We should have plenty of time for questions at the end, so I'll just kind of keep us rolling along. Certainly, quad tendon is a very hot topic in ACL reconstruction. The other hot topic, if you went to any of the lectures today, so I'll skip through that, is augmentation procedures, whether that be lateral augmentation, intraarticular augmentation, or more. And so I'm going to kind of delve into a little bit of that in a little bit more detail, in addition to a little bit of technique-type stuff. So we'll start out with the case again. So this is a patient of mine, 27-year-old female now. Has post three failed ACL surgeries, including a hamstring autograft, allograft, BTB autograft from the same side. Very active patient, former college volleyball player, wants to continue to stay active. As you can see, lateral recurvatum, hyperextension, high Bighton score, explosive pivot shift. This post-lateral corner injury, this is a difficult problem. This is a difficult patient to deal with. This is the one that you kind of dread in clinic, right? A three-time ACL failure, obviously there's a lot going on here. You're probably not just going to throw another ACL in there the same way that she's had three times only. So we've got to think about some of these types of things, and we've got to think about how are we going to approach this, both scientifically, but then from a practical standpoint for this patient too. So that's when kind of this has come about again, and you guys have seen some of the talks on this today, and probably see a lot of it frequently. But the lateral side of the knee has kind of come around again. And so everyone's familiar with the Sagan fracture, and going all the way back to 1879, the lateral side of the capsule. And then Dr. Houston described the lateral side as the middle third lateral capsule ligament, and even described an extra-articular reconstruction at that time. Then it kind of got reinvigorated with Stephen Kleiss with the ALL, or the anterolateral ligament in 2013. And then it was described again in 2014 as a distinct lateral ligament. And so it's really gotten reinvigorated, and then now has come to the forefront over the last five or six years even. So this is some of Kleiss' work looking at the biomechanics of what he termed at the time the anterolateral ligament. And so they did differential sectioning of the ACL bundles and the lateral side of the knee. And so when they sectioned both the ACL bundles, it resulted in a 1 to 2 plus pivot shift. When they sectioned both ACL bundles and the lateral side of the knee, the lateral capsule, what he termed at the time as the ALL, they then got a 3 plus pivot shift at all specimens. So much, much higher, much more rotatory laxity, rotatory instability when the lateral side of the knee is involved. This is it when they went the reverse direction now. So first, they sectioned the ALL only. That gave them a 1 plus pivot shift just sectioning the lateral side of the knee. Then they sequentially sectioned both ACL bundles. Again, the result was an explosive high-grade pivot shift with rotatory laxity. So we know that the lateral side of the knee, when you see that Sagon fracture, you've got to be wary because there's something going on there. So that's now brought us full circle again to what do we do to address that? Or what do we do to address the lateral side of the knee? So there's a number of different surgical technique options that have been described, some of which were described already in some talks earlier today. So this is one that's been described many years over. It's called the lateral extraticular chinadesis. In this particular case, this is a modified Lemaire. It's pretty straightforward in how it's done. Al Gittgud did a nice demonstration of his technique today. But basically, you make an incision between the lateral epicondyle and towards GERDI's tubercle. You identify the IT band, strip off any surrounding soft tissues. You harvest about an eight centimeter by one centimeter strip of the IT band, typically trying to stay in the posterior aspect of the one, posterior one third of the IT band. Then you leave the IT band attached distally. You whip stitch the proximal in, pass the IT band deep to the fibular collateral ligament, the LCL. And then you fix it proximal to the lateral epicondyle. You fix the graft in anywhere from 30 to 60 degrees of flexion and neutral rotation. So it's not set over tension, the lateral side of the knee. And that's important. We'll discuss that more in a second. This is the ALL technique, or what's been called the anterolateral ligament reconstruction. Typically done with either semitendinosus or gracilis allograft. You whip stitch both ends of the graft in. You again identify proximal and posterior to the lateral epicondyle for the femoral fixation, although there's a little bit of debate about that. And there's some different biomechanical studies that say whether it should be posterior or equal to or anterior to the lateral epicondyle, but proximal to the lateral epicondyle. Then you identify the midpoint between the fibular head and GERDI's tubercle, approximately one centimeter distal to the joint line. Drill guide pins at both locations. You can assess your isometry through your guide pins and take the knee through range of motion. And then you can shuttle and fix the graft at both points with the implants of choice. This technique's been described using suspensory fixation, suture anchors, and interference screws at both the femoral and tibial sides. So what about some outcomes of some of these types of things? It's like I said, a very hot topic over the last few years. This was a nice study out of Europe that looked at the outcome of a combined ACL and ALL reconstruction technique with two-year follow-up. They had 92 patients. They had a 1.1% re-rupture rate in the operated knees versus actually a 7.6% contralateral re-rupture rate. So that's pretty good. 1.1% is much lower than what we