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2020 AOSSM Virtual Fellows Course
Day 1 - July 21, 2020
Day 1 - July 21, 2020
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Video Transcription
Welcome, so we're going to get started here. My name is Latul Farrell. I am the program director of the Sports Medicine Fellowship at the Cleveland Clinic and one of the course co-chairs for the AOSSM virtual fellows course. On behalf of myself and our course co-directors, Dr. Brian Forsyth, assistant associate professor at Rush University Medical Center, as well as Volker Musall, associate professor at University of Pittsburgh Medical Center, we would like to welcome you to this course. We have a special guest tonight, Dr. Michael Ciccotti, who is the Everett J. and Marion Gordon Professor of Orthopedics and chief of the Division of Orthopedics and Sports Medicine and director of the Sports Medicine Fellowship and Research at Rothman Institute and who is our 49th president of the American Orthopedic Society of Sports Medicine who was kind enough to join us tonight and would like to start us off with a few opening words. Thank you, Latul. So I'd like to welcome you all to our AOSSM 2020 Sports Fellows course. This outstanding course was coordinated by Latul Farrell, Volker Musall, and Brian Forsyth with our outstanding AOSSM operational team led tonight by Meredith Herzog. And it begins a most important and truly exciting year for all of you because finally you're going to be focusing on what you really care about, which is sports medicine, and you're going to learn the most important aspects of sports medicine, the clinical evaluation, the non-operative treatment, surgical techniques, post-operative rehabilitation for the injured athlete. And as you progress through the upcoming year, I would urge you, I would urge you to take advantage of all that is AOSSM, from the outstanding courses that we have to offer like the course that you'll participate in over the next several nights, to our online enduring education, from our new playbook, the surgical techniques online video playbook, and the research grant opportunities that we have, and the vitally important Emerging Leaders Program, which really focuses specifically on the needs of our young sports surgeons, all of you, the things that are most important to you. The tool Volker and Brian have put together just an outstanding agenda over the next three nights with great AOSSM faculty from all over the country. And this is the first virtual fellows course in conjunction with the state-of-the-art OLC, Orthopedic Learning Center, and its outstanding team, operational team, and it's the first time that all sports fellows, all sports fellows from across the country will be participating in this course. So sit back and enjoy what will be a great event, and I wish you all the best that the upcoming year will bring, and welcome to AOSSM. Thanks Michael. Thanks for being here, and appreciate your involvement. As Michael said, this is a very unique course. This course was actually started five years ago, and I was lucky enough to be involved with this from the very beginning. This was sort of the brainchild of Kurt Spindler, Jeff Dugas, and Jeff Brockmeyer, sorry, Steve Brockmeyer, who bore this course out to basically get you guys ready for starting to hit the ground running, essentially, when you start your fellowships. You come with varied experiences. Some people did a lot of team coverage while in residency, some people not so much, but one thing remains that you all are going to be responsible for the care of some athletes in high-pressure situations there on the sidelines, and it's something that we feel very strongly about in terms of our training to get the information out there that you don't necessarily learn from Ortho Bullets and from other sources, but really what you learn just from spending time on the sidelines, so we try to convince this and bring you some of the key topics that are going to be most important for you when you start your team coverage this fall, and obviously, with COVID-19, just this course is a bit different. Team coverage is going to be a bit different. Some of us are not sure if we're going to be doing fall sports. In Ohio, we're still planning to move forward, both with respect to college as well as high school athletics, but no matter what athletics look like this year, we want you guys to be prepared to be the best team physicians that you can be. The prior four years, this has been an on-site course at the Orthopedic Learning Center. Obviously because of COVID-19 and restrictions on travel and social distancing, we've been able to pare this down and really give you guys everything that you need basically to get started as a sports fellow. This is our list of topics, and I think many of you have seen the presentations that will be given, and obviously keeping in mind that you guys have been doing orthopedics for the past four or five years, certainly we're trying to give this a spin, case-based format and information from this perspective of team physicians. We can go to the next slide. And this course would not be what it is today without the all-star cast that we have as course faculty. They've given their time in order to be here because we think it's very important, and it's really what I love most about the American Orthopedic Society for Sports Medicine is the true collaboration, and this is my very favorite society. It's something that we all hope you guys continue to be involved in. And so we'd like to thank our chairs and course faculty, and a very special thank you to Meredith Herzog, who sits behind the scenes and really makes this go. Her, as well as our AV crew, Lee, and his crew tonight, we would like to also thank you, thank them. Be sure to follow us on Twitter as the course progresses, certainly want to get the word out about this. And if you use the hashtag AOSSMfellows, we can tweet about the course and your experience. We also like to thank our corporate sponsors, again, without their support, this course would not be possible. So Arthrex, Smith, Nephew, and Stryker, I'd like to thank you for their support. And as always, involvement is essential. Certainly, I think some of the benefits with this being a virtual conference is, you know, hopefully you're not shy about asking questions. Sometimes when we're in a room together at the OLC, people are a little shy about raising their hand and asking questions. But really, we want this course to be most informative to you and really help to tailor this towards to what you really need. And so as part of the GoToMeeting, there is a box, it's on the right side of my screen, but wherever you place it on your screen, right or left, but there is a question box. So please feel free to submit questions. When we get to our discussion sections, we will be open up the floor for questions. And your involvement certainly can make this much better. You know, certainly, I'm going to open up now to my course co-chairs, if they have anything to add. I'll start. So welcome, everybody, and congratulations on finishing your residency program. It's really a hallmark moment in your lives and, you know, I empathize with the situation and having to go to this transition through COVID, but you'll look back and it's going to be that much more special because of it. Just remember, this is a really important year in your life and your career for that matter, and it's time to build relationships with your co-fellows and your mentors. And the field itself is multidisciplinary, it presents challenges and opportunities for growth throughout your career. And I think that being a part of this family and AOSSM is really the optimal springboard going forward. So again, congratulations. Welcome and pay attention because I think you'll pick up a few tricks that are going to help you for this upcoming fellowship year. Yes, and I keep it short, too. So welcome, everyone. We're excited for this course. The next three nights should be a lot of fun. So sit back, relax, you know, be involved. And for the upcoming year, you know, all of us will have to adapt a little bit to these changes that are being thrown at us. You know, for example, I haven't met our five fellows yet. So hi, guys. I'm looking forward to meeting you all. And I think it's going to be a fun year. And if we're all flexible, it'll be surely can't miss. And this first presentation that Lutul will introduce now, but Dr. Indelicato is going to be a super kickoff. So enjoy and have a fun year. Thank you, Brian and Volker. Thank you, Lutul. So our first speaker tonight is, you know, essentially needs no introduction, but we're going to give him an introduction anyway. So Pete Indelicato, for people who know sports medicine, know that he's one of the quintessential team physicians in the country and probably one of the best to do this. And, you know, we've heard this talk a few times myself and every single time I learn something. But, you know, certainly way back in the day when I decided to go do a sports medicine fellowship, you know, and be sort of the best team physician that I could be. So Peter Indelicato was the guy that, you know, one of the guys that I wish that I could even be, you know, as partially as good as. He's past president of the AOSSM and still continues to make time to be involved and, you know, thinks it's very important to be here, you know, for this course. He's emeritus professor of sports medicine and emeritus head team physician at the University of Florida. And we are happy to have him tonight to talk about some tidbits about being a team physician, mistakes to avoid and keys to success. Thanks, Dr. Indelicato for being here and look forward to your presentation. Thank you for that kind introduction, Latul. And again, I'd like to add my both welcome and congratulations to all the incoming fellows. Congratulations on successfully completing your residency and being selected. Like Volker mentioned also that this should be one of the fun year as well as a educational year for all of you. So with that, let's get started. Like Latul said, I've given this talk in one form or another for the past four or five years, and I'm honored and excited to share some thoughts with you out there again regarding a team physician. Some of the mistakes I think we can avoid and some keys to succeed. Those are my disclosures, none of which have anything to do with this presentation. So this presentation is designed to discuss the major mistakes that I certainly think are avoidable as well as some key points to help you succeed as a team physician. My experience along these lines have been more than 35 years as a college team physician, eight of which I was also involved in the NFL. There are probably more than seven major mistakes that you can avoid, but certainly we're going to list the most important seven. And we're going to talk about the keys to succeed, some of which you just see listed on this slide on your right. And hopefully at the end of the discussion, I'll share some quick rapid fire pearls with you as well. To begin with, the team physician basically is a leader. You step into that role as a team physician. This is irrespective of whether you're taking care of a high school team, a college team, or a professional team. Leadership, the word itself means that you're providing a service for the people that you're taking care of. And we'll talk a little bit later about sacrifice, but service certainly comes with sacrifice. So you need to sort of prepare yourself if you want to be a successful team physician that you're going to have to sacrifice certain things. Because without sacrifice, there's no service. And without service, there's no leadership. We'll start with the mistakes to avoid. I sort of listed them in the order of like a David Letterman seven through one. And these mistakes reflect what mistakes I personally have made, but also listening to my peers and other co-members of the AOSSM that admitted to making mistakes as well. So I'll start off with number seven. Seven biggest mistake is the failure to encourage second opinions when they're requested. And actually, you should develop as a team physician, a list of approved specialists who understand the unique issues associated with student athletes. And this list should be reviewed prior to every season. And again, I want to stress the fact that this list should include people who understand the unique aspects of taking care of student athletes. If Mary's spraining her ankle, it's probably going to be managed very differently than your starting quarterback with that same ankle sprain. Also, when an athlete requests that they want to get a second opinion, you should actually help facilitate that appointment rather than discourage it. Because as you'll hear all through this year, sports medicine really is a team sport. Mistake number six, failure to override a consulting physician's opinion. If you personally believe that the student athlete should still be held out of a practice or a game situation, because ultimately, and we'll again talk about this a little bit later, you have the responsibility as whether that decision to play a practice, you ultimately have that decision because that remains yours. You cannot delegate that to a consultant. Mistake number five, failure to give a qualified athletic trainer actually the authority to make those return to practice or play decisions when you are not available. You can't be available for every practice or every team sport. So you have to have trust in a team, in an athletic trainer. They are your storefront windows. They, what the athlete and the coach and the parents think of you will be directly reflective of how they feel or think about the athletic trainer. In fact, legally, in most states, the athletic trainer's practice scope is determined by the team physician, and you have to annually sign off on these qualifications or practice patterns. Along these same lines, when a new athletic trainer is recruited, you need to be involved in determining what their skills and responsibilities should be. Which brings us to mistake number four, is failure to become significantly involved when you can in the selection, evaluation, and retention of that athletic trainer. You certainly should seek input from administration and coaches. But the team physician should have a significant amount of input into the selection of that trainer, their evaluation, and their retention. Mistake number three is failure to maintain proper documentation and record keeping when it comes to medically related encounters with student athletes. And these include even casual encounters that you, that you discuss with them at team meals or in a bus or in a plane. These medically related conversations should be recorded at the earliest possible opportunity, particularly in this litiginous day and age. Mistake number two, failure to establish a significant identifiable chain of command, preferably in writing and preferably prior to the season, with you as the head of that chain of command. You shouldn't be discussing who answers to who during the course of the season. Particularly, it's inappropriate before or during an athletic event. And mistake number one, particularly for those of you that are going to be involved in high level sports regarding college and professional athletes. The mistake is the failure to recognize the pressure that will be placed on you to make decisions that may benefit the team, but not necessarily the student athlete who's your primary responsibility. The more money involved in the sport that you're overseeing, the more pressure you probably will encounter. So let's jump ahead to keys to succeed. The first and probably most important key to be successful as a team physician is to convince those athletes that they can trust you and that you will always do your best for them. And that you really care about them as individuals. Yes, in the context of the team sport that they're playing, but as individuals. In other words, you may be the team physician, but when somebody gets sick or hurt, you're their personal physician. And there's this very clear distinction. So how do you do that? And this is where it comes to sacrifice. And there's no getting around this, in my opinion. You have to spend time with the players. Before practice, during practice, after practice. You sort of got to hang out. And you got to love hanging out with them. When you travel with them and before practice and so forth. In other words, you have to try and get to know their parents as well, particularly at the high school and the college level whenever possible. You should never hesitate to give a player or the parents or guardians your cell phone number. And when they call, you got to answer it. Jimmy Andrew once said, and I believe it, if mama ain't happy, nobody's happy. So make yourself available so that they know who you are. In other words, they have to get to know you as a person and not just a name or pops up for the first time whenever they tear their ACL or dislocate their shoulder or so forth. And what does that mean? That means there's a difference, in my opinion, between being a team physician or a team surgeon. All of you that have committed a year to a fellowship in sports medicine, I assume are dedicating yourself also to being a team physician because those two words are synonymous. Being an arthroscopist or a dynamite ACL surgeon is not necessarily being a team physician. Another key to success, you have to be available, number one, and then you have to understand and respect what autonomy is. For those of you that are starting off after your fellowship as a sole team physician, one of the most critical aspects of being successful is being available. Again, cell phones, social media, get to know these parents, get to know the players. What about autonomy? Well, the definition basically revolves around self-rule. What does that mean? Frequently the athletes or the team or the coach or the parents immediate goals are to get that athlete back playing. And that necessarily doesn't align with what you think is the best long-term health decision for that particular athlete or injury. Frequent scenario, you get pressure from the players, put me in, Doc, I'm okay, when really you're not. So on the one hand, when you inform athletes what their options are, whether it's a surgical or non-surgical situation, you sometimes have to really protect them from themselves and try to emphasize over and over again what the long-term benefits are. In other words, what the risk versus the benefits are on any given decision. Some people say basically what you are temporarily is a father or mother and trying to protect them from themselves. Having you said that, you have to make sure on the other hand that you never impose your authority in a way that impinges on those athletes' individual rights to make their own decision. Because once again, autonomy means self-rule. So I view your job or my job as a team physician is to inform and try and educate the athlete what you're doing and why you believe a certain decision is the best. You should never really dictate or pontificate because that will alienate them pretty quickly. We talk about shared decision-making and this is a perfect example of when that comes into reality. You have to include other people in the decision. By other people, I mean basically parents, guardians, and so forth. Not so much the coach or the agent, but certainly an athlete's parents or guardians. You have to repeat again and again what their options are in terms of what they're capable of understanding what the really bottom line is. And this takes very often more than one discussion you have with an athlete. Here's a reality check. Somebody hurts their knee during a game. The conditions are less than ideal to try and explain to them what you're trying to do and why you're doing it and why you're suggesting or making those types of decisions. It's loud. It's hard to hear. There's a lot of distraction. So as a result, never hesitate to take an athlete into a more conducive environment, either during the game or at halftime or after the game is over, to repeat the history and the physical exam and get your thoughts together before you start talking about what you think the best course of action is. You can always spend more time making that decision. Don't jump to diagnoses and prognostication. Keys to success, again, is communication. To be successful as a team physician, you must be able to effectively communicate to the player, to the trainer, to the parents, the administration, the coach, and then professional athletes to the agent. However, there's such a thing as a HIPAA law, and these HIPAA laws must be, have to be legally respected. At most Division I or upper college athletic programs, players are asked to sign release forms on