Welcome to the American Journal of Sports Medicine's webinar. Thank you for joining us. I am Alexandra Campbell, AOSSM Manager, eLearning and Educational Products, and I will be the operator for the webinar today. Before we get started, I would like to take a moment to acquaint you with a few features. There are options for how you can listen to this webinar. If you have any technical difficulties hearing the audio properly, please try clicking the phone call option and calling in for the audio, or switching the speakers that are being utilized. At any time, you may adjust your audio using your computer volume settings. To send a question, click in the text box and type your question. When finished, click the send button. Questions you submit are seen by today's presenters and will be addressed throughout the presentation, so please send those questions as you watch, rather than at the end. There is CME available for this online activity. Here are the disclosures. At the conclusion of today's program, we ask that you complete a brief evaluation by going to education.sportsmed.org and logging in. Please take a moment to complete this if you wish to collect CME for this activity. At this time, I would like to introduce our moderator. Mary Kay Mulcahy is a board-certified orthopedic surgeon specializing in shoulder and knee surgery and sports medicine, currently on the faculty in the Department of Orthopedic Surgery at Tulane, where she is the director of Tulane Women's Sports Medicine. Dr. Mulcahy is the team physician for Tulane's women's indoor and beach volleyball teams, the Big Easy Roller Girls, New Orleans Women's Rugby, the Half Moons, the Hurricanes, which is the women's professional football team in New Orleans, as well as several local all-girls high schools. Dr. Mulcahy is a member of the EJSM Electronic Media Editorial Board and will be moderating our webinar. And with that, I'll turn the microphone over. Thank you, Dr. Mulcahy. Great. Thank you so much, Alexandra, and thank you so much, everyone, for attending and participating. We're really excited to have this discussion tonight. We have great faculty. First, I want to introduce Dr. John Dickens, who is the chief of orthopedic sports medicine at Walter Reed Military Medical Center and professor of surgery at Uniformed Services University. Next, Rafi Mirzayan, who is co-director of sports medicine and the director of cartilage repair and restoration and director of resident education at the Kaiser Permanente Southern California in Baldwin Park, California. He's also a clinical professor of orthopedic surgery at USC School of Medicine. Next up, Dr. Chuck Bush-Joseph. He's currently professor of orthopedic surgery at Rush University Medical Center in Chicago, and he has been a team physician for the Chicago White Sox since 2003. Dr. Bush-Joseph is also former president of the AOSSM from 2017 to 18 and current chair of the AOSSM Medical Publishing Board of Trustees. Finally, Dr. Laith Jhershrawi is chief of sports medicine and director of the Sports Medicine Fellowship at NYU Langone Health. His practice focuses on the treatment of athletes, joint preservation, and advanced reconstruction of the shoulder and elbow. So thank you all so much for being here and for participating in this webinar. We really look forward to hearing everyone's talk. Alexander, great. So these are the learning objectives for the webinar, and we really hope that everyone gets a lot out of this. So we hope certainly that by the end, you'll be able to describe the indications and pros and cons of using anchors versus transosseous tunnels for patellar tendon repair, that you can discuss risk factors for patellar tendon rupture and repair failure and define key components of rehab. We're going to certainly go into detail on some of these things and determine the rate of return to work or play following patellar tendon repair and explain special considerations in the setting of a revision patellar tendon repair. So we have the outline here. Dr. Rafi Mirzaian is going to kick it off discussing an article that he wrote entitled Operative Treatment of Acute Patellar Tendon Ruptures. We'll have a little bit of time for questions, so again, please put those in the chat as Alexander suggested. And then Dr. John Dickens will discuss his study, which is the Incidence and Risk Factors of Acute Patellar Tendon Rupture, Repair Failure, and Return to Activity in the Active Duty Military Population. We'll then discuss a little bit in more detail that study. And then Drs. Lathe-Gerzawi and Chuck Bush-Joseph will give their talks about primary patellar tendon repair and revision patellar tendon repair. And then we will round out the webinar with time for Q&A. So we really hope that you enjoy it. I'm going to turn the microphone over now to Dr. Mirzaian to give us more detail about his study. Thank you so much, Mary, and thank you so much to the AJSM for inviting me to participate in this webinar. All right, so I'd like to start by thanking my co-authors, Jamie O'Dowd, who was a resident, and David Lehaugh, who was a medical student. They definitely did the bulk of the work and data abstraction from the charts of these hundreds of patients, so big shout-out to them. All right, well, let me advance the slide, sorry. There we go, sorry. These are my disclosures. So fortunately, patellar tendon ruptures are uncommon, and surgical repair is a standard of care to restore the extensor mechanism and knee function. The trans-osteous repair has been the gold standard for decades, and outcomes are generally reported to be favorable. However, suture anchors have gained popularity, and there are several biomechanical studies now that demonstrate significantly less gap formation during cyclic loading and higher ultimate loads to failure. And until now, there wasn't a paper, really a clinical paper, comparing anchors and trans-osteous repairs of patellar tendon ruptures, so we presented a large series of patellar tendon repairs and compared the outcomes and complications of trans-osteous and anchor repairs. Our hypothesis was that suture anchor repairs would have a lower re-rupture and re-operation rate over trans-osteous tunnels. We also reported patient demographic information, comorbidities of mechanisms of injury of this cohort of patients. Our inclusion criteria were traumatic patellar tendon ruptures, and exclusions were tears that were more than 45 days from the time of injury, if they were following a total knee arthroplasty or open injuries, if any grafts were used. So these were clean patellar tendon acute ruptures. We use the Kaiser Permanente Southern California database, and this is a community-based practice. And what's nice, if you're not familiar with the Kaiser Permanente, it's a large HMO in all of California, and our patients are essentially captured. And if they have surgery with me, and they go somewhere else and have a re-tear at another facility, we're able to capture that in the electronic medical record. If they choose to go outside of Kaiser, it would be a cash pay situation, so the patients are not incentivized to leave, so the patients are captured. Overall, 114 surgeons contributed to the series in 14 medical centers. Patient demographic information, repair type complication, time from surgery to release from medical care were all recorded. We used binary outcomes for re-tear, re-operation, and infection, and used the logistic regression models as well. We identified 361 patients with 374 knees. On average, this was 1.09 cases per 100,000 members. 