Good evening. Thank you for joining us for the AOSSM Fellows webinar, High-Risk ACL Patients, with faculty doctors Andrew Giesland, Alan Getgood, and Robert LeBron. Dr. Giesland is an orthopedic sports medicine surgeon at Ascension Gorgeous Orthopedics in Kalamazoo, Michigan, clinical assistant professor at Western Michigan University School of Medicine, and adjunct associate professor at Western Michigan University School of Mechanical and Aerospace Engineering. Dr. Getgood is a complex knee and sport medicine surgeon, associate professor, and orthopedic sports medicine fellowship director at Fowler Kennedy Sport Medicine Clinic at the University of Western Ontario in London, Ontario, Canada. Dr. Leprod is a complex knee surgeon at Twin Cities Orthopedics in Edina, Minnesota, and an adjunct professor at the University of Minnesota. Thank you to OSER for their support of this webinar. To submit a question on the GoToWebinar panel on your screen, click the questions drop-down arrow on the right-hand side of the panel. This slide shows where you input your question and click send. I will now turn this over to Dr. Leprod to begin the content presentation. Hi, good evening, everybody. I'm sorry my video isn't working so you can't see me, but part of it is I just got off the lake doing paddle boarding. So we'll go with that. I just need to get Alan and Andy's pictures out of the way because they're over all my slides. So hang on one second. There we go. So what I'd like to first do is thank OSER. OSER has been a great partner with AOSSM. It has also been a great partner with the Orthopedic Sports Medicine Fellowships, and they're sponsoring this tonight. And what we're going to talk about is some of the things to think about when you're looking at high risk and revision ACL reconstructions. So I'll go first and go through some of the things that I think about every single patient I see to try to get the maximum outcome. And then Dr. Gieselin is going to talk about the anterolateral complex and how to address it with reconstructions. And then Dr. Gekuit is going to go through the hot topic that's been coming recently of increased slope and how we can address it. And Alan is one of the world's experts in that. So I think you'll learn some good information tonight. These are my disclosures. So what I'll try to review is go through some of the causes and the diagnosis for tears and failures. It's important to know all these factors so you can avoid failure, and then try to decide when you need to revise and whether it's a one or two stage ACL revision reconstruction. So these are the factors to look at. Malalignment is essential, both in the coronal and sagittal planes with slope. You also have to think about concurrent instabilities and think about posterolateral, MCL that's untreated or the anterolateral complex. Meniscus tears, especially ramp lesions of the posterior horn, the medial meniscus, and meniscus root tears, especially lateral meniscus root tears. If you do 10 ACLs a year, you should be doing at least one lateral meniscus root repair. General recurve bottom measured by the heel height is very important because it can affect what type of grafts you have and your success rate. And then graft choices, autograft or allograft, or deficient menisci, the deficient medial meniscus or lateral meniscus can make a difference in the Lachman and Pivotshift test. Then recurrent trauma. And then beware of the bad original technique with the revisions. That is still the number one cause for revision ACL reconstructions. Now for slope, I'm just going to go through this real quickly because Alan is going to cover it, but basically higher slopes result in a higher rate of non-contact ACL tears. And think about this post-gradually is when you see something with a higher slope, those may be the ones for primary cases you want to look at that anterolateral complex reconstruction, or for revisions, you may want to decrease their overall slope. We did some work showing that tibial slope has a strong linear relationship to the amount of force that is seen on an ACL graft. And the flatter the slope was, the significance on loading of the ACL grafts was less. And six degrees seemed to be our pivot point. Below six degrees was important. So we're trying to decrease them to at least six degrees. There's a clinical study that I'm sure Alan will go through with Lucy Salmon that showed that if you had a slope of 12 degrees or more, there was an 11 time increase ACL failure rate and the overall success rate at 20 years was only 22%. So we need to do better in these cases and recognize slope early on. This is what it can look like when you have that increased slope, but basically the tibia slides forward. And this is what you can do for it to decrease the slope. You can do it with or without a tibial tubercle osteotomy, and Dr. Goetke was just going to cover that in detail. Posterolateral instability also has a significant effect on an ACL graft. And when I first started out in practice, that was a common cause of failures of ACLs. And unfortunately, it still is in my referral practice where patients are coming to me and there was an unrecognized FCL or a complete posterolateral corner injury. I did one today. We found out with our biomechanical testing, it's the varus that significantly loads the ACL grafts. So the papateus doesn't have a lot of effect on an ACL graft. And if you think about it, when you externally rotate the knee, the ACL becomes loose. So it's a varus that's the important part. And you should really be looking at either repairing or nowadays looking at reconstructing posterolateral corner injuries at the same time as an ACL reconstruction to reduce the risk of failure. We've also known through the literature, and there's other studies out there that show that when there's a torn MCL, it significantly increases the load on an ACL graft. And the Scandinavian registries are showing us good data that if you didn't treat an MCL and it was loose at the time of an ACL reconstruction, there's a higher rate of failure. So it used to be, we thought maybe we can let them go and they'll heal in, but you're probably going to end up with a much higher rate of failure if you do that. So you should look at doing reconstructions and doing appropriate rehabilitation to see if they do heal. And then this is something that Dr. Gieson will cover, looking at anterolateral complex injury. There's still a lot of controversy about what exactly the anterolateral ligament is. And also looking at a ligament extra-articular tenodesis procedure, and he'll go through that in