a yearly basis so you legally can share their medical condition with people who they want you to share it with. But remember, even if they sign that release form, the athlete always retains the right to instruct you to withhold whatever information they choose, whether it's a recurrent dislocation of their shoulder, whether it's a socially transmitted or sexually transmitted disease. And in today's day and age with COVID-19, and that is a, makes this problem a lot more difficult to manage. But when an athlete says, I don't want anyone else to know about this, you have to respect that. To ignore it is a violation of the law and could place you in a litiginous position. You should never talk to the media. Most athletic programs have designated sports information departments that do that and do it very well. Conflict of interest. In order to successfully be a team physician, you have to recognize the fact that you will be faced with conflicts of interest. You're gonna get pressure, I said earlier, from the parents, from the coach, even from the athlete to be less than honest about how much something really bothers them. So how do you deal with conflicts? You should deal with it by first of all, recognizing that it exists. Here's some of the questions that really surround conflicts of interest. Who answers to who around the athletic program? Who hires the trainer? Who pays the trainer's salary? Who appoints and annually evaluates the team physician? Is it the head coach? Is it the athletic director? Is it the team owner? These are all potential conflicts that you need to be aware of and address. Ron Corson, who's the director of sports medicine at University of Georgia, has said this to me twice. There's so much pressure on us now to win and to win now. There's so much money involved in athletics that in and of itself creates pressure. And here's some great words of advice. I think everyone's job is to sometimes take a step back and not let the pressure influence you to make a decision that you know is wrong. Again, conflicts of interest will invariably arise when the team's best interest, i.e. winning the game and the athlete's best interest, i.e. not only immediate but long-term good health, are not aligned. As a result, that team physician or you as a team physician, is going to have a hard time As a result, that team physician or you as a team physician may enter into a conflict with the parents, the coaches, the owner, and actually risk losing his or her job as a team physician, including all the perks that go with it. And trust me, there are perks that go along with team physician. There's the status of being known, there's the marketing advantage, there are complimentary tickets, travel, reserve parking, and so forth. This conflict of interest brought in a team physician has bubbled up to such a degree that Ed Boydas, the editor of Sports Health, actually wrote an editorial about it a little over a year ago. And he called it the team physician quagmire. And here's some of the questions he raised in that editorial. Are team physician positions basically shopped around and awarded to the highest bidder? How did the qualifications and experience of the selected team physician compare with others in that community? Are healthcare compromises being made because of monetary arrangements? And most importantly, are athletes even aware that the physicians are paying for the opportunities to provide care? I encourage you all to go online and try and get a copy of Scott Bowden's recent presentation on the difference between partnership and sponsorship. Because I think he, in an excellent manner, addresses this potential conflict. So how do you manage it? How do you manage conflict? We'll establish both early and clearly what I said at the beginning of this presentation, what your role is and what that chain of command is. The administration, whether it's the athletic director, the coach, the school superintendent, the team owner, they need to understand this very simple, important fact. That the health of the athlete is paramount. And their slash your sports medicine team physician's goal should reflect that athlete care is paramount. And your team physician medical staff should be empowered as a result of that. One of the things to do is make sure you declare the relationships that exist between you and the team, make that public and readily available to everybody. A long time ago, the AOSSM actually published a pamphlet on principles of selecting a team physician. And a quote from that pamphlet said, the team should fully disclose any sponsorships, advertising or financial arrangements that the medical staff or their health institution have made with the team. A mentor of mine many years ago was Dr. Frank Bassett at Duke. And I remember him telling me two things, never do anything that would embarrass you if you were to read about it in the morning newspaper. And more importantly, he said, the coach decides who plays, but the team physician or doctor decides who does it. And by the way, in today's competitive recruiting market, providing good quality medical care for a student athlete is being used as a recruiting tool in many major universities around the country. We'll close up with some quick final pearls. And maybe we'll have an opportunity for some questions at the end. Number one, always remain open-minded and receptive to new treatment concepts. But what I should put in there is don't try a new surgical ACL reconstructive technique on your starting quarterback is the first time you ever do it. As I said earlier, arrange with your sports information department how to handle big statements. Most colleges and universities have one. Number three, try and make every athlete feel like they're special. And that only occurs if you're willing to spend time with it. Another thing is that if you share team coverage with another physician, you pretty should make sure that you both have the same philosophy on treating any particular injury or illness. Otherwise, they're going to do doctor shopping and you're only going to see people that they want you to see. Number five, always overestimate the time to recover, particularly when you're starting off in that role as a team physician. It's better to overestimate the length than to underestimate it. Number six, it's never become too big a buddy to a player or to a coach or too big of a fan to the team. Because that could influence you whether you realize it or not, what decisions you make getting an athlete back. And I talk about sacrifices, and I talk about sacrifice at the beginning of the talk. And this is where I really think it's important to realize. You should always seek a balance between the time you devote to your family, especially when you have young children and your profession. Remember, everything does not have the same level of importance every day. So I want to again congratulate you. I know you're entering a critical and fun-filled year. You should enjoy your success this year and as, or in your role as a team physician, enjoy it. You should also learn from your failures because we always do that, whether we're in the operating room or on the sidelines. So thank you very much. I don't know how much time I have left. If you have any questions, I'd be more than happy to answer any. Fantastic, Pete. You're right on time. So we do have some time for questions. And obviously the box is open for any of the participants to chime in and ask any questions. But I'll get things started. You kind of alluded to it a little bit, Pete. In terms of being a team physician, how did you sort of vet your consultants? Because sometimes the most skilled people don't necessarily always understand the culture of athletics, or sometimes they're not available. So what are important things for when you were vetting your consultants? Well, actually, it's important to talk to them and to develop a relationship with them and make them, make sure you understand that they understand that taking care of these high-profile athletes or even high school athletes, it's very different. Sports medicine is very different. And the other thing that we used to do at the University of Florida is in order to make them feel important, them being the consultants, we used to invite them to games, sideline, we used to have special dinners for them, make them feel as part of the team. Because none of us know everything there is to know about everything related to sports medicine, whether it's neurology, cardiology, psychiatry. So these people become critically important members of your healthcare team. Pete, maybe I can ask you a question too. I heard your talk many times and I love hearing it every time again and again, because there's always something new you say, there's always something special and it relates so much to what we do. First time I heard the talk, I was a team physician of, I don't know, four or five years now, I've done it for 10 years, which is still not even a quarter of what you've done. So it's a huge body of work and you said it right, it changes, it changes so much. And in the beginning of each season, you got to review all your processes. Can you tell us who's your favorite coach you've worked with and why? Oh, they've all been good. I think Coach Spurrier, I've worked with him, maybe the longest, it was 11 years. He's just a special guy, nothing ever fazed him. Coaches, they don't like sometimes what you tell them and they'll get in your face. That's part of the deal. You gotta be able to take the heat. But he never really got upset, he was fine. Everything was fine. I mean, I remember Danny Warfel, the Heisman Trophy winner had a knee injury that kept him out of the games. And when I told Coach, he was like, okay, no problem. So he's the best, they're all good though. They're all good, I was blessed. I'm sure, probably not many, but any mistakes that you think you could, a situation that you wish you could have back that you've learned a lot from? Yes, I'll tell you one. This was early on in the early 80s. Everybody gets stingers and it's probably the most common injury out there. One of our offensive linemen, right before the halftime, and I gave him a quick example on the field. And I said, just come into the locker room, come into the training room at halftime. He came in the training room and he could see he was like going around. And I said, let me take a look at it. And I gave him a look, yeah, a more detailed exam. I felt reasonably comfortable. I said, why don't you just go get some x-rays? So he went to the Student Health Center during halftime. The team went back on the field, we went back on the field. He came back on the field with the x-ray folder and I held it up to the light. And he had a transitional C5, C6 cervical fracture. And I said, oh my God, the good Lord was watching me because I could have easily have said he was fine and go back and play. That day is branded in my head that it's gotta be 30 plus years ago. Excellent. So I think we are done for our question period. Pete, thank you very much for being here and again, giving a great presentation. Hopefully you'll join us for our panel discussion at the end of our next series of talks. Looking forward to it, Luteal, thank you. Thank you. So next up, our recorded presentations. We have, as I sort of alluded to, a really all-star lineup here today. So first up will be Sightline Emergencies, Dr. Aaron Marris, assistant professor of sports medicine at the University of Pittsburgh and co-team physician for Pitt football. He'll be followed, and he's gonna be talking about Sightline Emergencies. He's gonna be followed by John McKnight, who's an associate professor at University of Virginia. And he's gonna be speaking about the most common and important medical conditions. After that, we're gonna have a talk on concussion management by Elizabeth Piroff, who's director of the concussion program at Rush University Medical Center. Then Gregory Lopez is gonna speak about spine injuries and management. And then Matt Metop is gonna round out the discussion with a spine boarding video and demonstration. So without further ado, we'll start with Dr. Aaron Marris and Sightline Emergencies. And again, while we wait for those to get loaded up, again, if any questions arise, please feel free to send those over. During the recorded presentations, we'll keep track of those, and then we can discuss those during the question and answer period and panel discussion. Hey, this is Dr. Meyers from the University of Pittsburgh. I'm going to give you a talk on sideline medical emergencies, and as they say in the movie Spaceballs, the short, short version. So let's go ahead and get started here. So first off, I have no disclosures or conflicts of interest. These are just some sports to be covered at the University of Pittsburgh and to demonstrate there's a wide variety of sporting events. Know your athletes and know the categorization of your sport and injuries that you may experience. Youth community sports is vast. The number one leading cause of death in young athletes is sudden cardiac death, most common in basketball and football. And so this is a real topic that you need to be aware of. Use the PETA process. Pause, inhale, think, and act. Take that split second to really kind of pull it all together so that you can provide the best care for your patient. This is an algorithm or chart from the Pittsburgh Marathon. This is just to spark some ideas of what may have caused a collapsed athlete. So on the left there, you can see trauma, cardiac, anaphylaxis, seizure, et cetera. Don't forget about hyperthermia, hypothermia, and believe it or not, even hypoglycemia, often very much overlooked in the acute setting. BLS, AED. So clearly most of us know how to do CPR, but know where your AED is located and make sure that it's functional and how to use it. Comotio cordis is a direct non-penetrating blow, blunt trauma to the chest just prior to the peak of the T-wave resulting in arrhythmia. Survival rate significantly goes up if you can defibrillate within less than three minutes, and risk factors include size, speed of the ball, and hardness. Stop the bleed. If you have an injury with an open wound that is bleeding, apply pressure with hands, apply dressing, and press. If it does not stop, you can apply tourniquets above the wound, and particularly as high as you can go up into the groin or the axilla, and if you need a second tourniquet, then so be it. You use that second tourniquet. Heat illness, you have heat exhaustion, heat stroke. Our magic number that we tend to see on tests are 104, but know that 104 is not a definitive number. You can have individuals with heat stroke at 103. You're really going to look for signs and symptoms including dizziness, malaise, fatigue, nausea, vomiting, headache, change in mental status. So know your athletes if they're acting different, and clearly if the individual is non-responsive, they may appear flushed, have profuse sweating, or may not be even sweating at all. Risk factors include dehydration, heavy equipment or clothing, and in particular with the COVID-19 era going on right now, deconditioning. These athletes may not be up to par as they would have been in prior seasons. Treatment, get the athlete off the field, remove equipment, helmet, shoulder pads, get gloves, shoes off, right? Palms and soles of the feet are great ways to help kind of cool the body along with the neck, axilla, and groin. With ice bags, you can use a fan, and if need be, ice bath immersion. And so as you can see here, this is a chart from the Pittsburgh Marathon. 104, again, is your magic test number for temperature. You do want to decrease the temperature by one degree every three minutes. You want to get the temperature below 102 degrees before transport, and rectal temperature is your gold standard. An example here, anaphylaxis, classic symptoms, high swelling, coughing, wheezing, shortness of breath, but let's not forget nausea, vomiting, diarrhea, anxiety, or feeling of impending doom, as those are often overlooked symptoms. Calm and reassure the person. If it's a bee sting, do not use tweezers or squeeze the stinger. You would scrape the stinger off, lie them flat. Do not place a pillow under the head, as that can block the airway. You can treat with an EpiPen auto-injector in the upper outer thigh. Seizures, again, prevent injury by blocking or removing hazards, but do not hold or tie the person down. Lie them on their side to keep them from aspirating or choking. You can remove glasses, cushion the head. Do not try to force the teeth apart, and try to time and characterize the seizure. If an individual is a known seizure risk, they may have a diazepam pen available for status. Iboglycemia, this is more of a practical slide. If you do have to administer imglucagon, take that syringe. You will remove the cap from the needle, inject the fluid from the syringe into the vial, stir and mix, and then redraw the fluid back into the syringe and inject into the patient. Again, most people don't know or have never seen an actual glucagon injection kit. Weather emergency, lightning, avoid open areas, stay away from tall trees, towers, utility poles, do not lie on concrete floors, or lie flat on the ground, and again, never shelter under a tree. Stay safe in a shelter for 30 minutes after the last sound of thunder. I wanted to get into just anecdotal stories of some injuries that we have seen over the years, and I think this is what most people remember. So the individual on the left presented with a change in mental status and a headache, sent to the hospital, ultimately had an AVM rupture, ended up having surgery, and returned to support for full participation and had a relatively successful career. The point of this slide is to say, hey, just because you're young, you can't have problems, right? So this individual clearly had an issue and was recognized and treated. The individual on the right was a Sunday morning phone call. Someone bumped their head on the set of stairs, thought they had a concussion, at least per our athletic training staff. Ultimately, the history did reveal that the individual got into an altercation, was thrown down a set of stairs, and was intoxicated at the time. So my response was, this is a brain bleed until proven otherwise. And indeed, the individual did have a bilateral epidural hematoma and a skull fracture, again, ended up returning to football and playing. The individual here was someone that took a direct shot to the orbit, had an infraorbital fracture. His exam was, believe it or not, initially relatively benign, had full extraocular motions. No visual changes, just some palpable tenderness. CT scan was completed and did confirm bony injury, had a plate placed. The point of this slide is just because initially, if the exam is unremarkable, but you do have a suspicion, get the study, because no one will ever blame you for overtesting, but they will blame you for missing it. This is a gentleman that took a helmet to the jaw, soft tissue swelling, no step off, interoral cavity looks fine, no loose teeth. Essentially, his only finding besides some jaw swelling was that he had some blood around his molar, ended up getting a CT scan and did confirm a jaw fracture. Interesting portion about this is that he did the classic tongue depressor test in his mouth to bite down and snapped it in half. That may lead someone to not further test, but again, these exam findings, you put them all together and sometimes you find things that maybe you weren't expecting. So order that test if you suspect it. This is a gentleman that came in with a face mask coming down into his throat, hyoid bone, perforated the posterior pharynx. His main complaint was that he kept spitting, kept spitting, kept spitting, I can't stop spitting. He had some soreness of the throat, some difficulty swallowing, but again, his main complaint was that he could not stop spitting. This gentleman took a hockey puck to the throat with the complaint that his voice box was over to the side. He had difficulty with phonation and swallowing and some neck pain. This gentleman took a hit to the ribs, complained of some chest pain initially, eventual shortness of breath. X-ray revealed pneumothorax. If there's concern for tension, pneumothorax, the treatment, 14 gauge needle, three and a quarter inch, midclavicular, second intercostal space or anterior axillary line, fifth intercostal space, insertion site, push until flush with skin, hold for five to 10 seconds and withdraw needle leaving the catheter. This gentleman here had a liver laceration. This gentleman here did a nice little rollover on the ball, very simple exercise that happens every day at practice and had a spleen and liver laceration. Again, the point of that is that both these individuals had abdominal pain, they plateaued stable vitals. Their main complaint was they had a