All right, so it's 7, we're going to start because I think we got some really good cases and we can have a good discussion. And so we want to keep this as fun and interactive as possible. We did have to pivot a little bit because obviously we don't have roundtables in here, but I actually think it's going to be a little bit better. We're going to kind of have our faculty member present to a panel and get their input and then we'll have some time to discuss or have some open discussion with the group. So these are my disclosures, none are relevant for this course. So obviously being a team physician at any level is extremely challenging. If you're in this room, you know that already. There's no evidence-based guidelines to help us. So a lot of it is experience-based, either our own experience or learning from our colleagues. And when we compare it to throwing athletes, right, there's all these books and seminars and stuff. There's very limited information on collision sport athletes, despite the fact that they have a much higher injury burden and probably require more of our attention as orthopedic surgeons. So the purpose of this course is to kind of examine a variety of challenging cases, focusing on the collision sport athletes of football, hockey, lacrosse, rugby, so we can learn from each other's experience and take better care of our athletes, right? So very simple. So the outline, we had to pivot a little bit because of this room. So what we're going to do is we're going to have about 15 minutes per case. We're going to invite the faculty up here to present their case to the panel and we'll have a panel for faculty members up here. And we'll have that presenter stop throughout the case and anything's really fair game. Everything from sideline, you know, management to surgical decision-making to return to play. So really kind of, you know, pimp your panel up here and get them discussing. And panel, you don't have to agree with the person that is in front of you. So please, you know, if you have a different opinion, we want to hear about it and we'll discuss all the challenging aspects of the case. And then we're going to have time at the end. I'm going to try to save about five minutes at the end of each case for a little bit of open discussion and I'll walk around with the mic. And if there's stuff that's burning in between, I'll have the mic, I'll be walking around, raise your hand and we'll interrupt. So I want this to be as interactive as possible. So the cases that we select and we got, we had awesome cases. So a multi-ligament knee injury in a college football player. Then we'll go to an ACL graft tear in a rugby player, elbow instability in a defensive lineman, a clavicle fracture in a quarterback, posterior shoulder dislocation in an NHL athlete, and then a bony bankart. So really interesting cases with a lot to talk about. So with that, you know, this is our faculty. So Jeff Baer from Wisconsin, Ashish Bedi from Chicago, Steve Brockmeyer from UVA, Lyle Cain from Alabama, Kevin Farmer from Florida, Eric McCarty from Colorado, Mary Mulcahy from Loyola, Pat Smith from Missouri, and Brian Wolfe from Iowa. So really experienced team physicians. These are the people that I call if I have questions. So I think it'll be great. So with that, I'm going to start with the first panel. So I'm going to have Jeff Baer, Steve Brockmeyer, Pat Smith, and Eric McCarty come up for the panel. And then, Ashish, I'm going to have you kick it off with the first case. And then after this first case, Mary will come up. So you guys just stay for the first two cases, and then we'll switch up the panel. So if you'd just be able to click on your name. Oh, good morning. Thanks, G. I'll start with this first case, which is a knee injury in a collegiate wide receiver. We'll start a little bit with the history here. He's a 22-year-old Division I wide receiver. It's his junior year. Has no history of any knee injury. Unfortunately, he's also playing special teams, and so he's making the punt return in the first game of the 2021 season. Happened to be against Western Michigan University in that game. Has a contact injury and is carted off the field to the sideline tent. For sake of time, you know, physical exam has some varus alignment. Right away kind of has a bit of a fusion that's developed pretty quickly. And here's the other exam findings. Bit of a loose lockman and opens up a fair amount to varus and externally rotates. Quick neurovascular exam on the sideline is that he's intact and at least has a warm foot. Little hard to feel his pulses. I may have an image here. This is actually the start of that play, but I don't have the actual video of that. So maybe just, you know, taking a little bit of a step before we get into the rest of this. Maybe Eric, I'll start with you. Sometimes these are challenging. The, you know, players out on the field and you're deciding, do you examine them right there with everyone watching it? Do you decide if he can walk off or cart? In this case, I told you they carted him off. But how do you go through that decision making a little bit? I don't like to spend a lot of time on the field, maybe up in the middle of the field. So if we can determine that it's not a fracture and that they can get up, then I want to get up and get them off to the sideline and then decide where I'm going to do the exam. Is it going to be in a tent? I think it's a good idea if you have a tent. On our sidelines at the University of Colorado, it's very narrow. Right, Pat? Very narrow. And so, you know, you basically got room for your table and I might do it there. And if I think I need to do more, I'll just take him inside. But I think the location of the exam is not on the field. I don't want to spend five minutes, you know, on the field. Just determine quickly, OK, is it a fracture that we need to do something? Can we get him up? Let's get him off. Coach Sanders, Deion, and I had a nice discussion about this at the beginning of the season last year when I met with him when he first came on. And I said, Coach, I'm not going to go run out there when the player gets hurt. I'm just going to let the athletic trainer decide if he needs me to come out. And he's like, well, good, you know, because if the athlete's just laying there, then that means he's too hurt to go back in. I don't want a guy that's that hurt or that is not that hurt to just be laying there. He wants guys to get up. If you're not that hurt, get off. And if you're really hurt, OK, that's fine, but you're not going back in the game. You know, Pat, sometimes one of the challenges for me, maybe not in this position, is, you know, O-line men, oftentimes they're wearing a brace. Sometimes the pads from the uniform are kind of in the way. You know, how do you decide, you know, as you're on the sideline, how much of that you're going to undo to get your examination and how you're making that decision in terms of then getting back? Because sometimes you try to do the exam through those things to make this decision to not have it be multiple downs missed and missing a quarter. You know, what's your threshold for that? Yeah, no, I think that's a great point, you know, like Eric, you know, Missouri, we just have the trainer go out. I mean, the only time they ever call me out if it's, like, potential a neck injury, spinach or something major, right? So, we have the tent, so I'd like to get a good look at it there because the best exam is the early exam. But on those linemen like you're talking about, if there's any question, if I can get the brace loose at least and feel, if I can really feel like the MCL is lax or the LCR, I feel a bit of a lax, then I'll just take them into the training room and undress them and get a good exam. So, I think a good exam is key and try to, you know, because the trainer's waiting for what you say to tell the coach and whether, you know, the player's going to go back in or not. So, I think you have to do something early to be a little bit as definitive as you can and make the decision he's out and then take the further evaluation, take him inside where you have x-ray and everything else you need at least in a better setting. So, I think it's important to try to get as good exam as you can under the circumstances to make the decision that they're waiting for is can this player go back today, is he out? Yeah, and in this particular case, it was at least pretty clear from the exam and the rest that I decided that was not going to be a return that day. You know, Steve, one thing I have trouble with and even in this case had trouble with is sometimes I don't know in that setting, particularly when it's swollen and blown up like this. Is there a plateau fracture with this? He's tender everywhere. You know, this was in Ann Arbor. At this actual time, they don't have an x-ray unit at the stadium, just a mobile x-ray. Even before that, it was just fluoro despite being a big venue. But I imagine in some of the high schools, et cetera, you don't have that. How critical is it to have imaging right at that time? You have that at UVA and how do you manage it? Yeah, I mean, I think most stadiums that we've gone to have some level of imaging, but some do have these more mobile units. And so for bigger people or for more central injuries, that can be really problematic. You know, if you're trying to look at a shoulder or somebody's femur or whatever, I mean, that's not going to be sufficient. We have an x-ray unit in our stadium and have had since I've been there. And frankly, I do think that it's very useful for a variety of reasons. So you're talking about evaluating this knee. You know, this one sounds like it's pretty straightforward. But even if it's not and you've looked at it and you're not quite sure how bad it is or not, you obviously don't have advanced imaging there, you know, it buys you a little bit of time. So, you know, you have the players, see if they can wait there, you can send them in for x-ray. You know, these injuries evolve and there's a lot of like adrenaline, you know, these athletes don't manifest the injuries immediately quite as much as they will later. So we'll use it for that purpose too. But, you know, I think it surprises me at the University of Michigan, frankly, that you guys don't have full x-ray there. Yeah, a mobile unit and it may have evolved since, but kind of one of the portables that is limited in what you can do with it. In any case, these are his radiographs. We decided... Go ahead, please. Especially at the college level, a college or pro, you're going to have requirements that each stadium has, but the college, everybody's different. And there are places that we go in the Big Ten where there's no imaging on site. And so I think knowing the situation you have at the individual stadium beforehand is helpful about what you're going to do, what you're going to image. We're like Steve, we have x-ray right by our locker room, full unit, we can do everything. So it's not a big deal, especially if I'm sending somebody down that I'm going to evaluate down the locker room to get the x-rays and you know it right away. At Purdue, you're putting them on a cart, they're going halfway across campus, they have to be registered at the student health service, then they get their x-rays and then they have to try to print them out. So if you're sending somebody, it's 30, 40 minutes before you're going to even know what they have, which is painful. And that makes a big difference, what you're going to image, what you're not, versus if you can run somebody down, make sure what something looks like, and then bring them back out. And then you're also, the plane's leaving after the game. And so depending where you're at, they're not waiting for one person. So we've been in a situation where we've rented cars and