Thank you, Dr. Brown. And so I'd like to bring up the panel so that we can talk about what do we do with recurrent ACL tears. So Matt Salzer, Ashley Bassett, Anand Saithna, Miho Tanaka, and Nick Scaglione. All right. So the concept is we're going to talk about recurrent ACL tears, and we're going to change some of the variables. There's not going to be any pictures, so it's a little hard to see through the lights here, so that kind of works out. But the idea is that we're going to talk two patient scenarios. So we're going to talk about that 20-year-old athlete, and these are all revisions. So I'm going to put the presumption of we have an anatomic ACL reconstruction. It was fine, but they tore it again. Now what do we do to change the variables in terms of how do we prevent this again later on? So we're going to start off with, so we're going to talk about do we use the same tunnels? I guess we're going to take that out, because we're assuming that the ACL is relatively in a good position. So we're going to talk about graft options, otto versus allo, looking at do you reinforce that with a suture inter-articulately, and what your thoughts are on that. Do we do LAT? Do we do ALL? And what do we do about rehab? So those are the variables we want to talk about. So first one is we have a 20-year-old female collegiate soccer player. It's a non-contact pivoting injury. So pretty classic. Had a primary ACL reconstruction with BTB with autograft at 18. So now exam-wise, relatively normal, no hyperlaxity, nothing too exciting as typical Lachman 2A and pivot of 2 plus and positive Murray's. So let's start down the row. So Ashley, let's talk about what kind of grafts are you going to do for this collegiate cutting, twisting, pivoting athlete. Yes, absolutely. First, I'm sorry. I've lost my voice. So hopefully this microphone is picking up what I'm saying. So graft options, obviously, she's had a BTB done. You can do contralateral BTB, hamstring, or quad. In this scenario, I'm doing quad. I don't really like to do contralateral, and I like to avoid hamstring graft use in females. OK. She's going to go down the pike. All right, Matt. What do you think? Quad. Quad. I personally don't think that the autograft choice is an important consideration here. What's important is to address the secondary restraint lesions, including the extra articular structures. All right. So let's go a little bit more into that. So LAT, ALL, or would you add an internal suture with an interarticularly? There's only two comparative studies looking at ALL versus LMAIR, both in the revision ACL setting, neither show any significant difference in the outcome between them. But both are underpowered, so we don't really have the evidence to strongly justify one over the other. Both are good options. OK. So Miho, do we need an LAT? Yeah. I would add an LAT, and I'd also want to know what the tunnels look like, because for me, the graft option would really depend on whether I thought I could harvest something that would fill that tunnel versus needing something else. OK. So BTB, graft tunnels look relatively anatomic, good anatomic position. They're not that far off. What would you do? Not widened, though? Not widened. Yeah. So, I mean, if she had a previous BTB and the tunnels are fine, I mean, I think you could do anything. I would lean towards auto, and I think you would have all options available then. OK. Nick, what do you think? Yeah. I think in terms of the LAT or ALL, I think you're getting ahead of the game here. I want to know why this patient failed, and if the tunnels look good, that's going to be where your money is, then why is this just another injury, et cetera? So I would say to you that we need to be a bit more thoughtful about adding extra articular. But backing up, I would use a quad. It would be my grafted choice, all soft tissue quad for the graft. And then I'd like to see a little bit more about slope. I'd like to see a CAT scan in this case to be certain that your tunnels are where you want them to be. OK. Let me be a little devil's advocate. Do you think you can accurately measure the tibial slope? So CT scan, not X-ray? X-ray and CT scan on all revisions. Can I accurately? We could debate that, but I'm going to. Fair enough. All right. So notice that she has no hyperloxia on this one. So are you concerned with? So who on the panel is going to add something extra articular? Everyone. I would, but I'd also like to comment about what Nick just said. I totally agree that we've got to do a full assessment, but often in these cases, we don't identify a particular reason, especially here where the tunnels are well positioned. So probably her main risk factor is her age and gender and participation in sports. What we also know is that if you have a first failed ACL reconstruction, your risk of another failed ACL reconstruction is fourfold. And that's my rationale for adding an extra articular procedure. This patient is already high risk for failure since they've had one, and we need to minimize that risk. And then a key thing to point out here in terms of risk calculation is on that McMurray. So does she have meniscal pathology? Is that meniscal pathology repairable? Is the meniscal pathology non-repairable? If it's non-repairable, and now you end up with attrition, I think that's going to sharpen your indications for an LAT. Perfect. Yeah, Miho? Since we're kind of being thorough about this, in addition to slope, I would also get long leg alignment views to look for any sort of coronal malalignment at the same time. Is that standard for me and my revisions? Yes. Matt? I would also add in a more detailed physical exam, looking at dial