All right, thank you guys so much for being here. I know there's a lot happening. There are several ICLs happening at the same time, too. So thank you guys. We're gonna have a great discussion. Really, we're gonna focus this a lot on cases, maybe a teeny bit of supplemental information, but the bulk of this is cases, and we're gonna cover quad autograph, BTB, when and what types of augmentation you can consider, and a little bit about revision ACL. So I just wanted to start by introducing the faculty. First, Dr. Cassandra Lee. She's Chief of Sports Medicine at UC Davis. She's a professor in the Department of Orthopedic Surgery and is team physician for the Sacramento Republic FC Professional Men's Soccer Team, and her talk is going to focus on, there's no question, BTB is the gold standard for ACL reconstruction. I am currently Chief of Sports Medicine and team physician for the Loyola Ramblers in Chicago. I was just recently promoted to professor, so I'm really happy about that. I'm the past president of RJOS, involved with ISSA-COS, and I'm gonna be speaking about how quad autograph is reliable and reproducible, really for lots of different types of patients. Dr. Harris Sloan is Chief of Sports Medicine at MUSC in Charleston, South Carolina. He's an associate professor in the Department of Orthopedic Surgery, and is head team physician for the College of Charleston and Charleston Battery, and his talk is gonna be focused on revision ACL reconstruction. And then Dr. Clay Nolley is associate professor in the Department of Orthopedic Surgery at the University of Missouri. He's the director of the Mizzou Joint Preservation Center. He was just recently the host of the Anna Traveling Fellows, and really went out of his way to make them feel welcome, so that was very cool. He's associate editor for the Arthroscopy Journal, and his talk is gonna be framed in the case related to potentially a volleyball player, unless you changed it, which is fine, and saying that these types of patients always need some type of augmentation. So I'm just gonna, because my slides for my case are just tied to this presentation, I'm just gonna roll into my case. So this case here is a 14-year-old male soccer player, and I think really quad autograft is reliable and reproducible in this patient and many other types of athletes. These are my disclosures, none of which are directly relevant to the talk. The case, this is a 14-year-old male. He came in after injuring his left knee while playing soccer. He had an awkward kind of misstep and felt a pop. He had immediate pain and swelling, and was unable to continue playing. On exam, he had some swelling in his knee. He was able to straight leg raise, and actually his knee range of motion was quite good, with a little pain at the extreme of flexion. He was complaining of some tenderness over the lateral joint line, and had pain with McMurray test. He had an obviously positive Lachman. These were his x-rays in clinic, so no concerns there, very normal. So I've included some cuts from his MRI, so a couple of the sagittal images here showing the bone bruise pattern, and then he has a clear lateral meniscus tear, if you weren't sure, the green line clearly points that out, so love the radiologists for that. More sagittal images, so showing his ACL tear, normal medial meniscus, and then a single coronal cut, where you can get a glimpse of that lateral meniscus tear there too. So very briefly, touching on the many factors that influence graft selection. So surgeon experience, preference, comfort level are among the most important things influencing our graft choice. We also, of course, want to take into account patient's age and activity level, their sport, and their desire to get back to work or play. And then comorbidities and BMI all have an influence too, and you're gonna hear this as we talk about the different graft options. We want to know about pre-op, you know, high-grade pre-op knee laxity, any history of previous surgery. Also understanding the patient's preference and expectations, and any rehab concerns. All of these things are important pre-operative considerations. Highlighting a few of the many advantages of quad autograft, right, it can be harvested with or without a bone block, it's an incredibly strong, robust, reliable graft. It can be used in a primary or revision setting, and it causes minimal donor site morbidity, including things like anterior knee pain and numbness, which we may see more often with some of the other types of grafts. We do have to acknowledge though, of course, some of the disadvantages, that there's an increased risk of proximal patella fracture if you use the bone plug. There's a lack of bone-to-bone healing if you use all soft tissue. There's a risk of injuring the rectus femoris muscle if the harvest goes up into the muscle belly. And then you can see loss of extension and quad weakness, but that's pretty similar to what we see with BTV. So, touching briefly, just so everybody understands where are we harvesting, why is this important? So, the quad tendon is classically described as trilaminar, there's superficial, middle, deep layers, and based on MRI evidence, most often the quad is comprised of three layers. And for any of you who have harvested the quad autograft, you see this every time. The length ranges from about seven and a half to, seven to eight and a half centimeters from the proximal pole of the patella to the myotendinous junction, so that allows you to either do an all soft tissue graft or soft tissue with the bone plug. It really just depends on surgeon preference. And the width ranges anywhere from about two and a half to three centimeters. So again, just trying to give you some background on the graft itself. Touching briefly on the vascular anatomy, because this influences, you know, has a huge impact on why do we want to harvest in the central third of the quad tendon. So we have the medial and lateral arcades that are anastomosing, and they course between, you know, the rectus femoris and vastus lateralis for the lateral side, but they anastomose within and below the rectus femoris musculature. And so having a centrally based graft harvest within the quad tendon actually spares those lateral perforating vessels. It avoids violating the quad muscle belly and decreases the risk of developing post-op hematoma. So these are all things that are really important to keep in mind when you're harvesting the graft. Very briefly, there's a lot of biomechanical studies. I'm not gonna go into any detail on this, but Shum's showing in comparison to, you know, quad, or excuse me, in comparison to hamstring and BTB. So when looking at quad versus BTB, quad had less donor site peen, mean improved Lyshom scores compared to hamstring autograft. And then just showing that quad has comparable clinical and functional outcomes, so you don't have to be worried that patients are gonna have a worse outcome. And I think there's a lot of studies speaking to this now, but there was less harvest site peen and better functional outcome scores compared to hamstring autograft. So now really highlighting the rest of our keys. This is how I position my patients for ACL reconstruction. There's a lot of different ways to do this, but I put the affected leg in a leg holder, the contralateral leg I put in a lathotomy boot, or stirrup, or whatever you wanna call it, but it's flexed and abducted, and so there's a lot of space to get around the knee. That central picture is the incision that I'll mark out. Probably make that incision a little bit shorter now, but I still do a vertical incision, because I like that incision to be able to see where I'm harvesting and then to be able to close the harvest site completely. The hashed mark to the right side is just marking out the VMO. And so I do that every time. And then the picture on the far right is just showing, when you see the quad tendon, I will use actually a small portion of the ruler to mark out the central third, so I mark out 10 millimeters. And then I just use a standard 10 blade to harvest the graft. So this is what it looks like on the far left immediately after harvesting. And then on the right-hand side, just a still picture there of preparing the graft, and several companies now are offering different ways to prepare the graft. And then I think there's, actually, I don't know if I can play that video, but on the, is it possible for you to play the video? On the left-hand image, there's actually a video there, but I can't click on it. Yes, thank you. So this is just showing briefly how to prepare the graft. Oh, it's a little bit glitchy, sorry. But this is an important part. When you're just learning how to harvest and then prepare the graft, just take your time doing this. But here I'm securing this suture tape to the femoral end of the graft. So you secure the tape, do two passes towards the card, and then it comes, the needle comes up through the card, and then you pass it two or three times distally, and then tie that suture around the graft. In the central picture, this is actually the newer kind of cards that come for preparing the graft. The top one you can see has the cortical button. The card on the bottom, actually that comes with tape too, but that's the side I'm gonna use to secure on the tibial side with a button, with a circular button. So I'll show you guys the pictures of that too. This is the graft after it's prepared. I'll then, I put just a damp lap pad over it. I don't tend to soak it in Vanco. We can have discussion about that. But I just put a damp lap pad on it while I'm doing everything else. So I harvest the graft first, and then do all the intra-articular preparation. And then this is our patient