one of the things is to be careful and maybe be the one who does it because we do use a bump and because I scope and I scope a beach chair, that bump is critical if you're really trying to get low on the glenoid. And so I still use that bump. I rely on it, but I'm always the one who puts it in. I don't let somebody else put it in because then I know exactly where it is and how I'm positioning the arm and I'm getting more abduction than I am getting like it up way up. But I think part of that is being in the room when those kinds of moments are happening so that you know exactly what's happening and can control it. So I'm Beth Schubenstein. I'm from Hospital for Special Surgery and Matt invited me to talk about my complications and kind of how I deal with them. And it really stemmed from a conversation we had during his fellowship where we were talking about the fact that in your first couple of years in fellowship or after fellowship, complications are hard. Complications are always hard for everybody, but the more gray hairs you have, the more you can deal with it and your coping skills have improved. And I think what I have come away with, it's not if, but when. And again, I think to his quote, you're going to have complications. And I think talking about them makes them easier when they actually happen. Sometimes people like to shy away and not talk about them, but I think actually talking about them makes it easier. And I'll talk about that in my talk because I actually talk about complications all the time when I'm operating intentionally. So I have no disclosures relative to this. So for me, you know, I always want to see what are the things we can avoid. And Chris actually has this comment that complications generally or problems arise either preoperatively, intraoperatively, or postoperatively. So when you want to try to figure out where something went wrong, you can usually identify one of those three places where it went wrong. Was it in the preoperative planning? Did you miss something like you're doing a cuff, but they also had AC joint and you didn't address the AC joint. So they still have pain afterwards. Was it intra-op and a technical issue, which is probably most of what we see certainly with ACLs. It's generally a technical issue in terms of where we placed our tunnels or anything like that. Or was it post-op and you just didn't, or the rehab, it was inadequate rehab sometimes. Sometimes it's over aggressive rehab, but usually you can divide the problems that arise after in terms of where they occurred in the process. And that's a great learning point for me to look back and say, what could I do next time to prevent that and see that process in the, see it in the, ahead of time. So, and the other part of this that I was saying before, for me, I always want to know the complications of the surgery I'm doing, because then I can make specific efforts during surgery to avoid those intra-op complications. And that's really, that's, that's something I've learned a lot. I like this, this quote, to me, it says a lot, good judgment comes from experience. And unfortunately, experience comes from bad judgment. And I think all of us who do what we do know that because it's hard to be a surgeon in your first two or three years of practice. And when I practice, I was down the hall from Russ Warren and Tom Wikowitz and Joe Hannafin. And it was hard for me to take somebody to the OR to do an ACL when I knew that those three people could do a much better ACL than I could a year or two into practice. But you have to somehow, you know, get through that and accept you're well-trained, you know how to do this and you are going to get better. That's just what all of us do, hopefully, if we're doing the right stuff. So in the world of patella, I always try to figure out that the preoperative part of it is figuring out what you're treating. And that's true for everything. But in patella, sometimes it can be confusing, because these patients have a lot of things that are going on. And so for me, my Venn diagram has to do with whether or not we're treating instability, which is pure instability, whether we're treating malalignment and the result in arthritis or pain, or whether we're treating both, which exists in a lot of patients, they overlap. And seeing that ahead of time helps me figure out which surgery to do. And truthfully, I've seen patients come into my office who've had chronic patella pain treated with an MPFL, because they had tilt on their x-ray. So somebody treated the x-ray and said they have tilt and subluxation on the x-ray, they've never dislocated in their life. And an MPFL is not an operation for tilt or, you know, you can get the kneecap in the right position, but if it never dislocated, it's just the wrong operation. So I think knowing what you're treating ahead of time is super important. And the question that always gets asked in the world of patellar instability, is an MPFL enough? And I think we're still answering that question. And most of the time for pure instability, it likely is enough. But when you see something like this coming, obviously, in your head, just no bigger problem, I have to start thinking about bigger