All right, so I know we're maybe a minute or two early, but we're going to go ahead and kind of at least get started with the intro here. Thank you all for coming. I think we have a nice panel discussion today regarding a great and a very important topic that still remains challenging, I think, no matter where you are in your career. We're going to talk about different considerations and challenges in revision ACL reconstruction. We got a panel from around the country, Dr. Waterman from Wake Forest, who needs no introduction. I'm from Penn State. We have Dr. Seth Sherman, who's done conquering the East Coast and the Midwest and now has moved on to the West Coast and treating surfers and Barbie dolls. We have Dr. Edgar, who's so smart, they had to give him two degrees. And then our newest member, Dr. Newells, our young buck from Missouri. So we have a great panel. I think you'll hear a lot of different opinions. A lot of these things don't have standard consensus answers, so it'll be great once we do the cases. This is the kind of lineup for today. Dr. Edgar is going to talk to us about evaluation and workup. Dr. Newell is going to talk to us about osseous considerations, including bone loss and tunnel malposition. I'm going to talk to you about extra articular procedures. Dr. Sherman is going to talk to us about osteotomy, is extremely important in this situation. And then Dr. Waterman is going to make sure that we don't forget about the meniscus, which is also critical to revision ACL reconstruction and often takes a backseat. And then we're going to do some great cases and leave some time for questions. So without further ado, if you can pull up the Edgar talk, please. All right. So if you didn't notice, I'm a fill-in for the great John Dickens. So for those of you that would like a refund, please see Alex in the back. I'll do my best to cover this topic. This will be a collaboration of both my slides and his slides to cover what was intended to be covered. So I don't have any disclosures that are specific to this content. So the goal of this is really to get it right the first time. And I think you're going to learn a lot of stuff from the aspects of revisions that maybe we can apply for the first time, because as someone famous once said to me, concussions may kill you, but ACL injuries can ruin your life, especially if they fail, which is very true. We've seen lots of young people that have gone on to have significant problems and loss of sports careers. The main reason we're here is we're not as good as we think. Although we think ACLs do great the first time, it's actually just not true. Obviously depends on a lot of variables, which we're going to talk about today, but the failure rates range from 5% to 25%. Re-injury in the younger age group is through the roof at up to 32%, and a lot of people just don't return back to their previous level of function. Revisions are even worse. So when you get to this step on the road, it's a tough one to cross. We can get stability, but their function is still worse, and failure rates of revision surgeries are anywhere from 5% to 83%, which suggests that there's probably some concomitant injuries that we're not fully appreciating, or they've already done enough damage now that we're in a revision situation that people are having worse outcomes. So the patient interaction is by far some of the most important aspect in the beginning, right? So how important history is critical, how did the rehab process go, did they have range of motion difficulties, did they have limitations with flexion or extension, which might indicate some tunnel malposition, was it purely a pain problem, was it instability and pain problem, how long were they functional, did it happen, they were fine for 10 years and all of a sudden a recurrent traumatic event. So a lot of these variables kind of get you on the path of what you're going to think about. Obviously, getting the proper workup with the records is critical, sometimes impossible, especially if they had surgery at UConn, getting their records, but getting all the information from their previous surgery is really critical. So obviously graft type used, whether it was allograft, sometimes you can determine this by the incisions, but getting the real paperwork is important, you really want to know what their meniscus status or their cartilage status was, and if you can get a hold of their previous pre-injury, pre-surgery injury imaging, that's critical. So there are still allografts being used to this date, and those are sometimes the highest incidence of revisions that I see, especially from the community. We certainly know that there's five times higher rate in allografts versus autografts, especially looking at BTBs, certainly 26% compared to hamstrings versus 8%, and certainly in the younger patient, allografts is a huge no-no, and the failure rates are up to three times if you do use like a BTB. Even hamstrings, I think a lot of us are transitioning away from at this point, but they do lead to failure rates, especially with a small graft in a young person. Hybrid grafts we thought was a great idea to make the size bigger, but actually it turns out it's not so good. Stability trial certainly shows that adding an LAT can reduce the re-rupture rate and improve some of the function, but the reality is that even with an LAT, 25% still had symptoms of instability. Hyperlaxity, I think we've really become more in tune with, and this is something that's really important, the failure rates in these hypermobile people, which you can look at the contralateral limb and say they might even have like a pivot glide even though their ACL is intact, but a lot of times what we're looking at is how much recurve bottom do they have. Now, that speaks to where you might need to put the graft, so if they have hyperlaxity or recurve bottom, we use five centimeters, but it's usually pretty obvious and it's symmetric usually on both sides. That can impinge your tunnel, so sometimes you have to go a little bit more posterior. Timing is also really critical with these. Early failure we typically describe as less than six months, and late failure, this is usually related to surgical technique and the femoral tunnel is often the one that we mess up. The type of graft, diagnostic error, premature, return to sports play, all those come into play. So obviously it's a multifactorial process. We think of biological issues, we think of traumatic issues, and we think of technical errors. And the reality is there's a combination or a hodgepodge of all of these things. Biology is critical, but our ability to do this technically sound, make sure we didn't miss any other concomitant injury, and then the timing of sports play and making sure that people are safe. You're going to hear a lot about this today, but this is a great figure that Dr. LaPoie put together, but it shows how many factors influence the graft that can lead to failure if we miss them or don't address them. So critical assessment is important on the physical exam. You want to look at range of motion, you want to look at their muscle activity, you want to look at all these aspects as you're going through this whole process. Obviously the meniscus, which we're going to hear about, is critical to this. I also learned this from Dr. Leprod. High grade pivot shift is a lateral meniscus root until proven otherwise, which nine times out of 10 he's usually right. But it affects the forces and the grade of pivoting with basically an incompetent meniscus, which you're going to hear about later. The collateral ligaments are important. I'm in the world of Bob Arciero, so we focus highly on the posterolateral corner, but a lot more attention is being drawn on the medial side, and we're looking more at that. Medial and lateral collateral ligament laxities certainly affects the ACL, and that's the biggest thing with revision, so make sure you didn't miss something on one side of the knee. Obviously standard x-rays, definitely want to get mechanical access with these. Stress radiographs are really important. The lateral really looks at hardware, tunnel position. You really want to look at where this is as you're thinking about how to do this. You're going to be able to do it in single stage or two stage. And then the femoral fixation, this is really important. This is where we miss most of the time. We'll hear a lot of this. These vertical graphs we've seen a lot where they can have a limited anterior drawer, but they still have a pivot as sort of a central post in the middle of the knee. This is a very common situation for revision. As we're doing these tunnels, we want to make sure that our pin is really far posterior because most of the time we're drilling oblique tunnels, so we want to make sure it's as far back as posterior. Otherwise, the graph will be too anterior in the knee, especially if we're just central in the footprint. Tibial tunnel, for this one, we have to worry about too anterior where we get graft impingement or posterior where we're impinging against the PCL. This can often be revised, and sometimes with this one, it's harder to get around it, so you have to bone graft it and come back at a later time. The varus, you'll hear a great talk about this with if we have to do correcting osteotomies to support this, but this is obviously critical and important. So the slope, we've become more in tune with this. Obviously most of us would not do this at the get-go, but in revision situation, we have posterior tibial slope greater than 12 degrees. There's a significant increase in re-rupture rate, so it probably needs to be addressed in the revision situation, which you're going to hear about later. CT scans can be important, especially with bone loss and quantifying that, determining if we're going to be able to bone graft, where our tunnels are, can we get around it, and so forth like that. So getting the full workup is really critical. MRI is really to look at cartilage and meniscus involvement, especially if there's a history of pervious repair. And again, the process of returning to sport is really critical with this. I think a lot of times, we get people back a little too early or unsafe for them. It's not a timeline. It's a function of their ability to move and control themselves. And so I think it's really important to go through a