Thank you. Now I invite to come up Julian Feller, Laurie Himstra, and Jason and the first case represented by Lisa. Can we have the cases up please? I just wanted to ask, they're very great presentations guys, but Adam you said more than once that you were going to reduce the TTTG interoperatively to 10 millimeters. How do you do that? Measurements. So the, you know, same thing with the CDI and the TTTG pre-op. CDI is obviously a ratio and so you just have to do that math ahead of time, but the the goal is to get it close to 10 as much as possible. That's not evidence-based, it just seems that most people that would have a 10 wouldn't have maltracking issues. So yeah, literally if it's a 25 then I'll correct it 15 millimeters. Well I think that you're better than us because sometimes the tibia is so small it can't be moved 15 millimeters. Yeah that's that's why I do almost all medializations with a very posterior tibial cut because then you're using almost the entire width of the tibia and you can still have overlap whereas if you do the original described version you just you wouldn't be able to get it over. So we're gonna try to just do a really quick case. This is the first time patellar dislocation. It was in a gymnast, a good BMI of 19. Just wanted to emphasize that there was no J sign, that she did have a Beaton score, but I'll quite try to quickly move to the x-rays. You guys can't see that so much, but just the she did have mild valgus, right side five, left side two in the long leg films. These are the axial view showing a shallow sulcus. Looking at all measurements because I think one measurement doesn't do it, you can see that she does have sort of in between or a gray zone alta. She had closing pheyses. She had her menstrual cycle one year earlier. In MRI she had a lateral tilt of 22 and a TTTG of 14 millimeters. So when you're looking at the MRI she did have a little bit of trochlear engagement, PTI, patella trochlear index of 0.18 which is what again Roli Biedert's cutoff would be 0.012 as defining of alta. And I do like to look at the first slice with full cartilage coverage and you can see that she's engaging just a little bit of the patella so I just wanted to know what would be your treatment here? So this was the first time patella dislocator in a closing pheysis teenage girl, does gymnastics and would you do non-operative management? Would you do a reconstruction alone or with a distalizing TTO? So why don't we start with our Australian? Thanks Liza. For me it's A or B. I certainly wouldn't be doing anything bony while she's skeletally immature but I think first time dislocation you probably need to give her a run and see how she goes non-operatively. I suspect she'll redislocate so I'd warn her and her parents that she's likely to come back and if she did come back it would be an isolated NPFL reconstruction for me. Anybody have a different opinion? I think I think these are patients that I began to risk stratify you know certainly look that article from Huntington. You look at her she's skeletally immature, open pheysis, she's got some patella alta. She probably has greater than 70-80% chance of redislocation just with those factors and maybe even higher with some of her other indices. So I give him the option of non-operative treatment but sometimes when you explain to patients you have these risk factors and risk stratifying you may have a 60-70% chance of redislocation. I think a lot of people at that point will decide on you know surgical management. So if she had closed pheysis would you and you would you what would you offer her? So she had closed pheysis with you know certainly her alta especially that view on the left is where I get concerned where you got trochlea but you got no patella in it. I think that's the person that you can offer a distalization and I think being able to do it bony wise I think helps but you know I yeah even in the skeletally immature patient I will shorten through the tendon and actually get some pretty good results with that also. And when would you go back to gymnastics? So typical return to play after just standard MPFC reconstruction usually we're three or four months but if we're messing with the tendon or the trochlea then I think those patients are six to eight months recovery. Jason and Julian. I have a couple of questions one is you know what exactly was the mechanism of injury and second is does she have subjective apprehension because I think that the presence or absence of apprehension is important for me in terms of whether or not that's somebody I might her wrists are clearly high. So I'm gonna just fast forward to one x-ray and that's this one she dislocated landing from a from a jump she had I she did have a bait and score of six but it was important to me that it included the knees so she had greater than ten degrees of hyperextension. So do you use the hyperextension in your algorithm? I do now I will tell you that. Lori. You know we've been looking at that as well as bait and score for risk factors and we've so far been unable to demonstrate that knee hyperextension makes a difference but I think it does I just think we've been unable to demonstrate it. The only like sorry did you tell us her bait and scored because to me six so bait so she's got a high bait and then the other thing was just J sign would be a big. No J sign. So that to me is a big prognosticator so if they have significant alta they tend to get a J sign and that to me is a big decision-maker on whether I want to add something bony and then the only other thing I'll add is where she is she in her season of play so if you've got a high-risk gymnast and if she has a season you know you might want to time it so I wouldn't treat her non-operatively just so she gets back for her season and then she dislocates her first week where depending on the timing of her sport. So can we move on to the second case I just wanted to put up the second case I'll tell you the outcomes she failed non-operative management we reconstructed one side she went back and we dislocated the other side two years later she re-dislocated the side that I had done she was now a senior and we talked about a distalizing osteotomy and she decided to quit gymnastics she was okay in a day-to-day life and now five years later she's never re-dislocated so I think that to me we removed all hyperextension maneuvers that were