Okay, please stay with us. We're almost almost at lunchtime. And so please have the panel come up Fantastic everybody's getting settled Great we're gonna finish up before lunch case panel discussion telephemeral We've got a great esteemed Faculty and case panel. We've got a really international flair. We've got a MIT coming From UAB in Birmingham. We've got cost us from Mayo and Phoenix Diego's coming all the way from Mexico Pietri from Finland Sebastian from Chile and Nori all the way from Japan So I'm not gonna try to anybody's last name just to keep embarrassment at a minimum Anyway, we're gonna do a number of cases here and I'm gonna turn it over to Liza for the first case Thank you And I'd like to reiterate what we said for the cartilage try to keep your cases up your comments short and we'll try to give You enough information. This first one will start out as maybe a little bit complex 16 year old female bilateral patella femoral dislocations She had a first dislocation 10 years ago reasonable BMI for the United States Baton score was four out of nine But important that it did not include knee hyperextension and you can see that she has valgus I see here both the mechanical axis and then the femoral valgum Okay So now I'll keep going Looking at her patella. She had a patella height I gave you all of the canton to Sean's and so salvati as well as patella trochlear index So I think that all would agree that she is on the high side You can see that she's located at 20 degrees if you Look at other MRI measurements. She does have a lateral tilt That's not so much TTTG 19 milligrams And and what I'd like to call an empty sulcus sign if you look on the axial view with the first full cartilage coverage You look up and you don't see the patella. You see the patella tendon So at this point, I'd just like to ask there's a little bit more to the case, but why don't we start with you? Sebastian Number one, would you fix the Alta? Yes, there are many risk factors, but patella Alta is one of the most important So it's over 1.4 and cut on the sham. So you we should Have a particular height no more than 1.2 So in this guy in this case, we have to distal eyes until 1.1 or 1.0 No more than that, and then I'm going to go and ask trying to get back to this Mowat, would you do anything with valgus? I'm saying it a mit. I'm so sorry. I'm so sorry In this case, you could certainly consider a DFO But I think in this case you could kind of address it with a MPFL reconstruction and TTO with distalization So I would probably not go directly to a DFO So then let's just ask a more basic question if you're having valgus At what in a teenager closed growth plates at what time? What what would sway you to do a valgus a varicising osteotomy? Can I hear from Diego? Well, I don't do a lot of osteotomies in in in this kind of patient. I think valgus is Good for a female at this point if it would be a little bit more probably over over that number I probably think about doing a DFO. Okay, I'm just going to fast-forward this you saw these So would this change your opinion so this had an OCD on x-ray was never treated in fact sadly enough they Intelligent parents and intelligent child. They didn't even know that she had an OCD. Would this change your opinion on the osteotomy? How about you Sebastian? So valgus is a risk factor in this case so without this osteochondral lesion, I would recommend it over 10 degrees of Of mechanical axis. So in this case with this lesion we have like more Recommendations to do a baris. Osteotomy. It would be like a femoral medial close with osteotomy castus I Do the same actually with the 10 degrees with the the OCD to definitely do it correct that valgus So you're doing the valgus to preserve the lateral compartment and it doesn't hurt the patellofemal joint either, correct? How about you Petri? Yeah, definitely because of this Articular cartilage problem. I would do a DFO. Do you have a number in your head or a wapering line in your head? In this case even even less than 10 degrees I would do if it would be like four four or five degrees because of the joint Degeneration or problems I would do a DFO So we'll just go on. I'm sorry This was just the MRI showing the OCD lesion And so, you know, I think the thought process is to stabilize the patella, which I do agree We should correct the patella alta improve the limb alignment, which I do think helps stabilize the patella But it is debatable when at what value but to treat the OCD I think as soon as you have the lateral compartment at risk, it kind of kind of sways you so just very quickly She did have this was the the scope She did not have any penetration of that OCD and we went ahead and did a lateral opening wedge The reason I chose lateral is that if she needs more help down the line That you might need to do something about that OCD lesion. You already have that that lateral sided incision. Okay, take it away Paul Yeah, that's a great case. It really is I'm gonna move on to something a little simpler that we all face pretty much every every day to day in the office This is a 17 year old female dancer Twisting injury to the right knee landing during a hook jump two days ago during practice She felt a pop in her right knee when she landed and she felt another pop when she fell to the ground Unable to continue practice went to the urgent care had x-rays knee immobilizer Crutches the same thing we see all over the world Presents in your office today with her mom. She's had decreased pain since her injury, which great but a lot of swelling in her knee You know, she's never had a problem with the knee in the past and she's planning on attending college in New York to pursue dance Next year, so there's a lot riding on this So just on exam Moderate effusion range of motion obviously limited due to the effusion tend to really medially All over the MCL medial joint line medial patella really can't get a whole lot on exam She's scared obviously apprehension with glide testing Difficulty relaxing for a Lachman and really, you know can't really get her from Murray's so x-rays here Nothing real exciting on the AP