Well, I'd like to thank the speakers for really fantastic talks. We've got a couple of minutes and to answer some questions that came in. The first one is for Jocelyn. Based on your findings, it seems as though hemarthrosis results in more catabolic reactions. Do you see a role for PRP? Yes, and as you saw in the last slide, that's our next step on that study is to essentially repeat it with low white cell PRP. I think when we look at cartilage health, what we know about low white cell ACP, there's good evidence that this is, you know, an anti-inflammatory effect of the joint. It's helpful for cases of mild knee arthritis. There's in vitro studies showing that that can sort of decrease that macrophage response. So I think, yes, there's potentially a role, but more to follow in the next phase of our study in terms of looking at meniscal catabolism. All right. Our second question is for Dr. Jackie Brady. Does the presence of a J sign currently alter your decision making regarding what procedure a patient needs? That is a great question. The J sign, incidentally, I think is still Dr. John Fulkerson's main indicator for TTO in addition to his soft tissue stabilization. I think there's something to it. It certainly makes me raise an eyebrow. I'm an author on a study that says MPFL reconstruction alone is effective for patients of all measurements when we excluded the jumping J sign. So we know that with mild J signs and with apparently everything, but the jumping J sign it seems to work. I'm hoping that the Jupiter cohort will help us understand this. The one that really is compelling is someone with trochlear dysplasia, a big super trochlear spur and ALTA, because then you can bring that patella down past the spur. And for those of us who do trochleoplasty, I think it can avoid trochleoplasty if they have significant enough ALTA that you can sort of jump the bump, if you will. But I think we need more data for me to say that with great evidence basis. And it certainly makes me factor it into my list of sort of individualized risk factors. All right. And I have a dual question for Mary Mel Cahey. What is your preference for acute operative AC joint injury? And for the injuries, are you routinely getting MRIs pre-op as part of your workup? So, the vast majority of the time treating acute AC joint injuries non-operatively. So, giving them at least a trial of physical therapy, because most of the time they'll functionally get improvement. I think as with many things we do in orthopedics, it's all about educating the patient as well. So, helping them understand like that bump is never going to go away, but that functionally they can still get back to normal. So, I will always start with physical therapy. I'll sometimes inject the AC joint when I'm seeing them acutely. And then I see them back about four weeks later, and then we start to, you know, re-evaluate. Most of the time they've had pretty significant improvement in their range of motion, and then in terms of. Where do you get MRIs? Yeah, MRI. So, I do think it's helpful to get the MRI. It's very common, obviously, to have intra-articular pathology. The question that sort of begs the next question, like if there is intra-articular pathology identified, are you treating it? I would say no. For me personally, like I'm not scoping them first, treating the intra-articular pathology, and then doing the AC joint reconstruction at the same time. I'd love to hear, you know, comments from anyone in the group, but yeah. I still would fairly commonly obtain it, just so that we know all the additional pathology. But then I would usually start with the AC joint reconstruction and see how they do functionally, and if they continue to have issues down the road, potentially consider doing the intra-articular work. But most of the time you don't need to do that. Dr. Burns, do you want to comment on that question as a surrogate surgeon? So, for the AC joint, you know, I think one of the interesting things, you kind of skirted around it, which is you said the vast majority you treat nonoperatively, so it makes me curious as to, you know, who are the patients, and let's just say grade three, so it's controversial, you know, who are those patients that you might come in and treat acutely? You know, is it someone who, you know, wears a backpack for a living, or is there anything about patients that would make you decide acute treatment for an AC separation? I think the biggest group to consider it in is, or especially those patients with horizontal instability, because that causes a lot of functional problems, like we touched a little bit on, like the scapular dyskinesia. So, just something to keep in mind and really be evaluating those patients. I would still say 99.99999% of the time, like they're being treated nonoperatively initially, but you just have to have a high level of suspicion. I'll just add, if a patient is, say, over 40, I prefer to have the MRI, because I've had several cases of concurrent cuff tear, like full thickness tear with the really high-grade AC separations. And in that case, I do the AC joint reconstruction first, close everything