And I'm excited to introduce the moderators for our first session, Drs. Julie Dawes and Lori Heemstra. Thanks, Mary. Mary comes up and brings the microphone down, but I'm gonna have to put it back up again. Good morning, everybody. Thank you for getting up so early and joining us today. We have a really exciting program, as Mary's outlined, and I'm really looking forward to today. So I'd like to start our knee ligament session with a superstar. So Dr. Lynn Snyder-Mackler from the University of Delaware is going to talk to us about risk factors for ACL injury and re-injury in female athletes. Lynn? Thanks, Lori. I gotta bring the microphone down. Good morning, everybody. I'm on the back, I think. So I'm gonna talk to you in six minutes about risk factors for primary ACL injury and re-injury in female athletes. I have no disclosures. So the knee injury reduction programs work. We know they work. Start young. Implementation is the key. Primary barriers are whose job is it to do this? And the perceived barriers that's often cited is that it's expensive, which is really not true for the primary programs. They're free. The best resource that I can point you to is this Evidence-Based Knee and Anterior Cruciate Ligament Prevention Clinical Practice Guideline that was published in Journal of Bone and Joint, sorry, JOSPT in 2018. This includes all of the best evidence and it includes the programs, the progressions, and videos. We all know about clinical practice guidelines and levels of evidence and strength of recommendations. Look at all those A's, right? When have you ever seen those before? The bottom line is clinicians and coaches should implement knee injury prevention programs at level A. Re-injury's another story altogether. We all know the dismaying numbers. Our overall rate of graft rupture plus contralateral rupture is about 30%. And for those who return after revision surgery, there's an almost identical risk of a third ACL rupture. Unfortunately, our patients don't know this. They almost all expect to go back to full participation without a risk for re-injury, short or long term. So what's the biggest risk factor for second ACL injury? Number one by far is returning to level one jumping, pivoting, and cutting sports. Younger age is often cited, but younger age is merely a surrogate for returning to level one sports. So here's the conundrum. Number one risk for re-injury is returning to level one sport. Overwhelmingly, the reason our patients get ACL reconstruction is to return to sport. So first comes education, not just about the dismaying data concerning re-injury, but more importantly, what we can do about it. Biology matters. Graft healing and incorporation proceed under the surface. Dr. Connie Chu calls this process silent, and healing lasts about two years. In current clinical practice, we use time from surgery as a surrogate for graft healing and incorporation. But we have to begin to use the mounting evidence from imaging about this process in our clinical decisions. We can all agree that our patients are not going to wait for two years to return to sports participation, but recent evidence suggests that young athletes will wait for one year, but biology's not enough. Just waiting is not enough. They need really good rehabilitation. So secondary prevention starts with impairment resolution on day one after ACL reconstruction. You need a stable base. And don't cut corners. Throughout rehab, implement prevention exercises in a progressive manner. Promote confidence. They need a strong knee. Instill the importance of compliance with rehab and prevention exercises. Use effusion and joint soreness to guide progression. Both indicate a poor environment for graft healing. Use strict criteria to begin running progression. Use time and clinical findings. These are the ones that we use, and have used for probably 20 years. Use a return to activity test battery. We use, this is the ones we use, quad strength, four single leg hop tests, and two patient reported outcomes all over 90%. So passing this return to activity test battery and the running progression doesn't mean, oh, go right back to play. This is to begin on field or on court return to activity progression and a formal knee injury prevention program. So this is not clearance. Compliance is not great with primary prevention programs despite that overwhelming evidence I showed you for knee injury prevention. Motivation should be higher in the secondary prevention scenario because one injury's already occurred. But with secondary prevention, costs, that is like costs for visits, can be a real barrier. So the secondary prevention maneuvers that we incorporate into our later rehabilitation are these like Nordic hamstrings, step downs, standing jumps, jumping over cones, and tuck jumps. After that progression, we then go to a graded return to activity. So full speed agility training without pain or apprehension. Then unopposed practice of sports specific skills without pain or apprehension. Then finally we add an opponent because adding the opponent is the critical factor for injury, for primary injury and secondary injury. Almost never happens without an opponent somewhere in the field. And then finally full practice with the team. So this is our ACL sports trial. 75 of 79 passed this return to sport by one year, 100% between nine months and two years. In the men, at two years we only had one athlete of the 40 that tore, re-tore. In the women we weren't quite as successful. We had four graft ruptures and five contralateral, but still these numbers are lower than the total of about 30% you see in these young athletes. So in terms of implementation, as we wind up here first, education, while we know the re-injury data, the expectation of most athletes is full return to their sports with little or no risk of re-injury. You have to educate them that that's not the case. It's necessary to have the talk with all of the stakeholders. The prevention program is a continuation of the rehab program that you've been doing with your patients from day one. It's part of the rehab, not standalone. The primary prevention programs and the ACL sports secondary prevention program can be done in a group setting, in a gym, on the field, and as one good thing to come out of this pandemic, it can be delivered and monitored remotely. So the key points are, begins on day one, resolve impairments, start by building a strong base, pass stringent criteria for running and return to activity, incorporate secondary injury prevention exercises progressively throughout rehab, progress to a formal program in an individual group or remote delivery format, and then pass on field on court progressions using soreness rules and effusion testing. And no return before nine months, and if you're under 18, 12. And I just bring you back to this JOSPT CPG, thanks. Thank you. Thanks, Lynn. Next we'll have Jennifer Beck will come in and talk to us about the immature athlete. Wonderful. Well, thank you everyone for coming in today. I'm gonna be talking about skeletally immature ACLs and hopefully give you some tips for that difficult kind of middle section, those FICL respecting less than two year growth remaining athletes. I have no disclosures for this. So all I can say is that last talk, exclamation points, emojis, hearts, happy gifts. Yes, that's the biggest thing that we need to be doing in these young athletes. We all see these in our clinics. We know this is an epidemic and this is the number one thing that's gonna help save some of these knees, save some of these athletes from a lifetime of health consequences, both physical and mental. So trying to prevent these is really what we need to be focusing on in the future. My talk's really gonna be focused on this algorithm that Coker published and just the really three different ways to think about pediatric ACLs when you've got that middle school, high school athlete, the different buckets that you wanna put them into. The skeletally mature ones, we don't need to go into that. That's the bread and butter of everybody in this office. The closed FICIs, no growth remaining. You've got your choice and there's gonna be some great debates about different graphs and what we should do in that. I think the second next easiest one is this one, the really young kids. Those eight, nine, 10-year-olds, for whatever reason, tear if it's associated syndromic. All these different techniques, the IT bands, the all-epiphyseals, those are either in your training and in your wheelhouse or you have someone that you can refer them to in their community. So I think those are really easy to identify, those really young kids. And where we get stumped and I get the most questions is this middle group of this less than two years growth remaining, these males 14 to 16, females 12 to 14. What do we do with those and how do we know they go into that group? We know that males and females have about equal incidence of ACL tears in this age range and as data's coming out of all three of the age range, this is the one that's actually most likely to go on to re-tear and is actually the group that probably has the most to lose from their initial injury and potentially having to have a subsequent ACL reconstruction secondarily or on the contralateral knee. So biggest thing when you're gonna be looking at these kids, developmental staging. You need to figure out where in their growth cycles they are. Tanner staging, something that we typically leave up to the pediatricians. We're not as great as doing that in orthopedic surgery. And unless you're a true pediatric orthopedic surgeon or have a colleague down the hall, I know pile atlases are getting harder and harder to get. And so the thing I will draw your attention to is that the San Diego group really spent a lot of time and effort creating and validating this knee bone age atlas. You're gonna be having these MRIs all for these ACL tears. You're gonna be seeing, evaluating them. And so have these in your back room. It's not something you're gonna be ever expected to memorize all these little subtle findings, but they can give you a lot of secondary clues of, okay, is this kid 14 and really 12? Is this kid 14 and really 16? Especially if we're talking about the males. Making sure that we understand growth cycles, that the knee around the lower extremity gives us most of the growth, which is in contrast to the upper extremity where it's the shoulder and wrist that give us most of the growth. And it's the distal femoral physis that we get more of the growth from instead of the proximal tibial physis. Growth rates in females start about two years earlier than the males and definitely should be asking about menarche with these athletes. 