All right, what better way to close off a knee session than with a bunch of disasteromas? So I'm grateful to be the one that was charged with doing these. So thank you for everybody to allow me to do that. So up here we got Armando Vidal from the Steadman Clinic, Tammy Schiappella from Wisconsin, JD from Duke, and Bruce from Mayo. And we'll get into our cases. So this is a 18 year old female, Division I tennis player, and I always like to say trauma is no accident, but this is probably one of the few cases where trauma was a complete accident. She got her right leg caught in a ladder rung while she was on vacation with her parents. It was unclear if she dislocated her knee. She was referred to us for definitive care. No neurovascular issues, and she has significant knee instability. Now like Cassie, I'm a minimalist on this. Swelling and ecchymosis was noted immediately about the tibia and the calf. Bruce, why do I say it's important in terms of swelling and ecchymosis immediately about the tibia? Well, you want to know if there's an irreducible knee dislocation situation? Yeah, so irreducible knee dislocation, thankfully for her, this didn't happen. Also, when I see that, I get very concerned that there might be a distally based avulsion off the tibia. Her straight leg raise is intact. She's got significant valgus instability at 0 and 30. So Armando, why do we care about this? That gets my attention. You know, I think that we like to talk about, when we talk about the medial side, we always talk about the MCL, but I think we need to be more nuanced about our discussions of the medial side. So to me, this is probably a pretty significant medial side complex injury. And significant sagittal instability. So here we can see some x-rays. I won't go over this for too long, but they look pretty good, pretty normal. Now we'll get into our MRI. She's got a distally based injury and approximately based injury on her ACL. She got a complete PCL tear off the femur. Here's a lovely picture. You hate to see it. This is a MCL that is torn off distally and flipped into the joint underneath the meniscus, which is extruded. So now you have to be concerned that there's a meniscus root injury. And of course, surprise, surprise, there's our meniscus root avulsion off the posterior tibia. So it's a pretty bad injury for a D1 athlete. How are we going to counsel this patient, JD? Yeah, I think first of all, a D1 athlete with this injury, this requires some significant counseling just in regards to expectations. And then you got to talk about, you know, the timing and what you're going to be considering for order of fixation and approach. I certainly have some things here that I think you'd advocate for tackling these early and what that means. But I think for any of these, well, even if you're going the route of fixing all at once, I never tell them it's one surgery. I expect we're going to be friends and we're going to see two surgeries. It's probably going to require a manipulation, a lysis at some point, even if you're fixing multiple ligaments. So I think that's an important part to emphasize to them early to set expectations. Bruce, what do you think about one stage or two stages on this particular surgery? So first off, ABIs are normal, correct? Everything else is normal. Yeah. And just one little point about 3 plus opening in full extension to valgus implies that the ACL, the PCL, the MCL, and the post-media corner are out. So that gives you a good clue right away what's happening. Second thing is, is there an increase in external rotation at 90 degrees? Sure, let's say there is. Okay, so that would imply that there's a significant post-medial corner injury and that would dictate whether I do a one-tail or two-tailed medial reconstruction. For me, if the soft tissue settled down within, you know, probably less than two weeks, I would tackle everything at the same time. Meniscus root, two-tailed MCL reconstruction, and single bundle central pivot reconstruction. That said, if you have a very extensive medial or lateral sided injury like this, it's totally fair game to stage this. Fanelli has shown that you can do the collaterals, you can get motion and come back and do the central pivots. Standard would actually do the root, the MCL, and the PCL, and then come back six weeks later and do the ACL and take advantage of potentially doing arthrolysis and manipulation. So I think the literature will support just about everything here. I think it's safe to say that if we're going to stage it and do the MCL, we have to do the meniscus root at the same time, correct? Because otherwise you're kind of hosing yourself. You're not going to be able to jack open that knee to repair the root on a