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September 27, 2023

WTF is an ALL?

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Dr. Yoni Rosenblatt: Hey, guys. Thanks for tuning back into the True Sports Physical Therapy Podcast. On this episode, you're gonna hear Dr. Ashley Bassett of the Orthopedic Institute of New Jersey explain to us what the ALL is. It's the anterolateral ligament. But we're gonna dive into why it's important, especially how it affects ACL retear rates and ACL reconstructions. We're also gonna talk about LETs. And so that's the lateral extra-articular tenodesis, usually with the ITB. It is the latest and greatest. You've heard me talk about it on different ACL podcasts. Obviously, we have our own ACL course coming up, the True Sports Physical Therapy Guide, the ACL Rehabilitation. And ALL and LETs seem to be the future of ACL reconstruction. Maybe we'll change your mind on that coming up. But Dr. Bassett does a great job of really explaining what transpires in the OR, both with ACL, with the ALL, and perhaps with the LET. And then we get into different graft choices and what she likes to see immediately post-op. Even pre-hab, we dive into. And she just does a great job of making things clinically relevant, both orthopedically, orthopedic surgically, as well as physical therapy and how it's gonna affect your patients and your rehabilitation protocols and processes, and that's what we're about.

Dr. Yoni Rosenblatt: So great conversation forthcoming. Can't wait to get some of your guys feedback. Of course, look out for that new ACL course. We're about to drop it. So as soon as we do, we'll be offering discounts to all of our loyal listeners here. And we're always looking for feedback. So feel free to reach us @truesportspt on Instagram, or shoot me an email, We always wanna hear what we could do better or what you absolutely loved about the pod. Without further ado, here's my conversation with Dr. Ashley Bassett.

Dr. Yoni Rosenblatt: Welcome to the True Sports Physical Therapy Podcast. We got Dr. Ashley Bassett with us today. Her background is awesome. I can't wait to hear even a little bit more about her background. I'm interested to see if she mentions Harvard, [chuckle] because a lot of people just reference it as the school in Boston. But before we get rolling, Dr. Bassett, tell us about your background and how you got all the way to where you are today.

Dr. Ashley Bassett: Yeah, absolutely. So I grew up in New Jersey, where I currently practice now. So I went to a medical school in New Jersey. It was originally UMDNJ, Robert Wood Johnson. Now it is Rutgers University Medical School. After medical school, I went and yes, I'll admit, I did my orthopedic residency surgical training at Harvard, which was awesome. I trained at Mass General, Brigham, Beth Israel and Children. So it was a really well-rounded, really awesome experience. I learned a lot there. And then I did a one-year sports medicine fellowship training at the Roth Orthopedic Institute in Philadelphia, where I got to work with all my favorite sports teams for a year, which was really awesome. And then I returned to New Jersey to kind of return to my hometown, where I'm currently practicing now in a private practice called the Orthopedic Institute of New Jersey. And I've been there now for four years. So it's been really great. It's been a great journey.

Dr. Yoni Rosenblatt: And I've gotten to know you a little bit, more so through the shoulder world, but I'm really excited to dive into all things ACL and even more specifically ALL, as well as getting into some of your graft choices and things of that nature. We actually have an ACL course coming up. So we're putting together a ton of ACL content.

Dr. Ashley Bassett: Nice.

Dr. Yoni Rosenblatt: We're gonna talk about, in that course, the way we approach ACL rehabilitation and try to maximize our outcomes with our athletes. I'm really looking forward to hearing what it is that's new in your world with ACL, specifically. How would you say your approach to ACLs have changed over the last few years? 

Dr. Ashley Bassett: Yoni, I think I lost you there for a second. I heard "How do you."

Dr. Yoni Rosenblatt: I don't know. Tell me when you got me. Tell me when you're back. Tell me when you're back. How about now? 

Dr. Ashley Bassett: Can you hear me? 

Dr. Yoni Rosenblatt: Yes, I got you.

Dr. Ashley Bassett: Oh, I can hear you now. Yeah. There you go. Sorry, I lost you there for a second.

Dr. Yoni Rosenblatt: Okay, awesome. No problem. Okay, so tell... I was just telling you, we got this awesome ACL course coming out really shortly, the True Sports Guide to ACL Rehabilitation, and it really highlights a lot of the nuances and that which has changed in the last few years, looking at how to maximize our outcomes, I wanna know. From you, Doc, what have you learned and really changed with your ACL approach in the last few years? 

Dr. Ashley Bassett: Yeah, so a lot. I usually talk about why I love sports medicine so much, is because it changes constantly, which is really exciting to me. So in terms of starting with surgical techniques, so coming out of residency and fellowship, we were all doing independent tunnel drilling, meaning usually, the femoral tunnel and the tibial tunnel separately. But we were seeing a bit of trans-tibial, which is kind of the old school way of doing it. So I think doing that different surgical approach.

Dr. Ashley Bassett: Graft choice certainly has changed over the years. So I was trained primarily in BTB, or patellar tendon, as well as hamstring tendon. We really weren't doing quad tendon at all, and now it's a substantial portion of my practice. It's a newer graft. It's showing great outcomes. You can do all soft tissue, you can do it with a bone piece, so that's really exciting. So definitely graft choice has come a long way. And then appreciation of the other issues that you need to address the time of surgery. So knowing to look for those ramp lesion meniscus tears and those root tear meniscus tears, making sure that you don't miss those. Those can compromise outcomes, looking for other ligamentous injuries too, really looking on MRI and physical exam to make sure you're not missing a multi-ligamentous injury that can lead to ACL failure, and then, which we'll get into in a little bit, addressing some high-risk patients with the addition of an ALL reconstruction or an LET. So that definitely was not something I saw in residency. Not even in fellowship. And so that's something really new that I'm really excited to be doing in my high-risk patient population. So it's really come a long way just in the past five years.

Dr. Yoni Rosenblatt: That's awesome to hear you say things have changed and that excites you. I think that makes you an anomaly, because I get a lot of referrals from docs that are doing the same goddamn surgery they've been doing since they got out of school. [chuckle] And so I'm thrilled, and I know a lot of the listeners are thrilled, to hear that you're constantly changing, and hopefully, evolving just for the betterment of the patient, and that's really cool. I think it takes an amount of humility from the provider to say, "Hey, I used to do it like this, but I think I found something better."

Dr. Ashley Bassett: It's also uncomfortable at times. I feel when I pick up a new surgical technique, I'm not as fast. It's a little bit of a struggle at times. You're... And surgeons don't like to feel uncomfortable. We don't... We like having muscle memory and just doing it the same way we've always done it. There's comfort in knowing. But I think when data comes out suggesting that there is a better way to do something, we owe it to our patients to change of how we're doing it and go through that period of being uncomfortable, to make sure that we're doing the right thing for them.