surgery, because this is not a patient who's going to be controlled with an MPFL. And so, just like we were talking about before, when I look at something afterwards, and you see this, this was a problem with the person who decided that they could put a ligament in somebody who had such severe skeletal dysplasia, and didn't realize ahead of time that the forces with the vectors just didn't work, and that it was going to overwhelm this. And so this is a failed surgery. And luckily, you know, can be revised, but that's a complication of a missed diagnosis. So these are kind of the things that I see in my offices. And on the right, that's a radiology resident who can do that with her legs. And I show you the right one, the left one is more the classic obligatory dislocator, she comes into your office, they can straighten the knee, and it pops out. But the left one, she's dislocating inflection, and it's also voluntary, right? She can make her patellas go out. So I'll tell you, interestingly, this complication on the left, because I did have a complication on the one on the left, is that I fixed her, she's completely stable, her x-rays look beautiful, her MRI looks great, I put cartilage in her knee, and that came out great. And I did one side, and she hates it, and will never have the other side done. And she hates it because she's used to doing that. She's been doing that for 28 years. And she says, my knee is stable, but it doesn't feel like my knee anymore. And so that's a really good thing for all of us to understand if we're treating something in certain patients that, you know, patients don't like feeling that it's different. And in complex things like this, you are going to make them feel different because their normal pathology, their normal anatomy is pathologic, but they have to understand that. So that's helped me to counsel some of my more severely dysplastic patients, that you have to accept that this knee is not going to feel like your old knee, and it's going to be stable, but it's not going to feel like your old knee. So again, knowing that she's miserable from a surgery that I think is a great success, which clearly is not a success for her, has helped me figure out how to counsel other patients. And I see a lot of this severe dysplasia. So I have a great example of that, that I just saw back. So this is a patient of mine that I saw 10 years ago. She's 38. She's a videographer on movie sets. So she carries heavy backpacks and heavy equipment all over the place. She has a congenital dislocation. So she has almost an absent patella. It's not nail patella syndrome, but it's something like that. It's a tiny patella. And she has now, she's 38, she has arthritis. So she has pain now, not just instability. And she waited until this age, but she can't have a knee replacement because her patella is out to the side, like it's nowhere near where it's supposed to be. So we've talked about realignment surgery and getting her to be stable so that at some point she can have a replacement if she needs it. But I've counseled her and I said, I told her about the other patients that I have. I said, I have a patient whose knee is very stable. She will eventually be able to have surgery, but she grew up with a congenital problem. So she grew up with this problem and she doesn't like the fact that her knee feels different now. And so I tell patients and that way at least, and she's still going to make the decision that's right for her. And I said, you know, this is a preventative thing. And we're seeing the problem coming. We know you have arthritis. We know eventually you're going to need a replacement, easier to do all this realignment and corrective surgery now at your age. And then at some point be able to have a replacement, but you have to know going into it. I don't think there's much more you can do, but I feel better having told her about the other story because I feel like she's aware. And I think that's a lot of this is patients want to know what they can expect. And now I can share a little bit of a story where it surprised me because the case went so well and I was so happy and this patient refuses to get her other knee done and she's a doctor. So I think, you know, you're always surprised by what you think is good outcome and what they think is a good outcome. So I think to kind of brush through this stuff, there's a lot of gaps in terms of what we know. MPFL is one of those things. And the points that I'm going to make on this are less the technical points of the surgery, but that at each step along the way, whenever I'm doing a surgery with anybody in the room, I talk about the problems that occur. So when we're putting the anchors in for the patella, I talk about patella fracture. And as I'm doing it, I say, this is why we're trying to go closer to the cartilage, because if you go to anterior, you can get a fracture. When I'm doing the femur, I talk about the complications that we see on the femoral side, which are malpositioned tunnels. And we see them all the time. I talk about the fact that I want it to look like an MPFL. So I make sure in the OR that it acts the way an MPFL should. And I do that by looking at the anatomy. And