Good evening. Thank you for joining us tonight for the AOSSM Fellows webinar, In-Game and Post-Injury Return to Play Decision-Making, with moderator and panelists, Drs. Matthew Mitaba, Stephen Cohen, and Allison Toth. This is the final webinar of the series. After the case presentations and discussion, there will be time for questions and ending with a brief info presentation by Matthew Vukovic, the Surgeon Agent. Dr. Mitaba is tonight's moderator and panelist. He is a professor of orthopedic surgery and professor of physical therapy with the Division of Sports Medicine at Washington University. He is Chief of Sports Medicine with Washington University Orthopedics. He is also a team physician and medical director of the St. Louis Blues. Our two panelists include Dr. Cohen. He practices at Rothman Orthopedics, Sports Medicine, and is Head Team Physician of the Philadelphia Phillies. He is also a professor of orthopedic surgery at the Sidney Kimmel Medical College at Thomas Jefferson University. And Dr. Allison Toth is Associate Professor, Department of Orthopedic Surgery, Executive Vice Chair, Vice Chair for Faculty with the Department of Orthopedic Surgery, and is the Director of Patient Safety and Quality at Duke University. She is also Team Physician for Duke University and North Carolina Central University, practicing at Duke Sports Sciences Institute. To submit a question on the GoToWebinar panel of your screen, click the Questions drop-down arrow on the right-hand side of the panel. This slide shows where you input your question and then click Send. I will now turn this over to Dr. Mitaba for the first presentation. Great. Thank you, Meredith. Let me go ahead and get my... Okay, so I'd like to welcome all the fellows to this last installation of the 2020-2021 seminar. This will be three quick cases that hopefully engender some good discussion. So the first one is going to be a new case presentation. So the patient is a 14-year-old female with a history of recurrent patella instability. She has a history of an allograft MPFL reconstruction one year prior to be seen by us by an allograft outside surgeon. She did well until about five months post-operatively when she re-dislocated the right patella while bowling. She had several episodes of recurrent instability of the patella since that time. She was seen by the surgeon who did the initial surgery. He tried conservative treatment with bracing, physical therapy, and ibuprofen. However, she is now having instability essentially on a daily basis. She is very much into sports, plays basketball, volleyball. Her parents are very much into sports, as a lot of them are in the St. Louis area. And so that's what prompted her to get a second opinion. She had no significant past medical history or social history. She's a high school freshman. She plays volleyball, basketball, lacrosse, and soccer. On examination, she's a tall girl for her age. She's 6'1", 180 pounds, BMI is appropriate. Examination or focus examination, right low extremity. She has well-heeled incisions from her previous surgery and an intelligent gait. I don't have a video of her gait, but I do have this picture over here for what will be future surgery showing the marked unilateral genu-valgum of that right low extremity. She had a moderate fusion when she came in. Her range of motion was good, 0 to 130 degrees. Marked apprehension, she was tender at the adductor tubercle, the medial patella facet, as well as the lateral frontal condyle. She has significant lateral retinacular tightness. She had two-quadrant lateral patella translation at 20 degrees and significant apprehension at 20 degrees. Her BATEN score was 2 of 9, so no evidence of generalized ligament dyslexia. So here are her plane radiographs. You can see here her merchant view, obviously somewhat subluxed laterally, but not anything horrific. There was no obvious fractures there. Her caton to champ ratio on the 30-degree lateral view was 1.3, borderline elevated but not excessively so. She had no evidence of trochlear dysplasia on either her lateral view, and you can see from her stain alignment films, she was in unilateral valgus of 11 degrees compared to the contralto side. And I should say that there was no history of any sort of pediatric fracture, no trauma as a child, or any other growth disturbance that would have countered for the unilateral genital valgum. Here's her MRI. These are two selected cuts. You can see on the left-hand side, she had essentially a disillusion of her NPFL graft done previously. On the right-hand side, you can see the suture anchors in from her previous surgery. They appeared to be appropriately placed. Her TTTG distance was 21 millimeters, which is essentially the upper limits of normal. Just kind of go over some of the MRI indices we talk about in evaluating patella instability. The TTTG distance is the one that gets the most press. It varies somewhat between CT and MRI, MRI being a little bit lower, rather have a lower value compared to similar CT scans. Another indice that I would encourage you to at least look into your own patients is the TTPCL distance. That's the line essentially at the tibial tubercle, as in the TTTG, but also another line from the medial border, the PCL, and then that distance. And again, over 20 millimeters is considered abnormal in that measurement. So at this point, what treatment options do we have? The non-operative options are continued physical therapy, patellar stabilization brace, activity modification, which she was not interested in. As I said, the family was very much into athletics. However, this girl had difficulty with activities of daily living, so they didn't really think that non-operative treatment continued was going to be an option. So the operative options that I presented to them, as well as what we ended up doing, was an arthroscopic lateral release, patellar chondroplasty for some changes we saw that you'll see in a second, a revision of her NPFL reconstruction, distal femoral osteotomy, and then consideration for a tibial tubercle osteotomy. We didn't end up doing the tibial tubercle osteotomy in this particular case because I thought two osteotomies might be much, given the fact that her TTTG distance was only 21 millimeters, and her ketone dechamp was only 1.3, which is the upper level of normal. I didn't think that was necessarily indicated in this case. And there's also literature out there suggesting that if you do reconstruct the NPFL, you probably don't need to do an OMSI triad operation anywhere near as frequently as we have been doing in the past. So those were our options, and the family elected to proceed with the operative procedure. So here's our surgery. You can see on the upper left-hand arthroscopic view of her patella, she did have chondro-wear on that medial patellar facet. There was no full fitness defect, fortunately, when she underwent a chondroplasty. The trochle was pristine. She went on an arthroscopic lateral release, and we can argue about a retinacular lengthening versus release, but we ended up doing a lateral release on her. And then the distal femoral osteotomy was next, and this is the calculation I like to use. Basically, you take a line from the center of the femoral head to the 50th percentile. Whenever you want to correct genu-valgum, we would shoot for the 50th percentile from medial to lateral. Or is it going to change genu-verum, then we want to go back to the 62nd percentile, which places the mechanical axis just lateral to midline. We never want to put anybody into varus. So anybody who has