whole process with these patients, especially in the revision situation, to make sure that they're able to control themselves once the biology is up to speed. So again, in summary, let's try to avoid it in the first place, make sure our athlete's ready to go back, get a thorough history and physical, figure out what the cause is, why they failed. Make sure we get plenty of imaging, and let's make sure that we get a successfully sealed right first time. Thanks. Thanks. If you could pull up on Newell, Clayton Bone Tunnels. We'll keep rolling. All right. So I'm going to talk about single versus two-stage management of failed ACL, particularly with bone loss and tunnel malposition. Maybe. Was this working, Corey, for you? It was, yeah. So it's just a me problem, user error. My disclosures are available online. I always like to start with the case. Brian's going to have some great cases later, but I always think a case kind of exemplifies what we're talking about. There's a 20-year-old male, 2018, had a left knee ACL tear playing basketball, had an ACL recon with a hamstring. Then that next year, he had a right knee ACL, underwent an ACL recon with hamstring. Then just a few months later, he tears his ACL graft in his right knee again. He undergoes a revision, had an ACL recon with a quad tendon and internal suture augmentation. Then just a little over a year later, he tears that same ACL again. So now we've got a two-time loser. Of course, at that point is when he was referred to us to then handle this lovely problem in fun times. So this is what his MRI looked like. So you can see his tunnels on the femoral and tibial side aren't terrible. They're maybe not awesome, but they're not the worst either, but they're not great. But again, he's a two-time loser, so we've got to start thinking about things. Are we going to revise this in a single stage or a two-stage? So background again, we've kind of discussed some of this already. We all kind of know that the percentages of ACL graft failure anywhere from 2% to 12%, higher in younger patients with allograft, as Corey just showed you, that can lead from anywhere to 13,000 to 20,000 revisions a year. The most common cause again, as Corey alluded to, is tunnel malposition, but there's frequent causes of ACL failure, right? We're all aware of that. Tunnel dilation or widening, bone loss or resorption, graft type, as we just stated, malalignment, tibial slope. You're going to hear more about some of those things coming up. So single stage versus two-stage. Typically about 25% of revisions are staged. That can be for a number of different reasons. Yeah, that one was a two-stager. Can you click on that video too, maybe? I don't know why it's not advancing, but sorry about that. Don't make you guys go crazy, yeah. So sometimes based on tunnel malposition, if it's grossly malposition, that can be single stage. Tunnel widening, I'll talk about a little bit more extensively in a second. If there's significant loss of range of motion that may require lysis of adhesions or capsular releases, significant bone loss, again, malalignment, deformity requiring correction, as we'll talk about in more detail, concomitant procedures that may be required, such as a meniscal transplant or cartilage repair, certainly active infection. When in doubt, I think the answer is typically for a lot of people, stage it, but I'll give you data to support both certainly. So how about evaluating those bone tunnels in more detail? Seth had a great study and great article here, as you see at the top, that showed that if the bone tunnels were greater than 14 millimeters in diameter, it had an increased risk if the ACL revision was done in a single stage, an increased risk of failure. The study at the bottom looked at 88 single stage revisions, so every patient had a single stage revision, but they split the follow-up into patients that had bone tunnels preoperatively greater than 12 millimeters of widening or less than 12 millimeters, and the failure rate was double for the patients that had tunnels that were greater than 12 millimeters, 14% versus 7%. In addition, the patients that had larger, wider bone tunnels had worse stability on stress X-rays, Lachman's, Z-GAM, and follow-up pivot shift testing. So I think tunnel width is maybe a little bit debated in the literature, whether you use 12, whether you use 14, but certainly it's not the only factor, but you can kind of go by those numbers at least a little bit in your preoperative workup and your preoperative evaluation when you're first looking at these things in clinic, when you're evaluating single versus double, or single versus two stage revisions. Again, single stage revisions is still typically the most common, at least in this country. It's certainly okay to do that when there's adequate bone stock after any necessary hardware removal. So I think you see in the picture at the top, that screw is pretty vertical, and you can see you can get pretty, you can actually get posterior behind that screw and avoid it entirely with your femoral tunnel. Otherwise, you've got to take out hardware if it's in the way sometimes. And so if the tunnels are there or if the hardware is slightly malpositioned, you may be able to overlap that tunnel with your new tunnels. You may be able to change your drill or tunnel angle to avoid that or diverge from that. You may be able to overream previous tunnels and then use a larger graft. In that case, sometimes a BTB as a revision, as an option can be potentially helpful because you can take a larger bone plug off of the tibia and then potentially fill that tunnel on either the femoral or tibial side with a larger autographed bone plug. And then I'll talk about some other options here shortly. This is a nice illustration, credit to Amandouan, it's his illustration or at least he gave it to me. But tips for overlapping tunnels, I think some of these techniques are nice. So the first illustration on the left, funnel divergent tunnel technique, that's one that I alluded to just a second ago. You know, maybe the aperture at the femur is pretty similar or pretty close, but you can diverge where your tunnel goes from the previous tunnel if it's a trans-tibial or a vertical tunnel or if it's not quite anatomic or if you just need better fixation going one way or another. And then of course, you can adjust your hardware, whether you do an outside in screw or a aperture screw or something to adjust your hardware based on the tunnel position and location. The next illustration, utilizing stack screws. So basically you're filling up a large tunnel with more hardware to fill that up and give you better aperture fixation. And then the last one is kind of an old school one, but utilizing what are called match sticks. You can either do that technique or you can utilize even whole dowels and whole bone plugs to fill up a large tunnel where you need more bone. So how about significant bone loss and significant tunnel widening? In many cases, that's an indication for a two-stage procedure. The first stage, of course, being bone graft and then potentially performing any concomitant procedures that you may want to perform. If it's a repair or even an osteotomy, which Seth is going to talk about that in a little bit later. If you're going to do a slope-changing osteotomy, that may be something you want to consider staging with the slope-changing osteotomy and any other intra-articular work and bone grafting your tunnels in the first stage. Let all the bone work heal and then come back and do your revision ACL reconstruction. What are some of the options for bone grafting, large tunnels and bone loss? Autograft options are typically the Iliac crest and the proximal tibia. Allograft options include bone substitutes and synthetic bone void fillers. Cancellous chips with demineralized bone matrix, bone dowels, which can come in various sizes. And I'll show you an example of that here in a second. This is an example of arthroscopic tunnel bone grafting. So obviously it's dry. And so this is cancellous chips mixed with demineralized bone matrix. And so you can see we can, I'm actually using just a Yankar suction tip there, just broken half and put through the arthroscopic portal and enter immediately to then fill up the femoral tunnel with that bone graft. Bone dowels, these for me have become the workhorse for me for revision and filling up a large bone tunnels and bone sockets. So you can see that's most of the intercondylar notch of the femur there. This is what one of these bone dowels looks like. Again, you can get them in all different sizes. They work really, really well. This is it going into the knee, across the knee. And then this is that same, sorry, can you play that video for me too, please? This is that same, can you just hit click on the video on that last picture, the last picture. So this is that same knee from left to right. And so you can see we pretty well effectively filled that entire huge area of bone loss completely with that allograft bone. So a couple of studies looking at these in particular, this is the study on the left that was published in Arthroscopy. They looked at 21 patients with again, tunnels greater than 14 millimeters. So kind of that 14 millimeter cutoff and they utilize either overlapping tunnels or they were grafted with those allograft bone dowels. They CT them at three months. They found that the femoral side had a little bit higher union ratio than the tibial side, but both sides met the threshold for the grafts being viable and bony incorporation. When combining the two, the amount of tunnel that they both occupied was greater than 85%. So you really occupied both tunnels really well. They recommended staging at least three months between stage procedures to allow the allograft to at least incorporate somewhat. A study on the right published in AJSM was a two-stage, looking at two-stage revision and they did systematic review of bone graft options. They did not see any clear cut evidence favoring autograft. So again, Iliac crest or proximal tibia did not see any evidence for that favoring autograft over allograft bone matrix or cancellous chips. Allograft, as you might surmise, did have a little bit shorter incorporation timeframe, but in terms of the long-term outcomes, they didn't see any difference between the two. So what are the