Alrighty guys, for the interest of time we're gonna get started on kind of like this case discussion. I still don't have a very good inside voice. I'm working on it. Even with a mic, I don't have an inside voice. I don't have an inside or outside voice. I guess it's where we can't hear. I can't hear over the microphone anyway. Is it working? Can you hear us? You're good? You can hear us? Okay, all right. Yeah, for the interest of time we're gonna get started on kind of the first half of the dinner presentation. So we're just going to talk today about ACL repair and this case is put together by Dr. Brown. So this is a personal experience of mine with ACL repair. Can you guys hear? So this is a 27 year old active-duty female and a former collegiate gymnast, very near and dear to my heart. She presented to me for knee pain and instability. She initially had an injury on New Year's 2019 while skiing, which was an ACL tear and a high-grade MCL. She underwent a right ACL repair to the femoral condyle and a lateral meniscus repair and internal brace for the MCL injury in January of 2019. She never gained full stability and had a revision to a full ACL reconstruction with an hamstring autograft in June of 2020 by the same surgeon. She states she initially did better but never fully recovered. She never really felt stable and then continued to have medial knee pain. So I saw her in January of 2021. Her persistent instability was limiting her ability to stay in the Air Force and her workup revealed an ACL graft disruption and a medial femoral condyle OCD. So these were her initial x-rays. So lots of things to notice on the films here. She had a grade 2 B Lachman pivot and medial joint line tenderness, medial femoral condyle tenderness, and she was stable with her collateral testing. So more imaging, so graft tear, wide tunnels, lateral meniscus tear looked like it healed. And so I went in, so I did this in a staged manner for her given the widened tunnels and obviously this is not a case presenting my experience personally with doing the the ACL repair but you can see some of the the instrumentation kind of in that posterior and back wall from one of her previous surgeries at least. But I was able to get good tunnels. She did have that osteochondral defect. Ultimately I did a quad tendon all inside. She did well. She returned to active service and she has recently had a baby and is just enjoying herself in Korea. So but I guess let's stop right here and just kind of chit-chat about this. So how many here have had I guess experience with ACL repair, primary ACL repair? Pretty good number of you, all right. Yeah that's that's bigger than me. So I so the question is you know we ACL repair has kind of come come back in favor. So for your ACL repairs are they primarily in your younger patients or your older patients could you know given the the folks that are doing repairs here what are what are some of your indications in picking those patients? Like are they the you know the adolescent through 21 year olds or you know 21 to 30 year olds or you know 30 to 40? What what age group are we talking about? Post teenage, okay. Anyone else? y byddwn ni'n gwneud hynny mewn patients ar ddiwedd 21 sy'n cael risgo'n fawr iawn o'r newid ynglyn â'r rhai fwyaf. Felly dydw i ddim yn gwneud hynny mewn patients ar ddiwedd 21 arall. Mae'r cyfeiriadau eraill rydyn ni'n ei ddefnyddio ar gyfer gwybodaethau yw mae'n rhaid i hynny fod yn evulsiwn femoral, ond rydyn ni hefyd yn defnyddio'r test o'r cwrs ffyrdd, sy'n gwneud y byddwch chi'n rhoi'r gynllun yn 90 gradd o fflexio ac rydych chi'n gweld os ydych chi'n gallu rhoi'r cwrs ffyrdd yn ôl i'r cyfeiriadau femoral, ond rydych chi hefyd yn rhoi'r cyfeiriadau ffyrdd o ffyrdd, felly mae'r test hwnnw yn rhoi'r cwrs ffyrdd o'r cwrs ffyrdd i wneud yn siŵr y byddwch chi'n gallu gwneud gynllun ddiddorol ar gyfer eich arwain, ac i mi mae hynny'n un o'r cyfeiriadau sylfaenol. Mae'r gynllun ddiddorol ffemoral yng Nghymru, rwy'n credu bod hynny'n gynllun ddiddorol i mi. Byddwn i'n golygu beth sydd wedi'i ddweud, ac byddwn i'n dweud beth sydd wedi'i ddweud am sicrhau os yw'r Cynllun Ddiddorol yn gallu dod yn ôl, mae'n bwysig. Pan fydd cynllun ddiddorol Cynllun Ddiddorol yn datblygu, yn unig fel unrhyw beth eraill, fel cynllun newydd, efallai nad yw'n newydd, ond pan fydd yn fwy pobwl, mwy o bobl yn mynd i'w wneud. Pan fydd yn fwy o bobl yn ei wneud, byddant yn cymryd y cyfnodau gyda chynllunau. Ac, pan fydd hynny'n digwydd, bydd pobl yn ceisio cymryd Cynllun Ddiddorol