The Peter Attia Drive - #264 ‒ Hip, knee, ankle, and foot： common injuries, prevention, and treatment options

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:16.580 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

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00:00:26.780 wellness, and we've established a great team of analysts to make this happen. It is extremely

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00:00:53.260 of the subscription. If you want to learn more about the benefits of our premium membership,

00:00:57.840 head over to peteratiyahmd.com forward slash subscribe. My guest this week is Dr. Adam Cohen.

00:01:06.660 Adam is board certified in both orthopedic surgery and sports medicine and has extensive training

00:01:11.220 and expertise in various sports medicine injuries. He's the director of sports medicine at Ortho

00:01:15.920 Manhattan and serves as the team physician for Horace Mann Athletics. He also holds academic

00:01:21.120 appointments at the NYU Langone Health System and the Mount Sinai Health System. Adam previously served

00:01:28.040 as the assistant team physician for the New York Yankees and served as a consultant for the U.S.

00:01:32.900 Open tennis championship, as well as provided orthopedic coverage for the New York City Ballet.

00:01:38.600 This episode is in some ways a follow-up to the episode I did with Dr. Alton Barron, which focused on

00:01:44.720 the upper extremity. In this episode with Adam, we're going to focus on everything you need to know

00:01:48.900 about the lower extremities. This includes, of course, the hip, knee, ankle, and foot. For each

00:01:54.580 of these, we walk through the anatomy, what can go wrong, what causes injuries, as well as what

00:01:59.840 surgical and non-surgical management of these things looks like. We then end the conversation

00:02:03.920 looking at how someone can go and find a good surgeon if they need any of these issues addressed

00:02:09.100 as we discuss them today. In addition to our conversation where Adam, of course, uses these images

00:02:14.480 and models, he also runs me through the typical exams that he will do for each part of his

00:02:20.180 assessment. These exams will make a lot more sense if you can see them rather than hear them. So for

00:02:25.640 the audio portion of this podcast, we will not include any of the exam content. It simply won't

00:02:30.360 make any sense. So if you choose to listen to this in audio, you may still want to go and check out our

00:02:35.480 YouTube page to look for the exams. Of course, you may just choose to watch the entire thing on YouTube

00:02:40.140 so that you can see his images. So without further delay, please enjoy my conversation with Dr. Adam Cohen.

00:02:50.760 Hey Adam, thank you so much for coming from New York to Austin. Very excited to do this. And of

00:02:56.140 course, this needs to be done in person. We're going to do today what I did with your colleague,

00:03:01.220 Dr. Barron, a little while ago on the upper extremity, which is everything you need to know

00:03:06.360 about the lower extremity and its orthopedic injuries. So for each of the major issues, the

00:03:11.040 hip, the knee, the foot, we're going to talk about the anatomy, talk about what goes wrong.

00:03:16.220 We'll talk about the surgical and non-surgical management for those things. So thanks very much

00:03:20.360 for joining. Sure. Great. Thanks for having me. Appreciate it. Let's start with the hip. Let's jump

00:03:24.260 right in. So let's talk about the anatomy of the hip. The hip joint is a ball and socket joint.

00:03:31.040 I have a model here. Unlike the shoulder, it's a very contained concentric joint and much more stable

00:03:38.660 under normal circumstances than the shoulder. It's a deep socket. The socket is called the acetabulum.

00:03:44.820 This is the femoral head and the femoral head is covered with cartilage. We'll place this down for

00:03:50.840 a moment. If we just focus on the proximal femur, we have the head, as I mentioned, the neck,

00:03:57.980 and this is the subtrochanteric region. And this is the trochanteric region. The acetabulum

00:04:05.740 is formed in utero. It starts about fourth week in utero. And then by the 30th week,

00:04:14.180 it starts to develop. And I think that's a good starting spot because a lot of the problems that

00:04:20.860 we see or a number of the problems we see in the hip really start that early. There is a condition

00:04:26.940 called developmental dysplasia of the hip. It used to be referred to as congenital dysplasia of the hip,

00:04:33.080 but we felt that there are more factors involved than any congenital ones in particular. Basically,

00:04:39.720 what happens is if the hip is not concentrically reduced as either late in stages of pregnancy or

00:04:48.260 in early childhood, the first several months of life, in fact, the acetabulum will not form properly.