benefits of a two-stage revision? When you go back in, it looks a whole lot more like a primary ACL. So this is that same patient that I just showed with that allograft bone dowel on the second stage revision. That almost looks like a native femoral condyle or I would challenge you maybe that it looks pretty darn close to it. So that gives you adequate bone stock with minimal or no hardware to remove. If you remove the hardware in the first stage, you can do concomitant procedures previously as we stated. And then it gives you a second look. So if you did do a cartilage procedure or a meniscus repair in that first stage, you get an opportunity to get a second look at that when you may otherwise not have that opportunity. So this is back to our case now. So again, just to remind you, this is a two-time loser. The kid's torn both of his ACLs in the past. The right knee was a two-time loser ACL. So on arthroscopy, he had complete ACL insufficiency. He actually had a previous root repair that had healed. So again, I got that second look at that there. Everything else looked intact. So stage one procedure was debridement, removal of suture material, remover of old hardware, bone grafting of both of his tunnels with allograft bone dowels on both the femur and the tibia that were soaked with bone marrow aspirate. Here's the pictures of what that looks like on the femur. You can see all that old suture in there, and then you can see the dowel on the femoral side and the top right picture, and then the tibia on the bottom. You can see the bone tunnel initially, and then the bone graft of the tibial tunnel on the bottom right picture. Here's his CT scan. I typically, if I'm doing a stage procedure, I typically get a CT scan roughly at three or four months pre-op. You can see that those dowels really fill those bone tunnels really nicely and gives you an idea both of incorporation, but then also what your surrounding bone stock looks like. So the second stage, we did a revision autograft ACL using his contralateral quad with internal suture augmentation, and then we added a lateral extra-articular procedure, as you're going to hear from Dr. Dewan here in a second. So this is what that looks like. Again, look at the top left picture. That looks almost like a native knee, obviously without the ACL, but that femoral condyle looks pretty nice, pretty easy to drill, pretty easy to find your anatomic footprint. And then I would charge the same thing on the tibia as well, where you can see in the top right picture, and then the bottom left is obviously the autograft ACL, and then the radiographic image on the far bottom right. This is that same patient post-op, so this is what those incisions look like two weeks post-op, and then this is that same patient now, one year post-op. He's done playing basketball, thankfully, but is back working and doing very well from a two-staged ACL revision reconstruction procedure. So in summary, management of bone loss, both mechanical and biologic factors contribute to that bone loss and that tunnel widening after a primary reconstruction. Revision ACL success is dependent on graft position, fixation, biological incorporation. Both one and two-stage revision reconstructions can be successful in the appropriately indicated patients, and potential future solutions may involve biological agents to help us better incorporate bone graft and better enhance the overall revision ACL surgery. If you guys want a, like, more detailed summary of this, this is actually a really nice summary of management of bone loss and tunnel widening. Voos and his crew at Cleveland, in Cleveland, published this in JBJS in 2023. It's a nice summary of how to manage bone loss and tunnel widening. You can look at that later. Thank you. Yep. All right. So, we're going to talk a little bit about the role of extraarticular procedures, specifically the modified LaMer LET and then the ALL reconstruction in these revision ACL situations. As you've heard, revision ACL reconstruction is probably more common than we'd like to believe. We certainly don't want to get, we don't want to have that patient get on to a third or fourth time revision. So, you know, we need to spend a little bit of time here to try to really figure out the pieces and try to prevent that from happening again and I think you're hearing kind of all the jigsaw puzzle pieces through this. So, one thing that you need to ask yourself is what's happening to the knee at the time of either original ACL injury or recurrent ACL injury and what's the extent of injury of this? We talk about it as an ACL reconstruction, but as you can see from a lot of these talks, there's a lot of different components of that in terms of a coronal and sagittal alignment, a meniscus, a chondral injury, etc. But as you all know, there's a significant lateral component to these injuries and what is the extent of this and then more importantly, what we need to do to normalize the biomechanics of the knee so that we don't get back to this same situation as a third time. So, there's been some anatomical studies looking at this Freddy and colleagues looked at the lateral side of the knee with ACL injuries. These are primary ACL injuries and a very significant majority of them had macroscopic tears of actually the lateral capsule and subsequently the ALL and that those, the extent of injury of that lateral side of the injury also correlated to the extent of their pivot shift and grade of pivot shift. The ALL clearly does contribute to the especially rotational control of the knee and as flexion of the knee increases, that component of the ALL contribution increases and then not only in rotation does it seem to contribute to the biomechanics of the knee, but in anterior translation as well. So, that lateral side of the knee and not just the ALL, but really these multiple components including the iliotibial band, these deep Kaplan fibers and their capsule osseous attachments to the lateral femur are really very important in addition to the ALL in terms of controlling the rotation of the knee as well as the coronal plane stability. So, we talk about this lateral side of the knee, we're talking about more than just the ALL, we're talking about this whole complex of the knee that includes the iliotibial band, including superficially and deep, the capsule osseous layer as well as the ALL contribution from the interlateral joint capsule. And these compositive studies I think have made this fairly clear and I think at this point there's a pretty good consensus that indeed these really contribute to the rotational biomechanics as well as the coronal plane or sagittal plane biomechanics of that knee. So, if this ALC is that important in terms of the biomechanics, I think we need to consider that in terms of revision ACL reconstruction. Historically, there are a number of procedures that did this including the McIntosh, Veloce, Lemaire, Ellison techniques. These for the most part were abandoned secondary to how much they constrained the knee and then degenerative changes that subsequently occurred. So, we're trying to kind of keep the baby while throwing out the bath water, how can we maintain the control of the rotation of the knee with these lateral extraticular procedures but maybe throw away some of the over-constraint. And the two major ways that we do that in 2025 is essentially the ALL reconstruction as well as the modified Lemaire LET. Both of them essentially are oblique reconstructions coming from posterior and proximal to the lateral pacondyle to the tibia. The ALL finds a spot essentially between the fibula and GERDI's tubercle while Lemaire extraticular tenodesis maintains that iliotibial band attachment to GERDI's tubercle, has a little more anterior attachment obviously in the tibia and then is routed deep to the LCL. That's a difference between the two as well, deep to the LCL and then attached proximally and posterior to the lateral pacondyle. Well, which one's better? Well, if you look at some of the biomechanical data, if you believe the biomechanical data, essentially you have increase in internal rotation with sectioning of the ALL. But reconstruction of just the ALL does not seem to significantly improve the rotational biomechanics of the knee. And that makes sense from that interlateral complex we talked about before. And these biomechanical contributions are more than just the ALL. But yet with Lemaire LET, we had a significant improvement in the biomechanics, especially controlling rotation and translation. And then again, a similar study looking at sectioning of the ACL and then doing an ALL versus a modified Lemaire. And essentially a modified Lemaire was able to better control, actually improve control. So again, probably a little bit of over-constraint, but of rotation compared to the intact state. So why would the LET control better? Well, it's just simple obliquity, right? It's just simple physics. Essentially both come from a similar spot or attached to a similar spot, posterior and proximal to the lateral pacondyle and the femur. But the modified Lemaire keeps that GERDES tubercle attachment to the anterior tibia as a very oblique orientation, whereas ALL is a little bit more vertical. Clinical results seem to follow the biomechanical results where an LET does appear to significantly reduce that rotational component or at least a pivot shift phenomena with an ACL reconstruction post-procedure stability study. And this was done in primary ACL reconstructions and in hamstrings specifically, but it does seem to decrease the incidence of recurrent ACL re-injury by about 50% compared to ACL reconstruction without that procedure and specifically hamstrings. Stability 2 is currently underway. Additional data from this same data set seems to also indicate that outcomes were similar between patients that had ACL reconstruction as opposed to ACL reconstruction with LET, so no decrease in outcomes with an LET. And then complications, especially lateral hardware complications, also seem to be similar. So certainly it seems to be a safe procedure with similar outcomes and similar complications. The outcomes in terms of quadriceps and patellar tendon still to be determined. But what about LETs and revision ACL reconstructions, because that's what we're talking about here. So essentially Grassi and colleagues with