expertise shared and stuff that you won't find, right, the level five in the literature. Again, thanks to Volcker and Pitt's leadership on the STAR trial. I think that really has helped me to grow as a surgeon. And it's been great for him to share some of these cases and really go back and forth about some of the proposed management because we really don't have cracked the code, so to speak, yet on what is the best approach. I got two quick cases, and I also will just open it up to the floor for any questions that you have. Feel free to come to the microphone at any point in time. But I have two cases, and one, hopefully, that I'll draw out some of the concepts that we didn't discuss. So this first one is a case of mine. It was helped, prepared by my fellow, Max. So many thanks to him. I think he's still sleeping. This is the game that Pitt beat Meg Forrest. Oh, no, sorry. I don't remember. I don't remember that game, actually. I'm sorry. Not a lot of people remember that game because both teams kind of suck at it. Come on. This is an interesting one. We'll start off with you, Volker. This is an 18-year-old. He's a D1 football recruit. All right, so he arrives on campus this fall, and he has one-year history of injury. He falls on a flex knee during his senior football season. Unable to return to play, quote, unquote, rehabbed it. Was told he had a knee sprain. He competed in track. He presents today in the college training room. Mild effusion. His knee pain with workouts. Difficulty with deceleration, cutting maneuvers. No curveballs here. We're in a PCL section. How do you approach this guy? I can tell you, having been there, and if you weren't at the field watching what happened, your first instinct is ACL. It always is. And you have to make sure whenever you examine somebody for an ACL that you also think about the PCL. I know you already said it's going to be PCL. But I'm telling you, that'll be your most common mistake. And I've done this many times before. And only when the MRI came back, you're like, oh, OK. Now it makes sense. So how do I go about this guy, is your question? Yeah. Yeah, I mean, obviously, do an exam. Let me see what you have here. Yeah, so one plus effusion. He's got a pretty symmetric recurve bottom on exam. I can really stress him on both sides. Maybe up to about 15 degrees of hyperextension. He's got tenderness palpation medially, patellofemoral. He's got a stable 1A Lachman. But he has what seems to be a 3B. And we can dive into that, too. Posterior drawer, he's got a quad active SAG sign, pain with deep knee flexion. So I mean, the big question is, if you truly have a 3 plus posterior drawer, I would say it's unlikely that it's an isolated injury. Now if it is isolated, then yes, you can definitely put him in a posterior strapped brace, six weeks, full extension, weight bearing is tolerated, and let it heal. And it will heal. I haven't seen the MRI yet, but it will do that. But with a big drawer like this, I would be concerned that the corner is involved or the MCL is involved. And so yes, I would probably, on the athletes, I like to get stress x-rays. So I have more numbers I can work with. I get an MRI, obviously. And that's how I would start. Yeah. And Dustin, what do you think? You think at a year out, we can get this guy to scar in and heal if he has a proposed PCL injury, posterior laxity? I think it would be tough at a year. If this was presenting acutely, I had one like this in one of our high school football players this year that we treated non-operatively. And he went on to do great with it. But with him coming a year out, not being able to return to some of this stuff, I think it's going to be very difficult to get them to scar in at this point. So Dustin, what imaging are you getting right out of the chute? And let me just preface it by saying, at UNM and Pitt, you have coaches that I'm sure inherently trust you. Ours looks us with a very skeptical glance at every turn. And so anything we communicate always has to be very artful in the way we portray it. So to choose wisely, because Coach Clawson will be up your tail here shortly. Don't use the word tear. We had a turnover of coaching staff recently. So the coaches that we have now are a little bit more friendly, if that's possible. I'd get standard x-rays, potentially consider long-leg films with it. They don't do those at Student Health, unfortunately. Probably don't do stress x-rays there either. So we'd be looking at him. Funny you say that, yeah. He comes with these. It's non-quantified. You don't know any measurement parameters. But obviously, you can see stress imaging here. I'm sorry. I'll get out of your way. Showing obvious posterior laxity. These are not traditional kneeling stress x-rays. Nick can speak to this. But they do, I guess, suggest that posterior instability. I'd also submit to you that standard AP, patellofemoral views, all of which are normal. So you're getting MRI right out of the gates at this point? I am. OK. Mike, anything different? No, I mean, again, you might want to consider the full-length alignment films just to see what's going on. And then if you're looking at slope here, although it probably wouldn't be done or tackled in a primary situation like this, you can always get a full-length tibia, a good lateral of it, to see what the slope looks like. Would you trust me if I said his full-length alignment