Here's my disclosures. So we each have a couple cases, we'll see what we get through here. So here's my first one. So a 49-year-old female, she was referred from my PEDS partner. Always a great sign when they're 49, coming from the PEDS partner. So she's a functional CP patient, but she hikes, she bikes, she's very active with her family, limited to her lower extremities. She's been having progressive patella femoral pain, relying on her walker more and more, and worried that this may not cut it for her going down the road. So this was her exam. She had a little bit of a limb length asymmetry, some foot deformities, some atrophy. But most specifically, focusing on the knees, she had some limited range of motion and just debilitating pain any time you try to flex her up, some anterior knee pain with palpation. Good patellar mobility, no contracture, no instability. Mostly an anterior knee pain picture. Given her medical history, she's tried loads of things to try to get these knees to remain functional for her. Steroid injections, Botox in the tendons, lots of therapy, braces for support. And just for completeness sake, on imaging, really didn't have that bad of looking on knees other than this little focal lesion at the inferior pole of her patella, and a little bit of patella alta. So we kind of walked through a bunch of treatment plans. Do we continue the course? This just is what it is. This is a complex patient. But this is an active patient. This is still a sports medicine patient, in my practice at least. And so do we continue the course? And I try to talk her off the ledge. And then she throws it on me. She said, I'm heading towards a wheelchair no matter what, so you can't make me worse. OK. Well, now my hand is to the fire. I did refer her over to her arthroplasty colleagues, of course, just to make sure that she got all the opinions that she could want to get. And so I braved the show. And we decided to do a distalizing osteotomy, a scope, and potentially clean up some of that cartilage. Here's some intraoperative photos. And so overall, I think I distalized her about one centimeter. And anecdotally, or I guess in hindsight, we're slapping five. We got a good fixation. And then what I did not see, of course, until when she showed up later, and I'm evaluating this in hindsight, I could not appreciate it on the fluoro, was there's a nice little split down there at the bottom of the osteotomy site. And so again, didn't recognize this intraoperatively. We thought everything went great. And then she shows up at two weeks post-op and saying, it's been hurting a lot more lately. And by the way, I couldn't get the leg extender that I ordered for my wheelchair. And she's dangling at 90 degrees off the side of her wheelchair. And it seems more swollen. I'm just such a bad patient. I have not been compliant. And I'm looking, and I'm saying, what you should be saying is you're a dumb shit, Dr. Burnett, because you didn't recognize that interoperative fracture. So I'm going to pause there and poll our panel here. Aaron, you see this. You're two weeks out already. Pretty complex patient, just from a musculoskeletal bone structure quality. What's going through your head on here? Yeah, so very challenging patient. So you did the right things preoperatively. It's always a discussion with these patients. Is it pain? Is it instability? Is it both? This is, for me, a limited goals operation. We're not going to be able to completely solve this knee. It looks like you did a thorough evaluation of what her current spasticity regimen was. So these are ones you want optimized. If they have a baclofen pump, for example, you want to make sure that that's fully going and running. Sometimes we will fully Botox the quad right before surgery, just so they don't get that pull. But you did all that very thoroughly. Then just the time of surgery, technically, these distalizations, they can be fraught with complications. I think you did a good job distalizing her. Perhaps I've gone away from that step cut distally in that area. That's not the complication here. Just one thing to be careful of is I like to feather that in more. But otherwise, at this point, clearly there's a loss of fixation. Your fragment has moved positions. Don't try to bury your head in the sand on this one. Clearly this one is loss of fixation. Certainly get a CT scan to look at the bone stock that's remaining and those different things. Just recognize that this is loss of fixation and you have to do something to bring her back to the operating room. Armando, anything to add to that? This is one of my worst fears with these TTOs. You've been in the OR with me. I'm always very careful with that distal screw. It's very cortical. You're getting very narrow. I always tell the fellows, go really slow as you're putting that screw in. I actually keep my fingers on it, so as I feel it, go down. I can see how this would happen in this case. Those distal parts of those TTOs, they're kind of fragile. Travis, anything else before we press on? Not a ton to add. The only other thing is, this is, oddly enough, I was at my alumni meeting last night and one of these was presented there too. First it's not just you. And second, the proximal screw looks like it pulled out too, which is a little bit unusual I think, which suggests her bone stock's not awesome. So in doing so, because it didn't cut out of your fragment, it cut out of the back of the tibia. So I would say that in going into this, just in preoperative planning, if I were going back, I would plan to have something other than just metallic screw fixation when I was going to revise this. Yeah, so you beat me. Oh, sorry, go ahead. I just asked, so did you, how did you deal with the