Okay, so I'm here representing Beth Schubenstein. This is her talk. She talks exceedingly quickly and is brilliant, and I'll try to represent her while we only have a little bit of time here, so I'll skip around a little bit. Am I going out of here, out of the way? I'm just using arrows, right? Yeah. All right, maybe just click. Okay, cool. Okay, no disclosures. We'll sort of skip that stuff. We've been talking about great quotes and thinking about how to plan. One of the main strategies in patella femoral surgery is to identify what the problem is. Is it pain? Is it instability? Or is it both? If you don't do this on the front end, you end up treating a patient only for their instability, you can end up with a stable patella that is still painful. NPFL is often enough. We did a paper on a prospective cohort that is almost to its power that seems to indicate that most cases that don't have severely aberrant anatomy, huge J signs, NPFL alone should be sufficient. But there are cases where that's clearly not going to work, so these anatomic situations where you're asking your NPFL to pull the patella back into place, the NPFL should not be under resting tension. And if you need your NPFL to pull the patella back into place, odds are that it's going to get stretched. It's going to fail over time. So these are the patients that sort of jump out. Here's an extreme example of a J sign that's just dynamic with quad activation. And then that jumping J sign, that obligatory dislocation and extension. So these are the patients that you probably want to add something else. NPFL is the primary restraint to lateral dislocation. It's fairly isometric. We call this anatometric. It loosens in deep flexion. And if you're not careful, if you put it on tension, you can overload that medial side. We know that in the long term, complications decrease significantly. So if there's going to be something that comes of it, it's going to be in the early postoperative period. And then the rate of repeat dislocation is very low if this is done right. What we don't know though is who should get something else in addition to your NPFL reconstruction. So this is where it's kind of a judgment call right now. There are these dogmatic cutoffs. You guys have probably done peer to peers just like I have trying to justify your surgeries based on TTTG of 20 or not. And that's frustrating. And we're trying to do some studies that prove it one way or the other. But the gist right now is that if there's significant malalignment, so in my world, that's most commonly sagittal. So really high riding kneecap or coronal plane in the form of a really big TTTG or essentially the extensor mechanism turning a corner to get to its insertion. And so if you don't treat the patient with the right surgery, then that's where complications arise a lot of the time in patellofemoral surgery. So there's really dramatic dysplasia there. You can see where the groove should be. And there's a giant skewering up into the lateral gutter. Another reason to add a tibial tubercle osteotomy, which is usually the thing we add to an NPFL, is an unloadable patellar cartilage injury. So full thickness lateral or distal cartilage injury, you can unload that pretty well with AMZ. And you can see how that works there. So tips to get NPFL right. You want to make sure that your graft is as isometric as possible. As the fulcrum of the circle, the femoral placement is key. Beth is amazing and uses a mini C-arm. I can't pull that off. She checks her anatomy first to palpate those landmarks. So medial epicondyle, adductor tubercle, the saddle between those two is where your femoral insertion should be. Then she checks her isometry. And then she checks her image. And she gets an image like this, which is amazing. And I couldn't do it. And I was trying to quantify the number of mini C-arm shots that were equivalent to one large C-arm shot. And I just decided to make the leap. So I find it much more reproducible in my hands with a large C-arm. But you can pick what works for you. Okay, so in the patella, on the patella side of the NPFL, the dreaded complication is fracture. So it's really, let's see, it's really common to try to avoid that articular surface. Sorry, I don't know how to, oh, there we go. And be really dorsal. But remember, that's the tension side of the patella, and that's the risk for fracture. So if you've breached that dorsal cortex, if you put your tunnels or anchors too anteriorly, that's what we worry about. Beth used to use a docking technique. I was her fellow when she made this switch. Not even because she saw any fractures, but because she had a lot of young people with very small patellae. And so she was making a four or five millimeter socket in the patella to dunk the graft. Steve Arnosky taught us that tendon heals on the bone, not into bones. You don't really need to dunk a graft in this situation. And if you spread out the insertion point, you can get a little bit