Next up is Michael Elia, one or two stages for revision ACL reconstruction. All right. Thank you, Harris. Thanks, Adnan, for the talk. So let's jump right into it. So for me, my reasons to stage number one is going to be any patient with suboptimal tunnels, and that's either regarding position or widening. Also you can stage if there's lots of work and you want to stage it. Perhaps the patient is scared of having one large surgery, et cetera. You can stage for information, your sort of inventory staging where you're taking a toll of everything that's going on in the knee, and that gives you lots of information you could use to make a deliberate second stage. But hopefully we can administer some take-home points for you. So take-home point number one is there really is no right answer, only with what you are comfortable with as a surgeon. The results of one-stage versus two-stage surgery are unfortunately fraught with selection bias, but they are similar with good outcomes. And obviously there's a lot of decisions that we have to make regarding cost versus benefit of one-stage versus two-stage surgery, which I won't get into here. Point number two is to obviously know your patient, and this is almost as important as the technicalities of the case themselves. You need to know the overall goals of the patient, of the elite athlete that's looking to walk without instability. You need to know the rehabilitation timeline. What will two rehabilitations look like for a patient? You need to understand their social support. You need to know what their work situation is. What are their family obligations? Because these will all impact the decisions that you make, as well as medical comorbidities. And revision ACL surgery, as we know, is not a cookbook. You will have to make decisions based on what the patient you think is best served for them. Point number three is to know your knee. Understanding the tunnel position is obviously crucial. For the femur, you could look at your classic burnout on aortal grid. A good tunnel would be posterior and proximal, right behind the Plumensat's line. For the tibia, the Stoible classification, roughly about 40% the width of the tibia. But why have only some information when you can actually have more information? We routinely get 3D CT scans with subtraction analysis on our femurs and our tibias, where you can see the exact dimensions and locations of the aperture. You can understand tunnel widening and the morphology of the bone loss, which is very important to understand. Some tunnels are nicely conical. You can easily get a bone graft into there. But some tunnels, unfortunately, as we know, are either cavitary or mushroom-shaped or cone-shaped. And you have to do some thinking on the fly. The gold standard, obviously, is to assess the tunnel intra-articulately and intraoperatively. This tunnel in particular has some conical components, but also some mushroom components as well, with some serpiginous-type extension approximately in the notch. So you might have to think about how you're going to bone graft this if that was what you wanted to do. But if we're going to one stage, how can we really do this effectively? We have to understand how our bone loss is and what our options are. So number one option is hardware augmentation. We could do a single-stage revision with either stacked screws, like you see in this, whether it's biocomposite or metal. Or you can use jumbo interference screws. Obviously, these are going to be larger screws. And if they fail, you might have a little bit more of a problem with bone loss than you started with. But these are certainly options. Option number two is to fill the void with something. And there's lots of options on our table. Number one, we could use structural bone void filler, like calcium phosphate. You can certainly do this in a one-stage revision. There has been data out there showing that it works. You can use impaction grafting using prefabricated bone dowels, which is my favorite technique for this. Or you can apply the matchstick technique. Or you can deliver it morselized with DBM, putty. You can add PRP or BMAC if you like. And there's lots of different options to use to inject this substance into the tunnels. Option number three is to change your graft choice. For me, personally, I like to use bone in all my revisions if I can. If you have large defects, you can actually take pre-made BTB or Achilles, fashion the tunnel how you want, fashion the graft how you want. You can rotate the graft. You can flip the graft to get more bone in the tunnels. And use your soft tissue portion of the graft to give you a more anatomic ACL reconstruction. Option number four, tunnels, what tunnels? Obviously, this is a throwback to one of my favorite movies. If you get the reference, that's awesome. If not, then you have some work to do, unfortunately. But you can go over the top here, extra-articulate like we were taught back in the 1970s, 1980s, and get a very good result and neglect the tunnels completely. Option number five is to do a two-stage surgery. For two stages, for me, I like to use allograft, either cancellous chips, bone dowels, which is really much my workhorse. They come in prefabricated sizes, 12, 14, sometimes 16, that you have to order before this case, as well as demineralized bone matrix. Sometimes you have to worry about hardware, either hardware that you cannot get out or hardware that you do have to get out. And if we have to think about this, then we could certainly diverge the tunnels. Let's say it was done inside out. You could do the other one outside in. Just change the angle of your tunnel with the same aperture, and hopefully you'll get a good result. You could take out the hardware and redo it, or again, you could do it over the top on the femoral side and neglect the hardware completely. My philosophy on two-stage revisions versus one-stage revision, I almost always one-stage this unless I really have to two-stage it, but that's just a personal preference. If I want more information to make an educated decision, then I will do an inventory arthroscopy because it's a quick rehab. Number two is if there's huge bone defects and the patient can handle two surgeries, and my preference is to do a two-stage. Number three, if I'm thinking about any sort of osteotomy plus meniscus transplant plus ACL, sort of the granddaddy of them all, I will always do an osteotomy first with bone grafting, allow the bone to consolidate, and essentially I'll have virgin tibia and virgin femoral bone that I could use for my meniscal tunnels and my ACL tunnels. So going back to point one, there really is no right answer, only what you are comfortable with. So my overall advice is be thoughtful, be deliberate, and execute the plan in your mind before the case and you will execute it during the surgery. Thank you.

ACL revision surgery

patient-specific factors

bone loss

surgical strategies

surgeon confidence

one-stage vs two-stage

surgical techniques

patient goals

surgical planning