Dr. Yoni Rosenblatt: Hell, yeah. And the patient comes first. And I think sometimes, unfortunately, that gets lost. So you mentioned ALL, which is really what I wanna dive into today. Tell us what the hell the ALL is and when you first... When it kinda came to your consciousness that there is this ALL in the knee and then it might make a difference.

Dr. Ashley Bassett: Yeah, so it's kind of a funny story. So I remember exactly when I first learned about the ALL. Not because I was in residency or something, educational book, because my sister who is not in medicine at all, she's a lawyer, she sent me a news article that just said, "Scientists discover new knee ligament." And she sent it to me and she said, "Do you guys throw parties when this stuff happens?"

Dr. Yoni Rosenblatt: It's a good one.

Dr. Ashley Bassett: And I laughed. I was like, "We probably should." But I remember reading the article, and a lot of my established attendings were like, "We knew about that. It's not new. It's always been there." But I think what those scientists did is they identified the importance of that ligament. And up until that point, no one really cared about the anterolateral ligament, what became the anterolateral complex, because who cared? But now we know it contributes to rotational stability, specifically in the setting of ACL injuries, and so there's definitely more of a highlight on its importance. So you asked what the ALL is, so the anterolateral...

Dr. Yoni Rosenblatt: I think I said, "What the hell is the ALL?"

Dr. Ashley Bassett: Yes. [laughter] So I can definitely expand on that.

Dr. Yoni Rosenblatt: Okay. Please.

Dr. Ashley Bassett: So the anterolateral ligament, now, we know it's more of a complex. So the anterolateral complex is composed of the superficial and deep portions of the iliotibial band, as well as anterolateral ligament, which is actually a thickening of the anterolateral capsule. So it's encompassed within the capsule. And so I think understanding that it's a complex really leads us to understand better the surgical techniques to address it. So there's... We'll get into it a little bit, but there's ALL reconstruction, there's LET. Why are there so many different surgical techniques? Well, because it's a complex, and each of these techniques addresses that complex in a different way, with the same goal of restoring that rotational stability to the outside of the knee.

Dr. Yoni Rosenblatt: Okay, so it lives along the outside. It prevents tibia from rotating on femur, or femur from rotating on tibia, depending upon that which is fixed, right? 

Dr. Ashley Bassett: Yes, absolutely.

Dr. Yoni Rosenblatt: Okay. And then is it always damaged with an ACL tear? 

Dr. Ashley Bassett: No, that's a really good question. I don't know that we know the true instance, and I think the problem is it's really difficult to identify on MRI. But you raised a really good point. The mechanism of ACL injury is that plant dynamic knee valgus rotational injury. So it's not just injuring the ACL, it's injuring the anterolateral capsule and possibly the ALC. I think if we see a Segond fracture, we know it's an avulsion of that, maybe iliotibial band, lateral capsule. We know there's an injury there. That's a sure shot, we have to do something there to address it. But what about the MRI looks normal? Should we still be addressing that? And I don't know, we have fully clarified that answer you get at this point.

Dr. Yoni Rosenblatt: Yeah, but good answer. Sometimes it's okay to say, "We don't know," right? 

Dr. Ashley Bassett: Yeah.

Dr. Yoni Rosenblatt: Okay. So patient tears their ACL. You're looking at the MR? And are you looking at the health of the ALL on an MRI, or you're waiting till you're in there? 

Dr. Ashley Bassett: So it's two-fold. So I definitely look at the MRI and see if I can identify an avulsion of the ALL or an injury to the anterolateral capsule, or a Segond fracture that wasn't appreciated on x-ray. But mostly, I'm basing my decision as to whether or not I think that has been compromised in my physical exam. So for me to add in an extra-articular lateral stabilization procedure, whether it'd be an ALL or an LET, I do LET. Some people do ALL. I think it's... The decision, it's equivalent in terms of outcomes after either technique. I just do LET. For me, deciding on who I'm adding that to, it depends on the physical exam. So if they have a high grade pivot shift, if they have significant anterior laxity, so greater than 5 millimeter side to side difference if they're high risk, so generalized ligamentous laxity with a Beighton score of greater than four or a generic or bottom greater than 10 degrees, or if I see on MRI an ALC injury, those are the patients that I'm definitely doing a LET in. And there are other indications too, but they are more patient-specific. I would say on exam, those are the things that I'm looking for.

Dr. Yoni Rosenblatt: Okay. They have a disruption of ALL or they have this increased laxity. Tell me how you approach an ALL disruption, or I guess reconstruction, or reinforcement? What are your options?

Dr. Ashley Bassett: Exactly. So I think there's two main options that you can do. So you can do an ALL reconstruction or you can do a lateral extra-articular tenodesis and LET, iliotibial band tenodesis is also called, 'cause it uses the IT band. So you can do either one. And at this point, there are a couple of studies, looking at both, and they've found pretty equivalent outcomes. So for me, I just feel more comfortable with an LET. The only difference... Not the only difference, but the main difference between an ALL reconstruction and an LET is that an LET uses local graft, so the iliotibial band, while the ALL uses a free graft. So usually, an allograft, like a semitendinosus allograft, you could harvest an autograph, but I don't think most people are doing that. So there's two fixation points with the ALL, 'cause you're taking a graft, you're attaching it to the distal femur and the proximal tibia, usually at Gerdy's tubercle, versus the LET, you're leaving it already attached at Gerdy's where the IT band actually attaches and you're just attaching it to the distal femur. So it's another reason I like LET. It's only one fixation point to worry about versus two. So I'm usually doing that LET. And I can talk about about how I do an LET a little later if you want me to, but ALL reconstruction, I'm not usually doing, 'cause I just like the locally available graft.

Dr. Yoni Rosenblatt: Okay. So you're usually going to LET. And then what you described is you keep a fixation point at Gerdy's tubercle. You then what? Remove a proximal attachment and slide it over? 

Dr. Ashley Bassett: Essentially, yes. So I take a strip, so make about a 7 centimeter incision, find the posterior edge of the iliotibial band, take a strip that's about a centimeter in width and about 7 centimeters in length. I whip stitch the... I detach approximately. Like you said, whip-stitch about 2 centimeters, and then I shuttle it deep to the LCL from anterior to posterior, and then attach it via an anchor, basically a suture staple technique, just posterior and proximal to the attachment of the LCL.

Dr. Yoni Rosenblatt: Okay. So it's like you're kind of putting the seat belt on the lateral knee just to give it more stability and decrease that rotation around the tibia. That's really cool. I always wonder, how the hell do you guys learn this? When do you learn this? Is this like a webinar?

Dr. Ashley Bassett: Yeah, so it's so funny. This is something where I really think people need to be comfortable getting in a lab and teaching themselves new techniques, because this is something that's been shown in studies to really help patients, particularly high-risk patients, and it can't be, "Well, I didn't see in a fellowship, so I'm just never gonna do it." So for me, I saw enough multi-ligamentous reconstructions in fellowships that I felt comfortable along the lateral aspect of the knee. So I did a lab with my rep, and I basically just did the approach, harvested the piece and did it, and I felt comfortable enough at that point doing it in the operating room. It's a lot of very similar surgical approaches to the lateral aspect of the knee, and then using a very similar anchor that I use for like anchor repair and MPFL reconstruction. So I didn't feel too foreign, but I definitely... I practice any surgical technique that I'm doing for the first time in a lab setting to make sure that I work on all the kinks there.