more detail. But it's important when you do see an increased pivot shift and you don't see these other factors that can be overloading your ACL, that possibly adding this type of reconstruction can take more of the stress off your ACL. And Lars Engebretsen showed that almost 30 years ago, that when you do this type of reconstruction, you can unload the ACL graft and give it a better chance to let biology catch up in a revision case. Also look at medial meniscus ramp tears, so posterior horn tears of the medial meniscus. Remember that the meniscus attaches about a third of the way up the posterior horn. It doesn't attach to the top of the meniscus. So you really have to look through that posterior medial portal adjacent to your PCL, the Gilquist approach, and then look down on it. If you can't see it, you can switch to a 70-degree scope, or you can stick a spinal needle through the posterior medial portal and pull on the capsule and see if you can see it. The Europeans commonly add a posterior medial portal. It's almost routine for some of the high-level surgeons there to make sure they don't miss these ramp tears. So try to figure out a way that you can always look at it and not miss it. Because if you do, the biomechanical studies show that it'll overload the ACL graft. There's a much higher rate of failure also. What about lateral meniscus root tear? Dr. Gieselin's study showed us that when you do have a lateral meniscus root, you can lead to a lateral compartment overload that can lead to arthritis. And we're starting to see that more and recognize why these patients have some arthritis with ACLs when they have untreated root tears. But the other thing that we see clinically, and if you look for it, you'll be able to figure it out, is that they almost always have a 3-plus Lachman and 3-plus pivot shift when there's a lateral meniscus root. So if you're examining the patient on the table and you see a 3-plus pivot, you shouldn't be just thinking that you have to do an anterolateral ligament reconstruction. Maybe all you need to do is do the lateral meniscus root repair, and that'll take care of it for you. You don't have to add these other type of extraticular procedures because you're still going to end up with arthritis if you don't fix it. And what about non-anatomic root repairs? You really have to put the root back where it should attach. Because if you don't do an anatomic repair, you're going to end up with joint overload. And the complication for this is osteoarthritis, which we want to avoid in these younger patients. Look always at heel height when you're assessing an ACL, because if you do have a heel height that's more than 5 centimeters above the table, you have an increased risk of failure. And Chris Larson has showed us some good studies, and our Korean friends have also showed us this, that if it's more than 5 centimeters, your failure rate is really high, especially for a hamstring graft. The failure rate approaches 25% to 30% in the studies. So you may want to look at using a BTB, even if it isn't part of your normal graft choice, when you do see this much recurvotum, because if you do a lot of ACLs, that's a really high failure rate. Then graft choices. The graft choices should depend upon the patient's age, their gender, and their overall laxity. And the BTB graft is a graft of choice for athletes and higher risk. There's some newer information coming out about quad tendon, but you have to be careful, because there are some studies that show that it may be a higher failure rate too. But number one is to avoid allografts, especially in patients less than 25 years old. Right now, I will use autografts in patients up to age 60, and other than a few days of extra pain, they seem to heal in very well and don't have the problems with allografts with stretching out. And if you have to, use a contralateral BTB if it's already been harvested, or if you don't have a hamstring autograft. And other things you can look at is quad tendon. But look at autografts as much as you can, especially for revision ACLs. Now the interaction of your ACL and the posterior horn and the medial meniscus is essential, because if you do have a ramp tear, you should be able to pick up on your physical exam that you see the Lachman tests that you want to run and get a medical student, because you know they can get it right the first time. So when you do have that separation posteriorly of the medial meniscus, it's going to cause extra tibial translation. So look for that, because it can overload your ACL graft. The same thing for the lateral meniscus. The lateral meniscus is important for the pivot shift. So if you do have a deficient lateral meniscus, which has been shown to increase the lateral compartment translation by up to 7 millimeters, you have to look at a lateral meniscal transplantation at the same time. Otherwise, you're dooming that need of failure, because the ACL will be overloaded. What about recurrent trauma? In almost all the studies, that is one of the lowest things that causes recurrent pathology. It's something you have to think about. But remember that technical issues are number one, and missing these other things are number two. So recurrent trauma is actually not that common. And if it's your own case, you maybe want to take a close look at what you did, and maybe you didn't think you put the tunnel where you needed it to be, or maybe you missed a root tear or something. The options in that case, you can drill larger tunnels. You can use larger interference screws, which I don't totally agree with. You can use bigger grafts, but that should be autografts rather than allografts. And you look at bone grafting and second stage reconstructions. I'd encourage everybody who does revision ACLs to get a CT scan, because you can look at your tunnel size and see what your trajectory is, and it's just information you wouldn't normally pick up on your MRI scans. And if the tunnel is greater than 12 to 14 millimeters wide, there's papers out there that say 12. Most of us agree that 14 or wider is way too big. Or if they overlap with an old tunnel and make it so you're going to have a bad tunnel position because the previous one was not quite ideally placed, then you should consider a bone graft as the first stage. Multiple errors in the femur are still the number one cause of failure. People tend to put them to anterior, which Dr. Clancy called resonance ridge many years ago. If you look at the old article by Bernard and Hertel in 1997, that's still considered the gold standard with the grid that I'm showing in red below. And use a lateral