All right, so my job is to show a surgical procedure, which we're going to do. I'm going to ask the panel a couple of questions before we start. I don't have any disclosures, I actually have more panel than I thought I had. So this is what we're talking about. Big hole, need to do something about it. You could just debrief this. Here I grafted it, turned out pretty well. Same thing here, big hole, lateral lesion, you could argue debriefing this lesion as well. I grafted it, single plug in this setting, turned out pretty well. But to the panel, we have a number of options for where to get the graft. We can do autograft, and you can get it from costochondral. You can use the femoral condyle, lateral, medial. You can also do allograft. You can get a lot of different sources for that. When you talk about using the femoral condyle, you can argue medial trochlea, lateral trochlea. Some papers also suggest that the cartilage is thicker throughout the knee. So with that, let's start here. Walk down the road. Where do you get your graft, and why? I like the medial trochlea mostly because it sees less compression from the patella, but also because of the Veserita study, but I think it just, you create less donor site problems there. Medial trochlea ridge. Same. You can go medial or lateral, I think. So if you look at the published literature, the great majority of the papers that are published are using lateral trochlea. I think it's actually interesting that most of my panel is actually medial trochlea. I'm medial trochlea. Do any of you use allograft? Buddy, where do you get it? What do you use? So I actually will occasionally use a distal humeral allograft and try a capitellum, fresh. And is that hard to get? Yes. Yeah. So that's an important point. It's really hard to get a distal humerus because they have to prepare the deceased differently for a presentation in a coffin, and so you have to actually talk to the family and get a release in order to be able to get that. But you can get it if you need it, but it's really tough. You use it when the lateral margin of the capitellum is involved, along with the origin of the radial and the humeral ligament, you need cartilage that comes around the corner. So that's the indication for me for that. Are there any other options for that panel? Costochondral. Costochondral. You're talking about a lateral? Yeah. The lateral wall is gone. Yeah. I think for a big one, I think Buddy's right. I think your allograft's probably going to be good. Can you stack multiple plugs? You can. So then, pre-cut plugs, you don't know where they come from. It's important to know that the majority of the harvocyte morbidities come from the lateral trochlea. So then, what are the indications? I'll put up what the evidence said, but do you guys have any disagreement with this? I generally like them to have failed, unless they have an uncontained defect like that. If they're a contained defect, I want them to fail a debridement before I do a... So you would do a debridement first, and then, as long as it has a lateral wall, you'll debride them first, and then bring them back and do notes. Yeah. Yeah. I do it very similar. As long as the lateral buttress is intact, I generally have them fail a debridement. Is that true for both gymnast and pitcher? Yeah. Because a gymnast has this distal lesion, often very lateral, and they have to have a solid subchondral plate upon which to bear weight. And if you look at the literature, what little there is on a gymnast, very low return without reconstruction methods. I don't see a lot of gymnasts, because you suck them all up in... Buddy? So for me, if I have any possibility of repairing it, then I'll do a modification of Mike Hausman's technique. I'll take a vented anchor, hydroxyapatite, take out the regular stitches and sub in PDS. I'll gap the lesion open, clean up the bed, like Jeff and Larry were talking about with the debridement. Put that anchor in, because it has a cannulated spot. And then use the PDS to sew the lesion back, even if there's minimal bone, if it's extensive. So I would rather do that first. Now if it's completely free, and the loose body is floating around, then usually it'll either be a microfracture or a graft. You can always use a little bit of the tip of the olecranon for a graft if you have to if you're in the middle of it. It suddenly changes, or I shatter the piece when I'm trying to repair it. I think I'm going to run out of time on my talk if I don't go through the study. So here's the case I'm presenting. So this is a large OCD in a 12 plus 1 year old, large lateral, unstable by all criteria, fragmented, displaced in situ, asymmetric fill material, I'll show that, and