Dr. Yoni Rosenblatt: And you do it... So you do it until you feel like you've got it. When you approach that first patient, do you tell them, "Listen, I'm gonna try something. It worked in a lab. I think it'll work on you," or you just say, "Yeah, I've been doing this for a while?"

Dr. Ashley Bassett: I do tell people that LET in and of itself is a uncommon procedure at this point. I tell people how many I've done. So the first one, I did tell them that I hadn't done one before, but it's showing really good outcomes. To me, it's a, technically, I won't say easy, but of all the techniques you could add in, a simple procedure to add in that's been practiced. And so I'm very upfront with people about that. But I also tell people that I don't think there's a lot of people around the country doing these five a day. It's not that common. I think if you're using the correct indications, you're not doing this every time you do an ACL. So I think it is an uncommon procedure, at least for now, and so I think they should just have to be comfortable with that.

Dr. Yoni Rosenblatt: Okay. So give me a percentage. How often are you doing this? 

Dr. Ashley Bassett: So I would say at this point, if you'd ask me that when I first started, I would say maybe 5% of ACLs. Now, I think I'm appreciating more that hyper-laxity concern and those more high-grade pivot shifts, so like chronic ACLs, we know they have a higher grade pivot shift 'cause they've led to all that compromise of the surrounding soft tissue with all those years without an ACL, so definitely appreciating that more. And I take care of lot of female athletes. And females tend to be more hyper-relaxed. So I think I'm appreciating that more. And I'm also giving patients the option. So we may talk about this in a little bit, but there are a couple of studies that just came out looking at adding an LET to patients, just because they participate in high-level cutting and pivoting. They didn't have laxity, they didn't have a high-grade pivot, they didn't... All they did is a high-level football in collegiate sports, and they had a significantly lower rate of re-rupture after a primary ACL with the addition of LET.

Dr. Ashley Bassett: So I started offering this to patients who are planning on playing in college and giving them the opportunity. I'm not pushing them one way or the other, but I'm saying, "Hey, this may lower your rate of retear. It's an additional incision, it's longer surgery, it's more pain, but it may lower your risk" and some patients are going for it in that setting. So I would probably say maybe it's more like 10-15% now, but it's still not 50-50.

Dr. Yoni Rosenblatt: Well, what are some of the downsides? You mentioned decision, maybe some lateral pain. Although I don't see that a ton.

Dr. Ashley Bassett: Really?

Dr. Yoni Rosenblatt: Yeah. What else are you worried about? And what prevents it from being the gold standard? 

Dr. Ashley Bassett: Yeah, so it's funny you mentioned lateral pain and I wonder if why you're seeing it less is because the change in the implants and the technique. So the old school way of doing this, and I did it this way when I first started, was to use a metal staple along the outside. And I take care of a lot of females, like they're gonna feel that right through the skin. They already have a prominent, a tight IT band, that didn't help anyone. So now I do that suture staple and I'm seeing less lateral pain, like you pointed out. So I think maybe we'll see that decline. I definitely talk about more incisions and incisions to heal. Sometimes the brace can rub on that outside, the lateral incision, so I warn people about that.

Dr. Ashley Bassett: Longer surgery, longer surgical time. Now, in terms of quad strength, some studies have shown slower to regain quad strength. The stability study, which is the biggest randomized controlled study, looked at addition of LET to hamstring autograph and found that all the way up to six months, they had quad deficits compared to ACL alone, but it equalized at 12 months.

Dr. Ashley Bassett: So I tell people like, you may lag behind the person next to you at rehab, who's like doing a standard ACL, but you will get there. It just may take a little bit. I think I want to point out, as people always talk about like risk of arthritis, a lateral compartment overconstrained and risk of arthritis. There's a big systematic review looking at this and found no increased risk of arthritis, especially when I tension it, I do minimal tension and I hold them in 70 degrees per LaPrad's study to make sure I don't overconstrain. So that's not really a concern to me. I just make sure I try not to over-tension them.

Dr. Yoni Rosenblatt:
Yeah, do you see increased difficulty getting their full flexion back or maybe even extension? 

Dr. Ashley Bassett: In the early phases, I do see some difficulty in progressing motion. I don't know if that's because of the slight increase in pain because the additional incision and the work over there, or if that is more just because of the extra tightness, but I have not had a patient not get back their full motion. And I can say, and I'm going to knock on wood as I say this, I have not had an ACL patient go on to need a manipulation or a lysis, but I also work with fantastic PTs. And I'm not just saying that 'cause I'm on this podcast. I make sure any ACL goes to a very established ACL physical therapist that's going to work diligently on motion with them. And so I think as long as they're in the right hands, I don't think that I worry about LET compromising, at least their long-term motion.

Dr. Yoni Rosenblatt: Do you instruct the therapist or change, I guess, the protocol for the patient? Does it change anything about their rehab process when you add this LET? 

Dr. Ashley Bassett: It doesn't. And in fact, I make a point to tell the therapist that because people see this new procedure and they're worried, I mean, no one wants to hurt something, break something, rip something that was just reconstructed or repaired. And I tell them that it's exactly the same as a regular ACL. My goal is 90 degrees by two weeks, 120 by four, full motion by six. And it doesn't change with an LET. And if anything, I tell people they may have to push them a little harder.

Dr. Yoni Rosenblatt: Those are great goals. Where'd you get those? 90 by two, say it again, 90 by two weeks.

Dr. Ashley Bassett: 90 by two, 120 by four and full by six. And I do let my patients in on a little bit that everyone hit, usually everyone hits 90 by two, that 120, that jump to 120 by four weeks is definitely challenging. But because I push them to get to 120 and I'm so on them, they usually hit around like 110, 115, and they're a little discouraged with themselves, but they're like pushing to get there. And then by the time I see them back at six, they're near full. And I always tell people that the quicker you can get back motion, the better you're gonna feel, the easier your recovery is going to be. Once that stiffness starts to set in, that lack of extension or that lack of flexion, I really worry about it holding back recovery of quad strength and all the other things that I want to be a part of your rehab.

 Dr. Yoni Rosenblatt: Yeah, do you see people usually struggling with extension more than flexion? Let's say specifically with ALL. Do you notice a difference? 

Dr. Ashley Bassett: I haven't. But then again, I'm curious to see what you think, 'cause you take care of a lot of patients with sports injuries and ACL. I use a brace still after ACL reconstruction. And I know there's lots of studies coming out that say you don't need them. You don't need it, I know.

Dr. Yoni Rosenblatt: Why do you use a brace? 

Dr. Ashley Bassett: I'd still, because honestly, that exact reason. So I have them sleep in a brace, locked up fully straight.