here. So normal medial meniscus on the left, and his central on the right-hand side is just showing his ACL tear. Here is his vertical lateral meniscus tear. The rest of the body of the meniscus actually looked fine. And so then I used a rasp, of course, to sort of roughen up the edges, help stimulate healing. I used an all-inside device to repair the meniscus. And then you can just see sequentially, and that's his final repair. Then we went on to do the ACL. I drill my tunnel actually inside out, so a retrograde. And again, every company has their own, you know, different options to do this. So that there's a video on the right-hand side just showing after we've already drilled that tunnel. So I have the scope and the anteromedial portal, and I'm looking up the tunnel as we drill that, and as we pass the suture down. And then I actually also use this same view when I'm passing the button up the tunnel. These are, sorry, these are just some still images here. On the right-hand side, just the tibial guide. Here on the left, a still image of the button coming up. I take a picture of that. I think patients just like to see it, because then they can also correlate. They see the button on this arthroscopic picture, and then they see it on the x-rays. And they like to see that, and it gives them an understanding of what we did. Let's see if we can get the video on the right-hand side to play. There we go, okay. So this is just showing, this is just passing the sutures initially. So we're pulling the suture out through the femur and advancing the other sutures that are attached to the cortical button. That's gonna suspend the graft in the femur. And we'll see the button coming up here. So that's just that. And then, now I've put the camera back in the anteromedial portal, and I'm gonna watch the button as it advances up the tunnel. So actually, sorry, we already flipped the button there, but we're advancing the graft. But when I'm advancing the button, I watch it go up that tunnel and go out through the femoral cortex. I will then, every time, I use a mini C-arm, and I check and make sure that the button has flipped appropriately. I think, do whatever technique you want, but I would do something to confirm that the button has flipped, whether it's a mini C-arm or regular C-arm, or if you use the arthroscope, whatever you do, but just confirm that it's flipped so that it's not caught over the IT band. And then, just a couple of still images. This is the graft, this particular patient has graft after it's advanced, and then on the far right is in its final position. And then, I'll use this circular metal button on the tibia to secure that, so suspensory fixation on both ends. And then, I back it up with an anchor, which, do you have to do that? I don't think you absolutely have to do it. It makes me feel a little bit better, but I always do that supplemental fixation. And then, these are his post-op x-rays. So, just a summary. Quad Autoreq really is a great option for primary or revision ACL reconstruction. There's lots of evidence in the literature showing that patients have great functional outcomes and minimum morbidity. So, if you haven't tried it yet, I would encourage you strongly to do it. Do it in the lab, do it with a partner who uses this graft often. You can talk to us. Like, many of us have very good experience with this. So, I would encourage you to use it now, use it often, it's a fantastic graft. So, thank you so much for your attention. So, next up, we're gonna have Dr. Cassandra Lee talking about BTV. Just a quick show of hands. How many people in the audience utilize quad autograft, use it as quad? How many of you use it as your primary graft? Mostly. So, a few hands went down. Okay, we're about to see who uses the next graft as their primary graft, I guess. All right, who uses BTV as a primary graft in a young athlete? Roughly about the same as probably a primary quad, so we're about half-half. All right, so, looking at why BTV's still the gold standard. So, all right, I have no relevant disclosures. So, talking about our patient. So, this 20-year-old male football player, Division I running back, sustained a non-contact injury during a game, exam-wise, exactly as you'd expect, lateral joint-line tenderness, full range of motion, so you see him directly on the sideline as you're covering this game. So, effusion, you start noticing it's increasing lockments at 2B and a pivot at 2+. So, nothing explosive, just a regular, kind of standard ACL. So, how do I do this? I don't want to touch the screen. I know, same. Can you play the videos? When you, if you try to click it forward. Would it work? Oh, there it is, got it. Okay. There we go, so, sorry, super fast. Just see if you can blink and not see it. So, just ACL tear, no meniscus tear with that. I'm still working on trying to work up the visage system in our medical record stuff, so. So, I'm still working on it. But this one's maybe a little bit better, so. All right, so, this one, then you can get an idea a little bit more that there's some lateral joint-line issues, big lateral meniscus tear, so. Kind of see it right there, kind of radial at that anterior horn body junction, in addition to an ACL tear. So, yep, super fun tear. All right, so, treatment options. So, you know, you got a Division I player who's wanting to maybe go on to the next level. For ACL reconstruction, I think the decision tree includes autograft versus allograft, right? Looking at which graft you want in terms of autos, looking at quad, patellar, tendon, or hamstring, quadruple, single, double, whatever you want to look at. Are you going to do suture augmentation? Are you going to add any scaffold augmentation? Are you going to add anything extra-articulately laterally, right? He's going to go back to a highly competitive cutting, twisting, pivoting sport. And then options for the lateral meniscus tear. So, you can either trim that out or repair that. And then how would you change your weight-bearing status based on what you're looking at in terms of that repair? And are you going to limit any of the range of motions? So, a lot of variables to consider in terms of how to optimize that outcome. And then, so, what are you going to counsel your patient in terms of, you know, short-term, right? Because this kid, all he cares about is like, hey doc, when can I get back to playing? When can I get back on the field? Can I get back for next season? You know, is this a spring ball? You know, so a lot of those questions versus like long-term, right? What are the quality of doing anything with that meniscus or if you take it out or keep it in? So, as we all know at this point, the MOON study has been going on for so long that I think at this point, we know that allograft's not a good option, right? For someone who's in a cutting, twisting, pivoting sport that is active and young. So, looking at age group, for each 10-year decrease in age, graft rupture increases by two to three times. So, allograft does have a four times higher greater failure rate than autograft. And so, in general, odds of re-tear of BTP versus hamstring was really no difference, but in general, allograft definitely has a higher re-tear rate. So, allograft is certainly not, it is an option, but not in this patient, not in this situation, right? So, in terms of how we looked at grafts, and I think Mary talked about some of this overall, but just get an idea of what would be optimal, right? So, our minimum requirements is we want something that is roughly about seven centimeters in length. You want something cross-sectional area-wise, collagen-wise, very similar to what you have for the native ACL. BTP can be considered gold standard, right? So, we have our standard 10-millimeter rod tendon strip, two bone blocks, it's flat in the middle, so less collagen overall inside, inter-articularly when compared to the quad tendon. Hamstring can vary from anywhere from one strand to eight strands, however many you want to get into, get that critical size for that patient. There is definitely more collagen and fibroblasts than patellar tendon from a basic science standpoint, but there certainly are some issues with trying to predict the size. And with quad tendon, everything that Mary talked about, so I'm not gonna go over that. So, some of the characteristics you guys have seen, probably some type of slide like this within the literature or within talks, but in general, you're looking at what the native ACL is with regards to, in comparison with a quad graft, patellar tendon versus hamstring. Overall, I would say everything is very similar, anything you look at is always gonna be stronger than what we have for a native ACL. However, you wanna think about how biologically this will integrate. When you look at patellar tendon, you're gonna have bone-to-bone integration. That's gonna be consistent, that's gonna be quick, it's gonna happen within six weeks, right? So when you have that bone-to-bone healing very quickly, you're not gonna get the patient back to play, but certainly you have that integration very fast and you don't have to worry about that. So BTP autograft overall, it's a high load to failure. Again, higher than a native ACL. Within animal models, we look at three weeks if you test the graft, the graft fails at the bone tunnel interface, right? As opposed to six weeks when the graft fails, it's gonna fail within the mid-substance. So we know that this graft is integrated. In general, if you look at the literature, patients will have a higher proportion return to pre-injury level of activity with a potentially low risk of graft failure. Problems is with this is, you know, you have anterior knee pain, you potentially have lost range