So we're going to welcome up our panel here, Drs. Brown, Colvin, Matava, and Frank. And we're going to present some cases here. And these are all sort of my personal cases. And certainly, we wanted to have a panel that, A, varied sports experience, sports slash military experience in both, as well as care of other high-level athletes. Because certainly, I think many of us don't necessarily take care of professional athletes on a day-in, day-out basis. But I, myself, I took care of the University of Arizona when I first came out into practice. And I took care of the Browns when I first came back to Cleveland. And I think sometimes, being able to push the limits and see these athletes or soldiers in this environment kind of lets you know what we can do for our everyday patient. I think it makes us better doctors for our everyday patients. So if, for instance, you see that, so in the NFL, you see somebody, they have an MCL sprain. And how many times are you doing acute MRIs on MCL sprains in your everyday patient? Almost never. But then these guys, they come, they get off the plane. The next day, they get their MRI. MRI shows an MCL sprain. And then they're in the training room every few days, every week. And so you get to see that progression of these injuries. And as I always tell the fellows, when I see somebody in the clinic, they have an MCL sprain, you typically don't bring that patient back to your clinic every week to see how they're doing. You say, OK, come back and see me in three weeks. They come back in three weeks. They're great. You send them back to play. Maybe they were ready to play a week after they saw you or two weeks after they saw you. And so I think that's what sort of that high-level activity, the training room especially, has really taught me over the years. And so we're going to go through some cases and see kind of the nuances. And full disclosure, I'm primarily a football doc. I take care of a college, so I take care of everything. But my passion for sports medicine was largely because of football, because of personal experience. And I think everything kind of gets spoken about from a football standpoint. So we'd like to get some other opinions about some other sports and how we will handle these things even at different levels. So this is an 18-year-old college football player. So a right knee medial meniscus tear happened acutely. So when I saw him in the training room, trace effusion, ligaments were stable, had lateral joint line pain on palpation and full range of motion. And this is his injury. So he's got a medial meniscus tear. This is the actual case from my college training room. He's got this flap that's flipped down into the medial recess. He's also got a little bit of edema, but his cartilage was actually OK. And you see this guy, and he sort of wants to play out the rest of the season. And he's certainly able to do that, able to do some return-to-play stuff. How do you manage this in your athletes? So starting at the highest levels. So Leah, what kind of conversation do you have for this kid? He's an adult, so he's above 18. And he really wants to play. He or she really wants to play. So I'd want to know kind of what time in the season, kind of what their career expectations are. You said 18, so he's pretty much young. Is he red-shirting? Is he not red-shirting? He's not red-shirting. He's a starter. And we are a third game of the season, third game of a 10-game season. You said trace effusion. So pain was not corresponding to the medial joint line. He had lateral joint line pain. Is he having mechanical symptoms? He was not really having much in the way of mechanical symptoms. So he's here just basically for pain. My knee hurts. So I mean, you have the long conversation about how valuable the meniscus is. And it doesn't look like it's displaced. You definitely see the bone bruising. He doesn't have any medial instability. So he's got this flap here, which is flipped down into the gutter. So the discussion is you want to save as much meniscus as possible for the long term of career. Granted, he's a starter. He's a freshman. I would encourage this to be treated surgically. But I would definitely respect the patient's desire, depending on what they want to do, to try to return to play. Coach says this is our starting linebacker. He's the quarterback of our defensive unit. And this kid's going to be an All-American this year if he plays out the year. He's looking good out there. And can he play? Parents are saying, can he play? Can we get through this? I would let him try to play. OK. Rachel, any different thoughts? Same. I would echo. Long conversation. These are third week in the season. If you scope, he could, in theory, be back in two to three weeks if you do a meniscectomy. And we just had this debate when I was in England last week with professional footballers in terms of bucket handles. And some very high profile, outstanding surgeons that I quote and trust, I was very surprised to hear that mid-season bucket handle or mid-season tear like this isn't one of their pros. They take it out and let him go. They don't have any conversation about repair. And even though we're all pushing meniscus repair in that level athlete, they take him out and let him go. This is an 18-year-old footballer, American footballer. He's not an EPL professional soccer player with a multimillion dollar contract. But maybe he's going to get a multimillion dollar contract in the future. So