driven back afterwards because we couldn't get back to the plane on time. It's a great point, and I've been with that experience in Purdue as well, Jeff. The other thing is at least even for a home game at a facility like this, if it's a spine injury, the portable unit does nothing for you. So you're automatically to the hospital or student health. This is next day injury clinic films, standard plane radiographs. No real tricks there. I'll just show, of course, he got an MRI, and I'll try to click through this here. Sorry, I know it scrolls here pretty quickly, so I'll go through that a couple of times. So, Eric, I know that's going through pretty quickly, but initial thoughts or impressions on this. His knee is, you know, obviously very swollen the next day, but exam is pretty similar. A lot of varus instability and a positive Lachman. Some tenderness along the medial joint line, interestingly. Yeah, you know, and that's where you see the bone contusion is on that medial condyle, and so, you know, obviously there was a varus injury. It'd be interesting to see, and we like doing this, watching the injury film, right? And often, you know, I think most of the big colleges, but you wouldn't have this in high school, of course, but to have the ability to look at the injury video, and it's been very helpful to see what the mechanism is because, you know, you typically miss it, and you didn't even see this player get hurt when it happened. They're just on the field, and so that would have been helpful in this to really see, you know, how did he get hit, but, you know, it looks like there's a lateral side injury. It was hard to tell just as you went through it, but there's a lateral side injury. There's a medial contusion, and then their ACL. I thought the meniscus looked okay. Yeah, agreed, and I'll try to give you maybe a little bit of an axial here, and to your point, Eric, I couldn't agree more. The replay can help a lot with these. You can't see it because you're either behind some alignment on the sideline, so even if you're trying, at least if you're my height, you can, and on the other hand, it does give you insight. In this case, we did actually watch the replay, and it was kind of a direct blow that resulted in a various moment as he was trying to return the punt. You know, Pat, at this point, you kind of have this information, and he's with you all of, you know, 24 hours, so then all these questions start to come up. You know, we thought, Eric, just like your assessment, this was an ACL. The LCL in corner was involved. There was this lot of medial bruising, probably from the varus mechanism, so there was signal in the medial meniscus, but didn't necessarily see a clear tear. As he's asking you, Pat, you know, timing for surgery and what's this mean since it's the first game of the season and all that, what would your thoughts be a little bit on this, and how long do you rehab this before you, you know, go after it? One other thought, I don't know that you necessarily needed it here, but don't forget about stress films. Sometimes in these injuries, I will actually get radiographic stress films. This one, that's pretty clear, is varus was, you know, three plus, but on some of these, you're not sure, and stress films can be helpful, so I just want to make that point. You know, for me, this injury, you know, it needs to be fixed. He's going to be out this season. This isn't one that you're going to rehab the lateral side and try to let him play in a brace or something, no chance, so it's got to be fixed. I think it is important to really time it right. You know, you've got this lateral-sided injury. Look to meet kind of more mid-substance. It didn't look like an avulsion off the tibia. The ones that are off the tibia, sometimes they come off commonly as a sleeve, and the whole lateral car ligament, post-lateral corner comes off as a sleeve. Those, I think about repairing, and I try to get those, you know, within the first 10 days, two weeks if I can. For motion, for me, most important is extension. I want them to have their quad firing if I can. If they can get flexion, you know, at a 90, I'm fine with that, doing it in the first couple weeks, but this case, I think he's going to need probably a graft, a post-lateral reconstruction more than a repair, so I would say you could do that within, you know, give him three weeks, if need be, to get decent motion, but, you know, I do repairs, and so I think that's important, and I think it's best to get those done early, and I always augment my repairs. I always, you know, like to augment with an internal brace on those to get them moving earlier to support him, so for me, he's out the season and probably needs a graft and a post-lateral corner reconstruction with a graft. What are you using for your ACL? Nowadays, I use quad tendon, so I've switched from BTB. I've had good success with the quad. I usually brace them, and for me, it's, you know, I've seen, you know, I'm the oldest guy up here, so in my 39 years, I can tell you the BTB grafts, I've done hundreds and hundreds of them. One thing you'll see later in your lifetime, if you see these patients back, they all get patellofemoral OA. I think that when you do a BTB graft, there is some degree of contraction of the patella tendon, and they tend to get some degree of increased patellofemoral joint forces, so I've seen that over time, and also I've seen anterior knee pain, and anterior knee pain exists. If you study your patients, which I have studied them, they do have it at a young age, and it doesn't go away, so that's one big benefit for me for the quad is that you don't have anterior knee pain, number one. Number two, you can get a really large graft, and even the big guys, so I switch, actually, to quad tendon. You know, Steve, you know, there is this continued discussion and evolution of ACL graft, of BTB, now quad tendon becoming popular and being seen more at the combine. In this case, Pat, as you picked up, it didn't really look like the lateral side was an avulsion mechanism. It looked more mid-substance, and I didn't think any primary repair was probably sufficient in isolation. In this type of athlete, does it all have to be autograft for the lateral side, too? How would you approach that side of it? Is that allograft, or do you feel that there's a higher threshold with his NFL prospects? Yeah, so I agree pretty much wholesale with Pat's approach to this. This is a reconstruction on the lateral side, and, you know, graft for the ACL. We use patella tendons for our athletes, and, you know, I don't have the benefit of seeing these people 30 years out yet, but I do, I hope that patella tendons, or BTB graft harvest, and, you know, some of the other features of that, you know, maybe we won't see quite as much morbidity from it. On the lateral side, most of the time, we're using allograft tissue versus autograft tissue. You know, there might be a circumstance where we'll use their own tissue, but, you know, these are elite athletes, and so there's a cost to harvesting graft, and, you know, for extra-articular injuries on the medial or lateral side, typically allograft works as well as autograft. Great. For sake of time, I'll show what I did, and then, Jeff, I'm going to ask you a little bit about the last question, where the parents are asking you, given this injury and the timeline for recovery, does he have a better prospect to come back and play another year at Wisconsin or Michigan, or should he go ahead and go on to the combine? So I'll just start here, I guess. You know, plan, procedure of choice, all of these, and I think we just covered this, you know, with graft choices, it sounds like BTB or quad, and everybody agrees on some form of a lateral-sided repair or reconstruction or both. We chose to do exactly, Pat, what you said, gave him a little time of prehab. I also treated him and condemned him to future patella-femoral OA with a BTB graft, and then we did go ahead and open up the lateral side. Again, this was mostly mid-substance tearing with stretch, so I did a lateral and posterolateral corner reconstruction with allograft. I actually have put some suture augmentation for collaterals. I think that's one of the areas that it's made more sense for me, and we did kind of a standard, more R0 construct. I did not place the additional leprod-based tibial tunnel. You could criticize me for that, but at least I think the biomechanics of that for me have looked equivalent, and I didn't want the additional dissection there in this kid, but a point of potential discussion, and those were his post-op radiographs. You know, thoughts a little maybe briefly on that. You know, Jeff, you've done some of these multiligament knees, and there's limited real estate there. You do the same construct every time. Is it a little bit variable based on what's injured there? Yeah, I think it's variable on it. I think for me, I had a high school senior fullback do this, almost the exact same injury, this one, and of course he signed with us already, so he came to us. He had his PCL, too, and so we did that one for him. It was, for me, it's really which reconstruction I'm going to do on the lateral side depends on how much rotational dial they have. If I really think their dial is significantly increased, I'll go to more of this leprod reconstruction. You can do it either as a single graft or as two grafts and split the limbs, and I've tended to use Achilles because I can use it for almost anything, and the other thing I have an advantage with Achilles is I have many of them in the freezer versus any of the other allografts that I tend not to have as many. I have not loved the perineal grafts or the posterior tip and so forth. Those just haven't worked great in my hands. I like the bone block, but I think your reconstruction is exactly what I would've done. I would've done the same thing. I like it, and like on that kid of ours, he did not have a big dial, and so I just did just a Larson reconstruction on the lateral side. The rehab for these, I think, is really hard, and that discussion with the kid about where he's, and the family, right, you know, as Jimmy would say, the mom's the most important person in the room when you go on. So, I mean, these are ones you have the discussion, you see them the next day, the family's there, you have that discussion with them, and you really go through everything. I think your timing was sort of perfect on this, and I agree with Pat on that, sort of that, if I'm going to repair it, I want to get there right away. If I'm going to reconstruct it, like this case, that three weeks, four-week time, but you want to make sure he's getting motion back because if he's stiff, you're going to have a hard time with him afterwards. Usually, we don't have that problem with our college athletes or pro athletes just because they have PT, they have the athlete trainers every day. I got a question from the audience. Actually, I actually, so I have guest faculty, Dr. John Uribe is here, okay, who has a ton of experience with multi-legs and football players. So, John, talk to us about lateral side repair versus reconstruction. When are you doing these? So, I think the MRI is something that you should really, really study hard and see what you can fix. My approach to these on the majority is, and a lot of it has to do with the exam and the dial test, but these are basically low velocity. So, you'll be able to fix a great deal and augment it. I truly like to get these in the first few days where there's no scarring and you put that anatomy back and just, you can augment it. And to me, that's given me the best opportunity to get them back originally. So, I just think our job really is to try to reconstruct the anatomy as closely as possible. And unless the things are so shredded, but even