All right, thanks very much. Yeah, I love giving this talk. And Sabrina's going to cover some of this, so I'm not going to talk too much about the prerequisites and preliminary procedures. But you do want to have optimal alignment as much as possible, unload articular lesions, and restore retinacular supports is the basic concept here of what we're doing. So sometimes a compensatory tibial tubercle transfer preliminarily is important, although we know we can stabilize the patella. Beth Schubenstein has shown that even in the face of a high TTTG. So we can make it stable. The question is, when should we move the tubercle? And I do think there are times when it is very helpful to the patient and the outcome. So it's in the armamentarium for sure, in the instability patients. I'll use an anterior medial transfer when I'm unloading a lesion in the patellofemoral joint as well as the lining. And that's what this looks like, tapered anteriorly, very important technical point so you don't have a step off in the stress loader. So one of the reasons I think preliminarily, again, before doing an MQTFL, it's important because of this phenomenon, which I see from time to time, but not usually 29 years. Here's a person who had a tubercle transfer on the side that you see on your right and never had one on the left side 29 years before for instability. The only procedure done on the one you see on your right was the tubercle transfer. And the other side, life got in the way. The person never had it done, and they ended up with an end stage arthritis. So there's no question that balancing the joint and balancing articular loads is important. Distillization, again, just a commentary. Sabrina's going to talk about this. There are tremendous loads applied when you pull that down. Be very careful. Don't overdo it. Trochleoplasty, is this something you want to do preliminarily with an MPFL or MQTFL? I'm very cautious about these and less inclined to do them all the time. This is a work in progress. You're going to see some really good research in the next two or three years, which I think will begin to explain why doing the deepening groove trochleoplasty probably is not such a good idea in most people. So on to the real reason for this talk, and that is structure around the medial side of the patellofemoral joint. So we started doing some of this anatomy probably 10 years ago. And then Miho Tanaka took off and ran with it and really did a phenomenal job. She's dissected over 50 knees. She wrote up about 32 of those in JBJS showing this anatomy. And subsequently has another publication on the femoral side, which is, I think, just coming out. But the point being that you do have options in reconstructing the medial side. It's not just the MPFL. There is certainly an MPFL component. In most people, not all people even have an MPFL. When you look in the deep side, some people only have an MQTFL. Some people only have an MPFL and don't have an MQTFL. But almost everybody has a combination of the two. So you can really reconstruct either one or both. Orthoscopic imbrications, I think, are pretty far and few between these days because the MPFL or MQTFL reconstructions are so good. And just the morbidity is low, properly done. So doing these imbrications becomes very much less appealing. So again, focus on anatomy here. This is all about the anatomy. When you look closely here, you see the adductor tendon coming along from your left right into the adductor tubercle towards the posterior aspect in front of that sponge there. And that's cadaver knee. And you can see the fibers coming up off of the whole adductor tubercle and some coming out of that sulcus between, I think you can see the medial collateral to your right, the adductor tubercle to the left with the tendon coming into it. So it is really important to understand this anatomy when you do this type of surgery and not just plug a graft in somewhere where an x-ray directs you. But look at this complex anatomy. And this particular specimen here has really a very dominant MQTFL. So it's just interesting that it has a very different appearance when you look on the deep side. And actually, these fibers decassate in a very profound way with the deep VMO tendon. So it's not even so much about just going into the quad tendon. There's also a complex in there with the VMO, which probably explains why VMO strengthening has historically been helpful in instability patients because you're actually tightening up the medial patellofemoral complex when you do that. So look at this work from Smigielski. This guy is a Polish orthopedic surgeon. He's an exquisite anatomist. I asked him how long it takes him to do a dissection like this. He said it took him about a week. And I believe it because these structures are tissue paper thin. If you haven't dissected out an MPFL or a medial complex and you set out to do it someday, you'll see what I mean because you'll probably go right through it before you even knew you were there. So it's very, very, this is exquisite. But look how complicated this is. You can see all the fibers going into the quadriceps tendon as well as into the patella. There's a big tibial component coming up into this complex also. So it's not just the MPFL. And understanding this anatomy, this is from Miho Tanaka's work, will be really helpful in your reconstruction. The nice thing is it enables me, anyway, to do an MQTFL reconstruction, which I think is more benign for patients because you don't have to make drill holes in the patella. And as Sheetal Parikh showed and many other surgeons now, you predispose these patients to patella fracture by drilling into the patella. I think Sheetal showed six fractures in his series of the patella. So this is serious stuff. So femoral side fixation has to be correct. That's really important for this type of surgery. It must be anatomically correct. Make all incisions as large as you need to to see that anatomy. So mark it out, and then make your incision right there. This is why you can add that modifier 22 in big people because it gets pretty deep in some of these really heavy people. And then find your adductor longus tendon. It may take you a little while, particularly if you haven't done it before. Just find that. And it's a glistening white structure, really easy to identify. Once you get familiar with it, it's just behind the VMO muscle. And really, this is the key to accurate surgery, not radiographs, in my opinion. Our study that I did with Corey Edgar when he was a fellow, we showed that when we did radiographic determination, it was, on average, about eight millimeters off from where we thought anatomically the femoral side graft should be. We think we did the radiographs really well. We think we did the surgery and the identification of the anatomy really well. Eight millimeters isn't much. But when you look at the studies out there by John Elias and others, it's enough to affect the behavior of the patella and the loading. So these should be anatomically precise, just like an ACL. And as Sanchez Alfonso told us, there is basically no standard radiographic method that will give you precise, consistent location for the femoral origin of the medial complex. So this is what it should look like when you have an anatomic. This is a pretty big incision. Most of mine are not that big. This was earlier on. But don't be afraid to make a bigger incision if you need to. Most of the incisions are like an inch and a half, two inches. And then you bring it up under the VMO. And then at that point, you basically just put it into the quadriceps tendon right above the patella. So we'll go through that step by step here. You can see the adductor tendon coming in at the bottom there where the little blue dot is on the adductor tubercle. And then that blue is the native medial complex in this particular patient. The red dot is on the medial epicondyle. So you can see everything clearly. So when you have your incision, you can see this. You know right where you want to put that socket. And so there it is right where the blue dot was. That's 100% anatomic. You can see, of course, this is a cadaver knee. And you don't always see the medial fibers in someone who's had an injury. But that's the spot. And as you will see here, you can see the fibers through the blue. Plug in the graft, and you bring it right there. 100% anatomic every time. And I think we owe this to our patients to do these correctly every time and rely on the anatomy. Bring it up under the VMO. This is looking up from, you're looking still at the medial side. This is pulling it up through the VMO from below. The femoral side is at the bottom of the picture. And then we're making incision at the VMO insertion in a separate one in the quad tendon. And then basically, it's pretty easy. We just pull that graft around the corner and underneath and then suture it down. Very easy to tension because you cycle it, as Jack Farr has talked about, setting it to length. Suture it down where it's at its longest length. Even if your surgery is off a little bit, better to make it too long than too short. These work out really well, even if you are off. But if you use this anatomy, you're not going to really be off very much. And the data with this, and this is true across the board with MPFL and MPTFL studies, including our own, very consistent, great results. It avoids this tragic complication. And really, I say tragic because you don't ever want to have one of these in your patient. These are young people. And that's why I think we should put these grafts into the quad tendon. So range of motion, early, single motion a day. Then we weight pair them right away. Physical therapy at six weeks and light running, usually by about four months. Thank you.

surgical procedures

patellofemoral joint instability

alignment

tibial tubercle transfer

cadaver dissections