00:04:55.180 So, for example, if the ball is shifted out of the socket, let's say due to positioning in utero where

00:05:03.700 it's not completely in, the acetabulum will not form correctly. What that means is, is that after

00:05:11.620 birth, if it's sitting outward, this deep socket will not form and it'll be quite shallow. That has

00:05:18.780 major implications later in life because if it's not deep in the socket, it's sitting on the edge of the socket,

00:05:24.920 which means there's greater pressure here and that pressure can lead to mechanical overload and arthritis.

00:05:33.140 So, even conditions that happen much later in life can start quite early.

00:05:38.900 So, a child that's breached, for example, during pregnancy, one of our kids was breached. As soon as he was born,

00:05:45.000 they immediately said, he has hip dysplasia. He was in a brace for nine months. He was in a

00:05:52.540 splayed open brace for nine months. And I remember sort of freaking out thinking, oh my God, he's never

00:05:58.220 going to be able to do anything. And they're like, no, he'll be fine. Like, as long as you keep him in

00:06:01.540 this brace. And he was in that brace 23 hours and 45 minutes a day. He basically only came out of it for

00:06:07.640 a bath. It was actually hell on my wife. But nine months later, his hips were fine. That's kind of

00:06:14.580 remarkable.

00:06:15.540 So, it's called a Pavlik harness and it actually is quite comfortable for the child. You can put it on

00:06:22.060 and take it off without much of a fuss. No more fuss than normally. But we know that if the ball is not

00:06:28.300 sitting in there, in that socket, it will not form properly. So, the harness keeps that positioning

00:06:35.500 until the acetabulum forms properly. You know, the exams that pediatricians do, we always check the hip

00:06:42.160 and we want to make sure that it's in the socket. I think going forward, a lot more physicians and

00:06:48.160 orthopedic pediatric specialists are using ultrasound to better quantify that the hip is in the socket

00:06:54.620 because we really don't want to miss any dysplastic hips. If you have a dysplastic hip, you are going to

00:07:03.220 get arthritis. Now, it doesn't mean it's going to be symptomatic necessarily. It doesn't mean you're

00:07:08.740 going to need a hip replacement. But people who have dysplastic hips, that is an acetabulum that did

00:07:14.780 not form properly, are going to get arthritis. It's a mechanical problem where the forces are

00:07:20.920 unevenly distributed across that ball and there's edge loading and that will break down over time,

00:07:27.880 no matter what you do. Do we have a sense of what the incidence is of congenital dysplasia or whatever

00:07:34.860 the new name is? Developmental dysplasia of the hip. As far as... How many children born or for every

00:07:40.320 thousand kids that are born? I think it's about one in a thousand. I think I might be wrong. I would

00:07:45.360 need to check on those numbers. The important part is, is that we shouldn't miss any. And if we're basing

00:07:51.220 it solely on an exam, I think we're going to miss more than if we base it on ultrasound. And the

00:07:57.240 ultrasound is really not that hard to do and certainly teachable. But that confirms that the

00:08:03.140 ball is in the socket and the socket is healing properly. There was a study once done many, many

00:08:09.080 years ago where it was an animal study and they put a cube-shaped object in the acetabulum and the

00:08:17.700 acetabulum formed in the shape of a cube. It is going to develop based on what is sitting in that

00:08:24.500 area. And if you wait too long, what happens is the soft tissue deep in the socket will become

00:08:32.040 hypertrophied and it's harder to get in. So I have patients that I've seen who they come in to see me

00:08:40.200 because their hip hurts. They're 28, 29 years old, never had a problem before, did not suspect anything

00:08:46.900 wrong, get an x-ray of the hip and they have arthritis. And it's quite a shocking development

00:08:52.860 because you don't know. You don't necessarily know. And for folks just listening, the plain x-ray

00:09:00.360 is a good enough tool for that diagnosis because you'll see the absence or thinning of cartilage

00:09:07.100 where you should see it as in that diagram there. Yes. For arthritis that becomes symptomatic,

00:09:13.040 we can usually see that. There obviously is a spectrum where the process starts to happen

00:09:19.540 before we're even clinically aware of it. And I think that's the future. That's the trick is to

00:09:27.500 find out before someone has clinical arthritis, do we know about it and what can we do to avoid it?

