We're going to do just a little bit of housekeeping. We've got one more minute before we actually start. So the lineup for today is we're going to have four papers. I would like the next speaker to be ready. We will do all four papers in a row. After you give the paper, come and sit up here, please. And then we'll have some time for question and answers. Then we will have some techniques that we'll talk about. And then the last part of the session is the debate. And that's the thing where you have to pay attention because we're going to listen carefully. And then they're going to show the cue code and you have to pull it up on your phone and then vote. And if you don't vote, that makes the whole thing not half as much fun. So please have your phones in the ready. So I think it is actually 2.20. Do you want to take it away? Okay. Well, thanks, everyone. I think we can get started here. This is Concurrent Session A, Best Patel Pharma Practices. So we're going to start out with our paper session. We can have Joshua Graham come up. He's going to be talking about the number of patellar dislocation events associated with increased chondral damage of the trochlea. This is data from the Jupiter Group. All right, thanks for giving me the opportunity to speak today. My name is Josh Bram. I'm a PGY-4 at HSS. This paper is number of patellar dislocation events are associated with increased chondral damage of the trochlea. Data from the Jupiter Group, I'd like to thank Dr. Green and Dr. Schubenstein who are here today. All our disclosures for the group can be found in the app. Just for some background, patellofemoral instability is frequently associated, as we all know, with chondral injuries. And past literature has really shown this most commonly affects the medial patella, the lateral trochlea, and the lateral femoral condyle. The national trend over the last decade has really become earlier operative intervention for cases of patellofemoral instability, given high rates of recurrence. However, the influence on the number of the number of patellar dislocation events on chondral wear patterns and frequency is not well established. So the real aim of this study was to better understand the association between the number of events in chondral damage in a large prospective population of patients undergoing stabilization procedures. This involved a review of approximately 1,400 patients from the Jupiter Registry, identifying those who underwent primary patellofemoral procedures, about 92% were MPFL reconstruction, from 2016 to 2022. Lesions were classified using the International Cartilage Repair Society classification through direct visualization either arthroscopically or through an open arthrotomy. Lesions grade two, so extending less than 50% of the depth of the cartilage to grade four, were defined as abnormal. And we divided the number of dislocations into three groups for ease of comparison. One single dislocation, two to five dislocations, understanding that often more recently surgery is recommended after the second dislocation event, and then more chronic, greater than five dislocation patients. We were able to include 938 surgical patients who underwent, again, primary patellofemoral procedures with a mean age of 16 years and 61% female patients. As you can see, we had a pretty nice distribution between the different dislocation counts with actually almost 20% having more chronic patellofemoral instability. Of these, 62% of patients had some sort of cartilage injury, 40% of patients had a medial patellar injury, 13% to the lateral femoral condyle, and 12% to the trochlea. In univariable analysis, you can see that a greater number of dislocations beyond five was associated with more trochlear lesions. And interestingly, a lower number of dislocations was actually associated with injury to the lateral femoral condyle, which you can see in the second line here. Combined patellar and trochlear lesions were also more common in the more recurrent instability group, but there was no association between the number of dislocations and patellar wear, as you can see up top. In multivariable analysis, just going by region of the knee, for the patella, older age and a higher BMI were associated with patellar wear. Trochlear, for the trochlea, the only independent risk factor identified was dislocation count greater than five, and for the lateral femoral condyle, that dislocation count actually fell out in the multivariable, and only younger age was associated with injury to the lateral femoral condyle. You can see those here. So I think just to keep it short, this is the first large prospective study to demonstrate that multiple patellar dislocations can result in increased and more severe chondral damage, and may caution surgeons over prolonged nonoperative management for recurrent patella femoral instability. This study was accepted for publication in AJSM a couple of months ago. I'd like to thank again my co-authors. All right, we're going to move on to our second paper. This will be Return to Sport in Isolated MPFL Reconstruction versus Additional Tibial Tubercle Osteotomy by Sam Montgomery. All right, all right, good afternoon, everyone. My name is Sam Montgomery, and I'm a fourth-year resident at NYU, and I'll be presenting our research title, Return to Sports in Isolated MPFL Reconstruction versus Additional Tumor-Tumor Gastroenteromy. These are disclosures, nothing relevant to this talk. Lateral patella instability is common and increases with younger age in females, particularly those participating in competitive sport. Most first-time dislocators without the presence of a loose body are treated conservatively. However, first-time dislocators have a 30 to 50% risk of repeat dislocation and an increased risk around 50 to 70% with marble dislocations. If these patients are not treated, it can lead to early degenerative processes and arthritis within the patella-femoral compartment. There are multiple risk factors for patella instability, including patella alta, ligaments dyslaxity, limb alignment, including increased femoral interversion, an increased external rotation, trochal dysplasia, and increased TTTG distance. Isolated MPFL reconstruction is the workhorse for patella instability. However, it fails to address extensive mechanism of myeloma and patella alta. Concomitant TTO should be considered in patients with elevated TTTG and positive JSON, patella alta, or patients with patella-femoral osteochondroplasty pathology that she won't offload. The comparative literature describing rates of return to activity among MPFL reconstruction with or without concomitant TTO is limited and lacks consensus, especially with respect to return to sport. Therefore, the purpose of the study was to investigate the rate of return to sport and sport psychological readiness between patients who underwent isolated MPFL reconstruction versus a matched cohort who underwent MPFL reconstruction in TTO. We hypothesized that there would be a similar rate of return to sport and psychological readiness between these groups. This was a single-centered retrospective review of prospectively collected data between 2012 and 2020. Patients eligible for inclusion were patients between the ages of 15 and 45 who underwent MPFL reconstruction with or without TTO with a minimum of two-year follow-up. These are our exclusion criteria. Two blonder readers independently measured TTTG distance on MRI, classified trochle dysplasia, and measured patella height. Eligible patients were sent surveys and patient-reported outcomes were recorded, including MPFL return to sport index to determine psychological readiness to return to sport. Patients were matched one-to-one by age, sex, BMI, and length of follow-up using propensity score matching. Multivariable regression was performed to determine whether MPFL return to sport index was associated with return to sport. There were 37 patients in the isolated MPFL reconstruction group and 37 matched MPFL with concomitant TTO with a mean follow-up of 52 months. Patients in the TTO group had significantly longer symptom duration of instability. There was no significant differences in patient-reported outcomes and no difference in psychological readiness to return to sport. Increasing MPFL return to sport index was significantly predictive of return to sport, as well as return to pre-injury level of sport. Fear of re-injury was the most cited reason for lack of return to sport. There were similar rates of return to sport and return to work between groups, although isolated MPFL reconstruction returned to both work and sport faster. Our study had some