secondary surgery. Yeah? 100%. All right, Tammy, in terms of autograft or allograft, particularly for the ACL, you've got this complicated injury in a D1 tennis player. What's your go-to graft choice for the ACL on this? So it's autograft. Probably quad. Depends what we've used already on the PCL, however. Bone patellar tendon bone is also reasonable. Okay. Let's say it's a revision setting. You're thinking along the same kind of fashion. Do you prefer autograft for like a D1 athlete like this if you can get it? 100%. Okay. How do you tackle the root plus the MCL? I briefly touched base on that. JD, you want to go into that a little bit? Yeah, I think, you know, just touching on or expanding on what we were talking about before, I think accessing that root, you need to do that ahead of time. So go ahead and prepare that. Do your tunnels. Get that all ready to go. Go back. You can do your MCL. You can then do final fixation on your root after you've completed the rest of those ligaments. Okay. And Armando has briefly mentioned about stiffness. Do you have any helpful hits to limit stiffness postoperatively? Losartan, some people talk about Relaxin. Are you concerned using Relaxin in a patient that you've just reconstructed their ligaments on, et cetera? I don't have any experience with Relaxin. I mean, I think that you want to get them moving quickly. So I think you choose fixation that allows you to move them pretty much instantly. We use Losartan a lot in our practice because Johnny Huard's unveiled. I'm not sure it really helps so much for like macroscopic scar tissue as it does more at the microscopic level. I think it's pretty well tolerated medication with low risk profile. But I think getting them moving early, if you want to have Losartan at a low dose, I think that's reasonable. Great. All right. So our plan for this case was exactly what Bruce had said. An ACL reconstruction. I agree with Tammy on this. We did a quadriceps autograft with bone block. You can do all soft tissue. You can do a bone block. There's really no data to support one or the other. PCL single bundle all inside using a quadruple semi T. MCL repair with reconstruction. So we augmented this with an Achilles allograft after repairing all the structures, your POL and your superficial MCL at the distal aspect. And then a root repair. And as J.D. was saying, we have to prepare the root repair before we fix it. So we prepare that root, pass your stitches, drill your tunnel, but don't fix it until the very end of the case because you want to make sure that your MCL fixation is not going to get in the way with that. So here's some operative pictures. You can see the classic drive-through sign on the medial compartment gapping widely. The meniscus is going up with the femur. So that, again, confirms the distal side and injury of this. You can see the meniscus root avulsion posterior medially. So we went ahead and fixed that. Here you see the quad autograft in the top left, the PCL sitting right behind it, as well as the bottom right corner. We've eliminated our drive-through, fixed our root, and we had a pretty good reconstruction at this time. John, any role for double bundle PCL in this case? Yeah, I think certainly that's consideration for potentially some biomechanically improved stability. In this patient, personally, I would do a single bundle. Anybody different? Yeah, myself included, I went single bundle on this. And she's done well from the stability standpoint, but she did get stiff, as one would expect. So rehabbing her was quite tough. We did have to go back in for arthrofibrosis, clean everything out. She's got most of her extension back, so that's a good thing. Her flexion is still a little bit limited. We've hit her with one or two Medrol dose packs to try and decrease that kind of inflammatory process. And this is her. She's finally hitting her tennis balls again. You know, she's certainly not back to full sports and full activity, but she seems to be tolerating it pretty well, which is nice. I'm going to go ahead and make the assumption that she's going to return to full activities because I never make any mistakes. Is that really your case? Yeah. Oh, yeah, yeah, yeah, I know. You know, a funny, funny story. I think it's Strauss' case. Now she's back in Brett Owens' hands and, you know, call him up and say, hey, buddy, you want to just take care of this girl? So poor Brett's got this now, but she's doing great. So second patient is RW. He's a 30-year-old male with left knee pain and instability for two years. He had a prior four ligament reconstruction three years ago after a trampoline injury that was done by a very good surgeon. Surgically, the procedure went beautifully. Worsening symptoms