what's gonna be down there. If you do have a graft mismatch where the graft is out of the tunnel, I mean, obviously you can take the whole graft out, which I don't recommend. You can twist the graft clockwise, and each repetition is gonna shorten it by around three millimeters. You can flip around the bone block. If you know that you're gonna have a mismatch based on your calculation, and suture the bone block on the opposite side of the tendon, you can take your bone block off completely and then reinsert it as an interference bone block, or you can create a trough, like Berthe was saying, and then lay the bone block down interiorly and secure that with a staple. I've done all of those things. I think that you, but it's really made a difference for me is one, checking the length of the patella tendon on the pre-op MRI is very simple, because if you have people with a patella ulta that have a very long tendon, at least you know what you're getting into. Number two, I don't hesitate to make a separate incision for the tibial tunnel to put that where I need it to be, and I found that patients don't mind that extra incision. It's very small, so that will be away from your graft harvest incision, which you can then keep smaller. I used to make a longer incision and be able to always put the drill guide into that incision, but as I said, I mean, I think that from a technical standpoint, it's okay to make that a separate incision and really control that. Awesome. All right, guys, well, thank you so much for the excellent discussion and for being here. We really appreciate it, and enjoy the rest of the meeting. Thanks again. Thank you.

AOSSM conference

ACL reconstruction

Dr. Mary Mulcahy

BTP graft

quad autograft

patient-specific factors

graft preparation

LET procedure

Dr. Adnan Saithna

two-stage revision

LAT technique

TXA use