13 had bilateral repairs during our study period, and 8 had a contralateral repair for a bilateral incidence of 5.8%. The average age was 39.8. The majority were male. The predominant sport where the injury occurred was basketball, and there was a disproportionately higher tear rates in African-American patients, and the average BMI was 31. Overall, the patients were fairly healthy. Diabetes was the predominant comorbidity. Tear location, 80% or 82% were off the inferior pole of the patella, 8% off the tubercle, 4.8% mid-substance, and 2.2% were complex tears. The average number of implants used was almost two. These are our results in a slide. Essentially, there were no differences in the patient demographic information between the two groups or the tourniquet time. We did have a significantly higher re-rupture rate in the transosseous group at 7.5%, and there were no re-tears in the anchor group. However, there was no difference in the re-operation rate, in the infection rate, or the release from medical care between the two groups. So in conclusion, our primary repair of patellar tendon rupture with suture anchors demonstrated a statistically significant decrease in re-rupture rate, but there was no difference in the re-operation rate, infection, or release from medical care. The age range was similar to prior studies, nearly 40 years of age. As I said before, there was a disproportionately large number of African-American patients, which is similar to our triceps paper that we also published in AJSM from the same database, and the majority occurred during basketball. There was limitations in our study, as you'd imagine. It was retrospective. There were also a larger number of patients in the transosseous group compared to the anchor group, but there was a statistically significant higher re-tear rate in the transosseous group. And we think that a randomized controlled trial in the future would better analyze these findings. So thank you for your time. Great, thank you so much for that really concise summary of your study. Yeah, everybody else, all the other panelists would turn on their cameras too. We'll just have a couple of questions here before we go on to Dr. Dickens' talk. So Rafi, you noted that re-tears occurred in about 24 of 321 transosseous repairs, which was 7.5% versus none of the anchor repairs. And do you have any thoughts? I mean, I know you talked about randomized controlled trials moving forward, but do you or your co-authors have any thoughts as to why that may have happened? Why the transosseous was higher, the re-tear rate? Yeah. I mean, I just think you get better fixation with anchors. I mean, a lot of repairs that we used to do, like distal biceps repairs and things that we used to do, bone tunnels, have gone away to using anchors and biomechanical studies show that it's just a stronger repair with the anchor. So part of the reason I switched to anchors was that I was never happy with tying knots over the quad tendon, essentially, not really necessarily getting it over the patella, over the superior pole of the patella and getting it right over bone. So I always felt like that there was some gap, gapping that would occur as a knee was flexing and that knot was not directly on bone, it was on the quad tendon. So that was, I think. Thanks for those thoughts. Now rapid fire, John, anchor or transosseous? Yeah, I'm still doing transosseous and I can talk a little bit more about that, but transosseous for me. Chuck? You know, I've gone to anchors, I was transosseous forever and I appreciate Rafi's point about that ability to get that proximal knot secured without having that interposed soft tissue that may cost you some gapping. Mary, if you want, just a quick point I'd like to get, Rafi, did you get, were you able to get any information on the timing from when a diagnosis of failure or re-rupture was actually made? That's always a curious thing for me, do these patients fail traumatically or in your mind, did they just fully stretch out and eventually present with pain and weakness? Yeah, so the majority of them were acute re-tears. That's what we really looked at. It wasn't like stretching out or an extension lag. As I said, this was a retrospective study, the chart and the documentation wasn't clear as far as some of them did not document range of motion clearly. So when I say re-tear, these were true re-tears that had an acute injury after the surgery. Right, so yeah, you noted a third of re-tears occurred between zero and 90 days post-op, so interesting. Leith, I didn't forget about you, so transosseous or anchor? Suture anchors, I've been doing it since I came back to practice in 2000. And I have been able to convince all the trauma people at our institution to convert from transosseous to suture anchors. And they're loathe to using any sports device, but they saw how easy it was to use suture anchors and how at least reproducible the results were. And my findings have been very similar to Rafi's study. Well, John, I won't leave you hanging out there, I do transosseous too. And to everybody's point, a little bit about the soft tissue. So I actually will feed the sutures underneath, like basically through the tendon, so I'm not tying it exactly on top of the quad tendon, I'll feed it through to try to get rid of some of that soft tissue bridge and make sure that it's on the proximal pole of the patella. So great discussion, now let's move on to John's talk, where he's going to give us some more information about his study. So hopefully you can see that. So yeah, I appreciate the opportunity for AGSM and the opportunity to kind of have this webinar and have this discussion. I think it's, you know, I've already learned some stuff here and I hope everyone else has as well. And we're going to talk about a study that is