All right, so I think we're ready to get started. So I'm going to introduce to everybody, this is Dr. Volker Musall. Volker is a professor in the sports medicine division and department at the University of Pittsburgh. He and Freddie and the whole crew up there make it happen all the time, cover all the pit teams. And Volker has a particular interest in the knee and ligament stability and instability. Volker is an avid researcher. He's also an avid biker. He manages to stay on the bike rather than managing to get off the bike and get injured. He has a family full of kids who also like to bike and he's a great guy and a good friend. So we welcome you, Volker. Thanks for giving your time to this and really appreciate you doing it. Thanks, Jeff. I appreciate the invites. I prepared a talk and Rafa, my fellow, helped me prepare the talk. It should be about 30 minutes or so and hopefully we can discuss after. I'm just going to show you a quick case to start the case. And so this is a 21-year-old soccer player. They have the typical injury, you know, pop, thinking about ACL. And as you see on this pivot shift video, it's a really high-grade rotatory knee instability. So whether you want to call it grade 2 or grade 3, I personally don't care. It's just a very large pivot shift. And sorry for that noise there. Radiographs are quite unremarkable. Of course, your eyes are going to the lateral plateau. They're going to the lateral femoral condyle sulcus and looking at the slope. All those parameters seem quite good. Here's an MRI. It just kind of runs through. You have the bone bruise pattern. Check. ACL is busted. Check. And then the menisci look okay. Maybe they are posterior horn medial. Something going on. If you look at the collaterals on the coronal images here, you know, of course, you want to see integrity of MCL. There's maybe a little bit of fluid there on the femoral side. And then the IT band, everything lateral is intact on this case. So the summary here, and I'm not going to go into more details until the end of this talk. ACL, high-grade rotatory knee instability, what to do. So when we review this, rotatory knee instability, you know, Sagan described this, you know, hundreds of years ago back in France as this avulsion fracture on the lateral plateau there. And then really Jack Houston classified this as an anterior medial, posterior lateral, anterior lateral rotatory instability. So a little more detail on those. So the anterior medial rotatory instability is really the excessive valgus strain and simultaneous external rotation. So the MCL gets compromised in one way or the other, plus the medial meniscus with the separation of the capsule there. So you can have superficial MCL injury. The whole posterior medial corner can be involved, or more subtle injuries. This is, of course, not so subtle in the stress radiograph, but on your exam, you can do the anterior drawer with an external rotation. And you'll see an increased anterior drawer if you move that into external rotation. And then, of course, the dial test and your valgus stress. For treatment, if it's an isolated grade 1, 2 MCL, let's just say grade 1, everybody is very clear on what to do here. Once the MCL gets more high grade and you're looking for evidence, you will be lost because there's a lot of anecdotes and very little hard evidence. The STAR trial that we're doing currently with 25 sites in the U.S. in our second year will hopefully clarify some of that. But there are these quote-unquote bad grade 2 MCLs where the meniscus can float a little bit, where you maybe have a large ramp lesion in the back of the meniscus. Those may be operative. And then, of course, the grade 3s where the MCL is completely off, especially on the tibia, those are bad actors and no-brainers for the OR. So the grade 2s are the in-betweeners. Here's a big grade 3, very clear cut. There's basically a repair. And your preference will be autologous tissues, not even grafting, but repairing everything. And most of the time you can get away with this. Very few times will I put a graft on there, more in the chronic cases. Then there's posterior lateral rotatory instability. So that involves the LCL, popliteus, FIP ligament, lateral head of the gastrocnemius. So here is the reverse. You have the ACL, hyperextension, and varus moments. And your plateau subluxus posteriorly. So for your exam, you have the increased laxity in 0 and 30 in your varus stress. And also the external rotation dial test at 30. Now, if it's positive at 90, you may want to look at the PCL. And obviously, there's the reverse pivot shift test, which I don't do very much, but external rotation. And then this apprehension test. So here's, again, something that's quite clear. Gaps open on your varus stress. I do this in the ova under anesthesia quite a bit with fluoro. And then on this MRI, you can see everything is torn off there. So in those cases on the lateral side, a little bit different from the medial side, we go to grafting quite quickly. Even if you can repair tissues, I usually put fibula-based allograft on them. That's what you see on this image. The peroneal nerve gets exposed every time, even if not injured, just so you can pass your graft carefully. And then, of course, what you all have been waiting for, the anterior lateral rotatory instability, which seems to be the only thing we talk about these days. That's why I put it last, so we can talk about it a little bit more. But there's obviously more to it than just the ALL. And like I said in these last few slides, there's more to rotatory instability than just the anterior lateral. But so the anterior lateral stabilizing structures have all these names listed there. Mid-third capsule layer, you know, anterior lateral ligament or complex. And, of course, the capsule osseous layer. And it's really quite synonymous. About two or three years ago, Al Gatgood and Charlie Brown, they called all of us together and said, let's go sit down and let's figure this out together. It was a really fun meeting, but more on this in a little bit. So here's what happened in 2013. Steve described this ALL as a brand new structure that in this particular way, we really haven't looked at. And then all of us really went to the lab and started looking at, wait a minute, you know, how exactly does this look like? Can we come to that same image? Here is when you go sort of from the most basic to the more clinical. This is what these next few slides will go through. You see fetus specimens, right? So on the right is what we did in our dissections. And Freddie has a connection over there to the women's hospital. And so there's quite a bit of specimens that we dissected