typically see just in the routine historical standard ACL re-rupture rate literature. They had improved patient-reported outcomes as well with very little complications. How about lateral extraticular tenodesis? This is the stability trial. Again, I mentioned outGETGOOD. This is one that's won a number of different awards because it's a randomized control multi-center trial. They looked at single-bundle hamstring ACL reconstruction alone versus single-bundle hamstring plus a lateral extraticular tenodesis. Again, a randomized control trial at 618 patients at a mean age of about 19. So these are young patients. These are the ones that we worry about. These are the ones that re-tear, right? Young athletes, young patients. Their results showed a clinical fare, which they defined as any form of instrumented laxity at 40% versus 25% for the ACL versus ACL plus LET. The important one that they highlighted was the graft re-rupture rate. So for ACL, hamstring ACL alone, it was 11%. Hamstring ACL with a lateral extraticular tenodesis, 4%, which was statistically and they deemed clinically significant. Their number needed to treat to prevent one re-rupture if you added an LET was about 14.3 patients. So if you have a very busy ACL practice, that's not very many patients to potentially prevent a re-rupture or a re-tear. As we all know, any of you that have experienced a re-rupture or a re-tear, it's pretty devastating, particularly in a 16 or 17 or 18-year-old athlete. So how about comparisons of ALL versus LET? There's not very much in the literature. There's mostly biomechanical studies. This was one of the better biomechanical studies that was done. It was a robotic study. They looked at 10 cadaver knees. They tested both intact knees, a sectioned ACL, where they sectioned both what they term the anterolateral ligament or the anterolateral capsule plus the Kaplan fibers beneath the IT band. Then they did an ACL reconstruction or an ACL reconstruction with an anterolateral complex, which is the term that most people utilize for the lateral side of the knee now instead of just ALL, the anterolateral complex procedure such as an LET or an ALL reconstruction. They noted that if you had deficient anterolateral structures, it increased tibial internal rotation by an average of about 4 degrees and anterior translation up to 2 millimeters versus just the intact state alone. So again, that kind of goes back to Kleiss's work, where he showed that if you just sectioned the lateral capsule or the lateral anterolateral ligament or the lateral complex of the knee, that could sometimes give you a trace or a 1-plus pivot shift just from not having an incompetent lateral side of the knee. So that kind of fits with this same biomechanical study. Then when you looked at the ALL and the ALT, it decreased internal rotation to even lower than the intact state when it's combined with an ACL reconstruction. And so this is something that is still in the works and something that's to consider when we're doing these procedures. Because one of the criticisms of doing a lateral side of procedure, or one of the question marks I should say, is people say, OK, do you potentially over-constrain the lateral side of the knee? Do you have long-term ramifications of over-constraint on the lateral side of the knee? And that's to some degree still being borne out in the literature and still being borne out in clinical studies. And it's certainly something that's worth discussion. And we can discuss what are the relative risks versus benefits of a re-tear in a 17-year-old athlete versus possibly some degree of abnormality or some degree of over-constraint versus the intact knee. And so it's something that's kind of ongoing. This is like one random study that I found on the bottom in the literature comparing where they tried to do a review of ALT and LAT studies. It wasn't the greatest study design, but they found 10 studies and tried to pool them together. And they found that patients with a positive pivot shift either got an LAT and then had a re-rupture rate of about 4.9% if they had an ACL reconstruction with an LAT versus only about 2.3% for an ALL. Like I said, it was just, there's not very many clinical studies in the literature directly comparing them. It's not the only one that I'm aware of or that I've found. But they also reported similar patient-reported outcomes to both procedures when combined with the ACL reconstruction. So what about return to sport? So this is actually a nice study by the Santee Group that looks at return to play after an ACL reconstruction combined with an anterolateral ligament reconstruction. So it was a retrospective review looking at patients that had an isolated hamstring autograph versus a hamstring autograph plus an ALL reconstruction. So it was a full reconstruction. They had 111 matched pairs of patients, and they showed no differences in their activity scores, no differences in limb asymmetry, agility, or psychological readiness scores. And so basically their conclusion that adding an anterolateral ligament reconstruction at the time of an ACL recon did not delay any sort of functional recovery or return to sport. So that's important because, again, thinking about this in our young athletes or athletes in general. So today, in 2022, what are the indications for a lateral augmentation procedure, whether that be an LET or an ALL or some combination of those things? Well, I think we have to consider it in high-risk patients. So that's our young patients, potentially females with high amounts of ligamentous laxity, recurvatum, or a very explosive or high-grade pivot shift. If they're returning to high-risk or pivoting sport participation, there was a nice abstract today looking at alpine skiers. That may be a consideration as well. If they have increased tibial slope, we know that that's a factor in ACL failure. Certainly that's something that is being looked at being able to be, you know, the bony procedures are something