Patellofemoral Instability (with Elizabeth Arendt, MD)

On this episode, we delve into the topic of patellofemoral instability. We are honored to welcome Dr. Liza Arendt, a renowned expert in orthopedic sports medicine and a professor at the University of Minnesota. Dr. Arendt shares her journey into the field, her experiences as a trailblazing female physician, and her extensive knowledge on knee conditions.

The episode covers a wide range of topics, including the evaluation and treatment of patellofemoral instability, the importance of detailed patient history, physical examination techniques, and the role of imaging in diagnosis. Dr. Arendt also discusses her approach to nonoperative treatments, the use of various physical therapy modalities, and the decision-making process for surgical interventions.

Listeners will gain valuable insights into the nuances of treating patellofemoral instability, the significance of body movement patterns, and the evolving paradigms in orthopedic surgery. Whether you're an orthopedic surgeon or physical therapist, this episode offers a comprehensive overview and expert guidance on managing this complex condition.

Don't miss out on this opportunity to learn from one of the leading voices in orthopedics. Tune in, and if you find the content helpful, be sure to leave a five-star review and a comment. You can also follow the SKC Podcast on Twitter and Instagram @theskcpodcast, visit our YouTube and Facebook pages, or contact us via email at [e-mail].

Episode Transcript

(00:00):
Music.

(00:11):
Podcast. This is Dr. Benner, and I'm here with Scott Bauman,
my co-host, for another episode.
If you'd like to find us on social media, you can find us on Twitter and Instagram at the SKC Podcast.
You can go to the Shelbourne E-Center Podcast's YouTube and Facebook pages to
check out our content there.
If you'd like to contact us, you can email us at theskcpodcast at gmail.com.
You can find us on all major podcast platforms. And if you like what you hear,

(00:35):
check out our previous content, leave us a five-star review and a comment for
those that that come behind you.
As Dr. Benner was talking about with previous content, specifically last week's
episode, if you haven't listened to it, go back and listen to that one. We had Dr.
Kameth on from the Cleveland Clinic over in Ohio, and he talked about low-dose
aspirin as a safe and effective prophylaxis for DVT prevention in total knees.

(00:55):
So we had a great conversation about the efficacy of low-dose aspirin,
and if you haven't listened to it, go back and take a listen.
Tonight, we have another guest talking about patellofemoral instability,
and she's a recognized expert that I think I've seen talking about this topic
at about every meeting that I go to, and I've always enjoyed listening to her
talk. I know she's a contemporary of Dr.

(01:16):
Shelborn's and has had a lot of time discussing these neat topics with him and
debating things as well.
So it's a pleasure to have Dr. Liza Arendt on tonight's show.
She did her medical training at the University of Rochester for medical school
and residency, and then went on to orthopedic sports medicine fellowship at
the University of Minnesota, where she has worked ever since.
She is professor and vice chairman of the Department of Orthopedic Surgery at

(01:40):
the University of Minnesota and a team physician for Gopher Athletics. So, Dr.
Aaron, thank you for joining us tonight, and we're glad to have you.
Thank you for the invite.
So, let's start with just kind of your introduction to medicine before we dive
into the subject matter.
I just always think it's interesting to hear how people got to where they are today in medicine.
So, how did you you get involved in medicine? What was kind of your gateway into our field?

(02:04):
Well, I come from a blue-collar background, even though my father was a white-collar
worker in a blue-collar area in Chicago.
I'm one of nine children. I'm the seventh of nine.
And all of us were somewhat involved in our studies in math and science.
My older brother did want to be a doctor, and he went on to be a biology teacher,
but that sort of first spurred my interest.

(02:26):
I thought that if I got the grades, I'd go into medical school.
That was kind of a simple solution for me.
And I sort of, I hate to say it, I like the idea of having some independence as a female.
Growing up in a Catholic environment, the only women in America,
positions of a profession were teachers, nuns, nurses, and not really so much doctors.

(02:52):
So I kind of thought that nursing or some field of medicine would be what I
was aspiring to when I went to college.
Yeah, well, that's great stuff. And then once you got into medicine,
how did you end up choosing orthopedics?
Well, it kind of chose me. I'll try to make this quick.
I I went to a college in 1971 and 1975, as you quite remember,

(03:14):
that that was the year the enactment of Title IX.
Title IX was enacted in 1972 to be fully sort of incorporated into the colleges in 75.
So we did not have, we had two female sports when I went there.
We were a Division III school in upstate New York.
And I wanted to play volleyball. I played volleyball in college.
I went to try to, so I went to a gym class. It's the only place I could find

(03:37):
that could play volleyball.
Teacher called me over and said, what are you doing? You know volleyball.
I said, yeah, but I want to play it. Well, why don't you help me teach it?
So I started helping teaching the class.
And that was just around the time that Title IX was rolling in.
And we decided to create teams.
So we created a volleyball team, a women's basketball team, and we had a women's

(03:58):
field hockey team already.
But the other part of that was that they needed a female athletic trainer.
Because at the time, we only had male athletic trainers, a male training room.
It was part of the football area.
It was connected to the men's locker room. It was not co-ed.
And they felt that this was a necessary component. So they kind of talked me
into being a student athletic trainer, which I did.

(04:20):
And that's what really opened up to me this great field of musculoskeletal medicine.
And I believe I would have been a physician, but I would have gone into something
extremely boring like pathology or microbiology because I kind of like looking under the microscope.
But I'm certainly glad that it changed my mind. So that's really how I got into
it, by being an athletic trainer first.
And then when I went to medical school, I started hanging out with the orthopedists.

(04:43):
And that's how I got here today.
Very good. And, of course, then I assume that is how you then went into sports
medicine once you were done with orthopedics. She felt like,
I assume that that was a kind of a natural progression on how to stay involved
in that realm a little longer.
Yes, I think I was very interested in body mechanics and I've often toyed with
the idea of exercise physiology as well.

(05:04):
But I think that when you go into sports medicine in particular,
as opposed to let's say oncology or arthroplasty, you know, you really have
to analyze the mechanism of injury to best be able to understand how to treat overuse injuries,
improve overuse injuries, and maybe even mechanism of injury and things like ACL,
but tell from a location, et cetera.

(05:26):
So that, that was, that was really the driving point. Cause I really liked anatomy.
I really wanted to know mechanism of injury, et cetera.
And knowing your background, as Dr. Benner had said, everybody knows,
including ourselves, that you're really an expert in the field when it comes
to the treatment of knee conditions, specifically patellar instability.
So knowing the background of how you got into medicine and specifically into

(05:47):
sports medicine, how did you further that focus into something specific like
the knee joint and, like I said, in particular, patellar instability?
Well, actually, my first foray into looking at sex-specific injuries was actually
the ACL. And that's actually how I got to know Dr.
Shelburne, because obviously that was the big focus of his, probably still is.

(06:07):
And I ended up having the privilege of being on the NCAA Safeguard Committee from 1990 to 1996.
And they did have an NCAA database, what they call the ISS, Injury Surveillance System.
And I thought, why not try to find a database that sees if women have more injuries than men?
I was a teen physician at that time for both men and women. and that's at our school.

