Thank you guys so much. So really we'll open it up to questions. Any questions from the audience to start? Yeah, please, up front. Thank you for your talks. They were very enlightening. You mentioned you've gone from partial thickness squat to foot thickness squat. But the difficulty in terms of getting out to higher end extension, how do you minimize that over-stretching? You've taken foot thickness every time to avoid that complication, but it is certainly in my... I've been doing quads maybe two or three years, and certainly there's been more patients struggling with extension in the first three months than with the chair hand. Yeah, so sometimes what I'll do is I'll go a little bit narrower. If preoperatively I see their tendon is very thick, I'll go a little bit narrower in my parallel incision. Okay. And so that's generally speaking what I try and do. If you harvest your graft and you're struggling to get it through the graft tube that you want to get it through, trim it down. So I don't mind and will routinely, if I take a graft that I think it's a little big, I'll trim it down. But usually the most anterior layer will separate from that quad, and you can take that off if you need to. Just... So you're taking a preoperative stemmer squat or extension? Yes. Okay. The other thing I would say is I've gotten a lot more aggressive with soft tissue, like anterior and notch resection, soft tissue resection. Because one of the things that I've encountered is that I'll go back in, it's not necessarily a true cyclops, but actually anterior notch soft tissue, like hypertrophy. And I don't have a great, perfect explanation for it, but I have seen it more frequently with quad grafts than with my VTBs, like the same thing. And that blocks some of their extension. And so I'm a lot more aggressive now in the primary surgery at resecting that soft tissue, but I'm also a lot more aggressive and have a lower threshold for going back in for a possible resection of that early on if they're really struggling to get their extension. And I think there's an actual block, or soft tissue mechanical block for their extension. I'm a lot more aggressive at going in, resecting that, and they usually get, that restores their extension, and then they do very well. But that's kind of made me more aggressive at the index procedure. You know, for a long time people were talking about trying to leave as much of the remnants and leave as much of the localized soft tissue as you can for proprioception or whatever it may be, which is fine. But I think at least with the quad graft or soft tissue grafts in general, I've gotten a little bit more aggressive at resecting some of that soft tissue, particularly in the anterior notch and in the anterior fat pack. Yeah, I almost would take the blader and, you know, go around the sort of, almost like what I would previously do with a notch blast. Yeah, I'll kind of ablate that soft tissue along the lower front cortex sort of all the way up to that 12 o'clock position. I'll just sort of burn all of that off. Yeah, I do too. I do exactly the same thing. Just like completely clear off that wall so you don't have anything, any risk of sort of that hypertrophy that he was discussing. Did you have a question, please? Yeah. Just a couple real quick on the harvest. I saw you publish Mr. Weinstein. I know he's done like thousands of them. Do we know how many throws you have to go out the back with that proprietary two throws, three throws? And then the second part of that is how many knots do we have to put? When I train fellows, it's like, you know, like is it two knots, a certain knot, and two half inches? Because if you get too big of a knot on the femoral side, sometimes that stops that graft at like 18 and you can't get it up in there. But I guess one is how many throws up and down, and how many knots do you guys put on when you're securing it with that device? Yeah, so I think X does two down and two up. I don't like that. And my reasoning why, and I did my fellowship with him, so in bold disclosure. But I think if you only go up and down twice, you end up converting that length to width because you kind of are shortening that as you tighten it. So I usually will go kind of, you know, I'll take three from the end of the graft towards the central portion of the graft. And depending on how it looks, I'll either go two or three. But my last throw I'll do is I'll cut it and I'll pierce the tape with one of those sutures. So I'll split it and then tie it, and then I do try and vary that knot so I'll pass it back through. Usually I get that knot to dump into the mid substance of the graft so it doesn't hang up when you're passing it. How many knots are you typically, like is there, do we know how many knots? Yeah, no, I don't think we know either. Yeah. I actually don't think that knot feels any tension at all. Yeah. I think that that is, but there's so much internal friction as you pierce that tape so many times, I don't think it really matters. At least three. Yeah, you know, three or four, yeah. In the second, the graft tubes, we try to get as small as we can, full thickness tube. Are you going typically half over when you're reaming? Yes. Is that the deal? Okay. Half over. You don't have any problems with the relaxity? No. We're actually now looking at tunnel dilation after a quad, so I personally think that the quad fills that tunnel and doesn't allow a lot of synovial fluid extrapolation because it's one block of tissue, and I think when you compress that graft down, it will expand back in that tunnel and does not cause a lot of tunnel dilation. So we have actually very low tunnel dilation post-surgery in our quad group. Yes, on that question, what I found was I started off doing full tunnels on the tibial side, and