All right, panel, so I'm going to have some fun with this. I feel like, once again, I'm among giants, and I'm really honored to be able to present some cases to these guys and get some thoughts. So my panelists, as you see, I have some disclosures that are in the book, and they don't relate to this talk. So the first case is a case of mine, which is a 28-year-old, six-foot, six-inch, former Division I basketball player. In 2011, he had an ACL done elsewhere with an allograft, but he was able to complete his college career for the next few years. He comes to me just this last year with complaints of pain and instability. He said he's able to play basketball whenever he's braced, and he lives for basketball. So not playing basketball is not a great option for him. So here's his plain x-rays, and pretty unremarkable. You guys have a little bit of a distance to see these. He does have a little bit of spurring on his patellofemoral joint, a little bit of spurring medial lateral compartment, but not much. You can see kind of where his old graft is, but not real well, his old tunnels. But again, not a lot to add on that. So MRI report. I always read the MRI report before I look at the MRI, and his MRI report says mild tri-compartmental osteoarthritis unchanged, partial thickness tear of his articular cartilage on his medial and lateral femoral condyles, and his ACL graft is intact. No acute, meniscal, or ligamentous tear. So without looking at his MRI, you get this report. What are you thinking before you go in and see him with his history? I'm going to start with Chris, because you're closest, haha. It looks normal. I mean, if the graft's intact, I don't always trust the MRI, so the physical exam, I didn't quite catch it. We'll get there. Usually I do the physical before the MRI. Yeah, but you're going to go see this guy. You looked at his old records as he comes in. You see this, and your PA or somebody went in and gave you this history. Well, he's complaining of instability, so I think something's going on there. Based on what I see here, I think it's going to be really dependent on my physical exam as to how I would want to make recommendations. Right. So Bruce, when you have somebody comes in and says they're unstable and their MRI says their ACL graft is intact, what goes through your mind? The MRI means absolutely nothing. I think you've got to rely completely on the examination. Grafts can look completely normal on MRI and be completely dysfunctional. Jim, anything to add to that? Well, it was an allograft, right? Correct. So the Moon Group has shown quite clearly in young people you don't want to do allografts. They usually stretch out, so you probably think his allograft was either stretched out or vertical or something like that. And the other thing I think about on this is that they missed another instability. I mean, like posterolateral does not show up on MRI, especially chronically, so he's giving out it may be posterolateral also is another thing I would add. The other one's PCL. Correct. They had a PCL injury and they did an ACL. Okay. We'll go on. So your MRI tells the story. Jim, what do you see? Looks like it's a vertical graft to me, so you'll control AP, but you won't control rotation. And it looks just a little bit wavy. Posterior cruciate looks okay. Patellofemoral joint looks okay, too. Yeah, it's pretty vertical. That is the most vertical graft I've seen in both planes, I think, in my entire career. Well, the thing that worries me, quite frankly, is allografts have a tendency to form cysts. And if he gets cystic changes above and below, now you're talking about a whole different thing when you're going to try to revise this. Correct. I don't know. I don't see big cysts. You know, Jim, that thing is so out of position. I bet you can put a new graft in there, but I agree with you, especially with allografts. This thing is so far out of place, you can probably do a primary revision. I'd like to see the x-rays and see it a little bit more. Which sometimes is your best friend when the last surgeon did not do a good job. So, articular cartilage status, somebody look at his... Bruce, why don't you look at his condyles? What do you think? Well, the lateral side looks like there's a defect. There's some cysts behind it. Anything medial on this gut? I know it's a limited gut. Nothing glaring. Okay. Alrighty. So, now what? Chris, pre-surgical planning. What are you going to tell this guy? What's your thoughts before you go in? So, you examine him. I think for some reason I missed my EUA. A lot of my EUA is in the OR. I kind of get a baseline EUA, but he's got a pivot shift on your exam. He's got no LCL, no MCL laxity. What are you going to think about? I mean, it sounds like it's a central pivot problem. He's got what looks like intact medial lateral meniscus. His pivot shift was three plus? Correct. And his Lachman was? He did have a two. Two plus. So, it's a rotational thing. So, for sure you'd be doing an autograft. I think this graft is so far out of place that you can easily do this in a single stage, is what I'd say. But I'd need to see the x-rays a little bit more. But I think single stage, I'd probably use BTP autograft as my revision graft. I'm assuming his menisci are intact, but I'd really want to know. I don't know if that MRI is old. It could be old, and the meniscus may have deficiencies in it. So, probably single stage, BTP autograft. I'm not sure I would add an extra articular here. I guess I'd have to see the pivot shift before I made that decision. Anything else? The Mars data is very clear for revisions that autograft performs much better. Three-time failure rate with allograft, so I'd use auto. My preference in a high-level athlete like this, or wants to remain highly active, is a BTP as opposed to a hamstring. And I would have probably a low threshold to do a IT band tenodesis here. Jim, anything different? I would do a BTP autograft. If it's a plus-three pivot shift, like you say, I would do an allograft gracilis ALL. And I would look at that lateral femoral condyle. If it's something that I thought, you know, it's 10 millimeters or so, I'm either going to use an autograft oats or a fresh allograft oats, depending on what it looks like. But I'd have one available. That's what I'd be doing. I wouldn't stage it, though. Any other ways to address the