(06:31):
And we had so many ACL injuries. They were, even as it came in from high school,
but also when they were college participants and we had very few on the men's
side. And so I was struck by that curiosity.
So that was really the first, I looked at the database. I did it over two years.
And then published it, well, actually presented it at ACSM. And then we ended

(06:51):
up doing a five-year study, which is the one that was published, I believe it was 1993.
And I wasn't the only person looking at it, but it was really what I think is
sort of a landmark paper that showed a fairly big database where men and women
playing the same sports, and the database collected in the same way, showed two times,
actually three times higher rate in women's soccer and women's basketball than

(07:14):
men over a college period.
And that was all three divisions, one, two, and three. So that was really the start.
Then just a quick caveat. So then as you probably know, we had a lot of injury
mechanisms going into how do you solve ACL injuries?
And they looked at functional valgus, knee, hip control, et cetera.
And when I came back and tried to incorporate this into the training room,

(07:37):
my female athletes, I found that a lot of these sort of body movement patterns
were more prevalent in people with anterior knee pain and with patella dislocations.
And so that got me kind of thinking, you know, was this, you know,
what was the relationship?
And I think that the ACL was a little bit more prevalent and sort of captured the imagination.

(07:58):
But I think that patellofemoral pain and instability, though maybe not as common,
was maybe a bit more disabling. And nobody knew very much.
To me, the patellofemoral, big black box, nobody could tell me, like, why do we do this?
Why do we do that? that you know that the treatment was always the
same you you know you you do a vmo advancement
you move the tibial tubercle and you know

(08:20):
and you cut the lateral retinaculum and but and everybody
regardless of what you had you could have anterior knee pain you
gain the total stability it seemed that everybody it was a one-size-fit-all
so that's what got me thinking there's got to be more to it and that's really
got me into the patella femoral joint and here i am today only joint well it
sounds like you know a big part of your practice and a big part of what inspired

(08:42):
inspired you to go into medicine was just looking at female athletes'
injuries and just the relative paucity that there was of females in orthopedic
surgery and in sports medicine.
And I know you've been a leader in that realm of, you know, more and more female
sports medicine physicians.
So quick sidebar from talking about the patellofemoral joint,
just maybe a more interesting topic is what was it like to be a female team

(09:05):
physician at that time and how has that changed over time? So you can probably talk about that.
Yes, I could. And I will say that I was very much accepted by the physicians, not so much the coaches.
Football, when I did my fellowship, I was sort of the fellow that went along
with football. I never did football as an independent physician.
And the policy at that time was that a woman couldn't be in the locker room

(09:29):
on game day. Now, this goes back to 19...
I'm trying to think my years now. It would be about 1980, 1981.
No, no, it was later than that. It was 1985.
So 1985, I was not allowed to go in the training room.
When the doctor that I did my training under said, hey, you know,
she's a fellow, blah, blah, blah.

(09:49):
He said, okay, she can come into the training room, but she can't say anything.
I don't want, you know, she has to be silent, you know, stand behind the wall.
And, you know, I accepted it. I mean, what are you going to do?
But it was just, it was interesting.
And I also remember another incident is I decided I was doing Saturday morning
training room for the football team.

(10:10):
And I rode my bike to the, the training room and I wore what I thought were
very, you know, I don't have a body that I try to show off, but I wore very,
very long kind of to the knee culottes, a very,
you know, a polo shirt with like this little sports related jacket over it.
Everything Everything went fine.
That Monday, my, my, my fellowship advisor said, so you went to the training room on Saturday.

(10:34):
Did you ride your bike? I said, yeah, as a matter of fact, I did.
And he said, well, you hit shorts on.
I said, well, technically they weren't shorts. They're culottes.
But, and he said, I wouldn't do that again.
And I, you know, and so it was like, I just thought that this was so crazy.
So, I mean, I felt that I had oversight over the silliest things,
but, you know, I learned a long time ago just to keep focused on the target.

(10:55):
The target was my education.
And even though these sidebars were an annoyance, they never really interfered
with my education because he went to bat for me to get into the training room.
Now it doesn't matter. I mean, now, you know, women are team physicians and
going to the training room as well as men being team physicians for women and
going into their training rooms.
And so I think that things have changed quite a bit in a pretty rapid period of time.

(11:19):
Yeah, great stuff. And so it sounds like you're kind of a trailblazer in that
regard with many other females, I'm sure that you can name us as well.
But, you know, great, great stuff from the from the past there.
So once you were in sports medicine, kind of got your start,
as you said, in the ACL, then you became really a recognized authority in patellofemoral instability.
So, what I was hoping to do tonight is kind of walk through just a,

(11:41):
not a specific case, but just talking about how we take care of patients with
patellofemoral instability.
You know, at our office, when we look at our data, we have 10 to 1 ACLs to patellar
realignments when we go and look at our database as it relates to data.
So, we have 10 times as much ACL reconstruction data as we do patellofemoral instability data.

(12:02):
And we're still able to learn what we can from that, but it's just not as common of a problem.
And, you know, Dr. Shelbourne's point has always been, and I agree with him,
that, you know, if you're a general orthopedic surgeon, you do just a few ACL
reconstructions a year.
You know, if you're doing 10, 15 ACL reconstructions a year,
you're maybe only seeing one or two patella dislocations.
So it's not something that's super common.

(12:24):
And it's something that I think there's some real benefit in having specialists like Dr.
Shelbourne and yourself who really focus on these things. So,
you know, let's walk walk through, you know, kind of how that works when a patient comes in.
What's the initial history you're really interested in? What questions do you
want to make sure you get answered that may or may not be part of a normal history
you take for a patient when you really start to hone in on this might be patella

(12:46):
instability, one of those kind of initial history points that you want to make sure to hit?
Well, I think in today's sort of acute injury clinic and the need to know,
you get an ACL, you come to a diagnosis of an ACL pretty quickly.
Most people who injure their knee get a big fusion come in get an mri and the
mri pretty much tells the story with patellar dislocations it could be that

(13:09):
way but traumatic patellar dislocations are one.
Category, but there's a lot of people who have sort of global laxity that may
have some instability that doesn't really present as an acute hemarthrosis.
And so I do think that you have to be a little bit more investigatory.
In addition, to me, the first thing that I try to do is separate out pain from instability.

(13:32):
You can have both, but one of the things I ask is, why do they think their patella is dislocating?
They may not use those words, but describe the instability episode,
try to think about, you know, what was the mechanisms of injury again? And does it make sense?
The second thing is, do you have pain in between? Like I always say,
like when your knee is behaving, you know, do you have much pain?

(13:53):
And most patellofemoral people don't.
And then if they do, then you think a little bit more about some arthrosis that's
in that patellofemoral joint.
And the third thing is that I, especially when they've had long standing episodes
of their knee, let's say they've had it for 10 or 15 years.
I always ask, well, why now? what brings you to the physician now.
And typically, some people say, sadly, some of it's an insurance issue.

(14:17):
Sometimes it's because it really didn't bother them that much,
but now there's overriding pain.
And that typically means there's some degree of patellofemoral arthritis.
So I try to divide out those categories. I try to talk to the patient.
These oftentimes are young females, sometimes young males, and make sure that
the patient, to the extent possible, speak for themselves.

