Good morning, everyone. It's great to see so many people here this early in the morning. And we really appreciate everyone joining us for this really exciting session. My name is Dr. Sebastian Rilke. I'm a postdoc research fellow at the Hospital for Special Surgery, working for the research group of Dr. DeFelice. And it's my great honor to welcome you all to this ICL on the role of ACL repair in today's ACLs toolbox. I'm extremely excited to get the chance to moderate this ICL, and that we were able to bring together this powerhouse faculty. I think everyone here in this room is well aware that with the adoption of new arthroscopic techniques and selective patient-reported, outpatient-focused algorithms, ACL repair has regained significant attention in recent years. Many studies on contemporary techniques grounded in lessons learned from historical outcomes have been published within the last recent years, and basically are laying the foundation for today's ICL. I'm really looking forward to the next 90 minutes, during which I'll guide you through this ICL, and I want to welcome our faculty. Our first speaker is Dr. Mark Sherman from Staten Island, a clinical associate at the Hospital for Special Surgery and attending surgeon at the Richmond University Medical Center, who wrote the seminal paper on ACL repair back in 1990, being the first to differentiate outcomes for tear types. He will shine a light on ACL repair and its historical context. Next up, Dr. DeFelice, the pioneer of modern-day ACL repair from the Hospital for Special Surgery, will provide us with his insights drawn from 15 years of experience with his double suture anchor repair technique and preservation-first approach. He will shine a light on ACL repair and its technique with dual suture anchor repair. Next up, Wimi Duogui, director of sports medicine at MedStar Washington Hospital, and the chairman of the MBA research committee and consultant for Washington's major league sports teams, who's going to share his experience of ACL repair with cortical button fixation. Next up, Bertrand Sonnericote from Lyon, France, a world-renowned orthopedic surgeon, global leader in the treatment of knee injuries, founder of the Santee Group, and current president of the French Thoracoscopy Society. He will provide us with the Santee experience on ACL primary repair. Next, our speaker from Rome, Italy, Professor Monaco, Edoardo Monaco, a leading sports medicine specialist and member of the Santee Study Group and the ACL Study Group, will share his experience on ACL primary repair and the role of additional extra-articular lateral procedures. And last but not least, Andreas Gamal from the Hospital for Special Surgery, also a leading orthopedic sports medicine specialist and expert in the field of biologic joint reconstruction, joint preservation, will be discussing the role of biologic augmentation and his experience with the Bayer implant. With this and no further ado, I want to welcome our first speaker, Dr. Mark Sherman. There are my old slides. Good morning, everybody. There are my old slides. This is how I prepared. I'll show you in a second. A lot of old papers, coffee, everything's ready to go here. And I have, you know, a few things to say. That's how we used to do it. And Bertrand just told me that he wasn't born in 1990, which I found interesting. And he's done 9,972 ACL reconstructions. In 1979, I was a hotshot resident at NYU Bellevue. I came to special surgery as the only fellow. And the Monday clinic, first patient was a knee injury. I saw the patient. I came out. Dr. Warren, Dr. John Marshall, who ran the clinic, was there. I went over the case, and they said to me, what's the lockman? And I looked at them both, and I said, what's a lockman? They rolled their eyes. I thought my fellowship was over at that moment. And now look at me. I'm giving a history talk. It's a little frightening to me. But a lot has happened in my life in ACL surgery. I see my friend, Dr. Gomez, here. My son, Seth, is here. There are a lot of people in the audience. Billy was a resident, and he's making me feel old. So if you look at the history here, it goes back a long way. 1895, Robeson did a primary repair. And if you haven't read this study, if you're an ACL surgeon, please read it. Because it's amazing what someone knew in 1938 in a short treatise, even Palmer. Certainly O'Donoghue in the 50s. By the way, this is a third edition. I did not have his first edition. Thank God. I would really be old. But he really sort of set the pathway to repairing ligaments. And then, of course, Dr. Fagan, John Fagan at West Point. He was a master clinician. And he really did a lot of repair work, except he used a couple of chromic sutures. And he did that open. And if you looked at that initial paper, there were dismal failures. And essentially from his paper, ACL repair was destroyed. That stimulated a lot of other people to write. And if you look at the other authors, the results weren't all bad. There was a group of patients that actually did fairly well. There was science going on. Steve Arnofsky showed the blood supply to the ACL. And we had shoot the chilled proprioceptive fibers to the ACL. So there was a lot to say that maybe we should preserve this ligament during this time frame. And when you look at some of the studies by Scaglione at the Stedman Group, the results were good. But these were certainly not ACL repairs in a way because there was a lot of things going on to augment it. Semitendinosus, tenodesis in the lateral side. So you really didn't get a feel for whether primary repair would work. And that was my stimulation. Because what we had to do was sort of say, let's do only primary repair. So for 10 years of my life, all comers. And we took them all. And there was an open repair with multiple 2L-TEBDEC sutures. And when I always say, I'm known to Sherman classification. When you think about it, it wasn't very brilliant. It was either torn proximally or in the middle. Somehow everybody keeps talking about it. But it really wasn't a brilliant observation. But I did very carefully look where they were torn and how the quality of the tissue. We looked at a lot of factors. And the important part of this study, I think, was very pure. In that when you looked at the results, if you failed in any category, you failed. To be a clinical objective test, you had to have a negative lockman, negative pivot shift. You really had to have good clinical patient reporting. And most important, your KT-1000 numbers were normal. So it was really strict. And 54% failed, but 46% worked. And that was very important. Who were those people? It was very consistent who those people were. And I think that's a very important takeaway that affected my life for the last 30 years. So, unfortunately, after that paper, when I was walking out of the room, I was so proud of myself. Dale Daniel came up to me. I don't know if many of you knew Dale. He was of great fame with the KT-1000. He said, Mark, you just proved you never have to repair an ACL. So I was devastated. But I realized that Dale, 46% worked. And this was not an average age of 23. This was an active population of patients. And there was a period now for 20 years where the ACL repair was abandoned. Strand wrote that one paper. And Martha Murray, from 2006 on, still continues to do that work that this ACL has potential to heal. And then we came along to the awakening, I call it. Greg's here, Dr. DeFelice. And, of course, arthroscopic repair, this was a type 1 lesion. He was bold enough to say, hey, maybe this can work. And when you look at his early data, 9 of 11 worked. At five years, 9 of 11 objectively worked. So we were on the road to say, hey, maybe this can possibly be a factor. And then other studies came along. And these other studies are all very similar. The proximal tears tend to work objectively. You know, when you look at patient-reported outcomes, you got to be very careful. 82% of my patients love me. They still give me lasagna. They're all failures. So ACL insufficiency, patients can love you as well. That was the deceiving part of ACL repairs, frankly. But we had to look at who succeeded. And when you look at these people, this was, I think, one of the great studies. Eduardo's here as a part of it. Because this is very comparing ACL repair to a reconstruction with even an LAT reinforcement. And when you look at the results, one, it was a great study because you looked at the appearance of the ACL in an MRI. These patients returned to sports and when their subjective and objective results were equivalent. So this was a real supporting paper for the success rate of a primary repair. Though it wasn't pure either. I'm addressing Eduardo because they did a little lateral capsule repair with those primary repairs. So it wasn't a pure ACL repair only. So we all know the advantages. It's common sense. We don't have to do a reconstruction. Well, it's nice to save the ligament. There's no question that we have to ask in this panel answer, I hope. Internal bracing, scaffolding, biological modulation. Will these things affect the results and be the answer in the future? I still think the selection, if you're going to do this, be fussy. Because I don't think there's enough data in 2024 to start supporting it for everybody. So I think if you are going to do ACL repairs and you really specifically look at this category of patient, you're going to have a high success rate. Honestly, all my life, I always thought they were my best needs. Always. They were better than my reconstructions. They always looked better. And 25 years later, I still see these successes and they're better. So it's an interesting fact. This is what needs to be done. Anything less than this, I don't think we're going to get the knowledge about what we have to do in the future. They have to be prospective. They have to be greater than five years. We have to see what the architecture of the ligament looks like. You can't just go by patient-reported outcomes. You