So we have a good panel here today. We have Travis Mack from the University of Utah Health, Aaron Kritsch from the Mayo Clinic, and Armando Vidal from the Steadman Clinic in Vail. And my name's Justin Ernert. I'm from the University of Utah Health as well. We were just chatting. We love this session because it kind of gives us an opportunity to share our pitfalls, but also what we've learned and how we've managed them. And I think it's something that gets lost amongst these meetings of kind of flashiness and glam and glare, and this is probably some of the most educational stuff you get. So we're always actually excited to air our dirty laundry. And we encourage you to participate, ask questions, come up to the mic at any time if there's something that you want to put in or teach us about as well. So without further ado, so this first case is a 38-year-old male. He's a pretty high-level skier. He's a computer programmer. So he works a few hours a day and spends the rest in the mountains, of course, unlike us. Hurt his knee skiing about a month ago, and pretty straightforward. He's got a 2B Lachman, otherwise pretty uneventful. X-rays were unremarkable. His MRI was about as classic as it gets. We see the pivot-shift contusion. He's got a little bit of prepatellar bursitis. And ACL tear, did not have any meniscal pathology. So I had originally counseled him towards a soft tissue graft. He's kind of getting towards 40. And at least in the skiing world, a lot of people favor the soft tissue grafts over the BTB. But we still will talk about all of them. But despite all of that, he came in wanting a BTB, which I thought was perfectly reasonable. He explained to me his kind of skiing level. He's jumping off cliffs. He's hiking up and down mountains. He's pretty active. And so with that in mind, we went forward. Before and after, pretty uneventful. No issues, anything like that. He shows up at two weeks. X-rays, I thought, looked pretty good. Liked my tunnels. No issues. He's feeling fine. Life goes on. And he starts out into rehab. Well, at about one month post-op, he was walking down the sidewalk. Makes the same walk every day to get his mail. There were some wet leaves. And he slips and hyperflex, does kind of a baseball slide onto his operative knee. Calls the clinic. He says, I think something's wrong. Well, what's going on? He's like, my knee looks like an eggplant. And so we bring him in. And so this is his X-ray. So I think we can all determine the diagnosis here. So I guess the first question is, is anybody, Travis, are you getting any advanced imaging on this patient? For this one, I probably would, only because it will help with my intraoperative planning. You have a patellar tendon rupture, obviously. And they take on lots of shapes and sizes. So the counseling and the planning, whether you're going to augment, whether you're going to have to reconstruct completely, or just do a direct repair is going to, I don't like to figure it out on the fly with these. So I probably would. But again, you could do it either way, whichever you prefer. Armando, how are you counseling this patient? He's panicking, skiing his life. Am I ever going to ski again? How are you walking him back off the ledge this moment with these X-rays? Well, I mean, I think this is an injury. I mean, his tendon was healthy prior. I think that he can have a good outcome. So generally, I tell them that this is going to be a bump in the road. And we already had a nine-month recovery at a minimum going into this. And that may change our timelines a little bit. But I think the ultimate outcome is probably going to be the same. It's just going to be a little different course than what we planned. And we're going to get him through it. And phase one and two will be different. And they'll catch up at some point. But I try to kind of put it in the perspective of their global recovery, not just what's going on at that moment, which is, as you indicated, can be pretty overwhelming to them. And then, Aaron, normally you see this patellar tendon rupture. And it's kind of like, ah, patellar tendon rupture. We'll piece that thing back together. What are your new worst case scenarios, knowing he just had a BTB harvested a month ago? Or what are you thinking about anatomically? Yeah, so I agree with Travis in terms of intraoperative plan. I would definitely get preoperative imaging. You want to check your ACL graft as well. Could he have any new meniscus tears? All those sorts of things. You don't want any surprises. You want to be prepared and perhaps overprepared when you're dealing with bringing someone back to the operating room. So I worry a little bit. I mean, you've lost a third of that patellar tendon. You have a bone defect where you've taken out your graft. So I think you have to have options available for your repair, possible augmentation. And then, obviously, post-op, now he's had an injury. He's had two surgeries in a short period of time. Now you start to worry about arthrofibrosis, and quad atrophy, and prolonged rehabilitation, recovery, and time on crutches. And you can develop a pretty long list of what are your new worst case scenarios. Yeah, so these were all things that we talked about. I did not get an MRI. And I hemmed and hawed about all the things you guys brought up. But at the same time, I had just happened to have a case fall off the next day. And I was like, hey, let's just get this knocked out. He wanted to go sooner rather than later. So rather than planning through the MRI, I just counseled him on that. We're going to check your ACL and meniscus. And if we have to revise it, we will. We'll consider allograft reconstruction or augmentation versus an autograft pending on the ACL. And he's a pretty reasonable character. And we had plans A through Z lined up extensively before going in there. And he was ready to get it knocked out. So we know that the outcomes of ACL reconstruction are good. And the outcomes of patellar tendon repair are good. Do we know the outcomes of a post-BTB patellar tendon rupture? If we look at the literature, there's limited literature, for goodness sake. If you look at Bernie Bock's database of almost 1,750 ACLs, he had one patellar tendon rupture in his time, a guy that pretty much is exclusively BTB, right? So not a common phenomenon. Same with Don Shelborn, 2,500 ACLs, whether it was the ipsilateral or the contralateral, a 0.25% re-rupture rate. But as you can see afterwards, actually able to achieve good outcomes. And he followed this up with a more outcomes-based study that showed their strength does return, but maybe it just takes a little bit longer in these patients. So we went in there. We scoped. His ACL graft looked like it had maybe taken a hit, but the tension was actually pretty good. So we just left that be. And then we opened him up. And basically, it was a mess. So there was the central defect. One side was stranded proximally. I could only actually find one side of the distal component. It was kind of a mess. The MCL was also ruptured in half there. It was almost a complete retinacular soft tissue injury stemming from that central tendon. So we kind of just piecemealed away. We first found the two proximal fragments there, got some better pictures. And then we just started identifying things. So I got clamps proximally on the tendon, medially and laterally. I have a clamp on the MCL. I've also started identifying the hamstrings. You can see there on the lower left. And the decision was made to repair what we could and then augment over the top with the hamstring autograft. So what I did next, so on the left there, you'll see kind of side-to-side repairing the tendon flaps that were available. And then I drilled a transverse tunnel through the tubercle. And I've tried to make this a little schematic. So the blues there are my proximal tendon ends. The red was the distal one. And there's my bone graft defects. I could not find anything worthwhile distally on the medial side. So I kind of opposed them and side-to-side them. But then I also whip stitched the tendon itself. And I tied it through a tunnel over the tubercle. Definitely used mini-CRM to make sure I was not putting that tunnel through the defect from where I had harvested. And so I set the tension with his native tendon that I could. And then I took the hamstring tendons and weaved them up the sides of the patellar tendon. And I took the gracilis and kind of just sewed it side-to-side within the native tendon. And then also into the periosteum of the patella itself. So kind of leads me to my next question. I'll pause here. Travis, how are you going to manage this? Are you going to anchor it into the tubercle? Are you going to drill into the patella? Give me some thoughts on how you would reconstruct or augment this. Sure, so admittedly, I've never, at least yet, encountered this acute problem. But I have done this technique with a chronic repair reconstruction combo. And what I did at that time was to do the hamstrings. You already have a tibial-tubercle tunnel, which I would have made as well. You have a lot more bone stock, obviously, in the tibia. Bring the semitia cross up and over the gracilis straight up. Sew them together. I did make a bone tunnel in the patella. I probably would here as well, honestly. And that may bite me. It didn't then because, again, it wasn't a BTB. So admittedly, I don't know. But I probably would have only in so far as it's a transverse tunnel. That said, you have a vertical piece of bone defect inferior. So as far as the compromise of the integrity vertically versus transverse, I'd like to think it's not extraordinarily higher. And I have had issues only in so far as having things stretch out if it's only a soft tissue repair versus bony component to the patella. So that might be wrong. And that may bite me. So that's probably what I would do. Armando, are you thinking autograft is the right choice? Or would you think allograft? Any differences on graft selection for augmentation? I'm not sure it matters here. I think it's dealer's choice. I mean, I like the choice of an autograft. I like the biology of it. The only thing that sometimes I'll add in these cases, I haven't had one quite like this either. But I've had some pretty blown out patella tendons that are hard to really define the anatomy and get good fixation is. I like to augment it. So I'll put a transverse screw through the patella. It may be challenging with a previous BTB harvest. Cannulated headless screw and a similar one in the tibial tubercle. And I'll weave some sort of fiber tape or similar suture through it to act essentially like a surcloge to protect it. And that'll usually protect you from 0 to 60, maybe 0 to 90, depending