limitations, first, due to the retrospective nature of the study. There may be differences in demographics that we couldn't completely control for, and we were unable to collect baseline patient-reported outcome scores. Secondly, the range of follow-up was relatively wide, which could bias patients' recall and their ability to return to activities. To mitigate this, patients were at propensity match based on follow-up. In conclusion, patients who underwent MPFL reconstruction and concomitant TTO had similar rates of return to sport and psychological readiness to return to sport compared to isolated MPFL reconstruction. Also, patients who underwent isolated MPFL reconstruction returned to sport faster compared to patients with concomitant TTO. Increasing MPFL return to sport index score was significantly predictive of return to sport and pre-injury level of sport. These findings are helpful when managing patient expectations regarding return to sport with concomitant TTO as indicated. Thank you. Next, we have paper 37, outcomes of medial patellofemoral ligament reconstruction in patients over 30 years of age. Dr. Bob Magnuson. Thank you, and I'd like to thank the program committee for allowing us to include our paper in the program. Let's see, here we go. Oops, that's not me. Sorry. Maybe I should have. Let's see. How do I get that to go back? No, no, but it's on the wrong. Got it. Yeah. I thought it was already on me. Sorry. Thank you. All right. You can't trust me with anything. Sorry. So, without further ado, again, I'd like to thank everybody for the opportunity to present our data, and it's great to see the patellofemoral room getting bigger and bigger and mostly full, so that's fantastic. I'm going to talk to you guys today about outcomes of medial patellofemoral ligament reconstruction in patients over 30. I'd like to thank my co-authors, and I would like to choose one. Oh, boy. I'm all over the place here. Yeah, I hit that. There we go. He is the most experienced presenter up here just for. I seriously, the residents have no trouble, but I'm up here, like, struggling away. Goodness gracious. I tried that. It didn't work. See? See? It's not just me. Sorry. Sorry. Yeah. Let's see. Yeah. Okay. Now it's working. There we go. Sorry. I'm going to try to use this, actually. There we go. All right. Sorry. Sorry. So, we don't have any disclosures that are particularly relevant to this discussion, but you can check the program for our other disclosures. So, as we know, patella dislocations are pretty common in young, active patients. They can lead to recurrent instability in many cases, and they have a substantial negative effect on patient outcomes and function. MPFL reconstruction has, of course, risen to prominence as it does restore stability by decreasing lateral patellar translation in the vast majority of people. It's kind of become our gold standard for the treatment of most patients and has very low recurrence risk overall. We've seen a lot of work lately looking at factors that can influence outcomes of MPFL reconstruction. These include anatomy factors like TTTG distance, patella height, dysplasia, things we've talked about, physical exam findings like the J sign, particularly large J signs, technical factors including graft choices, fixation, tunnel position, articular cartilage status as was alluded to earlier, and finally demographic factors. And what I want to focus on today, obviously, is age, the last of these factors. There have been some prior studies looking into the effect of age on outcomes of MPFL reconstruction. Several studies like this by Lind et al comparing teens to adults, but the adults in this population were an average age of 23. Similarly, Laurie Heemstra's excellent study looking at predictors of patient-reported outcomes in a large cohort with a multivariable regression analysis demonstrated increased age did lead to poorer outcomes, but it was a little unclear how many of these people were really older patients, like over age 30, let's say, and what was really the driver of these poorer outcomes, be that instability or pain or something else. So our goals were really to evaluate the impact of age on outcomes of MPFL reconstruction, particularly in patients over age 30. We also wanted to identify specifically what factors were contributing to any poorer outcomes if they were there, including whether or not it was pain or recurrent instability or just decreased function. So we hypothesized that patients over 30 would actually demonstrate similar subsequent instability risk and similar patient-reported outcomes to younger patients undergoing this procedure. We utilized a retrospective cohort design looking at 228 isolated MPFL reconstructions performed at our center over the last 12 years. They were all performed for recurrent patellar instability. We utilized chart review to identify history and patient factors and anatomic factors, as well as articular cartilage status at the time of surgery. We subsequently followed up patients via chart review, as well as contacting patients at a mean of 3.8 years post-op to obtain patient-reported outcome scores and determine whether or not they had recurrent instability. We then divided patients based on age, greater or less than 30, and compared these groups. So our results, if we look at our table here, we can see that, obviously, the older patients were older, as we expected, but we also had a few more higher prevalence of females in the over-age 30 group and also slightly similar BMI but increased risk of articular cartilage damage in this older group, as was shown in the previous paper. Imaging factors were very similar between the two groups, the only difference being, again, the cartilage damage greater in the older group. Looking at our outcomes, we noted similar recurrent dislocation risk, about 5% in both groups, and we did note increased pain and decreased ADL function in the older patients, and obviously we saw a substantially lower activity level in this group. We did utilize a regression analysis because we did see, again, some differences between those two groups beyond just age, and even controlling for factors including sex, BMI, number of prior dislocations, the anatomical factors we described, and cartilage damage, we still saw that pain did continue to be a significant factor in these older patients, so they continued to show increased pain in spite of controlling for these factors. So the key points, recurrent dislocation in this cohort was about 5%, you can expect 5% re-dislocation rate or similar anyway based on age. We did see the patients over 30 have much more articular cartilage damage and they had more prior dislocations. We similarly saw that they had increased pain but not increased patellar instability following surgery and obviously much lower activity levels in this older patient population. We do have some limitations here, the biggest one being our preoperative scores. We don't have preoperative pain scores on these patients, so we don't know if these over 30 patients had more pain going in and therefore more pain going out, or if it was something to do with the procedure itself, we don't know the answer to that. We have relatively short follow-up, we don't know if these results would change with longer follow-up, and we have incomplete follow-up. We had 80% follow-up on dislocations but only about 64% of people completed patient-reported outcomes. So the takeaway here is that you can expect good stability following MPFL reconstructions in patients over 30, but you should probably inform them that they may have a little increased risk of pain as opposed to your younger patient populations. Thank you for your attention. And the last paper of the session, Paper 38, Comparison of Clinical Outcomes and Return to Sport Rates Between Osteochondral Allograft Transplantation and Autogenous Chondrocyte Implantation for Articular Lesions. It's a mouthful. In the patellofemoral joint, and this will be given by Vishal Sudaram. Oh, sorry. Kurt Campbell. Yeah. Hi. Hi, Kurt. All right. Good afternoon, everyone. We have no relevant disclosures. So patellofemoral cartilage lesions have been seen of 23% to 58% of the cartilage damages, cartilage defects that we see at time of arthroscopy. The patellofemoral compartment is a very complex joint due to the very complex topography of both the patella and trochlea. It has significant biomechanical loads. There are a variety of different cartilage restoration techniques that we use, microfracture, osteochondral allograft, and the two that we'll be looking at today, osteochondral allograft and autologous chondrocyte