Dr. Yoni Rosenblatt: Okay. So you're saying, what, like a Bledsoe coming out? 

Dr. Ashley Bassett: Yeah, they have a Bledsoe coming out of the surgery, and I do it for six weeks, but there's many, many studies that are showing you don't need to brace ACL patients after surgery. But for me, I worry about that extension, and I just feel comfortable keeping them locked out straight at nighttime, and then unlocked during the day for them to move. And so I think that helps. What do you think? 

Dr. Yoni Rosenblatt: I mean, here's my counterpoint to that, which is when they're in that Bledsoe, like any adhesions or arthrofibrosis that I've seen, they're not missing 20 degrees of knee extension, right? Like they're missing their last five or three. If you see your patients in that Bledsoe, they're sitting at three to five. Like if it's gonna freeze...

Dr. Ashley Bassett: I totally agree.

Dr. Yoni Rosenblatt: That Bledsoe ain't helping, would be my counterpoint.

Dr. Ashley Bassett: I completely agree with you, 'cause I've actually said that to people. I'll watch them put it on, they'll put their leg on the table, bend it to five degrees, and then put the brace on and pull extension. I'm like, that's not doing anything. So I show them, you gotta put it on, you gotta get the leg straight, put it on. And even then, then you can apply like a hyperextension to get it a little bit more. But I tell, that's why I say to people, you gotta go to physical therapy immediately after surgery, because as you pointed out, a brace isn't gonna get you there, CPM isn't gonna get you there, nothing's gonna get you there, than someone putting their hands on you and stretching you into full extension and working on your flexion.

Dr. Yoni Rosenblatt: Yeah, I've noticed, oh, I think you're right. Thanks for that plug for PTs.

Dr. Ashley Bassett: Of course.

Dr. Yoni Rosenblatt: How quickly do you send them in for rehab? 

Dr. Ashley Bassett: So I see all of my patients on post-sep day three. Though it's interesting, I was chatting with one of my colleagues, she sees them the day after. But I just see, I operate on Tuesdays, I see them on Friday. And I have them start their PT as soon as we do a dressing change on Friday. So I make sure that they have a PT already identified before surgery. Once their surgical day is booked, they book their first PT visit for after that. I wanna see them, check the incisions, drain the knee if I have to, put a lighter dressing on, and then I get them into PT that day.

Dr. Yoni Rosenblatt: You'll drain the knee that Friday? 

Dr. Ashley Bassett: If they need it. So if they have a large hemarthrosis, then I will drain it to decrease some of that tense effusion and allow them to make more progress with motion. If they don't need to, I don't. I don't love sticking a needle into a sterile knee that I just operated on. But if it's gonna really like hold back their quad recovery and their ability to flex, then I will drain them.

Dr. Yoni Rosenblatt: Where did you get that? That's an awesome idea. Where'd that come from?

Dr. Ashley Bassett: That came from a very experienced PA in my practice. So when I first joined my practice, I was given, I guess I borrowed this PA who's been in practice for 20 years. Her name is Diane. So I'll make sure she listens to this episode.

Dr. Yoni Rosenblatt: Thank you.

Dr. Ashley Bassett: And she, and it was great because when I first started you're still figuring things out. Like you're fresh out of fellowship, you know all the data, but like truly practicality, like in the operating room, having her be there was really helpful for me. And first post-op, she was like, oh yeah, I drain every single ACL. And I was like, I had never seen that before. First couple I was hesitant to because I was worried about they just had surgery, this and that. And then I started and I just saw a quicker recovery of motion and patients are just, they feel better. They just, they had less pain, less inhibition. And so now I do it again, if I feel they need it. If it's a mild effusion, then I just will ice, tell them to ice and leave it alone. But if it's a good size effusion, I will drain them.

Dr. Yoni Rosenblatt: Do you have any idea what percentage of your ACL reconstructions require a subsequent scope because of motion or arthrofibrosis? 

Dr. Ashley Bassett: Me personally? 

Dr. Yoni Rosenblatt: You.

Dr. Ashley Bassett: Zero.

Dr. Yoni Rosenblatt: What does that mean, you've never done a scope? 

Dr. Ashley Bassett: Lysis of adhesions and manipulation after an ACL, no. I've had to do one in my entire practice thus far. And it was because of a patella tendon repair and he went on to arthrofibrosis and I lysised him. I do tibial tubercle osteotomies and BFL reconstructions and ACLs. And I haven't had to, but again, I'm, so for me, when I hear patients have gotten stiff and I ask them how frequently they saw their surgeon and they said, well, he said to come back in four weeks. That's not, if someone's stiff, I'm seeing them weekly to make sure that their motion is coming back. I'm calling their physical therapist. I'm upping their PT visits to four times a week. I don't care if they run out on the back end. We'll address that then. But for me, getting back motion is the most vital thing. So I think it's because I'm so... I stalk my patients to make sure that they are doing what they're supposed to do. I think that's why I haven't seen that.

Dr. Yoni Rosenblatt: If you didn't graduate top in your class and then go to Harvard, I would have said you should have been a PT. Because like that obsession is essential. That is a crazy statistic, doc, that you've done one. That's really amazing. It makes me want to talk to the surgeons that refer us patients to consider. I think that draining idea is fascinating because that big swollen, angry knee just keeps it slightly flexed. And then you're dead.

Dr. Ashley Bassett: Exactly, exactly.

Dr. Yoni Rosenblatt: So maybe it's that. What other interventions are you doing like when you start stalking them to prevent it from adhesing? 

Dr. Ashley Bassett: So it's all, I think setting the goals has been really helpful. Making it clear what I want them to hit. Making sure they have PT set up in advance. I think even if they delay like a week, it starts to set in, like you were saying. Definitely keeping a close eye on them and doing the drainage if necessary. I've drained people sometimes a second post-op visit. They start PT and they get swollen 'cause they're doing more. I'll drain them then. And then I do a, I'm sure you've seen this, that you do this a lot. I do a cryo cuff in all of my ACL patients and I put it underneath the dressing and I run it continuously for the 24, every 24 hours for the three days. And then afterwards I have them iced numerous times. So I make sure that they are doing all these different approaches to make sure that they have the best chance of limiting their stiffness.

Dr. Yoni Rosenblatt: Well, it sounds like they have a really good chance. What is your tourniquet time on the average ACL and then how different is it with the LET? 

Dr. Ashley Bassett: Yeah, so for me, I...

Dr. Yoni Rosenblatt: By the way, is this like asking how much money you make? I don't know if this is like over the line, but...

Dr. Ashley Bassett: I think it's so funny because when we do our board collection, they make us say how long our tourniquet time is, which is almost like you're gonna get in trouble if it's too long. So for me, obviously, you wanna try to keep tourniquet time as low as possible. I started doing my graft harvest without tourniquet because I felt like I didn't really need it. What I really need it is when I'm drilling the tunnels in the knee and I wanna make sure that I have great visualization for what I'm doing inter-articularly. So for me, I don't inflate until after I harvest the graft, the graft is being prepared, I close everything up, then I go up with the tourniquet and then I go into the knee and I start doing my inter-articular work.