films were normal? Yes. Slope was otherwise within normal. I trust you with anything. All right. Appreciate it. Thanks for giving me that leeway. You're welcome. Because we didn't have it. So you can see the imaging here. You can appreciate the coronals, far left, axials. I know we're in kind of an awkward viewing environment. And then sagittals, far right. And they're just going to continue to cycle through. Mike, do you want to take a stab at what you can see from a 15-degree oblique angle? Yeah, I can't. Obviously, there's PCL deficiency. I can't see much. The lateral meniscus looks OK. The medial meniscus looks OK. It doesn't look like there's any root injury. I can't really tell what's going on with the corners from my obliquity. So are the corners OK? The thing is, the corner usually looks OK. And you just have to rely on your gut and what the literature tells you. And so I think with a big drawer, I don't know what you measured, but this is probably 15 millimeters or more of posterior drawer. And Chris Hanna has shown this really, really nicely. It's one of the work from the 90s, where the corner takes up more forces if the PCL is out and vice versa. So this is one I would probably do a PCL reconstruction and also do fibula-based LCL reconstruction. Now, in a chronic case, you can definitely argue for the double bundle. You would probably do that. Maybe you can talk about that. Before we head there, Dustin, assuming this is acute, how are you managing it? Volker talked about immobilizing, probably putting a little bolster underneath the tibia. What's your non-operative rehab scheme for this individual if you catch this acutely? Yeah, I'll work on a range of motion, get them into therapy, but with the prone-based therapy like Volker had talked about. And then I'm also a PCL jack brace or some sort of brace that provides some anterior translation of the tibia. So spring-loaded brace. Mike, do you do anything different? Not much, no. I think commenting on what Volker said about the corners, it's often easy to mistake a posterior medial injury from a posterior lateral injury, especially in the chronic cases. So it's really important to get a very good physical examination on the patient, especially when they're under anesthesia, because the last thing you want to do is the wrong corner. Yeah. So we took Volker's advice. We didn't use the worst tear. We said PCL insufficient knee and some suggestions of something going on medially. And the concerning feature is he continued to have these pretty significant recurrent effusions. At this point in time, are we heading to surgery? Is there anything else that you do differently? When you say recurrent effusions, I mean, obviously, you would have that with a PCL, but you may have a concern about articular cartilage. I don't know if the MRI showed that. I didn't look at it that closely. Tibia, bone marrow, edema, that's really the only thing that jumps off there. Maybe a little bit of subtle chondrosis. Yeah. I mean, after a year, I mean, this is a guy who probably needs to get this fixed, right? So you have a conversation. I usually have everyone in the room that wants to be, the athlete wants to have in there. So there's coach, and mom, and athletic trainer, and the player, if the player wishes to have all that team in there. But I would lay all the procedures out, surgical treatment, six weeks in the brace, prone therapy after that, and one year before you return to sport. So then they can talk redshirt and all these other things. They say, I read some studies that says the NFL athletes almost never have to have these isolated PCL tears treated operatively. He comes back with recurrent effusions. I've seen big linemen with huge posterior drawers, and they're fine and stoic. And they don't want anything done. And so then they don't get anything done. But if you're asking, hey, does it make a difference with OA down the road? I would say, yeah, it will. Because with that much posterior drawer, it's a matter of time before the medial condyle cartilage goes, before the patella cartilage goes and trochlear. So I would restore this. Yeah, so here is, let's go ahead and play it. So you can see the source of the effusion. He's got this chondral damage a little bit underneath the patella as well, assessment. You can see that gelatinous tissue is formerly known as the PCL. You can see as we peel that off, it comes off very readily. We listened to Mike's advice. We made our posterior portal for some of the dissection. You can see the hemorrhage that's there posteriorly. And I agree with Mike. I think a transeptal approach to take down that veil so that you can work quite capably is very helpful. So that's our diagnostic arthroscopy. Interestingly, let me see if I can get this to play. He did have what seems to be a pretty sizable and chronic ramp lesion. So here you're looking posteriorly. And so this is a constellation that I hadn't really seen before. And I'll tell you, after just finishing the ESCA Traveling Fellowship, I think I'm fixing normal ramp lesions because they are so common. I think we have been neglecting these for quite some time. So you can see us performing a posterior medial repair here. The first stitch, we used absorbable PDS. And then the second stitch, we're going to use a high tensile non-absorbable suture just for better pre-approximation. The first time I saw a ramp