We're going to be having a good, very interesting revision ACL panel discussion now, and I'm going to call upon Professor Mendes and Dr. Aaron Kiritsch, yeah, here we are, and we have fantastic global experts on the panel, and over to you. Ladies and gentlemen, good morning. First of all, on behalf of Visa Cause, I would like to thank Anna for this kind invitation. It's really a pleasure to share with Anna this speciality day in such a hot topic, revision ACL reconstruction, and it's also a pleasure to have a co-moderation with my good friend Aaron Kiritsch from Rochester, Minnesota. We have a very nice panel with five very well-known experts, and I will introduce you the first case. So this is a 20-year-old male, a professional football player, soccer is accessory on that, so it's the real football, injury involves flexion, external rotation injury, diagnosed with a Lachman 3-plus and a Latva P4-shift 3-plus, and he was submitted to an ACL single bundle reconstruction with BTB. At six months, no pain, no swelling, normal range of motion, good functional testing and isokinetics, psychological ready, normal Lachman, normal anterior drawer chest, but he had the Latva P4-shift 1-plus and a dial test 1-plus, and he's telling us that his knee is not normal when he does pivoting exercise. Everybody is pushing. The imaging shows a nice graft, well-positioned, and a nice MRI on the healing of this graft, and because we like to evaluate the risk factors, we evaluate the bone morphology, he has a normal frontal axis, a normal slope, and we like to evaluate the portal ratio that it's the plain surface of the lateral condyle, when it's short and there is a lateral condyle more curved, we show in these two papers that there is a higher risk of rotation instability. And because we are very aligned with engineers and mathematicians and other scientists, we think that we cannot fix and we cannot improve what we are not able to measure. That's why, in this kind of population, to improve our indications, we do stress MRI with this device, studying 360 degrees around the knee. When we studied this patient, we showed that PA was almost normal, so 1 millimeter and 2 millimeters normal side to the other side, and it was confirmed by the LACMA test, but when we studied the rotation, this patient that seems to be only a slight rotation instability showed an important rotation, internal and external, with 7 millimeters in internal rotation and 4 millimeters on external rotation. So with this kind of measurement, we are able to identify this kind of population that has rotation instability. We also know that if we don't control rotation and if we stress one fiber per time, we rupture all grafts and all the ACL. We show that in this study with finite elements. So this is really important, and that's why in this patient, we decide to do a lateral continodesis just to control the lateral rotation and special, the internal rotation. And with this kind of surgery, we were able to put this patient playing in four months at the same level that he was doing before. So question to our panel, starting with New York City, Bob, do you rely on clinical examination only to decide your cases, or do you think it's useful to do some measurement, measuring laxity for indications? That's a great question, Joao. I currently just rely on my physical examination, but at our institution, Carl Imhauser, who's an engineer, has been working for the last 10 years with Andy Pearl to develop a knee tester, and currently it's still in the research phase, but to evaluate the knee in six planes and evaluate all laxities is the goal to come up with patient-specific surgery. But I don't think it's ready for clinical practice, at least not at our place. Yours looks like it is. So I need to put them in touch with you to learn a little more about your machine. I think it's very useful. When you start to use it, in some special and dedicated cases, it's game-changing for the decision. Any disagreement on our panel, or any comment? So next question, is bone morphology risk evaluation an important tool for your decision on lateral tenodesis or ALL reconstruction? Xining, what do you think about that? Well, I actually, I don't think I use a bone morphology as a risk indication on whether I do LAT or not. I mean, you can look at the lateral femoral contact index, and if it's more deep, a lateral femoral contact is a risk factor for failure. But for me, typically, if somebody comes in with a clinical exam 3+, pivot, they're very rotational and stable. Those are the patients I'm thinking of adding LAT and primary ACL reconstruction. It's more based on clinical examination, more than looking at the lateral femoral cortex. Feel free to put your questions on the microphone if you want. Any disagreement on our panel, any comment? So let's go to the amount of internal rotation and PA transluction importance. We know that laxity on ACL is 3D, and some patients has a huge PA transluction, some patients has an important rotation, and some is mixed. Do you think this is an important measurement and an important evaluation for your decision? Kaleshi? Yeah, I think you got to take into account rotation in all planes of motion. I think for me, anterior to posterior is pretty much reestablished with the ACL, but the rotation is where I'm looking at the LAT. So in a patient that has a very explosive pivot shift, hypermobile, those young, high active athletes, especially if you're using the hamstring graft, those are the ones that I have the LAT for. Thank you. And next question to Ashley. Are you routinely proposing lateral tenodesis in patients with IRIS, less than 25 years, ACL reconstruction with important rotation instability and explosive lateral pivot shift? What is your percentage of indication for lateral tenodesis? Yeah, so absolutely. In that line there, I'm definitely recommending an LAT. And I think as time has gone on, I've definitely, it's been more who not to do an LAT in. I feel like a lot of the patients that have ACL tears that