I agree. I have that long conversation, I think. But if he said, I want to play, it's a risk-benefit analysis. He's an adult. I would let him play. It's not like I would say he cannot play, especially if he's not wanting to have surgery. What am I going to do, sit him on the bench? This is not going to heal on its own. This is not one of those that with a little rest is going to get better. But I would say, if you play, you have at risk of, number one, making it worse. Number two, if you play and you're able to play out, and I get to the end of the season and we want to scope you, it may not be repairable. We may have to take it out. This may compromise your future ability to play next season. This may affect your future ability to get a contract. So there's longer implications than just next week's game. But ultimately, I would let him play if that's the decision he and his family came to. I could care less what the coach says, to be quite honest. Alexis, would your opinion change either if this were a high school athlete? Senior, this is their last hoorah. Possibly got to get through the season in order to get scholarship opportunities. No, I think it would be similar. So high school, similar. Say, what if this is a stable, longitudinal, red-red tear, Matt, in an NFL athlete? So what we would consider reparable tear. It's not unstable, necessarily, so it's not a bucket handle. But definitely red-red tear. And this is something that you know you otherwise would be able to repair. We're kind of mid-season contract here. This is a person that can play. But you know there may be some risk to that. So I actually had that exact scenario with the Rams. It was a third string quarterback. And actually published this, so he's aware publicly. I can tell you who he is later on. It was an intelligent guy we had. And I agree with what Rachel was commenting on. I don't think we can be paternalistic in the situation like we tend to be sometimes. I think it's your job to lay out the pros and cons. There's risk for arthritis if you take it out. But there's also a 20% risk that repair is going to fail. And now you're going to take it out anyway, OK? And we might all get arthritis just because you take it out. He has a contract, or he has a chance to get a contract, has a limited career span, OK? You're going to do things to him not necessarily you're going to do for other patients. And so this particular patient I had, after the pros and cons were discussed like with him and his wife, he went to have a meniscectomy. And you sort of feel bad when you're doing it. But he went on and made the team. He eventually went on to start. And Ryan Fitzpatrick just retired last year after a 13-year season and made over $100 million. He graduated from Harvard and wants to start a hedge fund someday. And again, publicly disclosed, he gave me permission. Because this comes up a lot in this situation. And I've told this story to others. And some people were appalled that you would take out a bucket handle tear of a meniscus. But again, he liked to have surgery because it's just the pain. But again, I echo what everyone else on this panel. If they're not having mechanical symptoms and they understand the risk of further tear, I don't think this is repairable anyway. So I think you're still going to be taking this out eventually. But yeah, this is like the next scenario was like if, say, word, not this tear, but like that longitudinal tear that you sort of speak up with that. Yeah. So if people in the audience may disagree with my case, but that was a case that we were actually faced with. So in a pro athlete, keep in mind, that's important too. If I could just echo that, I think sometimes we get up at these meetings, whether it's Academy or AOSSM or anywhere in between, and we say we must always do this. I even said it yesterday, never micro fracture the patella. It's very easy to say we have to do this and have to do that. I think in reality, not just with pros, but with college kids trying to make the Olympics or trying to get a pro contract or just really want to finish their season, because that's what they've done for the last week. How many in the room have been an athlete in some way, shape, or form? How many played college sports? So at that time, that was your whole life, right? That was it. For some of us, that's why we went to college. And so I think it's OK to do what you might think is the wrong thing executed well, like taking out a piece of meniscus, taking out a bucket handle. It's OK to do that when you think about the goals of that patient in that time. And again, as was just mentioned, even if you do a perfect repair, it's not always going to heal. And for those high-level medial meniscus bucket handles, I would argue the failure rate's even higher than 20% in the highest-level athletes. And so you're hosing them for a recovery and then another meniscectomy. So I think it's what we want to do is preserve the joint, preserve the meniscus. It's what we train our trainees to do. But in reality, that's not always the best treatment option for your patient at that time. And even for your everyday patients, they're a laborer. And you repair that meniscus, and they're going to be non-weight-bearing for some time away from their labor job. If they lose their job, they lose their house, their car, all these other things, those are hard decisions that you have to make. And I've made that decision that, hey, we're not going