x-ray and you can see where your graft is. And the ACL center is going to be about 25% from the top and 25% from the back. So it should be in that back quadrant and you can see it's below Blumensat's line. So if you look at your x-rays and the screws above Blumensat's line, by definition that graft is probably in a bad position. Technical errors in the tibia, it can be too anterior, mostly it's too posterior, sometimes it's too medial, but it can cause multiple problems including flexion contracture, graft impingement, and ultimately cyclops lesions. Usually central posterior grafts don't have good rotatory control. And the new hot topic is causing detachment or partial detachments of the anterior horn of the lateral meniscus. So there's some studies from Japan that show if your pin drifts just two millimeters from the center of the ACL to the lateral meniscus, the lateral meniscus can extrude and those patients are getting overload and arthritis. So that's probably something all of us have done and not even really recognize it. So you really want to make sure that you're not taking out that anterior horn of the lateral meniscus. Postoperatively, you have to look at your PT protocol because that can make a huge difference on your success rate. Returning to play before nine months, there's an increased retear rate, whether it's autograft or allograft. So if you're going to let your players go back before nine months, you better do some good testing and consider using bracing because the rate of retear is significantly higher. If you have revisions, if you have that extra recurvatum, if you have an increase in slope and other things going on, you may want to consider one of these newer dynamic ACL braces because they're going to put extra protection for your ACL graft that a static brace can't do and the static braces have been shown not to work as well. So dynamic bracing may be an option for these high-risk and primary revision ACL reconstructions. Time-wise, historically, failure rate's been roughly 30%, so we can tell our patients historically about 70% of the time revision ACLs work, about 50% to 60% return to sports. When we looked at ours, looking at staged and unstaged and trying to address all these things, root tears, ramp tears, slope, alignment, and everything, and then looked at our outcomes, we didn't find any difference between the staged versus unstaged, and the patients were equally satisfied. They didn't care that it took two surgeries to fix them. What they cared about was that their surgery worked, so we're able to drop our failure rate for the two-stage down to 6% and single-stage down to 10% following the protocol and making sure we try to address all these issues that we've gone through. So in summary, looking at high-risk ACL tears, you really need to think about all these issues from looking at the X-rays and chronal and sagittal planes, and then looking at the menisci and other things that are associated with instability. For revision ACLs, remember technical errors are unfortunately the number one cause of failure. Malalignment can also be a problem that can lead to recurrent failure, and concurrent instability like posterolateral MCLs need to be assessed, and then be prepared for those secondary stabilizers to look at repairs of roots or reconstructions with the anterolateral complex, or look at two-stage surgery, which include bone grafting or osteotomy. Thank you. Meredith can you hear me okay? Yes. Perfect. Are my slides appearing all right? Yes. Wonderful. So thanks for the opportunity to present with this group. I think this is a very important topic of course. So from a diagnostic standpoint for understanding patients that are at risk for these types of injuries, we have to be very careful in the sense that I can't discuss that. And one of the postgraduate moves that he taught me or that I've been thinking about is when you have a patient with a really high gridlock or pivot shift you have to look for that root or ram lesion. But an evolving topic is to also evaluate for that anterolateral complex injury. And of course you can't forget the collateral ligament injury and that certainly needs to be treated. We can't focus primarily on the anterolateral complex because it's a new topic and forget about the collaterals. MRI is certainly going to be useful in the acute management, I'm sorry, the acute evaluation of these injuries. However, in the chronic setting it's going to have less utility and my video isn't playing here because it's running off PDF. But you can certainly evaluate MRIs for injury to the Kaplan fibers or to the anterolateral complex including ALL or the capsule osseous layer. But in the chronic setting you're not going to be able to see these so I would not rely on MRI for diagnosis in that setting. And again the Kaplan fibers, ALL, COL, you're going to hear a lot of these terms. These are all involved in control and rotation. So a lot of us learned about the ALL or it got popularized about seven years ago with the Journal of Anatomy paper by Stephen Klaus when he reported on the ALL and the lay media, lay press picked it up and it became everywhere and residency programs were talking about it and it became a hot topic at meetings. But this really isn't a new structure. It had been previously described but varying nomenclature had been used and there have been reconstruction techniques in existence for decades. Because of the increased interest in order to shed some light on this topic and develop consensus around it Dr. Getgood and Dr. Brown convened a meeting in the fall of 2017 where we reviewed the anatomy, biomechanics, and clinical relevance trying to come up with some recommendations for managing these injuries and further research. Part of the anatomy discussion focused on the ALL and there's a fair amount of debate regarding the structure of the ALL and the importance of the ALL. On the left you can see the fibular collateral ligament and with internal rotation of the tibia you can see the anterolateral ligament with the pound sign there and you can see that it overlaps the fibular collateral ligament but there's a fair amount of debate on the anatomy and the biomechanical relevance of the structure. Looks like it's skipping some slides here. Do you see that Meredith? It looks like yeah we can hear you okay we just see we see the biomechanical results study shown right now. Yeah that skipped over a few slides I can just I can cut through that. The next slide was showing the capillary fibers and the anatomical relevance of that and the capillary fibers have a role of restraining internal