I'm from New York, so it's always good to banter with Mike Galea, and I spent eight years at University of Missouri with Pat, and Clay was our fellow. I'm getting old. And so it's really just great to hear their thoughts. And I want to keep this lively, and hopefully some of the things that I say will spur interest and controversy, and we'll have good room for discussion at the end. So I'm going to go over current concepts in graft choice. My disclosures are in the program. I think a big disclosure for me is my heritage bias. I trained at HSS, then I went to Rush for fellowship, and so much of the literature and pretty much almost exclusively a lot of the ACLs I saw were bone, tendon, bone, and that's just what I grew up with. So I saw how it went well. I saw how you can get out of trouble a million different ways, and so got over that learning curve the hard way. And so I think a lot of surgeons around the world who do predominantly hamstring, they have trouble when it's their elite athlete, they choose to do a BTB, and they haven't done one in a while. And so hopefully we can talk about tips and tricks in that regard. But for disclosure as well, here's my current practice makeup. So this is ever evolving. And so you can see here, you know, really 50% quad now, 40% BTB, about 9% allograft, and we'll talk about that. And maybe to Pat's dismay, or just for controversy's sake, I don't do a lot of hamstrings. And we'll talk about why or why not. And that doesn't mean they're a bad graft choice. They're an outstanding graft choice and a very popular one, and a very effective one. So that's just where I stand right now. Surgeons obviously, you all, we all have strong preferences. We just got this published in Gysicos. This is ACL study group, so international high volume surgeons. And you can see when it comes to primary ACL surgery around the world, it's about 50% hamstrings, and then the rest are BTB and some quad is coming into the mix. When it came to revision, that's where a lot of the world surgeons start thinking about the patella tendon and utilizing quad more effectively. In America, we can see when we're talking about those young athletes, we're talking about NFL, NCAA team doctors, and the Moon Group, there was a BTB preponderance. But when you get to the recreational athletes, those older athletes, that really switches over towards more of a hamstring group. Here's just looking at one slice trends in Scandinavia. You can see a tremendous amount of hamstring preponderance there. So we kind of take a step back in a 10,000 foot view as we wrestle with this every day in our practices. What's the ideal graft? Well, obviously, we want it to be low morbidity and very easy to use. We want to have favorable biology, optimal neuromuscular return, low re-rupture rates. And so that really doesn't exist if you want to check every single box. Graft biology, we're talking about several things. One is healing at the insertion. So we all know bone to bone healing, healing like a fracture, fast healing. We've talked about that for years with patella tendon. We think about soft tissue to bone healing. Dr. Rodio and others have showed us that this heals differently. This may take longer. Pat and others did have a nice histological study talking about the potted plant and the histology there. So hopefully with all inside techniques and smaller sockets, we've normalized kind of some of those differences in graft biology, but we still need to understand and think about them as we choose our grafts. And so if you're going for fast aperture healing, you're really thinking about BTB and quad with bone. I do quad without bone, but I think if you're trying to go fast on the aperture, that makes sense. And I think this is an avenue for great opportunity for potentially augmenting with biologics. Which ones? I don't know right now, and we need to study it more carefully. But if we can get the aperture to heal and the graft to heal to bone, I think that would be an outstanding thing going forward. Similarly, we're talking about ligamentization. We all know the basic science behind this process. But when we look at it, all of these graft choices take quite a long time. Allograft takes an even longer time. So again, I think this is a wonderful and ripe opportunity for us all to dial in and consider what and how, what ways we might be able to use biologics effectively. Adam Anz gave us a series of great talks with some basic science and clinical work to try to move in the right direction of ligamentization, because I think that when we're talking about accelerating return to sport, we're getting pretty good on a lot of the other aspects. But when we look at some of these grafts on MRI and you look at them serially, we still have some issues there. What about harvest morbidity? I think BTB loses there. Obviously allograft takes the cake. There's no harvest morbidity, so that's a check for allograft. Early functional return, again, an allograft would win, as we don't rob Peter to pay Paul. We start scratching our head there, but then you look at the re-rupture rates, and that's where it's completely discriminatory against allograft, and much in favor of the autografts, particularly for our youngest athletes, where it counts the most. Obviously at this point, I