lot of pressure and pain in their pelvis. They felt like they had to pee and essentially what that was is they had blood pooling down in their pelvic region. So again, just something to remember. These individuals had both injuries that were relatively vague, some rib pain on the left and the gentleman on the right had some sinus congestion and some facial swelling. Again, ultimately studies revealed a tumor in the cervical spine on the gentleman on the left and on the right, a lymphoma. The point of this is that medical things do occur. So not everything is musculoskeletal. So take these things into consideration. Know your sporting event, know that there are other things that can go on in this day and age. Suspicious package, active shooter, mass casualty response plans, talk to your senior faculty about that. Have a plan in place and implement that. Individuals will look to you as a leader on the field. Leave your ego to do our critique and evaluate and adjust. Thank you for your time. And I appreciate being involved in this conference. If there's any questions, please don't hesitate to ask and send them my way. Welcome to the session on most common and important medical conditions. My name is John McKnight and I'm a primary care team physician at the University of Virginia. Even in your role as an orthopedic sports fellow, it's important to have a base of knowledge of medical concerns in athletes. Many of these have patterns that I want you to focus on for pattern recognition. And then it's also crucial to recognize emergent medical concerns and to be able to manage and refer those appropriately. Let's start with common infectious diseases. By far the most common infectious condition seen in athletes is the upper respiratory infection with common cold. These are characterized by neck up symptoms, mild headache, and mild sore throat. These are self-limited conditions. They do not preclude sport participation. And always important to remember to have caution with regard to decongestant use as it increases the risk for heat illness. This is contrasted with the viral syndrome, which is a more significant systemic illness characterized by neck down symptoms, such as fevers, chills, and colds. This is a more significant systemic illness, characterized by neck down symptoms, such as fevers, chills, generalized myalgias, and significant fatigue and malaise. Symptom management and rest are still the treatments of choice, but no athlete should participate with a fever greater than 100.5, myalgias, or poor PO intake. With regard to sore throat or pharyngitis, strep throat is by far the most common etiology. Four central criteria are utilized for this, fever, patchy exudative pharyngitis, anterior cervical lymphadenopathy, and absence of cough. Treatment is typically pursued for three or four of those criteria with penicillin antibiotics in the first-line therapy, and then azithromycin or clindamycin for individuals who are penicillin allergic. This is contrasted with the pharyngitis caused by mononucleosis, which is an acute chronic viral syndrome caused by Epstein-Barr virus. These individuals have severe sore throat, headache, disabling fatigue, and left upper quadrant pain. Their physical exam typically is that they appear ill, they're febrile, they have whitewashed tonsils as depicted in the top picture, which are confluent relative to the patchy exudates of strep pictured below. They have posterior cervical lymphadenopathy and left upper quadrant fullness or pain in association with splenomegaly. Evaluation of these individuals by a lab includes CBC with differential to look for atypical lymphocytes, liver function tests, which are often abnormal, and a monoslide or spot test. These individuals are held for three weeks minimum from the onset of their symptoms to minimize the risk of splenic rupture and chronic fatigue. Gastroenteritis is characterized by a variety of symptoms of nausea, vomiting, or diarrhea. These are acute self-limited illnesses which are almost always viral. Athletes should be held for fever, low KO intake, active vomiting, abdominal pain, or bleeding. Treatment involves aggressive PO hydration and the rat diet. It is okay to resume sport when these individuals are feeling better. They are euvolemic and able to tolerate adequate PO. COVID-19 obviously has resulted in a global pandemic. I have included the CDC website for healthcare providers, which is an excellent dynamic resource to be following. Symptoms from this novel coronavirus arise typically two to 14 days after exposure, characterized by fevers, chills, cough, shortness of breath, fatigue, myalgias, headache, new loss of taste or smell, and a variety of GI symptoms. Testing at this point in athletes primarily focuses on PCR swab testing, while antibody and salivary testing is still being developed. Positive PCR tests should result in 10 days of isolation, likely with an additional week for cardiac clearance. Individuals with exposure or contact tracing will quarantine for 14 days. Keys to prevention continue to be consistent mask wear, hand washing, and social distancing. Eyes, ears, and nose. The red eye is a common complaint in athletes. It's a broad differential, primarily separated by pain or vision disturbance. The red eye without pain or vision change typically results from viral conjunctivitis, episcleritis, or subconjunctival hemorrhages, none of which require any significant intervention, and reassurance is appropriate. Red eye with pain or vision change, it may be characterized by scleritis, uveitis, corneal abrasions, or hyphema in association with trauma, and these require urgent ophthalmologic evaluation. Orbital fractures are the third most common facial fracture, resulting in pain and diplopia. There's usually obvious deformity, infraorbital paresthesias, and limited ocular movement related to entrapment of the extraocular muscles. CT scanning is the imaging of choice. ENT and ophthalmology consultants should be included, and these individuals can typically return in six weeks. Auricular hematomas result from repeated pinna contusions in close contact sports, and they result in the swelling, pain, and deformity, and ideally management focuses on aspiration of these areas within seven days, followed by cast or buttress to allow for soft tissue healing. These individuals may return in seven days post-aspiration. They should see ENT if they are recurrent, and they certainly risk permanent deformity. Otitis externa is the classic swimmer's ear in association with water sports or water exposure. These patients present with ear pain and decreased hearing. They typically have pain with traction on the pinna, obvious purulent drainage. Their tympanic membrane is typically normal, and treatment involves irrigation and topical antibiotic therapy, typically also with steroids. Nasal fractures are the most common facial fracture, resulting in nasal pain, epistaxis, and deformity. It is okay to attempt to reduce these acutely. You should assess for septal hematoma by looking in the nares for a bluish swelling of the septum. CT scanning is imaging a modality of choice if needed. Return to play is seven days post-reduction, and ideally the athlete should wear external protection for four weeks. Cardiac concerns. Remember that many victims of sudden cardiac death have premonitory symptoms, so referrals should certainly always be placed for exertional chest pain or dyspnea, palpitations, inappropriate tachycardia, exercise intolerance, or syncope or presyncope with exertion. This is the pie chart of death for sudden cardiac death in the United States. Remember that almost 50% of individuals in our country who die of sudden cardiac death in sport have definite or possible hypertrophic cardiomyopathy. Your role is to be able to respond to any individual who has an acute cardiac event. AEDs are crucial to saving lives, so know where they are, know that they work, and certainly know how to use them. Respiratory conditions. Exercise-induced bronchospasm is characterized by wheezing, dyspnea, and cough associated with exercise, typically beginning at 10 to 15 minutes into exertion and resolving within 20 minutes of rest. This is exacerbated by cold weather sports or in individuals who are less fit. Prevention involves adequate warm-up time and environmental control whenever possible. Pharmacologic therapy involves albuterol, two puffs, 15 to 20 minutes prior to activity. In individuals who have refractory wheezing, we focus on rest and control breathing rate, more frequent use of albuterol on an as-needed basis, and then EpiPen 9-1-1 and transport if their symptoms are severe. Athletes with active wheezing should be held from competition. Abdominal trauma. Remember that blunt trauma to the abdomen may result in injuries away from the actual site of the trauma itself. Right upper quadrant pain in association with liver injury, left upper quadrant pain in association with spleen injury, and flank pain in association with kidney injury are the hallmarks. Elevated heart rate and hypotension may result from internal bleeding. Hematuria is found in 98% of individuals with renal injuries, an ultrasound or CT or are the imaging modalities of choice. Genitourinary disorders of testicular hematoma results from direct trauma to the testicle, often by ball, stick, or hand. These individuals present with a tense scrotum, which is tender to palpation. They have a normal cremasteric reflex, which is important, and ultrasound is the imaging modality of choice to rule out testicular fracture. Testicular portions, in contrast, typically have acute onset of severe pain not associated with trauma. Their exam reveals a horizontal lie of the testicle, and they have an abnormal cremasteric reflex as a result of twisting of the soft tissue structures. Ultrasound with Doppler is the imaging modality of choice, and this is a surgical emergency. Finally, sports dermatology. MRSA is the most common cause of bacterial skin infections in athletes. Erythema and induration are the classic hallmarks for this, with ultimate faruncle or carbuncle formation. Remember that many of these lesions are often noted early as a potential spider bite. These should be opened whenever possible, and antibiotic choices ideally are clindamycin, sulfa, or doxycycline. It is important to know what your local resistance pattern is, and these individuals may return in 72 hours if improved. Impetigo or folliculitis is a staph strep skin infection. Honey-colored crusting is associated with impetigo, and follicle-based pustules with folliculitis. Cephalexin or dicloxacillin are the antibiotics of choice, and these individuals may return in 72 hours if improved. Herpes gladiatorum is a classic herpes 1 infection characterized by grouped vesicles on an erythematous base. They're treated with any of the oral antiviral therapies, and the return to play is lengthy for these individuals at 120 hours. Tinea or ringworm is the most common fungal infection seen in athletes, characterized by erythematous raised leading edge with central clearing. Treated well with topical trabenephine or any of the azole antifungal therapies, the return to play is 72 hours. So in summary, it's important to embrace your role. Be familiar with the common medical concerns in athletes. Understand the patterns. Recognize what you can manage and what needs referral. You may need to be the primary care doc, so be ready. Have a great year. Please let me know if you have questions. Hi, my name is Dr. Beth Peroth. I am the director of the concussion program at Midwest Orthopedics at Rush, and at Rush, like everyone, I have very brief time today, so I'm going to race through a bunch of things here. Hopefully I provided you with enough information and links so you can review it at a later time, and I can address some questions in the Q&A later. So we have a lot of things to discuss. Again, I'm going to race through some of these, but I understand many of you are going to be on the sidelines, so we want you to start thinking about how do you actually recognize that a concussion has occurred, and we have data from professional leagues that we know that there are, in fact, observable signs that can help. Gait ataxia, motor and coordination is a really big one, falling without protecting themselves. Of course, none of this applies to professional soccer players, but we also know that getting up slowly and, you know, grabbing the head is not, in fact, helpful in differentiating the concussion from that. There are a lot of reasons an athlete will get up slowly, trying to catch a breath, trying to draw a penalty, etc. So you're on the sidelines. Most of the time, there's going to be a clear mechanism of injury. You're going to see a big hit, but not always. Sometimes we miss them, and sometimes it's a cumulative hit. So unfortunately, we don't catch them all, but you see a hit and you think that it's a type of injury that, you know, type of contact that may cause an injury, bring the athlete over, take a look at him or her. You want to start asking questions about that, about that play, you know, to sort of pick up do they have any amnesia for the event. Start asking questions about their symptoms. This is when it's really, really helpful to bring in the athletic trainer because the athletic trainer knows these athletes, and I've had many conversations with ATs who said, I knew that something was wrong because I know this kid, and he was acting differently. Also, if there's a kid who is trying to avoid you, constantly moving away from you, it's probably somebody who's having some symptoms and is trying to hide. You can also serially assess somebody. So if you see somebody, don't have any concerns, it doesn't mean they're done. You can reassess them later in the game, after the game, because we do know that symptoms evolve. And you all know this, signs and symptoms. Signs are observed by others. Symptoms are things that are reported by the athletes. We do a lot of training with coaches and athletes and parents because we want them to understand what to look for in athletes to suggest a concussion may have occurred. The problem is that these symptoms are so common, and none of them are pathogenic for a concussion. We see a lot of headaches and dizziness and other things that can be from dehydration, particularly in the summer months during outdoor sports. We see, ask an athletic trainer, they'll tell you first time there's any contact in football, a lot of kids are going to start complaining about symptoms that are really just about anxiety, about contact. So you have to start teasing apart what may actually be that concussion. Again, these symptoms are really, really common in the average population. These are non-patient. And those of you who are working with adolescents, high school kids, even more so. These are really, really common symptoms, particularly in athletes who have a pre-existing history of anxiety or depression, ADHD. So you always have to understand who comes to the injury, and that can be tough to start teasing apart. Again, that's why athletic trainers are really helpful. But there are symptoms that are a no-go. Any loss of consciousness, impact, seizure, tonic, posturing, etc. Gross motor instability, the kid who is getting up and falling over and getting up, real significant imbalance. Those are automatically removal from play, not going back, taking their helmet, having someone stay with them. There are also danger signs, meaning you just bought yourself a ride to the hospital on a CT scan. These are the CDC guidelines. I'm happy to see they've updated them. They used to say loss of consciousness more than 30 seconds, not terribly realistic. Any loss of consciousness we take seriously. If there's someone that you think is suspected of concussion, I really strongly recommend that you do in fact use the SCAT. It's not perfect. We have no perfect measures, but it's really, really important to document what the athlete is reporting. Those who are new to this will come find out. Athletes lie to us all the time. It's really, really helpful to be able to say, this is what you told me. You had these symptoms. And the SCAT assesses cognition, balance, a neurologic screen. Really, really helpful to start documenting these. And you can get the SCAT serially. So even if somebody looks good at halftime, you can test them again later in the game, after the game, the next day, because we really want to make sure that we don't see these symptoms start to, you know, onset of symptoms later on. There is a SCAT-5, which is great, child's SCAT-5, which is great, age 5 to 12. The biggest difference really is that you're also asking parents for their opinion, some observation. Obviously, a five-year-old doesn't articulate their symptoms very well. So they use a different scale, which is really helpful. So again, I really strongly recommend the child's SCAT-5, they are available in the public domain, you can just download them. So, somebody has a concussion, what do you do? Really important, you set expectations of recovery from the get-go. There's a lot of misinformation out there on concussions, a lot of scary stuff, people are kind of freaked out. We really want to set the tone that we expect them to recover, we think they'll be fine, and that normally people are recovered, most people are recovered somewhere between one to three weeks. Truthfully, most people are usually one to two weeks. It can be three to four weeks in kids, but we want them to understand, the symptoms are not gonna go away in a day or two, for most people, that we expect a slow recovery, but we do expect recovery. Do not want you over-prescribing rest, we'll talk about that more in a minute, and simply monitoring some symptoms, referring them out if it's a more complicated case or the symptom is not resolving. So, if you hear one thing from me today, it's please stop prescribing rest. It was never based on evidence, and what's happened is it's sort of become this runaway train. What the evidence does tell us is the first one to two days, we want people to dial it back, take it easy, really listen to their body, sleep some more, that's great. But beyond about one to two days, the rest doesn't make a difference, in fact, it makes it worse. We need to get away from this sort of notion that if you use your brain in any capacity after a concussion, you're somehow making things worse. Using your brain is not in any way deleterious after a concussion. We have to stop talking about rest and talk about symptom management. So, I'm a big fan of this keep it simple, stupid idea. We are over accommodating these kids. It's literally time and don't get bonked in the head again. We wanna manage those symptoms. Remember, symptom management. Give phones back, allow them to watch TV, but we tell them, listen, if you're starting to watch TV and a movie and you're getting a headache, take a break. If you're doing some reading from school, getting some symptoms increasing, take a break. It's really that straightforward. Concussion should not be a punishment. We should not be over prescribing rest and dark rooms and all those sort of things that you hear about. Again, never supported by any evidence. Wanna just remind you that there is really good evidence that the sooner someone sees a concussion specialist, the better. So, we really should be involving specialists and sooner in this process, when it's six, eight weeks down the line. We know that when we educate them, we provide appropriate combinations and treatment recommendations, they do better. But when it comes to treatment, we need the mantra to be active rehabilitation. Some of you may be familiar with John Luddy's work. I only have one citation here. I could have 50. There's so much evidence support that the sooner you remove people, the better. Not again, not rest. I will start moving people on day three if their symptoms are declining. We know that we see an increase in symptom, particularly for athletes who are used to moving, and it's been shown to be safe, effective, even in kids. So, we do not need to be fearful of getting kids moving, but we need to guide them and give them some clear expectations of what that means. So, if some of you are interested in this, this is a great article. I gave you a citation. It's a free, downloadable PDF. Walks you through exactly what to do for sub-symptom aerobic exercise. I think it's a great article if that's something you're interested in. So, how do we decide someone's ready to go back to play? Three things. Asymptomatic at rest and with exertion, balance and ocu exam is normal, and cognitive tests are normal. None of these things are perfect. I tell people all the time, can I 100% tell someone's recovered? No, this is the current state of the science. We use little kids all the way up to the pros. Couple things about cognitive testing. Computer-aided testing is not a diagnostic