Good afternoon, everyone, it's a pleasure to be here. Thank you to ARNA for allowing us to present our work. These are my disclosures. In 2017, we won the Richard O'Connor Award from ARNA for our study that demonstrated a threefold reduction in ACL graft rupture rates in combined ACL and anterolateral ligament reconstruction compared to isolated ACLs. So it's a particular honor to be here and update you on some of the things that we've been doing in the meantime. Briefly, the surgical technique is to try and replicate the anatomy of the native ALL. The intra-articular portion of the procedure is constructed from a tripled semitendinosus with an additional strand of gracilis. That additional strand of gracilis exits the femur, forming the extra-articular reconstruction. There's no doubt that this has been controversial, and in his recent editorial commentary on our current study, Dr. Rossi stated that the proof is in the pudding and that the pudding is clinical results. He also said that as of now, the pudding is tasting pretty darn good, bon appetit. But what does that actually mean? So in 2017, we published re-operation rates, which are a particular concern given the history of extra-articular tenodesis, and we demonstrated that our re-operation rate was 13.1%, and when we compare that to similar series of isolated ACL reconstruction, it's certainly not excessive. CARTUS, 26.7%, HETRIC, 18.9%. We've also recently demonstrated that in patients who have a meniscal repair, a medial meniscal repair, those who have an ACL plus ALL have a two-fold reduction in secondary meniscectomy rates, and we attribute that to better restoration of normal knee kinematics. Other authors have recently said that patients with hyperlaxity, a Baten score greater than five, have significantly better outcomes with a combined reconstruction, and that's also been demonstrated by Kim et al. for revisions. Just a couple of weeks ago, we demonstrated in AJSM that with 1.5 Tesla MRI in acute ACL-injured knees, over 90% of patients are demonstrated to have an ALL injury, and that can also be seen at lateral exploration. And this is something to highlight, because yesterday we heard a talk on whether the ALL is Blarney or overkill, and certainly on the basis of those clinical results and these pictures, I think it's hard to believe that that might be the case. And certainly this U.S. survey of AOSSM respondents demonstrates that over 40% of surgeons have performed an extra-articular procedure in some of their patients. One of the main indications is elite athletes, and there's not a lot in the literature, so that's the purpose of our study, to document the outcomes in those professional athletes. So this is a series from Bertram, Sonri, Kote, and Leon, who I've co-authored with. We have 70 professional athletes, you can see the distribution of sports there. The mean follow-up was about four years. This slide demonstrates that the proportion of patients with a meniscal tear who had to repair was very high, but that didn't result in a very high secondary meniscectomy rate. The ACL revision rate was only 5.7%. Three of those patients were participating in soccer, and the other one in hockey. The other reasons for re-operation were uncommon. Return to professional sport was 85%, the mean delay was eight months. IKDC, Lishome, and knee laxity parameters post-operatively were excellent. At the latest follow-up, 22% of patients had retired from professional sports. The reasons they gave for this were their age, some of them didn't have a contract, some of them were participating in education instead, and only one patient reported that their retirement was due to their knee. This is a high-risk population. It's demonstrated by their very high contralateral graft rupture rate, which was 27%, half of them before the index procedure, half after the index procedure. There's very little published in the literature regarding professional athletes and outcomes after ACL reconstruction, so it's hard to compare, but this is a series from Camath et al. that described the outcomes in the elite collegiate athletes, and their re-operation rate was considerably higher than our series at 51%. Similarly, for the retirements, there's not a lot published. There was only one study we could find, and May et al. reported that 67% only were on the active roster three months after ACL reconstruction. We can't compare that directly with our study, because obviously there's difference between the distribution of sports and the populations, but it still allows us to have some context. In conclusion, combined ACL and ALL reconstruction is associated with excellent outcomes in professional athletes with respect to graft rupture rates, return to sport, and re-operation rates. Thank you.

combined ACL and anterolateral ligament reconstruction

Richard O'Connor Award

ACL graft rupture rates

surgical technique

re-operation rates