that could potentially be correctable. But that's something to evaluate, and certainly in the revision setting, something to be very cognizant of. If they have meniscal deficiency, we know especially the medial meniscus as a secondary stabilizer to the ACL is very important. Again, that can be correctable, potentially with meniscal transplantation or other types of procedures. But that's another factor in play. If it's the revision setting, if there's a sagon fracture, meaning that there's obviously a lateral sided or a lateral capsular injury. And then what about contraindications to an isolated augmentation or even an augmentation added? Certainly if there's a posterolateral corner injury or if it's in the setting of a multiligamentous knee injury, then you need to evaluate those structures, or you need to reconstruct or assess those structures in association with this. And an isolated lateral procedure like an LET or an ALL is not going to be able to adequately address a posterolateral corner injury. If they do already have lateral compartment chondrosis or early osteoarthritis, that's something to consider as well based on some of the biomechanical data that I just discussed and showed. This is another relatively hot topic. I'm kind of transitioning a little bit. What about intraarticular or internal augmentation? This has gone through a lot of iterations, and truthfully, luckily I'm glad I did not practice yet at a time when some of these things were coming out. For some of you that have been in practice for a little while, you may remember some of these things like Gore-Tex or some of these other types of things. I've never seen a Gore-Tex, and I'm glad that I didn't because apparently they did really, really bad. And so in the early 90s, there were these synthetic grafts with polyester and carbon fibers and collagen replacements of various kinds and different types of scaffolds that people were trying to do to augment the ACL or in some cases replace the ACL intraarticularly within the knee. And they had very, very high complication and even higher failure rates. And so most of these things at that time were largely or in many cases completely abandoned. And then you saw a push in the early 2000s to moving towards more double-bundle ACLs. And as X mentioned in some of Dr. Fu's work, double-bundle ACLs and more anatomic ACLs and trying to be more anatomic with an ACL reconstruction and not thinking about any type of extraarticular or intraarticular things. And then now we've progressed from that on since then. So what is internal suture augmentation now in 2022? So this is very different from a polyester replacement or wrapping the graft in a polyester replacement. And Cassandra mentioned BARE, which is something different from this talk as that's more typically related to primary repair. And so that's a different talk for a different day. But this is the technique. And so it's utilizing suture tape, which is a very thin, 2-millimeter wide and flat, completely flat, non-abrasive interwoven suture. The concept of it is that it's a seatbelt concept. So it's there to help support the graft and help minimize stress on the graft, particularly through the early healing phases. The technique for incorporating it is actually relatively straightforward. And so you can utilize it with any ACL graft that you do. You can basically do your standard ACL graft prep for the most part, whether that be BTB, hamstring, quad, allograft, you name it, whatever you prefer. And basically, the most straightforward thing is you loop the tape or the suture, whatever you prefer. Or you can either loop it around or even through one end of the graft. And you typically do this on the femoral side. And then you have a couple different options. You can either sew the tape within the length of the graft so it's incorporated with the graft itself to enhance its strength. Or you can leave it as independent of the graft and then fix it distally independent of the graft so it's truly independent and truly that seatbelt or that loop and suspenders type of concept that it's independent to the pants and vest of the graft itself. The distal fixation can be anything that you prefer as well. You can tie it over a cortical button or you can do independent fixation on the tibia with an anchor. So this is a really nice study that kind of looks at a review of a number of different things. So it reviewed 22 different studies. So it's a big study that kind of brought it all together for the summary of the literature of suture tape augmentation, internal suture tape augmentation. So it looked at six biomechanical, three animal, six or ten technical, and then three clinical studies. And so for the biomechanical studies, they looked at tape augmented grafts versus ACL reconstruction alone. And for the tape augmented grafts, there was anywhere from 12 to up to 73% greater load to failure. There was 17 to 60% reduced elongation. So I mentioned that and the importance of that, particularly in the early healing phase. And then there was load sharing at 200 and 300 newtons, with the suture taking about 31% and 20% of the load. And so what that means is, and so one of my mentors, Pat Smith, is kind of one of the leaders in this area. And so what that means is in the early loading phase, in the early flexion and early loading phase and recovery phase, that the suture helps take some of that load. And so up 31 or 20%. And so because we know that some of the graft elongation that occurs or some of the issues with graft elongation typically occur early on or in the early loading phase. And then potentially you have poor healing or stretching out of the graft long term, which then long term can lead to increase in re-rupture or re-tear rates. So the animal studies showed no differences in any sort of complications or ligamentization rates or histologic findings. So this is different than like the old school grafts that I mentioned at the beginning, where they have