repair was actually bought by Sierra. You showed it at the W Society many years ago with exactly this technique. And I agree with you. If you have such a big lesion there, yes, you better fix this. You can argue if you maybe fix it from the front with an all-inside device, which can work, by the way, or you do it that way. But yes, this is a contributor to your big instability. Do you still fix it this way, or you use the all-insides, Bob? No, I make a posterior medial portal and use the shoulder crescent hooks, just like Brian did in that, and do three vertical sutures. Yeah, it's there a lot. At least in chronic ACLs, it's probably there 15% to 20% of the time. Quite remarkable. I guess what I'd ask the panel is, do you think that that ramp in an isolated PCL is sufficient to generate that much translation in somebody that maybe has some level of hyperlaxity? Yeah, because it's a posterior medial corner injury. So I would even think, at this point, I may even change my plan and say, hey, I think a PCL, maybe a double bundle, large. I like Achilles allograft, because it gives you a 10 and a 6 tunnel or whatever. With this big posterior medial corner repair, it may be all you need. Can I just make one comment? Yes, sir, please. So Jerome Jennings and Craig Morgan independently described the ramp and fixing it in 1982. In an obscure little journal called the Journal of Arthroscopy. And never given much credit for it, to be quite honest. But that's, what, 40 years ago now? 40 years ago? Yeah. That's great knowledge to have. Thank you. Yeah, that's interesting. Because I think, I completely agree that when you're doing any ligament work in there now, you really need to be looking for these ramp lesions. You can put it, you know, whether or not you make a portal necessarily initially, but you can even use your spinal needle. You can probe the meniscus. You can use a 70 degree scope. But you need to be looking for the ramp lesions. And I think, you know, with the size of that, and then the PCL tear, that can account for your grade 3 that you're seeing on the exam. I would still, you know, once you fix it, triple check. Make sure you don't have a corner or something like that with it. Yeah, this goes to the point of not fully understanding the posterior lateral versus the posterior medial until you get in there and you see that. Like Volker said, the whole plan changes. Yeah. Yeah, and it sometimes looks a little synovialized, especially in these chronic settings. So it's hard to know if that little eddy is just normal capsular laxity, or if it's an old tear. But it really looked interesting. And it also dynamically changes from flexion to extension. So I think that this is a different ICL, talking about the ramp lesion entirely. But I thought it was an interesting constellation. In this case, we did end up using quad autograft with a bone block. Obviously, high demand, athlete, collegiate. Talk to me a little bit about graft choice. Would you still go with the Achilles aloe? I still want to talk about the ramp lesion more, because I'm Me too. Trust me. I will answer your question, but I've never seen it. And in the ACL, we haven't seen it, if we haven't, because we don't look there. So after you talked about it and others, I started looking. And you see it a lot. And sometimes I think we over-fix it, when it's not all that necessary. I haven't seen it in a PCL. Has anyone in the room seen it in a PCL? Yeah. OK. Maybe it has seen me. Yeah, we just put together a study looking for ramp lesions in multiligament knee injuries. And they're a lot more common than we thought they would be. They're probably about five times less common than the- Right there, obviously. Yeah. Yeah. Obviously, they're much more common with ACL involvement than without ACL involvement. But your isolated PCL, post-traumatic corner, can have a fair number of ramp lesions that are missed. And so in the ACL, you see these tiny, you know, that Bertrand calls hidden meniscus ramp lesions. Do you see hidden lesions in PCL? Have you? You know what that means? Yeah. Right. Yeah. Yeah. I mean, I've only seen one really big one. And I'm sure I've missed several in multilegs. But I've seen one large ramp. Yeah. Well, they won't be hidden if you look. Yeah. Yeah. So the other thing you can do is, if you're concerned about it, take your spinal needle and use your spinal needle as a probe. You know, from the posterior medial portal, you can see, elevate the meniscal capsule ligaments and see if there's any insufficiency or any tear there. My question for Brian is, did you fix this ramp lesion before you peeled off the capsule posteriorly to do your approach for the PCL? No, I just prepared it, passed my graph, and then proceeded to do this with the posterior medial portal. You can actually see the graft as we back up. You see the blue from our markings. Yeah. This is more of a theoretical question. I don't know the answer is. You fix the ramp, and then you start elevating capsule posteriorly. Does that change the tension on your ramp repair? I don't know. Yeah. Yeah. It's a good question. Very rare constellation. Maybe, since Dr. Birkfeld is here, too, I would love to hear from you. Do you do all of your PCLs with the inlay, or do you do also some of them arthroscopically? And if you do, do you see these lesions then when you do open approach? Well, first, Volker, I stopped