really can't. You know, the KT-1000, you know, in my era of ACL surgery was everything. You couldn't present a paper without those numbers. And, you know, anyone have a KT-1000 in their office, in this room? Okay, great. You can sell them because they're hard to get. I have one, and I'm retiring now from surgery. So if anyone wants mine, I'm offering it. But you should have it. You know, the last time I gave this talk, that's Dr. Ron Losey. So he fell asleep in the middle of my talk, which was really making me feel good. But if you look around this group of pictures, you know, you always stand on the shoulders of great people. In my life, I had the honor of really being a friend of Dr. Fagan, Dr. Losey, a little town in Ennis, Montana. And I think about it, that this man created concepts, the pivot shift, et cetera. And now we have gone around in a big circle where we have guys like this who weren't even born when I started. And it's a thrill to be here with you. And I hope they answer a lot of the questions that I was asking today. Thank you, everybody. Good morning, everyone. I'm very excited to gather such an esteemed group to share their experience with ACL primary repair technique I believe should be a part of the surgical armamentarium of every surgeon who treats ACL injuries My name is Greg DeFelice. I am a sports traumatology surgeon at HSS in New York City Over the past 15 years I've pioneered and championed a procedure that I call selective Arthroscopic anatomic ACL primary repair It's one procedure in a treatment algorithm for ACL injury that I call the preservation first approach this treatment algorithm focuses on how the ligaments torn and The quality of the remnant tissue rather than simply if it is torn as the current one size fits all reconstruction for everyone algorithm does These are my disclosures So Why did I decide to go against the grain and repair the ACL again? My early experiences as an attending at Jacoby Medical Center in the Bronx taking care of a socioeconomically challenged population Led me to question why we do what we do, especially regarding the treatment of ACL injuries You understand better why we do what we do today when you look back at the history of ACL treatment and thanks to dr Sherman for agreeing to be part of this ICL and for sharing his first-hand clinical experience with the historic approach to ACL primary repair if you don't look back and Learn we're doomed to repeat failures as we all know In medicine we have treatment algorithms for everything for fractures such as this non displaced fracture We wouldn't hesitate to treat it in a cast or some form of immobilization For a more complex fracture like this common noted one We would use an intramedullary rod. This is obvious since graduated treatment algorithms are central to everything we do in orthopedics except for the ACL The large majority of us will treat both the complete type 3 ACL tear with poor tissue quality on the left and the complete Type 1 ACL tear with excellent tissue quality on the right with the same reconstructive approach In fact a large number I would dare to say the majority of the people in the room Will take the graft before even looking in the knee to assess the tear type and tissue quality That is what I was taught to do as I'm sure many of you were However, at least for me this makes no sense whatsoever And I hope that after this ICL you will at the very least look in the knee before you take the graft If you do you will learn what I learned that far more tears than you think have a chance of being repaired I Spent all of my time in training learning about how to do the surgeries But very little time about the recovery process When I left the privileged environment of HSS where I trained and began my practice in the largely underprivileged Bronx I quickly learned that there were many more variables that affect recovery than I appreciated Here are just a few Faced with this challenging environment, I quickly realized that ensuring a successful recovery for my patients would require some innovation At the time in the early 2000s because arthroscopic cuff repair was burgeoning with new gadgetry I realized that I could use similar techniques in the knee with good effect and Minimizing the morbidity of the procedure would predictably lead to easier recoveries After all if you close one eye and tilt your head the cuff does look like the ACL in reality I often refer to my technique as the cuff repair of the knee Let's go through how I perform anatomic arthroscopic primary ACL repair for proximal tears this QR code will link you to the technique paper Using schematics we could see the anatomic approach that each bundle is addressed with its own suture anchor fixation Here the AM and PL bundles are fixed with four seven five knotless suture anchors at the origin of the ligament Suture augmentation runs down the anterior third of the ligament is fixed distally with another suture anchor and Finally core stitches from the PL bundle or anchor are passed through the ACL and tied to compress the PL bundle to the wall Further enhancing the double bundle nature of the technique Here's a video of how I do it Looking In the notch you can see here a very nice type 1 ACL tear with excellent tissue quality At this point most people would take out the 5-5 shaver and Send that one to its grave Using a schematic we're going to use a do a bonnell type stitch With a high-strength suture I'll skip any names exiting at the top of the ligament For the AM bundle you can see it here try and avoid hitting the other sutures, right? So if you feel resistance you want to stop then we're going to repeat that up the PL bundle The sutures are going to then exit towards the wall because that's going to give them their optimal Positioning with the knee flex at 115 degrees allowing access to the PL Origin we're going to drill tap and then tighten and fix the PL bundle with a knotless suture anchor I Use an accessory inframedial portal to do that We cut those sutures and now with this with the suture passer We're going to go back through the ligament and pass the core stitches from that anchor through the PL bundle With the ligament controlled we can now have access and More safety perform a very slight notch plastic just decorticating the front wall so we can get some bleeding I don't like to morsel eyes the origin the insertion With the knee at 90 degrees of flexion will drill tap and and fix the AM bundle again with a knotless suture anchor this time We're going to have a suture augmentation in the anchor cut those Sutures and now we're going to tie the PL Core stitches to again compress the ACL up against the wall Those will be cut and then the final order of business is to simply drill up with a cannulated 2-4 drill pin Using nitinol wire to pull that suture augmentation down I used to try and put it up through the center of the ligament just for sexiness purposes But what happens is when you try and pull that that tape down through the ACL you end up loosening your repair So it really does better to sit in on the anterior third of the ligament With the knee in full extension we tighten that one everyone asks me how tight do you make it you just pull it so it's Snug you get the slack out and then you anchor it down. It's not meant to be constraining to the knee Here you can see the end how anatomic it is. We've got no impingement. We've got full range of motion and a nice negative Lockman We've published on the multiple benefits of this procedure I'm on Starting first with the anatomic restoration I use the techniques for types one and two tears Proximal a quarter of the ligament to restore the bundles of the ACL directly back to their origins as I mentioned I point this out because most many techniques only repair the ACL to one point of fixation and I Strongly believe that we should restore fully restore the anatomy When you read the outcomes papers keep this in mind as not all repair techniques are the same and yet all of the outcomes Are lumped together One of our most recent papers looks at the biomechanics of suture augmentation directly We undertook this study to investigate the concern that the suture augmentation was providing the stability and not the ACL and that it would eventually fail In addition that it might stress shield the ligament and the tibia creating all sorts of issues in this paper We used intraoperative lock meter measurements to show that there was abnormal anterior tibial translation prior to repair that the repair Normalized this translation and then that the suture augmentation did not change it any further So, what do we find t1 is the laxity under anesthesia prior to repair and t2 is the laxity after repair You can see the significant decrease in anterior tibial translation provided by the repair T3 is the laxity after suture augmentation was fixed and you can see that there was no change This paper in my opinion should put the matter to rest the suture augmentation does not over constrain or chest nor stress shield the knee Continuing on with the low morbidity of the procedure The study aimed to evaluate how often patients think about their operated knee after ACL surgery comparing repair with reconstruction It's pretty simple. If you don't think about your knee on a daily basis, it's likely that you're doing better than if you did Results showed that patients who underwent primary repair were less aware of their operated knee on a daily basis than those who had Reconstruction and to give you some reference the repair patients scored 85.3 patients who never had surgery on their knee generally score around 89 The minimum morbidity allows patients to follow a milestone based protocol rather than a time based protocol Which allows much faster return of range of motion? This study compared post-operative outcomes between AC repair and reconstruction Patients were assessed at one week one month three and six months Repair patients had significantly better range of motion at one week in