Ladies and gentlemen, good morning. It's a pleasure to be here. It's a pleasure to co-moderate this session with Joy Boyd and especially a pleasure to see our two societies go together along the way working together in our education mission with the fantastic relationship between our two leaderships. We have a very good panel today, very diverse on gender and on geography. We will have Seth Gamratt from South California, Christopher Reading, Keating from Ohio, Katherine Logan from Denver, Colorado, Bob Marks from New York City, Kate Wetzel from Melbourne, Australia, and Enda King from Qatar. To start I will show you some cases and the idea is just to motivate our panel for the discussion I have written to play. So the first case is a 25-year-old male football player from the Portuguese First League with an injury and hyperextension during landing and he had a large grade 4 traumatic cartilage rocker lesion that you can see on the image and he had normal patellofemoral alignment. He was treated conservative and at nine months he came to have an arthroscopy with removal of a loose body and micro fractures. At three months of follow-up he had a very good recovery, symmetric isokinetic, symmetric functional tests, a slight discomfort in squatting and landing, no swelling, no pain in normal range of motion. However, the cartilage showed this image in Fatsat and T2 maping. We had a pressure player who wants to return to sport, wants to play a crucial game at the end of the season. Can you do it? We did not allow him to play. He played only seven months afterwards with better results on the symptoms and better results on the image. And we prepared some questions to the panel. Do you think, and I'm not going to address all of them, but those that are more important. Do you think location size depthness of the lesion matters on return to sports? Is there anything more relevant? Do you want to start Chris? So a couple comments. I think microfracture in these young athletes can give you some good short-term results, but they don't tend to hold up long-term. As far as the size and location of the lesion, obviously the larger, more critical to look, the larger the size of the lesion, the more critical the location, the more likely they are to have breakdown of that microfracture repair site and more likely to be symptomatic. So I think it does factor ultimately into the decision-making. Moises, what is the South American vision? I think that very similar to the case that just presented and actually if you don't have any other thing to do, you can do microfracture, but I don't believe on microfracture to professional soccer player because I think that they can run, but when we do this deceleration or even jumping and in soccer each six seconds you need to do an expected movement. So in my case, I would do something different, like I show it main set cartilage if possible or some other kind. Do you allow that patient to play at three months on that situation? No, I think that three months is very few time and of course sometimes you have the pressure of the team, the coach, everybody, but you need to take care about that because if the athletes is doing okay, he wants to come back, but you need to tell him that we have dangers to come back and the lesion can increase. So I think that is very few time. I wouldn't expect a little bit more. Seth, can we allow a totally asymptomatic football player at three months after microfracture in this situation to play with abnormal MRI? Well, I think your case showed it. What we saw was immature healing on the MRI and you took an MRI three months later was much better. So I would I think waiting was much better for this particular athlete. Catherine, do we have any objective criteria where we can rely on? At that three-month mark or later? No, no, seven months, but we want to be sure that this player can play. So I would like to have some strategy to decide. Sure, I do take an approach to my athletes. I really do take a very comprehensive sort of data-driven approach throughout their sort of recovery. So even I think first of it is you have to sort of lay it down from the beginning as far as setting that expectation so they know at that three-month mark that I wouldn't be allowing them to return to sport no matter how they feel. But in my office, I also start doing some small testing as early as six, eight weeks out. You know simple things like force plate squat symmetry and then each sort of follow-up visit sort of adding in things like single leg squat looking at their valgus moment doing drop jumps down the line and sort of I think you know as Dr. Webster sort of talked about you know confidence is an issue and that's going to be really important. So I think if you integrate these small steps of testing early it starts to let them understand one, what are the rules that return to play? But two, you know what's the expectations? Can they build their confidence and know that when they do get to that return to play piece they're ready? Thank you. Bob, any tips on this decision-making process? Thanks Joao. Not much to add. I agree with everything everyone said. I just want to also mention that every patient and certainly every athlete is unique in terms of their desire to return, their level of competition and so forth and I think that taking into account some of those factors could sway this decision, which obviously was the right one, worked out well. But for example, if the if the athlete was right near the end of their career and had a chance at a championship or they had a chance to get a contract and without return to play their career is over, those are situations that require a detailed discussion of the pros and pros and cons and if the athlete understands the risk to them they may elect to accept those risks if everyone's on board and it's reasonable. Kate, anything to add to that tips on your side? Completely agree with Bob. The whole context for the decision-making is really important to consider. Not just the medical side of things, but how the impact on the athlete's career and other aspects of their life as well. Thank you so much. Next case is a case of an ACL, a 20 years male professional football player, you can imagine that Portugal is football and so isolated complete ACL tear. He was operated with an ICL, a single bundle reconstruction with BTB and that had five months of follow-up. He has no pain, no swelling, normal range of motion, symmetric isokinetic and functional testing. ACL, RSI, very good, normal Ackman, normal anterior doral test and dial test. He has a slight lateral pivot shift and the only thing he mentioned is my knee is not normal when I do pivoting exercise. The player, the manager and the coach are pushing to return to sport. Regarding the x-ray, the tunnel seems to be in a nice position. The MRI shows a nice image too for five months. Because he had these symptoms, we use a strategy to evaluate bone morphology. We have several studies on that to try to identify risk factors. We are very focused on the lateral femoral