sydd wedi'i gysylltiedig neu'n ychwanegu ymlaen i'r amgylchedd ac yn ceisio gwneud ei ddigwydd a'u defnyddio'n gynhyrchu sutr fel amgylchedd ar gyfer cynllun ddiddorol iawn ar ddiwedd y cas. A'r heriau yw, bydd y pobl hynny'n cael cynllun ddiddorol. Bydd y pobl yn cael cynllun ddiddorol. Bydd y pobl yn cael cynllun ddiddorol. Felly, rwy'n meddwl, fel aelodau'r ffyrdd, i gyd yn yr ystafell hon, mae'n rhaid i ni fod yn hawddus gyda'r technigau hyn a gwneud y technigau hyn er mwyn sicrhau ein bod ni'n cymryd ein pobl sy'n cymdeithasol. Nid ydych chi'n gallu cael y cyfnod yn ôl os nad yw'r cyfnod yno. Nid ydych chi'n gallu gwneud hynny. Ac mae sgaffoldiau, ac rwy'n gwybod bod cymdeithasau yma sy'n cefnogi hynny, sy'n cefnogi cymryd y newidiad, ac rwy'n meddwl mai mwy i ddod yn y dyfodol ar hynny, ond nid ydych chi'n gallu gwneud y cyfnod o sutr neu sgaffold. Mae angen colegion. Rwy'n meddwl, Grace, mae cynllunau da iawn yn mynd i'r ôl i gydnabod gwasanaeth tŷ bwysig. Dyma gwasanaeth tŷ bwysig i gyd. Felly, yn ogystal â'r rhwydweithredol ac rwy'n meddwl byddwn ni'n dangos rhai llyfrgell am sut rydych chi'n edrych ar y cyfnodau tŷ bwysig, oherwydd eich bod chi'n cofio, mae'n rhwydweithredol. Felly mae'n rhaid i chi meddwl amdano'n wahanol o'r rhai o'ch cyllidau eraill lle mae'n rhwydweithredol, lle maen nhw'n gallu gofalu'n well oherwydd nid yw gwasanaeth tŷ bwysig yn mynd i'r ôl. Felly'r nesaf o'r sgwrs hwn, nid yw'r nesaf o'r sgwrs hwn, nid yw'r sgwrs hwnnw, yw ein bod ni'n mynd i siarad am y type o gysylltiadau ar gyfer argyfwng. Ac eto, rwy'n credu bod hynny'n lle, nid i ddefnyddio'r Lytwyl, ond rwy'n credu bod hynny'n lle y maen nhw'n mynd i'r ôl yn mynd i'r ffyrdd o ran yr amgylcheddau. Felly, rwy'n mynd i'w rhoi'n ôl i chi. Wel, fel y dwi'n dweud, pob peth sydd yn ôl yw newydd, felly pam ydyn ni'n siarad am ymgyrchu ar gyfer ymgyrchu? Ac mae llawer o Llyfrgell ar hyn o bryd yn dod allan yn dweud bod hynny'n pwysig opsiwn pwysig. Ac, felly, yr hyn rydyn ni'n sylwadu, er enghraifft, yw bod y technegau sgwrs yn well. Rydyn ni'n cael nhw'n gysylltiedig yn sefydliad ein pobl, ac mae hynny'n ofal, ac fel y dweud Rachel, mae hynny'n beth gwahanol iawn. Felly, yn hanesol, roedd ymgyrchu ACL yn cael ei ymgyrchu gyda datganiadau pwysau yn y astudiaethau o'r diwethaf i'r diwethaf, ac roedd ymgyrchu ACL wedi dod i fod yn standard golau. Wel, mae'r ymgyrchu yn caniatâdau, sy'n golygu, os ydyn nhw'n cyflwyno ar gyfer ymgyrchu, rydych chi'n parhau eu anatomia gwleidyddol, rydych chi'n cael tunelau bôn fwyaf, dydych chi ddim yn rhaid i chi ymgyrchu graff, ac os ydyn nhw'n cyflwyno, gallwch wneud ymgyrchu ACL pwysau fel y byddwch chi'n effeithiol nad ydych chi'n ffwrddio brydiau. Felly, ymgyrchu'r astudiaeth, un o'r astudiaethau o'r diwethaf oedden nhw'n dod allan am ymgyrchu gwahanol, ac maen nhw'n desgrifio y grwpiau gwahanol o'r ymgyrchu sy'n dangos pa ymgyrchu oedd y caniatâdau bwysau ar gyfer ymgyrchu ACL. Felly, yr hyn y mae'r astudiaeth hwn yn ymgyrchu'r caniatâdau o'r caniatâdau sy'n cael eu dod allan ymgyrchu'r caniatâdau o'r caniatâdau were better set for repair. So again, we're talking about collagen. We're talking about tissue. Right. So if you if you I mean, so again, this is like and I think these are to the to your points where you actually can take the tissue if it can reach the notch or reach the condyle at 90 degrees as well as figure four. Chances are it probably has some synovial sheath around it. And that's probably it makes more of the ideal candidate as to not candidate, ideal tissue as to what can be repaired. So this this paper kind of delineates some of that idea. So they looked at the different types of like how how the synovial sheath is affected, like if one bundles in there, if there's two bundles in there, you know, obviously group C, that's just silly. Like, why would you try to repair that? That's that's definitely pushing the limits to not indicate it. And so now we're talking about some of the techniques. So this study looked at ACL repair with suture ligament augmentation and why it fails. And so they were comparing ACL repair with this suture ligament augmentation versus ACL reconstruction with quad or BTB. And these patients were 7 to 18 years old. There were 22 patients. So not a big study. And the follow up was almost three years. They did have a higher incidence of graft failure in the first three years. And I, you know, I think a lot of this talked about the the patients. This was not a good patient selection group. So the adolescent patients