when I was pulling the graft through with a full tunnel, I really struggled to get the graft up, and I did have to over-ream by half a millimeter, but when I did it on the side, the graft is passing much easier now, and I don't have to go up half a millimeter. This is definitely easier to pass an on-side graft than up-side graft. I like, when I was doing, I think one of the reasons that made me switch is I was doing one on a high-level basketball player, and I had to pull so hard, and the graft got stuck, and I was like, I'm not doing this anymore. My second question, when you're doing these extra, the LETs or whatever, I've had to revise a couple. I used to see them frequently in the OR, but it's, you know, hitting your, you know, if you're all soft tissue, you've already passed your ECL on the formal side, maybe leave it on the tibial side. I've seen at least twice where that LET, the surgeon, when they're, whatever they're fixing it with, either a staple or they're using a suture bottom type thing, they've actually, I think, skewered their suture coming up, and it didn't fail right then, but when that patient was either back to sports or healing in the six, eight, nine months, I think, you know, when they eventually fail, I think the surgeon nicked, you know, that ECL, whatever, type of whatever device they used. And if we got to be anatomic or an ALL, sometimes it's like they're right next to each other. You don't want us to go non-anatomic. Do you have any tricks or tips on how you can avoid that complication? Yeah, that's a great question. I think, one, it's usually aim in proximal and posterior with your guide pin when you're doing either the ALL or the LET. That's one of the reasons I actually like the LET over the ALL, and that's why I like the all-suture suture right here, because it's small. I need the 1.8 versus the 2.6. That's smaller than using, like, a 4.5-millimeter ring hole to dot the graft into, because obviously so it's a smaller footprint and smaller area. So that's actually one of the reasons I like the LET over the ALL, if you're doing, you know. And then I think, for the all-inside technique, you know, you can be anatomic at the aperture in the joint, but you can move or you can change where it exits, right? And so you can drop it. You can drop it down a little bit more distal, and so that gives you a little bit more room proximal and posterior to close your LET or your ALL graft. And so if you're doing that particular technique, you can drop your hand a little bit with the guide, still come in at the anatomic footprint of the aperture, but you're a little bit more distal at the exit, and that gives you a little bit more room to work with proximal and posterior for your lateral augmentation procedure. What do you do? Is this ramp to the middle or forward? That's how I typically do mine. So, same thing. So obviously you're going to try and drop your hand quite a bit and try and come, and it's a little bit harder, for sure. And then the question just becomes whether or not you're going to drill all the way out or not or what your fixation is. If you're using a screw at the interference aperture, are you using like an extra portable screw or not? Do you typically still do like aperture fixation with an interference screw if you're drilling a portal? Well, for soft tissue, I would do a button. Yeah. For BTV, where I've got a metal screw, I don't really worry about it because you're only going 20 centimeters up into the thermal side. But it's that button with the suture going down the thermal funnel that I worry that you could nick. You may not know it right there on the table, but that's what we have. What I would recommend doing is if you... So I prefer an LET specifically for this reason. So when I drill my thermal funnel and my passing stitch, if I know I'm going to do an LET, then I make my incision from the beginning and I do everything, you know, I'll drill my thermal funnel through that so I can kind of see where that's going to be. And then when I have my passing stitch in, I'll go ahead and put in my anchor for my LET. I don't care if they converge because I use the soft tissue anchor like Clay uses and it sits on the cortex. So I don't care if those funnel converge if I just have a passing stitch. So my anchor's sitting, but then I pass my draft. Everything's already fixed. And then you just tighten everything down at the end. I don't worry about tunnel convergence. The other thing you could do with the technique you do is drill your pin from the AM portal, you know, and then mark your LET spot and or drill your... Kind of like he's saying, and or drill a provisional pin, guide pins for your LET and see if you get any convergence or see where they are. Or bring your guide pin out for your MCL and look up your tunnel. Just look up your tunnel and see if your guide pin's crisscrossing. And if it is, redirect it a little bit. Yeah. Yeah. It's actually put your camera through the... Until you get more comfortable, you put your camera through the tunnel so you can kind of watch for this. Yeah. Watch up there. And using these knotless anchors also makes it very small. Yeah. I think that's... Yeah. At least you do that before you do your... You know, before you pass your draft. You'll see it. Yeah, I agree completely. Like I'm doing my LET similar to what we've discussed. I use the all suture anchor too. I think it's tiny. You don't worry about it. Not nearly as much as when you're having to drill a bigger hole with the interference screw. And Cassandra, just the suggestion of looking up the tunnel. Like that's a great way to check. And I think there was a question in the back of the room first. Yeah. With the internal brace, I know early on there was a thought like you didn't want to pull