to repair this thing, or we're not going to do this chondro replacement thing. We're just going to pluck this thing out to get you back to life, because nobody's happy if you lose your house and all that stuff. And then re-tear down the road with that. And then keep them out longer. So how about, because we all deal with the wrestlers. And the wrestling situation is, and why I wanted to have that in there, so the wrestler with the repairable, like the fully repairable, peripheral lateral meniscus tear. So Alexis, you see this, and they come in, and they've already had every single person on their team, coaches, people around the country hitting them up on Twitter. Don't let that doc repair your meniscus, because they all fail in wrestlers, every single one. That's what they're being told. And I will say, I have had this exact case. And I did repair it, and then he did re-tear it. So I would say, actually, yes, I probably would go with what Rachel was saying, is that there's no one answer for everybody, and we always want to repair it. But I think in retrospect, I probably would take it out. So I will repair menisci, and say my high school, and I take care of a small college. And those wrestlers, and I've had most of those heal and do fine. I've even had a pretty high-level high school basketball player who was really going to be a scholarship D1 person. And he tore his meniscus, buck and handled it. And I said, we're not going to chop this out, because you're a high school kid, and you've got to live with this for the rest of your life. So we repaired it, and I said, if we can get you back for half of your season, are you OK with that? And he agreed to come back for half a season. So we sent him back, which I would never send someone back on a repair to basketball at three months. But we sent him back, and I said, worse comes to worse, you re-tear it, we take it out at that point. But for this kid, he's an inner city kid, this was his chance out of the hood, essentially. And so I said, I can't send you back at six weeks or two months, that's just crazy talk. But if we're going to repair this, if we keep you out for half the season, we get you some film. And he went on his team, went to the playoffs, and ended up winning the state championship. And he sent me a video of him dunking the ball during the playoffs and stuff. And so we do take some chances here. I think if you're at Iowa, this is probably a meniscus that you have to cut out, the buck and handle. But in my division three athletes, they're not making money. They're not going to get famous out of this stuff. So I will try to repair those if they're fully repairable. I will tell you, you did come in and say, I don't want you to fix it. Yeah. Yeah, they know. So I think also something to consider is how you're going to repair it. You know, I trained under Frank Noyes, who was an inside out meniscus repairer. Nothing has been shown to be stronger. Things are easier all inside. I guess I would ask the audience and perhaps people in the panel, would you change your repair technique on this particular kid? Because you know the stress that meniscus is going to be under, especially if you let him go back to play a little bit sooner than normal. I tend to favor inside out repairs for all buck and handles because when I use whatever anchor system I'm using, I'm not disparaging the anchors. I never know exactly what I'm shooting into. Whereas you do an inside out repair, you can pull those stitches out. You know what that tissue's up against. Would you change, I guess the question is, would you change your technique based on the patient? In the basketball player, yes, because I wanted to put a lot of stitches in. And I worry about less meniscal trauma with the inside out than with a lot of the devices that I favor for most of my meniscus repairs. I would as well. I would do an inside out for, and I do inside out for most of my high level athletes. I don't like the little fletches. Any other questions about that case before we move on? All right. So this is kind of more of a quick hitter, hopefully. So high school football game, your personnel on the sideline, you got three ATCs, two for my high school, one for the visiting high school. I'm the home team ortho. We had ortho resident and EMS squad there. So as it always happens, 335 pound kid face down in the field, nose tackle. So never the skinny kids. And this is the- What kind of high school you go to with three ATCs on the sideline? So we have a really big high school. So we had two at our high school and the visiting high school had one. We're lucky to have one in Missouri, especially, and I'm being serious, in some, it's not a state law that you have to have an ATC on the sideline. We're often covering- It's not a state law? It is not a state law, and I think it should be. So our ATCs, they do a lot of our rehabs for our athletes in the training rooms. We have to have two for all the sports and stuff. You're fortunate, then, in Cleveland. State law is a huge. Does everybody have a school that does not have an ATC for sports? This has become an AOSSM issue that we're pursuing to see what it is around the country. Because I can tell you, in rural Missouri, a lot of schools don't have an ATC. And the parents could care less about it. One of the reasons they think it happens is because of this new master's degree requirement. You have less people going into the field, quite frankly. So people are