one month by nearly 30 degrees Nearly double the repair patients achieved full range of motion at one month and repair patients also had fewer fewer complications and no infections Minimal morbidity also leads to minimal opioid use which is good for everyone This paper was a prospective comparison of Repairers versus recons to prove to us. What was obvious that is repair is less painful than reconstruction We found that repair patients had a significantly improved quality of recovery Significantly less post-operative pain and use 87% less overall opiates compared to reconstruction patients In fact over 50% of the patients only took Tylenol post-operatively All Of these benefits are a bit intuitive, but none of that really matters if repair doesn't work This is our most recent outcomes paper on the roughly three and a half year follow-up of a hundred and thirteen patients We found and published that the failure rate for patients under 21 years old was very concerning at 38% Thankfully, this was only 20% of the cohort. So it was a very small number of failures Whereas the failure rate for patients over 21 was encouraging at only 4%. We continue to follow this cohort with 95% follow-up, which is around eight years on average now and five years minimum, and we're encouraged by the data. We found no further failures in the younger group, suggesting that maybe it's not that the procedure shouldn't be done in this group, but perhaps that my early indications were somewhat flawed. In addition, in the older group, there was no significant further deterioration of outcomes. It seems that roughly 1% of the patients who have ACL repair in the over 21 crowd will have a re-injury each year, such that at 10 years post-operatively, 90% of the patients are still doing well. This compares very well with reconstruction. Our results are corroborated by experiences of our colleagues. The majority of systematic reviews on ACL repair, like the one recently published in AOSSM by some of my colleagues at HSS, erroneously lump outcomes from all different repair techniques and patient ages, such that accurate conclusions about the best methods are difficult to draw. In this paper we just published in Kista, we obtained granular age data from the authors of a majority of the studies that allowed us to evaluate age as a risk factor for revision rates for all types of repair, including suture anchor repair, DIS, and the bare, as compared to recon. Kudos to Dr. Rilke and my co-authors for going the extra mile to obtain this revealing data from all of the authors. We included 12 studies, nearly 1,300 patients, and it showed that the rest of the world has had a similar experience to my group. That is, there are more failures in the younger patients under 21, but in the older patients, the outcomes are similar to, if not better than reconstruction. Here's one clinical example. I include it because if you never see how well these patients do, you will not have the motivation to change what you do and learn how to repair the ACL. As you listen to how I treated her, be honest and think how you would have treated her. Okay, year and a half out of skiing injury, 27-year-old female, very active, partial tear, tried to live with it, didn't work out, kept having instability. The trouble was she took an MRI and it said that her ACL was intact. So she went to see a bunch of doctors and they offered her a reconstruction. She found me, and hopefully we're gonna be able to repair her. You can see how much her tibia's moving. She's loose, even though the MRI shows that her ACL looks intact. The trouble is, is it's not tight against the wall. So it pulled proximally and now it's loose and that's why she has these symptoms. You can see the gap at the wall with the ACL centralized as part of the PCL. We've got excellent full range of motion. This is our LET incision and our Lachman is completely negative. Patient was rather ligamentously lax, so we included an LET. I put out all the pictures from pre-op, intra-op, and now we're post-op. We're four months out, she's doing amazingly well. We've got excellent full range of motion. We maintained her hyperextension and the Lachman is completely negative. She is doing great. She's running, she's jumping, she's hopping. She's got no symptoms for the first time in several years. Patient asked, said her knee felt so good that she wanted me to do the LET to her other leg. 24-inch box jump, single leg. Anyways, I'd like to thank my research team who've worked hard to put this topic on the map. They've all had very bright futures and I've been honored to work with them. Thanks for your time. Thank you. Okay, so I'm gonna talk about my experience with ACL repair, internal brace augmentation and cortical button fixation, talk about my journey. If you'd have told me I was gonna be on this podium talking about ACL repair 15 years ago, I would have laughed at myself. But it's interesting to see over 40 people here in the room and see where we've come over the last 10 years or so. So August will be the 10 year anniversary of my first ACL repair. What we know is that the current gold standard is ACL reconstruction. There's high rates of patient satisfaction in the short and medium term. We all know this. Four to 8% failure rate overall. And a massive body of literature showing significantly improved functional outcomes after ACL injury. So if you look at this, you're thinking, well, why are we even talking about this today? So disclosures, it's registered on the AOS website. But I think what we're gonna talk about is the gold standard, really gold. Wiggins' study, the meta-analysis in 2016 showed that when you combine risk factors of athletes younger than 25 years who return to sport, they have a secondary ACL injury rate of 23%. So almost one in four patients. Ross' study in OJSM in 2020 did a systematic review of NFL athletes. These surgeries, ACL reconstruction, were done by the best surgeons across the country, across the world. And what they found is that only 67% returned to play. It took them an average of 12 months. And when they compared their experience, they had greater declines from their pre-injury performance level than controls over that same period. And so if you actually look at the people that were returning to play, they were the super athletes who were now average when they returned. So I would contend that we're certainly not perfect at this and we have more work to do. And then Jensen's study in 2024 is an interesting systematic review that showed the weighted rate of failure of return to sport was 25.5% after ACL reconstruction. And the most cited reason for failure was fear of re-injury. So the knee doesn't feel right. And I think Dr. DeFelice had pointed out how the knee feels different after ACL repairs we'll get into. So this gentleman on the, I guess on your left, Dr. Gordon McKay is the reason I'm here today. So in 2012, I was at a conference and I was talking about a technique that I developed in the shoulder. And he gets up on the podium and he's got a polka dot tie and a kilt on. And he says, I'm repairing the ACL. And everybody like burst out and laughed like, what's this, is this for real? So for me, it was interesting because I was taking care of a professional baseball team at the time. One of our players had gone down with an ACL tear. And I said, hey, listen, we're gonna do an ACL reconstruction in eight months, you'll be back to play. And he said, hey, poppy, you know, I love you. I would have you do it in a second, but my agent wants a second opinion. So he went out to Dick Stedman. So he goes out to Dick Stedman and Dr. Stedman calls me a couple of days later. And he says, in his really soft voice says, with years of confidence behind it, you could tell. He says, you know, I'm doing this technique where I poke some holes in the bone and I stimulate a healing response. And I lay the ligament down and they do pretty well. And I'm thinking, what? And I just reflected back to all the lessons I learned from my mom about if you don't have anything nice to say, don't say anything. And there were crickets. And I hung up the phone and I immediately called Dr. James Andrews, who was a mentor and a friend. And I said, Jimmy, you know, what should I do? In his thick Southern accent, he said, well, well, Wamey, I think you should let him do the surgery over there, but make sure you tell your GM to get another catcher next year. And I, you know, and so sure enough, we got another catcher. But he came back for spring training and I examined his knee and I did the Lachman and it was negative. Firm end point, maybe 1A laxity, maybe, no pivot shift. And I thought, man, that's just scar tissue. This is nonsense. So I'm literally trying to rip through the scar tissue because I'm thinking, you know, this is, I'm trying to protect this guy. Long story short, he played four years as a catcher after that. And after the fourth year, he was going for a pass ball and retore his ACL. And I got a wave of calls from friends and colleagues saying, man, patting me on the back, saying, you know, you were right the first time you should have had it done. And I said, well, wait a minute. He got four years at the major league level playing with this ACL. And there was another player for Detroit Tigers who had the same procedure, also a catcher, who ended up playing out his whole career with an ACL repair, the healing response technique. So it got me thinking. And so this is in the background of me meeting Dr. Gordon McKay and everyone else is ready to throw tomatoes. And I'm thinking, let me talk to this guy afterwards. So his first case is he had 20 patients that he had done something on. And the next year he came back, 2013, and now he had 50 patients. And the year after that, he had 150 patients. I said, man, this guy's probably onto something. So I flew him into DC. He showed me some of the stuff he was doing and I decided, you know what, I'm gonna try this. I'm gonna wait for the right patient. So my first