under the electron, under the microscope and everything. So you can see even in that very early stages, there's no thickening of that anterior lateral capsule where the arrow points to. There's clearly an LCL and clearly a patella tendon. It looks a little bit like water, which is very different from what the American Journal described here in 2016 with Camilo's work, which obviously shows a very strong tissue. So there's some disconnect here. When we looked at immune histochemically, what's happening in the anterolateral tissues, this is what you see. Nothing, right? So there's no tendon or scleraxis. There's no precursors that we could find. And we published this in Istiklal's. Here's a series of dissection that I think over the years, maybe about 100 specimens or so that overall were dissected. And when we did this work and published this in 2017, it was about 30 specimens. So I thought what we really thought would be important is not to show you the finished product, right? You go to dinner, you see a beautiful plate. That's great. But how is it made? And I think looking under the hood, I think, is more fun. I'm not a chef, but in anatomy, I certainly think so. So here on the left, you can see, you know, the skin is taken off and the fat, but everything else is exactly as you find it. You can see the LCL, the biceps tendon, you have that thick IT bend. Of course, the superficial layer, you can see you have the patella tendon and also the iliotibial to patella tendon fibers. So then we basically took off the IT bend and reflected it. And that's the picture on the right. And then you can see more the deeper structures. And you can see the capsule already shining through. And then you can see the deeper layers of the IT bend down here. And then in the next levels of dissection. So on the left, again, you can see that deep layer of the IT bend, which is not, you know, a ligament. It's just when you fold that IT bend back up, then there is the IT bend again. And then in this middle structure, you can see then the capsule osseous layer. And then here's the capsule. And if you just keep dissecting in the end, you will end up with what Steve, you know, showed us too, a strip of capsule or you can call it ALL or whatever you want to call it. But I think the importance here is, you know, what is it that restraints, you know, your external, your internal rotation and your interlateral rotatory instability. And for this, you need to do some biomechanic testing. So the video shows a knee specimen. I'm going to go back and forth one more time. That while it's being moved from flexion to extension, simultaneous internal rotation and vagus moment is applied. So simulated pivot shift and contained continuously. So this bright green line shows you what the force is that's picked up in the ACL. And you know, everybody knows that the ACL is most taught or picks up most force near extension. And then you have the interlateral capsule. It also picks up force in response to this simulated pivot shift test, but more on higher flexion beyond 60 degrees. Then you have the LCL and there's load sharing there between the interlateral capsule and the LCL. And then when we dissect everything down, just I showed you in these last few slides, that so-called ALL really carries negligible force. So this is one study that we did and think it really helped us understand this. Now, this one, I think I like even better. Now, here you're looking at the same specimen, the robot, the same sort of simulated pivot shift. But now you have this array of strain markers that we put on the interlateral capsule, 30 or 40 of them. So we can then measure with a camera system, the strain between each of these segments. And then this rainbow map will show you with red being more strain and blue being less strain, where most of the strains occur. And that red bar that we drew across is what the proposed ALL is. You can see all these errors are a bit all over the place and certainly not along the line of this proposed ALL. And therefore, we called it a continuous sheet of tissue rather than a true ligament. And I think this is a pretty powerful method, too. Now, here is more some clinical data, some retrospective data. But, you know, I think, you know, a lot of criticism that we faced early on is, you know, quote unquote, you're just a hater, right? There are lots of letters to the editors and lots of fighting on the stage. And that's all good. I think that's how we advance, you know, our science, our community in discussions and learning from one another. So here, you know, unbiased, we just basically looked and grabbed all the knees in a small series, 40, that had a high-grade pivot shift. And we measured that with our pivot shift device I'm going to show you here in a few slides from now. So we knew this is a high-grade shift. And then we just had the radiologists look at MRIs and blinded them to it and said, tell us how you grade the antilateral capsule ligament, you know, complex, whatever, and do it like you would with an MCL. So grade zero being nothing going on, grade three being a complete tear. So you can see there were two or three that had a complete tear. The rest were basically just sprains. But there was a correlation. And I think that's the interesting part here on the right side. So with an antilateral capsule sprain, you had a high-grade pivot shift. But so you did also with median lateral meniscus tears, not with an MCL, not with a posterior corner. So interesting data, which is very much in contrast to Andrea Ferretti's study, where he described basically that the antilateral ligament gets injured in 90% of all the ACLs that he dissected. So they made a what they called routine incision on the lateral side for each of the ACL surgeries and encountered hemorrhage or some tearing and described it in this arthroscopy paper, which when we look on the lateral side, either through the scope or sometimes open, we can't really find less than 90%. But what we did, and this is maybe not dissection, but ultrasound. In ultrasound, you can see quite a little bit of, it's quite sensitive looking at all the structures. We can see the LCL, we can see the IT band. And then we also graded by ultrasound, grade three being a Saigon fracture where the star is set on and grade zero being nothing. So you can see, we really didn't see an ALL per se, but we saw some thickening there and some injury to it in about 28%. So an interesting finding. So let's get back to that antilateral consensus meeting. So here, what we did is we all agreed that the antilateral ligament, this has been in layer three. So it's a capsular tissue. We agreed that there's variable morphology, which