(14:38):
And then I try to establish their strengths, but not so much typical,
like what does a dynamometer for your quad show, but how are their body movement patterns?
Do they have that functional valgus knee? Do they have that anterior knee excursion?
What kind of core stability do they have?
A lot of times these are really skinny young girls, a little bit,
no real body definition, and they really don't have too much body,

(15:03):
lower extremity strength.
And so I think that it's It's important to establish where the patient's coming
from and then what do they want to do? What do they want out of their knee?
Are they going to go back to being a multi-sport athlete or do they want something more solitary?
And what degree of strengthening do they do now?
I mean, I don't mean you should be strengthening every day as a pre-adolescent,

(15:24):
but I do think almost all sports has to have a component of strengthening along
with learning good body movement pattern. And I think that that's a little bit
lost on these club sports and maybe.
A grammar school sport where, you know, you've got 30 kids on a team or something
like that. So I think it's important to try to, that's where I think physical therapy comes in.
So yeah, a couple of interesting points you brought up there.

(15:46):
A lot of times, as you know, when patients come to us with ACL tears,
diagnosis already made, they already know they have an ACL tear.
So we spent, still spend time asking people about the details of the injury,
but in reality, the, you can see the look on the parents' faces,
on the kids' faces, like we already know where this is going to just,
just tell us what's going on versus, versus the patella femoral patients.
It's they, they may, they may not know that. And the patella subluxation,

(16:10):
I think was something that I made a lot more, I diagnosed patella subluxations
a lot more early in my career for just stuff that I didn't know when I,
when I didn't know what the answer was.
And a lot of times that gets pinned to, well, I think they're,
I think their kneecap might have went out and, and that,
that diagnosis, diagnosis in quotes gets to us a fair amount or we have to like
you said dig in on why do you think it's come out how do you have that that

(16:33):
question's an interesting one that i i don't know that i ask in that
specific way and is that is an interesting way to look at it i
always think it's important to to to figure out also is this a one knee problem
or a boat knee problem because it's a traumatic problem where everything you
had a bad injury that made this happen or were you just walking across the living
room one day and the kneecap came out and i think there are some clues to be

(16:54):
learned you know in history as as you you've stated,
a lot more important in patellofemoral instability than it really,
as it really relates to ACL tears or other kinds of knee problems.
I wanted to make another point, and that's going to show my age,
but when you think about the ACL, the landmark physical exam was the Lachman's,
maybe the pivot shift, and that was approximately mid-70s.

(17:17):
That was for people who were skilled in doing the exams and did enough exams
that they knew how to do it.
So when it kind of reached the average general surgeon or general orthopedist,
it might have been mid-80s and early 90s. And that was just about the time that
MRIs had enough clarity on trying to diagnose.

(17:37):
Acute injury might have been easier to diagnose, but they began to look a little
bit more of what does a chronic ACL injury look like?
They ended up making sure that the cuts, the sagittal cuts were turned along
the length of the ACL, et cetera.
So that whole evolution with ACLs was, we had a similar thing with MPFLs,
but we didn't even know the MPFL existed as a ligament per se until probably about 2002,

(18:02):
2003, maybe a little bit before that.
And when we ended up doing more MPFL reconstructions, that sort of captured
the minds of the sports medicine physician because now they had a relatively easy operation.
Of course, all operations have their technical issues, but also one that was
arthroscopically driven, which sports medicine people love.

(18:24):
And probably the majority of our patella dislocations in this world will do
fine with an MPFL reconstruction.
So that kind of captured the imagination of the the average sports medicine
physician, in my opinion.
And at the same time, we began to know a little bit more about,
you know, the bone bruises with the patella dislocation and,
you know, what, and then making all these radiographic measurements.

(18:46):
And all of those radiographic measurements really came out of,
initially out of Lyon, France, and that sort of menu a la carte with Henri de
Jure and David de Jure and others.
And I think that, you know, we're very driven by measurements in radiography.
In the the telepharmal knee and
i and i think hip is kind of close behind that
but you know we're getting to that point with acls too i i was

(19:10):
convinced from early on that there's going to be an anatomic equation that puts
an acl knee more at risk you just you see it in families you see people even
with a good reconstruction you know get injured again and i think we're not
completely clear on how to measure it and what to do about it but now that we're
looking at convexity of the the tibial plateau,
the length of the tibial plateau, et cetera, the curvature of the lateral femoral condyle.

(19:33):
I do think that there's going to be an equation that's going to put a knee at
risk and whether we advise them not to do pivoting sports or not is something
that will have to unfold in the future.
Because a lot of these anatomic things, we can't change so easily.
Yeah. I also thought there was an interesting point that you made.
A lot of these kids are pretty young and the temptation, you know,

(19:55):
you're in a busy clinic, you have 25, 25, 30 patients to see,
you're trying to get from one place to the next.
And it's much easier to just ask mom and dad what's going on and not,
and, you know, turn, physically turn your body away from the patient and just talk to mom and dad.
So I try to be very intentional with the, with the pediatric,
with, with younger kids in general and high school and middle school kids in general.

(20:16):
Turning and facing the, turning and facing the patient, talking to them directly
and kind of, I'll just sometimes I'll just sit there until they talk,
which sometimes can be a little wild with middle school kids,
you know, mom and dad are trying to talk.
They kind of look over quickly, but quickly turn back to the patient.
I feel like one, one, you get the information directly from the,
from the injured person.

(20:36):
Plus it creates that kind of, you know, middle school and high school kids,
you know, they, they, they, they need to trust you just like the parents need to trust you.
And sometimes we forget about that. And I think directly engaging with them,
make an eye contact with them, turning your body towards them makes,
makes a big difference. Yes. Well stated.
Now, going back to the physical exam piece of it, when you mentioned the Lachman's

(20:58):
for the ACL, and I thought you gave some great examples of some specific history
questions when you're evaluating these patients with patella femoral instability.
Are there any specific physical exam tests that you perform?
And I know you mentioned you noticed that there's poor core control.
Is that something you're observing? Is that something you're testing?
And if so, how? And what other tests are you looking for with these patients?

(21:19):
Well, there's a whole slew of things I could say, but I want to focus on if
you have a relatively quiet knee, maybe a little bit of a chronic issue.
I think that they, you know, you look at a straight leg raising effort,
of course, and they, people can have a very subtle lag.
They never really get to full extension. And you find this much more in the
patella femoral compartment. Then you look at range of motion,

(21:41):
and then you look at how the patella tracks.
And there is this thing called a J sign where some people call it dislocation
and extension, but you know, the patella actually starts a little bit outside
the groove and then hops into the the groove and varying degrees of flexion.
And it can be very subtle. And I think subtle ones don't necessarily need to
be fixed, but I think that noting tracking is important.

(22:03):
So for me, I look at, you know, of course, range of motion, quad control in
that open chain range of motion activities, tracking of the patella in particular in early flexion.
And then I would say the laxity of the knee.
Now, as Rodney already mentioned, you can have bilateral issues and patellofemoral
disease much more so than with ACL disease in my experience.

