Okay, great. Thank you very much, Al. So we'll have all the panelists up here. If the audience members want to come and ask questions, please use the mic. There's also the app. We'll see if that also comes through. But yeah, definitely feel free to come to the mic. All right. So maybe just to get started, do you guys all use radiographic landmarks? Is it predominantly anatomic? If you just want to share your thoughts on radiographic-anatomic combo versus one or the other. So I will actually use the C-arm pre-op just to see, you know, what the instability is. So I have to see I'm in the room the whole case long. And then, yes, I will use anatomic landmarks on the X-ray or on the C-arm. Like I showed with the MCL, I think isometry is important. You can actually have a real problem there. And since the MCL with the ACL together is the stiffness maker, if you listen to this ICL, that's probably what you heard in every single talk. So I think isometry is certainly important so that you take one factor out why this knee may get stiff than many other factors anyways. I think it's dealer's choice. And you can certainly use radiographic or anatomic. They both work well. I mean, early on in my practice, I did a lot of radiography. After that, after I got comfortable with the anatomy, then I stopped really using fluoroscopy. Pretty much with all the multiligaments that we do, we don't really use them. We use anatomic landmarks. But I mean, if you've got a case where there's a lot of heterotopic ossification, you know, proximal avulsions of the femur, of the MCL, the postulata corner, and those landmarks are not going to be discernible, then radiographic analysis is definitely going to be helpful. Revision settings, revision cases, anything where there's other hardware in there, always have a C-arm in the room. And there's no harm in using C-arm. There's no harm in not using C-arm as long as you know what you're doing. So just, you know, dealer's choice. Yeah, anatomic for me, I hate using fluoroscopy. I hate wearing lead. I don't want to wear lead for all day, every day. So yeah, I've stopped using it. But you know, it's available, and if I need it, I bring it in. Yeah, I think your landmarks anatomically should guide it, and then using some of those tricks that Volker mentioned to assess the osometry. But the only time I've used it is spot check on the medial side, otherwise not. All right, great. Thanks, guys. So again, feel free to come up and ask questions. But as I said, we'll keep going here. But how often are you guys adding an extra limb for the posterior oblique ligament? Are you relying on the external rotation, Slocum test? When are you guys adding that extra graft, as opposed to either doing just an MCL repair, like Volker showed, or reconstruction on the medial side? When are you adding that extra POL graft? Go ahead, guys. It may depend on, obviously, timing, and also on the severity of the injury. So if you get in there early, you can repair that and just bring it up. But in a chronic grade three, you know, with a huge amount of rotation on top of it, that's when I would add it. Yeah, I agree with Volker on that. Full extension gapping, significant full extension gapping in a chronic setting, then I'll add it. I think the important thing is to recognize that a posterior oblique ligament does not control external rotation laxity after medial rotatory laxity. Again, I think it's something that we talk about, or people talk about an awful lot, and it's just incorrect. So the indication, if you're doing something on the posterior medial corner, is if you've got increased valgus gapping in full extension, or internal rotation full extension, not external rotation laxity. So for me, a POL reconstruction happens when I've got a deficient posterior medial capsule. If I don't have a deficient posterior medial capsule, in other words, if there's some tissue there, I'll repair it and augment it sometimes with a synthetic. Want to go to Jackie? Yeah, go ahead, Jackie. Thanks for the great session. I was wondering if you guys could address with PCL the femoral sided peel-off that's been described as repairable, and whether you employ that in multi-ligament injuries, and if so, what is your sort of level five or better timeline on when you can't use that anymore? And I guess the context of this is that I saw a patient in clinic who has a beautiful femoral sided peel-off in the setting of a multi-ligament injury, but oh by the way, trauma is a chronic disease, he accidentally blew up a propane tank in his fire pit, and so he has a burn that has to heal before we operate on his knee. And so I'm kind of wondering, one, if I could do that at all, if I wait, I'm thinking probably not, but then would you do it in an acute setting? Yeah, in an acute setting for sure, and I would base it on obviously the look on the MRI. If you really, if you take the peel-off out of the picture, look at the rest of the PCL, and it really looks clean, I would do it. And I would do it more often in a PCL than in an ACL, but I've done it in both ACL and PCL, just the repairs, usually on the femoral side. And in the multi-ligament, it actually works really well. I showed you that one case. Now, but I would also base it on the fact that when I bring in whatever fast pass, first pass, you know, whatever device you bring in to pass