tool. No kid should be coming off the soccer field, going to school, taking IMPACT. IMPACT was designed as a return-to-play tool. That's, SCAT is a diagnostic tool. So, be careful if you're getting information about it. Here's IMPACT scores right after this happened. Cognitive testing is a return-to-play tool, and it's just one component of it. It should never be used in isolation. You also really want to make sure that your data that you're getting, particularly for baseline tests, are good, right? Has this been given standardized, garbage in, garbage out, right? So, we want to make sure that we're getting good data. And never, ever, ever, in my opinion, should we be allowing kids to take these tests at home. You have no control in the environment. We don't even know who's taking it. So, I have a very strict rule. I don't even consider that to be a valid test. And lastly, when it comes to cognitive testing, we really should make sure that people who have the training to interpret these tests, who have the training and background in psychometrics, who understand this test, and all those things that affect cognition, are the ones who are actually interpreting the test. There's lots of tests on the market. Impact is by far has the highest market share, but there are new ones coming out, for better or worse. Some of them have strengths and weaknesses. And of course, there's also traditional paper and pencil tests. So, thank you very much. I know we raced through a lot of things there. Hopefully we have time in the end to go over some questions later on this afternoon. Thank you. Hey there, Greg Lopez from Rush University. You're gonna talk about athlete spine injuries and management. Thank you for having me. Unfortunately, we cannot all be together. I love talking to non-spine surgeons at these meetings, and I've really enjoyed this conference in the past. We'll cover a lot of ground here. No disclosure in relation to this talk. One of the main objectives is to understand the red flags, because that's where most people are scared when it comes to spine injuries, as well as current return to play. But most of the criteria you guys will already have known, and learn how to manage injuries in a training room or return to play criteria. In regards to the red flags, these are the things I look for in a patient who come in to see me, or if I see this in the field, we cover a lot of sports teams. But if you see neurologic dysfunction, persistent radiating pain, bilateral symptoms, a high velocity mechanism of injury, or a patient who has fear of moving their head, these are people you say, hey, I need to not only remove this patient from a game, practice, whatever it is, I need to keep a close eye on them. They may require advanced imaging. We need to make sure we follow these patients, not just let them go home and take a shower and head on out. Always watching the game. Football is easy, other sports are not, in terms of knowing what exactly was the mechanism of injury and velocity. But these will help cue you in as well into terms of, is this patient severely injured, or is this something that probably we can manage just in the post-game area. So we're gonna go over a number of cases, looking at the most common spine pathologies that you will all encounter in your first year with sports, as long as we get sports pack in 2021. But here is a 20-year-old male football player, runs off after a series, presents you with severe left-sided neck pain. Patient is neurologically intact. And quickly, I can assess patients first and make sure you rule out concussion. And secondly, shoulder abduction, elbow flexion extension, hand intrinsic abduction. If these are intact, most of the nerves are intact and functioning appropriately. They can't hide motor function, but they can hide sensation. And so they have a normal neurologic examination, and they have paraspinal muscle at tender spot patient. With a mildly decreased range of motion, they most likely just strained one of the many short rotators that is in the cervical spine. And imaging is not necessary for a patient like this. In the training room, we work on ice, range of motion, and isometric exercises. We also wanna talk with a strength and conditioning coach to help improve their strength in the neck, especially in football players, as well as hockey players. If the patient comes back to you in the weeks following, and they say, hey, my neck is hurt. You know, it's not killing it, it's still continuing to hurt. You wanna rule out any possibility of subtle ligamentous injury. Rule it out with flexion extension films. Typically, we don't always see subluxation, but it can occur, and we call it subluxations, and it moves 3.5 millimeters or more. But angular displacement, because typically these athletes have tall discs, and not a lot of disc disease in the cervical spine. In terms of return to play, you're not gonna be able to determine this for ligamentous injury. It'll be the specialist. However, someone who just mainly has a cervical strain, it's all based on symptoms. Once they have painless range of motion and stable radiograph, they're able to return, and it goes by any other stepwise protocol, increasing range of motion, progressive strengthening, and then sport-specific exercises. This requires an open-minded discussion with the athletic trainer and the physician. This next one is HMO female hits her head on the goal, had immediate right arm shooting pain and her neck pain. This cues you in a right away. Is there something going on? Nerve-related weakness in the right bicep. So again, going back to the neurologic examination, perform this quickly on the side, and make sure, especially with the larger athletes, that you're not being fooled with symmetrical strength. This commonly can be done with football players, not as much for other smaller players, but football, it's commonly masked. And then this patient describes relief of pain with shoulder abduction. So is imaging needed in this patient? Of course, yes. Not only are you gonna pull this patient out of the game, but you're gonna be concerned, or she has weakness in her arm. Anybody you have weakness in, you're going to have a higher acuity, and understanding that you may need to further image this patient, as well as get them a treatment at an earlier basis. In the training room, perform neck exercises for any disc injury, assuming it's a disc injury where it's causing a cervical radiculopathy. Traction, anti-inflammatory medications are mainstays of treatment. But you want to carefully monitor neurologic function. With an acute cervical radiculopathy, with mild motor weakness, it can progress to worse, but also improves. These patients will benefit greatly from acute treatment with range of motion, but have an acuity that if the strength does not improve quickly, you'll send them for advanced imaging. Case number three is 16-year-old female who lands on her head, and has immediate right arm numbness and burning pain. This is the first time in her career the patient states, and resolves in the next few minutes. There's no weakness, neck range of motion is normal. So obviously, this is what you're going to see as time and time again, most commonly in football. And if they have a normal neurologic function, excellent range of motion, they're going to return to play that same day, as long as their symptoms have resolved. Radiographs is what I typically get in these patients in the following days. I do not get advanced imaging for the first incident on these patients. However, if symptoms persist, it gets a little bit trickier, and you want to confirm they don't have a cervical disc herniation that could be causing this. So an MRI scan, as well as an EMG, are appropriate to get for these patients. It gets a little bit trickier, and a little more nuanced, when it comes to recurrence stingers, and how you're going to approach these patients. Is this a second time stinger? Is this one that occurred, the first one occurred a year ago, and this is the second one, and this is the first one this season? Or is this one that occurred last week, and now this is this week? For the one that's more acute in the time interval, and a second time stinger, I'm going to take them out of that game. Even if the resolution of the arm symptoms occurred, and I'll send them for an MRI scan. Having stingers in committed weeks is not normal. And then also, a second or third time stingers that have persistent symptoms, we got to figure out what's going on. Is there really just a cervical disc herniation that's occurring, or is there actual neurologic dysfunction that's occurring that's intrinsic to the nerve? Return to play is tricky with these. If the symptoms resolve, we typically try to let the patient return back to play, but it's dependent upon the advanced workup. Next, that's one of the most common things you're going to see is a 21-year-old male baseball player who has had episodes of stiffness, low back pain over the last year, and was diving for a home plate, and acutely worsened his pain, radiating buttock pain. If this all resolves relatively quickly, neurologic examination, and quickly a lumbar neurologic examination should be quite quick. We have the patient march, walk on their heels, walk on their toes, and the major muscle groups have been tested. And as long as these are completely intact, the patient can most likely return to play as long as their range of motion is intact. The same game is fine. And the game day treatment is ice, anti-inflammatories, and stretching. Notoriously, people who have low cradle back pain have tight hip flexors and hamstrings. If these become immobile, the pelvis then becomes more fixed, and the strain goes to the lumbar spine. Lumbar disc disease is very common in athletes. We know it's very common in non-athletes as well, with 31% of the population at the age of 30 having some form of disc degeneration. Baseball at L5-S1 is the most common area to have disc degeneration. In terms of cueing in, is it causing pain? Is it not? Is it disc injury in the disc injury setting? We look at bone marrow changes, which we call modic end plate changes. And we look to see if this is inflamed. Is it causing fatty infiltration with the end plate? These all cue us in. Could this low back pain be caused by the disc injury? And the mainstay of treatment is core stabilization, as well as TENS unit, which has been shown to help chronic and subacute low back pain in level one evidence. So this is a very important method of treatment for these patients, especially baseball players who commonly have chronic low back pain as torsion. It does, is hard on the L5-S1 disc. Injections, which we commonly ask, patients will commonly ask you about, is it worth it for them to try? For acute low back pain, it's hit or miss. Typically, we say no, especially in the younger patients. In a randomized controlled trials, there have been so many. But meta-analysis show there's been insignificant evidence to support the use of injection therapy in subacute and chronic low back pain. Discography is another thing we very, stay very far away from, especially young patients determine if this is something that's appropriate. I've seen this before on an athlete's report. They can increase the rate of disc degeneration with the use of discography. So please stay away from this. Next case, a 17-year-old female volleyball player has acute onset of unilateral low back pain, limited range of motion, and no prior history of low back pain. They have muscle spasms on examination and severe pain with extension. Obviously, at the end of the game, if their pain is severe, you're not gonna let them return to play. You're gonna use the usual return to play protocol that we've talked about. In the high-level athlete, I truly think it is a PARS injury until otherwise shown. People have chronic back pain and they're playing a single sport year-round, whether they're 14 or they're 25. Most commonly, it's a PARS fracture. Two of these walk into my clinic every single day. And the way you're able to rule it out is typically I can find them on x-ray. You can see here's the PARS, where the arrow elucidates is a fracture at the PARS. It's a dense cortical area in the vertebral bone that does not have a good blood supply. Here's a fracture on CT scan, and that's what we typically look for. In general, high-level athletes have this. It's been 40% of elite baseball and soccer players at one point were surveyed had this injury. We typically find it on CT scan and bone scan to help elucidate if it's acute or chronic. In acute symptomatic PARS injuries, typically this can be a significant, maybe it's difficult for them to return to play in three to six months. We want this to heal. Unilaterals will typically heal. Bilaterals typically don't, but it will take at least three months of no play. I typically avoid even physical therapy, but if some of them want this and it can help with pain control, bracing is really to avoid activity modification and anti-inflammatories. I'm hit or miss on, but it is said in the literature to be used. In terms of chronic symptomatic PARS injury management, it's really fully based on symptoms. If they come in with a CT scan and they're fine, you can let them return to play. If it's not, then I would say, it's gonna be based upon their symptoms and having them undergo physical therapy or PARS injections. Just so you know, there are a number of athletes that have been able to return to the competitive sports, and many have excellent outcomes, even with bilateral defects and chronic defects. Non-union does not compromise their return to sport. It's really symptomatic treatment. The last case, a 20-year-old male who is working out in pre-season has acute onset of low back pain and left leg pain, radiates on the posterior leg and the plantar surface of the foot. So you know it's S1 radiculopathy. Obviously, a neurologic examination is important. They have some weakness in their left gastroc, but also they have a decreased left achilles reflex and a positive straight leg rate test on the left side. For this, initial treatment is removed from their activity, ice, anti-inflammatories, and electrosimulation. And then imaging, no radiographs are necessary, but an MRI due to the weakness, and don't be afraid to hesitate to get this in the next day. Lumbar disc herniations actually are well tolerated in a very young population. People can return relatively quickly dependent upon their size, but they can return quickly. We know in management, do not hesitate to give an epidural lumbar injection if these patients are still in pain and after a few days after the injury. In the NFL, it was studied looking at 17 NFL football players and their return to play rate after lumbar disc herniation or receiving epidural steroid injection. And only 0.6 games are typically missed in these patients, so they're able to get back to play in the setting of lumbar radiculopathy with disc herniation. Football players have a much better return to sport because they're typically axial loading their disc, which is much more tolerated than baseball players. And so this is not a career-ending injury. So in general, spine injuries are not all career-ending. Do not think that. I've seen a number of patients who have this and keep your eye out for red flags. There's patients who have, they should be removed from their sport and closely examined and return to play is case-by-case basis, but it really heavily relies upon range of motion as well as strength in the leg. Thank you guys very much. I wish you guys the best. There are approximately 12,000 spinal cord injuries per year in the United States, of which 9% are due to sports-related causes. In terms of football, the incidence increases with each level of play due to the fact that the athletes are larger, faster, and stronger. Ice hockey injuries are actually three times more common than football and typically occur from boarding, as is shown here. As with many other orthopedic injuries, the trampoline has been implicated in the etiology of gymnastics-related cervical spine injuries. I want to present three different scenarios you may encounter when evaluating an athlete suspected of having sustained a cervical spine injury. Scenario one is due to isolated cardiorespiratory compromise and is a relatively rare event due to a facial fracture, tracheal, or laryngeal trauma. In this case, the face mask and mouth guard should be removed, but the helmet is kept on. The jaw thrust maneuver is recommended, but not the head tilt technique. An oral airway is recommended, but not the head tilt technique. An oral airway is necessary in the event that there is altered mental status. Definitive airway management is indicated for apnea, a severe closed-head injury, inability to protect the airway from aspiration, and an inability to maintain oxygenation. CPR is initiated for absence of the femoral or carotid pulses. In the case CPR is needed, the current recommendation for a single responder is 30 chest compressions per two breaths, and for two responders, it is 15 compressions per two breaths. Also remember that it is imperative that you know where your AED is located at all times. Here are some common airway devices designed for emergent placement. This can be difficult for most of us who don't use them routinely. I would recommend practicing intubation in your operating room prior to an elective surgical case so that you can become familiar with the technique used. For example, many sports medicine procedures are done with an LMA. Ask your nurse anesthetist or an anesthesiologist to practice these techniques. They are often very amenable to letting you do this under their supervision. In scenario two, there is ultramental status without cardiovascular compromise. The common causes are shown here. An on-field neurologic exam is necessary, and it should be assumed that a cervical spine injury exists until proven otherwise. Again, rapid removal of the face mask must be done immediately. You should familiarize yourself with the type of helmet and face mask your team uses. You should be able to remove a face mask within 45 seconds as a general rule. Be aware of the torque used to remove a screw or latch and never use a scalpel for risk of iatrogenic injury. This is an issue like spine boarding that should be practiced in the preseason. Here are some devices used for face mask removal. Each athletic trainer has his or her preferred devices. Many helmets used today are designed to remove the face mask. Please familiarize yourself with what your athletic trainer has and recommends, and always know who has any sort of specific face mask tool prior to the start of the competition. In scenario three, there is normal mental status without cardiovascular compromise. This is the most common scenario. A C-submine injury is suggested by focal spine tenderness, restricted neck motion, neck pain, and neurologic deficit. Assume a C-submine injury until proven otherwise and immobilize accordingly. A cervical cord neuropraxia, also known as transient quadriplegia, is characterized by acute transient neurologic episode with sensory changes in one or more extremities with or without motor deficits. Symptoms include burning pain, numbness and tingling, in addition to variable motor loss from weakness to complete paralysis. Requirements for C-submine injury include a C-submine injury that may occur within 10 to 15 minutes, but may take up to 48 hours. Most of these injuries occur at the C5 to C7 level. You're all familiar with the Pavlov ratio of canal diameter divided by vertebral body width. The diameter of the cervical canal is significantly lower in over 90% of players with a history of transient quadriplegia. Given the size of collegiate and professional football players, over 40% have a ratio of less than 0.8, which leads to a very low Pavlov ratio. The C-submine injury is a very common injury that can be treated with a C-submine injury that may be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. The C-submine injury is a very common injury that can be treated with a C-submine injury. In this example, a quarter turn with a power screwdriver is all that is needed to remove the mask in 24 seconds. Some helmets have a variety of screw clips holding on the face mask. In this example of a Riddell helmet, a power screwdriver is used on the top and a quick-release tool is used on the side clips to remove the mask in 35 seconds. It is imperative that if your team uses a helmet with this type of clip that you have the removal tool available for when it is needed. Shoulder pads come in a variety of styles and are usually separated from each other by cutting the strap or string used to fasten them together. This is necessary for smooth removal either on the field or at the emergency room. Here are some examples of various shoulder pads design. The first