forthcoming in AGSM that we looked at, not unlike Rafi's study. So no disclosures for us. I think as Rafi mentioned, these are infrequent injuries in a civilian population, generally between 0.68 and certainly less than one for 1000 person years in the civilian population in terms of incidents. And as you can see here, it's often a sudden eccentric quadriceps contraction with the knee and a mid range of flexion. There's certainly limited epidemiological information, return to activity information, relatively underrepresented study or injury in the literature compared to some other injuries that we commonly see. And we also know that the U.S. military, you know, being a young, active and kind of high intensity group, has some opportunities to study this in terms of being able to evaluate relatively rigorously some of the demographic and injury variables and within a closed health care system. So we set out to look at defining the incidence rates and risk factors for the surgical repair of teletentant ruptures, defining the demographic and clinical and surgical risk factors for failure, and then looking at the return to a high demand activity level. So this was a retrospective review. We had 504 isolated teletentant ruptures. These were primary teletentant repairs done within a five year period. We had a minimum three year follow up within our group. We included those who had an index surgery, active duty military, the surgeries performed in our military health system, they were isolated tears and had minimum three year follow up. We excluded those that had concomitant injuries, i.e. ligamentous knee injuries or multiligamentous knee injuries, and those with associated fractures. We looked at demographic information, we looked at the surgical information including the transosseous as well as the anchor technique for fixation, and we looked at outcomes primarily returned to activity as well as reoperation rates. We defined return to duty importantly in the military population for ability to return to full duty, which requires passing a physical fitness test including running without physical restrictions. We defined failure as either re-rupture, revision surgery, or a persistent extensor lag. And then in terms of the epidemiological definitions, we looked at the total person years of our military population overall, which is the summation of all of our active duty population across the five year study period as a denominator compared to our cohort that was involved in this study to determine the incidence rate. So importantly, I think these are the top three takeaways in terms of the risk factors for patella tendon tear. So if we look at sex, certainly male individuals were 12.6 times more likely than females to have a patella tendon rupture. In terms of race, the African American race was 9.2 times more likely to have a tear compared to Caucasian. And then age, that group that was between 35 and 44 was the next most significant risk factor for patella tendon tear, more so than the 18 to 24-year-old population, which was actually our least likely to have a patella tendon rupture. So this is just the tabular version of that, but I think the take-home point here is that our overall incidence of patella tendon rupture was 6 per 1,000 person years in our active duty military population. When we looked at the reoperation rate and failure rate in these 504 patella tendon repairs after a little over three years of follow-up, 10 of 15 were due to an actual re-tear. Five of 15 were due to an extensor lag, and Chuck, to your point, we identified these failures at 11 months overall as a mean in this failure group. In terms of the transosseous repair technique, we had 409 knees that were in this group. Failure rate was 3.4%, not significantly different from the 36 that had a anchor, and that failure rate was 2.8%. In terms of return to high-demand military duty, we had 449 patients that we had complete data on to be able to assess this. More than three-quarters of those returned to full unrestricted duty without any sort of limiting condition and did so after nine months. We had 14% that returned to activity. They did have some restrictions, and we had nearly 10% that were unable to continue their military service in part at least due to their knee condition. So overall, I think looking at this, the 6 per 1,000 person years in the military population is certainly greater than the 0.6 to 1 per 100,000 person years. In part, this is probably due to the younger patient age and some of the demographic factors. In terms of the risk factors for patella tendon rupture, this data, I think, supports that by White and Owens as well as others that identify age, sex, and race as important risk factors for this. Actually, if we look at patella tendon ruptures overall, this kind of follows in nicely with other studies that have identified this as the second most common major tendon tear just behind Achilles tendon tears that we see. And our 3% reoperation rate, also very similar to Rafi's study, and sort of corroborates that in terms of no difference in terms of transosseous versus anchor techniques. So in conclusion, the incidence of patella tendon rupture certainly is substantially higher in our younger populations and the military populations as seen here. There's non-modifiable risk factors, sex, race, and age that certainly influence the incidence of injury, but we can generally expect overall return to high demand activity regardless of the method of fixation. Thank you. Great. Thank you so much, John. I thought that study was really interesting. And in reviewing the actual manuscript, another specific point that I found to be quite interesting is the difference in the military branches and the rate of patellar tendon rupture. So in your study, you noted that Navy service members had the highest rupture and actually re-rupture rate among all branches of service. And that was significantly higher than the Army and Air Force service members, which had the lowest rupture rates. Now we don't have, you know, we have the Army perspective here. We don't have our Navy or Air Force colleagues a la Tokish and Preventure to weigh in, but perhaps you can give us your thoughts of why there may be that difference in service branches. Is it related to baseline physical fitness? Is it related to activity level? What are your thoughts? It's obvious. And the answer is number one. It's baseline physical fitness. And our neighbor colleagues just can't hold muster for the rest of this. No, I think some of it is probably related to some of the nuances and how they sort of code a little bit differently in terms of their limitations afterwards. So a little bit