patient was a young man who was a yoga instructor. And he said, hey, doc, if you do an ACL reconstruction, I'm out for three months, I'm gonna lose my job. I need you to do something. I said, well, I have this technique. And it was, you know, full disclosure, this is experimental. If it doesn't work, it doesn't burn a bridge, let's see how it does. And so we did the surgery. And at two months, I said, hey, I think you're clear to go back. And he kind of had his head down. And he looked at me, he said, well, I went back at two weeks. Two weeks, his knee's stable. I said, all right. So then the next case I had was a young lady who needed to go back to, she tore her ACL. She had all kinds of scholarships, Division I scholarships in track and field and soccer. She lost all the scholarships after she tore her ACL. And she said, her parents came to me and said, you know, we need this scholarship. Our daughter can't go to school if she doesn't have a scholarship. So I said, well, I have this technique. She's like, I gotta compete in Penn Relays in four months. I said, if we do your ACL and we reconstruct it, you're not gonna compete four months. It's just not gonna happen. So we did the repair. And four months, she PR'd in 100 meter hurdles at four months out postoperatively. Went on to get a Division I scholarship and competed all four years with this ACL repair. So this really opened my eyes and began my journey as to why I did it. And I think we may have been throwing the baby out with the bathwater. I mean, there's significant strides in terms of what we're able to do surgically in terms of physical therapy over the last 30 years with arthroscopy, MRI, understanding of anatomy, technical advances, rehabilitation principles and surgical materials. And there's now an increasing body of evidence that supports these concepts. So we've seen good results with modern day techniques. Dee Felice has championed a number of these articles. Dr. Sathna and Dr. Bertrand St-Henri-Conte will talk a little bit about their results. And then Muller, 2023, had a cortical button technique, level three match pair comparison, statistically significant improvements in all PROs and no difference between ACL internal brace and ACL reconstruction. Sathna's article with Bertrand St-Henri-Conte, probably the most important thing was the forgotten joint score was statistically better in the ACL internal brace group. And I think you'll see this as a common theme. But there's caution in younger patients. Albright's study had a 48%, 49% failure rate. Sathna's article showed a 5.3% failure rate in their overall, in their ACL internal brace group, but no difference in failure if over 21. But I would contend that, you know, I hear this a lot, like, oh, you can't do this in younger patients. But if you look at younger patients in ACL reconstruction, they don't do so great either. Paterno's article had a nearly 30% new injury rate and six times higher than uninjured controls. Wiggin's article, which we mentioned before, showed almost 25% failure rate and one-fourth failure rate if you're under 25 return to cutting and pivoting sports. What are the contributing factors here? Well, I think volume of work. These athletes haven't developed full neuromuscular coordination. And if you guys have ever removed an ACL, I think about this all the time. Now, when I remove it, I didn't think about it before I started doing repair, but it's flimsy. It's not designed to withstand tremendous stress. In fact, if you look at studies comparing the strength of an ACL graft tissue to the actual native ACL, it's much stronger. What it is, it's like Tom Brady. Tom Brady can't function without his offensive line. What it does is it syncs signals to the brain to coordinate muscular contraction to protect the knee and create physiologic stiffness in the knee. And if you can't do that, when you put an ACL graft in there, it's a rope that your hope is strong because it can't do that. So I think there's lots of things to learn and things that have been there for us to see, but we just sort of were kind of lazy about it. And I think that time is done. So my experience, this was my first retrospective case series in 2020 that I published in Asmar. 23 of 27 patients, 86% had a successful result. 14% failed and required revision to ACL reconstruction. 11 of the 27 patients with successful ACL repair had preoperative baseline data and showed statistically significant improvements in all PROs. So this led me, Greg tried to recruit me to bring our cases together at that time. And I said, Greg, keep doing your work. You're doing great work. I think we need a prospective comparative study. So I actually just published the first US-based level two prospective comparison last year, looking at ACL repair versus reconstruction. We had 60 patients in each group, excuse me, 30 patients in each group, total of 60 patients. We had 91.6% follow-up. And what we found was there were three failures in the suture-augmented ACL repair group, 10%. Average was 19.6 years. In the failure group, the average age of the untorn was 24.6, so again, this common theme of younger patients have a higher failure rate. There were no re-tears in the conventional ACL reconstruction group, but I had one patient who couldn't return to sport because of pain and stiffness, but there were no actual re-tears. So if you look at the patient-reported outcomes, the most important take-home point here was that there was a statistically greater improvement at three months and six months in the IKDC subjective integnor score for the suture-augmented ACL repair group versus reconstruction, and I think this is because of a number of factors. One, you're preserving proprioception, and two, you're not harvesting a graft. And I have a young lady that we did, and I have several patients actually, but this one lady in particular, who eight years prior to seeing me, she had torn her ACL and had a reconstruction. She saw me for having torn her other ACL. We did a repair, she came back, got back to skiing, got back to running, and she said, I wish we'd had this surgery eight years ago when I had my reconstruction, because it felt like a knee scope. So what are the facts? We have limited high-quality evidence still. It's just a fact. But there's a trend in favor of better results with proximal tears, as we learned from Dr. Sherman. A number of recent studies demonstrating good results in the short-term with ACL repair for proximal tears, and a higher incidence of re-tears in younger patients. My indications are a 25 to 55-year-old healthy fit with moderate pivoting cutting activity. Sherman type one, maybe two. I'm moving away from the type twos. High-grade partial tears, absolutely. They have to have good tissue quality. And a really interesting one is desire to return to play in season. I just operated on a young lady from Seattle, Washington, who came to see me, who said, listen, I'm not planning on playing soccer beyond my senior year. I'm a captain this year, I have to play this year. I really want to play. And so we sort of shared decision-making, went through the process with her parents. We know that return to play is gonna be about four or five months for her. And I had experience with a young ODP athlete, Olympic Development Program athlete, who I'd fixed years ago, did a repair on her. She came back at two months, and I said, you're doing really well. So when I see you at five months, if everything looks good, potentially be able to go back to play if you kind of clear all the rows. She said, fine. She comes back at five months. I said, how are you doing? She says, great. I said, well, your knee looks good. I think we're ready to play. She says, well, yesterday I had the game-winning goal in the national championship game. I said, what do you mean? She said, well, after that last visit, I felt so good, I convinced my dad I should play. And so she was playing from two months on. I was pissed. To say the least, I'm like, you're making me look bad, you're in our study. But then she went on to play at the next level, Division I College, for four years. So she played for four years, played six years on this knee ligament, and then retore her senior year in college. And she came into me in tears, and she said, if it wasn't for you, I don't know if I would have ever been able to do this. I not only got to play high school, but because I was able to play high school, it enabled me to play at the next level. She gave me a hug, and I said, you know, it just, there's an art to this. And you see the results in ACL reconstruction, and I would contend that you can't say that this is a never, don't do this, don't operate in young patients. I think you have to weigh everything. So a desire to return to play in season is one of the things that I consider here when making a decision. And a patient with a solid understanding of the risks, benefits, and alternatives, patient and family, has to be on board. So I use an adjustable loop tension technique. Here's a Sherman Type 1 ACL tear. Decent tissue quality. There's the lateral wall, which I like to clear off. I drill my pilot hole, where I'm gonna go with my drill hole. It's a 3.5 millimeter drill hole, and then I poke holes in the bone after I do this. I think this is important. If you don't make your pilot hole first, you'll kind of fall into one of those holes when you're trying to drill, and it's a pain in the butt. So here we have two separate adjustable loop tension devices that I pass into the knee. And you can even do more than this. Potentially, depending upon how many fixation points you want, I like to use two. They're different lengths. There's a 35 millimeter and there's a 25 millimeter, so I can space them out, and it won't over tension one section. And they both share the load. I like to draw them out of an accessory inframed portal so they don't get tangled. And now we're gonna bring the button in. So we bring the button in. We flip it on the lateral cortex. And then we tension