Kind of try to make this a little interactive, so I know we have a lot of people here with a lot of varied experiences, both with respect to time and region of the country and training. So I'm going to talk through some cases. So again, nothing to disclose. So first case, 14-year-old female. She has bilateral patella-femoral instability, and her instability began ever since she was basically walking as an infant and was spontaneously reduced. She's currently a teenage or a cheerleader and functional, but continues to have fairly frequent patella dislocation. So she's got a valgus knee, increased medial lateral excursion. Her left patella tracks normally. Her right patella has a marked J sign, and she has a laterally positioned tibial tubercle. So these are our images here. So we can see, you know, slightly subluxated patella on the AP. She's got a bit of a bone spur, so what I would say is a de jure B trochlea on the lateral. And overall, the groove does not look terrible in this merchant view. So these are her stats. So de jure B, CDI was 1, so she's not ALTA. And this is what her MRI looks like on the right side. So based on this, so not ALTA. She's got some dysplasia, but not the worst that I've ever seen, and she's got this patella sitting like this on the MRI. Any thoughts for how you would approach this in terms of treatment? So these are people, so, you know, someone that we just do, go to Leah. Okay. Anyone else have any questions, any other information that we want to know? So we heard we want to know TTTG. What else do we want? Yeah. So, so her right knee, so she got trochlear dysplasia subluxated patella. Her TTTG as high as 25. So this is an MRI, MRI measure. So this is probably even higher, say if you looked at a CT scan. Go ahead, Kevin. She does have genu-valgum also. Yeah, I'm going to say her, I'm not sure. I don't remember if we measured her. I don't think it was bad. Yeah. Yeah. So she was definitely like, it was probably more of an L sign. So it was kind of the most, most severe kind of obligate dislocation when she went into extension. So treatment wise. So with those parameters that we have here, who's doing TTO alone? Anyone? Any takers on that? No? NPFL alone? Who does an NPFL by itself on this patient? Don't be shy. All right. Anybody just doing a lot of release and getting out of dodge? All right. Good. So, oh, my numbers aren't here. So, that's unfortunate. That's okay though. So we're going to say that's her J sign. We're going to say that's her patella alta, which she did not have. And then we're going to call that her TTTG. And then her dysplasia, we'll call it that. So she kind of really leaning towards more of an NPFL plus. So this is the procedure that she got, not with me. So she got a lateral release and TTO patella chondroplasty. That's what we got. So that's where they put her. So post-op, of course, she fell two months post-op and guess what happened? That's where patella sits at. We can see the screws there. So it looks worse than her non-operative side. So six months post-surgery, she successfully returned to cheerleading after she completed her rehab. And then she dislocated her other patella. And then she got another lateral release and TTO. So three years after her right distal alignment, realignment, she began to have painful recurrent subluxations and dislocations. And she went to see another surgeon concerning this. And this is the TTO side. So that's where patella is sitting. So they moved her tubercle, but didn't do any soft tissue stuff other than the release. That didn't work. And then you can argue that the TTO also did not get moved very far. So second opinion surgeon says, what are we going to do? So we're going to do a revision. So they're kind of barking up the right tree in some respects. And so I thought that we'd do an NPFL reconstruction with allograft tendon. At this point, anyone doing anything different for this patient? Does your B, not ALTA, has had a TTO already and did not have any soft tissue stuff done before? Anybody doing anything different other than NPFL? Do you have a post-op TTTG? It was not very far off the pre-op TTTG. It might have been five millimeters lower. So it was maybe 20. It went from 25 to 20. Trochleoplasty. Anybody else takers for trochleoplasty at this juncture? This is the case that Dave Dedeck would call out as that giant sort of bossing of the supratrochlear spur. I think we beat ourselves to death at the IPSG meeting about the various versions of the du jour B, the du jour D. And there's sort of the good, the bad, the ugly, even within the morphology. So that big launch ramp into the lateral gutter, I think, is itself a problem. So I think it's going to be the elephant in the room. I worry that that plus a jumping J sign, I'm not sure. I don't know. I think a lot of us would start with NPFL TTO and reserve trochleoplasty for a salvage situation. But here she is one surgery into this. And so I would think about trochleoplasty as well. All right. So. You got to hold it down, hold it down. OK. I can repeat it for you. We're wondering, how much bone do we take, and how do you execute the Peterson trichoplasty? I take how much Dr. Brady tells me to take when I text her pictures of my cases. That also works. But it always feels a little terrible, because it's cartilage, right? So you're taking your acetone and cutting cartilage. You're like, how much cartilage can I take? It shouldn't be there, so maybe it's OK to take. But not a number. Would you go back to the lateral pre-op? Yes. Because I don't think we know. I don't think we know as a specialty. But one thing to think about, this isn't a perfect lateral, but where is your crossing sign relative to the femoral cortical line? And if the crossing sign is just way anterior, then you've got to worry that you're going to take way too much cartilage to get it back to level. But I think you use your crossing sign as a guide here. I think that's what, like Seth Sherman thinks a lot about this. We keep trying to figure out how to study it, and we keep hitting a brick wall. But I think that's where we're currently thinking, is where is the crossing sign anterior to posterior? And can you use that as a guide? All right, research. Sidebar. Your patella overlap, right? But like a crossing sign patella overlap. Yeah. She is of average height. I think she's about 5'4", 5'5". What? My mom's very tall. And my wife's very tall, too. All right, so left patella, second opinion, blah, blah, blah. All right, so nine months post-op. After her NPFL reconstruction. So she had atraumatic recurrent dislocation, and then finally she came to see me for her third opinion. So she's still got a J sign, severe patellar instability, and a deficient lateral retinaculum. Now what are we thinking for this? So I think not just to kind of belabor the point. So we've had an NPFL that has now failed. We've had a persistent J sign, and this tubercle, which is not ideal. So this was her x-rays. And so if we had to critique these, so patellar tunnels, I like. They're high, up on the proximal half of the patella. That femoral tunnel, I'm not quite so sure about. So that's where that NPFL tunnel was placed. And when you look on the x-rays, that's her NPFL graph, which is now stretched out. And when you look at that tunnel that was placed for the NPFL, probably a little bit distal. So you look at things and say, well, was this surgery done well the first two times? What can we add on? Because you don't want to kind of keep reinventing the wheel, and we thought we could do something different now. So we decided to do a trochleoplasty for her. Because at this point, now this is a salvage procedure, right? And so, yeah, question here. You're still in my thunder. All right. So dislocated patella. So she got a revision NPFL. So we revised her TTO. And this is the first time I've had to do this. It is not the last time. And so this is what she looked like intraop. And it's kind of hard to see, but her patella is riding laterally. And then so when you put the patella into her existing groove, this is sort of what it looks like. Patella, trochlea, and she's kind of making this hard right-hand turn. And so after we revised the TTO, which actually was not hard to do, we revised her TTO, got that moved over. So we're more in line with this here. And then she also got a trochleoplasty. I do a thin flap technique. I just have a hard time cracking through the cartilage like D-Duck and DeJure, who are much better surgeons than I am. But I do a thin flap technique. But we got things more better aligned for her. And so she did very well. I think we've got five years of follow-up on her now. Her mom actually was one of the scrub techs down at the main campus. So we get some follow-up on her. And she's doing well. She's off in college and doing great things. Any questions about that case? Yes, Miho. Did she have to go away to learn