broader approximation of tendon to bone. So she made the switch while I was a fellow, and I carried that into my practice to just use anchors on the patella and take the middle of the graft and press it against the prepared bone. So it's sort of scrape that subchondral bone, stay as far away from the dorsal surface as you can. And then on the femur side, apologies, I'm not sure what she was looking at there with the arrow. I think I might've moved the image up. I think it was pointing at the very dorsal anchor placement there. And so this was a late fracture from a tension-sided failure. So femur side, malposition tunnel is vastly the most common complication that we see. This x-ray is a sign of struggle. So you have three different attempts at MPFL reconstruction, all of which were two anterior and one was sort of wildly proximal relative to the anatomic origin. This will lead to graft failure because it's not going to be isometric as they bend their knee sort of high and tight. So proximal or anterior is going to be taking up tension inflection and you're either going to capture the knee or you're going to loosen the graft. One thing has to give. So that's where it ought to be there. And here's another example, very high and anterior should be way down yonder. And then another, and you can see that tight rope on the distal patella, which is a little distal. But again, as the fulcrum of the circle, the femur is what matters the most. So what do you do when you encounter a patient who's had a poor MPFL? You have to figure out what the problem is. So is it just instability again? Is it stiffness? Have they captured the knee? Is it osteoarthritis? Have they overloaded that medial patella femoral joint? Figure out what went wrong the first time. So avoid tunnels on the patella if you can. Keep your holes small, keep them away from the dorsal cortex. Use anatomic landmarks on the femur. Check your isometry. Set the length, so don't over-tension your MPFL. It does not want to be on resting tension, and we can talk about that a little bit more if you'd like. And then there's some evidence that if you, so there's that aberrant tunnel again, and if you bring it down, you're going to have a much more isometric construct. If you set the length of the graft with the knee inflection, you're going to have less post-operative apprehension. But it depends on your technique here. So I do a pull-through technique where I pull hard and I let go, and then I take the knee through a full range of motion. So in theory, I'm setting what the knee wants, and so I think if I bring that home wherever I put it in range of motion, that should be isometric, it should be what I started with. But if you have an anisometric graft, like Dr. Fulkerson fixes it on the femur first, then you've bought it. He uses anatomy, he does not use fluoroscopy. He's bought his isometry, then he checks where his graft is tightest, fixes it in that degree of flexion, and then it's only going to loosen from there. So you have to kind of pick your technique there. So there's an example of over-tensioning. It's not always this obvious. Sometimes in extension, you can still get translation and they just hurt, and it's hard to figure out what's going on. So sometimes you have to do a stepwise, like I'm going to release the graft and see if you're better sort of deal, which is not the most comfortable concept sometimes. So here's an example of a 16-year-old basketball player who first dislocated when he was 13. He had three total episodes and underwent MPFL at age 15. Post-operatively, he had pain and swelling with rehab and competition, and then he finally re-dislocated four months after returning to play. Not terribly lax, but did have a J sign, crepitus, effusion. Range of motion was good, though. Did have apprehension, though, and no endpoint to translation at patella. And you might have trouble seeing it from the audience there, but that is his original MPFL on the femur. So pretty anterior. You can see on the cross-sectional imaging here in a minute, you can see that lateral tilt on both sides. They were trying to dodge the phisis. He was not terribly ultra, maybe a little bit. So a little bit anterior on that MPFL tunnel on the femur. I think they were trying to preserve the physis there. But importantly, if you look at his patellar anchor, it headed for articular cartilage and did breach. So he's got a cartilage injury, which explains the crepitus and the effusions there. His TTTG is 17.4, which is sort of in this nebulous range where we're trying to make decisions. So you can see that anterior femoral tunnel over here on the sagittal. So options here, do you address the cartilage? Beth elected to treat the cartilage, because she was noticing that he had a J sign, which is Dr. Fulkerson himself's main indicator for a TTO. And he had effusions and crepitus. So she was putting him in the category of pain in addition to instability. Had an unloadable lateral cartilage