It's funny, I was putting this talk together, and I think we love to come up here and give these amazing presentations on these crazy complex cases, and we do slope-correcting osteotomies and multi-legs and huge cartilage cases with osteotomies, meniscus transplants, huge bone grafts to the glenoid, and we present these cases and they look amazing arthroscopically, the x-rays look perfect, and everybody's expected to be able to perform like that on every case, and I think it's unrealistic, I think that we all want to achieve that, but the reality is that even those of us that do a lot of this volume have complications, and I feel like at times the Academy or AOSSM meeting is like the Instagram of orthopedics, we present these cases and they're this idealized version of what the world should be like, and amongst ourselves we talk about these kind of crazy complications that we've had, but we all have complications, and this one that I'm about to show is probably my most humbling, there are a couple of my former fellows in the room, and I actually have told every fellow this exact case, I've either shown it to them or talked to them about it, this may be the first time Justin is actually seeing it, but I definitely talk about it every time they do a BTBA CL with me for the first time, so this is my worst case ever, this is December of 2007, I feel like this is cathartic, I feel like I'm, you know, forgive me father for I have sinned, but it's 15 years later, over 15 years later, and I still think about this case every time I do a BTBA CL, so this case, we're not talking about a multi-leg, we're not talking about some big complex osteotomy, this is a case that I've done probably, a BTBA CL probably two or three thousand times in my career, and it's crazy how sometimes the simplest cases are the ones that create the most challenging complications, so this is a 19 year old male, he's a Division 1 lacrosse player, he is, you know, straight forward ACL, lateral meniscus tear, we do a straight forward BTB, autographed ACL with lateral meniscus repair, I still get post-operative x-rays on all my ACLs, I'm curious, who gets routine post-op x-rays on all their ACLs? Yes, I'd say it's probably two-thirds, I still do it to this day, it's helpful to me, I think as you're starting out, it's helpful to know that you are doing what you think you are doing in the OR, it also helps cover you if you have an issue down the road, you have a baseline, but this is his post-op x-ray, which I think is actually, looks pretty straight forward, I've critiqued these x-rays multiple times over the course of the past 15 years, I think the rotation is off in that lateral, but I don't see anything obvious, you know, he was BTB autographed, I'm an intermedial portal driller, I still am, 10mm tunnel, 10mm bone block, 7x20mm metal interference screw, which is still my technique, this is 2007, so there were really no extra articular augments, really uncomplicated from an intraoperative standpoint, I was there, I'm there for all my cases from start to finish, fellow put in the screw, but I don't think that really had anything to do with it, and it's interesting because I gave a talk on intermedial portal drilling last year, and I put this video together just to show how consistent our tunnels are, and I look back 15 years later, and I don't see much of a difference, I think my tibial screws may be a little bit eccentric and not aligned, but I think my femoral tunnel really hasn't changed too much. So he lives out of state, he's again a college lacrosse player, I get a call five weeks post op, he packed up his stuff, went back home, and his family, his good friend's a North Peak surgeon, he calls me, he says his knee is really swollen, he's in pain, he can't walk, and I assumed he was infected, right, that's, if I got that call at five weeks, I'd say that this is probably an infection that's unfortunate, and he said no, he's got a fracture. I said fracture, did he blow out the back wall, was I too thin, am I too low, he said no, he's got a femoral fracture. And has anybody seen this, because I have talked to many people, I don't think I know anybody who's younger than 60 who has seen this complication. So Hoffa fracture after BTB ACL, it's pretty humbling, right, I've done probably 4, 4,500 ACLs in my career at this point, still the only one I've ever seen. So these are his X-rays, or sorry, his CT scan and his MRI. He's got, I actually thought it was AVN at first, he's five weeks out. You see these images, I wish I had a better sequence, but literally these are the images that I shared with all my mentors and colleagues back in 2007 that I spliced in here. But this is his fracture, but I thought for sure this was, had that geographic pattern, I thought it could be AVN, actually looked up the vascular supply lateral femoral condyle, it's pretty robust, it's pretty rare to get AVN on the lateral side, medial side's a different story. So Travis, thoughts, this is catastrophic, right, 19-year-old stud lacrosse player. Yeah, I mean, it's subpar for sure, but at the end of the day... So my wife tells me actually... I mean, if you don't, you know, I don't know, they say a chance of cuts, a chance to cure, for me it's a chance to cry. It looks like that bone block's a touch posterior, which is, so thin back wall potentially. That being said, I mean, so the fellow put the screw in, you know, oddly enough, if it was thin and it didn't have fixation, it probably wouldn't have happened. So then you got to think it was strong enough to get fixation, and then you propagate anteriorly, so that doesn't make sense, because it should blow out the back. I have no idea, I can't understand biomechanically how this could happen, to be totally honest with you, how you propagate a fracture anteriorly like that, but at this point you have to fix the hopper fracture, so otherwise he loses his condyle, but it sucks. Aaron, somebody's coming out of, you know, some remote part of, you know, Minnesota, they call you, they've got this at their first post-op x-ray, have you seen it? It's just so strange, because, you know, this patient had extremely hard bone, and the reason I say that is, you know, in your post-op, that tibial bone block, you know, you can see where you put your suture holes, so that's the one that has, like, amazingly