attention to the internal brace. You wanted to leave it with the plaques. And are your talks that you're not really worried about especially? Are you guys just fixing that pull attention now, the internal brace? Or are you trying to live a little bit less? Yeah, that's a good, great question. So there's a couple different biomechanical studies looking at different knee positions where it could be fixed at 60 degrees, 30 degrees, or full extension. I think one of the key is about is fixing it independently. But it typically is a little bit more lax in flexion because it takes more of a strain more of a load as you go through about 30 degrees, 36 degrees of knee flexion. But to answer your question, yeah, fixing it in extension neutral rotation. And then I wanted to ask just the speakers too about internal brace use in general. So for you guys, I mean, Clay, obviously it was a big part of your talk. But for Harris and Cassandra, like are you guys using internal brace at all? Do you have specific indications? I'll say for me personally, I don't use internal brace at all currently. So I don't know. I'd just be interested to hear if it's a routine part of your practice now, if there's very specific indications where you will consider using it. I would say I do a couple a year. I did one not too long ago for someone who was immunocompromised. And I was worried about them healing and having a prolonged healing time. But I would say for the vast majority of patients, for me, if I think I need to do something else, I'm going to go lateral rather than go in the joint. Yeah, okay. Cassandra, any other thoughts about that? I actually don't use internal brace. If there's any question with my graft at all, then I use something for extracting or even an actual physical brace. Yeah. Yeah, I mean, I think Clay presented excellent biomechanical data. There's some very good supporting evidence. I think we're still currently lacking on some of the clinical data. I just don't, yeah. I don't know. There's a lot of research, of course, ongoing about that. The one thing I would just add to that is I'm always cautious to present some of that type of stuff, especially if some of it's a little bit proprietary, because I worry that people sometimes latch onto that and apply it broadly to every single thing, which obviously the clinical data doesn't quite support, and maybe it will at some point, but it certainly doesn't yet. But having had the unfortunate opportunity to revise a lot of ACLs that were not done very well, but people put an internal brace in hoping that that was just going to fix their poorly done ACL, and then I had to take that out and take out that suture. It was not very fun. And so I wouldn't say that that's the end-all, be-all. None of this is, obviously. But I think it's an interesting option, and certainly the biomechanical data looks good, and some of the early clinical data looks good, but we're still in the works of kind of truly understanding how much different that's going to be or what the long-term outcomes of that are going to look like. And actually, just before asking another question, it's just a show of hands in the room. Who is using internal brace to augment their ACL in any scenario, just ever in your practice? I do it for repair. For repair, okay, yeah. Okay, great. What about internal bracing for an AMF? You're using quads now, it's a good graft. We don't have any data yet to support routine use of an ATL, unless they're hyperlaxed in this revision and they're 16 or 17. But the idea of bracing the intracranial ligament in the acute phase of an ACL injury rather than having to take the sinus lobe out. Yeah, that's a good question. There are some people that are proponents of that and that are talking about that. I haven't done that in the primary setting personally myself, but I think it's certainly a concept that it's a good question and a useful concept and application of the same ideas and thought processes, for sure, stabilizing the anterolateral aspect of the knee. I started also just doing LETs for a contralateral ACL also for me now. Just if someone has had a previous ACL on the right side, they come back in and they tear their left side, I'll throw in an LET because I think that's a risk factor for re-tear. Yeah. And then just since we're on this topic because I was curious what you guys were doing, so Harris, that would be an indication in a primary setting where you'd do an LET. So Clay or Cassandra, and then certainly opening it up to the group, are you currently doing an LET in a primary setting? Do you have specific indications? Yeah. I mean, I showed what the literature shows in the stability trials. With hamstrings. Yeah. Yeah, with hamstrings. We should see what PTB and quad stability. Yeah, I think that that's the big question. But, yeah, I have done. So I showed the young female soccer player. That one was a revision, but I've also done it in young female soccer players with significant hypermobility in the primary setting, especially if I'm doing a concurrent soft tissue graft, which oftentimes is the quad ACL now. So, yeah, in those high-risk patients, I've started doing an LET in the primary setting. I think the stability trial, it's going to be great for sure. Like there's a lot of interesting data to come from that. Sure, please. So I don't hesitate at all to use quad grafting now for almost everybody, but what if you have your 275-pound D1 legit high-level football player? Is it okay to put in a 65-millimeter graft? I'd put it in 70, but yeah. Yeah. All right. Yes. For me, so I think it's the best ACL I did. Yeah. It certainly seems nice. It's going to be very, very solid when you do it. It's a huge scrape. I mean, I will say that, you know, I think as Cassandra showed very well, you