Okay. Good morning. Oh, hey, everybody. Thank you so much for being here first thing this morning. Sorry that I'm sort of losing my voice. This is from singing last night. I do enjoy singing. Anyway, but we're excited to talk about optimizing ACL reconstruction, a case-based approach. I'm going to just introduce our faculty. So we have Dr. Cassandra Lee from UC Davis. She's Chief of Sports Medicine, Professor in the Department of Orthopedic Surgery, and she is the team physician for the Sacramento Republic Football Club, the men's soccer team there. And she's going to be speaking about no question, BTB is the gold standard for ACL reconstruction. Myself, I'm at Loyola in Chicago. I'm the Director for our Women's Sports Medicine Program and Chief of Sports there. I help take care of Loyola University Chicago, and I'm going to be focusing on quad autograph is reliable and reproducible. Then we have Dr. Clay Nully, who's an Associate Professor in the Department of Orthopedic Surgery at the University of Missouri. He's the Director of the Mizzou Joint Preservation Center and an Associate Head Team Physician and Primary Surgeon for Mizzou football, soccer, softball, tennis, and swimming. He's also an Associate Editor for the Arthroscopy Journal. Clay will speak about ACL reconstruction and a female volleyball player, or if he changed that case, that's fine. These patients always need some type of augmentation. And then Dr. Harris Sloan, who's Chief of Sports at MUSC. He's an Associate Professor in the Department of Orthopedic Surgery and Head Team Physician for the College of Charleston and the Charleston Battery. And he's going to be focusing on a re-tear of prior ACL reconstruction. So we'll bring up Dr. Lee. I need something, that's okay. All righty, well good morning everyone. So, ACLs, that's what we're talking about this morning. I think I have the easiest task of this morning to talk about BTBs, because it is a gold standard. No questions asked, or whatever. I guess you do have questions, but we'll see. All right, so I'm gonna introduce my patient. So, I have a 20 year old football player. He's a D1 running back. He has a non-contact injury during game, right? Exam, you know, we're here for ACLs, so obviously you can see some of an ACL. Full range of motion. You see him on the field as after the injury happened, so the effusion is growing right in front of your eyes. There, he does have Lachman 2B. He has a regular pivot shift, nothing explosive, just regular, straightforward, two plus pivot shift. MRI. Yeah, one day I'm gonna figure out how to slow these things down, sorry. Take my word for it, there's an ACL tear, there's a lateral meniscus tear. So, just enter into the radial lateral meniscus tear at the body, not at the posterior horn. So, not a risk for variant or whatnot. So, questions are now treatment options, right? He's got a couple years left in eligibility. He thinks he's gonna go to the pros. So, now we're talking what kind of graft options. I think this is not debatable at this point in terms of autograft versus allograft. The question is which autograft you choose, right? So, today we're gonna be talking about different graft options, right? I don't think hamstring is dead yet in this country, but certainly it seems like we have a little bit of bias against hamstring. That being said, I think within my own practice, I feel like hamstring is making a little bit of a kind of resurgence back up. So, we'll see. I mean, I think the pendulum keeps on swinging every couple years, but I think as we get more data as we go along, it's worthwhile to kind of consider and revisit, but this talk is about BTBs. So, we'll talk about what we can do. And again, the panel will talk about different things about augmentation, scaffolds, sutures, and anything else you wanna add to the slides. You wanna add belts and suspenders. So, the idea is then what do we do with the meniscus, right? We know that the meniscus are critical to our stability for our ACLs, right? They are really important for secondary stabilizers, and it does have an effect on the stress that your graft sees. So, certainly you wanna be fairly aggressive about repairing any meniscus tears if you can. And your best shot at potentially repairing a meniscus is gonna be at the time of your ACL, right? Because you have a huge amount of bone marrow and all those healing factors within the joint. So, go for it. If it is even a little questionable, they're young, probably go for it, especially on the lateral side. It tends to be much more, it has a little bit higher healing rate than the medial side. So, the question is how do we look in terms of short-term outcomes and long-term outcomes, right? I think a lot of times when you see your football players, they'll have that inherent bias of seeing whoever they have on their team, and they'll see like, well, I'll have what they have, right? Or even your trainers and your coaches will have some kind of inherent biases. So, as I mentioned earlier, allograft is not really a great option. We know that from the moon data, right? So, there's repeated study after study showing that allograft in this age group, in our highest risk age group of patients who are going to go back to high level of activity, cutting, twisting, pivoting sports, allograft is not your answer. So, then in terms of looking at graft requirements, so what do we want from a graft? How do we recreate the ACL, right? Because the whole point is how do you build a better mousetrap, how do you create and recreate the anatomy, right? So, our wish list is we want something at least seven centimeters in length. You want something that kind of matches the cross-section of the ACL, right? It's tough, the ACL is not really a true circular cylindrical bundle, right? It has, it's a different shape. It can't be ribbon, it can be multiply described. So, I think BTP is considered the gold standard. You know, we have a 10 millimeter wide tendon strip, we have two bone blocks. It is flat, there's less collagen fibers at the quad tendon, again, I'm not gonna try to steal the thunder from my panel here, but I mean, I think it's the gold standard. We have bone-to-bone healing, it heals reliably. You kind of eliminate any of the biologic issues that go along with it. And then, so, and you've seen multiple study, you know, multiple kind of talks looking at all the different kind of parameters of how we have our grafts, right? BTP, hamstring, quadriceps, load of failures. How similar is it to native ACL? Because you want to kind of put something in that's relatively similar, right? And any graft choice we do have is gonna be stronger than what we have in the native ACL. So, with regards to load of failure, right? Mid-substance or where does it feel? Does it feel at the bone-tendon interface? I think it depends on the timing, right? Because anytime we put it in a graft, it's gonna have some kind of biologic resorption, right? So, when you have, but from a biologic standpoint, if you think about what a BTP is, right? It has a bone-tendon enthesis, meaning it has a transition tissue. Your body doesn't have the ability to really regenerate a good enthesis, which is your fibrocytes, your tendons, your tenocytes into your, taking you way back to med school into the histology, but taking your tendons that go into your fibrous chondrocytes that go into your subchondral bone, all that calcium and all that kind of structure is not something that's gonna heal and regenerate, right? Your body's gonna make a scar when you have a soft tissue to bone-tendon interface. This is already there, right? So, all you're doing is having bone-to-bone heals. So, it's gonna heal reliably and within when fractures heal, right, and this is cancellous bone. So, you know this is gonna heal very reliably. So, in general, we've seen in studies that patients have a higher proportion return to play and higher ability to return to pre-injury level, right? Because the whole point is we wanna get our athletes back to play, not just kind of like winging it, but to be back at performance level. And then we do have a slightly lower risk of graft failure. We've seen meta-analyses that kind of prove this, but there is a caveat, right? You are robbing Peter to pay Paul. There is an issue with patella-former arthritis. Whether or not that becomes, how symptomatic and how debilitating that is, that's always the difficult part. There's always risk of patellar fracture, and if rehab isn't done right, there can be an issue with patellar tendonitis. So, with regards to risk of failure, plenty of registries, plenty of systematic reviews, but this is the Scandinavian registry of almost 50,000 primary ACLs, and show that BTB are statistically less at risk for revision, and it's similar across age and sex, right? And it's what we see that is a slightly lower risk of failure, and especially in cutting, twisting, pivoting sport. So, realize this, that the Scandinavian registry, you're gonna have a hell, a lot more hamstring tendons than patellar tendon, right? You're looking at the bias in the Europeans, right? We can have well over 40,000 hamstrings as opposed to 6,000 BTB, but BTB is still showing an advantage over those hamstrings. So, this is old meta-analysis, I'm gonna skip over it, kind of, but meta-analysis over meta-analysis over meta-analysis over the years, right? 