No, I guess I'll go ahead and talk about my approach, and it'll be interesting to see how my approach and Ed and everyone in this room were kind of evolving, and I've got this titled My Approach Today because it was different five years ago, ten years ago, twenty years ago, and it's probably going to be different in the future. My disclosures are up to date. So first time patellar dislocation, historically we treat these all conservatively because the earlier study showed that repair equaled conservative, or vice versa, they were no better than conservative management, so why put somebody through a procedure? And based upon this literature and others, Don Fithian in Sports Health in 2011, they had a treatment algorithm for primary patellar dislocations, stated first time patellar dislocations should be treated conservatively unless there's evidence of a displaced osteochondral fragment. So that's where we were in 2011. Treated conservatively, however, recurrence rates are highly variable, and obviously we know because of the risk factors why some of them are only 15% and others are 44%, but nevertheless, there is a risk for recurrence, and even if they don't have recurrent instability, their function, six months post-injury, 58% of the patients continue to have limitations, and 55% failed to return to sport, and that was also from Don Fithian. So newer evidence looks at some of the non-operative versus repair, and you can see in these three studies that repairs, if a specific surgical technique is followed, can equal the reconstruction and MPFL in the child, significantly reduce the risk rate, and Llewellyn showed the risk factors higher would be trochlear dysplasia, patellar ulta, and age less than 25. So the key concept is each patient will have a unique pattern of injury and unique risk factors that require patient-specific treatment. The unique patterns of injury, mechanism, and site. So the mechanism can either be a low energy or a high energy. So a low energy non-contact would be, for example, internal rotation and valgus stress during activities of daily living. That's pretty unusual if they have normal anatomy. High energy non-contact, like they'll miss a baseball swing or a golf swing, high energy contact, direct knee to knee, site of injury, femoral sites, as we know, has a higher dislocation rate, patellar, lower dislocation rate, and then interstitial is intermediate. So if you look at repair versus reconstruction, there are a couple of earlier studies that showed the repairs did not work adequately to recommend them. However, Jason Dragoo reported that if you have a strict criteria and you can identify a single site of injury on the MRI and you repair it at that single site, he only had a 6% re-dislocation rate compared to none. So I think that shows that maybe repairs now have a new place in our armamentarium. If you look at the unique risk factors, we all know about trochlear dysplasia, patellar ulta, excessive lateral positional tuberosity, age less than 25, open physis, and then lesser like valgus malalignment, prior dislocations, and some type of global cartilaginous pathaloxity. Parikh looked at the risk factors and odds for recurrent patellar instability, and he looked at all these across multiple different authors, and so they're all agreeing that these factors contribute. And then as Sabrina talked earlier, the group at Mayo has developed their own scoring system. These were two earlier scoring systems, but as you see, their timeframe was only out to 3.1 years, and the average time to have a recurrence is 3.7 years, and so they're going to miss 50% of these. So you really need to have a longer timeframe to base your scoring. So this was the development of ESE, presented it yesterday, and also is published in arthroscopy with their RIP score, and this is based upon all those standard types of measurements that we've discussed, ranging from dysplasia to ulta. When you look at the RIP score, you'll see that some risk factors are not on it, and this is secondary to they were using multivariate regression instead of univariate, which other studies and the fine and gray competing regression found that some of these, for example, we all think of ulta. You've got to have ulta as one of your risk factors. Well, in this particular scoring, it did not come out, so it comes out to a zero. Also maybe they're small numbers. I was talking to them, and, you know, in my heart, I think a du jour A is much lower risk than a du jour D, but in this scale, they all get one point, and then it really doesn't look into generalized patholaxity, excessive femoral anteversion, genu valgum, et cetera. So this is the score, as you were shown, and the biggest factor there you can see is age less than 25 in skeletal immaturity, so if you have a young patient with open physis, they're in their intermediate zone already. So one of the factors is the TT divided by the patellar length. You may not be familiar with that. This is just to normalize it over different size people. For example, if you have a normal patellar length of 30 with a normal TTGG, they get a .37, which is obviously you get a zero point, but in the 18, that's sort of marginal, and if they have a smaller patella, you can see that it can become consistent or consistent enough to give them one point, so that's the reason for that new measurement. If you look at the risk factors, so at 10 years, the low risk factors, if you have a zero to one, there's a 100% chance that you're not going to re-dislocate again. Let's flip to the other side. The high risk factors, almost 80% are going to re-dislocate at that time frame, and that's certainly unacceptable. You can see this. The red at the bottom is a straight line because they're not re-dislocating, and if you look at the intermediate ones, they get their dislocations out of the way early in the first couple years, and then it's flat again, but those with those higher risk factors, those with four or five points, they continue to have increasing numbers of dislocations as time goes on. So they are taking this RIP score, and they have it now available for you on mdcalc.com or their mdcalc app. These are three examples. Yeah, they show up adequately. So you can see, I've just put up one, so it's an older person with normal TTGG, normal de jure. They get one point, low risk. They don't need surgery. Look at the other side, so it's a young person. They have open FICEs. They have trochlear dysplasia and a high TTG. I mean, they are going to have five points, and so they're a very high risk for dislocation. So this is my algorithm today. It'll probably change tonight after I talk with my patellofemoral friends, but for osteochondral fracture, I will treat it with open reduction internal fixation or debridement. If they have a low to mid RIP, I'll repair the MPF restraint. If it's a discreet tear, if it's a high RIP, I'll reconstruct it when the knee is quiet. Most of these are not urgent, and so if I can let the knee calm down, think about how you would treat an ACL. It's not a timeframe, it's just when the patient can really activate their quad, their infusion is going down, their range of motion is improving. If we look at high energy, if they have high energy with a low RIP, I can conservatively manage those people. High energy with a moderate RIP, I'll repair if there's a discreet tear, and then this is the intermediate zone. This is when you talk with the parents and the patient, and what are their goals? What are their activities? Are they at a high pivot sport activity? And so you may in the future discuss MPFL reconstruction when the knee is quiet and high energy, high RIP, reconstruct when the knee is quiet. And then finally, low energy. So if you have low energy, you know automatically they're going to have a bunch of risk factors. So this first one, if they have a low RIP and low energy, to me that means there's something wrong with their ligaments in general. So they have some sort of patholaxity. So I'm thinking do they have an airless-danlos variant or something like that. Low energy, moderate RIP, repair if there's a discreet tear, and discuss the pros and cons of medial patellar restraint reconstruction when the knee is quiet. So this is sort of in between. We get the patient, parents involved for a low energy, high RIP, I think they need to have surgery. So that will be done again when the knee is quiet. Low energy, high RIP, so it's the same patient but now they have an excessively high TTTG. I'm going to add a TTO as you've heard. And then also if they have a du jour type D, this is the dome. In my practice, we looked at 100 patients. We had 4 out of 100 had du jour Ds. So trochleoplasty is not indicated very often. But I think in this case it's difficult to balance it. So that would be, obviously you could have combinations above, but this hasn't taken into account valgus, internal rotation, et cetera, that you should be evaluating at the time of initial treatment. Thank you very much. Thank you.

patellar dislocations

conservative treatment

surgical technique

recurrence rates

personalized approach