articular cartilage? I just want to make a comment about preoperative planning. So on every revision case, we typically get hip-to-ankle films to look for coronal malalignment, as well as single-leg standing lateral x-rays to look for sagittal plane deformities. So just something that I see when people come in with three, four-time failed ACLs, and it all seems very simple. It's an allograft. It wasn't put in properly. It's important to get sagittal and coronal plane alignment studies. Am I allowed to ask a question? Certainly. So I've had this question for a while. What number do you use on the sagittal plane before you're going to do an osteotomy? What's the number? Because I've got a bunch of my friends that got all kind of numbers. Give that to Bruce. Yeah, I think, first of all, I think the alignment feels a good idea. I usually look at the contralateral knee, and that's important to me, the number there, neutral, or maybe they're a little bit of varus, and I think that's important. To really go to a femoral osteotomy with a valgus is what we're talking about here. They've got to be at least three to five degrees side-to-side difference in valgus. The sagittal is second, so posterior slope. Oh, you mean tibial slope? I think the number is usually 15 degrees is what I've been sort of taught, but I don't think I'd go with this one with the sagittal slope. No, so I wasn't making a comment that I would do that. I just wanted to make sure you look for it. So Philip Norett's criteria is 13 degrees of posterior slope with 10 millimeters of anterior translation and intact menisci. And more recently, there was a study by Lee that showed if it was 12 or above, it significantly increased the failure rates for ACL. And one of my partners, Diane Daum and some of our other team with Critch and Stewart, they looked at early failures with ACL and found that with increasing tibial slope, it was almost like a linear line going straight up. So I think, I'm not saying for this case, but I do think it's important that we consider not just coronal plane alignment, but sagittal plane alignment. Clearly, in this case, allograft, vertical graft causes a failure here probably. So does the status of the patellofemoral joint change your choice of graft at all? If you went in and he had grade 3 chondrochasis on his patella, would you change your choice of graft? I would. I'd use a graft-linked hamstring as my second choice. That's too much patellofemoral disease for me. We get away with twos. I do a bunch of athletes, they tend to tolerate it well, but I wouldn't do it on him. I would do another graft. Yeah, I would go with either, if I did hamstrings, I'd probably triple it, so I'd make sure I have a big enough size, or you could do quad tendon without taking bone would be the other option. I would do a contralateral BTB. Okay. So here is his diagnostic arthroscopy. Here is his trochlear lesion. His patella is pretty good, so here is his trochlear lesion, which really was not picked up well on his MRI. I've already played with this a little bit, so it is debrided. Here's his very vertical graft, as you see, rather incompetent and also very vertical. The other remarkable thing is how large his lateral femoral osteophyte is, and had to do a fair amount of work to take that down. His medial meniscus was okay. He had this surprise lesion on his medial femoral condyle, which by the time I got done debriding this, it was only about 8 millimeters, and it was pretty far medial, but was full thickness. All right. So his lateral side is the side we were worrying about on his MRI, and you can see why when you look at this. This is his lateral lesion. All right. Thoughts now? So we've got the ACL figured out. Would you change anything you do in the ACL still BTB, or is that trochlear enough to change you to go to something else? Anybody change? You're going to change? BTB change? I'm not going to BTB. With the trochlear lesion? No. Quad tendon or hamstring. I'd use this from the same knee. When I think, when we see all this, I think the MRI you had pre-op probably was old. No, that was actually relatively new. Well, we only saw a couple cuts, so I don't know. The trochlear lesion was pretty much missed. All right. What are you going to do with this? You've got three lesions now. What are you going to do? The top lesion is his patella, which was pretty minor. This is his trochlear lesion. This is his medial femoral condylar lesion, and then his lateral femoral condyle. How big is the lateral femoral condyle? The lateral femoral condyle lesion is about 10 by 25. I would do biocartilage on the trochlea and treat him with Walt Lowe's program that we use for the NFL. I would do a fresh allograft on his lateral side. That's too big. I'm not going to get that deal. To me, the best thing for articular cartilage is new articular cartilage for that lesion, because it's just too big. Chris? If you see this when you go in, and I didn't know it, I would probably just do microfractures here. On everything? Yeah. Again, alignment films would be nice to have. His alignment was good. I would probably do microfractures as my first stage. He's in a little varus on his opposite knee, and he's actually fairly neutral on this knee. Those look like pure chondral lesions. Yeah. The only concern is that lateral side. He had that bone edema underneath. Chondral lesions. What are you going to do? Yeah. I think for the lateral side, we would typically use an osteochondral allograft for that. I don't microfracture. I do low-speed drilling. I was hoping maybe ... Here's his trochlear lesion. I also did his ... That medial one was a slam dunk, because it was pretty small. His lateral one, I don't have a lot of hopeful. I drilled that also, but I took cartilage biopsy for a possible later stage procedure. This is pretty impressive with the amount of osteophyte that was present, and that's what's left of his graft. I wasn't scared of his femoral lesion, or his trochlear lesion, just because it was fairly walled on both sides, and his patella was fairly normal. I used his BTV, because this guy's going to keep playing basketball. All right. We just had time for one case. I think we are good with time. I appreciate my panel. I hope you all learned something from that. Thanks again, guys. All right.

ACL surgery

allograft

pain

instability

basketball