ESCA looked at a systematic review of a number of studies in this arena, and in general they found actually a very small number of recurrent injury in revision ACL reconstructions with LET, somewhere about 4%, which is much lower than most other studies as you know. 80% negative pivot shift, 74% were able to return to their previous sport, fairly good results with an LET used in the situation, clinical situation of revision ACL. So how do you do this? Fairly easy procedure. It only adds really about 15 minutes to your surgery. Your incision goes from about grazed tubercle to the lateral epicondyle. The two biggest errors that I see, especially with my own residents, is they either don't make the incision distal enough, so they try to kind of cheat it approximately in order to get enough length, which makes it tough to find the LCL, or they don't have it posterior enough, which also can make it hard to find the LCL. So make the incision, don't cheat it approximately, give yourself enough distance to the GERDES tubercle and make sure it's posterior enough. You harvest about 10 to 12 millimeters. You can use a quadriceps harvester if you want. I just tend to use Army Navies and manipulate the skin to get that proximal aspect. Whipstitch or graft. You pass it underneath your LCL. This is critical as a pivot point for your rotatory biomechanics, and really is the modification of the lamar as opposed to just a lamar. And then you dock that into either a tunnel. In this video, which is by my friend Alan Getgood, he uses a staple. I don't use that. I was using a interference screw for a while, and then now I use just an all suture anchor place there, and then just sew it down, and then I sew it back to itself over to give itself a recurrent dual fixation. So in summary, as you hear all these talks about the meniscus and slope as well as alignment, I think you need to consider the rotational biomechanics of the knee and essentially what happened during that original injury, and how do we recreate those normal biomechanics, and how do we really address the totality of the injury, not just the ACL or the meniscus or the cartilage. Some level five considerations for using an ALC in my hands. If I'm doing a revision ACL reconstruction, and perhaps the reasons why the original index surgery failed aren't strong, I won't hesitate to add an LET. I think it's an easy thing to do. I think the data is compelling, and it really doesn't add a lot of time. Be a little bit careful about when you're putting that suture anchor or tunnel for your proximal fixation for LET in terms of it converging with your ACL reconstruction tunnel, and there's a few different techniques in order to avoid that, but just keep that in mind. And then anytime I have a patient, whether it's a primary or a revision situation that has a high grade pivot shift, a Batten score over six, and or a significant lateral sided injury with a lot of fluid in the lateral capsule of the tibial band, et cetera, I don't hesitate to add an LET. Thanks. All right. Hi, everybody. I'm glad to see so much enthusiasm over revision ACL. Look forward to some lively case discussions and banter later. My task is to talk about osteotomy, particularly looking at slope correction. Not advancing. Now it is. My disclosures are available online. Hopefully the formatting is not an issue throughout, but when you see a knee like this, you really need to be hyper aware that the problem is more than just the ACL. This is the 3B Lachman and the explosive pivot shift. And you can see the tremendous forces that are acting on this knee joint in anterior translation and in rotation. My dad, about 15 years ago, sounded the alarm bell on this issue of slope and ACL injury risk and failure of reconstruction at similar times across the pond in Australia, where Leo Pincheski was looking at the same thing and really saw in his population of hamstrings that there were catastrophically alarming failure rates, particularly above 12 degrees. Others also were looking at slope and it being a major issue for repeat ACL failures. And so really just going to cut to the chase about how we think about it and what we do. I think the first thing is just to have this conversation and really to measure it in every single patient. So if you're not looking for slope on your short lateral x-rays for screening, and then if you have more suspicion on long single limb tibias, and it's not only about slope. David DeGeorge at this meeting as well, he's taught us about also looking for that anterior tibial translation. You can see both here, but if we start looking for it, then we might act on it. In primary ACLs, I would say that we're not getting super aggressive in 2025. We're going to use our best grafts. So for me, that's BTB or quad. We're going to look for and fix all concomitant pathology. So that's roots and ramps and corners and everything that Corey talked about. We're going to consider LATs like Aman just hit on. We're going to have strict rehab and rehabilitation protocols. We're going to test them rigorously before returning to sport. And we're going to have really honest conversations with patients about their relative risks of retear and their underlying risk factors. Now, a recent study this year was looking at changing slope in primary ACL. I would say for me, it's not game ready. It's quite controversial. In their study, at least, they saw with a number of a slope above 16. I think others have talked about slopes of 18 and above in primaries that you may consider it. And at least in their series, there was improved stability and reduced graft failure rates. But I've not done one of these. I'm curious to see if any of my panelists here with me have done a primary ACL slope change. In revision, we're similarly going to do our best operation. And for me, I'm going to consider tackling slope only if there's really no other major reason for that initial failure. And so we do our root cause analysis. And there's often always these other problems, right? Tunnel position, graft choice, meniscus deficiency, secondary stabilizers went back too early. And so it's pretty rare that I'm going to tackle slope as an isolated procedure in the primary revision setting. However, if you have patients who come in, they're also in varus. And maybe they have meniscus deficiency. They have chondrosis that's symptomatic, so pain and instability. And you have to treat their coronal malalignment. Then these days with novel technologies, it's actually quite easy to do single-plane cuts and two-plane corrections. So you can balance coronal, and you can also reduce slope. And so I think that's really kind of a workhorse for me. And you can see one of those systems just planning a single stage, two-plane osteotomy, plus sneaking your ACL in there. And so you can do it all at once if you need to. And then really, it's these challenging kind of, as Clay alluded to, the ones that have failed multiple times. Those are ones where we're just really going to go down the checklist and address all the problems, including the slope. And there's quite an excellent rationale for doing this. We know that slope changing can decrease the forces when you do these osteotomies. These techniques, however, have been challenging in the past. In doing it freehand, I was fortunate to go to Lyon, France, and to watch both Bertrand Sonnery-Cotet and David Dijor do this. And while they have done this forever and do it freehand, for me, it's scary. And for you, I'm sure it's scary as well. And so I think it's a big incision. You're getting closer to the nerve vascular structures. And so until we started getting more thoughtful with the evolution of patient-specific instrumentation and dialing in our indications, I really haven't gone into this until the last several years, probably the last five years. Here's surgical outcomes, though. They're quite well supported in the literature. It's still controversial. We can hear from these guys as well, whether we're doing this above the tubercle, taking the tubercle off, going in for tubercle, doing this in two stages, in one stage. So a lot of nuance still, but definitely literature support for slope changing osteotomies. Certainly here, we're looking at them in repeat revision ACLs. So here's a patient I did when I was back at Mizzou quite a while ago. Two-time failure, slope was 15, meniscus deficient, explosive pivot shift. So all the things that we've been talking about, this is the one from the beginning. Both knees had the same examination. And so in my first stage, this was a manual cut. So getting my pins in position and then using a laminar spreader basically so that I can chip away at the back quite carefully and then closing down the slope anteriorly. And this is a closing wedge, so you really don't need large plates. You can do one or two small plates. You can do staples. You can do whatever is your preference. For that gentleman, he healed it, but still had significant functional instability. So I could come back once the osteotomies healed. In my first stage, I took inventory for meniscus deficiency, whether he had cartilage issues, whether he had tunnel problems. You can bone graft if you need to. So you can get all of that intra-articular pathology on your checklist in the first stage. And then you come back, took out the hardware, revision ACL. My graft of choice is quad. I did a medial meniscus transplant, as I think Brian's going to talk about in a minute, and an LET. So I mean, this is a lot of work. This is a long time for that patient. This is not for necessarily return to the highest level of sporting activity. But these can be excellent stabilizing procedures for normal people who are in a really, really challenging jam. And you can see at the end of the day, the slope reduction. And you can see the final product on the right. Lastly, the evolution of PSI has been a real game changer. So this is Matt Preventer's technique. And what I want to show you here, this is a case of mine. So that's the PSI guide. And it's actually a medial approach. So it's a comfortable approach that's similar to an HTO. You can see that I put a pin across the back, so inside the cortex. And so you're protecting that hinge. You also obviously have your neurovascular retractors, just like you do a standard HTO across the back. And then you're cutting