in shredded cases, I think you remember our O-lineman who dislocated his knee, complete dislocation, everything was shredded. But we took him to the operating room and you can approximate it and get it and then you augment it. And, but the next year he was all pro. So, I just feel that most of these can be repaired as opposed to reconstructed. That's great. So, for the sake of time, panel, stay put. Mary, we're going to have you pop up there now. So, we're going to have some more time to talk about ACL graft selection. I know we touched on it, but Mary's going to present a case about ACL graft rupture. Great. Good morning. Thanks so much for being here. And, Gee, thanks for the opportunity to participate in this ICL. So, we'll switch gears a little bit talking about revision ACL reconstruction in a rugby player. And let's see if the mouse will cooperate with me. Okay, perfect. These are my disclosures, none of which are directly relevant to this case. So, this is our patient, not this guy. But, anyway, a 20-year-old male who actually presented about a month after injuring his right knee while playing rugby. He complained of immediate pain and swelling. He was unable to continue playing. And important to note is that he's status post right ACL reconstruction two years previously with hamstring autograft. So, on exam, he was able to straight leg raise. His knee range of motion was actually pretty normal, no pain with range of motion. Some tenderness over the medial joint line, and he had pain with McMurray tests, and an obviously positive Lachman. These were his x-rays in clinic. So, Eric, just seeing these, you know, what are you thinking? And what are your other thoughts in terms of other imaging or workup at this point? Yeah, you know, you can see that he had some type of soft tissue. It doesn't have to be soft tissue, but it looks like it probably was based on the button. Although, you know, people will use the button for a BTB, but I don't see that. So, soft tissue graft, and, you know, things look fairly good alignment, which is important in a revision ACL, because that's what we're faced with. And just looking at this, it looks like joint space is good, and I would definitely get an MRI on this, and I'd get that first, and then if I have any question about it, I might get a CT if I really can't tell about the tunnels. Yeah, Pat, I was just going to ask you specifically, what are you thinking about the tunnels, just seeing these x-rays? Are you concerned enough? Are you going to jump straight to a CT? Yeah, I mean, I think the femoral tunnel looks to anterior and the tibial tunnel a bit as well, first of all. Second of all, I think you've got a standing AP. I always like to get a standing Rosenberg view, and then, he looks to me like he's got a little medial joint narrowing, so I'm a little worried if he had some meniscus before. So, I like to get a standing film, hip to ankle, on these patients as well. And you get a standing lateral to get his tibial slope doesn't look bad, but I think those are things you need to think about. You know, it's a revision case, so I would get a good standing lateral measure slope. I'd get an AP hip to ankle. And again, I don't think the tunnels are perfect. And there's a little bit of widening on the femoral tunnel. You know, the question is, you know, I don't think it's, you know, I don't know that you necessarily need to get a CT. I think you can measure it decently here, but I always think about, you know, whether to get a CT if they're really big to get some better measurements. But soft tissue grafts, you do get this problem. And the tibial, you know, what is it, 10 or 11? So, I don't, you know, those are things I'm thinking about. So, a little bit more imaging for me. Worry about the tunnel position. And then, you know, besides an MRI, think about a CT, but probably not necessarily. Perfect. Thanks. All right, I will show you guys included some of these cuts from his MRI. So, Steve, just looking at these two cuts, what are you seeing? Well, I mean, these two cuts highlight a couple of things. You know, the cut on the left, you can see some meniscal pathology. And I use that term purposely. I mean, you'd want to scan the meniscus all the way and obviously have some information on what was done in his index ACL. You know, he could have had a repair and, you know, these could be traversing areas from the prior tear. This could be a new tear. The second cut, you see some graft tissue in the tibia. I agree with Pat. I do think the x-rays, you worry that the tibial tunnel might be a little bit on the anterior side. Tunnels on the x-rays, again, weren't terrible, but maybe not perfect. And you could see some, you know, tissue in that tunnel, but hard to really evaluate what's going on inside the joint with that one cut. You don't see an ACL there. So, if that's the best cut to see graft and there's not much there, then you know that there's not much there. Which it was, unfortunately. But also, I don't recall off the top of my head if he had any meniscal work done in his initial surgery. It was done in an outside hospital, but all excellent points. Did he have a pivot shift? I mean, I'm assuming he did on the MRI. In terms of, yes. Well, we're going to, I'm going to include a couple of other cuts, too. But, so, just actually a little sort of side point, too. In clinic, I don't tend to try to evaluate for pivot. I don't know, what's your guys', you know, Steve, is that something that you're trying to do in clinic, you know, when you're seeing them a couple weeks out? I always try, but I don't find that it can be that reproducible. It's really dependent, depends on the patient. There are certain patients, for whatever reason, that, you know, can relax enough and you can kind of distract them a bit and you can get an idea as to whether they pivot or not. You know, that's why the Lachman test is so useful. The ACL is really a rotational structure, but the Lachman can give you a feel for whether it's lax or not. But, certainly, under anesthesia, the pivot shift is going to guide treatment quite a bit. Absolutely. So, then, these are two other cuts that I included. No obvious lateral meniscal pathology. And then, I just included a single coronal, just so you can get a little glimpse of his femoral tunnel. Jeff, any other comments just about, based on the imaging we've seen? Are you worried at all about the diameter of his tunnels? And then, what are you thinking? Would you get a CT in this case? I mean, full disclosure, I did not. But, just any other thoughts about the tunnels? I'm not super aggressive on getting CTs, especially in this case. He's only had one done. It was trans-tibial previously. I agree with that. I think the tunnel's a little bit anterior. I think I'm probably going to be able to miss it in my revision, because I think I can get my new tunnel back there. I would have, this would be a situation, I would have bone graft, a dowel available for me, because if I needed to just structurally fill that femoral tunnel, so I could put my new tunnel behind it, where I could have an interference screw, I think I'd be fine. The anterior tunnel, the ones that are off, and I think this one's going to be off enough that your revision will be pretty easy. The ones that are off a little bit are the hard ones. You can't correct for anterior on the femur, and you can't correct for posterior on the tibia. This one from the tibia, I can just push that back. I'm going to do a patellar tendon on a revision, or a quad. The problem with a quad is you have a really tight graft, but I may have to move it a little bit more. But patellar tendon is probably my go-to on this kid and a rugby player. So I can push that tunnel just back a little bit. I think I'm going to be really good. I think I'm going to be able to drill a new anatomic femoral tunnel without difficulty, but I'd probably have bone graft available just in my need. Now you could also use a interference screw, a bio screw, or something like that to fill it if you needed to. I'm not a huge fan of those. I think sometimes you get a lot of reaction to those, or you can get reaction to those. The bone dials I've been happy with. But I think this is a one-stage reconstruction. The one thing I would say I'm concerned about on his coronal MRI view is that medial meniscus is one that I'd be concerned about. Hopefully those are just some suture passes from before, and it's not as bad as it looks, but I always worry when I have a vertical tear with a horizontal tear that those don't heal great, even if you do an inside-out repair on them, so you have to be a little bit careful with that. Yeah, all excellent points. Thank you so much. I'm going to skip over the subsequent couple of slides, just obviously lots of different things contribute to failure of ACL reconstruction. Certainly we need to keep in mind position of the tunnels, which is one of the major contributing factors. So just for some more opportunity for discussion, so obviously we're talking about revision ACL reconstruction here. Single versus two-stage, Jeff just kind of led into this, but Eric, other thoughts approaching this case? You know, I think sometimes I'm not sold because I didn't see enough of the images that that tunnel is anterior. I can't tell though. I mean, I really can't tell from the images that we got. So I'm a big fan of doing it all at once if we can, and if we can't, I've got no problem doing a two-stage because I want this to be a really, really good ACL reconstruction, and if I can't do it the way I need to do it, then I'm going to come back a second time. I like either BTB or quad for this revision. I think either one would be great. I think you can do a lot with both of those graphs, and then I'm going to also add an LET on this as well, and that's going to be almost pretty standard in most of the ACL revisions that I'm doing. Perfect. Pat, what are your indications for two-stage for revision? For me, I try to do it all at once. If they have huge tunnels, if it's really in that 15 millimeters or size greater, sometimes those I will stage, but in this case, I think it's easily done. There's one area where I would prefer the BTB autograph because from the bone plugs helps me fill the soft tissue sockets in the femur and tibia, so I would go BTB autographed. I would use an internal brace as well. I agree with Eric. Rugby guy, high risk of re-injury, but I think with the dowels, I think you can really get away a lot of times with even when you think they're large to go ahead and do a single stage with the dowels and drill through them. My preference, especially in an athlete, is to try to do one surgery as opposed to staging them, so I think in this case, I would for sure do one, and I would go BTB autographed. Perfect. If you were to two-stage it, if you used bone dowels or some other type of bone graft, how long are you waiting to go back and do the second stage? Yeah, so my partner, Mark Miller, really developed the bone dowel technique, and they've looked at it pretty closely as far as consolidation, et cetera, and so typically, it's right around four months, so you do your graft, you probably deal with the meniscus maybe if you have any plans to correct an angular deformity or any type of osteotomy you do at that point, and then typically consolidation by about four months. You can see it on x-ray, but a lot of times, you will want to get a CT on that. The bone dowels do consolidate pretty well. It's still allograft bone, but typically, that's sufficient to be able to reconstruct and put the graft exactly where you want to put it and get it nice and solid. Can I say one thing about two-stage? I've had a couple cases where I've staged it, it can come back, and the meniscus re-tears. You've got to be very careful, so I do not do