think we're all cautioning against allograft for primary ACL reconstruction in the young athlete, adolescence, failure rates upwards of 30% versus 11%, the moon group, young age, and allografts, risk factors for subsequent surgery. The MARS data for revision ACL, this did effectively change my practice. Autograft was better than allograft, and so you may consider what autograft choices you have, and I think the quads become a very useful and effective choice for myself and others in the revision setting, even after a BTB that's failed on the ipsilateral side, but we can talk about that. This study showed improved sports function, patient-reported outcomes, decreased risk of re-rupture, no differences between BTB autograft and a soft tissue autograft in this study too, so it doesn't have to be BTB, but I think if you have the opportunity to give the patient's own tissue in a revision setting, I would encourage you to do it. Here's my overview, 22-year-old revision ACL, I'm going autograft and trying to steer clear of allograft, and I think it's relatively dealer's choice amongst those options there. Again, I would not throw allograft out completely. I think as you saw in my own personal practice, I use it selectively. In older patients, recreational athletes can have that discussion. I think now that I have quad in my armamentarium, and others who use hamstrings effectively, for that older athlete, the pain level is less than a BTB, and the rehab's a bit easier, and so I think you can have that discussion, autograft versus allograft, in the 30-, 40-, 50-year-old. I don't think it's an age now that I live in California, everyone, they're 60 and as active as a 20-year-old, so I think it really needs to be physiologic, and that discussion. But here, it's essentially dealer's choice, probably a little less BTB. I find it very hard to use a BTB as we get to my age. I think that the pain levels and the intensity of the early rehab may not be worth it. 17-year-old female soccer athlete. This is where I think the anterior chain BTB and quad rise to the top, at least traditionally. If we look at some of the data that's been presented at this meeting, and other meetings, we see that ipsilateral rupture rate, and it's different. It's higher for hamstring, 17 versus 3%. And so if you're going just based on that, then I think that BTB, or as I'll show you, quad, would potentially win. Again, hamstrings failing at a higher rate than BTB in several different studies presented by different authors. Granted, these are not all the highest level of randomized controlled studies. Some of these are cohorts, case series. But nonetheless, that's a preponderance of our data. But I think we also need to respect that and take a step back, and not generalize those results. This is a study that came out of the Mayo Clinic, our friend Aaron Kritsch, looking at the rupture rates of BTB versus hamstrings. And this is a meta-analysis of RCTs, prospective cohorts, and registries. And the bottom line is that the number needed to treat to see these differences is extremely high, and that the differences in those rupture rates across the board are extremely low. So we temper that statement somewhat. And then, obviously, as we, Al Getgood's also at this meeting, and Michael, I'm sure, talked about this in his section. If you have a high-risk athlete and you do hamstrings, do your best graft choice, but consider protecting it with a lateral extra-articular tenodesis or an anterolateral ligament, whichever is your preference. And in the stability study, over 600 patients, they actually showed reduced graft rupture and reduced risk of rotatory laxity in that scenario. So I think there's ways to get around that concern, that hamstrings might have a higher failure rate. And then this is the study that Clay alluded to. This is Pat's study. So this is a single, expert, high-volume surgeon doing all-inside technique with a quadrupled semi-T. Not sure if it was protected with suture augmentation. He can comment on that when he comes up. But no difference. So if you have that technique and you compare that to your own gold standard, then I think it's a very reasonable graft choice to use. But I think if we're talking all of us and you have the 16-year-old male, he's a sprinter, hurdler, I do worry about taking the hamstrings. And so I'm going to go to BTB or quad. And similarly, same kind of patient with an MCL injury, the hamstrings are a dynamic stabilizer. And so if I have other reasonable graft choices, I'm not quick to take the hamstrings in that scenario either. A male wrestler, I worry about, obviously, the kneeling and the kneeling pain. And so I think any of the autograft choices, but maybe quad comes into the mix for me. Just giving you a flavor of where my head's at based on the best literature. I think also of neuromuscular patterns. I think a lot about the anterior versus posterior chain in the endgame. We want the hamstring to quad ratio to be favorable. If you're able to get your athlete to land broad-based inflection, probably doesn't matter what graft choice, you're not going to re-tear. They protect their ACL with their musculature. And so again, if you have these quad-dominant athletes, they land stiff, they land awkward, their trunk position, their hip, their