lesion. So here's that cartilage lesion there. She actually did some cartilage restoration with a particulated allograft here, which grows in. And at HSS, they do a beautiful job of rigorously studying their cartilage restoration procedures. He had a post-op MRI that you can see. He's starting to get some fill there, but definitely better alignment. And that's his other tunnel in the more anatomic position there. And how are we doing on time? Should I wrap it up? Sure. Yeah. We're at one minute from... Okay. So one minute on TTO. Is that okay, real quick? Yeah, yeah, yeah. Okay. So TTO is a really powerful add to your instability work. You can medialize, you can anteriorize, you can distalize for ALTA. You can add risk. You can unload cartilage defects. That's another reason to do it. So you can customize this. I don't use a jig. There are some jigs out there. There's some cutting guides, but you can really dial in what you want to do if you freehand it. Just know that if you distalize for ALTA, that's a powerful thing to do, especially if they're very dysplastic, but you add risk of fracture. You add risk of non-immune. So you have to be a little slower with the rehab and make sure that you trust the patient to not waver on that thing. But I'll wrap it up from here, and then anybody can chime in with questions. Does that work? Yeah. Sorry we're a little bit over on time. We're not going to get to the ACL stuff, but we are more than happy to stay. So it's just about 8.30 now. The awards presentation starts at 8.45. Certainly feel free to pop out whenever you want to, but we're more than happy to stay and talk about cases. If we want to stay in a group, we can certainly do that too. Questions on anything or anything that people have as far as advice or thoughts in the OR technical tips, anything along those lines? Yeah, please. Yeah, please. I had a question. Just in general, post-op patients, how often do you get some phone calls back to check on patients? Because obviously, it's maybe more helpful if there's a complication or not. But I have some clusters that do something wrong, and I've kind of thought back and forth with what I've been calling back to see how they're doing. Sometimes I've heard that it doesn't really help since they're in pain and sleeping, and really just trying to talk them off their meds. And sometimes, by the time I've seen them get better, I can't tell whether or not that's helpful or not. That's a great question. Yeah, that is a great question. Go ahead. Yeah, something that I've seen work really well, and probably the best person well-known for this, Don Shelburne, who's in Indianapolis. Many people know him as a big ACL surgeon. He has a team, and he has either a nurse or a physical therapist, somebody who's already met the patient. He has them. I think it's amazing, but he has them call the patient daily for weeks to see how they're doing. I think that's a little over the top, but the point is it doesn't have to be you. I think having a trusted member of the team check in, and that's part of their job. Whereas the surgeon, I think all of us are running around clinic, OR, doing other things. If we have a team that can be at a desk and check in and answer a lot of the questions that are very basic, and then fill us in as surgeons when we need to be brought in because the patient's really having a problem, that can be a good strategy is having a team that works with you, somebody that you trust to answer those questions. I do think that patients really appreciate it. I think when you're worried about something, or there's something special then reaching out, but I think it's not as easy or doable to call every single person. I do know surgeons that do that. I'm amazed, and I think that that's terrific, but I think this idea of having a team help you and then reaching out when you need to can be useful. I think one time that it really helps is if your surgery went late in the day, and they went home like, I don't know, I'm sure this happens everywhere. Like there's a change of shift, right? That happens in the PACU a lot of times. And so I don't know which PACU nurses are giving instructions. We've had a lot of turnover at our institution, especially with COVID. And so if my surgery went late, I didn't get a chance to circle back and talk with the patient postoperatively. And or they have a complicated thing that I just want to be like, don't externally rotate your shoulder with your subscapular anatomy repair, etc, etc. Then that's the patient that I'll give a call and make sure that we're clear on the guidelines and they're doing okay. Or if I have their email, like I get up at very ungodly early hours right now because I have small children and that's the only time I can do anything in life. So I'll send them an email at some four in the morning hour or whatever. And they, they tend to appreciate it. But yeah, there's only so many hours in the day. There's only so many you can