hard bone, and if anything, you know, to Travis's point, I mean, this should blow out a back wall, like all of your stress risers are going the other way, so I would just, I mean, was there anything on that preoperative MRI, was there an abnormal pivot shift that could have propagated or something really strange, I mean, that's what I would go back to, is that preoperative MRI, and just was there any sort of injury variant that could cause this, because I just can't see how, you know, putting that in alone is going to cause this intra-articular propagation. Yeah, Justin, any additional thoughts? I am scraping the barrel, but the only thing, and still I would find a hard time believing it, is I've seen, you know, some surgeons that when they drill their tibial tunnel, they'll put the pin into the femur, and if they're doing that a couple times, perhaps creating a stress riser, but I still wouldn't believe that that would cause a fracture like this, right, from one pinhole. The thing that I'm looking at this that worries me is, you know, we say, oh, we got to go in there and fix it, is, you know, how much of it has loosened, and then reducing that with the metal screw and graft in there seems terrifying to me. Yeah, well, you'll see here in a moment, it's enough of an issue that it's rare, but it's, people have done biomechanics on this, because, you know, it's interesting, most of the papers have come out early 2000s, and I think people have stopped reporting on fractures after BTBs and ACLs, but it's a very rare complication, there are actually several case reports, I mean, there's probably less than 20 in the literature, it's not something, my gut is it happens more frequently than we think, but who wants to report on a complication like this? But most are from the early 2000s and late 90s, really, when ACL reconstruction, it's modern era really started to take off. It was frequent enough that somebody did a biomechanical study on it, right, so, Travis, you were saying, I don't understand how this could happen, right, so, Sawbone study, they looked at single bundle, double bundle, they loaded it intact, single bundle, double bundle, and what's interesting is single bundle really has no stress riser, so I still don't really know how this complication occurred, and it wasn't like he fell or fell off a ladder, he was lifting a lot of boxes, but essentially, this is the Sawbones of a single bundle, and there's a fracture, obviously, you can load this thing to failure, the fracture pattern is up into the diaphysis if you load it to failure, and no different than an intact femur, but it's interesting, if you do a double bundle, you get a fracture very similar to the pattern that we had, essentially, this sagittal plane split interarticularly, so, my gut, you know, I was a Pittsburgh, you know, Freddie Fu Turing fellow, maybe I'm a little bit low, and that was one of the critiques, I reached out to everybody that I knew at the time, I reached out to my mentors at HSS, at Pittsburgh, and through our moon group, and it was interesting, a lot of the guys that had been around, the gray-haired guys said, I've seen this before, you know, and this is when we came really low, and we used Gore-Tex grafts and a variety of things, and maybe it wasn't that it was, you know, double bundle, but maybe low enough, more posterolateral bundle that it created this stress riser, so, just being mindful, I think we've gone away from that, I think we've kind of, most of us are kind of closer to the lower part of the intermedial bundle, but maybe it was a little bit lower than I would like, and I have moved my tunnel a little bit more superior as a result of that. Mark Miller had a paper on this, he had a case report, interestingly enough, they had a hamstring graft, it was a 10 millimeter graft, they had, you know, and they don't know, right, because it's not like they have a case series, but they identified potential risk factors as larger graft diameters, a 10 millimeter hole, larger tunnel diameters as well, fixation that requires tunnel dilation, and I would argue this doesn't require tunnel dilation, but the amount of hoop stress when you put a 10 millimeter bone block into a 10 millimeter hole and a 7 millimeter screw must be pretty high, probably equivalent to tunnel dilation, and intermedial portal drilling, again, because it has allowed us to get lower, but again, I think that the tendency is we've moved away from those really low posterolateral portals, and this is, again, 15 years ago, so I reached out to all my mentors, this was, you know, imagine, I'm two years into practice, I came out in 2005, you can imagine how humbling it is, you feel like you've got this operation nailed down, you're trying to tackle some of the more complicated things that we've presented, and one of your more straightforward cases ends up with this complication, it's pretty humbling, it remains humbling, so one of the guys that I reached out to is a name we would all recognize who's now retired, said, you know, we drill a 10 millimeter hole, we fill it with a 10 millimeter bone block, we then put a 7 millimeter screw in, the hoop stress must be really, really high, I'm surprised this doesn't happen more often, and I'm actually surprised too when I think of it in that context, so you can see this was from Mark Miller's paper, I wish I had post-op x-rays to show you, I don't, he actually, and it's not even a great ending to the story, so he was fixed back home by a very well-known surgeon, unfortunately that piece went on to die, and he had a massive osteochondralograph, so I don't have a happy ending to give you, but it's again, just to show you that even those of us that present on the podium and give these talks and have high volumes of knees can get complications that are, that can be pretty bad, so what have I learned? I wish I had some technical consideration, I'll show you how I put my screw in now, but one is to run to your complications, not away, and that was something that Freddie taught me, so we may learn some nuance about how do you avoid perineal nerve injury or fracture from a TTO and some technical aspects, but at the end of the day, it's a very human endeavor that we have, and I think you got, I think somebody said, you know, Bernie Bacchus say, like your patients, but love your