genu-valgum, we want to go to neutral. So the alpha angle is what our correction is going to be. And then I did an opening wedge distal femoral osteotomy. And you can check this two ways. First of all, in general, there's about a one-to-one relationship between the number of degrees of correction that you have, as well as the number of millimeters to open up that osteotomy. So in the example here, you can also do the trigonometric measurement. The tangent of A equals B over A, whereas B is the distance that you open up the osteotomy, A is the length of your cut, and then the tangent of A solves for B, and that's the amount of millimeters of opening. So a simple way to do this, though, is just to measure from that 50th percentile mark up to the distance of where you want to do your osteotomy. That should be the same length of the cut that you make, and then you can do your measurements from there based on that relationship. And so this is the calculation that we had. Here we see I end up using an Arthrex PUDU plate on the upper left-hand side, and you can use a variety of implants. This is the one that I happen to select for here. The guide pin, you want to place just above the insertion of the MCL. The osteotomy, it's very imperative that, obviously, you don't go all the way across. If you do, you need to stabilize it laterally with some sort of either a staple or plate. Staples, I think, are not as optimal because they can be very prominent, so I would recommend a plate here. But then you can see on the upper right-hand side, there's our fixation. We filled it with autologous bone graft, and then I used a semi-tenosus autograft. She had already had an allograft reconstruction, so we used a two-limbed autograft from her hamstring. And then as far as sequentially goes, it's very important that you can see in the upper right-hand, the left right here, here's our guide pin where Shiloh's point is, and then we over-drilled that, and we put our guide pin in place. And just kind of for osteotomy verification, for your osteotomy, once you do your correction, you can argue that using a BOVY cord, which is shown here, is not as accurate because it can bend. You can also use the alignment rod from a total knee system, but I think it is helpful at least as you start to do this in practice to check your alignment to make sure you're sort of in the ballpark that you like. Just to kind of review Shiloh's point, it's distal to the intersection of Blumensat's line and the posterior femoral cortex is between the adductor tubercle and the medial epicondyle, and so you should measure this on every one of your cases. I think it's imperative if you do an NPFL reconstruction that you use fluoroscopic visualization. Some people talk about doing this blindly. I think that's a mistake because I think the landmarks of the medial epicondyle will throw you off. So this is essentially where Shiloh's point is, and I would encourage you to, if you're unfamiliar with that term, to look up the original literature in AJSM that describes it very well. So some relevance of graft placement. You know, the Virginia group talked about if the graft is too proximally attached to the femur, so-called high and tight, that means that the graft will be over tensioned and flexion. They may have patella frontal pain and progressive chondrosis and eventually graft failure. If the insertion on the femur is too distal, then you have a graft that's called low and loose. In other words, you essentially lose your check brain with persistent stability. So again, that's why it's so important that we're trying to anatomically reproduce that NPFL attachment in Shiloh's point. So here's our patient's final postoperative x-rays, AP and lateral views. This is three months postoperatively. Her merchant view looks essentially balanced compared to the contralateral side. You can see on the right-hand slide there, here's her mechanical axis, which is identical to the contralateral limb, which is good. Here is hopefully the video will work. You can see she has essentially normal gait. Her alignment, to me, looks pretty good. So far, she's very happy and looking to get back to basketball. So with that, I'll conclude. Any questions from the attendees? Any questions, Allison or Steve, that you might have about this particular case or perhaps how you would have managed it? Yeah, Matt, I think you bring up a great point that when somebody has that degree of valgus, I think you really have to think about whether you should do a tibial tubercle osteotomy because that correction of valgus often is enough and centers the patella quite nicely. And so something that I do in that case is after I've done the distal femoral osteotomy is look at their, like really evaluate that alignment of the patella while I'm doing that MPFL or about to take that on and really make sure I feel like that MPFL, we don't want that to have to act. It needs to be just a more of a passive restraint. So I think it's really a great point if you're correcting valgus doing a distal femoral osteotomy, you got to probably need to be careful not to overcorrect by doing the tibial tubercle as well. I think I've found frequently you don't have to, so that was a nice point. Right. And I think there is even some, a push afoot, there certainly was the meeting in Nashville last week to not do the Emsley triot perhaps as much as we had been in the past, or you know, you look at the TTTG or the TTPCL, if it's over 20, you have to do something. I think that's sort of old school thinking. I guess time will tell with further literature, whether or not we need to be doing as aggressively as you are on the tibial tubercle. I think that for the, what I see a lot happens in the literature is that, talking to conferences and that sort of thing is that people do a focus in osteotomy for isolated patellar instability with no evidence of any sort of chondral wear. This girl had some mild chondrosis of the medial facet, but I think a focus in is an overkill operation for this particular problem. Remember, a focus in osteotomy will translate the patella both medially as well as anteriorly. This person, the people who have this problem just need to have medialization and that's it, unless they have sniffing cartilage wear of the lateral and distal part of the patella, which this person didn't. Now, Matt, why do you think that she failed? Do you think it was her valgus that that was just, it was that not being corrected? Do you think that was the major problem here? What else? I didn't see like some, say, coronal images on the MRI to try to look at graft placement. Do you think this could have worked with isolated NPFL? I don't think, I think you nailed it on the head. I think the valgus was too much. And again, I regret not taking a preoperative video of her gait. It was so marked, the amount of valgus she had. She even raised the same question and she didn't know anything about orthopedic surgery. She knew that one leg was different from the other and the mom asked the same question. So I think you have that, you know, not seeing or participating in the surgery, the insertion point on both the patella as well as the femur looked to be appropriate. And I have to assume that the graft tension was appropriate when the surgeon did it. And there was no other evidence of trochlea dysplasia or, you know, significant patella ulta or anything like that to implicate as being another cause. So I think the primary reason it failed is probably the isolated gendered valgum or the unilateral gendered valgum. Matt, I think that's an excellent