on how isometric it is. And that at least gets you to that first phase, because this is a pretty tenuous. Your challenge here is going to be moving them. How stable is this? How aggressive can I be with motion? And then you've got to weigh that out against the risk of arthrofibrosis, like Aaron was talking about. So you've got challenges on both sides. Aaron, how are you managing the patella? Are you doing a tunnel? Are you avoiding it completely, especially with that bone defect in there? Yeah, the bone defect definitely makes it interesting. So I would probably do a hybrid technique here, meaning some trans-alseous sutures as well as some suture anchors. The nice thing is we have a lot more options in terms of suture anchors. So here, if I'm augmenting with a hamstring, typically I'll make a socket in the inferior pole of the patella, a vertical socket that Mike Stewart taught me. Here with that bone defect, I might just opt for surface fixation and a lot of soft tissue sutures. Yeah, so these were the things that were going through my head as well. I chose to not muck around with the patella at all. And we'll see if my little schematic. There's kind of the final product. It kind of looks like a mess. But you can see the two grafts going up. The gracilis was obviously shorter. And so the gracilis was basically just weaved side to side and then into kind of the periosteum of the patella with just high-strength sutures. But then the semi-T was long enough where I actually did your fiber tech technique but used the graft as a cerclage up around the superior pole of the patella and then sewed it into the quad itself. So kind of looking at the picture on the left, the green is the gracilis graft. And then the purple is the semi-T graft. And I did kind of almost like slits like you would for an MQTFL reconstruction and weaved it through the quad and sewed it at each iteration and then tied it to itself as well. Can I just point out one thing here that I really like? Is you use so many points of fixation. Some people hang their construct on one knot. They have this beautiful repair augmentation and they tie one knot. And they expect that to hold up through cyclic loading. So here, essentially, you have 150 spot welds, if you will. So even if they have a little aggressive moment or a little slip or that and they feel a little something, you're going to have a safety here. That was exactly my thoughts. In hindsight, I kind of like your idea of maybe an anchor, maybe more superiorly in the patello or even like a transverse, just like 2.4 tunnel to pull the stitches through or something. And then maybe adding like the tapes or collage just as a backup as well. Admittedly, this was one of those cases where the resident's like, what's our plan? I go, I'll let you know after it's done. So but in the end, here's our final construct. And so taking it through a good range, it seemed pretty stable. And then, of course, we also kind of reinforced the MCL and retinaculum along the sides as well. So this is still early in the game. He just came back for his post-op, first post-op. So this is very fresh. But here's our x-ray. We're still sitting good right now. And so we're going very slow with his rehab. He's been locked out for about 3 and 1⁄2 weeks and just started a little gentle bend. Can I just ask a question? So setting the tension, sometimes the chronic ones, the mid-substance ones, sometimes I'll take a x-ray of the other knee. Not that you have a lot of choice, because you have to co-opt and get compression across there. But I don't know, compared to his other side, do you think this is a little Baja? Or were you concerned about it? Yeah, it definitely is a little bit Baja. And that's a good point that I forgot to mention. So while I was in there, that was definitely on my mind. I erred on the side of getting as much of his own tissue opposed as possible, because I felt like that's the biology. that's the workhorse of this whole thing. And knowing that my construct was gonna pretty much be all soft tissue and suture, not anything more rigid, that this will likely stretch a little bit with time. But yeah, definitely a worry. And I think that's a good thought process. The key here would be not to put a rigid surclage with Baja, right? You'll have a really hard time getting that motion back. 100%, so. All right, I'm gonna pause there. Justin, while Travis is pulling up his talk, anything in retrospect about the harvest that you think, you know, do you look back on that case and say I was eccentric or I was too wide or did it change your practice at all in terms of what you're doing to harvest the BTV? That one did not because there were other ones before that have already changed that. And so if you ask the residents and fellows, I make them check inferior pole and tubercle about 30 times during the harvest to make sure we are centered. Because yeah, I've had a case where not this happened, but was eccentric on the patella and the patella fractured, right? So I'm quadruple checking that every time. So I don't think anything, I think this was a pretty traumatic fall, right? So. Excellent, so we can continue in the lovely experience of our operating rooms at the University of Utah. So thank you all for coming. I appreciate you taking the time to join our ICL today. Hopefully you learned something and then don't encounter these. So this is a patient of mine. He's a 49 year, she's a 49 year old female. She had a collision at work with a psychiatric patient. She works on the ward as a nurse. She felt a pop in her left knee, had significant instability. She had a history of an ACL reconstruction and MCL repair 20 years prior. She said her knee never felt right, but it's now worse. Continued valgus and rotational instability. So this feels much worse now. 2B Lachman, two plus valgus at zero and 30 and at a SANE of 20 at that time. Her x-rays are visible there. Here's her MRI summary statement. She had an ACL graft tear. From my perspective, the tunnels were malpositioned. As you can see on the sagittal, that tibial tunnel is somewhat posterior and the MCL was incompetent. And you can see the tunnels from their attempted previous MCL repair that she described. So we planned this and maybe I'll stop there for a moment. Armando, what are your thoughts here? That tibial tunnel is pretty far posterior. So I'd wanna see plain radiographs that have a low threshold to CT scan just because it may be just far off enough where you're gonna have some challenges. Is that the, are those the ACL tunnel points on that coronal? Yes. So that's so high, it's probably out of your way. So I think my gut is you're gonna be okay on the femoral side, you probably won't even touch it. MCL is incompetent by exam as well. So opening in full extension. Yeah, so I'm thinking I'm probably gonna get advanced imaging in the form of a CT scan or at least reliable x-rays to see if I have to stage her. That gives you an opportunity to look in there. If I didn't stage her, I would revise her. She's 40 something. 49. 49, so I'd have a low threshold to stage. I'd probably do an allograft ACL and I'd have a low threshold to do an MCL recon at the same time, depending on the EUA and the findings at the time of surgery. Anyone else wanna add? Aaron, Justin? The good news is if she has a root tear, your tunnel's already drilled, so. Okay, Aaron? Yeah, in this one I might also just look at her coronal alignment, making sure she doesn't have any valgus. You know, the lateral meniscus there doesn't look perfect. You know, it's just gonna potentially compromise your MCL revision reconstruction there. Okay, just by show of hands in the audience, who out there, we've had lots of conversations in this AOSSM meeting this year about stage versus not stage surgery with osteotomies and others. Who out there would do this in a staged fashion? Depends. Okay, who would do it in a single stage? Oh yeah, it's about how it breaks out. It's interesting. Okay, so I did not get any of those imaging, images, CT, long-standing alignment, maybe. I mean, again, we're worst case in the OR, right? So we're learning. So I decided I was gonna stage this because I was terrified that I'd do something bad if I didn't. So staged bone tunnel grafting, as you can see there, the tibial tunnel is extraordinarily posterior. You can see that on the top and bottom left image. So, and by extraordinarily posterior, I mean entire root gone. It was effectively drilled out, so there was no lateral root. Then you can see, that's my probe over the top. That's the posterior aspect of the tibial tunnel with my probe over at the PCL footprint. So to Justin's point, you could do, theoretically, a PCL root in this if you needed to. We did not. We bone grafted the tunnels and got out of dodge. So now that you come back, you're gonna wait, how long, guys? Those are bone dowels? Those are bone dowels. They're made out of ephemeral head allograft. Yeah, so I routinely go back at 12 weeks. I know a lot of people CT scan them and wait for radiographic change, but in 20 years of doing this, I've never seen a solid bone dowel like that not incorporate sufficiently to go back in. So I'd go back in at three months. Same. Okay. Does anyone use Cancellous chips or is everyone on the panel using bone dowels? Bone dowels across the board? Okay. So now we're gonna go back and we're gonna stage this. Justin, what are you gonna do? Yeah, so I agree, allograft ACL, and assuming that the MCL still feels loose, I would do an allograft MCL reconstruction as well. Yeah. Okay, all right. So given that this was a revision and I was feeling incredibly influenced by my peers because they say everything else different on the podium when they present this, never do an allograft in a revision, they say I decided not to. So I decided to do an ACL reconstruction with a BTB autograft, an MCL reconstruction with Achilles allograft, and a Lemaire because this was a revision and I thought that this would be, you know, we'd make her bombproof. She's an active skier and loves Utah and wants to get back. So here's what we did. Here are intraoperative pictures. That's my plan. Awesome. What's it, Travis? Just walk us through what you have. So you have a BTB screw. Yep, so the screw, metal screw on the femur is your BTB screw. The metal screw sort of on the lateral going sort of side to side is your MCL interference screw. And then on the tibial side, you see there's a biocomposite screw for the BTB bone plug, which you can't see. And then you have this screw and washer for the MCL reconstruction. Is that hole below it from the old surgery? That is a backup swivel lock. Got it. For the MCL reconstruction, sutures in the graft pulling down over the