rotation as well. One of the main influences is the restraining internal rotation in the absence of an ACL so they're a secondary stabilizer and there's the proximal and the distal capillary fiber and those are reviewed really nicely in GetGood's paper in that consensus paper that we wrote but there's also an important structure called the capsule osseous layer the retrograde convoluted fibers and those have a role in restraining internal rotation together with the anterolateral ligament and the anterolateral capsule. If you work through that paper that GetGood paper and those were in the slides I'm not sure they're not loading but there are a series of consensus statements made regarding the biomechanics of the native structures as well as the biomechanics of the reconstructive techniques and the primary soft tissue structure the stabilizer for coupled anterior translation and internal rotation your extension is felt to the ACL but we can't forget the IT band including the capillary fibers lateral meniscus ALL and the anterolateral capsule and that's outlined really nicely in that article. As Dr. LaPrade mentioned there have been a lot of historical biomechanical studies and one of them was by Dr. Engebretson out of Oslo actually at the University of Minnesota at the time and he evaluated the role of the lateral extra-articulative tenodesis with concurrent ACL reconstruction in the lab and what they found is that performing a lateral extra-articulative tenodesis at the same time as the ACL resulted in unloading of the of the graft of the ACL graft which may have a protective role during healing. A downside of the historical techniques were that they limited rotation and ultimately the biomechanical studies revealed that there was reduced internal rotation compared to the native state but a potential benefit of that was a decreased ACL graft force with the LAT. We did a systematic review a few years ago on the anterolateral ligament reconstruction techniques and there were far more techniques that were reported than actual outcome studies on the techniques and most of these were pretty similar with a free graft connecting the tibia and the femur but the attachment points in the tibia and the femur were pretty variable and you can review the illustrations in this article but they're all variations on the same idea that it was an extra-articular structure fixed proximally at the femur and distally at the tibia which is which is uniquely different than the lateral extra-articulative tenodesis that Dr. Getgood published on recently with the stability trial where you leave the distal attachment at the GERDES tubercle and proximally bring the graft deep to the FCL and fix it on the femur. So this is more implant heavy procedure when you're looking at the ALL reconstruction techniques. The big question really and that my residents ask me is what's the relevance of this so we can review the anatomy and the biomechanics but they want to know what is this indicated when should they use it in their practice in the future and based on the study that we had back in 2017-2018 there wasn't great clinical evidence there's level three and four studies but not randomized trials at the time. This slide is a little bit out of date because since this time Dr. Getgood with the stability trial was able to report on a randomized trial of hamstring versus hamstring plus LET. So we do have some more information on it but still the evidence is a little bit mixed and indications may include revision ACL settings, higher grade pivot shifts, ligaments laxity or recurve bottom in young patients returning to pivoting activities. So I'd like to review some of the studies that show us the available evidence. There was a slide on here by Ferretti that looked at patients that were treated in the year 2002-2003 and they evaluated hamstring versus hamstring plus a modified McIntosh which is similar to the modified Lemaire but the graft is dunked deep to the FCL and sewn back on itself and what their study revealed is that there was a no change in the development of lateral compartment arthritis and there was a decreased failure rate. Sonnery-Catet has been a big proponent of anterolateral ligament reconstruction and published a non-randomized trial prospective study but non-randomized when they compared hamstring to BTB to hamstring plus ALL and they found a reduced rate of failure with the hamstring plus ALL. Dr. Getgood's study that I've been referencing was recently published in AJSM and won the O'Donoghue award at the median last summer at AOSSM. They were able to evaluate a large number of patients in a randomized trial and the results revealed that the primary outcome of asymmetric pivot shift had a 40% failure rate with ACL alone but when you added the LET it went down to 25%. Again, that's a physical exam of asymmetric pivot shift and graft rerupture fell from 11% to 4% so there's clearly a protective effect of adding the lateral exterior tachycardiasis when you're doing a soft tissue ACL reconstruction. So in summary the anatomy is quite important. If you don't understand the anatomy the biomechanics won't make sense. So that's the building block. So being aware of the cap and fibers, capsule osseous layer, antilateral ligament. Recognizing the role that these have in the native biomechanics and their main role is restraining intramotation. A lot of variable findings regarding the biomechanics. Some showing under constraint, some showing over constraint, and some showing restoration of normal stability in the biomechanical studies. And clinically there are limited outcomes available but the ones that are available in the randomized trial I just reviewed are showing promising results but we certainly do need further long-term study longer than just the short-term two-year results that are available thus far. So I apologize for the technical issues with the slides but thanks for your attention. Great, thanks. So I'll take over now Andy. Congratulations on getting through that when you have so many technical issues just shows you really know your subject. So thanks very much first of all to AOSSM and also OSER for the invitation but particularly Rob for asking me to join this panel. I'm just trying to get this on the screen here. So Rob's asked me to talk about the role of posterior tibial slope and ACL tears and as he's already said really it's become really quite a popular topic but the question really always comes to us is when you should maybe address it so hopefully you'll have a little bit of a better idea at the end of this talk. I just have some disclosures