00:09:35.780 And I also think it's important to really discuss what arthritis is because I know just from my own

00:09:40.860 patients, I say you have arthritis and there's a lot of conversation of what, what actually does

00:09:47.000 that mean? The surfaces, the ends of all long bones have cartilage at the end. It's a layer,

00:09:53.900 it's a very smooth layer. And the only reason joints move pain-free without friction is because of that

00:10:01.500 cartilage. The coefficient of friction of cartilage is so smooth, it's smoother than ice on ice. There's no

00:10:08.760 man-made substance. I mean, it's smoother than Teflon and it's a biologic substance. It's constantly

00:10:15.000 remodeling, albeit slow. It is a biologic tissue that can adjust to the pressures. So part of arthritis

00:10:24.840 is the loss of that cartilage. The cartilage starts to thin. The chondrocytes, which are the main cellular,

00:10:32.360 is the cell of cartilage. Its job is to create proteins to make the extracellular matrix so that

00:10:41.700 it remains healthy. But chondrocytes, the cartilage itself is avascular. It gets its nutrition through

00:10:49.080 diffusion from joints and they're not very efficient at making the extracellular matrix, which is imperative.

00:10:56.380 So if there is overload of the cartilage, the chondrocytes will respond. And sometimes they die.

00:11:03.840 Sometimes they go into senescence. And cartilage, if you take the knee, for example, 2% of the cartilage

00:11:10.700 is chondrocytes. They don't have a lot of leeway when the load is substantial.

00:11:17.480 So when a person comes to your office and they're complaining of hip pain, what is the most, I don't know,

00:11:23.780 called the three most likely sources of that pain. We'll go through some of the examinations so people

00:11:29.480 can sort of see how you will go about gathering that information. But what would be the top three

00:11:34.300 most common diagnoses you'll encounter for a person with hip pain? And let's maybe bracket this by saying

00:11:39.100 a person under 50. So, you know, if someone comes in with hip pain, right away, I'm sort of thinking

00:11:44.540 about the different layers of the hip. So in my mind, I'm thinking, is this a bone problem?

00:11:50.360 Is it a bone cartilage problem? Is it a connective tissue problem that is a ligament problem?

00:11:58.260 Is the capsule too loose? The ball is held in the socket by a capsular layer. Is it a muscle and

00:12:05.520 tendon problem? So we sort of, from deep to superficial, we have bone cartilage, and then we have connective

00:12:13.000 tissue, ligaments, capsule, and then we have muscle tendon. And then we also have to recognize that

00:12:18.720 sometimes hip pain is referred pain. That is, it could be coming from your back. So we're thinking

00:12:23.720 about those separate layers. And then we're also thinking about location. So someone who has pain in

00:12:30.220 the front of the knee, sorry, the front of the hip is different than someone side of the hip, back of

00:12:35.100 the hip. So we need to tease all those factors out. So someone under the age of 50 would not necessarily

00:12:40.700 be thinking about arthritis, but it obviously is always on your mind. Finding out a clue to what the

00:12:45.820 diagnosis often depends on when it hurts, where it hurts, and what their activity is. So for example,

00:12:52.620 you know, I think about patients that come in, they say, you know, we have the endurance athlete,

00:12:56.060 we have the power athlete, we have... The non-athlete, presumably. The non-athlete, the individual who is

00:13:03.340 flexible, gymnasts, ballet dancers, they sort of have different patterns of hip problems. If we start with

00:13:09.640 the endurance athlete, let's start there. Endurance athletes is when we start deep down in the joint,

00:13:15.540 the first thing we have to rule out is that this is not a stress fracture. Stress fractures can happen

00:13:21.580 in a lot of different areas in the lower extremity, and we separate them out as to high-risk stress

