for the old hamstrings, right? My disclosure is here, is in the program. So this is from the ACL study group data published earlier this year, just looking what people in the ACL study group have used over the years. You can see the numbers. Hamstring is still the best at 50%. Quad tendon in the ACL study group surgeons around the world is only 10%. So I would say to you that not all hamstring grafts are created equal. And so I think that we have to talk about what we do today in 2021. And I would just promote the ability to do an on-site technique, particularly what we call the graft link technique, as some major advantages. Number one, you just use a semi-tendonous only, leave the gracilis alone. We have suspensory fixation on the femur and the tibia, which is a huge advantage for retentioning and better graft biology for healing. We did the study a few years ago looking at the difference of healing with screws on a graft versus suspensory fixation and showed the normal four zone integration of a graft only occurred with the socket suspensory fixation in this canine double button model that we did. Now, what about the retentioning? I think this is huge. This is a biomechanical study new and unpublished where you put a screw on a soft tissue graft, you lose 62% of your pretension, but you capture about a half millimeter of that by the ability to retention with the adjustable loop device. So I think this retentioning is a major factor in terms of improved stability. This is what I do in every case after the ACL is preliminary fixed. I stress it, let my fellows do whatever they wanna do, beat it up, pivot shift it, and then I retention on the femoral side with the suspensory device here you see with these handles and I retention the tibia. So all these grafts are recycled and retentioned and I think this is a huge advantage interoperatively. So why do you see the semi-tenosus only? Obviously you preserve the gracilis so you don't have the strength loss. Toshiro showed that as did Gabi in terms of hamstring strength and interrotation. And these grafts are just 65 millimeters. You just need the semi T. All inside, they don't have to be that long. So what about this technique? Does it stand up? We published this last year looking at the use of this quadruple semi-tenosus graft link compared it to BTB, the gold standard as X mentioned earlier. But we took it one step further. This was in a high risk group, 24 years or younger. It's a randomized controlled trial, 64 total patients, 32 in each. Our primary outcome measure is KT-1000, standard other PROs. But look at my average age in this study group was 17.7. So these are pretty much in that adolescent age group. So we found our KT-1000. We started about six, manual maximum both. Ended up at zero for BTB and 0.3 for hamstrings. This is the lowest KT two year follow up in a hamstring reported outcome. I think it's that retention allowed us to do that. Our most statistically significant, our only statistically significant finding was this, anterior knee pain, which was higher in the BTB group from six weeks on to two years over the hamstring group. Our other results were basically no difference as seen here. We did have two re-tears in the graft link group compared to no re-tears in the BTB group. That was not statistically significant. Had three contralateral tears in the BTB group, none in the graft link group, also not statistically significant. Return to support at the same level, favored graft link, but it was not statistically significant. In terms of our re-tear rate, if you look at the literature for hamstrings under 25 years old, it's been reported as a high numbers all the way around. Our 7% I think compares very favorably. So for me, the take home message from this study was I think this quadruple semi-dosis grafting technique is an excellent and reliable approach, even in young athletes, comparable to BTB with stability and PROs. I think that importance of the retention ability is why it is a very viable technique and you avoid the anterior knee pain. So what about hamstring versus quad? X presented his data. What is the literature? He showed some of the literature, but not all the literature. This was just published, a study this year looking at return to football, and this was NCAA college team. This was a semi-T and gracilis quadruple graft, 7% re-injury rate, 79.5% return to play, 17 played in the NFL. So these hamstring grafts obviously were durable even at that high level. Christian Fink, who X mentioned, he published this study a couple years ago, showed no difference in his quad versus hamstring in his PROs at two years. This was a study published earlier this year looking at 475 patients, pretty split between hamstring and quad. Graft failure rate 9.4 for quad tendon at two years, 11.1 for hamstring, no difference. One-year follow-up apilaxity was basically the same for both. Rate of re-operation to cyclops, as we heard, was higher for quad, about double that for hamstring, and rate of re-operation for meniscal injury was a bit higher for hamstring, but basically the same as quad. This study also showed that increased risk of arthrofibrosis with quad tendon, this was an adolescent group, 1.9% just for their hamstring group, 6.3 for the quadriceps tendon for re-operation for scar tissue development. What about knee extensor strength? This study published earlier this year looking at quad tendon was similar to pterotendon, weaker than hamstring, of course, you'd expect, but the limb symmetry index found the quad tendon did not reach 90% even at 24 months postoperatively in this study, so I think extensor mechanism weakness is still something to consider. Martin Lin's study, again, looking at quad versus hamstring, showed the increased laxity with quad compared to the hamstring, more positive pivot shift, and a higher revision rate for quad tendon versus hamstring or BTB. So in conclusion, I think that the quadruple semitenosis is still a reliable graft with minimal morbidity, decreased risk of arthrofibrosis, you avoid anterior knee pain, and you preserve your quad extensor strength. All-in-side technique, I think, has that particular advantage of allowing retentioning on both sides to enhance your stability. We showed it was comparable to BTB even in young athletes. I think hamstrings have stood the test of time and study, and quad tendons have some maturing to go. Thank you.

graft options

ACL reconstruction surgery

quadruple semitendinosus graft

graft link technique

hamstring grafts