0:00

We'll open it up to any questions.

0:02

Yeah. So, so Brady, thank you.

0:04

I mean, great cases, some of 'em a little bit complex,

0:07

but let me, uh, we have a few minutes for questions

0:11

and hopefully some answers.

0:12

So Brady, I'm gonna start with you, uh, submitted questions.

0:16

There's two, regarding the femoral tunnel screw,

0:20

is it crucial to be at 10 o'clock, two o'clock?

0:25

What about the position of the femoral screw

0:28

with ACL reconstructions?

0:31

So you'll probably, that's a good question.

0:33

You'll probably get different answers, uh,

0:35

from different orthopedic surgeons.

0:37

So depending on the screw position will,

0:42

um, kind of confer different stability to the knee.

0:47

So some surgeons will say, well, I meant

0:49

to place it a little bit lower, uh, to confer, uh,

0:52

more rotational stability

0:53

of the knee while other surgeons say, I want

0:55

to put it slightly higher to confer more, uh,

0:58

translational stability.

1:00

And that is where you start to di dive in the discussion of,

1:03

uh, whether we should be doing double bundle reconstructions

1:06

to more, um, anatomically approximate the true, um,

1:11

an anatomy of the ACL.

1:14

So, um, I think for just one bundle, I think the 10

1:17

or two o'clock position, uh, in that Corona plane is,

1:20

is a relatively good position.

1:23

Good. There's another question here.

1:25

I don't quite understand it.

1:26

I'm gonna read it to you the way it appears here,

1:29

and maybe you can clarify it.

1:32

It says this, if there

1:34

are any infection post ACL reconstruction,

1:39

when there is an indication to re operate.

1:41

Uh, so I think, is there any infection

1:45

in post ACL reconstructions when there is an indication

1:49

to reoperate?

1:51

Do you un I'm not quite sure. I, I

1:52

Don't quite understand that.

1:54

But I mean, from the infection standpoint,

1:56

the patient should obviously be seen by their physician,

2:00

have the relevant, um, laboratory parameters, um, in hand.

2:04

That would include things like E-S-R-C-R-P,

2:07

which we know are non-specific, um, as well as white count.

2:10

And if there's any concern for infection.

2:13

Um, you know, as radiologists we're often called upon to,

2:17

um, aspirate the joint.

2:18

Uh, sometimes do bone biopsies,

2:20

but more often just to aspirate the joint,

2:22

at least get a white count

2:24

and see if the fluid in the synovial, uh, space is,

2:28

is a high white count.

2:30

Um, and then of course send the, uh, the fluid,

2:34

whatever we get for culture and sensitivity.

2:36

Okay. I have one question I wanna ask,

2:39

just a general question.

2:40

When, what are the situations

2:42

where they might do an ACL repair rather

2:46

than a reconstruction?

2:48

Well, that's a really good question.

2:50

Um, sometimes they'll do it, uh, for partial tears.

2:54

Sometimes they'll do it for very high, um, uh, tears or,

2:59

or tears near the roof of the intercon or notch.

3:02

That's, uh, you know, that's few and far between.

3:05

Um, they are doing that at some high-end, um, places, uh,

3:09

like Steadman, uh, Hopkins and Philippon.

3:12

Uh, our orthopedic surgeons are not doing them as much.

3:16

Um, most of them, the vast majority are undergoing

3:18

reconstruction, so they're clearing out the native ligament.

3:21

But for partial tears, you might see that done.

3:23

I've even seen, um, patients undergo, uh,

3:26

isolated single bundle reconstructions for partial tears

3:30

as well, rather than a complete reconstruction.

3:33

Okay. Thanks for many.

3:35

Uh, I have a submitted question, uh, which is,

3:39

would it be helpful to drain the morel lala la

3:42

lesion to speed healing?

3:48

I don't know if many you're you're muted right now.

3:50

Yeah, she says one second.

3:52

She did turn the light on. Sorry. That's

3:55

Good. I've lost the screen.

3:56

Um, the general consensus is

4:00

that these tend to recur after drainage.

4:03

It's not just a single episode of bleeding.

4:06

The injury that takes place also disrupts the lymphatics.

4:10

And so there tends to be lymphatic fluid

4:12

that just keeps collecting, uh, in the, so the

4:16

accepted treatment for these is to do prolonged compression,

4:20

and if that doesn't work, uh, to then try to attempt

4:24

to sclero de the lesion, um, by putting in some kind

4:27

of irritant to try to get it to seal.

4:30

So, uh, we don't even try hydrating these

4:33

because of the high rate of them, uh,

4:35

they fill right back up.

4:38

Okay. I have a, a question I wanna ask you.

4:40

I've seen several cases of Lyme disease in the knee

4:44

and, uh, some of them have had prominent lymphadenopathy

4:48

as well as myositis.

4:50

Is that one of the diseases we should think of

4:52

with lymphadenopathy? Yeah,

4:54

I didn't mention it.

4:55

I think the cases of Lyme disease you've seen must have been

4:58

sent to you from outside

4:59

because we don't see Lyme disease here in California.

5:03

Certainly the literature emphasizes the importance

5:06

of particularly pop platia edema

5:09

as being very distinctive in Lyme and lymph nodes.

