It's a great presentation, great discussion, while we get my slides loaded up here. My full disclosure, I started my career doing a lot of hamstring, and I was out at University of Arizona, took care of some athletes out there, and when I came back to Cleveland, I was taking care of the Browns, and at that time, quad was not even in the conversation, and I said, I'm not going to be the one NFL doc putting hamstrings in NFL players, so I made my transition to doing BTBs, and I haven't really looked back. I agree with a lot of the comments that were made about donor site morbidity. I think in terms of failure rates and things like that, I think it makes sense either to be BTB or quad, and I think quad definitely fits for the person whose practices are largely hamstring practices. But at the same time, so we all, many of us know the late, great Bill Grana. Bill Grana was my partner out in Tucson, and we looked up all our results from Tucson, and there were zero failures in any of his athletes that he did hamstrings on, and he was the early first adopter of hamstrings and got shouted off the podium by Jack Houston when he was a young staff member for basically blaspheming the BTB ACL, and so I think any ACL surgery done well, save for allograft, because I studied, which actually was mentioned earlier by one of the earlier speakers, that study, we looked at U of A athletes, and it was a 60% failure rate in allografts that were done at the university's level. And so that changed practice out at the university, but certainly what we do know is that hamstrings, when done well, can do well, but I choose to do BTB because of some of the athletes that I see. But the quad people are slowly, slowly starting to try to win me over, but I won't be the last person off the bandwagon, or last person on the bandwagon. What worries you about a quad tendon? I'm an old dog. I'm not trying, I just don't want to change. I like, BTBs are, for me, it's an easy thing, and my incision is not that big, and I have a resident here, I actually have two former residents here, I'm not sure Rachel saw me when I was a younger staff person, but Alex is here, and my incisions for BTB, they're bigger than quad incisions, but they're not that big, you know, I can get my incisions down pretty small with my BTB, it's all about mobilizing things and whatnot, but I just, I've been doing it for so long, I just don't want to switch at this point. And I get good results. I do get some anterior knee pain and stuff like that, but, you know, it is what it is. And I worry about the length of quad tendon, too, and I don't like, yeah, I use interference screws, I use a button and an interference screw, I like aperture fixation, I don't like the idea of putting suspensory fixation on either side, but that's just me. All right, so, we're going to talk about bare moon, or bare ACL, so bridge-enhanced ACL restoration is sort of the new name, so not just repair, but restoration. These are my disclosures. The biggest disclosure is that I am one of the enrolling surgeons for the bare moon study, so we've seen the results from bare moon, and we'll present some of that stuff here for bare, as well as hamstring, but this is now the study who's putting bare against the gold standard BTB, the gold standard. So where do we stand with ACL outcomes, you know, failure rates, BTB about 7.9%, even in the young athlete, but there is some OA that happens in ACLs, and some of this is due to meniscus and what's preserved and what's not, but some of it, you know, even when you look at long-term studies, there's a higher risk of OA in these knees, so there's post-traumatic OA. You look at sort of some of the things that Volker alluded to, when we look at sort of what are patients happy, we know that patients, some of the moon data, only about 60% or so get back to their previous level of activity, not all patients are happy with the ACL graft, and so, you know, is this graft related to some other factor, and this is why, you know, certainly repair has come into the conversation. Return to sport is not as high as what we thought prior to some of the moon studies coming out, and it can be pretty low in some of our competitive athletes, and this stuff is very concerning. Again, this is that moon data that we sort of talked about, 70% return to play for football, and 43% return to the same level of play, that's worrisome, and, you know, and again, I'm not going to candy coat it or stick my head in the sand, and yeah, there are some athletes and patients that I've had that did not return to their prior level of functioning, you know, after, and this is one of our head scratchers, and why not, their Lachman's feels great, they're not having a ton of pain, but they just never go back, so there's a lot of factors that go into that, and in this day and age, why are we still talking about repair? You know, I hear these nightmare stories from Bill Grana and Jack Andrus, who are, you know, the senior, senior people at the Cleveland Clinic about, you know, how they were repairing ACLs back in the day, and they all failed, and, you know, and these were just not, you know, great, great