know, BTB is still kind of the gold standard, and if you come to these meetings very often, you're going to hear most people say that for contact athletes, BTB is still the gold standard, which of course it is because it's what we've used for 40 years. But I also know a lot of people at the combine, and I asked a couple guys who are at the combine this year, and there's more and more quads showing up, but they're not downgraded at the combine for having a quad ACL versus BTB. So that tells you, you know, if you know anything about the combine, don't downgrade anybody who doesn't know anything if they can. And so that kind of tells you that, you know, more and more people are getting passed on the technique and it's more kind of mainstream and doing pretty well. I'm worried about how it would affect prospects like three, five years ago. Like I'm worried about how it would, but I think now it's kind of amongst, you know, people who take care of a lot of athletes, they don't worry about it so much. X has some NFL guys, I think, doesn't he? Yeah. Yeah, great question. You know, for a month or two, the U.S. soccer team and all those high-risk athletes are getting quads. Getting quads, yeah. Did you have another question? That was my exact question. Okay, perfect. Over here, please. Just a comment on that. You made a comment, you know, you're really using shorter and shorter quads in the drafts, and I would agree. In my practice, I've been shorter because the worst thing you can do with a quad tendon is bottom out. And so 65, 70, it doesn't really matter on that. For, you know, an NFL guy, you've got to stay back drafted or not. You just don't want to bottom out because you've got to get attention. Actually, it seems like also now, you know, we started going really long initially to make it essentially like all the other drafts we've ever used. As soon as you shorten it down, their quad activates way faster. I mean, not even close, but it's way faster. So the shorter draft, it's not going to cause any issues. I will say, if you have that athlete, so the tendency, of course, especially when you've got a big 6'6 line or whatever, you guys say, okay, bigger, I've got to go bigger. I've got to go big. I'm using the soft tissue draft. Bigger is better. That is not always the case. Obviously, you don't want to put a 7-millimeter draft in your 6'6 line, but don't try and take like a 12-millimeter draft and stuff like that. That's like hot stuff. Yeah. And so because, you know, Harrison and Sherri showed some of that technique, and I think sometimes some of the loss of extension is because people say, well, I can take a 10 or 11 or 12-millimeter draft, so I'm just going to. But that's not the right approach either. There is a happy medium, for sure, with all these soft tissue drafts, especially with quad draft. And then a question for you guys, too, and then I'd love to hear from the audience about closing the harvest site. So, Harris, you said you close it. I close it completely, too. I believe in that. I think we don't have a ton of great data in the literature to support whether it's absolutely necessary or not. But, Clay, Cassandra, what are your thoughts about that, too? Yeah, definitely. So, I mean, I still try to struggle with taking partial thickness, and then the reality is you kind of miss yourself. So, yeah, a lot of times I do take full thickness, and then when I do close, if there's any question or concern about getting there in the breakfast, I actually throw it away through my stitches because I actually will throw a stitch through the central segment of the draft that I've taken. So that makes sense. I do the two peripheral stitches to close it up, but I actually put a third stitch through the central part, too, so that, in my mind, I have, I mean, research may well come out in a couple years. But, in theory, that will help kind of tighten down that part. If you haven't used number one Stratafix, I don't know if anyone's familiar with that. I'm not a joint surgeon, total joint, but that is a game changer. It makes that closure. We do, like, with the fellows, like a four-centimeter, and while they're doing the graph or I'm doing the graph, I tell you, well, that Stratafix is a barbed, like, PDS, and you can close that thing in literally, like, 15, 20 seconds. So you don't have to throw a multiple. Huh, interesting. So, yeah, I guess I'm asking two questions. So, one, of course, if there's a rent in the capsule or whatnot, you have to close that. But I'm wondering, so say there's absolutely no, the capsule's still intact, you'd harvest it just down to the level of the capsule, that's intact. Do you close still the harvest site? Like, I would close that 100%. I don't mind doing that at all. I actually think it's totally fine. But then I would definitely, I would close it either way. Yeah, me too. I think if you have a full thickness graph, especially in, like, the pediatric patients where the capsule will separate from that quad really easily, if you don't close that, then their capsule will hurt me. And I don't think that's... Right. No, I agree completely. I close that every time. In the, just a show of hands in the room, for those of you guys that are doing quad, how many of you are closing the harvest site? Everyone. Okay, excellent. You can use, like, you know, a lot of people use, like, a rotator cuff type future device that, you know, you can pass it with. Yeah, there's a lot of different ways to close that, and that was a great suggestion, too. So I think we're at 8.30. Thank you guys so much. This has been an excellent discussion. If you have other questions, we're happy to answer those. Have a great day.

ACL reconstruction surgery

graft materials

complications

graft success

surgical techniques

internal braces