And this is a real-world case, something we see too much of. This is a case of a neglected knee. 32-year-old female, hotel manager, 20 years of recurrent instability. Biggest problem is morbid obesity. Her best BMI is 40.5. She's had extensive therapy. She's been in weight loss programs most of her life. Here's her range of motion. Three plus lateral apprehension means she's very, very, very apprehensive. She's got a very prominent J sign, a large soft tissue envelope, normal in quotation marks tibiofemoral alignment, and normal in quotation marks rotation. This is what her knee looks like with this very prominent maltracking. Here are her plain films. She's got substantial dysplasia with a pretty big trochlear bump. Her patella height index is in the high normal range, and she's got this stuff here. One of the axial cuts on the MRI, you can see full thickness chondral lesion on the patella with some subchondral edema, and even more prominent on the lateral trochlear ridge. Now we're looking at a dynamic CT scan from your perspective as you're sitting on a table examining her, and she's actively extending her knee. And this is what you're trying to picture through her soft tissue envelope. This is what is actually happening. And then from her perspective, she's looking down at her left patella, and this is what's happening. So measuring out her bisect offset, which is a good way to quantify the J sign, her maltracking, by breaking it down into quadrants, and she's got 100% bisect offset. So radiographic summary, good-sized trochlear bump, a lot of maltracking, 100% bisect offset. Her TTTG distance was 27. Ulta, her TTTG distance was 27. Ulta patellar height is normal. She's got full thickness chondral defects on both the patella and the trochlear side with subchondral changes as well. So her problem is malalignment with dysplasia on a lateralized tuberosity, maltracking with this very substantial J sign, or bisect offset, and OA. So what are we gonna do? I should make it clear that her primary problem is instability, that's what bothers her the most, recurrent instability. I mean, I really tried to get her to sit down on this, although I was talking to her about the pain, like, how do you quantify the pain, and how much is the pain? Like, they just never really answer a lot, and that's why it's hard to. But how much do we have? Nothing. Okay, let's go ahead and move on here. So this is what I ended up doing. Her primary problem was instability, not pain. She clearly has substantial osteoarthritis, and is gonna need some sort of replacement at some point. So we're addressing her needs right now by doing this combined NPFL reconstruction and an antramenializing osteotomy to unload the arthritic lateral patellofemoral joint and to prevent recurrent instability episodes. So follow-up at nine months, it's now almost two-year follow-up, no instability episodes. Her J sign is diminished, it's not normal. She does not have straight tracking, but she has also less pain. So in addition to no additional instability episodes, less pain, and now she's able to actually walk for exercise and is involved in this aerobic exercise program. So of course, things are gonna deteriorate. The goal here was to stabilize her knee and get her exercising. And at least so far, we've accomplished that. Yeah. So I didn't do a lateral lengthening, I did a lateral release. And I don't do many lateral releases or lengthenings except when I'm doing substantial osteotomies. I think most of the time, patients with recurrent instability are too loose to begin with. So I agree with you completely. I use my 80-20 rule. 80% of instability doesn't need a lateral release. 20% might be a lateral lengthening. But she's also a malalignment patient. And in the malalignment group, I usually find that they are tight. So you did do a lateral release for her. And what about the cartilage? Did you address the cartilage? No, I didn't. Her cartilage was in pretty bad shape. So beyond what I thought would benefit from a cartilage restoration procedure. Can I make one more comment? Dave actually was talking at the table about maybe doing a PFJR in her. So what are your thoughts on her age, her activity level, and anything else in terms of indicating her for a PFJR? So to me, pain is the primary indication. And that's not a major part of her complaints. So at some point, yes, but not now.

knee issue

recurrent instability

morbid obesity

chondral lesions

NPFL reconstruction