the located inflection? She was located inflection. Great question. Yeah, it just came out in Extension. Yeah, if you had seen her before that TTO, would you have done a trochleoplasty? No. So I do trochleoplasties, obviously. But it's not where I start out for. Like, that dysplasia that we see here in that bump, I laugh at that bump. Like, that bump, I'm like, that's not a severe enough bump for me to do a primary trochleoplasty as an index procedure. But I would have done TTO combined with NPFL for that patient. Robbie? I was trying to reserve comment on the bump ectomy. I don't believe in the bump ectomy. Because I think you cut the bump, and it's a cliff. So yeah. When you were doing the revision TTO, so you did the trochleoplasty first in the case? So I did the TTO first, because we completely detached her trochlea, just so we could have exposure. So one of the things I hate most about trochleoplasties is exposure. And most times, I'm trying to do the trochleoplasty from my lateral, because I do a lot of lateral lengthening. So I'm trying to do it from the lateral side, which I think is the wrong place to do it from, because it's a struggle. I think it's better to do it from a medial arthrotomy, but I don't like violating my medial structures. So it was nice to kind of just take the TTO off and be able to just see it. And when you revised the TTO, what pushed you to do, besides preoperative planning, but I was curious how the tracking was after normalizing the TTTG? So the tracking was fantastic. But so with anything patella-femoral, you want to make sure that your tracking is fairly good before you add your NPFL in. So you want to do whatever releases you're going to do, or lengthenings you want to do, you want to realign things. And the patella should track fairly normally, just with all that stuff, before you add an NPFL. Because if it doesn't, your NPFL is just going to stretch out over time. That's what we saw in her. And so we did her lateral lengthening. I think we revised. Actually, we did a revision of her lateral. So we did a lateral lengthening, because it was still scarred in there. We moved her trochlea over. And after you do all that stuff, things track fairly normally. And why I also like the trochlea plastic is you can lateralize the groove along with that, because she's high. So her true TTTG is probably close to 30. And so you can't get all that back with the Elmsley triat. So I don't do Fulkerson's for instability. I do them for cartilage and whatnot. But I do Elmsley triat. And it's hard to medialize an Elmsley triat more than a centimeter. It can be done, but it's very hard, because you start to lose bone-to-bone contact. I like presenting that case, because it's just everything that you could possibly do wrong about patella femoral stuff. So I just wanted to maybe put you guys to more of a detail. So we talk about normalizing your TTTG. What is normal? How much do you correct? How do you determine that? So yeah, and it's for me, I don't even look at TTTGs below 20 as being abnormal for me. So and really for me to even think about doing realignment and stuff, it has to be over 20, but kind of closer to 24 on the MRI. Abnormal, in my opinion, is anything over 20, what the textbooks say. Some people do it, have a lower threshold if you're doing cartilage work or some other, you got other things going on. But I don't do a whole lot of TTOs for people with a TTTG less than 20. Nice paper recently on the arthroscopy journal, I think out of China, looking at height-specific TTTG cutoffs, where they looked at symptomatic versus not, and by height. I don't know what 167 centimeters is, but if you're shorter than that, they said the cutoff was 18. And if you were taller than that, 21, or 21, yeah, or 22. But I thought that was great, because we've been looking for a way to really have a size-specific cutoff, and that's one step closer. 5 feet, 5, 5, 5, 5, 5, almost 5' 6". Thank you. That's interesting. Yeah, so I think I'm going to start taking that. I mean, I think we all do take that a little bit into consideration when they're right over at 20 and think about that. But I think that pushes us in that direction, too. All right, so next case. So 21-year-old female. She's had symptoms for four years. Failed conservative management, so PT, bracing, the whole nine, anti-inflammatories, orthotics, whatever. Had a chondroflap on MRI, and this is what she had. This is her lateral facet of her patella. She's got this chondroflap, which she maybe had a trauma four years prior, maybe not. She doesn't quite remember. You see that patient, and you see this during surgery. How are we, Kevin, how are you managing this? And so say her TTTG is 15. She's not unstable, and you see this lesion. No patellar instability issues, no other instability issues inside the knee. So just isolated kind of chondral. She's not alter, so isolated chondral issue on the patella. She did not sit lateral, so everything was decidingly very normal in her, which was kind of the head scratch on this. And I think she, I'm not sure if she's like a rugby player or something. She fell on her knee and ended up with this lesion. What's that? She's got a chondroflap on MRI, and she's got some mechanical symptoms. But often things are bigger once we kind of get in there than you know, but that's part of the discussion table So what do you have ready for this? All right, well, how about you, Volker? What do you have ready for this? So again, her TTTG, we're gonna say her TTTG is 14. She's not sitting lateral. She's sitting perfectly in the center of her groove. Her CDI is one. She's got no subchondral bone marrow edema. She's got something that maybe looks like a flap on MRI, but it could be just a fissure also. But she's been having mechanical symptoms as well as, like true mechanical symptoms, as well as a few recurrent effusions with increased activity. No, her trochlea is pristine. No subchondral bone marrow edema. Full thickness at the time of arthroscopy. You couldn't really tell that from the MRI. So anybody in this room do a microfracture at this time? Patella? That just warms my heart. That really warms my heart. If anyone's thinking about that, when you leave this course, you should no longer consider that an option. There are many, many things. I'm going to be very blunt on this. There's many things we do that we all will debate. And there's a lot of right answers. And almost never is there a wrong answer. But that is a wrong answer in this case. And the reason is because it burns bridges. And microfracture is not successful for these types of defects in the patella femoral joint. Over time, you'll have good six-month. I agree with you. The only thing I'll say that I agree with you, however, all of us who do CTs comparing some sort of novel cartilage transplant or cartilage technique, the historical control or the control group, I'm part of a study right now, is microfracture. And if we truly believe that it didn't work, then we wouldn't be ethical if we enrolled our patients. So it does work for some lesions. But the durability goes down at a minimum of two years. And typically, at five years, there are just better treatment choices. And particularly in a bone that is as sclerotic without marrow like the patella, that's not what microfracture was designed for. There's no bone marrow that's going to leak out of the patella to form a fibrocartilaginous clot, maybe in the trochlea, but even then. So please, if you leave here with one thing, just please do not microfracture the patella. So as Volker alluded to, thank you. So she's got no improvement, did aggressive rehab, still with mechanical symptoms and pain. So at the index procedure, again, we cleaned her up. I'm not a big ACI person in general, so I don't take Harvest unless it's like a kid or something. But she's a little older. I'm sorry? The size was small for an ACI woman, too. True. Was it bigger than 4 millimeters? No, that was bigger than 4 millimeters. But it ended up being a little bit bigger than 4 millimeters. Yeah, well, you'll see. So yeah, so she, so say she has a one centimeter defect, lateral facade of the patella, what are your considerations now? She's well aligned, Kevin. She's not unstable. She tracks normally. So what are people doing in the patella-femoral joint? So I can talk about what I do, but what's everyone else doing in the patella-femoral joint? Per se, isolated lesion, good shoulders, pristine trochlea. Osteochondral allograft, with or without a TTO, depending on where it is. Anything lateral, anything central gets a TTO. My medial lesions, depending on the age of the patient and their demands, I sometimes will just do an isolated OCA. From where? From patella to patella, or from condyle to patella? From patella to patella, always, for me. And while you can do mix and match for condyles, I personally don't do that, but you could. But for