of motion, there's a risk of patellar fracture, risk of patellar tendonitis, and of course, patellofemoral pain. So a lot more rehab probably goes into rehabbing and recovering from a patellar tendon. So when looking at what, you know, for autograft, so patellar tendon versus hamstring tendon, looking at, we looked at the Scandinavian registry, so 45,000 ACLs, quite a few, right? So 6,000 patellar tendon, 38,000 hamstring tendon, follow-up of three years on average between zero to eight. So revision rate for patellar tendon, still very low. The hazard ratio is 0.63. And you have a decreased risk of revision with as the age increases. So overall, patellar tendon is significantly less risk for revision, and then, but slightly more pronounced in the cutting, twisting, pivoting type sports. So overall, we know that the BTP is a pretty good graft. There's also meta-analysis after meta-analysis. So this is one from 2011, which I would make an argument that this may not be the most up-to-date just because of techniques that might have changed. But overall, we can see that patellar tendon has better Lachman pivot instrument and laxity with, but there is a significant loss of extension for range of motion that's statistically significant, may not necessarily be clinically relevant, but certainly you can see it from a statistical standpoint. And there is a trend towards a loss of extension strength. And again, this is not in comparison to any of the quad tendon, because we've also seen that within the literature too. But hamstring also tends towards loss of flexion, which makes sense, right? Where are you robbing the issue, right? So this is an older meta-analysis. This is a relatively newer meta-analysis. Guess what? Same thing. Patellar tendon, better pivot shift, better return of injury activity. Hamstrings, less pain anteriorly. And less kneeling pain. Surprise, surprise. And then another meta-analysis in 2017. So just kind of going along the years and just kind of revisiting the literature. But out of 47,000 ACLs, 36,000 patellar tendon, 7,800 hamstring. 2.8% re-rupture rate for patellar tendon. 2.84 rupture rate for hamstring. So just a skosh more, right? But overall, both graphs are viable options. Slightly higher rupture rate for hamstring tendons. Within the MOON group, again, some of our best data coming out in terms of a prospective cohort study. Again, if you're not familiar, it's a multi-center consortium. Seven sites, 17 surgeons. Looking at the highest predictive value for revision was the high-grade peroperative laxity. And I think Clay's gonna kind of hopefully address that a little bit. Graph choice. And then age. So odds of ASO revision is two times higher for hamstring as compared to BTB. So overall, BTB still inches out and is in front. So long-term outcomes. We know that out of five prospective studies, looking at graph re-tear rate of the side versus contralateral is relatively similar. Interestingly enough, contralateral's always a little bit higher. But looking at, certainly, yeah, patellar tendon, you will have a little bit higher risk of osteoarthritis present in about a quarter of patients. But this is, again, associated more with medial meniscectomy. And the question is how much that's related to knee pain. So in our case, we have our patient that we decided to go with patellar tendon. He's going back to a cutting, twisting, pivoting sport. This is gold standard. He's a football player. They can rehab anything, because they'll just say, yes, coach, and have no issues with it. So this is kind of what we see in there. So standard, make sure you have anatomic tunnels in a good position. And then this is that radial tear on the lateral side. So now there's a little bit more tools that allow you to do different configurations in terms of how to repair a radial tear or even a kind of intrasubstance tears. At this time, there were some instruments that haven't quite made it. But now I do a little bit more aggressive in terms of my side-to-side repairs for these radial tears. Definitely not weight-bearing him. So in the long term, I can say that, in general, there's good to excellent outcomes with patellar tendon and hamstring tendons with 81% return to sport, 65% return to pre-injury level. Patellar tendon has a high load-to-failure strength and low donor-insight morbidity. But patients potentially do have risk of anterior knee pain and patellar fracture. So, thanks. Thank you. Next, we're going to have Dr. Clay Nolley talking about augmentation in this volleyball player. Thanks, Mary. All right. My disclosures are available online. So this is an 18-year-old female volleyball player. She had a previous ACL, hamstring ACL reconstruction, and then sustained a re-injury, had persistent pain and instability in the knee, unable to run due to instability and pain. Her physical exam shows some notable quadriceps atrophy, positive Lachman's, pretty impressive pivot shift. There's her pivot there, which you can see is a pretty impressive pivot shift, positive McMurray's. She was a hyperextender. She hyperextended about five degrees, maybe even a little bit more than that if you look at that video, and then had pain in both extension and deflection, novaris valgus laxity, negative dial, negative posterior drawer. This is her imaging. And so you can see the button from a previous hamstring ACL reconstruction. Of note, her alignment and coronal plane and her posterior tibial slope are within normal limits. So I know I'm showing a case that's going to be a revision case here, but I'm not going to harp necessarily on the revision nature of this, so to speak. Harris is going to speak a lot more to that next. So I'm going to harp on a little bit more of the factors that maybe went into why she retore and then some of the things that, you know, considerations for both the primary and the revision setting to prevent that. Here's back some more of her pertinent imaging here. So obviously you can see the ACL retear, the middle picture, and the picture on the right you can see a pretty obvious meniscal ramp tear. Here's the first diagnostic. Here's the video. That meniscus looks pretty normal from the front. I'm not going to even pull on it. It looks not too bad. But then Gilchrist maneuver, go through the middle of the knee, and then you can obviously see the very apparent ramp lesion. It's not quite as huge as the chronic ramp lesion that Aaron Critt showed this morning if you guys attended that session, but this is an obvious meniscal capsular separation and a pretty obvious ramp tear that I think was actually missed on her index surgery previously when she had the primary ACL. So here's our problem. Here's what we got. So we have an ACL retear after a previous hamstring autograph, medial ramp lesion. She has hyperextension. She has hyperlaxity. She's got a high-grade pivot shift, and she plays a cutting, pivoting sport. So she's got all the things, right? Like this is our highest risk athlete. This is the athlete that we all worry about when they walk into your clinic, whether it's a primary or revision setting. This is the athlete that we say, man, like what are we going to do here to make sure that this patient can go back to play but doesn't retear again, right? So why augment the ACL? I'll go through this pretty quickly. We all know that there's tons of ACL reconstructions done every year, one of the most common procedures. It's why you're all in this room and why we have a full room for this talk. Retear rates are pretty high, as high as 20%, which is a lot and something. So how do we decrease retear rates? And so there's a lot of things we can do. Appropriate graft choice is one thing. You heard great talks from both Mary and Cassandra, obviously. In this population, you're not going to hear any of us talk about using allograft. I think we're all pretty much on board with that and all understand that. Appropriate rehab, that goes without saying. But then appropriate return to play timing, that's for a different talk or maybe we could even discuss it in the discussion section and question section. But what things can we affect at time zero? So improve knee stability. So that could mean lateral augmentation and that could also mean improved graft construct strength with internal augmentation. So these are things that we can do as surgeons at time zero to potentially decrease our retear rates going forward and when they return to play. So what are we talking about? Well, these are the main options. And some of them you heard today, but I'm going to go into a little bit more in depth on each one. So anterolateral ligament reconstruction, or ALL, lateral extra-articular tenodesis, or LET, and then internal suture augmentation. And you see pictorial versions of each of those on the right side of the screen. So we'll start out with ALL. This is a cadaveric study that looked at both internal translation and, or internal rotation and anterior translation tested through a variety of degrees. And they showed increased laxity when ACL reconstruction alone was done with increased anterior translation, increased internal rotation. But the addition of an anterolateral reconstruction restored those values to near similar values to the intact knee. This is actually a clinical study, a little bit of heterogeneity, but it looks at 11 randomized controlled trials looking at ACL reconstruction alone versus ACL reconstruction plus some form of anterolateral procedure. And obviously different studies looked at different things. But again, long and short of it is, ACL recon plus an anterolateral procedure showed improved pivot shift grades and decreased graft failure rates regardless of the technique for the anterolateral procedure, regardless