and just throw off the gloves and let's get going. So let's talk about BTB. BTB alone is a way to go. Let's not overthink this. Simple, straightforward, let's go for it. So this is our patient. Let me introduce you to our patient. So this is our housewife who wants to, you know, third-year-old female if she fell while hiking. And so she wants to get back to playing recreational tennis, doubles tennis on the weekends, right? So let's be realistic here. Her exam, standard ACL, right? So it's just a little bit of a pivot and a lockman. So there's nothing explosive. There's no significant laxity, but she does have a little hyperextension. So again, let's be realistic. Let's think about what this is. This is a young patient who wants to get recreational, you know, do recreational tennis on the weekends. We're not talking about a big pro like Serena, okay? So why is BTB the best? Plain and simple, it is the best. So this is hot off the presses from AGSM in February of 2024, looking at the Kaiser registry. So looking at all primary ACLs out of Kaiser, mostly in the West Coast here in California. So 21,000 ACLs, quads, patellar tendon, hamstring. No difference in the revision rates for quads and hamstring and BTB, but there is a higher risk of revision in hamstring compared to BTB, a hazard ratio of 1.5. So there is a difference. Let's look at BTB. So when we're looking at our patient, you want to look at why we don't want to come back to this, right? Why we don't want to have to revise this. So BTB is still the best because looking at the Scandinavian registry over about 50,000 primary ACLs. Again, the risk of revision is much lower for BTB with a hazard ratio of 0.63. So, all right. And BTB is shown to be superior to hamstring tendon in joint laxity. So this is a retrospective cohort out of Korea looking at 237 patients, looking at BATEN scores, so generalized hyperlaxity. Overall, looking at Lachman pivot, measuring anterior tibial translation as well as outcome scores. In patients with a generalized laxity, BTB has significantly more stability and better PROs than hamstring at two and five years. So long-term outcome, much better for patellar tendon. Now, what about hyperextension? We saw that our patient does have hyperextension about 20 degrees on the contralateral side. So this is a retrospective cohort, about 10,000 patients out of Sweden looking at the jury of hyperextension on the contralateral limb. And so hyperextension was associated with greater anterior tibial translation pre and post ACL reconstruction. So what you need to look at is you have to consider a graph that is superior, has superior properties for anterior tibial translation, which obviously is BTB. So let's talk about return to play and strength. So in terms of functionality and getting her back. So, you know, preventing risk of re-tear is one thing, but the other part is looking at how do we, what are we looking at in terms of strength? So this is a prospective study looking at two-year outcomes after an ACL, primary ACL reconstruction with hamstring versus patellar tendon, looking at quad strength and single leg hop. So limb symmetry index for BTB at two years is 97%. Hamstring, they didn't get that symmetry, 89%. So our housewife really wants to have her legs symmetric. So we need to focus on that. Next, you also want to look at persistent inferior hamstring strength is loss at all time points for hamstring. And then also when it comes for quad, so for BTB, the quad does have a deficit, but it does recover after one to two years. Much faster for hamstring, but hamstring is an issue for still inferior hamstring strength for all time points up to two years. So stability one trial, it's the biggest thing about stability one trials. We're looking at high grade, high risk patients. This is not that patient, right? So adding an LAT or adding soft tissue graft, as long as it increases the graft diameter, that's probably a good thing. And then also if you look, the patient is older than a 0.83, which she's outside of that group that we're looking at. But in general, that reduces the risk of graft rupture. And she didn't really have that high grade pre-op robloxity. So in conclusion, take home is that address the meniscus, repair it, get your secondary stabilizer to be functional again, do an anatomic ACL reconstruction correctly with a BTB autograft, let the bone do its job and controlling the anterior tibial translation. And maybe, just maybe, she can pretend to be Serena. Now we're gonna hear. Well done. Thank you.

ACL reconstruction

bone-patellar tendon-bone autograft

BTB

hamstring tendon grafts

joint stability