condyle. Measuring that line X, that it's the line of the more plain part of the lateral femoral condyle, we put an index. That measurement related with the AP distance on the lateral tibial plateau. We have a ratio and the threshold is 0.8. It gets 0.55 for he has risk on bone morphology on the lateral condyle. Another thing that is very important for us in these cases is very difficult with the clinical examination only to be sure if he's stable enough to play football again. And so we use our device to do the stress MRI. We can do a 360 degrees evaluation in stress, PA, AP, rotations and the interesting situation is that on the left you see the medial tibial plateau. He has no movement on the tibial plateau. So that justifies that the Lachmann was normal. But when you test in internal rotation, you see that the lateral tibial plateau advance 12 millimeters compared with 2 on the normal knee. So it seems that he has an increased rotation, an increase in stability in rotation. Because he was at five months, we did an arthroscopy of course on him with that symptoms and we identified that the cover of the footprint on the postolateral bundle was not so good as it should be and we would like to have and we did at five months a lateral external tenodesis. He returned to play four months later at nine months of the injury, keeping his activity in the same club and the same position. So the questions to the panel. Should we rely on clinical examination only or in your hands, in your experience, it's important to have a tool to measure? You know that a lot of scientists say that if we don't measure, we cannot improve it. So starting again by Chris. I think obviously the you need more than just a clinical exam. In fact, it expands to you know functional. We see athletes that are incredibly gifted and even on exam they may be suboptimal, but they're able to perform at a very high level and their confidence level may be quite high. The things that Kate measured. Ultimately, you need to take into account their exam, their psychological status, their neuromuscular function, their ability to perform, and as Bob Marx referenced, do some type of risk-benefit analysis of that particular player in the situation in the season in the career, but more specifically to this, I do think that objectifying a patient who feels like his knee is not as trustworthy as he'd like, and if they've maximized a neuromuscular, they still have some issues, need to quantify and look a little deeper for some unrecognized rotary instability. Moises, do you think it's useful to to measure rotation instability in this kind of patient or you rely only on clinical examination? No, I think that's of course first of all the clinical examination, but if we have objective data, it's easier to indicate something else, mostly in professional soccer players, so in those cases, I think that if you have this data just in beginning, explosive pivot shift, how you do the extra-tubular millimetre together with the ACL reconstruction, and the same way that we need to consider the lateral plateau, because it's important, also we need to consider in some cases the posterior slope, so it's the same thinking, and regarding to come back, the parameters to come back five months later, return to play, depending on the condition, I think that's too early, because we know that as much earlier you come back, the possibility of rupture is increased. In the past, I remember many years ago, when I thought, oh, my soccer player came back in five months, it would be wonderful. Today, I don't do anymore. Eight months, nine months is the average. Seth, one of the advantages of this kind of measurement is you can easily separate what is the rotation instability, what is the transluction instability, and the two together. Do you think that we need to think 3D in these kind of patients, having both measurements to know the amount of transluction, the amount of rotation, and all together? I think that's a great question. There's a lot to unpack here in this case. So, in my practice, adding a LET happens for three categories. Number one, they have a lot of hyperextension. Number two, they have an explosive pivot shift. Number three, if they have laxity. And so, I think I try to make those decisions preoperatively and do the LET at the time of the index ACL. But this new technology to look at the MRI and internal rotation looks fantastic, and I'd love to see more work on that. Catherine, what is your strategy nowadays? We know that the young guys below 25 years old are a problem, a recurrence rate. Do you propose on a routine basis ALL of lateral tenodesis on those patients with explosive lateral pivot shift? Yeah, I probably, as Seth indicated, probably have the same sort of buckets that I think about LET plus revision, I would say, is the ad that I put in that population. And I think even more so, I have a high sort of adolescent female population. So, I think that's where it's really coming up the strongest. Bob, same question. What is your strategy, a routine lateral tenodesis when you have a very unstable rotation patient below 25 years old? So, my indications for a LET in a primary ACL reconstruction is generally someone who's young, typically 20 and under, with hyperextension and returning to cutting and pivoting sports. The other indication is Andy Williams has a lot of experience in professional soccer, and he's found a lower re-tear rate when he uses, and published on it, when he uses patellar tendon autograft with an LET in those athletes. So, that's something else I've done. Thank you, Bob. And finally, Kate, what is your, what is for you, return to sport? And what is for you the same level? I, when we talk about that, for me, it's always a confusion. I know, I'm laughing at that. It's, even though we've been measuring in inverted columns this for 20 years, we still have debate about what is return to sport. Traditionally, I think we think of it as returning to competitive sport. Level really depends on the type of competition the person plays. And you've got to remember, if you're part of a team and the team's dropped down a level, you might never get to the same level. So, I think we can get, you know, too fancy with it. Essentially, for us, 80% of our patients play high-impact pivoting sports in Australia. It's Australian rules football, basketball, netball, soccer, and it's whether they can return to those sports. In the same manner as what they were pre-injuries, how I best classify that. Thank you, Kate. A quick remark, Bob. We are just in time. I'd be remiss if we didn't mention the stability trial, which showed in a primary hamstring, the LAT decreased the retail rate threefold. And so now stability too is underway to see how it affects BTB and quad tendon. We don't know the results yet. Thank you. Thank you, Joel Boyd and AOSSM for this kind invitation. Thank you to all the members of the panel and to our audience. Thank you so much.

sports injuries

traumatic cartilage injury

return to sports

ACL tear

objective measurements