greater than 30 degree contracture. It's running, there we go. You can see these are flex fused, 0, 20, 40. I think you guys should all be aware that the more you flex the elbow, the better you can see these OCDs when they're anterior. It's deep, it's only 7 millimeters, 9 millimeters is a critical number. You guys have any comments as we go? Would you debride this? How many of you guys would debride this? If it's contained, I would, it's 12 millimeters. Would you debride this? Raise your hand. If it's contained, I would. No. I was waffling until now. Now I would say no. One that big, I think. What I said was I was waffling until he showed the last picture and the answer was no. So this is a picture of the femoral condyle, open physis, but you have 17 millimeters of space to get your graft. So we're going to start off with arthroscopy and clean up the synovectomy, the synovitis, because this kid's got a 30 degree joint contracture. You know there's going to be some debris and stuff in the anterior compartment. Do you have to take out the anterior capsule to get them straight? Or can you just do the synovectomy and they'll get straight? I think you have to take out the plica in the back for sure. Yeah. So there's the plica gone. So you have to take that out, because that'll get the extension back. You may get minus five, but you don't have to release the capsule. You have to take out the plica. This is a volleyball player, not a gymnast, but as a gymnast, I'd have to get her hyperextended. You can see this, a 30 degree scope, switch to the 70. You guys use a 70 to give you a better view? Yes. 70 degree scope. This goes up and down. In a rock classification, this would be a trampoline, but it's really a trapdoor, and you'll see this in just a second. My probe easily falls underneath. The whole thing just strips along the side. The whole thing lifts up. So this is a completely unstable lesion without any bone underneath it. There's no bone on the backside of this. Would any of you think about fixing this piece? You would repair it, even if there's no bone on the backside? I would really think about it. I almost always find a little sliver of bone, and so it depends on what you have. If you have a big defect, you have autologous tissue there, and so I would try to gap it open and see if I could hinge it, leaving it attached laterally and slip inside of it. If I can, then I would think about fixing it. If I can't then, but I don't do any of the absorbable pins, screws, any of that kind of stuff, but I think if you use a suture technique, Mike Houseman has shown us that, that you can get that fixed, and it would heal 80%. So you think suture's better than fine wire, pull-out wires, 26-gauge wires? I like sutures better. I use PDS, and I protect it until I think that that's gone, which is usually around 10 weeks. Do you see opposite side, radial head, chondromalacia when you use sutures? I have not, but I protect it. I figure out where they're going to hit on those knots and stop it shortly. So here you can see that this is all cartilage. My knife just slides right through it. The piece comes up. It's a pretty big piece, and it goes all the way to the outside margin. I knew that from my MRI, that I had no real lateral wall posteriorly. So that posterior lateral margin, there's no lateral wall. So I knew that if I was going to fill this thing, when I drilled it out, it was going to kind of... It sure looked like bone there. That's not bone. I mean, you guys, how many of you saw bone on that PCS? Bone on the back of it. Look, everybody thinks, John, you're wrong. You're just lying to me again. I'm never wrong. Hey, John. John, two minutes. I talk too much. That's true. Two minutes. We got Neil waiting. You got two minutes. Yep. Sorry. Or not too much further. So... I'd graft that for sure. So you'd graft that. I'm going to actually move this forward just a little bit. So here we are sizing it. So I go to the knee and I get my medial trochlea graft. And I just simply harvest the graft off the medial trochlea. And you can see the hole that it leaves. This is a little bitty kid, 10 millimeter hole. I could have taken a couple of smaller plugs. And then I go and get cancellous graft off the tibia. And I sew the plug back in. So here I'm just showing that you can't always get to these through the ankineus. Do you guys do a trans-ankineus approach to this to be perpendicular sometimes? I think that's really helped me a lot to be able to get this thing in square where I need to have it. So we drill this out. And you'll see as this drills out, that back wall is kind of beat up. That's because it really is on that back wall. So again, we're going to put this graft