Brown's been kind enough to be an unofficial faculty for us, and we've relied on him a lot here. So. Horry bailed us. Yeah, he's Horry's replacement. But I wanted to get people's opinion on this. This is a case I was gonna present, and I wasn't sure what the timing would be. But it looks like we have time. So a 43-year-old laborer, skiing injury in Vermont in powder. It might sound weird to have powder in Vermont, but it happens once a year. And he's a laborer. He knows his knee's unstable. He comes to me maybe a month out. He's got an effusion on his X-ray. You can see there. He's stable for various velocity and posterior drawer, and he has normal range of motion, but a high-grade Lachman and pivot shift. His posterior slope is about 12 degrees. And you can see from his MRI that he has a proximal complete ACL tear. The lateral meniscal root doesn't look 100% normal. Maybe there's some meniscal femoral ligament intact, more posteriorly, the ligament of Risberg. But certainly abnormal-looking lateral meniscal root, a little impaction injury to the posterior lateral plateau. And this is his diagnostic arthroscopy. EUA was similar to his exam while awake in the office. You can see his proximal ACL tear. It's scarred to the PCL. And that's his lateral meniscal root. And it's not the best picture, but it clearly shows that the probe is elevating the lateral meniscal root off the tibia. So in this patient with a high-grade Lachman, high-grade pivot shift, complete ACL, a skier, 12-degree slope, and what looks like a torn lateral meniscal root, who's considering debridement? Anyone in the room that would just debride this and let it be? That's not necessarily the wrong answer. It may be an option if it's not terribly unstable or if the meniscal femoral ligaments are intact. So I'm not trying to throw that under the bus. But anyone strongly considering that? How about just leaving it alone, not touching it, not debriding it, but not fixing it? Anyone want to go that way? And then how about repair? And then how about anyone that's just not quite sure, don't have the information yet to make that decision? All right, well, a lot of hands went up for repair, and that probably wasn't a fair question because we've been talking about repair this whole time. But the reason I show this is there was just a study that came out in arthroscopy at the end of last year and an editorial that came out also in arthroscopy at the beginning of this year saying that these should be left in situ, not treated because there's no influence on ultimate outcomes. And that circulated through a lot of orthopedic surgeons and some debate on whether you should really leave these in situ. Because when you look at this tear and you're probing it and it's not attached, we can infer the lack of attachment to the tibia would suggest that it doesn't have a structural integrity. So this patient underwent a BTB-ACL reconstruction, a lateral menisca root repair. And you can see, you can barely see the sutures in the back there. I used suture tape and a two-tunnel technique and tried to reproduce the normal attachment. But I think this case highlights it. A lot of patients or a lot of surgeons might say, well, this is a 43-year-old. I don't want to limit their post-op rehab. And I would just leave it alone or debride it. But I think you need to consider repairing these because as we know, skiers have a higher rate of re-tear. And we know that lateral meniscus has an important role in biomechanics. Any comments from the other panelists or anyone in the room? I think this is a good case because it brings in a couple of different things. So I think this acutely, you want to think a little bit differently than this, which is not chronic. And what I mean by that is in an acute setting with the ACL and the root tear, with the high-grade pivot shift, I feel pretty comfortable feeling like an ACL reconstruction and the lateral meniscus repair is gonna restore all of that. In a chronic setting, it may restore all of that, but I'd be a little more worried because I think there's some secondary constraints, some secondary stretching of things we don't understand. And so I would have a low threshold to add a natural lateral complex procedure because even if you repair the meniscus and the ACL and the exam's good, I just worry that in a chronic setting, there's that much more stress on your reconstruction repair that maybe adding that is gonna give you a slightly higher likelihood that this turns out. So I would just say, think about it in acute and chronic deficiencies a little bit differently. And he ended up having surgery around five weeks, so he wasn't quite chronic, but. But if you saw this like a year out. Oh, absolutely. Yeah, yeah. The other thing you could, what we tend to do is we would fix the root and see how much reduction in the pivot shift. If you got a grade three pivot and you fix that root and it's now a grade one pivot shift, you probably don't need the XRT curve, but if it stays a grade two or more, then it's telling you that you need more to control the rotation in that case. Then you probably think about it and do that XRT curve on it. I had, I saw a hand. Yeah, I just wanna check, Hector, right about your graft choices, B to B auto, I assume. What are your thoughts on that over 40 year old skier about your graft options? How do you make decisions in that active population over 40? Yeah, well. In the skiing population. So he specifically was easy because he actually had the same thing on his contralateral knee about four years prior. So I said, well, let's just do the same thing. I mean, it was B to B with lateral root and my partner did it and he did great with it. And so that was, in his case, that made sense to do that. I think graft choices is a tough thing to consider. I've seen patients over 40 that are active and have an allograft and have failed it. And then I've regretted offering them that. And I've, you know, you see some of these patients that have some anterior knee pain or maybe a prolonged recovery. He had no issues and he was begging me to go back to work. And that's not based on me. It's just his, that's just him. But begging me to go back to work at two weeks on crutches and doing more office work. So I don't worry so much about donor site morbidity. I worry more about failure. And so I'm pretty aggressive in offering a B to B auto. Whereas I did a 69 year olds the other day, a former ski racer and his preference was for allograft. And I went that way because he had patellofemoral chondrosis and it just didn't make sense to do B to B. Do you see any anterior knee pain in your skiers that you've done a B to B or a quad on? You know, I think it's a concern. It's not, if they're not complaining of it, it's not something I'm probing into a lot. I'll ask it and see if they have any pain or a general question if they have any pain, but I'm not specifically focusing on that. There's a poster I was gonna go look at later today looking at grafting your tubercle harvest site with a graft post, you know, graft harvest. I don't think we know enough about that. Martin Lind, who's in Europe, told me about a technique where he'll take a bigger chunk and then rotate it and then fill that defect site so they don't have the kneeling pain and it fills the tibial tubercle defect a little bit better. So I think there's things you can do to help minimize the anterior knee pain, but I haven't seen it to be a real big risk in skiers with B to Bs, you know, aside from other groups. I don't know if there's other opinions on graft selection. On the kneeling pain, that's the main thing our patients will kneel or pray. If we do B to Bs, we do, as you suggested, bone grafts. So I take a huge tibial bone plug and then I contour that to fill the patella so it's flush. And then to fill the tibial defect, we use a core unit. And you get a nice cylinder of bone and you can sculpt that and it fits, it's flush. And so one of the tests, when they come back, we have a little prayer mat, and I ask the patient, can you pray? Most of them can pray to the bone graft. Keep your incisions low and kneel. Don't put them up on the patella. And those are the things we find help a lot. Wonderful. I mean, the B to B autograft selection is just kind of moved up, you know, it's like we used to say, well, there's no way in a 50 year old or 60 year old. Now we've got 65 year olds who are doing bone patella tendon bone. But I think you can do a hamstring graft on somebody who is older, whatever that means. I think if they're that middle-aged hypermobile patient, I wouldn't do a hamstring graft. But if they don't have a lot of hyperlaxity in the knee, I think you can do a hamstring graft and I think you're probably fine. I think where you get into trouble is really the young, really, like, you know, 20s, teens, you know, very active. That's what we're talking about staying away from. I think once you get to 40, 50, you gotta still be careful of that really hypermobile middle-aged person. But otherwise, I think it's okay. All right, well, I think that brings us to 8.30. I think it was a great discussion and thanks, Dr. Brown, for joining us for that. Thank you. Thanks.

Dr. Brown

case

skiing injury

ACL tear

meniscus tear