I think you should all understand that each patient, each knee is different. And then describe the attachment sites too. With respect to the Saigon fracture, which was actually tested on the OITE a few years back, it is not the ALL. It is multiple structures that attach to the area of the Saigon, the antilateral capsule, the IT band, even some anterior fibers of the biceps. And then we also said that the primary soft tissue stabilizer for the antilateral rotatory instability is the ACL, right? That is the most important. And I think sometimes that gets a little bit forgotten, forest and trees kind of thing. And then the secondary stabilizer, IT band, that's the most important on the lateral side, the meniscus, and then the antilateral complex as well. As far as biomechanics goes, there are some, of course, procedures. I know you want to know indications that we get to that. But there's potential to quote unquote over-constrained, bad word. So I don't want to use it very much because if you ask me what I mean by this, I really can't tell you. Maybe lateral compartment arthritis induction 10 years from now. Who knows? We just don't know that. But causes for making it too tight, obviously, is if you're pulling the graft too tight where you fix it or you put the foot in external rotation. And in my mind, if you put an extension, not a good idea because I just showed you it's taught in 60 degrees of flexion and beyond. So as far as indications go, there's no clear indications. You can maybe quiz the panel after this talk and see what everyone says. But maybe for some revisions, maybe for some high-grade pivot shifts, there's some generalized ligamentous laxity. And then young patients with pivoting activities, that's everyone. So that's pretty broad. So Mark also asked me to show you just a few things about the pivot shifts. I'm going to go fast here. Unless you want to stop me, then please slow me down. But the pivot shift, obviously, is a clinical exam where you reproduce what the patient is telling you, your knee shifts. We did this, you know, when I say we, I probably mean the old people, you know, Slocum, Houston, and so forth. Because at the time, there was no MRI and people actually complained of instability. Today, nobody complains of instability. They come in, the ACL is torn, we fix it, right, if you be honest. But what happens is when the ACL tears, that pivot point of the knee kind of shifts a little bit more media. And so therefore, when you translate anterior, you also have obligatory internal rotation. Roli Jakob, this is a young Roli Jakob in 1978. He described this and made this classification system that you still use today, which was never validated, by the way. These are all the ways you can quantify the pivot shift. I'm not going to go into detail. Some computer navigation, electromagnetic tracking, and so forth. And so we developed this little iPad app that simply stickers on the side of the knee. There's a video that the iPad takes, and it takes about 10, 20 seconds. And you get a curve that shows you the translation of these two markers on the tibia with respect to the one on the femur. And then you get, you know, translation over time. And it costs exactly nothing, which is nice. Unfortunately, it's not available on the App Store. I'm still working on this because the university owns it, not me. But we used this app to leverage ISSA costs to fund us with a grant, which we're very grateful for back in 2012. We teamed up with Bologna, Göteborg, and Kobe. We did this in 100 patients. I wish we did it in 400. Hindsight is 20-20. But we basically validated the high-grade versus low-grade and put those numbers out there. And AGSM liked it enough to publish it, which we're also grateful for. Some clinical studies. So Bertrand Stonry-Kote has done a ton of work on this. He's one of the most published people right now in ACL and interlateral. So this is 500 patients. And he showed that with addition to the ALL, he reduced the failure rate much. And so did GetGood with StabilityOne, which I think is a very elegant, randomized control study using hamstring tendons in 600 patients and leveraging a 10 multicenter system. They showed also a reduction of more than half in their failure rate. So I think this is very interesting data and we're probably going forward to think a lot about this. When he published this, we also thought about lateral tenodesis a little bit. And we thought it might be interesting if we do this and use the system that Scott Tashman and Freddy Fu developed with a three-dimensional in vivo kinematics running up and down a treadmill. So we had 10 patients in each arm. You know, it's a bit of a very labor intensive study. So don't criticize me for just using 20 patients here, but in future studies, we will do more. The graphs that you see here, I will show you in blue, basically an ACL and in green, ACL and tenodesis. And you can see on the left side, the translation, anterior translation on the right side rotation, which has not changed. But at six months, look at the picture on the left. You can see that when you perform an ACL and a LAT, there is a little bit more posterior translation. The tibia station is slightly posterior compared to just doing an ACL. So this is very interesting data, but at 12 months, that was leveled out and not significant anymore. So we just submitted this to AGSM a few weeks ago. So you will hopefully see this soon, but this is an interesting paper I'm gonna come back to in a second. So lastly, I wanna just real briefly talk to you what we think individualized ACL means. So we think that when you do an ACL, it really should take into consideration all the different circumstances that a patient is and their profession or sport, how unstable they are and also how big and small, all the peripheral lesions and the ACL is. So to me, what this means is, if you see me do an ACL that's isolated with nothing else in the fellowship, that's about 15% of the cases. That's not very much. And Jack Manitre showed that at ACL study group, very similar data. So more than half the cases get meniscus. They have root repairs, ramp repairs, and then in the complex situations, not acutely, but these transplants and a few of these lateral plasties or tendon diseases. Now, when we look at the ACL, we actually go ahead and pre-op. We do a little bit of a templating like we do in the total knee world. We do measure the angles. We measure the size of the notch. So for example, 24 is a very large notch and I measure the quadriceps, the patella tendon. So I know which graft might work best. And I measure the size of the tibial footprint. And then of course, you talk with the