things to do, and what we know is an intra-articular ligament, so it has poor healing potential, and so rates in the literature anywhere from 40 to 100% of healing, it's a hostile environment, synovial fluid, ligament ruptures, there's this gap in between, and that gap can't be filled, but there's also things that happen to the cells of the ACL also that make repair not necessary, or that make healing not possible, and we know there's, as mentioned, there's some issues with ACL reconstruction, this is not one of my knees, my incisions are much smaller than that, but, you know, certainly there's morbidity of graft harvest, there's the numbness, anterior knee pain is a real thing, and, you know, and it's something that may not get better, so, you know, you can PRP these patients, you can hydrodissect their fat pads, you can do all kinds of things, shockwave, and some of those patients, anterior knee pain remains, and we go out and we take out the old ACL stump, you know, you get rid of all the sensory proprioceptive fibers, and so certainly there may be some rationale for preserving that. And then we still haven't solved this issue of post-traumatic OA, so even in the ACL without meniscus tears, some subset of those people still go on to get arthritis. Martha Murray has really been huge in terms of pushing this, and as I was sort of doing a lot of the research, and I know Martha Murray really well, obviously, through the stuff that we've done with the bare moon study, but, you know, this, you know, sort of road started in the early 2000s, it's not like a new thing, she started doing a lot of the basic science research, animal stuff, and looking at what happens to the ACL with respect to healing, and she's really dedicated her life to this. And as with any ligament, there's this sort of cascade of events that happen, so inflammation, you start to get this epiligamentous regeneration of tissue, things start to proliferate and remodel. Well, in the ACL, you have these stumps, and this stuff is kind of stopped short, stopped short because, it's stopped short because, you know, certainly you have this stump, and you end up with this, you know, cap that happens over, and there's some contractile fibers that help to contract this tissue, and so these ends just can't get back together, so what was it that we were missing? It's this lack of tissue bridging the structure, so MCL, you get a clot that forms tissue and that can repair, not inside the joint. This is a ligament that wants to heal. We see the MCL on your left, you know, big blood clot in the center, but what's messing with the ACL? We don't have that bridge because there's no way to form an organized clot. So enter the bear moon, or the bear construct, and this is basically an implant made from extracellular matric proteins along with collagen. This is derived from a protected herd of Angus cattle over in Europe, so we don't have to worry about mad cow disease or anything like that, and that's a question that patients are going to ask you. It's hydrophilic, so it loves fluid, so actually you put blood into this thing and this thing swells to, you know, well it takes fluid 5 times its weight in fluid, and it begins to soften and conform because it feels like styrofoam, but as you add fluid to it, blood, it really softens up, kind of almost to the consistency of bubble gum as you do that, and it's about 2 by 4 centimeters in size. So what are the relative indications? We sort of mentioned some of these things. So it has to be a fairly acute ACL tear. So a lot of the thinking that we think when we're repairing ligaments and things around the knee anyway, once you kind of get so far out from injury, you know, the tissues start to change, the healing potential goes down, so as part of our study, and as part of Martha's early work in the group up in Boston, you know, less than 45 days is what they thought about repair. So these are things that you have to get to if you're going to do the repair. It's not something that you can do late. Isolated ACL, so obviously you can do ACL along with meniscus and other cartilage stuff, but not necessarily multi-ligamentous injuries. So that's not what this is for. In my opinion, and this is sort of me, so in the non-athletes, so not something that we would ever do in a high school or collegiate or professional athlete, you know, recreational athletes I think are best, kind of lower demand people, not going back to high level sports, and the important thing about this, this is not for avulsion injuries off the femur. So if you have no tissue in the femur, you're not really bridging the gap, you're going from ligament to bone, so this has to be for somewhere along that mid-substance of the ACL. And again, contraindicating elite athletes, OA, inflammatory arthritis, people who smoke, multi-leg injury, chronic injuries, you can't do this for it, and in my opinion, again, and people are doing them in kids, we have a person who's in a greater Cleveland area who's doing ACL repairs in kids, and I get to see some, they're pretty easy revisions in general, but you get to see some of those, and it's just not