I don't go right to image. You can go to image first, but you have to check isometry. And for me, I say that all the time, because I've seen so many what were MPFLs that were done on fluoro, but, you know, they're a little too high for that particular patient, or they're not high enough because the patient has ALTA and, or the patient has trochlea dysplasia, which wasn't accounted for when the studies were done. So you really do want to check your ligament in the OR. And I tell everybody, because then if you can move it a few millimeters and make it act the way it should, you run much less of a risk of that patient getting too tight, over-constrained, can't bend their knee, or, you know, they bend it through all that, and then they get loose and they stretch out your graft. So knowing what the complications are for me has helped me talk through the case at each step. I don't think an x-ray has to be perfect, right? You like the fluoro to look perfect. To me, it's a ballpark. I care much more that it's going to act, and I'm comfortable bending their knee afterwards. As long as I know I can bend their knee, and at the end of every one of my cases, I take a picture of that knee with the foot touching the buttocks, bent all the way. And I take that picture to show the patient that they can bend their knee all the way, and also because I know my fixation doesn't change. Then I straighten the knee out, make sure it's still stable, and I know that patient can go to rehab, and there's not much that's going to happen to that knee because they really, it's not going to stretch. So as I said, I talk through this when I'm doing the surgery. This is the complication that we worry about on patella. So when we get to the NPFL, this is the problem that most people worry about. I started by doing a docking technique, and it was a tunnel, and it was a five-millimeter short tunnel, which I convinced myself that's not something that would fracture. And I think it's less likely to fracture because it was a 20-millimeter tunnel, and I didn't put any fixation in there. I just put tissue in there. But the truth is, the disadvantage of anything that's a large tunnel, no matter what's in there, fixation or tendon, is going to be a fracture. So I moved to anchors when I started to research this because I wanted them all to be the same, and I do a lot of cartilage, and the tunnels were convergent with a lot of my cartilage procedures. So I started just doing anchors, and I liked the broader attachment. But even with anchors, you put an anchor that's too anterior, and a colleague gave me this one. I'll tell you which ones mine are. This one is not mine, but I have lots in here, so I'll highlight that. This is an anchor. It's a 2.4 little tiny anchor that was placed a little too anterior. Active patient, you know, slipped. Four months later, boom, fracture. So it's, you know, it's not... Even though I went from tunnel to an anchor, you still have to be super careful. So like I said, when we're in there, I always say, I want you right against that cartilage, like we do when we go shoulders. Like everyone knows, you're supposed to put the shoulder, you know, the bank heart. We want to put it right on the cartilage. Same thing. You know, your instinct is to avoid the cartilage. I want you to err towards the cartilage so that you're not too anterior. So I talk about these because I've seen them and because that's what I worry about. And I feel like for me, talking about the complication at the time is the thing that makes me feel better because I'm intentionally avoiding it. And sometimes you still get them, but at least you're intentionally avoiding it. So I make a capsular rent. I aspirate on every patient I do an arthrotomy and I palpate the surface and I can see the cartilage. When I'm putting the anchor in, I see the cartilage so that I know I couldn't be any more, you know, posterior than I am. So when we get to the femoral side, the complication, as we all see, has nothing to do with fracture. It's a big bone. Problem is nobody can figure out where to put it. And when they do figure out where to put it, or when we do, usually it's because the graft has failed or something's happened. And when we used to have metal anchors, it was much more visible, but these are usually always visible because it's a hole. So you can usually see where somebody's put it, including my own. And before I used to image everybody, because I used to just do isometry. But when I started doing research about six, seven years ago on this and collecting all my patients, I started getting image on everybody just to a fluoro pic so that it was documented so that we could look at it. And sometimes I'm surprised by where my tunnel ends up, even when I think it's a good tunnel. So, you know, I put the pin in and I check it and I look on fluoro, but that's not even always the right answer. So lots of malposition tunnels that I've seen. And too low is a better error. So I do also know that. I say that in the OR all the time. I tend to err too low. If I have an error, right, when I'm checking it, I tend to be on the low side. And that's because that's an error that I can tolerate better than too