18 months or so pre-menarchals when they're gonna be going through their peak growth velocity. And I think the one confounding factor is if you're looking at some of these very hyper-specialized athletes, runners, the aesthetic sports, the gymnasts, menarche can definitely be delayed in those. So you have to make sure and question some of those other physiologic categories in that population. The boys a little bit two years later, their peak growth velocity somewhere between 13 and a half and 15. So non-operative management of pediatric ACL tears, something to talk about. We know there are some copers that could be out there. Not every kid playing Fortnite all day may need his ACL taken care of. But obviously, you don't risk any sort of iatrogenic injury to the physis. We know that instability continues, meniscus tears continues once you start getting to the three to six month range. And so, in obviously this room, people are gonna be pretty surgically aggressive taking care of these. I also wanna just mention that some kids can get partial tears. And Coker did this survival analysis taking a look at what are the factors of kids with ACL tears that are partial that potentially can be copers and can do okay. And it's really kids under the age of 14 and ones who have less than 50% involvement on their MRI. And these are the kids that you initially rehab, you're pretty confirmed. You know, Lachman's feels not great at the first visit, looks like there's some edema in the MRI, but they can come back at six and eight weeks and actually feel like that ligament has tightened up over time. So surgical management, biggest risk is that we do something bad to the physis. We go on, create an osseous bridge, premature facial closure, deformity, leg length discrepancy. That's what we all worry about. We know anatomically that over the top position in the femur is right where the distal femoral physis is. And back in 2002, when we really were starting to advance our techniques with this, Coker did a large study taking a look at just the experts in the group. And they did comment that this happens and you get growth disturbances, but it's pretty rare. He took a look at his population of this middle age range, this physio respecting age and did MRI 16 months out after he did a transphysio ACL and said, well, about 11% of these have a physio bar, but clinically that didn't correlate with any findings. So I think we're not really sure what to do with this data quite yet. In a larger study, the systematic review took a look at transphysio and physio sparing techniques and tried to quantify how serious is this problem? How worried should we be? And it looked like, you know, less than 1% in the transphysio group and in the physio sparing group, about 1%. But admittedly, these numbers are pretty low. So I think we need a lot more research on really how often this happens, what we can do to prevent it. So what can we do to prevent it? How do we need to be physio respecting? So soft tissue graft is gonna be our number one thing. We can debate hamstring, quad, all the new techniques. The one thing I would say is that kids should not be getting any sort of allograft outside of any sort of collagen disorders or syndromic conditions. Graft size we'll talk about in just a second, especially for that femoral tunnel. You know, I talked about this with the residents that your start point for your tunnel is not gonna be changing, you know, that anatomic footprint, but your tunnel trajectory needs to change a bit. Graft tension, we know very little bit about, about how important that is. We've got some studies that maybe say if we over tension these grafts, they'll go into some valgus, but we don't know as much about how to quantify that. And then obviously we don't wanna be putting screws or any sort of bone, anything like that across the physis. So Kevin Shea and his group did a MRI study of a bunch of pediatric age cadavers and actually did this imaging study taking a look at what would you do if you actually drilled a five millimeter hole, six, all the way up to nine millimeter hole through these MRIs and what percentage of the physis would it actually take out? And I think the couple take home points is not surprising the femoral physis was more affected. It's more undulating, less flat than the tibial physis. And that even with some of these large size grafts, these eight and nine millimeter grafts, it still stayed below the threshold that we think 7% is about the affected rate that we would need to potentially cause something. So I think this was reassuring data that when it comes to graft size, we don't need to be saying fives and sixes, but we probably don't wanna be putting 10 millimeter grafts in these kids. So what are some kind of key pearls about your tunnel? So taking a look at the tibia, you've got your red line of where you don't really want it, that blue line of where you do want it. So it's gonna be a little bit more vertical and central so that if there is any sort of bar, it's actually less likely to affect the child. You want less than 7% of that physis involved. And usually your start point's gonna be a bit more distal. You're gonna change that guide. You're gonna have a larger angle of inclination and you want it to be more central, but you do need to take care of where the tibial tubercle is and not be so central that you affect the tibial tubercle. For the femur, similarly, so that red line on the femur is where you probably don't wanna be, the blue line where you wanna kinda get your angle is that the start point's the same depending on where you're going. So where that foot point of your ACL graft is gonna be the same. But you do wanna have a little bit more of a vertical as well as anterior trajectory to get a little more central within the physis and similarly less than 7% of your physis you want involved. So hopefully gave some tips and unfortunately the cubs will be coming in in a couple of weeks. And so thank you for having me today. Thank you. Thanks, Jennifer. Can I ask Dr. Adam Anz to come up? He will tell us about ACL repair. Can a synthetic scaffold help? Yes. Welcome. Thank you. All right, I do have a disclosure. I've been told it'll be 20 seconds. Well, that screen is up. Let's see if that's true to state. Done. All right, ACL repair. Can a synthetic scaffold help? To think about this concept, we need to break them down into ACL repair and synthetic scaffold because both ideas in themselves need to be considered. With ACL repair, largely in the 90s it was abandoned. Renewed interest in the past decade and that advancements, that renewed interest is now based upon advances in arthroscopic techniques as well as the emergence of biologics. Those two things combined have refocused our ideas on ACL repair. And I don't have my entire talk memorized. Is there a non-MAC talk after this? That would be easier to. All right, here we go. Here we go, got it. All right, we're back in the game. ACL repair, predominantly abandoned in the mid 90s. Renewed interest in the last decade. Advances in our techniques, yes. Emergence of biologics, yes. Promising short to midterm results by the developers. And so think about the developers versus the early adopters. And those two groups need to be considered independently. Risk factors for failure at this time have been encouraged as young age, highly pre-injury sports level activity, missubstance ruptures, and when there's not good stump tissue left. All these things to be considered with ACL repair. This review is excellent for a good scope of everything there and its current. Now thinking about a synthetic scaffold as an independent subject all in itself. The history of synthetics with ACL surgery predominantly involved ACL reconstruction. It heated up in the mid 80s, pardon the pun, initially as a replacement to the grafts, later as an augment to grafts. Initial enthusiasm was later curbed by reports of complications. So again, this idea of early developers and early adopters. Device