something you should really do in those under 18 in my opinion. And again, avulsion injuries, and definitely not for revision surgery. So when we talk about intraoperative considerations, not every ligament is going to be reparable by bare standards. And keeping that in mind, you always want to have a backup. So you talk to the patient about the possibility we may be able to repair this, but what's going to be our backup? We're going to do our quad, or BTB, or hamstring, whatever you're using. You have to have something on the ready. So you want to say, okay, is this an avulsion injury, if it's an avulsion injury, not the right technique. Looking at tibial stump size, so anything greater than a centimeter or so is big enough for us to put suture in, for the suture to hold, and for us to do this repair. And then the circumferential area of the tibial stump should be greater than 50%. We look at vascularity, like something like this ACL here does not look very vascular. You know, you say it may be multiple bundles, even though you have more than a centimeter of tissue. But you can imagine trying to place sutures into this stuff. It's just probably not something that's going to hold at the end of the day. And then, again, what's the chronicity of the injury? Is this something that's very acute or not? And this has been some of the challenge with B.A.R.E., because sometimes patients go see another surgeon or another provider, and then they come to us, and they're already three weeks out at that point, and having to clear schedules sometimes to get them on the schedule so that we can do this quickly can be a challenge, especially in a knee that's stiff and swollen, and they need to do some prehab. So we looked at this with our group, and in terms of, can surgeons, number one, identify these things as what's going to be reparable and what's not? And so we all took videos and surgery of our ACLs, and we probed them. We took multiple angles, and we put probes in and everything to kind of help measure things. And then 11 surgeons across multiple centers all basically ranked whether this was repairable, what's the size of it, what's the length, and this is sort of what we came up with. And so some of these things you look at, and there's a lot of agreement when you see, like, a picture on the upper left-hand corner, so that, yes, that's a big, robust ACL, long footprint, it's wide. You know, this is something that certainly can be repaired. And there were some mixed things. And we also were very much in agreement when things that were, like, not repairable. So the one on the far right, on the upper right. But also looked at, we can see the stump here, the stump length, you know, again, somewhat mixed in these, but, you know, or when it was just, like, nothing there. When you get inside, it just looks like the ACL is, like, melted away. And then looking at whether the footprint's intact versus, you know, not completely intact. And there was not as much agreement when looking at how many stumps were still there. You know, and so, but the most important things, you know, is it long enough and is it big enough to hold suture? We were pretty good at. And so looking at this here, we can see, again, on the far right, you know, something probably not going to be good for repair. Here we're looking at stump length. And again, the probe is about five millimeters, so that's pretty easy to measure and know exactly is that going to be enough tissue for you. And then looking at, you know, the length of the footprint, I think this is a little bit harder. And I struggle with this because, again, you know, you sort of look at this and, you know, what's the true definition? What's the length going to be? Probably a little bit less important to me. And then, again, looking at bundles was a little bit, I think, easier, but, you know, certainly that's something that we struggle with. So the take home was that 76% of ACLs were rated as reparable, so repairable. And so when you're talking to your patients about this, they were going to go to the operating room. We're going to look at repairing this. But, you know, one in four people were going to get in there and not be able to repair. So we have to be able to switch gears and then do our reconstruction. And I'm a person that, essentially, if we have a positive MRI and we have a positive exam under anesthesia, I harvest my graft first and then I do my ACL. I don't stick the scope in first. And it's just a little bit annoying that I have to stick the scope in first, take a look around, and then pull that out and then do my harvest and everything. But, again, it's, you know, not that hard to do. But, again, it just kind of took some getting used to with that. And then, again, we are very good at looking at something repairable. And part of this was also looking at seeing how much vascularity does this thing have. Sometimes you get in there and even with an acute ACL in a young person, it looks like an allograft revision case, you know, because there's no vascularity. Everything's like kind of stringy and whatnot versus some that just have a very robust stump with, you