the collagen implants or things like that. Because the histology would be significantly changed in some of those old things. And so there is a very thin piece of tape. And so there's no evidence of histologic findings. One of the major concerns was, because it's intra-articular, it's not extra-articular, what about stress shielding? The animal studies that have been done have shown no major evidence of stress shielding, particularly with the way that you prepare it. If you prepare it where the suture is either embedded within the graft or posterior to the graft, so it's not anterior, so it's not into the interconnel or knots or anything like that, then the potential for stress shielding is very minimal to none. The clinical studies, they're ongoing, there's a couple decent ones in the literature now, but they show mixed improvement in IKDC scores and return to sport versus just ACL reconstruction alone without any sort of tape augmentation. But there's been no differences in complications in the early clinical studies. So the primary conclusion as it stands right now for internal suture tape augmentation is that there's very strong biomechanical evidence to support it, particularly in the initial loading phase and in terms of the seatbelt concept of support for the graft. But certainly there's clinical studies still ongoing, and so we'll see how that shapes out in the near future. So what are the primary potential indications for suture augmentation at 2022? You're going to see kind of similar things to what you saw earlier, but revisions potentially for high-risk patients, such as our females, high ligamentous laxity, recurvotum, high-risk pivoting sport. And as I stated, there's pretty solid biomechanical data to support it, but we definitely need more clinical data before this gets broadly applied to every single ACL patient or every single patient that we see. So let's go back to our case example. So this is not an easy case. So again, just to revamp, 27-year-old female, she's a three-time ACL loser, very active, tall, skinny, ligamentously lax, very positive Lachman's, recurvotum, she has a pretty significant pivot shift, and she had a mid-substance ACL re-tear and a posterolateral corner injury, and pretty significant varus malalignment, because she's now been like this for about a year, because she bounced around to a couple different surgeons who said, you should just not ever run again, and you should never have another surgery again, until she finally got to me. And so I staged this one, because this one obviously is a little bit complex. So these are her images in her first stage, so you can see she's got all these old tunnels. That's the femur on the top right with an old screw, a lateral root tear as well. But the lateral compartment and the medial compartment shot, luckily for her, looked pretty good. And the lateral meniscus there looked pretty good. And so that's all very lucky for her. And so this is me taking out the hardware. You can see these old screw holes. So what I did is I just basically reamed, I took out the old suture, reamed an entirely new, completely new tunnel there, and then I bone grafted it. You could potentially make the case for doing this in a single stage, but because this wasn't the only procedure I was doing in this one, I didn't do it in a single stage. I did it in two stages. And so we did a high tibial osteotomy as well with bone grafting to correct her varus and get her back to neutral alignment. Let that heal in. So now you can see this is the second stage surgery. So now her femoral side looks almost like a native femur now after we bone grafted it previously. So looking at the lateral femoral wall and the intercontinular notch there. Now we basically have a whole new bone tunnel there, which looks good. Here's our autograft quadriceps ACL with an internal suture embedded within it. And there's the graft in the knee. As you can see, you can't see the suture. It's posterior to the graft interwoven within the autograft there. And then we did a lateral extraticular tenodesis in addition to a revision posterolateral corner reconstruction. So there you can see our lateral extraticular tenodesis from the IT band coming underneath our posterolateral corner reconstruction with the FCL portion of the posterolateral corner there and coming proximal and posterior to that. Here's her stability testing postoperatively. And so this patient's about two and a half years out now. And I actually moved away from the practice where I was where I did this one, but I've specifically followed her because it's a very interesting case. Certainly when I had one of my partners down there continue to follow her and she's still doing very well. He follows her on about six month intervals and she's back to running and doing some of those type of activities. She's not playing volleyball anymore, but she's back to running and doing some of those things. So, okay. So I think that's what we have for talks. But we wanted to save plenty of time for questions. So if you have any questions specifically for any one of us or any of the talks or just in general, we're happy to take those now. In this case, did you treat the osteotomy was a B-part osteotomy with a slope problem or she had any slope problems? Great question. It was borderline. Her slope was about 11 to 12. And so for me, it's got to be over 12 for me to correct the posterior tibial slope issue. And so I didn't do a biplanar osteotomy in this particular case, but that's a great question because it's something to evaluate, particularly in someone who's a three-time ACL loser. I have a question. When you speak, the comparison between left arm and right shoulder, you said that in the right shoulder, you use allograft, something, or allograft? You can do either one if you want. You could use either one, potentially, depending on where you are. In Europe, they use more autograft with a little bit less access to allograft. In the United States, the