test, varus, thalgus, laxity, all the, I mean, we're talking about all these things that kind of we get back to with the full workup. Yeah, fair enough. Yeah. So I kept this vague enough to kind of open all the doors. So all right. So next case, though. So now what if I change one of the variables? Go ahead and think. So she's collegiate soccer player. She's going to go back. Now she hyperextends a little bit, minus 30 to 130, Baton score of 5, pivots a little bit more explosive. Jill McMurray, what's going through your head? What are you concerned about? Ashley? Yeah. So she has all of the main risk factors for having ACL failure. She has a Baton greater than 4. She has a ricker bottom with greater than 10 degrees or at 10 degrees. She has a high grade pivot. And she's young. So this would be someone that, I mean, obviously, after the extensive workup we just talked about, this would absolutely be someone that I would add an extraticular stabilization procedure to. OK. So does anyone think any other factors on this that we haven't talked about that you would treat this patient a little bit differently than the prior patient? I think it's worth a comment just saying that Camilo Jalito specifically published on this topic. He has a comparative series comparing isolated ACL versus combined reconstructions for people with hypolaxity and showed that there was significant advantage to combined reconstructions in this population. Yeah. Fair enough. All right. So does anyone actually stop and counsel your patient about what her expectations are in the future? Is anyone having that talk? Yeah. I do. I mean, I think this is someone where I'm going to have a definite discussion about risk of arthritis in the future, risk of re-tear in the future. And one of the ways I sort of talk about extraticular ligament reconstructions or augmentations is that we know that those are going to increase the risk of arthritis. They did in the 1990s. And we don't have data on our current ones, but they're probably going to. But what I would sort of balance that with with this patient is that's being balanced against your risk of ACL re-tear, risk of meniscus re-injury, and all of those things are also going to substantially increase risk of arthritis. And then there's also, you don't want to have to go through this again. And so this is definitely someone where I would say this is where I'm going to add something probably for me an LET first, but I'd say that's why I'm doing it is to decrease your arthritis risk in the future and decrease the chance of you having to come back. This is a patient I spend a lot of time with. And on the topic of counseling, I think a key point here to be made as far as revision is understanding as well where is her mental status in regard to the failure? What was her mental status in terms of did that contribute to her re-injury? Did she fully rehabilitate? We can talk a little bit about performance, and then what are we going to do differently? And also, we can talk about kinesiophobia. I think there's some very interesting emerging research about looking at mental status and looking at some of Melissa Cristino's work out of children's and some of Liz Baskin's work too. So definitely a huge part of the female athlete, what you have to look at with a female athlete. All right, so we're about halfway through. Let's go ahead and flip the script a little bit. Now we're going to talk about a 40-year-old weekend warrior, whatever that may mean, how you want to take this. So same idea. Let's look at the variables. What graft we're talking about, assuming what's going on in the tunnels, what the workup is. Is it any different than compared to that 20-year-old collegiate athlete? And when to LAT, when to ALL, when to do a potential intraarticular suture reinforcement. So Ashley, you're up. So I tend to lean towards autograft pretty consistently in patients, even in the older cohort. I know some of the MOON studies. 40's older? Thanks. Sorry. Even the studies suggested that over the age of 30 or 35, they can do pretty well with either graft choice. I'm still leaning autograft. I had a hamstring autograft, so they have either option as a male. So I'm not as concerned about patellofemoral pain, although it is anterior knee pain could happen in either sex after ACL reconstruction. But I would maybe lean towards BTV in this patient, but I would have a discussion about it. OK. For me, I kind of think back, you know, this is Kading's data. We've all seen that chart where autograft goes down, allograft goes down. By the time they're in 40, it's under about 5%. But the caveat there is that was looking at ACL revision, not necessarily ACL retear. And so if you actually look at the studies that have looked at ACL retear versus ACL revision, there's a gap, right? So a 40-year-old may not want to have revision. This patient is someone I'm going to say, you know, this is what the ACL does. What supports do you? This is a second lawyer that once a year they play, you know, table tennis, in which case maybe not. If they're playing basketball in a league every single weekend, that's going to be different. That's a patient where I might consider an autograft. If they are playing pickup basketball on a weekend two times a year, I probably would go with an autograft. I would use a BTV, not a soft tissue autograft. And we also know that these patients have a higher rates of progressing to arthritis with ACL reconstruction over 40. So this is somewhere I probably would hesitate on doing anything on the lateral side for that reason. So you'd look for probably BTB? BTB allograft. Allograft? Allograft. OK. Allograft. BTB allograft. I just want to make sure. I'm