top of the bone, the screw and soft tissue washer. Thoughts, criticisms? Again, this is worst case, this didn't go very well. So I'd love your thoughts on what you're thinking here. I think your choice of graft is reasonable. I don't think autograft is ever an unreasonable solution. And so I think it's, we said allograft, but the reality is some of these 40 plus year olds in the mountains are more active than our 19 year olds. So I think autograft is reasonable. I think augmenting the lateral extraticular, augment like an LET is also reasonable. I think the MCL for me is if they open in full extension, I'm gonna do an allograft and probably, potentially a POL imbrication if they have intermediary rotatory instability. So I think this plan is reasonable. I think your tunnels look good. I think the MCL is probably the more challenging part of this whole surgery. I think getting that right is harder. I always joke with our fellows, it's the easiest ligament to reconstruct, but it's the hardest to get right in terms of isometry. But I think this looks good. Okay. So she comes in at six week post-op, says I'm doing better, but what's this bump? And she points to the front of her knee at the tibial tubercle. I'm feeling different at this point. And here are her x-rays. So as you can see on the lateral, there's something going on with that tibial tubercle that doesn't look entirely right. So at this point, I thought I should get advanced imaging. So here you have it. We have her medial tibial tubercle, which has been avulsed. Her lateral tubercle is okay. And the MCL screw looks okay. And you see a intersection of that tubercle with her BTB tunnel, where the screw, the biocomposite screw is on the top left on your axial section. And then obviously the sagittal shows maybe a hinge point of that tibial tubercle fragment. And obviously the 3DCT shows our graft harvest and the tunnel position and whatnot. So thoughts here, Aaron? A lot of thoughts running through my head here, none of them positive. Had this happen to Mac? So tell me again, how far post-op did this happen? Six weeks. She said, she doesn't know. No trauma that she can recall, although she's back on the wards and she gets bumped around by psych patients routinely. I mean, standard post-op protocol. She didn't have weight-bearing restrictions. She's range of motion unrestricted, no crutches, transition off out of the brace. But at six weeks, she's out of the brace, but she was in the brace up until four weeks and then transitioning out of the brace from four to six weeks. So nothing crazy's happened. She's on the wards. She says she gets bumped, but she's not doing any lifting or anything like that and doesn't recall any trauma. She didn't slip on any wet leaves going to get the mail or no, okay. To Utah, that might be. Did not recall anything. Yeah, so I mean, obviously, you know, you have a displaced, you know, tented skin situation. So, you know, you have to, you know, think about bringing this back and, you know, fixing it in terms of, you know, how do you fix something like this? I'd have to see, but it looks like you have a fairly large piece of bone there. So, you know, the question is, could you get, you know, maybe just some small screws to fix it, you know, front to back or have suture anchors or collage options. What do you think was the stress riser here medially that caused that propagation? Was that one of your, the screw or anchor or? Screw. If you look, my hypothesis is and my theory is that, again, we're trying to learn from our mistakes here. So the issue here, if you look at that axial, I clearly was not paying enough attention to the space between where that MCL screw is, the BTB screw and then the tibial harvest. So, you know, I try to give myself a centimeter and I think maybe that is around a centimeter, but now you have an additional. And when you were putting that screw in, I mean, was it like a solid, really good bite, like worried the screws almost gonna break sort of thing. So do you think in retrospect, it was kind of those hoop stresses that propagated at the time? Yep. And again, you mentioned it before prophetic as usual, that this is a older osteoporotic lady on the bone tunnel grafting and the staging. And I think that plays a role here. Obviously, she's not a 19 year old person. She's like me, we're not quite as good as we once were, even though we think we were. So her bone quality is not as good, you know, so. I will say too, I think, you know, typically for me, when I'm anchoring my superficial MCL, it's usually about six centimeters distal to the joint line. So it could have been probably a little bit more distal and eliminated that. Having said that, you had guys like Andy Williams who were doing these short MCL recons with really good results. And so some people are anchoring it there, but it could have made, you know, in retrospect, maybe even more distal. Great. That's exactly what I was thinking. But then I also am thinking, you know, we do multi legs with like three tunnels there and it's not a problem. And your screw is projected posteriorly while your tunnel is projected superiorly. So you'd think they would diverge away and, but hindsight's 20, 20, right? So there you have it. This is what I did. So we took her back the next day and I put a plate and screws on top of it. What Aaron said was again, spot on. There was enough bone there that I was able to actually get that proximal screw in the fragment. We left it, that hinge point proximally intact and effectively just shoved it down and put a plate screws over the top of it. And it worked out totally fine. The ACL integrity was not compromised. The bone was not, the screw was not, the biocomposite screw was not compromised. I didn't need to do anything else with the fixation. So in that regard, that's what we did. These are her six week post-op films and this is her at a year. So everything healed up nicely. Not my happiest day in the world, but it turned out better than it could have. I look back on this because it had never happened to me. And it turns out that this has happened, albeit infrequently. Three case reports in 20 years. Mine, I guess, makes four. So they're very rare. That said, they do happen. All of them were effectively treated with OIF without any deficits. I did not change her recovery, by the way, because she came in walking in and just asked about the skin. So I felt like her extensor mechanism was adequate enough that she could continue rehabbing normally. Morals to this story for me, don't estimate tunnel convergent. Be very cognizant of it. I know I'm very careful about my tibial tunnel more so than I have been in the past about the distance between my tibial tunnel and my tibial bone harvest site, especially in osteoporotic bone. ACL, BTB, MCL, reconstruction lameres, as you've heard on the panel, knowing this, it's a lot of surgery for a 50 year old. So in retrospect, I probably would do an allograft on this moving forward. Posterior tibial ACL tunnels are dangerous. This is a testament to the person there before me. Beware the root, don't ream it out. That's unfortunate. And as long as you're open about the issue and do your best to fix the problem, patients are, she loves me, I have no idea why. I hate me for this, but she loves me. So it works okay. Thank you. And as Armando's getting his talk up, I think, you know, we kind of discussed, you brought up a good point about autograft versus allograft and revision, you know, ACL. You know, we're certainly influenced by the great work of the MARS data. And when you look at, you know, that paper showing a higher failure rate, you know, the odds ratio is like 2.1. But when you look at the overall, you know, rate of failure for allograft is quite low. And when you calculate the number needed to treat, it's like 50, you know, revision ACLs with autograft would prevent one, you know, rupture with an allograft. So not unreasonable to keep in your armamentarium. All right, well, here we go. I always feel like I should start this talk out with forgive me, Father, for I have sinned. I feel like I'm at confession. I actually love this ICL because, you know, we sit here and let's see if that's, oh, all right. We sit here at these talks, right? And we give all these ICLs and we give these talks and we show you like our glamorized cases, right? Like we'll show you these dual level osteotomies with like perfect corrections and completely healed and intact hinge, you know. And it's really the Instagram of orthopedics if you think about it, right? And I think the reason this ICL is always pretty popular is because this is real world. We're all going to have complications. We're all very experienced knee surgeons. And we all have these crazy complications, often from our relatively routine cases, like a BTB ACL. So I'm going to share with you still what is my worst complication of my career. These guys have seen it. I know there are several of my fellows, either current fellows or former fellows in the audience. And you guys have all heard me talk about this case. I don't think you've actually ever seen the case itself. So this was 2007. I've been in practice since 2005. So this is my second year in practice. And I think that for those of you that are either going into practice or early in practice, it's important. Because it's easy when you get a bad complication to say, gosh, I don't think I can do this. This job is hard. I think for those of you that were at Dean Taylor's talk yesterday, he said the reason it's so great is because it's hard. But these complications will really test your resolve. So this is a standard ACL for me. This is a 19-year-old male. He's a Division I lacrosse athlete. Tears his ACL in the lacrosse field. Really uncomplicated injury. I don't have the full data set, because he was from December of 2007. But I'm going to share with you what I have. So he had a BTB autographed. We did intermediate portal drilling, which is what I've done my entire career. It was a 10-millimeter tunnel, 10-millimeter bone block, 7-by-20-millimeter screw on the femur. No extraticular augment, because we really weren't doing that in 2007. And as far as I can tell, it was a relatively uncomplicated procedure. These are his post-op x-rays. And I've gone back through this case to look and say, gosh, how has my practice changed since 2007? It's been 17 years. So two years ago, I gave a talk at one of the meetings. And it was a debate between intermediate portal drilling and outside in. So I put together my 20 last BTBs. And all I did is I took them. I took a screenshot. I didn't know what the outcome would be. And I put together a video to see what it would look like. And this is that video. And it's