2011, BTB's better, sorry. In 2015, same thing, BTB, better pivoting, better pre-injury activity levels, but there is a caveat of having anterior knee pain. Same thing in 2017, same idea. Both graft options are viable, but slightly higher rupture rate in hamstring compared to patellar tendon. Within the moon, again, odds revision is two and a half, two times higher for hamstring as opposed to patellar tendon. So, you want this as a one and done. You don't want to have more injury, because we know from the Mars data that any time you go back to do revision ACL, you're gonna have a 90% chance of having it, some type of articular issue or some type of meniscal issue, right? You open our young athletes up to arthritis. So, that's what ultimately we wanna kind of decrease. When it comes to long-term outcomes, this is five prospective studies looking at 20-year outcomes data, and they pulled kind of all the data to look at how these patients get back to strenuous activity and how much arthritis there is. But we know that the arthritis is really gonna be truly related to kind of the meniscus status, right? And if you have to do kind of any kind of revisions. So, back to this case, our football player certainly had ACL tear, that's his ACL stump on the left side, went in with good old-fashioned BTB, reproducible, good bite, good fixation, and then, of course, addressing the meniscus, really tough lateral meniscus tear. So, he was able to get this with a kind of all-inside, side-to-side repair type thing. So, with regards to BTB, why is it the gold standard? We have good long-term outcomes. These are good to excellent outcomes with BTB, with both, right? But overall, BTB allows you to return to sport and at level of performance higher than all the other graft choices. It has good high-to-low failure strength and low donor site morbidity, but yes, there is a caveat of the anterior knee pain and that risk of a little bit more patella-femoral arthritis. So, thank you. Perfect. Thank you. Okay. Oh, thank you guys so much. Did I just do that? Okay. I was like flipping through there. So I'm going to focus on quad autograft and why this is a reliable and reproducible option. These are my disclosures, none of which are directly relevant. So this is our patient. She's a 20-year-old female collegiate soccer player who came in about two weeks after injuring her right knee while playing in a game. She had significant swelling. She was unable to bear weight initially and did have some sense of instability with walking. On exam, she still had some swelling in her knee. Her knee range of motion, though, was actually fairly normal, but she had pain at the extreme of flexion. She had tenderness over the medial and lateral joint lines, had pain with McMurray test, and had an obviously positive Lachman. These were her x-rays, which were totally normal. So then, of course, we went on to get an MRI, and you could see that single sagittal view on the far left just showing a little bit of bone marrow edema on the posterior medial tibial plateau, her ACL tear, and that central sagittal image, and the PCL is normal on that far right image. And then we can see the characteristic bone bruising pattern, and then a single coronal view just showing that the posterior roots of the medial and lateral meniscus appear to be intact. So we will get back to that. Dr. Lee did a great job of covering graft choice. I'm not going to go into detail on all of them, but just commenting a little bit on some factors that influence graft choice. So certainly, surgeon experience, preference, and comfort level do impact graft choice. Patient age and activity level is certainly something we want to be taking into account. And then their sport or occupation and their desire to get back to work or play. We also, of course, have to consider their comorbidities and their BMI that may impact the approach or the technique that we can use in that patient. And then keeping in mind high-grade pre-op knee laxity, and probably a couple of our other panelists are going to comment on, you know, maybe that's an indication to add something else in addition to the ACL. We want to know prior surgery, certainly ipsilateral or contralateral ACL reconstruction, the patient's preferences and expectations have to be taken into consideration, and then certainly trying to identify and address any potential rehab concerns. For quad autograft, there are a lot of advantages in that it can be used with or without a bone block. It's an incredibly strong, robust, reliable graft. You can tailor the diameter to what you want, but it is, it's a lot of collagen. It can be used in primary or revision ACL reconstruction, and causes minimal donor site morbidity with regards to anterior knee pain and anterior numbness. We do have to acknowledge though some potential disadvantages in that there's an increased risk of proximal patella fracture if you harvest it with a bone plug, and then there's a lack of bone-to-bone healing if you do an all-soft-tissue graft. There's also a risk of injuring the rectus femoris if the harvest goes up into the muscle belly, and then you can lose extension and quad weakness, which overall is quite similar to BTB. Early on, definitely it's more pronounced in patients who have quad autograft, but they do recover that strength. A little bit about the anatomy. So, the quad is classically described as trilaminar with a superficial middle and deep layer, and then there's a thin fatty layer that separates the rectus femoris and the vastus intermedius, and so over 50% of patients have a trilaminar quad. Length in general ranges between 7 and 8 1⁄2 centimeters from the myotendinous junction to the proximal pole, the patella, and this allows you to harvest either an all-soft-tissue graft or using a bone plug from the patella. So, really you can do whatever is your personal preference. The width ranges anywhere from 2 1⁄2 to 3 centimeters, and that greatest width is found about 3 centimeters proximal to the insertion on the patella. A little, you know, about the biomechanics. Comparing quad to BTB, quad has been found to be superior with regards to load to failure, strain at failure, and Young's modulus of elasticity. There's a significantly larger cross-sectional area and a significantly greater ultimate load to failure. There are several studies in the literature comparing quad, hamstring, and BTB. This 2022 study showed that when looking at quad versus BTB, there were no difference in several parameters, including side-to-side difference in stability, but quad had significantly lower donor site morbidity. And then similar, when comparing with hamstring, you know, similar outcomes except quad had, again, lower donor site morbidity. So, the main take-home point here was that quad had comparable graft survival, functional outcomes, and stability compared to both BTB and hamstring autografts. And donor site morbidity, though, was significantly lower with quad compared with the other two types of autograft. Now, getting back to our case, so this is how I tend to position my patients. I put the affected leg in a leg holder. I put the contralateral leg actually up in a lithotomy boot. It's kind of abducted and flexed out of the way. You can see in that central picture, that's what the incision looks like. It measures about three centimeters. I'll mark out the VMO every time, and then a single picture there on the far right just showing, I tend to harvest about seven centimeters. In an average-height patient, I'll harvest about seven centimeters. For a shorter patient, I actually will go a little bit shorter. This is what the graft looks like on that far left, and then a still image on the right just showing the prep of the graft. When you're first learning to do this, definitely it takes time, because obviously securing that tape to the graft is really important. That's your whole fixation. But it's just like anything else that we do in surgery. The more you do it, the faster it becomes. And that will, sorry, I'm going to go back here. Is there, that, on the far left, is that a video? I think that's a video. There you go. Thank you so much. So I actually usually just have somebody help, like an assistant just help me hold. You can also clamp this to the graft prep, whatever is easiest for you. But you just put the special clamp on with that card, secure the tape. I'll usually do two passes, approximately three passes, distally, you cut one of the sutures, wrap it around, tie it, and then just dunk that knot. And then do similar fixation on the tibial side, because I actually will do a suspensory fixation on the femur, and then a cortical button, the, sorry, the ABS button on the tibia. But so you have suspensory fixation on both sides. That central picture shows you what the graft looks like with the two cards still in place. So you can see the cortical button up there, approximately. And then on the far right is just after we've removed those cards. And then I'll put this, we put it on the graft master there on the back, under tension. I'll wrap it with a damp lap pad, and then go and do everything else intra-articularly. I tend to harvest first, and then I'll do the scope. There's no right or wrong. Whatever is your preference is fine, but yes, I harvest, and then I'll do everything intra-articularly. So in the few pictures from her case, so, actually, medial meniscus looked totally fine, very pristine cartilage. There's her ACL tear, so really bruised as well. Her lateral meniscus also was intact, so thankfully you didn't have to do any, address any meniscal pathology. On that right-hand picture, just showing the guide, so I'll drill a retrograde. All the companies that we work with have some type of device where you can do this, but yes, I tend to enjoy, like, that's my preference, to drill the femoral tunnel, retrograde, and I drill about 22 millimeters. I want about two centimeters of the graft in the femoral tunnel. This is just showing that drill after it's opened, and then here we can see the tunnel, and then is that one a video too, guys? Okay, then it's on this slide. Can you play these so you can play that left side? All right, so this is just after we've drilled that tunnel, just pulling the drill out, and then we'll feed this suture down. This is really important, obviously, guys, you guys know this, if that guide moves at all, that external guide, then it makes it really difficult, sometimes impossible, to get that suture down, and then that's a real pain to find that again. And then on the far right is from this actual case with this patient, just showing that suture fed down, and of course, that's what's going to be used to pass the graft, ultimately. This is our guide already in place after drilling the, after putting the guide pin in for the tibial tunnel. On the right-hand side, you can see that intra-articular aperture for the tibial tunnel. So I drill a full tibial tunnel, but I do the ABS button, so it's essentially suspense refixation on both sides. And then there's the cortical button coming up into the joint, and on the far right is, as it's going up into the femoral tunnel. So I will actually view from the anteromedial portal, so I can watch the button go up the tunnel, and out the cortex. I will then use a mini C-arm