up, and then do an arthroscopic cuff repair. But that's a very specific indication for that. And I'd like to go back to the first talk on the, or the second talk on the use of blocks. I'd like to go down the row and ask people, if they use regional anesthesia for the surgeries that they do, what are their indications, and are they concerned about the paresthesias and other potential side effects from that? So let's start at the end. You know, I do use regional anesthesia, and, you know, as Dr. Beck pointed out in her talk, the vast majority of complications or concerns are acute and resolved within six weeks. You know, I would say that her presentation certainly gave me pause about thinking about, wow, there is this very small subset of patients that might end up with long-term problems. Yeah, I use regional blocks too, you know, especially for ACLs and other surgeries we're doing with bony work, a standard knee scope, no, of course. And we tend to use an adductor canal nerve block, and actually our anesthesiologists have started injecting some local, like posteriorly, as they do commonly with like total knees. And patients tend to do quite well from that. I thankfully haven't seen any significant complications, but I agree, Dr. Beck's talk was excellent. It certainly gives us some things to think about. Jackie? I use regional for anything more than a simple scope typically, but I don't like to use the femoral nerve block and block the quad. I worry about that, especially in athletes, and so I ask my anesthesia team to use the adductor canal or saphenous block. They think that it gets some of the VMO in retrograde fashion, but I hope that we don't see as much motor weakness. It's tough because some of these post-op patients have difficulty activating their quad and then you start to worry. But yes, I'm in that camp as well. Yeah, I use regional anesthesia since we're sort of focusing on knees. You know, an intra-articular block is very effective and you can put it in as you're prepping, even before all the scope stuff is up, and if it sits in there for like five minutes, it's extremely helpful. For a simple knee scope, an intra-articular block is excellent. But for instance, for ACLs, I like to use, I don't use any tourniquets, so I don't have any thigh pain. So you avoid the issue there with having to sedate your patients more heavily or needing a general anesthetic. And then I, yes, we do an adductor and like a lower sciatic, so it doesn't get all the hamstring, but it's kind of to help you with your femoral and sciatic tunnels. And then I do ask them to leave me enough to put 10 of ropivacaine in the joint, which is less chondrotoxic. And again, without the thigh tourniquet, they don't require a lot of pain medication and they do well post-op. I know some people are worried about the sciatic, but it's a low sciatic. And a low dose. At HSS, the anesthesiologists are extraordinarily skilled when it comes to regional anesthesia. We all pretty uniformly stopped using femoral nerve blocks because of the delay in recovery of quad function. And a couple of patients had literally four to six month significant delay in quad function. Probably, and some of those may have been pre-ultrasound where they got a little too close or into the nerve. The thing that's interesting is even with these very well-skilled people, there are a subset, a small subset of people that get an inflammatory response likely to the local anesthetic. So they have an ultrasound that shows they're not in the nerve, they're perineural, they're very safe, and then you still have patients that have some of these complications. So I tell every patient when I see them in the office that that's my recommendation because it makes a huge difference in terms of pain. But I always tell them that having, you know, numbness and tingling for a while is a possibility. And then the anesthesiologists tell them as well, but it tends to be in a more stressful environment where they're not hearing what the anesthesiologist says. So I think, you know, as surgeons, it's incumbent upon us to kind of educate the patients and let them know that. Like Jen said in her video, I think you have to tell them about that. They can't just hear about it the first time in the pre-op area. Right. Well, we've got one more question. We could probably go over it quickly. We're two minutes over, but I don't think anyone else is coming into this room. And it was about the use of functional bracing for shoulders. And do you use functional bracing? Is it helpful in recovery range of motion? Is it helpful in supporting recovery from surgery? What's your thoughts? Yeah, I don't. Yeah. I don't use functional bracing either. Yeah. I haven't either. Yeah. Yeah. Okay. Well, we're thrilled that this is a large group. I'm sure these folks can stay around for a little bit longer if someone has a specific question. Do you? Or do you have to run to Complex Knee? Yeah. Any questions, let us know. And thank you for your attendance. And thanks to the five speakers for really fantastic talks. Thank you.

orthopedic topics

PRP

J sign

AC joint injuries

functional bracing