implantation. So autologous chondrocyte implantation, as we know, two-step procedure. We're able to match the topography. This is for mainly surface-based lesions, osteochondral allograft. Single-stage, you also have to match by size, and we like to use orthotopic graphs. This study was kind of the inspiration for this current study. What they did, they looked at differences in clinical and functional outcomes of osteochondral allografts to all knee cartilage restoration procedures. And what they found was similar Kruse Jr. and IKD-C scores. They were significantly higher outcome scores for trochlear ACI lesions. But they did find that traumatic lesions had lower patient reported outcome scores and higher failure rate. Overall graph failure rate was reported to be about 21% for osteochondral allograft versus the 4% for ACI. So our objective was to look at clinical outcomes and return to sport among patients undergoing osteochondral allograft or autologous chondrocyte implantation, or MACI, for patellofemoral articular cartilage defects. We hypothesized that patient reported outcome scores would be similar. Patients have a similar return to sport for both the osteochondral allografts as well as the autologous chondrocyte implantation. However, we thought that lesion size would predict outcomes post-operatively. This is a retrospective review. A single institution over a 10-year period looked at all patients that had a minimum of two-year outcomes. These are exclusion criteria. We looked at demographic factors, looked at also lesion-specific factors such as size, location, grade, presence of cystic changes in bone marrow, edema, as well. Collected patient reported outcome scores and assessed whether they returned to sport or not. Here are two typical cases. Top one, osteochondral allograft or trochlear defect. And bottom, you can see a MACI for a similar trochlear defect. We had a total of 95 patients in our study, 40 in the osteochondral allograft group and 55 in the ACI slash MACI group. Similar demographics, similar lesion sizes. There are no significant differences between these two cohorts. In terms of etiology of the cartilage defect, there are no significant differences. Most of these defects were due to degenerative changes. However, we did find that the patients in osteochondral allograft group, they had more pre-operative osteophytes of chondrocysts on their MRI images compared to the ACI group. So there may be a little bit of selection bias there. We found that patients in the osteochondral allograft group had higher pain scores compared to the MACI group. When we dove a little bit deeper into this, we found that patients with the trochlear osteochondral allografts had the highest pain reported scales, although their lesions were actually smaller than those in the ACI. So something for us to dive a little bit deeper into. Similar outcomes based on all different etiologies when we looked at all the different KUS subscales. So lesion size was associated with worse outcomes, where the bigger the lesion size was, the worse patient-reported outcomes were. And that was across the board for both MACI as well as the osteochondral allograft. So what we found, clinical functional outcomes were similar for osteochondral allograft as well as MACI for patellofemoral defects at a mean of five years. Patients undergoing osteochondral allograft may experience more symptoms, particularly in the setting of trochlear defects. We should be a little bit more careful when we're doing trochlear defects. Lesion size was associated with worse outcomes. So the larger the lesion size, the worse outcomes we found. Overall, we had similar outcomes for both MACI and ACI. Thank you. So we'll invite any questions up to the microphone, please. And I'll start with a question for you, Joshua. In your study, could you try to explain to me the difference between your lateral femoral condyle injury and your trochlear injury? Yeah, so in the Jupiter registry, after every procedure, attendings are given sort of like a pictograph of the knee and are asked to mark exactly where the lesion is located and specifically denote more proximal trochlear-ish lesions versus femoral condylar lesions, which are more like a deep reflection where the patella is articulating in the patellofemoral joint. I think one of the reasons we think that we found a higher proportion of lateral femoral condyle lesions with the initial dislocation group is that perhaps those are more traumatic patellar dislocations that therefore jumped out in deep reflection and knocked off a portion of the femoral condyle, whereas in more chronic, greater than five dislocation patients, it's just chronic wear on the trochlea and extension. Seth, you have a question? I have a question for Kurt. Can you give us some insight on any measured alignment parameters and or the use of concomitant TTOs? Were you more apt to use TTO with cell-based repair, which may be my preference versus OCA? And just clarifications would be really helpful. Excellent questions. So 75% of our patients had concomitant tibiotubal osteotomy with a higher rate in the cell-based. So some of you were pretty aggressive with the cell-based in terms of unloading the patellar femoral compartment. You know, TTT distances were similar between the two groups, so there were no significant differences. In terms of patients with other concomitant procedures, they were all matched pretty carefully. Was it a significant difference of TTOs? No. No significant differences. Same. Okay. Thank you. Yep. We're waiting for David, but I'm going to just throw a question to Sam. This return to sport, or I'm sorry, your return to sport index, you said that it's predictive of how they go back to a sport. When do you deliver that? Your return to sport RSI score. I'm sorry. You said when do you deliver it? Well, you say that it's predictive of that they would return to sport. So that means you're giving it before they return to sport. So when do you give them, that patient, that outcome measure or that PROM? Yeah, so the passing rate for the score was around 56 on the index score. So with that, usually patients are returning to sport around six, if they have a concomitant TTO, around six months or so. When are you administering the surgery? Do you do it at one time or postoperatively? Postoperatively, around two weeks and then about a month. I see. Question for Kirk. The anatomic source for your graphs for the trochlea, were they all whole structural trochleas that you harvested or were some of those plugs? These are all orthotopic graphs. So we use trochlea for trochlea, patella for patella. Excellent question. And I have one quick question for Bob as Jackie comes up. Did you have any idea, I know this was retrospective, but the timeline between the first, more or less, the first dislocation and then when they went to surgery? Because the older age just might mean an older timeline. Do you have any sense of that? Yeah, that's a good question. I don't think I included it in there. There was a little bit longer time from the first dislocation in the older patient group. I don't have the number right in front of me, but the number was definitely higher. Yes. Yeah, my question is for Bob as well. That was a great study, and I was wondering if you looked at or are interested in looking at the physical therapy post-op and any differences in the groups? Because I found myself sort of falling into two assumptions. One, that the pain is related to more cartilage injury, but then two, maybe the working adult doesn't follow through with the PT all the way to the return to sport testing. Did anybody have a Biodex? I know this is an elusive population, but is that on your radar at all? Yeah, that's a great question. We initially kind of thought this would be a lot driven by cartilage, which is why we tried to control for that in our analysis. And there's clearly some effect beyond that. I do think the rehab is critical after these patellofemoral procedures, of course. And you can certainly imagine the working 30, 40-year-old population maybe not hitting the rehab quite as hard as those in their 20s trying to get back to sports. And you can see that reflected in the activity level being much lower in the older patient population. But I would also caution, again, that we don't have those pre-op scores, which I wish we did, because that could really tell us if you really can expect the similar improvement in pain maybe if they're having some pain after a NPFL reconstruction, although we're doing these operations, obviously, for instability. But there certainly is more of an overlap