who were higher, who were involved in higher impact activities, had a significantly higher rate of failure in the first three years and then the ones that underwent a primary ACL reconstruction. But they otherwise didn't have a difference in their other outcome studies. Okay, so this was a paper that really talked about it was the first, it was the most recent clinical outcome study that compared, it was a systematic review and Dr. Sathan was a part of this study that really looked at a compare at comparative studies with ACL repair versus reconstruction and so there were five, 19 studies were included, there were five actual comparative studies and 14 non-comparative studies. There still weren't a lot of patients in this group and what they did find though is that there was no significant clinical difference in outcomes when it comes to looking at side-to-side laxity, their Lachman test, pivot shift test, they had a good range of motion and this was actually showing that the ACL repair is a safe option because it's really negating the old studies from in the 70s and 80s where ACL was not deemed to be a viable option. What it also noted though in these review studies though was that you know as they're comparing the ACL reconstruction and ACL repair there was a lot of bias because there were a lot of this a lot of studies were performed by the inventors of the said product that was assisting or that was being utilized for the ACL repair. So the study was limited by a low number of patients but the there was no complications as it related to knee laxity when they did have an appropriate selection criteria. So I guess we can also go back to so let's let's go back to the case right so we have a 27 year old female she so within what we consider criteria she's probably at the right age group to do this so the question is why did she fail right and then so but this could also be how the what the type of terror since we don't actually have the imaging from the original injury this certainly can be one of those you're just trying to pull tissue that just can't go to where it needs to go so you can't force something to happen that doesn't but what I find really interesting about this case is that your second tunnels I so I guess can you go to the images yeah well that's the art of what we do right doing the right surgery just because we can do it doesn't mean we should do it but I find it really interesting as to so we talked a little bit about with the talks that we just had with regards to ACL graft options so we have a 20 27 year old patient fairly active still military what kind of graft options would you guys use just by show of hands who would use an allograft if her job is to get back into active duty running jumping and doing that whatever six minute mile first the pilot this first officer in the pie so who here would put an allograft in her are you asking for the revision of the primary repair so say let's let's go back one case before she presented to dr. Brown so so she failed her primary ACL repair so now she has an unstable ACL so well so now you decide she's now indicated for ACL reconstruction who here would then put an allograft in her no takers all right who would put a hamstring autograft we got one two huh however many strands you want of a hamstring that's the appropriate size both hamstrings appropriate size fatness with that Fallsman criteria so we have two three three all right what about patellar tendon okay I'd be curious where you guys should practice you because I wonder if this is I still have a bias that I bet this is still kind of geographic although Jocelyn's thrown me off because your East Coast because I think the other two guys are West Coast so and then last is a quad tendon who would do quad autographed Wow we got a majority of quad autographs here all right so clearly a lot of us drink the quad autographed Kool-Aid I'm on the quad autograph there you go all right actually I wanted to ask you do you have any issues so quad seems to have seems to have less donor site morbidity but do you see issues with quad inhibition and remnant pain along that quad can you hit your microphone button yeah I'll see quad weakness up till six nine months they usually will get it back when I was at Ohio State we had a really we could measure them whenever we wanted so we could keep track but I tell people they'll be a little bit weak I I left so I haven't had don't have long long follow-up on that but most of them got it back it was like a turning point it was