from medial to lateral, but you're cutting actually all the way through, right? Super tubercle. And so we basically can wind up in the same place that I showed you with the laminar spreader freehand and then close it down. You can also, with PSI, change a little bit of coronal plane correction. So if you have some valgus or varus that you need to dial in, you can do that quite easily. And this is a paper that Rob Leprod just put out. It's a good summary, I think. There's some nuance for sure. But let's just go through for one minute. So for primary ACLs, really high thresholds. Is that still up there? It's not on my screen, but I kind of know what's going on. So if it's above 18, that's when they might think about correcting the slope. Obviously, if we have that middle ground, that's where we're doing our best graft and doing the LET. In the revision settings, you can think about slopes above. For him, it was 14 or below. And then whether you had that tunnel osteolysis, that 12 to 14, and that really predicted what you might do as far as taking care of both the slope problem and the tunnel bone grafting in stage one, and then coming back for your ACL in stage two, or whether you can manage these types of things in single stage. So I think it's a good algorithm, and I encourage you to take a look at it. Just in summary, slope obviously is a major risk factor for ACL injury, high-grade laxity after rupture, and failure of ACL reconstruction. At the very least, let's walk out of here and measure it on every patient using 12 degrees as a cutoff. Understand and counsel people that it is a risk factor for failure of primary ACL. I consider correcting it in select revisions and in most repeat revision ACL reconstructions. Thank you very much. All right, thanks. For a frame of reference, how many in the audience are doing more than five revision ACLs a year? Okay. And how many are routinely looking in the back part of the knee, trans-notch, in order to inspect for either a ramp or a root? Okay. All right, good frame of reference. So we're going to talk a little bit about the meniscus in the face of the failed ACL. My disclosures can be found online. They're also shown here. Most of what we're going to talk is a little bit, could you go back one, is a framework. Would you mind taking me back one slide? What we're here to talk about is really that we, is more of a framework and really a discussion about how we really just don't have it quite right yet. We have a high rate of re-rupture and the question is, is that a failure of our graft? Is it a failure of our surgery? Are there other things that we're not considering? I think it's more of the latter. And also, how do we facilitate having these individuals return at a more reliable rate? Whereas previously we had been at six months, now we're at eight to nine months and some we consider you see languish up to about a year without having full return to support parameters. And also we got to address the elephant in the room, which is the rates of osteoarthritis. Is that an indictment on our surgery? Is there something we need to be doing better at time zero or on the reboot in order to make it better? And I think it all starts, as many of us have alluded to with some overlapping slides, is we need to know where people have come from. We need to know the pitfalls to do a root cause analysis and trying to really delineate everything in the rehabilitation timeline, looking at return to support criteria, looking at that prior imaging and just following that out and only then filtering in some of the new information. Additionally, when you discuss the re-injury, don't just blow by that. Try to get a sense for the level of energy, whether there were any antecedent symptoms that can intimate whether there's a pre-existing meniscus tear, a missed meniscus tear, or is this a re-tear and try to get a sense for any effusions, joint line pain, prior treatments, and then also bracing and the current desired activity. So you can kind of marry your plan with what's to come. The pivot shift that we've talked about is really a good proxy for the degree of rotational stability. And I'd submit to you, this not only comes from the ACL, but the lateral ligamentous complex, a lot of the dynamic stabilizers, and then increasingly we're realizing the role of the meniscus. All right, I think these should fire, if those all four will go simultaneously, they should. Just go back three slides, I think. Yeah, so here's the Pivot app that we've used through the Stability-2 trial. I think that allows us to really adequately assess three-dimensionally how the knee is moving. And you can see these are all individuals that have persistent instability even in the face of having intact cruciates, some of which actually have well-positioned cruciates. Some of them are meniscal deficient, some have completely normal menisci, some have completely normal slope. But you can see there's probably a line between party trick and pathology, and we need to figure out where that is ultimately coming from. Additionally, I think it's important to realize that with these multiply injured knees that there's a high rate of combined ligamentous, chondral pathology, and meniscal pathology. So if you're not seeing anything, that's probably the exception rather than the rule, I think, in our practice. And nowhere is it more challenging than this concept of the little mort. You know, the lateral meniscus oblique radial tear, Pat Smith, Bruce Levy, Aaron Critch, a lot of help to understand this type of tear morphology. And you can see it's type 1, 2, 3, and 4. And you can see the rates or prevalence in terms of presentation. This type 4 is really a dreaded one because you have that really hypermobile flap. It's very difficult to manage. It's directly adjacent to the neurovascular structures, and it can be quite humbling. This is what that looks like arthroscopically. And when it is hypermobile, we can talk about some of the ways that you might address that. But what this does is it renders the knee meniscal deficient, right? Those hoop stresses are disrupted. It also contributes to this high rate of rotational instability. Sometimes that dislodged graft and attenuated tissue can block your ability to see this lateral meniscus root. So making sure you're really probing that and getting a full view. And this radial oblique tear, just make sure you're assessing for that, trying to identify that, and if possible, repair it. Because you can see when you have an intact ACL graft and you either debride or ignore that lamort, whether that's an incomplete or complete, it still leads to high rates of increased AAP translation, which during a critical phase in the graft maturation could potentially lead to re-tear or ACL insufficiency. So definitely consider that. This is what a second look scope of that looks like, and it pretty reliably heals. I'm quite surprised with that. Additionally, ramps. I think ramps is something that I always thought was something that would present itself very readily. But what you can see is very subtle spectrum of pathology. It's not always that full thickness, increased excursion. Sometimes it's an undersurface tear. Sometimes it's a healed one that you're capturing that was missed at the time of the first surgery. And so maybe here are some of the tells that you can lean on that I say, this is really going to lead me to pie crust more aggressively, look in the back of the knee, and really assess it with a spinal needle. Striae. So if you see those striations going from medial to lateral, that's definitely a tell. But then also that posterior medial tibial bone bruise on the medial aspect is a key contributor. So make sure you're looking at that. Here are some others that have been identified in the literature. This is what that looks like for me. Again, I like to assess that in both flexion and extension. I'll take a spinal needle through that posterior medial aspect, and I'll just lift that tissue up. What I'm trying to see is, is there any diastasis there? And if it is, how far is that retraction off the edge? Do I have to fix it with a suture hook coming through posteriorly? Or can we do a manually assisted reduction and an all inside device, which requires three hands and a little bit more synchrony in your team? The other thing to look at in a revision setting is this concept of passive anterior tibial translation. I think this was a very under-recognized source of failure when I saw these patients, because they're going to be edge loading both their articular cards on the femoral condyle. That meniscus is definitely going to be compromised. And so the question is, is this just a lack of passive restraints? Or is this more of an adaptive change with some capsular contracture? I think we can probably discuss that. Definitely, it's bringing in this concept of sagittal tibial slope, which is a block on an incline plane. But it's also affected by that meniscal status. You really got to look at this concept of the meniscus bone angle and its ability to reduce the effects of that posterior tibial slope, both medially and laterally. So an increased slope in a deficient posterior horn, that's your worst case scenario. In terms of meniscus extrusion, we know the effects of this in the ACL deficient state. And so very often, we're looking at adjunctive ways we can promote joint preservation, but also graft preservation of our ACL. And so I'm really looking at ways that we can better re-contain the meniscus, if I can use that term. So either the capsulodesis, centralization, or in certain cases, meniscus transplantation. What we've shown is, with Zeffanini's work, you can look at these case series, high rates of being able to return to play, low rates of failure. I would say that that's adjacent to what we would see in a primary ACL state, and they have high survivorship, improved function, and definitely significantly reduced pain. This is what that might look like. This is actually one of my first ever meniscus transplants when I was in the military. You can see a very aggressive meniscal notchplasty, probably an oversized bone plug. Getting that in there with anterior and posterior plugs and reducing it is half the battle. And then it's just a bucket handle meniscus. So in summary, patient factors, technical errors, concomitant missed