with pain, I think, at least has been my anecdotal experience in the older patient population. So I was glad to see that we were able to restore stability and function pretty well, but that pain certainly did persist. That's great. Thank you. OK. Well, great discussion. I think we're up on time. I'd like to thank our speakers again. And you guys can take your seats. In the meantime, can I have the rest of the panelists, the debaters, and the video technique, including Jackie, come up and take your seats up here, please. While you're doing that, I will introduce Dr. Lee Pace, who's going to be showing us his video technique on trochleoplasty. And I want to thank Miho and Liza for letting the order be switched so that I can get to the airport. I really appreciate that. And I also want to thank AOSSM for giving me opportunity to present this technique. Oh, I've got to hit Start. That's right. OK, so I'm going to present what is called a thin flap groove deepening trochleoplasty technique. I consult for products in this demonstration, but I don't get any royalties for them. So this is purely technique-based, so just very quickly, introduction. Trochleoplasty indications for me are for a patient with recurrent patellar instability with high-grade trochlear dysplasia, defined as a flat or convex trochlea. I think most people are OK with the convex. There's more controversy around the flat trochlea. I routinely perform soft tissue rebalancing in every procedure with an MPFL reconstruction and lateral retinacular lengthening. I do not routinely perform tibial tubercle osteotomies in conjunction with this, regardless of the TTTG measurement. Here is a case presentation. This is a 16-year-old female, bilateral knee recurrent patellar instability. She's failed bilateral refeens in the past locally. She underwent a successful left knee trochleoplasty, MPFL lateral lengthening with me earlier this year. And now she wants the same done on her right knee. You can see her convex trochlea, some early wear on her cartilage signal change on her patella. And you can see lateral actually with the prominent super trochlear spur. So I perform, again, what's called a thin flap, developed by Hans Barider. I published my version of that in Arthroscopy Techniques a couple of years ago. Dave DeJure just recently published his thick flap group deepening technique, both available for free, open access, and arthroscopy techniques. So here is the pre-op EUA. This patient under anesthesia has about three quadrants lateral translation in high degrees of knee flexion. You can see up at 60 degrees, I can still dislocate her laterally. And she stabilizes around 70 to 80 degrees of knee flexion, consistent with high grade trochlear dysplasia. We start with an 8 to 10 centimeter laterally-based incision. We're going to dissect down to the lateral retinaculum. And then I will dissect the subcutaneous tissue on the anterior aspect of the patella so that I can get to the medial aspect of the patella to do patellar fixation for the NPFL reconstruction. I then perform a Z opening of the lateral retinaculum to close later to complete the lengthening at the end of the procedure. I'll kind of identify those transverse fibers that come up from the iliotibial band and then separate superficial and deep layers until I get down to the longitudinal aspect of the iliotibial band. And then I make sort of a hockey stick cut there. I perform an arthrotomy to get into the joint. And then from there, I will do a quadricep tendon split so that I can then dislocate the patella medially. And then I'll place some static retractors with K wires in. And then we'll put a Hohmann retractor in. And that's how we get our exposure. Demarcation of the new groove. The proximal aspect of the trochlear groove in these patients is typically a slightly medial. So I will mark that out. And then I'll mark out where I want to put the new one. You can see a little bit of trochlear cartilage wear consistent with what Jupiter said. She's had more than five dislocations. And I'm going to plan that just straight up from the roof of the intercondylar notch. We do a T split of the synovium to get all that non-chondral supertrochlear spur visualized because I want to get rid of all that after I elevate the flap. I then do a flap elevation, initial flap elevation with a half inch straight as well as a half inch curved osteotome. And I will start on the lateral side and I'll use the smaller quarter inch osteotome to start elevate in a thin osteochondral flap. This will actually go in several centimeters on the lateral side. And then I use a half inch curve to start detaching the osteochondral flap approximately. And then around medially. And I'll usually take this in a couple centimeters all the way around. And you can start to see the flap starting to pick up already. And then this is a proprietary burr designed for trochleoplasties. It goes underneath the osteochondral flap. There's a flat marking hook to tell you where you are. And it works best taking out little triangles of bone, sort of taking it back and forth and pivoting off that smooth marking hook. And this is, I use this exclusively just for the lateral facet. It doesn't really work medially. So I just, I'll use that to detach the lateral aspect of the trochlea. From there, I'll actually sit down so I can put the trochlea at eye level and I can see underneath the osteochondral flap. And then from there, I'll use a curved osteotome to advance more distally immediately to elevate the flap. And this one came up pretty nicely, but sometimes you have to elevate a little bit, go back to elevate to get it up without creasing and cracking or anything like that. But I'm seated for this whole process so I can see exactly where the osteotome is going. And then my assistant is watching to make sure that everything feels good on the chondral side. You can see this is just kind of coming up And it's usually down just probably a centimeter or so above the interchondular notch. You can see I've got really nice elevation with plenty of room to work there. And from there, I'm gonna then thin the osteochondral flap further. I like to use a sheathed burr because it gives me maximum control. I can hold it right next to the burr so it doesn't slip away from me. And the assistant will provide a little thumb pressure. You can see a little bone things flying around. Little bone, a little hand pressure, thumb pressure so that I can efficiently resect bone. I like this burr as opposed to some other high-speed burrs because I feel like I just have more control over it. And sometimes I'll use the burr that you saw previously to do some additional resection. But I'll get this, I'll just keep thinning and thinning and thinning until the flap becomes moldable. I make it very moldable up top and a little less moldable distally. You can see it starting to bend a little bit there. And then from there, I wanna create the apex or the base of the new groove. I want to have a very fixed location to where I'm resecting bone. So I'll get a quarter inch osteotome and I'll basically follow in the subchondral bone beneath that previously demarcated purple line where I want the new trochlea to go. You can see I'm taking this from proximal to distal to create a spot to cut to. And then I start resecting the nonchondral spur right here. You can see I can just cut to that and I can take out these little triangles of bone and I'm taking more proximally and less distally and I'm doing everything I can to preserve as much of that lateral trochlear height as possible. But you save that bone because you can use it as bone graft later. So you can see now that we've got, and I do pretty much all this with an osteotome nowadays. And then from here, I'm sort of assessing. This is, now I think I like what I'm seeing here. I think this looks pretty good. So now I'm gonna start using thumb pressure to start molding it. And you do gotta kind of push hard. This is why I don't do it arthroscopically because you gotta get your thumb up. You can see now I'm starting to get a groove that I like. That's looking fairly reasonable. I probably wanna get that just a little bit deeper, but that's not bad. So I'm gonna accept this and I'm gonna bone graft to build the flap up a little bit. You'll be able to see that. So I use six strands of number one Vicryl loaded through a knotless anchor. This is absorbable suture. So it goes away in six to eight weeks. We're gonna place the first anchor just in the very distal aspect of the osteochondral flap, just above the interconnular notch. And this is the only spot where the cartilage gets