shaking their head. Do you guys have any comments on that? Keith Kenter is currently the chair of the Council of Delegates. And he is working with some of us on creating a survey to go out to the members. So AOSSM members, look for that to come out. Because we were noticing that on a global scale, too. And I think it really leads to disparities in care. So I think, hopefully, you'll see that legislation come about in relatively near future. But yeah, it's a really good point. Because I think the urban places versus the rural places and the underserved communities, and it really changes the pathology you see in clinic. Because they don't get their ACL caught at first, and then you get an ACL in a bucket or something. The thing that makes it even more complicated is some of these rural schools, they're going to be smaller. They have less money. They have less athletic trainers. They also have less kids. And so now you have kids playing both ways that you don't necessarily have at a class five or whatever they have in your school that has 50 kids playing football. So sorry for getting off on a tangent. OK, that's an important topic that we're dealing with. So you see the arrow on our nose tackle here. He's the visiting team here. And then arrow goes away. So keep your eye on the nose tackle. Let's see if we can get that video to play. I want to show the videos. So he goes down on the field there. Someone falls into his leg, his own teammate. And that's him on the sideline there, or him on the midfield there. So that's his knee. So it's kind of hard to see, but that's not where your knee should be. It was 90 degrees to the femur. The tibia is 90 degrees to the femur. So of course, this 335-pound kid, he's all sweaty in what we thought was a needless location. So this is your team that you have on the sideline. Is anyone not reducing this before you send it to the ER? We're not attempting to reduce it before you send it to the ER. Anyone? So we're all going to try to give our best shot at getting this thing reduced. And so that's what we did. So while the kid was still face down, I was the first one out onto the field. And I just basically just gently grabbed his leg and just kind of tried to correct the deformity, essentially. And then after that, what are we doing management-wise? Is that a kid that you can slap into a knee immobilizer and send home with the team on the bus? RTP. So we're checking neurovascular status on the field. And so you send this kid to the ER. So this is one of our marquee high schools. We actually have a ER, a freestanding ER, right across the street from the high school. So it's like the best case scenario. So we sent them over to the ER to get x-rays. And then they transferred them down to the main campus. But this is somebody who I'm calling ahead to the EED, say, this is what we're doing. His knee looks fine now. But we reduced the knee dislocation. And this is what we need. And so I called the resident down at main campus, say, this kid's going to be coming your way. This kid was 16 years old. And this was not a knee dislocation. It was a Salter-Harris II ficeal fracture. So somehow, this kid's growth plates were still open at 16. But it looked like a knee dislocation. The reduction was great. And it ended up being best case scenario. So instead of getting a big multi-leg surgery, he got two screws across and did great. So any other management tips with that in terms of how you manage these knee dislocations and stuff on the sidelines? Lutul, when you call ahead, what are you asking for? So I say, this is a kid that needs to be seen urgently. So it's not somebody who's going to sit out in the lobby for it. No matter how busy you guys are, it's not some kid who's going to sit out in the lobby for two hours waiting to be seen. I say, this is a potential neurovascular injury, so forth and so on. This is what my exam was like on the sideline. So if anything's changing, then certainly we may need to be concerned about heightened pain, change in neurovascular status. And then this is a kid that, again, I don't want to sit in the city. Because it's a freestanding ER, this is a kid that we need to get down to the main campus ASAP. Has he gone back to playing? He did go back to play the following season. Do you ask them to do ABIs? So yeah, so we're going to get to that, potentially, one of our cases. So we still have this problem in Cleveland at certain places where they're still getting CT NGOs for everybody. And every time the residents call me with somebody with a knee dislocation with a CT NGO, I ask them why they're still doing that. But that's an uphill battle that we're trying to fight. So D1 Cleveland road game, first quarter, the starting quarterback had a first time patellar dislocation. And it's out. So you want it right out on the field, Alexis. And this patella is out laterally. And so is this something that you're doing on the field? Do you get them to a quiet place and try to do it in the locker room? How soon are you trying to get that patella reduced? I think if you're there and just pop it in, it's good. So his knee's kind of bent on the field. What's your reduction maneuver for that? Put force on the patella and extend it. Yeah, so it goes right back in. And so sometimes people say things like shoulder dislocations, which I'll argue that. I'll give a shot with a shoulder dislocation on the field. Some people don't believe in doing that. So you believe get into the