I've most recently been in practice in San Antonio, Texas for a number of years and then just recently moved back to the University of Missouri as faculty and to help Pat take care of Mizzou athletics. So we're gonna jump right in. We got a number of topics to cover today. I'm gonna be starting out with all inside ACL reconstruction and then we'll go down the line. We're gonna save hopefully enough time for a question and answer session at the end and then we've got a couple of case presentations as well if we have enough time. So my disclosures are listed online. So we'll start with a brief background. As most people know, there's upwards of 300,000 ACL injuries annually in the United States. The gold standard has typically been a patellar tendon, bone tendon, bone reconstruction. The advantages of that are many. It's a reliable graft tendon. You get bone to bone healing, but there's some disadvantages that go with a BTP as well. There's minimal thickness. The patellar tendon is more of a ribbon as opposed to a tubular or circular type of graft. In some cases, for some people, it can be non-anatomic placement or can be difficult to place the graft. And the graft tunnel, you can have complications and or donor site morbidity and then you can have implant complications as well depending on what kind of implants you're using. And the most often cited one in the literature with BTP is post-operative anterior knee pain. So what are the advantages of an all-on-side technique? Appropriate graft placement with anatomic landmarks and anatomic reconstruction in tunnels. You get better footprint coverage in some cases. And then you can also get appropriate tensioning with the graft. The surgeon controls the bone graft interface, which is kind of nice because you really put it exactly where you want to and you can create bone sockets instead of full complete tunnels. And it's a potted plant type of concept where you create bone sockets as opposed to coming all the way out all the way to the femoral or tibial cortex, which often results in less morbidity and in many cases, less post-operative pain. You get a line-to-line socket graft fit. And then you can really kind of control the amount of graft that you put into the socket and get that solid bone tissue tendon interface. And so it's also minimally invasive, which means less post-operative pain and swelling. And then that ideally then results in improved and immediate post-operative physical therapy capabilities. You get improved cosmesis. So you can see these minimally small incisions can be done with this all-on-side technique. There's minimal hardware, no screws. So theoretically you have minimal cyst formation. What about the disadvantages? It's always important to point out some of the disadvantages. It is somewhat technical. So you use independent drill guides, independent drilling. That means that that requires intraoperative evaluation and appropriate graft prep for the length of your graft and appropriate preparation and planning for your tunnels and your socket length, including the depth and the diameter. And it may require conversion to a full tunnel if you don't preoperatively template or intraoperatively template and you don't have enough room and enough depth. But in my experience, that's never happened as long as you're preoperatively planned appropriately. Typically, you can use an all-soft-tissue graft. You can use cortical suspensory fixation now with the bone tendon bone graft as well. But typically the all-on-side technique is done with an all-soft-tissue graft of choice. This is a study we did looking at the dimensions of the ideal socket depth based on male and female sex and looking at the intraarticular distance and then the average socket depths on both the femoral and tibial side. So the development of the all-on-side technique has started many years ago, and it started initially with stemming off of a trans-tibial technique, as you see here, and then trying to develop more of a socket, sockets as opposed to full tibial and femoral tunnels. Then you see this developing an outside-in kind of retrocutting guide and device. Again, the idea being to create more of those sockets as opposed to full tibial tunnels and full femoral tunnels. So how about some of the clinical outcomes? So this is a clinical and functional outcome study of the all-on-side technique. There was 92 patients doing an anatomic ACL reconstruction, and they showed significant improvements in IKDC, lysome, VAS, and Tegner scores, so all the patient-reported outcomes. The mean side-to-side KT2000 difference was 1.7 millimeters, which is pretty good. So their conclusions were that an anatomic ACL reconstruction with the all-on-side technique led to improved functional outcomes, and there was no differences in stability between the ACLs reconstructed and the contralateral ACLs that had final follow-up. More clinical outcomes. So this is a randomized control trial of all-on-side technique, and their methods showed 148 patients at a minimum of two-year follow-up, 76 all-on-side, 74 with a full tibial tunnel. The results showed no differences, again, in clinical outcomes, no differences in patient-reported outcomes, no differences to the femoral tibial socket, and no femoral widening. And their one primary statistically significant difference was lower VAS pain scores with the all-on-side technique at post-operative days one, seven, and then 1.5 weeks. Continuing on with the theme here, this is cortical button versus aperture interference screw fixation for ACL reconstruction. Another randomized control trial, two-year follow-up, 32 patients in each group. Again, you're seeing a theme, no difference in anterior-posterior knee laxity based on KT1000 testing, no difference in functional outcome scores. So this one was a systematic review, so getting a little bit more patient data and more patients, so it's 526 patients, 13 studies. The minimum clinically important difference was reached for IKDC and lysome at both 12 and 24 months. Important to note kind of complications, and so overall, a pretty minimal complication profile for a large systematic review. There was graph re-rupture in about 2.5%, which is pretty well in line with the literature, and there was loss of extension in about 1% of patients. So their conclusions were that this technique is minimally invasive with low graph failure rates and strong short-term patient-reported outcome measures. So here's another study, again, looking at tunnel widening in particular. So this was all hamstring autographs, and then they compared the interference screw versus suspensory fixation on the tibia, 22 patients in each group, again, two-year follow-up, and then they did CT assessment of tunnel widening at one year, and so the results showed no significant clinical differences, again, common theme, but they did have some increased tunnel widening with the bioabsorbable screw group at 2.4 millimeters versus 0.8 millimeters, and that's a commonly quoted complication or potential risk in the literature of potentially using screws as cyst formation or tunnel widening around the bioabsorbable screw. Another nice study done here. So this is one that Pat recently did, which is really a well-done study, randomized controlled trial that was recently published. And so this is prospective randomized controlled trial in young patients, so now we're talking