come into my clinic, they fit a lot of high risk categories. They tend to be adolescents. They tend to participate in high risk cutting and pivoting sports. At that age, they're all going to play D1, they're all going to go pro, so they have that all ahead of them. And so I do worry about decreasing their graft re-tear by adding an LAT, and I don't think it adds too much to the case. The other thing to consider is I do take care of a fair number of female athletes. They do tend to have some hyperlaxity, which we know is a risk factor. And definitely I'm looking at a high grade pivot, a three plus pivot, or high grade anterior translation on exam as another indication. And then my last one would be revision, especially in the setting of not having an identifiable reason for failure. I'm definitely adding an LAT to that case. Do you use it more, depending on the grafts, more in hamstrings than in BDB and quad? I tend to stay away from hamstrings, so I'm going to do a soft tissue graft, I do quad, or I'm going to do BDB. I tend to do mostly autograft, I can't remember the last allograft that I did. So I am, typically if I'm doing an LAT, it's usually in a patient that I'm doing a quad, whether they tend to be more skeletally mature or they tend to be older, and I think they might not do well with a BDB. And so I tend to be adding the LATs to my quad soft tissue grafts. Thank you, Ashley. So Peter, what is the best? Is ALL reconstruction smoking gun or vaporware, or what is the best, reconstruction or lateral kinodesis? Well, it's basically simple in the way that we deal with it. First of all, the clinical examination tells us if the pivot is more than the translation, if it's a revision or if it's a hamstring, then we go for that additional rotational concept where we believe that works and where literature supports that. And then it's technique related. Focus showed that if you go over the top, you already have your hamstring, you put it in position over GERDI, and that's your LAT or ALL, whatever you want to call it. So if you go for your BDB, then you can choose. So most of the time, if you go for hamstring, you go towards the ALL principle, where if you go for BDB or quads, you would rather join the LAT principle. My mentor, Mark Martens in Antwerp 50 years ago, he was the big Macintosh. He didn't even know how to go into articular, and it worked. They all played. There was lateral hyperpressure afterwards and so on. So that whole concept links to each other. Thank you, Peter. And the floor is to you, Aaron. Second case. Okay. So this is a little different patient than your professional football player. It's a 22-year-old. At this point, he's not quite sure what he wants to do in life, but is a parachute instructor. And he's the guy in the back there with the green helmet. And he gets into trouble on his tandem jumps when it's enthusiastic orthopedic surgeons on the front there. They don't always know how to get their legs out of the way. So he felt a pop when he hit the ground. And here, we don't have to debate what he's had for grafts because he's had the entire trinity. He's had a patellar tendon. He's had a hamstring. And he's had a quad, all from the same knee, and unfortunately has failed all three. So his exam, he has an isolated ACL, but he does have a two-plus pivot shift. His other ligaments seem to be intact. So here is x-rays. This is a standing AP and a lateral view. You can see evidence of a few previous procedures there. Peter, I'll kind of start with you. What do you think about his socket tunnel position, considering he's had three ACLs? Well, I think he needs a testing on the portal device first. Obviously, it's a salvage case procedure here. This patient requires stability for the job he wants to do. I presume the surgical techniques have been done well. I would for sure dig into that slope. I need to know how that slope looks like. And with that, you can obviously debate the tunnel positions, but I don't know which one is from when, to be honest. So we'll have to do a CT scan, do a full setup, do a full leg standing, and do a proper workup. Okay. I think that's excellent. So just looking at his MRI here, he's got some suggestion of signal at the medial meniscus posterior horn capsular junction. What's interesting is his graft is completely absent. So suggest maybe this has been going on a little bit longer than just this one incident injury. So you wanted a bony alignment film. So here's a long leg standing coronal view and a standing weight-bearing single leg stance of the tibia. I do think it's very important that you train your radiology techs to get a weight-bearing full lateral of the tibia. Don't accept a non-weight-bearing lateral of the tibia. Ashley, what do you think about his measurements here? Yeah. So that's quite a profound posterior tibial slope there. So that's probably the reason for his three-time failure. So we think normal is about 7 to 10, so greater than 12 usually is an indication to address it with an osteotomy. So that definitely needs to be addressed in any sort of revision surgery. And he also has some valgus alignment, which could also be addressed at the same time as addressing the posterior tibial slope. Yeah. So kind of open it up to clutching the rest of the panel. So in this case, what is your list? What absolutely needs to be addressed? Would everyone correct that valgus? It's five degrees. Do we know is that a substantial risk factor? He doesn't have any lateral compartment pathology. Is that something we need to correct for him? Yeah. I think for me going down this list, the valgus alignment could be important if they had some meniscal deficiency or cartilage lesion that you're trying to offload. But just with this case, I probably would not address the valgus alignment. But the posterior tibial slope needs to be addressed. You could do that through an anterior closing wedge osteotomy or medial osteotomy of your choice. I think you also have to look at the ramp lesion. Obviously, we know the medial meniscus is a