locker room before you try that. And that's just time for spasm and adrenaline and everything else to decrease. So I think almost any dislocation, I am trying to get reduced, at least give it a shot on the field first before trying to do things in a locker room. So with that, so first time patellar dislocation, what are we telling this athlete as you're talking to him in the locker room after the game? What's your expected kind of return to play for that, Leah? So first time dislocator and a contact athlete, I mean, this is typically a surgical indication. But let the effusion cool down. First, I would want to get some imaging, make sure that he doesn't have a loose body. So x-rays, no loose body. His parameters are mostly normal for the most part. This was he caught a helmet to the side of the knee and the patella. Sorry, I left that out because that's important. So he caught a helmet to the side of the knee, and that's how the patella came out. So I would actually let him rehab, meet protocol, try to use a patella stabilizing brace if he needs it. And then I would let him try to play. And this was second game of the year. We were going into a, we had another game, and then we were going into a bye week. And then, you know, so I was looking at maybe third game back or so. No other, and he has not had any other episodes of instability once he was reduced? Never have. Matt, first time patellar dislocation, high level athlete, is there any indication where, so barring loose body, is there any other indication that you'd say, OK, this is something that we're going to need to do a surgery for in this athlete? If his parameters are normal and there's no loose bodies, I would say no. Some people would argue that if you have a tear off the patella where you can put it back, but I would argue if there's no loose bodies, there are no. In my experience, when it's a male football player, they tend to have loose bodies and stuff because I think it takes more trauma than perhaps a petite female who has more liminously lax joints. But I would let him go back to play under these parameters you're describing. And all these things, so sometimes with the management of athletes and things like that, so things like bi-weeks and stuff like that begin to come into play as to telling them and counseling as to when you're expected to return to play. So he was able to get back for that third game just with the bi-weeks. We had three good weeks of recovery. And I think, again, with this being sort of more of a traumatic episode, we got his effusion down. And I think if you're going to treat these, you can't put them into an immobilizer for a week or two and then try to start rehabbing them because you'll never get them back in a good time frame. So if they need to go into an immobilizer right after the game, I do that. But as soon as we see him in the training room, we kind of get him moving, get him into their patellar stabilizing orthosis. This quarterback was our quarterback at Arizona. And this was national news. He's gone on to win a Super Bowl. So he never had a surgery for this. And so no loose, but we did get an acute MRI for him just to rule out loose bodies and stuff like that. I would say in this case, even if he had trochlear dysplasia, elevated TTTG, patella alta, I'd still do exactly what was just mentioned. So even with high risk parameters, you tell them you're at high risk, even if it was a traumatic injury, your morphology is such that you're at high risk, but go play. What if he sheared off, like, is this like the bucket handle meniscus? What if he sheared off like most of his patella and it's a repairable loose body? Do you still put the option on the table of removal and return to play? So I would say that would be a lucky unicorn kind of case, but regardless in this type of athlete, I'm taking out the loose, he's not gonna be able to play with that loose body most likely. So I'm taking out the loose body and I'm telling him, I could stabilize you. Hopefully, you know, with a greater than 98% success rate, hopefully the patella will never come out again, but you're out for the year, or you can come back in two weeks with the loose body removal. And that would, in this particular athlete, that's what I'm doing. I have a strong opinion on that, but Alexis. I'm just curious, is there any situation where anybody would surgically fix a patella dislocation the first time there's no loose body? In an athlete. In an athlete, like what type of athlete? I don't know. That's a good question, because I think most of the high level athletes, we trust their soft tissues and their alignment is fairly normal. So you're right. I think it would be a rare thing if they don't have a big loose body, but I actually just had my first Macy case this Wednesday is on a football player who sheared off half of his patella and thankfully we didn't have to have that conversation because he ground it into a million pieces. So it was loose body removal and biopsy and deal with it later. But I put on the table, do you want to come back to play in the intervening time and do I put you at risk for having this happen again? And even though it wasn't repairable, it sort of felt terrible to do that. But you're right. I think we trust their soft tissues, we trust their mechanics, and so it's less likely that we operate on a first timer, but I mean, it's concerning if their anatomical features are abnormal. I've operated on a first timer who