Thanks very much, Liza. This has been a great session. I want to thank the program committee for offering us this opportunity and this beautiful forum here. We've learned a lot about the patellofemoral joint in the last hour and a half or so, and I think it's fitting that we're finishing up on return to play. So here's an example of a 17-year-old. He sustained his third patella dislocation playing soccer, and on examination, he's got normal tracking. There are no chondrolesions on his MRI. He's got a normal TTTG distance and normal patellar height. So the recommendation for him is to fix his MPFL reconstruction. But he and his parents need to know what to expect after surgery, and we saw Jackie describe this study earlier, this study out of HSS that talks about really excellent results at two years following MPFL reconstruction, 90% returning to sports. Well how do they get there? Here's an example of an isolated MPFL rehab protocol that was created in a combination of surgeons and physical therapists and athletic trainers. It's extrapolated from the ACL rehab literature, and it provides a generalized approach using phase-specific guidelines. So here's an overview of that protocol, and we're looking at phases, giving guidelines, helping the therapists and the patients, general timelines, and criteria for progression. So in that first stage, of course, the first phase, we're really concerned about getting the quads to work, progressing very quickly to weight-bearing, bracing initially and extension until the quads are strong. And then in the second phase, trying to get the patients off of the crutches and out of the brace, generally within several to up to six weeks, and normalizing gait. Our physical therapists are using modalities like e-STEM to help maximize quad recovery and manual manipulation to improve our knee range of motion. In the third phase here, really important to emphasize proximal neuromuscular control as well as distal, thinking beyond just the knee, and we want to clear those patients to progress into their sports-specific progression. So it's really important to improve the neuromuscular control so we can avoid creating this dynamic valgus force which, when it's coupled with the femoral internal rotation, can theoretically put excessive loads on our graft. And then finally, progressing with the sports-specific activities and trying to use some objective criteria, maybe functional criteria, maybe strength-related criteria. So how do we do in terms of protocols? And this systematic review looked at 53 published rehab protocols for isolated NPFL reconstruction. And they found that, in general, we do a very good job in providing weight-bearing restrictions, range of motion restrictions, and providing timeline criteria for return to play, but not so good in terms of objective, patient-centric, or subjective criteria. Okay, switching gears, how do patients do after isolated NPFL reconstruction? Well in this systematic review of 27 studies, 1,200 patients, they found that return to play was about 85%, which is quite good, but only 68% returned to the same level of play. It was approximately seven months, and there was about a 5% incidence of recurrent instability. But not all patients can be treated successfully with isolated NPFL reconstruction. And so in this review of 26 patients who failed NPFL reconstruction, the authors demonstrated a strong association between these anatomic risk factors. These are the patients you're going to consider a concomitant osteotomy on. So second case, this patient has previously undergone NPFL reconstruction and developed recurrent instability. There's some dysplasia present, there's borderline elevated patellar height, and then a lateralized tuberosity with a TTTG distance of 23. So in this patient, a concomitant tuberosity intermedialization and NPFL reconstruction revision was performed. So what about the rehab protocol for concomitant osteotomies? Well that protocol obviously parallels the NPFL protocol with an emphasis on pain control and wound healing, but remember there's a substantially increased risk of fracture. So we're going to have to be more careful with the weight-bearing progression. So here's an example of a typical protocol, starting with non-weight-bearing, locking the brace in extension, early range of motion, moving quickly, progressively increasing the amount of weight-bearing until you reach a point where you feel like the shingle is beginning to heal and the risk of fracture is decreased. I'd encourage you to consider radiographs somewhere around 6 to 12 weeks postoperatively, and particularly before starting a running program or cutting and pivoting and jumping. We're looking for objective criteria that varies based on the protocol, and of course we're going to want to have our therapists or athletic trainers help a progression through sports-specific activities. So how do they do after combined tuberosity osteotomy and NPFL reconstruction? In this systematic review, 10% of the patients underwent concomitant osteotomy, similar return to sports rates, including 92% and only 71% at the same level. The authors found a non-statistically significant difference in return to rate between the osteotomy and non-osteotomy patients. In contrast, in this retrospective study of 100 patients, 71 underwent isolated NPFL reconstruction and 29 with the concomitant osteotomy, there was no difference in return to sports, but there was a statistically significant difference in return to sports at the same level, and it took significantly longer to do that. Here's another case. This patient has very substantial ALTA, CDI is 1.48, and in this case a distalizing osteotomy was chosen to address the ALTA. We have to be concerned, particularly in the distalizing osteotomy group, especially when it's a step-cut type osteotomy, to watch carefully for healing. And if you look at the complication rate following a distalizing versus a non-distalizing osteotomy, we know that the complication rate is significantly higher with a distalizing osteotomy. Last case here, we've seen a bunch of these jumping J signs, and in this case this patient has this large trochlear spur. He may choose to do a trochleoplasty on this patient. What do we know about return to sport after trochleoplasty? Well, Dr. Deduck showed this series already, and he allowed return to sport at about five to six months, and about 85% of these complicated frequently revision cases, the patients returned to sport. So to sort of summarize, athletes undergoing patellar stabilizing surgery have a high likelihood of returning to sports, about 90%, and about 70% at the same level, somewhere in the six to nine month range with a low risk of recurrent instability. And when the pathology requires concomitant osteotomy, there's a higher risk of postoperative complications. It takes a bit longer to get back to sports, and a lower number return at the previous sports injury. And finally, we need to communicate carefully, I think, with our therapists and our athletic trainers, especially when there's a concomitant osteotomy, especially when you're concerned about shingle healing. Our protocols need to address brace use, range of motion, weight-bearing progression, and provide expectations, not only for the patients, but also for the therapists and the family and the coaches. And then providing timelines helps establish realistic expectations for everybody. Remember this is just a template. It should be modified based on the specific sport and the specific needs of each of our patients. Thank you very much. So that ends our session for this morning. Thank you for your attention, and this was a great session, everyone. Thank you.

patellofemoral joint

MPFL reconstruction

rehab protocol

NPFL reconstruction

communication with therapists