from the time from injury. So the one thing that they showed was patients undergoing either an LET or an ALL did have increased risk of stiffness and adverse events. So this is something that we have to balance and think about. This is a study, again, a lot of heterogeneity, so I won't go through it line by line. But there were biomechanical studies that showed, again, the same thing that you would, that is a common theme here. So internal rotation and pivot shift is decreased if you add an anterolateral procedure. And then clinically, if you add an anterolateral procedure, the retear rates were decreased from what we showed earlier for primary ACLs alone. In these studies, most of them showed the patient-reported outcomes, however, were relatively similar. So this is a basic anterolateral ligament reconstruction technique. Hopefully the video will play. Can you play that video for me by chance? Can you hit play on that video, just on the picture for me by chance? There we go. So typically you use either a gracilis autograft or allograft for an ALL reconstruction. The initial incision and guide pin is placed just proximal and posterior to lateral epicondyle. You can do this through a larger open approach or you can do this through a relatively minimally invasive approach if you're doing it with a concurrent minimally invasive ACL reconstruction. You basically drill line to line for both the graft and the anchor that you place. There's a number of different techniques that you can do. This technique is going to demonstrate using an anchor. There's now techniques that demonstrate using knotless fixation and utilizing suture anchors. And so there's a variety of techniques that you can utilize to place this graft. Anybody that's done any type of extra-articular reconstruction can be very comfortable with this because that's what it basically is, right? It's an extra-articular ligament reconstruction. But then you make the second incision over Gertie's tubercle, between Gertie's tubercle and the fibular head, about one centimeter below the joint line. Again, drill at this same location. You can usually use fluoro when you first start doing this to confirm your location. Then you tunnel the graft, which you're going to see here shortly. You're going to tunnel the graft distally with a passing suture and then you can check isometry. I usually leave that pin in on the tibia to check isometry. Hopefully that's going to tunnel there for us. And then like I said, you leave that pin in on the tibia to check isometry. And make sure that it's not too tight and the graft's not too tense. And then after that, you're going to drill the tibial socket. And then you'll secure the graft distally, like I said, with various forms of anchors. Typically secure it with the knee in neutral position at approximately 30 degrees of flexion. So you can see us checking isometry there. And then that's pretty straightforward with the anchor. How about lateral extra-articular tenodesis? So this is the stability trial. Most of you are probably familiar with this by this time, but for those of you that aren't, just briefly, it's a multi-center prospective randomized control trial looking at single bundle hamstring ACL reconstruction with or without a modified LaMer LET. So those are the two groups. And it's our patient, right? It's patients less than 25 years old with two or three of the following, grade two pivot shift or higher, high-risk pivoting sports, generalized ligament laxity. So it's our patient. It's the patient we're talking about today, right? This study looked at 618 patients, average age of 18.9 years. Again, right online, our 18-year-old female volleyball player with hyperlaxity. They showed that ACL alone versus ACL plus the addition of a lateral extra-articular tenodesis, the re-rupture rate went down from 11% to 4%, which was statistically significant. The number needed to treat with an LET to prevent one graft re-rupture was 14.3 over two years. So any of you that have a very busy ACL practice, that's like a couple months of patients at most probably. At three months, ACL alone had less pain, but that then equalized at one and two years, so equal outcomes at one and two years. So big study. This is a simple technique for it. This is the technique that we utilize. So again, relatively similar to the ALL. You can make an incision over the lateral epicondyle. You can incise a one-centimeter roughly wide strip of the IT band and the central to posterior one-third of the IT band. I'm using a double-edged scalpel blade, as you can see here. It's the same one that you can actually utilize for a quad tendon harvest or harvest and other things. If I'm doing a quad tendon in an LET, I use the exact same 10-millimeter wide blade for both of them. Aim towards Gertie's tubercle, and then you release the IT band proximally, typically about eight centimeters long is a decent distance that you need to get an appropriate amount of graft for the LET. Then you pass it beneath the lateral collateral ligament. You're going to see us pop it underneath the lateral collateral ligament there. And then you secure it proximal and posterior to the lateral epicondyle. Again, there's all different types of anchors that you can utilize here. We're going to drill and utilize a knotless anchor. That's kind of dealer's choice. Most of the biomechanical studies and the clinical studies are pretty equivocal in terms of what anchor you use. I prefer a knotless anchor because it's usually obviously done in concurrent with an ACL, and I don't have to worry about potential tunnel crisscross or getting into my ACL tunnel when I use a small knotless anchor proximal and posterior. This was, you know something is becoming a hot deal or a big deal any time somebody forms a consensus group that just reviews that, right? So this was the Anterolateral Complex Consensus Group from 2020. And they came up with all kinds of recommendations. But the biggest one and takeaway that's relevant to this case is that there's clinical evidence lacking clear indications. But for a lateral extraticular procedures, it may be indicated in the setting of a revision ACL, high-grade pivot shift, generalized ligament laxity or genuine recurvatum, and young patients returning to pivot activities. So our patient here is 4 for 4 there. So you can guess what we're going to do here in just a little bit. How about augmenting the graft itself? And so there were some good talks. S. Sherman gave a good talk kind of about some of the background on that, but I'll go into a little bit more detail. This was a study done by one of my mentors, Pat Smith, just looking at different size of suture tape reinforcements. So looking at small, which he classified as 8 millimeter, and standard or 9 millimeter grafts with and without internal suture augmentation, eight specimens in each group. This was a biomechanical study, again, placed loads at 250 or 400. And they showed that with suture tape, it significantly decreased dynamic elongation, both in the small diameter at about 38% and the larger diameter graft by about 50%, versus the standard, excuse me, at each of those loads in the small diameter, 38% and 50%. And then for the standard diameter or the 9 millimeter graft, a little bit less, 15% and 26%. But they still showed reduced elongation and higher ultimate load failure, particularly in the smaller grafts, so the 8 millimeter grafts. This is a study looking at with BTB. This is Matt Matava out of Wash U in St. Louis. So they did eight standard ACL BTBs and then eight with suture tape. They did cyclic loading through a variety of loading for over 500 cycles. They showed no difference in graft displacement between groups, but the one with the internal suture augmented had 104% higher stiffness and then a 57% higher load to failure. So they concluded in vivo that the augmentation increased graft construct strength and stiffness. And then how about an outcome study? This is 40 augmented versus 40 non-augmented with internal suture, roughly the same age. The re-tear rate with the augmented was 5% versus the non-augmented was 17.5%, so significantly higher in this case. Relatively low numbers, but still a pretty significant statistical difference. The Tegner levels were actually a little bit higher for the augmented and no difference in other outcomes. One more study, this again has one with a little bit of heterogeneity, but again the biomechanical portion of this is a theme that obviously you're already seeing, so the studies that had graphs that were augmented overall performed better with load to failure, reduced elongation and at different loads, and then relatively similar patient-reported outcomes overall with minimal difference in complications and graph failure. So what's the rationale for internal suture augmentation? It's not an artificial ligament. There's really minimal stress shielding of the graph. For those of you that have been through the iteration of ACL reconstruction for many years, it's different than putting in like the old school Gore-Tex or something like that or some of the things that were tried to be put in in the early 90s. It's not replacing the ACL, it's not replacing the ligament, it's independent of the graft itself and it's load sharing, and so you think of it as a seatbelt, the seatbelt concept where it's there to just kind of help support the graft and give you improved graft support. The reality of it is we still need more clinical data and a lot of that is forthcoming. This is kind of how it's done. You can loop the suture through the femoral cortical button or through the bone plug, whether you're doing BTB or suspensory fixation or around the graft. It can then be sutured to the graft