technique's typically been described using an allograft. That's the only way I've ever done it. And being an extra-articular ligament, similar to MCL or even the lateral side, posterior lateral corner or LCL, most of the data would show that allograft does as well as an autograft for that type of thing. Yes? I'd like to ask the panel, what percent primary ACL reconstructions they do a lateral extra-articular on right now? And secondly, I can see somebody who's had three ACL surgeries tolerating a big lateral incision because she just wants to have stability, but it's harder to think of these primaries going around seeing small incisions than everybody else tolerating a big lateral incision. So two questions in that. What percent do they do right now? And secondly, do they tolerate that big lateral incision for a primary? Cassandra, you can take it first. So I'm based here in California. They get very upset about any incisions in general. So yeah, so I'd say zero. Right now, I'm not doing any for my primaries. I'm still waiting for some of the data and literature. I'm following Alligator's group and trying to figure out what the indication is. But I also don't really use hamstring anymore within my practice. And then, yeah, so I don't do any in primary, but certainly in incisions. I have a couple on the books that I'm waiting to do because they failed first time around. Next. Yeah, it's less than 10%. They have to be hyperlaxed, mostly young females. You can do this. We have a technique that will come out and view many, and we're going to send it probably to arthroscopy. If you find the epicondyle and you go just below it and you make a four-centimeter incision, you can do it smaller, so two inches. And you just go. Most of that needs to be, two-thirds of it is distal to the epicondyle, okay? Because the only thing you've got to be able to see, you can use Army, Navy, scrape and see the IT band, and then you need to know where the LCL is. And sometimes the LCL is not that easy to feel. So you've got to see it. And then we do it using that same double-blade knife, so we get a 10-centimeter thing. We slide it up. We know exactly where we are. We pop in through a little hole with arthroscopic scissors to cut it. We pull it out, and it's a little tiny incision. I can tell you we followed the ones, and Al Goetker got us doing this about a couple years ago. I don't use staples when I do it. I don't like that because they're a pain to get out. I can't tell you whether that works or not yet, but I can tell you that there's not a lot of morbidity with it because you're only going about five centimeters proximal to the epicondyle. It's not like that pediatric technique where you go way proximal. We only go about five centimeters up, and then we don't close it. I did one of my five-star wide receivers because he's lit on a primary, but he's a super lax guy. I'm worried about doing it, but I don't know if it works. GetGood stuff looks pretty good. If you're not using a staple, how are you fixing it? There's two ways to do it. You can either use that same type of adjustable loop suture and put it through. Just suture it to the IB band, drill a little. If you find the epicondyle and there's a good paper about two centimeters proximal to it, there's a dead spot, and it's about three centimeters long, and it's conical shape. Anywhere in that range is going to be where you want to be. If you go just there, you can use a knotless all-suture. Knotless all-suture or even one of these that has a swivel. I use a knotless suture. I pull it through. I do it at about 30 degrees. I do it in neutral. I don't think anyone knows exactly how to do it, but I haven't captured a knee at all. On those hyperlaxed girls, their exam feels good. Whether they're going to fail in a year, I can't tell you that. I use a knotless all-suture anchor for it. The technique is published in Arthroscopy Techniques. If you just search my last name, it's open access and not proprietary or anything. It works really well. I'm the same as the panel. We actually did an ACL with an LAT in our first collegiate football player, and he's a five-star cornerback who's like a super hyperlaxed kid, like 10 degrees of hyperextension, loosey-goosey kid. I would still say that's pretty rare. He's cutting, pivoting, super hyperlaxed. The vast majority of the time, if I'm doing it, it's in the revision setting as well, just to echo the panel. Next, do you have any NFL guys with quad tendons? Yeah, we've had probably five. Were they downgraded at all at the combine, as you're aware of? Originally, when they went through, we were in the same room as Bradley, and Bradley would sometimes, he was unconvinced about it. Now, they will downgrade a hamstring, definitely an allograft, but they don't downgrade the quad tendons. What's his name down in Houston? Wallow. So, Wallow, who's a patella tendon guy, is now doing 70% quads. So, Wall was doing them, and the problem with NFL guys, I always ask them what they want, because if you're over 62, you're going to do a patella tendon on everyone, because that's what Andrews did. And if you're younger, you're going to be a little more open to doing it, and I think you just ask them what they want, because they usually come in and know they want something. My college guys are open to a quad. I've done almost all, for the last 10 years, all of my college guys have gotten quads on girls, all my college athletes, and we published on revision in arthroscopy, that we've done 100 revisions using quad, and it's been a good graph for that. But I think you got to be careful when someone tells you this graph is this much better. I mean, they're all good, but none of them are great guys. Between, we need to look at 14 to 20-year-olds. Everyone has, that moon data is exactly what we just pulled, 10% failure rate. I mean, it's, and you got to talk to the females of that age. It's just bad. So until we all solve that, nothing's a gold standard graph. We can all