your stitch, if it doesn't hold, then obviously you have your answer. I pass a loop through it, and maybe like a figure of eight, it doesn't go. Now, your last question about chronicity, I don't know, I'm going to pass to, I'm going to pass to you. What do you think? I'm going to pass on chronicity. Yeah, that's the tricky one. I mean, I've never done a chronic peel-off lesion, so I have no level five evidence to either support or not support that. You pass, pass to Al. Yeah, I'm going to pass that to get good. Don't pass again, Al. Is there a course you'd like to plug on peel-off lesions? Yeah, we were actually doing one in November. Yeah, again, you know, I think it's actually relatively straightforward because you'll get in the knee in the chronic scenario, and it'll tell you whether or not there's something there that you can repair or not. But I mean, ultimately, for anything that's chronic, particularly in the joint, I'm still probably going to be doing a reconstruction. Now, the beauty about a thermal peel-off, particularly if you're forced to do it to treat them non-operatively, is you can get them in a brace. If you can't put a brace on, depending on his burn, you may actually get that thing to heal up, and he may not need any PCL surgery later down the track. So, you know, I think your clinical examination and your arthroscopic findings will tell you what you can do. Thank you. That's great. Go ahead. Good morning. Thank you. I'm interested in your thoughts on the ACL and post-scholastic coronary injuries, acute injuries, the fibular base versus the combined fibular-tibial base, and whether you would rehab them differently if you do the Leprod approach versus the fibular-based approach. My understanding is Leprod is relatively aggressive with his rehabilitation with his approach because of the stiffness of his reconstruction. So, you know, in most cases in ACL coroner, I just do a fibular-based reconstruction. If they're chronic, chronic grade three, if they have, you know, huge instability, I add that second limb into it. I wouldn't change my rehab based on it. My rehab maybe changes based on, you know, the body habitus, ultra-low velocity. You know, I go as far as fixing them post-op for six weeks, just praying for stiffness to come, which will never come, by the way, on a 500-pound person. Have you seen it? They don't get stiff. You wish they get stiff. We wrote a paper, and here's my plug, we wrote a paper in arthroscopy showing that the obese patients do not have a higher rate of stiffness. So, yeah, they don't get stiff. In fact, they loosen up. Right, but if it's not the ultra-low velocity, I do my regular rehab. What do I do? I usually protect them for like the first 10 days or so, you know, maybe in a brace that's straight, and then I get motion going, you know, and weight bearing as tolerated does not mean full weight bearing. It means as tolerated. So, if they have, if there's somebody home, they can do weight bearing as tolerated. If they're not participating, then obviously I would go no weight bearing. Yeah, these patients are not going to want to weight bear because they have a lot of pain. But in terms of, I agree with Volker, for my post-op corners, I'm typically doing the fibular-based. I'll add in a tibial limb if the rotational instability or the varus recrovotum instability is very significant, then I'll add that other limb. But, you know, we're part of the STAR trial, you know, looking at delayed versus early rehabilitation, flexion range of motion, weight bearing. You know, we don't have the answers yet. We're trying to get those answers. But, you know, if you had to talk about clinical gestalt, I mean, when you're doing these cases, you're going to arrange them after you do the reconstructions. And you could look directly at your grafts and see, number one, are they getting tight and stretching when you're flexing the knee? Because that could tell you that your tunnels are in the incorrect position. If you want to do anything, you'd rather have the grafts loosen when you flex the knee so that you're not really worrying about creep so much. So, I mean, if those grafts are staying isometric or they're loosening appropriately in, you know, 60 to 90 degrees of flexion, then I see absolutely no harm in getting them ranging right away. Awesome. Thank you. I had a follow-on question. Maybe we can direct it to Al. You addressed it in your talk. When do you start considering a high tibial osteotomy? As we get subacute, chronic, what time frame do you start to think osteotomy is a tool to load share with your posterior lateral corner? Six weeks, 12 weeks? Yeah, I mean, there's no real grid evidence. I mean, some people will say, you know, if it's greater than six weeks, then you're sort of into a chronic. I mean, it doesn't really make an awful lot of sense to me why a chronic's any different than an acute. If you've got significant varus and you're worried about the lateral side's going to stretch out, it's going to stretch out whether it's an acute knee or if it's a chronic knee. I mean, you could argue maybe that the capsular structures, you know, the secondary stabilizers may be more chance of healing in the acute scenario. So, in really significant varus, we will think about it. And I have got cases where I've even done double level osteotomy in cases, and I think you