proximal gap there? Did you take that distal bone and put it proximally, or what was between, did you just leave a gap there, or how did you manage that? So that was, this was why we're doing this, right? That one was more of a step cut, so it was almost like a slid down, there was a nice transition actually from the tubercle into the flare of the anterior tibia, so there was not a step cutter gap per se, like there, you know, there is now distally, if that makes sense. Yeah. So, I mean, one other thing to consider is, you know, structural bone graft there proximally, you know, if you really make a nice transverse shelf, then sometimes what we take is just like a piece of allograft actually, and fix it with a screw, so we have a screw of allograft actually above the tubercle, just gives you a little bit more of a buttress, because once that distal screw failed, everything is going on that proximal screw, and without a buttress, you know, and her being dangled at 90 degrees, that's, you know, that's tough to win. Yeah, so ideally, my cuts would have been inverted, correct? All right, so Travis, you dipped your toe in, so you're talking about things other than metal, I did not get a CT, would have probably been a good call, but with just this picture, you made the decision to take her back pretty urgently. What are you calling for, for fixation on a case like this? Those are four or five screws. Yeah, so you have a central screw in your proximal, really what's going to be your only fragment at this point. So I'm effectively thinking of two things. One is I'm going to be using the patellar tendon for fixation, and then likely either a screw post for suture anchors, I'll probably start with suture anchors, but sometimes those can get hairy too, but I would have screw posts for backup. And then the second thing I would consider even augmenting, at least talk to the patient about the concept of potential sort of pseudo-patellar tendon reconstruction or augmentation, either with her own hamstrings or potential Achilles allograft, but I think in this case, you can probably get away with either an allograft hamstring or her autograft hamstring. What I've done too, Justin, in these cases, like extension mechanism failures on the patella side is some sort of circulage, and it's tough because it can saw through the bone. So I'll put a transverse cannulated screw through the patella and through the tibia, and then feed my wire or fiber wire through it to help support it. Whatever you do for fixation, just as a backup, with the intention that it will break eventually, but it'll support you. All right, we'll press on. So similar shared thoughts that I had going in, long story short, is I called for the kitchen sink. I called for anchors. I was planning on drill tunnels, allograft prepared, maybe even salvaging that bone. And we talked about all of that going in versus just treating this as almost even like a distal tendon avulsion and treating the tendon. And at this point, we're in salvage mode, right? Like we said, I'm heading for a wheelchair. You can't make me any worse. Well, I proved her wrong on that, right? So we need to at least get her back to a baseline. And so surprisingly, when I got in there and I got a picture, I'll show you that the bone stock on the distal piece was still intact laterally. And so I was able to get another, I think that's another, that's a 4-0 Kancella screw directed at a new trajectory, and then up top, upsized it to a 6-5 screw. And both of the screws automatically with these new trajectories had better bite than even the first time around. I did exactly what Travis and both Armando had alluded to and put some anchors in and then ran the anchors on each side of the tendon up the collateral sides of the tendon. But then I also surcloged inferior to the patella and through a bone tunnel in the tibia. In hindsight, the idea of using like a Kenyon lead screw or something sounds like a really good idea. I'll keep in my back pocket. But we were able to salvage this. I don't love the idea of that little step off in the gap distally in the bone. And one of our partners, Travis, actually suggested to put even a small plate over the top of this. I just worried about her soft tissue integrity with having a plate right on top of the tibial tubercle or even off to the side. But surprisingly, this actually came together in a decent fashion. And so I had recently seen her at three months and even despite my hesitations, she progressed her rehab way faster than I wanted her to. But she's now up and walking, using the walker occasionally. Her range of motion didn't get any different, which I was not surprised about given her CP. But she said she was pain-free with her ambulating and much better before surgery. So we paid our dues and got her, I think, what she wanted out of all this despite taking the long road. Any closing remarks or anything? Anything different or? Yeah, I mean, this obviously turned out well. And just one other thing, you know, again, consider that CT scan. That can just be really helpful in planning options before you get to the operating room. And then the second thing is I've seen these sent in, you know, at six months, chronic nonunion sort of thing. And what I like to do is I just use a one-third tubular plate. What I actually do is cut the top screw hole and make it a claw plate so you can actually put that in the top of your tubercle. And then, you know, you can use two seven screws, actually downsize your screws and get three, four, five screws along the entire kind of tubercle and shaft. So that is another option if your bone stock here was worse. Yeah. Great. Okay.

patella femoral pain

distalizing osteotomy

fracture

fixation

CT scans