in. And I don't push it down in, we twist it down in. This looks like I'm hitting it, but I'm really just kind of very gently tapping this. I know, it looks like I'm hitting it. I'm not. The middle of this is at the height it's supposed to be in. But the sides are actually too proud. So I didn't describe this, John Radischka described this, but you taper this, you contour the margins. So you end up actually with a convex contour. So here's the graft. You can see the contour of it now fills that whole hole. So moving forward, here's what it looked like before, and here it is now. So any comments, guys? Nicely done. I think that was very well done. It's pretty. Any comments about technically things you do different? No, it's interesting. I don't know when, maybe I learned the trans-Zen can use approach from you, maybe. Because we've talked about it before, but I've done it a lot. And I think it makes a big difference, because trying to retract it back and then lever it always pushes you the wrong way. So I think that's one of the key technical points is to get it that way so you have a straight shot in. It makes a big difference. John, when do you go to multiple plugs? So if it's, I sometimes see these are huge, I mean, I sometimes see the whole lot of sides gone. Last comment, because we've got to get to Neil. So I'll use a six and an eight, or two eights when it's really big. Great, thank you. All right, if you could tee up Dr. Elitrash, that would be great. Neil, we can see you. I know you can't see us. Can you just speak so we can see if we can hear you? I can't hear him. Neil, we don't have any audio, or perhaps you're not speaking. Is he talking to me? Yeah, Neil, I'm talking to you. It's George Paletta. We just want to make sure we can hear you here in the audience. We can see the specimen. Hey, George. George, I can, I'm sorry, George, I can't hear you. We can hear you. You're good to go. So George, I'm sorry, did you say we're good to go? You're good to go, yes. Good to go. All right, thanks. Hello, everybody. Thanks, George. We have a right elbow with a proximal UCL tear. We've got some great assistants here, Justine Ray, originally from Pittsburgh, now in Naples, great physician's assistant, and Ian Patton, one of my fellows from Colonel and Job, who's going to Augusta, Maine. So we've already made the incision. Prior to making the incision, what I would recommend is figure out where the ulnar nerve is, if it's in its groove or if it's subluxed prior to making your incision, because sometimes just with positioning of the elbow, if you've got a really unstable ulnar nerve, that nerve is going to be sitting on the crest of the epicondyle. You want to know that before you even make your incision. In this case, the ulnar nerve was sitting posterior to the epicondyle and posterior to the intermuscular septum. So upon making the incision centered over the epicondyle, the next thing to do is to do a subcutaneous dissection to find those significant branches of the medial antebrachial subcutaneous nerve. Those will be crossing, usually crossing just distal to the epicondyle. If you don't find any distal to the epicondyle, do a good dissection right over the epicondyle and the septum, because if there's not any major branches just distal, you'll find a web of those nerves coming across the epicondyle, and also more distally, as you see here. So when you find any of the significant branches or veins, then you just put a vessel loop around those, mobilize them well so that you'll be able to preserve them and get them out of the way. So, the next thing, we'll put a, next thing is what I do is I find the intermuscular septum attachment to the superior aspect of the epicondyle, and I can feel the nerve just behind that. So with my palpating finger, I'll hold that nerve down so I know exactly where it is, and then usually I would, in a live patient, I would take a bovie and incise the attachment for the intermuscular septum at the superior aspect of the epicondyle. With your finger protecting the nerve, the nerve is insulated and you won't have any conduction down to the fingers. Of course, we don't have a bovie for this, so can I have the little scissors? So we've separated that. And then with an elevator, just strip down the septum attachment on the epicondyle. And expose the inter-superior aspect of the epicondyle, like so. Now, dressing the ligament itself, you'll see the two heads of the flexor carpi ulnaris, the posterior portion going across the joint back to the olecranon, and the other coming up to the epicondyle. And so if you look at the version of the epicondyle, this is important, because this will take you right to the ligament. The version