or it can remain independent and then you can pass and secure it on the femoral side with whatever technique you typically like to use for securing the femoral fixation of your graft based on what you're using, and then you can secure the tibial side of the graft again as normal or you can put it into an anchor. And then you typically secure the tibial side independently. I will typically use a suture anchor independent of the ACL fixation, and so then that's what the graft looks like kind of coming through the knee. So indications for ACL reconstruction augmentation, either ALL or LET, high risk patients, hyperlaxity or high grade pivot shift, cutting, pivoting, twisting, sporter activity, revisions in a young patient. For ALL specifically, probably if they've had a previous lateral sided surgery or they've had any sort of IT band injury or disruption, maybe they should be used in most primary ACLs, especially young patients. The Stability 2 trial is going to give us a little bit more information on quad ACLs and BTB ACLs, not just hamstrings, but there's a lot of people advocating for that already. How about for internal suture augmentation? I use it for every single allograft ACL reconstruction, which is a pretty small percentage in my practice in particular, but for every single one of those, revisions is potentially a role. Small grafts, as that biomechanical study showed, so if you have a small gymnast or a small patient, you're going to get maybe a less than 8 millimeter soft tissue graft. Primary ACLs in high risk patients with a soft tissue graft, so if quad is your primary graft or hamstrings is your primary graft, maybe a consideration, and there's a number of studies that show that maybe it should be used in those soft tissue grafts. That's kind of trending, but further studies are needed. And then again, the question, should we be doing this particular augmentation in most primary ACLs, particularly with soft tissue grafts and particularly in high risk patients? That's kind of coming from a clinical standpoint. So that's kind of the video of kind of, again, that final ACL with internal suture augmentation going through range of motion there, and you can see it kind of coming up into the notch with the suture augmentation adjacent to it, independent to the graft fixation. So here's our case again. So coming back to our case, so she had a meniscal ramp tear, so we're going to fix that. Can you play that video for me? These should all be videos. Click on that picture for me. Back there in the back. AV. It's on Facebook. Yeah, thanks. Appreciate it. Sorry to take you away from the social media. I'm just kidding. So a meniscal ramp repair, so we did a combination of all inside, you can see the all inside stitch here to the capsule, and then also coming from a posterior medial portal. Can you play that one for me too, please? Sorry, I don't know why these ones aren't playing, but go ahead and click on that one for me too, please, so I can just move it through. So this is one coming from the posterior medial portal where we did kind of a crosshatch stitch and then actually tied that off to the posterior capsule through a posterior medial portal, and then that's what the final repair looks like. That's a video too, but so you can see us probing the final ramp repair, but that's not the primary part of this talk, so I'll keep moving. We did a quad ACL recon. She had had a hamstring before. We did a quad ACL recon with internal suture augmentation, so that's what it looks like going into the knee. I'll just keep moving. That's what the graph looks like with the ACL, and then you saw the video. I think that's a video too, but it's the same one from before, and then I showed the lateral extraticular tenodesis technique. I think I showed a number of the step-by-steps of this here too, but we'll just keep moving through that because I showed that technique earlier. Okay. So here she is two weeks post-op, so this is what the incisions look like, so this is a revision ACL with quad and LET. This is what her incisions look like two weeks post-op. I think you're going to have to play that video for me. Last one, I promise, sorry. And then this is her six months post-op after this, and so doing a jump test, so you can see she's still got a little bit of quadriceps atrophy, so she was not ready to return to play yet after a revision ACL, but you can see that the incisions look like healed up and looks like pretty well, so she went back to playing volleyball at about ten months, nine and a half months or so. So that's it. Thank you. And then rounding out the discussion, Dr. Harris-Sloan from MUSC talking about revision ACL. All right. Thank you guys very much for coming. Here are my disclosures, none relevant to this talk. So 22-year-old female basketball player, history of bilateral knee ACL reconstruction, presented with right knee pain after a non-contact injury, noted pain and instability. Previous ACLs were hamstring on both sides. On exam, she had full range of motion at this point, grade 2 B lock and grade 2 pivot. No significant dial, and so anytime someone comes in with a re-tear of an ACL, I think really scrutinizing the posterolateral corner is extraordinarily important to make sure you do not have a missed posterolateral corner injury if this patient did not have a significant amount of knee laxity or recrivotum. So here you can see the x-rays. So I think the tunnels to me seem relatively well positioned. The posterior tibial slope on this patient was at 10 degrees, so not high, but I would say sort of the upper limit of normal. And then on any revision case, I think getting long leg x-rays is probably a good idea to ensure that there's no unrecognized malalignment. Here are the MRIs, if we could just play the videos. Basically this, these MRIs are, come on, click on the video for me, champ, thanks. The MRI show really no significant tunnel dilation, and I think, again, the tunnels are relatively well positioned. She has a medial meniscus ramp lesion and a lateral meniscus tear as well, and then the one video on the right, that'd be awesome, sorry, last video, thanks. Again, no significant tunnel dilation. So for me, I did not order a CT scan in this patient because I felt relatively comfortable with tunnel position and size based off the MRI plane radiographs. So in summary, we have a 22-year-old with a current ACL tear. She has significant risk factors, her age, her gender, her sport, borderline high posterior tibial slope, two previous ACL reconstructions, one on the affected side and one now on the other side, and medial and lateral meniscal pathology. So the questions that we really need to ask ourself is, can we do this in a single stage or do we need to stage it, what's our graft choice, do we need to do something other than just our standard ACL, do we do an osteotomy in this patient, and then some postoperative considerations. So we're going to put this patient in a brace, both immediately post-op or as time to return to sport comes. This is actually what we did, so I'm going to talk about my case, then I'm going to talk about some of the literature about what we know about these topics. So this patient had a medial meniscus tear, she sort of had a ramp lesion as well as a sort of more central tear, and I think if you can save the meniscus, you should always try, especially in the revision setting, because that is going to provide a lot of stability and support to your ACL graft. So that was the medial side, this is the lateral side, we fixed both, both were done in an all-inside fashion. And then in this case, I think any time you're approaching a revision case, it's a good idea to drill the tunnels first to make sure you don't need to stage, unless you're 100% certain that you're going to do it in a single stage. I almost always drill tunnels first, so in this case, we were able to retro drill her femoral tunnel and then her tibial tunnel, and I liked our tunnel position, I had good circumferential bleeding bone, I didn't think that the tunnels were malpositioned or significantly dilated. So at that point, I went and harvested my graft and I chose to use a quad tendon graft in this case. I do it through a minimally invasive approach, there's a video on the right. So again, I like to use this quadriceps harvester, but there's again a lot of different options that you can use to harvest a quad in a minimally invasive fashion, or you can do it just through an open incision if you prefer. But I think this gives you a nice, really predictable graft that for me has been very effective. And this was sort of our final construct in this case, I elected to augment with suture augmentation and also do a lateral extra-articular tenodesis, and I'm going to talk about some of the science and some of the gaps in the science that exist around treating this type of patient in a revision ACL. And here's our sort of final construct. So this study really I think brought to light a lot of, or changed the practice I think for many. When I was a resident 10, 11, 12 years ago, a lot of people kind of picked allograft as their primary graft of choice in a revision setting, and I think this study really changed the way we think about it. This study looked at over 1,200 patients and showed that an autograft revision ACL resulted in a much lower risk of failure by 3X. So a significant risk reduction in recurrent tear. The key with revision ACLs is we know that revision ACLs don't have as good of outcomes as primaries, and a multiple revision ACL is really disastrous. The return to support rates following multiply revised ACL are very low. This study, again, over 3,000 patients with a relatively young mean age, higher return to