5:12

I I just generally include infection in my differential if I

5:16

have lymphadenopathy.

5:17

Okay. And I'm sure what,

5:18

what exactly is causing the infection varies

5:20

depending upon where you're living.

5:22

I know in India it's always, they say tuberculosis.

5:24

I say cocc city or my Cause you say potato. I,

5:29

Uh, I have just a comment on one of the things

5:32

and, uh, any input from you is fine.

5:35

The, the, you were talking about ganglia intimate

5:38

with a gastrocnemius

5:40

and, uh, I agree with you that in the cases I've seen,

5:44

it's been the medial head that more often I see

5:47

that alteration.

5:48

So many years ago, one of our scholars began a study, uh,

5:52

never published of what the femoral attachments were

5:55

of the medial and lateral heads.

5:58

And on the medial head there were often two attachments

6:01

of the tendon with connective tissue in between,

6:04

whereas the tendon

6:06

of the lateral head was a single connection.

6:08

So we thought maybe because of that difference in anatomy,

6:12

it might explain why the ganglion cysts are more

6:15

common on the medial side.

6:17

I don't know if you have any comments about that or, or,

6:20

You know, I've talked to you about this over the years.

6:22

I, I personally think there are two heads

6:24

of the lateral gastroc anemias

6:26

because I often see an attachment at the lateral condyle

6:29

and then a separate bundle of fibers that inserts just

6:33

above the FCL that's often confused with thickening

6:37

of the upper FCL.

6:38

So I'm not convinced, I, I'm not convinced

6:41

that the anatomy is different

6:42

and I don't know how many specimens they had,

6:44

and I never saw the specimens from that

6:45

Part. There wasn't a lot of

6:46

specimens,

6:47

and that's one of the reasons we didn't publish it. So I'll

6:49

Show you, I'll show you some of the cases sometime maybe

6:52

next week of, uh, what looked to me like a,

6:56

a separate bundle coming over the FCL from

6:59

the lateral gastroc.

7:01

So I don't think, I don't use that as a distinction.

7:05

Okay. Uh, another, I just have a couple more things

7:08

I wanted to ask you about.

7:09

Uh, we talk about the ligamentum mucosa

7:12

and the course of the ligamentum mucosa as it courses

7:15

through hoffa's fat pad curves up

7:18

and attaches to the patella, often near the junction

7:22

with cartilage in the inferior pole of the patella.

7:24

And I've been impressed with all altered patella tracking.

7:28

When we do have fat pad edema,

7:30

we often have edema about the ligamentum mucosa.

7:34

Is that something you have seen at all?

7:37

Uh, you know, I've noticed it,

7:38

but quite honestly, I see so much edema around it.

7:42

Whenever there's a joint diffusion,

7:43

like I think fluid from the joint can track

7:46

along that structure.

7:47

So I don't think it's a very specific finding

7:50

for tracking dysfunction.

7:52

I I, you know, our practice has a lot of injuries

7:55

with big effusions and you'll often see that happening.

7:58

So it is a non-specific finding.

8:00

Yeah, we were gonna start a study on that and,

8:03

but we never got around to really, uh,

8:05

doing anything with it.

8:07

Uh, I wanna ask you another thing

8:09

because, you know, we deal with Achilles tendinosis.

8:12

It's often a bilateral process.

8:14

How often do you think quadriceps tendinosis,

8:18

if you image the other side,

8:19

would the quadriceps tendon more likely be

8:22

normal or abnormal? What do you think?

8:24

I think tendinosis is a bilateral process. I, I really do.

8:28

But I think the activities that people do, first of all,

8:31

their protoplasm, you know, you're born with a tendency

8:34

to turn into, as you say, mucus or calcification, right?

8:38

Like, I'm definitely leaning towards the mucus side on my

8:41

life or maybe fat.

8:43

I'll keep that in mind.

8:45

Yeah, I think fatty degeneration go with that.

8:47

But, um, my,

8:48

I suspect it's bilateral when I see things they're

8:51

so often bilateral.

8:53

Yeah. And I just mentioned that

8:55

because there's a famous NFL quarterback who, uh,

8:58

had a rupture of his achilles tendon.

9:01

I won't mention his name, he's back playing again,

9:04

but I wonder what his other ankle looks like

9:06

and what his other Achilles tendon. No,

9:08

I'm sure there are certain sports like kicking at are done

9:12

on a unilateral basis,

9:13

but most of the tendinosis I see is it's not related

9:17

to one physical activity.

9:19

It's just sort of the way they're made aging.

9:23

Okay. We're gonna stop there.

9:25

We, we've gone to a little bit later. It's been a long day.

9:28

I would remind everyone that we're back to the four hour,

9:31

uh, time tomorrow.

9:32

We're gonna head down the lower extremity

9:35

and tomorrow we'll be spending time on the ankle and foot.

9:38

I want to thank thank Brady and Minnie, a spectacular day.

9:42

Terrific lectures. Uh, I learned a lot.

9:45

I even took some notes here.

9:47

Uh, you know, so I really appreciate, uh, the quality

9:51

of the lectures and how complete they were.