Thank you, and I'd like to thank John Kelly for inviting me to do this. We're going to switch to adults, so there are no open FICEs in this group. So this is the orange group as opposed to the apples. So this is what I use. My disclosures are on the Academy website, and I'm going to go through what I think are the steps that I take to get a successful ACL reconstruction. It starts with a high-strength graft. You proceed through anatomic positioning, and then you have to fix it well. So how do we select a graft now? Most of our studies don't have enough patients that you can actually say one is better. That's why meta-analyses really have fallen into what we rely on. So they offer us that opportunity to combine data. My preference, actually, though, is to really look at registry data. Registry data has huge numbers. The only endpoint we have is revision surgery, but it's a very good way to look at it. And that probably represents the people that are in this room, those number of surgeons that are out there doing surgery. Two of the meta-analyses in the last 10 years I'll highlight. Both still tend to show that bone tendon bone is a more reliable graft for stability, but it comes at the risk of anterior knee problems. The Scandinavian registry agrees with that. The risk of revision was significantly lower in the patellar tendon group versus hamstring, so that hamstrings continue to come up as not quite as successful in high-demand athletes. So this is the Scandinavian registry data. You can see the risk of revision is substantially higher than that for patellar tendon. The Kaiser registry, similarly, another large population presented about four years ago now, look at the risk of revision, hamstring versus bone tendon bone, statistically significantly higher for hamstring autograft. We know why hamstrings are inferior. The MOONS group has reported this, and it really is graft size, so that if you're going to use hamstrings, you're behoven to come up with a way of making hamstrings a bigger graft. As you probably heard, hamstrings in teenagers are not a good choice, so you want to use hamstrings in a more mature population, at least I do in my graft selection. So there's numerous other ones. The only meta-analysis is from Chi et al. It's an oriental population, and they actually found no difference between bone tendon bone and hamstrings, so it's perhaps getting better for hamstrings, but I still have a strong bias for bone tendon bone in high-demand patients. How do you increase the diameter of a quad graft? What I use is a quadruple semi-T. It's a short construct. You can basically get the construct down to seven to eight centimeters long with two adjustable flip buttons. Reliably, it gets you 8.5 millimeter grafts, except for small females, and a small female often add the gracilis, and it gives you plenty of graft within the tunnels, 20 to 25 millimeters in each tunnel, which is more than enough for fixation. So single bundle, high demand, bone tendon bone, moderate demand, recreational athletes, those people that are 25 or above, hamstring is my choice, and then as a final on lower demand, I use allografts in the population that's greater than 40 or for other extenuating circumstances. All of these are done medial portal. I believe medial portal is the best way to get things anatomic. Freddie Fu, we owe great credit to for refocusing us on the anatomy of the ACL, and I think we're all directing things to be more anatomic and less relying on trans-tibial drilling, although certainly trans-tibial can work. So I drill the femoral socket independent through the medial portal. You can certainly do that outside in, and there are a number of guides that make it very easy to do that presently. Trans-tibial I've done in the past. I think you can get around it to get good positioning, but it makes it a little more difficult than doing independent tunnels. So here we are. This is going to be a composite of right knee ACL reconstructions, standard findings. I am somebody who, get off it. So I preserve a tibial remnant. This is an ACL that's scarred to the PCL. We've got a small cyclops, and I like to leave someplace between 8 and 10 millimeters of tibial remnant, not that I think it gives anything more than a resistance to flow and makes it less likely for you to have dilatation of your tibial tunnel. I do a minimal notchplasty, if anything. The vast majority of my patients don't get a notchplasty. Chronic cases or those that have a very small notch, I'll do it for visualization. I always look medially. You want to be able to see your footprint. When I have the fellows prepping the notch of the knee, I want them to leave that footprint on the femur so that you can use that for focusing where you're going to put your femoral socket for the reconstruction. Then go back. The scope's now back laterally. I'm just going to use my shaver, and there's a myriad of ways to mark what you want to do, and I actually just create a line that's the midpoint of the femoral footprint, halfway bottom to top, and then I can try to hit that with a drill guide when it becomes necessary. I then go back. I want to make sure I've got enough fat pad cleared out, that intermeniscal ligament is as low as you want to go. You obviously want to preserve that. I drill the femoral socket at 120 degrees of flexion, so if you don't get out some fat pad, it's going to be a problem. Obviously, if you're doing these independent and you're going for independent through an outside-in drill guide, that's not a necessary step. Hitting my pin, I want it to be at the intersection of the posterior attachment of the anterior horn of the lateral meniscus, and I want this midway medial-to-lateral on the spines. Let me skip up to the next one. I usually drill the femoral socket right away. I didn't show that. I'm going to jump to the tibial socket here. This is an over-the-back guide. Typically, because we've got some cartilage back there, this will be an 8 or 9 millimeter over-the-back guide to be sure that we're not violating the articular cartilage. I place it with a knee at 90, flex the knee to 120, and then when I drill it, here we are at 120 degrees, this is a standard beef pin. I'm cheap. I'm trying to do this inexpensively. I do not use a lot of money from the surgery center, so I drill the beef pin out through the skin. I don't move that guide. I don't move the knee, and this is a 2.2 millimeter nitinol wire. It's the nitinol wire that comes with the interference screw, titanium interference screw. It allows you to flex and extend the knee, so you can look at it from all sorts of directions. You can see me bending it there, looking back from the medial side, no problems with bending and then you can ream over it. The advantage of reaming over it is you can bend it away from the medial condyle as you put your drill in, so you're not likely to injure the medial condyle, and at the same time it doesn't fret as much as stainless steel when you're drilling over that. So this is drilling with your flip button for depth, so I will drill this, find the depth of the lateral cortex as I go through it, and then ream to within 5 millimeters of it. Typically with this technique, the depth of the tunnel will be someplace around 30, occasionally 35 if you have somebody larger. You can then come back and look at your tunnel from the medial side. You want it entirely within that footprint. You want to be sure that you've got a decent position in the cortex behind it, and you don't want to have violated the articular cartilage. So finally, rigid fixation. There are numerous ways to fix the grafts. One tendon bone, I'm a titanium interference screw, and why do you use titanium instead of absorbable? Well, fellows cannot break titanium. They can break any absorbable screw you put in. No creep, highest strength, but certainly the absorbables are a reasonable alternative. There's a myriad of ways of fixing soft tissues. Cross pins probably aren't appropriate for medial portal. There are numerous flip buttons. Every company has one, and I've actually gone to them for suspensory fixation because of this short, fat construct that I'm using for hamstrings. So suspensory flip buttons, they all have a slightly different technique, and with soft tissue grafts, you have to be very careful with them with cyclic loading, so you want to make sure that you take as much creep out as you can. So here, visualizing from the medial portal, I watch the button go up through the hole in the femur, and you want to watch it flip. I think if you don't see it flip, that's potentially a reason to take a C-arm view, but I don't do that routinely. I like to watch it flip. Ashish Bedi has a great article that just shows that if you cycle and then not over your buttons, you get very minimal creep. So I routinely cycle all of them, and then I flip. Once they're cycled, I re-tension. Always re-tension them in full extension because if you inadvertently flex the knee and re-tension, you can over-tighten it, and I back all of these up with knots at either end. So here we are, final construct, looking from the medial side, and you want to have a well-placed graft, strong, anatomically placed, and then fix it well, and be careful to cycle your grafts and tension them all in full extension. Thank you.

ACL reconstruction

graft selection

quad graft

socket drilling

graft fixation