like three months four months all of a sudden their quad was fine so I do see that that it is a little bit delayed as I've gotten better and harvesting and staying out of the muscle a little bit I've had less of that that's kind of part of that learning curve you know at first I would every once while I'm getting the muscle a little bit and I think those patients were a little bit slower oh yeah I definitely saw that so you think it's more muscle based as opposed to partial or full thickness harvesting the other graft good question you know I I gone back and forth I actually prefer almost doing a full thickness now and like right down the center of the tendon and I've have MRIs on you know maybe 10-15 people that a year out because they had an injury and their quad tendon almost looks normal I mean it's pretty remarkable how that heals up afterwards even doing full thickness so I've gone to doing mostly full thickness and I haven't I haven't looked at the patients to notice if there's a difference I think it was a key was if I got in the muscle and I veered off a little bit that was the problem or if they didn't have a shorter tendon and I got up into the rectus a little bit at the top of the tendon we're confused back here that middle top picture why is there a big tunnel if that was a repair does anybody understand why so this was I saw her for her third surgery so she had undergone the repair then a reconstruction and subsequently a revision reconstruction yeah so I'm sorry I so I kind of I'm loosely pulling the pictures but not really so we're talking about if you were revising her primary repair that had failed big like Twitter battle but I get a lot of education from people I'd never see and never interact with at meetings and who are really smart really high-volume surgeons and it's I think it's fun to share our experiences and it does represent a new era of education but anyway we talk about social media another time but one of the big debates that came up was quad inhibition after ACL with quad reconstruction and I I used to be a hundred percent BTV that's how I was trained I was kind of very dogmatic on that and in the last two to two and a half years I've become kind of 40% quad and I learned everything I know about quad from John X at Emory and I do it his way so all soft tissue no bone block 63 to 65 millimeter graft and and you can really on adults we were just talking about kids but on adults or skeletally immature sorry skeletally mature you can get that length every single time there's no concern and you don't need a bone block so I have found when I heard this on Twitter and saw this on Twitter I I have found that in my practice I've not seen the quad inhibition that that I think some others are experiencing and I don't think I'm certainly any better of a surgeon than anyone else I take a full thickness graft I repair the full thickness defect with micro sutures up and down I use a one and a half centimeter incision at most and I use a proprietary harvester to help do that very in a very small way but I think the lack of harvest site pain that they have relative to BTB again I don't have experience much experience with hamstring I think that they in my practice they get their quad back just as fast as BTB because they don't have as much pain I think if you take a bone block they do have more pain but I think with the all stuff tissue full thickness harvest if you close that defect they don't have much pain there certainly is a learning curve to harvesting and I would encourage a big incision before you before trying to get it real cute and small but I've not seen that and I've not seen the lack of unless I put in a too big graft which I sometimes do because that's the danger with quad it can be too big I've not seen difficulties achieving full extension so I don't know I I think that maybe compared to hamstring they might lack in their quad function a little bit early but compared to BTB for me it's been about the same I would agree with you I said I've seen the same result when comparing to BTB I do think when comparing to hamstring they do feel a little they complain more about stiffness and and just a little difficulty mobilizing their kneecap compared to quad to to the hamstring but I do believe they move faster than they do with BTB and for that very reason for pain I have a question about this because I got on the quad train pretty early especially from my military history for those that are taking care of college and professional athletes have