violated right here. So this will go in. And then we're gonna have now, what are 12 strands of sutures, and I'm gonna split them up in groups of four, four down the middle and four on either side. And so we're prepping the first socket here, and then I will hand the anchor off to my assistant. I will hold the trochlea maximally reduced and have my assistant put the anchor in. Do not over tension the sutures. This is how you can kill cartilage. Ask me how I know that. So you want the sutures to hold it down, but not compress it too much. And I've decided I wanna add a little bit of bone graft to that. So from here, I will use as shims that previously resected bone graft to elevate that lateral trochlea and also just kind of fill in any gaps if it's not touching down perfectly. And now I'm sort of checking my depth. I'm aiming for four to six millimeters of trochlear depth with a lateral trochlear inclination of around 20 degrees, and I'm happy with that. That looks good to me, so now I'm gonna buy it. So now it's just sort of rinse, repeat with the push lock. So I'll take, I'll drill another socket laterally, and I'll kind of, you can put that wherever you think it belongs, and then you'll put those push locks there, and then you'll put another strand, the sutures with the push lock, and you'll put these other strands of suture with a push lock right there, and then it kind of completes that, those three strands of suture. Now you can see here, that looks like a nice trochlea, looks quite normal. Early on, I did a lot of high-grade to low-grade, now I try to get them normal. And now you can see, even without doing the MPFL reconstruction, she's completely stable, whereas before she was able to be dislocated. I'm not showing the MPFL reconstruction, but I do a V-graft MPFL reconstruction. Once that's done, then I will close the retinaculum in a lengthened fashion, knee gets flexed 70 degrees, I just bring the deep layer up to the, or I assume the superficial layer up to the deep layer, and just sew it where it goes. And I've never not gotten length, and this is probably, I don't know, 14 millimeters of length that's achieved here. So this lengthening is dogmatic for me at this point. As far as post-operative management, this is a day surgery for me. They weight-bearers tolerate with no range of motion restrictions. They are aggressive with their early motion. Getting flexion is the main challenge, but not a huge challenge. I did not have a single arthroscopic license of adhesions in 2023, and I do about 60 a year. I do not use a knee brace after this either. And I would love to stick around for questions, but I do have to go, so thank you guys for your time. I appreciate it. Thanks, guys. Thank you. Thank you. Our next video technique will be by Miho Tanaka, and she's going to tell us about her technique in regards to the medial soft tissue complex. Dare I say MPFL reconstruction? All right. Thanks very much for the opportunity to give this talk today. I'm going to talk about MPFC reconstruction. Let's see if I can get these slides to work. I have no relevant financial disclosures. So this is a case, 21-year-old female dog walker who had a twisting injury of the knee, ended up having recurrent instability. I'm going to kind of get to the technique here. So imaging-wise, she had no significant patella alta, no major trochlear dysplasia, no large osteochondral fractures, although she did have some chondro pathology. The focus is on the soft tissue today. The dynamic CT showed that she did not have any sort of jumping J sign or any super trochlear prominence. And her alignment was normal in terms of her weight-bearing axis, and aversion, and her TTTG. So the clinical summary here, 21-year-old female with left knee recurrent patellar instability, no malalignment, or large osteochondral fractures. She was indicated for a soft tissue reconstruction. Now, the medial patelloformal complex is the primary stabilizer to lateral patellar translation and consists of fibers attaching to the patella and to the quadriceps tendon, and this is variable in its attachment site. But we know that despite this variability, that the midpoint is fairly consistently at the junction of the medial border of the quadriceps tendon and the articular surface of the patella, meaning that the fixation can be on either structure. We know that when we look at this broad insertion on the extensor mechanism and on the femur, that there are multiple configurations that we can make when we're performing this reconstruction, but that the most isometric are the anatomic fibers that we can see here in green, and all of the rest of the configurations shown here are actually not as favorable, especially if you attach it to the patella. This tends to tighten inflection, and attaching it way up on the quad can be affected by patella alta. And so if you're using point two, which is kind of what we think of as Schottel's point or Fugino's point, then the most isometric point is gonna be at the midpoint between the junction of the medial border of the quad tendon and the patella. So this is why I do a single bundle reconstruction, and I consider this a midpoint to midpoint reconstruction, and the fixation can be either on the patella or on the quadriceps tendon. I have moved primarily over to MQ-TFL reconstruction over the past few years. This was initially described by John Fulkerson, and this avoids the risk of patella fracture completely. He described this as doing the fixation on the patella, I'm sorry, on the femur first, but I like to fix on the extensor mechanisms in first. So this is the technique that we're gonna show today. The most important thing is to remember that even though we're fixing this to the quadriceps tendon, that the insertion site should be right on the midpoint. So here's this patient's examination. This is the contralateral knee, which is asymptomatic. You can see that she has quite a bit of translation on the other knee as well. When we look at this other side, I think this is why it's important to really think about the glide test, not just an extension, but also inflection, usually around 30 degrees, and then of course into deeper degrees of flexion as well. But here, this is where you really see the difference in the stability. So getting onto the technique, this is making an incision right at that midpoint that we discussed, and then I'm making another incision at the junction of the medial and central thirds of the quadriceps tendon. Both of these are partial thickness. I'm taking a right angle clamp, and then I'm gonna, that's my resident's head, he's 6'7". I'm gonna retrieve the graft. I've sized this to a 5'5", and once I pull this through, I fold it over onto itself, and then I'm gonna secure it to itself using a looped suture. And I'm doing this from medial towards the patella over the course of approximately an inch, and I usually put five or six sutures here. And you wanna end right at that midpoint, so right as it reaches the supra-amino corner of the patella. Then I cut off the needle, and I have a free needle here, and I'm placing this right through the periosteum of the supra-amino corner of the patella. So this is very similar for those of you who use anchors here. It's a periosteal fixation, and I tie this down. After I've done that, then I'm closing the proximal aspect of the quadriceps tendon defect with a non-absorbable suture. And so this prevents the proximal propagation of this defect in the quad tendon. So here's the final fixation. This is kind of what it looks like. You can see it's looped through the quad, but the midpoint is where this arrow is. So this is the midpoint, and that's where we've put that stitch right into the patella. So moving on to the femoral side. So separate incision, always posterior to the medial epicondyle. And I'm feeling for the juncture between the medial epicondyle and the adductor tubercle, and you can palpate that groove there. After the palpation, I'll place a pin there, directing the pin proximally and anteriorly to avoid the neurovascular bundle and the joint. And then I'm gonna check this on x-ray, and I think the fluoroscopy is important. You always have to have a perfect lateral, as Corey Edgar has shown us. And I always cheat this posterior to a shuttle's point because we know that with this pin, I'm still gonna ream an eight millimeter tunnel, and then I'm gonna place a screw behind the graft, which means the graft is gonna be at the anterior margin of this tunnel. And so that means that you wanna make sure you're more posterior than where you think your graft is gonna be. Also, we recently showed