Thank you, everyone, for being here this morning, Saturday, 7 a.m. It's a rough morning for a lot of people. I want to talk about the role of post-lateral corner and post-termedial corner on ACL graft and how to maximize your success on ACL reconstruction. We know that when we have an ACL injury, there's oftentimes an associated injury on the anterolateral corner, the post-termedial corner, and the post-lateral corner. Why it's important to recognize this? Because you increase the strain on the ACL graft if you don't address those structures at the time of the ACL reconstruction. In a diagnosis, it's important to be comprehensive. As Andy was saying, we need to not only do the normal maneuvers, but also try to understand rotational instability, which is one of potentially the most difficult things to understand. Is that coming from a post-lateral corner? Is that coming from the anteromedial corner? It's really difficult sometimes to determine where these are coming from. So therefore, it's important to have a high level of suspicion so that we can go and look in the MRI and try to understand exactly what we're dealing with. In chronic cases, it's always important to have a long limb alignment X-ray because sometimes an osteotomy may be all they need. Artis and Dr. Labratt published this where 42% of the people that had a post-lateral corner tear that had a various alignment and had an osteotomy did not need a post-lateral corner reconstruction. So that's how powerful an osteotomy can be. Imaging, we always like to get stress radiographs. I think for the younger folks in the room, it's not only important just to diagnose this, but also to know the severity, to know the extent of the injury and understand exactly what we need to do moving forward. This also allows us to understand how many or which structures were involved. These are the limits or the ranges that have been published before in the literature, but I would encourage you to read those papers. On the lateral side, it's basically 3 millimeters to know if you have an LCL and more than 4 if you have a combined injury. PCL, if you have more than 12 or more than 8, you have a PCL or combined injury. And on the medial side, it's similar. More than 3 millimeters for an isolated MCL and more than 10 millimeters for a post-medial corner. We just published a study looking at people that had an ACL tear, basically isolated. Those people do gap more even in the absence of an LCL injury. Now when you add an LCL and when you have both, even when you section, when you change the sectioning method, they have to have at least 3 millimeters of gapping to know that they had an ACL and an FCL. So every time that you have more than 3 millimeters, it's probably because both of them are compromised. The MRI, it's sometimes easy to find them, but sometimes it's not. On the post-lateral corner mainly, you rarely see an avulsion of the FCL. Most of the times you're going to see this type of waviness on the FCL. Sometimes you can see an avulsion of the publiteus tendon like you can see here. And if you get lucky, you can see the PFL that has been avulsed or at least injured. On the medial side, it's important to know a couple of things. If it's detached proximally or distally, it may make a difference in regards to what you do and how much you weight. If you have a standard type lesion, you're going to be more aggressive with surgical repairs. And now we know that, for example, when you have the POL that has been detached and it's more than 10 millimeters away from the bone, those are the people that may not heal on their own, even if it's a proximal sided injury. In regards to biomechanics, in an ACL intact knee, PLC structures are the main restraint for external rotation, but they have little to no role in anterior translation. When you have a PLC deficient knee, there's increased strain on the ACL graft in varus and varus and internal rotation, as well as valgus. This is why it's so important to reconstruct the lateral sided structures in the event that they're injured. Clinical outcomes, we know from recent papers that if you have a failed PLC diagnosis, you're going to have an increased risk of ACL failure. And the same thing happens on the medial side. If you have a full posterior medial corner tear and you don't address that at the time of the injury, then you're going to have an increased failure of the ACL reconstruction. We did this consensus statement with the ESCA group, and we gathered 35 people from all over the world. There's several people that are here today. And what we found was that a lot of people don't know exactly when to treat those grade three tears of the MCL conservative versus surgically. Most people said that they would let them be for six weeks and then address them at the time of ACL if need be. Some people said that they would go acutely and fix them both because there's a higher chance that the ACL would fail if the MCL is not healed. Most people agreed if you had a surgical standard lesion or if you have bony avulsions or intra-articular entrapment, those should be fixed. When combined with ACL injuries, treat the MCL