Let's go from this one. All right, so we'll play a little bit of catch up. So this study focused on elite athletes undergoing primary ACL reconstruction. Now elite athletes comprise a higher risk patient population as they subject their ACL reconstructed knees to significantly higher forces in an effort to return to play at elite levels. This likely explains the increased risk of re-rupture which can be seen in the literature. This most recent BGSM paper which evaluated European soccer players undergoing ACL reconstruction which reported a 9.3% revision rate similar to the Erikson et al. paper in 2014 which reported a 10% revision rate in professional soccer players in the MLS undergoing primary ACL reconstruction. While ACL re-tears are bad in any patients, in elite athletes the missed second season can frequently be career ending. Over the past decade we've really elucidated the biomechanical and clinical benefits of anterolateral procedures. Al's talk earlier was the perfect talk as his group showed two years ago that the addition of an LET is effective in reducing the risk of re-rupture in high risk patients undergoing primary ACL reconstruction. Now as Al mentioned and as he mentioned today, we do need more work to understand which patient populations this would benefit the most. So in 2014 based on work done by the senior author at Imperial College showing that a modified Lemaire reduced the force in the ACL graft, he began adding a modified Lemaire to all elite athletes undergoing primary ACL reconstruction. Due to the increased morbidity of this procedure, he felt it important to continue to monitor the effectiveness of the LET in reducing the risk of re-rupture. The secondary outcome was assessing the effects of combining with patella tendon ACL reconstruction versus a hamstring tendon reconstruction. To achieve this a retrospective review of all elite athletes undergoing primary ACL reconstruction were the senior authors performed from January 2005 to June 2018. And to focus on the highest risk patient cohort, a very elite athlete population definition was used including only athletes that are paid to perform their sport as well as non-paid athletes performing at a national or international level in non-revenue sports. 456 patients were identified of which the majority played soccer and rugby. 82.5% were male and the average age of the cohort was 22.5 years old. The primary outcome measure was ACL re-rupture as defined by undergoing revision ACL surgery. Out of the 465 patients, 339 underwent isolated single bundle ACL reconstruction. 117 underwent ACL reconstruction combined with the modified lamaritine adhesis. In the isolated ACL group, 31 failed and underwent revision or 9.1% compared to only four or 3.4% in the combined group. Looking at our subgroup analysis, first on the bottom left, when LE2 is added to a hamstring ACL reconstruction, it decreased the re-rupture rate from 9.9 to 3.6% versus a patella tendon where it decreased from 7.7 to 3.2%. I wanna point out that while LEC does seem to be as effective in both, neither of these individually reached statistical significance. Now, similar to Al's stability study, this study focused on a high risk group of patients. And while there's a benefit to studying these high risk groups because it allows you to identify differences between two treatment protocols, it's very important to then acknowledge that these results may not be applicable to all patient populations. And by no means are we suggesting that every ACL get a lateral extraticular adhesis. In addition, our study was based on clinical notes as well as team notes. And this was not a database study and was not based on publicly available information. So while that decreases the risk of missed re-rupture, that was greatly pointed out in AJSM this month, there's still a possibility for a cold ACL re-ruptures that did not undergo revision and thus were not counted in our study. So in conclusion, the study shows that the addition of a modified LAMARE, lateral extraticular tenodesis, reduced ACL re-ruptures in elite athletes undergoing primary ACL reconstructions. The benefit seems to be similar when it was added to both a hamstring tendon ACL reconstruction, as well as a patella tendon ACL reconstruction. And due to these findings, the authors would suggest that the patient being an elite athlete be a consideration for an indication of adding a tenodesis in a primary ACL setting. Thank you.

elite athletes

ACL reconstruction

re-rupture

lateral extraticular tenodesis

LET