you done quad tendon ACL reconstructions on those patients because that there's some controversy there I have to I would say mostly my female athletes right now because I think with some of the systematic reviews that are coming out that have shown like you know you compare the 18,000 hamstring ACLs versus like the 8,000 BTBs you have that just hint of a sliver of point something percent higher failure rate with hamstring in the adolescent teenage in the adolescent age group so I think for my for my female athletes I tend to bias more towards quad because I think for me I just can't get a consistent number out of a hamstring and my concern is also just having gone in second looks or even our revisions is that sometimes that hamstring does not look like anything but the hamstring you put in there originally like it does not get men ties it does not get any synovial synovium it doesn't do anything and unfortunately I've had to go back on some of my quads because I think whatever it is with the collagen exposure or the type of collagen cross-linking whatever it is or just the fact that it's just a big chunk of collagen is that they do they can synovialize really well almost too well they kind of create a cyclops lesion so I don't think it's that uncommon to go back in for a quad to take out that cyclops lesion that usually shows up around that threat three to four month three month range where they just can't quite get that extension they have a little bit of fusion and you go in and that I mean if you guys look at that graft I mean it looks like a nine month nine month ACL graft. For those that are that are doing quad primarily but not doing it in your higher level your collegiate professional athletes would anybody like to comment on that or are they just not seeing it? To share my experience with this at CU athletes again when I first started division one collegiate athletes it was BTB or nothing like I firmly again I'm very biased against hamstrings not that they're wrong and they do great with great surgeons I'm just not good enough to do that so it's so for me hamstrings are no-go and I think the literature is very clear that in that particular patient population especially young female soccer players there is a very clear difference in recurrence of tear rate as well as laxity rate so laxity and retear are not the same thing but laxity often leads to less satisfaction and inability to return to the same level of sport. For my co-athletes it took me a while mentally to say I would even offer quad because I would just say you're getting a BTB and this is what we're doing but then I had a few that I had to do revisions on that already had a BTB or had a contralateral quad and they came in and they said Dr. Frank you're doing a quad or another surgeon is doing it and knock on wood they're they're doing great. I think my biggest case that made me a believer was I had a 14 year old high level like super high level national team soccer girl skeletally almost mature but not mature enough for me to want to use a BTB so I did a quad on her and she did great she came back and tore the other knee a year and a half later and she was skeletally mature so then I had a decision to make because in this patient population for me it's BTB or nothing and what do you do in that case because she's so happy with the quad on the other side so I did a quad and she's done great and so again that's n of one but I think in these higher level athletes even the most high-risk athletes I think quad is very acceptable Bert Mandelbaum with US soccer does quad on every single person and all of those athletes talk so those are the ones that come in and see when when I see them and they say I'm Bert did my friend or did my other knee and I got a quad so I want a quad so I I think it's it's scary if you're used to doing BTB and your training like mine was was BTB or nothing but I think if you do more and you get more comfortable that the results not just with us in this room but nationally and internationally they're just as good I had I want to put some perspective to this conversation I like it it's an awesome conversation you all know how many people pass return to sport test yes how many how many percent 25 those 25% I mean or anyone disagree with me that's what the data shows that's what we see you better yeah and so those 25 that pass those tests they have quads I'm just gonna show this up here real quick like this eight weeks after surgery so it's not it's not really an issue you can see it