support with autograft, improved knee laxity with autograft, lower retear rate with autograft. So again, just more data to support that we should probably be using autograft in a revision setting. Now is one autograft better than the other? This was a study that looked at quad versus hamstring versus patella tendon in the revision setting, relatively small numbers, similar PROs, but you can see that at least in this patient population the hamstrings had a higher rate of retear. Quad tendon, I think, for revision is relatively newer. This was a study that we did looking at over 606 patients, was a systematic review and meta-analysis. We compared quad to hamstring, quad to BTB, and then quad to both hamstring and BTB. And basically we found no difference in retear rates and similar patient-reported outcomes. So this is a study, I think some people who use quads use them selectively, and they say, for my cutting and pivoting athletes, I still like to use BTB. And I think that's totally fine. I don't think there's anything wrong with that. And I think we're learning more as time goes by and more studies. So this was a study looking at that high-risk population, cutting, twisting, pivoting athlete, compared quad to BTB. And again, relatively small study, but no difference in return to support rate, no significant difference in the retear rate, although there was zero in the quad group. And again, another sort of similar study, quad tendon, soccer players are the worst patient you can have, right? Young female soccer player, five-year follow-up, again, no significant difference in the retear rate, similar PROs. But again, really small studies. I don't think we know the answer to this question yet. So what about lateral extraticular tenodesis? This is sort of Dr. Getgood, sort of Mr. LET, I love that he published this study. So LET in this patient population didn't actually reduce the risk of retear in the revision setting. Relatively small study, only 74 patients, but they didn't notice a difference in the retear rate, whether you added an LET to revision or not. And no significant difference in patient-reported outcomes either. I suspect that study was probably underpowered. There have been some other studies that have shown that a lateral extraticular procedure does reduce the risk of retear in the revision setting, and this is one of the studies. So almost 800 patients, again, augmentation group. And this is either an ALL or an LET, so I don't think we know does it matter, is one better than the other. I think probably just controlling rotation from the lateral side is really what we're talking about. But augmentation group had better IKDCs, better rotational stability, better translational stability, and lower risk of failure. This was a study from the Santee group, and they looked at, you know, hamstring grafts with an ALL versus a BTB with an LET. So sort of two variables in each group, but again, no difference in retear rates, no difference in laxity, no difference in return to support. There's very little data, despite sort of my case and Clay's case, to support the use of suture tape in the revision setting. I think there's a growing body of evidence to support it in the primary setting, although I still think there's a lot to be learned. My rationale for using it in this case is I don't want this patient to retear again, because again, the multiply revision, multiply revised ACL is not a happy patient in general. So I think there's probably little downside, and it might help. So my sort of strategy, especially in the last one to two years, has been to sort of throw everything at the revised, the revision ACL to reduce the potential risk for injury. But I really can't say there's good data, at least I have found in my literature search, to support the use of suture tape in the revision setting. I always get asked, what about a quad for revision after someone's had a primary patellar tendon? Does a second hit to the extensor mechanism result in a weaker quad? We looked at this in patients who previously had a patellar tendon autographed, and those who had a hamstring autographed, and then went on to have a retear and were revised with quad. And when we looked at their isokinetic testing at six and 12 months, there was no real significant difference in extensor mechanism function. So I don't, you know, this was a relatively small study, but I think I feel relatively comfortable in taking another piece of the extensor mechanism. I don't really care if they previously had a VTB. I'm happy still doing a quad or vice versa if I need to. And then let's talk a little bit about rehabilitation. So this was a really interesting study from the MARS group, 843 patients. I think for me, I don't generally brace most of my primary ACLs, and I'm a little quicker to do it in the revision setting. And I still use braces, especially if I have medial and lateral meniscal pathology or a big meniscus tear. But in this study, in isolated revision ACL reconstruction, postoperative bracing actually resulted in slightly worse outcomes, higher association with additional surgery, and functional bracing for return to sport resulted in slightly better outcomes with a sort of questionable decrease in retear rate. So the sort of takeaways for me from this study are early weight bearing, early range of motion, no brace is probably okay in the revision setting, and may actually be beneficial. Thank you very much. Let's see if this actually works. Can you, oh, there we go. You guys hear me? We're happy to take any questions from the floor, too. Go ahead. And there's a microphone back there, too, if you guys don't mind using it so everybody can hear. Thank you so much. And thank you all for being here. We appreciate this. All right, can you hear me? Can you hear me? Okay. We can hear you. So since we don't have any long-term data yet on LET procedures or the lateral procedures or suture tape augmentation, my concern is that in some of these patients we might be over-constraining the joint, and long-term we might be putting them at a higher risk of osteoarthritis. So I'm just wondering among the panel members if you guys are concerned about that, and just in general what your thoughts are. Thank you for that question, and I guess just to, for a little bit more information before diving into that, just starting with Clay and moving down, how often are you using internal brace just in a primary setting? And then Cassandra and Chris. Internal suture very rarely in the primary setting still. I'm waiting for a little bit more clinical data. LET in the high-risk patient in the primary setting, which in our institution or country is usually a female soccer or female basketball player. And I use LET primarily, not ALL, and I'll go into more detail after they say it to answer your question. I don't use suture augmentation. Again, I'm waiting for all the data, and I'm just not convinced that it really does that much difference. And I am concerned about load, you know, everyone says load sharing. I wonder if that's more of like shielding, so that's why I'm still kind of waiting for some more data. When it comes to LET, again, based off of the stability trial, I will use it on my high-risk females for primary, those ones that have really big pivots, the ones that are that young gymnast athlete who wants to go back to something that's not exactly, it's pretty high intensity. That being said, I absolutely share the same question about LET. I mean, we've done, this is all in our literature, actually, from like 34 years back. Nothing's changed. The modified lemur is still a modified lemur, right? So we know that there was some over-constraint, and I don't, especially when patients who have lateral meniscus tears, lateral chondral lesions, I'm really hesitant to do anything on the lateral side. As a follow-up to that, though, I think if you're trying to look at the old data on the modified lemurs from, you know, what we did years ago, we're not doing the ACL the same way. I mean, most people used a trans-tibial technique back then, which was going to over-constraint the joint anyway. So I just wanted to point that out. And a lot of those were the primary surgery, right? So this is augmenting in ACL as well. So I think they're very different. So I probably do an LET on about 20% of patients. I do have significant concerns if there's an irreparable lateral meniscus tear. I've been using suture tape augmentation more often, I would say, over the last year. I think a couple of things that are absolutely critical, though, if you're going to augment with suture tape, it has to be independent, and you need to fix the suture tape in full terminal knee hyperextension, okay, to not over-constrain the knee. And the last thing I do is tension the graft. I like to do it all inside. But if you tension the graft last, and you fix the knee in maximal hyperextension, put the knee in max hyperextension, fix the suture tape, the ACL gets longer as you go into knee extension. So as you flex the knee, that suture tape, if you've done it correctly, should get more lax. And so then I'll put the knee in a neutral position and tension my ACL. So the ACL should feel tension first. I was part of the anterolateral complex consensus study, and we met for three days in London. And we could, we went through the literature, we could find no evidence of over-constraint. Everyone says that, but there's been, if you go in the literature and look, you just won't find it. So that was our conclusion, that that was not a contraindication. And just to piggyback that, thank you for saying that. I appreciate that addition. I think that's one of the reasons. So I primarily will use a lateral extraticular tinnitus, so