intraoperatively, and maybe this is something we can talk about throughout our discussion, but I do that every time, just to make sure that the button has flipped appropriately. I think it's good to do something, whatever you want to do, whether you extend your incision, or you put the scope down through the lateral incision, something to ensure that that button has flipped appropriately, because I think everybody in this room has probably been fooled about where that button is sitting. And then can you guys play this, please, on the left-hand side? Great. So this is just, we're gonna see the cortical button coming up into the joint. All right, it's happening here. But yeah, so we'll see that there, and then again, I'll watch that initially from the anterolateral portal, and then I switch my camera to the anteromedial portal, so that I can watch it as it goes up the femoral tunnel. And you can play the video on the right, please. And then now we're just seeing our graft coming up into place. And again, it's about a 22-millimeter socket with the goal of two centimeters going into the femur. And then a picture from this patient's case is her graft coming in, just when we see the sutures on the femoral side, and then on the right-hand side is after it's been secured on the tibia, too. And then just a few still pictures to show you as this button comes in. If it's a 10-millimeter tunnel or smaller, it's a 14-millimeter button. If it's 10.5 millimeters, then you have to use a 17-millimeter button. But, so it's not very big. That's what you see when it's going in. And it just, it slides very easily. I don't know how many in the room have experience with that. And then I'll back it up, actually, with an anchor. And I always do that. So these are her post-op pictures. Post-op x-rays, rather. And just a brief comment. So I'll have, she's weight-bearing as tolerated. I do tend to use a brace. I'll have her in a hinged brace, locked in extension just initially with weight bearing, and then progress as her quads strengthen, as the quads kind of wake up. So, in summary, quad autograft really is a great option for primary or revision ACL reconstruction. There are many studies to speak to excellent functional outcomes and minimal morbidity. So, if you're not doing it, definitely take a chance to do it in the lab. Do it with one of your partners who's doing it, and then really, you know, don't hesitate. Use it now. Use it often. I think that it's a fantastic graft. Thank you so much for your attention. Next up, we will have Dr. Nutley. All right. I'll bring up those slides. I'm glad to see a pretty good crowd today. The 7 a.m. ACL on Saturday is not always well attended, so everybody must be pretty interested in ACL, so that's good. So, I'm going to talk about a pretty hot topic, or it continues to be a hot topic, which is ACL reconstruction augmentation. My disclosures are online. Case example for this one, too. Let's see if that video plays. Yeah, good. So, this is a 21-year-old female volleyball player who already had a previous hamstring ACL reconstruction and then sustained a re-injury. Had persistent pain and instability. You know, some quadriceps atrophy already. Lockman's pretty explosive pivot shift, as you saw there. McMurray's hyperextender, as well. So, she hyperextended about 8 degrees or so, 8 to 10 degrees in extension. So, this is the dangerous patient, right? So, female, jumping, pivoting sport, hyperextension, hyperlaxed. Like, this is the patient that scares all of us or keeps all of us up at night because they're the highest risk, potentially, for re-tear after an ACL reconstruction, as this patient already did. So, this is the scary patient. This is her x-ray. As you can see, her previous ACL tunnel's not terrible. And so, that part is at least good, I guess, in her previous cortical button. This is her MRI. A little bit of widening on her tibial tunnel. Tunnel's maybe not in the perfect position, but again, not horrible, not terrible. And you can see her ACL re-tear. And then, as we scroll through, you're going to see a medial meniscus ramp tear, too, on the posterior meniscal capsular junction, there. So, you see her medial meniscus ramp lesion, there. So, just a quick point out. This is not a meniscus talk, but I think it is when we're talking about optimizing ACL reconstruction. We always have to consider all the concomitant factors and all the concomitant injuries. When you look at this, that looks like a pretty normal meniscus from the front of the knee. But hopefully, everybody does this. When you even probe it, it's not even that bad. But then, you drive through the knee. You do a Gilchrist maneuver, and you drive through the knee, and it's pretty evident that's a pretty significant medial meniscus ramp tear. And that particular ramp tear, I would posit you cannot leave that alone. That's got pretty significant displacement. The previous surgeon actually left that meniscus ramp tear alone. And so, that's a risk for re-injury and re-tear, as it's a secondary stabilizer for the ACL. So, this isn't a meniscus talk, but I think it's an interesting example when you're talking about revision ACL surgery. So, here's her problem list. ACL re-tear after a previous hamstring autograft, medial meniscus ramp lesion, hyperextender, hyperlaxed patient, high-grade pivot shift. She wants to go back to a cutting pivoting sport. She's a college athlete. Not an easy case. Not an easy problem. So, why do we augment the ACL? So, everybody knows ACL, common surgery, everybody that's here does a lot of them. Reported re-tear rates anywhere from 3 to 20%. That can be up to 20,000 revision ACLs a year. So, how do we decrease the risk of a re-tear or need for a revision? Well, certainly appropriate graft choice has been discussed. You just heard an argument about BTB versus quad. I think we would all agree in this patient, allograft is not the best option. Appropriate rehab, that's been discussed. Appropriate return to play timing, that's out of the scope of this talk, too. But things that maybe we can control at time zero. So, that's improved knee stability. So, that may be lateral augmentation, or it may be improved overall construct strength with internal augmentation. So, I'm going to go into some of those things here in a little bit. That video you can see is just an example of graft passes with internal augmentation associated with it. And I'll go into that and show a couple more videos and examples of that shortly. So, here's kind of some of the things we talk about when patients say ACL augmentation. And there's a lot of different terms that get thrown around. You guys have probably seen a lot of talks and a lot of papers on that, on these different things this week. Most of the time, people kind of classify it and break it up into a few different things. ALL, or even what people would more term anterolateral complex now. But ALL, ligament reconstruction, you see the illustration at the top. Lateral extraticular tenodesis in the middle illustration. And internal suture augmentation, along with the graft in some way, shape, or form. And we can get into some of the details of different ways to do that, if interested, as we go along. So, this is a little bit of an older study now. It's a little bit dated, but I think it's just kind of nice to still kind of think about the anatomy of the lateral side of the knee. As I said, I think more and more people are kind of talking more about the anterolateral complex of the lateral side of the knee. But when you hear the term ALL, this is kind of what people are talking about. And this is one of the original anatomy studies that Brophy and the crew at Wash U in St. Louis did, talking about finding this area of the knee, this capsular area around the lateral side of the knee that goes obliquely over the lateral side, roughly from about 5 centimeters in length and 6 millimeters in width. With the distance from Gerdie's tubercle being about 22 millimeters, and the distance from the joint line being about a centimeter distal to the joint line. It's under the most tension with tibial rotation with the knee at about 30 degrees or so. And so, based on this and some other studies, that's where a lot of people put that reconstruction. But again, we can talk about that in more detail, or that's kind of always being debated too. This is kind of an interesting study, just looking at different types of specimens, and looking at both the IT band and its involvement in anterolateral rotatory instability, and then a Lameritian odysseus, and then an ALL reconstruction, and then what the kinematics look like. And it's a systematic review of a bunch of different biomechanical studies. Summary of it is the IT band acts as a secondary stabilizer to the ACL. It resists internal rotation, and in particular, internal rotation during pivot shift. And the anterolateral corner reconstruction, whether you do some sort of ligament reconstruction, whether you do a lateral extraticular tenodesis, some sort of lateral sided procedure, improves that residual rotatory laxity of the knee. And so, that's the main idea. This is one of the first kind of reviews of a number of different clinical outcomes. So, another systematic review, looking at 20 studies, 11 of which were randomized control trials, looking at ACL recon alone, versus ACL recon plus some sort of anterolateral procedure. As you probably guessed, the ACL plus the anterolateral procedure improved pivot shift grades and decreased graft failure rates, regardless of the technique or time of injury, or time from injury. The only major difference was that patients undergoing LET versus ALL had a slight increased risk of stiffness and adverse events. But I think a number of studies since that time have kind of shown that not to be, to continue to hold true. This is like a summary article. So, there's a lot of heterogeneity in this article. But it was kind of nice, if you want to go and read about it, because it kind of summarized, looking at randomized control trials, but then also biomechanical studies, and a number of different things. And so, it was kind of a nice systematic review and meta-analysis of a number of studies. But long and short of it is, for the biomechanics, the anterior translation, internal rotation, and pivot shift were restored, and superior, or