but they're not really relevant with regards to the ACL tears. So I'm going to go ahead and get started. I just have some disclosures but they're not really relevant with regards to this talk. So I'm going to talk a little bit about the biomechanics of slope and ACL strain, talk about who's at risk. We are talking about this the at-risk population, maybe some case examples and then also how we go about correcting it. So this is a study actually done in 2004 by my now partner Bob Giffin when he was a fellow down in Pittsburgh with Chris Harner. It was one of the first studies to look at what the effect of posterior slope has on the ACL. It's a biomechanics study and they showed that that posterior slope resulted in increased shear strain and ACL in stance phase with the three times body weight loading. The ACL has to resist 0.5 body weight and an increase in four degrees of slope results in 200 newtons. Axial load results in an increase of three millimeters anterior translation. So really that increase in slope with increase in axial load really does have quite a significant effect on your anterior translation. More recently some studies from Rob and one of his fellows at time, Andrew Bernardson, did great work looking and really showing the direct proportional relationship of graft force and tibial slope. So with increasing tibial slope you end up with increasing graft loads and the converse of that is the effect on the PCL. So with a decreasing slope you end up with reduced, you end up with increased force on the PCL as well. So really there is quite an interesting relationship between slope and both cruciate ligaments. So what happens well when you're walking, I've already stated about the stance phase. So here you have a patient in stance phase. Now this is actually, if you look at this radiograph, it's a lateral radiograph of someone who's had an opening wedge, medial opening wedge, proximal tibial osteotomy. And one of the sort of classic complications with this particular type of surgery, if it's done incorrectly, is a risk of increasing the posterior tibial slope. And so here you see, and there are a number of different ways of measuring that, but you see with the increased slope you get an increase in anterior translation. So on weight bearing basically you get an increase in slide forward, which of course then causes an increase in strain on our ACL. So what about the relationship between slope and ACL injury? This was a study quite some time ago, in 2006, looking at tibial slope and its relationship to ACL deficiency. And so basically patients who had an ACL injury had a mean slope of 12 degrees compared to controls, where it was just over eight degrees. And also an increase in slope was observed in patients with a higher grade pivot shift. Now Rob's already mentioned this particular study, but that original study in 2006 showed 12 degrees, and it really comes through in a number of other studies from Leo Paczewski's work in Australia, as well as Bruce Bennion, really showing that anything over than 12 degrees is associated with an increased risk of ACL injury and subsequent ACL injury. And of course, the more recent study that Lucy Salmon with Leo Paczewski and Justin Rowe recently published, the association of increased slope along with younger age really can have a catastrophic effect on the survivorship of our ACL grafts, and it's something we always have to bear in mind. If we look at patients with high grade rotatory laxity, when we start, you know, these previous studies have mostly looked at radiographic measurements of slope. Now we can start looking at it with MRI. And then with MRI, then you can differentiate between lateral slope and medial slope. And this study by Volker Mosel in Pittsburgh has very eloquently shown that an increase in lateral tibial slope with a mean of 9.3 degrees was significantly associated with an increased anterolateral rotatory laxity as measured by a quantitative pivot shift using optical tracking software on an iPad. From Italy, Stefano Safagnini's team also looked at this and again looked at a number of morphological characteristics on MRI, similarly to Mosel with in terms of looking at medial slope, lateral slope, a number of measurements of notch width, condylar width, as well as lateral formal condyle offset, and showed really that with an increased lateral slope, and then with, compared to a control group, increased lateral slopes associated with the failed ACL reconstruction, with a further increase in lateral slope being associated with multiple failures. And that can be seen with medial slope measurements as well, just maybe not to the same extent. What they were able to sort of show with this diagram is that with increased proximal tibial, lateral proximal tibial slope, as well as this increase in lateral formal condyle offset, you would end up with this really quite increased risk of ACL failure. Now we've been looking at some of the data from the stability study that Andy's already talked about, and so this was a 90-cent randomized clinical trial in patients under the age of 25 years old, randomized to hamstring tendon autograft with or without a tenodesis. So you've got quite a large dataset to play with. And when we look at our demographics with a mean age of 19 years old, and because we then really focused on what we tried to really focus on high-risk patients, they were included only if they had either generalized ligamentous laxity, had a high-grade pivot shift, or they're going back to contact pivoting sports, as well as Baton score. So you can see here there was really quite a mixture of different patients with a number of those criteria. When we look at predictors of high-grade pivot shifts, so this is examination under anesthetic pre-operatively, after doing a receiver operating curve, we could see that actually nine degrees, similar to what Volker Mosal had shown, seemed to be the sort of the cutoff point in terms of what was associated with the low and high-grade pivot shift. Now this wasn't statistically significant. It was probably more associated with more problematic in terms of our sample size than anything else. But this would suggest there's a 60% increased risk of having high-grade rotatory laxity as opposed to low-grade with a slope greater than nine degrees. When looking at predicting clinical failure, again, this is very preliminary work, and we're still working through the dataset in terms of all the measurements that we've done. But some of the early data that when we started looking at slope, there seemed to be a slightly increased risk of failure if there