know, blood vessels running everywhere. And those are the ones that you kind of get happy about. So this is the case of one of our more recent B.A.R.E. patients. So 39-year-old male, left knee instability, injured his left knee playing basketball. And this happened about 30 days ago. And a very active guy. He's a track coach, does a lot of running, basketball, but, you know, certainly not a professional athlete, kind of, you know, weekend warrior. This was his MRI. And what we do know is that it's very hard to look at an MRI and say this is going to be repairable or not, because we don't know if that's an avulsion. And you can kind of see there, it looks like there's some tissue on the femoral side, you know, here. And then there's some stuff down here. But again, you really have a hard time telling that just from the MRI. But on exam, he had a trace effusion, had a 3B Lachman's on grade 2 laxial and valgus. We also had some MCL injury too. And so this is the person that we talked to about the B.A.R.E. So this was his diagnostic scope. Had isolated ACL tear, so no meniscus work, no other ligamentous things. But we can see how that sort of stump looks, you know. I would say it's kind of hard to see, but, you know, this has some decent vascularity for being 30 days out. But you can kind of see how this stuff is kind of rounded off, already synovialized even at 30 days. And he was probably a little bit longer than 30 days at this point. And then so we indicated him for the study. And since this was a prospective randomized study, so, and obviously it's not double-blinded study because we all know what's going on, but the patient doesn't know. So we look inside the knee, we say this is indicated, and then they, you know, not an envelope anymore, but they go into the computer and say, okay, this person is randomized towards B.T.B. or this person is randomized for B.A.R.E. So he randomized for B.A.R.E. And so when you talk about what do you need inside the knee, so cortical fixation button. So I use an endo button so we can say that because this is not the CME portion of the course. So for the study, it's designed to be an endo button. And, you know, they have just free endo buttons that you can use from Smith and Nephew. As we'll see on the video, the number two ethabond is what goes through the actual implant. And then your toggle sutures, whatever you want to use, whether it's fiber wire or something, just something strong enough to pull that through the cortex and then toggle the button once it gets to the other side. And then we needed this really long vicro stitch, and that's what we needed to stitch the stump. Cannulas, whatever you want to use, I used an Arthrex Passport for my anterior cannula, my working cannula. And then we used suture passing devices. So the video is going to show a Scorpion device, fast pass, first pass, or other like instruments that you can use for that. I like to suture lasso or acupass just because it's a little bit less traumatic. The Scorpion has a big needle to it, and so I kind of worry a little bit about that. And I will say, if you're only a knee doc and you don't do any shoulder and you've not done shoulder for a long time, sometimes the suture management can be a little confusing with this. About 20% of my practice is still shoulder, so I still do a lot of shoulder shuttling of sutures and things like that and not tying with knot pushers. And so this becomes a little bit easier in that setting. But this is sort of what we have. And so when I agreed to do this talk, we had a few more bears that kind of went down between my agreeing to do this and then this talk here. I found it very difficult to kind of get all this stuff videoed and put something together that would make sense. So we are using a training video that we got from the company. And here we can see the endoblade being threaded with our number two ethabond suture or Ticron, whatever you want to use. And those of us who are familiar with endoblades, you need a toggle stitch for that. And again, this is what we look at. So a graft that's going to be repairable, so a stump on the femur. And a stump on the femur does not have to be big, but there needs to be a stump on the femur and a stump on the tibia. And then as part of this, so you have to do a notchplasty as part of the technique for this. And then all this stuff is that Martha and others figured out a long time ago. So at least three millimeters of notchplasty is done. And a hard thing for this is these tunnels that you drill, like in the femur, you're not supposed to put that through the center of the ACL. You actually put it in front of the footprint on the femur. And this is the endoblade reamer that we're using now to pass this. So this does not end up not in the footprint. So you're probably more like on residence ridge or just anterior to that. And then you want to cut down on your pin there, because you're going to have to tie these over the lateral cortex. So depending on where your pin comes out, so cutting down through the skin and IT band and getting down, because you're going to have to have that button flushed and then tie your