00:13:27.800 fractures and low-risk stress fractures. Risk of bad consequence if not treated? Correct. So

00:13:34.760 if someone comes in and they have a marathon coming up and they say, my hip hurts, we have to make sure

00:13:41.720 that this is not a stress fracture. Femoral neck stress fractures, and just... This is the femoral

00:13:48.500 neck. So this here, you can have a stress fracture right in that area. And it usually just starts as a

00:13:54.260 little... So just differentiate a stress fracture from a fracture. Sure. So a stress fracture is something

00:14:01.280 that occurs slowly. So a stress fracture, at baseline, potentially normal bone with a substantial

00:14:09.400 load to that bone that is in excess of what the normal healing capacity is of that bone. That is,

00:14:16.680 bone constantly remodels. Every time we put stress on it, the microarchitecture is changing. There's

00:14:22.980 small, tiny micro fractures that occur from normal weight bearing. The body is very capable of adjusting

00:14:29.220 to that load and making new bone. When you start exercising or working out or running, the bone

00:14:36.180 will get stronger based on the stresses that that bone sees. So for runners, for example, if you are

00:14:43.760 training properly, there's no reason to expect that that bone can't adjust to the increased load that

00:14:49.480 it's seeing. But oftentimes, due to overtraining, where you're not giving that bone enough of a chance

00:14:56.620 to heal, you develop these tiny little micro fractures that aren't given enough time to then

00:15:02.980 heal. And then it gets compounded when you go run the next day and the next day. And you're increasing

00:15:08.700 not only the number of times that you run, but you're increasing the distance and the speed all at the

00:15:14.620 same time. You get groin pain because that's where stress fractures of the femoral neck hurt. Right away,

00:15:21.200 we know we need to rule it out. And they tend to occur in the femoral neck. And we have two locations.

00:15:27.900 Either this is called the compression side, and this is called the tension side of the neck.

00:15:32.780 And tension sided fractures, where you get a little crack in the bone here,

00:15:37.900 are much more severe than compression side. But the bottom line is that we need to know that this exists.

00:15:44.200 And the patient will feel groin pain, which is otherwise difficult for them to differentiate. I mean,

00:15:50.900 they're not going to come in and say, my femoral neck hurts. Correct. What is the actual feeling?

00:15:55.160 Does it feel akin to what you would feel if you pulled a muscle in your groin?

00:15:59.080 It does, except it's very weight-bearing dependent. So most people come and say,

00:16:05.920 I think I tore a muscle. I think I have a muscle strain. I don't see a lot of muscle strains in runners

00:16:12.960 without an injury. You run, you're training, you're not necessarily going to get an acute injury like

00:16:18.920 that. So sort of the presentation is slightly different. But it hurts in the groin. And right

00:16:24.240 away, you don't let them run until you find out if it's a stress fracture. And here's why.

00:16:30.180 Sorry, the MRI is the gold standard?

00:16:32.220 It is. So x-rays, we always need to get x-rays to make sure you're making sure that the joint

00:16:37.460 looks healthy. There are other conditions that can cause groin pain. But it's usually negative.

00:16:42.640 It's usually hard to detect a stress fracture right when the pain starts. The MRI is the gold

00:16:48.920 standard to see that. It used to be bone scan, but that is impractical. And an MRI really is

00:16:54.560 excellent at looking. Because you can see the architecture of the bone, and you can see

00:16:57.940 basically what we call edema in the bone, or bone marrow lesion, and sometimes a crack in the bone.

00:17:04.620 And it's graded. There's stress reactions, and then there's stress fracture. A stress reaction is

00:17:10.760 like a pre-stress fracture. And the reason why it's a high-risk stress fracture as opposed to a low

00:17:17.120 risk is if it becomes a complete fracture, which was the other part of your question, what's a

00:17:22.300 complete fracture? It's where this completely separates from the ball. And that's very important

00:17:28.620 in this area because the blood supply to the head comes from this direction. So all of the nutrients

00:17:37.020 that the ball sees comes from this direction. If this breaks and the blood supply is disrupted,

00:17:46.060 and that's not corrected quickly, then the bone in that area no longer has blood supply. It will die

00:17:53.840 and can't support the cartilage anymore. The cartilage will collapse, and you get AVN of the head,

00:18:00.400 and that is a hip replacement, which is obviously difficult for anybody, but for someone who's

00:18:07.620 in their 20s, 30s, 40s.