this in. Sometimes, you see I have the probe in there. I do that so that the sutures don't get tangled. And then this essentially completes the repair. This is done. It takes about 15 minutes to do this. So now we're doing the internal brace. I think this is critical to have the internal brace there. It protects the tissue early on while it's healing so that it doesn't stretch out. And this is just a check rein. You don't wanna over tighten this. You just want it to lay there. As we know, there is some laxity in the ligament at rest, and that's the technique. So why I like the adjustable loop tension cortical button technique? You can assess the integrity of the repair prior to internally bracing. It's strong cortical fixation. There's no risk of anchor pull out. You have ability to re-tension. So I'll re-tension after I take it through if I feel like it's a little bit loose, which is nice. I used to tie it over a button, and once you tie it, you're done. You're stuck with it, and you really can't mess with it. So this really allows you to assess the knee dynamically. So technical pearls, mini C-arm to confirm the button's fixated on the lateral cortex. Assess the repair before internally bracing. Again, you don't over tighten. It's just a check rein. I like the microfracture of the femoral notch to stimulate healing response. Don't over-tension the winch mechanism because you can actually pull through. I actually did that once, and I had to convert to an ACL reconstruction. So just really just want to lay the tissue down. That's really what you want to do, and really have had some excellent results over the years, over the last 10 years with this technique. So in summary, ACL reconstruction's the gold standard. There's concerns that remain regarding return to sport, OA, recurrent knee injury. There's promising new data supporting modern day cortical button internally braced ACL repair. But there's concerns over results in younger patients. Just be aware of that. And there's still a need for more high quality evidence and data to validate the current body of evidence. But really exciting stuff we're doing here, and glad to see everybody's interest today. Thank you. So first of all, thank you very much for your invitation. It's a great pleasure for me to be with you. As I told to my fellow for the last 20 years, ACL surgery is not only force-Newton resistance, but mostly biology. This is my disclosure. Sorry. This is my disclosure. I love this cut. You know, I have the similar experience 10 years ago when I start to talk about the ILL, so you can observe the evolution. Which is funny. I mean any single surgeon would try to make it again. Everything that was abandoned in our surgery, there is always the same. To avoid criticism, do nothing, say nothing, and be nothing. Why to change? First, because we have to be honest and to recognize that our clinical result for ACL reconstruction is still unacceptable in 2024, in terms of graft-future rate, reoperation rate, and return to sport. Therefore, it's logic to have this new interest for the ACL repair. It was abandoned in the past due to the bad result, but we can expect better clinical outcomes with modern technique. So the two surgeons who promote this modern ACL repair was, for me, Gordon Mackey and Greg DeFelice. It's all about biology, which is for me something amazing, because it's the most important thing that we can do for our patient. The first paper we can find was in 1885, with this case report of PCL and ACL repair. So it's a long story, and you know that it was mostly abandoned following this nice publication by Figging showing bad results with a five years follow-up. However, these two superstars, my mentor Pien Schomba and Richard Tenman, recently passed away. In the 80s, look what they said. ACL ruptures should be treated by suture repair augmented bilateral tenodesis or augmentation. So we could say that 20 years later, they were right. We talk about the very important description by Mark Sherman of the type of repair that we can propose. I also performed this study ten years ago with the French Arthroscopic Society, where we showed that when you harvest the ACL remnant, you could find inside everything we need, which means mechanoreceptors, vessels, synovium. So you don't have a dead tissue. That's the reason why repair works perfectly well. So my first experience, because I'm a lucky man, it was in 2017. It's a world-class slalom girl from Slovakia. She had a failure of the conservative treatment four years before, and I had to do an ACL reconstruction. So she missed the Olympic Games in Sochi, and she sustained contralateral ruptures in September 2017, and the Olympic Games was in February 2018. So she went to see what do you propose. I said, no, we can try with the conservative treatment. She said, no way. It fell four years later. I have to participate to the Olympic Games. So I said, okay, go for the ACL repair. Then, because you know my focus of extra-articular reconstruction, I did this repair, exactly the same technique as shown by Winnie, but I had an percutaneous ILL. The funny story is of recovery. We were totally amazed and totally surprised because the evolution was something totally crazy. I would say one week evolution for her was one month for an ACL reconstruction, and we were really scared to deal with this recovery, and I will talk to you later on one of the explanations for this fantastic and amazing recovery following any ACL repair. So finally, she was the flag bearer for her country at the Olympic Games four years, four months, sorry, after this ACL repair and ILL reconstruction. So we were so happy and very enthusiastic with this ACL repair. So as we know with the Santee group, we perform this match study where we compare ACL repair to ACL reconstruction. So the objective of this study was to compare with a minimum two years follow-up, ACL repair versus ACL reconstruction. We enrolled 75 patients in each group where we perform for the isolated reconstruction BTB or hamstring, and for the group of repair, it was with a bouton and fix with a swivel lock. The difference that we pass always the internal brace inside the ACL because we are afraid to have any debris inside the joint. So in terms of clinical outcomes, we do not find any difference in terms of epilepsy, in terms of pivot shift. The isokinetic test was much better for the ACL repair group. The functional score was better in the repair group, particularly the forgotten joint scores. The rotund tooth spot was similar in both groups. However, we have a higher rupture rate in the repair group. We find a significant difference in terms of ruptures, 5.3 in the repair group versus 0 in the reconstruction group. And we observed that the failure in the repair group was significantly in younger patients. So following this, we start to say, okay, how to consider this group of repair? What we can propose? What is the biological process? And in fact, one of the main questions is always the same with my volume of ACL. For the last 20 years, I said, is there any place for healing capacity of spontaneous healing for an ACL? And look at this case. It's a three months control after these proximal tears with a perfect healing. This one is really amazing. You can't imagine that you could have a spontaneous healing, but it can occur. However, we have a pretty good expectation with a 3T MRI scan because you see we can perfectly observe in this MRI isolated tears of the PL bundle. So you could imagine that this case could heal spontaneously very well. Also, it was described 10 years ago by Bob Marks that in a ski patient, you have a good healing capacity because it's mostly isolated proximal tears. So it's also one important observation that we had. In Europe, we have a lot of ski injuries. The very important, I would say, improvement we had in the last 20 years is understanding the biological impact of an ACL injury or ACL reconstruction. So I recommend all of you to read the publication by Christian Letterman, which is very, very amazing. What we have to know that's following an ACL ruptures or an ACL reconstruction, we call it a huge heat inflammation with a lot of cytokine, which is one of the reasons for this inflammation, for this remnant destruction. So it's very important. And what we believe now is when you do an ACL repair, probably due to the diameter of the tunnel that you perform, you don't have this second heat. That's probably the reason why you have this amazing recovery. You do not observe any quadriceps shutdown following an ACL repair, probably because this heat inflammation is much, much less than if you compare to an ACL reconstruction. So we performed this study recently published, where we analyze the factor we influence the hormone of ACL remnant, because it's a very important question when you deal with ACL repair, based on over 5,000 ACL reconstruction I have done. We found that increased age at the surgery was positively associated with a big remnant. We also discovered that a longer delay between accident to surgery associated lesion and female sex, we don't know why, is a risk factor for small remnant. So when you have additional injury, cartilage, meniscus, probably you have this huge heat inflammation and then you have the destruction of the ACL remnant. So it's also an important factor we take in consideration to perform a repair or not, the delay, but also the associated lesion. So we make an evolution in our ACL reconstruction technique and the next video you will see is very funny story is one of my fellow is now doing is, we call it assistant in Paris, in a very nice academic department where they only do BTB and they said that ACL repair do not do not be done because it's totally stupid. This guy is a 34 years old, has proximal tears and he called me, said I'm very embarrassed, I told my ACL what to do. I said okay, try the conservative treatment and let me know. Two weeks later he called me, said oh my god, I'm unstable. So I said okay, what