All right, so I think we've got a little bit of time left. If anybody has any questions, you can feel free to just raise your hand or just, and any questions for any of the panelists. I have a case too that we could do, but we've got about 10 minutes, so let's want to get all the questions for sure. Go ahead. Yeah, right here in the middle. Thanks. One of the things I hear at the college I take care of from the athletic trainers is they really struggle with quad atrophy after a quad tendon harvest, and if you're a team position, you see your own patients, but people go home and get surgery in their hometowns too, so they're not all mine. They're from all over. And they sometimes have trouble getting them strong enough or really functionally ready, and sometimes it's two seasons. So can you comment, do you have anything that the technique of harvest would minimize that problem? I think our best available literature would suggest that the atrophy from quad is actually less than the atrophy you might see from the patella tendon, and I think my experience is that, actually, and not what you just alluded to. I think we've all probably seen after, you know, the patella tendon is the final common pathway of the musculature, and we've all seen profound atrophy. Perhaps it's related in some of those patients to losing terminal extension early, which is the critical pitfall. If you can regain your full extension, patella mobility, and quad activation, I think that that gets you in the right foot, and Don Shelborn's preached this for years, and so, you know, I think I've not seen that problem with the full thickness harvest. You know, I think if you do partial thickness, you may have even less concerns of that. I think repairing the quad helps. I think, you know, certainly been using early blood flow restriction, you know, as well as an adjunct to try to reduce atrophy and improve quad strength, but I'm not sure if the other panelists have any experience with BTB versus quad and the atrophy issue. You know, I've, I really haven't seen that so much. You know, I actually do less BTBs, and even now in my college players, I'm not doing BTBs exclusively based on the study that I did, and part of that study, you know, I think we talk about re-tears. I've always thought with the BTB, and Seth commented a little bit about this, they always get atrophy, and so, to me, even though they're cleared functionally at whatever, 6, 9 months all your testing, you know, they're never 100%, they're like 85, 90% do visoconnect, we do biodexon, whatever. I think some of the re-tears may be because they go back and favor that knee because of the quad atrophy, and maybe they overload their other side for that BTB contralateral tear. So, I went to quad pretty, you know, I've used it for several years, but after my study, you know, it's interesting, you do a study, and then you look at the data, and I thought, you know, anterior knee pain is everybody else's problem, you know, they're not as good a surgeon, maybe, you know, that's why they have anterior knee pain. I didn't think I had a problem with BTB, to be honest with you guys. I did it for many, many years. I'm meticulous, I bone graft the femur, the tibia and the patella, I close the periton, I do all, you know, and then, at the end of the day, those are my patients, and most statistically significant finding in my study was anterior knee pain, it was pretty high, it was there, so at that point, I had to look at the data, right, you know, I did the study, so it's me, it's not anybody else, I did the cases, so at that point, I said, I got an anterior knee pain problem in these young people, and they're 20 years old, they're having anterior knee pain, that ain't gonna go away, guys, you know, and as they get older, I think it's still an issue, so then I switched to quad, exclusively, really, from BTB, so I think there's less atrophy, that's what I would say, because I kind of agree with that, I think it's not quite as an insult, I do, like Seth, I do a full thickness graft, I close the defect, so. I don't do too much quad, I mean, I do a fair amount, but BTB is still my gold standard, I can't testify one way or another if one is better than the other in terms of the atrophy, I mean, just, I guess, anecdotally, how many in the audience are routinely using BFR now as an adjunct to their ACLs for the rehab? Yeah, so I mean, maybe, what, 20, 25%, I think that is showing a lot of promise, I mean, we're gonna have some data that's presented this year, I think, at the academy, that really shows early promise with BFR, so, you know, this is unrelated to the graft choice, obviously, but something that everybody should think about, because I've been pretty happy when my patients are getting BFR now, when I'm worried about early atrophy. I would just piggyback on that, just, as we all know, rehab is such a huge component of everything we do, but especially ACL rehab, and BFR is a big component of that, I think, in all of our practice now, and then just early post-op rehab in general, so, you know, for my ACL patients, they're getting in, we're working with therapists that I have a very good relationship, and I know you mentioned sometimes they go to other towns, and that can be harder if you don't have a direct relationship with those therapists, but they're getting in with a therapist within post-operative day 1, 2, and 3, starting that