anything for meniscal repair. If I'm going to stage them, either a lateral root that I fixed, I thought was perfect, it was re-torn four months later, so just be cautious about doing a bunch of meniscal repair work if you're going to stage it, because then he's unstable, so I've gotten away from that. I'll just graft him and then come back and then do everything once. One thing I would say, Steve says he gets CTs. I think when I've gotten CTs, all I've done is scare me, and so I get the x-rays, and as long as the x-rays look good, and I'm three to four months. Now, if I have a huge defect, then I'm winning six months on a huge defect, but if I needed to stage this one, but I agree with Eric too, is in my discussion, because it's a hard discussion, as Pat was saying, about if you're staging them, you're adding three to four months to their rehab, right? Yeah. But I tell them, I'm here for your second ACL, I don't want to be back here for the third because I accepted something and gave you a non-anatomic ACL. We already know that's the reason the majority of these fail, and so I don't want to be back here for a third time. I want to get it right the second time. Yeah, excellent point. And then, Steve, are there times when you're going to consider taking graft from the contralateral lower extremity? I honestly can't recall a case where I've had to do that, and I think if you've burned all the grafts on that side, then you can. I know there are some surgeons who really favor that approach. Obviously, the patients typically don't favor that approach. In this circumstance, you have two good, really solid graft options, and I think a BTV or a quad are good options, and this patient, I kind of side towards BTV for the reasons Pat said with the standpoint of bone, filling in these areas where there's tunnels. So Eric, a question for you before you comment. So if this patient- I was going to comment on that. Yeah, go ahead. No, you, and go ahead. What were you going to comment on? Well, so the comment was that I actually, if I, and my athletes at the collegiate level, I'm doing a BTV, and then my first option is to go to the other side. So, and I've been very happy with that, and it's amazing what these athletes say. They say, oh, Doc, that wasn't as bad when overall rehab, it's very interesting. So there's something to what Shelbourne did now 30-something years ago when he started doing those, but anyway, I just want to comment on that. Eric, can I just clarify, for this guy, you're going to do ipsilateral BTV because it's hamstring as the primary. I am, but I've got no problem- But if you have a BTV that's failed- Yeah, then I'll go to the other side. Okay, then quick question just going down the panel. If his primary graft was BTV, ipsilateral BTV, are you going to do an ipsilateral quad in this case, or are you thinking about going to the contralateral lower extremity? So if it was my collegiate athlete in rugby, then yes, I'm going to suggest that. If they don't want it, I'm fine doing quad. I would do quad from this side, and I have about 20 patients that have had BTV failures where I've done quad revisions, and they've done really, really well. So I've never actually ever taken a graft from the other side in my entire career. I haven't either. It's a great point. Yeah, agree. I have not quite 20, but I probably have five to eight where we've done both BTV and then quad, and so that would be my choice typically, is ipsilateral quad. Jeff, anything else to add to that? I would go the same way, and I do a bone with my quad. I typically don't do a soft tissue quad, and as long as I ... I can see it usually on the x-ray, but on the MRI, if you're concerned, you can see your bone fill because I always back fill really my patellar side a lot. I would go either way. I've done contralateral like Eric did, and I've had the same response from the guys is that it went really easy on the rehab. So two quick comments from me, and then I'll just go show what we did. So I also have not harvested from the contralateral or lower extremity, but just a great point that you heard from four very experienced surgeons. I think that this has been a change over the past several years, feeling comfortable harvesting from both ... using both BTV and quad from the ipsilateral extremity. I think that earlier on, we just weren't sure if the patient already had extensor mechanism, could we still use extensor mechanism, proximal or distal, and patients do fine. So we touched on this a little bit. Should we do LAT? Should we augment with suture augmentation, and then post-op protocol? For the sake of time, I'll just show you guys what I did. So these pictures are not from this specific patient, but just to show you how I positioned the patients. The affected leg is in a leg holder. The contralateral leg is in a lithotomy boot, actually, to get the leg up and away. The central picture shows the incision. I actually make that probably about half that length now, but I do make a vertical incision. I think that's really important. I like to see what I'm doing. And then on that far right side is just how I mark out the central third of the quad tendon. I use a standard 10 blade to actually start to harvest it, elevate it off the proximal pole, the patella. So obviously he had quad autograft. And then I just elevate, I put an ethabond suture in that to get some tension on it as I harvest proximally. Then on the left-hand side, you can see just prepping the graft on the back table. On the right is the final prepared graft. And then a few of his intraoperative pictures, so he had that medial meniscus tear, which I repaired using an all-inside repair device. A couple of these pictures. The final repair is on the right-hand side. And then a picture of his notch with basically nothing left from his ACL. He had a tiny lateral meniscus tear, I just trimmed that. And then a few pictures from his case. So I drill retrograde, so just looking up that thermal tunnel there. The button coming into the joint in that central picture. And then on the far right is the graft coming up into the joint and into place. Same tunnel? Or did you do a new tunnel? So I did a new tunnel. It was no problem to avoid the old tunnel. And then I did do an LET in this case. So we're all very familiar with modified LaMer technique. And these are some intraoperative pictures from this patient. So central third of the IT band. On that right-hand side is the LCL. So I just feed a suture under there to then feed the IT band under the LCL. And then I'll place an all-suture anchor in the femur. It's a tensionable mechanism, so then it sort of is an onlay technique for the IT band. And then I actually fold it over onto itself, which you can see on the left-hand picture. Suture that to itself, and then cut the remaining graft. And then these are his post-op pictures. In this particular case, I used a biocomposite interference screw. I backed it up with an anchor on the tibia. I actually, in the past several months, have transitioned to using a small metal ABS button on the tibia. I still drill a full tibial tunnel, and I back it up with an anchor. He's done great. So I think, for sake of time, we'll stop there and see if there's any questions. Yes. If there's any questions. Question. And then... I've done a few with bone. I typically do a soft-tissue graft. This is one where you actually, you know, depending on the tunnel, so I might hold off on harvesting graft until I assess inside the joint, and then you can make some judgments because you do have the option of using bone, and that bone can fill a tunnel for you. So, you know, typically for, you know, primary surgery, I use all soft-tissue, but, you know, you could, and certainly this might be an advantage to take a little piece of bone. I'm all soft-tissue, and I do all inside, so I do a closed tibial socket. But I'll make one comment. If you do take bone, favor toward the central or medial aspect of the patella. The lateral patella or bone is more sclerotic, and the risk of fracture is greater if you get on that lateral side with your bone plug if you harvest bone for quads. So if you do it, I would try to save central and medial for your bone plug harvest. I'll say one thing I do is because the bone on the quad side on the proximal patella is very different than the bone on the tibial side, or the distal side of the patella, and so I will harvest mine. I use a parallel blade to harvest it, and whenever I do quad ACL revisions, I always get my tunnels first, and then I'll come back and get my graft. But for a primary ACL, if I'm doing a quad ACL, I'm still drawing all my tunnels because of fluid extravasation from the quad because I do a full-thickness harvest. But when I come and cut that, so I'll free it up. I whip stitch the end of it so I can lift it up. I've done my vertical cuts and my inferior cut on the patella, and usually I'm only going for about 15 millimeters or so, so a fairly short bone block for it. And then when I lift it up, you'll be able to lift that up and come underneath, and I'll take the bovine. I'll just take a little bit of that fat off that's at the proximal pole of the patella, and I'll bring my saw sideways and come underneath it and just stay parallel to the top of the patella. Then you just take that out, and you have zero problem with the patella fracture with that. But that works really well for me, but I agree. You do have to be careful where you're at because the quad can easily put you off medial or lateral when you come down to harvest that. I do all soft tissue quad. Just one point about soft tissue grafts and tunnel widening. So I think all, I had to say all, but I think most soft tissue grafts have tunnel widening if you look at them. Usually on the tibia, it's pretty uniform. On the femur, it's kind of a funnel look. So the part of the joint's kind of wide, and it gets narrower, you get towards the cortex. And so if you have a BTB as an option for revision, you can always use a big bone block from the tibia. So you don't want to take a big bone block on the patella, but say you've got a 15, 20 millimeter wide tibial tunnel, you can harvest 20 millimeter deep tibial tubercle plug, which is a single stage bone graft. So I think the only time that, I mean, we never bone graft the tunnels, done lots of revisions from soft tissue to BTB. And you kind of have an autograft single stage bone graft by using a big tibial plug. Yeah, thank you. You typically, real quick, Loud, do you typically make those kind of shorter so you can pass it in the joint? You know, a big 15 plug or something like that, getting it through the notch and into your socket. Yeah, so generally the bigger plugs needed on the tibial side, because that's where most of the widening is concentric. On the femoral side, you almost never need it because it's harder bone. You're putting a 10 plug and a 10 screw or a 9 screw into a, you know, 12 or 14 or 15 millimeter tunnel. Yeah, you can always fill that with a screw. So this is the tibial side. So the smaller patella plug we put up in the femur, the bigger tibial plug down the tibia to fill the bigger hole. Yeah, that's great discussion. So we're going to invite Lyle up here. We're going to switch up the panel. So Pat, stay put. Ashish and Mary and Dr. Wolf, you're staying put. All right, so I'll get started as everybody's getting seated. So this is an instability case of the elbow, a defensive line. My real case, this was, I believe it was 2017. I was trying to remember the date of this game. Some of you recognize it. So this is a 19-year-old sophomore defensive end during the first game of the season. So this is one of the many games of the century we've had in the last 17 years. This was first game of the year, Alabama, Florida State. We were one. They were three. So