case. And Allison, unfortunately, I stole my thunder about, you know, anytime something fails and you're going back to do it, you always want to analyze, you know, what was the failure? You know, obviously evaluating, you know, a CT scan can certainly be helpful to evaluate, you know, tunnel placement to look if there's any abnormalities. Clearly the valgus is a pretty big factor here. I guess a couple of questions I have, number one, when you're doing a revision MPFL, you know, how did you handle the patella tunnel or how did you handle, you know, the old tunnels? And then the second thing is, I'd be curious, and I don't know that you have the answer in this case, but what's the TTTG distance look like after you've done the distal femoral osteotomy? And what's that number look like, you know, because, you know, you would expect it to change probably marginally, not dramatically. And like you said, it probably is enough to allow the MPFL reconstruction to handle it. So what are your thoughts on that? Yeah. So I guess if I can remember your questions. And one of the questions that one of our viewers in the audience asked is, when do I add a medial patella tibial reconstruction? I tend not to add that. Perhaps the two of you on the panel do, and you can, if so, I'd love to hear your thoughts on that, a medial patella tibial reconstruction. In terms of the previous graft placement, she had basically a bioabsorbable suture anchor in place. It wasn't a screw, it was a suture anchor, and so we're able to pretty much drill right through it. Obviously, under fluoroscopic visualization, it was not an issue. Luckily, her growth plates are closed. That's a whole other topic, but it was not an issue for her. And how much the osteotomy changed her TTTG distance? I can't tell you. I did not measure because we didn't do a postoperative MRI or CT scan. I have to think it's going to improve it somewhat, but again, her preoperable was only 21 millimeters, so if anything, it helped it a bit. So that's what I would say. Did I cover all the questions you had, Steve? You got them. Okay. Do either one of you two do a medial patella tibial reconstruction? I don't. In fact, the only time I've done a patella tibial reconstruction is lateral when someone has created medial, like, iatrogenic instability and then had to do that as a salvage to get the patella more lateral. Pretty unusual, but that's a good salvage for that problem. Yeah. So I have not, I guess, it's unfortunate we can't have a dialogue with the audience here in terms of picking his or her brain as to what their experience has been during their fellowship or residency, but I don't, and I don't know anybody that routinely does those as well. So any other questions from the audience or the panelists? If not, then we'll go on to Alice's second case. Great. Well, thanks a lot. Okay, Matt, are you seeing my screen? I am seeing your screen. Okay. Hopefully you're seeing the good presentation mode. Okay. So I'm going to be discussing a return to play, so an in-game injury, and then return to play decision-making in a college basketball player. So this is a Duke women's basketball player, a team I take care of, and a very talented player of ours, starting forward as sophomore in January of that season. They're having really a pretty good season. She went up for a rebound, had somebody like try to rip the ball away from her, from behind her while rebounding, and sustained anterior inferior shoulder dislocation. You can see an actual picture of her on the court here holding her shoulder. And though this isn't her picture, you can see a picture of a similar deformity that I noted on the court with the player, where you can tell she had a dislocation. She's complaining of some numbness in her hand. And so the question's like, basically, what now? So you're in-game, and an athlete has a shoulder dislocation. You know, it wasn't a really violent hit like football, and this is the first dislocation. So question is for the panelists here, so Matt and Steve, do you reduce this? You think you're going to reduce this immediately? Do you insist on getting some imaging first? Can you do this at your facility, or do you think this person needs to go to ED or get sedation? How do you handle that? Well, I think when you're on the court, you know, I think you can certainly attempt the general external rotation to see if you have any likelihood of getting her back in without making it, you know, to be such a dramatic episode. But clearly, you want to get the player off the court. You can get back in the locker room, evaluate, you know, what condition their pain is in, their neurovascular status. If you think that there's no evidence of a fracture, I think it's reasonable to attempt a reduction. I do the same thing, covering football a lot of years, we would reduce them right on the sideline if necessary, sometimes on the field, if it's quick enough. If you get them early enough, you can reduce them. In this particular situation, basketball is a little more intimate. There's less players, the crowds are on top of you. I would, you know, get them off the court, get them in the locker room. I would do a general reduction or attempt without getting a preoperative radiographs first. The chance of a significant, you know, human neck fracture, like you might see in an older person is insignificant in this person. So I would try to do a close reduction and then get radiographs after that. Luckily, you know, this person's in a Division I facility, which you may very well have had an imaging. Washington University is a D3 facility. We don't have imaging there at the stadium for a basketball venue. So we'd have to take them to the hospital afterwards, which I would do eventually. Allison, do you have imaging, just out of curiosity, at your facility? Yeah, we don't, or we didn't at the time. We do now, but we didn't have a fluoro or x-ray right at the facility. We would have to take a golf cart and take them down to our sports medicine clinic, which is a short, like, would have been like a two-minute ride. But this is dislocated. She's really uncomfortable. As Steve said, certainly getting her off the court, getting her out of the, you know, out of the crowd, taking her back to the training room. And I would certainly, as I did in this case, elected to reduce her, you know, without, so there's sort of different options then, you know, like, do you use like lidocaine injecting the joint or not? I chose not to in this situation. You could do a variety of reduction techniques, I suppose, I probably wouldn't recommend the one on the upper right, the old Hippocrates method. I also, you know, I think the milch maneuver can be, you know, reasonable, but I generally prefer Stimson or a prone technique, whether or not you have to manipulate the scapula or not, just letting the athlete relax for a moment and doing some gentle traction there and reducing it usually kind of calms them down to lay down a little bit. And generally, that seems to be one of the easier ways to get that in, that may not be as practical on a football field, but if you can get them on a table of some kind, it's usually pretty helpful. Guys, do you think there's one technique better than the other? Matt first. I do tend to, if I'm going back in the locker room, I have used lidocaine before, because I think it's helpful, especially in a muscular male athlete where the force, theoretically, to dislocate it is going to be higher. I do like the Stimson maneuver on the lower right hand. I also just find if you get these athletes right