tackle. Yeah. Great question. I very, very rarely do lateral releases. I seem to have the world's greatest population of Ehlers-Danlos in the Pacific Northwest. And they all come to me with their patellar instability. So you really want to avoid lateral release in ligamentously lax patients in particular. If you do a lateral release with an aggressive medialization, you can end up with iatrogenic medial instability. So if, if I'm doing a lateral release, it's in one of these examples where the patella is just living on the gutter and I cannot physically get it on top of the trochlea without a release. There are those in practice in the sort of international patellofemoral study group, group of experts that do a lateral lengthening will make it kind of two layers and gain a centimeter or so. I haven't had a lot of patients that I felt like needed a lateral lengthening. And so I'm very extreme in my practice. It's, it's either you're getting a big release in order to get you back up on the trochlea or, or not. Examining that patella in full extension and seeing if you can evert it to neutral, get a thumb under that lateral facet is very informative. And if their Baton score is high, I would stay away for sure. Yeah, I will say I like the lateral lengthening at times. I don't do it a ton either. I mean, I don't do a release independent at all. I think the, you know, the literature is certainly clear for that. But in conjunction with, with some type of stabilization, but I've liked the lengthening. I think just conceptually, it makes sense to me to leave some tissue on that lateral side for the reasons of incompetence, like Jackie said, that you can create this iatrogenic medial instability, which I've certainly seen as well. But the lengthening is not a hard procedure either. It's just basically dissecting between the layers and then just letting them slide and suturing it down with vicryl. So yeah, I've liked that. Yeah, I've liked that when, you know, but I probably only do that, I don't know, once or twice every other month. Yeah. Do you have any tips on how to document your surgery report and then when discussing with the patient when it's not something major, but it's something that certainly you've had, there's a partial tear or crack during the procedure and you felt like you couldn't really fix it and then how to put an extra screw. And sometimes it's something, you know, you strip the screw, but everything seemed to be okay. Any tips on that? When to mention to tell if the patient has the right medicine? Yeah, I think that's a hard question. I feel that constantly when there's, one of the examples I have in my ACL one is exactly that, where it was a revision and I was using, for whatever reason, they didn't have the normal screw I was using and I decided to put the position a little bit different and it basically severed 50% of the graft and I went to look and I was like, oh man. So, you know, it's obviously not great, but I ended up just putting suture in it and kind of putting it across and tying it over a button on the lateral side and she's done fine. But yeah, I mean, I think it's important to still document it for sure, especially if something goes wrong, to put it in the note. I don't try to make it a huge thing, but I do put it in there and document kind of exactly what happened so that if I look back or if somebody's revising it or something down the road, you know, you can get the sense like, oh, this didn't go perfectly. And then I'll just tell them and, you know, I don't know the right balance necessarily always of when do you make it a big deal and not. And some of it I think is reading the family and knowing, you know, are they kind of alarmist or not, but at least just telling them, hey, you know, we did have to do some extra suturing on the graft and had to put an extra button. That's why you see that out there. It felt very stable afterwards. We're gonna go a little bit slower in a rehab. So I've tried to just be open with it, but not, you know, make it a huge deal unless it really is a big deal like Alison's case where the person's really sick. Yeah, Matt, I think those are great points. And, you know, in your operative note, like I have a line in there, I'm sure many of us do complications and I like it when it's none and I hope that's the case. But, you know, what I would say is that if it's like, you know, oh, the screw is a little bit long. So I replaced it. I don't do that. Like I don't list it because I think it's pointless and it doesn't really, it doesn't impact the patient except potentially financially, I suppose. But the, something like a graft getting cut or being concerned with like a meniscus, like a couple of sutures ripped out. I don't think, I think that it may be a challenge. I think those cases where you think it could be a problem down the road with whatever happened there, I think those are the cases that you need to document. And of interest, when you look at medical legal