like a modified LMAIR, just like I showed in the talk, and over an ALL, generally speaking, because I have the same concern as you, though. I think leaving the IT band intact distally, and then putting it as an onlay on the, you know, just proximal and posterior on the lateral firmacondyle, I just think there's less chance of it versus putting an allograft in there where, you know, we think we're in the right position, or we think that we're pretty slick with it, doing it minimally invasive, but is the tension exactly what we know it is, or what we think it is, if we're all being honest with ourselves, right? So I just think, you know, we're all human, and so no matter how many you've done or how slick any of the techniques are, I think the LAT has less room for human error. And so that's why that's my particular lateral extraticular procedure of choice, because I don't think I'm going to, I think there's less chance I'm going to over-constrain the lateral compartment. But that's a question that everybody always asks, and I'll get good, or some of the other people's answer is, we don't 100% know, none of the studies have shown it yet, but we don't have 20-year follow-up data yet to have those radiographs 20 years from now and see what those patients' knees look like. But it's a risk profile, right? So the 18-year-old female volleyball player that I showed that already had an ACL tear, or the one that, like, Harris showed, and now you're talking about a revision, like, do you want that patient to have a higher risk of re-tearing yet again? Because you know they're going to go back and play. You know they're going to go back and do something, right? So you want to risk another re-tear, or do you want to risk them possibly having a little bit of over-constraint and maybe getting arthritis at age 50 instead of age 60? I don't know. I'm not saying that that's the right answer, but I know I treat a lot of athletes, and if I give the athlete that choice and that option, we all know what they're going to choose every day of the week, right? Like, get me back out there and don't let me tear my ACL again. And so I'm not saying it's 100% the right answer, but it's a risk-benefit profile that I think we all try and balance every day, right? Yeah, I agree with those comments. And just adding, I mean, I'm not using suture tape augmentation regularly. I think there's some data to show that it doesn't seem to be worse, but I just don't know that there's data to say that it's a lot better. So I'm not currently doing that in my practice. And for LET, I'll do it in a revision setting for sure. And then I think in these very, very high-risk athletes, it's really appropriate and there's good data to support that. And also, stability one really clearly supports doing LET with hamstring autograft in the primary setting. I do think we should, there's actually a pretty good body, growing body of evidence to support suture tape augmentation, and I don't know if this is going to turn out to be true long term. And most of it's come from Pat Smith. I think he was a special interest in looking at this, but he looked at his hamstrings that had a lower risk of re-tear, it was like 2% versus I think it was like 10%. His quads had a lower risk of re-tear, his BTBs had a lower risk of re-tear. So I mean, he's not the only one that's shown that. But that's also sort of what he does, right? So if anyone's interested, there's a podcast that we just did talking about his suture tape augmentation. And I think it's very interesting. He studied it first in the lab in dogs, ensuring that there was no reactive synovitis, then he did the biomechanical studies, then he went on to clinical studies. So it was a very thoughtful approach to looking at this problem. We don't know yet, but I would say, I find it interesting that a lot of the people on the panel earlier this morning were using suture tape augmentation. So I especially think in the high risk patient, there's probably little downside. If you put it in independently, it shouldn't stress shield the graft, but we just don't know. I agree, it's something that we will have to study in the future. I'll just play devil's advocate on the flip side of the coin. I showed a case where I did it, and I used it, and I've done it in, like I said, in revision settings and even some high risk primary settings. I'll just caution you, just like any new technology that we have or any new thing, it's not the end all to be all, right? The key, as we all know, is still doing a really good, well done ACL reconstruction, putting your tunnels in the right place, whether you use quad, whether you use BTB, whether you augment it laterally or not, the root of all this is our ACL reconstruction, right? And so that's the primary factor that's gonna decrease your revision rate, is doing a really well done ACL reconstruction, and then all these other factors. And so definitely just don't add suture tape and do internal suture tape with every ACL, thinking that your re-tear rate's just gonna go down just because you put some 1.8 millimeter tape in the middle of the knee with it. I mean, I showed a lot of the studies that show great biomechanical data, and I think there's definitely something to be to that, and I think there's a lot of promise there, and like I said, I've done it, so I'm speaking full transparency here, I use it. But the person that he just mentioned, I'm in the same town, and he doesn't see his revisions, I do, and so I've had to revise some of those cases with internal suture in them, so I'm just being honest. And so I've revised those cases, and so they do re-tear still, and so it's not the end all to be all, and so I know we show all these new techniques and some of these different ways of doing it, and we're all hopeful that these things will help us, but the key is doing a really well done ACL reconstruction, and then figuring out what things we need to augment it with, you know, with these difficult cases. Out of curiosity, though, what do the revisions look like? What happens to that tape? Is it there? It's still there, so the graft usually is gone, and the tape is still in the middle of the knee, and it's loose, and it's lax, and it takes the shaver and the biters like 20 minutes just to cut it out, because it is pretty solid, I mean, it's pretty good material, and it makes the revision painful, because it's all, you know, I have to cut all this out, tape out in the middle of the knee and stuff, just like any other revision, I guess, with a ton of suture, but yeah, usually the graft is there, and the tape, I mean, the graft is gone, and the tape is still there, so I guess it gives it a little bit of credence. I think it's very hard to control where it goes. And I try and not fight it. Sometimes I'll try. If all things were equal, I'd prefer it to be behind the ACL. It's nice in the picture when it's for the front when you're trying to show what you did. But I think sometimes I'll try and shimmy it towards the back. But I don't think it probably matters. Yeah, same thing. So I try and put it posterior. I think everybody tries to, just makes your pictures look prettier, if nothing else right now. That's what really matters. Potentially decrease on the risk of graft shielding, like Cassandra talked about earlier. So try and put it posterior. We've tried different things to make that happen. You can put a little suture right at the top corner of the graft and suture it into the top corner of the graft. Depending on what graft you're using, if it's a BTB or an all soft tissue, you can suture it as it comes through. The reality of it is, any technique you're using as you're pulling the graft up and in, sometimes it turns, it twists, and things like that. So it's not always easy to get it perfect behind the graft. And then once it's in, you can try and push it behind before you fix it distally on the tibia and things like that. So I think most people try to get it posteriorly. Nobody's shown clinically that it makes much of a difference. But again, we don't have the long term data on that. So I don't know for sure. Yeah, well, I don't know if that's a good question. Oh, I can take that. I mean, I've had quads re-rupture. I'm not the only one up here that has complications, right? No, no, you're not alone. I know, I was going to say, I don't look like I'm the only one that has ACL complications up here, but it has to do all these extra things. So I've done two contralateral quads, one in a patient that had a previous quad and a previous BTB, and then one in a patient that had a previous BTB but didn't want anything done to their ipsilateral knee. I've done contralateral BTB, not primarily like Shelbourne does and all that data. But yeah, and so I'm not afraid to go to the other knee. It's not my primary choice or ideal choice, I don't think, for most of us. But I wouldn't be afraid to go to the other knee. And then Harris pointed out a good question, too, or a good point, too, for anyone that missed it. People, a lot of times, question about using a quad if they've had a previous BTB in the ipsilateral knee. And what does that do to the patellofemoral contact pressure or patellofemoral mechanics? And I don't have any hesitation for using it, especially when you're talking about using an all soft tissue quad. I would have a hesitation in taking a bone plug again from the patella, as we could all surmise. But I don't have any hesitation in taking a quad graft again, even if it had an ipsilateral BTB. But to your first part of your question, and I'll be done here in a second, if they had a previous primary quad, my revision graft is now a BTB. So it's funny how things just kind of twist over time. Like, when I was in training, I