core, they basically are an ACL tear waiting to happen. And I think that taking from that overpowering anterior chain, as long as you can get that quad back to 80-90% and get that ratio the way that you want it, the hamstring quad ratio at the end, I think that you can do some good there. And I wonder, is it that the BTBs get back better and so they give themselves more opportunities to get hurt again, and that's why the contralateral rate is higher? Or is it because these were quad-dominant athletes, and so on the ipsilateral side, we have normalized that HQ ratio, maybe we didn't pay as much attention to their dominant strategy on their other leg, and when they go back, they do the same thing. And so, you know, it's clearly a problem. The contralateral issue with BTB is real, and I think it's real different than with the hamstring graft. Nonetheless, I still think BTB is our gold standard, and I think we present it to our elite athletes that way. And for my contact collision football athletes, for our men and women's basketball athletes, I think it's the first graft choice we're really talking about in our clinics. There's good, bad, and ugly with BTBs, so it's an imperfect operation, and some of those complications, like fracture, can be catastrophic. But also scarring, and patella baja, and kneeling pain, and risk of arthritis, and the like. So I think there's a lot to think about. Here's just my one thought on BTB that's evolved or changed for me. Using suspensory fixation on the femur. For me, there's several different benefits here. I have a press fit at the aperture, which is nice, especially if you have a higher risk patient that may fail and that you need to come back. You have no hardware. You basically have a clean pallet at the aperture, and I think that that's excellent. And the way I do is intermedial portal reaming. Once I get that BTB plug in, I can pull that graft as hard as I want to, and it's not coming out of that socket, which is very different than a previous trans-tibial. And so the suspensory fixation is there, and obviously it's important to have fixation, but I think that press fit and that initial fixation is also very comforting. I can accommodate for graft mismatch, which is definitely a concern of all of ours, particularly with some of our larger athletes. If I have a socket or a tunnel that's a bit longer, I can just use the suspensory, and I can dial up another 5 millimeters, 8 millimeters, whatever I need to do, essentially converting it from aperture to kind of like a two-incision style without having to do anything open. It's really just pulling on the pulleys, and so I think that that's quite beneficial. And then lastly, I've found that once I provisionally fix the femur, I put my screw in on the tibial side, I can cycle and re-tension, and I think that the grafts at time zero, which may or may not be important, feel stronger to me, or at least I have the opportunity to change and reduce that initial creep or that initial laxity, whereas if I did screw and screw, I had no opportunity to do that. And so for those reasons, I was able to make that change on the femoral side, and I think it's been beneficial. We submitted an abstract looking at, I think, 50 of screw and screw and 50 of this technique, and there was no difference at all in any of the early or mid-range complications or stability rates, and so hopefully you'll see that coming out at one of the meetings in the near future. We wrote this on mismatch because it was something that scared me, and I think scares a lot of us. Have a plan. Have that plan way before your surgical case, and then I think it'll be less scary. We can talk about tips and tricks in a discussion, hopefully, about how to handle mismatch. I consider other options in the young athlete now. If you have patella alta, like you see in this patient, that's a very long patella tendon length that's going to be 60 or above, that's going to be a concern for mismatch, and so you might want to do something different. If you have patients, this is an extreme example, but issues with the patella tendon from prior childhood ailments, calcifications, previous surgery, et cetera, then I think you might be steered in a different direction. Kneeling sports, I think it's important to consider other options, and open apophysis is also a challenging one to consider, a bone tendon bone in certain circumstances. Patients with poor pain tolerance, I'm also a bit concerned. Are they able to handle that early rehabilitation? And so that obviously leads us to what Dr. X called in this infographic, the graft of the future. I would argue, and you'll probably see at this meeting, that this is the graft of the present for a lot of us. And when you look at the data that is coming out on the quad versus the BTB versus hamstrings, so far, so good. Significantly less harvest pain compared with patella tendon, that's an obvious concern that we've talked about. Better functional outcome scores compared with hamstring, so that's at least equivalent or better, and similar graft survival. I think that with any, I guess quads been done by several, like Walter Sheldon, like John Fulkerson, for decades, so I wouldn't call it quote unquote new, it's time tested. But for the vast majority of us who are in our relative