sutures down there. And then these are the passing sutures that we're going to use for our implant. And these are, you kind of got those docked and just kind of leave them there. And then for this portion, just again, your AcuFix drill guide. And this you can drill just up through the center of the tibial footprint and then drill that with an endoblade reamer. I use a fiber stick to help pass my sutures here just because it's rigid and it's just an easy device to use. And then we, you know, the second set of passing stitches, we pull those down and get those kind of docked and out of the way. I use a far medial arthroscopic portal, the same one that I use to drill my ACL. I use a standard high and tight lateral portal. And then I make an accessory medial portal on the other side of the patellar tendon. And then I have two passports in place and I just pass my sutures from left to right. So I think it's a little bit less complicated than using a Scorpion. And I use Scorpions for my rotator cuffs, but it's easier to pass this back. And that's kind of, you kind of want to have this crisscross configuration. And this is a vicro suture, so this is going to go away. But you want to crisscross that through. And then that's what you're going to use to simply just reduce the ACL. This is not a structural one. So that's the one that you're going to tie over the button, but it's mainly just to reduce things. And you're going to put the free ends through the button because that's going to tie on the outside of the femoral cortex. And you're going to go ahead and pull your femoral-sided passing suture through, and then you're going to seat your endo-button on the lateral cortex. You want to kind of keep some slack in the suture because you're going to have to pull that also through the tibia and leave that loop pretty long. They have a towel clipped through that just to kind of maintain the loop there. So we've secured in the outer cortex of the femur. And then my accessory medial portal at this point, then I will enlarge that because you don't want a soft tissue bridge here, so you want to make sure you can put your finger in there. And now they're taking a Keefe needle, and sometimes I'll use the Arthrex, just the fiber loop needle, or you can get a regular Keefe needle like this, and you're going to pass that through each quadrant of the implant. And you can see this implant is truly like Styrofoam. I remember the first time doing this, I was like, you've got to be kidding me. This thing is going to go into the knee. And so you kind of make this sort of quadrant stitch, and those are the stitches that go up and through the endo button. So they go through your implant there. And then the steps, you really want to wash off the knee because you don't want to be dragging anything else into the knee. So your other stitch, now you're pulling that through, and you want to, again, keep some slack in that so you can insert this into the knee. And in the meantime, your anesthesiologist has drawn some blood for you, and then we're going to take that. And as we, you want to make sure, and you don't need a, and this incision is pretty legit in terms of the size of the incision. So you don't have to make a big incision to do this, and you'll see why exactly. And so take this blood and start dripping this all over the implant. Gets kind of messy here. And as you start to drip blood in here, and as it absorbs the blood, it begins to get softer and softer. And you want to drip that on the top and then start spreading it all around the sides of the implant. And this whole process takes about 10 minutes for this to kind of soften. You don't want this too soft because it will fall apart if you put too much blood on it. And the key to this is once you go to feed this into the knee, so you want all your blood on the top and the sides, but you want to kind of keep the base of it kind of firm a little bit just so it's something to push and introduce this into the knee. And even though it gets soft, you want it soft enough to, again, hold the suture and still be somewhat resilient, but not too soft where you can't, where things pull out. So you just kind of work it in there, and if you need to add some more blood, you can add some more blood. And it gets pretty slick at this point, so it's easy to kind of push it into the knee. So these blue stitches in the right hand here are pulling the ACL stump out of the way. So now you're going to feed this in between into the gap essentially and again by keeping the base a little firm this goes right into the knee and it conforms and you know basically you know you can kind of feel this going into the notch. I had a lot of doubt the first time I did this but once you do it for the first time is you know you kind of see it kind of works out because you know she's taking a long time and those who've been doing this have taken a long time to get this perfected to this point. So that's your blood clot essentially. You basically slide that all the way in into the notch and still keeping some traction on your stump just so that's out of the way and so once you're kind of happy that you're