All right, so this is a 34-year-old desk worker, right knee, lateral patellar dislocation after a fall history. She had bilateral patellar dislocations like 14 years ago. So MRI, I apologize, I don't have the scans. The computer didn't like that this morning, so I'll just describe it. She had a hypoplastic trochlea, TT distance of 14, non-displaced fracture on the medial side of her medial patellar facet. On the coronal, she had some edema of her tibias, thought secondary to her fall. So I guess the question is, what I wanted to start was, if this lady is going to end up in the operating room, can we talk about how we find, I know several of us have already talked, or several of you already talked about, whether you're going to use x-ray, you're going to use ultrasound, you're going to use the anatomic position. How do you do that? Andrea, start for us, if you would. So I usually use the anatomy to get me in the ballpark, put a pin in, confirm the location on the floor, then do, I know it's not isometric, but I can't pronounce the other word, just make sure that it loosens inflection, and then move the pin as needed, and then overream. So anatomy, fluoro, and isometry. Jack, you use x-ray? Yes, I use fluoro, because I have a lot of patients with a BMI of over 30, and I actually use the fluoro to actually select my optimal skin site. Most people have a tendency, if you just look at the limb, and you're going to make your incision where you kind of think it is, and you can't palpate the adductor, it's going to be too anterior, and then you're fighting it the whole time. So that's my use. And then I do it similar. I locate it first with anatomy, then fluoro, and then I check anatomic matrices. Anybody got it, Pat, can do anything different? I actually like the fluoro, and once I get my spot with the incision, I use a little guide, find my spot, check which point, and then I make my dissection, and I can feel the saddle. But fluoro helps me. We started using ultrasound just out of curiosity, because they usually get a block. So sometimes, if they're not too heavy, you can identify your incision position with ultrasound. Just one comment on that is, I agree with Jack. I actually don't make my incision based on fluoro, but if I'd always air posterior, it's much easier to just retract anterior. And the number one problem that I see with patients coming in with failed MPFLs is that it's too anterior. So I think if you just start posterior, you're more likely to succeed. And I think it depends. If you do your surgery like Ned, which is, I think, how I do mine, if you fix it to the patella first, or at least you have the sutures on the anchor, it's really easy to check the isometry. Or Jack, can you tell us how you say that word? Anatomometric. Yeah, anatomometric. So here's the scope, the little condal defect, but what the MRI had seen was there on the medial patella facet. So this was basically to remind us to talk about that. So obviously, the goal is to avoid what you see in the picture on the left. And again, this is Bob Burks, and this is how Bob does it. But I think that trying to use two, as many methods as you feel you need to get that point, if you feel like you need to use fluoro interoperatively, I use the tendon position. And then if I need any help that doesn't end up isometric, then I have no trouble using fluoro. I'd like to just back up to discuss surgical indications. Sure. Because when it's 14 years out, that means she's pretty stable. And then she had a significant trauma. There was a lot of ecchymosis, so that was a big event. So in some of these, I will kind of reclassify them. In other words, I'll just act like it's a first-time dislocation. She probably has the risk factors to warrant surgery now. But I'm just saying, just because as you've had that many years intervening, you can almost treat them like a first-time dislocation and re-analyze. The MRI showed, and I wish I had the MRI picture, but there was a questionable loose body along the medial side of the patella. And obviously, we didn't find that. How many people would routinely do MQ-TFL or don't do that? Does anybody routinely do? Jack, do you vary it? I do both. There's a technique where you can do a subperiosteal dissection at the proximal pole of the patella for about 10 millimeters. Then I do the quad, just like John, so I have two arms right about Tanaka's point. Sabrina, what do you do? I use suture anchors unless it's a revision. And then a revision, I either do an MQ-TFL. Or in PFJs or revisions, a lot of times I'll turn down the central third of the quad, which we haven't talked about. Anybody else? The downside is, remember, every one of those anchors cost you $300 or $400. So if you include the quad tendon, and there's no difference, which I like to do, one in the quad and one in the patella, it's a money saver. So here, critique, go ahead, critique this. So what I do is to make a patella small, 3 millimeter, actually 2.9 millimeter hole in the patella. I like to put my stitches, the two sutures, then use those as, I'm going to try to check isometry. And I'd like everybody to speak about it. There's the adductor tendon. Dissect, like Ned showed us to do, and then pull your sutures out here. Use