of instability and global discomfort for the past 18 months. He works as a custodial engineer, and he is a smoker. On the physical exam, he's got standing varus. He's got medial joint line tenderness. Tubi lochman, significant drawer posteriorly, opens up to varus. Doesn't really open up so much to valgus. It's more like one plus, but I'll get to that in a bit. He's got posterior lateral rotatory laxity as well, positive dial. Range of motion is good. He's got healed prior incisions. Here are his x-rays. You can see on the left, I mean, he's not tremendously arthritic, although it looks like it might be with all that extra bone, but I think all that extra bone is a consequence of the prior four ligament reconstruction that he had. You can see that there's some tibial subluxation on the view on the right. That PCL is clearly not functioning very well. In terms of osteolysis, it doesn't look like there's a tremendous amount of osteolysis after this case, which is what he's got going for him. This is his imaging by his walk, and my partner Eric Strauss was kind enough to say that the knee is a hinge joint, but not in my practice. Unfortunately, it's a polyaxial joint many times in my practice, which is what this gentleman has. Here you can see his examination under anesthesia. So here's your clear posterior drawer. Lachman is positive, and the knee looks like an elbow. It looks like I'm doing a valgus instability test on an elbow, and that thing opens up like wildfire at zero and 30. So any further workup in terms of radiographic imaging? We'll start with Armando. Well, I think you need a long alignment film, obviously. You just got to figure out, you know, where he falls. I think I'd have a low threshold to get stress radiography on that medial side. I don't think, you know, I use it like a striker, you know, compartment pressure test. It's just to verify what I'm seeing clinically, so I think I don't need it for the PCL unless you just want to follow your outcomes later, or the lateral side. They're clearly incompetent, but if the medial side's in play, which it sounds like it might be, I'd want to stress that medial side. Yeah, he got stressed beforehand, and included here his medial side was actually okay. So here's our alignment film. All right, you can see he's got asymmetric varus. Even if it was symmetric, I think that still probably wouldn't change my plan too much, but he's certainly got some varus gapping there. Why do I, why am I concerned about his lateral joint line, Armando, on this? So going, touching back on that osteotomy talk I gave earlier, I think that you have a challenge here because your joint congruence angle is really high. So if you just do it the way we were all taught, with like Miniachi's technique, and you don't account for that, you're going to overcorrect. So you need to compensate for that when you do your surgical plan, because this is going to be an osteotomy, it's a chronic lateral sided injury. Okay. Here's our imaging. I don't know why it's kind of reverting to the other one, but let's just assume that he's meniscus deficient, and he's cartilage deficient on that medial side. So he's got a meniscus deficiency issue, he's got some chondral damage on the medial side explaining his pain, and this chronic instability issue. Here you can see the CAT scans. What do you think about the, Tammy, what do you think about the amount of lysis in the tibia? Well, I don't like it, so I think he's going to end up with a two-stage procedure, probably the osteotomy and the grafting first, and then return him for more soft tissue surgery. When you two-stage your ACLs, what do you typically use for bone grafting? I usually use dowels. Bone dowels, okay. And do you have a number, or do you just use sort of like a clinical gestalt? A number in terms of my... Millimeters of opening. Millimeters of widening, rather. I go based on position of the tunnel. So if the tunnel, as we've learned in the earlier panel, is too posterior on the tibia or in just the wrong place on the femur, those are going to need to be grafted in many cases. The widening issue would play a role depending on, again, position of that tunnel and where it's going to end up cutting into or intersecting at the opening into the joint with my ideal tunnel placement. Okay. Anybody concerned about a possible infection in this patient? All right. Well, thankfully he wasn't infected. But he's still smoking. Well, he was smoking at the time, but we counseled him and we made sure that he stopped smoking prior to this surgery. We got lab tests on him and everything. He was actually quite involved with his care. So this is, you know, our WTF moment. Treatment options. So, you know, we'll get back into