could not stay, could not keep his patella reduced. So he was not meeting return to play. Every time he hit about 30 degrees from zero to 30, he was subluxing, not completely coming out, but subluxing and it was an easy decision. So basically he made the decision or his knee made the decision for him. I've had the same situation when on their merchant view that the involved patella is markedly tilted and subluxed compared to the contralateral view that's solely due to the trauma. I fix those because the same reason that she just mentioned, it's not going to stay put for the most part. But again, that's not very common though. Yeah. I would say I operate on quite a few first time patellar dislocators and maybe I'm aggressive. I do the same thing with shoulder instability, but I'm a big, again, believer in post-traumatic osteoarthritis is real. It happens because joints are unstable. It's not just in the shoulder or knee or hip, it's in any joint. So for the high school athletes and for me, the weekend warrior, like skiers who dislocate with or without high risk factors, I say, this is what will happen if we don't operate, most likely you'll be fine, but it could happen again if it happens again. And I kind of tell them if it happens within the same year, then I typically treat that as recurrent instability and we should stabilize that for sure. If they've dislocated once in their teens and then came back with a new injury 30 years later, I don't consider that recurrent instability. That's just a second unlucky injury. But I think that stabilizing a knee for the first time is totally reasonable. I just lay it out for the patient. I just say, you have surgical risks, infection, bleeding, blah, blah, blah, fracture, all the things, or you have the potential risk of this never happening again. And most people who are super apprehensive and super nervous about their kneecap coming out again, those ones pick to have the surgery and are willing to give me four months of rehab. So I offer it on almost every single one. And again, maybe I'm aggressive, but I do believe that any sort of subtle instability is sheer against cartilage and sheer against cartilage is gonna lead to the development of OA over time. We know that. But I think in this athlete, high school, college, wants to go on to the next level, we gotta let them play. Yeah, and I will say, so my comment on the cartilage thing, so I'm a big proponent of trying to save natural stuff because I have, none of my options that I have is better than what, if it's a piece that has bone on the back of it, so I'm gonna try my best to convince them to let me not only fix the cartilage, but stabilize her knee at the same time. And that's the one kind of no-go for me is, I've had the joy of having patients refer to me after they've had loose bodies thrown in the trash that I know was repairable. And now I'm like, okay, what do we do? Are we doing now Macy for you? Or are we now doing bulk? Or doing a big allograft plug or something? And it's just not a great option. So I will try to, and I think that's an important part of their stability. So I kind of call them, they're kind of like bank card injuries almost, bony bank cards or like a bony heel socks or whatever, where I think that decreases their sort of, their basically is an on-track legion essentially. And so I consider those the same as being part of my stability for those patients. I think we talk a lot about the athlete that doesn't want surgery or that wants the least invasive. That's not always the conversation. Some athletes, especially depending on where they are in their career or where they are in the season, they're like, if this is surgical, let's go. Let's just, let's go, let's get this done. So it's not always about what we can do to get them back on the field as quickly as possible. Sometimes where they could go back on the field and that is the one time where there may be some conflict with coach versus the athlete. Coach is like, hey, we kind of need this person. Athlete's like, hey, I really want this fixed. I think that that has actually been a more difficult conversation than the return, returning someone with a medial meniscus tear to the field. All right. I'd like to hear your guys' thoughts on MPFL repair versus reconstruction in this patient scenario. Any patient's done, don't do it. Yeah, repair, don't do it, ever. Yeah, I did a lot of repairs early in my career. And this young lady came in, and I did a repair on. And I saw her post-op, and she was back to sport. She said, thank you, doctor. I'm doing so well. I'm like, hey, let's see you extend your knee. And she extended her knee, and she had the J sign. And that killed repairs for me forever. And that was probably like eight years ago. And I'm like, I'm done. I will never do it. And she felt fine and never came back for anything else. And I was like, yep, we're done with that. So, Latul, that was the patient I presented yesterday and the one you sent me. The doc that was originally going to treat him was wanting to take out the loose body and do a simple, like a little repair. That's how the docs tell the patients. I'm just going to take this out. And while I'm in there, I've got this tear off the patella. I'm just going to put some stitches in it. You'll be good as new. And that's why repair rates have a pretty high failure rate. So I would argue that until we better understand novel techniques with patella MPFL repair, just like