creep, infectious, non-infectious knee effusions, and synovitis, as well as accumulation of synthetic materials in the knee joint, and premature development of osteoarthritis. Cortex and Dacron were removed from the market in the early 1990s, and the LAD was withdrawn in 2000. For a nice systematic review, and it is a very nice systematic review, see Batian Arthroscopy in 2015. Again, as we drill down on that systematic review, you'll see some similarities in terms of the materials, mainly polyethylenes, polytetrafluorines, and polyesters. doop, doop, all right, here we go. Also, when you think about these devices, they had a high failure rate. The lowest failure rate was in the large ligament, the highest failure rate was in the leads. The highest non-infectious synovitis rate was in the cortex graft. The lowest was in the large, or in the leads too. As we've looked at long-term data, however, and this was published in 2019 KESTA, the large ligament had a failure rate of 33%, and effusion rate of 5%. So there's this recurring theme of synthetics in the knee, of effusions and high to mid failures. This idea has been developed further, the braided polyethylene polyester suture across a repair, and that's what I'm gonna focus the next portion of the talk on. This idea has not just been thrown spaghetti at a wall, but it has been developed with both canine study and biomechanical study, and that's the base of our knowledge. The articular capability study first with Pat Smith in general knee surgery 2019, six canines, they implanted it alongside the native ACL, and looked at four and six months with both arthroscopy at four and six, then histology at six months. And what they found was that there was no to mild synovitis. Now that synovitis was what they deemed would be similar to instrumenting a canine knee, that the canine is a very reactive entity in and of itself. Similarly, or interestingly enough, the intact state of this brace was lower than a BTB simulated model in their hands in terms of synovitis. The articular capability in the model has been followed by the biomechanical validation of repair constructs. So when we look at repair constructs, this has initially been studied without bracing, showing us that these fixed constructs are less strong than the adjustable constructs, and then also with the addition of a brace, these fixed constructs are outperformed by the adjustable loops as well. With lowest gap formation with higher loads, seen in adjustable loops, braced constructs. Hats off to Cohen Widgets and his colleagues for that work. Now we think about the clinical study. There's many studies, almost 24 out there on ACL repair, modern in and of itself, but we have to consider this technique that we're studying and thinking about today, ACL repair bridged with a synthetic scaffold. For that we have, again, the clinical study of the developers, the first steps, and the clinical study of the early adopters as the second steps. The first steps, McKay in 2015 published a case series on 68 patients, average age 34, failure rate at one year was 1.5%. He reported his two year data in 2019, and the re-rupture rate was 4.2%. The early adopters in 2019, Galargi, had a 22 patient cohort study compared to reconstruction, and an average age of 14, so really young patients, and they saw a high re-rupture rate at nearly 50% in the repair group, similar PROs. This was followed in 2020, Artemeyer, 24 patients, average age 33, did not report their re-rupture rate and reported similar PROs. There was three case series in 2020. Those case series varied based upon age, and that's something to consider as well. If you look at the cohort with a 27 average age, had a failure rate of 15%, which was the highest in these three case series. The cohort with 33 as the average age had a lower re-rupture rate at 11.4%, and the cohort with an average age of 42 had the lowest re-rupture rate, something to consider. In conclusion, the history of synthetics in the knee should sit hard on the gut, pardon the pun. Braided polyethylene polyester suture augmentation is being developed in the right way, thinking first with the preclinical animal model that showed a promising safety profile, followed by a biomechanical development, optimizing constructs. ACO repair requires deliberate patient selection, I think is the state of the art. There's the excitement of the early development, but we have to consider that they are the early developers, and then temper this and clarify it by the early adopters, and we are eagerly awaiting these next round of clinical results with the optimized constructs. And with all things, you have to consider a translational pyramid starting at the base and developing to the top. Thank you for the attention, and apologies for being a Mac. Adam, why don't you stay up here, where hopefully we'll have time for questions, and for those of you who haven't played this game up here, that is like your worst nightmare. Next, gonna introduce Martha Murray, true pioneer in ACL repair with biologic augmentation. Thanks, Julie. So today, I'm gonna talk to you about biologic augmentation for ACL repair. These are my disclosures. So when we look at a history of ACL surgery, and Adam did a great job kind of reviewing some of this, we started off with primary repair of the ACL, but then basically moved to augmenting primary repair with a tendon graft, going to tendon reconstruction only and dropping the repair part, moving into tendon and extra-articular augmentation, so inter-articular graft plus extra-articular graft, as well as then using larger tendon grafts, and as Dr. Anstras presented now, supplementing those tendon grafts with synthetics. And all of the goals of this is really to increase the mechanical strength of a replacement ACL. But despite all of these changes, we've had no real significant change in patient outcomes, whether they're patient-reported outcomes, apulaxity of the knee, or failure rate. So we took a different approach and said, is this a biologic problem? So we know when a patient tears their medial collateral ligament, the ends bleed, they form this nice environment around the torn ends of the ligament that contain all kinds of nice growth factors that are conducive to tissue healing. In contrast, when the ACL tears, it's in this inflammatory environment of the injured knee joints with that angry synovial fluid that contains things like matrix metalloproteinases that actually break down tissue rather than help it to heal. So we think that one of the reasons that the ACL may not heal with primary repair in a reliable fashion is this. If we look at the top row, the medial collateral ligament tears, the ends bleed, they form that nice clot between the torn tissue ends that serves as that environment for the ligament to heal back together. In contrast, in the bottom row, we see the anterior cruciate ligament may tear, and even if we sew it back together, there's no clot that forms between those torn tissue ends, and because of that, the tissue is very challenged to heal at all, and so eventually our repairs will fail. So if that's true, and if this is a biologic problem, could we put something around those torn ends of the ACL that would change the environment around those torn ends, something that contained the growth factors that are so important in healing in the medial collateral ligament? If we could do that, could we get the same thing that happens in the medial collateral ligament, where that clot is gradually resorbed by healing tissue, could we get that to happen now in our ACL, and end up with the healing ACL? So we went to an animal model and tested this hypothesis, and in the porcine model, if you do an ACL transection, and then you wait three months, and you go back and see what happened in the knee, excuse me, what's happened is here, the sutures have torn, the ACL ends have resorbed, and all you see left there in the notch is the posterior cruciate ligament. So we said, okay, well what if we try this bridge-enhanced ACL restoration thing? So let's take a soft porous implant that we can put between those torn ends, and then we could load it with the patient's own blood, and could we simulate that nice healing environment? And when we did that in the animal model, what we saw was now we have restoration of that ACL tissue, so the two ends heal back together, and we have something that looks like an ACL. So just basically, this is how, let's see, hopefully this will play, and it won't just advance. Can somebody click on the movie for me just on the screen? See if it'll play? Yeah, if you just click on the black, it should go. So this is just a cartoon showing you what the basic idea is. So here's a knee, this is showing an ACL. In a minute, it's going to rupture, hate that part. Okay, so there's the ACL torn, so the ends bleed, but the blood doesn't really form a clot between those ends, it's kind of dispersed into hemarthrosis. So when we do a bridge-enhanced ACL repair, we put a stitch in the tibial stump that goes up through a small tunnel in the femur, and then we can place this nice sponge in that notch, allow the patient to sleep, we can draw blood from the arm, and then we can take that blood and add it to the sponge. The sponge soaks it up and holds that blood there, so the blood's just like it would be for the medial collateral