patella, due to the morphology of the patella relative to every other part of the knee, the cartilage thickness relative to the bone is going to be a mismatch. And we don't know that that's a potential problem if you do a well-done graft. We've all seen, I always tell the patients, the x-rays are going to look funky. We don't know if the donor morphology matches your morphology. But at least with a patella to patella, I have a pretty good shot at that. In addition, almost no lesions other than pure lateral lesions, almost none of them, you can get a perfect contour from a condyle to match the contour of the patella. And certainly an off-the-shelf plug, which I love for a variety of indications, but not for this. Again, it's the morphology and the shape. And I think people are afraid of doing this in the patellofemoral joint because of that issue. But if you use a patella graft for patella and a trochlea graft for trochlea, that eliminates at least that one potential issue. I think other options can vary between either a Macy type thing, so yeah, a little bit more expensive, but definitely much more customizable. And all lesions are one and a half by one and a half, right? But then you have also the other off-the-shelf options, so like the, oh gosh, I'm going to get all the names mixed up. But there's the putty, there's the frozen grafts, the ones that have holes in them, the ones that have laser cut holes in them. But my understanding is a lot of those allograft options off the shelf are a little bit more difficult to get approved by insurance. Yeah. So this was her defect there, so bigger than a centimeter or around a centimeter or so. This is after we just kind of cleaned that cartilage flap up. So we dropped a plug in there. So I think I do a lot of osteochondral plugs and osteochondral resurfacing in the patellofemoral joint. I worry about other surface treatments. And I find structural things are kind of work best. I think technically you want to, you can't use the typical recipient site oats instrumentation for this. You have to drill this because the bone is still thick and hard. So you want to make sure your rep has that for you. And she's done well with this. Go ahead, Kevin. I have not gone that route. I consider that a surface treatment. And I worry about surface treatments in the patellofemoral joint. Structural. And it's nice because you go, these people, they get going right away. I don't, you know, I put them in a T-ROM and their weight bearing is tolerated and extension just for the first few weeks and then not on stairs, but we unlock the brace and let them get going with that, you know, sheer joint, not compression. How much of your 360 degree cut are you able to match that? It can be hard to match. It becomes more easy to match with a scalpel blade. Sometimes, so sometimes we do take a scalpel blade to the edges that are maybe a little bit prominent. I think someone's done some research looking at that, that that was an okay technique to do, but I don't do it on all, but you know, occasionally we'll take a 15 blade and just kind of contour the cartilage. And I think that's the other benefit of using size match patellar cartilage because you got a thick cartilage cap that you can actually do that. patella yes allograft yes sorry so yeah so I will take autograph from patients but I will not take autograph from a patella in a patella femoral case I think I think you're just asking for trouble sorry to further it more just the forces through the patella femoral joint or the patella itself I like Highland cartilage in general fibro cartilage is bad and even some of the other proprietary named surface treatments I still think it's less than Highland cartilage and it's kind of tongue-in-cheek but um but also I just think you get bone-to-bone healing at six weeks and you got some live chondrocytes that you're putting in there right away I've had some good good results with that I have a low threshold, I almost never anteriorize, but I will, you know, anterior medialize, so I will do AMZs for these or Fulkerson's if their anatomy warrants it. I don't necessarily want to cut the tubercle if they're already quote unquote normally aligned. I worry, I worry about skin complication even if you're not the old McKay which you know put them very far forward which was bad but I still worry about skin complications and other things with that. I know. All right. All right so this another patella femoral. I think we're gonna be swapping back and forth patella femoral case. So this is 12 year old male so his skeletal immature fell and hit a rock. The other caveat this is my my youngest son's best friend. Objective findings had no J sign. The CDI was 1.3. Had a crossover. Sometimes can be very difficult to see that crossover in our pediatric population because they're still kind of growing but you get a sense that he may have a bump there but I still call this a de jure and do you do an acute MRI for this when you see that a vulse piece here. So who are who's doing so in all comers with patella femoral instability who's doing acute MRIs out the gate when they show up to see you? Who's not doing MRIs initially for uncomplicated patellar dislocations? So you asked me that question eight years ago. I didn't get MRIs on nearly anyone because I felt that a lot of could be treated non-op so why get an MRI because I worry about chondral pieces now and other things so probably the last you know eight years of my practice I've getting MRIs for everybody regardless if they if they've dislocated. There may be a few exceptions but I typically will get an acute MRI because not all every loose body can be seen on an x-ray but this is not a loose body this is a vulgin of NPFL. So TTTG is 15 millimeters in this kiddo and so this is where he sits on MRI had a pretty sizable NPFL piece. Who's repairing this here? Don't be shy okay good stuff so so NPFL avulsion again my kids best friend very good friends with his parents so we did an NPFL avulsion repair for him for that lesion there's my number so no J sign TTTG is low de jure you know CDI 1.3 I'm not really looking at that as being that bad so so we did a repair for this I use suture anchors to kind of get this piece back down would anyone use anything besides so I got some other pictures here but someone anyone use anything besides suture anchors anyone put a screw in this? So Lutul is this this is your NPFL like a lot of times these are distal and medial and distal to the classic classically held sort of insertion or origin of NPFL depending on how you think of it this you think this was truly an NPFL avulsion piece? Yes so this was not like a chondro piece that we've knocked off or anything like that and so I thought it was fairly medial with this so that top suture is almost at the top of the patella there with proximal being to our our left and distal being to the right. I've also seen these avulsions though they're like a crescent type avulsion at the they're more distal and so I've repaired the fragment with the suture anchors and then done the NPFL at the proximal half of the patella I think we're along the same lines they seem to be more distal than the typical NPFL footprint but they're still like an avulsion. So in any case I would I'd be worried about stretch within the substance too and so I think I'd be inclined to do a graft plus a repair if possible and you know you can weave it into the quad if you run out of real estate that kind of thing. I did not do that because I felt that it was sort of right in the NPFL zone there and this is um you know sort of the first video is what we're looking at operatively I think the piece is distal it's pulled distal but you can see more of the injury area up top here and then this is after we've sort of gotten things back repaired and you can see that piece is pretty superior there or straight medial anyway I felt we had gotten things back repaired fairly well anatomically. So did very well with this and then was that field day and I fell during field day and dislocated again at this point definitely and this is looking at so the intraoperative pictures so this was still intact but again it's sort of mentioned we worry about things being stretched out as a part of the injury pattern originally so everything had healed and but again he stretched things out and dislocated so that we went and did an NPFL reconstruction and lateral lengthening and so that's the question sort of what went wrong here and again looking at you know again plastic or a deformation of the soft tissues along with an avulsion that happens and other than doing anything else that we could have done differently with this other than index NPFL or MQTFL or something along with this so and this was prior to like a lot of studies that would show that you know some of these injuries a lot of these injuries just don't do very well with the avulsions and so your incision