when it happens, like you're describing here, just some gentle inline longitudinal traction distally and then gentle rotation often is all you need to do to put it back into place. And this girl, I'm not sure how loose jointed she is. Sometimes females are a little more lax than males are. That's all it takes in a female athlete. Steve, your thoughts on reductions? Totally agree. Typically, as you mentioned, supine, if you're generally able to get it in that way. Okay, guys, great. So then we do get the radiographs a little bit later. We take her over to the clinic and get the radiographs. And you can see, you probably see a small Hill Sachs here, but you don't see any definitive glenoid bone loss here. So like at the moment, you're thinking, okay, this doesn't look too bad. Hopefully she's going to be okay, but it's a D1 athlete. I'm going to get an MRI for sure to evaluate this to decide what sort of be sure about the bone loss. And so you can see on several images, so I'll just make it clear. So she doesn't have any glenoid bone loss here. And you can see the Hill Sachs lower left there. So a small Hill Sachs as it goes. And if you look at her anterior labrum on the bottom images, center and far right, you can see their anterior labrum is generally in place. She did get a bit of a periosteal sleeve injury there, but you can see her labrum still in like a reasonable position. And so looking over this whole situation, it's January, sophomore season, first dislocation, and this sort of a small amount of bone loss in a Hill Sachs, but the labrum is not displaced in my opinion. So I had to make a decision about what to do. And so I'll ask you guys in a minute about it. But so basically the decision here, it's January, should she return to play in the same season or should she undergo immediate surgery in a non-athlete with a first dislocation or a high school athlete or different time of year, sometimes you'd say immediate surgery is always best. So what are some of the considerations I'd say, whether it's a recurrent or first dislocation, probably more likely to let her go back on a first dislocation. If there's bone loss already and like the labrum is quite displaced anteriorly or the capsule, it looks like a more severe capsule or injury, those may influence the decision to go back. If I think that there's going to be more damage because she's already got bone loss, if I let her go back, that may influence things. The sport can matter too. Basketball is a sport, high contact, a lot of overhead work, especially a forward here. So she's going to have a high risk of re-dislocating. Is this her senior season NCAA championship game or is this a younger athlete in the mid-season? So there's definitely some things to think about what the stakes are here. And some of it's talking with the athlete family preferences. Here you can see her in her sling. So I decide at this point, I'm going to let her return to play. So I'm going to ask you guys if you would agree generally with letting her return to play or letting an athlete return to play in this scenario with that MRI. And if you did have her return to play, what's the timeframe and what do you think the criteria should be from a rehab standpoint to return to play? How about you first, Steve? So Allison, I do think pathology matters. And I think the MRI scan can really guide you for this. You know, if you had somebody with an anterior labral tear that's peeled off, it's sitting over the edge, then the likelihood is higher. And you know, the discussion is always, well, what's the risk of re-dislocating if I fix it surgically or not fix it surgically? And you can argue about the numbers somewhere between 40 and 90% will re-dislocate. And you know, if you treat it surgically, it's somewhere between probably 5 and 10%. So you know, those numbers can be dramatic. That being said, I think, you know, given she's got an on-track lesion, a small hill sacks lesion, minimal labral, you know, tearing, I think three, probably somewhere in the neighborhood of two to four weeks of rehab. She's got to have full motion back, full strength, no apprehension, you know, and you can probably get her through two or three months potentially. But you know, I think a second episode for me would pretty much seal the deal. Matt? Basically my same approach. I think everything on her anatomy, as Steve said, is favorable. We didn't really talk about on-track, off-track, but it seemed based, the story you were telling was that it was a small lesion, probably not engaging. So as far as the rest of it, I've had a blues player come back in 10 days after a first time dislocation. It was during the playoffs. And so obviously he's more motivated perhaps. The average person who dislocates in high school, it's about six weeks. I think I would agree 100% with what Steve said in terms of a two to four week timeframe with all the parameters that he mentioned. I don't remember if you said it was her dominant or non-dominant shoulder in terms of how that affects her position. Is she, you know, is she mainly under the basket? Is she a three-point threat? All those sorts of things. That's more of a coaching game strategy issue, but it may play a role into what her decision is and your decision. Yeah. So non-dominant, but she's a forward and so her main role is rebounding. So it's both arms overhead all the time, a lot of contact. So in any case, great points, guys. I think that that's what I was hoping for is that you would kind of discuss that timing. And we look at an article by Brett Owens back in 2012. The average time for an NCAA athlete, anyway, to come back was about three weeks. And the criteria, as mentioned, you know, Steve having full range of motion strength and I think also sport-specific function, right? Like so a lineman has something different they have to do with their shoulder than a basketball athlete. And making sure a basketball athlete can get overhead and rebound safely and feel comfortable without apprehension is, you know, what she'll need to be able to do. There's also, you know, being able to wear a brace perhaps, and we'll look at that in a moment. What's the risk of redislocation, you know, treated, of course, without surgery here. And it's pretty high, as you can see some of the data. And then John Dickens' work in AJSM 2014, where this was a prospective multicenter trial, especially with the military academies. And so about 73% of NCAA athletes with an instability episode were able to return to sport. That includes subluxations, by the way. And actually they were able to come back as quick as five days after injury, which I wouldn't necessarily recommend, but that's the data. And then 64% who returned had recurrent instability, and 30% were able to complete the season despite the recurrence, but 33% of those couldn't complete the season with the second dislocation. And so I think it's just important for the attendees of the meeting here to know some of this data when you're counseling athletes, parents, coaches at some of the risks of returning. So you've got to decide based on the anatomy, but you ought to know the information kind of about the risk of recurrence too. And so what about bracing? So for an athlete, now a Sully brace is something that athletes that have to have a lot of movement like a basketball player could wear, and you can see some of the different configurations down at the bottom of the screen. You can wrap the Sully brace in different ways around the shoulder to help stability. There's different braces, for example, for football or sports