(22:26):
But I do think that looking at quadrant translation, and you really want to
move that patella two or three quadrants to the lateral side to show the incompetence of the MPFL,
doesn't mean you necessarily have had an injury because you can have laxity,
but I think if you have asymmetry, that's really important. And I find it interesting.

(22:47):
I mean, it almost seems so dated now we are in 2024, but I would say 2005.
2010, I had people literally go into surgery and operate on patella stabilization
without ever testing if the patella was unstable.
And I don't think anybody, hopefully, would have gone in and done an ACL reconstruction

(23:08):
without proving, at least under anesthesia, that they had a pivot shift or a positive lockman.
So I think we're well-trained enough now, but people just didn't understand that.
And again, it's not foolproof.
Apprehension sign is a very common one, but not everybody shows apprehension.
But everybody should show translation, increased lateral translation of the patella.

(23:30):
And it may be, if it's different than the other side, you've landed the diagnosis.
If it's not, if they're both, you know, lax, then you might have to search a little bit more.
That is that hyperlaxity? Was that an injury?
But usually between the history of the physical exam, you have your, your situation.
And then for functional valgus knee, I actually look at bridging.
I look at both coronal plane with the functional valgus knee and a sagittal

(23:53):
plane where you have what we call anterior knee excursion.
Basically your, your butt, your body is upright and you bring your knee forward
over the toes such that they don't engage in good squat mechanics and good squat
mechanics are necessary for good athleticism of your lower extremity.
And that's true for ACL and MPFL stuff. But I do believe these young skinny

(24:14):
females have that anterior knee excursion quite frequently.
And so I look for it, but I got to tell you, I have this exam that my,
my therapists go through before they see me, if they're a chronic injury, if they're referred in.
And so I get all the the information on their strength and their body movement
patterns before I even see them.
And that helps me incorporate everything at once so I can talk to the parents about a solution.

(24:37):
Yeah, we originally coupled that medial lateral translation with just holding
my thumbs against the lateral patella and then putting my index fingers under
the medial patella and almost just lifting it up.
It's almost like a Walkman test for patella femoral problems.
You can check side to side and see if somebody says, I've never had any problems on this knee.
Go over and lift up the medial side of the patella, stabilizing the lateral

(24:58):
side, and then go into the other side.
And really seeing that patella tilt almost, you know, sometimes 60,
70, even almost 90 degrees, that it's kind of incredible sometimes how far,
you know, that will lift off and can be a useful ag jump.
But, you know, the J signs is a big one. I've been noticing more in one patient
in particular that I've had that is having recurrent instability after a tibial

(25:22):
tuberculosis osteotomy where I moved medially and not distally because his measurements
weren't measuring high,
but he did have a J sign.
And now post-surgery, he'll tell his track normally on x-ray, but he has, as Dr.
Shomer calls it, an L sign, where
he's gone from a little slight J sign to moving it over a little bit.
Now it jumps even, it's almost like it made it jump even more to the lateral side.

(25:45):
That's a buzzkill when they come back to clinic and you start to notice that.
So let's pivot and talk a little bit about imaging.
Once you've gotten that initial history, You've done your physical exam and
you're starting to review images.
I feel like at meetings when I see cases up, almost always we're looking at
MRI scans and CT scans immediately.
And I would assume that almost everybody starts with plain radiographs in clinic.

(26:11):
So kind of what's your go-to views that you really like and how do you progress
on to further imaging from there?
I get standing radiographs hip to toe. I think that's important for young people
because you can gain so much more with that.
Obviously, you can see coronal plane alignment, which maybe isn't so important,
but it's good to know a lot of these people have slight valgus knee.

(26:33):
If you still have open growth plates and you have high valgus,
say greater than four degrees, or the weight-bearing line falls in the middle
of the lateral compartment, you should think about guided growth because a valgus
knee will aggravate that sort of Q vector.
The reason I like to get long leg films is also because you can get a hint of
whether the limb is inversion.
And in our institution, we point the toes forward.

(26:56):
And if you have increased external tibial torsion, and you point the toes forward,
that's going to force the femur to internally rotate.
Rotate and of course if you have an aversion in order
when you when you're standing upright you have you internally rotate the
femur and when you see that you usually see that the
lesser trochanter are hidden and you also
see that there's rotation of the tibial spine

(27:18):
that sort of abuts the lateral femoral condyle so of course you can couple this
with your physical exam but i think that long leg alignment view gives you a
good a good view of chronoplane alignment and just a hint of limb version although
you can't say with just the image alone whether it's femur or tibia then you
go to of the true lateral, I think that that's really important.
And that's really where I look at my, you know, all of my trochlear thoughts,

(27:40):
like how deep the trochlear is, whether how long the trochlear is,
whether it has a super trochlear spur, I think those are important.
And then of course you measure, I measure patella height on the true lateral.
And then I think the third component of that is a low flexion angle axial view.
I do Lauren's view, which is a little bit from my upbringing in upstate New

(28:01):
York, close to Toronto, where the Canadians do more Lawrence view.
That's a 20, 60 degree view. I usually just do the 20 degree view.
Most people in the United States use the merchant's view, which is a 30 degree
view, but I think it has to be low flexion.
If you go up to 45, you're going to miss a lot of patella subluxation.
So for me, true lateral, low flexion angle, axial view, and a long leg view.

(28:25):
I don't think the PA view for me is as is important. I know that the sports guys are crazy about it.
To me, I think that it doesn't tell me much more than the standing alignment view.
And in a young person, I mean, are we really looking for medial compartment
narrowing or lateral compartment narrowing that you get on the PA view?
So I deserve that more towards the arthritic realm.

(28:46):
So maybe as you push more towards age 40 or something, I don't get that routinely in my patients.
Do you have a specific degree of flexion that you try to get your lateral view
in for patellofemoral instability patients.
As you know, if you put the knee into full extension, it's hard sometimes to
be able to judge whether that patella tendon's really been pulled out to length
or not, and whether you're getting a true assessment of patella height.

(29:10):
That's interesting. Yeah.
But I think it's more by accident. If you, you know, I spent a lot of time in
France thinking about things and looking at the way they do,
but they do what they call a monopedal x-ray where they're actually standing
and then they, they're standing on one leg and they lift the counter leg up,
you know, sort of like a stork because you have to get an image of the knee.

(29:33):
And so you have to move the other leg out of the way.
So they believe that if you do that monopedal, you're forced
to have the patella stretched stretched out to its longest length because you
were actually for most people you're activating the quad i think
that that's a little bit tough and that has not just been the the
custom in the united states but if if you're going
to so most people just put the the the image

(29:53):
leg forward i think that it's usually around 30
degrees but the canton de chance is not dependent on a specific
degree but if you think about it if it's in full
extension you got to do something with the other the leg the reason we
adopted this sort of forward stance is that
you you get the other leg out of the way so you kind of do like a little like
an early lunge so i think that the patella tendon is usually stretched out if

(30:17):
you're getting to be about 30 degrees of flexion i don't think that's true so
much for the mri the mri you know we typically try to get it in full extension.
Or as close as to full extension as he wants to be and a lot of times if that
patella is not the patella tendon is wavy, so it's not out to length.
So I don't really know what to make of that so much, but I do think you have

(30:37):
to be, that's why I think the MRI is a little bit more or less precise in terms
of the looking at the position of the patella on the MRI.
Yeah, I agree with you on the low flexion axial view. We see so many patients
come in with Houston views where the knee's bent, you know, 75, 80 degrees.
And you see that image pop up and you see so much of the femur.