saw that case before. So, I think you just have to look at it on an individual basis. I do often pay an awful lot of attention to the contralateral side. If they're in constitutional varus on the other side, then that can be a real problem for your post-lateral coronary reconstruction. Yeah, those are great pearls. So, we'll take one more question from the audience here, and then we'll answer some of the online app questions. So, go ahead. Hey, good morning. Thanks for your talk. So, with the patient with the perineal nerve that's improving, I saw the slide that you get a six-week, three-month, and six-month EMG. How does that change your management, or is it mainly for counseling the patient with those nerve injuries, or does that change timing of surgery, or when you involve other people to do some of the more, like, reconstructive procedures for the nerve? So, in general, for me, it doesn't change very much, but there's a very interesting case that I have of a young girl that I wanted to enroll in the STAR trial. They had an arcuate fracture. They had a perineal nerve that's sort of impending, not out, but weakness on the foot and some numbness, and mom insisted on early surgery so that the nerve would improve, and I told them I have no evidence for that. I did the early surgery, and the nerve improved. So, this is totally anecdotal. Do you have more evidence on going early to improve nerve function if there's not an obvious, you know, scar sitting on it? Yeah, there's a fairly large series from Louisville, from the Clannad Institute, that showed that if you do a decompression at the early phase, that you can get an improvement just by doing a decompression. I loved, I mean, for nerve injuries, I like to go in very early and explore the nerve, so I don't do any nerve repairs or anything, so I refer them on to one of my colleagues, but essentially, by doing the exploration decompression at the early phase, I can look and see what the zone of injury is, and there's some prognostic factors there, so if you've got a greater than six centimeter length zone of injury, that's a poor prognostic factor, and you can have that conversation with your patient at that early time point. You can make the referral. I'll send photographs over to the plastic surgeons, and then they start the process in terms of doing nerve conduction studies and planning treatment accordingly, and they tend to do, depending, I think, what the tests show with that sort of three-month mark. They may then do subsequent tests at a later stage if there's any evidence of any nerve conduction velocity. But Al, in your patients, do you actually, in your own, do you actually see the nerve improving when you go in and just release around it? I mean, every multiligament case that I do that involves the lateral site gets a neuralysis, but the nerve function, in my hands at least, does not change. I think if you've got a dense palsy, then very rarely you will get an acute change. If you have pain or altered sensation, you can definitely, that's a different story, but you can definitely get an improvement. But you will also see patients that by doing a decompression, they will recover later on. Is it the decompression, or is it just they were going to recover anyway? Who knows? I think what you said about the zone of the injury is probably the key thing here, and how dense is the palsy. If it's a complete perineal nerve palsy, I don't see how doing a decompression is going to help us very much. I think the ones that are incomplete, by decompressing that nerve, especially with acute fractures, sometimes those bony fractures are very sharp. You can actually cut the nerve in half. I mean, those are ones that you might maybe be a little more acute on. I've seen it where that bone can just rip right through the nerve. I don't know if you guys have seen that, but that bony fragment could just slice right through. I mean, those you might be a little more aggressive on, but the partial ones are going to improve, and they'll probably improve better if you go in for an early neurolysis. The completes, I don't think it's going to. I think it's just throwing your hands in the air and hoping for the best. To your point, I think that there's a lot of anxiety about, you know, a complete nerve out, and so that six-week time point is definitely premature, but I think it offers at least some sense of where this is going. Really, 12 weeks and 24 weeks is where you start to see, if any, improvement, and so our neurology team likes to look at that. They also do a dynamic ultrasound at that point in time. It doesn't often inform management. I think it's more helpful for preoperative counseling in the medical legal ramifications. I'd also add that I typically wait almost, I tell patients, like, things can potentially improve up to a year, so, you know, before really talking about transfers, things like that, I really, you know, maybe engage a foot and ankle surgeon if it's a complete palsy, like, you know, maybe like after six months, but, you know, I'd say, you know, I usually tell patients that until about a year, I've seen patients where there wasn't much function, you know, seven, eight months, and then they come back for the year follow-up, and there's, you know, some function comes back, so I would definitely encourage that. All right, so we'll take some