do you want to do? He said if I stay here, I would have a BTB, I don't want, I want you to do my surgery. I said okay, first you must deal with your professor to avoid to be killed and second, what you want me to do? Say Bertrand, you must do what you will you will have done for your knee. Okay, and it's funny when we, he has a positive like mind with a positive pivot shift and look when I start the surgery, this fantastic proximal tears. So I say okay, if it's my knee, I will do, I will ask for a repair. So as I told you, we always try to avoid to have a synthetic tissue inside the joint. So there is nothing special here. We suture the ACL, but we harvest the gracilis in order to perform this ILL reconstruction. So this is a landmark for my ILL. ILL always perform, which is two lamps, which it is our routine ILL reconstruction and we do it perpetuously. So we pass the gracilis inside my ACL stamp. Then I use a suture and I use my gracilis to perform this ILL reconstruction. So it's a combined repair, which is fantastic for the biology, but also probably this protective effect as a belt for with the ILL with this gracilis and we do not have any single implant than just an interference screw for the femur. This is the final aspect and this is what we do now when we perform an ACL repair. So it's look like a normal ACL. So our indication is now patient, we ask for a repair because there is some communication for that. I would say that we now try to avoid patient who's doing pivoting sports because we have a big rate of failure and we always combine this repair with this ILL reconstruction using the gracilis. So in conclusion, ACL repair is a valuable option for proximal tears. Patient selection, as we all said, is a key point. Lateral extracellular reconstruction is probably an important belt protection and we don't use in top athlete because it's too much risky. I would say that for me the most important message is that the greatest advance in ACL surgery have been made thanks to better understanding of the biological problem involved. So as said by Greg, repair if you can, augment if needed, reconstruct if necessary. Thank you for your attention. Good morning. Thank you for the invitation. It's a great pleasure and honor for me to be here. I come from Rome, Italy and I would like to thank my two No This is okay. Okay. Sorry. I would like to thank my two friends who inspired me in the field of ACL reconstruction. Bertrand was the first one to push me in this kind of surgery and suggested me to start this kind of surgery and for sure Greg, the Felice as we say in Italy, who I had the pleasure to visit in New York, unfortunately just some days before the lockdown. So I was not able to go in the OR, but I still remember this crazy live surgery you've made with the whatsapp connection from my hotel. It was very nice and it inspired me a lot in this kind of surgery. In my opinion, this is not a surgery. So it's not a technique but mainly a philosophy of treatment, which is the philosophy of ACL preservation. And the goals are the ligament healing rather than its replacement with a tendon. Restoration of anatomy and function of the ligament and of the joint. Preservation of functional sensory function of the ligament and also avoid harvesting related morbidity. There are many many papers we have already seen in the last year. Human and animals papers showing that ACL, especially in the one third proximal part, has a huge healing potential and it can also heal spontaneously as showed before by Bertrand. We also have some cases of spontaneous healing, but this should encourage us in trying to repair it. And so it can heal by four different phases of healing, such as other ligament of the knee and of our body. In fact, it was already clear in 1999 that at the time of a chronic ACL reconstruction, most of the ACL healed, but in a non-anatomical and so non-functional healing, most of them were reattached to the PCL and so they cannot stabilize the knee. Unfortunately, this is due to the adverse factors that we have inside our joint that are against anatomical healing of the ACL. So the goal of ACL reconstruction in my mind is just to pull back the ligament in its femoral insertion, hallowing the ligament to heal itself on its stamp and on its femoral correct anatomical placement. These are two second looks of our experience showing the healing of the ligament at the level of the femoral insertion site. This is another interesting case. We did a lot some years ago at the beginning of our experience, multi-ligament injuries involving the medial side and the ACL. We were doing MCL open repair and we found this kind of perfectly repairable ACL with a proximal tearing. So we performed this technique that I learned in my university from the old-fashioned techniques from Professor Poudre and other pioneers of knee surgery in my university. This patient, unfortunately or fortunately, had arthrofibrosis. So 40 days after surgery, she had manipulation under anesthesia. I also performed a second look arthroscopy and as you can see here, the ligament was perfectly healed after five weeks. So this was very, very encouraging, these kind of results. We also enrolled 15 volunteers who agreed to perform a nanoscope ambulatory evaluation after ACL repair, so we could evaluate the macroscopic appearance of the repaired ligament and the tension. It was satisfactory in most of the patients and was also comparable with the signal intensity of the MRI after repair. And we also Sorry Maybe it's better. Performed a nanobite tissue biopsy to study the collagen expression in repaired ligament and we compared it with a normal ligament and with a reconstruction ligament. And of course, these are two different tissues. So the ligament is very similar to a normal ligament and it's different to attend on, which we usually use to replace the ACL. And also there is a high number of alpha smooth muscular actin positive cells. That means that the ligament is able to produce collagen and fibroblasts and so is able to heal. As we have seen, there are many papers showing good results and also not inferior results comparing ACL repair and ACL reconstruction in the last years, but there are some factors that should be considered. We have the tear type and tissue quality, the synovial coverage of the ligament, the age of patients, post activity and interval to surgery, which in my mind is crucial. The age, especially, we already have seen this beautiful paper from Sebastian and Greg, the age of 21 is the limit for a serious person actually, but also the level of patients. This is a study on the duty militants, 26% of failure. Again, the risk factors, younger patient and high level of competition or activity. We found similar results in a soccer player, which are a very high risk category of patient, in this case of 50 patients, 16% of, we found 60% of failure. And again, even in our paper, the risk factors were the age, younger than 21 and high level of soccer activity, Tegner 9. But so the ACL can heal, but we have a failure rate in younger patient and high-demanding patients. But this is the same problem that you have to manage with ACL reconstruction techniques. Because we have even bad results in young patient and high-demanding patients. So we should consider LIPs in this particular patients. And the other aspect that we should always remember is this, even if the technique is different, the injury is the same. So we are treating a knee who sustained a rotational injury, and so we must consider and treat associated lesions that are often associated with ACL. And so what's the rationale to add a lateral extrategral procedure? It's the same as for ACL reconstruction. The first one is the longer lever harm, which is better able to control rotational stability of the knee. The other very, very important aspect, which is maybe crucial also for ACL repair, is the protective function of the LIP. Reduction of the stress on the ACL. The decrease of force applied on the ACL, especially in pivoting loads. And so this leads to a better integration of the graft and also maybe to a better healing of the repaired ACL. And last but not least, treatment of anteroradial tear, which are so often associated with the ACL reconstruction. There are many, many papers, also from our SANTI group, showing that LIPs are effective in this kind of high-grizz patients, so high-level athletes and pediatric patients. So they should be taken into consideration also in association with ACL repair, as we suggested with my friend Adnan in this recent newsletter article on J. Isaacos. There are some studies reporting results of ACL repair and anteroradial structural treatment. This is one from our group. We compared the ACL repair and ACL reconstruction and LIT, not in free results, in terms of KDC, AP, cytoside elasticity, and SNQ evaluation at MRI. We also treated 10 patients who had an associated proximal tear of the ACL and second fracture fixation. We always fix the second fracture, and we publish our technique of combined repair and fixation of the second fracture. Good results and no failure in this group. As we already seen, Gordon McKay proposed this technique of ACL repair combined with ALL internal brazing in patients with high pivot shifts, second fracture, and high levels post-activity. And they show good results in this population. And also, as already Bertrand showed, this technique proposed by Jean-Marie Fayard, an ACL repair augmented with a one-strand gracilis and ALL percutaneous reconstruction. We performed in our institution 170 ACL repair, 116 patients reached the minimum two years of follow-up. So I want to show you our still unpublished data on this population. We had a 10% of failure rate. Again, unfortunately, the age was crucial. We have all the failure in patient younger than 29, and no failure in patient older than 29. So there was a relative risk, increased relative risk for a younger patient. We had good results, good stability in the patients. And