in an answer session now, so Dave and Kurt and Brian, if you could come up. You know, George, even when the science is there, it's always entertaining. Since he is my elder, I have to, you know, I have to respect what he has to say. Back in the early 80s when I was an orthopedic resident, it was actually George's first book that I read on orthopedic rehab. I think he wrote that in the 30s or the 40s. Which one was it, George? The 20s. Okay. All right. So Dave, Kurt, Brian, thanks for your presentations today. Brian, you mentioned, you know, the role of osteotomy and unloading some of those defects. How about unloading braces? Is there a role for this in sport? Can you get an unloading brace on an athlete and still have him perform? Yeah, I think you can get it on. I think you can perform. I just don't think it's likely to be enough. I don't have any problem trying. We've done it in some valgus, like bigs in the NBA. And sometimes it's more about the, I think the proprioceptive phenomenon than actually making them have less pain. I just question at the level of the higher, at the level that these athletes participate in sports, I really question their ability to, for example, reduce adduction moments and so forth. I don't have any problem trying. I just don't know how well they're tolerated. And I'm not sure how effective they'll be, but it would depend on the sport, I'm sure, to be honest. It's just, it's not a go-to to solve the pain issue, to be quite frank. I think it has a role. I'm just not, I'm envisioning your question related to these higher level athletes. Okay. Questions from the audience? So Dave, you saved the last couple comments there for lateral release. That seems to be one of your least favorite. And you always save that for the end in your patellofemoral procedures, is that correct? Well, I think that just there's a tendency to misunderstand the role of lateral release. So I try to make that point emphatically, that that's not the answer for patellar instability. It does not correct an anatomic risk factor. You may develop lateral retinocular tightness. You may need to balance the knee at the end. When I just look at all my patients with MPFL reconstructions, probably 10% need a lateral lengthening. If I start moving the tubercle, by default, I'm gonna make the lateral retinaculum tighter. The more medial I move the tubercle, the more distal I move it, so it may be more likely to need it. And especially if I have a patella with chronic tilt and subluxation that tracks laterally over time, the retinaculum gets tighter. So I think of it as balancing my knee at the end of the case. Rarely I can't center the patella in somebody who's got a lot of risk factors, really terrible tracking, and I have to do it early in order to center the patella and get the right tension on the MPFL. But it's just really, and the thing at the end, to get things balanced and just right. It's not the solution to patella instability up front. You mentioned the word lengthening, though, which I think shouldn't be lost. Yes, thanks, Brian. So I virtually never do a just full lateral release now. I do a lateral lengthening, which is a Z lengthening in layers, so I can repair what's left on the lateral retinaculum, which does much better clinically, better quad strength, less effusions, less pain. You avoid iatrogenic medial instability. The easiest mistake for me to make with an MPFL reconstruction is to make it too tight. We all want to pull on a graph like an ACL, and that's not what you want with the MPFL, but there's still that tendency, so if you repair the lateral side, you help to avoid that problem. Question? So also for Dr. Yip, for your young patients, if you are doing any type of guided growth, do you do a soft tissue reconstruction at the same time, or do you wait until the guided growth procedure is done? In that case, what's the program? I would almost always do the soft tissue reconstruction. Could you repeat the question so everybody can hear you? It's a good question. So if somebody's still got more than 12 months of growth left and you're gonna do a Fisio tether, a guided growth, with one of those two whole plates, femur and or tibia, do you do a soft tissue procedure, meaning an MPFL reconstruction at the same time? Yes, I would, because generally, that person I feel is very much at risk for a catastrophic chondral injury from a patella instability event, and I've seen them, I think we've all seen them. The growth plates are open, you're trying to wait, and then, boom, they shear off a huge piece of cartilage. So yes, I'll do an MPFL reconstruction, and you can very safely do that with open growth plates. I have a question for Dr. Cole. You talked about, during your presentation, doing a combination of procedures of bone marrow and cartilage allograft, et cetera, and trying to combine these to try to get the best of all worlds. What's your age cutoff? Do you do that in a 20 or 30-year-old? Would you do that in a 40-year-old? Or a 50-year-old who's active? Is there an age cutoff for that type of procedure? I don't, in the area of cartilage, it's less about the, it's not age as an independent variable, it's that older people have a different disease. And it's rare that I find, I think that if you took an individual who macroscopically had a focal or localized area of cartilage loss, and you put him in his or her 20s, take that same person, put them in their 40s or 50s, I think they're, unless they're traumatic where they had a perfect knee, which is not that common, most of what I see is degenerative, quite frankly. And I think these older individuals, chronologically, have lived with their problem longer in many instances, and they are really behaving like arthritic patients despite having visual localized loss. And our experience is that they don't respond as predictably well. That being said, we just looked at our OA graphs in people over 40, and we do the same as under 40. Now, maybe 40 is not old enough, but I don't have a whole lot of people over 45, because they just, by that time, they're usually too far gone. They've just coexisted with their disease. So if you were asking about the sort of, or the ability to respond or deliver an orthobiologic, I'm not sure if that was hidden in your