Okay, we're going to get started a minute early because we've got a lot we want to get through. We want to sort of maximise the enjoyment and the entertainment for the crowd and for the panel. My name is David Parker. I'm from Sydney, Australia. I'm the President of ISACOS, and this is a symposium that ISACOS has put together. We're a partner society of AOSSM, and we're very grateful for the opportunity to collaborate and contribute to this fantastic meeting. And we'll have AOSSM and other partner societies join us in Munich next year for what will be our fabulous meeting, which we hope to see you all at. My co-chair is Alan Getgood. Alan's from London, Ontario, via Northern Ireland, and we're looking forward to having a very robust discussion. We do have a global panel. As you'll see from the map, we've got a number of people from the US, but we have the rest of the world represented. We have all of the continents represented around here, which is what we like to do at ISACOS. We like to sort of have that appreciation of the knowledge that comes from the interaction from all of us around the world and get those different perspectives that we can provide. I'd like to thank all of our panel for contributing and turning up. They're all very busy people, and I'll just introduce them to you on the screen here. We have Eliza Aron from Minnesota, David Figueroa from Santiago, Chile, Kyle Martin from Minnesota, Volker Masell from Pittsburgh, Rachel Frank from Colorado, Dave Lee from Singapore, Seth Sherman from Stanford, Seth's not quite here yet, he likes to make a grand entrance later on, and Matt Olivier from France. So it's a fantastic panel. I'd like to thank them all for coming along and contributing their wisdom. They've all been told that we're going to go fairly gently on them, but not completely gently, but we're all friends, so I think we should be okay to get through this unscathed. You can find our disclosures, if you're interested, at this QR code in the program. So let's get started. So firstly, this is a knowledge base to see how many people know their flags of the world. So Volker, do you recognize that flag? Chile. Chile. Well done. Okay, Volker's off to a good start. So this is a case that's come from David Figueroa, and I'm going to introduce him. We'll ask David occasionally about the case. So it's a 14-year-old male. You can see they're scurvy and mature, and they haven't really had an injury, but they're presenting with knee pain with activity. We can have a quick look at those X-rays there. Maybe I'll get Eliza. Are you seeing anything there of concern on the X-rays? I might help. I'll show you that one. That one's a bit easier, maybe. Open growth plates, centered patellas. It looks to be like an OCD, maybe, lateral femoral, lateral trochlea, or something. Something not quite right. Okay. Alignment looks pretty normal. No real concerns there. Deformity. Okay. Eliza, do you want to carry on? You're on a roll. Yes, please. Okay. I'm so sorry. I can't—well, with a lateral OCD in general, I think they're often well-tolerated, I'm going to say, but I'm not sure if I feel that there's fluid under there, and that really would make a difference to me, whether there's fluid or not. Okay. So do you think that's a lesion? Obviously, it's symptomatic. It sounds like it matches the symptoms. Would you consider that a lesion that's stable inside you that will probably go on to heal, or do you think it's potentially unstable and the prognosis is worse and it needs intervention? What can I say? That if I think it's stable, I think that I would tolerate it before I'd go in and try to fix it, but I'm not quite—I mean, maybe I would try to do something arthroscopic to see if it's stable, and I just will also say that they probably have patella alta because you can see that you have the full cartilage coverage and you look up and there's no patella, so there's a certain amount of patella alta. Would you agree there's a fair bit of, essentially, fluid under that right-hand image, under the lesion? I'm going to answer my question. What do you have there? I'm going to get my question here to Kyle. All right. We're passing it further down the line. We've already started taking over as a model. Moderator is bound to happen. Kyle, do you think that's unstable? I certainly see some edema, especially in that middle picture behind it. As we go over to that furthest one from Liza and myself, which is a little harder to see from here. Yeah, there's maybe a bit of concern behind it. Okay, I need someone who's gonna be decisive. Okay, is there a decisive surgeon on the panel? Yes, there is now. Seth, is it stable or unstable? I think it's unstable. Thank you. Okay, so what do we get? Okay, so we've had a decision. So that's one of the most important parts of being a surgeon, right, is actually being able to make a decision. So I think we've had some decisions made here. A quick question to Liza. Liza, you mentioned about patella alta and obviously there was reduced patella trochlea index there. Is that known to be associated with these types of lesions? Is that something we should be aware of? Not to my knowledge, but I will say that I'm trying to get the patellofemoral study group to look at them because there's just not enough of them in any one group to make it. But I think that it is associated with patella alta and you get more stress laterally as it comes in. Okay, so we've decided, we've all agreed that it's an unstable lesion and we've agreed that it needs intervention. I think if you have an unstable lesion in this age group, the prognosis is not good. If it's stable, it's good prognosis to heal. So David, you've moved on and you've done an arthroscopy. Tell us what you found. Just do the soundtrack for the video. Yes. So we performed this diagnosis arthroscopy and as you can see on the lateral side of the trochlea, there is a big fragment. I would say it's very unstable. We take our time to do that, not to increase the instability, but as you can see. So we'll move on to your next video. Yeah. And you can tell us what you did. So once we established that it was an unstable fragment, we debride the bone and the subchondral and the calcified layer. We perform some drilling first and then we fix it with two or three nails bio-absorbable. Okay. Now can you just elaborate a bit more on how you prepare the bed? Because often when you go into these, there's like some fibrous cartilage tissue, there's not very favorable tissue for healing. How do you prepare the bed of that lesion before you do your repair? We just did some microfracture there with the drilling guide and we debride all that soft tissue that was between the subchondral bone and the bone. Do you see? It looks like it's a trapdoor. It looks like it's connected. Did you lift it up like a trapdoor? Yeah, I lift, yeah, yeah, sure. Okay, now you've got a great arthroscopic view there. Obviously you've done a very nice job there. I'm gonna, do you add anything, or does anybody in the panel add anything like BMAC or some sort of magic powder that you wanna put in there? Rachel, you're from America, but the home of all these new things that we can add to make things heal. What would you add to that, anything? Well, I think it wouldn't hurt to add a biologic augment to this for sure, including biologic augmentation with either PRP or concentrated bone marrow aspirate. That being said, in a skeletally immature individual with some good base prep, I don't know that you need it. I don't think it would hurt, but I don't think that you need it. If it was free, I would for sure add BMAC, but in here in the States, it's not free, and so that, and it's pretty costly. It's over $5,000 in my institution, and so $5,000 for unclear benefits, I don't know that I would do that in a skeletally immature individual. I think these cases, in my experience, and maybe I'm a terrible surgeon, these are the ones that humble me the most because you feel like you can get a great fixation. I'll actually make a mini open incision and really scrape that bed. So you might do it open? I would do a mini open in these cases. He