superiorly restored, with an ACL plus some sort of anterolateral ligament, more than just an ACL alone. And then the clinical studies, the ACL and ALL, retail rates were variable, but overall decreased, compared to ACL alone. So, how about the specific, can you go back and, can you play that video for me, please? So, talking about kind of techniques a little bit. So, in terms of the anterolateral allograft ligament reconstruction, you can use autograft. You could use potentially a gracilis autograft. Most of the time, I would say most people, and I personally, would use an allograft. So, this is just a quick kind of video that shows kind of the technique of how to do that allograft reconstruction. You can make a small incision directly over the lateral epicondyle, and usually drill line to line for both, and you can use either an anchor, or you can use a screw, depending on what you prefer to use. You know, here we're putting in a knotless screw along with the graft. Place it proximally, then you can tunnel distally, and then you make a separate incision, and place a guide pin between GERDI's tubercle and the fibular head, about one centimeter below the joint line, again, as that anatomic study discussed. And then, again, you can either tunnel your graft through that area, and pass it, again, with either a suture anchor, or a cortical button on the other side of the tibia. We'll show here in a second. If you leave that guide pin in, one of the nice things you can do, if you can fix your graft on the tibia, or the femur first, obviously, people do it all different ways, but if you fix your graft in situ on the femur first, and then pass it, and you leave that guide pin in on the tibia, you can check isometry. So, if you're, anytime you're doing any sort of allograft reconstruction, or particularly when you're talking about the collaterals, or the lateral side of the knee, you can leave that guide pin in place, and then there you can see we're checking isometry, taking the knee through flexion, flexion and extension to check isometry of the graft, and check the mechanics, and then you can use a number of different things. Like I said, you can use cortical buttons, you can use suture anchors, and then you can use screws to fix the graft distally, typically with the knee in neutral position, neutral tibial rotation, and about 30 degrees of knee flexion. So, how about LAT? So, that's kind of the lateral ligament reconstruction. What about LAT? This is kind of the big study that a lot of people typically quote. This is the stability study, the stability trial. Most people are probably familiar with this study now, because now they're on to the second phase of it, and almost finished and rolling with the second phase of it, which will be great. But if you're not familiar, this was a multicenter prospective randomized control trial, looking at single bundle ACL recon with hamstring alone, versus single bundle ACL recon with the lateral extraticular tenodesis. They looked at it in the patient, in the patient example that I just gave, our patient for today, and for this case. So, it's the high risk patient. So, patients less than 25 years old that had two or more of the following, a grade two pivot shift, or greater high risk pivoting sport participation, and then generalized ligamentous laxity. So, in the stability one trial, this study, they had 618 patients, average age of about 19 years old, which again, is the high risk patients. And what they found was that ACL reconstruction, mind you, with hamstrings in this trial, but ACL reconstruction alone, versus ACL reconstruction with an LAT, the rupture rate was 11% versus 4%. So, it reduced it about 7%. That was statistically significant. The number needed to treat with an LAT to prevent one graft re-rupture was about 14 over the course of two years. At three months, the ACL patients alone had a little bit less pain, but that was equalized over one to two years. So, that spurred a lot of interest in the LAT. Can you play that video for me too? Actually, I can play it. That's great. This is a technique that we published in ATAC. It's just given the example of a relatively minimally invasive technique for how you can do an LAT. So, incision is pretty centered over the lateral epicondyle, centered to slightly distal, so you can access the iliotibial band. Typically, take about a one centimeter wide strip of the iliotibial band in the central to one-third, central to posterior one-third of it. I use a double-edged sickle pull, as you can see, to kind of drive it right down. And that double-edged scalpel is one centimeter in width, so it works kind of perfectly. Aim towards Gertie's tubercle. In the video, Gertie's tubercle is marked with an X there, so the foot is in the left in this video, and obviously, the thigh is to the right. And then, you can release it proximally, typically eight centimeters long or so. Whipstitch the proximal end, pass it beneath the fibular collateral ligament, and then you can secure it proximally, just proximal and posterior to the lateral epicondyle. Again, people kind of are debating the exact optimal location for the placement on the femur, but it's generally in that area. And then, for the proximal fixation, I think at this stage, it's dealer's choice. People have described a lot of different techniques, a staple, an anchor, a button. I typically tend to use a knotless suture anchor because it's pretty quick and easy, but the fixation, you can use pretty much whatever you want at this stage. So, here's a nice study kind of looking at comparison match study, revision ACL patients, two-year follow-ups. They matched hamstring with an ALL to BTB with an LET, and they basically showed no differences for the most part. No differences in re-rupture rate. No differences in re-operations. Significant differences, at least. No significant differences in complications returned to play, patient-reported outcomes. The hamstring ALL group had a little bit shorter surgical time, but that was just, you know, in their particular group. So, how about, so that's all the lateral side of the knee. How about the internal portion of the knee? This has kind of become reinvigorated over the last few years. This is kind of one of the initial biomechanical studies that kind of started looking at this again and kind of re-spurred this. And this is a study looking at independent suture tape reinforcement of both small and standard diameter grafts. So, in this particular study, they termed small grafts as 8 millimeters and standard as 9 millimeters. And then they looked at them with and without suture tape, eight specimens in each group, and they loaded them with different loads, 250 newtons versus 400. And the reinforcement of the graft significantly decreased the dynamic elongation of the graft, particularly in the small diameter grafts, which you would maybe obviously surmise. So, in the small diameter grafts, it decreased the load in the dynamic elongation by 38% and 50% at the respective 250 and 400 newton loads. And then the standard diameter was 15% and 26% at those respective loads. So, their conclusion based on this was that independent reinforcement led to reduce the elongation and higher ultimate load defayer, particularly in smaller ACL grafts. This is a clinical study that Matt Matava and the crew at Wash U did using independent suture augmentation with BTBs. A lot of times people think about it as soft tissue grafts, but they did it with BTBs. And then they loaded them and did cyclic loading for 500 cycles. So, what they found is no difference in graft displacement, but there was a lot higher stiffness with the augmented group. And there was about a 57% higher load defailure in the augmented group as well. So, their conclusion was that suture augmentation increased the overall graft construct strength and stiffness. This was a clinical study looking at hamstring ACLs with suture tape reinforcement in adolescent athletes. So, again, this is the dangerous kind of athlete population that I'm talking about a lot. They had 40 augmented versus 40 not augmented, young patients actually. So, 15 and 14, 15 years old on average. Retail rate for augmented versus not augmented was 5 versus 17 and a half percent. So, that's a pretty significant difference, obviously. And then the augmented group had higher tegner levels, but otherwise no differences in their other patient reported parameters. This is another one. This is kind of a scoping review of a number of studies. Again, a little bit of heterogeneity, but basically the biomechanical studies when lumped together showed that the tape augmented grafts did better, a lot of variability, but they had increased load defailure, reduced elongation, a lot of the biomechanical things that you probably would expect to see with this augmentation. So, what's kind of the rationale for internal suture augmentation? You know, historically, people have talked about different types of things that have failed. For people that have gone back far enough or have operated long enough, you've probably seen some different types of augmentation or even some artificial grafts. And depending on if you're international or not, you've definitely seen some artificial grafts that have been put in place that failed miserably. This is a little bit different than those types of things. It's much smaller. It's much thinner. And so, there's a lot less stress shielding of the graft itself. And it's not meant to replace the graft. It's meant to be kind of more of an addition to a graft. And it's independent of the graft itself. So, the concept being that it's load sharing, particularly load sharing at those higher levels. So, it's more of a seatbelt concept as opposed to a replacement type of concept and able to give the improved graft support. We certainly need more clinical data. And that's always coming out. And that's certainly forthcoming for the time being. So, this is kind of what some examples of what that can look like. There's a lot of different ways that this is done. Each company now has a different way that you can do it. And whether you do a BTB or whether you do a quad or whether you do hamstrings, whether you do suspensory fixation, there's all different types of ways that you can use for all different things you can use for fixation of this, certainly. This