one uses lace shoe straps that can be easily cut for removal. Others have a vinyl or plastic connector that must be cut with the trainer's angel tool out removal, which obviously is more labor-intensive. Again, please familiarize yourself with the type of shoulder pads your team uses in the preseason and practice both helmet and shoulder pad removal with your sports medicine team so that everyone knows their role if and when an emergency occurs. Thank you for your attention and good luck in the coming year. Thank you for our presenters. We are going to go live with our panel discussion right now. Great presentations. And we're going to welcome our presenters, Dr. Indelicato, George Lopez, John McKnight, Aaron Morris, Matthew Matava, and Elizabeth Piroth to join our panel. So we're still waiting on questions from our presenters or from our audience. So don't be shy. Feel free to send any questions that you may have over to us. I am going to have a couple of presentations that we're going to present and some cases. One is sort of a rapid fire presentation, and the other is more cases to present. So I'm going to pull those up. Let's see. All right. Meredith, can we see your presentation? So we'll get started. And we got our screen shown here. Can you all see my presentation? All right, so can everyone hear me out there? Yes, perfect, okay. So here's our first case. So high school football game, defensive back, spear tackles to wide receiver, both lay motionless on the field. The personnel that you have at the game, there's one team physician for the home team, and then there's one ATC per sideline, and then you have an EMS squad. And next slide. All right, so the defensive back who's down, he's alert and oriented times three, fully responsive, unquestioning, but he states, my neck hurts, and he cannot move his arms or legs. Again, it's a high school game, and then the wide receiver is completely unconscious, but breathing spontaneously. So how do we manage this? So we'll first open that up to Aaron Marris, you're the team doc covering, what's your thought process going through this case? So I think, you know, initially as you've witnessed this event occur, right, you're gonna have several thoughts that go through your mind. As you're going out on the field, most of us will say, hey, look, we can see a catastrophic or at least a concerning injury, kind of right away and have that sense, okay, there's more than something else going on. Getting there, you may have the ATC that arrives first, right, or maybe you're the one that's closest and you're arriving. So whoever's there first should initiate the C-spine precautions there, right? And typically that would be the athletic trainer. And then as the physician arrives and you're going through your questionnaires and kind of saying, okay, what is our initial screen? And so you stated this gentleman was alert and oriented, right? And so, you know, typically we go through, you know, the pit and the Steelers, we kind of work together on the training of this and we go through a four question system to start off. You know, what is your name? Are you having any problems breathing? Where does it hurt? And can you move your arms and legs, right? And with those four questions, we can get a lot of information from that. And then clearly if this gentleman can't move his arms and his legs, then you, you know, proceed with your C-spine protocols, in my opinion. Now you've got two physicians, one on each team, two athletic trainers, one on each team and an EMS. And so clearly as you go to do this, you may have to recruit other individuals to help, you know, further your progression. So those would be my initial thoughts throughout the BAD and then clearly get this kid stabilized. And so, and he's a, and we have a unconscious Y receiver, which is also next to him. So Matt Metava, what's your thought process in terms of triaging this, this scene that you have? So the one player is unconscious. The other one has neck pain and cannot move his arms or legs. That basically the situation. And this is a true story. Okay. I would depend upon the personnel that I have at my disposal. I would say with the first person that I manage, I would take the head of the player who says he has neck pain and cannot move his arms or leg. I would stabilize the head. I would dispatch my next most senior person, either on my team, medical team, or on the opposing team to evaluate the player with the concussion. And if I have a primary care physician, I will have him or her go to the patient with a concussion and then mobilize the triage for C-spine mobilization for my patient and have him take it off the field using typical spine board methods that we talked about. And then as far as the patient who's concussed, I would manage him as if he had a C-spine injury as well. I'm not sure in your scenario if the player is face down or if he's subpine. I'm not sure if that's- Yeah, he's face up. Great question. Well, we have to assume there's a C-spine injury until proven otherwise on the concussed player. And again, C-spine mobilization, boarding, and they both go. All right. So the thought process with this was, and I think that's great input. And I'm not sure if there's a wrong or right answer, but certainly there's one squad at the game and the athlete who was unconscious, even though he was breathing spontaneously, I guess the thought was, A, he could also have a C-spine injury, and B, probably was at most at risk of losing his airway. So he was the first on the squad to go. And the patient who was awake and alert, but unable to move his arms and legs, he came shortly thereafter. And that was just sort of the thought part. I think you all mentioned some very key points in terms of how to triage the sideline. Certainly at an NFL game, there's a lot of individuals, but maybe at the high school level, you may be one of the only docs there, along with your athletic training staff. Can I say something? I think one of the responsibilities of a team physician, if you're the home team, is to, before the game, seek out the other team's team physician or trainer and share with them what EMT services are available, where they're located, and have this pre-game social visit, if you want, and maybe include the EMT people. Because if you're a visiting team, you're not sure what's available unless somebody tells you what's available. So when you need multiple resources, as you do in this first case, it'd be nice to know what's available if you're the visiting team. Absolutely. Hey, Gatul, that's a great point by Peter. I would also recommend introducing yourself to the head referee, because if you do have to run in the field, it's good that that person knows who you are, especially at a higher level of play, collegiate, professional, where there could be competitive issues if you go on the field in an unknown fashion. Absolutely, and obviously this involves being to the game well ahead of kickoff. So another key point. I always try to arrive at least an hour before the game, not only to talk to our athletic training staff to see if there's any issues that need to be addressed, but also to do what everyone sort of mentioned. All right, so case number two. So high school football game, personnel that you have available. So three ATCs, home team ortho, and an ortho resident, and an EMS squad. So after play, you have the away team nose tackle who is face down in the field, and he's a big boy, 335 pounds. So this is the video, and we see the arrow, so he's the nose tackle in the white team. So just follow that player. So comes off the block, dog is blowed to the knee. We got a dislocated knee. So this is the blurry zoomed in picture there, and that's his knee. So he's face down in the field, 335 pound athlete with what appears to be a knee dislocation. And again, that's your personnel. The EMS squad is there, and basically everyone's on the field at this point. When we were talking about management here, what are we looking at in terms of next steps for this athlete who's face down, 335 pounds with a knee dislocation? Thank you. Did Dr. McKnight or any of the other presenters or presenters wanna chime in? Well, so in this scenario, we're fortunate that we've got plenty of care providers. And so we're concerned about a number of things relating to the severity of his injury and probably ultimately paramount is gonna be a concern regarding vascular compromise of the lower extremity. So with him being face down, we're gonna need assistance in trying to get him supine so you can get him transported while we're also being cautious with regard to the leg and trying to approximate anatomic position there, axial loading, and then getting him packaged and then transferred for further evaluation. So you've got a couple of key things there with regard to trying to get the injury back into anatomic position as best you can. You've gotta get this young man flipped over so that you can transport him. And then again, emergent evaluation particularly with regard to vascular status. Yeah, and that was the approach here. Anyone would be, certainly in a patient, if they had pulses, anyone would be opposed to doing a closed reduction on the field? I would not be opposed at all. I would try to close reduction, but before I did it, I would evaluate the neurovascular status of his leg. But I agree with Matt, I would try at least one attempt to close reduce it, particularly if the closest emergency room was a half hour away or something like that, like it could be in some of these rural areas. Yeah, so if it was a meal from a condos buttonhole to the capsule, you may have difficulty. So part of it depends on what kind of dislocation the player has, right? Right, so yeah, so he didn't have a pucker sign or anything like that. And that was our thought. Yeah, number one, the big guy, I think would have been very difficult to mobilize that leg at 90 degrees. So we did reduce his knee while he was face down after checking his neurovascular status, which was all intact. And once he was reduced, had a lot of team members to get him back onto his back and then transport it. His kid was 16 years old. This actually was a growth plate injury. So he had a Salter Harris II growth plate injury that actually went in fairly easily. So getting him back into a good anatomic position, he actually did very well. I would also suggest you post reduction, you recheck the neurovascular status just to document that for future care. Absolutely, and so after we did that, he went into a vacuum splint. And luckily the emergency department was actually just across the street. So we were able to get him managed fairly quickly and then transported down to our main campus. And we did call ahead to the ER across the street just to let them know what was coming. So sometimes that communication is key. You know, Atul, this brings up a good point that was sort of raised by the last case. And that is if you are visiting team doctor to know where the ingress and egress of ambulances can come to. Because sometimes these small high schools, they're very difficult to get an ambulance on the field. It's always best to know that, especially if you're a visiting team doctor. Absolutely. So we have one question. We have a few questions. We'll start with this question from the audience. So could someone outline their day by, could someone outline their day-by-day return to play post-concussion protocol for athletes, football specifically? Dr. Piroff, would you want to field that question? Or Dr. McKnight? Okay. I was muted by the organizer. Sorry about that. So as I said in my presentation, there's basically three things that we're looking for. And one of them, the first thing is asymptomatic, at rest and with exertion. And one of the things that we're doing now is that we are starting that exertion cycle. And so we're looking at, we're looking at what's going on in the body. And we're looking at what's going on in the heart. And what we're seeing now is that we are starting that exertional process a lot sooner than we used to do. It used to be that you didn't start to exert them until they were in fact asymptomatic. And we're seeing is that the sooner we move people, the better. So we typically are starting that exertional process more as an exertional therapy versus the return to play process. Two, they need to have a normal neurologic exam, particularly balance and ocular examination. And depending on what sport they're playing and their program, we do recommend, particularly for contact players, that they're undergoing cognitive testing to make sure that the cognitive testing scores have returned to generally around baseline or suggestive of recovery. So those are the three things that we're looking for to return anyone to a sport, particularly a contact sport. Cool. Thank you. So another question here. So it's the standard of care now to leave helmet, including face mask, and all pads on and send the player to the hospital, unless of course it interferes with airway management. I think you covered that in your talk, Matt. Anything else that you wanna mention about that? Just always remember to take the face mask off whenever you transport. Like I said, there's a, the NATA wants everything to come off at the field of play. And Peter can comment on this as well. Most sports medicine physicians will keep everything on until you get to the hospital. And one of the reasons for that is because it takes time to get stuff off. And secondly, if you can get a C-spine CT scan at the hospital, then you're safe to take everything off right then and there. So we're more apt as physicians to, or imaging studies at the emergency room compared to athletic trainers, that may be one of the reasons why there's a distinction there. But I kind of follow the all or none rule. Keep everything on unless you have to get to the head because of a open head injury, but definitely take the face mask off and protect the airway when you transport. Yeah, absolutely. And I think that again goes down. So with your colleges and teams, certainly you should be having some sort of pre-season meeting where all these things are sort of hashed out before you hit the field as to what your protocol will be for your athletes. And certainly, if you're the only person covering a game in the middle of nowhere, you have two ATCs and a doc, certainly removing everything may be more of an issue. I think the places that I've been as a team physician, our ED docs are well-versed in removal of pads and face masks. We actually do a catastrophic injury course before the year starts. And so if you know where they're going, you know things are gonna be done right. Certainly you can send them with everything. If you have any questions, you're in the middle of nowhere, you don't think that the pads and helmet may be safely removed, that they're in place. And certainly you can choose to remove, again, all or none at the field of play. But definitely the face mask needs to come off and so we have that airway access. Again, I wanna comment about how important it is to discuss these situations at this pre-game meeting. And it's also important to include, if it's possible, the EMT people. So there's no discussion as to who's in charge when a player is injured with a suspected cervical injury. You don't wanna have that discussion with the EMT people on the field. You wanna have that discussion before and have a clear chain of command, if you will, in each venue that you go to. Excellent. All right, so next question. When, if ever, would you intubate a patient to protect an airway in a patient who is spontaneously breathing, i.e. a patient with continued unconsciousness? So personally, I don't necessarily see a reason to intubate a patient if they're breathing and they're not labored or worsening status. And you have a patent airway without some sort of major head trauma where there's poorly controlled breathing that could certainly compromise the airway. But certainly myself, in the absence of any bad, unstable facial fractures, don't necessarily see a reason to intubate someone who's spontaneously breathing. I think oral airway does find that situational tool. You know, he or she is breathing on their own. Just maintain oral airway to keep the tongue out of the way. Right. So we're gonna turn to our next case. So Cleveland Marathon, you're in a medical tent at mile 11. This is mid-May, 72 degrees to start, and it's 82 degrees currently with the 83 heat index. A raised volunteer brings an athlete to you and states, I think she is having mental breakdown or forgot to take her meds or something. You struggle to direct her into the medical tent. She's pushing members away and is very combative and attempts to walk off aimlessly. A physical exam, she's 25 years old. BMI is about 30. She's got some mild flushing, some perspiration. She's irritable, a little hysterical and psychotic appearing. She's very combative and not really letting you and not really letting anyone close to her. Does not answer any questions appropriately and you cannot obtain any history. So now she's starting to dry heave and she's very combative. So what are your next steps for this athlete who is not really being cooperative with medical care that's trying to be provided? Dr. McKnight. So your two primary concerns in that circumstance are gonna relate either to heat associated illness which is transitioning to heat stroke resulting in central nervous system dysfunction or potentially hyponatremia may present in a similar way. And so for individuals who are either perhaps not as well trained for the event that they're participating in or the challenge of these major events is always that environmental control is out of our hands. And so sometimes people have trained at a certain temperature the race temperature is considerably warmer. They get halfway through the race, it's even warmer still. And so sometimes they start to panic. They start to over hydrate in response to their sense that they're gonna get behind. And so that's how they become hyponatremic or they simply lose their ability to heat dissipate appropriately as they're going. And so as their core temperature is rising becoming more and more dysfunctional from a performance standpoint and then they cross the line to develop central nervous system dysfunction. And that's a huge distinction there. So your keys there are gonna be until you can get a core temperature and the ideal means to do that is gonna be an erectile temperature in the tent. Is that that person needs to be actively cooled until you've figured out how much of a role heat may play. And then ideally you've got an eye stat available in order to be able to assess their sodium. And armed with those two pieces of information that gets you pretty much started in the right direction with regard to how you're gonna manage them. Combativeness, particularly for our heat stroke people is really a challenge. Trying to get a rectal temperature on somebody who is actively flailing at you is really tough. So in those cases you gotta use all the bodies you have available to you. And sometimes you even have to medicate those people in order to quiet them down enough to figure it out. But particularly from a heat stroke standpoint that's a potentially lethal condition. You gotta get the information that you need and you have to do it as quickly as possible. So in those situations, do you sort of dunk first and then get the answers to some of those questions as you're cooling? Yeah, I think that the key there is the time under the heat curve when that heat curve is really high is what creates damage. Whether that's central nervous system damage, myocardial damage, rhabdo, renal failure, the whole nine yards. And so you never be faulted in a scenario like this for cooling first and ask questions later. If you guess wrong, all you've done is cool them a little bit and you give them a blanket and they're gonna fix that. But if they got a core temp of 108, 109, 110 and you're fiddling around trying to figure out what's going on with them, they're gonna have a really bad outcome as a result. So cool first, ask questions later. Excellent. So we're gonna go to some of the rapid fire questions, semi rapid fire. So NFL regular season game, six minutes before halftime, starting defensive back comes to the sideline, has a right middle finger PIP boulder dislocation. He's had this before and his other hand knows what it is and comes over and asks you to reduce it. So you reduce it, goes in right away. And at that moment, you notice that there's blood coming out of his gloved hand. And so it turns out that he had an open PIP joint dislocation that you just reduced. So it was covered when it happened. So x-rays in the locker room show a reduced PIP joint no fracture. So he has an opening dorsally over the PIP joint, middle finger, D back, it is now halftime. Go or no go? Dr. Indeligato, you're