into the notch here you're gonna bring the knee out into full extension while kind of keeping your finger there just to kind of or your thumb there whatever just to kind of keep this in place as you extend the knee. And again because of this you don't have to worry about gaps or not have enough tissue to go all the way to the bone because that's not what it's designed for. You know the the bear is to you know to do the work in terms of bridging the gap. So we extend the knee all the way and then it's going to show another clip of this stump out of the way to kind of simulate what happens. So you got the clot in there and then you bring the stump down and now you're and these are being pulled from the outside of cortex of the femur and then you go ahead and and tie these down. I use a knot you can tie these down with your finger to if the incision is big enough but I go ahead and use a knot pusher to tie that down. You have to be careful though because since it's vicral suture even though it's number two one of the worst things that can happen if you break your suture and so so that's awful because now you have nothing holding things in place and so essentially have to start all over. I will use a button on this this this portion here and this is sort of more of the structural stitch because again that's the ethabond that goes in through the and so this is the vicral at their time but down below is the ethabond that goes from the button outside the tibia. So I tie down on the button I don't trust buttons on the cortex so I will also put in a swivel lock so that's what we're talking about in the other room so swivel locked is kind of backup fixation. And so what do we do for rehab and this is a quick procedure so this is not something that you know takes two hours to do especially if you're facile with suture passing you literally this is the case that can be done in a half hour 35 minutes you know the biggest time sink is waiting for the thing to soften up with the blood but um so it's not that could be done for fairly quick. So long hinge knee brace we limit weight limit flexion for the first few weeks partial weight-bearing times two weeks and then weight-bearing is tolerated with crutches after four weeks and then we get everyone into an ACL functional brace from 6 to 12 weeks and that was all donated by the study actually donated by Donjoy to use for the study and so and then after that it kind of looks more like a typical ACL rehabilitation but it goes a little bit more slowly in the beginning and we did have to adjust some things because you can't rehab a BTB like this you have to get BTBs moving and going. And so when you look at some of the outcomes so this is one of their first feasibility studies that was done in 2016 and they were comparing hamstring to bear and this is obviously short-term follow-up so just three months found that Lachman's were both good in both groups and did not have much excursion and obviously better hamstring strength in the bear group and really no adverse events and the way research works they said okay so it's feasible we can do this and then they open it up to larger studies and obviously we've been doing a lot of bears around the country. In 2019 kind of looked at that group you know so the further out no bear failures so they had when you look at IKDC and it's you know it's these research results are incredible because the bear actually IKDCs were better and actually the laxity was better with the bear and so seems a little odd not sure I trust that but also maybe more you know sort of it may be more of a indictment of hamstrings than anything else but and then this study most recently in 2020 also said that there was really no difference and it was not inferior to hamstring autograph and they did have two BTBs in a group but you know even though this is not significant they had a 14% failure rate with bear and only 6% failure rate with the hamstring and the two BTBs that they did but they you know said this is essentially not inferior to reconstruction. So food for thought what else is a consideration so looking at the very early you know research that went into this found that so up in the upper left-hand corner that's the ACL deficient knee so you see a lot of OA in the compartment you know this is the reconstructed knee with just ACL reconstruction in the pig model so get some OA and then when you look at the bridge enhanced ACL restoration really no OA in those knees and then when you used a reconstruction along with the bridge enhanced stuff you got still got some OA so this is kind of food for thought is there gonna be less chondral breakdown in this for some reason are we over constraining joints with with our reconstruction techniques that we're doing potentially and that has not necessarily been borne out in human studies just because we're so early on but that's gonna be something that's gonna be borne out hopefully over the next 10 to 15 years. So what's the future now we're comparing the bear to the BTB so we'll see how that goes. Bear is available in the market in most markets unless you're somewhere close to a one of the multi-center