pathology is key. And you want to look at the appropriate graft selection, because those definitely heavily contribute to ACL failure. Don't forget to assess for and look for posterior tibial slope, and assess that meniscus status and how that might contribute. At all costs, try to repair these structural meniscal lesions, because I think that can help in optimize your results. This is our team, and I think we'll take a minute and transition to the rapid fire slides, but contact me with any questions. Yeah, yeah. So we're at 8.05, so we'll do about 15 minutes. Here's the downside. So I do have a ton of cases, I have a ton of horrendous cases, but we're probably in about our 12th to 13th iteration, and I feel like Seth and Aman have seen all the ones that I could surprise them with. I do have a couple in the cooker, so if we come back next year, I can definitely hit you with some new stuff. But I figured we could kind of make them sweat a little bit in a different way. And so these are not necessarily specific to a revision ACL, but kind of all ACLs, and this is where stuff might go awry. So we'll go through kind of the panic button moments that I've personally experienced most of these, and then we'll engage in kind of a rapid fire fashion. Don't take too long. I'm looking at you, Aman. This is a brief, concise responses, and that way we allow everybody to get some airplay. And you can feel free to interrupt at any point in time from the audience. We'll definitely take your questions. I say the names have changed, but truthfully, these are all mine. I've seen these. I've done these. I'm positive this is not just a me problem, but it could be. And really confess, guys, if you have not had any of these, or if you've had new or different ones, just tell the truth. Okay. So Aman, this is, you and I remember the military days. This implant on the far right was a very popular one in my residency, and we were throwing these things in like gangbusters. And we're not gonna name names, right? We're gonna protect the innocent. But this is a bear to get out. So how are you addressing these implants that you've never seen before, belong in the Smithsonian? How are you vetting it? Is there a resource you go to? Let's start there. Who do you contact? Yeah, so we still are dealing a lot with these. There's a surgeon in our area at Penn State that used many of these implants for hamstrings, ACL reconstructions back in the 90s, and many of them. So we're still dealing with them in revision situations. Honestly, your best case scenario is if the tunnel is completely malplaced altogether, in which case, obviously, I leave it in place. I don't touch it. I don't try to even remove it. They're a bear. They're titanium as well. The implants you're showing on the left are all titanium. So not only are they large and take up a large amount of bone stock, but then they also integrate into bone and will often break upon removal. So your best case scenario is to try to avoid them completely. So it's peak with metal core. Corey, he's essentially dodging the question. Imagine this is obstructive. Who do you call? I mean, are you crowdsourcing this to Bob? I'm lucky. I'm like, hey, Arsura, what the heck is this thing? How do we get it out? Which has happened a few times. I'm fortunate that I've only seen a couple of these offshoot devices, these trans-suspensory devices. But they're a challenge. I mean, obviously, if it's in your way to make an appropriate tunnel, you got to get it out. Obviously, that's going to be a two-stage situation if it's that obstructive. It's a big hole. You can go outside in if you need to. I mean, it just depends on how you need to get the thing. But it is a big hole. It is an indictment when these companies have changed hands and ownership several times. And so you often have to call somebody that was never involved in the invention, which you do for both of these. Seth, have you ever seen this one on the left? Far left? No, thank God. Tibial one I have seen, but not the femoral. All right. So let's take this one step further. Imagine you do see this. Imagine this is, say, your PA's fiance. Imagine he's going to propose to her in six weeks. And so we need to do all these things. Here's my case request sheet. And this is called a bone mulch screw, for those of you that are unfamiliar. And this requires a 6-5 head screwdriver in order to remove that had to be mail ordered from California. And so we go ahead and remove it. But it does leave a pretty significant void. And oftentimes, there's encased bone over top of it. So really having the WinkWist hardware removal set for me, fluoroscopy in the room, any other pearls that you would have? Core reamer sometimes. Yeah, I was going to say big core reamer, like the biggest core reamer you can find and then just be ready to bone graft that huge tunnel that you create by creaming over the top of everything. Yeah. I think you've got to talk to the patient also. Anytime you see any of these implants, especially if they're titanium, that there may be some left behind. Especially with the ones you were showing earlier on the tibial side, those tines will often break off and will have no clinical consequence. But if you don't talk about them to the patient ahead of time, they're going to wonder what happened. Steph? I have a low threshold to consider two-staging these. You know, I think the times where, you know, if the only implant that's going to be left is the one that's going to be removed, it's going to be the one that's going to be the one that's going to be removed. And I think it's going to be the one that's going to be removed. But, you know, there's so many variables here that could go AWOL and you can have a huge crater and it's just a lot more comfortable to know that you've talked to that patient beforehand and that you could two-stage it if you want to lay up. Yeah. Yeah. And so my PA was in the room. She was prepping the meniscus graft and I really had a hard time getting this out. But once that was, it was a sigh of relief. Let's up the ante then. Clay, let's start reverse order here. This is one of my first cases in practice. It's the anterior wall blowout. And I'm not talking about the guy in the top right corner here. I'm talking about where you have lack of cortical contact anteriorly. And I'll tell you how this happens. So you have a tibial ACL guide. Somebody gets over exuberant with a bullet and then it elevates it up and you end up drilling a guide pin. That's fine. But then the reamer ends up taking you with a little less chatter than you'd like. What's your bailout? Yeah. Some of it may depend a little bit on what graft you were using with that. But in this case, potentially, if you hope that your hospital may still have like staples potentially, because you can come, you may have to extend your incision proximally or you may even have to come from above, but you can still, obviously, ideally, you probably would like to make that tibial tunnel a little bit more posterior, which is going to make it a little bit bigger. So you may have to bone graft it at the same time you're placing the graft, but then utilize staples and then maybe backup fixation on the tibia with either some sort of an anchor behind the staple even, or something like that. Seth, you have a weird look on your face. I'm trying to... I don't know. I'm just trying to think if Clay did this to me when he was my resident back in the day. Probably. But no, I think I would probably initially try to just change my tunnel orientation. It'll be more vertical, be more central. I would deal with that anterior gap later once I got a nice socket, and then I would use suspensory fixation. I think that can bail you out of a lot of things, because you have a good cortex elsewhere. So I think I could solve this problem. It would be annoying, but not the worst day. Yeah. Yeah. And it's a shame when you recognize this on the PACU film. So definitely, which was my case. And I think it builds a healthy amount of paranoia. So feel for that interference fit of the screw. Make sure you're making some adjustments. I agree. Go distally. And yes, we did use staples. I do fluoro in all cases, whether it's mini or full. At the end of the case, just to make sure my buttons or my screws are in the right place. But one of the people that Amman and I know very well, their first week or month in practice, a femoral B2B screw was in the back of the knee. They didn't know it at the time. You would have recognized it. So I think fluoro and drop is not a bad thing to consider. Yeah. Amman, you've got a solution. Talk into the mic for me. So another thing you can do, and previously, Clay gave it this year. But the bone loss talk, one of the things that I love using in revision ACL reconstructions is tunnel dilators. And I think this is actually a great opportunity for this. You can drill a small 5.5 or 6 millimeter tunnel just posterior to your blowout, maybe five, six millimeters wall, and then use your tunnel dilators essentially to expand that out to whatever size your graft is. But essentially, you're basically keeping now a brand new cortex. You're bringing that out anteriorly and creating a wall. And then you're still now, if you want to use interference fixation distally, you still can. Yeah. So Corey, how about the medial tibial plateau blowout? I think we've all been guilty of thinking, ah, we're far enough away from the medial spine. And then you take that 10 reamer up and boom, that thing just fragments like a sheet of ice into the medial tibial plateau. Prevention strategies and what do you do when that happens other than change your shorts? Yeah. That's step one. Well, I think this speaks to Seth's point about having fluoroscopy, especially earlier in your career. But this can happen anytime. I think there's not much to do as long as the graft is not impinged against the condyle. Sometimes we get into the cartilage a little bit. I mean, obviously, just like Amal was talking about, you can certainly ream to the side. He makes a whole new tunnel and then just pushes the bone towards the bad tunnel. But this is also something that you can over ream it and use dowel grafts and sort of re-centralize a little bit. But I think the cartilage is no mas. Yeah. All right. This is another favorite of mine. It's the other blowout, the femoral tunnel