(30:59):
You're like, this is not an x-ray I can work with on a patella for a more instability patient.
And it's really striking sometimes when you look at how dead centered the patella
is on a Houston view, and then you back them off to the emergency view.
And the patella is tilted 45 degrees and 50% subluxed on the merchant's view. It's kind of striking.

(31:20):
We kind of do a little bit of both of what you were talking about when it comes to the lateral view.
We tend to take our lateral x-ray at like 45 to 60 degrees of flexion.
So we're sure that we have the tendon pulled out to length.
We actually get a quad contraction lateral where we take a lateral view with
the patient contracting their quad.
And it's almost like a radiographic j-sign that

(31:43):
you can see where the inferior articular surface of the patella is
versus the top of the trochlea and we
kind of use that as another surrogate marker of patella alta a radiographic
way that and we also use that when we study we'll talk about this a little later
talk about this visualization of how far to distalize people is on that quad
contraction lateral how far is the patella from the articular surface up out

(32:04):
of the groove that we probably need to reduce it down to,
to, to get the, to get the patella back in the, in the groove without coming
out with patella ulta. So that's one that Dr.
Shelbourne, I didn't know about it. Never, never took that x-ray as a,
as a resident or a trainee or a fellow, even until I got into practice and started
working on it and started to use it. So we found that an interesting one as well.

(32:27):
Also, I don't think I'd ever heard the word monopedial x-ray.
I heard that at the meeting just at AOSSM just recently.
Although pedo i think i know what that means i don't think
that must be a european european terminology yeah
very french and very german german yeah so
now that we've covered more of the exam when you get these patients in the office

(32:49):
let's let's shift gears and talk about some some treatment strategies for this
so let's just you know give me a basic case you have a young female comes in
with a first time patella dislocation you've done your exam you've nailed down
as patella femoral instability.
How are you treating that first-time dislocator? I think that in the absence
of a treatable osteochondral fragment, meaning that it's large enough to put

(33:11):
back or large enough to take out, I'd really encourage physical therapy first.
And there are a lot of people who don't agree with that because they feel like
they're likely to go on to re-dislocate.
So there are a lot of algorithms right now that say if you have,
Looking at the risk factors and the big risk factors are patella height,

(33:33):
high-grade trochlea dysplasia.
And I would say maybe lateral patella tilt.
I don't think TTTG has as much to play into this whole discussion.
And I'll explain that in a minute. But the more instability factors that you
have, the more likely you are to be dislocated. And probably those are imaging risk factors.

(33:53):
And probably the biggest demographic risk factors is open growth plates.
So that you could make a case of going quicker to surgery if you have,
you know, more than three risk factors or you have had instability on the other
side, which has not been,
which did not respond to physical therapy and therefore you went on to reconstruct the ligament.

(34:16):
But my reason for trying to slow down the process a little bit,
in my opinion, is that almost all of these could use some rehab or prehab because
I think that going into surgery,
being stronger in both legs, having better core stability is just going to make
the whole process better.
And I think that if you are trying to concentrate on strengthening and body

(34:39):
movement patterns and core before surgery, then maybe after surgery,
you can concentrate on getting your motion back and getting that sort of essential
quad strength back again. So that's my logic.
I think that the paradigm is changing. I can't criticize somebody for moving
a little bit more quickly.
If you have high risk factors, a strong family history, instability on the other

(34:59):
side, but I don't think rehab hurts.
I personally think it doesn't hurt in the ACL either, but you know,
most people want their ACL done fairly quickly.
And so they, most surgeons feel like, oh, if I don't do it, somebody else is going to do it.
But I think that in the patella femoral world, at least at this moment in time,
I think that most people favor rehab first.

(35:21):
I'm never in a big rush to operate on first-time patellar dislocators,
especially in very young kids.
That 12-year-old that comes in with a first-time patellar dislocation.
But you understand, they're a really good basketball player.
This kid's the best softball player on their team.
This kid's still 12 years old. I'm just not really excited about operating on

(35:43):
young kids for a first-time patellar dislocation.
One clarification that I will ask you about is how do you take into account
upcoming seasons and seasonality as it relates to sports participation?
You know, we do a lot more, and something we'll hit a little bit later,
we do a lot more imbrications than reconstructions when it comes to medial soft

(36:04):
tissues for patellofemoral instability.
And those patients seem to get back quicker and quicker the more we do those.
If we sometimes will make those, kind of do the math on,
well, if you hurt yourself and you have three or
four months going to until you're back to your to your
season and it's a first time dislocation if we
rehab that patient probably going to take a month six weeks to

(36:26):
get back to playing if we do a medial
invocation lateral release relatively smaller surgery
they'll probably be back by the time they they they get
their their season gets up and going and and
do we do we make it less likely for them to have recurrent instability
if we treat it in that way so we will kind of
take those those factors into play and maybe sometimes get

(36:46):
a little more aggressive on first-time dislocators based on
seasonality do you have any of those thoughts when you're when you're talking
when you're talking to these young athletes and how do you handle that issue
well i'm not saying that sports isn't important to a young person but i think
that it's less important and if
the season is important to them i try to weigh whether we we can get by?

(37:07):
Do they respond to taping? Do they respond to a special brace?
When they feel lack of knee confidence, is it during the game?
How did they initially, okay, was it a sports specific injury or was it standing
at a counter and turning? I mean, I think all these things have to be weighed.
I think with MPFL reconstruction, and I did plenty of imbrications in my day

(37:29):
too, but I felt that the failure rate, in fact, published on it,
the failure rate, again, Again, just a medial-sided imbrication without talking
about a distalization in any way.
The failure rate was over 50%. And then I realized, and what I started doing
is imbrications, and then if they failed, do an MPFL reconstruction.
And this was around 2002 to 2009. I did my first MPFL reconstruction in 2002.

(37:54):
I felt that they got back almost as quickly, to be honest.
And so I say three months that you can be pretty normal with everyday walking
and maybe start some sports specific activities and maybe four to five,
four to six months, depending on where you started getting back to your sport.
So that is, you know, not a small amount of time, but certainly less than an ACL.

(38:15):
And I just lay it out. I think that parents have to.
I can't say I'm not empathetic with the seasonal issues, but I don't make them
be the guiding principle of what I tell people to do or not do or give my opinion in that regard.
Just so much variation from athlete to athlete, sport to sport,
age is a factor, you know, how important their athletics are.