ligament, but now we've got a vehicle that's holding it in place so it can do its thing. And then we use our previously placed sutures to pull that stump up into the sponge, so that we've now created that nice healing environment around the torn ends, allowing the cells and collagen to grow into it and heal the ACL. So that's the basic idea. So with that idea, we opened a first in human study, this was a small cohort study, 10 patients in the B.A.R.E. group, bridge-enhanced ACL restoration, we just call it B.A.R.E. for short, and 10 patients had ACL reconstruction with hamstring autograft. The inclusion criteria for this were that the patients had to have a complete mid-substance ACL tear, and our age range was 18 to 35. And the results of this at two years showed that we had no patients developed an infection, no patients rejected the scaffolding material, there were no failures in either group requiring revision surgery at two years out, and both groups had good clinical outcomes. So with that preliminary data, we were able to open a second trial, this was a 100-patient randomized control trial of B.A.R.E. versus autograft ACL reconstruction, and again, patients needed to have a complete mid-substance ACL tear. The median age for this study ended up being 17 years of age, we're at Children's Hospital, so it's a mostly teenage population, but the median marks activity score of 16, which is the highest there is on that scale. We were able to obtain two-year follow-up on 99 out of 100 of the patients. So what did it show? One of our main primary outcomes was a patient-reported outcome of the IKDC subjective score, so age-matched norms for this score is at a mean of 88 points. In this trial, the ACL reconstruction group came in at 85 points at two years, which was very good, and the bridge-enhanced ACL restoration group came in with a mean of 89 points, and was proven to be not inferior to ACL reconstruction, meeting the first primary endpoint for this trial. The other primary endpoint for this trial was for KT-1000 testing, so this is instrumented AP knee laxity. Typically for this measure, uninjured patients who have not had an injury have less than a one millimeter side-to-side difference on this type of testing. Other trials for ACL reconstructive have reported a difference of one to three millimeters for side-to-side difference. For in this trial, the ACL reconstruction group came in in that range with a mean of 1.8 millimeters of side-to-side difference. The bridge-enhanced ACL restoration group came in at 1.6 millimeters for a mean. Again, this was found now to be not inferior to ACL reconstruction in this trial. So what about ACL retear rates in adolescents? We've heard a lot about this in this session already, so just to briefly review, for autographed ACL reconstruction at two years out in teenagers, the failure rate is typically between 15 and 20% in most studies. When we did the ACL restoration procedure in this trial, our retear rate was 14%, which is fairly consistent to that seen historically for ACL reconstruction in this age group, and is significantly better than primary repair without biology, without changing that environment that we saw in the Gagliardi study for these young kids. So biology is the way. In summary, when we can address the biology, ACL restoration using primary repair but changing that environment around the tissue that you're trying to get to heal leads to comparable outcomes to autographed ACL reconstruction in terms of patient-reported outcomes, knee stability is measured by instrumented KT-1000 testing, and revision ACL surgery rate. It's also, the outcomes for this procedure are also better than ACL reconstruction when we look at the ACL restoration of the ACL anatomy, so repairing the ACL actually leads to a more normal anatomy, and early patient-reported outcomes at up to one year, so it's a quicker surgery to recover from, most likely because we're not taking a graft. And similarly, as many of the patients in this study in the ACL reconstruction group had a hamstring graft, it actually improved, the bare patients had a much better hamstring muscle strength at all time points after surgery. So that's why we think biology is the way. So I'd just like to acknowledge our financial support as well as say thank you to my team, and thank you very much for your attention. Thank you. Thanks, Martha. It continues to astound me how graft choice is still a big, hot topic despite being in practice for, I'm not gonna tell you how many years. So we're gonna go next with a debate, and Dr. Jean Petzkowski is gonna come up and talk to us about why we should be using quads and bone tendon bone grafts for ACL reconstruction. Thank you. Good morning, and thank you for the opportunity to present. I have no financial disclosures. My bias, however, is that I am a former college soccer athlete, as well as a proud BTB recipient myself. And so when we talk about ideal graft concerns, of course we know that we want something that's strong with low re-rupture and persistent laxity rates as well as a reliable harvest strategy. Minimal morbidity on multiple fronts is ideal, and of course I would argue that we would like something flexible in terms of our fixation strategies to help us with those revision settings or in our more challenging cases. And then of course long-term functional consequences. So depending on the population that we're looking at, really any of the three available autografts is a reasonable choice. And our larger population studies that can contribute to level one analyses are gonna show us a very small but significant benefit in terms of re-rupture rates favoring BTB in the short term, at of course the expense of anterior kneeling pain in the intermediate term with the hamstring, I'm sorry, with those BTBs as well. Now rotational laxity may be somewhat better in the BTB group as well, but admittedly sometimes those studies are hard to interpret and how reliable is those manual pivot shift testing and does that really correlate to a great reason to return someone to sport, and I would argue probably not. When we look at quadriceps tendon, we don't nearly have as much data available to us, but those early level one and two studies do suggest nearly equivalent results in terms of re-rupture towards BTB in the hamstrings with minimal morbidity. But the question that we need to answer today is what's the best graph for the elite woman athlete, not just the all comers. And so of course we all know these two very significant caveats in terms of the elite woman athlete and her representation in the literature, but thankfully all of these graphs for the most part are as strong or stronger than the native ACL. When we look at competitive athlete populations, however, those re-rupture differences tend to expand a bit. And the Moon ACL group with about 50% women did note greater than two times higher rate of re-rupture in the hamstring group when compared to BTBs. When we look at systematic reviews directly comparing sex differences in ACL reconstructions, we noted higher instrumental laxity rates in the women with hamstrings versus both women with BTBs and against men with either one of the graphs. And a series looking specifically at young women athletes also noted instrumental laxity results were better with the BTBs and higher rates of re-rupture in hamstring. Right, so why are the hamstrings we think more likely to rupture in this population? Well, unfortunately women do tend to have smaller hamstring tendons and we know that there's a size threshold for a successful graft. Now to some extent, this may be predictable in MRI, but if you find yourself with that small graft at the time of surgery, you know that you're going to need to do something to change your surgical plan. It can be that tripling or quadrupling a semi-T if it's long enough, going to the contralateral leg for a harvest, doing an LAT augment, doing an allograft, albeit controversial and not really the topic of this discussion. Also of note is that knee hyperextension in reccurve bottom greater than five degrees is going to impart about a five-fold higher risk of re-rupture with those hamstring grafts we don't see with the BTBs. And unfortunately for these patients, generalized ligamentous laxity as well as knee recurve bottom are both more common in women athletes, predisposing them to ACL injury in the first place, as well as re-rupture after reconstruction. When it comes to the harvest time with careful technique, if you're taking an extensor mechanism graft, you can get what you need every single time. And these are easy to measure pre-op. Quad tendon is very flexible, bone block, no bone block, full thickness, partial thickness. It's a great option. Now with modern drilling techniques, of course we have concerns for graft tunnel mismatch in the case of BTB. We also know that there's multiple strategies to deal with this to include consideration of a bone tendon autograft, which doesn't harvest bone off of the patella at all. And the early clinical outcomes here will show it's a reliable graft technique that gets you the right length that you need every time and also mitigates that risk of patellar fracture. Now, in terms of the hamstring, we know that these harvests are plagued by tendons that are diminutive. They fall short of that eight millimeter threshold. We