amazingly internally consistent. It actually looks very similar to that x-ray. So I look back on this. And I say, gosh, these are from 2003. I don't know that it's changed dramatically in the 16-year interval between the two. Well, so he's a division one lacrosse athlete. He's actually, I was working here in Denver at the University of Colorado at the time. He was about six weeks post-op, give or take. And he was getting ready to head back home. Lives in California. And was packing up his dorm to go. And he gets to California and said, gosh, my knee is killing me. It just blew up on me. I can't walk. I don't know what's going on. I said, well, you're probably infected. I mean, that's what I think, right, when you see that. And he goes to see his local orthopod, who's a good friend of the family. And I get a call. And he says he's got a fracture. And I was like, oh, man, a fracture. Did he break his patella? Did he break his tibial tubercle? Did he blow out the back wall? And he was like, no, he's got a fracture. This is by far the worst complication I've ever had. This is, again, practice for 20 years. I still tell our current fellows about this kid every time I think about it. I think Aaron throws up a little bit every time. We still talk about this case ever since I showed it. So half a fracture after uncomplicated BTB ACL. The reason I have these x-rays is because I shared it with everybody I know. So we were part of the Moon Group. I trained at HSS. I trained at Pittsburgh. And I shared it with everybody I knew. I sent it to Dr. Warren at HSS and the group at HSS. I sent it to Freddy and Harner. I sent it to Bergfeld and Spindler and all the guys. And it was actually fascinating, because all of them, especially the older guys, had said, I've seen this before. Oftentimes, back in the era when they were doing Gore-Tex grafts and a variety of different things. So it was really helpful to get their perspective on it. So this is what it looks like. At the time, I'm thinking he's got AVN. And if you look at that axial cut, it almost looks like the pattern. Sometimes you can see lateral femoral condylar AVN. I really didn't know what I was looking at. But this was pretty sobering. So thoughts on this? Aaron, this is obviously going to change his recovery. This is a game changer, right? The course of this kid's trajectory has just dramatically changed. Any thoughts? What's the next step? Yeah, well, I did throw up here. And I was getting some water. So I'm better now. But you did things very correctly. So I would just take a step back. And when you see a complication that you've never seen before, you have to get help. And sometimes that can be in the literature. Sometimes that's calling a good colleague. Sometimes that's calling the people where you trained. And in your case, it's just so uncommon. You did that due diligence. I think the second thing is you have to spend a lot of time with this patient. Just like you said, this is a course trajectory change for his lacrosse career and life. And there's a lot of unknowns in terms of how this is going to turn out. So this is a patient that I'm going to see in the office and look them in the eyes and clear my schedule and spend hours with them, honestly, in divided sessions. Because they're going to have to go through a process as well. And really trying to make the focus where we're going to move forward. We're going to try to do things as best we can. So that's just any complication. And in terms of this specific complication, obviously, we're dealing with the intraarticular fracture and possible devascularized bone here. So for me personally, this would not be my wheelhouse. So I'm going to have to phone a friend. We've got wonderful trauma colleagues that at this point, I would have to get involved with this case. And I'm fortunate to have those resources. Yeah, I agree. I think the best for everybody in the audience, I think that first point is key, which is you run to your complications, not away from your complications. And then Freddie was great about that. And all the guys that trained at Rush, they always talk about how Bernie Bach would say, like your patients, but love your complications. So I think the human tendency is you want to put your head in the sand. But these are patients you need to give your cell phone to. You've got to let them know that they're being supported, because they're going through a lot. They're losing a little bit of faith. This should have been a straightforward 19-year-old ACL. And they need to know that you have support. And even sharing with them that you're talking to colleagues about it, I think, is helpful. Travis, any other thoughts? Are you going to fix this, or are you going to send this out? I like Aaron. This is outside of my wheelhouse. I can talk about how I would fix it, and then I would send it to someone else to actually fix it. So I was fortunate or unfortunate in that regard. So he was back in San Diego, which is where he's from. So he wasn't in Colorado anymore. So he was fixed back there by a team that has experience with this. But Justin, any additional thoughts? How is this going to impact his recovery? When you talk to him, are you going to say, this is just going to delay your timeline like yours, or is this a game changer? Well, I will tell him, being a little bit earlier in my career than you guys, and to some of the audience here, I'll tell you, these things catch you off guard. You don't have time to go in. Let me look at the literature, or what have other people done? And the patient sitting here, what can I do? I need this better, right? And so it's a social conundrum, not just a medical conundrum. And I found that I give my patients, their families, my cell phone, everything. I tell them, I've never seen this before, and we need help. And you have to be honest about that. You can't paint this pretty picture. And I say, this is now different than what you had before. And it's a possibility it's not going to be as good. But then I also think, in my mind, I forget if it was you or who I was talking about this stuff with yesterday, most of the worst complications can be managed with well thought out, simple solutions, right? And so as you're earlier in your career, if you're going through training or fellowship, you shouldn't only be paying attention to why Armando's using a 10 millimeter bone plug, but where could this go wrong? And then what would we do next? And so compiling that Rolodex of solutions is what helps get you through this scenario. But at the end of the day, as far as counseling their recovery, I'll be straight honest. I say, I don't manage HAFA fractures. I have a friend that does. I'm going to go with you to meet that friend. I'm going to be in the surgery when he helps fix you, if I can. And we're all going to learn and move forward from this together. I agree 100%. And this is where you clear. I think the other thing that happens, too, is this pops up on your regular route. This is a routine visit, right? Like you've got a schedule of 40 patients. Your ATC pulls up the x-ray, and you look at this, and your heart sinks. And all of a sudden, the trajectory of your clinic for that day changed, right? And potentially the trajectory of your OR for that week. This is where you're clearing people off. You're making calls. You're calling friends. This takes full priority when this happens. So these are very rare. In fact, I had never heard of one before, and I haven't seen one since, thank God. But there are actually several case reports in the literature, mainly from the early 2000s, where I think our tunnels were a little bit potentially lower and were, honestly, certainly in the infancy, I'd say, of modern ACL. The etiology, I'd say, of this one is unclear. So in terms of trying to figure out a root cause analysis, people have looked at this. And biomechanical studies have shown that for single-bundle ACLs, this is the sawbone models, there really is no stress riser. There was an era, in fact, when I was a fellow, shortly before this, where we would do double-bundle ACLs. It was kind of the heyday of double-bundle, right in 2003 to 2007 or so. And that, you can imagine, creates a pretty big stress riser. Inappropriate loads can create a fracture similar to this. But this was a single-bundle ACL. Mark Miller looked at it. They looked at, essentially, dilation. They have a case report, one, and they talk about how this happens. Larger graft diameters, I'd say 10 is a pretty routine size for BTB. I think most of us, that's where we're at. Larger tunnel diameters, which makes sense from a stress riser perspective. Dilation of that tunnel, right? So there was an era, when I was a fellow, where you would drill a nine and you would take Lanny Johnson dilators and go nine, nine and a half, 10, and really create huge hoop stresses. I don't do that in practice. I do think there are very high hoop stresses. When we do BTBs, I think we probably get lucky a lot of the time. We make a 10-millimeter hole, we put a 10-millimeter bone block, and put a six to eight-millimeter screw. So the hoop stresses must be high. And they did identify intramedial portal drilling, potentially, as a risk factor. But this was also an era where we were going lower, right? So if you think about this era, we were all focused on AM and PL, and maybe splitting the difference and going closer to PL. We may have created higher risk of graft re-injury, better control of the pivot, but higher stresses across that graft. But again, I look back on the next tray, I'm not sure I'm much lower then than I was, than I am today, to be honest. And Bergfeld said this to me when I reached out to him. He said, you know, we drilled a 10-millimeter hole, again, we put a 10-millimeter bone block. I'm surprised this doesn't happen more often. So he was fixed. I wish I had an amazing, this isn't his x-ray, this is from Mark Miller's paper. I wish I had an awesome outcome, like these guys just presented. I wish I could show this is all rosy, and he got fixed, and he went on to play lacrosse, and his kids now play lacrosse. But he was fixed, and the piece died. Went on to AVN, he had a massive osteoarticular allograft. I kind of lost track of him after that time. He kind of got a little bit jaded, so it wasn't as close as we got to him. He wasn't particularly happy with his outcome. I wish I could tell you that he did amazing and healed, and this was no impact, and he was returned to sport at a year. So what have I learned? I wish I could share with you some orthopedic pearls to never get this complication. I will tell you how it's changed my practice, and I think my fellows that are in the audience, former and current, will now understand