conservatively first is what most people agreed on. And anatomic reconstructions are potentially the best to reconstruct this type of injuries. This is a recent study from the Moon Group looking at grade three MCLs with ACLs. And what they found was that there was no difference in re-operation rate or stiffness if they treated them conservatively or if they actually fixed them at the time of the ACL. There was no difference in PROs between early and delayed surgery. And also no difference between proximal and distal tears, which was interesting, at least in this study. This is a case presentation, and this is potentially one of the cases that I put this case because I think it represents a lot of people that we actually see in clinic. This was a second opinion that came to me. Sixteen-year-old female had her period three years ago, cheerleading accident, lateral knee pain, had an ACL tear, went to another surgeon in northwest Indiana, was told that she had an ACL tear and that she was going to get a hamstring graft. So she had an ontology case, significant instability, heel height. This is very important. When you have a heel height that is not symmetrical to the contralateral side, you have to suspect that something may be going on on the lateral side. 2B LACMA, busted pivot shift, 2 plus with varus gapping, a negative dial test. In my clinic, everybody that has any varus gapping will get a stress X-ray. These are the X-rays. You can see here that the visors are almost closed. And this is the gapping, more than three millimeters of difference. So in this case, she had an FCL injury as well. So what we did, and you can see it here on the MRI, there's some waviness to the FCL on that coronal image. So for this case, what would you do? Who would address the lateral side in this patient? Can you raise your hand? There's probably half. Anybody use a suture augmentation for this type of cases? Can you raise your hand? Okay, good. So this is what we did. We did a BTB, all epithelial on the femoral side, and trans-tibial on the tibial side, and then a soft tissue graft to the lateral side. This is her at four months. I usually allow them to start running at three months. She was normalizing her gait, but you can see that one leg had a significant atrophy still. And this is her at, I believe, nine months, going back to tumbling. So anatomy and biomechanics are the key. The injury mechanism, the history, and the physical examination are still the mainstay of anything that we do. If you have a high level of suspicion, always get a stress x-ray because that's what will allow you to know the severity of the injury, but also the extent and how many structures are involved. The MRI can also tell you about associated injuries. Address all injuries at the same time, if need be. On the medial side, you can be more permissive. If you have a grade three MCL, you can probably leave it alone. If you have a distal one, if you have an MCL that is entrapped into the joint, you should probably fix it sooner rather than later. For all the lateral sided structures, fix them acutely. And you can expect to have improved objective and subjective outcomes. Thank you. Well, we definitely have some time for some question and answer. I have a question for you, Dr. Chawla. What's your opinion on timing for lateral sided reconstruction? Should you do it early or late if you have ACL, FCL, or ACL postulatal coroner? Can you let the lateral side structures heal like an MCL, or should you look towards more early treatment? We did this in the consensus team, and we asked the same question, and everybody agreed that it should be done within the first three weeks. One of the mentors, Robert Pratt, used to tell me, when you have a chronic injury to the lateral side, the scar looks like nerve, and the nerve looks like scar, and it's completely true. To get there after six to 12 weeks, all that scar has scarred into the nerve and makes the dissection much more difficult. I think allowing for some range of motion, zero to 90, and getting some of the swelling down within the first two weeks is what I do. I send them to physical therapy right away to try to regain range of motion, and then as soon as they achieve that, I get them into the OR. How often do you find that these are fixable, meaning repairable with suture anchors, versus reconstruction? In very few instances, I think they're repairable. Most of the times, you're going to see that they're stretched out, and for those reasons, I usually don't trust those structures, and I just go ahead and reconstruct it. What kind of changes in rehab do you do if you're doing ACL, FCL reconstruction? You change their weight bearing, range of motion restrictions, return to play. Can you comment on those? I don't change it too much when I do just an isolated FCL. There's a randomized clinical trial showing that you can do partial weight bearing early on if you do just an FCL on top of the ACL. When I do a full post-lateral corner, then I keep them non-weight bearing for six weeks. I don't restrain range of motion. I'm usually very aggressive with range of motion because these people tend to