the anatomic position and put a guide pin in. And then what I try to do is to wrap the sutures around that guide pin, and then flex and extend the knee. Anybody else got a better technique or a different technique? Use the same. Same? Yeah. So that seems to work pretty well. Does everybody understand that? So you just wrap the sutures around, use a needle holder so you don't cut the stitches, and then flex and extend the knee. And as you flex the knee, those sutures should get looser, not tighter. Because if they're getting tighter, then you need to change the position. And if you can't find the position, bring the fluoro back in, because sometimes that'll help you. And the thing to remember is that high and tight. So if they're not getting looser or they're actually getting tighter, you're probably too high. So where do you start then? Because you inferred, but you said you have it at clamps. Are you clamping it at? Zero degrees, 10 degrees, 20, 60. I've heard, you know, gazillion degrees. I usually put mine at 20 degrees of flexion, and then tighten the sutures on your guide pin, and then flex the knee. And so anybody do anything different than that or anything better than that? No, the only thing you need to make sure is that if patients are dysplastic, theoretically, the reason to put it at 30 is because then, theoretically, patella should be engaged in a trochlea if they have a trochlea. So it protects you from over medializing them. But if they have a flat trochlea all the way through, theoretically, the patella could be too medial, and you set it with too much tension. John, any additional? I just really like Jack Farr's idea of setting it to length. So I'm concerned about any specific degree of flexion, but rather to just set that length at whatever the longest length is, wherever it occurs, I think is a good safety practice. So that was the discussion. So there, sometimes you can see with the scope. So I basically put the graph choices. Anybody use it? I know we were talking about allographs. Anybody use autograph? Pat? Gracilis. A lot of times, Gracilis. Gracilis, autograph. Because remember, the native MPFL is only 207 newtons, correct? So you don't really need to overpower this thing if you get it in the right position. So I use, this is probably a little controversial, I use a rotator cuff anchor in the femur. I don't drill a tunnel. And I just basically pull the graph down, and then put one of those sutures, kind of weave it into the graph, and then pull the, you can see, pull the graphs up through, and then stabilize it to the patella. Again, I think John's comment's good. You probably bend the knee as far as you need to to get the patella well-seated in the trochlea. So there's what we do, and then tie that at about 30 degrees. What's the ideal amount of laxity? What should we shooting for? If we could tie it really tight at 30 degrees, how much laxity do we want when we re-extend the knee? Jack, do you have any feelings? I have a lot of feelings. I don't like anybody to use the word tensioning, because tension means there's force in it. And what I'd like to have with the knee, so I'm in the trochlea, so maybe 10, 20 degrees of flexion, I'd like to be able to do one quadrant medially and laterally, and especially laterally. And if I have two quadrants, I'd rather have two quadrants than no quadrants. If it's no quadrants, I've over-tightened it. OK. Any, Pat, any? I make the point, when I pass my graph down my sutures out the femur with the sutures, I have to pull my graph tight. It's an interference screw technique. I don't have anybody touch those sutures. Amos showed the tension, the optimal tension on the Merrick experimental model was four pounds. So I just don't put any tension, so let the trochlea fit it. So I think the takeaway is don't over-tension your graph. A corollary of that, too, is you don't ever want to use your graph to pull the patella into place. The patella should go where it goes, and just put the graft in in that place. So you have to monitor it with a scope, really, at least I do, to assure that. Because if you pull it into place, and then the patient wakes up and contracts their quad, they're going to be pulling against that graft and could pull out the fixation or even cause a fracture, so. I think using the anchor on the femur is good. I think that's a good technique. And I showed that with the open growth plates. I think it's a good way to avoid drilling and injuring the growth plate. The way I show my technique, where you have such a long graft, I think there is a danger of having laxity in the two limbs of the graft. So again, I agree with everything that's been said, that you don't use the graph to pull the patella over. But you do need to go through that tensioning exercise. I'm sorry to use the word tension, but to get the laxity out of those two limbs. I know you mean length. And then you flex the knee at 30 or 40 degrees. And you've removed the laxity in your construct. And then you put your interference growth. So I agree with it. I totally agree that you shouldn't be pulling on the patella with the graft. Case two, can you put up? Go ahead. We just one more comment. If the patient has a lot of dysplasia, or one of these