quad activation, starting short arc quad sets and stuff like that, and then the offshoot of that is I think a lot of us have gotten maybe a little bit more aggressive with some of our weight-bearing protocols, even when there's meniscal repairs and that sort of thing, again, depending on the type of repair, so, getting between the concept of getting a little bit more aggressive with weight-bearing and a little bit more aggressive with the immediate post-operative physical therapy, I think that has negated some of the previous quad deficits that maybe developed from decreased early quad activation that we used to see after ACLs. Can I ask you guys about graft tensioning and what flexion angle you tension the graft at, and does it change based on patient characteristics at all, or graft choice? So for me, for the soft tissue graft, I typically do the all-inside technique that I learned, obviously, from Pat, and so, as he exhibited and has shown in the biomechanical studies that he's done, it's in full extension or even hyperextension, and so. For both the graft and the augmentation? Oh, no, so if I'm doing a lateral extraticular tenodesis, then I tension that at 30 degrees in neutral rotation, but for the graft itself, tension at full extension, if it's an all-inside graft like that. I guess, Pat, do you tension your, you showed your sutured augmentation at full hyperextension for the patient? Is your graft tensioning at that same flexion angle, at least? And then I, after I, and again, I have to put the tape in, and then I'm full extended, I fix my tibial fixation with my buttons passed there, then I do that cycling big time, and I just, I mean, I hammer the knee, and then I re-tension again in full hyperextension, so you know, the one thing we showed in our study, which was the hamstring, the quadded semi-tenodesis that we showed, the KTs at two years were like .1 millimeters, I mean, it was not one to two, and in the literature, that was the tightest hamstring that's ever been reported by KT 1000 at two years was our data, so I think they're tighter because of the re-tensioning. I think that's a huge advantage, and so it falls right into the quad, right? So if it's a quad, I do all, just like Clay said, you know, the all-inside with a quad soft tissue, do the same thing, but I think that re-tensioning is really huge for these tighter grafts. I guess for me, I wonder, because I do, when I use, you know, sutured tape augmentation, I'll do that in full hyperextension, but maybe tension the graft at zero or even five degrees of flexion, you know, and then cycle and re-tension, so that graft, again, is independently, you know, at time zero than your internal weight. I don't know if it makes a difference, but it seems to me that it makes me feel better that I'm definitely at a different angle and that it's just the graft when I'm tensioning. And I think it's really key to show you if you do the tape thing. When you flex an E to 90, your tape's going to be loose. That's the biomechanics of the knee. If you fix it in full extension or, you know, neutral, if they have it, or hyper, when you flex that knee, that tape's going to be loose. So people always say, well, is it going to be too tight? I'm going to over-constrain it. It won't. The other thing is, it doesn't, you know, people ask, well, does it matter if the tape's behind it, inside of it, you know, I don't know, and I don't want to say I'd be flipping here, but I don't really care. I just, I care that it's going to be lax in flexion, so I fix it in full extension. Now the caveat for me to tell you, though, is I'm an AM bundle guy. I think, you know, the AM bundle's more isometric. So I don't put my ACL grafts down the wall. You know, it's been reported a little bit higher failure rates if you start sneaking down toward the PL attachment site. Controls rotation better, but maybe higher risk of re-tear. But using the tape, I've always thought, okay, I should be in the most isometric position. So I'm AM on the femur, AM on the tibia with my graft placement with the tape. So I feel like, okay, at least I'm hopefully relatively isometric where I put my graft and then the tape's kind of in that same alignment as it would be, but I don't, I don't put my grafts down the wall. Mike, how do you decide whether you do the ALL or you do a tinnitus system kind of thing? Well, you want my real answer or my, I'm pretending to be smart answer? Real answer? Well, I teach a lot of residents and fellows. So sometimes before the cases, I'll be like, hey guys, you want to do an ALL or you want to do an IT band? Because they both work. If you do it right, they both work. If you had to ask me which one I prefer, probably the LET. And I base that on absolutely no scientific evidence whatsoever. I just, I like it. It works well. But if you do an ALL reconstruction well, you can see your anatomy. You're not just doing it percutaneously and hoping you're in the right spot. It's a great surgery. My understanding with that is that you have to be more precise with the anterolateral ligament reconstruction, especially if you're going above the LCL and if you're trying to do this percutaneous. And so I'd advise you just to be very aware of that, that isometry or anisometry matters and you can cause harm if you put it in the wrong place. So I think it's more forgiving with an LET. If you identify the LCL and you go under it, your