would do it open on the panel. I think, and I think Dave's done a beautiful job here, but I think personally doing it open allows us to do a bit more in terms of preparing that base. Now, David, you've done this case. Now, you go and talk to the parents afterwards. What do you tell them the chance of success is? Is it got 80% chance, 90% chance? I think it has a good chance to success. A good chance, okay. Good chance. Okay. We don't wanna use numbers. Okay, so this is what it looks like afterwards, and Volker, I know you wanna say something, you'll get your chance. But about a year later, they've turned up and everything was going well, but they start getting back into things and now the knee's sore again. And okay, this is the picture we've got here. Volker, what do you think about this? It was doing so well just a minute ago. One year later. So for me, the common denominator with doing poorly with cartilage surgery is you go too early to return of sports. Whether you allow it or not, they go at four months because they feel great and they shouldn't. So I try to avoid anything before six months is my rule. It can still happen, and so it did. And so now it looks crappy. You can now inject PAP and you can inject all these things and try to make them better and give them a brace and slow them down. But then in the end, I think you need to go, depends what you show me next and how many non-op approaches you've tried here. What's the prognosis for this? Is this gonna be fine or is it gonna need some intervention? Now? Yeah. A minute ago, I said there's a 90% chance of doing great. Now I'm gonna say he's done until your next surgery. Okay, so agreeing that there needs to be intervention. Is anybody disagreeing with that? Could I just ask a question? Do you think it has to do with a bioabsorbable screw rather than maybe a biocomposite? I mean, sometimes when you get a bioabsorbable, the MRI just looks crummy. I mean, there's obviously, it's more than just. We have done a few cases with the bioabsorbable. Other was the metal screw with non-head, but no, biocomposite, we never have this. But do you think that bioabsorbable might not be the right thing? Yeah, I've actually moved away from using bioabsorbable screws here. I use metal screws. And I go back in routinely at about eight weeks and take the metal screws out. And that gives you an opportunity then to assess the lesion. Because I find assessing MRI with a bioabsorbable in situ is very difficult to know the healing. Yeah, and I think that those, and they were smart nails, probably. My experience has generally been pretty good at those that are severely immature. I think a lot of this is about how you prepare that base and what the quality of the tissue is. Okay, so we've agreed that we're gonna intervene here. So what are our treatment options? Okay, now I don't wanna run, because we could spend all day talking about this. Seth, what are you gonna do? So I think you may have enough information here to do a primary osteochondral solution. So an osteochondral allograft is reasonable. You might've taken a Macy biopsy at time zero and you could do a sandwich Macy, if that's your choice, maybe with an unloading TTO. Okay, who's gonna do osteochondral allograft? Okay, anybody gonna do a Macy? Hang on, so but we're a global panel, do we all have access to osteochondral allograft? My next question was gonna be just that. So again, I think in the States, especially there's famous surgeons here, they just sort of say, go to the person, get me one that matches this patient perfectly. We have Macy, but it's expensive, much more expensive than osteochondral allograft. Okay, so in Australia, we can get it, but it's not as easy to get it from a far distance and the cartilage is probably not quite as alive by the time it gets to us. So we might use other things like Macy, but again, that's not reimbursed in Australia anymore, so it's expensive. So David, you can tell us what you did and then we're gonna go on to the next case. Yes, you can see the fragment was absolutely unstable. It was very easy to take it out. We open and we perform on two bone plaques of a French allograft. Okay, so I think the take home message from that is to recognize which lesions need intervention. That first one was obviously unstable and needed intervention. I don't think anybody disagreed that primary repair was an appropriate option for the first time for that. So it's a question of what else you do to supplement that repair. And then when it failed, then you've got your options and it really depends on what's available to you. But I think Volker's point about assessing, like for me, those repairs, they always get an MRI scan at six months before I even think about going back to any sport. Singapore. I didn't ask you. I was gonna test somebody else. All right. All right, great. Now we do actually have some extra seats up front. So if anybody wants to come forward, please grab a seat. We won't bite much. Okay, so. All right, so this is a case of Dave Lee's. So I'm just gonna go through some of the details and then we'll ask some questions and then Dave can tell us what he did. So this is a 32-year-old male who had an ACL-PCL reconstruction approximately 12 years ago and then unfortunately sustained an injury in another road traffic accident. So in 2017, had an MRI where his left knee was shown to have had a re-tear of his ACL and his PCL grafts and he had some meniscus and cartilage issues. So he was seen in the clinic for lateral knee pain and instability. Examination, lateral joint line tenderness, good range of motion, clear anterior laxity, posterior laxity with a very mild degree of MCL laxity and varus laxity, which was normal. So, Seth, right down the other end there. Seth, what are we seeing here? Hi, Al. So we're looking at a mechanical axis view. There's asymmetry of valgus and then we're looking, I hope those are weight-bearing x-rays. Looks like there's some degenerative changes. Obviously, lateral compartment on the MRI. Looks like there's clear meniscus deficiency, subchondral changes, bipolar. Not seeing the central view for ligaments. They don't look like they're there either. Yeah, so you can see in that bottom left MRI, you can see some anterior translation of his tibia. So it really gives you an idea that there's some ligamentous laxity. Mathieu, with that alignment film, talk us through when you see an alignment film like that, what sort of things are coming to your mind? You know, is it an adequate view? You know, what are the highlight points here that we really need to recognize? So we have a major valgus deformity in a, let's say, post-traumatic settings. He probably had valgus from beginning to the end. If you watch the other knee, you already have a slight valgus deformity. So the phenotype is valgus initially. The rest of the deformity is probably inside of the joint because of the meniscus issues and cartilage issues. There is probably also some, let's say, kind of flexion or rotation inside of the leg. So I'm not 100% convinced that it is the real good way to measure the deformity because you can see that, I think there is a slight external rotation inside of the foot. Anyway, it would be hard to do something better. So what do you do in that scenario? So clearly there's an issue that we don't have a really good radiograph. Do you have any techniques that you would apply in your clinic to get a better alignment view? So first, the good thing is to ask the radiologist to focus on that and to be sure that you are not doing something with a lot of external rotation. Then one of the good thing I do is we do a single-pedal weight-bearing X-rays because the patient cannot rotate anymore. And so if you want to be stable, even with crutches or something like that, if you do it in a monopedal stance, you always have a better view of the alignment, I guess. For me, it's the only way to do that. So when the radiologist said, we can't do better than that, I said, okay, do me a monopedal one. Perfect. Okay, so I think that's a really important take-home is that you don't necessarily always just look at