cases we've shown where the patella is sitting practically out in the gutter, I start with a lateral lengthening. So I have a big open lateral incision. And you have to be very careful that you might feel like you can translate the patella one quadrant laterally, but you're really just tipping it. So you have to make sure that those cases get a lot more complicated. And those I tend to fix in a lot more flexion, because then you can really engage it in the trochlea. But I think that's just something else to look out for. Very good. With the tension, it's really hard to put the anchors and get the right length of graft. It's so much easier the other way. So here's a guy, 24-year-old, initial lateral dislocation back in 2013. He's had numerous subluxations and dislocations since then. Tenderness along the patella, he's got a positive thumb sign, significant patellar overhang. Here's his MRI with a TTTG of 2.6. Anything we should take note here? Limited MRI, I agree. Looks like a du jour B, most likely. Yeah, a little nervous about that. How many of the faculty do trochleoplasties? You mean central groove deepening? Yes. Or just a little entry plastic? Either. Entry, yeah. Deepening, no. I'll take off a super trochlear spur on occasion. That's the most I'll do. So here he is arthroscopically. He's got that lesion over here. He had a pretty good, impressive femoral lesion, though. So he's been tracking pretty consistently laterally. So if you put the scope over on the medial side, you get a much better idea of where they track, as opposed to the lateral side. And I just wanted to make sure that I could reduce that patella without any kind of lateral procedure, as a lateral release or lateral lengthening. So if you can't get that patella reduced, how many people do a lateral release? Yeah, definitely. Yeah, lengthening. How many people do a lateral lengthening? OK, so pros and cons of lateral retinacular release. Anybody do a release? In the old fashioned way, where you just cut the lateral retinaculum and let the patella go over? Anybody do that anymore? I do on occasion, just enough to let it go to where it needs to go. And I think it works out fine. But I think the problem with lateral release is it's often overdone or done through the wrong indications. It's not the lateral release itself that causes the problem if it's done for the right reasons. So anybody use Jason Dragoo's technique of what he calls a pie crust, where he makes slits at different levels to let it lengthen? I haven't tried that. All right, so give us the scoop on why we should be doing lateral sided Z-plast-D lengthening. Jack? After, as was discussed yesterday, after the medial restraints are breached, the next restraint to lateral displacement is the lateral retinaculum. Adam had a paper on that yesterday. So if I'm going to keep it from going out the other way, you know, there's a certain number of people who have medial instability after a lateral release. Not a John Fulkerson limited lateral release, but I'm talking the community lateral release. So I would rather just maintain control of the lateral structures. Sabrina? I think another aspect is a lot of these patients do need some sort of cartilage procedure. And so if you're going to do an arthrotomy, I prefer to do my arthrotomy laterally. And the last thing I want to do is make a lateral incision. And so that lateral incision closed because I'm going to make them even tighter. So I think a lateral lengthening is imperative. Yeah, because Jim Bradley did his 41 athletes, he did lateral releases in all of them and had no recurrent dislocation. So I think that's probably the good point. You know, you don't want to go all the way up into the quad, so you have to do a reasonable lateral release. And I doubt any of his athletes had a beaten score of 7 or 8. No, I'm sure they did not. There we go. So we, you know, we'll use, you say, well, are you planning on doing an NPFL? We sometimes will mark that out just in case we decide we're going to. And again, there's the position. So everybody can be critical of this technique if they want. John, you're the inventor, so tell me how I'm doing. So I make an incision over where the tibial tubercle is because it's not going to be there very long. So that way when they kneel, they don't kneel on their incision. So I expose the lateral side of the tibia usually unless I'm just doing a very flat cut. So if I'm going to elevate it, I want to make sure I see the lateral side. Anybody not do that? I think if you're just starting to do these, you want to make sure you don't have a nerve acid complication. So I don't think it's a bad idea to see the lateral tibia. I leave the periton alone by just going under the lateral side of the tendon and then coming out the medial side. So that way I think I have a lot less tendency to get patella baja if I leave the periton. So there it is. We then- I use a 3.2 millimeter drill bit to outline the osteotomy. You put the first one in depending on how steep you want to be or how flat. That's what I think the individualization comes. If you want to anteriorize it because of degenerative disease, then it should be steep. If there's no DJD, then you can leave it flat. This guy had some