posterior and proximal, you can frankly tension that at a low Newton strength, at any theoretic flexion angle and not over-constrained. Whereas with the ALL, I'm pretty sure that you need to be meticulous with your flexion angle that you're tensioning it. First few ALLs I did in my practice, I tried the percutaneous technique. It wasn't great. You know, I'm a much better surgeon when I can see what I'm doing and when I have a full understanding of the anatomy. So I mean, although it's nice to tell patients we can do this with a tiny little incision, it's going to look great, yada yada, I mean, looks can be deceiving. So use anatomy. I think one thing about the ALL that I would say is that, at least from a biomechanical standpoint, the LET is more isometric and it is, you can be tight in flexion. You know, the way I do the ALL is, a couple of things that I do, Mike and I agree with you about making incision, everything that can help you is using floral because, you know, I think it's really important you're in the right place in the femur, posterior and proximal. So I use actually floral in the operating room. And my landmark is the lateral gastroc tubercle where the gastrocnemius comes in. That's where I strive to go. And even though you can feel it, there can be variability. So I do check floral, but I actually put in a non-isometric graft. I want my graft to lengthen in extension, be in posterior and proximal, the epicondyle. So my ALL is going to lengthen two millimeters or so. I fix it in neutral rotation at full extension because it's a check crane, as Mike said. But the advantage of that technique is it's loose in flexion, so that, relatively loose, so that you keep your internal rotation when your knees flex. If you put your knee at 90 degrees and you feel your tibia, there's some internal rotation that happens there. Which, if you do an LAT, a modified femur, you may be, you will be tighter in flexion. So I think that's something to consider. That may be one advantage of the ALL. That was about as tame as an honest answer from Mike Galea ever gets. We have one more question, I think, and then that may be about it. Go ahead. For Dr. Smith, the research that you did on the augmentation and the animal research, the biomechanical research, is very thorough. Why do you think you're not having, or we're not having the same problems as we do with other artificial brain? It's like horrendous results with the dortex and other things like that. Right. I think because it's small, it's two millimeter tape. You know, it's two millimeters wide, half a millimeter thick. You know, it's been around the shoulder forever. It's been, obviously, you know, people have retorned rotator cuffs with the tape in and people aren't reporting problems with synovitis or such. I don't know, it's weird. It wasn't made for this. You know, it's just kind of like it just hits the sweet spot, but I think because it's got that give to it, I think the tape's got the give to it. The other thing that happens that I don't think you can over constrain it, so when I've seen that failure that I talked about, the tape's loose, or even the one I showed you where the tape is loose, what's happening, where's the tape loosening? The tape loosens from the anchor in the tibia. So, you know, I use a swivel lock anchor is what I use. So, when there's a super high load and the ACL may re-tear, the tape just gives distally. You know, it just, that's where I think it comes to the tibial fixation loosens. So, but again, I just think because it's just somehow kind of a biologic suture, basically. So, and remember also, meniscal repair devices, it's the same suture we've used in meniscal repair for years. That fiber tape is the same polyethylene suture as fiber wire, so it's just made differently to get that weave to it. So, I just think it's a very safe suture and it's small and, you know, again, if it protects the grafts and, you know, for me that's important. I mean, you know, my re-tear, it's not that high normally, but I'd like it to be zero. So, that's kind of where we're heading and looking at. It seems like it does make a difference, but it's just lucky that it works that way. But it's totally different than the LED and certainly the large, you know, because that's polyethylene PET and that's some nasty stuff you don't want on your knee. But I think this has been shown to be good. So, but I did just what you said. You know, that's why I can talk to my patients. I say, listen, I've studied this. Yes, I worried about it. So, we did all the studies to get to that point and now I put it in every ACL I do today. I guess I've had the lucky opportunity to revise other people's primary ACL repairs where they put a fair amount of fiber wire and fiber tape in there. And I've never seen excessive synovitis in there at all. I mean, I don't know why it is. But, I mean, when you get the opportunity to go in on a second look and you just see suture, you don't see reactive tissue, you just see suture. I don't know what it is, but it's not causing that. In the interest of everybody's time and other stuff, I think that we'll end it there. Thank you all for attending. They asked us to remind you to please fill out the survey. It helps the planning committee know what topics they should have available for next year, too. Thank you all.

ACL surgeries

rehab

quad atrophy

quad tendon harvest

athletic trainers