So we're going to transition to our next session. And I'm going to bring up one of my most favorite people in the patellofemoral world, Miho Tanaka, who comes to us from Boston. We end up hanging out a lot of the same places because we both like the patellofemoral joint. So without further ado, she's going to give us some tips and pearls about evaluating the management of this wonderful, wonderful joint, the patellofemoral joint. Thanks, Miho. Thanks, Latul. Thank you so much. And thanks to the course directors for including me in the program. And congrats on a great, great course. So I'm going to be talking about patellofemoral instability in the young athlete. I have no relevant financial disclosures. So as we know, for a first-time patellar dislocation, this can constitute about 3% of all knee injuries. And this is most common in adolescents between the ages of 14 and 18. When it comes to who needs surgery, we know that up to 16% of patients will need to undergo acute surgery for an osteochondral injury. And then another 10% to 37% will undergo surgery for recurrent instability. So the question becomes, how do we know when to operate on these patients? Well, we know that the acute operative indications include a loose body that's greater than 1 centimeter or a repairable osteochondral fracture that's displaced. And this underscores the importance of obtaining an MRI at the time of the dislocation. After a first-time patellar dislocation, if they don't undergo acute intervention and they're treated conservatively, we know from Bob Magnuson's study that a third of them will become normal, a third of them will continue to be unstable, and a third of them will fall somewhere in between. And so being able to predict who is going to end up where, I think, is really the question that we're trying to answer now. This is Shatel Parikh's study. This was a retrospective study of 250 patients, all under the ages of 18. And they found that 16% went on to have acute surgery due to an osteochondral fracture or a loose body. And then of those who were treated non-operatively, 35% recurred at a mean of one year, and the majority of them within three years. And the multivariate risk analysis showed that trochlear dysplasia and skeletal immaturity were the most common risk factors for re-dislocation. Liza Arendt's study was prospective, and they found that 42% of their patients re-dislocated after primary dislocation within two years. And again, primary risk factor in this group was skeletal immaturity, as well as the morphologic risk factors of trochlear dysplasia and patellar alta as well. So the factors that we really think about in terms of after a first-time patellar dislocation, who's going to re-dislocate and might possibly need surgery are patient-based factors, including age, skeletal maturity, and bilaterality, as well as the radiographic factors that we typically think of in terms of trochlear dysplasia, patellar alta, coronal malalignment. And so we'll talk a little bit about these. Once they go on to need surgery, I would say the MPFL reconstruction is kind of the workhorse for addressing patellar instability. We know that the anatomical considerations have been evolving. We've gone from the MPFL to talking a little bit about the MQTFL, with the fibers attaching to the quadriceps tendon, and using the term medial patellofemoral complex, which allows us to accommodate the variability in the attachment of this ligament. We know that the midpoint of this is right at the junction of the quadriceps tendon and the patella, meaning that the graft could really go on either structure. For reconstruction techniques, if you're going to do an MPFL, then there's multiple fixation options. You can use anchors, sutures, screws, buttons. As long as you avoid multiple holes in the patella, avoid large holes in the patella, and avoid penetrating the anterior cortex, as Amanda Wan has shown, that this is on the tension side and can really increase the risk of patella fracture, which is one of the most catastrophic complications that we see after this procedure. The MQTFL is a nice alternative to this. And this is fixation on the quadriceps tendon, again, at the midpoint. This can be done through a slot in the quadriceps tendon. You can loop the graft through that. Most important point here is to remember it's still at the junction of the quad tendon and the patella, so not way up on the quad, but really at that midpoint. Graft options, you can use autograft or allograft. Most studies show that they're comparable in terms of redislocation rates. Some have shown that the allograft tend to have better patient-reported outcomes afterwards. Christian Fink has shown that you can use the quadriceps tendon, leave it attached on the supermedial patella, and swing it over to attach it to the femur, which I think is a nice, elegant technique as well. So lots of different options here. And of course, double bundle options will always come up in any sports lecture. This is MinnKoker's group publishing on 27 knees in 25 patients with their technique with good outcomes and return to sports just under six months. On the femoral side, there's been a lot of discussion about this. We know that the anatomic point is really difficult to identify, and this is why many of us use radiographs intraoperatively. Schottel's point is the most commonly cited, with a line along the posterior cortical line and distal to the posterior condylar line. Corey Edgar has shown us that we have to have a perfect lateral in order to identify this point. But Andrew Amos has also shown us that it's more likely a cloud as opposed to one specific point on the femoral tunnel. So a little bit about my current technique. I do what I call a midpoint to midpoint. So even though there's a lot of fibers above and fibers below, really focusing on that junction of the quadriceps tendon and the patella. Sometimes I will do an MP and attach it to the patella where the tunnel is a little more proximal than a standard MPFL reconstruction. And sometimes I'll attach it to the quadriceps tendon. I typically do this more for revisions. I definitely do this for a small patella. I think it's a really nice technique, and I've been moving towards this more and more frequently. If I do patellar fixation, I use a single tunnel that's a little more proximal, and I direct this distally in order to maintain good bony fixation. We've described that this is about 20% down the articular surface from the superior pole. And I just do a 4, 5, or a 5 on less than 10 millimeters in length. And I do basically a modification of the docking technique that was described by Chris Ahmad and Beth Schubenstein where we pass this. The sutures are on the opposite side, and then retrieved and tied over the bony bridge. For the MQTFL, the fixation point is the same. We loop the graft through a slot in the quadriceps tendon, basically between the medial and the central third, and then loop it back to itself, suture it to itself. And I also add a stitch there to the patella to give it that same fixation point that we're looking for. On the femoral side, I think this is really important. I look at the anatomy. Of course, you always want to be posterior to the medial epicondyle, always distal to the adductor tubercle. I check this on fluoroscopy as well. One point about Schadl's point, several have described that this point is a little posterior to the posterior cortical line. I think regardless, the main