that one radiograph and think that's the obvious alignment. Make sure that you really recognize that there are things that we can do to try and improve our alignment views. Okay, so here we've got a clinical examination and really showing, obviously, that AP laxity and looking at that PCL. It seems to be an endpoint there, but maybe a little bit of a posterior sag. Okay, so we've got some issues here. So ACL deficient, PCL deficient, lateral meniscus deficiency. We've got valgus alignment. Looks like there's potential limb shortening. I would say that's maybe not necessarily a true limb shortening. Probably secondary disinflection, some rotation, as Matthew has already mentioned. And so, okay, so we're gonna be going, anybody gonna do a non-operative approach with this guy? No, everyone in agreement that we're gonna do surgery? All right, so we've got it up. So in which case, then, we've got some considerations. So I'm gonna come down the panel. I'm gonna skip Dave, because he obviously knows what he did. So Rachel, you talked in the last one. Kyle, Kyle, tell me what you're thinking here. Yeah, I think those considerations really kind of highlight the main problems here. I would probably lean more towards a two-stage in this patient. He's already had a couple of surgeries at this point. I believe 12 years ago was the original one. Five years ago had a failure, unless this is just after that five-year-ago standpoint. But I think two-stage to the osteotomy, get neutral alignment. I would correct to neutral. I wouldn't try to put him into varus, especially given his valgus alignment on the other side. And then do the second stage, managing the meniscus and ACL, PCL at that setting. Okay, so we're all gonna do an osteotomy. Is anybody not gonna do an osteotomy here? Nope, perfect. Okay, so an osteotomy's gonna be done. Yeah, so Rachel, I'm gonna come to you now. Where are you gonna do the osteotomy? What technique would you use? Well, for this case, Al, this is a bit complex, especially with the previous ligament reconstructions. I would actually use some planning to help me decide where to do the osteotomy. I'm not smart enough to do this based on the X-ray alone, although before planning, I guess you had to be smart enough so it's not that it's impossible. I think you can, I didn't get a good understanding for his slope, but we have to deal with both ACL and PCL so I don't know where the slope is right now, but that's a consideration if you're gonna go to the tibia. Typically, for valgus, I like to go to the femur. In the U.S., many of us are trained to do lateral opening wedge on the femur more so than medial closing wedge, and I like a lateral opening wedge for this potentially, but I would use planning to really help me. I'd wanna understand joint line obliquity, but if you're asking for one line, one answer right now, my gut would be to do a lateral opening wedge on the femur. So talk me through, you just said planning. What do you mean by planning? Let's really get into that a little bit. So are we talking about doing 3D, are we doing imaging, are we doing CT scan? Yep, so in this case, I would do a CT scan and use proprietary software to help plan from hip to ankle, my correction. There's a couple different companies out there that offer this technology, and then once you plan, you can even 3D print guides to help make your cuts. You can 3D print plates to help do custom patient-specific instrumentation and plating for these patients. You don't have to, again, at the end of the day, we're all surgeons, we can do an osteotomy with staples, with plates, with screws, whatever we like, but the planning would really help me get more specific, particularly on a complex case like this. In addition, we're going to have to deal with tunnel management at some point, either during the first or second stage, and potentially with planning, you can place your screws in such a way that they won't get in the way of the future tunnels. So I think there's a lot you can do with the software for a case like this. Perfect, Seth, you got a comment there? Yeah, I just wanna make a point. When I see the weight-bearing line falling outside of the actual bones, I'm quite concerned about the deformities, plural, and I think, as Matt's taught me, this is one where we do measure precisely and potentially go for a double level. One large correction on one of the bones may cause trouble and may not lead to a balanced joint line, and so I might be apt to do this at a double level, and for me, I need the training wheels to execute precisely and safely for my patients, so I do use technology. Cool, so we've got the technology that's available that can help everyone, so Dave, you're gonna tell us what you actually did, but before we go on there, you've mentioned potential meniscus transplant. Liza, what do you think of doing a meniscus transplant in a case like this? Is it appropriate at this stage, or would you think about it as more of a second stage later on? I think you have to deal with the alignment, and he might do well with that alone. And then deal with the soft tissue, even the instability. I think that, and 35, right? 35 years old? Yep. So I think I would definitely deal with the bony, and then I'd deal with the soft tissue, and I'm not positive a meniscus transplant is needed, but I don't know enough about what's going on inside the knee. Okay, David, and what about in Sheldon? In my experience in these cases, I would focus first on the osteotomy, and I would look at the results of the osteotomy, and then I don't think it's a good case for a transplant, a meniscus transplant. All right, so Dave, do you wanna talk us through what you did? Yeah, so the considerations were all there. The question was whether medial opening or lateral, sorry, lateral opening or medial closing. If you're gonna do the PCL in the same stage, then obviously there may be issues in the hinge with the medial closing. We also looked at the length, and we wanted to correct him to perhaps about the same length, and so we elected to do a lateral opening. We didn't try to bring him to neutral, because like what Matt said, the deformity was both in the femur and the tibia with that kind of, so we brought him to just where his weight-bearing line on the other leg was, which was where he started off with prior to his both injuries, and so we staged, two stage. The first stage was the lateral opening DFO and a transplant. I used a soft tissue fixation technique, and that was for the first stage, and these are the post-operative x-rays. Perfect, so I think that's a really interesting point, the target in this type of case, right? Do you go to neutral, do you go to varus? Would anybody try and over-correct into varus when correcting a valgus knee? Yes, you would? Matthew, no? So I will not say that you need to over-correct to varus, but I will say maybe neutralize a little bit more for the sake of the implants, because we know that having here something like four degrees of valgus may be enough to destroy the graft in two, three years, so I would have done probably a small medial meniscus, closing wedge of the tibia to balance the correction. I think what you did is perfectly great. The limbs are perfectly equal now. The alignment is almost perfect, I would say, and great job, but you had a very, you had complexity to a surgery that might not need it, but I would be slightly afraid of having issue with the graft at the end. Yeah. But isn't valgus, a varus alignment, is that so much what the limb is doing, but if you place the femur in varus, that's the problem. So if by getting limb alignment neutral to varus, you put the femur in varus, then that forces you to externally or abduct your foot when you're walking, so I think that's where you have to look at what the bone is doing, and you cannot put your femur in varus, regardless of what the limb is doing. Gotcha. All right, and then the second stage, Dave, you did the implant removal, so you took some of the screws out, because as you rightly said, if you've got all those screws in situ, it makes life difficult for your ACL, PCL reconstruction, so