secondary stabilizer. So I think repairing that meniscus lesion is something we definitely need to do. Looking at graft choices, kind of went through all the grafts, right? He went through ipsilateral, quad, BTB, and hamstring. For me, this is forced surgery. I want the strongest graft, so I'll do contralateral BTB. And then the tunnels looked okay. I think when you get a CT, obviously, and get your tunnel dimensions, but anything over a 13, you start to worry. But I think you'll be able to do this in a single stage. One question. Go ahead, John. Do you have a threshold for the tibial slope? Any magic number? Yeah. I think once you're above 12, you want to start looking at it. So I think above 12 for me is my number. There are some consensus on the literature using the 12. Right. Tiger, if you have, you know, kind of graft choice, are you going to, I mean, he's pretty adamant. He does not want you to go to his other knee. You know, Mar's data is pretty clear in terms of revision graft choice. What are you going to do for him? I mean, if he doesn't want to go out of the knee, the best graft will be the other knee. It'll be all the graft for him. But he has three grafts in one knee. He doesn't want to go outside. You can do an L-graft suspension technique. You can do an L-graft with a tightrope button on their side, which makes it easy because when you suspend it, you don't have to worry about the tunnel collusion because with the interference screw and collapsing in the other tunnel, that's, you know, what I would do for him if I had to go back. If he doesn't want the other knee. But obviously, autograft would be the best option for him to decrease. How many on the panel would consider allograft in this case? Well, we have no choice if he says you can't use his other knee. I would have a long talk with him and explain the virtues of opening his anterior knee on the other side and harvesting that patellar tendon. President has a comment. I was thinking exactly the same thing. The allograft would be your only option if you don't let him touch the other knee. But just speaking for the Asian community, people do use perineus longus. I'm not advocating it. I'm not saying it's the thing to do. There is another autograft option if you wanted to use it from the same leg. What about a relative? Anybody using autograft from a relative? Probably not. So, Bob's mother-in-law here, Bob, I know you're a big proponent of kind of single-stage versus two-stage. Can you give us kind of your take on absolute two-stage indications for tunnel placement, widening and such? So, if the tunnel is so big that you know you can't get interference fixation based on the CT scan, pre-op CT scan, that there's just parts of the tunnel or the whole tunnel that are just so big that it's essentially like putting a pencil in a toilet paper roll. It's just going to be floating in there. Even a big interference screw isn't going to get the job done. So, in those situations, I'll two-stage. But they tend to be fairly rare because by going with divergent tunnels or slightly blended apertures, there are generally ways to achieve a single-stage with a stable fixation for the graft. In this case, though, the other thing is single-stage osteotomy versus delayed revision ACL reconstruction as needed. And if I couldn't talk him into using the other knee, a consideration is to do the osteotomy, correct his slope, maybe a little alignment adjustment as well as was said. And as CI did with that, although someone jumping out of planes at 24 is not likely to do. Wouldn't be super optimistic there. If the problem is the bone lost on the femur, do you consider to avoid a second-stage revision to do it in single-stage to do it over the top? Yeah, you could do over the top, you could do outside in, or sometimes, it doesn't look like in this case, but sometimes if the tunnel is malpositioned, you can diverge through a similar aperture. So different strategies, yes, definitely. So let me just show quickly what we did, then I'll take your question. So in this case, we planned primarily to correct the posterior slope. However, with the slope decrease in osteotomy, it's actually quite easy, and actually the tendency is to put them in a little bit of varus. So if you have a valgus deformity, it's actually quite easy to compress the medial side and correct that. He had a straightforward ramp lesion, fortunately, his cartilage looked fairly good. So here's our osteotomy, we're asymmetrically correcting that valgus as well as that posterior slope. And in this case, we did use patellar tendon allograft. When you look at his overall alignment, here he is a year after surgery, you can see we corrected the valgus, tried to give him some symmetry. And then here's the correction of his tibial slope. So question at the microphone. Yeah, I was just wondering, there's such a unanimity on the best graft for this fellow is an autograft, maybe from the other knee. Do you ever consider, because shared decision making, we're always no more than they know. I mean, do you ever just consider saying, if that's what you really think you don't want, then I'm going to send you to someone else? I mean, I'll give you a different take on the MARS data. I mean, clearly, when you look at odds ratios, it favors autograft. But when you look at the absolute relative risk reduction, it's about 2% at long-term follow-up, it's about 4%. So your number needed to treat is about 25 patients to save one failure. So I share that information with the patient, and maybe that's a little bit less compelling argument for autograft in this case than allograft. But we'll try to move on to the next case. We have five more cases, but unfortunately, we don't have time. So we will keep the five cases for next year. I would like to end this session thanking all the panel, all the faculty that worked with us. And thank you, Erin, for your moderation. Thank you so much. Thank you.

ACL reconstruction

revision surgery

knee instability

stress MRI

lateral tenodesis

graft choices