point here is that if you're going to drill a tunnel, then you should put a screw behind that. You want to make sure that your pin is posterior to Schadl's point. Otherwise, the anterior margin of the tunnel is going to be a little too anterior. So I do cheat a little bit posteriorly. Once I like that, then I check the isometry of this graft and make sure that there's minimal length changes between 0 and 60 degrees. And the fixation, I actually use an expanding anchor. This way, we don't have to rotate and over-tighten the graft, and this makes it easier to adjust as well. So what do we do when there's open physes? Well, there's several physeal spraying techniques. Of course, using a small anchor, distal to the physis, is an option. And these have been reported to have good results. You do have to use fluoroscopy to make sure that you're out of the physis. I like the adductor sling, and so this is my preferred technique. The MCL sling has been described as well. All of these have been shown to have good outcomes. Regardless of the technique that you use, you should avoid errors of over-tensioning. This is one of the most common errors that we see. The ligament only develops tension when the patella is laterally displaced. So Jack Farr talks about setting the length and not really tensioning this ligament, as over-tightening can lead to arthrosis. So overall, avoiding complications with MP or MQ or MPFC reconstruction, this is performed in the setting of lateral patellar instability, not medial instability, not patellofemoral pain. It addresses only a soft tissue deficiency, which means that if they have other morphologic risk factors, such as lateralization and tuberosity, ALTA, trochlear dysplasia, these need to be addressed as well. I'll really quickly, I'll go through these other factors, try to stay on time here. So when are soft tissue procedures not enough? Well, we know that in the presence of malalignment, soft tissue procedures are not able to restore the normal kinematics. Lauren Redler's study has shown that there's altered graft function as well, increasing the risk for failure. This is Andrew Amos' study and Joanna Stephen. They basically took cadavers. They cut the MPFL. They reconstructed it, showed that the patella kinematics were recreated. But if you lateralize the tuberosity another 5 or 10 millimeters, you could never recreate the normal kinematics of the patella. So this is why we have to address this with a tibial tuberosity osteotomy. It realigns the extensor mechanism, decreases the lateralizing forces on the patella, and decreases lateralization and tilt. And we like this, because you can tailor this to a patient's anatomy. You can medialize. You can distalize in the case of ALTA. You can even anteriorize in the setting of chondrolesions. But this can't be performed in the setting of open FIC. So that's an important thing to remember for adolescents. We can talk a little bit more about technique later. Last little bit about trochleoplasty. You know, the indications for this are not that clear yet. This is not as commonly performed in the US as it is in Europe. Some studies have reported a 40% complication rate. Overall, it appears that there's low rates of recurrence, but some patients continue to have pain. So I think we need more studies on this. Absolute contraindications include open FICs and the presence of arthritis. And really, I think for many of us, this is reserved just for cases where stability cannot be achieved. There's either a displacing supratrochlear spur or a convex trochlea, and you just can't get the patilla centered. So for these first-time dislocations, if you see one, you wanna make sure that you don't miss an osteochondral fracture or a loose body. If you do see that, then you should address it and repair or reconstruct the MPFL or MPFC at the same time. If there's no acute finding, then you have to risk stratify. So again, getting the MRI is helpful for this. Consider age, bilaterality, the morphologic risk factors. And if they're high-risk, you can talk to the patients about surgery. Low-risk, conservative management is okay. And I think the education and the decision-making part is important. If you operate on them, make sure it's anatomic. Do not over-tighten the ligament. There are fissile-sparing options as well, so don't make them wait until skeletal maturity to operate on them. And make sure to address any need for concurrent procedures and use the, sorry. And if you choose to forego some of these options in the setting of skeletal immaturity, make sure you talk with the patient about this as well. Thanks very much for your attention. Thank you. Thank you. Thank you, Miho, that was fantastic. Okay, so I'm gonna introduce my senior partner, Dr. Dennis Crawford. We're gonna shift into the ACL world here. And I've gotta say that while the pendulum has been swinging, as you all know, with the graft choices in ACL, Dr. Crawford has been a sort of stalwart voice of, there's still a role for allograft, there's still a role for allograft. So we asked him to weigh in, and he had to be with family this weekend, so he sent his regrets. He wants to say hi to all of his friends here. And so I will pass those along. But we have a prerecorded talk that I think should work with the audio. I'll let that go here. Hello, my name is Dennis Crawford. I'm a professor of orthopedic surgery at Morgan Health Sciences University. I'm gonna chat with you a bit about allograft for ACL reconstruction surgery. When we consider ACL reconstruction, we have to think of our aims and the considerations for that surgery. And of course, like any medical care, we wanna first do no harm. Our goals are subsequently to restore and normalize the pre-injury level joint mechanics, of course, and then to concomitantly protect knee structures which secondarily support knee stability and ACL function. This to facilitate a return to health, fitness, and occupational activity by reducing this instability and improving functional capacity of the human and the knee. This may potentially reduce future risk of degenerative joint disease and arthritis as well. But in avoiding complications, we must think about those intraoperative, perioperative complications and the capacity to return to sports and work and the functional limitations that may result from the injury and or the surgery. And the graft choice, autogenous tissue versus allogenic tissue, is only one of the many factors that we should consider with respect to meeting our aims in these considerations. Other factors are the age of the person at the time of the injury, the age of the injury, the graft type, aside from allo or auto, where's it coming from, the intent to return to work or sports, associated injury, anatomical morphology, like the tibial slope, biological healing potential, and of course, the surgeon's experience. The spectrum of complications following ACL surgery should be considered, and unfortunately, they're fairly inconsistently reported in the literature. I've broken them down to intraoperative, like tunnel malposition, which is extraordinarily important, and unfortunately, all too commonly an issue. Hardware problems, which in the modern technology of intraosseous fixation have reduced hardware complications to a low single-digit percentage. And patella fracture, which in the case of the autograft bone patella or tendon bone, can be as high and has been reported as high as 2%, so not inconsequential. Perioperative complications like hematoma are reported more commonly in autogenous autograft hamstring, up to 3%. An infection can be seen from anywhere negligible to up to 2%. Diabetes is a risk factor. Smoking, not yet proven to be. We did a comparative study many years ago and showed that the hamstring tendon allografts or autografts and allografts have a similar rate of infection, but that rate of infection was correlated with the increased diameter of the tibial tunnel. And when we changed our tibial fixation from the washer lock to something less aggressive, our infection rate dropped significantly. Post-operative complications, most famously, are graft failure. And in allografts, that's been reported to be around 3%, up to 45%. We'll talk about that study. Autograft, similar, 3% at the low end, 8%, somewhere in that range. Stiffness and Cyclops lesions are known, but poorly defined in the literature and manipulation under anesthesia and debris mine have been reported between 0% of the time to up to 5%. Weakness and pain are common. 