teller changes, so we made it relatively steep. Then put the second pin in. I don't use a guide. How many people use a guide? Jack, you use a guide? I use a guide. Pat, do you use a guide? I don't use a guide because all I do is get down at the bottom of the table and make sure that I can't see the second pin- well, my original pin because I put the distal one in in the same plane. So I think that lets me make a little bit smaller incision. Not true? True. Okay. So there we are. So we did the osteotomy. We're going to complete the osteotomy down the side. You put them in perpendicular. You put them in the same plane. You put them more anterior to posterior. I use a lag screw fixation type device, so I want to try to keep my screw relatively perpendicular to the osteotomy site. True? True. The downside with that is I probably take half the screws out because when they- you don't want to leave them real long, but they will stick out and irritate the PEZ. And so if you have somebody come back six months later or four months later and they got pain on the posterior medial side of the knee, it's because the screw probably is sore. They don't seem to me to get that sore anteriorly. Anybody else have a different- how often do you take the screws out? John? 50%. 50%? 50%. Yeah. So there we are. Talk to us about fixation. Lag screw, I started adding a washer to the top screw. I have had some fractures. People fall. If they fall in the first couple of weeks, they'll fracture that fragment. Anybody else got any fixation thoughts? I use a different screw. If you look at the Synthia screws, they're conical, so they're really not designed to be used without a washer or without a plate. There are different screws that have a flat undersurface, so they're really compression. Ned, you use two screws, plate? I use the same technique you use with the two guide wires and without a guide. I use two headless screws. I hate to use company names, but the Arthrex 4.5 headless screws has a very, very good fixation and compression of the larger part of the screw. I don't put them directly in front, but you can put them directly in front to get cortical fixation and it doesn't- obviously, they're level with the bone, so they don't need to be removed. Indica's Gary paper using smaller flathead screws versus these larger Synthia screws and fewer people had to have their screws taken out with that. The other side of that, if you need to take screws out, they're harder to find, so take your choice. And they're more likely to break. So what about- so I've done a couple of them because I got tired of having a fracture. A third tubular plate, if you can still find them, a third tubular plate down the front and one screw distal to the osteotomy. Anybody have any thoughts? I just do that for fractures and luckily the fractures have not been mine, but I just did one this week. If you use the one-third- the locking plate and I did exactly that, just extend it beyond the osteotomy. Yeah, I've had my own share of those and it's always kind of a pain to have to go back and do it, so. So are we done? Should we be done? That's not too bad, is it? You like that? We didn't know- we didn't make it- we didn't- he's not too loose, is he? I should just add that Bill has a great chapter on this technique in Chantal Parikh's new book, to give him a little plug. He just came out with a book on patellar instability that's a really beautiful book. Chantal Parikh. I can't remember who published it, I don't know. Really nice. How many guys would- how many of ladies and gentlemen would stop there? All right, so there is his test. I got him at about 20 degrees. Is that more than a quadrant? 1-2. 1-2. 1-2? Is that good? Yeah, I think- I wouldn't- I wasn't sure. Based on that picture, I would say no, but I 100% of the time in a patient like this would do an MPFL. I think you add 20 minutes to your surgery and if you do your MPFL correctly, you add minimal morbidity. Yeah, I did too. So we went ahead and abraded the medial side of the tibia. We put the small 3.0 millimeter anchor in there and then we pulled on the medial retinaculum. So I'll just cite this article. Jason says that if you have- if you avalanche off the medial pole of the patella, you can fix that. So we essentially found the- what we thought was the MPFL or the remnant of it and repaired that instead of doing a reconstruction, but I would agree I thought we needed to do something more. I mean, just to agree with you on a different level, intra-op- some of these patients are two, three months down the road by the time they come to surgery and I cannot dislocate them, but I have MRI evidence of recurrent dislocation. So I'm going to treat them as if they are. So I'm not going to use my exam on the table to say, no, I don't need to do it. Yeah, I think that's- and I really honestly wasn't sure whether to do it. We had, you know, looked at where his MPFL should go in case we needed to do it. But that tissue down there doesn't need to be that stout. I think that John showed the picture. It's almost see-through. So if you can get tissue that's along the medial side that I think is an avalanced MPFL on the patella, even if it was done a long time ago, once we fixed that, he