question, because some people talk about these, because you mentioned these other things, or the ability to self-heal. So if you're doing a marrow stimulation, age has been looked at as well. So I guess I wanna make sure I'm really answering your question, but there is a philosophical answer to that, which relates to the fact that I think you're treating a different disease. Even though macroscopically, it looks the same, I have the sense that it's a different problem in an older patient. But I'm not sure if that's exactly what your question was. Well, sometimes with that older patient, individuals begin to learn from, potentially in a unicognitive, or going farther down the realm, because are they degenerative? Yeah. Is it trauma on top of the degeneration, or what combination? So what point would you say, you're better to put you in another group, as opposed to go through the time and effort of allograft and biologics, because is this a short-term entity, or bridging something to get you to the point of unicognitive, or some sort of replacement? Most of these people who are getting these procedures have pretty clean knees. There is a young group who has really bad knees, and I'll still do it. But an older group with really bad knees, I won't do it. So I don't push, I do push the envelope in young patients, and that means these are people, these are kids who are 15 to early 20s, who have bipolar disease, and I will do it. I'll do a meniscal allograft, I'll maybe do a marrow stimulation for the tibia, an allograft for the femur, and an osteotomy, and have no problem doing that, because most of the things we do are building bridges that are temporary anyway, even a knee replacement. So you're trying to build a bridge where they're more age-appropriate, but you have obviously a more guarded prognosis in terms of the ability to deliver pain relief, in that patient. It becomes a salvage discussion, not because the operation is dangerous or other, we just may not deliver. But I would not invoke that salvage solution in a 40-year-old or 50-year-old, because I agree, we have other options, which are a whole hell of a lot easier to recover from. Full weight-bearing immediately, for example, off assistive devices right away, no bracing. I mean, it's a lot easier to recover from a partial that could get them to a more age-appropriate time when they fail that, when they may need a total. So, and then again, don't forget about osteotomy. Fortunately, a lot of these patients in their 40s and 50s who have bipolar disease are malaligned, and I don't even think about cartilage repair on those procedures. We like osteotomy, and they can do beautifully. That could be a great bridge builder, and you can ignore the cartilage problem. So Brian, with your increasing use of allografts in young people, those failures would present big problems. Is that another allograft? So it's, you know, early on, when I really started thinking about this problem, we're just trying to put things into this algorithm, if you will, based upon what we thought we knew, I was saying out loud that I don't want to do an osteocon allograft until the end, because if they fail, you got a huge problem on your hand. But I will tell you that you rarely, the way allografts fail is, they don't pop out and leave this big hole. They pop out, and they don't heal. You just do it again. So they fail in a variety of ways. About a third of our allografts end up getting something, like another scope or other. They usually fail either because they get progressive degenerative disease around the allograft, but I do have a sub-population of allograft patients whose grafts look perfect, but they still hurt. That's the worst kind of failure of all, because we got nothing for them. Fortunately, it's rare, but it absolutely happens. So I have probably done more than 800 osteocon allografts in 25 years, and I am no longer afraid to pull it. It took me a while to do it early, and so I struggle with this balance of doing less versus doing not enough, you know, to give them a longer-term solution, versus pulling something bigger to begin with. This is a debate in and of itself. How, what gun do you pull first? And again, it's not necessarily because of the disease or the solution. You look at the athlete or individual and the system they're in. That guides a lot of that treatment too, what their tolerances are. Like when I showed that young man, it's about the tolerances they have and how much time they have to recover and what they're looking for. They're like, look, just give me something simple. Let's see if that works. That's pretty provocative, you know, and it's safe. So all that being said, I'm not afraid of osteocon allografts. They generally heal fine. And instead of looking at it as a salvage, well, if you fail your MESA, you fail your myostomial stimulation, the threshold's pretty low right now to go early to an allograft, but I'm still very interested in trying something simple early when it's a patient like this. Okay. If that makes sense. Yep. So Kurt, just switching gears here for a minute, you know, with your ACL moon data, comment a little bit now, are the numbers high enough with meniscal repairs to comment on outcomes with the meniscal repairs? How does that look? Does that really increase the success rate of your ACL if you have a successful meniscal repair? Yeah. The question is not that straightforward to answer because I don't think we don't have what if we didn't do the repair. What we can say is that in the classic sense, when you have a red-white tear or you have a repair that looks like a good repair to heal, we can repair that. And it doesn't seem to have any negative effects in the first two or three years. Doesn't make you worse, doesn't make you better. So if you follow the algorithm that we followed, which was not to repair everything, repair things that had a vascular supply and to trim out things that didn't have a vascular supply, if you follow that algorithm, then it appears that you don't seem to have any two or six year problems. What appears, maybe even 10 year problems. We don't know whether that relates to post-traumatic arthritis even later. What we do know is that if you have a grade three or grade four hit on your articular