It should be great. So I'm gonna talk about the primary NPFL repair. So let's consider what we normally talk about with the management of the first-time patella dislocation. So we're a 15 year old skeletal immature traumatic patient. He does have a bony avulsion, but he has minimal traditional risk factors. So if you look at him from a demographic standpoint, he's in the sort of good group, if you will, on the stained side of that spectrum. If you look at his patella instability severity score, he really only scores a one. The only thing that really is a risk factor is his age. So based on this account, this is somebody that we would really consider highly likely to manage conservatively and have a low risk for redislocation. The issue is I think we need to consider this for our patient. Not every patient fits into the same box. So this same patient is a skeletal immature rugby player. He wants to return to at least the same level of sport and potentially higher. He already has potentially a cartilage lesion. And the problems I have with some of the measurements we have is it doesn't necessarily consider some other things. The correlation of a collision sport athlete. It doesn't really account for recurrent subluxations or the attritional wear of cartilage wear in a high level athlete. So to me, this comes down to a risk reward situation. What's the risk involved in doing surgery and what's the reward benefited by the surgery? I think in this particular case, the repair is very low risk with a high potential reward. So what's the data show? So this is a highly quoted paper, actually number 27 of the 100 most cited papers for MPFL, if you just Google that, and it's a randomized, or it's prospective randomized study. If you look at it, it says delayed repair of MPFL with anchors on the femoral side does not reduce the risk of dislocation. However, if you really look at the paper, mean age is 20. They didn't get to these repair until average of 50 days after the treatment, femoral side only, which I think is a difference, and the 20% re-dislocation rate in both groups. And it is the conservative care group actually had one patient that actually they checked it to treat an OCD lesion and then left them outside. So there are some otherwise randomized control studies looking at compare repair versus conservative care, but the devil's within the details. So if you look at the demographics like in this upper paper that's similar to our patient population, seven-year follow-up, 22 patients, 48% dislocation, 18% in the repair group, 12%, but they counted both dislocations and subluxations. So if you take the subluxations out of it, they had no dislocation, re-dislocations in the repair group. And the other one, basically a lower age group, the re-dislocations in the conservative group were 54% at 14 years, and the repair group was also similarly at 50% and 67%, but they all have lateral releases performing in all of them, but four. I don't think that really correlates what we would do with this. Most of these are tear patterns are off the femoral side in young patients. So the femoral avulsions is really what we're dealing with in this age group, which I think is an important characteristic. There's no data that looks specifically at the avulsion, bony avulsion, except for this one, and it says that it might make a difference in terms of repair. So does age matter? Yeah, the younger patients have femoral avulsions, which we think do a little bit better with the repair. So what does the data say when we look at all what we have? So this is a recent meta-analysis specifically looking at repair versus conservative care for the first time patella dislocators. Conservative treatment versus repair. Skeletally immature were excluded, but the mean age was 17. All levels of clinical evidence were included. 25 patients or 25 studies were ultimately compared. 40% of the studies were level 1 or level 2. Mean number of patients in the study, each study was 37. Mean age was 21. Mean follow-up of 48. In the rehab conservative side, the Kajala scores, meaning the functional outcome, was 82. Mean and 88 on the repair side. However, if you look at some of the outliers, in this one paper, 35% re-dislocation rates, and at this one, repairs were done at 50 days. So if you look at what's the re-dislocation rate, conservative care 30% in the MPFL repair group, it's 7%. But again, if you look at some of these outliers, these repairs were not done acutely. So what are the limitations? Pooled data, not all repairs are the same. For me, the takeaways were the re-dislocation rates were significantly different at 30% versus 7%. Similar sort of pain of reported outcomes, similar return to function, but at time zero, what are the influences of the fracture and motion loss were also sort of similar. So, conservative care on my own, this is a first-time dislocator and a football player treated conservatively with similar really normal anatomic findings. Made it back within three or four weeks. The next season had a dislocation on the first game with similarly a large bone loss. At this point, he's a senior season loss. I guess I should have fixed it the first time. He also had cartilage injury, bone avulsion, and now injury extending up into his VMO. So after return to sport, we don't know which result would you like. I'd rather go with the repair and have a good outcome.

patella dislocation

MPFL repair

surgical treatment

re-dislocation rates

athletic injuries