(38:38):
You know, I don't take care of Purdue anymore, but I did for about 10 years.
And I take care of Wabash College at the Division III level,
and the reaction to an impending, we may need to do a surgery,
we may not at the Division I level versus the Division III level,
it's just markedly different, especially in the football players,
where the majority of people at Purdue think that they have NFL aspirations

(39:00):
and zero out of however many players there are have NFL aspirations.
I shouldn't say that, maybe one, have any aspirations of playing at any higher
level after playing Division III football. ball.
So a lot of nuance that we definitely can't cover in this, but it's an interesting
part of the discussion that, you know, you really have to take the temperature
with the parents and the athlete and the whole situation.

(39:21):
You know, talking about the first-time dislocators that you want to treat non-operatively,
just a quick background.
Before I got into the research side, I was a full-time physical therapist working
in the office treating these patients. So, you know, I hear these non-operative cases.
It always makes my ears perk up and see how you handle these.
And And so, you know, talk about timelines with NPFL reconstructions and things.

(39:41):
When you see these first-time dislocators and you do want to choose to treat
them non-operatively, when you're working with, or I guess, how do you handle
that with physical therapy staff?
Is that something you refer out to? Are they working with an athletic trainer?
And do you see any specific modalities that seem to be successful for that non-operative treatment?
And, you know, Dr. Benning, you mentioned everybody really presents differently.

(40:02):
That's something I've noticed too.
You know, some patients bounce back pretty quick and we get them in the office
first-time dislocator, and they're pretty full motion, minimal effusion,
and they get their strength back,
and they're only maybe 20% down to start with, and it's pretty quick.
But, you know, can you speak to that and what that may look like in terms of
their rehab if you're treating these patients non-operatively?
Well, full disclosure, the more that I got into the patella from a world,

(40:23):
the less I saw of the acute injury, I saw more chronic, and the less I saw of the non-complex one.
But, I mean, obviously, I started off seeing all things.
I would say that early on, to me, I'm going to repeat myself again,
it's all about body movement pattern.
I think as time went on, I do think that, I mean, I'm not opposed to things like game ready.

(40:46):
I'm not opposed to, you know, BFR now is a big one for quad strength.
I'm not opposed to those things. Some kind of NMES was always,
or electrical stim can be important if your quad's not firing.
I think that those modalities play a role, but sometimes they cloud.
The the hard stuff and that is trying to change
your your body movement pattern which

(41:08):
become becomes a habit and and so that's what
i think is is hard to change you're probably
too young but you know i also went through a phase of
protonics which is really sort of that posture restoration where they
talk about sort of control of your pelvis with with you know sort of unilateral
tilt etc and they had a knee device that sort of emphasized using your hamstrings

(41:30):
as you walk and And they sort of tried to activate your pelvis to be more stable
because you were trying to activate your hamstrings as you walked.
So, I mean, I think all of those play a role. But I also think that a good therapist
can sit in a room by themselves and do a good job.
I think if I had to say one thing that has been the biggest help is some kind of video.

(41:54):
And I think that could be as simple as standing in front of a mirror and doing
exercises or videotaping. And now that you can videotape on someone's phone,
you know, the patient's phone, I think sort of just like with other sports,
I mean, let's get back to golf and tennis.
I mean, I think sort of seeing yourself and seeing some of those body movement
patterns and trying to then put up the picture and show people what you're talking about.

(42:17):
I think that, that sort of that patient feedback, that, that visual feedback has been very helpful.
And I think we had other ways to do it early on. Now we just use people's cell phone.
So that so i think and i also use mcconnell tape a lot i will say i think mcconnell taping
if your knee is not too swollen i think that it's a good way to control the

(42:37):
patella for patella instability and it helps to activate the quad i think you've
got better body movement pattern once you you sort of stabilize the kneecap
and and so we do use a lot of mcconnell taping once you get
through that acute swollen phase.
Do you typically see McConnell taping be successful while you're going through

(42:58):
the actual rehab exercises or more with functional things as you're getting
back to your activities or both?
Probably both, but I don't, I mean, if you're talking about like partial squats
and leg lifts, probably that, but once you start to do some more functional
activities and then get back to a sport, I think that's where it plays the biggest role.
The other thing, though, I also use it if somebody comes in and is complaining of instability.

(43:23):
We use it and just, you know, we do a step-up, a retro-step.
We also measure their partial squat. You can see that, you know,
sometimes you can say, what's your pain level? And they give you a pain score.
You do a McConnell taping, and then sometimes, I would say often,
it reduces your pain score.
We also do a qualitative exam where it improves your body movement patterns.
And so it gives us a little bit of a hint into, I mean, maybe,

(43:46):
dare I say, how much better they would be if their patella was stabilized and
in the correct anatomic position.
So we do a fair amount early on as well.
So you've had these discussions with the patient, you've done all your physical
exam, your imaging, you've gone through the non-surgical treatment,
and the decision's finally made for surgery.
So walk us through a little bit on what your options are for patellofemoral

(44:10):
instability and what your algorithm is like for what to do for whom.
I think the biggest factor you have to first decide on is if they need something more than an MPFL.
And I'm going to just include the lateral retinacular lengthening with that
soft tissue proximal operation, you can get an idea of whether the tissue is
tight and your final assessment is often made in the operating room.

(44:32):
But I think that I do look at measurements a lot. I look at the patella height.
The original manuala cart that was laid down by Henri de Jure said that a candidate
chance greater than 1.2 was a reason to reduce it.
So if you had a 1.3, you'd reduce it to under 1.2. And they aimed at one, so equal length.
I think that as we've now had the MPFL. Remember, the original algorithm was made without an MPFL.

(44:58):
And so we haven't changed our idea of ALTA. ALTA is still 1.2,
but we have changed our surgical threshold.
And I think for most people, the surgical threshold for ALTA is somewhere in the ballpark of 1.4.
And I think that, again, you can't hang your hat just on one number.
I actually look at lots of different measurements, but I think,
as you alluded to, Scott, I think patellar trochlear index, which which is a

(45:21):
measurement on MRI of the overlap between the patella.
And the lower end of the patella and the proximal end of the trochlea groove is important.
The original person that talked about it was Aroli Biedert of Switzerland.
And he said that patella alta was less than 0.125, which is like a crazy number.
But it's about one-eighth. But then I said, well, that's not too much. But what is normal?

(45:44):
So I went and I looked at a couple of different studies. And then we had our own studies as well.
But Don Fithian did a nice study out of Kaiser around that time.
And he found that normal was about a third. So I kind of look for that one-third overlap.
And so, I mean, if I had to give a number, I'd say, you know, 0.22 to 0.25.
And if it's under that, I think that it may be ALTA. The other thing that's

(46:07):
interesting to look at, if you accept that, you know, I originally said that
sometimes you don't have your quad contracted and your patella tendon may be wavy.
But I think a really nice way to look at the qualitative aspect of whether you
have patella alta is as you look at your axial slices and you see the first
full cartilage coverage on your axial slice and you look up,

(46:31):
if you don't see the patella, then you know you have alta.
And if you just see the patella tendon, then you know that you have ALTA.
You may not know how much to move it. You may have to make measurements to do that.
I think it's a really quick and easy qualitative image to see in your office.
So I do look, do I think this person can respond to MPFL alone,

(46:53):
or I should say a soft tissue stabilization, MPFL plus minus lateral retina
lengthening, or do I think they need a distalization? Yeah.
What would you say the breakdown is for you as far as how many patients you
do just an isolated NPFL reconstruction versus how many you're adding distal procedures?
Well, remember, my population has changed dramatically as everyone in town is

(47:14):
doing NPFLs. So they always send the hard stuff to me.
And early on, I was the only one doing NPFLs. But I think if you look at sort
of a population of people, probably, I mean, that's hard to say,
It depends on your population, but more than 50%, I think, would respond to an MPFL alone.
Okay. Tell us a little bit about what your procedure is like for tibial tubercle osteotomies.