can truncate them early, especially if we let our residents do it. We would never do that ourselves. And then lastly, in the case of revision, or if there's been substantial medial-sided injuries, sometimes they're not as easy to get off the tibia as you'd like. From a morbidity perspective, I think it is important for us to move past just that donor site morbidity in the early clinical recovery, but also look to the long-term functional consequences of using these grafts, particularly when it comes to quad weakness. Now, this is common to all ACL reconstructions. We see this in hamstring grafts. We see this in allografts. And animal studies will show us that mitochondrial health of the quadriceps is adversely affected by the ACL injury alone, independent of any reconstruction whatsoever. When it comes to knee flexion weakness, however, this is isolated solely to the hamstring grafts. And why is that important? Well, we know that our female athletes do tend to have a quadriceps-dominant stance, and unfortunately, those medial hamstring loss, which are a dynamic agonist of the ACL, are going to exacerbate that further, predisposing them to re-injury. Additionally, these are powerful medial stabilizers, particularly in a full extension. And in case of multiligamentous knees or substantial MCL injury, we should really exercise caution in harvesting those hamstrings. Anterior knee pain, again, common to everybody. It's the kneeling pain and that patellar fracture risk that are more common for these bone block extensor mechanism grafts. And we can mitigate that to some extent, likely with bone grafting. Wrapping up, in terms of the elite female athlete, I would argue that hamstrings aren't gonna cut it. Our BTB and our quadriceps grafts, they're strong, reliable, they impart reliable stability long-term, and they don't adversely affect the long-term function of the lower extremity. Thank you. Thank you. Thanks, Dr. Paskowski. And in the other corner, we have Liz Matzkin. Good morning. Thank you. All right, perfect. So I've been tasked with trying to convince everyone here why we should stick with the hamstring graft. These are my disclosures, none of which are pertinent to this talk. So our three main grafts, I think, especially for the female athlete, we just heard a little bit about, but we have our BTV, quad, and our hamstring. As we just heard from Dr. Paskowski, there's a ton of literature comparing patellar tendon and hamstring grafts. We're kind of fraught with it throughout. If you do a quick PubMed search, you'll pull up about 500 different articles. This was just a prospective randomized comparison of hamstring and patellar tendon, which demonstrated basically no significant differences with rate of graft failure, but that patellar tendon grafts had a greater prevalence of osteoarthritis five years after surgery. And I'm just gonna quickly go through this again. Just a ton of literature looking at complications, morbidity, donor site morbidity, differences, meta-analysis, you can find whatever you want here. So we can talk about this pretty much all day if we wanted to. This is another study that just looked at anterior knee pain after ACL reconstruction, demonstrating that most of us know this, that higher with patellar tendon autograft. So just to summarize some of these studies, if we look at our patellar and quad tendons, usually there's some loss of sensation after graft harvest, more anterior knee pain, there's questionable regrowth whether or not that happens, potential increase in osteoarthritis, and the risk of fracture if you're taking out some bone. If we look at our hamstrings, there can be also loss of sensation, there's less anterior knee pain. There is good studies demonstrating regrowth of the harvested tendons and potentially less osteoarthritis. I think what I really want to focus on though is graft size matters, and I know in the last talk there was concern about hamstrings not being of adequate size. We know that ACL grafts less than eight millimeters in diameter at increased risk for failure. Larger grafts have been noted to have superior outcomes. And grafts ranging from seven to nine millimeters in diameter have a .82 times lower likelihood of requiring revision surgery. So graft size matters. If we had a perfect graft, we would not have options. So I would just recommend that we all choose very wisely. And I think especially in our female athletes. We know our female athletes have a higher risk of re-rupture, a higher risk of having a contralateral ACL, a lower return to sport rate, and lower outcome scores after ACL reconstruction. So a quadrupled hamstring should be in everyone's back pocket. It will provide a reproducible graft size with minimal morbidity. So quickly looking at the biomechanical properties, and you all have seen this chart before, but if you look at our native ACL versus the quad versus the patellar tendon and the hamstring, the patellar tendon tends to have a lower ultimate load to failure and quite not as much cross-sectional area. So when I think about my patellar tendon grafts, I think of them as a ribbon. When we measure a nine or 10 millimeter graft, we're measuring width. We're not measuring true diameter. So I kind of think of my patellar tendon grafts like a piece of bacon. When I think about, and you can kind of see it looks like it there a little bit with some bone on each end. When I think about my quad tendon grafts, they're definitely a little bit more robust. They have more girth to them. So they're like a thick cut piece of bacon. You're still kind of measuring a width, but I think when we crunch that all together, you get more of a diameter measurement. When you think about a quadrupled hamstring, here's our quad tendon, you've got some Canadian bacon here. It's thick, it's robust, it's full of meat. Graft size is really robust here, and I think when you're measuring a quadrupled hamstring graft, you're measuring a true diameter. So I think it's really important that we're providing our female athletes with a robust graft. So this is just a quick videos of how we prepare this, but my rule in the operating room is nothing less than nine millimeters goes in my female athletes ever. And I think the thing to note here is that if I harvest a semitendinosus tendon, and I do a quick measurement, I quadruple it, and it's less than nine millimeters, I just go get the gracilis. In the last 11 years, I've never had a graft less than nine millimeters. So I think this is really important, and I'm gonna go into a little bit about why. This is just a quick study we did that you can predict your quadrupled graft size. So if I get my semitendinosus harvested, and I do some quick measurements, and I quickly know that I'm gonna have an eight millimeter graft, I just grab my gracilis, and off I go. It happens in about 15% of my female athletes when using these. This was a study we recently published that just looked at our quadrupled hamstrings in our males and females, and our average graft diameter in our females was 9.4 millimeters. Our males was 9.8 millimeters. And the conclusion was what I think's really important, that functional outcomes were similar at one and two years in both our male and female athletes. And this isn't demonstrated in most of the studies out there. Females tend to do worse when we look at outcome scores, and I think it's because we're not giving them grafts of adequate size. This was just, I just pulled some data off a global database. And what I really just want you to look at, the yellow line here on the bottom, is the global females. So these were females who had an ACL reconstruction. This is looking at the Mark's activity score. And you can see that they are below the males at every step of the way, at one year, two year, and at five years. And if you look at the green line, those are my, I'm sorry, the red line, those are my female patients, all of which received a graft of at least nine millimeters. And you can see that they kind of equalize to the global males. So I think this is really important, and something that we're looking a lot more into. So our female athletes deserve better. They all deserve a robust graft size with minimal morbidity. I think it's important that we provide them with this, and I think traditionally we haven't. So I think if you choose your graft, choose wisely. Make sure you're giving your female athletes a graft that's robust. And just have some choices in your back pocket so you can always give them a graft of nine millimeters or greater. Thank you. Thank you. Thanks, Liz. We do have excellent bacon in Canada, by the way. To round out our primary ACL talks, there you are. Where are we? We're gonna talk about LAT. This is Dr. Adnan Sethna. Good morning, everyone. It's a pleasure to be here. Here are my disclosures, if it's gonna advance the slide. And the reason we need a belt and braces approach is because we need to improve our contemporary clinical outcomes. So we've already heard that graft rupture rates are high, particularly in young female athletes, but if we look at high-risk populations overall, graft rupture rates can vary between 20 and 30%. We're also concerned about high re-operation rates and low rates of return to pre-injury levels of sport. That's one of the reasons we like to consider a lateral extra-articular procedure. From a