27% of autograft bone patellar tendon bones report one of those two perioperative complications. And autograft hamstring tendon, similarly, up to 17%, whereas allograft is not immune from those reports, but definitely a lower rate. Vascular complications, fortunately rare, typically associated with fixation, particularly those types of fixation that are bicortical, can be associated with hamstring harvest as well. DVT and PE rates are about 2% for DVT, about 0.02% for PE. There are no comparative studies suggesting that autograft surgery or allograft surgery is particularly increasing or decreasing that circumstance. Advantages to allograft use in ACL reconstruction are that you preserve the native anatomy, that you reduce the complication risk for things like fracture, weakness, and probably stiffness, and that your early recovery downtime is minimized. There's less OR time, typically, anesthesia, scar. Early physical therapy may be less urgently needed. And oftentimes, the cost can be lower because your OR time can be balanced against your graft purchase. In this recent JB Jess Open Access publication describing the various factors of healthcare costs around the ACL, the OR time was significant. And in fact, they described an average time for bone patellar tendon bone in the OR of 104 minutes, slightly higher, almost two hours for a hamstring tendon. By comparison, my primary allograft tibialis anterior takes about 52 minutes, so about an hour less. OR time at $150 a minute, the graft's about 2,400 bucks. OR time at about 9,000 an hour, do the math there. Predictable size is another advantage. Multiple grafts can be available. Is it safe? We'll talk about the considerations of graft source and how they're treated, but it seems to be. Equivalent outcomes, that's the big question. What's the rerupture rate? Is it any different than the contralateral ACL injury with return to activities? When we talk about allograft tendon as a choice for ACL reconstruction, we must recognize that this is a shared decision-making opportunities. The surgeon's equipoise in presenting options for treatment is really about the patient ultimately deciding on a graft choice when they elect surgery. The allograft can be particularly favorable for revision reconstructions, particularly when limited autograft options remain. I use this often in ACL. The single stage for tunnel widening might require a two-staged approach. So I use an Achilles with bone and can often avoid the two-staged approach by using the bone block in the larger tunnel. Primary ACL reconstructions is often an option for the low to moderate demand functional population. I don't consider it an age issue as much as a functional issue. Patients with very limited window for surgical recovery may benefit from the advantage of limited anatomical disruption of the surgery. And I favor this for patients who have pain management issues. I used to put that under the atypical settings category. Unfortunately, pain management and narcotic use abuse is a prevalent issue. Atypical setting, the associated periarticular tissue trauma, limiting autograft options can be the case, you know, after a tibial plateau fracture or a periarticular trauma care. Dysmorphic anatomy is pretty unusual, but can sometimes limit your autogenous options as well. And then the autograft's a good option there. Let's talk about outcomes. You know, the MOON group is quite famous. They study the knee injury in surgery. It's a study group. The Measurement of Orthopedic Outcomes Network founded in 93 by Spindler, Parker, Andrush, a cohort of studies, level two evidence, essentially more than 40 publications from the 19 physicians involved from seven academic centers. And famously in 2015, Kading from that group published on risk factors for subsequent ACL injury, essentially failure. And he said, the group said that there was a four times greater risk of re-terior with allograft for younger and athletic patients. And the graph to the right suggests that this risk is highest in the youngest and dwindles with age. This may not be universally applicable as the allografts in this particular cohort were not well-characterized. Other studies have looked at this and I've selected some comparative case cohorts and reports. Famously in 2005, a report in the American Journal of Sports Medicine showed a non-randomized study of bone patellar tendon bone, which was irradiated and treated with acetone solvent, the famous two-to-plus technique. 186 of 268 patients at six years were followed and a failure rate of 45% was seen with this clearly chemically harmful treatment method in comparison to the 6% of autografts. Polling, however, at the same year, suggested that soft tissue allografts were in comparison to bone patellar tendon bones. He looked at five-year outcomes of 159 patients of 219, and he showed improved early functional metrics in the allograft and no difference in outcomes at five years. A classic article from 2015, Batani looking at young military cohort that were operated on in 2002 and three, reported on 10-year results of the 99 patients randomized to either autograft hamstring or allograft posterior tib. He found a four-time risk of allograft rupture in a non-irradiated group, 8% versus 26% of those 79 patients that he evaluated 10 years later. We looked at a prospective randomized trial we reported in the knee in 2016. We took doubled allograft hamstring tendon and compared it to doubled allograft tibialis tendon and found that with low-level irradiated allowash tissue, there was no clinically significant difference between these two types of doubled allografts, and the failure rate was in the range of six to 4%. This is similar to what Malitis reported in 2017 from the massive Kaiser database. 