of the epicondyle is at an angle compared to the long axis of the humerus. So it's about a 12 degree difference between the long axis of the humerus and the epicondyle. The ligament lies not at the base of the epicondyle, but around the corner. So you go around the corner anteriorly, and there's going to be a very obvious raffae of the flexor that's going to be right overlying that. So, base of the epicondyle, go around the corner, you'll see the raffae, and that's where we split. So with the dissection, once you've made the incision in the myofascia, then with your scalpel, you take that down just through the muscular layer. And then at that point, you can use your messenbaum scissors and then just spread the muscle, and you'll see the muscle spread, spread, spread. And this is truly an internervous plane, even though it's the same nerve. The branches here, you will not cut across any major branches within a few centimeters of the epicondyle, but sometimes you'll see the occasional smaller muscular branch. You'll be able to identify them as you spread with your scissors. Then with a palpating finger, go down and feel the sublime tubercle. As soon as you feel the sublime tubercle, you can take your elevator and then elevate the deep muscular bed off of the underlying ligament. Now, we've created a proximal tear in this particular ligament, and I have suture already spanning my surgical split. So this is the... I'm going to take a send from me. Here, Ian, why don't you hold that back here, hold this right here. So I have the suture spanning the surgical split. This ordinarily wouldn't obviously be there. So at the point where you've identified the sublime tubercle, your next job is to find the ulnar nerve. You have to find the ulnar nerve because you cannot drill properly in the sublime tubercle unless if you do. The ulnar nerve is going to sit on the posterior border of the anterior bundle of the ligament. So your torn ligament you're reconstructing, you go just to the posterior border, and if you take a nice sharp elevator like we have here, hold that for me, Ian, you'll see some fibers that are going transverse across your plane, and as you tease those free from the ligament, all of a sudden you'll find the perineural fat, and that is your ulnar nerve sitting there. Now, the ulnar nerve will drape itself across the posterior slope of the sublime tubercle. There's going to be a leash of vessels just on the posterior distal end of the sublime tubercle. So as you're exposing the nerve, have a bipolar cautery ready because you're going to usually need to cauterize those vessels without hurting the nerve. The next structure you find is the medial ulnar ridge. The medial ulnar ridge is a very consistent landmark. Kind of an Army-Navy. Very consistent landmark, distal. Here you go. Distal to the sublime tubercle. Now, the sublime tubercle in these athletes can be deformed. They can have large osteophytes extending proximally. They can have previously been broken. They're going to have a lot of different shapes. The only way that you can know that you're in the center of the ligament attachment on the sublime tubercle is to find the medial ulnar ridge. So if you take a line, extrapolate a line from the medial ulnar ridge. Can you guys see that, George? Yes, yes, we can see it. I don't think I can hear George. George, can you see that ridge? Yes, we can see the ridge. Okay, if you extrapolate a line from the ridge onto the sublime tubercle, that should take you to the center of the ligament attachment. So at that point, what I would ordinarily do is mark it with a marking pen. So mark it with a marking pen right there. Then I'd take the scalpel and divide then the ligament right in the midline going from the medial ulnar ridge towards the epicondylar attachment. And so we've already done that here. The ligament was normal distally, and it was torn proximally. But now with the ligament split in this midline, you can see the joint. As soon as I can see the joint, I know now where I can put my drill holes in the sublime tubercle. So after I see the joint, I take the guide. Now at this point, you do put your protecting retractor on the ulnar nerve. That's the only time I really retract directly on the ulnar nerve. Otherwise, I'm doing indirect retraction of the ulnar nerve by pulling the muscle back, and that pulls the nerve indirectly back. But now I've got to really protect the nerve. So I take a retractor, and I make sure whoever's holding that retractor knows you've got the nerve. So you don't want to inappropriately pull too hard on that. This is the guide that we've designed for this. Now if you look at the stem of the guide, that gives you good alignment