simplistic perspective, the steering wheel analogy explains the rationale for a lateral extra-articular procedure pretty easily. So when we're driving with one hand, we would never dream of holding the steering wheel in the middle to try and control it because that's very close to the center of rotation, so it would be really hard to precisely control it. However, when we drive one-handed, we grip the steering wheel at the periphery and we can do so lightly and really control the vehicle well, and that's what a lateral extra-articular procedure does. If we look at this scientifically, what we see in biomechanical studies is that we get a more reliable restoration of knee kinematics. This is particularly the case when we have a combined ACL and anterolateral injury. In those situations, if you do an isolated ACL reconstruction, you can't restore normal knee kinematics. You can only do that if you do a combined reconstruction. In addition, we know from Lars Engebrigtsen's work in the 1990s that when you add in a lateral extra-articular tenodesis, it load shares with the ACL. We also know that this works. We have a whole bunch of clinical comparative studies that demonstrate significant advantages of combined reconstructions in young patients, those with chronic injuries, hypalaxity. We know that these findings persist at long-term follow-up. We know that it works in elite athletes and also in the revision ACL reconstruction setting where there's also numerous comparative studies now. So these findings raise the question as to whether the BTB graft is still the gold standard for high-risk patients. We know that from several surveys that was conducted in around 2014 that team physicians in various sports in the U.S. all demonstrate a preference for BTB grafts in these high-risk populations. And we also know that despite the trend towards soft tissue graft, that in these high-risk patients, that preference for BTB still persists in contemporary practice. However, as we've already heard, meta-analyses don't show any significant, important differences with respect to graft rupture rates or patient-reported outcomes with respect to BTB or soft tissue grafts. However, what we do know is that a systematic review of national surveys, which included Canada, Latin America, Asia, and Europe, all show a strong preference for hamstring grafts outside of the U.S. So that leads us to our study. I'm pleased to share these new findings with you from the Santee Study Group. This data is a single surgeon from Bertrand-Sonnery-Cote. We compared 1,009 BTB grafts with a match series, propensity match, with hamstring tendon ACL plus ALL reconstructions. The surgical technique for that combined reconstruction is we use a tripled semitendinosus and an additional strand of gracilis. So that ACL portion of the graft is four strands. We use a single femoral tunnel. The additional length of gracilis goes on to form that extra-articulate procedure. We had significantly higher rate of graft rupture in the BTB group, 10% versus 3.5% in the combined reconstruction group. This was significant, a mean final follow-up of over 100 months. We did Cox analysis to try and account for other risk factors including gender, age, BMI, presence of meniscal pathology. And when we accounted for all of those factors in the multivariate analysis, we found that there was a hazard ratio which conferred a 3.5-fold increased risk of graft rupture with an isolated BTB graft. Similarly, we looked at reoperation rates and found 20% versus approximately 10% difference in reoperation rates. And again, that hazard ratio is significant showing that other factors didn't significantly influence those findings. When we break down these reoperation rates, it's mainly accounted for by differences in revision ACL reconstruction, but it's also accounted for by differences with a significantly higher rate of cyclops lesion in the BTB group, which we've already heard can be a problem. And also, a higher secondary meniscectomy rate. That wasn't a surprising finding because in 2018, we published this study. In this study, we looked at patients who underwent a medial meniscal repair at the time of ACL reconstruction either with or without ALL reconstruction. And what we found was that in those patients who hadn't ALL reconstruction, there was a two-fold reduction in secondary meniscectomy rates. And what this suggests is that the ALL repair protects a medial meniscal repair by load sharing and also by more reliably restoring normal knee kinematics. These findings also seem to be valid in the elite athlete population. We've already heard about elite female athletes who are at high risk. This is another high risk population. This data is from the French national ski team. The isolated ACL graft rupture rate was 34%. It sounds very high, but this is the highest risk sport that I'm aware of for graft rupture rates. And every study since the 1980s that has reported graft rupture rates in this population has reported a similar rate. So it's really a compelling finding that in the combined group we demonstrated a significantly reduced graft rupture rate, and the hazard ratio for that finding was five-fold reduced risk of graft rupture. I'm going to close by saying that when we add in an extra procedure, particularly in view of the history of lateral extra-articular tenodesis, it's really important to assess the risk of adverse events. And in these preliminary results from our randomized control trial, we found no evidence of increased complications with adding that procedure. So in conclusion, combined reconstructions confer improved outcomes. Significant clinical benefits have been demonstrated in numerous comparative studies. I believe that our data poses an early challenge to isolated BTB graft as a gold standard, although of course further randomized control study is required. And my recommendation is that for these high-risk patients, we should consider a belt and braces approach. Thank you. Thank you. And if Michael is going to come and give us a revision ACL in six minutes or less, and if you have questions for the panel, we will have a couple of minutes for questions. So if you want to make your way up to a microphone as Michael's finishing up his talk, we'll be happy to call on you. Great. All right. Thanks for having me. So we've got about 15-minute talks for each of these, so I'm going to try and condense it into about six minutes or less. So first we're going to talk a little bit about two-staging. And what I tell our guys and our gals in our program is that there's lots of reasons to two-stage a revision ACL. First one could be for suboptimal tunnels, and that's either in positioning or tunnel widening or tunnel aperture location, or if you've got lots of work to do and you want to stage it. We're not all in the situation where we have five hands on deck that can help us in the operating suite. Second, if you've got a lot of work to do and you have one PA or low-level resident, it might be difficult to do a high tibial osteotomy with a meniscus transplant with a revision ACL all in one sitting. So know your options, know your ability, know the tools that are on deck, and use your radiographs. So obviously the first thing we have to do is critically evaluate our tunnel position. So where is it on the femur? Where is it on the tibia? On the femur, classically, we look at the Bernard and Ertl grid, proximal and posterior. Make sure you get a good lateral. For the tibia, we typically use the Staudley classification, about 42-43% from A to P. Know where it's supposed to be. And for every revision ACL that's done with soft tissue graft in my practice, they get a CT scan with three-dimensional reconstructions with subtraction analysis. I know not everybody may have the luxury of getting this, but I think it's a beautiful thing that we can do. We can see our tunnel aperture exactly by subtracting the medial femoral condyle. We can see exactly how much tunnel widening we have, and we can see the morphology of the bone loss. Is it cylindrical? Is it conical? Is it like a serpent? Those are all critical things that we have to look at. And if you have any doubts as a surgeon, there's really no harm in staging it. We don't have great data to say the two stage is better than one stage or vice versa. So this could be tunnels that are placed well with expansion. It can be tunnels that are placed okay, but you want them a little bit better. Or it can be for patients that have hardware issues. We run into this all the time. When you got revision ACL, sometimes you have to take out hardware. Sometimes you have to core over hardware to get it out. We can have significant bone defects. So two stage surgery, in my opinion, is always better than a failed revision ACL surgery. And I would submit to you to never forget the traditional over the top revision ACL, where sometimes you don't even need to make a tunnel at all. This is a case of a failed ACL with postural outer corner. The two tunnels actually combined. This is a huge lesion. I would caution everybody to not do a one stage for this kind of lesion, unless you're doing over the top. And we've got lots of graft options that we could use. We can use cortical catencellous chips, DBM, or putty. A lot of our industry has made good tools for us that we could use, that we can jimmy on up some bone into