that was your second stage, where you took some of the distal screws out, and then did the ligament reconstruction. So I think, I'm not gonna labor these points, I think we can get on to the next case, but good job, difficult case, Dave, great result. Thank you. So a round of applause for that. Just on that alignment correction point there, correcting to varus, I mean, ours and other studies have shown that alignment of that one degree of valgus is where in single leg stance, people have equal loading. So if you correct someone to neutral, you're offloading the lateral side, so you don't need to go beyond that in the varus. David, you recognize that flag? Yes. Australia. Thank you. Nobody said New Zealand. You said New Zealand, yeah. New Zealand has red stars for the audience, it's very similar otherwise. Okay, so this is a case of mine, and this is to illustrate a fairly straightforward point, so I'm gonna go through this one fairly quickly. So it's a patient who's got severe varus deformity, he's only 45 years of age, he's pretty active, he had a multiligament injury about 20 years earlier, and he had reconstructive surgery elsewhere, in fact, revision reconstructive surgery, and he came complaining mainly of increasing pain, increasing deformity, and occasionally you get instability, but if you question him more, it's not ligament instability, it's more pain-related instability, and sort of deformity-related buckling into a varus alignment. He's still got quite a good range of motion, his PCL was grade two with a good endpoint, otherwise the knee felt stable, and there is his deformity. So first question that I have, does anybody want to do a knee replacement on the panel? You're a sports medicine group, anybody in the audience want to do a knee replacement? Don't be shy, I know this is America, this is the home of knee replacement surgery, so I think a lot of places, people will get a knee replacement for this, certainly when I present it elsewhere. So this is the MRI scan, so obviously I'd do this on anybody I'm considering any sort of reconstructive realignment surgery, and his medial compartment was shot, but the other compartments actually were not too bad. He had some trochlear wear, which we've found in all our studies doesn't seem to affect the outcome too much, lateral compartment was fine. So I guess that's the first question, and when I put this up to a panel as arthropathy surgeons, I think Liza, you do arthropathy, don't you? What are you going to do? I would do osteotomy. Osteotomy, okay. But I just also want to make a point that in the patellofemoral compartment, it's medially based arthritis, or medial based chondrowear, and the medial based chondrowear is because of his varus deformity, and if you take him out of that varus deformity, his kneecap will do fine. Because iatrogenic patellofemoral arthritis is laterally based. So you have to be careful where that is. I think you'll do fine to ignore me saying that you do not have patellofemoral arthritis. So is that based on your experience, or is it based on cadaveric studies looking at the loading in that area after osteotomy? What's your basis for saying that? Is this your feeling or your experience? My basis for saying when you see medial-sided patellofemoral arthritis, you have to think either iatrogenic surgery, somebody's over-medialized the patellofemoral stabilization, or a varus knee, and I think that's just level five experience. I don't know the patellofemoral will do well, but I think that if you unload it, they tend to do better. I sometimes just put them in an unloader brace, not like this, but I sometimes treat medial-sided patellofemoral arthritis. I haven't seen, it may exist, I haven't seen studies looking at the effect of valgizing osteotomy on offloading the medial side of the patella. Anybody got any experience with that? No, okay. Matthew, now you look at this, and Seth made the point earlier, weight-bearing lines outside the joint. Is this something that you think we can correct on one level? No, I mean, you can, you can, of course, but the long-term outcome will be terrible for him because he will have, I mean, if you, first, you will try to do a, like Seth, 19-degree opening wedge on the tibia to correct those 17.8-something varus, so you will have a hinge fracture, the risk of nonunion is terrible, and the joint-line obliquity will be insane. So, for me, it's a complete no-go, and as you can see on the numbers, you have almost seven degrees of varus in the femur and 10 degrees of varus in the tibia, so it's pointing, the finger is pointing for a double level for me, so no question. Okay, so I'm going to show you what we did, and I'm going to let the panel, particularly Matthew or Seth or the other planners in the room, tell us if we're thinking along the same lines. So, when we have these planning things that we talked about before, that other guys were alluding to, yeah, we can plan everything, we can look at things in three dimensions, and we can do a virtual operation first to see before we actually pull the trigger and do the real operation. So, I said to our engineers, okay, so plan it in one stage on the tibia for me, tell me what it's going to look like. And you can see what it looks like here, we're going to create a wedge opening of 26 and a half millimetres, which itself is not particularly acceptable in terms of soft tissue disruption, risk of nonunion, hinge fracture instability, et cetera, et cetera, but we're also going to create 10 degrees of varus on the joint-line. And most of the studies, our own included, would suggest you probably shouldn't go past about three or four degrees, okay? And that's based on some long-term studies, it's based on some studies in the lab looking at gait analysis as well. So, we didn't think that was acceptable, and so we planned a two-stage correction, and when we're planning this, we're essentially trying to produce a relatively neutral joint-line, but achieve two or three degrees of mechanical valgus. So, we do this on the tibia to create a fairly neutral joint-line, and we do an opening on the tibia and a closing wedge on the femur. So, lateral closing wedge on the femur and a medial opening wedge on the tibia. And the other thing that does is it doesn't have a big effect on the leg length, okay, because you're taking some out of one side and putting it in to the other side. And so, this is what he's like in the diagrams. You can see there, and they actually tolerate it pretty well. You can get them moving fairly quickly. And then, if we look at it in the gait lab, the red line on the top of the graph is his adductor moment, so the force on the medial compartment pre, and you can see it's a huge reduction. And the green arrow is the ground reaction force in relation to the knee joint. And so, that's how we sort of quantify what we do. And this is him. And so, he did well, and he got a good result. And the other point for this, for the arthroplasty surgeons in the room, as you can see his joint-line there, it's fairly routine arthroplasty joint-line. So, just going back to the end of the room, Matt, any comments, any disagreements, anything you'd do differently? So, my only comments, we were discussing that with Seth three minutes ago, but should you do something on the sagittal plane or not? Because this PCL is laxed. I think I will not. Seth said he will potentially try to increase a little bit the slope or move a little bit the sagittal plane to stabilize further the PCL. Otherwise, I mean, this is perfect. Good job, boss. Thank you. Thank you. No, I agree there's a good theoretical argument for the PCL. I worry about it, and people got established arthritis and fixed deformity. You're going to give them a flexion contracture. And the other thing, for the slope-increasing osteotomy to work on a PCL-deficient knee, you have to have that laxity in the sagittal plane that those forces can actually work on. And in a fixed deformity, I don't think it has as much an effect. Okay, we'll move on to the next case. Thank you all. All right, anybody know which this flag is? All right, good, good, good, good. All