cartilage, if you have it on the medial femoral condyle, it affects you early. It affects you at six years. But if you have a grade three or four anywhere on any surface of your knee, it affects you at 10 years. But less than maybe 5% of the population, somewhere around there, have a grade three or grade four defect when we see them as primaries. So our take-home message, the other take-home message is that we know that subsequent surgery, any subsequent surgery on the knee, whether it's a revision ACL, whether it's a scope for cyclops or scope for a meniscus that failed, is one of the worst events you can have that give you pain, consistent pain at six and 10 years. And so I think that that gives us caution to say whether you should push the envelope on repair because if you lead to a second surgery, that clearly hurts the individual. And I think that's because when you have a second surgery, you create a biologic, a bad biologic environment for the articular cartilage. Kurt, that's a profound statement. How do you, like all the independent variables involved, I mean, how do you know, that's a chicken, the obvious question is the chicken and the egg. You're operating again because of a problem. And I think I heard you just say, I mean, this was one of the papers that came out of Moon. I think, so I probably signed off on it. I heard you say that the act of doing the surgery itself as an independent variable was a negative prognostic factor. Did I not hear it correctly? I cannot, I can't say that based on our data. Okay. But we can say that based on the data from the Canon study. So if you have a hemoarthrosis, that injury. Yep. And if you looked at those, they MRI'd those people before they had surgery and they had lost, degenerate MRIs, they had lost 20% of their proteoglycans and all their surfaces. And that never got replenished at the end. So the idea of a hemoarthrosis Sure. Is a negative for the articular cartilage. And if you think about that, then you have a huge hemoarthrosis after ACL reconstruction. After surgery. And probably after other surgeries. So there's the articular cartilage, we believe, becomes an innocent bystander to having repeat surgery that has to be done. Okay. We can say that second surgery for anything creates that that person's on a really bad pathway all the way down. Right. You talked about concomitant meniscus and paravasale surgery. I've gotten pushback from some of my therapists recently that I'm too conservative for an unstable meniscus or I'm going to keep them limited to 90, limit their weight very close to operative. Does that still occur in trend amongst the panelists or are you more aggressive? This, you would create an intense debate among the 20s people in Moon who like each other and agree on 90% and are completely, there's no evidence on what your pro-stop rehab should be with a repair. There are some people who say if you do more modern, all inside techniques with good fixation that you don't change the rehab at all. And there are other people who restricted it to the traditional rehabbing of waiting, you know, waiting six weeks before you started to move them. I was a six week person. Then I went to a, one of my friends is, I do the same thing. I don't do the common rehab. I don't wait at all. I don't change my rehab at all. And I went to a three week person and now I've become, I don't alter my rehabilitation early on. I mean, I want them to progress really rapidly but I still want to get their motion and get them to walk. So, but there's no evidence here and there's no agreement here. I have a question for Kurt if any of the panel can comment. Kurt, in your ACL data, you talked about failure rates. One of the things you didn't address in the failures was the connection of time to return to sport. At this meeting, we go through various cycles, accelerated rehab, three to four months, six months, doesn't matter. Has no effect on return to injury rate as the authors have said. How we thought the failures would slow down nine to 12 months. Comment on return to sport and its effect on injury rates and what you think the current status is after ACL reconstruction in the athletic population. We don't really have good data on knowing when they returned and what the failure rate was. We know when the failure rate is but we don't know when they actually returned. So I can't comment on data. My usual thing, when the pendulum keeps switching from real fast to real conservative and back again, that really means we are not operating on any good data. So it is a concern to me. I think that there are many reasons why you could potentially think about return to play. One of the proposals is, there's a certain amount of graft healing that has to occur and if that graft healing occurs on a bell-shaped curve and you send the average back at a certain time, then the people that are slow healing may be at risk to do that. I don't know that but we've never had a way to quantify the, we do now, it hasn't been studied, quantify with MRI or something the actual strength and healing of the graft. So that really needs to be explored. And it sounds like it could be simple to explore but it's really complicated because if you have an athlete in season, right, if you can't get them back for the second season, then why are you doing the ACL? But that's something that needs to be studied and we don't have a great answer for that. Yes. You can. Well, what I would tell them that, it's better if they're smaller than they're big because the smaller athletes seem to recover quicker for me because I think they have less, I tell them six months, five and a half, six months if they can do it, if they're ready. But that's the unique individual that can meet all the goals. And I tell them it's more likely going to be seven to nine months to be able to do that but as early as five and a half, six. I think a lot of that answer will come in the second half when Scott Rodeo talks about the biology of healing and probably get some answers from that. So let's at this point break for about 10 minutes and then we'll reconvene for the second half of the session. Thank you for your attention.

orthopedic rehab

unloading braces in sports

lateral release procedures

soft tissue reconstruction

ACL surgery