why I do what I do in the OR. But I think what you heard today is key. Run to your complications. Again, like your patients, but love your complications. Even simple surgeries can have bad complications. In fact, I do some pretty crazy operations. I'll do these massive reconstructions, the trifecta with meniscus transplant, osteochondralograft, osteotomy, dual-level osteotomies, revision osteotomies. It's usually not those that have the crazy complications. You're kind of prepared for those, and you prepare the patient for those. It's these routine ones, like somebody who gets spunk after a medial meniscectomy, a fracture after a routine BTB ACL that you may not have counseled as well because you have 40 patients to see. These are often the ones that surprise you the most. You gotta share your complications. You gotta share them with your colleagues so you learn. You gotta share it for the benefit of your patient, but you gotta share them with other people, right? Like, it's very humbling to be on this podium and share with you this complication. This is a disaster. But this is how you avoid these for your patients, right, is you share them with other people. I think people tend to hide their complications for a variety of reasons. And then lastly, from an orthopedic perspective, is I think you gotta respect the hoop stresses. So I'm a medial portal driller. I use an old-school offset guide. This is how I currently do my BTB ACLs. I hyperflex. Justin is very familiar with this. He did countless of these in Vail with me. I still do it this way. So I put my pin in. I use low-profile reamers. You know, pretty straightforward. I'll go to like 25 or 27. I think if you go lower, then potentially that's gonna be almost the width of a condyle. I make sure that I can feel the interface between the bone block and the femur. And then I still use metal interference screws, and there's always this moment, and I share with every fellow the first time they do a BTB with me, the story of this kid. And I let the hoop stresses relax a little bit, and I advance it, and I let the hoop stresses relax. And I've been doing that in probably a couple thousand BTB ACLs since that kid had his fractured. Still to this day, every time I do a BTB, I think about this case. So I think if there's a take-home point is run to your complications, love your complications, share this with your colleagues, both so you learn and so that other people learn from your mistakes. So thank you. And I have one more case, but I'll wait till Erin's case goes. Let me make one quick comment, Armando. So when you presented this before, this is why I love this specific talk. It affected me and changed my practice. So after I saw this, my bone plug is now smaller. It is now easier to slide in the tunnel, and I'm far more cognizant of downsizing a screw. If it feels really, really hard to put the screw in, I will go from a seven to a six. I do the same thing. I talked to James Boos, and he also heard about this through this talk, ICL last year. He's also changed his practice, so. Erin came up to me at the academy after this, and Erin's like, I've gone to a six. I'm doing a six millimeter screw now. Yeah, and I actually, we had to get special six screws in because we didn't have them in our, you know, on the shelf. So I talked to my rep, and I've changed my practice as well. And then just, I'll just say, you know, notching is very important, making, you know, room for your screw. Probably when I started practice, I was not aggressive as I should have been with notching, and I had some complications where, you know, the graft spins, the screw goes behind the bone block. You know, you compromise that tendon interface a little bit, so it's not easy putting that interference screw in. That's a tough part of the procedure. That's a good point, actually. I am more aggressive notching now than I was before, and I notched the whole length of the tunnel. You know, I think we tend to just notch at the aperture just to be able to find that spot, but I actually make sure that I'm, and I'm going at least 20 millimeters with that notch so I have a clear path for that screw and for that wire. Yeah, I'll also tap before I put the screw in as well. And I've started doing more of a taper on my bone plug, so, you know, my graft, the tendon is a 10, but probably the tip of my bone plug is like a five or something like that, so it's going in, and then by the time the screw passes that aperture, it's, you know, basically kind of a rip stop onto the graft a little bit, so. Yeah, I like it, I like it. All right, I'll hand it over to Aaron. I have one more case, but I'll do that after yours. We actually have like 30 cases lined up but it's only an hour and a half thing but we can go all day if you want. Okay so we had three very interesting kind of bone complications with fractures. Now we're gonna move to soft tissue injuries and I'm gonna share two cases with you both perineal nerve injuries. I think you know for us that operate a lot in the knee you know we worry about that perineal nerve a lot. So I don't have any disclosures. So here's a case so 21 year old fell off the roof. You can see here obviously the knee dislocation underwent a closed reduction and thankfully normal ABIs, the emergency department and the neuro exam was was 100% normal. We look at the imaging ACL and PCL were out and then this lateral side was you know completely dusted. I think when you see the IT band of all that just you know you don't see that very often. So here the IT band, the biceps, LCL you know the basically the naked fibula if you will. So we went early to the operating room and I can see proximals on the left, distals on the right and this thing is a full blowout you know the capsules out so when you open it essentially you're you know kind of looking at the at the femur. So here I'll just kind of go over the structures. Here's your IT band, this is your fibular head here, your popliteus, your lateral collateral ligament, your biceps and the nerve and then just note the location of the nerve and the the fibular neck that will come up later in this case. But again the nerve was completely intact normal exam pre-op. So in this case you know we repaired all structures but you know that that FCL did not really reach tension free and full extension so this is one we would certainly reconstruct as well with a semi tendinosis graft. So here's a look at the ACL PCL. We used all inside socket technique so we completed the ACL and PCL before going to the lateral side. So here are the final x-rays. I know there's a there's a lot going on here but you can see the sockets and screws for the ACL and PCL. You see the buttons and then these are just little old metal anchors. You know these are very old technology but thankfully they never pull out and actually work very well particularly in the proximal fibula when you're drilling both a full tunnel as well as multiple suture anchors for all those disrupted structures. So feeling good you know got through that case in a reasonable amount of time and then you go post-op check the patient and there's no sensory or motor function. So dense perineal neuropathy tibial nerves intact. So my esteemed experts here Justin what are you what are you gonna do you just examine this patient post-operatively? Yeah so I think you know you start simple loosen braces or bandages you know relax the knee with some flexion if you need to maybe give it a little bit of time to start and and see how he reacts. You kind of go back through your checklist like obviously you took a lot of time there to dissect out anatomy had no concern for like an iatrogenic injury of any sort. You know you think about your closure did I was local injected in that area was maybe a trainee a little too deep with a stitch or something like that and you kind of just go through your checklist but you start simple and then walk yourself back I think. Yeah that's that's beautiful so I would say we we loosen the brace flex the knee and within 15 minutes as you'd expect you know things are gonna come back quickly they do and it's amazing you can almost see them come back before your eyes and as you know his toe extensors came back but he still didn't have any you know ankle dorsiflexion and just like you said you you went through it perfectly we systematically went through and I think this is why you know if you're working around a nerve I think the last thing you do is you have to convince yourself before you leave the OR that that nerve is okay because you don't want to be sitting there in the recovery room now gosh do I need to take this back immediately for exploration and you should never be wondering about that you should always convince yourself you know before you leave the operating room. So you know these these braces you know we use these braces a lot and in this case I think initially we could we could say it was the brace potentially certainly when we loosen the brace up within 15 minutes it came back but I'll tell you you you have to absolutely either check the patient postoperatively yourself that would be preferred or delegate it to some trusted you know colleague on your team but you have to do this I still catch maybe one per year that you know in post-op recovery has a little bit of altered sensation or things and it's it's that darn strap you know like right on the fibular neck so near misses because if they go home they don't know exactly what's supposed to be right you know after their surgery so you know if you miss this and you don't pick it up to your week post-op that's a long long recovery but have you guys had any issues with with braces and catching perineal nerve compressions? Yeah I have I think a couple take-home points from this is one so the local anesthetic is important too like I've gone away from local anesthetic any of my lateral incisions either pre-op or post-op because I've had some subtle nerve issues even after lateral meniscus repairs so I've gone away that's what don't want that variable in the mix right like I don't want it to cloud my judgment about whether or not this is a post-op complication or some sort of local anesthetic mediated response I check any patient that has a potential for nerve injury myself like you did because it's remarkable how this patient may have been sent home by the nerve nurses because they also don't fully know what they had nerve block wise they may have been like oh he had a nerve block he's got a foot drop and you would have been unaware of it until it was too late right because if this thing was compressed for a couple days or even the remainder that day that nerve may have been dead forever I'll share with you another story of mine