like, I don't know if I could rehab a BTB at this age. I'm just saying. So BTB allograft. All right. Adnan? My perspective is slightly different. So firstly, with respect to the risk of osteoarthritis, I actually wasn't involved in this study. But from the Santee Study Group, there's just been a study accepted in AJSM, which looks at 10-year outcomes of anterolateral ligament reconstruction. And it shows no evidence of an increased risk of lateral compartment arthrosis with combined procedures. So I think we can be a little bit more reassured about that risk. In terms of this particular patient, he's had an ACL reconstruction over a decade ago and has done well for that time. So I would think that he's not really a high-risk patient. His mechanism of injury for his new ACL injury was traumatic. It's not a pivoting, twisting injury. He landed awkwardly while bouldering. So I don't really think that an LET is particularly indicated here. But obviously, we don't have all the information about the case. And so now we do. OK, perfect. Let's justify the extra articular. So McMurray's, if he's having a medial meniscus repair, we know that lateral extra articular reconstruction confers a protective effect on that. So that's one possible indication. But my overall statement is the same. In this patient, he doesn't seem to be a high-risk patient. So it's not necessarily something that I would strongly consider here. But it depends on the individual factors we find when we do the full workup. Miho? So the other thing I would add is that if he had an ACL 12 years ago and he's 40, I would really want to make sure that he doesn't have any sort of medial compartment wear and see where we're starting before we even start this conversation of function versus minimizing risks of arthritis. And then in terms of how to approach a revision, I think in general for revision cases, I talk to my patients about the addition of a potential LET. And usually, they have a sense of whether they think it's something that they want or something that they don't based on their own gut reaction. So we'll kind of talk through that. But I think either way is very reasonable. And then for graft options, again, same thing. I think if he's over 40, then I think allograft is just as reasonable as autograft. And I would kind of let the patient dictate that. But I think everything would be OK in this case. OK. Anything different, Nick? No. I would just emphasize that I think it's very reasonable to have a discussion with this patient about an allograft, a BTB, non-irradiated allograft. So this would be straightforward. And then I'm concerned about the Castaldi work, where now they're saying about a 59% of lateral compartment osteoarthritis longitudinal cohort. Again, the problem with the study is that it's kind of all comers and maybe some more non-isometric or more non-anatomic LETs that are thrown in. But there are some constraint issues. And I think the final word's not in. I share your concerns. But you kind of answered the question for me there. Because I think, really, we need to consider these extra articular procedures as separate entities. So the 10-year data that's just accepted in AJSM is for anterolateral ligament reconstruction. And that's an anatomic procedure. It's fixed in extension. And so the risk of over-constraining is very small. And that's been demonstrated in numerous biomechanical studies. When we compare it in biomechanical studies to a non-anatomical iliotibial band-based procedure like the modified Lemaire, we see that that iliotibial band procedure is associated with a higher risk of over-constraint. We actually don't have a good definition of over-constraint. Certainly, there's no consensus on that. In the laboratory, it's very easy, because you can measure the angles precisely. But in clinical practice, we don't have that ability. And right now, we're basing a diagnosis of over-constraint mainly on the development of osteoarthritis, which is obviously a long-term outcome that we don't really have a lot of data on. So for sure, over-constraint is an issue. But in terms of clinical reports of over-constraint, there's actually only one that I'm aware of in the contemporary literature, and that's a single case from the stability study. In terms of anterolateral ligament reconstruction, we have not identified any cases of over-constraint to my knowledge. Yeah, I think you're spot on. I think the takeaway has to be that the meticulous technique, whether it's an ALL or an LET, is essential. And I kind of liken this a little bit to the excitement of the elegance of double bundle that ultimately produced a lot of revisions for a lot of us. And I think that's something that we're just starting to see in terms of perhaps the takeaways when we go home and do some of these extrarticulars. And they're not being done in the Sante group by Alan Gekod. So I think we do have to be a little bit aware of what the final common denominator will mean. So that's why it's still a question in my head. OK. You guys have all avoided answering anything about placing a suture intra-articularly for with the ACL revision. So 30 seconds. Miho, what do you think? I have some concerns about that. You know, we've seen from the literature with the LARS ligaments that the anatomic ACL is not isometric. And so that usually the synthetic, you know, including sutures that don't necessarily change lengths do better if they're in a non-anatomic position. So I have not incorporated that into my practice. All right. Well, that is time for our session. So I'd like to thank all of our panelists.

recurrent ACL tears

management

graft options

patient scenarios

meniscal pathology