particular case, the pictures and examples, this is an all soft tissue graft with suspensory fixation. The internal suture is looped through the cortical button and then brought down through adjacent to the graft. And so, you see the video there where you see the internal suture. You see the graft being pulled into the femoral socket. And then you see the internal suture basically independent but adjacent to the graft. And this can be done, like I said, in a variety of different ways depending on whatever kind of technique you typically employ as your primary or revision graft and fixation method. So, in general, indications for ACL augmentation for some sort of lateral augmentation or anterolateral procedure. High-risk patients, particularly if they have hyperlaxity and high-grade pivot shift, if they play a cutting, pivoting activity or sport, revisions in young patients such as our patients that have the case example here. Specifically for an anterolateral reconstruction, for me, that's typically if they've had some sort of previous lateral sided surgery or previous IT band disruption or something along those lines. But I think you can discuss whether or not most, and I think the stability trial and stability too is still coming, is going to help us out a lot. But you can have a discussion about whether or not this needs to be in every patient, and especially potentially in every young patient. I saw Adnan Saytana in the back of the crowd there. He just won an award at this meeting for the great work that they're doing for their long-term follow-up, looking at LET augmentation. And he would probably argue that most, if not all, of these patients should have some sort of lateral augmentation. So, I think it's ongoing, and the clinical studies are ongoing, but it's something that we definitely need to be considering much more regularly than we used to. How about internal suture augmentation? For me, I utilize that in all allograft ACLs. The clinical data isn't quite there to support that, but I think it makes sense from a biomechanical standpoint. Again, revisions, you know, revisions, we tend to throw the kitchen sink at a lot of these patients. So, you've got to think about it. Small diameter soft tissue grafts, I think some of that biomechanical data really supports that. And again, it kind of just makes sense, right? Primary ACLs in high-risk patients where you're using a soft tissue graft, some of those studies are trending in this direction, and I think that's something that should be potentially a consideration as well. And then, again, you know, a lot of people are discussing now, should this be used in most or even all primary ACLs, particularly, again, if you're electing to utilize a soft tissue or all soft tissue graft as your primary ACL. And so, those clinical studies are kind of ongoing, and some of them certainly trending that direction. So, again, that's a video there of an all soft tissue graft with internal suture augmentation associated with it to back it up. So, back to our case example. So, we did a repair of that medial meniscus ramp. So, here you can kind of see what that medial meniscus ramp repair looks like, both all inside and using a posterior medial portal to come down in the back, from around the back. We did a quad ACL reconstruction with internal suture augmentation. So, you can see what that looks like there. We did a lot of extra articular tenodesis. I already showed you guys the technique for that, but again, we utilized just a central strip of the IAT band and then bring that, I think that's a video. Could you put that video play? Can you play that video for me? Yeah. And then again, we bring that underneath the lateral collateral ligament and then I utilize a knotless suture anchor that we place on the femur and then you can load that and then secure that down and reduce the LET down to the femur as you see there. I think for me, the lateral extraticular tenodesis, the modified Lemaire is a workhorse. It's pretty straightforward and pretty reproducible. You can see you can do it through relatively minimal incisions. And so that's been the lateral augmentation workhorse for me, but certainly there's plenty of studies to support multiple different techniques in both reconstruction and tenodesis. So here's what she looks like two weeks post-op. Those are her incisions. And then here's what she looks like six months post-op after each of these procedures. And so you can see getting more and more active, still not letting her be released to volleyball at this stage in time after a revision ACL, but she's trending that way at that point in time. Thank you. Excellent. Actually, I have one very quick question for Clay, just because I don't want to forget to ask you. For the internal brace, do you suture it into the, like into your graft? Like we have the sutures obviously on the femoral and tibial sides. Do you suture the internal brace into that? So we'll run it like underneath and through the prep sutures on the femoral and tibial side. So it'll take like a long night now wire with a loop on the end and run it underneath those sutures, like after the graft's been prepped. Does that make sense? So it's just underneath, but it's not sutured into the graft itself. It's independent and we fix it independently on the tibia. So it's independent. Okay. Thank you. I think that's really critical that the tape isn't sutured to the graft because you want the tape construct to be 100% independent. Yeah, that's what we wanted to clarify. And then I think it's absolutely critical that you fix, you know, I tend to put my tension, my ACL graft in a neutral position, but I fix the tape in a hyper extended position because we know that the ACL elongates. So you want that tape to be not the primary. You don't want the tape to see the initial stress. You want it only to see the stress at a higher load. So always fix your tape in a hyper extended position. Yeah. Thanks for making that point. And with that, we'll invite Dr. Sloan up here to speak about revision ACL. Thank you so much for having me. I have disclosures, but none relevant to this talk. Um, so our case is a 22 year old female basketball player. Um, she has a history of bilateral, uh, ACL reconstructions with hamstring. Uh, the left was done in 2017, right? 2019 and basketball injury three weeks ago, you know, pain and stability pops the usual story. So at time of presentation, uh, she had full range of motion, uh, great to be locked in grade two pivot and no dial. I think it's really critical that when you're evaluating someone who had a previous ACL reconstruction, you want to make sure that there's no other missed the ligament injury and specifically a postural out of corner injury. Um, here you can see her x-rays, uh, tunnel position is something you want to critically evaluate on your plane films. I think you, and especially in a revision setting, need to look very closely at posterior tibial slope and coronal plane alignment. So in every, um, revision case, I would definitely get long, like standing x-rays. Um, and then if you see, you know, some assessment of her posterior tibial slope, let's see if our videos will play. So, um, in this case, you can see a ramp lesion of the medial meniscus. Um, I felt like tunnel position, um, was pretty reasonable, um, both on the femoral and tibial side, uh, no evidence of any other associated ligamentous injury. So in summary, 22-year-old, high-risk patient, history of bilateral ACL tears. Um, you know, she's a young female athlete, um, and she has an associated meniscal tear. Oops, I'm sorry. Would you mind going back one? Let's see. There we go. So, so the things you have to consider, do we need to do a single stage surgery or is this something that we need to do a bone graft in return of the OR? Uh, what graft are we going to use? Do we need to do something in addition to just our standard revision ACL reconstruction? Does this patient need an osteotomy? And then a little bit, what do you do after surgery? Does this patient need a brace? And I'll talk a little bit about the very limited evidence that there is for, for that. So in this case, you can see here was her ramp lesion. Clay had a really nice video of that. Um, this was sort of a segmental meniscus tear with a more peripheral and a more central tear. I'm a member of the save the meniscus club. So we fixed it, um, as best we could. And I think that's really important for the stability of the ACL. Um, so, um, we redrilled her femoral tunnel, felt like we had good circumferential bone that was amenable to a single stage revision ACL reconstruction, both on the tibial, um, and on the femoral side. Um, so at this point we took a quad harvest autograft, quad autograft harvest. Um, and, uh, you had some really nice videos earlier of how that's done very well done. Um, and then this was our final construct. So in this case, we did a quad done. Um, and then this was our final construct. So in this case, I elected to do suture tape augmentation, uh, in addition to a lateral extra-articular tenodesis with our revision quad tendon ACL reconstruction. You can see our picture of the let, um, post-operative images. You can see here sort of very similar to the ones that you saw before. Um, so a lot of the data that has been presented, um, I think it's extrapolated to the revision setting and maybe that's not necessarily the case. So most of the stuff that I'm going to show today is, is specific to the revision setting. So how does graft choice affect, uh, outcomes after revision ACL reconstruction? Uh, this was a MAR study and basically we know that autograft outperforms allograft for the revision setting. When I was a resident, one of the indications for an allograft was revision ACL. That's no longer the case. I think it's the opposite. Um, we know that there's better post-operative outcomes and lower retail rates with, uh, autograft ACL reconstruction. Again, study after study autograft better than allograft for revision ACL reconstruction, higher return to sport, improved knee laxity, lower retail rate. What about, uh, amongst autograft options? Um, there's lots of studies that have looked at this. Uh, I still think that there's some controversy around this, uh, but in general, BTV and quads seem to have a lower risk of retail than hamstrings