(47:40):
You know, we've kind of, at our center, gone and changed some things over time.
Dr. Shelburne went through, you know, Don went through an evolution on fixation
techniques distally and how much to move people.
And at first was not distalizing anyone. one.
Now we have kind of a lower threshold for distalization.
First, it was one screw for fixation. Then it was two screws.

(48:01):
Then it was a small plate to cross the osteotomy site.
And now we use, I use a hell of a lot of hardware for a tibial tube with osteotomy.
And I've gotten really aggressive with the early rehabilitation.
That's what I feel like is shorten that period that the patient's in the brace,
shorten the period where they can't really use their quad and sped recovery.

(48:22):
So tell us a little bit about how you do the tibial tubercle osteotomies and
how maybe that's changed over time.
Well, I can't remember exactly when I did my first desolization,
but it probably was about early 2000, again, because I was highly influenced by the French.
So it was about the same time I was doing MPFLs. I have actually written about

(48:42):
my first, I think it was 70 patients. It was published at AGSM in 2017.
And I do, again, I look for, I've already said Cantor-Dachon,
so we're 1.4, patella trochlear index less than 1.5, and then I try to distalize.
I will distalize down to, I aim for 1.1, but I will accept 1.

(49:06):
Well, I aim for 1.1, but I never distalize it more than 15 millimeters. 15 millimeters is a lot.
And I looked at my first 70. I believe I hit 15 that were between 10 millimeters and 15 millimeters.
And the only thing that I found when you distalize it that much is that they
had a slightly higher risk of arthrofibrosis, which isn't too surprising because

(49:31):
you're pulling a quad a little bit more.
People have debated. You know, it's funny. I also, in that paper that I wrote,
I also looked at lots of other papers in my review.
Very few people are saying how much they distalize. So it was really hard for
me to know what was an appropriate amount to distalize.
And in the discussion of my paper, I think I found one that was sort of kind

(49:54):
of intimated that they went up to 15. I think that was one from Australia.
But I think that people aren't commonly saying what they distalize.
That particular, on all of mine, I put the degree of distillation,
which I measure with a ruler, and degree of medialization, which I measure with a ruler.
When you come to medialization, I've never quite understood the TTTG phenomena.

(50:15):
So let's just say you have a TTTG of 25, which would be high,
27, which would be really high.
What does that even mean? And how much are you going to medialize it?
I mean, are you going to medialize it down to 10, down to 12?
So if you're really up to more than 20, are you going to really medialize it
10 degrees? I mean, sorry, 10 millimeters or 12 millimeters.
So I began to be more curious about that. And then, you know,

(50:37):
if you look at this thing called a tubercle sulcus angle,
which ironically enough, the first person to publish the tubercle sulcus angle
was actually Lonnie Paulus and Tom Rosenberg.
And they did it, their paper that they looked at patella baja after ACL, of all things.
And, you know, they talked about if you bend the knee up to 90 degrees,

(50:57):
your tubercle should fall directly under the patella. So they call it a tubercle
sulcus angle, and it should be zero.
Now, for them, they measure it in degrees. I have a hard time measuring like
a degree if it's one degree, two degrees, three degrees. I kind of measure it in millimeters.
But I just use a tubercle sulcus angle, and sometimes I medialize it, and sometimes I don't.
It's all based on what it is on the table.

(51:21):
Now, if you look at the number of TTTG, the absolute number,
as you know, it could talk about lateralization of the tibial tubercle,
which is what we all think it is.
It can be the proximalization because you're more medialized if you have high-grade trochlea dysplasia.
But the thing that we missed, and it's only become into recent light, is thru-knee rotation.
So patellofemoral instability has a lot more thru-knee rotation than the,

(51:45):
let's say, normal people or ACL people. And we're not sure if you stabilize patella, if it changes.
It kind of makes sense if your patella is way off, like, you know,
you've got these really dysplastic people that maybe that pulls the tibia more
into external rotation, you have more through knee rotation.
But I think it's something, that's why I think the TTTG is just so oversold.

(52:07):
Now, I think TTPCL maybe has a little bit more legs.
But I do think that if you look at John John Fulkerson's original work for that
Elmsley triac, they're the first ones that did medialization.
But if you do an AMZ, that was for lateral compartment arthritis,
lateral patellofemoral arthritis or arthrosis.
And so for me, moving the tibia medially alone, I reserve primarily for lateral

(52:32):
compartment patellofemoral arthrosis.
And when I'm doing it for instability, it's usually combined with some distillation
or it's really a dysplastic knee where you're doing a bunch of stuff.
But I don't routinely say this
is TTTG of 23, so we've got to do a medialization. I don't quite buy that.
I think in our hands, distalization, we have really gotten a little more aggressive with distalization,

(52:59):
I would say, in recent years as we've increased the amount of fixation that
we put into the tubercle and been able to get more aggressive with the early rehabilitation.
Rehabilitation we've we've have a little bit lower threshold to
to doing that now that i think maybe we used to we've also gotten
a little more aggressive on how far we distalize people it's interesting
sometimes people come in with patella tendon lengths of 70 millimeters

(53:20):
where the patella is just so so high
you do that and we do that quad contraction lateral view and measure
from the bottom of the trochlear articular surface to the top of the trochlear articular
surface and it's you know 16 18 millimeters that
where the patella is coming way up out of the trochlea and
you know you do that thing where you start to you know
get them over the edge of the table and see how much flexion they come

(53:42):
into before they start to come out or how much you know
as you're taking them into full extension how much bent how much flexion they're
in before the patella starts to come out and it's some some relatively significant
degrees of flexion where it starts to come out relatively early so you know
there we we did a for those for listeners that haven't heard about our thoughts
on that we did a five-part series on that back at the end of 2023 23.

(54:05):
Go back and listen to those episodes if you want to hear more specifics about our algorithm.
But I feel like the distalization is just something that people are just kind
of afraid of doing. And I understand why.
Ones that I did with Don, I was a little nervous to do them as well.
But especially if you beef up the fixation and you're aggressive with the range
of motion, we rarely see a significant amount of flexion loss after that surgery.

(54:31):
And we've had a lot of good results with it. So I'm glad that you and others
are talking about that as well, because I just feel like there is a little bit
of a one-size-fits-all approach for some people that, you know,
if you have patella dislocations, you get an MPFL reconstruction, that's all people knew.
To me, that's like saying all ankle fractures get a lateral plate and medial screws.
What if there's no medial malleolus fracture? Sorry, you get your two cannulated

(54:53):
screws and your medial malleolus, even if you don't have that.
It seems kind of nuts, of course.
To me, it's the same kind of way. If I sit to have somebody talking about doing
it, have somebody who has, the patella has a significant J sign that's 15 millimeters
high on the quad contraction lateral.
It's bilateral. It's a bilateral symptom. Seems It's a pretty clear case at
Patel Alta that they're getting an NPFL reconstruction.