was a high tibial slope, again, greater than nine degrees. What this forest plot just really shows on the right-hand side is that as the slope gets bigger, the numbers of failures that we were seeing started to increase, and that's looking at our stable versus unstable. So that's our competent primary outcome of asymmetric pivot plus graft rupture. So more data to be shown there, but it just really shows that in these high-risk patients, slope should be definitely considered. So what about slope correction or sagittal plane correction? Well, it's really not a new concept. Our canine friends, this has been an issue for them for a long time. ACL injuries in dogs really have been a big issue. And of course, our veterinary colleagues have been doing tibial plateau leveling osteotomies for years to treat the ACL-deficient knee as opposed to doing ACL reconstructions. So it's clearly known about, and again, Bob Giffen, back in that study back in Pittsburgh, showed that with a reduction in the tibial slope with one millimeters of correction, equating to about one degree of slope change, could certainly reduce the strain placed on our ACL grafts. So what are the results of this type of surgery? Well, interestingly, it's a relatively uncommon procedure, and certainly in the literature, there's only small series. This is one of the first series that was published by Bertrand Sanaricote with his mentor Pierre Chamba in 2014. And this was a technique where the tibial tubercle was elevated, and then a closing wedge osteotomy is performed, and the tubercle then replaced back in situ. And there was really only five patients, so really very difficult to have any meaningful statistical analysis. But for sure, they were able to reduce the slope in the patients along with their anterior cruciate ligament reconstruction. Revision reconstruction seemed to do fairly well, but certainly the procedure seems to work. The procedure that has been popularized by David Desjardins and Leon is a very similar type of technique, except it goes above the tubercle, so the tubercle is left in place, and then just working around the tubercle. And importantly, again, in nine patients, they showed that they could reduce their post-operative tibial slope measurements were significantly reduced. And importantly, the pre-operative to post-operative patella height was not significantly impacted. So, I mean, it may be something that in a lot of these patients, particularly in their, maybe if their second or third ACL reconstruction, they may have a degree of patella bar as a result of fat pad fibrosis. So maybe actually leaving the tubercle in place, doing your osteotomy, and actually getting the patella back to a better height may not be such a bad thing to do. So what are my indications for anterior closing wedge proximal tibial osteotomy? Well, really it's failed ACL reconstructions with increased posterior tibial slope of greater than 12 degrees. And I think you always have to, you can't be too black and white about these things. I mean, if I have had patients who have had two or three reconstructions referred to me and the operation hasn't been done that badly, in which case, you know, maybe if it's only an 11 degree slope and they have a degree of a fixed flexion contracture, then doing a slope procedure may be a good option because you're really trying to do something different. You're really trying to change the biomechanical environment that that patient has been coping or trying to cope with for a number of years. But certainly the primary indication has got to be the failed ACL reconstruction. And here we can see the tibial slope in this particular patient. Interestingly, she had an LET as well. She's one of the primary, she's one of the stability study patients who unfortunately went on to fail. This view, I think, is very important if you're in your practice to ask for a lateral weight bearing view and extension. And because what you will then see, you will see that anterior translation and anterior translation, certainly anything over a centimeter is a real concern associated with the slope. And again, that may be something that you think about adding in an anterior closing wedge osteotomy. I would suggest that you should maybe go with caution, particularly patients who have already have a degree of hyperextension. This is a deflection osteotomy after all. So essentially you're going to create increased extension. And if you do cause a hyperextension thrust, then you'd be looking at doing other complementary or supplementary soft tissue procedures to try and control that. And that can be a very challenging patient. And also primary ACL reconstructions, while it seems very logical in many ways to do it in a primary ACL, this is a big operation that changes the anatomy quite significantly. And there may be other things that you can do, change your graft, look at a lateral tenodesis, maybe even counsel the patients about what type of support they go back to rather than put them through a large osteotomy. And that's something I think maybe you can hold off for the revision if needed. But there will be some parts of the world, particularly in the Middle East, where patients have really got quite extreme slopes, often 20 degrees. That may be something you want to think about in the primary ACL. So it really depends on your practice. But certainly I would advise caution in the primary ACL. So I'll just show you one case. This is a 24-year-old student who in January 2013 playing football had a non-contact injury, had an ACL reconstruction in April that year with a hamstring tendon autograft. He also had a partial medial meniscectomy at that time. That's always a concern, as we've already heard, is the role of the secondary stability of the medial meniscus. September 2013, went back to playing football, had another tear. October 2013, he had a revision ACL with a BTP autograft. And then in July of 2014, playing baseball, stepped on base, felt another pop. And then he was referred to me at Fowley Kennedy with this particular problem. So his examination, really high-grade rotatory laxity, high-grade anterior laxity with collaterals intact. You can see with a 14-degree posterior tibial slope with anterior translation in that extended weight-bearing view. And so we did an anterior closing wedge osteotomy, super-tubicle, brought it down, the closing wedge, fixed it with a couple of staples, maintained his coronal plane alignment, then did the revision ACL with a quad, plus added in a lateral tenodesis. And he's gone back to a pretty decent level of sport. Certainly we didn't recommend