My name's Adam Yanke from Chicago. Thanks for having me. I've been asked to just walk through this, and then we can have discussion at the end of the entire case. This is a little bit of an uncommon one. So this is a 26-year-old female, very active and athletic, likes to run as her primary activity. She says that she has uncomfortable patellar tracking and some pain with instability events that tend to happen when her knee is in a flexed position. She had a prior Ruh-Goldthwaite procedure for pediatric instability and true lateral dislocations and extension with a VMO advancement. Her other knee has some similar anatomy, but it does not track as far over as this one does, and I'll show you that on the video. And she has no complaints on that side. This is a video of somebody that had the same complaint. It's a different patient. But I thought this was really pretty amazing. This was a patient I treated for about a year or so, had a prior MPFL reconstruction that had failed, and he kept saying, every time I squat down or I do a high-flexion activity, I have no confidence in my knee whatsoever, and I feel like I can't do things. I can't jump, I can't squat. So he sent me this video, and it's trying to slowly lower his leg, and then it just drops. He can't continue to actively resist it eccentrically. And as he tries to extend it, he has to try to rotate or pull or tinnedise his muscles, actually, to be able to function the way that they normally would. So I thought that was pretty interesting, and I'll show you how that's related to this case. So on exam, she has really no effusion. She has some patellofemoral crepitus, but no arthritis. And then she has this dislocation or subluxation more so in flexion that you can try to reduce with manual pressure, but once you flex her down far enough, you cannot fight it any further. Excuse me. You can see that she does not have any significant patellar height or alta, but she does have significant valgus. So she's in seven degrees of valgus, and it is asymmetric. And we start building these factors. So you can see that a lot of it is that her distal femoral angle is asymmetric. So she has a shortened lateral column with regards to the osseous aspect, and Dr. Deduck has helped teach me about that as well. There's certainly some element of dysplasia here, but we don't see a bump. Her issue's not transition from extension and deflection, and she does not have a J sign. So there's some abnormalities there, and I would say that this is probably low-grade dysplasia without a significant bump. I don't think it's probably a D, even though that's listed there. And there's a little cliff when you come proximally, but again, I think that that step-off doesn't have a big bump to it, so it's kind of a different trochlear morphology. TTTG is only 5.6, and TTPCL is 12.5. So she doesn't have a lateralized tubercle, and it's not lateralized relative to the trochlea or relative to the native tibial anatomy. Here you can see the Ruh-Golthwaite procedure, so you can see the patella being split into two and coming under, and you can also see how this really does posteriorize that insertion when you medialize it, when you do a soft tissue realignment. And so that's something that's concerning for causing problems in the future for the patellofemoral arthritis. Here's her exam in the office, and so you can see as she bends down, the patella does track laterally, and the quad tendon starts to come off laterally as well. So the issue is they start to lose their mechanical advantage as they bend the knee because the quad is not going over the front of the femur, so they don't have a fulcrum to extend over. And so here we're doing this asleep now, and you can see that this quad tightness is really pulling the patella over laterally. So even if you do procedures to try to osseously realign the patella, the soft tissue has gotten used to this tracking, and so that becomes a much more significant part of the procedure. This is exam under anesthesia here. The picture, the video on the right's more important, so again, you can see how far over her patella comes, and you can see the large incision from the prior Ruge-Altweit that she had. We'll skip through this here. So I'm sorry the formatting on this is off, but we have a lot of different things that you can think about to try to see what reaches the levels of cutoffs that we're concerned about. You know, I don't think her dysplasia or tubercle position met any of the thresholds that we would be worried about, but she does have this flexion instability, quad tightness, and seven degrees of valgus. And so what we talked to her about was giving her a medial restraint, but more importantly, giving her that lateral osseous column back so that the patella doesn't wanna come off laterally, and then doing something with her quad or vasus lateralis to try to allow it to track centrally. So this is a pretty quick video here, but this is starting with a lateral lengthening, so we're doing a Z-plasty here, coming down along the LPFL. Usually you can define that pretty well. We're now transecting it a few centimeters posterior. And here, as we try to flex it, you can see the whole quad just comes over off the side. And so this is before an osteotomy, before any lengthening. Sometimes a vasus lateralis release alone will allow them to start to track centrally, so typically I start with that, which is really half of a V-Y quadplasty. That didn't get her there, so then we did a DFO, which I used just tricortical iliac crest grafts, and then just using a pretty low-profile plate that usually doesn't have to come out. You can see it doesn't go anterior distal. And then after we did that, we have the anchors in place for the MPFL. I'm trying to hold it, and you can see that it's certainly much better, and it does not flip over quite as aggressively as it had before, but it still was very difficult to keep her tracking centrally. And so this is kind of a decision point of how far are you gonna take it. We finished the MPFL. Luckily, that doesn't usually intersect with the plate much, so it's pretty easy to avoid that. But we did ultimately do a V-Y quadricepsplasty here. So again, that lateral aspect can be part of your vastus lateralis release to begin with, and then we kind of complete that on the medial side. Always hard to know how much to lengthen it, and one way to do it would be to put them at 90 and try to make it as tight as possible on how much overlap you can possibly get, but the more you lengthen, the more potential you have for quad lag and extension lag postoperatively, so that's a balance. So this was about a centimeter of lengthening here, and now she did track completely centrally, so there was no question now that she was coming over the center, and her quad had enough length