more nuanced in that perspective. You know, when we look at this compared to other studies, it's generally not the Navy population that's at risk for a lot of our traumatic injuries. It usually ends up being a different population. But the other component to that is the Marine Corps certainly falls within that cohort of Navy personnel in terms of the demographic. And although they're a smaller group, they do have a much higher kind of demand generally than most of our military forces. Yeah. Interesting. I thought it was really interesting. One other question about your study. So 21 patients had bilateral patellar tendon ruptures and repairs. Did you guys end up doing any type of subgroup analysis to determine risk factors in that particular group and time to return to duty? Yeah. No, we haven't. And that's a great question because I think we all worry pretty significantly about the bilateral patellar tendon tears, whether they're simultaneous or sequential. Because I've seen both come in presenting with bilateral or some that in their immediate postoperative period are recovering from one and have another on their opposite side. And I think they're at risk for some significant complications. And I think we all worry about those, particularly with regards to thromboembolic disease and whatnot. Yeah. I know it's a great point, but we haven't looked at that in particular. More to come. Next AJSM study. Yeah. Exactly. All right. I think we'll switch gears a little bit. So I'm going to invite Dr. Leith Jezrawi to give his talk on my technique for patellar tendon repair in the active patient. And when Dr. Jezrawi is done, we will actually transition right away to Dr. Chuck Bush-Joseph's talk. All right. Thank you, Mary. This is a lot of fun. I'm learning a lot. All right. Thank you, Mary. This is a lot of fun. I'm learning a lot, just like John said. So I'm going to show you my approach. And I think it's not only for the active patient, but it's also for any patient. This is how I sort of repair my patellar tendons. My disclosure is we get some support from Arthrex. That's relevant here because they're the anchors that are used in this case. So this is a 43-year-old, he's actually an African-American male, presents with right knee pain, swelling, inability to fully extend his knee after injuring it while playing basketball four days prior. His physical exam is the classic, he's unable to straight leg raise, and you can feel a palpable defect of the patellar tendon. His x-rays show the classic ALTA that you see usually with the patellar tendon rupture, and then the MRI, again, I usually get it to see if there's any other associated injuries, but it showed this inferior pole patellar tendon rupture. Now, so in terms of the indications for surgery, my approach is pretty standard. I try to get him in as quick as I can. I think it just makes the repair easy, but again, with something like this, this is not a rush like some of my distal biceps, which I think when you get those acutely, the surgery's far easier. So I make a midline incision, I do extend it up above the superior pole of the patella. I create my flaps, I don't think this is anything new, everyone kind of does this approach. And in terms of my incision, when I used to do transosseous, it was a little longer, but again, I try to extend the flaps medial and laterally to get into the retinaculum. There's often some residual tendon at the inferior pole, and then I make sure to ronjour it out. You could use a burr here, I don't think there's anything, but you really want to get a bleeding bony surface when you're doing this case. I curetted again, and I always want to make sure I get my finger under the patella when I'm drilling as well, as you'll see. And that's mostly for making sure that the resident, when I'm not drilling, doesn't pierce the cartilage. I usually start with the central hole, and I also tap with these. So you're drilling with a 3.2 millimeter anchor, or sorry, 3.5 millimeter drill, or 4.5 millimeter anchor. These are doubly loaded, in this case suture tape. You can use any of the anchors. It has a sort of a set stop, and you really need to tap on these cases. These are all doubly loaded anchors. And so now you have the three inserted. My contention is that this is a lot easier than transosseous in terms of technical expertise required. Again, I try to mobilize the patella tendon, especially if it's more than a week to 10 days. In this case, I start with either the medial or the lateral one, and I'm just going to pause this for a second to show sort of how I pass it. So if you look, I don't know if you can see my pointer, but the first set of incisions, one stitch from both either the far medial or the far lateral anchor is passed in a crack out type fashion, just to get more bites in the tendon. And the rest are all passed in a mattress. I like this type of configuration, especially with three anchors, each that are doubly loaded, that you're getting six different fixation points. And from my standpoint, I think this is stronger than the transosseous repair. So we finished passing the crack out, and then now we're passing the medial mattress, and we just work our way across. Again, I think this is pretty straightforward to do. Again, these are the middle anchors, so two sets of mattresses. In this case, the lateral anchor, I'm passing in a crack out fashion, one of the stitches, and then this is followed by another mattress. So you can see all these fixation points that you have really help with this. Then I do a surgeon's knot, and then start to tie all the sutures. And usually I do this in full extension, but you can certainly do this in 15 degrees of flexion in the acute phase. And it's really important, you know, certainly to get this right down to the patella, make sure there's no gap in there. I make sure this gauges my physical therapy, how much I can bend the knee, you know, certainly, and that will determine how aggressive I am in rehab, certainly if there's no gapping at the repair site. I repair the retinaculum as seen here with number two fiber wire. Again, you could use any of these high-strength sutures. And then again, I test it out. I have this bump over here, which bends the knee up to 45 degrees, and then I try to get it up to 60, and there was no real tension on the repair. In terms of closure, it's fairly standard. This case, I closed with staples, but you can certainly, you know, close with a monocryl and dermal bond plastic surgery. My PT really depends on the stress of the, how much stress or tensions on the repair site. Typically, I start physical therapy at about seven to 10 days post-op. I really get in, you know, quickly