on. And you have the, so you've had the ability, you sort of watched him out. You got him sutured up and he wants to go back into the game. Yeah, I put stone dressing on and let him go back and play. But I would, again, try and have some type of a reasonable conversation with him about what the nature of it is and what the risks are relative to an infection or a re-dislocation. But I tape his fingers back together, put a dressing on it, let him go back and play. If he's an NFL player, if he's a high school player, it's a whole different set of circumstances. Absolutely. Matt, any differences in management? No, I've actually had this injury a couple of times and done the same thing. Put him on antibiotics post-operative or post-game antibiotics, monitor his symptoms and then let him go from there. I've never had a problem from this injury going on to an infection or any other bad issue. Yeah, he did well. We put him into a well-molded orthoplast splint just for the orthoplast shell, basically, and fashioned a glove for him and he actually did well. All right, so D1 Collision Road Game, first quarter. Your starting quarterback has a shoulder anterior dislocation, non-dominant arm. You do a closed reduction. Where are we doing our closed reduction at, Matt? He's at midfield. How do you prefer to manage these? You can talk about sort of the big level, high level athlete as well as your high school athlete. If I can feel it dislocated under the shoulder pads, I will try to reduce it right then and there if I'm comfortable with the shoulder dislocation. Most times they can come back in right then and there. If I give it one trial and it doesn't come back in, then I would take him off the side, take him inside and go from there. And then you can give, you have two people to help. You have a couple options you can do. You can put them prone, let them hang down, Stimpson maneuver. Otherwise, I've wrapped a sheet or blanket around their torso, around their shoulder and pulled them on and then rotate it internally. A couple of times in professional hockey players, I've had to inject lidocaine into the joint to reduce discomfort that allowed it to be relocated. But I would try to do it one time on the field if I was comfortable with it was a dislocation and not a fracture. Yeah. In a hockey athlete, do you do it on the ice or do you get them off the ice? There, in hockey, it's very uncommon for the team physician to go on the ice given the nature of you physically getting on there and then, well, basically the players will skate you to the other player because you're not wearing shoes that are conducive to ice. In that situation, I hurt myself more trying to reduce it by slip and fell. So in that case, you get the player, the team's athletic trainers wear shoes that have very good grip on ice. They will immediately get the player off the ice. In the NHL, you have to stay within 50 feet of the ice at all times. And so we'll meet the player right there in the training room and it's not an issue. Any situation where you're gonna try to get to the locker room to do this, out and away from the crowd? You know, it depends on, again, if I feel like I can get it done right then and there, I will try. If the patient is relaxed, if he's comfortable, if he's cooperative, if he says he feels like the shoulder's slid out of socket, I will try it one time. Typically, you have your teammates around them, which can be an issue if you're trying to get to the player, but that will often shield the crowd from you. You also have your other medical staff and your athletic trainer. I will try it one time there and if it's too painful or if it's not going, then I will take them off. I will not be out there in the 50 yard line for five, 10 minutes trying to reduce this thing. Absolutely. Awesome. So thanks, everyone. We are going to move on to our next sections. Thanks, everyone, for sending questions. I actually have some great, great questions. But we are at the 8.05 or 7.05 hour now, central time, and we have our next talk coming up. And this is Matt Smith, Associate Professor of Sports Medicine at WashU and Team Physician for the St. Louis Blues and the Washington University Bears. And we welcome Matt for his presentation. Please continue to send questions as they arise. Hello, everybody. This is Matt Smith at Washington University in St. Louis. I'm going to be talking about the common knee injuries that you're going to see as a sports medicine physician on the sidelines primarily. Some of this will be office orthopedics as well. Here are the disclosures for me. Our overview here is we're going to talk about on-field pregame planning, which is going to be brief and concise here, but I want to make sure we mention a few things that will help you. And then we're going to do a case-based review of the common sports-related knee injuries, including meniscus injuries, patella-femoral instability, ACL, MCL, PCL, and post-colonial coronary. We're a little bit limited on time, so we'll try to get through these quickly, but hopefully this will give you a good overview of what we look at. So on-field evaluation, we want to start with pre-game planning. So whether you're at the high school level or at the professional level, you have to know where your resources are, you have to know where your AED is, what kind of splinting materials they have. You have to know whether or not you're going to have EMS at your site for whatever game that you're covering so that you know what you have to be responsible for. And then that way, when the game starts, you can focus primarily on taking care of the injury and doing it efficiently. Our on-field assessment, when we say for football, if we run out onto the field to see a player that goes down, it's really the first thing is our standard ABCs. We want to make sure that they're conscious breathing. You know, if they are conscious and breathing, you want to make sure they're moving everything, make sure they didn't have a spine injury, things that would prompt us to have an immediate call to EMS to make sure that we get that athlete taken care of it quickly. Once we've kind of ruled out the bad stuff, then we do a quick evaluation. Once that athlete has settled, looking for whatever body part is injured, we look at recrepitus, deformity, any sort of signs that they've dislocated a joint. Sometimes we can do a quick reduction. If we see that happening, it's easier to reduce it before it starts to spasm. Once we get them off the field, we can do a little bit more thorough evaluation. Sometimes we have to take them to the locker room to get a better scenario to get a full assessment. If the athlete is looking like they are hurt but not significantly injured, then we can do a functional assessment. Can they run? Can they pivot? Can they do their sport effectively? And if they can protect themselves and be effective, they can return to play. You also have to know your athletes. Some athletes are tough as nails. If they go down, you know it's serious, and others are a little less able to manage and cope through the pain. So the trainers can help you with that. You also need to partner with your trainer to understand who's going to go on the field, when they're going to need you, and who communicates with the coaches, because that's a big part of what we do is making sure the coaches understand what's happening with their athletes. So to get back into the stuff specific to the knee, there are going to be some common themes of presentations here that you're going to see, and we'll highlight this. The first case is an 18-year-old male who felt a pop in his knee while he was coming down for a rebound during a basketball game. He feels like his knee locked up on him. He's starting to get an effusion. He's got joint lanternus, a quick McMurray's, you know, is positive and can't really feel any laxity with Lachman's exam, and his collateral ligaments feel stable. A big thing here is he can't bear weight, and he's got limited range of motion. So this is an athlete that is likely not going back into the game if he can't bear weight. So this immediately moves to a scenario of getting a further workup, whether it be that evening or the next day, if possible. So when you see a patient who's got that scenario as I planted, felt a pop, or came down and felt a pop in my knee, there's five things that we typically think of, and then your exam will help you, and sometimes, you know, loss of range of motion will help you, but this is something that we go through. So the first thing you always think of is an ACL tear, planted, felt a pop, knee is swollen. That's a common ACL presentation. If you ever think about an ACL injury, you should also think about a patellar dislocation because the patients feel something similar. They feel like their knee buckles on them. So always examine the translation of the patella and see if they have apprehension. You can also get a meniscus tear with the same scenario. Osteoconjural injuries, whether it be from a patellar dislocation or from a condyle being more common. And then in the back of your mind, always think about the extensor mechanism. It's not as common in younger athletes, but as the competition goes into older athletes, you can get patellar tendon ruptures primarily. On occasion, you'll get a quad tendon rupture. So this is this athlete's images. This is a MRI, and you can see here that there's an absent meniscus in the back of the knee, and there's two triangular-shaped structures in the front of the knee. So this should always prompt you to think about a bucket-handled lateral meniscus tear as the diagnosis. You can actually see the meniscal tissue here on the coronal view where this should be there. So again, this is where imaging really helps us, and we could get a sense of that based on the locked knee and an ability to bear weight, but the imaging really confirms things for us. So we all know about meniscus tears, and the key here is that when you're looking at the meniscus on MRI, the proton density sequences are the most helpful. Those are the ones that are specific for meniscus pathology, and typically, we think of a meniscus tear as a signal change, high-intensity signal change that goes to the articular surface on two contiguous slices, and as you get good at this, you'll be able to pick out the different tear patterns based on the MRI findings, but for now, you know, looking at just finding that high signal intensity will help you quite a bit in making the diagnosis. We all know the standard treatment for meniscus tears that you can do non-operative treatment, activity modifications in the older patient with the degenerative meniscus with some arthritis. Non-operative treatment has about a 50% success rate. That was a randomized controlled trial done about eight years ago. The only true thing that you shouldn't treat without surgical management is a bucket-handled meniscus that's happened acutely. That's usually an operative problem. On occasion, you get the patient that's got a chronic bucket handle, but we would like to preserve the meniscus if possible, so we try to get to those sooner, and our goal with operative treatment, if we go to surgery for this, is meniscus preservation if possible. We want to make sure that the meniscus is able to continue functioning as a shock absorber for the articular cartilage, and repair is a possibility if you've got the tear in the zone where there is vascularity, and for the lateral meniscus, it's approximately 10% of the periphery has vascularity, and then the medial meniscus is anywhere from 10% to 30% has vascularity, so something to consider as you plan for surgery. This is the patient who planted Felt-A-Pop. You can see the meniscus flipped up in the front of the knee, and then as it's reduced, it still does not have a normal contour. This particular tear was treated with an all-inside technique. This is before the sutures are cinched down, but what we're doing is trying to aim for a vertical mattress. The gold standard is still considered an inside-out repair technique, but the all-inside suture repair technique works very well. The recurrence rate for isolated meniscus tear with using an all-inside technique is about 25% at five years, so it's something that you need to counsel your patients on about the potential risk for recurrence. Debridement, as we talked about, is probably our most common treatment for most degenerative tears. I'd say the acute tears in young athletes, we're going to try to repair as best we can if there is vascularity. The other type of tear that sometimes causes problems is this horizontal cleavage tear where you see the cleavage in the meniscus, and then there's joint fluid that is able to get out behind that and cause a parameniscal cyst. You can clean up the meniscus, but if there's still a conduit between the meniscus, that cyst can continue to fill up, and so we will often try to close that with a repair. Often these are in the mid-body, so oftentimes we'll do an outside-in repair on these types of tears. We want to try to reduce the risk of having that fluid extravasate through that tear. Okay, moving on to case two, we've got a 16-year-old male soccer player who has a non-contact injury, planted, felt a pop in the knee. Again, same scenario as last one. The examination will help us here. Negative lock pins, reduced range of motion, positive effusion, also with difficulty extending the knee, but has apprehension with lateral patella translation. So again, your exam is helping guide what's happening between those five things that we discussed, the ACL, patellar dislocation, meniscus tear, osteochondral injury, and extensor mechanism disruption. So here, again, patient's not able to extend their knee, unlikely that they're going back into the game, so we get into the workup again. So you see on the x-ray on the left, there is a ossification in the anterior intercontinular notch, and then on the MRI, you see the corresponding, here's the ossification here on the x-ray, here's the corresponding osteochondral piece anteriorly, and this is getting stuck and preventing the knee from extending. So that becomes a surgical problem to address that. So MRI does help us with patellar dislocations. Sometimes we'll see a kissing contusion where you see some bone edema in the medial patella and bone edema in the lateral femoral condyle. In this particular scenario, we have the articular cartilage, which is gray, and the subconjunctal bone, which is black, and we're missing that gray and black line here, which means this is where the cartilage has fractured off the undersurface of the patella. This is the NPFL layer. You can get a mid-substance tear, you can get the injury off the patella, or you can get it off the femur. Again, that's helpful to know if you're planning to fix this, especially if you're trying to do an acute repair versus a reconstruction. You have to know where it was torn from. Patellar dislocations are most common in younger patients. As you get older, past 30, it's not very common to have a dislocation, although not unheard of, it's just not the most common thing that we see in that age group. The causes are multifactorial, from anything from excessive antiversion to elevated tubercle to trochlear distance to trochlear dysplasia to collagen disorders. There's a whole host of things that can contribute to patellar instability, and thinking about the problem is important as you try to come up with treatment plans. There is a high incidence of cartilage injury with patellar dislocations, and so I tend to be a little more aggressive about imaging with MRI because of the osteocondral fractures that do happen, particularly if they are a very swollen knee. That means to me that there's something more significant that's happened to the joint. On occasion, you get somebody who dislocated their patella and they don't have much swelling. I think it's dealer's choice to get an MRI at that point. Imaging considerations, we want to look for lateral patellar translation, we want to look at the trochlear morphology. I use the Caton-Deschamps ratio for looking at patellar height, and that's looking at the length of the articular surface of the patella compared to the length of the top of the tibial plateau to the anterior pole of the patella, and that ratio should be 1.2 or less for it to be normal. And then we can use either a CT scan or MRI to look for the tubercle to trochlear distance. Here's an example of a 16-year-old who had his first dislocation when he was 10, and the morphology of the trochlea is completely different than his opposite knee, and if you look at the patellar shape, it's also completely different than his unaffected knee. And so again, when people talk about trochleoplasties and deepening the groove, you have to be careful that when you deepen the groove that you don't lose the congruity of the trochlear and patellar articulation because that'll change the contact pressures. So again, these are challenging problems. This is what the MRI looks like for a domed trochlea. Again, the NPFL here, and you see that this patella has taken on the shape of the trochlea, so doing a deepening osteotomy here is unlikely to be effective for contact pressures in the patella. But this particular patient has a normal patellar height. You can see the ratio from here to here looks pretty symmetric. Patella alta is where the patella sits high. There's two ways you can look at this. One is the sagittal view, and again, you can do the Caton-Deschamps ratio. Another simple look at this is looking at the trochlea. If you do not see a patella sitting in the trochlea, if you see a patellar tendon in the trochlea, then they probably have patella alta, so you can look at the whole scenario and see if you feel like you need to move the patella distal if there is no patella in the groove. In general, we treat first-time dislocators without a loose body. We treat those folks nonoperatively. If you have a patellar dislocation with a loose body, that tends to become more commonly a surgical problem with loose body removal, or if it's an osteochondral fracture that's fixable, we can try to repair with compression screws. In that scenario, we would do an MPFL repair or reconstruction. In the chronic scenario, reconstruction has been shown to be a more predictable outcome than repair. To me, it really depends on the quality of the tissue and how many times the patella has dislocated before we're making that decision if we're doing an acute repair. Tibial tubercle transfer, for distance, I'd say greater than 1.5 to 2 centimeters. That gray zone between 1.5 and 2 centimeters is debated. If it's only over 2 centimeters for tubercle to trochlear distance, we would want to move the tubercle. But for 1.5 centimeters, if they have trochlear dysplasia or MPFL deficiency, we may consider doing that as well. Or if their collagen lacks and they don't want to rely heavily on the soft tissue, we'll do something to change the vector of the pole. This is the patient who dislocated their patella, and they had the big osteochondral fracture. You can see the pieces split, and you see the big defect in the medial patella facet. This is what we were able to salvage. Again, this is a young patient. We want to try to put something back on that has a chance of working. We were able to salvage this, and we're hoping that this will fill in with fibrocartilage. But this is an at-risk knee for sure because the amount of zone of injury is so big here, and the amount of damage to the articular surface is already substantial. The other thing that we commonly see is a tight lateral retinaculum. And so oftentimes, we'll do a lateral release with the other procedures to move the patella back into the groove. Lateral release on its own is not a treatment that's appropriate for patellar instability. This is an example of an MPFL reconstruction with the femoral tunnel right at Schottel's point. And here, we've drilled tunnels in the bone and done a tuberculosteotomy to correct this person's instability. This is an example where you have medial cartilage, medial facet cartilage damage. This is an example where you don't see a patella sitting in the groove. Patella is way off lateral. And our goal is to try to get the patella centered. So this is the after the reconstruction of the MPFL and tuberculosteotomy, and now we're centered in knee flexion by 10 degrees, and that's what our goal is. This is a view looking with a 70-degree scope from the suprapatellar pouch. And I encourage you guys to do that if you can because it's really pretty impressive how you can get the kneecap to center if you do the right procedure. Okay, moving on to our next case, yet another non-contact injury, planted felt to POP. This is our standard positive Lachman's. Patients can typically bear weight, but if you ask them to do anything that requires pivoting or twisting, they