management you had a prior medial incision for the repair you're gonna do your NPFL whether you do two incision or one medial incision and then add another lateral lengthening just kind of you know separating those and how you manage that. Bless you. I extended his medial incision and snuck over the top to do the lateral lengthening so I didn't want to make a separate incision you know for him because you know we're out worried about skin bridges and whatnot. We got creative with the you know I do so many lateral lengthenings that it's wasn't that difficult to kind of sneak over the top to do that. Um, I think, I think he said TTGT, it was only 15 millimeters, and so again I didn't think that was at all, and the fact that he's scaly and mature, I didn't think that doing that or any of the other distal soft tissue procedures was, was warranted in this, in this case. Can you talk about your Fiseal Sparing Technique that you used? Um, let's see, I think, yeah. So I, um, so I, I use screws for my, um, actually this may not, so I use screws for, um, all my, um, my kiddos, um, for all my NPFLs, um, and if we're doing a, um, scaly immature NPFL, we will, um, so this is a, a truly scaly immature patient, so 11 years old, um, she's been dislocated since she was seven, mild J sign, CDI 1.2, uh, has a crossover sign, her TTTG is only 15 millimeters, um, and kind of mild dysplasia, so I didn't think her dysplasia was that bad at all. She's got some tilt on the MRI, um, again, so CDI 1.2, TTTG is not great, not bad, and then de jure, so, um, so the other Kevin Shea, uh, who wrote about, um, location of the NPFL attachment on the femur years ago, said that NPFL attachment is above the physis because on a lateral, if you use Schottel's point or if you use the anatomic site, it looks like we're right on the, the, um, the physis, but because it's undulating, um, you're looking at the sort of more lateral portion of the medial, um, aspect of the physis, which, which undulates, and actually, um, so when you sort of do a Schottel's point and you put the guide pin on it, it should look like it's slightly above the growth plate or right at the growth plate, but when you look at, um, an AP, you know, you're actually beneath the growth plate, and, um, and since the posterior aspect of the growth plate is concave, the anterior portion of the growth plate, um, anteriorly is convex, so when we drill our tunnel, we aim distal to the growth plate, um, and then we also aim anterior, um, as opposed to normally when I either drill straight across or I drill proximal, typically when I do an adult NPFL. Um, so you have to have a lot of good imaging, uh, as part of this, um, we know that the footprint's somewhere around 7 to 8 millimeters distal to that medial aspect of the, um, of the growth plate here, so when you're looking on the lateral, you're looking at this part of the growth plate, so if you start there, you're gonna look like you're on the growth plate, so, and we use a, um, a, uh, tenodesis screw for this, um, I use a two-tailed graft, um, and, you know, we've, I've done a lot of skeletally immature NPFLs, and we've, you know, we've not had any growth arrest, and I think when done well, um, you can do an anatomic NPFL without violating the growth plate. Anyone do anything different? Um, I know what my, my mentor would, um, loop the, uh, graft, uh, underneath the MCL, which is somewhat non-anatomic, uh, some people use anchors here, because they don't want to deal with the growth plate, um, anyone doing anything different? Jackie? I'll do a pull-through, because if you go back to that lateral, there is a little shelf of bone that if you kind of stay above Bluvin sats, you can do a pull-through safely, but again, you have to sort of go back and forth with your x-ray and make sure you're safe there, uh, but I kind of like the pull-through option, because then you can sort of dial in the, sort of the length that the knee wants by giving it a full range of motion. So if I pull through, you mean all the way through the other side, so I, I pull it through still, but I just use the tenodesis screw to help, uh, A, because I can see that the shaft on the, um, so I still go through and through, I use a beef pin, I pull the beef pin all the way through, so yeah, sorry about that, so yeah, so same thing, so it's the same way the adult, I do my adult MPFL, except for, um, I, uh, I don't like the tenodesis screwdriver for putting the, putting the graftings, I never know where that thing's going to end up, so I pull the graft through, and then I stick the, the, um, the tenodesis thing into the socket, and then just use, use that mechanism, I thought, what are you talking about, pull-through, yeah, so yes. I use the adductor tendon, um, as I mentioned during my talk. I've been really happy with that, I think, um, it's, you know, nice and posterior, it's a little bit proximal, right, because obviously it's a little proximal to the tubercle, but if you get it low enough, um, you know, I think it's slightly more anisometric, of course, but it's soft tissue, and then I do that to the quad, so it's soft tissue to soft tissue, so I think it's a little bit forgiving, also, from that perspective, um, and just not having to mess with, you know, all of this stuff, uh, I've been pretty happy with that, yeah. And on that note, Petri Salampo's published Harvesting Adductor Itself, and swinging that up as your NPFL, um, that takes a little bit more, uh, sort of anatomical knowledge of where you are relative to adductor hiatus as you chase it north, uh, so I haven't been willing to try that, but also a good option. Yeah, and I like this, because it's truly a percutaneous approach, my, um, my incision is big enough to get a screw in, essentially, and it's, you know, it's gotten smaller over the years, um, and so we don't make very big incisions anymore with this, and so she's done well, this is actually an old picture, she's now, I think she's a senior in high school, so she's seven years post-op, she actually dislocates, so they, her parents are diplomats over in, um, Azerbaijan, and, um, but they're American, and, um, and so she's a student over there, and she dislocated her other patella recently, so I got some feed, I said, well, her other knee's doing great, and, um, and they just said, look, you know, she's doing okay, she's done with her high school, you know, playing days, and so we're just gonna, you know, treat this non-op, so, and they didn't want to fly all the way back to the States to get taken care of. Um, alright, so, this is a, um, ACL case, so a 52-year-old male has medial knee pain as well as instability of his knee, he's had pain in his knee for many years, um, and can be as high as eight out of ten with activity, um, he floats somewhere around two to three out of ten, uh, wakes him up at night occasionally, um, and then his instability began last week after a fall while mountain, like, legit, like, mountain climbing, so he's a very active guy. So, um, he's got some mechanical symptoms, um, so what do you do for this gentleman, so this is, so he's, he's a thin person, so, um, this was actually when I was in Tucson, so not my typical Cleveland patient, um, so good range of motion, had an effusion, had a positive Lachman's, um, he had medial joint line pain on palpation and a negative McMurray's, um, so now what are we doing for him, so x-ray, so he's got KL3 medial compartment arthritis and an unstable knee, so he's got high grade chondral loss over the medial compartment, um, ACL tear with bone bruises and a medial meniscus tear in his knee, um, what are you going to tell this guy, you're done mountain climbing and, um, you know, we're not doing your ACL because you have arthritis inside your knee, what, what are our options for this gentleman, yeah, but this is when I was in Tucson, this is when I was like in my 30s, and so this guy was old at the time, not anymore, was that, I do, um, so I think we go into the options here, but do nothing, so we could do injections and PT, but that's probably not going to be good for this guy, he's a legit, like, mountain climber, um, bracing potentially, but, you know, he's somebody who, um, when you're on the side of a mountain, you can't necessarily have an unstable knee sometimes, so, um, so, I'm going through options here, Volker, we're here to talk about options, and the ACL and partial medial meniscectomy, graft options, brace options, post-op, so, um, so before we go over to the x-ray, so, so 53-year-old guy, he's, um, uh, very active, he's got some medial compartment OA, he's got an ACL tear, so, I think I already know the answer, so, who's doing quad tendon in this guy, got some quad tendon people, how about allograft, who's doing allograft potentially in this guy, so we got some allograft folks, and then, um, hamstring, any hamstring people? How about BTB, any BTBs in the crowd, mountain climber, all