80% of those patients were autograft, but in looking at bone patellar tendon allografts, the revision risk at two years was 4%, similar to our study, and this is in contrast to 2% for the autograft group. Now, systemic reviews at that time and since have suggested various things. If we look at Spindler Moon Group and his recommendations in 2009, he and Carey reported that short-term clinical outcomes were not significantly different between allo and otto. Tim Foster in 2010 similarly thought that graft source had minimal effect on the outcome of ACL reconstruction, and Lambine, in a review of 32 years of reports, showed no difference between non-irradiated allograft and autograft over that time. However, a report from the Moon Group in Sports Health in 2015, looking at seven studies in patients of younger age specifically, showed that a 3.5 higher rate of failure with the allograft. They looked at 788 autografts and pooled failure prevalence of almost 10% with allografts, 228 with the prevalence of 25%. However, in the two of those seven studies that assessed autograft versus non-irradiated allograft, no statistically significant difference in graft failure for non-irradiated grafts. Well, you know, meta-analysis pooled all this information, and, you know, I've got a number of these studies in micro font here, and I think fundamentally there are multiple findings. The red highlighted text suggests that autologous grafts have a lower rate of re-rupture, where the green text suggests the findings were that there was no statistically significant risk with regard to failure risk in the allograft group. And as you can tell, across these 11 meta-analysis, there's a mix of findings. Well, how do we explain that? Clinical heterogeneity may be the confounding variable which prejudices modern ACL allograft application. Clinical heterogeneity is the difference in participant characteristics. Examples are age, baseline disease severity, ethnicity, comorbidities, the types or timing of outcome measurements, and the interventional characteristics. Example, the dose or frequency of dose or the training of the surgeons. Well, for ACLs, that can include fixation methods, anatomic diversity, types of sports participation, which aren't always captured in these well-intended studies. And historical studies don't necessarily capture the spectrum of complications, as we pointed out, or the current modern approach. Rick Wright said it very well. The data is plentiful, but ultimately confusing due to poor control of a variety of factors in even well-intentioned studies. I think anyone here will probably think that an allograft has a little bit higher chance of failure, but that is not the only outcome to consider. These are the options for ACL reconstruction. It can be broken down into two broad categories, the soft tissue allografts, including hamstring, the tibialis, peroneal tendons, and fascia latae. Then there are the bone-associated allografts, including patellar tendon, quadriceps, and tendoachilles. And these graphs have some unique risk factors and considerations. Please refer to that talk on the online materials. We're going a little long, so in the interest of time, we're gonna move forward and we're gonna invite Volker Muschall to talk about patellar tendon, the old gold standard. Thanks for the invitation to be here. So I'm gonna go different on you. I will not give you any literature. You can ask me all this, but I'm just gonna do video and show you some stuff. Is that better? I hope. So just a quick little words for intro. So why is BTB the gold standard? And by the way, this is only in the US. Hopefully you all know this. You go in any country, it's which tendon? Hamstring, anywhere, everywhere. Can't kneel in Asia and be on your patella that at least is what the mantra is. I'm sure you can, but hold on, this is going too fast. So anyway, BTB is the gold standard. Reduce side to side knee laxity. Decrease incidence of tunnel widening. Now, tunnel widening, there's no clinical correlation, but we do so many revisions, you hate tunnel widening. So a BTB revision that's in an anatomic spot is so easy to do. So this is important. And then faster return to sport rate. So I'm gonna show you just one case, okay? So this is a 30-year-old who failed the ACL four times. They had allograft, they had hamstring, and then more allograft, and presented with medial knee pain, and you see the IKDC really poor positive pivot shift. And this is what the MRI looks like. So everything is busted. And BTB is so good, we wanna go contralateral. In this case, we went contralateral because his quadriceps through all of this has been so weak that we didn't wanna go at the ipsilateral. And I don't go contralateral a lot. But so very important here is to clear up the peritoneum because you should close that at the end. And that will also help reduce anterior knee pain. And then you either use a double 10 blade, or you use your eyes and just go parallel, and follow the cue angle. So very important, if they have a high cue angle, you should go and follow that. I like to use a saw with a little button on it so you don't go deeper than 10 millimeters. I start with the tubercle, not everyone does, but I like to lift that off first so I have free range at the patella, which is much more important because there is a fracture risk. And as hard as we just hammered into the tubercle, you'll never do that on the patella, so don't do that. But we can lift up, thanks for the laughs, very good. We can lift up and kind of look under and right and left and medial and lateral on the patella. I take a bone block that's a little bit smaller than 20 because the notch is never bigger than 20. Why would you want to put a big bone block in there and put a truck in a tiny little parallel parking spot? And then triangulated bone blocks. And then on the back table, if you did it well, you don't need to trim off any bone there. And very important, I always tell the fellows, just go a little smaller. If you have a 10 graft and a nine tunnel, so what's the big deal? Anyone? Exactly, no big deal. If you do 11 or 12, huge deal because your fracture risk, if the patella is a patella parva, and you didn't do a CT scan before, did you? So you have a small patella, but you have no idea that it is a small patella. You take a 12 graft, you're in big trouble. So I use this continuous loop button, but you can use a screw or whatever you like. The reason I use suspensory fixation, although Pittsburgh is the place where we were set with Ishibashi in 97, you have to do aperture fixation and use interference screws. The reason we use the suspensory is you can actually be completely independent in your tunnel drilling and don't be worried that you may have a posterior breakout. Who cares about that breakout? Only if you use a screw, you must not have a breakout. So anyway, here's his notch with old graft, lots of osteophytes, overgrown notchplasty. Don't do notchplasty, it's just not necessary. Just put the portals in the right place. I take a lot of time with the RF probe to really clean up the entire notch so I can see where the old tunnel is, the new tunnel should go. And so, admittingly, this is maybe a little bit low. This is the correct posterior position, but maybe I would like to go a little higher towards the AM. But you see on the corner up there, there's the old interference screw in a two-end here, two-high position. So to cheat and do this in a single stage, I like to go a little bit lower and avoid that, what people call semi-anatomic tunnel. And we use a flexible reamer system, high flexion at 120 degrees so the tunnel is long enough. And then avoid, of course, cutting the medial condyle. So we use a reamer that's only single fluted so you don't have to damage the condyle. Then we drill and ream, use a 4-5 reamer to go and breach the cortex. And you'll see in a minute that when you do this, you have a nice posterior wall. And in this case, it didn't really break into the original tunnel at all. So you can see the old screw there on the top and about a two to three millimeter posterior wall. The tibial tunnel is