high. Too low means they're going to get a little looser and they may have a higher risk of dislocation. Too high means they get over-constrained, they get pain, they stretch, then they fail. So which complication do you want to accept if you're going to get one? That's kind of how I think about it. But knowing the problem, when you see complications, by the way, when you see someone else's complications, it helps you avoid your own complications because you see it. And I used to have, in training, I had a thoracic fellow who worked with me when I was an intern, general surgery intern. And he said, the scope of your complications is limited only by the realm of your imagination. And that stuck with me, right? You don't know what can happen because you haven't thought about it yet. But then all of a sudden you see it and you're like, oh, yeah, that can happen because now you think about it. So I think seeing other complications and going through all of that is really helpful for me. For avoiding complications, as I said, I've changed. I no longer do any tunnels on the patella. I use anatomic landmarks and I always check my isometry. And then one of the complications that's very common is over constraining it, making an MPFL that's like an ACL, right? When somebody says, oh, like a rock, that is not what you want for your MPFL, although it is what you want for your ACL. So for me, a lot of it is this issue, checking isometry, but then also making sure to move the kneecap afterwards and make sure there's good glide and that there's equal translation both medially and laterally. And we do that constantly through the case to make sure that that patient has a kneecap that's not going to feel too tight to them and it's not going to cause them pain. Let's see. Okay. So tibial tubercle osteotomy, the other main operation for patellar instability. This one is a fantastic operation. I got trained by John Fulkerson over 20 years ago. I think it is so versatile. It's super helpful with malalignment, with pain, with arthritis and with instability. And it can really help. For me, the critical part on this is I always bump it out a little, but you can change how much you bump it out. It's like jacking up a car. You can jack it up a little, or you can jack it up a lot. And it really depends on the patient's symptoms. And with that obviously comes risk. This is patients, these are patients who had MPFLs as well. And you can see it works really well for me, even with trochlea dysplasia. The case on the left has a big super trochlear spur. So I'm not an overaggressive trochleoplasty person. I've done a few of them. I think they're needed when they're needed, but it's really rare. And I think anytime you can do something outside of the joint, again, it's what complication are you willing to tolerate? I'm not willing to tolerate a 15-year-old with severe arthritis. So for me, my complication of maybe having them have a recurrent dislocation is better, and then deciding if we're going to do a trochleoplasty. Distalizations have their own set of complications, risk of non-union. I always talk to every patient about the risks and I tell them about it, but I also tell them I've had them. I say, these aren't just hypothetical risks that occur on paper. I do a lot of the surgery and I've had fractures. I've had non-unions. And I think telling patients that makes them understand that this is not a theoretical risk. It's a real risk of surgery. I think it's a great operation. I do distalizations all the time. I think it's super helpful, but I manage them differently. And I think about what the problems are. Here's a patient on the left. That's the line that I never want to see. You'll see it throughout because I do a step cut and I like a step cut because I think it makes me, I think for me, it's more predictable in terms of how much I'm distalizing them and I won't get a Baja if I do it. Or if I do a feather cut, people like it better because they don't worry about it, but it's harder to judge how much you're lowering them. So for me, I like it, but I also know that this is a risk and I'll show you. So those top complications, the left one and the right one are both mine. On the left one, this is a non-union, the far left upper corner. She was a 18, she is an 18 year old when she saw me, an 18 year old D1 lacrosse player who had had instability and arthritis. And I went in and I did a, to build tubercle MPFL and we did some cartilage and she was rehabbing beautifully. Her cartilage looked great. And on an X-ray I got at like three months, her tubercle looked healed. So we started letting her run at four months. And one day I get a call from her and from her therapist and she's at therapy and she heard a loud crack while she was on the treadmill and had sudden pain. And so the way I knew she was, didn't have a united tubercle is because she actually fractured her screws. So of course I see the X-ray with the broken screws and then I get the CT and the CT clearly shows that it's a non-union. And I actually did exactly what we talked about. I phoned a friend, I called Jim Bradley. I was devastated. I didn't know what to do. This is someone who was about to be back, in