right, and so ACL with ATL, so, um, so real quick, Lutul, sorry to interrupt you, I just wanted to, um, say about the, if this, if this gentleman also, uh, sort of rock climbs in addition to mountain climbing, those are sort of two different pursuits, and the rock climbers, since we're sort of at an athlete's knee course, the rock climbers really rely on their heel hook and their hamstring to elevate themselves during rock climbing, so this man also rock climbs in addition to mountain climbing, I feel like those two are closely related, I think he and his cohort of people would be advising him to avoid hamstring, I don't know that there's any data to back that up, but just know in your patient population, if rock climbers come to see you, they might avoid hamstring for that reason. That's a good thought, I'm not a mountain climber or rock climber, and so I was not thinking about that, so, um, the other thing about this, so we think about maybe ACL and ATL, we do have x-rays coming up, um, he's a smoker also, so I'm not sure how the guy's climbing mountain, but he's a smoker, so now what, so let's say he's got a, his weight-bearing line is midway through his medial compartment, he's got pain inside of his knee that he's always had, and he's got ACL tear, Volker, what are you going to tell him? So, is anyone doing HTOs and smokers? That's the question. So, Robby, are you doing HTO and a smoker, opening wedge, closing wedge? Would anyone consider a uni with his ACL? I'm just throwing it out there. We have strong opinions. I think the, you know, the literature out there is horrendous, you know, looking at that, UNI's and ACL's. He's an active guy, you know, I kind of, he's 53, so he's not over the hill. Can I ask a quick question? Before this ACL injury, even though you said he had medial knee pain, that it's been there for years, had he ever had a single treatment for his medial knee pain? I don't know, this was a long time ago. I'm gonna assume that he had some treatment for it, but. But maybe it was not in your office or, you know, anyone else's office saying, I need an injection or I need an unloader or I need you to scope my meniscus tear or degenerative knee or whatever. So for me, and again, I'm always looking for a reason to say yes to an osteotomy. I love osteotomies and I don't think you'd be faulted for doing it and we saw your sneak peek of the picture, so I think it's coming up and you can play around with the slope a little bit with the osteotomy too. But I think we see this all the time in patients who have pre-existing kind of conditions in their knees, so to speak. They have medial compartment arthritis, lateral compartment arthritis, patella femoral cartilage problems, but they were dealing with that and then they have an acute and recovering from an HTO plus ACL is a different ballgame than recovering from an ACL alone. So I think it's, again, I think as I mentioned before, there's a lot of right answers for many of the problems that we see and I think we're gonna see that in this particular case. But that's something where I, when I see a case like this, I get asked all the time by my fellows because we do a lot of osteotomies, for the primary ACL who has elevated slope above 15, are we gonna pull the trigger and do a slope correction HTO plus the primary ACL? And I don't do that because they've had elevated slope their whole life. They probably have it in the other knee. I'm gonna do their ACL and hope I do a good job and if they fail, then I'll consider the slope. So in a case like this, if the medial symptoms weren't driving him to see any sort of doc before the ACL injury, I don't know how aggressive I'd be with correcting the medial sided symptoms. With activity, his pain is 8 out of 10 at times and he floats around at 2 or 3. But he didn't come to see you before the ACL injury. So that 8 out of 10 pain didn't occur. We're gonna say he saw someone in that situation. I think that's a different story, but that, that's where taking a good history is really important. But I will, I will tell you, and this, these just came from my group of cases, so I'm sure I took all those history things and whatnot before we decided to pull the trigger on that. But I will say that I've also seen the other thing where you've done an ACL on somebody and maybe ignored some of the other things and now they have a painful knee that's stable. And so, so we've seen, seen it both ways. And the fact that he brought that to my attention, I think that's something that I found that one hard to ignore. It's something that I could, I could fix and make better, even in a smoker. Yeah, so low BMI, 26 BMI, BMI 26 and healthy guy climbs mountains other than being a smoker. Yeah and and but you know in terms of so I look at ACL if you do a root repair those patients are not in weight-bearing or on crutches for six weeks and so this is you know that's why I say it may not differ that much depending on what you're doing through ACL. Robbie. All right, so he had some spotty, great four changes on his tibia. Had that on his medial femoral condyle. We saw his weight-bearing line. That's sort of what that looked like. There almost kind of looks like a chronically ACL-deficient knee, right? So he's got that sort of posterior medial wear and whatnot inside of his knee. And then that was his ACL. And so we did a hamstring ACL for him, and this was like 15 years ago. And then he got the HTL with him also. And this is one where we do the HTL. I put the most posterior screw in first. So I put the distal screws in first. I put the most posterior screw in to the HTL plate. And then I drill my tibial tunnel. In femoral tunnel, I drill first, actually. And I use a flexible guide pin so I can leave that in place and still manipulate the knee. And then I drill my tibial tunnel. And then when the tibial tunnel is drilled, then I drill my anterior screw through the HTL plate and try to dodge my ACL tunnel. And most times, or all times, I guess, I end up missing my tunnel. I don't like using BTBs in this case. And this was, again, in my time in Tucson. So this was before the quad invasion. And I don't like using BTBs, although I have been, because you worry about grass tunnel mismatch because you don't have a whole lot of real estate in that opening wedge portion of the tibia. And so this is a guy I told me he needed to quit smoking. I was not going to do his surgery. And this was back when I was sort of younger and dumber. And the guy showed up on the day of surgery. I said, did you quit smoking? He said, Doc, I had my last cigarette before I came in the hospital. And I just, again, I'm a very trustful person. And we trusted him. And that was the last cigarette that the guy had. And like, legit, legit, that's the last cigarette that he had. He had a young son. So he has a son who I think at the time was eight years old. He's like, I got to stop smoking for my son and for this surgery. So that was it. And so that was back in the day when we were keeping people in houses. He was in house for two days after surgery. And everyone goes home now. But because of that, he actually had more time to quit smoking and whatnot. So he did. So now, yeah. So they go home. They get a block, and they go home. And they do great. And that was a force, because we had 23 hours short stay at our ASC. And then because of staffing, it went away. So we either had to do these at the hospital, which I was not willing to do, or I had to send them home. So multi-legs, HTLs, everybody goes home after surgery. Because you're European? Yeah, and so my partner, so Rob Hunter was my partner at the time out in Tucson, and so he would do HCOs and smokers all the time, and obviously, you know, Hunter started out in Colorado way back in the day, and so he did closing wedges on his smokers because he didn't have to worry about a gap healing, and so again, I just don't like the idea of fooling around with the proximal tip, fib, joint, and whatnot with that, so HCOs, I think, and you can, I think, better work slope and stuff like that, get the plate posteriorly as possible. How did you fix the AC off on the tibia? Interference screw, so I'm a interference screw person, good question, and there was a post there too, just because, yes, so yeah, so you can catch, you know, you can see the tunnel, so it's actually right at the corner of the osteotomy site here, so yeah, and it's, you know, you can make that osteotomy cut a lot more oblique, but it's hard to do, so I think if you're making standard osteotomy cuts above the tubercle, you know, you don't have a whole lot of real estate there, and that's the other thing, you know, also when you talk about, well, if you just did the ACL, you could always come back and do another procedure, HTO, something if he was continuing to be symptomatic. I had my very first fracture through the plateau and somebody who had had an ACL prior that we