Dr. Ashley Bassett: And that gives me plenty of tourniquet time in case I need to do a meniscus repair or a root repair or a lot of other work that way I'm not running out of tourniquet. And so I would say with that change, I would say it's about an hour for the inter-articular work and all that, for a standard ACL. Adding an LET, so sometimes I'll go up and then I'll come back down with it just because I don't wanna run out of tourniquet time in terms of placing my graft and making sure I can get my interference screws in and have great visualization. And again, I don't feel like I need the tourniquet for the lateral approach because it's a pretty clean plane, it's not particularly bloody. So oftentimes I will deflate, do the lateral approach and then go back in and re-inflate the tourniquet so I can see.

Dr. Yoni Rosenblatt: And so that tacks on how much of tourniquet time when you re-inflate it? 

Dr. Ashley Bassett:
When I re-inflate, it's probably about maybe like 15, 20 more minutes 'cause you have to clean out all the blood that has inevitably like gone into the knee and things like that. But in terms of adding an LET to an ACL, I'm sure that there's a million ways of doing it, but I have a specific order in how I do it because for me, your lateral, your tunnel, you're drilling your ACL is lateral femoral condyle, I am just petrified of hitting my ACL. So I will drill, I'll harvest the graft, I drill my tunnels for ACL and then I come out and I place the anchor for the LET and then I place the ACL graft and then I secure the LET. And the reason why is the last thing I want is to be drilling for my anchor for LET and go right into my ACL graft because my angle is off.

Dr. Ashley Bassett: And people say, oh, you just aim proximal and anterior and you're gonna miss it. I'm not chancing that. So I just, I go out, I place my anchor, I go back in, I place my graft 'cause it's the most precious part. And then I go back out and I secure the LET once I know the ACL is safely in place.

Dr. Yoni Rosenblatt:
You learned that in the lab? Like, does that come along with your lab work? When do you figure that out? 

Dr. Ashley Bassett: So I just knew drilling in that area. I was worried. So I kind of learned tunnel management with doing like a posterolateral corner and an ACL together. And you worry about those tunnels being near each other. So when I first planned my first LET, I knew that I would be worried about that. And I drilled my anchor and I watched in the tunnel as I was drilling and it went right through the ACL tunnel. Now it didn't end up compromising. When the anchor pulled back, it was fine. But once I saw that, I was like, every time I'm gonna drill this, make sure it's set. Just for me, I think something training has always taught me is that things can go wrong at any point. The best laid plan. So anything you can do to minimize a hiccup, I think is beneficial. Even if it adds on 10, 15 more minutes, I think it's beneficial just to prevent that hiccup and that issue down the line.

Dr. Yoni Rosenblatt: So the reason I love having these conversations with surgeons is because too often, we don't know what goes on once that patient goes to sleep, right? And so it's interesting to hear about different techniques and the whip stitch and all this stuff. But the other things that you're mentioning factor in so heavily to what they look like post and also makes me think, maybe I used to see LETs get so damn stiff, specifically into flexion because of a lot of what you're mentioning. Like all of these nuances of, was something hit? Was something nicked? Was, is that gonna incite increased inflammation? Where exactly are they? Are they leaving it on Gurney's tubercle? What is there? All of that really makes such a difference in I think outcomes. And then that's what leads to us saying, you gotta see Bassett. You gotta go, I don't know why, but the knees are better, right? But it's hearing these nuances that is probably why. A big thing is that tourniquet time. Us as PTs, let me rephrase that. I didn't think about that. It just wasn't on my radar. Like why is this doctor's knees getting straight and quads are turning on and this doctor's aren't? So much of that could be tourniquet time as an example.

Dr. Ashley Bassett: Absolutely. Absolutely.

Dr. Yoni Rosenblatt: That's really interesting. Why do you think the LETs have poor quadriceps strength at six months? 

Dr. Ashley Bassett: Yeah, that's a really good question. I was wondering that when I was reading that paper and the only thing I could think of was pain because I know that pain can lead to quad inhibition. And I tell people that all the time. You have an injury, you fall on your knee and you basically have some anterior knee pain that it can lead to some quad shutdown. And all of a sudden then you're having this functional instability because your quad isn't strong and then it's like a vicious cycle. So that's what I was thinking. I mean, the graph they used was hamstring. So nowhere near the quad, nowhere near the extension mechanism. They didn't even use BTP. So it really doesn't make a lot of sense to me that the quad would be so impacted other than perhaps pain because I don't think the IT band contributes very much to that. And they only took a strip of it and they only closed approximately. They didn't close it distally. So it's not like the IT band got overly tight. So the only explanation I could think of was that it correlated with pain perhaps.

Dr. Yoni Rosenblatt: No, it's gotta be tourniquet time. It's gotta be tourniquet time.

Dr. Ashley Bassett: Oh, you think? Okay and they didn't report that. That's really interesting. They didn't report like use of the tourniquet or how much tourniquet time between the ACL Alone and ACL LET, at least to my knowledge. I'll check the paper.

Dr. Yoni Rosenblatt: So I think that would be interesting. Do you recommend electric stim, a home electric stim unit to your patients pre-op and then in preparation for post-op care? 

Dr. Ashley Bassett: So pre-op, I don't, but I do have all of my ACLs undergo prehab, even if they look good, just to make sure that there's no quad deficiency and make sure that their motion is full. I essentially joke with my patients that I'm gonna make your knee feel like you don't need surgery. You're gonna have full motion, no pain, no effusion and excellent strength. And then I'm gonna operate on you and set you way back because what you go into surgery with is predictive of what you're gonna come out of surgery with. More important to me than stim, although stim is definitely an important modality, is BFR. So I really love blood flow restriction therapy. So I have people do it pre-op, not only to help wake up the quad under less strain on an already inflamed knee, but also to teach them what it's like so they know what to expect post-operatively. And I start BFR two weeks after surgery once I confirm the incisions look like they're okay. And I continue it up until about 12 weeks or more if they are doing well with it. So that's something that's really important to me with regards to the ACL rehab. I mean, stim definitely, I think, has a role, especially with waking up that initial quad, but I think BFR is really like the future.

Dr. Yoni Rosenblatt: Okay, so it's the present.

Dr. Ashley Bassett: Yeah. The present, exactly.

Dr. Yoni Rosenblatt: What about this? What if you had your patients order a home stim unit pre-op so that when they wake up from the damage you just did to their knee, they can put those pads on their quads immediately and learn how to wake up their quad? If it's tourniquet time and it's quad recruitment, and those are, tourniquet time is higher, quad recruitment is worse, coming out of an LET, send them home with a stim unit. Tell me why you wouldn't.