00:18:09.820 So the treatment for this when you make the diagnosis is rest?

00:18:13.600 Is rest, typically. So if it's on the compression side, this is the compression side,

00:18:20.660 you can go on crutches until you start to have no pain with weight-bearing. Once you have no pain

00:18:27.260 with weight-bearing, you can continue along that path. It takes six to eight weeks to heal,

00:18:33.000 and then you can slowly start up your exercises to regain some of your endurance, physical therapy,

00:18:38.260 etc. And oftentimes, I'll get a follow-up MRI to make sure that it is healing and not increasing.

00:18:44.540 If the stress fracture is on the tension side, the other, because you can imagine if it starts to

00:18:49.740 crack on this side and the whole weight of your body is coming down this way, it can more likely

00:18:55.120 displace mechanically. That often will need to get surgery, which is to put pins in. We will often

00:19:02.900 just put three pins from here to here into the femoral head, and it will heal, and they heal

00:19:09.280 quickly. And oftentimes, you can let that individual bear weight sooner than you.

00:19:13.920 So paradoxically, the riskier stress fracture usually has the quicker recovery because they

00:19:19.240 go to surgery as opposed to the tension-sided stress fracture. You can often end up getting,

00:19:25.860 walking around doing what you need to do in your normal life, too. I've had patients with

00:19:31.220 compression-sided stress fractures who are having so much difficulty with just their getting onto the

00:19:36.740 subway, getting to work with the crutches. They wanted to have the surgery so that they can do that.

00:19:42.760 Are there any differences in hip injuries between men and women? I mean, one thing that stands out to me,

00:19:48.340 just having taken care of a number of patients, is, again, at least in the under 50 population,

00:19:54.740 it seems that far more female patients of mine have had hip issues than male patients.

00:19:59.820 I've had a number of females who have had hip resurfacing, labral repairs. Again, these are all

00:20:05.140 young women, so they're typically in their 40s. Is that just a small number issue, and that's actually not

00:20:10.420 a disproportionate finding? Or do women, based on the anatomy of their pelvis, are they more susceptible

00:20:16.220 to labral tears or other types of injuries in the hip? There are different patterns. There are certain

00:20:22.020 conditions of ligamentous laxity that are more prevalent in women, developmental dysplasia is more

00:20:27.680 prevalent in women, and so sometimes that sometimes is the inciting issue. There are other types of hip

00:20:34.300 problems that are more prevalent in men. There's a condition that we often have to treat that has

00:20:40.200 implications to a lot of the structures around the hip. It's called femoral acetabular impingement.

00:20:45.620 Femoral acetabular impingement is, we think, at least the prevailing theory is, let me tell

00:20:51.700 you what it is first. Basically, on the neck, right around here, it's actually sort of in the front,

00:21:00.120 a bump develops. If I look at the model, a model here of the femoral neck, and there's sort of one

00:21:06.240 here, and this is typically the location of it, and I'll just color it, you get a prominent bump

00:21:12.680 of bone. So this area, it's called the cam lesion, and what happens is it changes the shape at the head

00:21:21.840 and neck junction, so it's not really spherical. It's sort of this oblong shape, so that when it goes

00:21:29.760 into the acetabulum, it can pinch on the acetabular rim. And on the acetabular rim is not only the cartilage,

00:21:41.180 but the labrum. Let me show a picture. So if we open up the hip, and we look inside,

00:21:49.360 again, here's the cartilage, this blue hue, and this lining is called the labrum.

00:21:55.640 So if the ball is no longer spherical, but oblong, the cam lesion will pinch on the labrum,

00:22:02.380 and the labrum will tear, and will injure the cartilage that is connected to that area.