to come over the front of the femur. Jacqueline, I apologize for a bloody video. I think this one's worse. And then I took a dermal graft, which is something Jack Farr had talked to me about, just because there's a pretty big hole there. I tried to do a lengthening, but you can't lengthen enough to close that gap. And so this is just to give another biologic layer over the plate under the skin. Just makes me feel a little bit better. It actually acts a little bit like the lateral retinaculum or an LPFL here, so that you can't actually do significant tilt for her. You know, would it be a problem if you left it alone? I'm not sure, but that was something I was willing to add. This is postoperative, so unfortunately she did have stiffness. We did do a manipulation, and that was at about four months postoperatively, and so you can see that was her tracking on the right side, and now the tracking on the left. It really does stay central all the way through. And then this is the other guy that I showed you before preoperatively. So this is him at three months post-op now, and so he'll extend his leg, and then he'll work on slowly bending it down. And you can see that he now has, he's focusing still, but he has enough control to actively lower it in a controlled fashion throughout full flexion. And the other big concern with this is that if you release the vastus lateralis, if you lengthen the quad tendon, the conversation with these patients preop are, this really has to limit you a lot. You really have to want me to do this to you, essentially, because it's a big recovery, and there's enough moving parts that obviously you can create new problems that didn't exist before if things don't heal or go the way that you want. And luckily, if everything goes well there, the main hurdle that you have is getting their quad strength back, and it can take 12 to 18 months. This is not like a six to nine month recovery, at least in my experience, and that's a big part of the conversation. And if you do a big vastus lateralis release, this guy was a young, muscular guy that I showed the video of. You can see a defect now from what I created from proximalizing it, so there's some cosmetic stuff there, too. So happy to have any questions, but I think the biggest thing here is that if you see this, it's not super common. People talk about MPTLs trying to pull it over inflection, I think this is a good example of something where that just wouldn't be enough to get them over. Whether or not you think it needs to be added on top of this is a separate conversation, but you should just be aware this is a different animal and isolated MPTL obviously is not gonna help too much. Thank you. I have a question. Very nice case, and you show that when you have a paternal dislocation, inflection, it means that your quadriceps is too short. How do you decide to lengthen it on the proximal part or on the distal part? As far as the proximal part of the quad? Yeah, it's a great question. I struggle in figuring out which components are more tight, and so that's why I feel like sometimes they may ultimately need a quadricepsplasty, but a lot of people get better with just the vasus lateralis lengthening. So if you proximalize that alone, that's a big lateral pull for them, and I'm always very happy when I release that and they go directly central, then I'm done because now I haven't disrupted their extensor mechanism in continuity. If you do proximal, I'm not sure how you would address if their issue was truly the distal vasus lateralis, how you would be able to address that if you do purely proximal. Does that make sense? I just wanna make a comment. You obviously know this patient quite a bit from what he did. I would, here's a case, he said this as well. To me, that dysplasia was high grade and atypical. It was a convexity. Proximal, you did have a typical big spurt, but it was convex on the lateral x-ray. There never was like a really deep trochlear groove. It was almost as if it was absent all the way down, and actually, Silva Paz talked about this individually with this sort of like almost now-formed, under-developed lateral condyle. Extending your trochlea fast is so far distal that you can actually elevate up the almost the weight grade lateral condyle to capture these patients. Now, I think that the balance was there. I don't know if you can get a photo as well, but I think that would have done a very aggressive distal trochlea class to elevate up that lateral side. I've had a few of these inflection instability patients that knock on wood that has been a successful procedure. Yeah, it's interesting, so I skipped this, but they also have really weird anatomy because they haven't lived centrally their entire life, and then they come out distally laterally, so this notch went like halfway up the distal femur, so I'm not even sure how much you would have to deepen there, but yeah. When you're elevating, when you get distal, you actually dress the patient by their ulster. Distal lateral, yeah. Got it. Beth. Yeah, great, that's a great piece. Thank you for showing it. I have a question for you in terms of the medial side. Do you approach this medially? Do you ever think about doing it on just the infial, but also the infial? And where does that figure into your medial side? Are any levels of medial lateral that you can see in terms of the inflection? Yeah, it's a great question. I mean, if there's any time to think about it, I think it's with this case, and you could have added it on top of what I did, I think. I don't think that you could do less and have that overcome the tracking. You know, you might say that if you did the quadricepsplasty, vastus lateralis release, MPFL, MPTL, would that have been enough without the osteotomy? But with the asymmetric valgus, and she actually had a limb-length discrepancy due to it, you know, we were evening out a few factors. So I just didn't, I feel like the rest of what we did was powerful enough that I didn't add it, but it's a great question. Seth. Just curious about your thought process and the order of operations there. I guess, did you plan outright to do the DFO, the entire time, or were you going to not do it if you had better tracking? And why did you do the DFO for the quad lengthening? I was kind of following you there, and I just wanted to understand that better. Yeah, to me, the procedure I like the least of everything I did is the quadricepsplasty, because I just think that you can get the lag, it makes their quad weak, so DFOs can recover pretty well. So I have a low threshold to do the lateral release, vastus lateralis lengthening, and then bone, and then the quad lengthening at the end. So typically, that's been the order.

patellar tracking issues

knee pain

flexion

Ruge-Goldthwaite procedure

pediatric instability