right, so this is one of Rachel's cases, I think. Okay, so it's a 23-year-old male with left knee lateral-sided pain, swelling, catching, pain for quite a few years, pain with both sports and activities of daily living, so clearly quite disabling for him. Unfortunately, had a surgery previously, so a number of years ago, had a lateral femoral condyle microfracture and a partial lateral meniscectomy, and then had some bizarre-sounding drainage washout. So Rachel, just can you clarify for us, is this actually, was this an infection or is this just maybe just a hemarthrosis or something? Al, your guess is as good as mine. When you asked the patient about his surgical history, he said someone did a microfracture and then you asked, did he have any other surgeries? Oh yeah, a couple weeks later, they took me back, I was draining. So that made me really happy inside. Good, so interesting, interesting. Okay, so prior treatments then, so had a number of injections, so physiotherapy, icing, activity modification. So we're taking from that that he's really exhausted non-operative treatment, okay? So examination, BMI of 25, prior scope incisions heal well. So really not much going on in his exam, apart from some tenderness to palpation in his lateral joint line, okay? Reasonable range of motion. Radiographs, I think are pretty straightforward. I'm not gonna start quizzing you on all of this, okay? So if there was one extra radiograph that you would want, let's say, come back to you Kyle, is there another radiograph that you would like that we're not showing you here? Standing alignment would be definitely high on my list. So standing alignment, anything else? Patella femoral view, PA flexion view. PA flexion view, so certainly for me with lateral disease, I wanna see that Schuss or Rosenberg view for sure. And so there we go, so there's the alignment view. So element of valgus there, and just gonna blow that up and you can see, so now we're dealing with asymmetric valgus, weight-bearing axis going into that lateral compartment where he's painful, okay? So MRI scan, I'm sure you're all gonna get an MRI scan of course, and it confirms, well maybe, who've we got? David, David, what are you thinking of this MRI scan? Probably a kind of osteoarthritis in development, at least osteochondral lesion in the femur and on the tibia as a mirror lesions, a grade three and some probably grade four in some places. Great, now obviously it's difficult sometimes when you've only got single slices, right? But what we're actually seeing, if you really go through these images, what you can see is the posterior third of the meniscus actually looks pretty good, but the mid-body is not looking so good. See if this video works, it's not. Yeah, I'll provide a new video, you know? So you can make that full assessment. There you go, how's that? There you go, you get it now? There we go, so I think you can see that with that lateral meniscus, that posterior third's intact, mid-body's not intact. So when you see that, Kyle, what are you thinking there? So I'm looking at, I mean the cartilage, even just the condyle seems like it's flared out, a little flattened, so there's some chronic changes there that have me concerned just about the cartilage and his overall alignment. Everything seems to be lining up with overload at the lateral compartment. I would also try to dig deeper if I could to make sure there was no chronic infection based on the history of a second washout, but sometimes that information is not available. Perfect, all right, so next steps. Dave Lee. The first thing I would do is do some blood tests, make sure a full blood count, ensure there's no infection on board. So we've excluded infection, right Rachel? Correct. Perfect. So, I mean it looks like, I mean he's symptomatic, so I guess we are moving towards surgery. And in the surgery where you have to look at the meniscus and the cartilage, on the lateral view you can see the cartilage adjacent to the meniscus is not great. So I guess it's something that you would plan and proceed from the surgery. So what you're saying, so we've got a functional meniscus loss, right? So the meniscus is not functioning at all. So lateral meniscus deficiency, we've got the chondral disease, lateral formal condyle, asymmetric valgus alignment. All right, so Mathieu, what are you doing? Why are you asking me? No, I know why you're asking me. I will do an osteotomy first and see what happens. I will not do any more things intra-articular. I think there is a meniscus deficiency and a cartilage issue, but obviously the osteotomy, you can probably solve everything. There is, this is a German experience. The German will say, you do the osteotomy and you think about the intra-articular things. After that, I know that the U.S. experience is more do everything, correct intra-articular and extra-articular, but I will shoot first, probably do, I need the angles, but I think for me it will be globally a medial closing wedge of the tibia. Just looking at the x-rays. Volker? I think this would be exactly true for me if it's a varus problem, because you're not looking at a huge valgus deformity. The varus aiding osteotomy in my hands isn't as powerful. I might consider here going with the osteotomy, medial closing wedge on the femur, but also go intra-articular, where the same is not true if it's a medial disease in my hands. The osteotomy may be first and the only thing. This guy, let's say he's an in-season athlete. Seth, what are you gonna do, in-season athlete in this scenario? I think everyone's been saying they're gonna be doing some pretty major surgery, osteotomy, plus some other stuff, right? In-season athlete, what do you do? I think there's a role for potential staging scope. MRI underestimates the size, depth, location of the chondrosis. They may have mechanical symptoms and effusion, so you can scope them, clean it out, do biologics, use an unloader brace and see how they do. So in that type of patient, perhaps less is more, but that's not the strategy I would advocate here. I'm in the camp, just for the record, on doing the scope plus the closing wedge, medial osteotomy and coming back as needed for cartilage and or meniscus. Right, so Rachel, I mean, so you did the diagnostic scope. Maybe just talk us through your thought process here in terms of doing the scope first. Yeah, I think there's a lot of arguments for doing a staging arthroscopy here to better evaluate the articular cartilage. That tibia looked pretty bad, and that tibia may affect what I wanna do on the femur. In addition, that meniscus did not look horrendous, but the mid-body on the MRI didn't look great, and so I'm not the type of surgeon who will order meniscus or cartilage grafts unless I know I want to use them, and I never want to implant them and waste that donor if the patient truly doesn't need them. So the value of the diagnostic staging scope is to see what I can do intra-articularly. For the lateral compartment at age 23 with a biologically active joint, he's had an effusion, I want to do something intra-articular. I don't think an osteotomy on this valgus knee will be enough, although I think you could argue for that based on what Matt said. I think that it's a small amount of valgus, so it's going to be a small correction. I would not do the osteotomy first in this case with the staging scope because I'm going to plan to come back to do some sort of cartilage and or meniscus. I want one rehab with one limited weight-bearing protocol, and so for him, a staging scope is what I would do. All right, cool. So obviously, there's lots of different ways of skinning a cat, so the great thing is, I think we're all in agreement that alignment is key, and then there seems to be a bit of disagreement across the panel in terms of whether or not we go straight in with doing something biologic at that time or at a later stage. So just tell us then what you did do after you've had that, and then we'll finish up. Yeah, so at that staging scope, what the video would have shown you is the cartilage on the femur was sick, as we'd expect. The tibia cartilage