possible in gymnastics she changed the way she landed from a vault and from from the arms so for me hyperextension depends on the sport you play but to me it's a red sign and so the hyperextension greater than 10 degrees I may reduce my threshold for when I do a TTO distalizing and really important for the physical therapist to emphasize knee awareness because you can't really change hyperextension. Can we move on to the next case please? This will be presented by Moses. So the next case is oh come back yes it's a boy 21 years old professional soccer player and complaining about left knee pain to start running and slow down he had history anterior and medial pain in the left knee with progressive worsening 15 days before visit me he just showed the first episode of facial reconstruction when he had 2019 another group another team did it seven months later trochlea macrofracture and you came up to us in this situation normal gait lower limbs aligning left quadricep hypotrophy no edema ligament test negative varrovalgot stress also negative here you can see the image and MRI very clearly the condor detachment and fragmentation in lateral aspect of the trochlea with exposure of the subchondral bone measuring 1.6 per 1.1 centimeter so what to do look to Pharaoh what's your opinion these will have some suggestion but you can so no no mechanical symptoms effusions recurrent effusions for him no so you certainly I guess I'm assuming coming to see you because he can't play and he's having difficulty playing and certainly I'm sure he's done physio and things like that I think with that flap in a professional athlete I think you have the consideration of offering arthroscopy and maybe chondroplasty and trying to see if there's something else that needs to be done long term so for me taking an autologous chondrocyte implantation harvest at that time in case we need to come back Julian agree or a different opinion so I think even though may have done physiotherapy is clearly got quads atrophy and so for me it's quads quads quads in the presence of an effusion or any mechanical symptoms I'd offer him an arthroscopy and we're just starting a season of Australian rules football back home I did almost exactly this case last week but for me it's less is more I don't like doing anything other than a very gentle chondroplasty I just use a scalloped um shaver I think it's gentler on the articular surfaces maybe use a curette I'm not a big fan of micro fracture I think you get a much longer rehabilitation process so I'd probably be thinking of an arthroscopy with extensive quads work after that okay set different idea no I agree as a first-line treatment before you'd go to something big like an osteochondral allograft or a Macy type procedure I think you give him a chance with a scope perhaps lubricant PRP post-operatively okay here the exam and anesthesia the ACL the knee was stable and this is that a sloppy view Laurie with the image what do you think about I can't see it very well but it looks like there's pieces of cartilage everywhere except a touch to the bone so for me this patient I mean he has a way in a athlete that uses his knee a lot so we're still first steps first I'd clean it up I and I would get him on a course of physio and intraarticular injections we don't have a lot of cartilage options in Canada so that's pretty much all I have to offer him at this point in time until he maximizes that and you Jason what do you think about that I think in a professional athlete oftentimes less is more and the results of our isolated chondroplasty are reasonable if you do a other type of cartilage procedure it's more likely you're going to take them out of play and if he's 21 he's this may be that may be the end of his career so I think that I would probably initially do just a chondroplasty and observe him carefully I might take that piece for a biopsy for a Macy type procedure later so Adam you have the MRI image you have that telescopic image and now I show you when I opened the real image so did you change your opinion about the procedure since the beginning what you think about that no I actually would get excited based based on what you saw on the scope because the having the flaps having something to clean up for me is very encouraging that actually might see improvement so it depends if their symptoms were like the catching and locking that people were asking about or if it's swelling and just load related pain so I think that that's the differentiating factor and we took a look at our chondroplasties prospectively and when it's unipolar patella femoral and the Amadeus score is encouraging then it's 60 to 70 percent of people do well with the debridement so I would still be in that category but OA graft definitively if they have no other option after Andrew Farrell yeah I think preserve your procedure since the beginning I stand by that yeah and Julian I stick with what I said I mean that doesn't frighten me I agree with Seth's point that there is something to debride and I think that sort of gives me hope that we can improve a situation okay so I'm showing what they did in this case here we have the lesion we took out this piece this fragment big one and we have this instrument that we developed we made the contour and here is fragment we miss a cartilage as you can see and I'll clean a little bit to add the fragments in deletion so set any different opinion about that well no I mean obviously you had a preoperative discussion with him about restoring his articular cartilage in this it looks like you're doing one stage sort of autologous Macy Laurie this is a collage of membrane that I just covered elision yeah I mean this I don't have this option and I think I would still have we had them and see how he did it and then because our options would be like plug allografts so that's I can show you and this is the patient's cartilage that you took out and you meant this excuse me it's just a patient's cartilage this is the patient's cartilage cartilage and this is at least nine months later the professional one and I had the opportunity some months later because the other problem to have the second look and here we can show the trochlear the area where we cover with cartilage interesting and that's all I think that will end our session we also want to be on time

knee injuries

treatments

patellar dislocation

arthroscopy

chondroplasty