looking, there is no statistical analysis because we have not too much patient. But looking at the results, based on the treatment of anterolateral tear, we can see that we had no failure in the second fracture fixation, and just one in patient with LIT associated with ACL repair, while in all the other groups, no treatment, just ALL repair, or ALL repair in the internal brace, the number of failures was higher. We can, so we can augment our ACL repair using different techniques for LIP. The more used are the Bertrand technique for ALL reconstruction percutaneous. And also, we can consider the modified LEMER with a strip of eludible band, which is fixed on the femur. And so in my opinion, as we have a lot of indication now for adding LIPs to ACL reconstruction, we should consider the same indication in patient with ACL repair, except that for revision and chronic, that in my opinion are contraindication for ACL repair. All the other indication are good as for ACL reconstruction and for ACL repair. So in conclusion, we should remember that ACL has an intrinsic healing potential, but we must consider these key factors for success after ACL repair, so the indication are crucial. We should repair the right patient with the right tear, and always remember to augment primary ACL repair with LIPs in young and eye demanding patient. I want to leave you with some video that my patients send me after ACL repair. Sorry, there is the audio here. But especially the one who was a ski instructor who told me that he feels, wrote me that he feels the knee perfectly with no discomfort, the same as before surgery, and this make him the happiest person on earth. And this is in my mind the real goal of ACL preservation. Thank you very much. Thank you. While we pull this up, can I see a quick show of hands who does ACL repairs? That's great. I think 10 years ago at a meeting like this, this would not have happened, meaning this would not have been allowed. Five years ago, this would have been probably the last session with two people in the audience, but this is on a Friday morning at seven and so many people show up is wonderful. I've been sitting on the sidelines looking at ACL repair for years. My wife Sabrina Strickland and I are practice partners at HSS and we've watched Greg do this for years. What has held us back in the past was the concern over tissue loss. So I don't have to go into too much detail, but when I see a patient with a combined ACL MCL injury, the message is usually, oh, your MCL will heal. Don't worry about it. It will heal for some time, but your ACL probably will not heal. Why is this? The only difference really is sort of the bridge that's missing, meaning the MCL is enclosed. You have a clot. This clot remains stabilized, so there's some tissue regeneration, regrowth that can fill the inevitable gap if something tears, and the ACL doesn't have that. So as a concept, I always had an issue with, let's say, Sherman type II tears. How do I bring this back to the femur? Don't I make the ligament too tight? Worry about early failures. The early studies, as you've heard, were always very concerning. And what really made me switch and start implementing this, at least for a spectrum of ACL tears in my practice, was this bridge concept. I never had a problem with pure femoral avulgence repairing those back. So those without tissue loss, there were just not very many that I saw. Most of them had some tissue loss. I wasn't sure enough that I could repair this back, and that's why I decided to just do the same thing for everyone and do reconstructions. But Bayer, as an implant that became available just a couple years ago, for me, at least as a concept, literally bridged that gap, both functionally and sort of academically in terms of, well, now even if I lose some tissue, here's a way where I can regenerate tissue and fill the gap. I don't have to try with all my might to get something back to the lateral wall that may not want to go, given the tissue loss. So Bayer tries to address this concern for type 2, maybe mid-substance tears as well, although I haven't really expanded into that yet. Right about, I just texted my research assistant, we're about 100 Bayers now over the last year and a half to two years, and so far have been very happy. And we use them pretty much routinely. So for every repair, we do use the Bayer implant. I generally use Bayers in the winter, mainly because as you've heard as a repeated message, the ones that are most repairable tend to be skiing injuries, maybe a little bit older patients that have these proximal avulsions. So a primary repair, as you've heard, really depends on the anatomic restoration, getting somehow contact between the soft tissue and the bone, otherwise no healing will occur. Bayer is, I hope, at least somewhat more forgiving because you introduce a clot and stabilize the clot and bridge that gap. What started to convince me besides the conceptual work of Martha Murray is also the research work that she's done. This is the RCT that led ultimately to the approval. It was a randomized trial done mainly at Children's Hospital in Boston, where they looked at 100 patients and had sort of a 2-to-1 randomization between Bayer and hamstring autograft reconstruction. It was a pretty young age group, so 17 years. This is the high concern, high risk of re-injury age group. But if you look overall, the recurrence rate of tears was 14% in Bayer versus 6% with the ACL. So there was a difference. It may not have been statistical, but at least clinically somewhat concerning. But if you drill down into the data, and this is also something that you've heard, I think, here multiple times, in patients that were older than 20, they didn't see any re-tears. So if I look at my practice, I do keep this mainly for patients who are above the age of 20, similar to ACL reconstruction. If someone comes and is really interested in having a Bayer and is otherwise an ideal candidate, I wouldn't necessarily send them away, but for sure I would do an extraticular lateral tenodesis that you've heard as well before. The one fascinating thing, I think, about Bayer's or repairs overall is that they recover more quickly, which, if you think about it, makes sense. You don't harvest graft. You don't have any dornosite mobility. You have less quadriceps atrophy. People feel better if they have better muscle function. So if you look at the IKDC at six months, a much higher rate of patients achieved better IKDC early on at six months than if you look at the equivalent reconstruction. And there's not just a subjective thing. If you look at an MRI scan, and Martha Murray has done a lot of work looking at MRIs post-op, identifying the volume and the quality of the reconstructed or repaired ACL on MRI scan, the ACL graft, you see this curve in red. So yes, an ACL graft is much thicker than the original ACL, but there's probably a reason why we don't have thick ACLs in terms of notch impingement and stuffing. But the Bayer implant in blue is much closer to the original in black. And ultimately what we want is we want something that's close to the original, not necessarily thicker or stronger than the original. It also met all the primary and secondary endpoints in this trial in terms of the IKDC, the instrumented AP laxity. And this is not surprising. Hamstring strength was essentially unaffected in these Bayer repairs versus an ACL reconstruction. And I would say any reconstruction that I see has some deficit, whether it's quad, hamstring, and the Bayers come back much more quickly as I'm sure regular ACL repairs do as well. What also was interesting is the revisions are better. No one wants to see a failure, but if you do enough, you will see failures. And I think we're trained as surgeons to always think about plan B, do a lot of revisions, I think about 30% of my practice is revisions, and the management of enlarged tunnels that are never quite in the right position is definitely a challenge. With ACL repair, you don't have that challenge. Depending on what you use, we use just one tunnel, as I think you've seen in some of the techniques, and revising that is not an issue. You don't have tunnel widening. You essentially can do a primary reconstruction even after a prior Bayer, and the results of this trial bore this out. When they looked at the failed Bayers that then were revised with a hamstring reconstruction, the outcomes of the revision procedure mirrors essentially their experience with the primary ACL reconstruction. And especially in this young and patient population, failures will happen, and having a good plan B I think is a very valuable tool. So what is it indicated for? It's for the proximal and mid-ACL tier, so maybe expanding a little bit into the territory where primary ACL repair without a bridge is worrying us, and rightly so. If you have poor tissue quality, then this is definitely not anything you should consider. And I always talk to my patients, sometimes you see MRIs where you say from the beginning, this is going to be repairable, this is great. And there are some that are borderline, and for those I always consent them as a fallback position for a standard reconstruction technique, just so that you don't have to sort of scrub out and ask the family what they want you to do. So having that in your back pocket is a good tool. So again, what always made me consider wanting to repair these is, as you can see here, I felt guilty going in with these proximal tiers, and you look at it, and until you start probing, it looks almost like a normal ACL. It's not attached, but you have tissue that extends almost all the way up to the femoral wall. It just happens to not be attached. And to me, at least, shaving all that healthy-appearing tissue out always left me with a little bit of a sinking feeling, and these are the tiers that if you see them in your primary practice, so as Greg said, stick a scope in the knee first, take a look, and if you see something that looks like this, give it a try. You'd