0:00

Thank Brady.

0:01

Those are terrific. And you know,

0:02

it's interesting, your last case.

0:05

I have seen now I think four cases

0:07

of intermittent locking of the knee.

0:10

Whenever I get that history, the first thing I look

0:12

for are those popliteal, meniscal, uh, ligaments.

0:16

Because in all of those cases it was, uh,

0:20

the locking was related to in fact, flipping

0:23

of the posterior horn over the anterior horn.

0:27

That's what caused the locking.

0:28

And when we imaged it,

0:30

of course it was back in the normal place.

0:32

So it's something that, that I always, uh, think about.

0:36

I have a couple of, uh, questions, uh, for you.

0:39

One of the things that, uh,

0:40

maybe would be interesting is can you tell people

0:44

what is the, the combination of ligament injuries

0:47

that you see that suggest a knee

0:50

dislocation has taken place?

0:53

That's a very good question.

0:55

So, um, two ligaments

0:58

or bi cruciate injury is usually considered strong evidence

1:04

of knee dislocation and should be investigated.

1:07

If you have three

1:08

or more of the major ligament test complexes affected,

1:13

then generally the, it's a knee dislocation

1:16

until proven otherwise.

1:18

And that's a really good point that you bring up

1:20

because I show, I showed you the case in the, uh, patient

1:24

who presented dislocated,

1:25

but that's actually the minority of patients.

1:28

A lot of them actually present relocated, uh,

1:31

to the ER or their urgent care.

1:33

And it may not be known to the treating physician

1:37

that the patient actually suffered a

1:38

dislocation at the time.

1:40

So that's a very good point.

1:43

Yeah, I think that's important for people to recognize.

1:45

There is a, uh, question that just came in

1:48

that I think is an interesting one for you.

1:51

And it suggests really the fibular, styloid tion.

1:55

Do you have to state which structure is injured?

1:57

So I think it comes back to the arcuate sign

2:00

and pseudo arcuate signs

2:02

and the patterns of fracture of the proximal fibula.

2:06

So maybe you could make a, uh, a few comments about

2:10

the avulsion fractures that we see there.

2:14

Um, yeah, I mean I think the, they're,

2:17

they're often associated with significant poster,

2:19

lateral corona injury.

2:21

Usually a pretty high energy trauma.

2:23

Um, you know, like it's, it's the same with ACL footprint,

2:27

tibial footprint avulsions.

2:28

Like don't just pass the ACL saying

2:32

that the failure is at the bone.

2:34

You wanna also look at the ACL itself,

2:36

'cause it can also tear in the setting

2:38

of an avulsion fracture.

2:40

So I will look at those, um, ligaments,

2:43

but knowing kind of what I know from the literature,

2:46

the fact that those smaller ligaments don't confer as much

2:50

stability to the poster lateral corner outside

2:53

of those big three.

2:54

Again, to harp on it, the fibrillar collateral, again,

2:56

biceps verus and palmilla,

2:58

I don't worry about those smaller ligaments as much,

3:01

but certainly when you have the avulsion fracture,

3:05

that can be si a sign of a more significant injury.

3:09

Right. Uh, let me ask you, uh, something that,

3:12

that you mentioned, and I, I realize

3:14

that don't spend enough time looking for,

3:16

and those are problems with the Kaplan uh, fibers.

3:20

The only time I really look for them is when I'm dealing

3:23

with an ACL tear.

3:25

Uh, yet according to I think the data you presented, the,

3:30

I guess that represents maybe about 20 or 30% of patients.

3:35

What is the treatment, if, if you do pick up problems

3:38

with the Kaplan fibers?

3:39

Are they gonna do anything about it?

3:42

Uh, I don't think so.

3:44

I haven't seen any literature to date, but don't quote me.

3:47

Um, I, you know,

3:48

I'll cover a little bit in the postoperative talk, um,

3:51

especially with a LL

3:52

because the a LL is considered part of the lateral complex,

3:57

and with the more recent interest in that specific ligament,

4:00

there has been a kind of new interest in what's termed the,

4:05

the lateral extra articular 10 dcs.

4:07

Those are the procedures that they do.

4:09

And those are originally investigated

4:12

as far back as the sixties.

4:15

And, um, with renewed interest in this so-called new

4:18

ligament, a LL of course I put in quotes.

4:21

Um, but our orthopedic surgeons aren't doing a significant

4:26

number of these lateral, uh, extra articular TCEs.

4:30

And there are problems

4:31

because oftentimes the proposed types

4:35

of surgeries are often non anatomic.

4:38

So, you know, they've been studied for now over

4:41

almost 70 years,

4:43

and they're prone to problems with failures, um,

4:46

over tensioning of the grafts.

4:48

So, uh, there still remains a lot

4:50

to be learned about performing some of these procedures

4:54

to address the ant lateral complex.

4:57

Right. Okay. I have one other quick, uh, question.

4:59

I don't know if you'll have a comment about it,

5:01

but I once was talk, giving a lecture on the meniscus

5:04

and was talking about the popal meniscal ligaments,

5:08

particularly the antral inferior,

5:10

and I got an email afterward that

5:12

what I was describing was a lateral meniscal

5:16

fibular ligament.

5:17

Have you heard, and, and there are articles about it.

5:21

Do you use that term

5:22

or do you, what, what is your thoughts about that?

5:25

I still, yeah, I'm an, I, I guess I'm old school.

5:28

Uh, of course, like I said in the very beginning,

5:31

everything I learned, um, was from reading your articles.

5:34

And I, I would reference one by the Dr.

5:37

Peduto, uh, who wrote a beautiful article, uh,

5:40

outlining the Papa deal meniscal.

5:42

And some people will call him ligaments.

5:43

Some people call him Fales, uh, steel's Choice.

5:47

Um, and Clyde Helms has done some work on

5:49

that too back in the day.

5:51

Um, I still kind of refer to them as the, uh, ligaments

5:54

or popliteal meniscal ligaments or fales.

5:57

Um, but, uh, you know, I guess more importantly to, to,

6:01

regardless of what you describe them as, um, is

6:04

to identify them such as in this last case,

6:06

because they do help confer stability

6:08

to that lateral meniscus.

6:09

And if, if you're not looking for them routinely,

6:12

you could miss an injury that's, uh, clinically significant.

6:16

Well, absolutely.