operate on, some of the things you got to look at, the Japanese, their average age was like 42 years old. Well, we can do, all of us in this room, we'll never fail. Maybe Stephanie will fail, but the rest of us won't fail, because we're too old. So I think you just got to be careful when people start telling you this is the best. I never want to hear that, and whenever someone tells me I have a 1% failure rate, I just don't believe them. I'm curious in that case, because she had a, you said she had a corner and you did a revision corner, but you did a LET with it rather than a ALL. So, have you ever taken just a, you did like a Larsen moon? Yeah, yeah, modified R-C arrow. Have you ever taken an ALL, and then your S-E-L, and then the column just dropped, and then you had to do an ALL? I haven't, but I thought about it. Yeah, it's a great, yeah. You're right there. Because when you take that first little capsule, and you pipe feed it into your S-E-L, passing your I-T-B-N-E to that, and kind of violating that structure that you were trying to control, because it was kind of combined instability. Correct, yeah. Yeah, no, it's a great point, and if you talked to, like I said, if you talked to Pat, to Pat Smith, he only does ALLs. He doesn't do LETs, and his reasoning for it is just that, is he wants to be, he says, I don't ever want to take a risk of violating the capsule or violating even some of Kaplan's fibers underneath the I-T-B-N, which, you know, you could kind of argue about that or discuss about that, but that's certainly a real thing, and that contributes some inherent stability to the lateral side of the knee as well. The one other thing, not to digress, but for the lateral articular tenodesis, if you try that technique, as X mentioned, sometimes the L-C-L is a little hard to find. Put the knee in a figure of four, put it up and put it in a figure of four, wear a stress on it, and the L-C-L obviously becomes taut, and nothing else on the lateral side of the knee will be taut, and you'll be able to locate the L-C-L that way a little bit easier and still do it through a minimally invasive or a smaller incision approximately. I think there's a lot we don't understand about what's going on laterally. I don't like an ALL. It doesn't make sense to me. I think the PIT data is really good. We were in a study, a biomechanical study we did with Volcker up there, and I don't think it works. No one's done it. But when you talk to Pat Smith, when you look at what the... You got to go back with the guys who are probably 80 years old right now, 75 to 80. When they were doing what they did on the lateral side of the knee, it's really amazing. Pat showed me what Houston used to do. We did it in a lab together. And you kind of, they kind of take it if you... The lateral side, it's like a... They pull it up and tighten it, and you do that to an ACL-deficient knee in the lab. It's incredibly restricted. Now, whether that's good or bad in terms of arthritis, I don't know. But it does make a difference. I remember Losey used to do, you know, this stuff. We didn't even do an ACL on all these big, you know, he was, you know, 85 and still doing it. And these guys didn't pivot, and they were, you know, cowboys, and they were happy with their knees. So I think we're going to, you know, we always reinvent the wheel, but I think we got to talk to some of those older guys before they kind of quit. And so we don't reinvent the wheel. I think we can learn a lot from them. Without a doubt, there's just not... And I think if you look at our PEDS guys in America, they're the guys who were sold on the quad tendon, because you're going to get big enough. And we published a couple in AJSM and in the Pediatric Journal, and in JBJS, the technique. So the technique of how we do it is in JBJS, how we drill the tunnels. But you're always going to end up with, even as seven-year-olds, the youngest I've done, and we had an 8-millimeter graft in him. And you can, if you do your tunnels between the epicondyle bifurcate ridge, you can put a 10-millimeter tunnel and not hit the growth plate in almost everyone. I never do that. We're usually all stay like eight, but you're going to have, and that graft doesn't need to be six centimeters long. It's going to be on those younger girls. People are, it's going to be five and a half centimeters long. It doesn't need to be that long, but I highly recommend that. And you can go right through it on the tibia, because you're center-centered and you're not going to get a growth disturbance, even if they're really young, but the femur, you got to be careful. Yeah. You know, it's interesting you said that. So for you guys, help me out. So I have a, I have a girl that that's failed and she's... What I did with the other guy, who's 13 years old, is like, I was fighting for transplants. So I did an ACL reconstruction, but not violating the growth plates. Right. But, I don't know. He's 11 years old now. I have one coming in this week. It's a revision. So do I go ahead and do that? And do I do, and I think you got to be careful where you put the lateral, you know, because if you, well, the danger there is too, guys, is when you're center-centered in a growth plate, 7% is what you need of the feicial volume to cause a growth disturbance in animals. But when you're lateral, you can, you get that. That's where, you know, that's where they do epiphyseodesis. They just go lateral and get it. And you do it anatomically. You're close laterally. You put that IT band, you know, tenodesis, and you go above the feices. I would worry a little bit. So I don't know what I'm going to do. I definitely wouldn't. Yeah, because you don't want to tether down the. I wouldn't use a screw for sure, obviously. Yeah, definitely not. And I would be, yeah, I would use something smaller. I tested a 10-year-old three weeks ago with the same technique. I would tell you, if you use a quad graft, make it shorter, like X said. Like I made it 5 centimeters