we're understanding better techniques for primary ligament repair, like ACL repair, PCL repair, until we have better understanding of newer techniques, I would just exhibit caution with that. If you're going to go in to remove the loose body, I think that's one thing. If you're going to go in to remove the loose body and you want to stabilize the patella, I think you do a reconstruction because it's reliable. And then finally, I think if you're going to go in with the intent of repairing the cartilage, and if there's a piece of bone, like a bony loose body, that's different than a shear of cartilage. So I agree, I would want to repair the bony loose piece. Then I think you have to do the MPFL at the same time. You can't just repair the cartilage in that case. I think you have to do both because you have to stabilize the knee. And just never say never. Just in response to your question, I have had success doing repairs in the pediatric population with open growth plates where maybe I don't want to do an MPFL reconstruction because of skeletal issues. They had a clean tear right off the patella. I had to take a loose body out or repair it anyway. I've sewn that back down and have had good luck with it, so. Cool, so I wanted to get around this because this is something I'm actively dealing with right now, so. 18-year-old incoming freshman women's basketball player. She tore her ACL three months prior to coming to our university. And she's been getting PRP by her doc at home. She's already had two injections, and he told her that she can play without her ACL, and she's planning to play with an ACL-deficient knee. I am sitting and talking to her in pre-season physical examinations. Her ACL is gone, gone. So she's got a 3B Lachman. She's got a pivot shift. But she feels great. She had been playing some summer ball the last month in a brace. And she is, her doc, who she loves, and back home says she can do this. So what are your responsibilities as the head orthopedic team doc? And this is your patient, Alexis. What is our responsibility? And this is an adult patient, right? So 18 years old. Yeah, so this one, obviously, would have a pretty extensive conversation on how the PRP's probably not regenerating the ACL. But going through with her the, you know, I would say many cons of trying to play without the ACL. So, I mean, to me, I would say this one is almost black and white, like it has to be done. But again, she is an adult, and has to understand the risks and benefits. Wait, Matt. Well, one issue also, if she's an incoming freshman, this is a college kid, right? Yeah. You know, as a team doctor, you have the right to clear or not clear. And so I would not clear this girl to play basketball because I'm ultimately responsible for her as a team doctor. Obviously, that'll generate a phone call with the coach, with the parents, and all that sort of thing. And I think that's when you have your best chance to sort of rule out your, lay out your case and to repair it, like Alexis said. But again, if this is either a pro team or a collegiate team, you have the right not to clear them to play. This case is bringing up, for me, like a PTSD moment. So I have on my Rapids team, we have a guy who's doing great, so I'm gonna preface it with that, doing great. But he had an injury a couple of seasons ago to his knee, and his knee had an ACL reconstruction done in a different country a couple of years prior. And so we examined the knee. The knee doesn't feel quite right. It's not grossly loose. It's not pivoting, but it doesn't feel as tight as the other knee. Get an MRI. Shows that the graft has some signal in it. It's completely vertical, but it's not torn. There's no pivot shift, but it's not a, like nothing we'd be proud of. And when you look at his tunnels, fortunately, from a revision perspective, are in such a location that you could easily avoid them in a second surgery should you have to get to that point. And so I had to have a discussion with the coach. Like, what do we do at this point? Because this is a knee that's at risk, right? This knee is going to go at some point, but it's not gone yet. And we're in a playoff run. So what do you tell? Like, what do you tell the athlete? What do you tell the coach? So we had the discussion. I tell the coach and GM, this is a knee at risk. I would not be surprised if in the next year it blows. We could choose to shut them down now and revise it, but technically he does have an ACL. The ACL is intact and he feels he can play. And he's been playing with this vertical ACL for a long time. And so we elected to let him play. And then he blew it later on and we had to revise him and he lost a year. And he's doing great now, but that's one where you wonder, should I have just not cleared him at that point and redone it right then and there? It's hard to take someone who's functioning well and just had a tweak and subject them to a revision ACL. With this patient, so they've only torn their ACL three months prior. So that's not basketball season. So were they actively playing basketball prior to, like, were they full, they had cleared, they were doing? They were fully playing in the summer league. Yeah, so summer league basketball. It had tested the knee out and they felt fine. And she's meeting me for the first time. And so I'm the guy with the hot knife when I'm now telling her that she needs to have surgery and we don't treat these non-operatively. So, you know, we don't always