maybe more standard because you just go right next to the anterior root of the lateral meniscus. If you're afraid of impingement and place it to posterior, that's fine, except you're gonna make a vertical graft. The vertical graft is not only because of your femoral position, also because of a posterior tibial position, right? So we usually try to avoid that and be quite anterior. And you'll see in a minute after it's passed, there's no impingement. Passing a BTB is probably the hardest of the different graft choices because you have these bone blocks that have not so much friction. So you could lubricate them with mineral oil if you want to or round the edges so that it passes a little easier into the bone blocks and make the graft just a tiny bit smaller than a 10, maybe like a 9.8 or something like that so it can flow a little bit better. I do use C-arm. You can see in this case, the endobutton party on the side there from all these different procedures that they had. And then in extension or close to extension is where we do the tibial fixation, a little bit posterior draw, axial tension on the draw sutures. I don't set the tension to a particular parameter but use an interference screw there. So this is my summary. So it's the unofficial gold standards. I think obviously with the two bone blocks, there's no better way for you to get this to heal. But then know that the patellar tendon is pretty skinny. So it's a four millimeter tendon. So be aware of this. If you have somebody with a 20 millimeter footprint, a quad tendon may be better. Then BTB works really for everyone except of course, skelety immature. So be very careful with that. And then attention to detail will mitigate your donor site mobility. It's a true issue, but you can harvest cancellous bone from your tibial tunnel and pack that into your patellar defect and over-sew it so you can avoid that. So thank you very much. All right, great. Thank you very much. So next up, we're going to talk a little bit about the patellar defects. So this is a very common problem that we see in the patellar defects. Great, thank you very much. So next we have Robert Dewar to talk about quad tendon ACL. Thank you. So thanks for the AOSSM and the organizers for inviting me to give this talk. I went a little bit of a different direction and here to tell you why quad is the way to go. Perfect, all right. So these are my disclosures. My practice bias, I do primarily quads for pretty much most of my ACLs. I'll occasionally do a BTB for a bigger football player or if a patient requests it. I do an all self-tissue graft and an all-inside technique. So why all of the hype? So for any successful paradigm shift in orthopedics, really we need a few things. First, we need to have a positive personal experience. I think as orthopedists, we all strive to be better. I think everybody in this room is here because we are trying to get better and learn new things. We need the support of our industry partners. I love coming to the OLC and seeing all the pictures with the evolution of total hips and total knees on the wall. I think that's really cool. But a lot of innovation is driven by surgeons, but also by our partnerships with the industry, which helps us to make these paradigm shifts. I always get, of these view many notifications, there's a new quad ACL technique from a different company, I feel like, once a month. And perhaps most importantly, we need support from the data in our literature in both basic science and clinical outcomes. So why I got first interested in quad tendon ACLs? I was doing mostly hamstrings in my practice, and I always worried about getting a small graft. And we know from the Moon Group that doing a hybrid auto plus allo really isn't great for our young patients. And they always felt a little loose to me compared to my BTBs. Maybe I'm just not as good as some at doing the hamstrings, but anecdotally, I always kind of thought that. And so the issue with BTBs, I'm glad Volker showed his video there, you can see that big incision that he uses. His is actually pretty small, but I think, yeah. So a lot of these patients, they get this anterior knee pain or numbness, they have kneeling pain, and this large, ugly scar, unfortunately. So my personal experience or some of the advantages, the first one I did was in a two-time revision, had a BTB, had a hamstring, and so I got this beautiful quad graft, and I was like, wow, this is great. So I got in the lab and started learning the technique and really, really enjoyed doing that. So it's a large tendon, you can really customize the size and length of your graft. It gives options to your patients. If you can give them an option, do you want to do a quad or BTB or a hamstring? So it's good to have that in your toolbox. It's good to, you can do it, it's great for revisions. You can go to the same knee versus going to the opposite side. You can harvest with or without a bone block. If you have a widened tunnel, you can get a nice bone block there. All soft tissue for our pediatric patients with open pisces. And we can do a really nice minimally invasive harvest technique, which we'll show you in the lab tomorrow. Some of the disadvantages, I do use a lot of suture on either end, and there's not really data about that, but I worry when I'm putting these in sometimes that there's a ton of suture going into those tunnels. Sometimes we'll get a little bit in the joint too that I don't love to see. And there's a little bit of a learning curve with this harvest technique, especially the minimally invasive like I do. So what about the literature? We know from anatomic studies that we have a very predictable graft length. I use about a, I harvest about a 65 for my all inside technique. So most patients or pretty much all patients have enough length for that. In the same patients, the quad tendon is about 1.8 times thicker than the patellar tendon on average, and 88% higher intra-articular volume. And we have a thicker cross-sectional area versus the BTB, which gives us a nice fill of our tunnels. So biomechanically, we know that this has very similar properties to the native ACL. It is a little bit stiffer and a little larger, so you know, which is good and bad, which we'll get into that a little bit as well. So early clinical outcomes, there's several studies that were not large number of patients, and they included patients of all ages, but they showed less anterior knee pain, less kneeling pain, equal stability to BTB, better objective to stability than hamstring, and really no difference in failure rates versus the other two grafts. A couple of systematic reviews that are more recent that were pretty well done. Essentially, what they found is that for functional outcomes, post-op range of motion, and failure rates, quad tendon was equal to BTB, and quad tendon actually did better than BTB for morbidity, IKDC scores, and cosmesis. So I would, so Christian Fink, he looked at a large number of his quad tendons, so a very experienced single surgeon comparing his quad tendon and hamstring, and he had a much higher rate of failure with his hamstring tendon graft, and really a high rate in his high activity patients. So I'd be remiss if I didn't mention the Danish registry study that really put a damper on the quad hype train back in 2019. So they reported this much higher failure rates. You know, it was a little bit biased by the large difference in the number of patients in each group. Luckily, they went