were doing it by another doc who we did an HTO on a couple weeks ago, and that's the first time I've ever cracked up through the plateau, just through their tunnel, and that's not a good day, so, because then and now it turns into a trauma case. I do some trauma, but not that much, so, you know, now I'm fixing a plateau fracture, but so I think doing this all in one setting so we don't have to come back for somebody who I think was fairly symptomatic or symptomatic enough for me, I think was my reasoning for doing it all in one fell swoop, and the guy did great, again, stopped smoking, and actually, so, let's see, so, so touchdown weight-bearing for six weeks, he got, you know, was again, did well healing-wise, healed uneventfully, quit smoking the day of surgery, and then one year post-op, climbed a mountain, so he was back to his mountain climbing everything, and did well with that. I think that's the end of my slide deck. Any questions? I think we have some other cases here, too, so this is a young lady, and, you know, it's one of those things that I think what either, I think Rachel's, no, or Jackie was alluding to, maybe with a true, no, it was Miho, about the flexion dislocator, potentially, the true obligator or not, so this is a 14-year-old female, had one year patellar instability, she fell while cheerleading, no improvement with PT, so a lot of cheerleaders, apparently, so abnormal tracking, so her CDI was 0.9, so not high, she had a de jure, like a legit de jure atrochlea, and it's about the best lateral that you're ever gonna see, and then her TTTG was 10 millimeters, and she had this atypical bone bruise pattern, so almost in the area of an ACL bone bruise without the tibia to go with it, and, you know, we can kind of see, even with the MRI, she's got a lot of tilt there, but she's, you know, not fully located, but fairly located, and then this is her in the office, and as she goes into flexion, she kind of does that little wiggle thing, and this is something that certainly can be missed if we're just thinking this is just routine instability, and she needs an MPFL reconstruction alone, so she's a flexion dislocator, you can kind of see that on the, so that x-ray, for whatever reason, they did this merchant view and a lot of flexion, and that's kind of where she sat, so definitely don't want to miss these, because, you know, this is where instability surgery can go wrong, so she's obligate dislocator inflection, and it's kind of not clear exactly when this started, whether it was truly at that fall or some other time, so what are we thinking about if we get our dislocator inflection, so lateral lengthening MPFL and call it a day. Jackie? I'm not sure I have the right plan for this, but I was just going to point out that this, this is an example of how these du jour classifications don't tell the whole story, because yes, this is an A, but that A is super shallow the whole way up, and that, I think, has a whole lot to do with why they dislocate inflection, because there's just no bony containment. If you look at that lateral x-ray, yeah, sure, there's a groove line, but it's like a millimeter off of the lateral medial walls of the trochlea, so I'm a little worried that trochlear dysplasia is the primary driver of this in a way that that might be hard to overcome with soft tissue surgeries. I think it's, you know, the hypoplastic lateral condyle distally. She gets full motion, right? Sorry, she does get full motion. Yeah, that's tough. Can you show us what you did? Yes, so you want to have a good plan and be ready for all things, and this is pretty impressive. Like, you know, you see some people who kind of track laterally when you do their exam under anesthesia, and I like to look from up top, so I use a superior medial portal for viewing my tracking, so we're looking from the top medial portal, and we're looking down the pike with the, and so when she's even in deep flexion, this is sort of where she wants to start going, and when we go deeper in flexion, she goes even further out laterally here, and so you want to make sure you're evaluating this in the operating room, and there's some questions of whether you do diagnostic arthroscopy every single time you do an NPFL or every time you do an instability case. Does everyone scope when they're doing patellar instability? Anyone not stick a scope inside the knee when they're doing patellar femoral instability? I think there are some people around the country who don't scope. I think scopes, it's pretty brief, you know, in most cases. I don't have, you know, I don't have them open biters. I only have them put one bag of fluid up. You know, I tell them it's gonna be a quick scope, but we're gonna scope nonetheless, but, you know, to evaluate cartilage and whatnot, and she's obviously been, you know, sitting because she got some wear on her patella, and again, this is, these are tight lateral structures here, and so for her, you know, kind of have a stepwise approach to how we, you know, certainly do things, and you want to be ready to kind of keep moving along as you do things, and so this is kind of our plan here. So NPFL reconstruction, you know, we do a lengthening, but sometimes with these flexion dislocators, you cannot lengthen them enough, so you sometimes just have to do a release, and we kind of keep releasing structures until they contract normally, but then we also had to do a vastus lateralis lengthening. So essentially, we just, I think I have some pictures of it here, you just cut along the quadriceps tendon, and then that should continue to loosen things up, and you keep, you can also release the vastus lateralis from the intermuscular septum, because they have this sort of vector of soft tissues that are pulling everything lateral, so you want to kind of try to correct that. So I do a laterally based incision for all of my patella femoral work, typically, unless we're fixing NPFL avulsions, which don't work. So we do it long, we do it, so I do a small, if we're just doing NPFL alone, along with lateral lengthening, we do a kind of small anterolateral incision. For this, I kind of open her up a little bit more, and I don't unzip the entire knee, so if we're gonna add a TTO, I typically do a separate TTO incision instead of unzipping the whole thing, but that's, so it's a laterally based incision, because I think your work on these obligate dislocators is primarily lateral work that you're doing, and you can't just kind of throw an NPFL on this and kind of hope for the best, because they'll be stable for a little bit, and then either stretch it out in PT, and so, so Adam Yankee, what he always says, you know, you kind of want to line up the putt before you knock it in, so you want to kind of get everything tracking normally before you add the NPFL. So we start, yes, we didn't start with the NPFL, so we start with the lateral lengthening, and then I kind of range to see if her tracking is right, then we released it from an intermuscular septum, she's still tight, we did our lengthening, and then finally we could get her over into the groove, and she stayed there throughout the range of motion, so we did not have to go down to the tibia, because you heard her TTTG was pretty low. So this is the technique, and so we want to release this, so we release it from the intermuscular septum down here, there's some bleeders down here, so be careful with that, because this can bleed like stink, so we remove all this stuff from the intermuscular septum, and then kind of release this from the lateral border of the tendon. If they're still very tight, sometimes we have to lengthen the quadriceps mechanism, which is very easy to do, but for her we did not have to go there, because that's the next thing that I would do if just a straight lengthening here didn't work, and then, but we got her reduced, and then we added her NPFL, but so she's obligate dislocator, so we got to do more than just NPFL. All of her other factors are not very high. I like that Jackie pointed out the anatomy of that trochlear groove, because it is a bit atypical, because it was flat all the way, and so so that's something that you're, you know, even thinking about trochlearplasty or anything for that. So she did very well, you know, with the procedure, and got back to cheerleading and everything. What do you think about the role of a distal medial stabilization, like an MPTL, might be in these sorts of flexion and stability cases? Yeah, I think there's some some thinking that certainly that certainly may help, you know, with things not something that I'm doing in my own practice. I think that's still relying on something to kind of keep the patella located, and so I think the key is trying to get, you know, all these contracted structures lengthened or released, and kind of get the patella tracking normally, and then like know your MPFL or MQTFL or whatever, do the rest for you as a check ring. Great case. Are we tapping out yet? We have some more. Yeah, that'd be a good one to end with. Let's do that. So this guy, just real quick, so this is, so this guy is, so this is your, you know, age is just a number. 