make the right decisions with team docs, but again, I said adult patient, she understands, she seemed to understand the risk. She was dead set on getting the third MRI to see what the ACL was doing with all the PRP treatment, which looked worse than the, with the prior two MRIs they had done on this knee. So she actually made it back into all three preseason camp with basketball. And then second game of the year or second scrimmage of the year, she actually tore her other ACL. So now she's, so she just saw me last week, but she had already had a PRP. So she went back home, got an MRI. She came back and her knee looked more swollen than it was when, before she left. And I said, so what went down? And she said, well, I saw the other docs. I had a PRP injection. I said, oh. So yeah, so they've charged a lot of money for this. And this is something where it's almost, I feel like reportable to the board in some respects. But now she's now on board to get her ACLs taken care of. And so again, I still wonder, what's the sort of right choice in this? Cause we all have those athletes. So my first three years in practice in Tucson, I took care of a Juco. And our starting quarterback when I got there was, had no ACL, but he had been playing for two years without an ACL. We have a running back right now who had an ACL tear. When he got to us in college, I revised him. He retore it. And at that point he just said, look doc, I think I want to play without it. He's played three years with no ACL, broke rushing records, has the all-time leading scorer at the college now. And so we asked some athletes who are our compensators, whether you're Heinz Ward or whatever. So those are the things that we kind of balance. And so- So are you going to do both ACLs at once now? How do you do that? No, I told her that we will get her the most acutely torn ACL done in two weeks when she kind of gets her motion and everything back, if the inflammatory reaction from the PRP calms down. And then I told her at three months we could potentially do her other side and that would give her enough of a runway to get back for basketball in the fall. What's your graft or choice for this? BTB. I'm a BTB guy, so. I've had five patients I've done bilaterals on at one time and they've all have had no problems in terms of their PT, their everything. To my knowledge, they may have failed and never gone elsewhere, but yeah, it's kind of a daunting proposition, but when you think about it, it's like kind of like doing bilateral knees or hips. You know, you got one hospitalization, one rehab and save some time. Bilateral BTBs? In these particular kids, two were hamstrings. This was, and then BTBs otherwise. And how was their mobility? You sent them home same day? What's that? Home same day, no blocks? Yeah, no blocks because obviously you need to be able to, that's the other thing, if you're doing a revision, block the graft harvest site, not the one that's been reconstruction, and brace them because I've seen two people that have had their donor site not braced, but were blocked. They collapsed in the parking lot of the hospital. When they walked in the door, both tore their patellar tendons. I end up racing both legs, and they walk like a pirate with two peg legs. But that's how I do it, because I'm petrified of what was just mentioned. Yeah. So wait. So you have done bilateral BTBs before? Me, yes. Yes. OK. Yeah. Three out of five. This is how you get in trouble coming to these courses, because I'll send her straight to WashU if it doesn't turn out well. Well, no, we're just, you hear other people's perspectives, you know, that sort of thing. So. So now you got me thinking, because it never crossed my mind. I said, we're going to stage these, and. We're going to do it. One guy, you know, two of them were occupational. It wasn't because I'm trying to get back to the team. They had to get back to a manual. One guy was a truck mechanic, and he was pumping up the tires of some big semi, and the tire exploded. Yeah. And it just, you know, it was a trauma that took out both knees. Just make sure you put PRP in. Yeah. That's right. Can you ask her not to get an engine? Now you got me thinking. OK. So I think we are at our, a little bit over time. And thank you so much for our expert panel here. This was fantastic. And I think we're going to head back into the lab. So this afternoon are kind of, if we have things to finish up, I think there's some things that we probably can't do. Like, I think they probably packed up some of the arthroscopic things. But certainly, if we still want to do some, like, things like LET, stuff like that, we still have some ability to do those things. But largely dedicated to our chondral stuff, auto-allo and bulk allograft stuff, and then TTO for the afternoon. So, and again, obviously, if anyone wants to do just, like, any just straight up, like, just cadaver dissections to look at, you know, posterior lateral coronary anatomy, for instance, feel free to do those things also. Any questions about what we're doing this afternoon, lab-wise? Cool. And since we are kind of, this will probably be the last time that we're here together. I know some people are going to be having to head out as we get to get kind of close to the end. I just want to thank everyone for coming.

sports injuries

medial meniscus tear

treatment options

patellar dislocation

surgery necessity

ACL tear

risks and benefits

individualized treatment plans