Dr. Ashley Bassett: I think that's great. I think we definitely have to, I always am very conscious of costs and what insurances will cover. So for instance, like, you heard me mention CPM. If insurance will cover it, I think it's a great thing. People don't wanna do very much the first three days after surgery, they throw their leg in there. So if Stim will be covered or if it's not too cost prohibitive, I think that's excellent. I think anything patients can do to be active while recovering at home, within the bounds of their recovery, I think that's really important and that's definitely really helpful. I'd be curious do you see a difference if you get this information from the surgeon in terms of quad recovery and waking back up the quad based on the type of block that the patient has? 

Dr. Yoni Rosenblatt: Okay. So no, we don't get enough of the information, but that's why I love having you guys on. Also, it sounds like you host your own pod the way you ask me questions.

Dr. Ashley Bassett: Oh, sorry.

Dr. Yoni Rosenblatt: That's okay.

Dr. Ashley Bassett: It's a habit. It just flies out of my mouth.

Dr. Yoni Rosenblatt: No, that's great. Okay, so give us the options of what you consider with the blocks, and what you've seen most success with.

Dr. Ashley Bassett: Yeah, so it's really interesting. I'm gonna start off by saying that a recent systematic review that came out interestingly found no difference in outcomes, based on what block was used. But I call BS, I don't know if I can curse on this podcast. I'll just say I call BS. So I just, I don't believe it that if you do a femoral nerve block and literally shut down the nerve that innervates the quad versus doing an adductor canal block and just shutting down the saphenous or the sensory, but leaving the motor intact, I do not believe that they're gonna have the same recovery of their quad afterwards. I've seen patients for a second opinion that have had prolonged quad shutdown after femoral nerve blocks, so I won't do them. I will do for my, ACLs, I do an adductor canal or a saphenous block, which is essentially the sensory nerve for the femoral nerve. And then I do an IPAC, which is the, I'm gonna blank on exactly what it is, but it's something posterior adjacent capsule of the knee. It's basically, it is a block that goes to the posterior aspect of the knee to, numb of the capsule there. And that's really helpful and that can avoid the popliteal blocks. So, I think they're both really good, in terms of pain control. And then I don't worry about the quad getting shut down as much, just my opinion.

Dr. Yoni Rosenblatt: So I think that's awesome and I think that's just another thing to consider, when we're sending out. But also hopefully all the orthopedists that are listening to this thing now start to consider other options. So now you have tourniquet time, you have, what nerve block you're using, right? Now maybe you're getting a stim unit, by the way. A good stim unit is 250 bucks for home use, but insurance usually covers it. I think that's really important.

Dr. Ashley Bassett: That's great.

Dr. Yoni Rosenblatt: You mentioned, so we have all of our patients order them pre-op 'cause it takes a little bit just so they have it. We teach them how to use it, so they're doing it appropriately. So when they come in, they already understand how to use the quad. Hopefully. Another thing is BFR. Now BFR is getting a lot more affordable.

Dr. Yoni Rosenblatt: So they have units that are, you're able to get at home, you're able to find a good one for about 250 to 400 bucks. So you could do that. So there's just so much to do to make sure that before they walk in for visit one that they're on the road. You mentioned the cold cuff. I love the Preventice unit also covered by insurance. That provides compression. What I love about it is it'll cycle through both hot and cold so you can get, back and forth so that your body doesn't acclimate to the cold. I love that. And it doesn't get too cold the way a Game Ready does. But it will stay in the therapeutic so you can sleep in it. It's pretty awesome.

Dr. Ashley Bassett: That's awesome.

Dr. Yoni Rosenblatt: I'll send you some information on that, but let me ask you this, what's wrong with BFR if it's, if your wound is not closed, are you telling me that it increases infection rates or decreases healing time doc? 

Dr. Ashley Bassett: So it's so funny. That's just one of those things that's on there. Like if someone is morbidly obese, if someone has a history of vascular disorders, if someone has a history of blood clots all this, an interesting one also, not to go off on a tangent, but as skeletally immature people like pediatrics, there is no data saying it's bad, but there's no data saying it's safe either. So people are very hesitant. A lot of my patients are 14, 15 years old undergoing an ACL, so we just, we don't know. I think the thought is by decreasing blood supply to the area, you could potentially further compromise wound healing potentially in a patient that may already be predisposed to having wound healing issues because they're showing that they're slow to heal. Thankfully, I haven't had that often when I'm operating on an ACL patient, they tend to be young, healthy people. So they tend to heal up Well. I use all absorbable sutures and skin glue, so I haven't really had that issue. But if, I guess if I was looking at a wound that was just dehiscing and had a concern for an infection, perhaps I would hold off on the BFR to.

Dr. Yoni Rosenblatt: Fair.

Dr. Ashley Bassett: Maximize blood flow.

Dr. Yoni Rosenblatt: That's fair. That's fair. Here's what I always joke about, like, I used to have surgeons tell me like, don't be so aggressive getting the patient towards extension or towards flexion. And in my head I'm like, you, before they woke up, you ripped them into extension and ripped them into flexion. Like they'll be fine. But I would say the same thing with a tourniquet, right? You better believe, they're getting better blood flow with a BFR machine than with a tourniquet you just left on their leg for an hour.

Dr. Ashley Bassett: Absolutely. I mean, and also that's it. And that's why I tell people too is that BFR does not occlude all blood flow. It includes roughly 80% of blood flow. You're still getting arterial flow. It's including venous outflow, building up the hypoxic environment. So you're not, people think, oh my gosh, I'm completely depriving blood flow. No, that's what we do at surgery.

Dr. Yoni Rosenblatt: Exactly.

Dr. Ashley Bassett: There's not what's being done in the PT setting, so.

Dr. Yoni Rosenblatt: Exactly.

Dr. Ashley Bassett: Yeah. It's different. Yeah.

Dr. Yoni Rosenblatt: Which is why maybe you'll think about letting them do it in the first two weeks.

Dr. Ashley Bassett: Yeah, it's funny if some, if one of my PTs said to me, Hey, I really wanna get this started three days, I would have absolutely no problem with it. I think it's just like we've come up with a protocol, so we've stuck with the two weeks and also I've had PTs tell me this and I'd be curious to get your thoughts on this that I'll say, are you using BFR? And they say, well, we're working on the motion first. Like they don't even have beyond 45 degrees of flexion yet. And I go, oh, okay. And in my mind I'm like, I guess you can't do BFR if you don't have good enough motion. Like I would think you could still do straight leg raising and stuff. But it seems that if they're not hitting their motion goals or that first few days where they can barely bend to 35 degrees 'cause they're so inflamed, then maybe BFR isn't as useful. But what are your thoughts on that? Do you still use it in their early phases? 

Dr. Yoni Rosenblatt: Great question. You need your own podcast. I think it's all a matter of timing. So how much time do you have with the patient one-on-one. To make a difference. And so if you think your time is better used on motion, then okay, you're gonna skip BFR. I would argue the person who's gonna have the biggest effect on their motion is the patient. Do you think you're making gains in 45 minutes three times a week, four times? No. You're making gains in prone hangs. You're making gains with heel slides all day at home while they're watching Netflix when they come in, their motion should start looking pretty good. That's when BFR If they don't have one at home, then you're spending time on it. So that's point one.