patient. I think this is very important. I know you all know this, but it has to be what the patient wants too, right? So if they want early surgery, we'll talk to them about what that may mean with stiffness and so forth. And if they're motivated and have a good network around them, sure, you can probably do it on the same day, but that's not what our standard treatment is. And then you talk very early on, you talk about expectations so they understand return to sport is a long way off. And then we made this graph here a few years ago, but it's still kind of in my brain. This is a little bit how it works, you know? So you have low grade translation and acceleration. I didn't want to go too much into that acceleration thing, but low grade pivot shift. You could potentially, if it's an older person, really think about a non-op and then you have those explosive cases where you really, you know, an isolated ACL may not do the trick where you want to think about something in addition there. And so this is Freddy Fu's concept, really the anatomic ACL reconstruction. So you look at footprint anatomy, the variation in insertion sites and intention patterns, the morphology of the femur and the tibia with the slope, all of these parameters. And then we created a checklist too, where we can see, and it's helpful, if you read through this checklist, it's a JBJS paper, you can see when you read a scientific article, you can see whether they were actually anatomic or not in their descriptions. I think it's helpful to go through that because obviously everybody knows what a lateral x-ray looks like or should look like, but there's more to it. So here's just, for example, this bell curve with the different sizes of tibial footprints. So 16 here is, for example, an average size, but they can be as small as 10, 12, right? And if they are so small and the notch is small and you're slamming in an 11 millimeter quadriceps tendon, probably not the best idea. And on the flip side, if you have a 22 millimeter ACL on the other side of that, and you have a six millimeter hamstring graft may also not be the best idea. So I think it's helpful. And then this graph basically shows how we measure the exact footprint area and how much a graft would reconstruct of the native ACL. And Christoph Offerhaus is a fellow that published this. I think really, really nice graphic illustration of what a telotendon, hamstring tendon, and quadriceps tendon can give you as far as insertion site replication. And I think this is how we go when we decide on what graft to use. If you ask me what's my favorite graft, I really use all of them. And so here's some of the plans. I think hamstring tendons alone, probably some high failure rates there, at least the recent literature. Stability one, and European data shows that addition of lead if you use hamstring, probably a good idea. There's also our newest data on our little randomized control trial of 20 patient that shows if you use a quad tendon, patella tendon, there's currently really no difference when you add lead or not. But the real utility will come through this new trial stability two, where Al and his team in London, Ontario, teamed up, and Jay Ergang and I. And here we will leverage his Canadian network and an extended American network of 20 centers, 1,200 patients, half with quad, half with patella tendon, and again, half with and without lead. And this study was supposed to start in March, but you all know what happened in March. So we're currently funded, but not started. So this will be a very powerful study, and I'm extremely excited to go forward with this. Okay, so what did we do with this case? What do you guys think? So I used the patella tendon in this patient, and I think you can use quad as well, but I think this is an extensor graph. This is my hands, what I use in those active guys. This is how we place tunnels. So I placed very posterior, this middle picture here. You may be worried, ooh, you may break out the wall. You can see on the lower left, no, we didn't break out this wall, but I don't care if we do because I use suspensory fixation quite a bit. Here's how you pass the graph. This is a suspensory button. So I like that because the bone will heal whether you put a screw to it or not. And then on the tibia, I do put a screw. Here's the intraoperative picture. And if you preserve the stump, like on the lower right here, then you really know there will be no notch impingement. The French do this a lot. The Japanese do it a lot. It's a bit more tricky in your case. You gotta preserve that stump somehow, but if we can, I really like that a lot. And then we did this tenodesis here. So I just wanna play this video for you real quick. I know many of the residents and fellows like seeing these videos. So I marked with my blade there the posterior part of the IT band, and I leave that intact. That's why it's called modified lamia, not lamia. So the posterior IT band is intact. The insertion on GERD's tubercle is intact. And then about six to eight centimeters proximal from GERD's, you sever the IT band and dissect it off the vastus lateralis there. And then as you go further, just off the capsule. And then you arm it with a rib stitch suture that later on is not necessary anymore. So just a few stitches. Then you can expose the LCL here. That's what we just did there. This is anterior to the LCL right here. And then there's a cut posterior to the LCL. And so now you can pass a Kelly clamp or something deep to the LCL and pass this graft. Why should we go deep to the LCL? Well, because it recreates the tension pattern a little bit better. And Andrew Amos showed this in the lab in the Imperial College, because then the curves right across and sits there on what they call an isometric point, which is about a centimeter proximal and anterior to the LCL. I fixed it with a staple at 60 degrees of flexion, neutral rotation, and very little tension on that graft, maybe 20 to 40 newtons, not much, because you can make it too tight. If you close the IT band, which you probably don't have to, but we close it. And I actually learned that if you close it too tight, obviously the patient has some symptoms there for a while. So I take smaller grafts these days. Then the rehab is the same as it is with a regular ACL. You can see here on this lateral x-ray, maybe the staple could be a little bit more proximal, but the LCL insertion is here. So it's obviously proximal to the LCL. So this would be my summary slide here. So rotatory knee instability is really a complex issue. You can read that book that we published. Pretty much everybody that's involved in this, every author is in there. But in my