about our athletes or our recreational athletes. So these are the ones that, this is the hard patient population, right? These are the ones that have a high risk for re-tear, high risk for re-injury. And so there was 32 patients in the all-inside hamstring group versus 32 BTB, so the gold standard, so it's really nice putting it up against the kind of what is considered the gold standard for ACL reconstruction with the BTB. And so two-year follow-up, and so that resulted in no differences at KT1000, side-to-side differences, again, really important to measure that. No differences in patient reported outcome scores, no differences, and return to sport, which again, when we're talking about our athletes is really important, obviously. And then you can see there overall, very similar in terms of the patient reported outcomes, but the one difference being that BTB patients, again, as we've known historically, had more anterior knee pain. Interestingly too, one of the interesting findings is that there were two graph re-ruptures in the all-inside group, but there were three contralateral ruptures in the BTB group, which is something that we, again, have historically seen. It's a very frequent complication or maybe not frequent, but it is a potential risk that we see sometimes in the BTB setting. So just a kind of quick brief run-through for tips and tricks for the all-inside technique. Typically, you can do a retro-cutting device, so you can drill a guide pin in and then flip that device and then retro-cut a socket. Again, like I said, not a full tibial or femoral tunnel, but the device can flip and come backwards and cut your socket to whatever predetermined depth and width that you selected based on your graph size. And then so then that socket precisely line-to-line matches the depth and diameter of the graph that you've created, whether you're using an allograft or an autograft, whether you're using a hamstring quadruple tendon or quintuple tendon, whether you're using a quad tendon, whatever it is, you create the size of the graph and then you create the size of the sockets and match that line-to-line. And so then you ream that socket, like I said, to that predetermined depth. The graph prep, again, as I stated, can be your standard harvest of choice. You can utilize either a bone plug if you want to on one side or, in many cases, an all-soft-tissue graft. And then you can utilize cortical suspensory fixation if you prefer to utilize that technique on both the femur and the tibia. Some people will do it just on the femur, and most people will do it both on the femur and the tibia. The graph dimensions are typically about 60 to 70 millimeters in length and anywhere from eight to 11 millimeters in diameter, again, tailored to your specific patient and their size and needs for the overall graft size. So this is an example taking a hamstring on the top right. This is taking a quad tendon on the bottom left. That's an example of, you can see, a pretty regular or average size quadriceps tendon graft, about 66 or so millimeters in length. And then you can see there's the incisions and here's the graft going in. That particular one is also the quad graft. Graft passage, so passing sutures are passed through the intercontinental notch first, and then the cortical button is passed through and out the femur. You can actually visualize this from the intermedial portal. You can visualize the button going out the femur and then flip it on the cortex, and then you can pull the graft in the femoral socket sequentially, and then the suspensory fixation, cortical fixation, sits very nicely with the graft well-seated in the socket. And then on the tibial side, similar process, you can utilize passing sutures all the way from outside in and pull the graft down into the tibial socket. Sutures are then brought in from the medial portal down into the socket, and then you can either utilize an adjustable loop suture and pass the graft into the tibial socket all at once, or you can utilize a fixed button and pass the button down through the socket as well. So as we mentioned, this cortical suspensory fixation is the most commonly used. As I stated before, you can utilize a variety of different fixation devices. This particular one is a removable one that you can add to your adjustable loop device, and you can add that either, this particular one outside the knee, as you see here. The key with cortical suspensory fixation is that that button needs to be adjacent to the cortex. That's the entire construct structure, and so you have to make sure both the femoral and tibial side, if that's the technique you're using, that it is perfectly adjacent to the cortex. You can utilize X-ray intraoperatively quickly. Sometimes you can even utilize a small linear fluoro if you'd like to to confirm your cortical opposition. So this is a study that we did just looking at that. We looked at 100 all-inside ACL patients. 60 of them used intraoperative fluoro to confirm cortical button placement. 40 of them just utilized the intramedial viewing and watching the button pass through from intraarticularly alone. The ones that utilized the intraoperative quick fluoro spot, we had zero complications and appropriate button placement in all of them, as you can see in the picture on the right. The ones that just utilized intramedial viewing alone, four of the buttons were noted to be outside, not perfectly on the cortex. Typically what happens is they get caught on the IT band. And so we still typically utilize a quick, brief fluoro spot based on this study to confirm the cortical opposition. Many people, once you get comfortable with this technique, are comfortable with the intramedial viewing alone, but it's something that you can do very quickly and easily with minimal time. Post-op you can see, again, this is a quad incision for this particular one, but you can see minimally invasive incision, very cosmetic. Patients get excellent range of motion and able to start PT almost immediately and start moving the knee very well with minimal post-operative pain, minimal post-operative hemarthrosis as well. This is actually an MRI of an all-inside technique. It's six months. And then this is MRI at a year, and you probably wouldn't even believe that it was a reconstructed ACL if you didn't see some of the scatter from the tibial button on the bottom part there. But you can see well-heeled ACL and it looks almost like a normal ACL at a post-op one-year MRI. So in conclusion for the all-inside technique, modern devices have really simplified the technique and made it much more straightforward for us. The all-inside technique affords appropriate graft placement with an anatomic reconstruction, and you get excellent graft-to-bone apposition. And you have excellent clinical outcomes, as you can see, published in multiple studies, which are equivalent, or in some cases, even better functional outcomes to the standard full-tunnel techniques that have been described previously. It's minimally invasive, which again, as I stated, leads to improved post-operative pain, improved cosmesis. Thank you. This is my contact information. Please feel free to contact me or email me at any time. And I'll pass it off to Seth now, who's gonna talk to us about graft options in 2021.

all-inside ACL reconstruction technique

all-on-side technique

graft placement

clinical outcomes

patient experience