be surprised how good they look once you repair them. So this is an example that's probably the prime example where you can feel comfortable starting in your practice. This is not a high-risk patient. Some patients, as you saw one study by Bob Marks, some of these patients may not need the reconstruction. We live in New York, so most people do want to go back to playing tennis, pickleball, ski, so we don't have many patients who, when you tell them, yeah, you have an ACL tear, but we'll treat it with PT, are willing to go with this. But this is a patient who overwhelmingly will have a good outcome, so that's a safe one to maybe do as your first one. As you can see here, it's a proximal, probably going into the mid-substance tear, but very good tissue quality. And just going quickly through the steps, you've heard them before, you're trying not to really take anything out, so I don't really use the shaver. I think you saw a free elevator to mobilize the tissue. I usually use the most narrow, curved osteotome to scrape tissue off the wall, then I use a shaver just to do a light abrasion, minimal notch blast, essentially to get a bleeding bed. You saw some example of doing microfracture holes, either one I think works. You just want to bring some biology to this. You use a standard technique, I use a single drill tunnel, I don't use any anchors, and I use an adjustable loop button, which also you'd seen before, because I feel I can get a better sense of how tight I make this. I pass a suture, and you don't want to strangulate the tissue, so you pass them side to side rather than circumferentially around the stump. This was an early one using vicral suture, I've switched to non-resorbable suture since I think that's a little bit more stronger fixation, you can mobilize patients earlier. And the tibial, just at the anterior edge of the ACL, so I don't pass it all the way through. Bertrand showed an amazing technique, I think that requires incredible skill to actually pass this inside your ACL. I tend to be at the anterior footprint, use, as mentioned, this adjustable loop button, take a quick floor shot to make sure that you have flipped it correctly, because especially since you don't have a tunnel that goes all the way to the cortex, where you pull your button just through the essential cortical hole, and you can feel it jump out and be pretty sure that you have it deployed. Here you just have a narrow tunnel with a lot of friction, so sometimes you don't have a good feeling of whether you're out or not, and just having a small C-arm gives you that comfort. This incision here looks gigantic, I can reassure you it's not quite as gigantic as it looks on the scope. This is a gentleman who's, I think at that point, three months out, and it's a pretty small medial peripatellar incision that's sort of one and a half to two fingers width. That's what you use to pass the Bayer implant. This is an arthroscopy camera shot of what the Bayer implant looks. It's a bovine collagen, it's hard, it essentially turns into a hydrogel as soon as you hydrate it with either blood or autologous bone marrow, I tend to use the latter. It becomes squishy, you compress it, you have the internal brain sutures go through the implant and you essentially slide it along the sutures into the notch inflection, and then as you've seen in many other techniques, you extend the knee and you fix the additional sutures over the tibia with whatever fixation device you prefer. The protocol in the original trial is very, very slow, and probably a number of patients developed arthrofibrosis after this. We switched to an accelerated protocol, and this is already sort of the old news from a few months ago, now we start doing zero to 90, or even as tolerated from the beginning because we're pretty happy with our fixation, and these patients come back much more quickly, they preserve their quadriceps and hamstring strength much better than if you brace them and limit their weight bearing for weeks. This is an example of a six-month post-op MRI scan where you can see a reconstituted ACL, doesn't have any sac, and it's a pretty normal MRI signal. This is just a very quick, as I mentioned, we now are up to slightly above 100. This was our first 73 with the demographics, so we tend to skew a little bit more towards the ski population with an average age in the 30s, sports, a lot of ski-related injuries, as mentioned, the winter's busy with bear, the summer's much less so, and the typical ACL concomitant procedures, meniscus repairs, chondroplasties, meniscectomies, a few LATs in patients who skewed on the younger age group, follow-up, most of them now have reached more than a year. We haven't included our most recent ones in this. And in terms of complications, we've been very happy. We had two re-tears, one in tennis, the other one after a fall, about at a year. Early on, we had some patients with arthrofibrosis, so we had three lines of adhesions. We haven't really seen that within the last nine to 12 months. One cyclops excision, arthroscopic debridement, one meniscus re-tear, things you see with a regular ACL reconstruction as well. And with that, I think we hopefully will still have some minutes to go into our Q&A. Sebastian, if you would, that. Thank you very much. All right. Since we're a little over time now already, I still want to thank all our speakers for his comprehensive overview. I think it was a great session. We maybe have two minutes. We have maybe time for one question, maybe two questions. There's a mic right up there, so just go up there and... Thanks for the lectures. It was amazing. I have a question from Dr. Phyllis. You know, usually, sometimes when we look inside the knee, the ACL is torn in proximal, but it's not completely detached. It's attached a little distally. There is another classification, as the Asian group suggested. So what do you do? You detach completely and bring back to the upper? The second thing is, when you look inside, how you identify AM and PL, it's not how you identify these two bundles. Sometimes it's not clear, different two bundles. And the second question I have from Dr. Gomel, do you use fiber wire for passing the bear or not? And you fix on both sides? You can, if it's scarred into the wrong place, I just use a freer elevator and lift it off the wall. In general, I think AM and PL bundle, the tissue that's right in your face, right in the front is AM, and around the corner is PL. The suture passes on the PL bundle, you're taking a much deeper bite with the suture passer and getting it in behind. And that's the one that I pull up in deep reflection. So I use the footprint of the old ACL, there's usually, I don't clean the wall off, I leave the tissue on the wall so I can see where I want to put it. I just have a comment because I think this is wonderful. And five years ago, we really couldn't have done this. And now look at the panel that we have. I'm currently a football doctor in Madrid, Spain. Our place, we do 1,100 cruciates a year. And the football players, we're a FIFA center of excellence. On our football players, we seldom see a repairable football player lesion. But for 25 years, actually 45 years, I've been a ski doctor in Lake Tahoe. And as a ski doctor, we see these repairable lesions incredibly frequent. And I was blessed with my first five years in practice to help Dick Steadman do every one of his cases. I was his first assistant. And I published article in 87 on repair and elite level skiers, where we had a 90% success. They were all the type one and our failures were not in the type one. Dick further published, though, that if you do your micro fractures, just a micro fracture of the notch at people over age 40, you're going to wind up with about a 92% success rate over 40. And one of the things that I learned in Spain from the Sante group, though, is that if you flex the knee at 90 degrees and you see the intermedial bundle is reducible, then you put the knee in a figure four. We call it the moraga, position of moraga, which is a French term. If you put it in a figure four, you can see the posterolateral band. And if that is approximated, those repairs will almost assuredly, you can almost assure your patients you're going to get an adequate repair. Because you can reduce the intermedial and the posterolateral bundle. And you can see it by putting your patients in a figure four where you've got a reducible lesion. Another thing in skiers, the major injury in skiers occurs when the beginner and intermediate skier falls backwards. If they have an external rotation abduction injury, they get an irreparable tear for the most part. But if you fall backwards on your heels, or if you take your free doggers, if they take a bump and they land on the heels of their skis, your hips go below your knees, you get an internal rotation torque, and your cruciate literally snaps off the femur. So take a history of your ski patients, and if they tell you they fell backwards, you just start to think repairable lesion, and then you can repair it with the way that you like to repair it the best. But if they fall backwards, think repairable lesion. Take a history, how did you fall? Did your ski go out from underneath you, or did you fall backwards on your tush? That's the only comment. This is wonderful. And do it next year. Everybody write down, we should do it next year. I only came here because I wanted to support the group and make sure they have enough people to make sure they do it next year. Thank you for the comments. Thank you so much for your support, and thanks for everyone showing up this early in the morning. And if there's further questions, I'm sure the faculty is happy to answer questions later. Thank you.

ACL repair

anterior cruciate ligament

Dr. Sebastian Rilke

Hospital for Special Surgery

surgical techniques

historical overview

Dr. Mark Sherman

Dr. Greg DeFelice

Dr. Wimi Douoguih

cortical button

lateral extra-articular tenodesis

Dr. Bertrand Sonnery-Cottet

BEAR technique