68 year old guy, was out in Colorado skiing, and this is why I don't ski. One of many reasons why I don't ski. This is what he had. So he's, this guy's 68. So what do you tell this guy? We're not gonna do anything for you at 68, or do you go in and fix this piece? You can't really leave it there. I got some some views on the CT scan where there's a vessel kind of running right next to this thing, and so this is a multi-leg knee. So he had a MCL, he had ACL, as well as this PCL avulsion here. So this you got to do something about, and so technique that we sort of did not invent, but we wrote up in terms of the approach here, but yeah, it is. So you talk about, you know, planning and whatnot, and so when I'm, so whenever people are prone, so we went in to address the PCL first, and so whenever I put people prone, I put markings on, so I know where my anatomy is, and so know where I'm venturing since we're, you know, not in a typical area. But this is one of the most, this is one of the easiest approaches that you could ever do within Sports Medicine Open. So we didn't use the whole thing, and literally we just used this sort of arm of it, but it is extensile. So we use that, and then basically you come down, you move the semimembranosus, or you move the medial head of the gastroc over, and you go in this plane between the semimembranosus and the gastroc, and you pull all this stuff over so all the badness goes with it, and you come right down in the PCL footprint. And as I'm sitting here, I'm looking at my marks on the knee, I thought, okay, we got to put this screw into the right place, and do not end up medial with the screw. And so we put the screw in, I'm feeling good about myself, I'm high-fiving the resident, and we get our images, and I'm like, shit. And so I didn't want to take the screw out, I'm like, well this might be an issue when I come back for the ACL later on. So we left the screw where it was, the guy ended up healing very well, and so we came back, and at that time MCL had healed, so we just went back and did his ACL, because the guy wanted to get back to skiing, and we did a hamstring ACL. So we drilled our tunnel, we started way medial, and we just missed the screw. So with all the best plans, sometimes you still don't get it right, just kind of bonehead. And like someone said, if you have to drill from the lateral side, you can. I had to do that once or twice in my practice. Doesn't seem right when you're doing it, but aperture is important. We just put them onto the bed at the PCL, and then we put them back to the recovery bed, and he came back three months later, and he leaves, you know. And it's so much easier when you're like, just looking right at the platform. There you go, that's awesome. Great cases, Lutul. Okay, I'm gonna hopefully bring us home here, and we can take as long or as short as we want to take with this. And in theory, this is bread and butter stuff, but it really got us thinking when I was actually a fellow, and I think it's still worth a discussion. So this was when I was a fellow in New York, and we're covering the Liberty, and one of our Liberty professional women's basketball players was practicing. She sort of got clobbered while driving the baseline in practice, felt a shift, and sort of landed in hyperflexion and valgus. On the other side, she has a history of a patellar tendon ACL with good results. She has a moderate fusion, range of motion's limited though. Tendon palpation on the joint lines, one B lockman, a lot of guarding. Enter a drawer positive, grade two laxity to valgus, so a little bit of MCL suspicion. MRI two hours after the injury, because that's how we roll. She's got this lateral meniscus injury, and then residents and other trainees in the room, you'll recognize those bone bruises, right? So we're expecting an ACL tear to go with this bucket handle lateral meniscus. And there's that. I'll get my mouse out of the way there. And then she's got this peripheral medial meniscus tear. And so I just, I wanted to throw this out to, especially the faculty in the room, now what do you do? So you've got this big acute injury. I think most of you guys who are still learning are seeing us pre-have ACLs. BARE is emerging as the exception to that. You wanna go more quickly to repair it. But we worry about stiffness in this situation. So I guess among the faculty in the audience, what would be your plan? Would anybody just sort of go for all at once? Fair number, yeah, fair number of people. Yeah, there's some benefit there, right? And there's some evidence basis that if you do the ACL with the meniscus repairs, you're gonna have a better chance at healing your menisci, right? And so there's some real upside to that. Would anybody plan for a stage? Just right out of the gate. Anybody leave the door open, I suppose? So we hemmed and hawed about this a lot because we were worried about stiffness in this player. And anybody who's seen arthrofibrosis in a knee knows that it can be sort of a life-changing complication. So, oh yeah, here's the coronal. And you can see that lateral meniscus bucket even on the axial view there. And then she had an MCL grade two. Would anybody go after the MCL at the same time? No, okay, good. We didn't want to do that either. Okay, so acute ACL, bucket handle lateral meniscus, block to extension, peripheral medial meniscus, grade two MCL. So who, I guess let's say we're undertaking the meniscus repair for sure, right? We got to do something about that bucketed meniscus. Who would do inside out meniscus repair? Would anybody do all inside? Okay, any other comments? Okay. Hybrid, yeah, fair, right? Hard to get in the back. So for anybody who doesn't understand the word hybrid, we're talking like all inside at the very back and then inside out as you come around, you can reach a little bit better. Or outside in at the anterior horn. Yeah, right, right? If it's coming around the anterior horn, absolutely, outside in. And then, so we consented her for a possible. So this was a case with Jo Hannafin and those of you who know her know her to be a thoughtful and careful surgeon who's very measured and very communicative with her patients. And so she was team doc for the Liberty at the time and we took the patient with the plan for meniscus repair for sure and then a possible ACL. And there wasn't really a lot of evidence basis for like, well, what's gonna make us pull the trigger on the ACL repair and so, or the ACL reconstruction at the same time. But when we got in there, it was just all kinds of red. Just synovitis kind of everywhere we looked in the areas that didn't contain cartilage. So would anybody, this was, I think, within a week of injury. Like we turned it around really quickly. Would you wait longer? Like what would you do in this situation if you had, okay, you'd go as soon as you could, right? Okay. Yeah, yeah. What's that? Yeah, right, exactly. Yeah, right. Before that inflammation sets in. So really, you're going for it, okay. So academic, anyone here aspirating and injecting cortisone for acute ACLs in the office? I aspirate them, but I don't, I like to get the blood out. Not just aspirate, but just put a little cortisone in there. Could you make an argument for that on this case? Oh man, that makes me nervous. So Kurt Spindler showed up at the clinic when I was a younger attending and said, I do this for my ACLs and we did all this stuff at Vanderbilt that shows it's okay. And so I did it for probably about a year. And these patients, their knees turn around like nobody's business. Really? And then being like the scientific surgeon that I am, I thought I had like one or two more BTB failures than I should have had the subsequent year, so I stopped doing it. But they turn around like, it's incredibly, like you aspirate these patients, you put cortisone in there, and their knees are like fantastic. And then how soon do you do your ACL? I guess just when it's- They found it was no, it didn't matter. So yeah, no infection risk, nothing. So again, I am not doing that anymore. I haven't done it in probably five years, but just kind of food for thought, if anyone thought about doing that. That's interesting because I've actually gotten a lot of referrals because there's somebody in our community that does that a lot. And then I have delayed their ACLs. Even though the literature says you can do it, I just, I can't make myself do it. But it's good to know that you had a good experience with it. That's right, yeah. Dydw i ddim yn meddwl y byddwn ni'n rhoi'r sylwad y byddai'n iawn i ddefnyddio steroid yma. Rydyn ni'n ddiweddaraf wedi cyhoeddi meta-analyswm sy'n edrych ar yr effeithiol o vancomycin ar