blowout. Let's stay with you, Corey. So how and when do you scrutinize for lack of cortical fixation with either a primary or revision ACL? Yeah. I think it depends on what fixation mode you use. Obviously, it's theoretically less critical with the suspensory devices. For a BTB, for me, I'm still using a metal screw. Stay with quad, yeah. So I still need that screw, and I need the far cortex. It does happen. It happens not uncommonly. This is where that lateral incision comes into play, and you could just tie it over. And it's really, it makes people nervous, but we force the fellows to do it oftentimes in the lab. And it's really not a huge deal. It's a small incision, especially if you were planning on doing some sort of extra-articular tinnitus. But it's literally right there. You could tie it over a screw. You could use a staple. Anything you want to do. You could use a knotless anchor. There's any mode of fixation you want to do on that side. Yeah. Seth? I always hated putting in these metal interference on the femoral side. I had a nightmare in my residency where I cold-welded the screwdriver head because it was hard bone. That's different than the more typical blowout that you're describing. I switched to suspensory for my BTB about eight years ago and haven't looked back for multiple reasons. No hardware there at the aperture. You can cure graft tunnel mismatch by just converting it into the tunnel for a two incision. You can provisionally fix it. Do your tibial screw cycle and retention. So I found that my graft was better fixed. So I just avoid this problem, I guess, and I don't care if a little bit of the tunnel blows out. So he's talking about the second scenario where you're having a posterior wall blowout with a BTB plan fixation. So suspensory is an option. Redrilling is an option. To the left side, you're a lot of the quad guy, Clay. Have you seen this in your practice? Does it come in? And if so, do you always get it before you start tensioning? Or have you ever encountered this fateful x-ray where you've got the intraosseous button? Yeah. Unfortunately, I've encountered that x-ray after having docked the tibia and put the tibial button all the way down, which is when, like you said, your pants need to get changed or you're just really unhappy because your day's about to get a lot longer. But I think it's kind of already been mentioned, and Corey mentioned, you either have to back it all the way out and go at it potentially again, or that's when I don't have any hesitation to pivot to interference screw fixation of some sort. You may still have to back the graft out and re-suture it so that you can get a good suture tendon interface again and then pull it back through the tunnel or the socket again. But then I have no qualms about going to an intraarticular interference screw over the top at that point in time. Corey? We literally had one of these, like, I don't know, a month ago. Got an intraoper x-ray, saw it was flipped, and in clinic, fortunately, we got an x-ray and we saw that. So it was a discussion, and the exam wasn't horrible, but it was early enough, couldn't totally tell. Decided to take it back and went in, and I mean, it was, you could just pull the graft right out. So we literally had to redo everything, opened it, used a bigger, the enlarger buttons and stuff because the cortisol. Yeah. So the extended buttons. It happens. Yeah. Yeah, I would say Seth made a good point yesterday, and Corey just did too about a radiographic image. I think probably a lot of people do that, but I would second that. I mean, we published a study a number of years ago with suspensory fixation of getting a quick x-ray at the end of the case and not, and in the cases that we didn't, 10% of the time that button was either on the IT band or in a couple of cases in the femur. And so it's worth it. Usually it's the end of the case x-ray and half the time I'm already like one foot out the door admittedly, but if something's there, then you see it and you see it then. I think if you get that fluoro shot, you can also just make your open incision. If your button's recessed and you have strong sutures still attached to the graft, you can fixate that and then just accept the endosteal button. But maybe I'd also do aperture as well. So aperture plus like any kind of anchor on the lateral side and I'd be comfortable with that. But it's an ugly x-ray. Yeah. And this one on the far right came from a community partner that referred within the global period. So they showed up in clinic like this and obviously blacks. You know, I think I'll skip the UFO button, right? The one that's been pulled on the IT band. There's a couple of different ways that you can address that marking the intraosseous distance. Here's what I do just to show the audience. I'll put my camera over here in order to watch that flip and then I'll use a mark on that white suture in order to make sure I know the distance. So if you're in an adjustable loop type of situation as opposed to a fixed loop, I just want to make sure I watch it go past and then firm counter tension on the opposite side and then it's kind of plug and play with getting your soft tissue graft up. All right. Here's another one. The other thing real quick on that. For whoever is pulling on that at first, suspensory fixation, whoever has their hand on the, on, on that, on that pulling that through when they're on the outer thigh, when it gets close, when you visualize it through the AM portal, like you are there at the tunnel, when it gets close, instead of continuing to just pull continuous tension way out here with their arms flailing like this, put the hand right next to the thigh and just take the seat, the suture, and just literally just kind of gently roll it with pressure up against the thigh. So the sutures here and the thighs here, and you just gently roll it like that. So it just comes slightly and then you feel it pop through the cortex, but not all the way through the IT band. Yeah. Yeah. So not a, not a tug of war so much pulling with the arms flailing out here like you'll see. I got a quick question. Then we have one from the audience. So, so it's interesting that a iliotibial band x-ray. So someone was, I don't know, I think six weeks out from an ACL and have a lot of pain and I want to get involved. They had been done by somebody else, but they wanted to come in to see if it was normal, quote unquote. And they were having a lot of pain just on the lateral side of the knee, got an x-ray and it was there. And obviously it wasn't healed yet. So every time they were kind of moving around, they would feel this pain there. So the question is, I mean, you can't really retention it. So I mean, they ended up going back to their surgeon after I said that, but like, what do you do in that situation? If you don't catch it intra-op and you catch it post-op. I think you can still probably do post-base fixation with that residual suture, but it is dicey. You can either three-thread the needle, which I've done. So I always say don't remove that traction suture until we are at the last minute done, especially if you're not going to use fluoro. So you're talking about putting the camera in like the lateral portal, up the lateral cortex? Oh, through the lateral stab incision, yeah, yeah, yeah, you have to make a little bit bigger incision to do that, but yeah, yeah, yeah, you clearly aren't in the Midwest where our patient's thighs are this big, so you have to get hip scopes down the thigh, so. Please, yeah. Yeah, it's amazing. He's mentioned the value of the overtop position. When I visited Dr. Zeffanini in Bologna, he does that routinely for his Italian soccer athletes and it's remarkably stable and it bypasses the scenario. The point that you made about not taking your graft until you've checked all the boxes like is really important. I do that quite often. I will scope. I will look at the prior tunnels like if I'm trying to do a single stage and then I even sometimes ream those tunnels and make sure I'm happy, then I'll take my graft. It's a little backwards order, but it saves you and your patient because last thing you want is a graft in hand and you can't use it. I mean that's a disaster. Other questions from the audience, please. This is here for you. All right. Rapid fire. I'm on. Bone grafting. How long do you allow it to sit? Six months CT. Six months CT. Oh, your patients like you? Well, I mean, so just going back to the one that Clay showed earlier, that was four months. And that's the problem is that I used to do four months and I can't tell you how many CTs that I saw that it didn't look fully incorporated. Do you think that matters? I don't know. I don't either. But I don't know if two months matters either. Yeah. So if six months is a little better incorporation than four months, I go with six months. All right. Corey, hamstring graft. Ever in a revision scenario? No. No, but I got to go back to that other one. Like, so three months, dowel, x-rays, no CT. Correct. I'm the same way. And I've done, I've done like eight to ten weeks under duress. But I mean, just for a frame of reference, there are people, and I've done it a couple of times, that use those bone dowels in a single stage, right? And just fill up tunnels in a single stage and ream through them. Now, I'm not necessarily advocating for that every time, but that is an option. So they're not incorporated at all, clearly. Yeah, essentially, you're doing a single stage. I think if you're doing it in less than three months, you're essentially doing a single stage, which then begs the question, do you need to do a two stage at all? Yeah, good question. And I hate the always never game, but I'm, you know, I'm almost never using a hamstring. That doesn't mean it's wrong. I think a large diameter hamstring with the LET is not unreasonable, but I prefer quad after B to B. I prefer quad in general for revision. Clay, all right. So here's the extensor mechanism that you're going to see in some of these patients. What's your tolerance for Osgood-Schlatter, patella tendinopathy, or quad tendinopathy when taking that graft? Good question. So, I mean, there's a couple of different studies. They're older, admittedly, that say that you can still do it for both. So Osgood-Schlatter, BTB, quad tendinopathy, obviously quad, whether you take a bone plug with