because they're small. Did you do tenodesis? No, I did not because I was worried. There's no real estate. There's 4 millimeters between the popliteal hiatus and the feices. So I didn't, but, you know, we'll see what happens. I may regret it, but hopefully not. Buttons or tie-over post for the ACL. Tie-over post works great too. There's one more question. Sorry, yeah. For those of us, I guess, who are trying to stay partial thickness, do you have any tips for how to better have complications with wrapping things out proximately if you're trying to stay partial thickness? And I noticed in the video, I guess, your hand was like parallel to the tendon. But sometimes I feel like if I rate line it, I can dig in a little better. I'm just kind of curious if you have tips. We're using the tube or we're using the... The tube, yeah. Yeah, so I think it's really hard to do partial thickness with the tube. I don't do it, okay? That's one of the things I worked on. I don't do it. I do it with a knife because you can add traction. I just look at it all the way up. And once you get to 3 centimeters, then just take a key elevator and bluntly go. It'll find its plane naturally, and it'll leave that lower piece of capsule on there. But there's really... I agree with Fulkerson that there's not... I'm not sure there's a big advantage to doing partial thickness except if you don't want a giant wrap. Okay. Try to bluntly 3 centimeters up and then bluntly do it with the key elevator. Yeah, the key elevator is kind of key, like, you know, pun intended. Like, it really does. It really does make a difference. I mean, like, it does find the plane. As long as you take your time, take it off the patella. If you want to stay partial thickness, the easy part is just putting the key in there. But also if you're using the circular thing, I don't want to call it by its name, the key is not to... The tube, yeah. The tube, not to rotate back and forth. The key is actually to rotate. If you saw the video, you rotate the same direction the whole time because I think I finally truncated one of mine, like, number 26. I truncated it and I was like... because I had that 3 centimeters, I harvested it, and then it slipped up this way because I've been turning it back and forth. And then so, luckily, the skin was still mobile. I basically just went in and just free-handed it and took out the rest and just sandwiched it in and it was fine. But I think the idea is like, yeah, you're not necessarily digging your hand down, but the key is just turning it circularly in the same direction. Harris, you got any other tips back there on partial versus full thickness harvesting? Full thickness. So much easier and so much more predictable. And I think the problems with truncating the craft or skiving it in proximity are very, very much lower than full thickness craft. You know, Harris and I were just talking about that because we were involved in that study. You know, it's interesting. In that study, they'll say if girls, if you go over, I think, nine or nine, nine, nine millimeters, you're going to have trouble. I don't think that's all it. I think that you don't want to over stuff. So these guys put in 11 millimeter graphs and people that's Freddie. You can't be bigger than the footprint because it's a you're you're taking an hourglass structure and replace it with something conical. I think eight and a half to nine is probably the sweet spot. And and just make sure you don't make sure they get full extension and kill them on it. Don't don't be shy. And then if they're if you lose extension scope, they all have a Cyclops. You're cleaning it out. I just run the thing around circumferentially, take the Cyclops out and then their strength will come back. We published on five hundred that that we looked at strength at three and six months and a year. And the people, the average female is thirty eight percent strength deficit at 60 degrees per second at six months. Average male is twenty eight percent, but it's their strength is directly related to their motion. So the ones that did worse had worse extension, even even if they had full extension, didn't hyperextend than the others. So I don't know what came first, the chicken or the egg, but I think you got to be aggressive. Don't be afraid to take them back. I always used to wait the three months. And then it might, you know, Christian Fink and those guys are like, oh, it was Eggerson that said, take them back in six weeks. Don't worry about it. And he's right. I just take them back when they can. I give them six weeks or seven weeks, but I've taken them back, which is a hard conversation to have. You know, it's you know, it's a it's a weird market in Atlanta. And these people talk and oh, my God, my dad had to go back for a second operation. Like, well, you know, if you don't, you're going to have a constrained knee and arthritis. But if you frame it as, you know, your daughter's a super healer. And so we had to kind of control some tissue, you know, that's how you sell it. Super healer. I like that. It's not like the super foods that you guys eat here in California. Absolutely. OK, perfect. A question. Since you were actually you're seeing all these. I mean, not all these, but you're seeing these at six weeks. What does it look like in terms of ligamentation? It's unbelievable. And Harris could speak to this because we looked at a lot of this with Harris's fellow. It's unbelievable. They're completely synovialized. And it wasn't a lot of six weeks, but we've seen them at three months. And seven percent, it's a lot of it's a lot of ACLs. And we're I'm super aggressive, though, if I even if I have if they're straight, if I can pop them in hyperextension and they have pain, then I'll go in and just do it quick. And you'll see this little Cyclops, but it's synovialized. It's really fast. So if you guys have, you know, those those that nanoscope or the my eye of those things, if you get a chance, pop one of those in one