and other complications so I had a lateral meniscus repair inside out because I do inside out for everything uncomplicated at the time and I went to check on the kid who's a BTB ACL lateral meniscus repair and he had a foot drop he's like I was like how are you feeling he's like I got a lot of pain it's like where's your pain like in the front of your harvest he's like no on the lateral side it's like move your foot he was dressed being ready to be discharged as IV was still in he's got a dense foot drop at the time that surgery my resident there was a PGY 3 let the heading out and popped it back in I was unaware of that she just repositioned it we took him back to the OR and the sutures were tethering the perineurium the nerve itself was intact but but it stresses the point of what you did which is you have to examine these patients yourself because it's very easy for somebody to send them out you know so it's embraces is obviously that would be your first step it's loosen the brace flex any if it doesn't get better you've got some decisions to make about taking him back Aaron you know you talk about the brace at the fibular neck but the other thing especially with yours where the biceps is completely of all says more proximally now that nerve is completely uncovered as well and usually when you neuralyze it it sags back as well so it becomes this from this deep to now superficial structure proximally to so not just the fibular that you know the distal knee strap but the proximal one can compress it at that point as well I think so and how many in the audience have seen a brace cause a nerve compression to catch yeah I mean it's just the thin line between success and failure there is very very real okay so we're feeling better right that nerve came back or partially but it's three weeks now you know you really don't see any active dorsiflexion so again toe extensors are intact but no ankle dorsiflexion so at that point we got an ultrasound you know with with zero out of five the nerve was in continuity no neuroma and we're very fortunate we have a you know very expert peripheral nerve team at Mayo Clinic so they were on board would you do anything different at this point three weeks out from this case what are you telling the family at this point Travis first you say you're really sorry that this has happened and you're gonna keep an eye on it I mean you have you've done a number of things that have helped you one is you know the nerve is intact at least when you saw it this is likely a weird aberrant branch or something like that or I mean who knows we talk about there are a number of studies Bob Hoschkiss and others have published papers on peripheral nerve injury and recovery and how long it takes you can get nerve recovery up to two years I mean obviously this is different because it's a partial neuropathy but this is one you're gonna watch I also counsel them I tried to provide hope where there is some so in this regard I would be talking to them and saying you know if this doesn't come back this is what we're gonna do so I try to over communicate with patients and give them a plan moving forward so that they have something to look forward to or at least hope for in this case we can do tendon transfers if this doesn't come back here's the plan we're still gonna watch it but we we also counsel on Achilles tendon contractures you want to be very careful to make sure they can get their force of foot dorsiflex so those options down the road are still intact so yeah that last point is an excellent one you know as their nerve recovers you don't want them to also have to overcome their flexion contracture in the ankle so six weeks you know we're seeing this kid back early and often and really no change we did repeat the ultrasound you know didn't show you know any atrophy or anything gosh it's it's six weeks you to hope to see some recovery so now we're at nine weeks at this point we're getting an EMG and you know as I would expect based on his exam as a mononeuropathy involving the common perineal nerve so at this at this point you know for me the biggest thing is I'm trying to explain this you know I thought I knew my anatomy I thought I knew my exams and how in the world can you know EHL and everything else innervated by the deep perineal be intact so let's just look at that so how is that even possible so we go back to the tibialis anterior innervation so there is dual innervation from both the articular branch and the deep perineal nerve branch so if you go back to our patient right so the toe extensors were relatively intact but that tibialis anterior was completely out so in this case he had articular branch dominance of his innervation from his TA which is a known variant it's very uncommon but you know must have been the case for this patient so thankfully again we've got an expert peripheral nerve team so at 12 weeks going back and clearly you can see there on the articular branch that neuroma very bulbous very obvious couldn't pick it up on the ultrasound you know it's right at right against the bone there but clearly abnormal the deep perineal was completely normal and you know the question is what happened was it excessive retraction was it an inadequate decompression right there hard to know so what they did is they they performed the extensive neural you can see and they opted to perform a motor nerve transfer from the superficial perineal nerve the great news was that at three weeks he had a hundred percent recovery of dorsiflexion so obviously not probably the nerve transfer at that point but maybe just the decompression of the neuroma and the rest of the nerve so how close is that to your dissection for your fibular tunnel perfect segue I'll show you some anatomy so you know looking at our institution relatively high volume for multi legs you know two master surgeons that I've learned from Mike Stewart and Bruce Levy and if you look at you know over 200 patients they've treated there was just one iatrogenic nerve issue that's a patient that had some EHL weakness for three weeks so overall I think if we're careful you don't see this very often but Armando to you ask your question how how close is it well here you can see you know your typical LCL graft and your fibular screw and then here's your common perineal nerve with the articular branch so how how big is this safe zone you know in our patients and we looked at this did some intraoperative in real patients and then did some cadaver cadaveric dissections and the average is one centimeter but you can see that there are patients where it's as close as five millimeters so if you're really getting the anatomic spot for your tunnel that articular branch is is very very close so what I learned from this case was you really have to release that articular branch so you have to release all the way to the fascia of the perineus longus so this is what this looks like you can see the common perineal nerve here and in the forceps that is the perineus longus fascia so now I am actually releasing that I want to see muscle fibers I typically are MCing part of the either bifurcation or trifurcation at this point just to make sure that articular branch is out of the way of my fibular tunnel so for me it's no longer sufficient enough just to have the you know common perineal nerve it's got to be the articular branch that we're also protecting I've never dissected out I do exactly what you do I open up that fascia even release some of the muscle because I don't think it's there of any consequence and allows me to put my finger on the fibular on the fibular neck and push the perineal nerve down when I drill it but I haven't actually haven't dissected out that articular branch but you actually see it you actually find it on each of these cases now yeah I try to or at least I'm releasing that fascia for sure and I think I think you know what's the right amount of retraction because it is still under quite a bit of tension there so using your finger that's probably the right call rather than putting you know some sort of you know this could have been just a traction injury right that we were a little aggressive but I think you know you just have to see it and be very careful so fortunately for this patient you know they did well once they recovered here he is at a year post-op and again thankfully did did very very well so I'll kind of show a companion case but any other thoughts from that one you know it's multi-legs are hard you know you have to have a good nerve team around you if you're gonna be seen and doing a lot of them so yeah I think that the take-home points is you know obviously you after this complication you did a deep dive and not just explored all what the anatomy was but did a project to understand it better to educate everybody right which is how you scale these complications phoning a friend is your second point which is like get a period or a peripheral nerve team involved and and the reality is you can have a pretty amazing outcome if you really are diligent about pursuing your complications and trying to optimize them I mean that's that's an amazing outcome for any multi-leg let alone one that had a foot drop you know in the perioperative period so Aaron you may be I missed it but you're the decision making at three months so I'm thinking to myself if this happened to me what would I do and I probably would not and I would have been wrong I've gone back at three months to explore the nerve so what was your thought process there you have most of the nerve recovered you have a dorsiflexion problem what at three months why why go back yeah so again I rely on my expert colleagues but in this case you know post-operatively he had zero out of five you know tibialis anterior and at three months it was zero out of five and the EMG suggested you know it was you know affected just in that location so even though we couldn't find anything on ultrasound it just it made sense that there's some sort of injury there now if we would have seen some recovery at three months let's say he recovered even like two out of five yes in that case I probably would have continued to watch it put him an AFO etc but just the fact that there was zero recovery and it was such a strange case you know usually I would expect that you know everything's out EHL is out ankle dorsiflexors are out perineals are out but in this case just couldn't fully explain why why this was happening so the peripheral nerve team just thought okay this this has to be a structural issue here got it what's helpful to me Aaron just listen to this case is that you know usually the EHL is the last thing to come back online you know like they get their foot drop resolves and they still have a toe