Dr. Yoni Rosenblatt: Like most of the motion gains is education, not me cranking on your knee. So that's one. Two is early stages. It's not about regaining strength, it's about preventing atrophy. So just putting the tourniquet on, pumping it up, forget lifting their leg, we know that that is systemically going to release human growth hormone and.

Dr. Ashley Bassett: It does.

Dr. Yoni Rosenblatt: Prevent, or at least slow atrophy. So tell your therapist, number one, to buy our course, but number two, to think about like, you gotta prevent atrophy. It's not about hypertrophy in this early stage. Teach them how to do their motion at home, prevent their, atrophy in the clinic is what I would say.

Dr. Ashley Bassett: And I think you really hit a good point there talking about just the effects of that hypoxic environment for systemic, right? I mean, when we do proximal BFR for proximal benefits for the rotator cuff, it's proximal. You're not, depriving any blood flow to the rotator cuff. It's this way. So by doing that you are creating, as you said, all these growth factors, all these hormone levels that are going up and that is working that area and causing the changes that we're seeing. And there was a study that showed that. And I think that really keys in with just putting it on and having them do the simplest of exercises. I think would still be beneficial systemically.

Dr. Yoni Rosenblatt: Yeah, yeah. Yeah. I totally agree with that. I see the Eagles football over your left shoulder. What a lot of the NFL teams are doing is they're starting to use BFR for recovery. And so it's similar to what you're talking about where they'll, they're asking their body to respond, chemically to the pressure, it's not about the load. And so a lot of the football teams will take BFRs bilateral cuffs onto the flights because they're using it for recovery and they're simply getting the pump and holding all of that blood in their lower extremities to allow those healing factors to kick in. It's not about the load necessarily. So there's plenty more to be gained there.

Dr. Ashley Bassett: Absolutely.

Dr. Yoni Rosenblatt: Doc, I love your understanding of BFR. That is high level. It's awesome.

Dr. Ashley Bassett: Thank you. I gave a talk about it at a sports symposium, so I did have to educate myself a fair amount on it. And then I know you've you've referenced I need my own podcast. I have my own podcast. So we talk about BFR a lot on it actually. We talk a lot about modalities on there. My co-host actually used to be a physical therapist for seven years and then be went to residency and that's where we met each other. So she caress very much about that. So we talk a lot about, BFR on our show a lot.

Dr. Yoni Rosenblatt: Oh, I love that. Okay. That is awesome. Okay. I've already learned a ton. Let's, I want to throw a little bit more of a general question at you 'cause I'm really interested in your take. What do you think PTs screw up the most as it pertains to ACL rehab? 

Dr. Ashley Bassett: So we kind of just talked a little bit about this and you said it's more home and education and things like that, but it's the motion. So when I tell people those motion goals, I'm telling the patients, but I'm also telling the therapist, and thankfully as I said at the start of this, I have the benefit of working with some really excellent physical therapists and I make sure that I plug my patients in with people that are experienced with ACL recovery. But that's not always possible. My patients sometimes live in an area where there's one physical therapist in the entirety of that county. Right. And so they have to go there and that PTs very good, but maybe they deal with a lot of general conditions and they don't do ACLs all day every day. And so the biggest concern I've seen is not being aggressive enough with early flexion and early extension, specifically the latter yeah, it's a negative one, negative two, it's straight enough, it looks good.

Dr. Ashley Bassett: It's not, they're gonna walk with a limp, they're gonna have quad inhibition. It is gonna lead to all of these problems. I just saw a patient, I didn't do her surgery, but she's 10 months out from an ACL came in for a second opinion for diffuse pain. She lacks five degrees of full extension. What are we gonna do at this point with that? Right? I mean, she's so far out. We'll do some therapy and try to get her there, but she's missed the boat. So I think that's the biggest concern I have and that's why I communicate with my PTs. If I see a concern, I call them and I speak to them about it because I want them to be aggressive with motion. They're not gonna hurt anything by being aggressive with motion that I did in the OR. And so that's the biggest, that's the key point.

 Dr. Yoni Rosenblatt: Okay. So if that's what you kind of wish PTs were a little bit better at, what do you wish surgeons were better at as it pertains to ACL and maybe even specifically with LETs? 

Dr. Ashley Bassett: Yeah, so that's a really good question. I think it's twofold. So I think the first thing is that LET or ALL reconstruction is not a magic wand. Right? I think as these new procedures come out, we get really excited to just like stick them on everything and be like, it's gonna give me added security. But you can't forget the core of ACL reconstruction, right? Tunnel placement is the number one, leading risk factor for ACL graft failure. You put them in the wrong place, you're gonna fail. Not recognizing meniscus tears, other ligament tears, graft choice. You can't do an allograft in a 15 year old and stick an LET on there and think they're gonna do great. Right? We know allograft have a higher failure rate in that age population. So I think still doing the right things with your standard ACL, is important. Also when adding an LET.

Dr. Ashley Bassett: And then the second thing is that I think people are fearful to start this procedure. They haven't seen it before. They didn't learn it in their training and they're nervous to do it. And I would encourage them to go do a lab. It's not that hard. And I think that people can do it. And I think it's something that's really gonna change the trajectory of outcomes for ACL, especially in our high risk population. You probably see it too, the incidence of ACL is rising in young individuals. They're already at high risk for a retear and that sets them up for long-term knee issues. I think if we can protect these people with an LET or an ALL reconstruction, I think we should.

Dr. Yoni Rosenblatt: Yeah. I think that that's really well said. I had this conversation, with, another NFL doc, and we were talking about the success rates as measured by return to previous level of function or competition, specifically in the NFL. It is staggering how poor it is. It's unbelievable.

Dr. Ashley Bassett: It really is.

Dr. Yoni Rosenblatt: I think it's like 50%. So if it's sitting at 50%, what are we doing as a medical community to try to improve that? And I think at least conceptually, I don't know that there's enough data. There's, I know there's not enough data in the NFL yet, but conceptually this should nudge that statistic closer to a 100%. And so it's like having the ability to do that and also having the leverage to do that, right? Like, who's gonna be the first to put an LET into the raven starting linebacker? 

Dr. Ashley Bassett: Yeah.

Dr. Yoni Rosenblatt: It's so much involved.

Dr. Ashley Bassett: Exactly. When you take that first step. And that's really important what you just highlighted there, that what do we call success? Is it lack of the ACL graft rupturing, which that is a main reason to do LET or an ALL reconstruction. Studies have shown significantly lowers the rate of graft failure. But another thing studies have shown is it significantly increases the rate of return to pre-injury, level of play and high level competition. So it's exactly what you're saying that just them getting back on the field is not a win. If they kick a ball around for five minutes, then have to come off and they're not playing at the level they were playing at. I mean, yeah, you've given them a somewhat functional knee, but you've not restored them back to the level they were. And I think that's really important.