had about a quadrant, which felt good. I've just kind of been hearing what Bill's presenting here, but you've got to get the tracking really well balanced if you're going to do a repair or invocation, if you do it and they have all those dysplastic factors and they're not balanced, then they don't do so well with an invocation. Rehab protocol, I let them wait there right away, which I know is controversial. John, what do you do? Wait there. You let them wait there? I let them wait there, yeah. I put them on partial weight-bearing for four weeks and then progressive float by six. Do the same thing. Yep. Anybody got, we got time for one more? Or do you guys want to go? I got one more really controversial case if you want to see it. Please walk out if you've got to go. Yeah, yeah, if you've got to go. So can I get case three? Okay, you have to ask Pat because he's got to leave for a plane. Oh, Pat, yeah, if you've got to go, go. Okay. I should have shown this one first. This is the sports guy, too. Not that one. Go to four. So here, this is like, you know, like you pull your hair out. So I've got a 16-year-old female who is the state discus champion. She's a junior and she plays field hockey to stay in shape. And so she's out playing field hockey and she's got to play, she's got to throw the discus. This is October. She's got to throw the discus in March, April, May, otherwise she doesn't go to college. So she basically crumbles her knee. She's got effusion, tendonitis along the medial border of the patella, thumb sign, patellar overhang. She's got positive Lachman's and a positive McMurray sign. So there's her post-injury X-ray, MRI, her ACL tear. So I hate to read X-ray, so I'll just tell you what, or MRIs, I'll just tell you what it is. So she's got femoral ACL avulsion, she's got a medial meniscus tear, her TT distance is 22, lateral patellar subluxation, which looks like a transient dislocation, but no chondral derangement. The right knee was normal. What are you thinking? Not looking good for college. Pardon me? Yeah. Yeah. Ned, what do you think? I'm sure this is not the answer, but I would predict that she would not be able to compete if you did nothing. If you say, OK, we're going to treat you conservatively, we'll rehab your knee, brace your knee, and get you to practice, and get you to throw in five months. I would predict with the pivoting, with the shot put, I don't know what technique she uses for shot put and discus, but it involves rotation and pivoting with a flexed knee. And again, it's not the first time. I mean, I've done this, I've been doing this for a long time, and I've had a lot of patients to participate with a torn ACL, torn meniscus, and I think that they would have a hard time participating. So I would generally advise them not to try to go for that. I would take a little, you know, I would talk to them about it, but I think there is some potential hope for this athlete. You've got to get rid of the bone fragment, get things stabilized. This goes, in my mind, right to Beth Schubin-Stein's article, I think, because we do know that if we do a good MPFL or MQTFL, I absolutely would do an MQTFL, by the way, in an athlete like this. She will be stable by the time she needs to go back and play. The problem is she's not going to have much chance to get ready before that. But I think if you do an MQTFL and you get her, in spite of her high TTTG, you can make her stable and potentially get her back to play. She's got to be really motivated, and I'd tell them there's some risk that she wouldn't, but I do think it's conceivable with that approach. I actually had a patient like this just about a week ago. Anybody else? What would you do with her? Jack, you're being awful quiet. It just goes back and forth on, when you're doing MPFLs, if you do them on enough people, somebody's going to get stiff, and we do not want her to get stiff. We have to get Don with his extension brace out. But remember now, she's got a medial meniscus tear, too, and an ACL tear. That's what I'm saying. The more surgery you do on her, the more problems she's going to have. Any other comments before I show you what I did was probably harassing? Our option was ACL repair versus reconstruction, early return to sport. Obviously, we know that that's dangerous. MPFL reconstruction versus TTO, meniscus repair versus excision. Here's what we did. We fixed her medial meniscus. You can't see. We put a couple stitches and used a rotator cuff repair approach and locked them into her patella. We used an internal brace with an endo-button-like device in the tibia and then pulled all those sutures out through a femoral tunnel made with an outside-in technique and did an MPFL reconstruction. Go ahead. Let me have it. I think it's great. What'd he say? Yeah. All right. The only reason I bring this is because she actually did pretty good. This is her at the state meet in May. She didn't like her brace, so she wouldn't wear it. She won the state again and got a scholarship to the University of Delaware. You're the man. Yeah. That's sports medicine. Yeah. All right. I'll leave you with that. Thanks.

knee injuries

patellar dislocation

surgical treatment

MPFL reconstruction

ACL tear

medial meniscus tear