one versus three, first game of the year. And we played in Dallas, I think. I can't remember. So he's trying to hit the quarterback. And right as he makes contact with the quarterback, his other defensive end hits the quarterback and knocks him backwards. And so he ends up having a valgus flexion force to his elbow. Lands on the field, lays there. As we mentioned in the first series, I don't go on the field unless I get called out there generally. I saw it happen. I saw the guy lay in there. I thought it was a pretty benign injury. And they called me on the field. I was like, why are you calling me out there? And they said, well, he's got a dislocated elbow. So I got on the field. He's laying, as you'll see in this next picture. This is his injury picture again. So you can see his elbow is kind of in hyperflexion and valgus as he hit the quarterback. His hand kind of got stuck and he got pulled backwards. So I go out there. He's laying down with his arm on the field. And it just looks funny. Something doesn't look right. It doesn't look dislocated. He's got this big mass along his medial arm. But I took his arm and I flexed it, extended it. He had full range of motion. Really, definitely was not dislocated. He had a significant deformity, as I mentioned. But he was unstable to valgus stress. He had a large mass distal to his medial epicondyle. And so we had x-rays that were normal at the stadium. So first question, we'll start with Mary. So this guy's first game of the year. This is a game of the century. I mean, it's the biggest game of the weekend, the first weekend of college football. He's a junior that thinks he wants to come out this year and go pro. Big season for him. And he's dying to go back in the game. You going to let this guy go back in the game, number one? No, absolutely not. I mean, given the degree of pain, the acuity of the injury, deformity, which on initial evaluation, you're really not sure what that is. So getting him off the field, getting imaging. I mean, we had a great discussion with the first case about the variability in imaging available on the field. But certainly, we want to get imaging straight away. So if it's not available on the field, he has to go to the emergency room to get imaging, to evaluate for fracture, to evaluate for overall alignment. But I would tell him, no, he's not going back into this game. Certainly, we need a full evaluation to understand what's happening. Pat, Missouri's playing Alabama on national TV. You let this guy go back with a brace? No, number one, because we're still going to lose, even if he plays. So second question, was his older nerve OK? I mean, yeah, neuro intact. I mean, if you didn't see the mass and just watch him move, once he comes off the sideline, he looks normal. So you stress him, he's unstable and valgus, but he has full motion, feels good, has good function. Do you ever do a stress film like this? If you had a situation like this and you had a good x-ray and you say he's unstable on exam, would you get a stress film on him? Yeah, I think that's a great point. You know, we stress all of our throwing athletes for valgus instability. I think in this case, it'd be a good option. I mean, I think it'd help you make, I think you ease out. But if you did a stress film and he gapped open, you'd say, listen, there's no chance because it's unstable. Even a brace is not going to work. And then you put his older nerve at risk if he gets another valgus stress or more damage. Yeah, that's a great point. You know, in this case, he was so loose that it never really entered my mind to let him play, honestly. But, you know, if it were one of those cases where I wasn't certain, I think a stress x-ray probably does make some sense. Thank you. Anything else that you would do from at that time? Are you going to cast him, you know, splint him post-game? Are you going to – what are you going to do before you get home? You know, we're playing in Dallas. We're not going to be home until that night. And this guy, again, thinks he can play. Are you going to let him roll, put him in a sling, protect him? What are you going to do, Brian? Yeah, I mean, I've seen this a couple times. You know, they swell a lot. So I would put him in a sling. I don't think he needs a brace or a cast or anything. I would probably just put him in a sling, ice him. I'd have the fellow check him a couple times. I've seen a lot of four of them swelling with this. You know, I assume he's kind of going down the road. He might have lost his flexor pronator mass. And – but I don't think you have to do anything too special other than monitor very closely and keep them comfortable. So you're on the field, you're in the middle of the first game of the season, Ashish, Coach Saban comes out of retirement, doesn't like the ESPN gig. You're taking care of him, it's your new job, he's your new coach, and he asks you, hey, Dr. Betty, when's this kid gonna play again? On the field, he asks you that question, not after you have all the studies. What do you tell him? Unfortunately, I've not been in that situation with Saban, but with some other coaches, and I hesitate to give too much information right on the field, so I would say something like, elbow sprain, and not get into details, because they'll run with that. And I think my answer at that point would be, he's out and need a little bit more information to get back to you, and maybe get fired as the team physician. Yeah, he wants to know what day he's back, not exactly. All right, so this is the MRI. I skipped past the MRI, let's see if it'll play. Anyway, I'll skip to the chase. So this guy had a medial soft tissue injury, so he had a UCL injury and a medial flexor pronator avulsion. That mass that we felt in his forearm was actually his flexor mass kind of flipped upside down. He had avulsed it, and it flipped down in his forearm. By the time we got back and got his MRI the next day, it looked fairly normal in MRI, except for the avulsion, but I can tell you that entire mass was down in his forearm at the time of the injury. So he had flexor pronator avulsion, also UCL proximal avulsion. So these are the treatment options we thought about. Again, first game of the year. This kid, he is determined to play. He's not gonna have surgery. He wants whatever he can do to play. So would you do typical conservative treatment, brace him, try to let him come back after the UCL heals? Do you do some kind of biologics? Do you recommend surgical repair of the flexor muscle mass for the reconstruction graft for his UCL? Or do you do a flexor muscle mass repair with UCL repair, internal brace? We'll start from the other end. Brian, what are you gonna do with this kid? He's a high round draft choice kid. First game of the season. Well, I would tell him big picture, think keeping of his future in mind. I think he would struggle with non-surgical management, especially with the flexor pronator mass off, and that his outcomes, if surgery was done, probably be better sooner than later. So I would do a repair, try to repair the ligament, kind of separate, it's all one big sleeve, but try to do two-layer repair with the ligament, internal brace over that. And then often there's a big sleeve of periosteum on the epicondyle. You can kind of just do side to side soft tissue or potentially augment with anchors up there to fix his flexor pronator mass. But I also think they do pretty well in terms of timing. So I don't think this is a typical six-month deal. This is something that you could shoot for four months, maybe a little bit quicker than that if you're really aggressive. But I would try to nudge him towards surgery because trying to repair this or take care of this later is a whole different ballgame and I think a little bit less predictable. Any other thoughts, Pat? Yeah, I agree, and I worry about this guy's ulnar nerve. If you wait, I mean, this thing, the nerve's gotta be, it's gonna be in sconce and scar tissue here if you wait. I think their best chance is, and I agree with Brian, is fix it early. And I also agree, you can get these guys, I think, back fairly quickly, especially with some of the more stable braces we have now for the elbow. So potentially, for sure, I think, for your national championship game, you should be ready by the end of the season. So I would definitely do the last choice of, I would repair his ligament, internal brace, and repair the flexor pronator mass. So that's what I did. I did a UCL repair of his internal brace. I repaired his flexor muscle mass using some small suture anchors. I guess, in my thought process, the flexor muscle mass really determined the treatment on this kid. So if this were an elbow subluxation, full thickness UCL tear, elbow dislocation with UCL and lateral collateral ligament injury, I'll rehab those all day and let him play without surgery most of the time. Because, you know, those acute injuries heal. The flexor muscle mass avulsion really is what made me take this guy to surgery and recommend surgery. So we fixed both. You know, again, his goal was to get back to play. So we put him in an early range of motion brace post-surgery. I think the difficulty with these injuries, they tend to get stiff. Just like an elbow dislocation. The elbow dislocation patients, you know, I worry more about stiffness than instability, recurring instability. So we move him quickly. We try to get full extension by four weeks and try to get, do active flexion about six weeks to start pulling on the flexor muscle mass. Any thoughts about rehab, Mary? Oh, just a question, actually. How do you, what's your limitation or plan with range of motion immediately post-op? Yeah, so in his case, we kind of let the UCL determine his range of motion. So we did it very similar to the way we do UCL reconstruction in baseball players. So we started off at 20 to 100 degrees. Then we gradually, over four weeks, let him go from 20 down to zero extension. But probably a little more conservative than we would do in a baseball player, just because we, you know, if he loses five degrees extension, it's not the end of the world as a defensive end. We'd rather have him be stable. So we're a little bit slower maybe than a typical baseball UCL, but similar protocol. So, I think Brian mentioned earlier, kind of timing for return to play. So I, you know, again, this kid was, I mean, he felt so good so early. He was, you know, at three weeks he wanted to play, four weeks he wanted to play. And so I, you know, I was nervous because I knew the kids are high draft choice. The last thing I wanted to do is have him re-injure his elbow. So, you know, I did what I normally do is every time we played somebody in the SEC, I'd ask that doctor on the other sideline. So I asked J.P. Bramhall at Tex A&M. I asked Brent Bankston at LSU. I asked Dr. Andrews when we played Auburn. And everybody had different answers, you know. J.P. said six weeks. I was like, damn, really? Brent Bankston said eight weeks. Dr. Andrews said three months. I mean, I asked everybody all season long. I kept asking them, you know, when we're talking pregame, hey, I've got this kid, can I tell you? And everybody had a different answer. So thoughts from the panel, I'll just go down, starting with Mary all the way down. When would you let this kid play? He's chomping at the bit, he feels good. He's got a future in football though. I mean, I think it's challenging because it's such a rare injury, but six weeks seems way too early for me. So I'd be telling him probably three, four months. I'd say three months in a protective brace. You know, not that brace, but, you know, like the ACL elbow brace that they have. Rod? I fought this battle, and I think they got me down to 10 weeks on the last kid that we had. And he did fine. We had him in a big J.J. Watt brace, but I think you can