where you wear pads that are even a little bit better and can hold the arm more stable because it's built into the shoulder pad. So Sully's not usually worn for football or other pad wearing sports, just for the attendees to know about. So we got her fit with a Sully. She was able to wear it, but unfortunately, lo and behold, after, so I kept her out for four weeks and she was able to do everything quite well, like felt like she was cleared, was practicing with full contact without a problem in her brace. And then she was in an away game where I happened not to be that particular game. Went overhead, another rebound, recurrent dislocation, no surgeon with the team. They didn't have any facilities there and the team physician primary care sports with the team couldn't relocate it and they had to take her to an ER. And that was really not really a good situation. It took them over three hours to relocate her shoulder. This was really a traumatic experience, multiple attempts to reduce it without adequate sedation. And so, you know, whether or not that created a worse Hill Sachs or not, I'll never know. But we can see a comparison of the MRI of this athlete from January with the first dislocation and what kind of happened with a subsequent dislocation. So the Hill Sachs is quite a bit larger. And I think the most unfortunate thing is that you see the labral damage there, anterior inferior really injured her capsule much worse this time. And certainly her labrum is really not nowhere to be found on this MRI. So she sustained a fair amount more damage and probably worse than that, the psychological trauma for this kid, having this like terrible experience in the ER at Wake Forest. She's not going to play even if, if I thought it was a good idea to play, which I didn't, she would never have wanted to play because it was such a bad thing to go through. So you know, in terms of decision making, it wasn't that difficult, Steve, I think you had made the comment that if a second injury occurred in season, then she would, you know, the athlete would be done. As I said, it was easier to make that decision here, but maybe just a quick comment from each of you about that second MRI, second injury, what you would have done. Maybe Matt first. I would go to surgery if that's the main question, then in terms of how I would, I would fix it. We don't, we don't have a real measurement in terms of her on-track, off-track, I would, if it was a, excuse me, off-track lesion, I'd consider doing a REM plissage in addition to a labral repair. You can debate the merits of an arthroscopic labral repair versus an open reconstruction. You're going to lose a little bit more external rotation in an open procedure, but you will benefit in terms of the stability that it'll provide. I don't, I didn't study the labral, on the MRI much to say, but I think you'd probably, you could most likely do it arthroscopically, and then I would probably add a REM plissage to that. I don't, was there any glenoid bone loss? I don't remember you mentioned that. No glenoid bone loss, yeah, but more severe injury to the labrum and the anterior, like the periosteum, the sleeve, it was certainly a really quite a large avulsion there. Yeah, and if there's, if the labrum was nothing to work with, I would not have a, I would not be hesitant to do an open, an open repair. Steve, any thoughts to how you would, I think you'll agree that she needed, that she was going to move on to surgery. So, you know, in terms of decision-making, I'd tell you it's off track here with that Hill Sachs now, what would you do? Yeah, I mean, I agree with Matt. I think that, you know, certainly I agree with you, more damage, you know, the second time around and that you can always, you know, it's so easy to look back and say, well, gosh, we should have just fixed it the first time because, but I think you did, what you did, everything was right. You know, I agree that I would probably, I think in all likelihood, 90% of the time, I think you can do this arthroscopically. I think, like you said, if it was off track, then I would probably add the REMP massage to it. Okay. So, when we move on in the interest of time, so I did go to surgery. I did decide to do that REMP massage for the off-track lesion and because, you know, I showed the MRI and it may not have been as obvious, but I thought there was really, the capsule was so stretched out and there really was no anterior labrum to work with amazingly. So I thought it was better to do an open approach, but a subscapularis split as opposed to a takedown in this case, I thought that was also good for this overhead athlete and doing a Bankart repair there and the capsular shift and certainly some risk there of doing that open that she's going to lose some range of motion, but, you know, thankfully she didn't. She is kind of a lax individual in general. So I think in the final, like just saying as a cautionary tale, having an athlete go back in season, I think that as a team physician, so all of you on the conference, I have fellows are moving on to practices. You need to really be ready to treat acute dislocations of various sorts, but shoulder is going to be one you'll see, you know, be ready to do that, know what technique you want to use. If you need local anesthetic, if you have radiology access can be helpful. So kind of be scout that out, even if you're at a way game, I think it's pretty helpful. And then when an athlete, if you're going to try to have someone return, make sure you know some of that data so you can share it with the athlete, family, coaches, and everyone so that no one's surprised if that dislocates again, you know, I was really, I think forthright with the family about the risk of this and we talked about it and I know I still, I don't really regret the decision, but I think you have to live with it when something like this happens and, you know, prepared to move on and fix that. So appreciate the chance to present her case. I hope that's been helpful to the fellows. Thanks. Thanks Alison. There was one question from the attendees, whether or not there was a Hagel lesion present as well, and what's your preferred approach for Hagel treatment? Yes, that's a great question because, you know, if you look here, I think like I showed the, so the images, the coronals up on the top, I think you'll see that, you know, I think that's a good question whether or not there's a Hagel. I think, you know, she certainly her capsules really looks lax there. I'm not sure that's really the humeral avulsion. I think it's really just a stretched and I thought about that and I also felt part of the reason for doing this open mat was to evaluate that and consider whether that needed repair. I prefer to do that open. I know some can do that arthroscopic or prefer that, but I wanted to look at that directly and had I seen that, you know, on, you know, the scope or even open, I just would have fixed that open with anchors to the neck area. I do as well in terms of doing those open. Steve, any strong thoughts on Hagels? I'll treat the posterior Hagel through the scope and then I'll tag the anterior Hagel through the scope and then do it open. That's a good point for the fellows to tag it when you're looking right at it because sometimes it gets a little dicey in there in terms of what you're looking at. Yeah, it's so much easier. Just put a stitch in it and when you're coming down to it, it's right there for you and much easier to treat that. Great. Thank you. Steve, I guess you're next. Yes, I am. Let's see. You have me on the screen