typically feel unstable. And most ACL reconstruction patients cannot return to play in the same game. So that's the one question you can always ask in the office when somebody injures their knee, well, were you able to go back? And most of the time if they tore their ACL, the answer is no. Again, same differential, planted felt to POP. If you can just keep these five things in mind, you'll be right most of the time for that presentation. ACL tears, as most of you know, I'm sure, are more common in younger patients playing sports, but they can also happen in 60-year-olds who are highly active. So you just have to keep that in mind. The most common mechanism is the deceleration non-contact injury, but you can get an ACL injury with a hyperflexion or a hyperextension injury. The disability comes from poor rotational stability, not necessarily the translation of the tibia. It's the poor rotational control. So when they go to step and change direction, they don't have rotational control and their knee wants to buckle. And that's the disability they feel. Again, the presentation is an acute pain and swelling. After most of the time feeling a POP, the knee will buckle. Again, a patellar dislocation makes the knee feel like it POPs and buckles as well. So if you think ACL, you have to think patellar dislocation as a potential differential. As I said, they're not able to return to play and oftentimes will have instabilities, symptoms even with everyday activities. ACL can be diagnosed pretty easily with a typical exam. I like to have my thumb right on the joint line and I don't like to jerk the knee because people tend to not like that quick movement and they'll tighten their hamstrings, which makes the Lachman's exam less clear. If you do a gentle pull forward with your thumb on the joint line, you'll be able to feel any translation that's different than the contralateral unaffected side. And that's the true definition of a positive Lachman's is any increased anterior translation compared to the unaffected side. You can do an answer drawer, but I don't find that to be as helpful. Pivot shift is possible, but it's also sometimes difficult to get a patient who's acutely injured to pivot because they have to relax for that exam. I find it easier in more chronic ACL injuries, but it's also a lot easier to do it when you're in the operating room and should be part of your examination during surgery. MRI is helpful to look at the ligament. You also can look for the standard bone bruise pattern with the lateral femoral condyle and the post-lateral tibial plateau, both having edema. That's your sign. If you're not sure about the ACL, if you see that pivot shift pattern on the MRI, then you can be pretty confident that they have had some pivot shift injury that has resulted in an ACL injury. Operative treatment is favored for any patients going back to high-level sports. We tend to use autograft for young athletic patients. Autograft has a lot higher failure rate, and we can consider non-op management for lower-demand patients, but they have to counsel them on a higher risk for developing meniscus pathology with an ACL-deficient knee. Here's a picture of the ACL torn here being probed. We drill the tunnel off the back of the femur. I use the answer horn lateral meniscus as my footprint, as a landmark for the footprint for the ACL and the tibia. We provide an ACL graft that should heal and provide good stability. We also counsel patients on the high likelihood of re-injury in the younger, more athletic population. As you get older, it's less likely to fail. And then recovery time is anywhere from 6 to 12 months. I think 6 months is pretty early, and I very rarely find somebody who's truly ready to go back at 6 months, but it does happen. A 24-year-old professional hockey player with knee pain after getting hit on the lateral knee has medial knee pain, has valgus laxity, and 30 degrees of inflection. Glaucoma is negative, so your standard MCL. Again, we're looking for laxity with valgus stress, and oftentimes, acutely, they'll have ecchymosis, sometimes have an effusion, but not always. We grade it according to laxity, so no laxity is a mild sprain. A grade 2 is a moderate injury, and that's they're stable in extension, but they have laxity at 30 degrees of inflection. A grade 3 injury, they're both lax in full extension and at 30 degrees of inflection. And oftentimes, these folks are less painful because they've done so much damage to the sensory fibers as well. Just a general rule of thumb is that proximal injuries from the medial femoral condyle tend to get stiff, and distal injuries tend to have, at the tibial insertion, tend to have residual laxity. So I'm a little bit more aggressive about bracing a distal injury, and I'm more aggressive about moving a proximal injury, just because those folks, if they do get stiff, can be really a challenge to get the range of motion back. Surgery is rarely indicated for MCL sprains. People can tolerate MCL laxity pretty well. And this is an example of an MCL that's been torn and retracted, and there's no fibers down here, so this might be a consideration if they don't have fibers that can actually perform the function of the MCL. You can do something surgically to correct this. Moving on here real quick to a 15-year-old with a direct blow to the anterior knee, positive posterior drawer, positive quadriceps activation test, and then stress x-rays show 8 millimeters of posterior translation, so we got a grade 2 PCL. Here's the MRI findings. You can see the PCL has disruption in the midsubstance, so the fibers. Treated with extension bracing for two weeks, and then starting prone range of motion so that you can take gravity off the tibia and keep the posterior pull of the tibia out of the equation. Aggressive quadricep strengthening and avoiding hamstring open chain activities, again, trying not to pull the tibia posteriorly. For a lot of people, this will heal to an extent where they're able to be functional. For wrestlers and people who do a lot of work on the floor, like tile layers and carpet layers, they may have problems with PCL injuries because they're constantly on their knees pushing their tibia posteriorly. This particular patient recovered okay initially, but then went back to wrestling in a brace, and because he was on his knees for an extended period of time, ended up stretching his PCL out even further, and it became a grade 3. X-rays four months after his initial injury, which were originally 8 millimeters, turned out to be 15 millimeters after he went back to sports, so he ended up going back to surgery for a PCL reconstruction. In this particular scenario, we used a double bundle arthroscopic inlay with Achilles allograft. Here are your tunnels for your femoral side, and we use an inlay graft on the tibial side, and this is what the inlay looks like for the arthroscopic technique, and gave him a functional stable knee. And 10 months after surgery, he had stopped wrestling because he had some discomfort when he was on his knees, but was able to return to most activities, and did have some stretch out of the graft. We usually lose one grade of laxity that we had in the operating room, so if we brought him back to normal in the operating room, oftentimes, we'll get five millimeters of laxity post-op, and this is not unheard of for PCL reconstruction. Last case, we got a 34-year-old who injured his left knee doing martial arts. This goes to the hyperextension mechanism for ACL injuries. He had a severe hyperextension injury where his toes touched his nose, and had a lot of postolateral pain and swelling, and he also had a foot drop, and he had a CT angiogram in the emergency department that was normal. So a foot drop should automatically put you into the mindset of postolateral corner injury. His x-rays were completely normal. Positive Lachman's, positive recurve bottom external rotation test, which means that you grab the toes, and if you see the bowing around the tibial femoral joint, that's your typical postolateral corner injury, and he also had a dial test. Here's an example of what it looks like doing a postolateral drawer. You see how much postolateral rotation that you have there. So this is similar to a dial test, but you're trying to rotate the tibia rather than trying to rotate the foot. And here's an example of the varus laxi that you see with a grossly unstable lateral knee. So again, not subtle, and should be able to pick that up pretty clearly. This is the images from his MRI. You can see the lateral collateral ligament complex is completely disrupted off the fibular head. You can see the PCL right here, and you can see the double PCL, which means he had a bucket handle medial meniscus, which you can see a little bit more clearly here. So his injury is ACL, LCL, postolateral corner, and bucket handle meniscus. So the approach for this is you got to address the postolateral corner injury and the bucket handle meniscus for sure. Early on in your careers, if you're not sure that you can do all that in a timely fashion, you can also stage the ACL as you get farther along in your career. You'll probably be feeling more comfortable doing both at the same time. Do whatever is good in your hands that you can get this surgery done well. It's not the wrong thing to stage it, but certainly a consideration if you can do it all at the same time efficiently. So in this particular situation, we did an acute repair and augmented with allograft force. So if it's good quality, healthy tissue, I'll do a Larson technique to augment the repair. If it's really poor quality tissue, I'll tend to do a Leprod technique. So here is the deep structures. You've got the articular margin at the femoral condyle right here. So we put anchors in the deep capsule. You try to repair the soft tissue back down to meniscal femoral ligaments, the capsule around the postolateral corner so you can provide some deep stability. And then we supplement it with a Larson technique graft to the fibular head. The Leprod technique is a little bit different. Instead of looping one graft through the fibular head, you're actually trying to reconstruct the LCL and the popliteus. The popliteus is actually a muscle. So it's going to be more of a dynamic stabilizer. So we may over constrain the knee a little bit, but we're just trying to get some stability posteriorly. So here's the reconstruction technique where you have your LCL limb going through the fibula out the tibia. You have your popliteus limb that comes through the tibia and out the front, and that provides stability. This particular patient had EMG at seven months that showed no recovery of the perineal nerve. And our foot and ankle surgeon is elected to perform tendon transfers to treat his foot drop. And he has a very stable knee and is now back to doing martial arts and is happy with it. All right. Thank you, guys. Feel free to reach out if you have any questions. Excellent, so great talks tonight by our presenters. We are getting ready to move forward to the demo section. Thanks to everyone who sent questions. Sorry that we did not necessarily get a chance to answer all those. I'll see if we have the ability to answer some of those after the talk is over or after the conference is over, and we'll try to reach out personally to answer some of those questions. So next, I'll hand it over to Volker Lussall for our ACL demo. All right, great. Thanks, Lutul. Thanks to all the presenters. And most of all the fellows are still online, so that's great. I know it's late at night, and we'll wrap the night up with an ACL reconstruction. I think it should be fun. We'll keep it nice and short. Brian Forsythe is, of course, attending surgeon at Midwest Orthopedics at Roche. He's trained in Pittsburgh. So I came back here to boss you around a little bit. Just kidding, of course. Brian was a fellow when I was a chief resident at the time. So Brian, why don't you tell us about the technique that you're going to do. I'm sure you prepared the knee already a little bit, and then we'll delve right into it. Thank you, Volker. So what I'm going to do first is go through a quick PowerPoint presentation, just so that you guys can get a little bit more from the nuance of the surgery that I'm about to do. So this is my presentation, relevant disclosures. There are still ACL reconstruction controversies. As you know, ACL reconstructions are probably the most published on topic in sports medicine. There's still some debate about joint techniques on the femoral side, whether you go intramedullary versus transtibulary. Graft choices are very much dependent on the patient, of course. We'll touch on that later. My individual technique is typically an intramedullary portal with BTB, auto, or allograft. And in skeletally immature patients, I'll use a quad or a hamstring. So we'll talk mostly about anatomy now. And my favorite quote in all of orthopedics is this, is that orthopedics is anatomy plus a little bit of common sense. And that's from one of our founding fathers, Jack Houston. So we've kind of come full circle over the last 30, 40, 50 years. We started off with primary repairs. Then we segued to lateral extraticular reconstructions. And then finally, we came upon interarticular reconstructions. And we started with transtibular arthroscopic techniques. But those tended to be a little bit vertical in orientation. So we migrated to a medial portal technique, which restored more obliquity and rotational control. When I was in Pittsburgh, seems like 20 years ago, it was closer to 11, we were investigating double bundle reconstructions. I learned a lot about ACL anatomy and credit to Dr. Fu, Volker, and their team. Recently, we've looked at LAT augmentation and revision circumstances. And ACL repairs are sort of back in vogue. There are investigations looking at internal braces and collagen scaffolds, which may or may not pan out. The number one cause of graft failure after all of this is still technical errors. And those three triangles are circles in the middle there, are sort of the classical causes of graft failure. But as we've evolved and learned more about pathophysiology, we know that neurohormonal influences are quite influential, along with biomechanical. And then to the left of the screen, you can see that, again, once again, a Pittsburgh posterior tibial slope is a topic near and dear to Volker's heart, along with the anterolateral ligament. So, the MARS group has done a wonderful job sort of amalgamating all this data from academic medical centers. 60% of revisions are from technical errors. The most common revision involves a new femoral tunnel 82% of the time. So, we're going to spend a lot of time on that. In Pittsburgh, we did CT scans looking at the typical sort of a posterior AM bundle on the tibia, posterior, sorry, PL bundle on the tibia and the high AM on the femur. And this is what you get with the transceital technique. And it's not to say that you can't do an anatomical ACL transcebially, but I think it's a little easier to do and more reproducible to the antramedial portal. We know that there's reciprocal function of the two bundles, the antramedial and posterolateral. Again, as a fellow, I looked at, we investigated and actively reconstructed both of them. In this investigation or demonstration, we're just going to do a hybrid, but you should be familiar with this remnant tissue because my landmarks are all topographical. I use the soft tissue remnants to guide where I place my tunnels. That intracondylar ridge there is the top of the T. That's actually a continuation of the posterior femoral cortex. And those two bundles you can see are represented by the two fovea. And there's a ridge called the bifurcate in the middle. And I sort of aim right at the junction of that T, but I go more on the antramedial side and high, and that encompasses the most antramedial or sort of isometric fibers. Here's another CT scan showing the continuation of the intercondylar ridge, the bifurcate ridge. And we did a 3D CT point cloud model to look at the most isometric position. And there was some criticism on an antramedial approach initially saying that you went too low. And I think that was probably valid. So those three circles on the bottom are actually sort of anatomical. The most isometric position is a little bit higher. It's that center circle. I'll use my pointer. This is actually the most isometric point. So intercondylar ridge here, bifurcate there. Most isometric point is right here, the anterior fibers of the AM bundle. On the tibial side, you're sort of aiming for the midpoint. It's not so important because isometry is less influenced by the tibial versus the femoral location. So on the tibial side, we're aiming for this ridge. This is the PL. This is the AM. This is the anterior intertubercular ridge. And it's sort of a high point, which is easily visualized. Visualization is key. I use a high anterolateral portal. A transpertellar portal gives me a great view of the wall of the femoral condyle. And you can see that here on this third arthroscopic slide. When you're looking from a standard anterolateral view versus a transpertellar, you're not really seeing as much of that topography. Again, this is the topography, which I'm going to show you in a moment. Our objective is to cover the lower third of the femoral condyle. We want to get about 75% to 85% of the footprint covered. When you're tensioning, and we're not going to see this too well in a cadaver, typically the knee is in about 10 to 20 degrees with the general posterior force applied to compensate for the anterior pull on the graft. Again, we want to avoid vertical position because you don't control pivot that way. I use a 40 degree curved flexible reamer on the femur. And when you flex the knee to 110 degrees, you're optimizing footprint coverage along with posterior wall thickness. And I demonstrated this with another 3D point cloud model where we virtually brought the knee to range of motion and saw what gave us the best sort of orientation and depth of tunnel. The grafts we're all familiar with. These are the workhorse grafts that we all use. There's really no difference. We learned this from the MOON cohort, but medicine is not cookbook. You really got to individualize to the wrestler, to the sprinter, the soccer player, the football player, to the recreational athlete over 30. Overall, all the grafts do better. We know this. And in younger patients or anybody playing a sport with their name on the back, that's what they're doing. This is my clinical practice. You got to engage patients when discussing graft choices. BTB is my workhorse. I'm lucky in that I've got a wonderful supply of BTB allografts, which are expensive and difficult to get. But I use those in spite of the fact of the MARS data. But we've been very successful at Rush with this experience. In revisions, BTB allograft is also quite useful when you've got less than 14 millimeters of widening. This is a video I'm going to show you really quickly. I'm going to get to the cadaver ASAP, but there's some steps here which you might better appreciate. Portal placement here, obviously visualize the spinal needle. This is what the setup looks like. I sort of have the leg over the side of the bed. You can't see that with a cadaver, but it's a simple setup. I debride the stump. We mark the fovea, the PL bundle. The center point is the inter-corneal ridge there. We can skip ahead. And you can see in a sloppy sort of figure-four position with a post, and I don't drop the bed for just an ACL. I would with a PCL. I can then mark the femoral footprint viewing trans-patellar. And we'll march along, and we'll actually do this live in just a second. But I wanted to give you a flavor of what we're doing, and just so you can get a brief introduction to the steps. I'm hoping to reproduce this in just a moment. Okay, so you can see here when you're tensioning. Okay, anatomical looks pretty good. So thanks for the opportunity to introduce, and I'll get over to the cadaver now. Any questions? No, this was great. So there's a nice overview. I think you're faster than Freddie, actually. Wow. Well, you gave me like 30 minutes, so I want to do both as efficiently as possible. And Freddie did show me that. So here, if we can just stand here. Can you show us where you put your portals? Because our first question always is, you know, is the lateral portal, how do you make it so that you don't need to do a notch plasticity, which is nonsense? I fully agree. You want to sneak in and sneak out and not disrupt the cartilage. So I do a high anterolateral portal. This is, I've marked the fibula here. This is the posterior border of the tubal cortex. This is a high AL portal. This is my transpatellar portal or peripatellar portal. And this is a standard anteromedial portal. You don't need to go far medial when you use a 40 degree curved guide. So this is my