We'll now open up the session for question and answer. The microphone is at the front and you're also welcome to send in your questions through the app. If no one has questions to start, I see the microphone, what if we start with John and say, John, any issues in your series with Hill Sachs impaction fractures, did you monitor that? Were there any REM plissage procedures? Another question is why the dichotomy of knotless and knotted? Was there any change over time or was it that some docs used knotted and some did not at Rady Children's? It was an evolution over time and just in our practices from the introduction of the knotless suture anchor and even in my own practice, I slowly went to an all knotless construct using a knotted suture anchor, especially at the six o'clock position because I personally didn't trust the knotless mechanism and then as results were coming back and they seemed favorable, went to a knotless only construct and I think that was the same thing at the other institution. In regards to Hill Sachs impaction fractures, there were no REM plissage procedures done in this case series. Bony bankart was about nine in each of the knotted and knotless groups, so we did have some bony bankarts included in this. Did you record the size? Were some larger than others? No, we didn't look at those other factors. Question from the microphone. Thanks. Rob Wilson from Augusta, Georgia. I have a question for Dr. Malewski. I really appreciate the subject matter, something I deal with a lot with my patient population, and my question is if you have somebody who you know is coming from underserved area who's getting a repair, do you make your follow up pattern a little bit differently for them? Do you make more points of contact from your team or your care team? Do you do anything different in that particular setting to try and encourage a more successful outcome? Thanks, Rob. Rob, that's a great question. It certainly speaks to the aftercare of these patients, which can be challenging for any young meniscus repair patient. There's lots of factors that influence their ability to rehab well. I don't per se do anything different with my rehab with these folks, but I think certain patients that may have access issues, if you can identify those early in making sure that you have good lines of communication with their physical therapist, with their parents, with everybody involved in their care, that can definitely increase their treatment. This question is for Dr. Hayworth. For the distal clavicle fractures, for the sutures repair, what kind of sutures were they used for and what type of fractures, like minimal displace or lots of displacement? No, I think all of these fractures were at least moderately, if not significantly displaced. Just by the nature of them being indicated and knowing that most distal clavicle fractures in young people do well, these were either significantly posteriorly or superiorly displaced. The patterns were wide displacement, but different patterns in terms of oblique, transverse, and what level, i.e. how much of a distal fragment there was. For the suture-based repairs, you might have had less bone distally, but these were number two rated sutures, high-strength sutures, and it was a variety of different constructs in terms of sutures placed through drill holes between the distal and proximal fragment. Some were instances of there wasn't enough of a distal fragment, so holes were placed in the acromial side, probably the most common, though included drill holes through the clavicle at the level of the CC ligament and then a Mason-Allen construct through the base of the periosteum, which really is almost like a CC ligament repair, and then a superior periosteal closure over the top. Peter Waters and Don Bay were world-class pediatric fracture experts for many years and have used these and taught the group, and so, surprisingly, they do great. We saw, I think, only one case of displacement, and so you need to lock them up a little bit more, especially the SAGE group, but otherwise, surprisingly, they do as well as plates. Staying with Ben, briefly, do you have a series of patients with similarly severe fractures who were treated non-operatively, and then how has this study changed your practice? Have you gone to all suture-based repair? Yeah, so I would say it depends a little bit on the age. I'd say the older the adolescent becomes, the more likely I'm trying to use a plate if there's enough of a distal fragment to take some screws. Our non-operative cohort is just 5 to 6x the size, and so most of those are sort of minimally displaced and wouldn't warrant surgery, so we're struggling to find a comparative cohort. It's changed my practice to know that, really, the ones you need to look closely at the ones that are posteriorly displaced, because I've been trained to think those are the ones that do more poorly, so through the trap. A lot of times, we're pulling the fragment out of the trap, and it's hard to imagine that they would do well non-operatively, so axial imaging with radiographs or a low threshold for a CT in these young patients, you can't always make it out in terms of exactly where it's displaced. Excellent. Go ahead, Phil. Just a question for Dr. Yoder. When you were with the team at Cincinnati, Dr. Parikh and others, as you guys conceived the project, was the purpose to help augment for diagnosis, or was it more where maybe to go after surgically, and do you know how they may be using it now? That's a great question. The purpose was to augment for diagnosis, specifically, but we are considering future directions to see what the morbidity might be related to these capsular dimensions that we're measuring. If there is a higher recurrence of instability with a laxer capsule, for instance. As for what they're doing now, I'm not sure, and I have to defer to Dr. Parikh for that, but I know that it is something significant that we're watching. Great. Mason, I'll stay with you for a second. I'm not sure if you guys had in your control group, a lot of kids have generalized laxity to start. Did you check a Beaton score or their laxity scale in the control? If you don't know, that might be something you'd add, bring back to Chital. I do not know that, but I will bring that up with them. Great. Excellent. Thanks so much. We are right on schedule, and so we'll move to the next session.

Q&A session

surgical procedures

patient care

Hill Sachs impaction fractures

knotless sutures