that in knees with trochlear dysplasia, which is almost all patients that we operate on, the adductor and the medial epicondyle and the gastroctubicle actually appear at least three more millimeters posterior to what it is in a normal knee. So I do cheat posteriorly. Also, we always just wanna make sure that you have at least four centimeters of visualization of the posterior cortex in order for these landmarks to be accurate. So once I've done that, then I'm gonna check the length changes using this technique that I learned from Daschubenstein, really just making sure that you have less than five millimeters of length change between zero and 60 degrees. Once I've checked all three of those things, then we're essentially gonna buy this tunnel. I pass the graft first between layers two and three. I find it easier to identify that plane from the anterior side, and usual I'll check the scope, stick the scope in to make sure I'm not in the joint. I've brought the knee, let me just see if I can stop this here. So I've brought the knee into about 60 degrees of knee flexion, maybe a little more flexed here. And essentially, I'm just removing the slack from the graft. So as Jack Farr says, setting the length. And then I've looped the graft around the pin and I've marked basically where I want the graft to be at the aperture of the tunnel. And then because this implant is 20 millimeters long, I've marked 20 millimeters distal on the graft to where the aperture fixation should be. And so my tunnel is gonna be 20 millimeters. So that's where I'm fixing this graft. So this is an expandable anchor. And one of the reasons for using this for me is that you can deploy it and kind of control when you're actually gonna use this tunnel. So I've drilled now two and eight. I think it's important to clear off the soft tissue around this. And so here's this anchor that I'm gonna place. And before I have final fixation, I can actually check to make sure that I really like this, the length of the graft. So usually you wanna see here that they still have good translation in extension. So two quadrants in either direction. And this is really important, otherwise it can be overtight. But around 30 degrees, they should have less than half a quadrant as you can see here. And then finally, I'm putting my finger on the graft and bringing them into deep flexion and making sure that this slackens because if it doesn't do that, then they're gonna be tight inflection. And then finally, I'm deploying the anchor. This is an expanding anchor. And then I can use that last stitch just as a backup. This is an optional step here. Obviously do this on the backside. You never wanna do this on the front side of the graft because we've spent all that time finding the perfect tensioning spot. So complications or how to avoid them. The indications are important. This is for lateral instability only, not medial instability and not for patellofemoral pain. The reconstruction should be anatomic, meaning that it should be at the midpoint on the extensor mechanism as we discussed. And on the femoral tunnel, I like to check the anatomy, then check the fluoroscopy and then check the length changes. And then if all three of those are good, then I'll take that tunnel. Important not to over tighten as this can lead to arthrosis. And then when we can, we should address the morphologic risk factors that are also present with concurrent procedures, typically looking at TTTG distance, patella alta, and the presence of a large supratubular sperm. Thanks very much for your attention. And our last technique will be by Jackie Brady who will talk about tibial tubercle osteotomy. Yes, I'm gonna spend all of my time on how because Dr. Farrow is gonna tell you when and why maybe. Let's see if we can, okay, perfect. So technique for tibial tubercle osteotomy. There are many ways to do this. I'm gonna give you some simple tips for how to do it with the stuff that's generally in an OR. I'm gonna medialize or antimedialize first. This is in a right knee. I'll try to label it accordingly. I'm gonna make a six centimeter incision for a five centimeter shingle on average. If it's a big soft tissue envelope, you might adjust. So first goal, if I can get that to advance, is to get lateral to your patellar tendon. You can be just medial to your tubercle, just lateral to your tubercle with your incision. I like just lateral, but you can see if you want to harvest a hamstring, it's right there. And then you're going to get your retractor right under your patellar tendon. Let's see if I can get this to advance. There we go. So once you've got that, very imperative to do a first cut here at the top of the tubercle. So you can see me protecting that patellar tendon with an Army Navy. And I'm coming underneath, just across the anterior cortex, just above the tubercle with this osteotome. And my finger here is the poor man's caliper where I'm just laying it across the top to make sure I'm across. You can see I've just scored the anterior cortex there. Very critical not to forget that. Don't be this surgeon. I'm a little trouble advancing. Hang on. Bear with me. Let this thing propagate up into the plateau. This is a problem that's really hard to undo. He went ahead and moved it and fixed it. And this is a patient I saw in early practice. It's a talk for a different day. But don't skip that first cut. Very important. So then you're going to carry your cut down with a knife or a bovie along the anterior compartment's attachment to the tibial tubercle and then elevate your anterior compartment fascia. Here I'm using a cob. You can use a key, whatever elevator of choice. You don't want to plunge. Be careful. Two hands here. It might bleed a little bit. Some people use a tourniquet. And you can see me stopping approximately there where Gertie's tubercle is holding me up from connecting to my top cut. So then you're going to go immediately. And you're just getting to bone. There's not a lot of soft tissue between you and bone here. The window is a bit mobile. So I'm just going to carry it down toward, but not all the way to a point. So this is the medialization, anterior medialization. You want to keep that periosteal hinge intact. And then I'm going to place two 2-millimeter K wires. I've got my elevator there as a backstop. My proximal one is a bit deeper, but parallel to my distal one, which is very superficial. Again, anticipating coming to this point. And that creates a template. And I'm going to use my saw blade in between those two pins to just make one cut medial to lateral, score that near cortex, and then carry it across. Make sure it's one cut. Use a little irrigation if you're seeing smoke or anything like that. But then the pins are going to come out. And you're going to complete this proximally with your osteotome. So just working distal to proximal. Follow that line of your cut. Your osteotome is generally a bit thicker than your saw blade. And so it takes a little bit to get in there. Make sure you're in the same line. And this is where you can lose a little time if you're new at this. So just make sure you're almost all the way across proximally. You can't be all the way across, because you still have to get it off of Gertie's tubercle. But you can see me working toward my top cut there, making sure that I've got it almost all the way resected. And then you're going to come to the lateral side. And I'm going to find where my saw blade exited. So if I've medialized, it's pretty anterior. If I'm intermedializing, I'm a little steeper. You're going to look more posteriorly. And I'm going to bring that osteotome proximally from where that top cut started and head toward where the saw blade exited. OK, so you can see that angle of that cut separating tibial tubercle from Gertie's tubercle. So it's not quite a pure triangle. And then you're going to mobilize your fragment. So you take your osteotome medially and get proximal again. Make sure that that proximal aspect of the fragment is mobile, so you know it can wiggle. And then I'm going to move my osteotome this way. We slowed it down a little bit, so you can see it crack right here in a second. There, right? You're going to see it. No, not right there. There. OK, so you can see it crack. So your periosteal hinge is still intact, but your bone is now mobile. So you take a nice, sturdy thumb, and you give it a good shift, intermedially, medially, whatever your choice is with your template. And you're getting the read of your correction off of that lateral shoulder, OK? Remember that all osteotomies want to go back home, so you really have to encourage it to stay. Pardon