learning curve of incorporating quad into our practices, I think we need to pay careful attention to our own results, we need to pay careful attention to the literature, we need to see where it fits in our armamentarium. So this is kind of what the quad harvest at least can look like. This was early in my learning curve of a newer harvester, and so my incision, which has now gotten back down to comfortably three centimeters, I still do vertical incision, because I'm mostly a salvage revision knee joint preservation surgeon, and I have no pretense that someone or maybe me are not going to be back there at some point, and so I like to be able to just extend my longitudinal incisions, but that's just seeing a lot of horizontal incisions that are long and that have led to some issues down the road. But nonetheless, this can get down to a three centimeter or smaller incision, typically at the top of the patella. I always ready my back table before I go, I use tourniquet for harvest only, and then do not typically use it for the rest of my case. Fortunate for you, because this was an early learning curve on a new technique, we were able to have a slightly larger incision than typical. In that step, it's hard to go back, but let me see if I can. Can you play that video one more time if possible? If not, it's all right. At any rate, the first thing I do, so I'll just use a double blade, and I start from distal to proximal, and I want to pop just under, so I want to get either partial or full thickness on the quad, and I pop under the paratena, and I like to preserve that paratena layer if I can. And then basically I'll use a 10 blade and just peel the soft tissue of the quad off of the bone and whip stitch it, which is quite easy to do. And then once you have distal control, then you can use a device such as this that can slide easily over the distal quadriceps tendon, and then we can talk about whether it's better to kind of go 180 degree back and forth or full rotations, but nonetheless, this will give you the diameter quad that you'd like, 9, 10, or 11, based on patient size and surgeon preference. So typically, as Clay said, we're getting upwards of 70 millimeters length. I think you don't have to preserve that paratena layer, but I think it's an added bonus for me, and it's not terribly difficult to do. And then you can see here where we have taken the quad graft out the side of the cutter and then just basically kind of cigar cut the end, and you'll see delivery of, for me, it's a full thickness graft, and it's a large bore diameter, predictable diameter, and a predictable length. And so I'm fortunate to have a PA who helps me to prepare this graft and others on the back table, because time for prep in your learning curve is also a concern. I think you might be able to do BTPs a lot faster. So another thing to think about in your own practices, here's just showing that paratenon that is preserved, and then I run a zero-vicryl. Others with smaller incisions can use arthroscopic equipment to pass sutures or tape or whatever your preference is to close that defect, and even others leave that defect open. I tend to do full thickness, not partial, and so I'll close that defect. I will not close the skin. I'll just put a Raytec in the wound so that if I have a little bit of fluid extravasation, that's not a bad thing, and then I close it at the end of the surgery. So for me, that technique works. I think in the five or six years I've done the quad, I've had to stop my surgery once and put in one extra whip stitch, zero-vicryl sutures. So it's really not been a concern, but I know that people talk about it. And then here, you see pretensioning after preparation on the back table. I'm now soaking all of these grafts in vancomycin. We've published a couple of papers now, basic science, and some clinical summaries that you can read this year out of Stanford, kind of highlighting the relative benefits of that, and pretensioning, I think, is important. So my final thoughts, BTB remains that gold standard for elite athletes, but the quad is a very promising alternative, and in my discussions with patients, this has become sort of a dealer's choice. And so I'm interested to hear my co-panelists' thoughts. Know when hamstrings may have a higher risk of failure, and protect it, either adding a lateral tenodesis or doing a technique such as the one that Pat described, which has great outcomes in his hands. Sparing use of non-irradiated allograft in the older patient. We say older, but these are still the active older patients. These are not the ones that can do well without ACL reconstruction. And then in individualized surgery, we need to be patient-specific, assess every single risk factor. So that means tibial slope, that means meniscus status, that means coronal alignment, that means hyperlaxity, age, gender, you name it. We need to think about every one of them, and then match the graft choice and match your other surgical techniques to that. And obviously, for that task, which is a tall one, we need multiple tools in our arsenal. Thank you very much for your attention, and look forward to our other speakers and to some discussion.

ACL reconstruction surgery

graft choices

bone-tendon-bone grafts

hamstring grafts

quad tendon grafts

graft biology