back and kind of looked at this data a little bit closer, and they said, okay, in these lower volume institutions, they were seeing a much higher revision rate. So good news, we're back on the hype train. So Dr. X, I've seen him talk a number of times about his quad ACLs. I think he's up to about 1,230 patients now with minimum two years, mean age of about 20. So he reported an overall failure rate of about 4.2%. In his younger age group, a little bit higher, 8.3%. But there's a lot of literature coming out that we're almost in the double digits for a lot of our ACL reconstructions for these high-risk patients. They reported a lower infection rate using the MOON criteria compared to hamstring grafts. So for morbidity, you don't get the numbness. You do not get patellofemoral pain like you see with the BTBs. You do get a little bit of donor site pain, though that is very, very rare. You don't see tendon ruptures. You don't see patella fractures. I guess you could take a bone block in a revision and see that risk. You do get a little bit, there is a small risk of a hematoma, but again, a little bit lower donor site pain. So will this stay in the test of time? So I think we check all of our boxes here for surgeon experience, for the industry support, and in the literature. And so I'll leave you with this. Which option would you want for your child? All right, thank you. Thank you. Thanks. Okay, great. So next up, we have a very current topic. We asked a couple of speakers to address the LET versus ALL controversy. So first up is Jocelyn Wittstein from Duke to tell you about the ALL. Jocelyn. Okay. All right, well, thanks for having me here. And I'm proud of this collaboration with the forum and AOSDM. And I'm sorry, I put my picture on there because I thought this was a prerecorded talk. So I actually first started thinking about adding anterolar ligament reconstruction to my practice after this New York Times article in 2013 when parents were asking me, well, aren't you going to reconstruct or do something, repair the ALL after this New York Times article hit like the laypeople, basically highlighting the work of Dr. Kleiss, which is more or less kind of a rediscovery or renewed interest or re-description of what was previously known, of course, to Dr. Sagoon. So here's just a brief case presentation I'll mention and then revisit at the end of this talk. But this patient was a 23-year-old former collegiate soccer player who presented to me about four years out from previous BTB, so had nice tunnel fill, as we mentioned earlier, nice for revisions, but BTB does fail because there's bone there. She plays rec soccer, had a recurrence, had a somewhat vertical graft, also some increased tibial slope, some history of patella femoral pain with a history of a BTB graft in this particular case. And so in her case, I thought she was, because of being a revision and wanting to continue to play rec soccer, plus the slope, a bit of high risk, so I treated her with revision ACL reconstruction, in this case using a quadrupled semitendinosus, and then used an allograft semi-T for an ALL reconstruction. So we'll come back to her at the end. So overview here, we'll discuss anatomy, indications, techniques, results, and then, because we have a bit of a point-counterpoint, just my take on advantages versus disadvantages as compared to lateral extra-articular tenodesis. So anatomy has been well-described in multiple studies, but in general, the femoral-sided attachment of the ALL is considered to be just proximal and posterior to lateral epicondyle, something in the range of seven millimeters. Of course, these are all averages. And then tibial insertion is between the fibular head and Gertie's tubercle, about a centimeter below the joint line. So fairly easy landmarks of how pate when you're planning your procedure. We know from biomechanical studies, as well as post-operative studies, demonstrating benefits of addition of ALL or an LET that this structure does resist anterior tibial translation, internal rotation, and then combined with the ACL helps to control the pivot shift. So these are a list of indications that many surgeons use, including scone fracture, significant generalized ligamentous laxity, high tibial slope, such as greater than 12 degrees, especially when combined with an unstable-type meniscus, like a bucket-handle medial meniscus that you really don't want to see fail in the setting of high tibial slope. Revision ACLs, when you've got someone who presents with really chronic ACL insufficiency, so their whole knee is kind of generally stretched out a little bit more than just the acute ACL. And then some surgeons will say, in general, high-risk individuals, younger pivoting athletes. That's pretty broad. I wouldn't say I don't use this as a primary procedure on all young athletes. But for me, the high tibial slope, especially combined with a bucket-handle medial meniscus, scone fracture, revision, and chronic settings are when I mostly think about using this. Different techniques have been described, including autograft or allograft, bone tunnel on the tibial side or not. So you can see in the version in the AJSM publication for 2018 depicting more of a point-to-point fixation with interference screws. I don't really know of any comparisons between these different techniques in terms of outcomes. So the way I approach this, and there were some questions earlier about how you can avoid things converging or complications of things running into each other. I do worry about this a little bit with this procedure. So I have some pearls about how to avoid that. Ask me why I have them. It's because I've once had that happen. So I use a semi-tenon and an allograft. I do like to make a small IT band split approach before placing my femoral tunnel for the ACL. I like to identify the ALL insertion or where I would like to insert it just proximal and posterior to the lateral epicondyle. Based on knowing where that is, I make my femoral tunnel for the ACL somewhat strategically, and then I want to have some divergence. I do make the femoral socket for the ALL before passing my ACL graft. Don't want to inadvertently, as I have one time, speared like a suspense rate device after having the entire ACL done. And then I will secure the femoral side past the IT band and secure it on the tibial side. So we'll go through that. So landmarks are pretty easy. Palpate the lateral epicondyle. You can plan your little split there. The insertion on the tibial side is a small percutaneous incision, again, centered between the fibular head and Gertie's tubercle, about a centimeter below the joint line. It's usually a couple centimeters away from Gertie's tubercle. Do your intra-articular ACL work. Get ready for your femoral tunnel placement on the ACL. Before placing the guide, and I like to use an outside-in guide, I will make this little split in the IT band, and then I want to identify the area where I'm planning to attach the ALL on the femoral side. So find the lateral epicondyle, and then go just slightly posterior, slightly proximal to it. And then once I've identified that point, I somewhat strategically, if I'm able to, sometimes it's hard in an ACL setting, for instance, but I want to avoid where I'd like the ALL to attach on the femur. So I then place my outside-in guide, create my femoral socket for my ACL, and then I just leave the guide in there, and it's just a little way for me to know where that thing is