the gymnastics with the camera there, but I'm using my ruler to figure out my correction. Whatever you're using as your guide, your TTTG, your TTPCL, your PTLTR, lots of discussion to be had there. And then you're going to fix it. So here in the lab, I'm showing a cannulated system. Typically, in a clinical scenario, I use just a large frag set and lag by a technique. There are many ways to do this in some proprietary systems, so you can decide what works for you. I'll use two, maybe three screws. You want to make sure you've got good bite. Approximately, it's going to be a little more cancellous, so just be ready for that. Feel free to switch to a cancellous screw if you need one. And then just make sure that you've got good fixation. This is what it should look like. You can see that correction there. And that's medialization or antermedialization. So what if you want to distalize? Now I'm going to take a centimeter more on my shingle, anticipating taking about a centimeter away. I don't generally seek to distalize unless I think I need to remove somewhere around a centimeter. I'm going to switch knees on you here and try to label accordingly. And your goal here is to get to high normal. You don't want to overcorrect patella alta, right? So again, you're seeing those pins. The distal one now is deeper. It's not quite as superficial. And so I'm coming between them with my saw, same as last time. And once your saw blade is across, you're going to remove your pins, and you're going to mobilize your fragment approximately just like we did before. But then you're going to come distally, and you're going to either complete the cut just like you would an AMZ and feather it, or I like to do a step cut. I find it to be more precise. I'm not in cortical bone. I'm not as worried about non-union risk. And so I make a step cut here with the saw blade. So you can see it there. And then you're going to anticipate your resection. So you can see the fragment's mobile, making sure I've got a mobile fragment. And then you're going to take a ruler and plan your resection. And then you're either going to purely distalize and make those two cuts parallel to each other, or you're going to anticipate medializing a bit as you bring it down. This is where the art comes in, and you can preoperatively plan accordingly. So you can see here I've drawn an oblique line, anticipating some anterior medialization as I distalize. And I've scored that anterior cortex. And I've got my towel clip stabilizing it while I bring the saw blade through. I'm saving that fragment if I can. Then you mobilize it. A lot of people think you need to do a lateral release or a lengthening in order to mobilize a fragment enough to distalize it. Not true. As long as you separate those attachments right at the top of the tubercle and mobilize the tendon itself, this is quite forgiving. It'll give you a centimeter very easily. If you're worried, take your bump out. Take it off the triangle. And then you put it where you need it. Minimize the gap. You can see me setting it there, and I'm getting that read of my medialization proximally again and trying to minimize my gap distally. And then you're going to fix it in place. Again, two screws. And I've got my piece that I'm going to move into the position proximally. I'm not sure that that's a robust way to maintain your fixation, but it's a nice way to fill a gap, and it's nice to save the bone if you can. And so this is your end result here. Heading distally, I've got a star next to that dreaded black line. You need to watch that if you've got an avid jumper runner athlete who's going to try to really push return to sport timelines, because that's the dreaded stress fracture region, right? And so if they have tibial pain, you want to back them off a little bit. But generally, it heals quite well. And so I will leave you with that to discuss the why and when, perhaps. Thank you. OK. So moving on to the gold medal debate, if we could have Dr. Schubenstein and Dr. Farrow come up. So this debate is going to be NPFL alone versus NPFL and TTO. So we'll start with the NPFL talk. Did we just click on it, or? Yeah. Sure. Perfect. Let's see it. Oh, there it is. It's up there. Hey, guys. And thank you very much for having me, and a big thank you to the program committee. And a huge thank you to Bruce Ryder, who gave me his bow tie so that I could channel my inner Latul Farrow for this debate. So I'm speaking on NPFL. This is a debate. NPFL reconstruction, and of course, to Seth Sherman, whose suggestion it was. And so I'm speaking on NPFL. NPFL reconstruction is enough. And that's sort of my topic for debate. Let's see if we can figure out how to advance the slides. Here it is. No, I got it. I'll do that one. OK, great. Perfect. I have no disclosures relevant to this talk, and any of my disclosures are in the manual. So is NPFL enough? The answer is, most of the time, it is. The vast majority of the time, an NPFL is enough, especially for instability. If we're treating instability, you need an NPFL. What I tell my patients in the office, every patient with recurrent patellar instability needs an NPFL reconstruction. The real question is, who needs more? And the answer is, we just don't know. Patellar instability is a multifactorial problem. Trochlea dysplasia, prevalent in 97% of cases. Valgus, femoral antiversion. External tibial torsion, seen with a TTTG. And if you have femoral antiversion and external tibial torsion, your TTTG will be even larger. Patella alta and ligament dyslaxia all play a role and are anatomic risk factors for recurrence. A multifactorial problem needs a multifactorial answer. That's where I think we get lost. We need a scoring system that takes into account all of these things, all of the risk factors that we've just talked about. And the decision has to be individualized for each patient based on their risk of failing an isolated NPFL. So this magic number of 20, I want to dissuade any of you from believing that there's one number that will help us decide who needs a tubercle, because it isn't just one number. How can one measurement determine the need for a bony correction? This is a measurement that changes between MRI and CT, as Philip Schottel and Diane Dahm have shown us. It changes with knee flexion angles. So can 19.4 really mean that we don't have to do a TTO, and 20.2 mean that we do? It just can't be one number, because that just doesn't make sense. So what is our goal? Our goal in treating these patients is to keep the patella stable and to give them a high-functioning knee that allows them to do what they want to do with their life. We do not need to correct every number. That is extremely important. We do need to do the minimal amount of surgery to keep their patella stable and give them good outcomes. And I think the combination is really our goal. So does one number really predict the failure of an NPFL? No, one number by itself is not going to predict the failure. We have lots of studies that show, regardless of bony malalignments, that patients can do very well. Brandon Erickson published on our short-term data from our own institution in 2019. Dennis got this. Ours accepted for the mid-term, Liz Dennis. It's now being published this year in AJSM, which is the mid-term data on that same cohort. Still doing very well with very low recurrence rates, despite high TTTGs or a variety of TTTGs and variety of ALTAs. And Sapi Marineri did the same study retrospectively and really did not find the TTTG to be significant. It was more about the ALTA. And I think those are important factors. Do some patients need a TTT? Absolutely, but it is not based on a number. We need to know what we're treating. In this pure yellow instability category, an NPFL is going to work the vast majority of the time. And that's really all you need with maybe some cartilage and a lateral lengthening. Soft tissue, yes. Bony, no. In overload malalignment patients who aren't unstable, the patients who are the lateral maltrackers, different problem. They're not unstable. They need a TTT every time or a DFO. And then there's the overlapping group. And we want to be sure to isolate that group and see them ahead of time because they need both because they have both problems. But the pure instability group does not and will likely be fine with an NPFL. So what do we know about isolated NPFL? Huge high return to sport rates, great low re-dislocation rates. What we don't know, and this is where there's no clinical studies, is what combination of ALTA, elevated TTTG, trochlea dysplasia, valgus or antiversion predicts the failure. And it is going to be some