two months she was going to be back out on the field. And now we're revising her tubercle and I didn't even know what to do. So I changed the way I put my screws because of that. I don't put them both in the same angle. I put the first one in lag and compression and I changed the other one to resist different forces so that they're not both in the same direction. Jim had great suggestions for me in terms of changing it to a bigger screw, putting bone marrow, autograft in there. And I even started her on Forteo after that. So there were a lot of things that I thought that were kind of words of wisdom that I, you know, I was almost too connected to start to think about them. And just hearing a calm voice on the other end of the line helped me figure out what my game plan was going to be. And so I think that's important and it's changed the way I do the surgery. So I think for me that's helpful and I think about it whenever I'm doing these in these kids. The right one, far right one, it's that distal aspect that we talked about and had the, you know, the black line that didn't heal well. She was at school, she slipped on a floor about three or four months later and fractured right through her whole tibia. And, you know, her parents called me, she was in New Jersey, we had her transferred and they said this is a direct result of the surgery that we did. This is exactly what it, you know, it was an unfortunate error, it's unfortunate that she slipped. But, you know, this wasn't completely healed or strong enough and she had it. And so what we did is we CT'd her other knee to make sure the other knee was healed because she had the same surgery, you know, three months before and that one was healed. They were going to put a rod in her in New Jersey for the fracture and I asked them to transfer her because I said we spent all this time getting her knee stable, the last thing I want anybody doing is doing anything that is around her patella because her patella was stable. So she came to us and we did a plate and one of my colleagues, a trauma guy, did a plate and she did great. But that's definitely a problem. Baja is a big problem that we see, somebody who gets a little over aggressive with distalizing. And remember the radiology resident who I told you hates it. Patients who have ALTA do not want a normal height patella, they will be super unhappy. So I always set them at the highest point of normal, which is 1.2. I don't try to bring them to normal because the concern that I always have is making a Baja and they are miserable. You will take a patient who is unstable and make them very painful and that's a very unhappy patient, right? You've changed the problem, but it's a worse problem pain. So again, these are the complications that I have seen that I have done and that are my responsibility. And I think as Matt said, I think really embracing that and knowing that that's what what you want to avoid and feeling it because it's true. And it's made me a better surgeon to deal with those complications. And I think it has made me more thoughtful about how I interact with my patients, not just how I treat the complications, but how I explain things to the patients. And I think them knowing that they're going to be okay is their only goal. Knowing that you're going to be with them through to the end and make sure they're okay is really what they're looking for. So I'm going to fast forward through a couple of these things. This one is one that I didn't show last year because I didn't bring the images, but this is one that I like. This was one of those grafts. It was a young kid who had an OCD and she was a great kid. I loved her. I said, this is a simple operation. We put a big graft in from a matching patella, whole patella, fresh patella, fit great. I got the nice suction feel when you put it in and I left. And then my NP sent me this on my phone, the lower right picture at two weeks when she came in for her post-op and my heart sank. And I just thought to myself, wow, I've never seen that. I didn't think that was possible for the patella plug to just pop out on its own. It was a complete press fit. So it is possible. And I told them exactly what happened. And the patella I think is more at risk because there's so much cartilage and there's so little bone. And especially because in certain areas on the plug, you have almost no bone because there's so much cartilage. And so I went back and luckily the plug still fit and I popped in a couple of smart nails to hold it. But it does make me think every time. I don't put smart nails in for every case. I still do press fit, but it does make me think for the larger more cartilaginous grafts, it may be a good idea. And now this kid wants to be a doctor. And so she shadowed me in the OR already. So she's, you know, sometimes things come out of it if you, you know, cause I went through everything with her. So anyway, that's, that's kind of what my, my talk is about, but I think trying to talk about my complications when you're doing it, at least the Entrop ones, keeps you honest and also kind of helps you avoid them. Thank you.

complications

shoulder

knee

fractures

surgical techniques

patient expectations