We're going to call the other speakers back up and we're going to invite the audience to come to the microphone for questions. But first I'd like everyone to come on up. First I'm going to invite Sabrina to see if she has questions for each of our speakers. Sabrina. So, sorry, beginning with Adam. Is there a situation where you'd use a lateral uni, for example, or a lateral hemicondyle? Is there a smaller biouni that you might consider using a lateral condyle? So yeah, our smallest size did have the best matching ability and I think it's always about the availability of these grafts, too, so we don't have to wait too long and that's the whole purpose to consider the lateral for medial. And I think that if it's like a 17 by 20, then it's a consideration, but you just got to know that you're going to end up with a slightly mismatched graft with regards to the radius of curvature. You just got to know that going in, so you're not surprised when you have it. And Drew, if you look at the vertical TTTG or rather, you know, I get confused and I'm a patellar surgeon, but you know, if you just say the posterior position of the tibial tubercle relative to the center of the trochlear group, you found that patients with patellar chondral lesions had a more posterior tubercle. Why don't you think the Ketam Deschamps or the TTTG showed a difference? I think, you think it was just too small of a group or? Yeah, and so our, the CDI was, I think it was 1.08 in the patellar cartilage group and 1.04 in the regular, so it just may be too small of groups to notice a difference there. The medial lateral TTTG, standard TTTG was about 12 in both groups, but we excluded anyone with any history of instability. So, I mean, I think that's important and I think this is a super important study. I think it's a great job. Seth, so I'm glad to see that your complication rates were not increased and luckily I don't have this BMI problem for the most part in New York City compared to Missouri, but you know, I think the patient population needs treatment because we want to prevent instability in, especially in patients probably with a higher BMI. I'd like to see if they had the same placement of the femoral tunnel and do you plan on looking at any of the radiographic parameters, essentially see how well you did the surgery in a patient with a larger BMI? Yeah, I think it's definitely a technically more challenging exercise when you're dealing with the BMI above 30. You know, I use, like you do, a combination of anatomy, which is really challenging, you know, looking for the adductor tubercle and adductor fluoroscopy and isometry and that combo gets me in the ballpark to be safe, to avoid over-constraint inflection. I've not yet looked at it, but I get routine x-rays and I could look back to see the accuracy at least on radiographs, but I'd have to do more advanced imaging if I wanted to really evaluate critically the tunnel position and see if it's different. And for Jacob, you're essentially evaluating the press fit aspect of different plug heights for osteochondralografts. As you know, there's significant differences in the graft prep trays as far as line-to-line if they're slightly oversized. How do you think that would figure into all this? I don't know how familiar you are with this. Diametrically, I think oversized grafts will have increased resistance characteristics. The majority of the graft resistance properties are coming from the circumferential surface area of the wall and the host recipient tunnel. So I think increased diameter grafts would probably have increased resistance properties. Dr. Fulkerson? Yeah, question for Seth. I already asked him the question over here, but I thought for the audience it would be worth bringing up. I find these obese people are really hard to do a medial reconstruction on. In the last year or so, I've been adding a modifier 22. So I just wanted to throw that out there just for a comment. I appreciate that. And certainly, they take more OR time and require a broad array of skills to get to the right spots and to do it safely. So I think I will start doing that in those cases. Great. Yeah, just to make sure everyone heard the wisdom of Dr. Fulkerson, that when he takes care of an obese patient, he finds it more difficult and he modifies the CPT code with dash 22 for an unusually difficult or more difficult procedure. Bill, do you have any comments on that? Bill Beach? Yeah, I would just make the comment, how many people use the 52 modifier when it's a really skinny patient? The 52 modifier is less than normal service. So while I understand, but we surgeons are always like, oh, that one's harder, but we never want to get paid less for the one that was easier. So that's why they don't pay us a 22. I haven't had that problem. Yeah, sometimes the thin patients are also very high demand in the office afterwards. Next question. Yeah, I guess to keep it going with MPFL, is there a minimum size graph that should be used to perform that procedure? And which allograft is preferred? I think- Can you repeat the question first, just to make sure everyone got that? Sure. He asked if there is a minimum size graph that you would use for the medial patellofemoral ligament reconstruction, and which graph did I use? I'd say at this point, graph choice is dealer's choice. All of the graphs that we use are stronger Newtons than the native medial patellofemoral restraints. So I prefer to use allograft for these patients, typically gracilis, sometimes semi-tendinosis. I use a longer graph just for my technique so that I don't have any issues with just length so that I can suture it to the patella. So first off, Seth, congratulations, you'll be the national referral center for treatment of patella- That's what I was going for. And super obese. Just make sure you