gyfer ddatblygiad o septogarthritis ar ôl adeiladu'r ACL, ac roedden ni'n cael ychydig o 30,000 o bobl, ac rydyn ni'n teimlo bod ein astudiaeth wedi'i gysylltu â'r graffau BTB, ac rydyn ni'n cael miloedd o bobl. Felly, nid ydych chi'n meddwl y byddwch chi'n gallu ddweud hynny'n ddiogel iawn nid ydych chi'n meddwl y byddwch chi'n gallu dweud hynny'n ddiogel iawn nid ydych chi'n meddwl y byddwch chi'n gallu dweud hynny'n ddiogel iawn nid ydych chi'n meddwl y byddwch chi'n gallu dweud hynny'n diogel iawn ond rydyn ni'n cael fideo ar y technigau arthroscopaidd sy'n cael ei gynnal fel perl fideo sy'n newid ymddygiad okay thank you all right food for thought for sure so this was what i was a fellow when was this like 2013 14 um and all i saw in fellowship was all inside meniscus repair i think the pendulum is actively swinging and we've we've been shown that inside out has a lower risk of failure and so i think if if we had done this in this day and age we would have at least done a hybrid version of of some inside out variety um for the meniscus repair to minimize failure but dr hannifin felt like the synovitis was too robust the risk of arthrofibrosis was too great um and so we i guess we did not we pointedly did not debride the torn acl because we felt like the smooth muscle actin might give her something right if we can keep her her stable in some way so that these meniscus have a chance to heal before she gets that acl to stabilize the knee but we did meniscus repair and stopped and sent her on her way and she actually was getting um traded to Chicago. So we got in touch with Dr. Dahm, who at the time was the team doc for Chicago, and handed off her ACL reconstruction at a delayed date. And I think the thought process is worth marching through. And I don't know if I would do it differently now. I think the same risk factors are there. I agree that a flexion contractor would be my biggest worry. And this is a high-level athlete, and I think that's a real potential downside. So I don't know, food for thought as you treat the high-level athletes and those. Jackie, so not a high-level athlete now. So what if it's February, high school football player, they have some potential to get a scholarship, and now it's February. They need to be ready for August 1. Same picture. Are you delaying that, or are you trying to do everything in one setting to give this kid a shot to be back to play football in August? Because if you stage that, they're done. They're not coming back their senior year. Right. It's a hard decision to make. I think I would not let that change my decision. I think plenty of football players registered their first year. I think having a good knee that works is too important. I think that that kid's parents might march down the road and go to somebody else. But I still don't think I would take on the acute ACL with all those risk factors for stiffness. But that person may not get a chance to get to college to get their registered year. That's just kind of being devil's advocate. I've been on both sides of the road here. A, there's no shame in losing a battle, winning the war. So doing the meniscus and coming back later, there's no shame in that whatsoever. I felt early in my career that everything had to be tackled right away because I am a sports medicine trained doc, and I don't need to stage things because, damn it, I'm going to get this ACL done with everything done. But I've had, over the years, in cases like this, when we had a lot of time before they had me back for their season, and they were just so stiff. And you wonder, are they stiff because they got this bucket handle, or are they stiff because this is just a knee that's not ready? And I've been burned more than a couple of times where I've done everything, and then now they're stiff. I'll get out. We're going back for manipulations and debridements and all that stuff. And so, A, there's no shame in it. But there are some times when you've got to make that decision. Like, say, look, if we want to get you back for your senior year, this is the only way that we're going to do that. And these are the risks to doing that. Is there a role for reducing it? So if it's, but it's February, they get six months before August. Yeah. So that's huge. So you miss your entire, so I'm a former football player and whatnot, so you miss your entire preseason camp. That could be the difference between you starting or not. And it may be four weeks that you have to wait to come back. It may be two months before you're back in there. You just have to wait for them to resolve their stiffness, or else you're in no different place than that. But those are the things that we're saying, well, what if it's March? And so those are things that sometimes we're going to be faced with these things. And that, not being there on the first day or two days, may impact some people negatively, for sure. And I would add, in a professional athlete, even though this is a professional athlete, if you have someone in a contract year, or someone that, for the same reason, needs to be on the field, on the pitch, on the court, wherever, in six months, seven months, eight months, those weeks matter. Like, at that level, and it could be a year or two weeks matter, like, at that level. And it's, with a high school kid, a lot of us want to say, well, boo-hoo, go to college another way. That's not the reality for kids who are going to college with sports. This is their ticket to get an education, in many cases. So I think the weeks do matter. And maybe I just succumb to parent pressure and contract year pressure, where the GM and the coach is saying, I need this guy back now. Tell me what you're going to do to get me back, or get them back now. And so even three weeks, like, in a professional team, that's playoffs. One week is playoffs. And so that's where it sucks, but it really does matter. But outside the box, like, so if you're concerned about doing something that you're pushing the limits of trying to get these patients back, especially with these weeks and whatnot, we can talk about adding losartan, or any other type of, like, fibrinolytic type. Well, I guess it's not fibrinolytic. Whatever losartan does, right? Magic fairy dust, whatever. But you can kind of think outside the box and add. I've had a number of people come in with a range of emotions. Yeah. Yeah. Fair enough. Yeah. I agree with that. I think one of the things that, you know, I might consider is just completely keeping them on crutches and then just kind of hedging a little bit, right? So adding an extra week or something like that. Not waiting the full, you know, what you would normally wait for the ACL, but maybe adding a week, trying to see if they can get a little bit of motion, even if they can't get full extension, get more flexion, let the knee cool down and then see if that knee is, you know, a lot different than what it looked like then. And maybe you can do both, right? If if the bucket, I guess those who who would be hesitant, if the bucket were there, but it was full range of motion, would you prehab like what would you what would your timeline be if there's full range of motion, but a bucket you would still go? Yeah, I see. Yeah. And even if they have a bucket, they're lacking five degrees or so, you know, I don't want some PT cranking on their knee, you know, just yeah, and it's and the more they're walking around. They are even if you put them on crush, they're walking around on this thing. The more they're walking around on it, just grinding up this meniscus and whatnot. I think it's that's a problem. So yeah, I do. I agree. I agree with your point. So that's a very good point about kind of waiting a little bit because, you know, I've seen people walk in 10 years with a bucket status post bucket handle without any motion loss. And so I don't like the term lock knee for that reason, because you put them to sleep in the operating room and he goes perfectly straight. Yeah. I think I've taken us to the ending minute here, so I don't want to keep everybody up too late. Thank you so much for everybody's time and attention today. Latul, did you want to make any remarks about tomorrow? No, just obviously we start bright and early tomorrow. Looking forward to a fantastic day. We get to do the good stuff. We get to be in the operating room. Thanks everyone for your comments and questions and thoughts. I think I learn something every time I come to these, both from my co-instructors as well as the audience too. I love doing this stuff and so it's been a great time. Everybody have a great night and thanks for coming. Again, thanks everyone for being here.

patellofemoral instability

ACL tears

bilateral patellofemoral instability

NPFL plus treatment

chondral flap

osteochondral plugs

patellar dislocation

NPFL reconstruction

medial knee pain

instability

mountain climbing

professional basketball player

torn ACL