in the revision setting. Um, again, uh, this was a study that we did, uh, 600 patients looking at quad, uh, versus, uh, BTB. No difference in graft failure rates specifically between those two and similar patient reported outcomes. Um, one of the questions that I always get is if someone's had a BTB, do you worry about doing a quad meeting the second hit to the extensor mechanism? And the short answer is no. Um, um, this was a study that we did. And if someone had a previous primary hamstring autograft ACL reconstruction, uh, versus a BTB, and then went on to have a revision with a quad, there was no significant difference in their extensor strength. So I don't really worry about the second hit to the extensor mechanism. I'm much more worried about the risk of retail. Um, a little bit about sort of interlateral complex or lateral extra articular procedures in general. Um, so this was a really nice study. Uh, they looked at, um, 88 ACLs, revision ACLs, and then 86, uh, what I call ACL plus. So something revision ACL plus a lateral sided surgery. And there was lower failure rates with lateral sided surgery, better KT. So better translational stability, as well as better rotational stability, um, better equal patient reported outcomes, depending on the measures that you looked at, but there was a little bit more lateral pain in the lateral side, not unexpected, but I would rather have a little bit more lateral pain than a risk of a retail. So I think the results of primary ACL are pretty good. I even think the first revision ACL is pretty good outcomes. When you start getting in a second and third time revision, ACL reconstruction, you know, that the results really start to fall off. So we really need, if it didn't, if it wasn't done right the first time, you really need to make sure it's done right the second time. This was a really interesting study from sort of Dr. Getgood, um, who obviously did the stability trial that Clay mentioned earlier. And in this series, a lateral extraticortinodesis in the revision setting in this case, in this study did not actually reduce the risk of retail. Um, and there was no significant difference in patient reported outcomes. So it's not entirely clear. I think the majority of studies do suggest that a lateral extraticortinodesis is probably helpful in the revision setting, but not all studies. Um, again, another sort of study, less likely to fail with a lateral sided procedure, better stability, better outcomes. Um, I'm going to skip through that. Um, so what about suture tape augmentation? Um, I think that there's a growing body of evidence, um, to support suture tape augmentation in the primary setting. And a lot of people have extrapolated that to the revision setting, but there's actually not many studies that have looked at tape augmentation. In the revision setting. It's something that I use because kind of like Clay mentioned, I want to throw the kitchen sink at these patients. I want to do everything I can to reduce the risk, uh, of another ACL tear because the results are not good. So for most patients, I tend to do a lateral sided surgery and a tape augmented surgery, kind of like Clay showed. Um, in terms of postoperative, um, predictors of clinical outcome following revision ACL reconstruction, uh, this was a really nice, uh, study from the Mars cohort. Um, there, there's some evidence that actually routine early postoperative bracing, uh, results in worse outcomes. Um, and functional bracing, um, may potentially result in better outcomes. So, um, I, I still think that for me in a revision case, um, despite knowing this data, I'm a little like more likely to put someone in a brace, especially in their business jet revision setting, especially if they have a meniscus tear. But I did find that study interesting and thought I should, uh, highlight it here. Um, I don't routinely brace patients in the, uh, postoperative, uh, setting following a primary ACL reconstruction. Functional bracing is return to sport, uh, but I'm a little bit more inclined to do it in the revision setting. Basically what I do now is I tell patients, I'm not sure if this, uh, results in a reduced risk of a re-injury. Um, I think there's conflicting data and I sort of leave the choice up to them. Thank you very much. Great. Thank you guys so much for the excellent talks. So we have plenty of time for questions, actually a lot of time. Everybody was very on time with their talks, probably early. Congratulations. That's amazing. Um, so yeah, any questions, please come up. Um, go for it, please. Uh, very nice talk, Cassandra. First disclosure, I'm a big fan of BTB, but in a situation where you are planning a BTB at four weeks post-injury, you go inside and it's a Sherman's type one, so all of the remnant is still preserved. So how you are planning your, does your plan change or? So you're saying the ACL stump is relatively- Yeah, yeah, relative. So in BTB it's very difficult to preserve the remnant. So it's particularly if the whole of the remnant is still there. Yeah. So that's, uh, so I guess the question is, um, with regards to remnant preserving versus actual repair. Yeah. I'm talking about like, if you're planning a BTB, it's very difficult to do a remnant preserving. So you will cut off all of the remnant and then do BTB or? Yeah, I cut off all the remnant. Yeah, I'm not, I'm not a preserver. I, if it's, it's, if, if I've decided that the ACL remnant, I mean, if that's enough, then I would actually consider repair. It's someone that's four weeks. Um, but that's usually something we would see probably with the MRI and, and, and counsel patients pre-op. I, I will not do a surprise ACL repair. Um, it's, uh, but in general, I'm not a remnant preserver. Um, I always get concerned about, um, Cyclops lesions. And then whether you will add a LED in your primary ACL while you're doing BTB, is there any indication in your practice where you will add a extratic latinodesis while you're doing a BTB graft? I'm sorry, could you repeat that? I will never say never. Um, actually there's an interesting case that I have presenting in the revision ACL, um, kind of, uh, uh, later on today. Um, yeah, I think when you have certain factors where you recognize that perhaps the posterior tibial slope is a little bit higher than it should be, it's, it's within normal, obviously, but I mean, it's not within normal. I shouldn't say obviously that 12 to 16 range. And you're kind of like, this is a primary, I mean, we're not at the point yet where we're telling patients that we're going to do a primary osteotomy on for an ACL for a first time ACL. But I think that's the one time that I would potentially put in an LAT for, um, with the BTB. Thank you. Maybe we can pull the crowd real quick. So how many people are doing BTB is their majority of their primary ACLs? Maybe half. How many people are doing quad is the majority of their primary ACLs? Other half, it looks like. How many people are doing hamstrings? Any hamstrings out there? So, all right. All right. Lone person. How many people are doing some sort of lateral augmentation, um, with the majority of their primary ACLs, regardless of graft choice? All right. So we've got a few geo adenones in the back. How many people are doing some sort of internal suture or internal augmentation with the majority of their primary ACLs? So it looks like the other half of the crowd, but okay. That's interesting. Yeah. Thank you. Please. Just any tips on, uh, harvesting the quad and not skiving? Yeah. Well, this will be a little plug actually for a session at 10 a.m. Uh, actually, no, seriously, in that session, I'm going to actually demonstrate technique, um, for quad autograft harvest. There are, there's not one set technique as, oh gosh, she told me not to hit this. I'm sorry. I speak with my hands. Um, there's not one set technique, but, uh, but the way I tend to do, I'll do a small vertical incision. I think you saw actually probably like clay and hairs somewhat similar. I don't know. Um, there are some proprietary instruments that you can use to help harvest. I mean, I'd say practice with it, see what feels most comfortable in your hands. Um, but I'll make a small vertical incision. I then, I use a standard 10 blade actually to, I'll, I'll like cut a ruler at two centimeters, one of those little plastic rulers. I'll put that in. I mark out the central sort of nine to 10 millimeters. I use a standard 10 blade to release the, you know, the distal, maybe one centimeter. I'll use an at the bond suture to just be able to get some traction on that. Uh, and then I'll use the 10 blade to get probably maybe another centimeter. So about two centimeters total. And then I switch to Mets that Mets and bomb scissors has made an enormous difference. I started doing that about a year ago. It's very fast, very efficient, very reproducible. And it makes it so that incision can be smaller. Like I've definitely made my harvest site incision smaller over the past eight years. Uh, and largely in the past year because of transitioning to using Mets, I think it's super duper easy. Um, and then, uh, so yeah, you just release medially, laterally, approximately, or superiorly and inferiorly. And then again, every company has sort of their instrument of what you can use to then release the graft approximately. If you don't have access to these special instruments, you can just make a small separate incision approximately and just release it there. There's a lot of different ways to do this. Um, so that's how I do it. But, but yeah, we're going to talk about this in detail actually at that session at 10. My tip would be go full thickness, take your dissection up as proximal as you can get it before introducing whatever quad harvesting instrumentation that really is just going to be for the last third or less of the graft. And I think where people get in trouble is if they try and use it early and you're off plane a little bit, it's like flying an airplane. If you leave Africa and you're off by three degrees, by the time you get to the United States, you're in New York instead of Miami. So, you know, if, if you just use that for the last little bit, if you're off a little bit, it's not going to matter at that point. But if you try and use it for the whole length, that's where I tend to see people skive and get into