concerns, when you're upfront and forward, patients tend to do better with that, which I think it's against, sometimes you think that's against common sense, like thinking that you make patients aware of a problem then they may be more likely to see you if something really does happen. I think it's usually quite the opposite that they appreciate your honesty. And then if the point of telling them about it, of course, is that you want to make sure everybody's aware of having to be cautious so that there might be a problem. And I think that's really the advice to take on that. So, you know, I've had that instance on several things and I just tell the patient, we need to be more careful because something happened. And the other thing today, I'm sure all of you are starting to see this, patients now get their operative note. Like they actually get that copy and they scrutinize it, they come in with yellow highlights and especially if it's some of a complication. And so, you know, I still think it's like Ana, it's still a responsibility to take to put it in there, but it's really an interesting thing now that patients are actually reading that. In our institution, they've been getting their notes for three years. So, you know, I've sort of lived through that whole thing. It's not new to us at Duke about that, but it is a little bit challenging to have people who don't really understand a lot of the terminology now coming in with highlighted notes and all, but I still think it's just, there's still different ways to word things. And I guess I try to be on the side of being honest about it, but not being an alarmist. There's lots of, I think there's lots of ways. Like, you know, my favorite thing is, speaking of this like topic, we used to have something called M&M, Morbidity and Mortality Conference, and they don't like it now, it's Patient Safety Conference. And, you know, this politically correct kind of thing, which no, it's truly morbidity and mortality usually, but it is, there's different ways to word things. And I do think sometimes risk management does not like us to be so honest, but I think people appreciate it. It's my family member, I'd want to know from the surgeon if something really happened in there. That's how I try to look at it. I think the other part of that is if you're really worried, like if you come out of the OR with something on your mind, don't hesitate to hold the patient back a little bit on their usual rehab protocol. You know, I had my starting running back do my, I blew out my first back wall on my darn starting running back on a division one athlete, and I was just dying over it. And, you know, I did the right thing and backed it up and switched techniques, and he did great, but I was losing sleep, and I called my co-fellow because I didn't want to admit to a mentor that I'd screwed this up, and I was like, I should have gone into family medicine, oh my gosh, and he was like, just have him touch a weight bearing for a little bit. And like, and it was fine. We slowed him down and he took it really well, and nobody seemed to mind that. But, you know, you beat yourself up about it, and just realize you're not alone, and it's better to keep the patient safe and informed, you know. Question in the back there. So you just harvested a graft and hit the deck. Ooh. So I'll tell you, actually, this just happened to one of my good friends like a month ago, and it was a Macy graft, where then you have no bailout, really. And so she called, and I will say, for a structural graft like an osteochondral allograft, Brian Cole actually has published on this that you can do serial corhexane washes, saline, put it back in if you want to. Certainly I would go tell the family in the middle of it, but yeah, this just happened a few weeks ago where it was a new nurse, the team wasn't the normal team, you know, all these other kind of factors, and basically the Macy graft got contaminated. And so she scrubbed out, I think she did the right thing, scrubbed out, called and said, hey, what do I do? And I said, well, first of all, go out of the room. Leave the room, go to the bathroom, splash water on your face, and just take a breath for a minute. She was like, I am gonna kill somebody. And I was like, you can punch them later, but you still gotta get through this case. And so I said, look, just see what's available at the hospital and in the area. Call a couple of reps, see if there's particulated cartilage, if there's some other off-the-shelf option that you can have. I said, you know, the patient's fine. They're under anesthesia, they're okay, everything's fine. Called and she called back, she said there's nothing available, but she'd already made her TTO cuts and hadn't actually, or I'm sorry, had already put in her anchors for the NPFL. And she said, there's nothing available, and I was like, well, it is what it is. Like, this sucks, there's no way around it. This sucks, but sometimes you just have to leave