was actually quite disruptive as well, and the lateral meniscus was deficient. Based on that, he did not get better after the staging scope alone. He kind of resorted back to his symptoms, so we went for the trifecta, we like to call it. So we did the osteotomy. I did a lateral opening wedge, correcting him to the opposite tibial spine, and a lateral meniscus allograft transplantation using a bone plug technique, and a lateral femoral condyle osteochondral allograft transplantation using a snowman or MasterCard technique, so there's two plugs there. These posterior defects on the lateral femoral condyle are very tricky. You have to get the knee in hyperflexion to be able to do this. Fortunately, because we were doing a meniscus transplant, we didn't have to fight the anterior horn lateral meniscus to get exposure. My order of events for this is to do the osteotomy last, because of the degree of hyperflexion that you have to place the knee in to do the cartilage. So we did all of it. Here's the final result. This is before, this is many years ago, before I was doing planning and using software, so this is just a standard off-the-shelf plate, some bone substitute, and a little bit of overcorrection, just given how young he is. At age 23, I wanna preserve. You saw that tibia. That tibia looked awful. I wanna try to preserve that lateral compartment for as long as possible. So when you're going for that really big biological reconstruction, you're actually aiming for a little bit of overcorrection to really, truly get good offloading of that lateral cell. Yeah, you know, when I teach our fellows, I typically, for cartilage and meniscus allografts, I like to go to neutral. This is one of those cases where I overcorrect because of how sick that lateral compartment was. It's more of an arthritis case than anything else, and so yes, I'll overcorrect for arthritis, but when I'm doing straight cartilage or meniscus, I like to correct to neutral. Great. Well, great result. Congrats. Good job. Thanks. All right. All right, great case, and I think that really illustrates that there's, as Alice said, there's, the alignment was the key thing that I think everybody commented on and needed to be corrected, and to do that alone and reassess, I think it's perfectly reasonable. If you have the resources and the skills in one case like Rachel done, I think that's also great, but both perfectly acceptable ways to address that. Oh, there's a question. Is that gone? I have a quick question. Honey, I think. What consideration, beautiful surgery, what consideration did you give to the infection and that there is? Yeah, so I didn't sleep for like six months after this surgery, just waiting for the infection to come. And now that we're talking about this case again, I will not sleep for the next six months. He's actually done quite well. We follow him yearly. We did a preoperative workup, aspirated the knee, checked for, I held it for three weeks, actually just to check for P-acnes, because that actually lingers in joints other than the shoulder. Nothing grew and his numbers were all good. I did put him on prophylactic antibiotics for five days after surgery to ward out evil spirits, makes me feel better. And then I, again, didn't sleep and hoped for the best. But it is a big risk. It's a big incision with a lot of donor tissue. It's certainly a risk. Great, thanks for the question, Connie. Good question, good point. So the next patient is a patient of mine. So rugby league has been described not so much as a contact sport, but a collision sport. It's a bit like NFL without the pads. So this is a play, he's got the ball now and he's running, he's about to injure his right knee. And like all good Australian rugby league players, the opposition comes up and congratulates him on his injury, which I'm sure happens here as well. So, and again, you can see him coming across here and he's going to step off that right leg about now. And that's when his ACL goes. So he presents with a swollen knee, he's a bit stiff. His other ligaments are stable, he's got neutral alignment. So here's his MRI scan. And in the interest of time, I'll just go through it. So he's mid-substance ACL. There's a big trend in Australia right now to put ACLs in braces. You guys heard about this, put them in braces at 90 degrees. Hasn't quite caught on with the professional athletes so much, but certainly not for mid-substance injuries like this where they've got a big separation. You see big bone bruise there, but it looks like there's a chondral injury in that area of the bone bruise. His lateral meniscus root has obviously been damaged and he's got a chondral injury on the medial femoral chondra and probably a ramp lesion on his medial meniscus as well. So quite a lot, and obviously these things affect the prognosis beyond just an isolated ACL injury. So I just want to go across the panel and just find out what people are doing for their ACLs. Okay, there's going to be some, obviously, discussion points. Now, in terms of timing of surgery, most people are waiting for the acute inflammatory response to settle, get their range of motion back, the need to be quiet, or who's doing that? Anybody rushing in the next day, pressure from the coach, pressure from the team, or you're all sticking to your guns and doing the right thing? Everybody's doing the same thing. Okay, good. Now, what graft are we going to use here? And again, I'm not going to go through everybody and have a big detailed discussion. Who's using BTV? Rachel, I thought you were like the quads king. I would also use quad, either way, BTV or quad. Was that half a hand raise? Okay, so who's using hamstring? Nobody. Who's using allograft? So we've got pretty much everybody using BTV or quads. Okay. And how are we fixing the BTVs? Who's using screws for the BTV fixation, top and bottom? Who's using a button, top and bottom? Who's using a hybrid? Okay, what's that, button on the top, screw on the bottom? Yes. Okay, anything different? Okay. And the tunnel position? Okay, so we've got the footprints here, and I think we're all pretty familiar with the footprint, and you can divide it the way you like, but are people tending to put it more central or more in the anteromedial position? So who's more central? Who's more anteromedial? Everybody, okay. So I think that's been a trend that's happened. I think when Freddie did all the stuff for anteromedial, a lot of us moved it towards central and saw a higher instance of graft ruptures, so people have drifted back more towards the anteromedial, more isometric position. So the lateral meniscus, the root was gone. People are happy that it needs to be repaired in this scenario. Transosseous fixation, anything different? Okay, and what are we gonna do for supplementary procedures? Who's gonna add a lateral-sided procedure? Who's not going to? Just an isolated BTB? Rachel, you're still doing this thing with your hand. What is that? Did he have any hyperextension on the opposite knee? Just a couple of degrees. He wasn't like. I think with a BTB, I probably would not, but I would not be opposed to it. If we talked about it and he said, I want it, I don't think there's, I think the morbidity with LET is so low and the potential upside is so high. We just don't know, and we will soon with stability too, but we don't know if it's needed with BTB, with a well-done BTB. Okay, so it depends on who's doing an LET of some sort. Matthew, which technique? Diplomaire. DeepModify, a bit of the ACL because he's a pro. Okay, Al, I know you're a moderator, so you're sort of immune to questions, but you're the LAT king. So, what are you going to do? I'm going to randomize him in stability, too. And that has been and will be his answer for the last five years and probably the next three years. In 2027, I might change my mind. And then for the next 10 years, we'll listen to the results eventually, okay? Okay. So, there's a bit of division there, in terms of the LAT. My feeling with these professional athletes is you sort of just do everything. They're pretty tough guys, and the extra pain from LAT is not going to bother