moving into active flexion, passive extension. My goal is 90 degrees by week four. And certainly, when I did the transosseous repair, I was much less aggressive with physical therapy because I was really afraid, as Rafi brought up, a lot of that gapping that would occur with cyclical load and that is seen in a lot of the biomechanical studies. By week four, I'm starting active extension. The brace is locked in extension for six weeks, and then I unlock at week six to eight. I start strengthening at two months, return to sport program at four months, and then full return to sports by six months. And then he was involved in one of our studies looking at tendon healing at both six months and eight months, and you can see that the tendon is reconstituted and inserted on the patella tendon. Thank you. Great. Thanks so much, Leith. Mary, I appreciate that. And I think while I'm transitioning over, Leith, I just wanted to ask a couple of quick points that I'd like to get your comments on. Number one, do you remove the clot or do any kind of dissection of the fat pad from the patella tendon? And number two, are you placing your retinacular stitches before you actually tie your patella tendon stitches or, quote, after? Briefly on that. Yeah, that's a great question, Chuck. So I'll answer the second one. So that's been historically taught to us that we put the retinacular stitches first and tie them off. I tend to do that for a quad, though I mix it up and have really noticed no difference. Especially for a patella tendon, I think, you know, I have noticed no difference in sort of reattaching the retinaculum first versus repairing the patella tendon first. So in this case, you saw I did the retinaculum afterwards. And I really do advise, it really, there's no rhyme or reason why I'll choose one way or the other. It's whatever seems to be right there in front of my face that I could repair. In terms of your second question, in this case, I did dissect the patella tendon from the fat pad. I tend not to do that all the time. And because my concern is stiffness post-operatively when you disrupt that. In this case, his fat pad was so intimately involved with his patella tendon that I really couldn't see a clear demarcation. So I really wanted to free it up in this case to really get a good bite in the patella tendon. Thank you, Lacey. I think those are great points. It was a wonderful demonstration. And I also want to congratulate Rafi and John. Those are tough things to do when you're looking at so many cases. And I think the information you provided and published in our journals is very effective and useful for our listeners and our readers. I'm going to just talk a little bit briefly about dealing with that 3%, that failed patient, the who, when, and where. And we all get disappointed whether they're ours. And you don't feel as bad if they're referred in by another provider. But nonetheless, they appear and you have to deal with them. I have nothing to disclose with anything to do with this type of talk. I show this study here briefly just only to mention that the vast majority of patella tendon repairs that I'm doing are still primarily in the failed total knees or the total knee replacement patients. For whatever reason, I think in Chicago, we've got a lot of docs around town doing joints and they get a little slippy with their saw sometimes. And these patients are much more difficult to deal with as opposed to our sports crowd. I think John pointed out briefly that, and I highlight here, that really almost 10% of the patients who underwent the procedure were medically separated from the army, which really indicates that they obviously did not have an optimal return of function and were left with some degree of impairment. And obviously 3% ended up with a re-rupture, albeit short-term or long-term. I like to look at failures for patients who have a patella tendon rupture on three ways. The first is the most common, and obviously it's patella alta, and the patients present with weakness and pain and may be traumatic, may be gradual in onset. They may have tissue loss, they may have lost continuity between the tendon and the patella and they get proximal migration. The second group, which is a little bit more common, a little bit less common, I'm sorry, is those patella baja or the fibrosis. You know, the surgeon really pulled that patella down to make sure he was getting a solid heal. And oftentimes, I think patients or physicians overprotect these patients and patients end up with a quad shutdown, secondary to a poor pain management, coupled with extensive dissection and they just basically get that big scar ball. And then the third and hopefully the very least common is the patient who becomes uncontrolled sepsis and those are, unfortunately, these are very difficult patients to deal with and really often do need, you know, treatment and experienced hands with appropriate consultation. Now, as I say, there's a lot of patients who really, they may have radiographic parameters where there's a significant alta, right from the other side, but they're functioning, or their symptoms are minimal, or their demands are not that significant, and those patients are certainly best treated with observation. You know, a case like what you see here, a young patient, significant elevation, the time to shunt is well over 1.6, and these patients usually have significant functional disability. But I just want to emphasize, it's a clinical decision whether you decide if a patient needs a revision surgery and it's weakness and pain and or a traumatic rupture. So here's an example here of a young man, he had a patella tendon tibial tubercle, essentially a bony avulsion that was appropriately repaired, but he may have not been as cooperative as he should have been, and re-ruptured and was stuck with a significant extensor lag. And this is a time where I think a simple revision repair is appropriate and is safe with just those augmentation. And so in this case, I used two screws to retake it down. And in this case, I put two wires to augment it. I think when a patient fails a first or primary repair, I'm gonna add belts and suspenders. And you can see at one year out, this patient did quite well, was able to return to high school and even went on to collegiate football. So the second approach is, all right, the patient who re-ruptures, I think it was mentioned earlier, you can say, can I do a repeat primary repair? I really don't think that's often enough. And I think in these situations, you really should be considering adding a collagen. And in this case, whether it be a semitendinosus autograft or allograft, I think in either case that you