now? Yeah. Okay, so we're going to present an elbow case. So we've marched around the body, finishing up on the elbow. Those are my disclosures. This is a 27-year-old professional first baseman. He bats right-handed, throws right-handed. He sustains a left elbow valgus injury while attempting to catch a throwing ball after a bunt. Describes immediate pain over the medial aspect of the elbow. He's got no prior history and does not describe any tingling. So fortunately, as Matt and Allison know, when you work at a high-level team, you get the advantages of videos. So here is an example of the video. So you can see his elbow goes into valgus there. Actually glove comes off. Got a couple more angles for you here. So he's reaching for the ball, runner runs into him. And then one last one, this I think is really gives you an example of the valgus type of injury that he sustains. So on this clinical exam, his shoulder, elbow, I'm sorry, shoulder, neck, and wrist are within normal limits. He has painful but full elbow extension and has elbow flexion 120 degrees. Again, with some discomfort, pronation and supination are within normal limits. He's got no cubital tunnel signs consistent with injury to the ulnar nerve. He does have some pain with resisted pronation, the remaining elbow strength and forearm strength are normal. He has tenderness along the course of his ulnar collateral ligament, slightly over the medial epicondyle, but a little bit more so over his sublime tubercle. He does have pain with valgus stress and has a positive dynamic valgus milking maneuver. Plain x-rays are normal, no evidence of any fracture, no calcification, no bony avulsion. Here's an MRI scan. Here's a coronal image. We'll scroll through this here and I'll point out to you, here's the medial side, ulnar collateral ligament right here. We'll even do it again because I know it kind of moves through again. Steve, can you do an arthrogram on all of these? So on an acute injury, Matt, no arthrogram is necessary, especially for a traumatic injury. So for somebody who's got some chronic or just some vague medial elbow pain. Here's our axial plane, again, medially here, you can kind of track the course of the ligament. We'll go one more time through it. And we have the advantage and we really utilize the dynamic stress ultrasound here in Philadelphia quite a bit The ultrasound revealed acute distal injury near complete With 1.3 millimeters of gapping of his left elbow compared to his right elbow, which keep in mind. This is throwing side so our thoughts in our plan, so we essentially have a A high-grade distal ulnar collateral ligament tear the injury occurs in mid-september And I will tell you that at this point in time. We're right in the middle of a playoff run And so, you know, I'll kind of stop and allow Matt and Allison to to kind of come into play here You know thoughts about a treatment plan on a guy with 1.3 millimeters of of gapping of valgus stress September You know and what are your thoughts about how you would manage this in season? acutely I'll go with let's go with Allison first Thanks to you. So yes, it's a Certainly as I was mentioning my talk to you like the timing of the of an injury for an in-season athlete's quite important Right because if this is spring training, you know, it's a lot easier to make decisions about what you want to do But when it's a mid-september and playoffs professional You know, it's gonna be hard for you to convince the guy to do anything Never mind, you know really decide that you need to do surgery I also think the athletes position, you know makes a difference too. So this is a pitcher and his and his dominant arm That can be a harder thing to maybe work through But given the situation of the his position and the timing and the fact that it's only gapping The small degree that you mentioned I'm gonna try to get him through the season and you know I'm interested like PRP injection to decrease pain and you know, potentially potentially help healing bracing and Like trying to work him back as quickly as the injury allows where he can be effective both, you know Batting and play in his position So I would try to get him to return as quickly as possible in this scenario Having him understand he may you know worsen the injury by playing with it I would agree. I couldn't tell from the MRI. It looked like it was torn distally. I think you said Steve It was near complete tear was the substance of the ligament reasonably good except for where it was turned off torn distally So the the the ligament itself the the mid mid and proximal aspect the ligament were otherwise normal appearing So I think I would try to just he's not it's his non-dominant hand He's a first baseman certainly in a playoff run. I would brace him and I would try to do rest of rehab I would talk to him about PRP. There's no harm in doing PRP I don't know that I have a lot of literature to support it in this particular study But I started to think you're gonna try to throw everything at it given the situation that you're that you're in my blood return to play So since you brought up the PRP and obviously I listed it here thoughts about you know, whether you know Obviously the the MLV study looking at PRP for her, you know Routine you'd see all injuries more in the thrower in the in the throwers elbow Have you had experience with PRP and having a flare-up or you know? Would you be concerned that a PRP injection might actually well, you know might stimulate a little bit of healing could potentially Lengthen the recovery or do you think it would more likely shorten the recovery, you know a full disclosure I don't treat these as often as you do to be able to be able to you know, intelligently comment on that Perhaps Allison does So I can't answer your question. I'm afraid Yeah, Steve, I would say, you know same with the elbow. It's not something that I do routinely So I can't comment as much on elbow, but I feel like leukocyte poor PRP which is something that we would tend to do and and this type of more of an acute injury We're trying trying to get somebody back I don't think I've seen that difficulty so often like having a flare So, you know, I'm certainly more in favor of that, you know, then I would be against it Yeah, I would I would agree with you the Particularly around the knee. I think you don't see a flare-up I think because the elbow joint in the space is kind of a smaller area I've definitely seen you know Some reasonable flare-ups where you know, it'll take you know Somebody maybe maybe three to five days to be able to get back to rehabbing after a PRP injection So I think it's it's definitely something to consider. So we did exactly that and We we tried to treat him non-operatively and said well, we'll brace you We'll see how you feel. We'll start some regrets of rehab. We'll start some gripping and We you know, we started it got towards the end of September Unfortunately, we kind of fell out of the playoff race a little bit so we Rescanned them and and this is just a still shot of his MRI and you can start you can see right here at the arrow the distal distal tear This is more anterior than posterior. But so so still something concerning we did a full stress ultrasound which showed That he's still gapped and he was he went went from 1.3 to 0.9 millimeters compared to the contralateral side So now what would you do? So the season is essentially over you have a first baseman house and you mentioned, you know It's not as throwing arm, but one of my big concerns was this is the first baseman He's going to be faced with