drop so if you have this clinical presentation it has to be that articulate right there's right there's no other anatomic explanation for five out of five or four to five EHL and a complete foot drop in this context as far as I currently know yes so I just want to present a quick companion case and actually Armando you you actually alluded to this case so this was this was a case performed not by myself but I inherited and happy to take care of this patient but 11 year old you know lateral knee pain and popping diagnosed with lateral discoid meniscus I can clearly see the the discoid here on the MRI here were her intraoperative arthroscopy photos and you can see the one on the right you know it's a complete posterior capsular detachment so at the hiatus there there's absolutely no attachment so she's getting the popping from that and you know inside out lateral meniscus repair you know was performed and then post operatively I didn't really have details on that initial exam but Armando you know you said you had a patient like this where it was out you know immediately post-op and you went back and that's you'll see this play out in this case maybe the right call but regardless this patient's under someone else's care and post-op day for the family called in like just kind of wondering like hey we're she's doing great you know no pain but you know should she be moving her foot you know sort of call, which obviously just, you know, just hurts. So at this point, they brought her into clinic, and in this case, a more typical, you know, common perineal neuropathy with, you know, everything's out. So at that point, they were able to obtain an ultrasound, and gosh, we have just some unbelievable, you know, ultrasound experts, and you can see in this case how valuable that ultrasound is, because they were able to see it's significantly enlarged, you know, and they diagnosed that there was a constricting lesion in, you know, in the common perineal nerve, and, you know, this is within one week. So at this point, what was done exactly as you recommended, Armando, so this patient was taken back, and you never want to see this picture, but you can kind of see, so the common perineal nerve is there, and you can see there are two sutures that are completely surcloged around the nerve. So this is what it looks like after removing those sutures, so you can see that segment of nerve is fairly contused, beaten up, constricted, et cetera. This early on, you wouldn't expect to find an aroma or things like that, but the nerve was in continuity, and as a young patient, it was felt that, you know, we'll watch this after we remove the sutures. So at six weeks, you know, she was obviously placed in an AFO. She continued her meniscus rehab, and at six weeks, there was definite improvement in sensation. At this point, you know, she also had a little flicker of motor, so I think we're all feeling pretty good at that point. And then here's six months, so she regained her strength. She was able to discontinue her AFO. You know, their whole family has bilateral discoid menisci, and it's interesting because there's three daughters, and all of their names are similar. They're each two years apart, and they all have bilateral discoids, and it is unbelievable, but anything from partial meniscectomy, meniscus repair, meniscus transplant, double transplant, osteotomy, they have every single variation. So I have my clinical assistant actually prepare a chart because they all want to sit in the same room as well, so it gets quite confusing in terms of who's had what surgery, but delightful family and thankfully a good outcome here. So this is Armando's point here. Go back to the anatomy. You know, when you take care of these discoid menisci patients or any, you know, lateral meniscus patient, but particularly these young females, their lateral gastroc is like a piece of paper. It is nonexistent, it is very, very thin, so you have to put your retractor anterior to that lateral gastroc. If your spoon, your retractor goes posterior, then you're at risk for tying sutures around the nerve. And I think it's very easy to do, again, on these young, particularly females, they just, their anatomy of that lateral gastroc is not very developed, so you have to be very, very, very careful. So this is one that I always have eyes on. I'm putting that retractor in myself, and you want to make sure that those needles are coming right out in that interval. Any other tips? I mean, I think this might be where, you know, everyone in the audience sees this, sees a nerve issue the most is potentially with a meniscus repair, but any other ways to stay out of trouble? I'll tell you, since I've had personal experience with this, I'll tell you a couple of things that I have changed my practice from mine. So one is, it's an internervous plane, right, between the biceps and the IT band, and then you pull that lateral head of the gastroc back, and the tendon, that picture to the right is great, because the tendon of the lateral head of the gastroc is adjacent to the capsule. The muscle's actually posterior to it, so you need to get in front of that tendon. The second is that you can be lulled into thinking the nerve is safe if I'm in this plane. If you go around the biceps, you'll find the nerve on the other side, right? It's three-dimensional, so it's not like if you're in that plane, especially if you're dissecting distally, like if they have a fabella, fabella can hose you, too, because it resides in the lateral head of the gastroc. It makes it hard to get your retractor in there. You can find the nerve on the other side if you look around the inside of the biceps. So you have to be mindful of where that nerve is at all times, and not just be lulled into thinking I'm totally safe because I'm in an internervous plane. I did a root cause analysis after mine because I wanted to understand it better, like how did I miss that? So I went back to the anesthesia record, and there were two things that struck me with my case. So one is when the resident had the retractor on the lateral side, at one point she said, oh, there's a lot of fat, right? And it didn't resonate at the time. There actually is not a lot of fat on that lateral side. There's a lot of fat on the medial side, but the fat was the nerve, right? So I'm always mindful, do you see a lot of fat? Second is she had to change physiologically during the surgery, right? Because they're pretty light during these surgeries. So blood pressure went up, heart rate went up, and anesthesia was like, oh, what are you guys doing? I was like, oh, we're dissecting on the lateral side, and now I'm a lot more in tune to that. So there were two things that happened during that surgery that I could have caught in real time that have been helpful to me. So just a couple pearls. Is there a change? I'll ask anesthesia, how are they doing up there? And certainly if they see fat, that's a red flag. Sorry, Justin. I was just going to also add, by the time you're doing these two and the leg is up in like the figure four and upside down, and you have either a tech or someone not experienced with this anatomy catching, I've looked down a couple times, and the retractor is inverted, like it's holding the gastroc up. And if you're not thinking upside down while you're catching those needles or whoever's assisting you, you could really easily be protecting nothing. And so with every single needle that goes through, I'm not only just asking, I'm looking down and making sure that it's not even just angled posteriorly, but almost inferiorly as well, so that the needles are getting caught appropriately. I now will also, as I indicated earlier, I will post-op exam all these patients. I will always check them in recovery. So in mine, I took him back immediately. They went straight from the PACU back to the OR. He presented with a foot drop and lateral-sided pain. The lateral-sided pain and foot drop resolved immediately. He went home with five out of five dorsiflexion. His toe drop persisted for several months. So I think if you catch them really early, you can save yourself. I think at four days, it's tough. That nerve, sometimes, I mean, I'm glad it recovered. Sometimes it doesn't recover. But that can be a permanent nerve injury if it's been constricted for that long. Can I ask the panel a question? Actually, I'm curious now. If this was an all-inside meniscus repair and the patient has a foot drop lateral, what would you do? I'm familiar of a case that was referred to me with something like this. So I'm curious how you guys would approach it. Yeah. I have seen one that was referred in with an all-inside device that they did injure the peritoneal nerve. So first of all, I think if you're going in for meniscus repair, you better be studying your axial MRIs and know exactly where your neurovascular structures are. Because there's a lot of variation, right? And so we all know it's that lateral portal to the posterior horn of the lateral meniscus that's most at risk. So particularly for that one, I'm really thinking about my depth stop. I never really go through capsule only in that situation. So we love vertical mattress sutures, but I'll use a horizontal mattress and just go through the meniscus twice there rather than just once. So I would have done that all ahead of time. So I wouldn't have expected any potential issues having gone through those exercises to make sure I'm safe. But that's my approach. Yeah. I think you've got to explore those. I mean, 90% of meniscus repairs are all inside. But I think the lateral side, you've got to be mindful, right? A lot of these are smaller individuals. If you go 20 millimeters depth stop, like you were saying, through the capsule, I've seen some of these. I'm sure you guys have, too, where these little pledges are outside the skin because they go so deep. So you've got to be really mindful in those situations. But if I saw that with an all inside, and I don't do all inside, I would take that patient back to the OR and explore it. But that's more challenging, because at least if you've done inside out, you already have your surgical plane. You've already dissected it. You know exactly where your potential trouble is. In this case, you wouldn't. It's somewhere deep in the back. Yeah. Okay. So I think we have time for... Yeah. I can present more. Do you want to open it up to questions? Are there any questions in the audience so far on any of these? Excellent. This is going to tie in well to some of the cases that were presented already. This is from a BTB harvest. So this is a case of mine. This is actually a more recent one. This is probably about four or five years ago. So I'll just quickly go through it. So he's a 