should. And I think I typically will always do a transosseous tunnel through the tibial tubercle. And then if I've got sufficient length, I'll weave it up into the quad tendon to reinforce the repair. And if I don't have enough length, then I will drill a small five millimeter or six millimeter transosseous hole through the patella in a horizontal plane. You have to be very careful with that because the risk of rupture is significant. But I do feel that in these revision primary repair patients, you do need to add some degree of collagen. So here's another example is a young patient, I think he's 28, soccer injuries, four and a half months after patella tendon repair. You can see his normal knee, the operative knee's got almost a 30, 35 degree extensor lag, quite uncomfortable, very unhappy. I was referring down, even though his radiographs, his static radiographs look pretty symmetric, clearly an MRI scan showed that he had disruption and really was extending only through his retinaculum. In a situation like this, where it's chronic, you're well beyond that acute healing phase. I think these patients do need augmentation or addition of collagen tissue. So in this case, because I thought there was a significant gapping between the native patella tendon with some contraction of that native patella tendon, I felt compelled to put more collagen. And in this case, I used a whole Achilles tendon. And so we fashioned a bone plug down to an appropriate size. We'll make a groove, almost a reverse patella tendon harvest for an ACL, but I do in a trapezoidal manner. And then extend that over the top, close the gap, seal it within the patella retinacular tissue, and then even extend sutures on up into the quadriceps tendon. These patients gotta go a little bit slow in the rehab and they still will stretch out a little bit. That's been my experience with allograft tissue, but you're gonna see him here at about four and a half months after surgery. He's got full active extension, a little bit of elevation. So his radiographic indices are a little bit off compared to the contralateral side, but he was able to resume normal function and was actually back playing soccer at nine to 10 months after surgery. But the next set of problems you deal with is this patient here, patella baja or severe arthrofibrosis. Unfortunately for this man, mid thirties, traumatic injury, got infected, required four debride months to get his infection under control. And the surgeon was appropriately nervous and cautious about getting wound healing and closure. And so he immobilized him for an extended period of time. Well, he obviously was able to get the wound healed and a dry aseptic knee, but obviously with near complete ankylosis. And with this degree of soft tissue calcification, your primary goal is just reestablish some motion. And so in this situation, this was well beyond any attempt at an arthroscopic license. I went to an immediate open and tried to perform retinacular releases while maintaining the extensor mechanism and could not get him flexed beyond 40, 45 degrees. And so in that sense, I knew that I had to get to a more radical solution. And in this case, I detached the entire patella tendon off of the tibial tubercle, still had to perform further capsule releases, even along the deep MCL in the lateral capsule before I was able to attain at least 90 degrees of deflection. But with that kind of a gap, there was certainly no more primary repair. And again, in this case, I use a whole patella tendon, patella tendon, tibial tubercle construct. And so we make a reverse trapezoid into the patella. I wire it down as you can see, and then two screws into the tibial tubercle. In this case, because I had good motion on the patient, because I felt very comfortable with the degree of initial fixation, I did allow early motion. And again, you can see at four months, this patient had full active extension where he was completely fibrotic and had complete loss of his quad function before that. I just put this slide in because just to show you anecdotally, we've got some people around Chicago who love to throw dermal allografts and everything. Just because it works in a shoulder and a failed cuff repair, it does not work in this situation. And I'm not a fan of this at all. I think there's some literature about the use of mesh and Marlex mesh, but I think the dermal allografts in these situations are really poorly responsive. This patient was probably not a good indication and really had no muscle function to regain. Here's the serious thing that we most worry about is really that patient who had surgery, uncontrolled sepsis, and this patient had a primary tendon repair. He's a little bit older. He's maybe not as healthy, but again, he was in his late 40s, a complete rupture at surgery, had two subsequent debris months before he was referred downtown. Unfortunately at this point, uncontrolled sepsis. And so you've got to prioritize and prioritize in this situation, infection controls, number one, soft tissue coverage, number two. And then finally, number three in a delayed manner is really restore active extension. And so he required aggressive wound debris months. Unfortunately, there was significant non-viable tissue and he required skin grafting to get him closed. And so really to get infection control and a closed dry wound, I was really left with a dry ankylosis with deficient skin coverage. So in this situation, I essentially went back to that second or third patient that I showed you. In this case, reestablishing motion before trying to get active extension. So in this case, he required an extensive open debris month to regain full range of motion. I knew ahead of time that I was going to have insufficient soft tissue coverage and the size and the area of the defect was not a minimal to a skin graft nor to a gas rock flap. And so our plastic surgery colleagues actually felt that a latissimus free flap was most appropriate. And you can see, I used my whole patella tendon, tibial tubercle graft. Again, wired into the patella, screwed into the tibial tubercle with the quad tendon extension going up into the native quad. And with the, again, having the latissimus over the top, obviously wound healing was not a problem. We had a good blood supply. He did get a bit stiff and did require two arthroscopic lyses and able to eventually attain about 95, or about 100, 105 degrees. And he was able to play tennis for the next 15 years. And he's almost 18 years out now with good results. So in essence, I want to reiterate that the primary indications for surgery are not radiographic parameters. It's weakness and pain and loss of function. And if they have tissue