going, and then I place the guide pin for the femoral socket of the ALL. And you can actually look, if you want, in the joint and make sure nothing is going into that tunnel. And then I'll ream over it for my femoral socket for the ALL. I will then, oops, sorry, got ahead of myself here, essentially pass the ACL and secure it. So the ACL is done at that point, and then I will make my sort of pass deep to the IT band, find our percutaneous incision on the tibial side. That's going to be for later passage of the ALL. Secure the ALL graft on the femoral side, and then once this is secured with an interference-type screw, pass it deep to the IT band using the passing suture that we passed previously. And then this isn't a perfectly isometric graft. The ALL just isn't a perfectly isometric structure, but I do like to put the guide pin where I'm going to make my tibial tunnel, and just range it. I do secure this in extension and neutral rotation, but it shouldn't be over-constrained inflection, but I just want to make sure that there's not something drastically wrong. It's just a good little check, I think. And then we will determine our length. I'm using an interference fit type fixation here where that is going into a socket essentially. Obviously you want to make sure the length you leave to go into that socket isn't too long, but I've sort of marked it on that pin. And then I'll secure it again in neutral extension and rotation. And then you close the little vent in the IT band that you've made, and that's the structure that you've made. So what are the outcomes of addition of ALL to your ACL reconstruction? Dr. Sonari Kotet has shared a lot of outcomes with us, and he has noted very low re-tear rate. Just one out of 92 patients are indicated for combined ACL with ALL reconstruction. To your follow-up, I think what's very significant is the information on adding an ALL to medial meniscus repairs that this basically, they demonstrated when you add ALL to the ACL that there was greater than two times risk reduction of failure of the meniscus repair. So again, for me, if someone has a little bit of high slope and a bucket-handle meniscus and you're doing a primary ACL on them, that's a great candidate to add an ALL to kind of protect that. Systematic review by Littlefield et al. showed reduced re-tear rate, improved PROs, and select patient populations. And then this meta-analysis by Hurley looking at ALL plus ACL versus isolate ACL demonstrated ALL reduced re-tear rates significantly, reduced rate of residual pivot shift, reduced translation on KT1000, and showed some improvements in PROs. So when we're comparing ALL versus reconstruction versus lateral extraticular tenodesis, there's really not a lot of comparative data out there. They both have been shown to reduce anterior translation, residual pivot shift, re-tear rates, improve outcome scores. There's one meta-analysis that has demonstrated some higher return to the same level of play with the ALL reconstruction, but really, there are no direct, we're really lacking direct comparative studies. So it's hard to say. These are both obviously viable options for improving your outcomes, certainly in select situations. Advantage, possibly better cosmesis. Potentially it's more anatomic. You're not taking something from Gertie's tubercle up, so I don't know if that matters so much. But again, I think more comparative data would be helpful. Disadvantage, of course, cost of an allograft or need for additional harvest of an autograft. Back to my case study. She went back to playing recreational soccer at the age of 23, 24 with her revision with the ALL reconstruction. Had a new injury one year after returning to play, but it was her contralateral knee that was injured, and she requested to have the ACL with the ALL as her primary treatment on the contralateral side, which again, good discussion point perhaps. I think if someone has had a contralateral re-tear, or maybe it's their second side, maybe that's potentially a good person to add this on because they have a history there. And then funnily enough, her boyfriend, or his ACL, three months after she had her second ACL and ALL, and they came in asking for ACL plus ALL for him, and I said, no, no, no, being the boyfriend of someone who needed an ALL is not an indication, but he did have a high tibial slope and a buccal-handlemenal meniscus, so he got an ALL. So they're currently both back playing soccer, so sort of a fun little couple there. Here are the references, and this is available in the recorded version as well for you to review. Just grouped by anatomy, biomechanical comparative studies, and outcomes including those systematic reviews and meta-analyses. So, thank you. Okay, great. Thank you very much. So, next up is Adnan Sethna to talk about LET. Good afternoon, everyone. It's great to be here. Thank you to the program committee for inviting me. Fantastic talk we've just heard. I have a slightly different perspective, which I'd like to share with you. I like to make things super simple. So, the way I describe the rationale for doing an extra articulating thesis to patients is based on the steering wheel analogy. So, we all drive one-handed all the time, but when we drive one-handed, we never hold the steering wheel in the middle and try to rotate it, because that's going to be really difficult to do. Yet, that's what we're expecting an isolated ACL reconstruction to do. Instead, we hold the steering wheel on the outside. It's super easy to control. If we're a bit more scientific about it, 30 years ago, Ingrid Brettson demonstrated to us that an extra articular tenodesis load shares with the ACL graft. That means we protect the graft while it's healing, theoretically reducing forces on it, and we rupture rates. More recently, Imperial College London demonstrated more reliable restoration in knee kinematics. What does that mean? It means that when we have a combined ACL and anterolateral injury, which is very common, as I'll demonstrate in a moment, if you do an isolated ACL reconstruction, you cannot restore normal knee kinematics. That means the graft has unnecessary, unusual forces on it, again, predisposing to rupture. So, we've published a number of studies looking at the rate of anterolateral injuries, both on MRI and also correlating with lateral expiration. What we've demonstrated is that the rate of anterolateral injury in acute ACL injured knees is 70 to 90 percent across a number of different studies. So, it's super common. When you look at your MRIs, I would recommend that you start looking at the ALL if you're not doing it already. Here's an example of a patient who has a complete ALL rupture. When we did the lateral expiration, you can see the iliotibial bands intact, but just underneath that, you can see that you can look directly into the joint. What we show in the MRI images here is pre-operative image showing complete rupture, then at six months, then at two years. That ALL never healed, even though an ACL reconstruction was performed. Volker gave a fantastic demonstration. He's just left the room. I don't know if you read my slide, but I'm challenging BTB as a gold standard. We just published this study a couple of weeks ago in AJSM. It's the largest study comparing isolated BTB graft versus hamstring tendon ACL plus ALL, 2,000 patients. What we demonstrated was that at every follow-up period up to approximately 10 years, if you had a combined reconstruction, you had a