you know scenarios where you know He's a little bit more valgus than the typical, you know a position player Any thoughts about whether we rehab them let him go throughout the season or do we think about doing something a little bit more? Urgently now if the season is essentially done Yeah, you know Steve I think that the the fact that it's this sort of this distal disruption like that and and I think it's been a recent injury I think that Like most things you've got a chance to get that you've got a chance to do a repair I think the the risk you take is that if you let this just you know rehab and He's just not able to heal that any further that the first time he gets another valgus load that that's going to be gone And then and then you may lose him for part of the season So I think you've got significant time for that to recover So I'm thinking here more repair and maybe augmented with an internal brace or something Any other thoughts Matt no, I think that's what That I think that's a great option to consider first of all the rehab will be a lot less because spring change is gonna be And I'm not sure when you would consider doing the surgery I'm assuming at the end of September if you're out of it somewhere in that area You're gonna be coming back to spring training somewhere in February. So you have about you know, three or four months to go I know Jeff do this has talked about getting patients players back a lot quicker Relatively speaking then doing a formal reconstruction I think this that would offer you the best chance consider the fact you do have a decent ligament above or it's torn off Yeah, so that's it that's exactly it and essentially what we decide we discussed was in Allison You really mentioned this is this a player who you know The next time he reaches out to catch a ball. Is he going to be worried about it? And his thought was well, listen, you know, we've got the time. I'm gonna have to shut it down and rehab it Anyway, I really don't want to have to worry about it. So we did exactly that So on you know the day after I think was the day after the week after season ended We essentially took him in for a UCL repair with internal brace Just to kind of review this surgical technique. It's a muscle splitting approach. Just like you you approach the for UCL reconstruction you want to Evaluate the ligament you want to make a longitudinal split in the ligament to identify The only humeral joint and then evaluate the tissue quality You always have to be prepared that if you're going to do a repair you have to be prepared to do a reconstruction You're going to put the the first anchor on the on the avulsion side just distal or just at the sublime tubercle You're going to repair the avulsion using this suture. That's that's already attached to your Swivel lock type of anchor You do the repair you then? Do a side-to-side repair of your of your ligament And then you go ahead and put your here. This is an example of doing the repair of the ligament You're going to put your internal brace and put your proximal or your non of all side Anchor second you really want to achieve appropriate tension if you're doing the on the media epicondyle and you know any of you have done the reconstruction you're really kind of trying to get the for the reconstruction the midway point between the Epicon the tip of the epicondyle and the base when you're doing it for a primary repair you want to go just slightly proximal to that to try to maintain the the humeral insertion Normally put the second anchor in and about and you can decide whether you do it between 30 and 70 degrees I use 30 degrees Neutral rotation a little bit of varus load. You want to put a freer underneath the internal brace so you don't over tension it Again, you're going to close the native ligament assess range of motion. This is what it looks like And That's the final repair technique So, you know as you mentioned, you know, this was somebody that we kind of targeted. Okay. Well, you know by late December Which would be you know, early January late December get a bat in his hand Gives him a month or six weeks to get ready for spring training He returned for the season opener he returned for spring training games in early March Was cleared for full regular season activity played the season over on March 28th I will tell you he actually just hit a home run at Yankee Stadium Tonight in our game, but this is an example of a recent July game Where he hit another home run and he is a slugger. So Any other thoughts or or you know Discussion on this this case. I know we're kind of up against it getting close to our time here a Great case Steve I think You know a really good example of you know, just again having to consider multiple things like timing position of player And options but also fully counseling the athlete. So thanks for that Yeah, it's really good good good discussion it just that's what makes the sports medicine so interested in fun, you know You have different sports different positions different athletes different stages of their career all factor into how you're going to treat A specific injury. So thanks a lot for both you with your great cases So, yes this unless there's any other questions for Steve, which I don't see on the message board I guess unless Marathon that will introduce our speaker. Mr. Vukovic. Are you there? I'm here. Hi Matthew. Can you guys hear me? How you guys doing? Yeah webinars your All right. Am I able to share my screen then? Sure, I will give you access Everyone can see this? Yes. Yep. Okay. Great. So first of all, I just want to get started here. My name is Matthew Vukovic, appreciate being here. A quick little overview about who I am before we get into what we're going to talk about. I am a partner at the Gilbert Group in Beverly Hills where I specialize in life, business and disability insurance. I mainly work with high net worth individuals, a lot of A-list celebrities in Hollywood, professional athletes in all four major sports and then surgeons. I've been in this business for about three years now. And before the insurance business, funny, we're just talking about baseball players. I was a major league baseball sports agent for 10 years, ran my own agency, had an opportunity to exit. When I exited the business, I got inside into the insurance business. And that's kind of where this whole world started for me working with surgeons. I started getting involved in Beverly Hills in the plastic surgery market, mainly in Southern California, working with like UCLA, USC, Cedars in the plastic market, really talking to fellows and chief residents. As I'm sure everyone here knows, I kind of got connected to other folks in surgical specialties. So it led to ortho, neuro, CT and vascular really all across the country. And the biggest thing I realized as graduating fellows, most people here have jobs. Before that was, how do you find a job? How do you navigate that job market? And more importantly, how does it go throughout there in your entire career? And how does that relate to my previous world, working as a sports agent, guiding mainly high school first round draft picks to the draft, to the minor leagues and then to the major leagues. So I created a company whereby I helped out a lot of surgeons, find jobs and also get through their career as they were going through that. In addition, there's a podcast I started called Interview with the Surgeon. Some of you folks may have heard about that. I welcome you to check it out. It's very educational and very interesting as well. So first and foremost, I