loss, you need to add collagen. And how much collagen you add depends on how much tissue loss you feel you do have. When you're dealing with patients in the severe fibrosis, you've got to regain motion. In many of these patients, you can regain motion while maintaining continuity as long as they can develop a quadricep contracture to pull in that patella so they don't get that permanently recurrent patella baja. And finally, in sepsis, acute management, get the infection under control and get wound closure first. You can always deal with active extension or range of motion on a delayed basis. So with that, I'll cede my time back to Chairman Mulcahy and look forward to the questions. Great, thank you so much, Chuck. That was an excellent talk. John, Rafi, Lee, join us. Thank you so much. Chuck, I have a quick question. Have you had any issues with sort of creating that trough in the patella? Usually, when I do those reconstructions, I get nervous about, because I'll do the same thing as you do with the tibial tubercle, screwing it in when I'm reconstructing the tendon, but I tend to put anchors into the inferior pole of the patella and then sort of suture the tendon to that. I just wanted to know if you had any incidents of fractures when you create that trough, when you sort of wire down the patella and the graft together. That's a good question, and I have. Thankfully, none of them have been in young patients. The fracture that I have had, and I've gone away from in the total knee, the older patient or the total knee patient, where I've had a couple of patients who subsequently slipped and fell, and they obviously develop a fatigue fracture. The reason I stuck with the bone trough technique is just it's a reverse pedestal, so the wide part of the trapezoid is up top, and when they actively extend the knee, it's pulling it in. The key element on the trough is making sure that you preserve that inferior cortex of the patella, and so it acts like a mortise and pedestal kind of approach, and with that, I've been so confident, and you saw in my patients, I aggressively move these people and really have not had stiffness in these, even in the reconstructive fibrotics. In the older patients, or certainly in the arthroplasty patients, yeah, I've been burned enough that I've stopped the cutting grooves in patella, so that's a good point, and I should have emphasized that. And just one more question. The residents and the fellows asked me this question. At what point do you decide on these chronic patella tendon ruptures with ALTA? How do you decide when to do a VY quadricepsplasty to bring that patella down, and how do you do it operatively? Well, I would say in those patients, you know, it's really, I'm doing more VYs in situations of a quad, you know, the quad tendon patients where I can't, you know, I'm trying to get viable tendon down to the level of the patella, but in the patella patients, you know, I generally am not doing them because I'm just doing such an extensive retinacular release, and I'm releasing the quad from underneath the patella, that I just haven't gone there. My big fear in these patients is that if they don't have active quad function, that patella's just gonna, you know, it's gonna stick on down, and they're gonna get up with a Baja and a loss of motion situation. And in these patients, I think it's critical, if you're gonna start operating on them, to make sure that even a little bit of therapy beforehand, whether it be with electric stem or whatever, that they've got active quad function to be able to pull on that patella. In the motion loss patients, if they don't have active quad function, they will fail and they will get stiff again. Great, thanks for those questions. Those are complicated situations. I wanted to go back a little bit to revisit the post-op protocol. So Leith, you gave us your protocol. That was fantastic. I wanna ask John, what, you know, is there anything different you do in your protocol? And if you could comment specifically on brace wear, when you start unlocking the brace, what's your protocol for doing that? Yeah, so for a primary patella tendon, so not the complicated revisions that Chuck was talking about, because I think they're a completely different animal, I will, I'll range them interoperatively. I think we sort of alluded to that in some of the case discussions as Leith and Chuck mentioned, to get assessed of any gapping and what degree of range of motion that will occur. I generally leave the patients locked in extension for 10 to 14 days, see them back. I'll start range of motion from zero to 30 degrees. I'll be non-weight bearing for two weeks. And then I'll start range of motion generally about 10 to 15 degrees per week with the goal that at six weeks, maybe even depending on kind of how they're progressing, maybe a little bit sooner, they're at 90 degrees. Our patients are a little bit younger. So probably than maybe some of the other populations. So we don't generally see too much issues with getting them their full knee flexion back. So that's been a protocol that I've sort of kind of developed tailored a little bit over time that's been working for us. Fantastic, Rafi, anything you'd add to that? I don't know if he's, oh, you're on mute. Just lost the audio, sorry. There you are. Okay. Sorry, yeah, I do the same thing. I assess gapping and I just like Laith said, with anchors, I see less, so I can be a lot more aggressive with them. I also want to get them to 90 degrees as soon as possible, usually within four weeks. My rehab was literally exactly like what Laith does. So I just wanted to pose a question actually to the panelists. How many of you do an internal brace with your repairs in acute primary repair? Have you guys adopted that for a patella or tendon? No, I have not. How do you do it? The same thing that you did with the anchors. I actually suture the tendon first with a fiber wire loaded through the anchor that's already preloaded with the fiber tape. And then when I put it into the patella and secure it, I have the fiber tapes coming out and I just dunk it right by the tibial tubercle where the patella tendon inserts. So that kind of acts as the internal brace technology that we know for ACLs. I would say briefly, I've seen shown some of my older x-rays and I think I'm the oldest one in the bunch here. Routinely, we used to collage wires on everybody that we did a patella tendon repair on and we knew eventually the wire will break and sometimes you had to remove it. I think you always have to do something and Rafael Bialce, you've probably stimulated, I should be doing that maybe more often than I am. I've traditionally done basically just