Thank you to all our speakers. We have time for a few questions, and again, showing that we don't know much about the patellofemoral joint. I'll start with you, Dan. Once again, you know that there's more that goes into that measurement of TTTG than meets the eye. How are you using your findings clinically, and are you less apt to maybe move the tibial tubercle, or how do you make the decision to move a tibial tubercle as you're doing the surgery? Well, it just, it's really kind of more of an awareness of it, and that I really do believe that in these extreme cases of a fixed lateral patellofemoral dislocation or obligatory dislocation, there's definitely a spinning of the proximal tibia, and that's, and it's just getting frustrating because we're doing a static measurement of TTTG. I wish we could have a range of the TTTG. You know, what is it with a little external twist or an internal twist? So it's gotten me clinically in those cases to look, to start using Gerd Settlinger's PCL reference point, because it takes away the rotation. Well, we'll look forward to having your institution teach us more about that as time goes on. Excellent. Noah, nice comparative cohort. Did you look at femoral position and how it was different between immature or mature, and did you look for other risk factors that might have influenced your outcomes? And then, just have to ask, can you explain the rationale for mersaline tape, because this is something that's relatively new that we're hearing about, and I'm wondering how and why they're using it. The mersaline tape, Dr. Yoki has primarily been using for patients that he feels there's an increased risk of laxity, and so it's based on a lot of clinical exam, patella alta, and a lot of other findings, and then the question is whether or not the mersaline tape is just helping while the graft heals, and so the graft is whip-stitched into the allograft. The question is whether it just is serving a function while the graft heals, or it continues to explode throughout the course of the life of the graft. Is it set at the same resting length? Sorry? It's set at the same resting length as the immediate cut from the- Yes, exactly. They're tied together at the same time. Yeah, exactly. And then the other question about the femoral position of immature versus mature. In terms of the positioning of the- Did you evaluate it post-operatively? Was there a difference in immatures? No. We did not evaluate it post-operatively. That would be a good thing to look at and see if it's different post-operatively. No, we didn't evaluate it, but the thought is if it's distal to the physis, it wouldn't necessarily be changing as the physis grows because the femur will continue to grow, but it will stay on the same position on the distal aspect of the femur. Okay, I just wanted to remind the audience that the app is open. Mio, once again, great studies from using this model. I'm not quite sure how to interpret that. I'm not quite sure how would you interpret that clinically? I mean, do you think it's the abnormality of the bone? I mean, it has to in some way, but how are you interpreting your findings, and how are you going to help translate that to the clinician? Yeah, thanks. So I think a couple things. One, I'm hoping that maybe this sheds some light on the understanding of why NPFL reconstruction in the setting of multiple risk factors fails. So perhaps it's due to increased graft strain due to these length changes. The second thing, you know, the limitation of this is that, you know, I really was trying to look at the anatomy and the normal function of this, and this is based on the points we use for reconstruction. So we don't actually know that the anatomic points on these patients are the points that we used for measurement. But I'm hoping that, you know, this will also kind of lead into the discussion of it's not just looking at one specific risk factor and fixing it, but possibly the combination of those leading to increased risk as well. Now certainly most of our risk factors are anatomic, and those are the only ones you looked at, because obviously we have age and open physis also as risk factors. So these are, you're just talking about the anatomic risk factors as we interpret through imaging. Yeah. So they were intact knees, so it was the opposite contralateral, you know, asymptomatic knee. So they happen to have morphological risk factors because they tend to be bilateral, but they've never had a dislocation, didn't have any symptoms. And so we were trying to do, you know, kind of an in vivo study based on the cadaver studies that we've seen for the risk factors. Great idea. Thank you. Hayden, nice study. I'm interested in how you interpret this and how it might change our kind of clinical approach and clinical practice. So I guess one question, are you recommending MRIs for all first-time acute dislocations? Are there other imaging modalities, and do you think your data helps us to be maybe more aggressive or more conservative as we approach these problems? So I think our study would suggest that getting an MRI in all patients with acute first-time dislocations, again, would not capture all of these chondral injuries. So it's a difficult question. I mean, are you potentially wasting resources by ordering MRIs on all these patients? I don't think so, especially if they have a large, you know, loose body or defect that is identified. And I think it should just be considered on a case-by-case basis. There's some literature to support that sodium-based MRIs may help in identifying chondral injuries. I briefly reviewed it when I was writing the manuscript, but I think some further studies would be indicated on that. And what was the third part? If you have these loose bodies that are not showing up on x-ray MRI, is that an indication for surgery? If you had more sensitive imaging, I guess would be a way to ask it. So if there's no loose bodies yet, then there's no true indication, right, for surgery then. So does it make you more aggressive? I think it should make you more aggressive in that you should perform, if you're taking a patient to the operating room to do an MPFL reconstruction, you should do a, or our study would suggest that you should do arthroscopy at least. And I think most of us would do MRIs for acute dislocators, for wrist stratification, even without loose bodies. So I think that's becoming a relative standard of care. I'll turn it over to Liza. Thank you for our presenters. And we will now move to the last lecture of the session. Good job.

patellofemoral joint issues

surgeries

measuring TTTG

femoral positioning

risk factors