All right, not that there's anything wrong with that. So let's talk a little bit about, because I think you both talked about the stability trial, if you really cull out the stability trial data in terms of the high Baten score hyperextension, didn't seem to be that much of a difference in terms of the LAT added to the hamstring. So what's your thought about that? Totally intuitive, get it, get it, get it, but the data didn't seem to support that. What do you think? So I think we have a lot of other papers that come out now which do tell us that if you do a hamstrings alone, especially with someone who's got hyperlaxed and hyperextension, you're gonna have a significantly higher risk of failure, which is why, yes, stability trial was a good starting point for all of us, but now we have some more subsets of that same group in which they have studied this particular fact in much more details, which do tell us that, yes, adding an LAT is probably the best way to protect your soft tissue graft. How about doing a BTB and adding an LAT? What do you think? I think for now the- In this patient. In this patient. I probably wouldn't because, again, we're looking at the anterior tibial translation, the pivot, these are not explosive numbers, right? They're relatively standard for a regular ACL, so it also depends on someone who wants to get back to a specific cutting, twisting, pivoting. That's where you really want to protect that kind of rotational component. I think for now, just a BTB is probably the way to go. Yeah, I think I would agree with her. If you had a different patient profile, same numbers, but maybe a 20-year-old who's playing football or soccer, then I think, yes, a BTB with an LAT would be the go-to graft for me. Let's get down and dirty. Let's talk about tensioning for both of you. I like what you showed about maybe posteriorizing that just a touch, but let's talk about tensioning. How do you tension? Tell us your routine in this case, in terms of degrees. Yeah, so in this case, I'll fix the femur, cycle the knee about 20 times, and I will tension the graft near full extension. Close to extension. Kazza? What does near full extension mean? That could be zero, 15, 20. Zero. Zero. Ah, for minus 20, right? All right, yeah, so I do something very similar. I fix the femoral side first, cycle it a couple times, probably not 20, but somewhere less than that, and then I actually will extension, I will fix the tibial side and extension also at zero. Okay. Let's talk about rehab. So do you treat this patient differently? How aggressive are you initially with range of motion, particularly trying to get that hyperextension back, and if so, when? So I think in this particular patient, the meniscus repair is going to drive my rehab in terms of weight-bearing and range of motion. So let's assume we get the meniscus repair out of the whole equation, then I think in these patients, the first thing that I want to do is to prevent a flexion contracture. So bracing and extension for at least three weeks till the whole knee settles down, full weight-bearing, and I don't push them to get hyperextension. She's got hyperextension on the contralateral side, which is about 20 degrees. I frequently find that at the end of about two to three months, they usually sort of glide into a hyperextension of maybe five, 10 degrees. I have rarely seen them get the same kind of extension as on the opposite side, unless they're hyperlaxed. So hyperextension and hyperlaxity, they may not go always hand-in-hand for all patients. Dr. Lee? I think if you let the hamstring go, it's gonna stretch out anyway and become hyper, she'll get the hyperextension. So typically for my patients for BTB, I would emphasize much more on the extension. I don't brace them, but I definitely emphasize that and try to do that within the first three to six weeks. Expectation is probably within six weeks, but really I want it done in three. So you tell your therapist to basically move into hyperextension. Yeah. To get your chest up right. Yeah. Let's talk about, we heard in the last debate about the issues of intercondylo-notch stenosis. So how are you handling that in this group? What's your threshold and trigger for perhaps doing some type of a notchplasty? So I think if I'm looking at a notchplasty in a primary situation, it's almost never. So I'll always get a ruler in, measure the footprint on the tibia, and then I will sort of curate my hamstring's graft, maybe making it a five or a six strand, depending upon what sort of graft, sort of dimensions that I need. So I also don't, I pretty much at this point don't do any notchplasties for primary. But I think Sachin kind of touched upon it, is really for someone who's hyperextension, you really wanna emphasize where you're putting the graft within the footprint. If you treat it anywhere anterior, they're gonna have an issue with that on the notch. So it is, you end up having to put a little bit more posterior, but oftentimes when I put that guide pin in, I'll cycle the knee a few times, take a look where it goes in extension, and adjust accordingly. Any other questions from the audience? Yeah, going back to the extension issue, we're all obsessed about getting extension early on. We know that some of our patients lose a little bit of extension. How aggressive are you guys, and what time point do you say, I need to go back in and do a posterior capsulectomy, or some manipulation after surgery? You know, I think as we get further and further out from surgery, you lose extension, it's gone forever type deal. How aggressive are you about going back in? So I think if you're looking at doing a radical procedure, like doing a posterior capsulectomy arthroscopically, it's probably never in my hands, unless I'm dealing with someone who has, ends up from hyperextension into a flexion contracture, that's maybe 10, 20 degrees of flexion contracture, which is really something's gone wrong in the surgery per se. But you almost always find that, you know, they will drift back into about 10 degrees of hyperextension, a couple of them may go back to exactly the opposite contralateral limb, but I'm pretty much happy if they sort of go a touch where they started off from, and they're pretty happy in that particular instance. Yeah, in general, I also kind of give the expectation up front that they're not gonna reach that hyperextension as a contralateral side, especially with BTB. So I tell them that it's gonna feel a little weird, it's gonna feel like they can't lock out their knee, but as long as you can get it flat on the table. So you can kind of get an idea of the patient up front, usually I'll check them at one week post-op, but then that's, you know, that's standard, you're not gonna see anything different there. But if they're, you know, if you have any question about how they were pre-op, then I bring them around four week post-op to check and to just see how much, how they're scarring around their knee. You can feel how much mobility they have around their patella, and if they tend to be one of the scar makers, then I'll be a little bit more aggressive about emphasizing, having the PT work with them like two to three times a week, as opposed to like one to two. Last question. Yes, what is the age cutoff you're currently using for autograft versus allograft? And if you are doing an allograft, how often are you now adding an LAT? I think pretty easy for me, 0% allograft for primaries, basically because of availability issues, predominantly more than anything else. I think it's your ballgame. Yeah, so being in California, or being in the U.S., obviously we have a lot more allograft available than most of the world. I think it's anywhere in the 20 to 30, 20 years old, it's kind of a no-brainer. The moon and Mars, all that data shows us that we need to be doing autograft, right? 30s, it depends too, right? So 30 and someone who does recreational tennis versus like 30 who's, you know, a professional athlete. Those are two different animals. I think up to, for me, I go to probably up to about 40 for autograft, but there are plenty of mid-30s that I actually put an allograft in. And it also depends, if they are, if they have some of those risk factors in terms of the hypervelocity, the hypermobility, then I will say that I'm not putting LATs in my primaries. I'm probably doing them in revisions at this point. All right, thank you. I want to commend both presenters, but we have to have a vote, so. I know, there you go. 100. Thank you for that one person who voted. Stop. You should have stopped now, right? David, who owns the software, by the way? Do we know who owns it? It's a secret. I won't tell you, Sachin. David, you started the competition. What do we have here in terms of the tally? Ah, yes. You spoke of it too soon. You're getting a bit cocky too soon there, Nick. Okay, I think the photograph changes. We stopped. I know, we should have stopped. One person voted. I think if we think of the number and the people in the audience, each ISACOS person in the audience should get two votes. Oh, you're saying it's rigged. He's saying it's rigged. Okay, well, good job. All right, thank you all.

ACL reconstruction surgery

stability trials

autograft vs. allograft

rehab protocols

postoperative extension management