of these knees at eight weeks or three months. And you can you know, you did a fat pad ectomy. So you can kind of go in there and see easy. And it's amazing how synovialized that graft is. Using quad auto for any of your patients that have had BTVs in the past. Yeah. So that yeah. And that paper we published on that. That was our paper, right? Harris. Yeah. We published on that. And they they do fine. There's no difference. There's no difference in BTV that failed. I had a quad revision versus hamstrings that failed. I had quad revision with parallel extension. But don't do a quad with bone if you did a patella tendon. That's bad. What happens if your quad fails? Then what? The quads. Then I do patella tendon. Patella tendon fails. And I love the only graft. It's funny. I was trained on hamstrings. I hate hamstrings. I don't do them anymore. And I know Pat would hate me for saying it, but. Yeah. That's all I saw. There's no place for it in my practice. I mean, I think the guy who runs Arthrex tried to assassinate me when I said that, you know, he came up. You can't say that. I'm like, well, I like quad and I like patella tendon. I just I don't see a big space for hamstring anymore. Especially in young females, because the tendon size is very unpredictable. And sure, you can harvest the gracilis too. You can quadruple it. You can quintuple it. You can quintuple it or whatever. But the hamstring size is very unpredictable in young females, whereas the quad tendon size has been demonstrated. You you choose the size. And so that's my reasoning right there. Not because I think they're going to fail more. It's that I think they fail when you get a when you get a small or just not a not a quality graft. Have you ever re-harvested a quad after a failed quad? No, but I have re-harvested after I blew the harvest. Okay. Again, you get it's not like everyone I did is perfect. I you know, we talked about transecting it. I went right next door and I've done three of those. One in a quarterback from his league, not mine. Second on a cheerleader from his league. And so she's small. And I think I had one more, but those two I remember and I was like I was puckering. Okay, I'm like shit, you know, and they both got their quad strength back and did fine. So there's a lot of tendons. I just went right next to it and harvested. And we did a nice repair, but I went next to it. I have a third-time loser coming up. ETD failed, hamstring failed. He didn't go as efficient. He had a quad fail. Came to see me, did a five lane HDL on it, double grafted, everything. And he doesn't want me to touch his other knee. And on his MRI, his quad looks good. Like it looks like there's stuff there. So my plan is to reuse this. So there's two things. One, does he really need an ACL reconstruction? Yeah, I think he does. Okay, because sometimes you do all that. I'm not good enough to do that operation you did and you did. I have partners that do that because I'm scared. I've done a couple. I don't like that. That's a tough operation by plant osteotomy. That's a very hard operation. I think you could harvest it again. Just stay a little bit. What did he do, though? I mean, Harris, what do you think? Yeah, I had one like that, and I went to the other side. I just convinced him. Small and sick. You could convince him. Yeah, because that quad's not going to hurt that much on the other side. I think you got to tell him, look, you've been through all this. This is nothing. Shelborn did it on every one of his patients and still did it. He said, who's that running back? He did from the guy from was it Barclay? He just did take one. Yeah. Yeah, he came out with it on a wheelchair. Yeah, you want to be perhaps on both. He's back strong as an ox on that side. Yeah, I would convince him to go to the other side. I had one very, very similar to that, and he didn't. This is his last chance, right? Yeah. Yeah, he's getting up. God, that's a beast. That's a beast. And I'm sure you're laying a lot of crepe, but I use the word salvage a lot in that particular type of situation and say, like, you know, we're to the salvage point. And I know it doesn't sound nice, but, like, you just got to have to be real frank with them and say this is like he said, like Harris said, this is your last chance. We're going to do everything we can. We're going to throw the kitchen sink at you. But these are the things that we have to do. I mean, if you use this, the ipsilateral quad again, let us know what it looks like. Let us know what you think. But I would go to the other side. I was just on his MRIs. Yeah. I mean, you guys, Andrews did a bunch of that in the 90s when they reharvested the patella. That kind of went away really quickly. We never really heard. Typical, you don't see those results published. Nothing out of there. And that just went away. It wasn't published. So I just, I don't know. I'd be a little bit nervous. Unless you did it yourself and said, okay, I'm going to be lateral. You know, I'm going to be more lateral this time. You know where you do it. Like my graphs tend to go a little bit medial. I might go lateral and try it, but I'd still be a little afraid. I mean, I've had anecdotally going back to, so I staged a revision and then did a distal femoral osteotomy with Macy and meniscus transplant. And so I took her quad. And then so three months later when I went in to do the distal femoral osteotomy, I was like, that tissue healed. Anecdotally, I didn't measure it. I didn't do anything like that. But just because I did a partial thickness defect. And so from what I expected to be there, it was actually a fairly robust tissue. I can't tell you what kind of tissue histologically, but there was tissue there. Sounds like a good study. All right. Thank you all. Thank you all for joining us. Hope you enjoy the rest of the meeting.

ACL reconstruction

quad tendon

augmentation procedures

lateral recurvatum

biomechanics

surgical techniques

clinical studies

return to sport