00:22:07.120 So how does this happen? We think it happens because the growth plate, which closes in males,

00:22:15.200 late teens, slightly earlier in females, because of repetitive stress from certain sporting activities,

00:22:23.560 hockey, football, basketball, if there's impingement because of those high-stress sports,

00:22:30.220 that growth plate will have a delayed closure. And it will close later, and a new bone will form in that area.

00:22:38.040 And that's important because one of the risks of FAI that continues is you can get arthritis,

00:22:45.960 because if the cartilage is being injured, then it increases the risk of meeting a procedure later in life.

00:22:51.840 That's more common in men, FAI. It's certainly prevalent in women too, not as. Sometimes it's different sports,

00:22:59.760 but I think it's because the growth plate closes a little earlier in women that it may not be as much of an issue.

00:23:07.120 It also may be the type of sport. The power-type sport, where there's a lot of ground reaction force when you land,

00:23:13.820 tends to make this situation worse.

00:23:16.020 Now, in the shoulder, the labrum creates effectively the socket. So, if you have a person who's never had

00:23:24.700 a subluxation of their shoulder, that labrum is creating kind of a vacuum around the glenoid head.

00:23:32.300 This seems to be a much more stable ball and socket than the shoulder.

00:23:36.880 What is the role of the labrum in stabilizing that joint? I can understand how asymmetries can cause arthritis,

00:23:44.220 but just in terms of pure stability, you don't really hear about dislocations of the hip very often.

00:23:50.360 Obviously, the most famous example I can think of is Bo Jackson, which maybe we can talk about that case a bit.

00:23:55.440 But what is it that the labrum is doing from a stability standpoint,

00:23:59.140 or is it simply just providing a clean and neutral articulating surface for the cartilage?

00:24:05.680 It also helps to create a seal around the ball. So, it is a sort of a suction effect too.

00:24:11.800 And it's very similar to the shoulder. We have dynamic stabilizers in the hip.

00:24:16.140 It becomes more of a concern when the hip isn't formed normally.

00:24:21.320 Because then that acetabulum becomes flatter, which actually mimics the shoulder a little bit in terms of lack of stability.

00:24:27.920 Correct. And some of those patients who have instability of the hip because maybe they have some dysplasia,

00:24:34.980 so the ball never really is in the hip, they have greater motion.

00:24:38.080 I mean, ballet dancers would be a perfect example of that.

00:24:40.440 That comes at the cost of less stability.

00:24:42.060 That's right. And some of those individuals who actually have a hypertrophic labrum,

00:24:45.940 it actually gets bigger because it's being asked to do more.

00:24:50.340 There's also, I mean, you can see in the picture here, there's a ligamentum teres.

00:24:54.100 I don't know if you remember that from medical school.

00:24:56.120 Only slightly.

00:24:57.040 It's basically called the round ligament.

00:24:59.040 And we didn't think it did that much.

00:25:00.940 It provides some blood supply early on in life, and then later on doesn't really provide much blood.

00:25:06.920 But for people who are unstable, this provides a secondary restraint because the ligament connects the ball to the socket.

00:25:16.180 So one thing we need to be aware of whenever you're operating on the hip is to leave that alone in individuals who are unstable

00:25:22.100 because it's providing a bit of stability to that area.

00:25:25.040 Got it. Is this a good diagram to show how you do a total hip replacement or a hip resurfacing or explain what some of those procedures look like?

00:25:34.380 Sure. So in a hip replacement, basically you're taking off the neck.

00:25:38.380 You're cutting this off.

00:25:39.780 You're inserting a metal stem down the shaft of the proximal femur.

00:25:44.440 And then in this area, you're putting a metal cup in that region.

00:25:48.480 And then there's different ways to do this, but the metal cup then has a plastic liner on the inside.

00:25:54.120 And is that still made out of ultra-high molecular weight polyethylene?

00:25:58.900 Yes.

00:25:59.400 That's amazing. That's what they were doing 25 years ago.

00:26:03.440 Why has that operation become so tolerable compared to the version of that operation I saw in medical school?

00:26:12.060 Today, it's an outpatient surgery. The people go home. They seem to recover so well.

00:26:18.100 People used to be debilitated by that operation 30 years ago.