doing surgery a while ago. It's okay. We did all open posterior tibial inlay. And the killer curve, I see a slide there, I recognize that we made, we did that. But if we have a little time, can I share a little history with you? Please. This is a great session, by the way. I thought this was fantastic to see what you guys are doing now. And I did all my PCLs open, not arthroscopically. And they weren't difficult operations either. The big decision you have to make, and Volker, you alluded to this, is whether to operate or not operate. If you're a team doc and you get a PCL injury, how are you gonna treat it? Let me tell you what I learned. When I was at the Naval Academy, we reconstructed them. They were the worst repairs I ever had. And 100% follow-up, 100% failures, reconstruction of PCL. We used the medial head of the gas drum. That's what we did. So I was scared to death when I got into practice. What am I gonna do with a PCL injury on this professional football player? And I went around the league, and I asked every team doc, what do you do? And the Philadelphia Eagles doc said, well, there's three of them out there playing right now with isolated PCL injuries. And I said, what? He said, yes, they're playing with them. So I went back and we did the end of the season physical on the Cleveland Browns, and I had two players with isolated PCL injuries playing. Two, one was a defensive back, which really takes a lot of skill to play, and another was a running back. So I thought, wait a minute. Because I thought I would operate out. Yeah. Physical examination is crucial, and this is how you make the decision. And you guys have alluded to it. You're seeing the end result, but the physical exam, and you can use your hands, you can do it in the training room. The posterior drawer, if you do the posterior drawer, and your thumbs hit the femoral condyles, and they don't go beyond the femoral condyles, you may well have an isolated PCL. In other words, the end point comes and your thumbs have not hit the femoral condyles. The other thing is, that posterior drawer, if you internally rotate the tibia and repeat the posterior drawer, it should tighten. And that's the capsular ligaments. So the non-operative treatment was isolated. First of all, the mechanism falling on a knee. Posterior drawer, your thumbs don't quite touch the femoral condyles. That's an isolated injury. Internally rotate the tibia, repeat it, and it should be reduced. We documented it. It's reduced by four to five millimeters. That was all documented. That's the keystone. Then, but anything outside of that, you better think about taking them to the operating room. And I can tell you that it works. We have a lot of patients that are like that. Occasionally, they fail. The ones that, I think you guys pointed them out. They didn't have a good physical exam. They were operative treatments probably from day one. They just went on and had trouble. That's great insight. Thanks so much for this. And I mean, I know this is not a team physician course, but I'm sure many of you are. Those are the key questions. I mean, who do you operate and not operate on? And obviously, you won't get famous not operating. So it has to be out of your mind, right? It's really the key to treat that athlete, not anything else. Good, very cool. Yeah, and that's just the isolated post-op here. I have two more weeks than Volker on follow-up. So he's about three to four weeks out, doing great. I will answer your question because I do like the quadriceps with bone. I can tell you that for PCL, obviously everything is about length. And if you think 110 millimeters is enough, it's still not enough oftentimes. Now, maybe with the all inside, you probably dock it a little bit shorter. So my achilles are usually 110. If I do a quad tendon bone, if the bone block is 20, I get maybe 70 of a quad tendon, now I'm at 90. So the fixation on the tibia, I prefer putting the bone block in the femur, like you have done, will then not be so easy if you use an interference screw because it mainly grabbed the suture, not the actual tendon. So you may wanna back it up with an additional suture post. Suture posts I like, it's a great, easy technique to have, but in an athlete, it's very likely that they get, pressure there and fall on the knee and hate that screw and you don't want any second surgeries ever in an athlete. So I've done both. I don't know if I answered your question. Anything else, Dustin, you're talking about a double bundle concept. You would go allo, all allo in this guy? I would. Hybrid? Yeah, I think autograft and what you did with quad bone blocks, great. With PCLs, I like to stick to what you do best and doing the double bundle, you don't have to worry about your length on those with the allograft, everything comes out of, when I pass it, antegrate it all, comes out the tibia, you fix it and then you cut off the excess tissue with it. So I think, continue to do what you do best. Yeah. Yeah, and for me, I'm a single bundle surgeon for PCLs, but this is one that I would think strongly about doing double bundle on. I mean, if you do a lot of them, it's not that it's that far off in terms of the complexity or the difficulty of the case, but number one, for a high velocity athlete like this that has expectations, double bundle, I'd probably bail on my typical mantra and go double bundle on this. And the other