him going back to football. So how are we doing for time? I think we probably... Go ahead, Alan. Yeah. So this is just the technique that I use. So essentially, it's a midline skin incision, elevate tibialis anterior off, and then as well as take the sartorius fascia down. Just underneath the MCL. And then you have a medial retractor and a lateral retractor, and then you just apply a number of K-wires either side of the tubicle. And then using an oscillating saw, this is all done under direct lateral fluoroscopy control. We then place our osteotomes just hugging underneath or in between the two K-wires. And then once you've taken the wedge out, this is just drilling the posterior cortex, which is like a controlled osteoclase. It's just like a postage stamp to allow the flexibility of the posterior cortex. So as you come into extension, it closes down without springing out in the back and losing our stability at the posterior aspect. So then you just close it down. You can see there's a back cut behind the tubicle, just to give us a little bit more real estate in the proximal tibia. And then once it's down in place, we'll fix that with two staples. You can also use a simple locking plate. So there's a number of different fixation options. If you've got good posterior stability, then two staples will suffice. If you're concerned about your tunnels, you can always take that wedge out, use that autograft to bone graft your tunnels, and then come back at a second stage to the ACL and add in a lateral tenodesis if you felt that was appropriate. So I'm going to leave it there. I've got another case, but I think maybe we just hand it back to you, Rob. I think you've got another case, and we can discuss that further. So thank you very much for your attention. Great. Thank you, Alan. We're going to have Andy Giesen pull up a case, but just a quick question for you, Alan. Recurvotum causes problems, and don't these closing wedge osteotomies cause any problems with increased recurvotum, and what do you do about it? Yeah, I think it's something you've got to be very careful about in your indications. And I think if you already have pre-existing recurvotum, then adding to that, I would be very hesitant about adding in a tenodesis. Charlie Brown has done a number of cases in the UAE where he's done posterior medial capsular placations to try and control that, and then kept the patient in an extension brace, preventing hyperextension. And David DeJure also would recommend when doing these procedures to keep the knee in a brace and prevent hyperextension for at least eight weeks. And I think that's something that you can certainly work with. I would just say you'd be cautious. And one thing when you're dealing with a second failed ACL, they often have a degree of a fixed flexion contracture that may not have hyperextension like the contralateral side. So that for me is a much better indication to get on and do that. What's your experience, Rob? I agree. I haven't seen increases in recurvotum that are concerning. Maybe one out of five cases will have more recurvotum than the other side. But I haven't seen the one-to-one ratios that when we decrease and take out a wedge of 10 millimeters, I'm not seeing 10 centimeters of increased heel height, which I'm thankful for. So we want to go on now and do another case before we run out of time. And I'd like to ask Dr. Gieselin to present a case here, which is really relevant to a lot of us in our clinical practice. Andy, can you go ahead? I should be able to. Meredith, can you share my screen? I have it up right now. Can you see it? Unfortunately, I'm not. Yeah. Can you just invite me to share mine? Sure. I will do that. It may be useful for Dr. Goetke or Dr. LePron to show one more case briefly. It's given me a warning message requiring me to quit out of the window. So let me just run through that quick and if you guys could show one and then I'll pop back in. Okay, Alan, I got a really complicated case. So do you have a shorter one we could do in seven minutes? Sorry. Yep. I can do that. Okay. Meredith, I want you to share my screen there. All right, hopefully this will work for us. Okay. Come on. All right. So this is actually that girl that I showed you. This is, she had ACL reconstruction. She was part of the stability study. She had a hamstring tendon autographed with the lateral tenodesis and she had a re-injury playing soccer and she had further episodes of instability. So Rob, what do you make of those x-rays when you first see them? My concerns with the x-rays are the slope looks like it's increased, so I'm very concerned about that. Also, it looks like she's sublux anteriorly, I'm assuming that's a standing x-ray with the arrow there. I'm worried about secondary stabilizers to look for in addition to the slope as potential causes of the failure. Right. The other thing I see is that the tibial tunnel looks a little big. Yeah. It's certainly wide, and I don't have the CT scan, but I think I measured about 15 millimeters on her CT. So increased slope, increased anterior translation, her coronal plane, she was symmetrically varus. And so, I mean, it's just a few things to consider. She had a high-grade pivot, but she had normal degree of extension, so she didn't hyperextend. Her increased tibial tunnel diameter, 16 millimeters on her CT. Her slope was 18 degrees with one centimeter of anterior translation, and it already had a previous lateral tenodesis. On MRI, she had a tear of her medial meniscus, which did not look in any way repairable. So Andy, are you with us? Can you hear us okay? I can hear you. Perfect. Andy, what would you do in this scenario? And I appreciate I haven't given you all the information you need, but I'm sure you can run with it. Right. So increased posterior slope and tibial tunnel osteolysis, relatively neutral alignment, but she is in a little bit of varus. And like you said, already had an LAT. I don't think this is going to be a single-stage procedure. You're going to have to consider bone grafting, and a patient's already failed with the extra articular reconstruction. I'd give high consideration doing a two-stage procedure with anterior closing wedge osteotomy simultaneous bone grafting, and getting her set up for a vision ACL on the road. Cool. Rob, you have anything to add to that? My concern is with your medial meniscus showing maceration, you want to try to make sure you don't tip her into more varus, and try to bring her into at least a neutral position so you can unload the medial compartment. So how would you go about doing that? Would you still do an anterior closing