it unfinished, as Allison said at the beginning. So I said, just tell the family, we're just gonna have to come back. This is not ideal in any sense of the word, but hopefully your ultimate outcome is not gonna be affected. Just unload those patellar anchors, don't do the NPFL, and just come back in eight weeks and do it again. But yeah, I think if it is a structural graft, you can certainly consider for, at least for cardioid, for osteochondral, consider doing serial chlorhexidine washes, and there's a little bit of data behind that. But I don't know if you guys have thoughts on that. Yeah, like super quick with MACI, they always save the patient's cells, so it is not done. They could have you another graft ready in two weeks. And interesting with an NPFL, like if most of us probably do a absorbable screw or something, or a screw there on the femoral side, you can unplug it. You can basically take the screw out and just unplug the graft, even if you've already fixed it. It's really easy a couple weeks later to come back, take the screw out, pull your graft out, it's not gonna be healed very much. And you can redo this, you can just unplug that, flip that back over, fix it two weeks later, and refix the NPFL or something. Even though nobody wants to have to go back, another anesthesia, you don't really have an out there. Unless there was, and I would be a little cautious, I like Matt's idea of look around and see what's available, but particulated cartilage is not approved by most insurers. And so if you do something like that, and then the patient gets stuck with the bill because nobody pays for it, that is gonna be a huge problem. Because either you're gonna have a really mad patient that has to pay for something when MACI was already approved, or your cost, your center, your department's gonna eat that cost, because, yeah, so just be careful about that, but there is an out for that. I've seen a number of grafts, it's more like ACLs, where you harvested an autograft and it ends up on the floor. It's the same thing, like serial washing that. I wouldn't want to take another, especially if it was a BTB or something from the patient. You don't want to be harvesting something else from the patient at that time. And so kind of looking up some of that literature on serial washing with chlorhexidine is certainly something to think about. I think it makes us all pretty, it makes us nervous. But in that setting where you've harvested something like that from a patient, and then not using it or something I think is really difficult, you don't want to use an allograft in that setting, usually with a young patient or something either. I think an ounce of prevention is worth a pound of cure in this situation too, and it goes without saying, but Russ Warren taught me to have sterile baggies on the field, and so when you harvest the graft, I don't think there's a whole lot of learning involved in holding a graft, so I get to hold the graft, the resident does not hold the graft, I hold the graft, I switch tables with the graft, I put the graft in a wet lap, in a kidney basin, in a sterile baggie, not the sterile baggie, clip it to something stable, and then if it falls on the floor, it's in a sterile baggie, it's still sterile. I highly recommend that. I'm not that far into practice, I guess, to say that this is foolproof, but knock on wood, I haven't seen it yet, I don't want to see it, I haven't had to do serial washes. So I highly recommend a sterile baggie, it's cheap, it's reproducible, and you can hold the graft, and I just, I tell every resident, like at this stage of my BTV, if this cut is amazing, this might fly out of the wound, and so somebody has to hold the graft here, and just sort of emphasize, emphasize. Always a snake in the grass. Our team laughs about it, like it's a joke to them now, not totally, but just verbalizing it too, like back to the communication thing, of just saying, I always verbalize, I have the graft, or if the resident's there, just saying, okay, exactly, you have the graft here, and then when this Macy thing happened, I told the store in the OR, and they're like, oh wow, that actually happened, I'm like, yes, this is what we're trying to prevent, this can happen, and we don't ever want it to be in my OR, so. But yeah, I think the communications side of it is good, and even just little things, I always look at the floor before I walk back and forth with the graft, I tend to make a mess on the floor with scope fluid, and so I just don't want to slip and fall, and be hitting my head, and holding the graft up in the air, or something, so. Well good, we're kind of over time, wanna make sure that you guys have time to get over there, we really appreciate you all being here, happy to talk more if you wanna come up, but enjoy the rest of the meeting. Thanks so much for being here. Thank you.

patellofemoral surgery

Beth Schubenstein

pain

instability

medial patellofemoral ligament

graft placement