publish that with your address, the new address. And then one question to Drew and Adam. You mentioned that you had looked at the flexion angle, how the knee was positioned, but I don't see how you normalized for that. Because I can see how you use different coils, you have someone who has a bigger thigh. I mean, that measurement is probably somewhat sensitive to position. Yeah, exactly. Can you repeat the question for the audience? The question was, how did we control for knee flexion angle, especially with different coils, different patient size? In this study, we just excluded anybody who had flexed knee greater than 10 degrees, because we were concerned that as you flex more, the tubercle will be more posterior just due to the flexion angle. And then we've done a subsequent study that we're just finishing up, but where we actually in CT of cadaver measured this measurement at different flexion angles and found that it is fairly constant in that 0 to 10 degree range. And then with increasing flexion, it is affected by knee flexion. So the short answer is we do think it's safe that in that less than 10 degree range, that it's not affected by subtle differences in knee flexion. And there was no significant difference between the three groups in their flex knee position for that under 10 degree group. Great. Thanks very much. Thanks. All right. Julie Dodd has a question. Yeah, I just had one more comment on the 22 modifier coding. Make sure when you put your ICD-10 codes that you list obesity. So you link your procedure code to obesity and, and then also use the words altered field. Those are the ones that the payers are looking for. And so you put in your final paragraph of why you're getting paid 33% more because of the altered field because of patient obesity and also the difficulty with postoperative care because of brace fitting and wound issues. So can you sum that up again? So Julie is saying if you're going to bill modifier 22 for a more difficult procedure on an obese person, I'll start and you can catch me if I'm wrong, that there was an alteration to the surgical field and that there was increased difficulty with postoperative care such as. Such as wound problems and, and difficulty with bracing. Wound problems, difficulty bracing. And then what was the very. First one is just make sure you use the ICD-9 diagnostic code for obesity to begin with. And it might help. That's all I can say. It might help. Excellent. Sabrina. Another question for, question for Adam. Have you done the same study for cylindrical grafts? So we, for a single graft or for multiple? So the. For a single. We've done, yes. We've done surface matching for single based on size as well as for medial and lateral donors and found that there was not significant mismatch based on what we thought would be clinically relevant for getting a lateral donor for a medial lesion. It does get more significant the larger the defect is, but I think it's very reasonable. The next thing that we have coming up would be looking at snowman where we match ideally two circular plugs and compare it to the oblong plug to see if you get a better match when you actually do two separate plugs, which I think actually will be the case. So just to follow up on that, Adam, what's, before I sum it all up, what was the size that you think is acceptable for a single circular lateral to medial? Yeah. So for the matching, it was 22.5 millimeters. So you can go pretty big. Yeah. So just to make sure everyone got that with the oblong grafts, it's much better in terms of matching up, having a medial donor for a medial condyle, but for a circular graft up to 22 in diameter, you can use the lateral condyle, which sometimes is much easier to get. From a practical standpoint, medials are harder to find. And then the last point was that a snowman where you use more than one smaller graft, sometimes overlapping the two circles like a Venn diagram, that matches quite well also. That's what we're doing now, so I don't have the results on that yet. So that's still being studied, not a conclusion. And the only caveat for the single plug is as it gets far posterior, then you should be concerned about that size. But if it's distal, you can do the larger size. So distal, you can really get away with bringing the lateral one in. Very far posterior to use that on the medial condyle may not match as well. Sabrina. Well, I think it's more of a discussion and maybe somebody else on the panel has a comment because our second speaker had to leave. But does anybody here use a corticosteroid injection post-op before four weeks? No. I mean, I think there's a lot of recent research in the literature regarding arthroplasty and preoperative injections. I think historically we haven't worried a whole lot once the portals were closed. I don't know, Seth, when you were a resident, if we were still injecting patients in OR, but that. I think a couple of the attendings at HSS were doing that when I was a resident. I've not seen anyone in my current institution who is injecting intraoperatively. And for me, if I'm going to inject post-surgically for boggy synovitis or fusion, it'll be six weeks, eight weeks, or 10 weeks, you know, or beyond. Yeah. I did think that was a very clinically important study, though, because on the flip side, you don't know how long to wait. Four weeks was what the research showed. I'd probably wait six or eight, but before I'd heard this talk, I might make someone wait three months. And if they're not doing great after a knee scope, you want to make them happy. You probably don't have to wait quite that long. Excellent job. Fantastic research. We're going to invite up the next section, patella challenges and treatments. Thanks, Seth.

orthopedic surgeries

graft sizes

obese patients

tibial tubercle

press fit