thing I was mentioning to Dustin before is that, perhaps, and Volker touched on it, I've had a few patients come back to me recently that are objectively, excuse me, subjectively, they're doing very well after isolated PCL reconstruction. So I've got a few that come in with medial meniscus transplants at the same time. And we look at these patients and you're still getting that little bit of increased drawer and you wonder why some patients are tight as all heck and then some patients are loosening up over time. I'm getting postoperative x-rays on them and I haven't really appreciated this until now is that those patients that have the increased drawer, they're way flatter on their slope. They're way, way flatter. So perhaps on these flat patients, if we know about it beforehand, that might be a good indication to do a double bundle as well. But I think we don't have the information on that, but I think that that is a very good reason to do double bundle if you notice beforehand that the slope is flat or at least approaching flat. Yeah, we have one more question, but I think I'd like to open it up to the audience for questions that you may have. We have a great list of experts here and be happy to. Yes, sir, speaking of experts. Yeah, not really. Sorry, I need a hip replacement. The question I have for you guys is, what is the role, if there is any, of X-Fix in the postoperative care or management of multiligaments? Yeah, that's an excellent question. I think it was Azar who talked about the ultra low velocity knee dislocation and morbidly obese, which we're seeing just more and more of those patients. I had one come into clinic last week, 6'5", 400 pounds, was playing kickball and got taken out from behind and dislocated his knee. I think that's probably, at least in my practice, the role for using post-op external fixation. You could consider it also, I would think, if you have to do a revision multilig where everything failed. I haven't done that before, but I think that'd be a reasonable indication. Yeah, I can preface by saying I hate X-Fixes. And then I will tell you that the two times I've done it, a post-op X-Fix on that patient, I loved it. I just loved it. Because you lose your multiligament case on the ultra low velocity folks the moment they wake up from anesthesia. They're in bed and their legs are sort of, you know, like wherever they fit. So I've only done it a few times, but I loved it. Do you do it routinely, Bob? Not routinely, but in that particular case, it's usually the morbidly obese and essentially their limb is unbraceable. You can't really fit a brace onto them. I'm curious, single anterior frame and how long do you put? What do you do? For me, single anterior frame, if I'm doing that. And then, you know, four to six weeks for me. The four to six weeks for me. But, you know, the other patient population, we in the city need reasons to operate again, because lots of competition. We got to make money for those Hamptons houses. I would say the other patient population that I consider X-Fix on primarily is, and we see this a lot in New York, is your psychiatric patients. Patients that are, even they might be skinny, but you know that they're going to start weight-bearing on that on day one. So an X-Fix is really helpful for that. What I would love to see out there, and we don't have a very good one now, is some kind of hinged X-Fix for the knee. We have them for the elbow that work very well, but for the knee, it's just still like pretty iffy. I mean, that would be the game changer for me, because I like early range of motion after multi-ligament knee injuries. I'm a believer in it. We'll see what STAR trial shows, but I like getting them mobilized right away. If we can get a good hinged X-Fix, that would be like the game changer. Standard has a series that he described, the compass hinge. And the problem is it's very technically difficult to get your axis of rotation. And I think if you're a little bit off, it really can dramatically negatively impact your motion. What do you think? Absolutely. Does someone else have, I have one more question, unless somebody else has one. Okay, I can wait after you, that's fine. You sure? All right, so this one is a little bit more, I don't know if it's philosophical, but so back to the morbidly obese patient, let's just say BMI over 40. Do any of you try to get them to lose weight in a chronic situation, try to get them to lose weight before you do surgery? And how do you do it? Yes, I have one who, yes. I have a patient like that, that I vividly remember who was, I don't know what the weight was, but it was just absolutely ginormous. And I said to her, everything will fail, you must lose weight. And it was a hard conversation. Those conversations you all know are no fun, but you must have them. And actually people will thank you for it. This lady comes back to me and bypass and lost 190. And then we did it. Now, her knee was already horribly arthritic at that time. But I think those conversations are key. You have to dare go there. Not fun. Yeah, I agree. In the chronic setting, I discuss weight loss with them. In the acute setting, it depends what the injury pattern looks like. And then I think similarly to take that even one step further, the patients that are smoking and using tobacco, you really want to try and optimize them at least in the chronic setting as much as