push it a little bit. Ashish? Yeah, I'd probably say about three months. I think the challenge, Lyle, is like six, eight weeks, the elbow's moving well and the motion looks good, but it's still kind of immature healing. So it's just what risk you're willing to assume. Yeah, so I worried mainly about the flexor muscle mass, really. With our data, with UCL repair and baseball players, it's pretty strong at six weeks. We start plyometrics and that kind of thing with baseball. But having to grip somebody and tackle him as a defensive end, I worried about his flexor muscle mass. So I waited three months. So I told him three months. This is him when he came back in the semifinals playoff game. He's got the big J.J. Watt brace, which I think he thought was a badge of courage. And so this is the player. He was the front page of USA Today and ESPN everybody doing this, the sweet revenge. And if you look really closely, you can see his incision from his medial flexor muscle mass. Lyle, a couple questions for you. One, did he get back full extension and full flexion? He did, yeah. Yeah, I mean, we were pretty, again, pretty active with his motion. And when did you start, you know, the other thing we haven't really talked about for three months is how's his strength? And when did you start strength training his forearm? And did you guys do diametric? I mean, how'd you guys assess that he felt it was strong enough side to side? Yeah, so our athletic training team did a really good job of keeping, you know, side to side numbers. They would send me elbow flexion and wrist flexion numbers every week that they did on a dynamometer. We started at six weeks doing pretty light work and then, you know, kind of progressed. I mean, this guy, I guess, you know, being a first round draft choice kind of kid, he's a muscle maker, you know, I mean, different than a high school player or somebody else. He built muscle really fast. And so by 10 weeks, he was actually symmetric in his grip strength and his wrist flexion strength. And, you know, I probably could have played him at 10 weeks. It's just the timing of the season worked out where 12 weeks was kind of the semifinals. But, you know, really good point. I mean, you don't want him to be at risk because he's not strong or because he favors that arm and hurt something else. And that was a big question going back. I think the other thing that I've learned is that, you know, I've had four and three defensive linemen, one linebacker with kind of chronic UCL instability symptoms and pain. And it's a really great operation to do a repair in these guys. And they come back reliably three to four months, you know, when so you see some chronic instability cases like this, it's a great operation. And it's different than an ACL. They do come back this quickly. So I think it's the work that Jeff and you guys have done has been something I've transmitted, you know, into the football arena because you do see these chronic UCL patients, obviously not this acute case, but chronic ones do exist and they do really well if you fix them. So with that, well, it was a great discussion. Kevin, I'm gonna have you, I'm gonna have the panel stay put and I'm gonna have Kevin come up and present his case. Thanks, Lyle. Always hard to follow Lyle. He's got all these cool videos and stuff, but don't have those kind of, how do I get out of here? Yeah. So this is a case that I've actually dealt with this season trying to get my thoughts on the best approach. Yeah, so the discussion was if, you know, if this were a different player, a different position, would you play him sooner? And I think for me, the question was not the UCL, not the stability. The question was the flexor muscle mass, being able to grab a player and tackle them. Because obviously the elbow brace prevents valgus motion, doesn't help his wrist and his grip at all. So the question is, could you club him and have a club and an elbow brace? You know, I think you could probably do that. I'm not sure how effective it'd be, but I mean, it's possible, yeah. Yeah, yeah, yeah, I mean, it's a weapon, you know. That's like a two-year-old. Yeah, yeah, he would have lopped him on the head instead of tackling him, yeah. Yeah, a great point. I mean, I think going forward, you know, that's the first one I'd seen of these. I think I would, you know, in the next case like this, I think I'm a little bit, I might let him go back at eight, nine, 10 weeks if his grip strength is really good. Like the OCD glenoid the other day, right? I don't know. Like the OCD glenoid the other day. For elbow subluxation or just, you know, when you know, so there's, you know, obviously valgus opening, so you know that there's, you know, a UCL injury, acute, traumatic, in alignment like this. Those, you brace and you let them play, right? And do you image them? Because our, you know. Yeah, I was gonna say, you know, in a high school kid, probably not, honestly. I mean, unless I think their flexor muscle mass is off like this kid. Even in a dislocation, you know, prior to MRI being demanded by patients and family and coaches and everybody else. I mean, I think even an elbow dislocation with a good x-ray that doesn't have any bony fragments doesn't necessarily have to have an MRI because I don't treat UCL, LCL based on MRI on an elbow dislocation. Unless they have a flexor muscle mass or something else. So I think we probably over-treat and over-analyze these injuries a lot of times just because we have MRIs. So I try not to over-MRI them unless. Yeah, the imaging doesn't change. Yeah, the only way the imaging changes is if the flexor muscle mass is off for me. Really. Let me see if it works. Everything was fine, Farmer, until you came up. Lyle put all these copyrighted videos. Is this what it looks like if you're like, what's that look like? It's like the, what should be a sentiment of your head. All right, so I have some questions because I have some questions from the first one. So for the panel, a multi-leg knee on the road. Which one is it? What are you deciding, and this is really for everybody, how do you make that decision of whether you're gonna keep that guy there and maybe get a vascular study or whether you're gonna take that guy home with you? Lyle, what do you tell him? Jay, we're up. You wanna keep going or? Yeah, all right, well, think about that one because that's one question that I have. All right, so this is a case that I've kind of been battling this season trying to figure it out. So these are my disclosures. So 22-year-old right-hand dominant quarterback, lowered his shoulder running into a tackler, felt immediate left shoulders with non-dominant shoulder pain, and seasonality's important, obviously, in a lot of these injuries. This game is in the middle of November, so towards the end of our season, we're not playing for a national championship or anything. So he's got another season left, so we're kind of looking into next season. Initial evaluation, he runs off the field, tender over his left clavicle, nerve vascularly intact, obviously unable to continue. You can feel some crepitance on examination. Got x-rays at the field, this was at Missouri, I believe. Got x-rays at the field, and these were his x-rays. 22-year-old non-dominant clavicle. Mary, why don't you talk through your thoughts on approaching clavicle fractures in contact athletes? Yeah, very important discussion. So this is his, it's non-dominant, which is obviously critical just in general, but even more important in the quarterback. With this fracture in and of itself, I mean, that would be fine to treat it non-operatively. Like, it's really minimally displaced, very slight angulation, not comminuted. And it's not as affected, it's not his throwing arm. So, anyway, so in general, like, I think that would be fine to treat non-operatively. If it was his throwing arm, I think that makes it even more challenging, and certainly an issue that I think we all will face at some point. And in that situation, you know, I think you'd consider fixing it to get him back to play sooner. But with this being his non-dominant arm, like, I think it would be very reasonable to treat it non-op. Put out the line on that next step. Yeah, I think I would treat that non-op, and I'd kinda, you know, watch that with x-rays pretty closely and make sure there's no additional displacement that would occur. You know, plating's not a totally benign thing. You know, you got hardware there, and you got issues with that. And, you know, yes, you could probably get it to heal quicker, and then you got the question, is it healed? You know, you got follow-up CTs to look at it. You know, and they can have skin issues, they can get infections. So to me, I would probably go with non-operative initially and watch his x-ray pretty close. Great case. Great case, because I think you'll get a lot of different opinions on this. This is a wonderful case for combined decision-making. So, for better or worse, I mean, we've been pretty aggressive about fixing this from when Ned Amendola was at Iowa. I think the benefits of fixing it is they can get back to, they're comfortable more quickly, they can train more quickly. They're not uncomfortable trying to bounce around or trying to lift. So, I don't think it has to be fixed. I think the ultimate outcome in timing and things, you might gain a little bit of time with feeling better about playing with a plate on there. We have generally fixed these just more from the training aspect, and I think you're still staring at x-rays four, six, eight weeks down the road. Yeah, I was just leaning over and sharing with Brian. At the bottom part of your question there, Kevin, on the slide, we've had exactly this case in Michigan, in a quarterback, but in the throwing shoulder. Minimally displaced clavicle mid-shaft, and it went both directions in discussion. You know, we ultimately gave him and the family options. The whole family is a football family, and the discussion was, this might heal non-operatively and do fine, but when can I return, and it's a little bit later, and what if a non-union? And they ultimately end up going elsewhere and having it plated and treated. So I think it can go both ways, and you have to just give them the, you know, the probably fixing it is more predictable, and maybe a faster timeline for contact and return, but it comes with some risk, and if you treat it non-operatively, probably you'll do okay, too. Yep. Jess. I had this exact same thing in our quarterback, same time of year, too. And my question is, do you actually feel better letting him play with a plate and screws on it, that if he lands on it, that rips out, and you likely have an open fracture, versus you let it heal, and he's actually doing pretty well, he falls on it, he just refractures it, and it's probably gonna heal non-op absolutely fine. We went non-op on our guy, and if the coaches had more guts and played him the entire Rose Bowl, we probably won. But he went in and played a few series in the Rose Bowl, but, you know, he hadn't played much until, like, the week before, so. And then how about, we talked about different positions, how about approach, dual-plating, single-plating? If you were to fix it, let's say it's 100% displaced, different scenario that you know you're gonna fix, approach for dual-plating versus single-plating? Mary, thoughts on that? Yeah, so if I were to plate it, I would use a single plate, I would put a lag screw first, and then put a plate on that. Anybody feel strongly about dual-plating on all of these? So is there a downside to surgery? We mentioned, you know, potential downsides. I think in this era of medical legal issues, you have to be able to defend your decisions, and I think doing an operation to get somebody back quicker, although it can be beneficial to the