them at all. And okay, he's got these full thickness chondral lesions, lateral and medial. Who's going to do just a gentle debridement, get back to a stable edge and nothing more? Who's doing a microfracture? Who's doing oats or some sort of heroic cartilage restoration procedure? Nothing, okay. So, that's, I think, been a trend also in more recent times, away from microfracture to just doing a gentle debridement. Now, Sherman, do you not have a little fresh osteochondral allograft sitting in your fridge that you can just pop in there? No, sir. First-line treatment for athletes will be chondroplasty. Okay. All right. So, this is what was done, which I think was generally agreed on by most of the people. So, I had a BTV with screws, a lateral tenodesis, a lamar procedure, meniscus root repair. I did actually do a microfracture just a few years ago, might not do it now, and he returned to play the following season. So, why would you not do it now? Why would you not do microfracture now? Well, I think just the data around it, and my main concern is the ones that come back with that subchondral bony overgrowth, which can be quite a tricky problem to manage, then not suitable for a debridement. Totally agree. David, with that full thickness cartilage loss combined with that meniscus that didn't look so great on the lateral side, do you worry at all about over-constraint with lateral tenodesis in that patient? Do I worry? Not as much as I used to before we did our cadaveric studies and other people have published longer-term studies. I mean, there isn't good long-term studies in the sense that there's not randomized control long-term studies, and I think you can look at it two ways. You can say it over-constrains, and in our cadaveric studies, we did see increased constraint when we measured the pressures. It was only when we forcibly internally rotated that we got that extra pressure. The other way you can look at it is, well, if the lateral side is damaged, you need to protect it more. And if you do protect it more, you're going to get less subluxation and less damage. So you can look at it both ways, I think. But I think it's important that when you do your lateral sided procedure, that you fix it in a position that doesn't add more constraint than you want. So for me, the lamella fixed at about 30 degrees, and I absolutely make sure the foot's in neutral rotation. Okay. I think the next case is from … Can anybody recognize this kid? No do to boot it. All right. Good, good. Okay. So this is one of my cases. So, you know, you can't have Liza Arendt on the panel without bringing in a patellar instability case, really. It would be heresy. So 22-year-old female, recurrent lateral instability, okay? Since early teens, happens regularly. It's incredibly disabling. She's unable to do sport. This is a real problem. She doesn't get much pain, but she's otherwise very healthy. She has got normal coronal plane alignment. She does have a J sign, no effusion, positive apprehension at 30 degrees. She's got increased internal rotation of her hip of about 80 degrees with a normal foot-thigh angle. So I'll just show you the exam. Here's her J's, and then just her simple rotational profile. Okay. Sorry, I'll go back. I just want you … So she's normal foot-thigh angle, but significant internal rotation at the hip. Liza, what do I need to do now? What imaging do I need to get? Well, in the clinic, you'd have … For me, it would be a standing alignment view, low flexion axial view, which for me is a Lorenz view, but Merchant low angle would be fine, and then a true lateral X-ray. But eventually, you would have to do some kind of rotational profile. And for me, at the moment, it's a CT scan infer version. But I think there's other ways to measure it. What stays? Give us a sort of a take-home message of when should we be pulling a trigger on a rotational profile, CT or maybe MRI, depending where you are. What degree of rotation, when you're doing a clinical examination, you're looking at that rotational profile triggers that test? Well, you're trying to go after femoral anaversion, but I think tibial external torsion is just as much of a problem, but it's really more of a problem for patellofemoral pain, in my experience. But nonetheless, for femur, internal rotation greater than external rotation, or internal rotation greater than 80. And so for hyperlaxed, you might have both. Perfect. Okay. These are radiographs, so we've done our... Might I also say, you've got to look at the radiographs. That's telling you... It's not telling you that there's version of the femur, it's telling you there's version of the limb. Because you see that the condyle, the tibial spine is buttoned into the lateral femoral condyle. You don't see both of the walls of the intercondylar notch. And then the lateral condyle, femoral condyle, looks like enlarged. So for me, I think you can see it on your standing radiographs. And in our institution, you always put the toes forward, so you can't say whether it's femur or tibia. But I believe, Al, in your institution, you try to put the kneecap forward, which I think is harder to do in our large American population. But I think you learn so much from a good standing alignment view. So don't forget your radiographs. So are you happy with that lateral radiograph? Yes. Very nice, Al. Excellent. So you've got a cat on the shelf. Where are we going? We've got a 1.2 cat on the shelf. We've got a 140-degree sulcus angle. So I think you went through a few things. Got an MRI scan, lateral trochlear inclination of 5 degrees, tibial tubal trochlear groove distance of 10 millimeters, TT-PCL of 20 millimeters, and a patellar trochlear index of 23%. So Seth, with those numbers, what's that telling you at this stage? We haven't completed the whole story just yet. Yeah, I think for me, this is a surgical patient, obviously, recurrent dislocated. They have not had prior surgery. I always ask, when to do more than MPFL? I like to know, does everyone think that's a jumping J or a gliding J, I guess? Can I ask that? You can ask that, yeah. Raise your hand. So is that a jumping J? Raise your hand. Gliding. What? Gliding? I'd say gliding. Yeah, I would also. So it's not a jumping J. And I like to look at apprehension into deeper fletching because it helps guide my treatment algorithm. If they have a gliding J, apprehension only to 30 or so, you know, never had prior surgery, other side's normal. You could make an argument to roll the dice with a soft tissue stabilization, but you wouldn't be wrong to add a small bony procedure. So you know, the whole room may not be a whole room of telepharmal nerds. So tell us. Those are key clinical pearls. What do you mean by a jumping J versus a gliding J? What do you mean by that? How do you interpret that? To me, we don't all agree on that, but the jumping J I think is the one that the med student would see when they go in the room and go, oh, you know, it goes out every single time. The force vector issue is enormous. This one, some might say it was subtle. Some might say it's a J sign or no one I don't think would say that's a gruesome jumping J. Right. Cool. Okay. And you think when you see a J sign, Liza, when you see a J sign, what is it actually telling you? What is it? Is it something that you can deal with just a soft tissue procedure? Or do you think you're going to have to do more? The confusing part about this is that it's similar on both sides, and I'm assuming at this point in time, she's not unstable on the other side. She's unstable on the other side as well. She is? Yeah, she is. Okay. Well, that blows that argument. But I do think that- You didn't tell us that. You know, you have to say, is this like her de novo? Because I think if you're that way, the other side has a soft J, you know, you can maybe consider that this J isn't as important. But generally speaking, a J sign means you have to do something bony. What that is, is different, but soft tissues rarely work. It's kind of like having, let me put it in other terms, when you have a posterolateral corner and you've got a varus knee, you know, you have to