mind, treating rotatory instability starts with an anatomic ACL. Then you need to address all the concomitant pathology. So you have meniscus tears and what I just showed you, and even the tibial slope, maybe in revision cases, not in primaries. And in my hands, I consider that lateral tenodesis, I don't know. You can ask my fellows down there, you can chat with them, 10 to 15% or so. Here's just the vision slide real quick. Freddy used to do this. He made one in 2000. Actually, I made it for him for 2020. So now we're in 2020. So I made one for 2040. So here's the injury of the athlete. Here is 3D planning that you do. We do that anyway already. There's virtual reality. I think that's also already quite present. And then you can do three-dimensional arthroscopy. And then on the other side here, you get some stem cells. I stole this picture from John X. You can then use a scaffold and 3D print your new ACL and implant that. So what do you think about that? So, all right. Thanks guys. Awesome. Great talk, man. We're gonna take some questions from people. As always, the fellows, we ask you to send in questions. I'll start with one, Volker. When I do these, not because of my elbow experience, it really doesn't have anything to do with that. I think that this is a small piece of tissue on the lateral side, the ALL. It's fairly unimpressive. And so, taking a graft to me or taking a free graft anyway, or a tendon graft, I like the Lemaire idea, but I've been doing it with an internal brace and just sticking two little 3.5 millimeter anchors on both ends. Any experience with that? And what do you think about that? Yeah, you know, I totally agree. It's a small tissue using a free tendon graft. If you use a semi-T, that's probably two, maybe three times as big as what the lateral capsule structures would be. I struggle with this. Interesting is this, right? So the more you operate, the more you have failures. Don't tell me you don't have any, right? I've got plenty. Patient, I just reviewed an article with no failure, so it's rejected, but I recently had a patient walk into my office. I operated on his ACL when he was 13, open thysus, quad tendon ACL, and lateral tenodesis. I think, Seth, I forwarded this case to you a few days ago. And the tenodesis part is untouched. The MRI shows the ACL is completely busted. His meniscus is toast, yada, yada. But that tenodesis isn't. So in my mind, and if you ask me about the internal brace, it may have a role there, the function of the tenodesis is probably in these first six to 12 months to give you an extra check and prevent the tibia from sliding out to anterior. Maybe we can be more aggressive in therapy. I don't know. But my data that shows that the lateral tenodesis caused a bit more posterior translation in the first six months, maybe you can be more aggressive in rehab. This is just some thoughts. I haven't tested that. But I think after a while, it becomes redundant. I don't know what happens with the internal brace once the tenodesis becomes redundant. Will it then do anything anymore? Will it harm? Will it just sit there? I don't know. I have- Great question. Yeah, I don't know. Can you clarify just one thing for everybody? So I also do it open. I identify the LCL. I bring it beneath the LCL so that I can get to a point that's posterior and proximal to help me try to obliterate the pivot shift. Are you saying that you're bringing your graft anterior after you pass it under the LCL? And if so- Yeah, so I pass it deep to the LCL. I fix it proximal to it. But then the tail of the IT band graft, I flip it over itself and suture it on there again. I'm not fixing it anterior. Okay. Yeah. That makes sense too. And the staple is easy and cheap. I have used anchors there too, but I feel like I can get the tension actually better over the staple. I don't know. I like the idea of the staple. I drill a tunnel and it's A, sometimes it can be tough to judge your length. So you can dump this in a tunnel without bottoming out. So the staple I think is a good option. And plus you have to try to avoid your ACL tunnel. And inevitably they're always right in the same place or very close to it. So that makes drilling the tunnel very tough. Yeah. But the staple important part is, of course, I don't need to tell you this at all, but I know that lots of residents and fellows on the call, you have to make sure the staple is in the bone, right? So if you take a staple and you put it behind the femur, you can splice out and it looks terrible on your x-ray. I've also placed it on the tibia side when you do, you know, Safanini and Marcacci's method, where you go over the top on the femur and staple it there and then come back down on the tibia and staple it there. I've put it too close to the joint line. So I think intraoperative fluoro when you handle staples is probably a good idea. It takes a little extra second. The Lemire itself probably takes only 10 minutes. So you just add that little fluoro. It's probably a good point. I have a question here from Mario. LET decision pre-op or after reconstruction and stability testing? Go into DID or do you assess it at the time? Yeah. Oh, that's a great question, right? So let's start by saying this, right? So there's some nice anecdotes that you see in talks where people do a tenodesis. First, they show you a pivot shift. They show you a huge pivot shift. Then they do the tenodesis and now it's down one grade, okay? And then they do the ACL and now it's down one more grade. I think this would be beautiful if you can just say it like this, but it is not. It is not because every bone and every knee is different. So I think my decision is pre-op. Just like in a multiligament, when I decide, do I add the MCL? Do I add the LCL? This is pre-op. It's your patient talk and the MRI preliminary plan one. Then it's anesthesia and EUA. Preliminary plan gets modified and that's what you stick with. So I don't know if that makes sense, but so that's how I do it. However, rarely though, if you had a positive pivot shift after a well-done anatomic ACL, maybe you'll add LET and that would be extremely rare scenario. I wouldn't leave the OR with a positive pivot shift because that's the purpose of my operation, I guess. But I think with your pre-planning, you would have known that and obliterated it. Are you doing routine pivots on your post-op, in the OR post-ACL? Are you doing a routine pivot? Yes. All right. So, I mean, I'd be happy to talk more detail here. So here's the detail. So Andy Sheehan was a fellow with me two years ago and we're just in the acceptance phase right now with AGSM. So please look for that article. It's gonna come out any day now. We did exactly this. We