as far as that goes If you look at the patella, obviously Nothing too exciting there, but obviously the the lateral may give you some hints Can you guys see is that projected? Well Diego, do you make anything out on that lateral? Yeah We always wanted to take a look at the trochlea and look for that spur and see Something's happening there and obviously that patella Alta, which is always a an issue we know from Miho's work that Distillation is always good whenever needed, but it's also 46% more complications if if If it's not addressed correctly, so Okay, and anybody else see anything out on the lateral it's tough to project Yeah, yeah the big piece of bone the elephant in the room, yeah, okay. All right. I'm glad that you at least can see that Moving on initial treatment. So these are some of the common things You know just just going down the down the line Pietri. What would you what would you do here anything? MRI for sure. Okay. Yeah. Anybody have any other suggestions other than additional imaging? I Think that's what most of us would do So I met if you'll look at the MRI only gave you really two cuts here Tell me kind of what you see there pretty large cartilage lesion looks on that be off the patella Let me see what the size rule here looks like Yeah, so I'd Yeah, preoperatively, I'd look to patient a loose body that we'd like to fix it. This is an acute injury I'd like to restore cartilage and use her own cartilage back on that and then in addition to an MPFL reconstruction I usually do MPFL MQ TFL convo But yeah restore that cartilage. Okay. Yeah, don't jump too far ahead on us Okay, and and these are just some numbers to go with that just to substantiate your decision-making nothing So Nori, what would you think as far as your initial treatment with this now that you have an MRI and you've got You know your x-rays. It may be a bit too aggressive. But when we detect the fragment Also control, you know fragment detected within the joint. I do want to Yeah, I've done a couple of these and what we do is what dr. Kuga showed us mince cartilage the Demands the the cartilage there and try to fix it with with scaffold. Okay, we're getting there We're getting there. Anyway, yeah, you got mom mom obviously terrified with the mention of surgery So keep that in mind. So let's kind of break this up into cartilage treatment. Let's break it up to Telefermal instability. So let's kind of go down the line with some of these options, you know, you know starting costa starting from the in there What would you what would you do now that with the information you have so it depends on if there's some bone on that cartilage If there's bone in a kid this age, I'm gonna try to fix it Then I'm gonna think of a different approach and I'm I've gone to a lot of osteochondral holographs Okay, so you would jump right to an allograft with this. I would okay. How does everybody else feel? Well, I think at 17 years old you probably have good cartilage so you can use that cartilage as I said with Mincing there and just putting the scaffold to hold it. Yeah, I'd argue that even without Significant bone in that piece. Sometimes they're still fixable in a young person. So I would actually probably not jump to an OCA Okay, okay Could I just ask costas? I mean if it's that medial of a lesion, don't you find that it's a little bit of a harder Fix to do that medial side of the patella in terms of contour and maybe not being contained It is and I used to I've just kind of converted using those more often if I can't fit put the original in I found The osteochondral holographs it's taken some time and effort to get better at doing them But we're starting to get much better at contouring them better. Yeah, Sebastian. Where do you stand on that? Yeah, so in this case, we try to fix it And then you you should do like the MPFL reconstruction so you can have the same approach to make a mini open or mini atrotomy and make the Fixation. Okay. Yeah, we're getting there. So this is scope video here You can see that's a remainder of the patella there at the top And just with the typical chondral lesion we see in for your medial patella and you can see the hematoma You can see the fibrous tissue forming and you can see this is you know Kind of uncontained typically which is the way most of these lesions are there at the end cartilage is in one one piece But it's certainly beaten up. Does this change anybody's management after looking at the scope footage? No How about I give you a little bit more footage? So everybody's staying staying hold there. Let me flip through these Okay, so how about this does this help anybody there's a little bit of bone on there they'll make anybody lean No worry, what are your thoughts? No me oh, okay after the refreshment of the you know, the a Reason base I fix Okay, you fix primarily does this change anybody else who was leaning towards going to an allograft or mincing it? Does it change anything for you guys? No, I think what this would change a little bit of how I would fix it I'm typically a biocompression screw if I can with this little of Bone, I would probably try a some sutures over it some visceral sutures over it and hold it in place Like by the way, that sounds yeah any anybody using Darts K wires any anything else that we need to have in the OR for this anybody using metal All suture anchors, okay Anybody harvesting for Macy just in case I Tend to always harvest for Macy and never use Okay fair enough this anything else we need to have in the OR for this No No, okay. All right So I I'm right with a number of the way the panels this was in my or certainly not less suture anchors visceral suture Screwing anchors all that's part of the arm and terium Just briefly here a couple suture anchors some visceral over it into another anchor and this is your final product Hopefully that's what most of us would do but I don't think any of the other answers were incorrect Had this been more central would you would you've done a different way? Or is this how you would have done it regardless? I've used it central to cover the patella I haven't really had any any any