sites I think within a two-hour radius you can't do it of the testing sites and then again will animal evidence ever translate to what we see in humans with respect to post-traumatic OA. So ACL repair can be challenging you know we needed a biologic solution and I think there's a role for this in the right patient I think our our inclusion criteria in terms of some of the patients that we're doing this for or patients that I personally would not necessarily consider doing a repair in but I do think there's some lower demand patients that have the right kind of tear that really aren't trying to go back to high level sports that would do well with this because you know they have less pain they have less donor site morbidity obviously and in other complications and maybe that's all they need and again jury's still out as to whether it's going to protect against post-traumatic OA down the road. Thank you. Questions? Is anyone here doing any bear right now? Of course. Anybody who's not in the study who's doing bear right now? Yes. And anybody who's interested in learning how to do that here? Okay. All right. So we're getting there's some excitement about it and I do think you know I was adamantly opposed to bear I was adamantly opposed to being a part of this study and then Kurt Spindler left in clinic and then it was just me as to you know the big ACL guy there and then I said well you know certainly yeah I'm an academic surgeon and I think if if we're really gonna test this out we need to test it out at these centers where there's high-volume surgeons and we can really study this and so reluctantly I agreed to be a part of it and I am glad that I am a part of it. I think it needs to be done. I think it needs to be researched. I think comparing it against BTB we'll see how that turns out but you know I think it'll be some interesting results. Robbie. So so it was 18 as the low low range and all the way up to 50. Recruitment has been difficult to say the least and so we have extended and I don't know why there was an upper limit so we have extended the upper limit and then I think they're we're looking at lowering the lower limit to 16 which you know I said I said my piece about that but um you know it's I think that's because I think when you look at some of the studies like the the failure studies a lot of failures happened in Barron in those patients who were 18 and under and so you know you need something whether it's quad tendon or BTB these people are gonna put their knees to the test and so you need something that's gonna really protect that knee. Volker. I respect your approach a lot because you're right you know you you have to do this study and I think we're all looking forward to the results of this study and and I like it that you're open with your skepticism. You know what I like about ACL repairs a lot is the preservation of the stump. There's been so much publications on that and and I personally I love it when I find it I try to preserve the stump all the time and not only will you have better proprioception and all this you don't have any impingement because obviously the stump you know has been there natively so with the implant that you're inserting and of course it changes the shape and all that do you now have impingement or what what is your experience with that is this stump completely the most anterior part of your construct or is the bare anterior? So sorry so the bare should be up against the so deep in the notch should be up against the femoral side and so I think you know because and that's why I think some of the the technique you're pulling it out into full extension while holding the graft you know or the implant deep in the notch so yeah impingement is not an issue with these. I've had a couple people get stiff just because of the slowness of some of the rehabilitation so that we had to figure out but you you essentially only have ethobond suture holding the knee together at this point and so you know it's something where I think the side effect profile or other than failures you know I haven't seen any failures yet we're not far enough into the study but you're not gonna see much in terms of a side effect profile for this because you know again you're not harvesting anything patient well they feel great about it. And if you do a concomitant meniscus repair are you more happy or less happy that you have this big construct in the notch will that actually help promote healing of the meniscus have you looked at that? We have not looked at that in Barrett to my knowledge but you know certainly that implant has your extracellular matrix stuff and whatnot so maybe that can in the hole that you're drilling and whatnot essentially is a marrow venting on steroids essentially and so you know maybe it does continue to help and probably see some of the same results that I would think with ACL reconstruction as long as they remain stable. And they feel great early so we'll see. Any other questions? So we'll get a chance to see that in the lab tomorrow.

ACL repair

B.E.A.R. technique

donor site morbidity

surgical technique

B.E.A.R. implant

reduced pain

long-term outcomes