of the questions from the app. So the first question is, how long do you wait for the second stage when you're staging? How long do you wait for the second stage? Anyone want to take that question? So rarely staging, but you would probably wait about six weeks. Depends what you're staging, you know. You may do an osteotomy, and you may do the staging, but as Al said, you know, the patient usually doesn't come back and require us more, because the osteotomy is the key. So it depends exactly what you're staging. If you're doing, you know, ACL, PCL, and corner, and you want to do the corner first, then go cruciate, you do six weeks, but I don't really do that anymore. Anything else to add? We'll just fly through these questions here. All right, so Michael Lea likes to wait until he's out of the 90-day global, and then wait 91. It's expensive living in New York City, man. Got mouths to feed. All right, that's a candid point there. All right, so order of graft fixation, we covered it in the talk there, you know, PCL, ACL, collaterals, you know, potentially lateral side, and then medial side. Anybody would do anything different than that, or if you're doing all four? What was the question? So order of graft fixation, we presented, you know, doing the cruciates first, right, maybe PCL, ACL, followed by the collaterals. Anybody would do anything different for order of graft fixation? No, I mean, I think the key is you get the PCL done first, the knee is reduced, you know. If you do that last, the knee is sagging. It doesn't make sense to me. Yeah, the PCL first, and then I think it's dealer's choice whether you do the ACL or the collaterals in terms of tensioning. You're going to have different fields of thoughts, and you have different papers showing different things. You know, I've done it both ways, and I haven't seen any difference, and we've done a fair amount of them, but the PCL should be first. That's going to lock the knee. And maybe a key is when you do the PCL first, and you have three more to do, and it may not take another 20 minutes, that knee, if it's at 90 degrees, and it's a fat knee, the tibia will sag just by being at 90, so you need to protect that for the remainder of the case, for the remainder of the undraping, for the remainder of the bracing. You need to keep protecting it. A good mnemonic is, I always thought about it as palm, you know, posterior, anterior, lateral, medial, and the reason is you want to restore that central pivot, and then you're most likely to capture the knee with an overly taut medial side, so I like to do that last, so if that mnemonic works for you. Okay, perfect. So a few of you mentioned, you know, repairing, you know, the postural side, there's an avulsion. Are you typically also augmenting with a graft at that point, or if you have a really good repair and you're happy with it, you're just doing the repair on the lateral side? So if you want to go ahead. Mostly augmenting. Augmenting, yeah. Very rare that I just do a repair, and one thing, I would just go back to your question regarding the, you know, the fibular base versus tibial base as well, you know, if you're only doing a small number of multi-legs on an annual basis, and you're only going to do a leprade type reconstruction occasionally, you'll be scared of doing a leprade type reconstruction, so for me, I just do them on every single one, and then it becomes a very, very easy operation, because you're just used to doing it, so get, you know, and then once you've got used to doing it, then you can always start picking and choosing, but, you know, don't be an occasional technique person. Be careful. I agree with Geku. I always augment on the lateral side if I can. Sometimes it's hard to augment if you've got a large arcuate fracture, and there's really not much room to put a fibular tunnel in, because if you blow out a fibular tunnel, you're kind of hosed. You don't really have any options there, so, you know, for me, yeah, I'm always trying to raise the stakes by putting in some malograft, because that ligament tissue is stretched. When it rips, it's stretched. It's undergoing plastic deformation, so you're repairing stuff that's viable, but you're repairing stuff that's been intimately damaged, so by putting in a fresh graft on top of it, then you're just adding to the game here and giving yourself a better outcome. Yeah, I mean, Brian showed the outcomes with just repair alone were a lot poorer than reconstruction, so my practice, too, if I'm repairing, it's more augment, and there's always a reconstruction, so we reached the end of time here. I know there's a few more, you know, questions, but to be respectful of time, you know, you guys are welcome to go. We'll, you know, a few of us can stay back. We'll stay back, answer some questions. I know there's some other questions online. I'm happy to chat with it, share with you guys about it after, but thank you very much for attending, and I hope you guys enjoy the annual meeting. And fill out the survey, please. Yeah, that always helps to, you know, if you enjoyed your experience, again, that's really helpful for us to know, and potentially interested in seeing this in future years, too. Please fill out the survey. Thank you.

multiligament knee injuries

surgical planning

graft placement

timing and staging

nerve injuries

augmenting repairs