learned almost nothing but hamstring ACLs, like quadrupled hamstring ACLs, and then BTBs and contact athletes. That's all we did. In my first few years of practice, that's what I did. And then now it's kind of shifted, right? And so now my primary graft is a quad for a quad ACL. And then my revision graft is BTB with bone and quite a bit of bone. I take quite a bit of bone, because I want to feel, especially if I'm doing it in a single stage revision. And then I almost do no hamstrings. So I think BTB is my revision graft, but I wouldn't have any hesitation to go into the opposite knee. I had a patient once who had a partial patellar tendon rupture. And she also had an ACL tear. She had a meniscus tear. And this was maybe five or six years ago. And at that point, it wasn't clear whether we could really do quad autograft in that patient. So we ended up not. We ended up using an allograft, actually. But now, based on everything we've seen in the literature and this discussion just supporting that, I would have no hesitation to use quad autograft in that patient, for sure. And I wouldn't hesitate to go to the contralateral knee either in a patient who's already had the ipsilateral quad autograft harvested. But I haven't faced that situation often. from our fans, that kind of thing, does that change your algorithm at all, or does that just make them higher risk and you keep your algorithm as is? Yeah, yes, the answer is yes. I think in that sense, it goes back to the physical exam, right, so even if they have EDS of some sort, right, if they have an explosive pivot, you're probably gonna try to do some kind of extra something, right, whatever dealer's choice at this point, right, suture tape versus an LAT or whatnot. I mean, I think for those, some hyperextensible, just slightly hyperextensible, slightly, a little bit loose females will probably go more towards a patellar tendon, just because you get that bone-to-bone healing, you know that's gonna happen quickly. We've seen, I mean, hamstrings are, they're not dead yet in this country, but they're heading that direction, right, but putting a hamstring in, that takes a lot longer for that to incorporate, so whatever that is in their lust and in their biology doesn't allow that tissue to incorporate quickly or it will stretch out, so then you put the argument in is that when you put the suture tape augmentation, do you put some scaffolding in there, right, there's new products out there that with very, very little data, right, about putting some kind of scaffold augmentation with your kind of soft tissue graft, but in general, I think I tend more towards a BTV just because I know that bone-to-bone healing is pretty consistent and that enthesis is already set up, right, if you think of, so I think of, I'm a basic scientist, so when I think back to like how tissue incorporates, the Sharpie fibers, that's already there, it's set up for a patellar tendon as opposed to any other soft tissue-to-bone healing that takes longer, therefore, that's probably why it stretches out a little bit more. She's anti-anginal suture. Good question, I would add an LET. I would, yeah, I would just. I would do both. I would just echo what she said, for me, so for that exact patient, that algorithm is gonna make me actually lean more towards doing a BTV and trying to get bony fixation, aperture fixation versus soft tissue. We'd do an LET, too. I would do an LET, but the other thing that I usually do, so especially with soft tissue grafts, but any grafts, I'll actually try and like, I'm sure most of you do the same, we'll fix them in hyperextension or whatever their native extension is, right, and Harris alluded to this in his revision talk, fix them in hyperextension. Well, in that particular patient, in that case, that's like the one case where I won't necessarily try and go to like 15 degrees of hyperextension and actually fix them in more closer to neutral. Sometimes it feels different to them, right, because they've been hyperextenders and hyperlaxed all their life, but at least, hopefully, it takes a little bit of strain off of your graft and hopefully, I mean, I don't have data that says this, but it decreases the revision chances or the re-tear rate, I should say, by taking a little bit less strain off your graft with their native like crazy hyperextension. I put a very similar case on Doc Matter, probably like three or so years ago, and on the patient's standing alignment x-rays, she actually gapped like two centimeters on her lateral side, on both sides. Like I got stress x-rays and both were just like, like she had a completely blown apart post-lateral corner, totally normal post-lateral corner and symmetric on both sides on imaging, right, and on stress x-ray. And on that patient, it was interesting because I got so many different responses about what to do, because I don't think anyone knows. Some people said, oh, you gotta use an allograft because her own tissue is pathologic. Some people said, oh, you gotta do a BTP because you need, you know, aperture fixation, suspensory bone-to-bone healing. I just don't think we know. I think, so what I did is a quad with an internal brace. That was the first internal brace I ever did on a primary, maybe the first internal brace ever. And then an LET also. So far, so good. Diego. Thanks. Has anything changed with the use of the internal brace and the augmentation LET with rehab process and return to play in your perspective? I don't think that it does anything to change my rehab. I don't rehab them any faster. I don't do anything different. It's not a superhuman ACL. It's just a seatbelt. And so you don't drive a car faster because you got a seatbelt on. So no, I don't do anything different at all. I will say they, I don't change the rehab at all. The ACL still dictates the rehab like it usually does in those things. I will say they have more pain, especially if you do a decent size incision or anything, things like that, the first time you do it or a larger dissection. So they do have some more lateral sided pain initially. So you have to kind of try to manage that or mitigate that because you don't want them to not move their knee because they hurt more in that first week or two, you want them to keep it moving and get it moving right away. So that's been my experience is that they do have more pain, which a couple of the studies have shown too. But as long as you can mitigate that, then the rehab protocol stays the same. Yeah, I agree. I don't change my post-op rehab either. I have a quick question for the other faculty too. Just brace, immediate post-op. I mean, Harris touched on this a little bit in your talk, but like immediately post-op, are you using any type of pinch brace, like in that first period for quad inhibition or anything, are you using any type of brace? Only for meniscal pathology. Only for meniscal pathology. I brace still every ACL, but not because they need a brace, but it's because our Missouri patients don't pay attention and they won't like keep their knees straight. And so I brace them for the first week just to make sure and they'll keep their knees straight when they're sleeping or when they're moving around and things like that. So just so they keep their extension, but it's completely unlocked when they're doing activities and then comes off when they do PT. So just to make sure they keep their full extension, not because they need it for stability. Yeah, I use a brace immediately post-op just to help with ambulation. Like they keep it locked in extension when they're weight bearing, but when they're working with physical therapy, I have them take the brace off completely. They can take it off at night if they want, but I'll use it for a short period of time immediately post-op. Some other questions? The panel's thought on the use of the vancomycin wrap. I'm not doing it routinely. I mean, there's some good evidence in literature to say it can be beneficial. Fortunately, the risk of infection is so low, but yeah, it's not something I've incorporated routinely. Yeah, I do it. I mean, there was obviously the very huge study that showed the relative risk over a certain large population that won whatever award it won, I forgot, the Donahue, I think, or something like that. But anyway, so yeah, I just take one gram, mix it up with saline and put it on a sponge and then soak the graft after it's prepped for a short period of time. I don't know that it makes a difference. Luckily, fortunately, I haven't had infections either before or after doing that recently. And so I do it because that's what the literature says, but I don't know that you necessarily. Haven't incorporated it yet, but certainly continue to watch the literature, so. I do use it. I think the downside's probably pretty low. I think a lot of it probably gets flushed out when you fill the knee back up with water anyway, but I think the risk is pretty low. Yeah, I mean, the downsides would be cost. And then some people ask about, does it degrade the graft or does it decrease the biomechanical structure of the graft, which that's been proven that it's not the case and it doesn't do that. So then it just becomes whether or not you feel like it justifies the cost or not to add another gram of vancomycin to whatever the surgical costs of your case are. Great, well, excellent discussion. Thank you guys so much. And if you have any other questions, please don't hesitate to reach out, but we really appreciate you being here. Thank you. Good job.

ACL reconstruction

augmentations

BTB

quad autograft

graft selection factors

harvesting techniques

vascular anatomy

biomechanical studies

lateral augmentation procedures

internal suture augmentation

re-tear rates