Dr. Yoni Rosenblatt: Okay. So you said it's steadily and slowly rising. Your rate of doing an LET, you just highlighted it decreases, re-rupture rate. It increases the chances they return to previous level of function. This has to be the future of primary repairs, doesn't it? 

Dr. Ashley Bassett: I really think it is, and it just, it's, I was on a panel with, talking about LET and thankfully I did not get put on the spot with this question, but one of the guys, they were like, so who are you doing this in? Who are you not doing this in? And it was like, well, they're like, no, no, no, you gotta give an answer. Who are you not doing this in given that it's protecting against all this and everyone's hemming and hawing because no one wants to come right out and say, I'm gonna do it in everyone because it's gonna lower the rates. Because every study that has come out on LET, not everyone, there's one that it showed no difference, but only because of statistical significance. It's still trended to a lower failure rate. But almost every study has shown a lower rate of failure and improved return to pre-injury level of play. So that's a very good question. Why are we not doing it everyone? And I think if we fast forward five years, we're gonna see a lot more quad autograph and pretty much everyone's gonna be getting an LET based on this data.

Dr. Ashley Bassett: Okay. So that's fascinating because it was gonna be my next question of what you see the future is, you said quad tendon, you said LET, you didn't say ACL repairs.

Dr. Ashley Bassett: Oh, well, that was a misspeak on my part 'cause we definitely should talk about ACL repairs. Okay.

Dr. Yoni Rosenblatt: Tell me what you got.

Dr. Ashley Bassett: Yeah, so I do think that is the future, but I think it's important in terms of identifying what can and can't be repaired. So back in the day the ACL repair failure rate was like over 50%, like they all failed. And they all went on to have persistent instability and pain. But that's because I don't think we understood why repairs were failing. So I mentioned where I did my training, I trained with Martha Murray up in Boston at Boston Children's Hospital, and she developed the, ACL BEAR implant. And so you may be familiar with it for your listeners that aren't, it stands for bridge enhanced ACL repair. And essentially the goal of this implant was to protect the clot that forms at the site of the ACL in terms of allowing for healing.

 Dr. Ashley Bassett: So they use the example of like when an MCL tears, it forms a clot. That clot serves as a scaffold through which ligament grows and reattaches, that doesn't happen with an ACL. The synovial fluid has these enzymes that break down the clot and inhibit healing. It's kind of our body's defense mechanism. So this scaffold protects that clot and then you can infiltrate the clot with whole blood to kind of give it added growth factors. And so that really has changed the game, but you still need a good amount of tissue to put the suture in, pass it through the implant, and then reattach it. So you need at least I believe a tibial sump of about 50% still remaining. But you make that call at the time of surgery. So you, get in there, you look, it has to be a good substance tissue, it can't be significantly frayed, and it has to be enough that you can put suture in to put it through the implant and then reattach it. So I really do think, as you pointed, I really do think that is the future as well too. Very exciting data coming out about that.

Dr. Yoni Rosenblatt: Yeah. So, I had the opportunity to watch Baltimore based surgeons in a lab learning how to place the BEAR, and how to set that up. It kind of looks like a marshmallow to me.

Dr. Ashley Bassett: It does, yeah.

Dr. Yoni Rosenblatt: Right. That you like stuff in the knee. Can you just do a better job of describing that for our listeners of what it actually looks like and what the procedure is?

Dr. Ashley Bassett: Yeah. So it's about, I mean, you kind of put it perfectly, it's like a more skinny marshmallow, that essentially you kind of infiltrate with the patient's blood and you kind of make it this like mess of tissue and you've already put the sutures through it and you basically put it through a portal and try to position it between the ACL ligament that you are repairing and the lateral femoral condyle wall. Basically to protect that scaffold to allow it to heal in.

Dr. Yoni Rosenblatt: And so tell me some, you said the data's very promising. Tell me what they're seeing and where you see it going to.

Dr. Ashley Bassett: Yeah, so I think the biggest, the main part of the first phase of studies was to show that it was not inferior to ACL reconstruction. And so their study did show that it was not inferior to ACL reconstruction in terms of failure rate and things like that. They did find a higher failure rate just in general compared across our patient population with younger patients. But they make a really important note that younger patients in general are going to have a higher failure rate regardless of what you do. And ACL reconstruction is going to have a higher failure rate because those patients are getting back to super high levels of sports. They're putting more stress through their knee, and they still have some of the risk factors that predispose them for an ACL tear in the first place.

Dr. Ashley Bassett: The other thing that we saw, that I've seen in some of these studies is one greater return of, hamstring strength. So greater return of muscle strength because you're not taking a graft, right? So you're not robbing Peter to pay Paul, you're not compromising, creating that donor site morbidity, whether it be you're taking a patellar tendon with kneeling pain and anterior knee pain, patellofemoral pain or hamstringing weakness if you're taking a hamstring graft. And then interestingly, we talk a lot about on our podcast, the psychology of recovery and how fear of re-injury can hold people back. And they found that psychologically using the ACL RSI score that there was a significantly lower rate or in terms of, feeling prepared to return to sport. People felt psychologically more ready to return to sport at six months after a repair compared to a reconstruction. So they just, they feel better, they have their native ACL, they feel better, they recover quicker. So it's really exciting and I'm excited to see more long-term data in terms of where this is going.

Dr. Yoni Rosenblatt: Yeah. Okay. So, briefly give me an overview of your graph choices.

Dr. Ashley Bassett: Now for autograph. Again, if you had asked me at the start of my career, I would say almost entirely BTB, with hamstrings as needed for skeletally immature patients. I don't do hamstrings anymore. So if I have a Skeletally immature patient or a revision, I'm doing quad tendon. If someone is over the age of let's say 25, so they can't have an allograft, they're active, I will recommend Quad. I think it's an easier recovery and I think the data's very clear. It's a very good graft. But for my teens, I'm still doing BTB. I still really like the robust, bone to bone healing that I get from patellar tendon. I moved away from Hamstringing just because, I take care of a lot of female athletes. And I really do believe the literature that has come out suggesting that females have a higher rate of failure after hamstringing ACL.

Dr. Ashley Bassett: And I also don't like the idea of compromising the hamstrings in a population that is already quad dominant, which can lead to ACL risk of failure. So I don't do hamstringing ACLs pretty much across the board at this point. So you can find us in terms of my podcast on Instagram @thesportsdocspod, or on, Twitter X whatever it's called now at the Sports Doc pod. So that's where we are. In terms of me, you can reach me, you can email me if you wanna reach me. My email is just my first name, last name MD. So Feel free to email me with any questions. And then I'm also on Instagram, Twitter, I'm sporty surgeon on Instagram and on Twitter I'm just Ashley Bassett MD. So feel free to reach me on any of those avenues.


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