Thank you to everybody for inviting me to speak today. Let's see, we'll go. I have no disclosures and I'm going to be talking about what we've learned with the Jupiter Study Group. I'd like to first thank my co-PI, Chantal Parikh, who's not here today. Doug Mintz and Kathy Emery head up our radiology team. They are the lead radiologists, Doug at HSS and Kathy at Cincinnati Children's, Matt Vierkamp at the lower left and Simone Gruber, our research coordinators, Matt at Cincinnati and Simone at HSS. And this is the group that we meet weekly to make sure that we have everything kind of going in the right direction and Matt and Simone really keep us on track. This is the group of sites and surgeons. We currently have 22 surgeons and 12 sites and all of them have been integral to creating the Jupiter Group for patellofemoral instability. Jupiter, I give total credit to Chantal for coming up with this acronym, Justifying Patellar Instability Treatment by Early Results. It is a hypothesis-driven, multicenter, multi-armed prospective cohort developed to obtain sufficient subjects to better describe clinical characteristics and predictors of clinical outcomes in the young patellar instability population. After training and IRB approval, surgeons began enrolling patients in 2017 between the ages of 10 and 35 years old who had experienced a patellar instability event. Treatment is based on surgeon preference and surgeon decision, but it does require that if there's a medial-sided reconstruction, it is an MPFL reconstruction with a graft. So there are no medial reefings, no imbrications and no repairs. But with that MPFL reconstruction, you can choose from a la carte surgeries, again, based on the surgeon preference, including TTOs, coronal and rotational corrections, distalizations, trochleoplasties and any type of lateral lengthening procedures or cartilage reconstructions. Our baseline information includes patient demographics, dislocation history, physical exam characteristics and a baseline validated PROs. We have a patient IQ as our current data patient registry platform, and we switched about midway through. This has been a great platform to work with and has been customizable to what we need for the patellofemoral patients. The cohort is divided between first-time and recurrent dislocators, as well as between operative and nonoperative patients. As of December 31st, 2021, we closed enrollment from our first two portions of the study, and with our 22 surgeons from 12 sites, we had prospectively enrolled a total of 1,825 patients with just over 2,000 knees. As I said, Jupiter began enrollment at the end of 2017. We have had some early seed funding from PASNA and ANA, as well as two institutional grants, one from Hospital for Special Surgery and one from Cincinnati Children's. And as Bob Marks pointed out, why multicenter? This is a problem that really needs a large database and large numbers of patients to answer the big questions, certainly some of them being which first-time dislocator needs surgery, as the current standard of care is nonoperative in the setting where there is no osteochondral fracture or loose body. And of course, what surgery do we do for the recurrent dislocator, or said otherwise, when is an MPFL enough? We've learned many things from Jupiter. I would start with the fact that at the very beginning, our go-to was to get some help, and Rick Wright was kind enough to give us his time and his expertise, and a lot of multicenter hacks that we tried to implement. Radiology measurements have turned out to be critical. Radiology is, this particular field of patellofemoral instability is very radiology measurement heavy and getting the factors and the radiologists to find measurements that were reliable has been a very large part of our last few years. We're going to thank Peter Fabrikant for his help with this as well as our radiology team. And they have really worked hard because, as you know, after reading a bunch of different papers on patellofemoral instability, even the way we measure trochlear height can be different from one study to another. The way we measure trochlear depth or trochlear morphology can be different. And none of it really matters unless those measurements are reliable, and that's what we've spent a lot of time making sure that we are measuring reliable measurements, and then we will look for which ones are clinically meaningful. Centralized IRB, I know, has been said before, very critical to sparing a lot of time on our RA's part. Plan for RA changes, obviously, the turnover at each site is not infrequent, as most RA's are about one to two years, and having a very detailed training document and frequent meetings with our research coordinators has helped to mitigate some of the delays. Strong data platform, as I said, we started with a different platform and moved over about two years into the study. It took a lot of time to move. There were a lot of glitches, even with our current, but this platform has given us a lot of flexibility, and most importantly, it is user-friendly for both the patients and the RCs, and it gives us a very good way to view the data and to monitor the different sites. And I would say most importantly is the teams. As everybody else has iterated, these kinds of studies don't happen without teams. Teams at each site, and then teams of sites. Our teams are surgeons, radiologists, rotator, rotator core, sorry, I just was thinking about moon, research coordinators, research assistants, our epidemiologists and statisticians, and very important are our clinical and support staff in our offices that allow us to do this while seeing patients, which can be time-consuming. And this is our team of teams, and we're very grateful to have everybody participating. This is some of the early work that we've published. The first one is about surgeon reliability and assessing growth status, and this is, again, Pete Fabricant really took us to this to make sure that when we all looked at skeletal maturity, we could measure our own images and have inter-rater reliability. And we didn't at first, and what we saw is that there was a lot of poor inter-rater reliability, but then with clinical training, which means looking at a PowerPoint and everybody looking at the same PowerPoint on how to grade it, we found excellent reliability with this. And so that was our first paper. And the second one is the radiologist really had to find the reliable measures, and unfortunately that meant doing the same clinical training and when the measurements weren't reliable, really getting rid of them. Because if we can't have the same measurements determined by different radiologists, it really doesn't matter if we think they're clinically meaningful. Descriptive epidemiology is the next study. It's got in already a manuscript. It's going to be presented later today in the Patella femoral section from the evidence of the Jupiter cohort, and variability in MPFL technique, which was presented this winter, which will be in publication hopefully within the next few months. Future directions for Jupiter, we want to answer some of these larger questions that we all want to know what to do with those first-time dislocators who are in the high-risk group, and also which surgery should we be doing for the recurrence. And our ultimate goal is obviously the creation of a standardized algorithmic approach to all patellar instability. We look forward to more to come from Jupiter over the next few years. We've finished and closed out our enrollment for the first part. We look forward to starting our enrollment for our next project, which is due to begin this fall. And hopefully we'll be presenting some of this follow-up data from the early years in the next couple of years. Thank you very much. Thank you.

speaker

Jupiter Study Group

multicenter study

patellofemoral instability

MPFL reconstruction