team, you know, if there's a downside to that, I think it's hard to defend yourself in some cases. this is actually our catcher on our baseball team who had this fixed in high school. I didn't know he had to hit a plate in his clavicle and then warming up before a game this season. Pitcher bounced a ball and it hit him in the clavicle and he sustained this fracture right at the plate. And so I think that this is a plate-induced fracture just from a ball hitting it. So there's potential downside to it. There's no Florida State people here. This is Brock Purdy's brother, Chubba Purdy, played at Florida State. He was in the running three years ago to be the starting quarterback and he had a clavicle fracture in pre-season. Got it fixed, great surgeons, good friends of mine. I know them very well. But he got a C acne infection, ended up having three surgeries later, taking the plate out, bone grafting. I think they're going to McKee in Arizona to finally get it fixed again. And he's bounced around now. The last five seasons hasn't played much. And so certainly that was not a good outcome for him. So I think you gotta keep these things in the back of your mind now more than ever when you're making these decisions. And so as was rightfully said, this was a shared decision-making process. And I had a long talk with him and his family. I went through the x-rays. You know, I reached out to Dr. Uribe and G to get their thoughts and to put them in. And I got Delicato in my ear telling me to fix it right away. So kind of dealing with all these different inputs and thoughts. And so after a discussion, kind of a shared decision-making, I went non-op with it. A plan was to start a sling him for four to six weeks. He didn't listen, not surprisingly. I'm driving out to practice two weeks later and he's out filling passes, you know, and I see these social media videos of the workouts and he's doing clean and jerks at two weeks out. So it wasn't, didn't listen to the plan. And so here's his x-ray at four weeks. It hasn't moved, fortunately, but here he is at three months. And so now I'm starting to get a little bit nervous because now we're going into spring practice for three months out. His healing is not where I would like it to be. It's progressed some, but it's not, you know, not where I like it to be. So I'm starting to sweat a little bit about my decision here. And so we made a plan to get through spring practice. He's obviously, he's our starting quarterback. So to get through spring practice, non-contact. And then I had him on the schedule of Monday after spring practice to plate and bone graft and kind of be done with it. I was tired of looking at x-rays and worrying about it every week. And so, and then I put him on Forteo. So it would get, he has changed the plan at this point. So now you're three months. He's not, he's not tender. He's practicing, he's non-contact. But the x-rays again, not where I'd want him to be at three months. Did you CT him, Kevin, at this point? I did a CT and yeah, superiorly he's not healed. Inferiorly he's starting to heal. Superiorly he's not healed. So, okay, there was bridging callus inferiorly. Inferiorly, yes. And we changed plans or continue kind of. Did you, were you bone stemming him during this time? Yeah, bone stem, calcium, vitamin D. I haven't yet, but that, so that was the next step. And so that was the change that I made at this point. So I made the decision to get through spring. I put him on Forteo, went non-contact, played all spring. Did fine, had him on schedule for the Monday. We got spring game Saturday, took x-rays on Sunday. And he's had progression now in his healing. CT scan now showing basically he's a conferential callus, but with no real residual fracture line that was concerning. And so it felt better after things at this point. So I made a decision now to continue the non-app plan. I put him on another month of Forteo since he seemed to have a good response to it. And that's kind of where we are right now going into the season. So I'm sure I'll spend every game watching every hit and sweating it out. Kevin, can you just remind us too, the dosing for Forteo? Is it, you said you did it for four weeks, but is it once a day? It's a single dose. It's a pre, it's a pre-loaded vial that they just inject sub-Q daily. Yeah, it's a syringe that has 30 doses. And so you hit it sub-Q one day and then you twist it 90 degrees and the next day is available. We started using, so just to Brian's point, there's a lot of different discussion. I'd probably be on Pete's side. I probably would have fixed this guy day one. Just because contact and you're worried at three months, he still looks like that and you're nervous every night when you go to sleep. So I think I fix these contact athletes primarily just to sleep better at night, even though there are some side effects and potential complications. But we've been using Forteo since 03, 2003. We had a non-union tibial, we had a tibial non-union stress fracture that had been rotted twice. Got to us, really good player. I exchanged rotted and bone graft and did a bunch of stuff. And I called John Bergfeld back then and said, hey, is there anything new for bone healing? And he sent me to one of his research guys who was doing research on Forteo and non-unions. And so we've been using it since then. And pretty much any fracture that we have that's at a place where they can afford to pay for Forteo, which is about $3,000 a month cost, you can't get it approved generally by insurance because you can't document osteoporosis and all these other things that's required. So if it's at a place where they can afford Forteo, we've been using it in most athletic fractures since the last 22 years or 21 years. And I think it makes a big difference. So I think if I'm gonna non-op one of these guys, I would definitely use Forteo. And no osteosarcomas, I guess, that you know of. Yeah, I mean, and we've been through that. 20 years and that's good. No doubt, I mean, 21 years, you worry about it. The rat studies that brought that up, they used like 100x the dose per kilogram that we use in people. And so that's always a talk with the family. That has happened in the rat studies, but it's never happened in humans. Yeah, so as you'll know, it's a black box warning on Forteo for osteosarcoma. But again, that's based off rat studies. High dose in long-term use. There've been several NBA players who I know for a fact who've been on it for up to two years for navicular stress injuries. And so we've got more and more data now. So, Lyle, do you have your endocrinologist? I mean, I don't wanna, you know, we say Forteo, yes, but we pass it on to the medical guys. And so, you know, it's not like I'm prescribing the Forteo, right? That's not what I do. So the question is, you gotta make sure you have the medical people. You should, but trying to get endocrinology at UF is an act of Congress. So I end up prescribing it. I check calcium beforehand to make sure they're not hypercalcemic, because that's the one thing you can really get in trouble for. So what it does is it releases calcium into the bloodstream to allow for more calcium binding to, it actually stimulates osteoclast activity if you look at how it works. It's a type of parathyroid hormone, osteoclast, but it increases blood levels of calcium, free calcium for bone healing. So I check their calcium levels and so far I've not had any issue. Can I ask real quick? So you guys, those that are gonna fix this, you asked about dual plating versus single plating. So you showed the x-ray of the kind of medial fracture at the margin of the plate, and that's always the concern if you plate them. When you're plating these, what we've done on the ones that we're gonna send back fairly quickly is we've actually, that's a short segment fracture, but we actually put a pretty long plate. You essentially plate the entire bone, because the concern is a periprosthetic or a periplate fracture. Is that what you guys do, Lyle, and those that fix these, or do you do based on the fracture configuration? Yeah, so probably more aggressive than typical AO technique. I typically do four screws or eight cortices on both sides of the fracture. You know, the dual plating question, I mean, that happened with a famous NFL quarterback that had a non-surgical treatment of his clavicle followed by a refracture, followed by dual plating, and then ruptures of Achilles last year. That, I think, once you fix the clavicle, you've got two issues. One is every time you've got a screw hole, that's a potential stress riser for the fracture with the baseball player. So I think dual plating, in my mind, gives you more holes and more potential stress risers for refractures, so I don't do that. But I do think having a longer segment, maybe you've got less of a fulcrum as opposed to a short plate. So I do a single plate, usually Cephalad. You can do it on the anterior part if you want to, but I usually do Cephalad, and I do four screws on both sides. Yeah. Are you guys using vitamin D and calcium to keep your Achilles surgical along with the fractures? Yes, I do. They all get vitamin D, calcium. Yes. Sorry. Yeah, exactly, yeah, exactly. You guys are gonna get their vitamin D calcium. All of them. Exactly. Any other questions? Do you mind staying up here? Uh, hold on one second. I lost my paper. Is it under your phone? Yes, it is. It is a long night, guys. All right, so the new panel will be Lyle, Kevin, stay up there, Dr. Baer, and Steve Brockmeyer. And then Dr. McCarty will have you present your case. Yours is going. Well, I actually had him on for six months. I didn't get like, I think it was the fifth or even the sixth year. That's his late last year. And that's who played it, and we played a freaking entire thing. You know, skin-heeled like gangbusters. He looked like he was gonna go week two. We let him go. All right, so this is actually pretty quick, but it brings up some good points. So I want you guys to pay attention to this. It's a great video. All right, watch the player right here coming up. Puts his arms out in front of him, and you see he's holding his left shoulder. So watch this one more time. Player to the left. It's his left shoulder. So he comes off the bench. You know, we knew something was wrong. You know, it's okay, this doesn't feel right. We felt like it was dislocated, but we weren't sure exactly what it was, so we tried to pull on it a little bit, and nothing was budging, nothing was moving. We did have x-rays at the arena. And, you know, Kevin, you ever seen that in one of your collegiate athletes? I've not had one walk out posteriorly like that, no. No, so what about you, Jeff? Not posteriorly. Lyle? You think maybe he had a seizure before he hit the guy? He didn't hit him very hard, so it didn't look like enough of a force to do a posterior dislocation. Was this after he finished the rest of the game? So, yeah, I know, right. Hey, Doc, this doesn't feel right. What about you, Steve, have you seen this? I have not seen a posterior dislocation like in competition like this, but very interesting. Like it's some rotational, like, bringing through like this. Maybe he just hit the right slot. Yeah, I mean, exactly, and you saw that video. So I hadn't either. Has anybody had a posterior dislocation that's locked like this in a competition? And we've got some good experience here. No, Uribe says no. No, me neither. And so I'm saying, oh, okay, dang. This is, I haven't seen this either. So first time I've ever seen it. All right, what do you do? Kevin, what are you going to do with this? You've never seen it, and, you know, maybe been a while. If you ever had to reduce a posterior dislocation, I never did this in a residency. It was always the interior. Kevin, what do you do next? Yeah, I don't think I've ever, I