do something more. You've got to do something bony. So for me, this is the posterolateral corner of the patella femoral joint. Does that help the knee surgeons here? Okay. So we all agreement here that yes, she has got an element of trochlear dysplasia, but it's not too bad. She doesn't have an increased TTTG, and her TTPCL is within normal limits. She has a slight patella alta of a caton de champ of 1.2, but her patella trochlear index is 23%, therefore probably not clinically that much of a problem. Anybody disagree with that? If not, we'll move on. Perfect. Okay. So one point that Liza raised there I think is important. You can see her alignment films here, and it already gives you a very clear indication that there's something going on from a torsional perspective. And you can look at where her feet are pointing, the profile of her left trochanter is at the hip, and you can get an idea whether this is a femoral or a tibial torsional issue. And I just, you know, we tend not to focus on the patella pointing forward, particularly in patella instability patients, because often the patella is sitting lateral, and if you do that, you're going to internally rotate the leg. So we actually ask for the knee to be an AP if at all possible. Sometimes it's just very challenging. So have an AP of your knee when you're doing your hip-to-ankle standing. It's very helpful. Okay? So we do the CT rotational profile, and we get an internal femoral torsion of 55 degrees. Okay. David, 55 degrees, is that an important... Yes, it's caught my attention. I think it's out of the limits that we can agree. So in that case, there are some papers that favor just the NPFL reconstruction, but you have to look at that internal relation. I'm not an osteotomy surgeon, I just do NPFL. In these cases, I send this patient to the guy that does the osteotomy. Great. So you've highlighted the fact that it's a problem, you recognize that it's a problem, but you don't do that type of surgery, so you refer on to someone who does that can help you out. We've all got friends and colleagues, so that's fantastic. Volker, you're an osteotomy surgeon. What are you going to do? I just do a lateral release. I'm just kidding. No, I think you can do a femoral osteotomy, rotate maybe 10 degrees. I'm not sure that you should rotate much more than 10, 15 degrees and add an NPFL. The question is, do you go in the tibia and bring the patella down more? I don't think I would in this case. Okay, Mathieu, you're the osteotomy guru. What am I doing here? PRP. PRP. No, I just follow Volker's tracks, the rotation, medial side, NPFL, lateral release. I would do probably, I think, something around 30 degree correction of the antiversion on this one to get to 25, and I think it's going to work. Okay. We're going to run through this pretty quickly because we want to show one more case. This effectively, we've got help right there. There's proprietary companies that can develop, can help you with your planning, help you with your guides. This is just what was going on just in terms of an examination under anesthesia. You could probably all argue that that's a significant amount of internal rotation. We put the guides on. Very easy surgery because it's very helpful. Once the cut's been made, you can just rotate it around. One last question to you, Liza, if I rotate that femur externally, do I need to do something on the tibia as well? But you didn't say where the tibia started was. What was the external? Tibia's normal. What is that, 15 degrees? Yeah, it was like 20 degrees. I probably wouldn't. But I think if it's a little bit high, then I would probably do both. Okay. So if the tibia's normal, you don't need to, right? Yeah. Perfect. And that's the final result. Okay. David. Okay. We're going to do one last case, which I'm going to skip through Rachel's case. Apologies to Rachel because that's more complex to get through in one minute. And I'm going to have one question for the panel. I've got one question for Al, just on that last case. If someone did just an isolated NPFL reconstruction of that patient, what's the chance of failure? I can't give you a number, but if you look at the studies that have looked at rotational corrections versus an NPFL, the patient-reported outcomes have been shown to be better if correcting the alignment at the same time. So I think that's the key. It's not necessarily a failure outcome. It's actually more of a patient-reported outcome. Because the NPFL reconstruction tends to be pretty good. They're pretty strong. Stronger than the native NPFL. So if there are people in the audience who are only comfortable doing NPFL... I think with someone with that degree of deformity, you refer on to someone who's comfortable doing the appropriate surgery. Okay. That's a good take-home message. Okay. So have a look at this kid here. He's 13 years of age. He's going into a tackle. He gets hit to the front of his knee. And that's the angle that his knee ends up at in hyperextension. And so he's come to my public clinic a few days later. He's painful. He's swollen. He's a bit stiff. And interestingly, his PCL was obviously loose. So if I pushed really hard, maybe I could get it to just into a grade 3 zone. But with a normal force, it was grade 2. He had a bit of lateral laxity, but not a lot. And his ACL was stable. And his MRI showed this. So you can see the femoral-sided injury to the PCL. He's got bone bruising consistent with a valgus and hyperextension injury. His ACL was intact. But it was edematous. But it was intact. And his menisci were intact. And his post-lateral structures had some edema. But they're intact. And you can follow the structures all through from A to B. And the injury to the deep MCL, but not so much the superficial. So fitted with is clinical examination. So we've only got one minute. I want to know, who on the panel wants to do an operation on this kid? Anybody want to operate? Who's going to repair? Rach, are you going to repair that femoral PCL avulsion? Dave, what are you doing? I have done so. What? I have done so. You have done so? Yeah. It's like true confessions, is it? How did they do? So are you going to do it in this case? No, I mean, the thing is that, well, in certain cases, you can, with that amount of PCL stump, you can choose to do a proximal peel-off repair and brace the collaterals. Yeah, so I think that's the question. It's not so much whether we can. And when we have new techniques that companies have that show how we can nicely arthroscopically do a repair, there's a tendency to want to do it. But I'm asking you, do we need to do it to get a good result? Seth, are you going to repair it, or are you going to manage it non-surgically? I have no experience with proximal primary repair, so no. If it's isolated, treat it non-arthropodically. So it looks like the panel is leaning towards non-surgical treatment, which is what we did. So we put him in a PCL supporting brace. He was partially awake there for six weeks. He had the brace total for three months. He returned to training after six months, and he's returned to a pretty high level. If you watch closely, it's a bit of a blurry video, but this is him about nine months later scoring a goal. So there are things we see on MRI scans that we can make a good argument for doing surgery on, but I think if you think clearly and match the MRI with the physical examination and the patient, the capacity to heal, a lot of them don't need surgery as well. So on that note, I just want to thank this incredible panel for coming from around the world. Thank you. Now, thank you all for joining us, and please join us for the incredible meeting in Munich next year. So June 8th to 11th, mark your calendars. Thanks.

David Parker, MBBS, BMedSc, FRACS, FAOrthA

Alan Getgood, MD, FRCS

Elizabeth Arendt, MD

David Figueroa, MD

Rachel Frank, MD

Yee-Han Dave Lee, MBBS, FRCS(Ortho)

R. Kyle Martin, MD

Volker Musahl, MD

Seth Sherman, MD

knee injuries

operative techniques

David Parker

ISACOS

surgical planning

patellar instability

PCL avulsion

ACL/PCL reconstruction

femoral osteotomy

non-surgical management