problems. I don't know if anybody else had complications with this type of technique What about your post-op protocol Let's not jump too far ahead, okay, we gotta we gotta get the instability first So anyway, so cart cartilage moving on to instability treatment So I kind of divide these cases into cartilage repair and instability. So these are kind of the common Techniques we use let's let's kind of go down the line Petri. How do you how do you what do you feel about the instability? Treatment and we'll move on down These case MPFL reconstruction would be my option. Okay MPFL I used to do combination with MQ TFO. Okay, I do a reconstruction as well. I think John Kelly said we have to restore anatomy, but also biomechanics so you need something to restore the length of the of the of the native MPFL and probably the the complex not not only the ligament, okay MPFL reconstruction The same we have to consider that maybe it's going to be better to use anchors more than tunnels in the Patella in this case good point and and my only point to that was I used to MQ TFL just for that exact reason to Avoid anything with Patella since I'd already put some anchors in there Okay, so weight-bearing Brace, we probably need to move on through this Obviously most people would weight bear this an extension. I would imagine since it's non-contact and slowly progress. Okay, well We'll move through that Anything else before we move to our next case? I Would just like to advocate to consider Instead of being in full extension to be in a little bit of flexion Because when you're in full extension and you contract your quad the patella goes up and down up and down and if you put a Little bit of flexion in the knee. Yes me. I've never had a problem with the getting extension later But what's happening is that you can't the patella doesn't move? So I really like to just get a little bit of flexion to get that kneecap into the groove and not to have so much Superior migration when the quad contracts how much flexion you use? Well, it depends a little bit on their body habitus and the brace I'm using but I like to see about 20 degrees Great and when they're in rehab, they take it off and they extend But I think you should think a little bit about that because look your own knee if we contract it The kneecap goes up and down you're locking it at that 20 degrees and then letting them flex further than that Also, yes Locking it when they're walking and opening it up when they're sitting Just a thought. I mean, I didn't always do that, but that's how I've been thinking Okay, this will be quick and this will be our last case Alright, so this is a 13 year old male bone age and chronological age about the same BMI of 29 a good I would say Minnesotan, but he actually came from Iowa and he had a primary lateral patellar dislocation and a large Osteochondral lesion and I just wanted to point that out to the lateral femoral condyle. You can see that it was repaired The ORIF of that lateral femoral condyle and he had an MPFL repair Then he retore it doing sports He came up to see me and he had his ADLs were stable stable and day-to-day activities some sports Okay, again BMI of 29 keep that in mind and he used the patella brace All right. So this was his exam. You can see that he had everything you'd expect on the physical exam Important that he also had knee hyperextension 10 degrees He had a valgus knee on both sides. I mean the injured side of the non injured side TTTG is high, but I think that has to do with other factors and you can see his patella alter measurements I just want to show you one other piece of information and that is that we perform a dynamic a dynamic Emotion movement screen and he had everything you can expect. He stands with his knee hyper extended as he had a Adductor block a weight shift when he he fell into a valgus knee collapse. So I'm just gonna go back So what would your treatment be at this point in time Petri? Could I ask you how you might treat this? You're probably the only true pediatric orthopedic surgeon on the panel But others can chime in too. So Yeah Definitely for me. This could be a good case for a guided growth. So he has a bilateral valgus Significant and looks like it's coming from from the tibia So I would say I would do a bilateral guided growth. So do you have a number in mind? About how much growth you need to be remaining and how do you figure that out? Do you have your radiologist figure it out with a bone age? Typically I don't I don't that much Check the bone age whenever there's growth remaining and significant valgus. I have I consider guided guided growth surgery and Of course, I take a look about the expect expected growth remaining Whenever there's growth remaining, let's say open fights and femur For example, it's it's a possibility for guidance growth Does anyone else have anything to add to this case? I would say I don't do guided growth But I wanted to show this because I think it's important because you all see The telephemeral in children and I think we we miss the opportunity to do guided growth. Does anybody else have anything to add to this? All right. I'll just say quickly what what happened This is what I thought were the options and they aren't necessarily exclusive of one another And so what we did is we had a consultation for consideration of guided growth They agreed upon it physical therapy for improvement of body motion patterns a fitness paint plan that included dietary considerations Since he could do select sports with a brace that was perfect. You could keep this somewhat over overweight young Adolescent male active and then he had a stage patella from reconstruction after guided growth So this person ended up being a much fitter Slightly leaner person and went on to continue to do some sports and he had an MPFL reconstruction when he was age 15 So I think where that will end our day. I think we have lunch out there and then a lunch Speaker following that so you want to come up fashion and give the thank you panel

panel discussion

knee issues

patella dislocations

treatment options

cartilage lesion

MPFL reconstruction