again and again what the trick for us clinicians is to figure out who are those 75% before surgery who will struggle all along they struggle with hamstring they struggle with any graft except allograft now I would never do an allograft on a young athlete I'm just telling you they don't struggle with that as much so the pearls all the pearls that were brought up they're absolutely right you know when initially we were way too aggressive with quad harvests going into the rectus then you can see more inhibition like you just said but so anyway word of wisdom I was gonna say cuz I think you know all of our gold gold standard return to sport tests were pretty much done on BTB and hamstring and when you're talking about football players and you're talking about certain other high-level sports and that's not acceptable but I think at some point we're treating ourselves with just only thinking about BTB in the college and the professional athlete and kind of being able to take that risk and have that discussion athletes talk and and so I did my first professional basketball player with a all-inside quad and and you know knock on wood it's it's going well but you know there was a lot of discussion and you know a lot of the trainers were like oh my goodness I can't believe this is this was what was happening but this this athlete advocated for it so I'm pleased that was the first professional athlete I've done several college athletes and and it's all and I'm very happy with with that decision and and I think that there's going to be a big a big change as it relates to that higher level athlete and their graph choices all right I guess we can go back to head back to the ACL repair so I think in general if you look at a silver pair and I think just through our discussion we've kind of hashed this out a little bit as to who that ideal candidate is and I think it's still to be to be determined right we're in the process of kind of pushing the envelope and we'll see probably the next couple years as as the scaffold and stuff comes comes into play it's it will see what the indication is with regards to how that tissue is going to heal if it gets protected but in general right now for primary repairs with just suture suture sutures so I don't say the name of any suture with just sutures you want to look at for patients that are not younger you know not the teenage years so like younger the teenage years is not not who you want to put this in you don't want to do this in patients with a high pre-injury sports activity level or even mid substance ruptures right side to side repairs inside a synovium is probably not going to work unless you have some kind of thing to protect that tissue and then also you want to look at what type of integrity you have the tissue right if the tissue is contracted and blown up it's not you can't put things together again and expect it to work so that the tight indication is something that's kind of volts off the femoral side and you can get that there in 90 degrees of flexion and in figure four position and we know that the ACL can heal but we just have to be aware be aware of who we're trying to ask this tissue to do heal in all right so just some some basic some of the ACL repair techniques there was the the earliest one dynamic inter ligamentary stabilization I don't I don't know anyone that's used that I know that you know that's a pretty thick implant and at least in the studies reviewing it most of them had to undergo a hardware removal there's super suture tape augmentation probably the repair augmentation technique that we're all most familiar with you've got your just a primary suture anchor repair and now the bear technique so the debate continues on ACL repair overall consensus though is that there are more prospective studies that need to occur that actually compare repair with reconstruction with enough follow-up the high-quality evidence is limited because there's has been a lot of study bias in the most recent studies but it is showing promising early results for repair as a safe treatment as a safe treatment option as compared to the studies from the 70s and 80s and the and the most recent studies do show that the ACL has the capability to heal but patient selection is absolutely critical there's this concludes our session now we're going to hand it off to the tool to talk about what we can do with bridge enhancement repair

ACL repair

27-year-old female

persistent instability

graft options

quad tendon autograft

individualized treatment