it or not. So I would say that my tolerance is probably pretty high. So you'll rule it in. You'll include those. Seth, I just recently got an update from Helio, and there's a Stanford study that talked about patella tendinopathy. Can you speak to that? Or were you involved in that? Yeah, I think it speaks to what Clay was just saying, that I think, you know, you can take the graft, and it didn't have any significant difference. So if you have some... No increased risk of... Yeah, if you have tendinopathy and you want to take the BTB, then you can do it. That said, me specifically versus some of my partners, you know, if I see a significant amount of partial tearing and tendinopathy, I'm going to go again to the quad because it's right there, and I don't have that. But in our series pooled, you know, not perfect levels of evidence, it was fine. Corey? Yeah, so I think you just got to be a little careful... Basketball athlete, thinking about, you know... I haven't met a basketball athlete that doesn't have it. I know. So I think you got to be a little careful about how you fix it, because if you do it the way I do it, then especially on the femoral side, I'm putting interference screw in, and I'm using the enthesis as kind of a fixation point. So in that situation, I drill my tunnels a little deeper. I suture into the bone and also into the tendon to kind of back it up a little bit, and I'll be a little slower. But on the femoral side, on the tibial side, it doesn't matter for me. I just suture into the graft because at the end, it's not mid-substance. Yeah. What about this? You got something else? Yeah, please. Go ahead. Yeah. Yeah, to summarize just briefly, your question is about chronic posterior lateral root tear. Question is you need, if you need to fix it, and then also integrity of the meniscus tibial ligament, meniscus femoral ligaments, you want to take that? Yeah, so I mean, first thing I do is just physically examine the posterior lateral root. If it doesn't have a good insertion into the tibia, whether the meniscus femoral ligaments are intact or not, I go ahead and fix it. When I, when I fix my meniscus, when I fix my, the posterior lateral root concomitantly with an ACL reconstruction in my practice is probably one of the easiest meniscus repairs to do. Essentially, I put my root sutures in, the posterior aspect of my tibial tunnel is adjacent to the posterior lateral root of the posterior lateral root insertion of the, of the native meniscus, lateral meniscus. I basically just tunnel it into the posterior aspect of my tibial tunnel, and then I tie it through my bone block or a button distally. So if, if I have any concerns about a posterior lateral root tear, which I do think can, contributes to the rotatory stability of the knee, especially the pivot chip, I don't hesitate to fix that. So the only thing I'll add is, so obviously if it's the roots floating in the breeze, that's a little different. There's definitely situations where it looks like there's meniscal tissue that attaches into the tibia, but the, it's very loose, it's, you can almost like lift it up. And so it's interesting, Zephaniedi taught me this, and we're doing some biomechanics around it. You could tie it down like he does, which is what I used to do, or you could drill a separate tunnel, and that gets a little hairy. But he used some all-inside devices, and ACL's gone, so he'll put a stitch into the meniscus and into the PCL, and it works great, and it's the easiest thing to do. I usually use two stitches, works great, and kind of tacks it down and immediately stiffens it up and flattens it out, and then, you know, I treat them like a meniscus injury from rehab. Yeah, and another pro from a tunnel collision standpoint is having your dilator up in the tibial tunnel, then drilling for your root, and then that helps to prevent some of that convergence, or you can at least know if they're going to converge and reorient. We had a question here. The redo, load it up again type of thing, yeah. Clay, you're, again, our quad enthusiast, probably the most enthusiastic. I'm getting accused. You take that bait? I mean, one of the nice things about the quad is that you determine the size and diameter of it, right? So, I think one thing you have to be very careful about with the quad, both in primaries and revisions, since you asked the question, the quad does not behave like other soft tissue grafts, especially like the patella tendon, which is more flat and more of a ribbon. The quad is very thick. And so, the benefit of the quad is you can take a big graft. The downside of the quad is a big graft can completely fill the notch. You can lose extension, post-op extension, stuff like that. So, you have to be very, while you can take a bigger graft or a big bone plug with it, which is nice, you still have to be very careful with it. In terms of revisiting the patella, that's potentially an indication to go to the other side, a contralateral. I don't, you know, I try not to go to the contralateral side, but obviously, Shelburne in Indiana goes to the contralateral side every time in primaries. So, it's doable and it's possible, but if you're concerned about going to the patella for a second time, you know, that may be a time to think about going to the other side or even Brian even talked about, you know, a different graft selection before. I would just say, you know, I use quad soft tissue only, so I would be wary of quad with bone after BTB. And I think the more quads that I do, which is 70% of my practice now, the smaller diameter I'm getting. So, these are nines for the majority of them. And so, my thoughts on the tunnel dilation issues may be, you know, thought of separately than my graft because I'm not going to make a huge graft just to fill that tunnel. I just worry about all the things close it. Yeah, and I probably would go to a maximum like 11, 11 to 12, but that's a lot of tissue. I mean, that is a cylinder. Yeah. I've only done that when I have a little lower demand person and I'm trying to get away with, you know, something and maybe trying to not come back. But in most cases, I would do it in the second stage for like young athletic. Yeah, sorry. LAT is a part of a stage procedure. If you're doing a bone grafting or you're planning to stage, would you add it at the time of the primary? I assume bone grafting as your primary. Yeah. Well, it's not for everyone. That's what they used to do before they did ACLs. Yeah. Yeah. We have one over here and Cam Halito showed that when you do it with an intact but insufficient graph, it may be okay for not having to do a revision. Yeah, please. Say that one more time, I'm sorry. Yeah. Yeah, lateral side you mean? Yeah. Yeah. So the concern is do you over compress it or is that a contraindication for an LAT? We put this to the Delphi panel recently and there was consensus that that was not a contraindication but definitely a consideration. Are you asking if it's protective? Yeah. Yeah. I think it's a good option. Yeah. Good option. Yeah. Yeah, a good option. Not hard evidence to guide you one way or another. But I guess just to think other aspects of that through, like if I'm bone grafting tunnels, I allow weight bearing as tolerated and if I have to do a meniscus thing that makes me keep their weight off of it and I know I'm coming back for a second stage, if that meniscus is not displaced and they're being protected anyway, I might defer the meniscus for a later day. It just really depends. But sometimes I fix it the first time. If it's displaced, I tack it back. I might use all suture meniscus in that setting because I'm going to get a second chance at the meniscus. So I guess that may not have been exactly your question but that's what popped to mind. Yeah, yeah, so if you had a failed primary ACL, and I assume in intraosseous or interference screw fixation of LET? Yeah. I guess it depends on how, what the time gap was between the LET index ACL and your new procedure. It might not be an issue at all in terms of, especially if they're using all suture anchors or something like that. Yeah. No, I get a swoop a lot. Like, you're going to have, for, you know, tinnitus type fixation, you know, if you've got, you know, maybe a little more thermal lining in a matrix of more than 10 or 11, and you've got that interference screw sitting right next to your ACL pump, you know, how are you managing, like, drilling a new thermal pump? Yeah, I mean, I haven't had that situation personally. I would probably treat it like I would my primary, if I was concerned about doing a two-stage versus single-stage reconstruction, and do I need to take the old hardware out and bone graft it? But I have not had that situation. If you're doing outside-in, then that can be a little bit of a challenge. So, you probably would need to switch to, like, a flexion intermedial accessory portal so the obliquities change a little bit, and you probably don't have to deal with it. I've had a couple of them. The only time it's been a problem for me is if I had to do a post-auto corner, which I've had to do, and that's kind of a pain in the butt because now there's a hole right next to where I need to drill my LCL tunnel, and the dissection's a little bit more hairier. But, yeah, from an ACL, you just change your rotation. So, if you're going to do your outside-in, you really have to change your angle, or, to be honest, you probably just should go low anterior medial accessory, and usually the obliquities should miss it. So, the funnel technique. Correct. Yeah. If I have a revision LET, I'm going to use an allograft, and then it can be long. I go under the LCL still, but I can go anywhere on the corridor. I can get fresh bone and fix it whatever way you'd like, and then manage your ACL as you would. So, that's my solution. We're over time, but I appreciate all the questions. I just want to commend the panel. Great questions. Yeah, these are great. Obviously, a lot of discussion, including this anterior wedge closing osteotomy. So, feel free to grab us, but go enjoy your evening, and we'll see you tomorrow for day two. Thank you. See you. Bye.

ACL reconstruction

revision surgery

tunnel malposition

osseous considerations

extra-articular procedures

osteotomy

lateral stability

iliotibial band

LET

graft placement

meniscus pathology

surgical techniques