wedge? Yeah, I'd just try to take more off laterally than medially. So when you close it down, you're not putting him into more varus. Right. So for sure, that was what we planned to do. So actually, we planned to just do an anterolateral closing wedge, really just trying to get a little bit more of a coronal plane offload, as well as getting that slope reduction. And unfortunately, when we got in with the scope, her medial meniscus was really pretty badly trashed in the posterior third and had to be resected. So whilst her anterior third was intact, she effectively had a subtotal medial meniscectomy. I took the wedge out, bone grafted her tibial tunnel, her femoral tunnel was absolutely fine, would be able to reuse that. And so what would you do at this? What would you do now? If you're taking out her medial meniscus and you're planning to do a second stage, would you pull the trigger and doing a meniscus transplant in these, Rob, as well? Or do you think that's something you can leave for later? I don't think we have a great answer to that, because as young as she is, that transplant isn't going to last forever. The studies that you're well aware of, they last 12 to 15 years on average. So you have to use it for the right patient that has the increase in translation. So you have to rely on your physical exam. If it's a 2 plus Lachman, I think the closing wedge osteotomy may be sufficient to unload her like you've done very eloquently there. If she's got a 3 plus Lachman still after all of this, then your ACL is probably going to fail. So you have to look at adding in your transplant graft. But I don't pull the trigger and do it all the time, just because they don't always work as well in these younger patients. And there's a higher re-tear rate. And sometimes an osteotomy can do what you want, as long as there's not a lot of residual anterior tibial translation present. Right. So I mean, so here's her radiographs now after her first stage. So bone grafted her tunnels, hardware in situ on the lateral side, reduced her slope. But that lateral radiograph, she's still got anterior translation. Worse. What'd you do? Yeah, it's a bit of a concern. Well, I mean, of course, she had part of her medial meniscus not resected. So I mean, this was the thing is that, you know, it's sometimes you'll do them on the table and you hope it's like a dog knee and they're going to be tighter. But I found out by six months, their instability and translation seems to come back. You can change the slope, but as long as there's still the ligaments and menisci still deficient, they're still going to translate over time. They're not like a dog where you do the osteotomy and it takes care of it. Andy, do you think with, you know, she's had a previous LET, do you think you need to do some form of anterolateral procedure here? What's what are your thoughts there? Yeah, in this case, I'd consider actually using a free graft and whether you choose the ALL or try to mimic the LET type course at Gertie's Tubercle. But I think you have to think about anything you can do to help stabilize her knee and reduce the risk of re-tear. But it's a very nice correction of her posterior tibial slope. I'm surprised that she's still got that posterior translation of the femur relative to the tibia in spite of having a great correction of the slope. I think this may be, I'm not sure it's weight bearing because it doesn't have the arrow on it, so it may not actually be weight bearing, which may be why we're seeing that. But there's her post-operative X-ray and radiograph now. So she had, I did do the meniscus transplant because I was concerned of that anterior translation. What graft would you use, Andy, would you use a BTB here or what would your plan be? I'd prefer BTB. I think that's, certainly autograft, you could consider a quad, I suppose, but I'd prefer BTB in my hands. Okay, and the, yeah, so I did medial meniscus transplant. I did the, I didn't actually do anything on the lateral side. I just did a quad tendon autograft. And she's doing really well at the moment. And you can see her on her lateral radiograph that the reduction's pretty good. The plate then came out obviously at that time as well. So complex case, but hopefully illustrates some of the things that you can do around those types of needs. Well, that's a great case, Alan. It looks like you reduced her back, which is hard, but I think it just kind of pulls us all back to what we were talking about at the beginning is you have to look at these secondary stabilizers for these cases, and if you can catch it early on and you couldn't because their meniscus was already torn, but the first time around the, I think it's important to try to repair it as much as you can, and it's going to unload the ACL if you do that, as opposed to leaving it and hope it heals. So I think that's important to address. So we've kind of run out of time here, and I think we've had some great cases. I want to thank Drs. Getgood and Gieselin for their excellent cases and showing us some of the other things to think about with an ACL and not just looking at reconstructing the ACL, but looking at the secondary stabilizers because I think that's a better way to give us a chance of having these surgeries work, and then also we didn't talk about it much, but I mentioned it, that the post-operative rehabilitation is essential. It's not part of our profession anymore to be proud to send somebody back to full sports at four or five months post-op for ACL because there's a higher risk of failure, and for the higher-risk ACLs, consider looking at these dynamic braces to try to unload the ACL and give us the best chance of working over time. Meredith? Thank you, Drs. Gieselin, Getgood, and LaPrad for your preparation and presenting tonight's content. Thank you again to OSER for support of this webinar. Listed here are resources for attendees. These slides are available for download at OSER.com. If current fellows have not already applied for AOSSM candidate membership, the application fee is free for current fellows and covered by OSER. You may apply online at the AOSSM website. Next week's webinar is featured here, covering knee osteotomies and cartilage restoration with Drs. Michael Banfi, Robert Dewar, David Flanagan, and Seth Sherman. Thank you. Have a good night. Thanks very much. Thanks. Thank you, Allen. Thank you, Andy. Thank you, Meredith. Thanks, Joe. Thanks, Annie. Thanks, everyone. Thanks, Meredith.

High-Risk ACL Patients

webinar

Dr. Andrew Giesland

Dr. Alan Getgood

Dr. Robert LePard

management

ACL tears

risk factors

surgical techniques