a trans-osseous drill hole through the tibial tubercle with a number five fiber wire. And then criss-crossing it across the top of the patella tendon through the quad tendon as a backup. And I have had no complications from that, but I've routinely done something to sort of make me sleep better at night. Yeah. Yeah, I do like that, Raph. I mean, I've in the past before anchors would take a fiber tape and drill it through the tibial tubercle and then just wrap it around. Again, just like Chuck was saying, eventually it'll stretch out or break. But I do wonder whether the internal brace as you're going beyond 90, whether that will pull, how much stress is on the anchor itself and whether that is with cyclical loading. We know that the anchors don't typically pull out, but I've had some cases where they don't fail, but I've had some anchors pull out. And I often wonder whether this will contribute to it pulling out more. The patients are fine. It happens much later in the course after healing, but you get those reactions around the anchor sometimes, even the peak ones, and they come out. Well, that's interesting. I was gonna say, and I sort of, I didn't go into it, but we were talking about earlier the anchors and the transosseous techniques. And when we started to see some of the early anchors, at least in our institutions, a lot of them were being done kind of by a lot of different folks. And I think people who may not be as comfortable doing kind of anchor technology and that sort of thing, especially in the patella, which is much harder bone than a lot of other places where we put anchors, I think maybe not are tapping completely or aren't getting the good fixation. And to be honest, that was sort of the genesis for our study. I thought we might see something that was actually a little bit unfavorable for anchors. It didn't turn out that way, but that was sort of the impetus behind that. And I mean, anecdotally, just why I've been a little bit hesitant, maybe Rafi and you all are all convincing me I should be doing anchors and I'll do it in my next one, I guess, but. I'm still on transosseous, John, I'm holding strongly to it. But I was scrolling through some of the great questions from the attendees and actually several of them related to any augmentation, suture augmentation, wire, et cetera. So we just had that fantastic discussion. Leith, I'll throw this one to you, switching gears a little bit, although you and you had brought it up with Chuck. How do you determine the length of VY lengthening if you're incorporating that into like a revision situation or whatnot? Yeah, so it's rare. I agree with Chuck. I rarely do it in the, the one that I remember doing it on was a patella tendon chronic that was, his patella was at the mid thigh level. And I'm exaggerating, but it was one of those ones where he scarred in and I did all the releases and I could not get that down. So I did do a VY. So what I do is I put the knee and that's a great question at 45 degrees and I measure the gap. So let's say the gap is three centimeters. The triangles, your two, the V portion of it has to be double that. So six centimeters on each side. Now you can imagine you get to a point and you can determine this pre-op if the gap is eight centimeters, right? And that's problematic. Meaning when I say the gap to get the patella down into sort of that correct seated position in the trochlea, then you got to make arms that are, or the V part 16 centimeters. That may be getting you into muscle and that's where I've had my complications. The higher you go up and if you start getting higher into the muscle, there's more bleeding. And what you end up doing as you bring in that down more, you end up getting more devascularization. And I think that's, you know, they talk about devascularizing the patella. It happens and it happens with what I just described. And you think you're a hero, you think you're a great surgeon. Chuck shows all those, you know, great videos and they're sometimes challenging cases. And when you try to be a big hero, sometimes you can get that. So, you know, I would be careful about the extent of your VY. You got to be careful about going too high, but that's how I determine the amount. Thanks for the tips. You know, Mary, I just want to augment something that Leigh says that some of the complications I've had in some of these complicated revisions, usually they're more commonly in the older patients where I'm doing a quad revision and I was doing transosseous tunnels with using sutures that have Kevlar cores. And I don't think you can do that. And I went straight back to just regular braided suture because the Kevlar core sutures in a situation where there's gapping or the quad tendons pulling on or even the patella, I had two patients that developed longitudinal stress fractures from that violin string poking in and out and ended up with these longitudinal fractures that required secondary stabilization. So that was one of the, that happened to me in revision patients who are older with quad tendon, but that sort of helped stimulate me to go back and go to become a full-time anchor guy as opposed to a transosseous. Great. Well, thank you guys all so much. I mean, I can't believe it's already eight o'clock. It's been a fantastic discussion. I certainly have learned a ton and I hope everybody who's listening in has learned a lot too. If anybody has questions that's listening, please don't hesitate to email any of us. And we really appreciate you being here tonight. Thanks so much, Chuck, John, Rafi, and Leith. Those talks were excellent. Really, really appreciate this fantastic discussion. Mary, I'll add one point that Chuck brought up that's very important on the revision cases. I was very impressed. The tendencies for people to not get them and those chronic cases, revisions with all that allograft moving quickly because we want scarring to occur, but it's the exact opposite. You want to get super strong fixation and move them quicker because if you don't, the quad scars down, everything scars down. And when you finally bend them, your construct starts to rip. So that was great, Chuck. I do the same thing. I try to get them moving right away. Yeah, thank you for making that very important point because I do think we'd all think we have to protect it. We have to go a lot slower with these patients. But yeah, excellent point. Got to get them moving so that they don't get stiff. All right, with that, I think we'll close it out. And thank you again so much. Excellent studies, John and Rafi. And really, thank you all so much. Thank you. Bye, take care. Take care, guys.

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