there and get a nice result. If you've got a conical lesion or a cylindrical lesion, sometimes you can use these bone dowels, which is my preference, because they've got a nice strut to them. They've got excellent mechanical properties. And they really do heal well. And classically, I can do a revision ACL after this, about three or four months after a procedure's done. This will skip, but ultimately what you want to see is a nice bony fill here. Really use your probe to make sure that all that bone is really integrated well and very nicely. So now we're going to fast track a little bit different. We're going to slope changing osteotomies. I think everybody in the room knows that sagittal plane is very, very critical. Helps prevent creep on the ACL. Helps control our rotation. Helps control translation. And we don't want to miss these, especially in the revision ACL setting. So there's been a lot more play lately in the literature regarding anterior closing wedge osteotomies. So classically, we say that pathologic anatomy is about 12 to 13 degrees of tibial slope. But you really want to make sure you have a very good lateral x-ray of the tibia before you're deciding what your slope is. And when we're doing these, we want to correct to about four to eight degrees. And there's three different ways we can do it. We can do it above the tubercle, you can do it through the tubercle, or you can do it underneath the tubercle. And they all have risks and benefits, pros and cons. If you go above the tubercle, you've got great healing. That's nice metaphyseal bone that's going to heal like gangbusters. But the problem is, you're going to change the patellar height. If you take off the tubercle, that's another great thing. You can dial in your patellar height. But at the same time, you've got two osteotomies now that have to heal. If you go below the tubercle, you're not changing your patellar height at all. But it is a little bit more diaphyseal bone, so the union rate may not be as good. This is a case example of a 24-year-old female who had three ACL failures. Her menisci were intact. She had totally normal coronal plane, totally normal collateral ligaments. And you can see that her slope is about 16 degrees, and this was missed. So this is a case where we used the mechanism, excuse me, the technique described by Bertrand Sonnery-Cotet, where we do a super tubercle osteotomy, close it down, throw in three compressive staples, and then put a new ACL in. Now sometimes you have to think about slope with coronal alignment as well, and I think patient-specific osteotomies are really getting a lot of play, because they're an excellent thing that we can have in our armamentarium, so we can really dial in the slope and the coronal alignment. So I would encourage everybody in the room to really start looking into this, because I think this is the future. My indications for a slope-changing osteotomy, number one, a primary revision with very significant slope, I start thinking about it. I don't do it in all of them, but I start thinking about it. For re-revisions with minimal other causes and increased slope, absolutely, they're getting it. If there's a re-revision or a revision with increased slope, varus, meniscal insufficiency, etc., then I'm really thinking about my patient-specific osteotomies, because I think we've got a tremendous tool there. And then we'll go into anterolateral augmentation. I think Adnan did a fantastic job of describing all this, so I only have to do about one slide or two slides on this. We know that the presence of anterolateral injuries could be up to 90 percent in patients with ACL tears, and we've got great data showing that ALL reconstruction, as well as iliotibial band extra-articular tenodesis, can significantly improve the outcomes in revision ACL surgery, and the literature keeps coming and coming and coming. So my indication is to augment at this time. I look at this in almost every revision ACL at this point, because I see very little downside unless you over-constrain. So a well-done ACL that's failed, large pivot, hyperlaxity, elite athlete, or contact athlete. If you're not thinking about this, then I think you're doing your patients a disservice. We really have to have this in our toolkit, and with that, thank you all. Thank you. Thank you. Anyone to the microphones for questions? Yeah. In the front here. Thank you. All right. How do I turn this on? Hello? Hi. Alvin Hsu from Nemerus-DuPont Children's Hospital in Delaware and New Jersey. Am I allowed to ask two questions or just one? Okay. I'll ask two questions. So number one, if I— Oh, yeah. Okay. Thank you. For Dr. Snyder-Mackler, so can you share more experience on the remote delivery of your injury prevention program? Because in our practice, we've been trying to do that throughout the pandemic for either physical therapy, the sport-specific return to sports PT, or the injury prevention program. We have found that it seems like it's sometimes not as effective as the traditional all-in-person sessions, probably because of the compliance, but also sometimes hard to correct the form of the kind of movement training they're doing. I feel like just like the dancing classes, martial art classes, they try to do remote classes, but it's not as effective as in-person. So I'd like to have your kind of experience on that. I would agree with you that that's the case, but you definitely can do more than you think you can with these later stage kinds of things, like you have them in the clinic early where you're correcting those really bad movement patterns, reinforcing that. And then when you're getting to these more advanced kinds of programs, you should have corrected those things earlier, and so now you're just advancing them through these progression gestures and maneuvers, these prevention gestures and maneuvers. And in the later stage, do you still bring them back, say every once a month? Sometimes we bring people back, but I mean, a lot of times, the questions I get from therapists are, how do you keep getting visits paid for, right? So our preferred method is to do it in a group, right? And then we just charge people if they can a little bit, and if they can't, we bring them in certainly and take them along with the other group. Yeah, that's what I've been doing too. I've got a question for Dr. Maskin. So it seems like if you do the quadruplet hamstrings as a routine based on the video, it seems like you're doing mostly all inside ACL, right? And that means usually you have to use suspensory fixation and sometimes even flip cutters for the kind of back drilling. So can you talk a little bit about how that impacted part of the cost of the surgery from the perspective? Thanks. So I don't know exact costs, but I think there are certainly benefits. I don't think the buttons are more expensive than using screws. I'm not sure that if you're using a retrograde reamer, usually the sizing is the same on both sides, so it's just one reamer. But I think some of the benefits of doing it are you can really put your tunnels anatomic and you can control your tunnel length, which can also be a benefit in a smaller female athlete. Thank you. And in the interest of time, I think we'll cut off the questions. I'm going to keep our panelists up here and invite Dr. Nick Scaglione to come and pimp the panelists. Thanks, Julie. And my charge is to take us through a few cases. My disclosure is on the Academy website. So we have an esteemed panel to query about what they really do. So as a 19-year-old D1 female soccer player, she had a left knee injury, twisting valgus impact pop. And on exam, she had limited range of motion. You see 20 to 70. She appears to be unstable in terms of her anterior cruciate ligament, but she has grade 3 plus barn door opening of her MCL, both in full extension, of course, 30 degrees of flexion. Her plain films are relatively unremarkable. And Dr. Dodds, any comments on the ACL-MCL tears that you see? Yeah. I mean, I worry about that MCL. It's like destroyed. And so this may be one that you may not be able to treat non-operatively. And so this is what we're dealing with. She also had a lateral meniscal tear. Question that I have for Dr. Heemstra is timing. So you're seeing this patient at two weeks post-injury. What are you going to do regarding this 20 to 70 degrees range of motion? What are you thinking about regarding graft choices? What are you thinking about in terms of what you'll get away with the MCL or not get away with? Internal brace, and we'll skip return to play. But she's anxious about this because she's a player. And does this change the dynamic relative to combined ligament injury, Dr. Heemstra? Yeah. So that's a lot of questions. So timing-wise, I like to wait on these at least a couple weeks and see how they do. I think that we've confirmed it's not a lock knee. There's nothing blocking extension. So a couple of things. I like them to at least get reasonable range of motion. And I like the knee to quiet at least a little bit. So wait a couple of weeks. And the other issue is just that quads activation. So I find if you operate on them when their quads are completely shut down, it's really hard for them to get the quads back after. So giving them a couple weeks to settle and maybe get those quads activating I think actually improves their return afterwards. Are you