We'd like to open it up to the audience if anyone has any questions. Please feel free to come up to the mic. My name is Pedro Iturbide, I'm from Mexico City. I have a question regarding the study that you guys made about the fluoroscopy after the ACL on the bottom. We have had that problem many times and we're trying to fix that with bigger incisions. I mean, I understand perfectly the thing you did guys, but would you rather think that it's easier and more reliable just to be bigger incisions to make sure that you had the bottom side than to actually get the fluoroscopy and you know all the money that that will cost? Yeah, thank you for the question. It's a great question because certainly using fluoroscopy adds intraoperative time, there's radiation involved to the patient and those in the room, so it's certainly a cost benefit analysis which is certainly not something that we did and it's a great question. Part of the procedure, as I mentioned and as I'm sure you're aware, is that it's very cosmetic and it's very minimally invasive and so what we found in the first group that had no abnormal button positioning, well part of that was because we used intraoperative fluoroscopy and if that button was off the bone, we made a bigger lateral incision and we went down and we found the device and we opened up the IT band and we put it right on the bone. And so we knew that none of those were going to have abnormal positioning because we directly visualized it and so but we're trying not to do that, you know those patients have greater postoperative pain, you know more scar formation, more adhesions of the IT band potentially and some of those types of things and so certainly it's a cost benefit analysis and ratio and that's certainly something that could be done but to us it's worth it. It's typically a one shot view, we use a mini C-arm oftentimes actually now instead of a full C-arm so you can wheel it in very quickly, one quick shot view, it's confirmatory and then you wheel everything out and keep going. Thank you. Any other questions from the audience? Okay, please feel free to go up at any point. So a quick question for Dr. Sethna, what are your indications for doing ACL and ALL in the professional athletes, is it across the board, is it only a certain subgroup of patients? The indication for professional athletes is just that being a professional athlete. Our other indications are patients with high-grade pivot shift, we mentioned that this comparative series now showing a clear role for them in hypolaxity, revision situation, but professional athlete in itself is an indication because of their high risk of graft rupture. I indicated that the contralateral graft rupture rate was 27% demonstrating their high risk. And then in quick follow-up to that, did you guys notice a difference based on sport, difference in outcomes? Yeah, I'm happy to analyze that. I mean, Bertrand has a very high ACL practice, he's doing 600 a year, the total population in the study was 70 patients. So because we had a multitude of sports, it's impossible to kind of draw out the different comparisons between sports. Thank you. Chris? Okay. Sure, please. ACL repair papers, I just may reiterate for us the timing to operation and what's your cutoff for how late you would do a primary repair? And second question, motion problems in your follow-ups? Want me to start? Yeah, sure. We've recently published or it's in press a paper looking at the timing variables and we looked at 300 patients of which we repaired 44% and we did a logistical regression and found that if we got the patients before four weeks, that we had a three times higher likelihood of being able to repair them. And that's kind of always been the literature has favored that of going in early. But I will say, as of right about now, I've done about 250 repairs and around somewhere between 30 and 50 of them, I've repaired between six months and 11 years post-injury. And I've published on the 11-year post-injury one with two-year follow-up MRIs and everything. And what I've found is that if it's a type one tear, many times it will hold its length and it'll just scar to the PCL right next to it. It'll be loose because it's off the wall, but if you get to them and you find that, you can take it off the PCL and reattach it with a very good chance of getting it to heal. Yeah, the only thing I would add is that a lot of these tears are high-grade partial tears that we've clinically called complete tears of the ACL. There's some attachment of the anterolateral, intermedial bundle sometimes, or postolateral bundle that's kind of tethering it and holding it in place. In the past, we didn't even think about it because we're just reconstructing everybody. But these patients, sometimes you see them out six months, a year, and the tissue's still sitting there and really a perfect candidate for repair. I agree. We try to get them within four weeks. If you do them too early and you have to do a reconstruction, I get concerned about stiffness. And in some cases, we've had to stage the reconstruction in patients that weren't amenable to repair. But four weeks has been kind of the sweet spot. One last point there is asking about stiffness. Generally, I won't go if they don't have over 115 to 120 degrees. If I think there's a good chance we're going to be able to repair it. If I think it's going to be a recon, then I'll wait. Because like when we said, you don't want to get stiff. But you rarely get stiff with the repairs. Out of the 250, I've had two patients who've had stiffness who had to get manipulated. One didn't do any therapy, actually went home and sat in bed for a month. And then the other one was an idiopathic arthrofibrosis. Diego, please. Concerning the augmentation for the ACL paper, I'm still doubting, how do you tension the augmentation with the actual ACL? And regarding your post-op protocol? The reconstruction is tensioned independently of the ACL graft. So the femoral screw fixes the ACL graft in the single femoral tunnel for this procedure. The additional length of gracilis is then passed through the tibial tunnel and back to itself. The femoral screw is fixed in full extension. That's where it's tensioned. Zero degrees of rotation, full extension. Did you have a second part of your question as well? Post-op rehab. Oh, the post-op rehab is the same for standard ACL. Okay. Dr. DeFelice, in your primary repairs thus far, have you looked at differences in outcomes between men and women? Actually, we haven't addressed that. We've published the first small series of 11 patients, 2-year outcomes, 5-year outcomes. We just published the first 56 patients, 28 with an internal brace, 28 without an internal brace, and we'll go from there. We haven't analyzed issues between male and female. Okay. All right. Great. I think that's probably it for this session. Thank you all so much.

fluoroscopy

ACL surgery

indications

graft rupture

outcomes