don't think I've had to reduce one even as a resident. Yeah, I certainly would go through my typical approach with, if in the training room, I'd maybe consider doing an intra-articular injection with a lidocaine or a marcaine, and, you know, try to see if some traction, and, you know, probably inter-rotation would pop it back in would be my thought. How about you, Jeff, what would you try? I have not reduced one of these except for a chronic one, but that was in the OR and releases. But I think this one I would, you know, just try to get some traction on them. I think you're going to get them to pop back in relatively easily is my guess. And you probably, he's a hockey player, so he wants to get back in the game. So you probably, I think you could use a lidocaine, but I think you're going to get them probably just a little bit traction, counter-traction on them. I bet you'll get them in. We tried that. Couldn't get it in. Didn't work. Then I would numb him up. I injected it. Didn't work. What are you doing next? Problem or fault. Lyle, what are you doing next? Yeah, I've actually reduced probably five of these in the office. Maybe we have more seizures in Alabama than we do other states. They've all been seizure cases, everyone. Usually comes to the ER, they usually get misdiagnosed because they have an AP of the shoulder that they say is normal. And then they come to see you in the office and they've either had an MRI that shows them dislocated, which has happened a couple of times, or they just come in and you get your normal x-rays in the office and they're dislocated a few days later. And so I've got a technique that I've shown, I know I've shown Steven and some other people, of just a way to hold the arm for leverage for anterior instability. It actually works for this too. It has to do with using the body as a counterweight. You get a good grip on the forearm and you pull anterior. And I've been able to reduce all these in the office, even the chronically posterior dislocated shoulders from seizures. So I think if you can't get it reduced, you obviously have to go to the OR. But if you're gonna do it in the OR, I would do it with a plan to then fix what the pathology is so it's not just a reduction and go back home. So I would take them if I was gonna go to the OR and plan to have a surgical plan as well, whether it's post your labor repair, plus or minus something in the front for the reverse heel sack. So I think it's, if you can reduce in the office, great, then you've got time to plan. If you can't reduce in the office, then you've gotta be prepared to do the full Monty at some point. All right, so the problem is muscle spasm, right? So he's got muscle spasm. I couldn't get it at the arena. We're going to the ER. I follow the ambulance to the ER and we had a sedatum. And I wasn't gonna try to fix anything that night. I mean, we're gonna try to get this. But the problem is muscle spasm. So your chronic ones, they're not all spasmed up. And despite everything we tried and even had the EMTs give them or the paramedics give them some, I could not do it. But once we got him basically asleep and relaxed in the ER, I was able to do it. So we got it reduced. So here's the, Steve, I want you to look at the MRI that we have next. And I don't know why it's funky like this, but sorry about that. You know, AV problems once again. So take a look at that so you can see, you know, look, posterior is to your right. He's got a moderate reverse heel sacks. And again, I apologize for this, the way the funkiness came out on this. Yes, he's got a posterior labral tear, maybe like almost like a labral capsular injury. Yeah, exactly. So let me just show you the, you know, here's a better picture of it, but doesn't look too bad posteriorly, right? No. What's your next plan? That's a good question. So, and he has no history of any prior posterior instability, right? No. Where are you in the season? You know, is this guy plays a lot? Mid-season, he's a veteran defenseman. Okay. You know, so posterior instability is different than anterior instability, but this may be different than standard posterior instability is because it's kind of a, you know, kind of a different case. But, you know, the reverse heel sacks probably doesn't, you know, that reverse heel sacks, or really any of them, doesn't necessarily change, you know, whether you operate now or operate later. And so this is one that I probably, you know, kind of see how it played out a little bit. So I'd, you know, I'd probably sit him for just a little bit, I'd rehab, I'd kind of see how the shoulder responded from a clinical standpoint, and just kind of wait it out. I probably would plan, you know, chance of recurrence is, I imagine, pretty high, you know, just because he's a professional hockey player, but, you know, this might be something you can wait and fix at the end of the season versus. So, Jeff, I mean, I'm not gonna ask Lyle, you don't have hockey in Alabama, but Jeff, you've got, hockey's big in Wisconsin. What do you think about this in the hockey player Wisconsin? No, I think I would go the same way. I mean, you're in a fairly long season sport. If you're in mid-season, you know, this kid, you're probably talking, you know, a month and he's back on the ice. He may be back even a little bit faster with posterior versus anterior, but he's gonna come back. I think you had the discussion about fixing him after the season's over. The question is that this guy goes the entire season without any other issues. He, you know, especially playing in the playoffs, he may not need anything after the season's over, but that's what I'm thinking about. If he had recurrent instability, just couldn't play, then I think you move up the timeline and get going looking at the next season. So, Lyle, you got something you want to say about him? Yeah, yeah, I just, I mean, I would predict just based on that MRI and based on the fact that he was a lot pusher dislocation, he'll have a capsular tear, a big capsular tear. Yeah, so you'd plan on surgery or? No, I'd let him try. I mean, he's a hockey player, right? So, I'd let him try, try to play. I mean, if he's an offensive lineman, I think it'd be unlikely he could play. Same case, different sport. I think as a hockey player, maybe he can play because they're tougher than most sports. Is this his low hand or his high hand? Yeah, I just, you know, honestly, I can't remember. I think this is his high hand, yeah. But from a surgery standpoint, my expectation is he'll have a capsular tear because his labrum doesn't look terrible. So, as you know, and this has happened in college now, but this is where you discuss with the athlete, management, and then agent. An agent, you know, really kind of makes sure that everything's okay with this player, right? And that's who directs the care. Unfortunately, the athlete looks to the agent more than they do the doc. But got a second opinion. So, rehab, sling, return to play. So, here he is, you know, not too long afterwards. You know, he's got, you know, really good motion. This was like two weeks later. Remember, you know, just look at him, left shoulder. You know, he had a little pain in the front. So. Can you wear a little harnesses in hockey? Can, they don't work great, but you can. Does a harness help with the posterior? Sometimes they like the compression. The Solly can be pretty beneficial. So, strength was good. I'll just keep going, but, I mean, you look, I mean, his strength looks good, motion looks good. So, what next, Kevin? Either Sully, I like Harnesses better for post-year than football, I don't know. Again, I don't know with the padding and the hockey, but I would progress forward to see if you get him back. So there he is, and he started with a, I think it was a Sully, but he didn't like it. He felt like it restricted him, so, you know, they taped him a little bit, he felt better, and then end of the season, you know, should we do surgery? What should we do? Brockmire, what do you think? Yeah, I'd push for surgery, even if he has a very uneventful residual this season. The surgery would be to address the posterior component. I've actually found that these aren't that, even something like that, you'd think you'd see really well in the joint. You know, in MRI, they're an internal rotation, and then when I do these in beach chair, you know, the arm's out in external rotation, so you'll see it, but it doesn't look like it's in the joint, so a lot of times, you don't have to do anything with the reverse heel sacks, but if it extends into the articular surface, you could consider addressing it with, like, maybe a plug or something like that, but for him, I would, yes, I would encourage him to get it fixed, and I would do a stabilization, whether it's a labrum or a capsular repair. Yeah, Lyle, one of you guys, he might, hey, Doc, I feel good. I mean, I got no pain. I was able to finish the season. Why do I need surgery? Yeah, I mean, I think in this player, it's similar to anterior labrum in a football player. Same idea is that, you know, I think there's probably more pathology there than he feels because he's a tough hockey player, so I think I would, in the offseason, I would at least scope it and try to fix whatever posteriorly is torn. Any difference, Kevin or Jeff? No, I was going to say there's one of my favorite studies that looks at this issue. It looks at more anterior. I think Dickens was the author, but military football players, and they found that this exact scenario had an instability, made it through the season, did fine during the season, and if they either, if they didn't fix that population, they had a 60% recurrence. The following season that they did fix it, they had, you know, less than 10% recurrence, and so that has changed my approach. Hey, you've done well this season, but your risk next year is still high. We should take care of it in the offseason. I mean, that was my thoughts, too, and I told him that, but opted for no surgery, played subsequent season, but he had pain from midseason on until the end of the season with no instability episodes but had pain, and he was getting symptomatic and then opted for surgery end of the season. Was not a huge tear. You know, standard posterior bank guard, reverse bank guard, and did not do anything with the heel-sax lesion. He did great, so anyway, just an interesting case because how often are we going to see that type of thing, right? Anyway, Brian, I hope your thing works because I'm not sure. Where is Brian's? Do you want to try and see, or? Yeah. You're good? Okay. We're out of time, aren't we? Yeah, we're out of time. I mean, no, even two weeks later, he's feeling great, so it's like, okay, and in the season, he felt great. Yes. Yes. That's what I'm saying. I did it. It was awesome. Well, I want to do the second. We got one of our guys come in. Contract situation. That's right. Can we get back to business? Absolutely. This is another process. This is a BGS episode. Yeah. No, he didn't do a lot of bench press. Definitely demonstrate, like, the idea of satellite management. That was awesome. I learned a ton, as always, so I really appreciate the faculty here as well as everyone who attended. I think we all learned a lot, and it was a really great discussion, so unfortunately, we ran out of time for that last case, which, I mean, I scaled it down to six. I thought for sure we'd get to six, but great discussion, and hopefully, we'll do more of these type of things in the future, so thank you, everyone, for coming. Faculty, can you just stick around for one minute? I want to get a picture with everyone. Thank you, everyone.

sports medicine

orthopedic injuries

collision sports

football

hockey

lacrosse

rugby

ACL injury

UCL repair

clavicle fracture

rehabilitation protocol

shared decision-making