combination. So we need a patella ISIS, just like they have in shoulder. We need an ISIS score that's going to identify preoperatively which patients have an unacceptably high risk for recurrent instability with an isolated ligament. Luckily, we were awarded the grant from AOSSM two years ago. This is the multicenter grant. And my co-PI, Chantal Parikh, and I started to do this on a multicenter scale. So I've collected data, which we're following at our institution, but we're now following this with 17 sites and 29 surgeons, and we should be finished collecting 850 patients within the next year. And the goal is to follow these patients, consecutive patients done regardless of TTTG, regardless of ALTA, they get isolated MPFLs and to follow them out. And we look forward to publishing our results. There are exclusion fractures, obviously, if you see large laterally based lesions that they don't have just isolated instability, they have overload. And again, they fall into that middle category. They need a TTTG. So that's an exclusion factor. Obviously a jumping J sign, which we all know is just a much bigger problem. It's not just instability. It's a very different animal and they also need a correction bony. But the current guidelines that we use often are ALTA above 1.3 or 1.4, a TTTG of greater than 20 or trochlea dysplasia as Lee Pace just told us, which necessitates in his hands, a trochleoplasty. I would disagree. It is none of those. It's going to be some combination of these. And that's why we need this ISIS score before we decide to use any one number. So for Dr. Farrow, why would we not do a TTO? It increases the time out of work and out of school. It limits your weight bearing. It increases your risk of DVT. It increases your risk of fracture and delayed union. There's much more hardware pain because there's really very little hardware in an MPFL and it increases your time to return to sport. Thank you. And now we'll have the rebuttal by Dr. Farrow and why we should think about bony procedures at times. So, yeah, thanks for the program committee, our moderators for being here. I love this room, a lot of people here to learn all about patellofemoral issues. We finally arrived. And as usual, Mijo is getting me all put together. Perfect. So there we go. So I have nothing to disclose. There we go. So Dr. Schubenstein is one of my patellofemoral all-stars, one of my favorite people in the patellofemoral world. We're going to call her the queen of the isolated MPFL. But this gold medal debate, it's kind of like politics. You got to be careful what shows up on the internet. That looks like a TTO. So lots of great stuff out there looking at isolated MPFL reconstruction. So as mentioned, high anatomic factors versus low, low redislocation rates, patient-reported outcomes are great when comparing those two groups. Even Beth actually showed similar things, high anatomic values versus low, low redislocation rates, patients are happy. This from Dr. Hamster in Canada also showed with a lot of abnormal factors, they still do well with respect to patient-reported outcomes with isolated MPFL reconstruction. The one caveat we'll talk about later, patients with increasing age don't do as well with isolated MPFL. So are these well-done studies? Absolutely. Short-term follow-up? Yes. No comparison group? And so they really haven't proven the inferiority of MPFL plus TTO. So this is MPFL, pretty happy, shows up with his ice cream. All of a sudden, MPFL plus TTO shows up and adds more ice cream. MPFL's not happy anymore. MPFL redislocates. So there's value in comparative studies. So what's our algorithm? I do agree with Beth on that. So we look at patients, TTTG, above or below 20, we start to think about it, CDI 1.4. And in this article, taking that approach and doing those groups, we can see they all increase from their preoperative values. But what about comparison studies? Combined versus MPFL isolated? So patients do better with the combined surgery, no recurrent instability in either group, but we have to pay attention to better function and kinematics. Just not redislocating is not the only part of the equation. So patients with the combined procedure did better than the patients with the isolated MPFL. And this is just for kind of low, what I consider low rotation, 17 to 20 millimeters. And then finally, the study from Mary Mulcahy looked at higher reoperation rates in the single group versus the combined group. So what are my indications? So patients with high TTTG, obligate dislocators, obviously. If we need to offload cartilage, obviously can't do that with an MPFL. So severe ulta, revision situations, severe dysplasia in older patients, I start to think more about it with lower values. So when not to do it, when the anatomy does not support it. So low TTTG, CDI, don't do it in the spoker. You will be, you know, because if that doesn't heal, that's a problem. And then skeletally immature, you have to think about other things. How do we do it? So I use the AMZ triat technique primarily. The AMZ and Fogerson were not designed for instability. Those are chondral offloading surgeries that were designed for arthrosis. You don't have to do those in instability if you don't want to. So I use large fact screws, bicortical fixation, and we want to normalize the TTTG. You don't want to go overboard with that. So this patient, not your isolated NPFL patient. So 16 year old, CDI is high, TTTG is 19. Her patellar tendon is draped over the side of the trochlea. So you want to be careful. So we use this technique. We actually outline the entire trochlea with a drill bit. You can get away with a four centimeter shingle with the AMZ triat technique. I will go longer if we're going to distillize because we have to remove some bone at the end. And like Dr. Brady said, we'll typically have a shingle or create a green stick distally for extra fixation. But if we're going to distillize, we have to take the whole shingle off. And this is about a six millimeter shingle. And then we peel the periosteum back. We take off that distal two centimeters of bone. And then we translate that proximally. And then we go big or go home. Two large fact screws. I countersink these. I very rarely ever remove screws. You can ask my fellows. I don't remove screws on my patients when they're countersunk and fixed properly. And you don't want to over medialize. And they heal and they do well. Kirk Campbell showed that return to play rates are high with combined procedures. And this study from Lori Hamster also showed that in patients who are older, they do worse with isolated and PFL reconstruction. So my threshold in those patients are lower. What about safety? We looked at a large cohort of patients, a lot of different surgeons, not even sports medicine specialists, all of them, and low complication rates, low rate of hardware removal and major complications. And surprisingly, Dr. Schubenstein also wrote a paper earlier showing that A, she does TTOs and that it's fairly safe and easy to do. So in conclusion, not one size fits all for everybody. Don't be scared to add the TTO when needed. So high rates of return to play, low complication rates, lower threshold in older patients, and use when the anatomic factors are high, and use with a J sign, and it's useful to address chondral issues when needed. Thank you. All right, guys, this is the part where you've got to cooperate with us. So we're going to put up the barcode. So get your phones ready. And then what you'll do is the barcode will come up, and then you obviously vote for one or the other, and then we have about 60 seconds to have things percolate, and then it'll come forward. So is it working, guys? What's he? Oh, I have that on the next one. Oh. This is, like, how to ask a question. Oh. Oh, okay. So everyone has, so I can advance now? Okay. Yeah, okay. So it should show up now on your screen. Okay, here we go. 27. 26. Countdown. Do-do-do-do. Do-do-do-do. This is the award. Here we go. Here we go. 19 seconds and counting. That also shows there's a lot of people still in the room. Great. Seven, six, five, four, three, two, one. Oh. Ludolto. Farrow. Congratulations, Dr. Farrow.

Elizabeth A. Arendt, MD

Miho Tanaka, MD, PhD

Joshua T. Bram, BS

Samuel Montgomery, Jr., MD

Robert A. Magnussen, MD, MPH

Kirk Campbell, MD

Jacqueline M. Brady, MD

James L. Pace, MD

Beth E. Shubin Stein, MD

Lutul Farrow, MD

patellar dislocation

MPFL reconstruction

tibial tubercle osteotomy

trochlear lesions

chondral damage

osteochondral allografts

autologous chondrocyte implantation

trochleoplasty

quadriceps tendon fixation

knee stabilization