with that medial ulnar ridge. So if you put that stem in line with the ridge, and then what I've done is I've marked a mark on the anterior portion of the sublime tubercle about 5 mm distal to the joint, so I know I'm not going to drill into the joint. Then I position my guide with the stem even with the medial ulnar ridge, and I use a 3.5 mm drill for this. So I'm the one that I want to be protecting the nerve, and I'm holding the guide. Then I have my assistant drill the posterior one first because I know I've got the nerve protected. I'm not going to get distracted and then have to come back and do it. So I do that one first. As soon as that's drilled, don't toggle me, there you go. Okay. That's going to give you a nice bridge that's at least a centimeter apart, and you will not have gone into the joint because you planned it distal enough. As soon as I've done that, then I take my curettes, a series of curettes, make sure that the holes communicate nicely. Now, this is a nice tip. There's a broad tendon that comes up from the flexor mass across the anterior slope of the sublime tubercle, and it is intimately opposed to the ligament itself, and it comes up and it detaches just anterior and just more superficial on the upper condyle to the ligament. You can see that hopefully here. You see this. It comes up across the top. Now, I've already mobilized it a little bit, so it's already a little bit mobilized off of the ligament, but this is that broad tendon. I'm sorry, maybe you can't see it. This is the broad tendon right here. So when I've drilled that anterior drill tunnel and I use the curette, then what I do is I take my scalpel, I lift up on it, and I elevate that tendon bed. I don't want to transect it. I just want to elevate it because I'm going to use that later, and also this is probably a dynamic tensioner of the ligament itself, so I want that tendon to go back where it came from at the end. So I've elevated that off sharply. Now, take these nicely sized needles. This is a blunt needle with a nylon wire on the end. Pass that through my drill tunnels. Now I want to pull the free ends through. Where's the free end? Got it. Okay. I save that. Snap. So now we have our surgical split in the ligament extending up to the epicondyle once again. The attachment for the ligament is not at the base of the epicondyle here. It is around the corner, and we've dissected it well enough that we can see now where the native ligament should be attaching. Hold that there. I'll take a pair of pickups. Here we go. Ligament. Ligament, right? So now we've removed the septum attachment to the epicondyle. We take our drill guide, and what I do in a real case, I'll swing my chair. I'm down here near the hand looking straight upwards, and I line it up like you would line up a pool stick. So here's my epicondyle. I know the dimensions of the epicondyle, and I know where the septum was. I take my guide, and I put the guide directly right where I can see where the ligament normal attachment would be. I've lined that up. Okay. Now, I've already dissected free the septum, so I take the other ring guide, the ring guide, place that into that 4.5 millimeter drill tunnel we've just made. Once again, with my protecting finger here, I'll protect all this soft tissue so I don't wrap up the soft tissue around the nerve in my finger. Go ahead and tighten that down. And I like to do this drill tunnel myself, not having the assistant do it. And send. Swing the ring guide across. I put a little marker into the drill socket I just made so that I have a good idea of how far away I want to be. I don't want this bridge to be too small. Okay. Good. And then before I turn the drill on, we can see where that goes down. I see my bridge. I hope you guys can all see that. I confirmed I have enough space, okay? And just drill that. Okay. Then I mark that with a spinal needle so that I can find it. All right, so now there's some nice curettes that we have that we can join the holes. Go right to the big one. And then there's the next smaller one. And I want to do this until I can feel the two curettes touch. We're making a chamber within the epicondyle big enough to hold three strands of the graft. And I'll be able to feel my curettes touch, and I can also feel that I'm hitting the needle. So I know everything's communicating. Then we just take – how are we doing on time? Hey, Neil, this is Luke. Apologize, regrettably, we've run out of time. The next session's about to start. Suture. Suture loop, vicral loop. Neil, I guess he can't hear me. Okay. Thank you very much. Thanks, Neil. Thanks, everybody.

surgical procedure

ligament tear

elbow

graft sources

autografts

allografts

ulnar nerve