get stiff, so I try to get them moving pretty early. I usually brace them until they recover quad function, and once they do, I tell them that they don't need it anymore. Charlie Brown? There's been recently a lot of emphasis on the role of the deep medial collateral ligament, and in current reconstruction, we're reconstructing the superficial medial collateral PLL, and now they're talking about adding another graft for the deep MCL. I'm just wondering if you have any experience or your thoughts about the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL. I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL. I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL. I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? I think it's a great question, Charlie, and I think we really do need to look at the role of the deep MCL? That being said, I think adding another graft, which is something that I've not done in practice, clinically at least, may be something that we need to do more and more in the future based on those studies that Andy Williams has popularized. Yeah, I think that's a good point. That's Dr. Williams' work out of London, and Jorge's point on the proximal anchor, that's my preference, too. If I'm doing a superficial MCL reconstruction, I'm putting that anchor 12 millimeters below the joint line, and then the other one 6 centimeters below the joint line, and from a biomechanical standpoint, stiffness goes down as length increases. So if you have a really long graft and you don't fix it proximally, the stiffness of your reconstruction graft is going to be lower, whereas if you have the two fixation points, the stiffness of the graft is improved. The other thing is that in Dr. LaPrade's early biomechanical studies looking at rotation, they didn't find a difference in valgus gapping or gapping the medial compartment on valgus loading, but they did find a difference in rotation, and if you didn't fix it proximally or secure it proximally, 1.2 or so centimeters below the joint line, those cadavers had increased rotation. So I think it is important to fix that. That doesn't fully reconstruct the deep MCL, to Dr. Brown's point, but that helps with the rotational stability. If you're just reconstructing the FCL and not the rest of the posterior lobe, what's your preferred technique for grafting? So I usually use a semi-tendinosis graft. I usually do the dissection first because I don't want to have fluid extravasation. I want to be able to find the nerve easily. I make all my tunnels and I leave all the passing stitches in. Then I do my ACL, usually BTB autograft, and then I go back and pass the sutures and the grafts. Just one tunnel, beam or other? One tunnel in the femur, one in the fibula, yeah. I don't know if it's a question, but I just wanted to bring up one thing that I've been thinking about is, you know, you showed that sort of cadaver demonstration video where you were internally and externally rotating the tibia, and you can see when you internally rotate the tibia how the FCL becomes lax in that image. And we also talk about this coronal FCL sign on our MRIs, and I think that if you have severe anterolateral rotatory instability and the FCL is parallel and you do a varus stress radiograph, you may see, like you said, excess varus opening. And so what I've done is I've done a little posterior drawer, externally rotate the tibia, and then repeat your stress. And if it tightens up in that case, I don't think, if the MRI shows that the FCL is dark from top to bottom, I don't think it's an FCL insufficiency in that case. If it's an acute injury, I think it may be a severe anterolateral rotatory instability. So there may be cases where we're reconstructing FCLs when, in fact, it's anterolateral rotatory instability making the FCL incompetent. Any thoughts? I fully agree with that. And that was one of my first comments in the talk. Sometimes it's very difficult to differentiate where the instability is coming from. You just know that there's some rotatory instability, but you really don't know. Most of those cases are also associated with ACL tears. So you have rotational instability from that, plus this, plus maybe a ramp or a root that may happen in 20% of the cases. So it's difficult to know. When you look at the obliquity of the anterolateral complex, the anterolateral capsule and the FCL, they're not that far off. So you can imagine that the anterolateral complex has some role in restraining varus laxity. However, there's not been, to my knowledge, biomechanical studies looking directly at sectioning the FCL versus sectioning the anterolateral complex of the knee and ACL deficiency. So I don't think we have the answer for that. You want to look at your MRI, but in chronic cases, we know that the anterolateral complex, you're not going to see much typically. And you're not going to see much with regard to the FCL on chronic cases. So you're a little bit limited there. And examination is pretty important there. I think based on timing, it's a good time to transition to Dr. Larson.

post-lateral corner

ACL graft

rotational instability

FCL injury

rehab considerations