pivot shifted every patient after the ACL. We actually sterilized these yellow markers. We did it before and then during the case. And we did it after the tenodesis. And then in other patients, we did it after the ACL. So we fixed one and the other. And unfortunately, it's just not true that after each tenodesis, the pivot shift grade goes down. It's true for some patients, it really is, but not for every. And that's because, in my mind, well, obviously it's multifactorial, but I think the bony morphology is what dictates this more than anything. But Mark, your question, do I pivot shift? Yeah, I pivot shift after the ACL is fixed. And that, in the beginning, feels a little bit crazy because you don't usually do this. But through these studies that we did, yeah, I've gotten used to doing that. Well, no, Ty, the reason I was asking is because we did a study looking at the effect of over-tensioning your ACL graft in the OR or not. And we were doing KT-1000s sterilely in the OR before we put the dressings on, after we'd closed up. And when we were talking to people about doing it, a lot of people just freaked that we would actually put that much force using a KT-1000 in the operating room or even, you know, we did it at six weeks, three months, six months. And people were like, you know, they couldn't believe we'd be doing the KT in the first six months. And so I thought a pivot, particularly, you know, I use a regular leg holder and, you know, that means you have to undo the whole leg holder and it's a little bit tougher to do that, that some people that would freak with that. So I was just kind of curious. I make my decision on using it, you know, to augment based on the degree of pivot, you know, under anesthesia before I start. I make that call then, you know, because I think it's better to control rotation eccentrically than it is centrally, right? It's hard to control the pivot through the center rotation. So I think if you have a big pivot, then I think you need to do you need to augment it in one way or another let the modified lamar I think is a great way to do it um or you know just jeff using his internal brace as a as an all or some other all substitute whatever you want to do but I think you make that decision based on the degree of pivot if somebody has a minimal you know just a trace pivot I'm not going to do a lamar I'm just going to do my acl and I'm going to be done with it but if they have a if I they go at a two plus I'm going to do something about it but I want to argue back and tell you that I believe if you do an anatomic acl your pivot is gone and I believe that because I tested that now you also know that about 10 percent of the patients have a gliding pivot shift because they are hyperlaxed and that's published and that's there and unless you test the contralateral knee before surgery you will never know so if you still have a pivot shift afterwards that may be that gliding pivot shift that they're used to having but you didn't know because you didn't test the other side I think then you have a trouble that you potentially make this thing too tight so we always test both sides you know on clinical exam but you know when I when I spent some time in the or was that Stefano Zaffinini you know they'll do they were using their instrumentation navigation system to check the pivot and the pivot didn't disappear it got better like by a grade when they did the acl without doing the augmentation and then they tested after doing the augmentation it never fully disappeared but they were using a hamstring they weren't using right but you know patellar tenograph but yeah but I would argue still that you may be able to eliminate it at time zero but your strains on the graft are going to be increased um if you don't augment or if you don't go eccentrically to help protect it and that that's I think you're going to continue to have that risk of rotation and failure that's no data that's just a hip arthroscopist talking so and I mean I'm interested like I said stability too where we will test quadriceps and patellar tenon ACLs with and without the lead I think that'll be very interesting so I'll throw a little bit of Alabama wisdom at you that one of the things that Dr. Andrews says all the time is that there are a lot of things that see us that we don't see and over the course of our careers hopefully we see more of those things that maybe we didn't see in in the beginnings and you know I think that as we've gone through our experience here as you said there's 10 percent of these people that are a little bit more lax there's probably some of these people we get a lot of revisions we get a lot of failed you know knees that we have to fix on the multiply failed ACL I don't care what their MRI looks like or what I think their exam feels like I'm putting some form of ALL in their knee if they're on their third ACL there's something that we're missing you know especially if I thought the ACLs were well positioned or their tunnels are well positioned yeah there's something that we're not seeing that may date back all the way to the initial injury and now on MRI you're not going to see that and then so are there some things in the beginning that we may have lost or that there may have been a lateral capsular injury or some subtle lateral sided or post lateral corner injury that that at this point would be almost impossible to undo reliably and to me I think that's one of the places where I've seen the benefit of these type of techniques in the population of people that I end up seeing which is the sometimes the third and fourth you know failed ACLs so have you seen the same do you how do you feel about doing it in those settings? Yeah absolutely when I when I look at the two and three times failed ACLs my first look actually goes to the atrial slope and and most most every time that slope will be higher than 10 degrees and so and I just had this discussion with Al Getgood I don't know if Al if you're on the line then maybe chime in but we just had this discussion what do we do in our revisions and so I just looked up my last 100 some revisions with Philip my fellow who's on the line too and so my preference in those cases is obviously you do CSI that's that's what Freddy always says you do CSI right crime scene investigation what was wrong what was done wrong and you find the tunnel is done wrong and whatever else but two times done wrong and three times done wrong and you still fail there's there's more to it right and so you sometimes see that the roots have been neglected and you go after those you can sometimes see that the meniscus is just toast right that's that's what Moon and Moss showed us and and