know we only have a few minutes here. And so I just wanted to kind of establish, the biggest thing that I see, and I think in any profession, so much so that we don't talk about that much in the surgical space is really value outside of job description. And when it comes to that, I relate back to the professional athlete. And being an agent, I realized one thing, that no matter what you do, if you get done negotiating a $40 million contract, which in baseball is guaranteed dollars, exactly the next day, the player is going to ask you, what are you going to do for me next? And I learned that very, very much the hard way a lot during the baseball world. But I think that that relates to the surgical space. And what I mean by that is, I think it's important for all the fellows that are entering the professional job market now for the first time, to really understand what your value is to the financial service professionals that you need to be working with as your career goes along. Whether that's insurance agents, financial advisors, CPAs, or trust and estate attorneys, and other folks like that. And it works like this, your value to someone like that is very important. You're going to work for the next 25 to 30 years, you're going to make high six figures, some people have the opportunity to make seven figures. And so you know that you're a very qualified client for those folks. But the biggest thing that I see a lack of is in the communication of realizing is, what does that person do for me? Or how can they actually help me out? In the professional sports world, in the celebrity market, it's all about what can you do for me? In the surgical space, you spend so much time, you dedicate so much of your life to being the best surgeon out there focusing on patient care. And now's the time where you have to focus about yourself a little bit as you start your career. And so I would ask you to, when you're talking to insurance agents, when you're talking to financial advisors, ask them, you know, what else can they do to help you out in your career? Maybe they're connected to physical therapists within their client based network. Maybe they know sports agents, maybe they know someone that can actually help you out. And so all I'm saying is that if these folks get paid for what they do, kind of ask them, what else can they do outside of their job description that provides value to your world? I believe that if you take that approach in the business mindset, it will actually help you out as you go throughout your career as a young surgeon, then as you go into years five and years 10, and so on, and so forth with that. I just want to talk about disability very quickly as you make that transition to the professional world. It's really important to understand one thing, which is state versus state rates, meaning that let's say that you're in California right now and you're going to be taking a job in Texas. Well, the rates in Texas are a lot cheaper than they are in California. And so with that being said, as you go to increase your policy based upon your current guaranteed salary, right, minus the employee benefits that you'll get either through an academic institution or through a health system, it's really important to see, can you save money? And if you can, make sure that you apply for that actual state. A lot of folks who are here will be going in private practice. Now a lot of private practices I do work with do offer pretty strong employee benefits and some don't. They allow you to opt in or opt out. And so here, if that's the case, make sure that you maximize your own personal policy and really understand what does that mean. So for instance, if you go through an employee benefits package through an academic institution, understand that God forbid you go on claim, those benefits that are being paid through that group plan are actually going to be taxed. And so there's little things like that, that I think don't get discussed enough about, and seeing that your ability to make income is your ability to be a surgeon. I think it's really important that you understand how that stuff works. And then as you get along throughout that process, as you go on throughout your career, there'll be other avenues to secure higher levels of insurance, mainly through Lloyd's of London. And so I think the biggest thing here is that consider yourself, you've gone through medical school, you've gone through residency, you're just now getting through your fellowship, you're about to start that career for the first time. It's super exciting. It's so cool. But realize that now you're back at square one again, you've got to establish yourself in the community, you've got to establish yourself with the leadership, wherever you're going to be, you've got to establish yourself with your current mentors, and hopefully you will add on extra mentors as well. And so I think if you approach this more like, in my perspective, a baseball player going into the professional side of sports, you realize that outside of the OR, there's a whole nother world out there. And so make sure that you're being smart about how you're approaching people, how you're branding yourself on LinkedIn, or Instagram, or if you get involved in TikTok, things like that. Be very cautious about what you do, be cautious of who you align yourself with, really rely on your mentors to guide you through the process as you know, in those first couple years. And then as you get to going throughout your career, you will have the ability or potential have the ability to get involved in other things like industry deals or startup companies and things like that. And so all in all, coming from the sports agent background, I realized that the surgical space is so interesting to me. What you all do is absolutely amazing, I cherish it very much. And so I just think that if you approach it like a business person, I truly believe you will, you will see more success outside the OR. And in doing so, I think it will allow you to ask certain questions when people want to work with you, you got to ask them, you know, what are you going to do? What other value can you bring to the table? How can you help me out? If you want to accomplish something in your career, see how you can do that and see what makes sense. I only had a few minutes, I didn't want to go over too much time. That's all I got for everybody here. If you want to get in contact with me, by all means, I've got my email address here just Matthew at surgeonagent.com. Instagram is at Matt Vuke. Looking forward to work with folks here. And again, if I can help anyone out get in contact with whether it's sports agents or anything like that, I have a lot of connections there. I just want to be a helping hand and know that there is a resource of someone like myself out there that wants to be able to help you out and add value to you in your role in any way I possibly can. Great. Well, thank you, Matthew. We appreciate that. Thank you. Thank you, Matthew. Thank you very much for your time, appreciate it. Thank you, Drs. Cohen, Matava, and Toth for your time and preparation for this webinar. And lastly, I just want to say to all the fellows on the line, best wishes on your future career path. And thank you for your participation in the webinar series. Goodnight. Goodnight, everybody. Goodnight.

AOSSM Fellows webinar

in-game return to play

post-injury return to play

decision-making

recurring patella instability

treatment options

non-operative options

surgical options

radiographic evaluation

individualized decision-making