complications, right, so you get closer to them, you don't get further away from them, I think the two is that even simple surgeries can have pretty bad complications, and I think we take them for granted, you know, you may have a day with six, seven cases, and the BTB ACL is the easiest one on the schedule, but you need to be as mindful, not that I think I did anything wrong in this case, but you need to be mindful of every case, I like to share my complications, it's cathartic for me, I think it's important, you know, again, I think, you know, Chuck Sue's in the audience, Justin's in the audience, and all these, I've shared this with every single fellow that comes with me, because I said, you know, this is something you need to think about, share them with colleagues so that people get educated, so they don't repeat your same steps, and again, I think it's important for you, I think we underestimate the impact on ourselves as surgeons, you know, people talk about moral injury and all these things, and not to get out of the scope of our talk, but, you know, this has an impact on all of us, we lose sleep, you know, you don't, and it's important for you as a provider to heal as you recover from these, and again, it's 15 years out, I still think about this kid with every single BTB ACL I do, and then lastly from a technical perspective is to respect the hoop stresses, so this is how I do it now, this is not going to be any major technological feat here, but I still do medial portal drilling, I use old school over the top guides, I've used them for almost 20 years now, my technique has not changed dramatically, low profile reamer, and the only thing that I do now, and it's funny, I actually call it, the name of the kid, I call it his moment every time I put that screw in, I pause, because these, the bone can be very dense, Aaron pointed that out, you can see how dense it is, and once you start getting a little bit of bite, I just give it a minute, and I probably even wait longer for most cases if the bone density is good, and I let the hoop stresses relax, and I may do multiple kind of stress relaxation points, and again, very rare, I think it's probably unlikely any of you guys will see this in your practice, but again, one of the more complicated, you know, complications so to speak that I've had, so I'll save case two for later, we'll let Travis talk, but any comments, concerns, anybody seen it, any from you guys? No, I'll say that my only comment is, when I see complications like this, sadly I have many of them, not this one, but others, what goes through my head is, how can I fix this and avoid it in the future, and the most terrifying part of this case is I have no idea, so specifically, I don't know if this has been an experience of anyone in the audience, the folks on the panel, but there are some BTB screws that are biocomposite now, and a lot of folks are going to them, myself included, only because they're easy to revise, and you know, you have a 5% plus failure rate, no matter how good you are, so, and sometimes in hard bone, you tap them, then you put in the biocomposite screw, and it fractures as you're putting it through, it's just because it can't withstand the relative torsion, or the torque rather as you're putting it through, and then it breaks off, and it breaks off at the, I'm getting into the weeds a little bit, but it breaks off on the face of where you're putting your screw in, and you can't get it out without effectively destroying your bone block, so one of the things that I've done, which I was very proud of myself until right now in doing this, is you just put a metal screw right through it, and it'll just effectively expand its way in, and you know, take care of the rest of that biocomposite screw, of course you're adding bone block to biocomposite screw to metal screw to hoop stress, and it's going to make it even worse, so I'm starting to reassess that for now, that didn't mean to scare you, yeah, no, I mean, honestly, how do you fix this, I don't know, how do you avoid this, probably stop doing that, honestly, I don't know, what I would say, I'm glad we're talking about the technical aspects of putting, because I still use a femoral metal interference screw, I personally, I just, I think bio screws breaking down over time into a joint just doesn't make sense to me, but, you know, but using the metal screw, I mean, a mistake that I made my first year practice is I did not notch generously enough for the screw, and I had some, you know, I injured some grafts trying to put in too tight of a screw, so that changed my practice, and I typically, a hard bone case like this, I'm running that notch up like three times, maybe even four, because loss of fixation is never going to be an issue, I shouldn't say never, is not going to be an issue, so I think just making a little bit more space for your screw maybe would be the takeaway, you know, for the audience for this case. One quick question, now that I'm thinking about it, still trying to figure out how I can never have this happen to me, any of you use a 6x20? I've always done 7x20, if anything, I've gotten bigger in some cases of revisions, or, you know, anything where the bone is soft, but I've actually never gotten smaller. No, but you actually read my mind, I was talking to Voose, and he's starting to go down to size 6 screws, if nothing else, to get more graft to bone surface area, but as you've all said, there's never been a problem to me where I'm like, wow, my interference screw's floating in that tunnel, instead it's been like, if I push any harder, I'm either going to break this screw or break this femur, and so, notching, tapping, everything to make it go in, it'll still squeak, right? And I bet you a 6 screw would still squeak. Yeah, you shouldn't two-hand the femur. Who here in the audience uses 7x20 for their BTBs? Anyone use anything smaller? Okay, we've got one in the back. Okay, what do you use? 6x20, the smaller divisions. Okay. Anyone use bigger? Only if I have issues and need to go up, but I think that was one time, usually 7x20 or 6x20. Anyone here use bigger than 7x20? Okay. Any issues? It's all bone quality. All bone quality. You're right. Yeah. Yeah. Okay. All right, Travis.

orthopedic surgeons

complications

BTB ACL surgery

femoral fracture

learning from complications