(55:15):
To me, I've just gotten to the point where I'm much more aggressive with those.
So I think that's an interesting place that we're still continuing to learn about.
And, you know, it's through the contributions of you and other experts that
have been on the panel and guys like Don Shelmore that have taught us about
what to do on those. Just interesting debate, though.
And I still think there's a lot we don't know and a lot we have to learn with it.

(55:37):
I agree. That's what keeps me from the game. Yeah, absolutely.
You know, as we close up here, what are some things that you wish surgeons out
there knew about patella dislocations that maybe they don't?
What do you think is the most common thing?
Yeah. One point I forgot to mention, which is I learned late in my career.
Knee hyperextension is a very difficult thing to treat.

(56:00):
So if you hyperextend your knee, very hard to control that kneecap.
And it's a little bit of what we call a functional patella
alta you can't really change it with physical
therapy i mean i'm sorry you can't change it with surgery you could
maybe change it with physical therapy and it really means you know kind of controlling
that quad as you go to terminal extension so for when i have hyperextension

(56:21):
and for me that's greater than 10 so kind of fitting along the bait and score
i might lower my threshold for when i do a distillation and i I also might lower my aiming point.
So I might aim a little bit more for one. And sometimes I put people in braces
that, that have a hyperextension stop.
If I feel that they're kind of klutzy and can't, you know, they have a harder

(56:43):
time kind of getting into the habit of not hyperextending their knee,
but hyperextension is a, is a, you have to look for it.
And we miss it, especially in a lot of these young females, where they hyperextend
their knee and that's when the kneecap goes out, not the typical mechanism of
planting and, and pivoting.
Yeah i'm with you on that when you when you do that when we do that hyperextension lateral

(57:03):
it's it's amazing sometimes how what degree of
hyperextension the knee is in when we get that x-ray you know
i'm always focusing on how high is the patella but sometimes
you turn your hand five degrees to the right like whoa
look how much you know that means you start drawing lines like that means 15
degrees of hyperextension when it's getting that high so yeah an interesting
point as well so well that's one of them i guess but any other points that you

(57:26):
when you talk to people about patellar dislocations that you really wish surgeons
out there knew, but you don't think that they do.
I think that I would not be quick to rush into surgery.
Again, that's sort of my bias, but that's the way I was raised.
I also would say that I very rarely do cartilage restoration with the same time

(57:47):
as I do patella stabilization.
Now, that's rarely needed in a first-time patella dislocation.
Of course, if they have an osteocondyl fragment that's large enough, you put it back.
But I think that a lot of the wear pattern when you have chronic instability
Stability is because of the lateral translation of the patella that comes into
the groove, sort of laterally tilted, and that wear pattern is more on the lateral patella facet.

(58:10):
If you have cartilage wear that's completely from a dislocation,
it's more a medial patella facet.
So if you have that lateral patella facet, I think if you realign the patella,
they do better. I don't know how much better, but they do better.
And I think to combine routinely that, you know, oh, their cartilage is so bad,
you know, let's do macy or let's do, you know, some kind of cartilage restoration.

(58:31):
And then you've got bipolar disease and you've got to do bipolar Macy.
I just think it's too much. And you don't know how that person will do.
People always say, well, you know, do you do cartilage restoration?
And I said, well, I went through the first half of my career,
never having cartilage options.
And then I went through the second half of my career having some,

(58:52):
and I just never thought it was a smart idea.
When you go over to Italy, they have so many cartilage options.
You know, they're kind of leading the way with a lot of their studies,
and they do very few in first-time patella dislocations. You go over to Australia,
they don't have a lot of cartilage options. You go to France,
they don't have a lot of cartilage options.
I think in the United States, we're a little bit cartilage crazy, personally.

(59:12):
And I think that I rarely do cartilage restoration at the same time that I stabilize
the patella for the first time.
Maybe a revision. vision, and then you've got to kind of separate out what's
your problem. Is it instability or is it pain and swelling?
And sometimes it's both, but usually you can kind of flush that out a little bit.
Yeah, I think that last point's really important when you brought it up earlier

(59:35):
and now you brought it up again that I think is really an important one.
I remember a couple patients in particular that came to me for a second opinion
where, well, we think we need a kneecap instability surgery.
I've seen three other doctors, all of them say I need surgery,
and they think you need to do it because they don't do it on a regular basis.
And you have the patient come in and start talking to you a lot.

(59:58):
I've had, I dislocate all the time. My knee's big and swollen.
I've maybe had a prior surgery, maybe not. And the knee is really stiff.
The quad is, you know, down 20% quad girth compared to the other side.
We put them on the Cybex test and their quad strength's down by 50%.
And their knee has a five degree flexion contracture and a 10 degrees of flexion

(01:00:18):
loss. loss, and they're saying, we need a kneecap surgery, and we have upcoming
season here coming up soon as well.
Those are some difficult conversations sometimes. Like, what's the main problem?
How often is your kneecap coming out? Well, you know, my kneecap's not really
coming out that much anymore, but it hurts like hell.
And so we need to get this surgery because I hurt.
And those you kind of get, and you know this probably more than I do because

(01:00:40):
you're even more of a referral surgeon than I am.
That sometimes you get really put in a box on, they were told that Dr.
Arendt's the person that's going to fix this, but she's going to do this,
and this is what she's going to do.
And, you know, as you're starting to ask those questions, look at those images,
you're thinking, I don't want to do that.
How am I going to tell this patient that came here for that specifically?

(01:01:01):
You know what? I don't think that's the right thing at this point.
I think if we do that right now, I'm going to make you worse instead of better.
And this operation that we're talking Whether it's medial patella for malignant
reconstruction, tibial tubercle osteotomy, whatever it is, that is an instability
operation principally.
As we're discussing it, you're having pain because your knee's dislocated several times.

(01:01:24):
You're swollen. You're stiff. You're weak. You're deconditioned.
And if I do a surgery, all that stuff's going to get worse for quite some time.
So I've had some uncomfortable discussions with families about stuff like that,
as I'm sure you have as well. Well, great stuff from Dr.
Aaron. Thank you very much, Liza, for joining us tonight.
We really appreciate you taking some time late at night here to discuss all this with you.

(01:01:48):
And it's been really educational for us and we believe will be for our listeners as well.
Well, thank you for the invite. And I'm encouraged by the enthusiasm you guys
have for sharing this knowledge in the podcast forum. So kudos to your team. Seriously.
Dr. Aaron, I second that. This has been truly a pleasure and an honor for us
to be able to talk to somebody who's so knowledgeable and respected in the field

(01:02:09):
like you are with the treatment in orthopedics. So we appreciate you coming on tonight.
If anybody wants to get a hold of us, you can get a hold of us on Twitter and
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Music.