trouble. And then full thickness makes it way easier. I would say minimum three centimeters from the patella. So in Mary's talk, you saw that kind of what I think is part of the graph of the, of the quad tendon is three centimeters proximal to the patella. So depending on which proprietary system you use, there's one specifically, if you don't, again, if you start too early and you use the, that system, you can easily truncate and that's one where you kind of skive up and end up getting just the rectus and not the whole full thickness. Right. So the key is, I think you have to get minimum three centimeters, harvest it off, get that full thickness. I'm going to try the Metsenbaum things. I kind of just- It is so much easier. I use a traxin stitch. I use a traxin stitch. I use a 15 blade and I just cut straight down kind of from there. But again, I found just from lots of snafus is that you need it for certain, one of the proprietary ones, you have to get minimum three, three and a half centimeters off the patella. Yeah. And, and just adding one other thing too, I agree completely with Harris. I don't, I don't use any specific type of device, but I still, the graft is completely freed up before I'm putting in the sort of circular instrument to then just cut it proximally. So do all of that work ahead of time. I agree completely. And I will, I usually harvest the depth of the tendon. I don't just automatically go through capsule too. I try to preserve the capsule, but the bottom line is if you create a rent or you just, you know, go full thickness and release, like remove the capsule from the beginning, it's fine. You just have to close it. But I try to keep the capsule intact. And then the last point is to do it when you actually harvest it or cut it proximally, is do it in flexion, like greater than 90 degrees typically so the whole quad's under tension. You can, you can bring the knee out into extension if you want to externalize it or to get better visualization of the quad approximately while you're exposing it or even partial flexion. But then when you actually go to truncate approximately, bring the knee all the way up into flexion. So you have adequate tension and you can hold pretty consistent tension on it all the way across. Yeah. And I, I mean, I showed just one picture of how I will position the patient, but the knee is inflection the entire time that I'm harvesting and then releasing. That's a very good point, Clay. Thank you. One more thing though, if you do do full thickness when you're in flexion, just be careful when you're very at the patella part of it. So just don't smack down because you're actually at the trochlea. The trochlear cartilage is surprisingly right there. Yeah. Yeah. Did you have a question, please? Yeah. Fantastic panel. Thank you very much. I'm just wondering for, since you routinely use x-ray, have you ever noticed the button? It's not on the IT band, but there's like thick capsule or periosteum. And I guess my question is I'm routinely using x-ray right now, but it's funny. I did it in training. I just first year practice. So I'm checking every time. And I've noticed sometimes a little bit of thick capsule. I wonder, is that okay? It's not the IT band, like I've looked at it, but do you need to spread down and make sure it's on bone? Or do you think being on that capsule, even thick periosteum is okay? Yeah, no, I mean, I've definitely seen that too. And I think we can see it, especially to our young patients who may still have very thick periosteum. But no, as long as you're below the IT band, that's totally fine. It's a very good point. Thanks for bringing that up. But yeah, I use mini CRM every time. I'd actually be interested just to pull the room too. Who uses mini CRM interoperatively to check that button? Maybe 50%. Okay. Yeah, I do every time. Is there something that other people do? Other people do something else. What do you do, Harris? I follow the sutures as they exit the lateral thigh with the arthroscope. And I go down and I can see the IT band. Yeah. Push through that rent and I can actually see the button directly visualized. Right. So I think doing something. Is there any, yeah, Luke or? I do exactly what you said. The lateral suture. I actually make a pretty cool slide. Yeah. And you can just follow them right down. You can see that button. A lot of times. Yeah, yeah. If you see a dimple on the lateral thigh like so, I don't use this here because again, it's very painful and I would say probably 90% of the time my resident does pull it out of the IT band no matter how slow we go, but I've gotten used to the, you feel the feel like it's kind of a springy feel, but you can also see the thigh dimple a little bit and you just, tonsils your friend, so you just kind of go down. Oh, so quick mention on the other end, so you have, you're holding the scope and you're also holding the other side, so when your resident is trying to go like way out, you know. Oh, I know my, my, yeah, my residents are very trauma oriented, so the, they pull hard, they pull hard. The one thing I would consider and I would posit just especially for you starting out in practice and in board collection, potentially you're going through that period, to at least consider getting an x-ray before you leave the OR, even if you're not using an x-ray to confirm femoral cortical button placement, to confirm the buttons are cortical, both femoral and tibial, before you leave. The worst feeling in the world is when they come back to the post-op clinic and that button has breached the cortex and is actually intraosseous, you didn't check it before you left the OR and it happened in the OR, if they have bad bone or something happened or you reamed out or you reamed out too far, that's a bad feeling in a bad position, maybe none of you have ever had that happen, you're lucky and so it'll happen at some point in time and so it's better to find it intra-op and it's just one x-ray. I think do something every time to just make sure that you know where that button is. I have a question for the panel. Yeah, Harris please. If you have someone who you plan to do something lateral on, right, young, high-risk patient, generalized ligamentous laxity, et cetera, and you get in and you find that very common anterior horn body junction radial tear at the lateral meniscus, does that change your plan to do an LET or something lateral? I know there's biomechanical studies and there's theoretical concerns about increased risk of lateral compartment constraint, but the clinical studies haven't really shown a difference or a higher progression of lateral sided arthritis, but if you see that or a big lateral femoral condyle osteochondral injury, does that change your plan to do something laterally? Because I did one the other day, radial tear, I fixed it, I did an LET, but I can't say, it's hard for me to ignore that. I mean I don't think if I went into the case planning to add an LET, that wouldn't change my mind. Like I would still do it. Clay? Go ahead, Cassandra. Yeah. So I mean I think there actually was a study that just recently came out looking at longer term follow-up, 15-year follow-up where they did a lateral augmentation. Now it's different. They did it different 15 years ago than we do it now, and you could posit maybe they over-constrained it more or we do different techniques or whatever, but nonetheless they did it and 60% of them had lateral compartment arthrosis. Now again, don't know what the meniscus status was, don't know what the cartilage, but like so it's a real concern and it's a great question that you ask. Generally I think, you know, that's one of the, for me that's one of the reasons for doing LET over a lateral ligament, like especially an allograft reconstruction, because I feel like the LET is more of an, and especially if you use an onlay technique, is maybe not quite the same type of, there's less flex factors, in other words there's less potential for us to do something wrong and over-tension it, than if you're putting a reconstruction and you're tensioning it on both the femur and the tibia and you're trying to hog it down. And so for me, I would still do the LET in that patient that you presented because they're a high-risk patient. Yeah, but I think, I think you mentioned a little bit about clades, like we're not hogging on it, right? You're just setting the length. You're just putting it down there. You're not, you're not actually trying to tighten it and that, that is a very real concern. It does cross my mind, but again, if I had the pre-op plan of going in with it, I would execute that. I just wanted to answer your question, basically. So there's a few perspectives. Firstly, the study Clay mentioned, that's a really important study, and that was a randomized control trial. So it's actually one of the few randomized control trials we have looking at long-term outcomes of extra-articular tinnitus. But exactly how Clay mentioned, nobody's doing that technique today, and when you look in detail at that study, what they actually found was that the patients who had a higher risk of arthritis also had a significantly higher proportion of lateral meniscus tears. So it's not really clear that it's due to the lateral extra-articular procedure. Now in the contemporary literature, although we don't have 20-year follow-up, we do have 10-year follow-up, and in those studies, there's actually no evidence of over-constraint or of osteoarthritis in excess of the control groups. The other context is we've published a number of studies which demonstrate that if you have a meniscus repair performed at the time of ACL reconstruction, and you do a lateral extra-articular tinnitus, the risk of failure is substantially less. And so load-sharing with the menisci, and more normally, restoring knee kinematics is actually protective of your meniscus repair. We've demonstrated that specifically on the medial side, we haven't really investigated quite so much on the lateral side, but it would make sense that the same findings apply. And so my recommendation would be that if a patient has a meniscus tear, particularly one that you're repairing, that you would actually want to do a lateral extra-articular procedure to protect that. And in the next session, I'm going to be sharing some more information about that, including