Rick Wright published this that in a revision you have what they have seven percent of the cases that have neither meniscus or cartilage issues so I look after all this and then and then I look for that slope and if all of that is clean I know this good slope is fine meniscus is fine oh yeah they're getting a lateral tendon disease no question but that's rare that's rare most of the time they're getting the slope corrected I do that more and more these days in the second revisions and meniscus transplants any other questions from the fellows out there we still got you know 70 of you guys on the line hey Jeff can I can I ask you to pass off one of the pearls that you had said to me when we were talking on the phone I don't know a month ago or so you you were talking about um failure rates in the medial portal approach versus trans-tibial approach based on graft on graft type yep you want to comment on that yeah so you know I trained at HSS and we did patellar tendon grafts in the leg holder and we drilled through the tibia using an over-the-top guide and I can remember Dr. Warren and Dr. Wickowitz and Olchek and Hanifin and all these guys these great giants of surgery teaching us these things with great outcomes good results I came to Alabama and Dr. Andrews did it the same way trans-tibial patellar tendon grafts you know hamstrings for revisions occasional primaries with hamstrings so my entire training I mean I was comfortable doing hamstrings and patellar tendons and then we got into the medial portal stuff and the thought that we weren't able to get there through the tibia so we did a couple of studies looking at that because it didn't make sense to us what people were saying that there were people going around saying it was malpractice through the tibia and you know that seemed a little bit odd to us since we didn't see anything like that I mean we were absolutely not seeing bad results with our trans-tibial things so we had a couple of opportunities to discuss these things Mark Clatworthy who's a very talented but very busy ACL surgeon in New Zealand had an interesting study that he presented at the Herodicus meeting and subsequently published where through four periods in his career he went through four different stages of ACL surgery he went with patellar tendon through a medial portal patellar tendon through trans-tibial hamstring trans-tibial hamstring medial portal and he found that the worst outcomes from all of them were drilling the ACLs with patellar tendon grafts through the medial portal at which time Russ Warren stood up at this meeting and said the worst mistake he made in this entire career was listening to all the morons that told him he had to drill through the medial portal and he went away from me what he had done for 30 years and had good results with and so he went back to doing it through the trans-tibial and we did the same thing because we went to medial portal and we saw more failures than we'd ever seen with our ACLs under two years so we went back to drilling them through the tibia and we did some more study and we looked at some mathematics of geography and geometry and and figured out why that works so what I teach our guys is number one if you're drilling a graft for a tunnel for a patellar tendon graft the graft material is on the back side of the graft it's a ribbon and you're placing that material low in the tunnel so if you're drilling a hole like this the graft material is sitting on the back you don't want to drill that dead in the center of the ACL footprint because then you're putting your graft material in the very worst possible biomechanical position it would be better to be a little bit high than a little bit low we've seen that a couple of times whereas if you're drilling a hamstring graft you truly have a round mass of collagen and you want to try to put that dead center on the anatomic origin so I drill my tunnels differently I drill my hamstring tunnels a little bit lower on the clock face than I drill my patellar tendon grafts because of where that tissue sits at time zero and biomechanically has to interact through rehab and healing so I've seen much less problems much less failure than I had when I was doing my patellar tendon grafts through the medial portal so that's just been our experience I would tell you Lyle would say the same thing and so would so would Benton Dr. Andrews when you tell him he has to drill through the medial portal he will he'll throw a fit about that because he vehemently disagrees with that so that's been our experience and we've kind of gone to maybe switching it up depending on what the graft source is. That's I think that's it's helpful you know I I would agree with you I worry about you know the non you're so much more non-isometric and I think the the fixation is more rigid on the on the patellar tendon graft as well that I think it would put it at greater risk. I can I can tell you I have in my life not once drilled transstibial so I wouldn't know how to do it and one part may be interesting it's the switching part right you because Martin Lynch showed the same thing with the Danish registry the same exact stuff right they all came out at the same time it's like oh no you can't go through the portal but then you know there's some learning curve stuff too so because you can obviously also go outside and I think the position of course is important and and the rectangular tunnels have also been discussed for those that use quad or patellar tendon and then you fill the material more into the tunnel so I think all that makes makes a lot of sense. Hamstrings is bulky but hamstrings has different fixation right and now you also violated the agonist to the ACL and you take some flexion power away so I think all these factors have to come in when you're using when you're choosing graft choice and drilling technique. So you started down a path there Volker can I can I lead you down that path a little bit more and actually about that the the ribbon the ribbon technique. No I didn't lead you down that path Jeff did. Well Jeff said ribbon you said slotted the slotted tunnel or whatever you you were kind of hinting at that you know adding to Jeff's comment do you want to you and Jeff want to comment on the ribbon technique? Sure sure so the if you want to use that technique you'd basically drill two little tunnels into the femur like K-wire tunnels and you connect it with a with a slot maker with a dilator that is more oval than round and so now you know the idea is that you make that tunnel right like Jeff said along the ridge just posterior to it and the big question that the hamstring lovers asked in the 90s is why would you make a round