it. Is it one stage versus two stages? Is it an opening wedge osteotomy versus a closing wedge osteotomy? So Bruce, what do you think? So for me, this is a two-stage 100% of the time because I got to get a better lay of the land. So this is intraoperative stress fuse. This is knee arthroscopy to assess the cartilage, meniscus, take advantage of that time to bone graft all of the tunnels, and then have a better idea of what's going on. I think these are ones that you tend to overcorrect big time because you've got asymmetric lateral joint space openings. So you got to account probably two degrees for that. You've got to thrust. You got to account for another degrees of that. So even with all the, you know, body clad and all the software programs, you really have to be careful not to overcorrect this. Okay. John, is it going to be opening wedge or closing wedge for you? For me, it's opening wedge. That's just my treatment bias. I'm not sure if anyone else is the same, but you can certainly do closing wedge. I think there's, you know, especially in a smoke or a good reason or consideration to do a closing wedge. Mark Hurd, raise your hand if you're doing a closing wedge osteotomy on this. Opening wedge. Whoa, we agree. My God, we're going to mark this for my calendar. All right. So our plan was a high tibial osteotomy using a custom system because we were able to dial our slope into it. So his slope was actually okay. If we thought his slope might've been bad in one plan, we could always address that. But, you know, I love these custom osteotomy systems because it allows us to get our angles perfect. So you could see that the great majority of the deformity here is coming from the tibia. It's 82 degrees. It's pretty far off on the MPTA. Armando, if you saw a lot of stuff coming from the distal femur, would you consider a dual level osteotomy? I mean, I would consider it. It would depend on how much correction I could get and what kind of, you know, I think where these systems are deficient is they don't really account for what your joint line of liquidity is going to look like. So you have to kind of manually do that a little bit. So I would consider a dual level osteotomy only if it was going to create more than, let's say, four degrees of joint line of liquidity or if the correction was too great on the tibia. But I think you probably could do it all in the tibia here. And Tammy, you would bone graft this at the same time as the osteotomy? I would. Okay. So here's our custom guide getting for our gap of about 13 degrees. We wanted to get him close to the lateral joint line, but not overcorrect on this. This is one of those dicey situations that if you overcorrect, they're probably not going to tolerate it very well, especially in the setting of chronic multi-ligament knee instability. So have to make sure you get kind of close to the lateral side. Here's our osteotomy. Went nicely and went smooth. We made him non-weight bearing. Follow up nine months. He actually has no more medial pain. He's got improved gait. His biggest issue preoperative was his thrust. That's what he couldn't handle. It was the chronic varus thrust that he had. So his varus thrust is nearly gone. He's got full motion. He's back at work. Very happy with the functionality. And here you could see his mechanics and his gait are so much more improved. And here's a combination side by side. The picture, the one on the left is not working, but you can clearly see the difference. So he's pretty happy here. After all was said and done. Next step, ligament reconstruction. He's happy. Is it worth going back? Bruce? No, I mean, it depends. So if his pain's gone and his instability is gone and he's functionally happy, I would leave him alone. JD, the nice thing is you've set him up. You set him up now, right? Because you don't know ahead of time what he's going to be like. You assume you're going to take care of the thrust, the progesterone. If you put him a little bit into valgus that 40% of the time, you don't need to do the revision post lateral coroner, but you've set yourself up for success. Now, if you need to do the ligaments. JD, you trying to be a hero? No, I mean, Mark's comment was spot on with this. I think what you did with the osteotomy and the alignment has pretty much done all the work for you. Great. Yeah, I agree. No, we're not going back in on this gentleman. He's pretty happy with what he did. He's actually not smoking anymore. So that's a win. And we're going to stop there because we have to go into our next session. But I'd like to thank the panelists for their expertise and for their participation. So thank you all.

knee injuries

case studies

ligament tears

ACL reconstruction

osteotomy