significant advantage. Overall, in multivariate analysis, if you have an isolated BTB reconstruction, you have a threefold higher risk of graft rupture. That strongly challenges BTB as a gold standard. Not only that, but if we look at global trends, Australia and Brazil, they favor hamstring tendons for elite athletes. There's recently been a survey of national surveys published actually, and that demonstrated that in the US, Latin America, Asia, and Europe, hamstring tendons are preferred over BTB. All of these things are challenging BTB as a gold standard. We also published last year long-term results of any type of isolated ACL reconstruction, so BTB or hamstring tendon versus combined reconstructions, and this is 10 years follow-up. If you have an isolated reconstruction, fivefold increased risk of graft rupture compared to combined reconstructions. When I first started my journey with extra articular procedures eight or nine years ago, this was a slide that was frequently distributed to teach us about indications for surgery. But at that time, none of these things actually had any evidence behind them. But for you guys starting out now, all of these things have evidence to support them. There's a whole bunch of comparative studies demonstrating advantages in young patients participating in pivoting sports, chronic injuries, hyperlaxity. I just mentioned our long-term study, get good stability study. We already heard about it's protective of medial meniscal repair. So if you have a patient who has a medial meniscal repair at the time of ACL reconstruction, if you had an ALL reconstruction, your secondary meniscectomy rate is reduced twofold because it confers a protective effect on that meniscal repair. And we've also published in elite athletes significantly reduced graft rupture rates. That's in the primary setting, but there's also a number of comparative studies for the revision setting, almost all of them demonstrating significant advantages. So one of the aims of this talk that I was given was to compare the two procedures and tell you why I thought an iliotibial band procedure was best. But sorry to disappoint the program chairs. Unfortunately, there's not really any evidence to do that. I could give my personal opinion, but if we're factual and evidence-based, there's only two comparative clinical studies. This is one of them from the Santee study group. I wasn't involved in this particular study, but it had a small number of patients, but they were matched. So that's a good advantage of this study. 40 patients in each group. They didn't show any significant difference or clinically important difference in terms of graft rupture, return to sport complications, and the laxity patient reported outcome measures. So I'd put it to you that both are good options, the modified lamar or anterolateral ligament reconstruction. Just as we individualize our ACL graft choice, you can individualize your extraticular procedure. The surgical technique, I'll just go through this very briefly, but we can obviously go through it more in the lab tomorrow. And I've got some videos to show you too, but you can either do this as a combined reconstruction or independently. This is the example of the combined. The example, sorry, the benefit of the combined reconstruction in terms of using a single femoral tunnel is you don't have any problems with tunnel collision. So the ACL portion of the graft is triple semitendinosus, single strand of gracilis. That additional length of gracilis shuttled underneath the iliotibial band through a tibial tunnel back to the femoral origin where it's fixed in extension. It's percutaneous, so there's no significant incision there as opposed to the modified lamar where you obviously have an incision and the iliotibial band harvest. I won't go over the technique, but we can again do that tomorrow. So, but the most important aspect of my presentation actually is to teach you about the pitfalls to be aware of and avoid. The most important one is tunnel collision. We'll talk about over-constraint, iatrogenic injury to the LCL, hardware-related complications. So tunnel convergence, I'd urge everyone to read this paper from Jay Coratel. The main finding of this study was that if you drill your ACL tunnel from a medial portal and you do a lamar, you have a 70% chance of tunnel collision. So it's really important that tunnel collision occurs predominantly at the cortex. So if you're using cortical fixation for your ACL graft, you're really at high risk of a problem. So strategies to avoid tunnel collision, you heard some in the previous talk, I have some other ones outside in drilling, you can put your tunnel anywhere so you can specifically avoid that collision. On the right hand side, there's a picture of a post-operative CT showing an outside in drilled ACL tunnel and you can see that it's nowhere near your extra-articular tenodesis so it's very safe. Another option that you can have is use a femoral ACL screw rather than cortical fixation because a collision occurs at the cortex so that minimizes problems too. So here's just a slide showing that, you know, this procedure is often described as being done percutaneously but I actually prefer to make a small incision, see that LCL really clearly, I put a guide wire in there and make sure that I'm not going to cause an iatrogenic injury. And this is my final slide which is a little video and it's just showing how I test an isometry of the ALL. The ALL should be tight in extension and lax in flexion to allow normal physiological internal rotation. This is how I avoid over-constraint. If you get that position wrong, so for example if you put your femoral fixation right at the lateral epicondyle, you over-constrain the knee. So you can see it's tight in extension but when we flex up it's also tight so you're going to over-constrain the knee and that's important to avoid. The worst position is actually if you put it distally which is my last video clip. So if you're distal and anterior to the lateral epicondyle, it's tight in extension because we fix it in extension but when you flex up the knee you can see that it's really over-tight and you can't get physiological internal rotation. So it's something to play around with in the lab but also I do this intraoperatively as well to make sure that I'm replicating that normal anisometry and not over-constraining the knee. Thank you. Okay, so we realized that we had a little inadvertent merge of topics. Dr. Crawford was always listed for allograft and somehow he got listed for hamstring so we're going to run over the hamstring talk because we're running a little late and thankfully our faculty that are speaking for the industry sponsored talk next door will try to touch on it a little bit in their talks and ask your faculty as you work through the lab tomorrow what the role is for hamstring because that is certainly a very tried and true well-known and favored graft. So the next thing that's going to happen is you're going to go get some dinner out in the lobby here and then if you would proceed next door if you'd like to learn from Dr. Browder, Dr. Lee at the Smith and Nephew talk you can eat in there. Okay, thank you. Many thanks to all of our speakers.

ACL reconstruction surgery

Miho Tanaka

surgical techniques

allografts

biomechanical properties

anterolateral ligament (ALL) reconstruction

knee stability

graft failure

lateral extra-articular tenodesis (LET)

complication reduction