40-year-old male. He had an ACL 15 years ago with a BTB autographed. He actually did pretty well. If you look at those tunnels, I think we all agreed those tunnels are pretty egregious. In fact, I actually put this in my revision ACL talk as well, because that tibial tunnel is so far anterior, and that femoral tunnel is also very anterior that you could essentially revise them like a primary. He had a scope by an outside surgeon about a year before, and he was told his ACL was intact, but he continued to have instability and knee pain and presented to us with the following MRI. So you can see meniscus is intact. PCL is intact. He's got this weird kind of band at the roof of the notch, which I think is what they saw. It actually was more scar tissue. He's got a pivot contusion, but actually a pretty well-preserved joint. So a pretty straightforward case. We had a lengthy discussion about grafts, and we belabored this earlier, but we elected to proceed with a contralateral BTB autograft. This guy is hucking cliffs on the weekends. He's in the summer. He's doing all sorts of crazy stuff, mountaineering, fly fishing, et cetera. This is what it looks like at the time of the scope. You can see why they told him his graft was intact, but it was this thin layer of scar tissue that was really hard to identify as any sort of structural ACL. This was his revision, pretty straightforward, beautiful BTB autograft, again, a contralateral graft, and these are his post-op x-rays. So left his original screws in. You can see my new screws, I think in a more anatomic position. I backed it up on the tibia just because it was a revision. So I get called from the PACU, and they said, hey, PT got him up. He felt a pop in his right knee, his contralateral knee, his harvest side knee. We want you to come check him out. So I went to go check him out. He's got his post-op dressings on. He's got a straight leg raise without a lag. He's got five out of five strength. I was like, he probably just felt a pop. It's probably nothing major. So he comes in for his 10-day post-op check and get his x-rays, and this is his contralateral BTB. This is one that arrests you in the middle of clinic. This is one where you're going, you're like, oh, man, I've got to think twice about this. So imaging-wise, what would you guys get on this? Would you get a CT? Would you get an MRI? Would you get both? Justin, you already had experience with that patella tendon. I would go with a CT probably on this. I don't think the MRI probably helps that much, so I would just go straight to CT. Trev? I would also get a CT. This looks like the medial inferior aspect of that patella ripped off because you can see the shadow on the lateral. So it's not the entire inferior pole, so a little unusual. Maybe some extension from the harvest saw or something. I don't know, but that's what that looks like. But I'd get a CT. Yeah, very astute in terms of picking up where that is. Aaron, any additional thoughts? So this is his CT. I also elected to get a CT. I think you can get a CT much quicker. Medial side of that's off, which may explain why his straight leg raise was intact. I'll show you his sagittal here. Lateral side looks pretty good. Harvest site, and then that medial facet is just totally off. So now we have at least compromise of two-thirds of his patella, 10 and the third I took out, and the third that's now fractured off. So any additional thoughts, Justin? We don't need to belabor extensor mechanism complications from BTB harvest, but are you going to take him to the OR acutely? Are you going to take him that night? What's your plan? I don't think you need to take him that night. I think you take as quick as reasonably possible. This is not a regular on-call patella fracture. You want your normal day team and your normal X-ray tech or whoever you may be. You're thinking about the thing with these, unfortunately, from experience, is that the reed is not there. So the CT is kind of valuable in understanding the reed that doesn't exist centrally. The other thing is, compared to a very traumatic patella fracture, is the retinaculum is all intact. So it's not like you can easily get to the articular surface without completely doing an arthrotomy. So you have to be thinking, well, if I can't get where I need to, do I need to arthrotomize fixation without a reed, and how am I going to piece that all together? And so usually I'll kind of call for a little bit of everything, various size cannulated screws, suture passers in case I want to cerclage anything together, and just kind of, again, a day team procedure with the kitchen sink available. Yeah, I think 100%. You want your team available, you want the right equipment, and you want to be prepared for all possibilities, soft tissue repair, bony repair, backup fixation, cerclage, et cetera. Travis, any additional thoughts? You know, this is like the other side of what happened to me. Yeah, totally. It's fascinating. The upside is he has an intact extensor mechanism-ish. Ish. Yeah, and so as far as impacting recovery, if this goes the way – and this has articular involvement, so it's going to be a little different as far as risk of arthrofibrosis, et cetera, but I think you're going to do okay with this, actually. I don't think it's going to drastically impact his recovery. It's also his contralateral side, so there's really no intraarticular injury that has been caused prior to this, so I would expect a really good recovery for this, honestly, and I think he's going to do well. Yeah, and actually that was my perspective on it as well, which is it's not going to arrest his BTB or his ACL side recovery at all, and this should be a pretty healthy knee and should heal pretty well. So I think we talked about these numbers. These are rare. You guys shared this already. They can occur displaced or nondisplaced, and outcomes in general are pretty excellent. Theories abound about why this is. With the plug, I'm pretty meticulous. My fellows in the audience can attest to this. My harvest is very particular in terms of keeping that very narrow, keeping it as narrow as humanly possible, keeping it centered on the patella, and keeping it to a third at its greatest. But the theories are length of the plug, depth of the plug, technique for harvest. I do not use an elevator or like an osteotome to elevate it, but I don't impact it. I literally use it just to get underneath the plug, and I lever it out. I feel like the entire harvest needs to be done with the saw. And you can see how, obviously, from a transverse fracture standpoint, you can imagine the stress risers that we create when we harvest these are pretty high. It's actually surprising to me that this doesn't occur with more frequency. So what was interesting about this case, and if I had to change my practice, is I did not get an MRI. I just got a CT scan. When we got in there, the medial facet was off. And I think you shared this in your talk. He had a Z injury. So his extensor mechanism was intact because his retinaculum was intact, but he fractured off the medial facet, and then he avulsed the patella tendon off the lateral side on the tibial tubercle side. So it actually was a complete – I've never seen a pattern like this. I should have taken pictures, but I really wasn't prepared for it at the time. So we used a cannulated screw through the medial side. We used knotless or essentially swivel lock anchors to fix the patella tendon, and he's done amazing. Actually, he's a fly fishing guy. He's offered to take me fly fishing multiple times, but Travis, as you indicated, he did fantastic. The PCL side is bomber, and this side actually remarkably has done very, very well. And we actually MRI'd him. He was curious about an MRI at the year time point, and both sides of this healed. But I think the take-home points for me is if you have time to get an MRI, get it. I think it can help you. It wouldn't let me delay, or I would not allow it to delay my time to the OR. But in this case, it created this weird Z pattern that I think you can see. And again, Justin, you shared in one of your slides. So interesting case. And obviously, I think in terms of ACL surgery, probably our harvest site is our highest risk in terms of complications. Will you go back to the original x-rays? Yep. To the fracture? Yeah. Whenever I see these cases, I try to think to myself, how can I do better and avoid this from happening again? Go forward. Yeah. So that's hard. I'm trying to think how you could have identified that that lateral patellar tendon rupture was there. It doesn't have ALTA. No. Yeah. It was a surprise for sure. And it was pretty cleanly evulsed off the tibial tubercle. I think my gut is that it fractured, and then you have such a high eccentric load when the leg – because essentially he hung his leg off the edge of the table, right? So the fracture probably occurred first, in my opinion. And then you have all this eccentric load concentrated to just a third of the tendon, so the forces are really high. And then evulsed it. I don't think they actually occurred simultaneously, but I'll never know. I have a question for the group. Do you guys use the saw to make your transverse cut at the superior aspect of the plug? Mm-hmm. So I've started, and I think Tom Hackett was what got me onto this in a previous fracture, is rather than using a saw there, I take a 2-millimeter drill bit and just postage stamp perforate superiorly and don't use a saw at all transversely. And then I still do the lever ejection. And if you do enough little drill holes and maybe one little wrap through the postage stamps, it comes out nice and clean. Because I was noticing when I was transverse sawing, the saw oscillates beyond the plug a little bit, right? And so I've gone completely away from transverse oscillating on the harvest. I don't know. Yeah. Additionally, I think that's a great pearl because it does go beyond it by definition because it's a centimeter wide, so it has to. It's probably 2 millimeters on either side. And it does give me a little bit of pause about doing BTB autos and patients in this age group, kind of like yours, Trav. I think it's not the same population as our 19-year-olds. So I think with that, I think we're at time. If you guys have questions, feel free. We'll be up here. But I think we've shared with you some of our highlights, so to speak. But hopefully that's helpful to you guys in many ways. So thanks again for coming to our ACL this morning. Thank you.

orthopedic experts

ACL surgeries

surgical complications

patient recovery

imaging techniques

graft types

BTB graft

patellar fracture

peroneal nerve injury

multi-ligament reconstruction

surgical planning

postoperative assessments