you can. Yeah, in the acute setting as well though, you have the opportunity to go after any capsular injuries and collaterals. And I'm a big believer in repairing collaterals and augmenting over them. So you just get more bang for the buck. So, I mean, it's hard to do that acutely to say weight loss and wait and see what happens. Yeah, can we go to the other questions? Yeah, real quickly. I understand the idea of early reconstruction in some of these knees, but when there's a vascular injury, is there ever a pause of, we need to give this a little time for graft maturation and kind of a follow-up on that. Any tips on doing PCLs with recent BKAs and how you handle that surgically set up, et cetera? Thank you. And you're saying ipsilateral BK? Yeah, correct. Okay, that's a tough one. I have not encountered that one yet. But a lot of these are polytraumas, which are just terrible. And then what was the first part of the question? Vascular. Oh, vascular, yeah. So if there's vascular injury, those are the ones that I typically delay, usually three months or so. We have a really great working relationship with her patients. We have a really great working relationship with her vascular surgeons. I've talked to them multiple times. As far as I know, they have not put the graft over the medial condyle. So I do not routinely get a pre-op CTA after they've had a vascular reconstruction. We'll still use Tourniquet, they said after even six weeks with graft maturation that they're fine with that. Absolutely agree. I delay that for as long as it takes before the vascular team is happy. I can tell you one case that I've never encountered again is somebody who had a contralateral AKA. So he relied on the multiligament knee and the multiligament knee was stiff and loose, which I have never seen before. I'm sure some of you have, but what I mean by this is the range of motion was 0 to 90 and there was a heart block and nothing after 90. And he was so lax and varus and valgus and antiposterior that he couldn't use that leg at all. So we had to do something. So releasing and multiligament on the one leg that he had. So it's hard and that motion, we never fully got back either. I guess I'd share the one thing when you have encounter a vascular injury, that is another scenario where I would probably liberally use X-Fix just because I think it stabilizes your length, it protects your graft. In terms of your question about the amputees, BKAs, there's a good series from the military and I'm not sure where it's published, but Walter Reed in San Antonio and then in our experience in El Paso. It's something that especially with the collaterals can create a lot of stability issues and fit with kind of donning your prosthesis. So I think the central pivot is probably less critical, more of the collaterals. And if you're having a problem with distal limb control, having a shanspin in the residual limb is very helpful just to control varus and valgus, but that's a rare circumstance. Another reason to delay on a vascular case is a lot of these patients have fasciotomies at the same time as skin grafts that have to heal and you just don't wanna muck around. Did we have one more question? And then while he's coming up to the microphone, just be sure to fill out your evaluation of our ICL. This is very helpful for us to know what you wanna hear more of and your additional questions and we'll be available also after this panel. I just had a quick comment that this was a really, really good instructional course. You guys should be commended. It was outstanding and heard it from our godfathers here. I just wanna thank you. Thank you, thank you. One more question. Thank you for that feedback. You all touched up on graft choice. In your KD2s, ACL, PCLs in younger patients, you would normally do autograft for an ACL. Are you still doing that even though you have concerns about violating the extension mechanism or what is everyone's philosophy on that? Yeah, for actually all of my multi-legs, I still do an autograft ACL. It would be interesting to look at that literature because I don't think there's really much out there comparing in the multi-legs, autograft ACL versus allograft, but I still do autograft ACL. Yeah, I agree, especially for young athletes or young patients, then I'll use an autograft. And I still like BTB. And I'm not so sure it matters in a multi-ligament setting. I do, too, use autograft for the ACL now, but it's more like, oh, you know, when athletes talk to one another and other doctors talk about you doctors and say he and she and they use and, you know, it's allograft's gonna blow up on you in five years, all nonsensical stuff. But so going with the flow made me go with autograft on the ACL in those cases. Yeah, and there's systematic review to compare allo versus auto for PCL. Obviously, low-level data, but it shows no difference. I think that that probably falls under the level five evidence, but hopefully we can get some of that from STAR when it comes about. I think that's a great question. Any other final comments while we sign off here? Volker, Dustin, Mike? No. Brian, great job. Yeah, thank you for everybody for showing up so early on a Friday. And please finish out your questionnaires. Thank you.

multiligament knee injuries

orthopedic surgery

physical examination

graft choice

external fixation

morbidly obese patients

vascular injuries