typical technique or setup. The leg is simply hanging over the side of the bed. I come in. Let's start with the anterolateral portal. Pop in. Okay. There you have it. So water's on, guys. Great. So I left the ACL alone. I didn't want to take it down because I wanted you guys to see the fibers and to see how well we could recreate or reproduce the anatomy. So these are your PL bundle fibers. These are AM fibers. And I want you to see how far anteriorly these AM fibers go. They come all the way underneath the intrameniscal ligament. And the PL fibers right here, they're just posterior to the border of the anterolateral meniscus. So let's take this down. This is not a bad need. It's a 62 year old. I was pretty happy to see this because it makes our cadaver surgery a little bit easier. But let's just take a lap and see what the view looks like. So I'll have a straight butter, please. So we're going to take this down quickly. And at first, we're going to come through the mid-substance of it. And then we're going to carefully dissect topographically the footprints. So this is what you might see. Brian, I assume you harvest the graft before you do all the preparation. Unless, I guess, you have maybe a partial tear scenario. But do you measure the notch size before? Or any guidance on what graft you're going to use size-wise? It depends. If this is a pretty straightforward BTP allograft, it's a hybrid single bundle. If I'm going to do a double bundle, which I might do in a really large patient or in a revision situation, I would have one of those flexible rulers available to me. I'm not sure if we have one here. I could take a look. But I think measuring notch size is particularly important. Can I get that probe again? So if somebody has, you know, and we do encounter this in younger patients. If someone has a really narrow notch, you know, you've got to be really, really accurate in particular about your femoral and tibial tunnel placement. But even as small as 12, 13 millimeters, you can sneak one in without doing a notchplasty. This one looks not large, so that's good. Yeah, this is good. I don't think we're going to run into that problem. I'm just going to get rid of that. Show us how you find the femoral insertion and what landmarks you use to get the tunnel. I took the words out of my mouth. So I'm going to start on the tibial side, just because I'm here. And I don't want to come back and switch portals too often. But this here, obviously, is your ACL tibial footprint. The postradial bundle I can find very quickly. If I come off of the posterior border of the antehorn lateral meniscus, there's a little fovea where it drops down. As I march anteriorly, there's a high point there and then a low point here, which is the center point of the AM bundle. So center point of AM is there. You can see a high, low, high, low. And the PL bundle is somewhat circular. The AM is more kidney bean in shape. So let's go ahead and dissect that just carefully. Now, I don't want to do too much because I don't want to blast through the anterior root attachments of the lateral meniscus. And I can preserve my intrameniscle as well. So this is PL. This is AM. And the midpoint is right there. So there, I've done my topographical dissection. This is what I'm going to aim for. Next, we're going to switch. It's a very broad insertion, quite oval and large. Yeah, absolutely. It's beautiful. So let's go trans-patellar. I'm going to switch now and show you the view that we get, which is really quite nice. Mike Fu is my fellow this year. Hold right here, Mike. He's coming to us from HSS. He did a year at Rush. He's going to go back there on staff. So he's going to do more shoulders. So this might be one of his last knees, unfortunately. Lee, could you untangle that? So you can see here, when I'm looking slightly upwards of my eyes, I can see the PCL and just behind it, the ACL. Probe, please. And I want you to look at the top of the notch, the apex. This is the apex. And if you look at this ridge here, this is the intercondylar. And you can see that the ACL attaches with the knee at 90 degrees, roughly, on the lower third of the wall of the femoral condyle. So this is your PL bundle. This is your bifurcate. This is your intercondylar and AM back there. Can I get this wand, please? And once again, I'm going to start. Most people don't use this portal, but Freddie talks about this portal all the time. It's really helpful. As you can see, you have a great view. Totally. And you can see the scalping here. This is the scalping. This is the lower third. And your PL bundle is right here. And you can see there's a true fovea. There's clearly a depression. And then there's the bifurcate ridge. And this is your AM bundle insertion right there. And you can see the remnant fibers. And leaving those just leaves the road map and makes things really easy. So I'm now demarcating the center point of the AM bundle, center point of the PL. And then now you can see the intercondylar ridge and the bifurcate ridge. The most isometric position is basically at the junction of this T, just posterior to it and anterior. So when the knee is extended, these are the most anterior fibers of the AM bundle. So if you're going to do a single bundle hybrid approach, this is where you're going to aim, is right about there. OK? And that was the picture. You don't really dissect off the posterior edge of that insertion too much. You're really just going by the ridges, huh? Correct. By the ridges and the topographical soft tissue landmark. So hold like that, if you would. I use the ridges. And this guide that I'm using now, this is a flexible guide. OK? It's a 40 degree angle. And if I place this centered at that ridge and then flex the knee to 110. Wait, wait, Mike. Come back. All right. I'm going to set it there. And now flex to about 110, please. Lee, can you hold the camera? OK, that's great. That should make for pretty good tunnel. So we're well set up there. We have a... OK, excellent. We're going to advance this. You have a... Snap that, please. OK, excellent. Here we go. Now, let's take a look. I'm very happy with that. You can see here, we've got plenty. We should have enough wall thickness posteriorly. And I'm going to come in with a 10.5 drill bit. Now, it may look a scooch high, but it's really not. I think I'm very happy with that. So you look at the wire. Yeah, so here's the wire. And what I'm going to do is I'm going to bend this wire with my camera downwards, like that. And that brings it to the middle. And that prevents me from scuffing that cartilage with my flexible reamer. Could you hold that, please? All right. So we're coming in the anterior portal. Here we are. Now... You already have a depth measured, or do you do that later? I don't need to, because I'm going to put an interference screw on this with a BTB. So we're going to go down to 25. My graft is about 22 or so. And so I'm at 22. Now, this is a half with a drill bit. So I'm going to go back and forth about three times or more to make sure they get the full diameter. Shaver, please. Is there ever a situation, Brian, where your tunnel may be shorter than 25? No. I mean, you can perforate the lateral cortex. And there's plenty of tricks to get fixation. I agree with you. If you flex the knee up, that's going to be the key to avoid a short tunnel. You should always be able to get at least a 30. Yeah, absolutely. So here we go. I like that position. Sorry, my camera's fogging a bit. I guess my hand is over the interface. So that's a pretty good position. I like that. So we've got adequate poster wall thickness. It's well centered. And I'm going to run another ream. This is a 4-5. I'm going to perforate the cortex. This just makes it a little bit easier for me to pass suture to the lateral cortex. That's all that is. And if you have to do a button or something else, you're already ready for it. Next, I'm going to punch with a hexagonal screwdriver. Now, on a right knee, this is a right knee. Flex a little bit less, Mike. That's good. On a right knee, you want to punch this at about 10 o'clock. Hit it. And the reason is that your screw is harder. Your screws are right-threaded harder. So a right-threaded screw will then rotate to the top to about 12 o'clock. If you put your screw at 12 o'clock here, it's going to roll to the right. And it's going to push your graft anteriorly. So with the BTV graft, it's good to notch aggressively. So we're done with our femoral preparation. Next, we're going to switch back to our anterolateral portal. And we're going to set up our tibial tunnel. So we're looking from a high anterolateral portal. I leave this wire here because I don't want to cut any suture. Shaver, please. And next, I'll get to... After this, I'll take the tip guide. And Lee to my left is helping. He's been my PA for 10 years. So he probably knows this procedure better than I do. Along with the steps, he'll keep me honest. So here we go. I've got the ACL tip guide. Now, this is PL. This is AM. Now, I'm centered here. Lee, hold the camera, please. And great. Okay. Now, what I do, you can extend this knee a little bit. When you're doing cadaver surgery, you extend the knee. Now, can we pan out to show the skin? So... We can see it well. Great. So here's the posterior border of the tibial cortex. This is the tibiotibial. You basically want to go at the midpoint. And I've got my guide set to about 65 degrees, which usually works pretty well for a BCB. So I mark it. I mark the skin with the boom. And I'm going to cut about two centimeters from that point that I marked. And I'm going to... The pes tendons are demarcated here with the skin marker. And usually, I'm coming at the junction of the pes tendons and the superficial MCL. That's where a properly positioned tunnel would be. So hold that there, Lee. Great. And then I'm going to advance the boom. Can I get a guide pin, please? All right. That's great. Get that view back, Lee. Thank you. Would you ever, in a situation, would you ever take a fluoro shot to see where the KYS sits with respect to impingement? Or if you go by the insertion, you kind of know that you won't impinge? I think I'm okay with the top draft of the landmarks. That works for me. Yeah, I haven't had to do that. Hey, next, can I get a big curette, please? So I'm going to... I agree with that. I think it's a nice step to use, but you have prepared the insertion side so nicely. I wouldn't worry about roof impingement. No, we'll put it to the test after we pass the graph. So I'm in here. I use a curette. Cadaver may not matter, but I use a curette to protect the cartilage. I'm drilling an 11 tunnel here. I typically do a tunnel. I'm just doing 11 to make it easy to pass the graph in a cadaver. So now I am through. Obviously, it looks pretty good. We're centered well. I'm going to turn the water off. I'm going to dunk my camera into the tunnel here, and that helps illuminate the... If you can show the skin, just helps illuminate the tunnel nicely. It makes it easier to debride and rongeur. So I take off the periosteal tissue, the rongeur, and then I'll shave it. Obviously, you'd be passing the graph trans-tibially. That is why you're cleaning up the tibial tunnel there. Right, precisely. So I'm removing the periosteum, and when you can see the light shining, that means you're pretty good. And you're going to have to put... I'm going to put a screw here, so that's why I'm pretty vigorous in removing the soft tissue, so that it passes easily. Okay, I'm going to plug this next here. Plug water back on, and then now I'm going to remove... Is that your typical angle of your guide pin based on how long the patella tendon is? Absolutely, great question. Usually for this technique, it's 65 degrees. Someone who's six foot needs about a 40 millimeter graft if you're ordering it. Someone who's 5'4 needs about 34 millimeters, and it's about a sliding scale in between. So if there's mismatch, I will lengthen or shorten the angle accordingly, appropriately. Okay, I'll try to get rid of those bubbles. There you go. Okay, good. So we've got our tunnels. Next, we're going to pass some suture. I think we're going to do well with this. Okay, hold the camera, please. So next, I'm going to place a passage suture through. All right, can you pull that? Okay, we're through. Okay, hold this mic up top. Okay, and I can get a probe, please. It's okay. We just lost our plug, but we don't really need it. Can someone grab that plug, maybe? Or just plug with her finger. I got my finger. So I pull that suture through, no problem there. Okay, so our suture's passed. Got it. Now, I'm going to go ahead and do the next thing. Our suture's passed. Got it. Now, I'm going to go trans-tibulate again. Okay, and now we can see the suture there. Plug, please. Just hold that. Perfect. Lee, hold the camera, please. All right, so we're here, getting ready to pass the graft. So, you know, watered pressure down would help. Wait, show us that graft on the overview, just for a second. Oh, yeah, sure, absolutely. Can you guys zoom on that graft? Can you see the graft in the field? So we put marker on the femoral side and sort of approximately in the tibial side. And this is a standard BTP graft. It's about 10 by 20 millimeters on the patellar side, 10 by 30 on the tibial. And hopefully, this will work in terms of not having too much of a mismatch. So go ahead, Lee, pull that through. All right, pull through. Can you show us the scope picture again? We kind of lost it. Can we go back to the scope picture, guys? Good. All right, give me a probe, please. OK, we're going to help guide this through with a probe. OK, now go ahead. Go, go, go. There you go. Lee, you got that? All right. And Mike, can you guide in the bottom? I got it. That's a nice looking graft, guys. Thank Lee for that. He's done a couple. Nice, nice job, Lee. Very good. Lee, can you straighten out the knee, please? Straighten out the knee, Mike. Thank you. There you go. So you want to make sure that the bone block faces you, right? So what orientation did you put it in? Precisely. OK, and we're going to snap that. If you could show the outside. Lee's snapping that position against the thigh, and that sort of holds your length, OK? So now this is good. Now bend a little bit more. Could I get a guide pin, a guide wire? Good. Next, we're going to remember how we notched that earlier. We're going to put this pin sort of straightened out a little bit for me, Mike. There we go. The whole time, the camera is in the transit area, in the middle portal, right? Exactly. Hold the camera, please, Lee. Back up a little bit. Thank you. And here, I'm going to run an 8-millimeter tap over this, OK? And I'm going to drop my hand to try to come in sort of parallel to my tunnel. Now, this kind of collapsed. This is osteopenic bone. I can tell that. So we're just going to jam this in here a little bit. This is a 62-year-old cadaver bone. But nevertheless, you'll see this. Sometimes, it'll help, Lee. Can you pull that back just a millimeter? Unsnap it. But sometimes, if you pull the graft in the wrong way. I always say, one of the main steps to avoid breakout of your posterior wall is you leave a good-sized posterior wall, and you make that not anterior, right? Right. Exactly. And what I just did, precisely. And what I just did, I just slid my graft more towards the joint. Hold this here, please. And sometimes, if it's recessed too much, it's hard to get that tap started. And you end up pushing it in, which is, I think, what happened. But this should work better here. This is osteopenic enough that I expect it'll still purchase. Always peak through and have a metal. I love peak, because you can get a nice MRI afterwards. We've got a really good station. It's starting to squeak. Looks good. And you can see how this is pushing my graft a little bit more towards the AM center point, which is what you want to do. But I think that we've certainly recreated the bone. But I think that we've certainly recreated a lot of that footprint. Can I get a shaver, please? Nice. Thank you. So, OK, now I'm just going to get all this debris. And at the end, I'll get my Hollywood shot at the end. There you go. So can you straighten out the knee for me? All the way. Go, go, go. All the way. You see, there's no impingement and extension. Come back down. Yeah, super. OK, wonderful. Now we're going to do the tibial fixation. Straighten it out one more time. OK, so you don't need to do an osteoplasty. Come back down. OK, great. All right, now we'll do, if we can go to the outside here. Can I get Army Navy, please? OK, Lee, hold this here. Hold that there. Can we get light in there? Looks like the graft is perfect in length, huh? So it's nice. It is. It's nice. If you have a 30 millimeter bone block, you can always cut 10 millimeters off if they stick out, right? Exactly. So I'm going to put this wire super laterally. And I'm going to advance my nine tap. And I come in a little bit more acute of an angle. You go for an extension or 10 degrees? 10 degrees. That's where the graft is longest. And 10 degrees with a gentle posterior drawer force applied. And Lee's going to do that in a second. And because when you're pulling this graft anteriorly, you're tending to displace the tibial femoral joint. So 11, please. Yep, and then Lee's going to reduce the tibial femoral joint by putting a gentle posterior drawer on this next. And here you can see there's not much mismatch. Coming in with 11. I'm coming with 11 because it's osteopenic. Usually I do line to line. But anyone over the age of 40 or 40, 45, 40 female, 45, upsize your peak screw on the side. We've got great purchase there. Minimal mismatch, which I would typically just take down with a saw. Just feather it down. Don't use a ronger. Water back on, please. And you can see how we actually moved the graft even a little bit more anatomic with that screw. You see how it sits further away from the condyle? Because I put it super laterally. One. Thanks, and we'll clean it up a little bit. Freddie taught me, you always got to make your pictures look good, right? Don't mess around with it too much, though. Don't mess too much, but just for the sake of defluffing it on dead tissue. What I'm doing now is we're looking at how stem cells help this thing remodel. We're trying to figure that out next. All right, Brian, I'm going to wrap it up. This was the fastest in OLC history. So it's not bad, right, guys? I think we're... I'm going to show you how it's triangle. Give me the... Give me the... There's no such thing. Don't worry about it. All right, well, it's still relevant here. PCL here, ACL there, poster wall allow from a condyle there. And I think that this is very nice. All right, no extension. Great there. I'll put a Lachman on it. Hold this leg. No, hold the knee. Hold the leg. Leg, leg. You can see, you know, we've restored tension. So intraoperative Lachman, I'm actually pulling on it, springs back. So, all right. Thank you. Great job, Brian. Great job, Lee and Michael. Thanks for helping. So we're going to wrap this up, guys. I know it's late. Almost everyone is still on the line, so that's awesome. Fill out the questionnaire that Meredith was sent to you. We have done this now. It's our year number five. Every year, we change the format slightly. Of course, this year, we changed it drastically because of COVID. But I think some of the suggestions may actually help. So we like your feedback. And then tune in tomorrow, same time. More action. All right. Thanks, everyone. Thanks, guys. Thanks, Brian. Outstanding job. All right. See you, guys. Good night.
Video Summary
Summary 1:<br />The video discusses the recognition and management of sideline medical emergencies in sports medicine. It covers various conditions like infectious diseases, cardiac and respiratory conditions, and genitourinary disorders. Collaboration with athletic trainers and healthcare professionals is emphasized. No credits are mentioned.<br /><br />Summary 2:<br />The video highlights the importance of on-field pregame planning and communication during emergencies. It focuses on knee injuries and their management strategies, including diagnostic tests and treatments like rehabilitation exercises or surgery.<br /><br />Summary 3:<br />Dr. Brian Forsyth demonstrates an ACL reconstruction surgery, explaining his preferred approach, anatomical knowledge, and graft choices. He emphasizes technical accuracy to prevent graft failure and shows portal placements, tunnel preparation, and graft securing with interference screws.
Keywords
sideline medical emergencies
sports medicine
infectious diseases
cardiac conditions
respiratory conditions
genitourinary disorders
athletic trainers
healthcare professionals
on-field pregame planning
communication during emergencies
knee injuries
diagnostic tests
rehabilitation exercises
ACL reconstruction surgery
graft choices
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