tunnel to put a small two millimeter patella tendon in there right and so that's that's basically why you know and whether you I know you want us to discuss whether the ACL is actually a ribbon or a bundle and I don't think that matters. I think before I let Jeff talk on this I would say read the KSSTA article that came out a month or so ago on the anatomy of the ACL on cadavers that were tested and yes you know in those that were 50 and older in the old specimens you have these c-shaped type of tibial footprints and in those that are younger specimens so obviously our patients are more in the younger category it's more oval and there's certainly two bundles to it and if you stretch them they become a ribbon so all right Jeff your turn. Yeah I don't think it's a ribbon necessarily in vivo but I think what we put in there certainly is a ribbon when we put it in there so I think it has some ribbonish behavior at times and and I think we're putting a ribbon in there if we're doing patellar tendon grafts so I just and I'll say this my fellows hear me say this all the time ultimately you have to do what works best in your hands and and if you're great at doing hamstring grafts and drilling them in outside in and upside down and backwards then that's what you should do and I see more people getting trouble surgically and outcomes wise trying to do things that they're just not it's out of their comfort zone the operating room should not be uncomfortable and and if you're you're not going to get the best outcomes doing something you're not comfortable doing if you've been trained a certain way and you've seen it work and you know how to make it work you should stick with that and learn over time over your career as you become better surgeons and you become more experienced and more facile with trying new things you can try those things but as you start out you definitely should do what you're what's in your comfort zone or you're going to find yourself on the wrong end of some outcomes not not not on the beginning of your rotation though they need to be doing it your way on your rotation don't they well they do everything my way I'm saying when they get out of my out of my purview and out there in their own oh okay just wanted to be clear your own hands I think that's fine to say you're doing it my way if you're getting out there and you're you're comfortable being a hamstring guy to go ahead and do that but based on evidence now we need to be able to risk stratify those hyperlax young females for example or you know other high rotators that you may need to add the things that Volker is discussing so I'm a btb guy and I use quad and I very rarely use hamstring so I'm less apt to have to add a let for a lot of cases I'm adding them for you know more challenging cases or revision like you discussed so and you have to be mindful that we can't say that they're all the same but it wears best for you necessarily I think we you have to think more carefully when you're a hamstring guy would be my definitely young athlete we got a couple more questions here from the audience this is from Kathy Hannah Miranda in the case of a high grade pivot shift associated with lateral meniscus posterior root tear with a plan to do an anatomic reconstruction with a btb or quad autographed plus root repair is there still a role for let in this scenario you can go to the panel and everyone can answer it there's always a role for it in my hands I'm happy to see the lateral meniscus root because I know I reduced that uh I will restore not just the anatomy but also the instability I probably don't add a let to it how about you guys I agree I agree as well yeah same agree yeah I mean it depends if you know if depending how big the panel is and who else is on the panel you will get answers from 100% let to never let and so but I think you repair that meniscus you'll be fine just don't miss it so you actually need to take that time figure out for post year scope yep that's the point is don't miss it um another one can you comment on taking quad above a prior failed btb have you seen any issues with two hits to the extensor mechanism awesome I love that question well like uh Jeff said like Jimmy Andrews said I haven't seen it but it may have seen me I have patients that come to me and I did their btb now they failed the other knee and they beg me not to do btb please do quad because it hurt and I have patients exactly the other way around I did quad first and now on the other knee they beg me not to do quad again it was such a tough rehab um so there are always these outliers I have done quad tendon with bone in cases where there was btb taken but I do a ct scan beforehand and if this is a patella parva you shall not but a large patella and a big football lineman lineman and bone graft on the patella was taken years ago and is fully bone grafted and healed over yeah take quad tendon bone that's rare though mostly it'll be soft tissue only and I take a partial thickness strip I close the defect I have not seen issues again I may be my ignorance I've done about 10 to 12 of those uh x has done I think last time I talked to him at the panther symposium over 60 uh ipsilateral uh quad after btb and I haven't seen the published series on it yet but uh you know actively said that he's not having issues I didn't have issues with atrophy or without bone fracture yeah yes that sounds coming back to you Volker and saying don't do the same thing yeah don't do it Volker whatever you did it hurt too much do some do some different it'll hurt less I'm telling you and I've seen it from the btb folks and from the quad tendon folks um most patients uh obviously have very little donor side issues otherwise he wouldn't do that um hey quick commercial since Seth mentioned panther June 12th we have panther webinar you can find the free link free of charge five o'clock in the evening eastern time on the cost and ask our website thank you don't don't worry Freddy you'll send that out to everybody so they'll all get it right drink drink hey dread river distillery might want to sponsor the panther meeting that'd be nice in person please yeah for sure I'll show up how are you there count me in do Steve Cohen how are you I'm well excellent all right um no other questions from the uh fellows or any other comments from the faculty thanks for having me appreciate it great job man enjoyed having you always learn something from you thanks same here be safe everyone see you thanks thanks guys thanks

Dr. Volker Musahl

knee stability

ligament stability

rotatory knee instability

University of Pittsburgh

treatment approach

collateral ligament

meniscus injuries

surgical techniques