thinking about a particular graft for the ACL? She's a soccer player. I would do a soft tissue quads tendon. Soft tissue graft. OK. And are you thinking, if you had to do the MCL, are you thinking repair? Are you thinking recon? Are you going to make that decision later on? Are you going to make that decision at EUA? I think I'd like to make that decision. I like to be ready for everything. So if I go in there and that tissue is really awesome and I can get a really excellent repair, I think I'd probably be OK with that. But I'd have to be really confident in the repair. I'd be ready to go ahead with a reconstruction if necessary. Dr. Petzkowski, we took the patient at seven weeks. And at that time in the EUA, she had significant opening of the medial collateral ligament with valgus stress, both at full extension and 30 degrees. We decided to do a BTB autograft for the ACL. What do you think about doing a medial collateral ligament reconstruction vis-a-vis allograft, autograft, or just a repair? I think based on that imaging appearance, I would be very hesitant to do the MCL repair. I think just a lot of energy went through that tissue, and I don't think that I would trust it, especially in a soccer player. And so for that one, I would err on the side of reconstruction. I think tibiant allograft is perfectly reasonable. I've used Achilles in some cases just because I do like that broad fan. I think that does a nice job of replicating that tibial insertion. Dr. Matzkin, Dr. Hamster said she would use a soft tissue graft for the ACL, assume hamstring. What do you think? I agree. Personally, I would use either a quadrupled semitendinosus, plus or minus gracilis, or I think a soft tissue quad would be good for a female soccer player. With regards to the MCL, I agree with what's been said. If the tissue's extremely robust, I would do a repair, probably with an internal brace. If the tissue's not, I'd have a very low threshold to reconstruct. Dr. Olaya, what do you think about internal bracing of MCL injury? Do you believe in it? I used to believe in it, but not so much anymore. I find it hard to believe that one long piece of fiber tape that goes up six to eight centimeters above and below the joint is going to really help me control my valgus stability, especially in an elite athlete. This is one that gets an MCL reconstruction with allograft tissue, Achilles, pretty much every day of the week. All right. I didn't tell him about this, but we did Achilles tendon allograft. The only comment I would add is about one centimeter below the joint line, we place small suture anchors to bring down the deep portion of the MCL to below the joint line so you don't end up with a reconstruction from the condyle to seven centimeters below the joint. And then this is just a split tail tendon Achilles allograft with a screw and washer. Anyone have a problem with that? Adam? Dr. Antz? I think that's a lot of hardware. I used to use these staples myself. I think there are some good, reliable suture anchor constructs that can be used. The double pulley system of knotting or linking together to 2.6 knotless suture anchors is nice and it's gotten me away from a similar construct that I used to use in the past. Okay. Thank you. Post-op, we made the patient toe-to-hitch weight bearing for six weeks based on the tunnels. Did start immediate full extension and range of motion 90 degrees. Had a lateral meniscus repair, I should point out, and then a hinge brace orthosis. Dr. Hamstra, return to play nine to 12 months or are we, from what we learned this morning, is it realistic in any way or should we at this age group be telling them this is going to take 18 to 24 months? Yeah, that's a great question. Nobody likes to stomach hearing the 18 to 24 in a perfect world. I would say two years back, but I'll probably never get it. For us, they'd have to pass all those tests that Lynn talked to us about and it would be minimum 12 months, absolute minimum. Dr. Snyder-Mackler, anything different in terms of your functional battery on a combined ligament injury relative to recovery and return to play? Are you going to screen them a little bit differently? I think she's gone. She's gone. I think she left. Okay. How about Dr. Beck? Yeah, I think that all of the physical exam maneuvers, I'm really big about my return to sport testing really particular and I'm very upfront with them about my expectations why we're doing it and then for me really harping on a prevention program afterwards getting that started even at a six-month time point. Okay. This is a 32-year-old female with an injury to her right knee. She was skiing. She's a recreational skier, I would point out. She has findings of a grade one pivot with a slide and a one plus anterior draw with Lachman, so not a lot of patholaxity, no other collateral laxity. She comes in with some restricted range of motion. Plane film's not remarkable. ACL appears to be torn. Dr. Murray, anything about this MRI regarding this tear that would help you decide what you might want to do relative to reconstruction, repair, et cetera? No, I think for whether I would decide repair versus reconstruction depends on factors other than the pre-op MRI. We really talk to the patient and find out what they are interested in in terms of what procedure. It doesn't really matter the type of tear so far for all of the patients we've done repair on, so that's not really a factor that we consider. All right. Well, this is her MRI, isolated ACL, Dr. Seth. This is her arthroscopy, Aden, and she's got intercontinental notched stenosis. She's got an ACL tear. I will submit to you that she wanted to have a repair because she read about it, and she had a friend in Boston who had it, and she came in with a very strong preference, and this is what I found when I went in. What do you think? No, sorry, Aden and Seth. I think it certainly looks repairable. It's very close to the attachment site, and we have some data that supports ACL repair. We have approximately 80 patients in a match series, 80 in each group, and in that study, we have shown that the graft rupture rate is just slightly higher but not significantly different. It may be that our study is underpowered since we only have 80 patients in each group, but in terms of return to sport and patient-reported outcomes, it's non-inferior, ACL repair is non-inferior. I think there are some potential advantages, including possibly quicker recovery, certainly less morbidity, no donor site morbidity, so I think it's a potentially good option, and provided she understands the risks and benefits, I don't see any reason why it wouldn't be appropriate. Dr. Alea, are you excited or are you nauseous? I'm going to need to take my psych meds a little early today. Dr. Murray? No, I think, Nick, I think this is a fine option. I think we have plenty of data to show that these can work, especially in a 32-year-old non-elite athlete. I mean, am I a full-time believer in ACL repair yet? No, I don't think I am, but I think that I can get there as more data comes about. So for me, this is, I would probably, if she wanted a repair, I would give her the data, I'd do a repair if she wanted one, but personally, I would probably just do a quad tendon autograft on this. Dr. Murray, I don't see any type of biological augmentation other than the hemarthrosis here. What's your thought about this with this, quote, internal brace and repair? Yeah, so I think it's a lot of suture material that's going across the joint. I think it's, I think you may be able to feel like you're getting the tibial stump back to the femur when the knee is in flexion, but I worry a lot about what would happen when you extend the knee and are you going to get gapping between that tibial stump when you go into extension. And I think once you get the gapping, I think it's, you're really just relying on your suture. So when they fail, your repair is going to fail. That would be my concern here. And last question, doctor, and this is the million dollar question, Dr. Dodds. So we did this repair on this 32-year-old female recreational skier, and she asks you, when can she return to skiing, and what's the post-op regimen? And to make it more complicated, she comes back at six months looking great. What do you do? I would have told her that if I did a repair, her return would be a whole lot longer, and I'm not a repair... How much longer? Well, I'm not a repair believer, so I would have put a BTB in her in the first place. So I just, I don't see, I don't see the long-term studies. I don't see, I just don't think we have it. And we've been down this path before, and I know it's a bit different, but especially without biology. Dr. Anz, what would you tell her? Just the time. I think a six-month time is reasonable, but I echo a lot of the thoughts just expressed. I was an early adopter, and I saw this patient, and I treated this patient with this technique, and I was high-fiving myself at the end, and then she came back a year later with a bucket meniscus. And so I was an early adopter, and now I'm an observer at this point of ACL repair. All right. Okay, well, thank you very much. Thanks to the panel.

ACL injury

re-injury

female athletes

knee injury reduction programs

ACL injuries

ACL repair

bridge-enhanced ACL restoration

quad tendon

bone tendon bone grafts

ACL reconstruction

risk factors