our recent international consensus statement on when to do an LET, but meniscus repair is one that came up in that discussion. Thank you. Yeah. Thanks, Adnan. Thanks. Questions, please. Hey, guys. Good morning, and great talk. I had a question regarding quads, specifically. Previously I was doing hamstring. I found that when we were affecting the posterior chain, we weren't seeing the AMI issue as much, but now that I've gone to quad, I've seen that a lot more. So obviously, technical things aside, but rehabbing these patients, you guys see that, and if so, what are you doing when you're on the PT side? Yes. You want to comment? Go ahead, or is there a play you guys want to comment? I think getting terminal extension early is absolutely critical in terms of return of quad function. I think it's a big, bulky graft. I think making sure that you're, just on the technical side, making sure that you're not overstuffed and there's not notch impingement, I think, is really critical, because I think, and I've had this conversation with my mentor, John Exelad, is it a chicken or the egg thing? Do people lose extension because their quad is weak, or do people have quad weakness because they have difficulty getting extension early? And I still don't know that I'm convinced as to one is the main cause of the other. It's probably a combination of both. So I guess for AMI, it's not necessarily a loss of functional active extension. They actually have a lot of block to extension, and we'll find that the hamstrings are over active in that scenario. So the question, because the quad graft is so stiff, especially if we're doing a full thickness graft, we'll find that a lot of those patients, whereas previously, if you're taking hamstring grafts, you're losing that neural pathway. But with the quad, we see it, even in patients preoperatively, some of them will have a AMI profile. Are you using blood flow restriction, some of those types of things, early post-op? Absolutely. So you can regain that, get rid of that inhibition and try and restart and reactivate that neurologic process. Exactly. And so it's interesting, a lot of these folks will lose their extension, not initially, but after the fact. So after the hamstring starts to become pretty hyperactive. So it is a big challenge. I find that with the quad, the graft is so stiff that I see that a bit more. And I think even in the video, Clay, that patient had a little, probably say that they had maybe a couple of degrees loss of extension. So they're still functional, but without that terminal extension, it does become a little bit of a challenge. Yeah. They don't regain that full activation. You're right. I would posit, though, that Harris's point is a really big one because I think, and it's interesting for, I imagine for those of you that do a lot of quad grafts, you've probably at some point seen this, the Cyclops lesion or the anterior, so-called anterior localized arterial fibrosis, whatever term you want to utilize, because it's somewhat different than the historical Cyclops lesion for a BTB, right? So Cyclops lesion for BTB is on the tibial side, Cyclops lesion, anterior arterial fibrosis, whatever. But the quad is actually on the femoral side. It's actually in the notch, which blocks extension in a different way. And so, and it has to do with the graft and that sort of thing. And so I think we, historically, have not been great at recognizing that, or we just assumed it was going to be fine. And they lack that two to three degrees of extension. And oftentimes they will lack that right away or very early on. And if they struggle to get that, like then that inhibition that's already occurring, as you alluded to, which is a great point, they just, they can't overcome it, like, or it takes a long, long time to overcome it. And so I think doing some of the things that we talked about, so early blood flow restriction, immediate rehab. So I like those patients see PT post-op day one, post-op day two, and are doing straight leg raises, straight leg raises, straight leg raises, and then making sure that they maintain that extension. So Harris asked about bracing. How many people in the quad, just a quick show of hands, how many people for just a primary ACL, isolated ACL reconstruction, use a brace immediately post-op still? So most of the crowd, actually, which is kind of surprising, I guess, since most of the studies show you don't need to. Clay, do you? You raised your hand. Yeah, I do. I do, but only to keep them in full extension or even hyperextension. That's the only reason I use it. So most of those braces do have a hyperextension. Correct. But I put them in minus 10. Yeah, same thing. I do the same thing. But you still end up at zero. Yeah. Right. You're still at zero. Yeah. Yeah. Or they actually flex their knee because it's more comfortable to flex their knee and they're in pain. Yeah. That's annoying. I don't have data to support this, but we've been adding IPAC blocks into all of our ACLs. And I do think that it probably, we actually looked at this in a prospective randomized control trial with and without IPAC block. And I surely expected them to have better extension. They actually had better flexion early post-operatively, which I have no explanation for. And there was no difference in extension. Maybe we were just underpowered to show a difference in extension. But I think adding that IPAC block does, even though our study didn't show it, my intuition is that it actually probably does help get them a little early better extension. I think it makes a difference too in pain. I would avoid femoral blocks. Hopefully most people aren't doing femorals on ACLs, no matter what your graft is. And then there's even some data coming out that like even avoiding blocks altogether, even adductor and IPAC, which I do the same thing. We do adductor IPAC combo. But there's some data coming out that maybe even avoiding blocks altogether, just so you don't have that risk of that one anesthesiologist that maybe wants to just kind of leak a little bit more towards the femoral nerve or whatever. I'm not blaming anesthesiologists in here or whoever does your blocks, but there's some evidence that's saying just even not doing blocks at all and have them doing straight leg raises in PACU, like as soon as they wake up, may provide some benefit or some decrease in that inhibition started to happen. We'll see. Do you have a question? Yes. Thanks. Hi. John Packer from University of Maryland. So we've had a lot of discussion about the high-risk athletes for obvious reasons, but I was wondering what the panel thought about, let's say you have a 19-year-old college football player, does not have a high-grade pivot shift. I do both grafts, but I do mostly BTPs in the college athlete. Are you guys doing augmentation on these athletes? I have a lot of debates with my partners about it. I'm not a believer yet that we need it for this type of patient. I just haven't seen the retail rates and I'm just curious what your thoughts were. I probably do an LET in a quarter of patients in the primary setting. I don't know. I seem to be using tape augmentation a little bit more frequently because I think it's very easy and low morbidity. I haven't seen many downsides to augmenting with tape, but I understand some of the reservations from historical perspective around putting something synthetic alongside your ACL graft. But I do think that Pat Smith was very, he's published probably as much on tape as anyone else, that he was very systematic in his way he did it. I think if you do it the correct way, which is totally independent of your graft, that there probably is very little downside. The other thing that I've started doing is putting the tape posteriorly, and recognizing my picture that the tape was anteriorly because I wanted to show it, but I've started putting the tape posteriorly intentionally because I'm fixing it in hyperextension and I think that I don't want it to impinge on the graft inflection. So if it's hyperextended and posterior to the graft, then I think it's less likely to be a problem as long as you fix it in hyperextension. So your question is a great one, because you specifically asked about the college football player, contact athlete, which is my favorite athlete, because I take care of Mizzou. So it's a good one. So I specifically asked some of the guys at the Combine, and so it's interesting because depending on the age of the NFL physician, you may get a different answer. So if you talk to Lee Kaplan or Jim Bradley, they're going to tell you, you can't do a soft tissue graft, you should do BTB, it's the gold standard. Cassandra would probably agree. But if you talk to other folks, they'll tell you that they're not going to get downgraded if you use a quad now or that the athlete's not going to get downgraded at the Combine necessarily. If you do that, I will tell you just to be frank, even though probably quads, 70% of my primary graft in the contact football player, I will use a BTB just because I don't want them to have any chance of getting downgraded. And typically I don't augment that unless it's just some of the factors, like I said, if we're hyperextender or if it's a revision or something like that. So being honest with that one there, even though I'm a big quad guy. Even from a kind of augment standpoint, we talk about these seizure tapes, but I know there's other proprietary stuff out there that you can augment the soft tissue portion of the BTB. We just don't know anything yet, right? So ideally kind of trying to add bulk to the soft tissue part of the BTB. We'll see, right? We know it's out there. We just don't know. We don't have any data to support that. And I agree, I think for that particular patient and your specific question, I wouldn't plan to augment. I don't think that we have to. I don't think that there's convincing evidence in the literature right now to say that we need to. So I agree with the comments that were made. I would use quad though. All right, guys. We're at 8.15. Thank you so much for the excellent discussion and thanks for being here.

ACL reconstruction

BPTB

quad autograft

lateral extra-articular tenodesis

internal suture augmentation

revision ACL

graft choices

functional bracing

surgical techniques

patient risks

biomechanical evidence