00:26:21.520 So a lot of the approaches are different now.

00:26:24.580 And honestly, in every aspect of the surgery, technology has helped us.

00:26:30.500 So back when I was training as a resident, almost all of the hip replacements were done through a posterior approach, an approach through the back muscles.

00:26:38.440 So which muscles were actually getting cut?

00:26:40.940 Through the gluteus muscles.

00:26:42.380 Which are huge.

00:26:43.340 Right. And now you go anteriorly. Now I don't perform, it's not one of the surgeries that I perform hip replacements, but it's much easier to spare the muscle and the ligaments when you do an anterior approach that is an approach from the front.

00:26:56.500 So you're saying less of the morbidity is due to less muscular damage on the approach?

00:27:03.860 Also, just the way we medically manage patients around the surgery.

00:27:08.380 We give medicine to decrease blood loss.

00:27:11.000 And so the whole process has become much more efficient and safer, to be honest.

00:27:17.660 And a resurfacing leaves the femoral head intact and only addresses the acetabulum?

00:27:24.720 No.

00:27:25.020 It's the opposite.

00:27:25.940 Yes.

00:27:26.260 And I don't do this. I'm not going to speak to the different intricacies of that.

00:27:30.940 But there are ways to preserve the amount of bone that you're taking if the individual is young.

00:27:37.260 I think that's done less now, actually, lately.

00:27:40.520 So we talked a little bit about what are kind of the problems that people will show up with when they're young.

00:27:45.880 When people are seeing an orthopedic surgeon north of 60, 65, I'm guessing it's arthritis and fracture that would be the dominant injuries.

00:27:57.000 Is there anything else that's showing up as significant?

00:27:59.180 In addition to those problems, we also see muscle and tendon problems.

00:28:04.040 In particular, we see issues with the tendons on the side of the hip.

00:28:08.420 And this is actually not just in older individuals, but all individuals.

00:28:12.560 The main abductor of the hip is the gluteus medius, which you can see coming out.

00:28:18.540 It sits on the back of the pelvis and attaches at the edge on the lateral or the outsides of the femur.

00:28:26.400 And these muscles help to...

00:28:28.740 Is that glute med and min?

00:28:30.340 Yes, correct.

00:28:31.460 And glute max is not shown here.

00:28:33.780 Correct.

00:28:34.180 The glute max comes across here and attaches a little bit lower down on the femur.

00:28:38.820 And that's not depicted here.

00:28:41.040 So this muscle is incredibly important.

00:28:43.200 In fact, we consider this to be the rotator cuff of the hip.

00:28:47.100 Just those two?

00:28:48.300 Just those two, correct.

00:28:49.720 The gluteus medius and the gluteus minimus.

00:28:51.720 And it has a very similar profile.

00:28:53.780 And just as in the rotator cuff, it starts to degenerate after a certain age.

00:28:58.220 Same thing happens in the hip.

00:29:00.640 This will...

00:29:01.380 Weakness of the gluteus medius is very difficult because it's incredibly painful.

00:29:07.360 Doesn't have great healing potential.

00:29:10.020 We also see this in endurance athletes as well from the repetitive stress.

00:29:13.540 And we also see this in unstable patients because those muscles are trying to dynamically keep the ball in the socket.

00:29:21.620 So they are working harder.

00:29:24.340 Ballet dancers in particular have incredibly large gluteus medius minimus powerful.

00:29:29.440 Part of the reason is because they're asked to do a lot to stabilize the hip.

00:29:34.480 So we see tears there all the time.

00:29:36.440 And we often approach that just like a rotator cuff.

00:29:39.420 So are most of the injuries you see here underuse or overuse?

00:29:42.740 It sounds like they're mostly underuse.

00:29:44.620 I don't think so.

00:29:45.520 It depends.

00:29:46.160 So the older we get, it doesn't necessarily matter whether it's overuse or underuse.

00:29:51.460 These things will happen because that is just the normal trajectory of tendon problems, tendon pathology.

00:30:00.680 The tendon cells over time start to degenerate just like all of our cells.

00:30:06.340 And they go through process of senescence like all tissue.

00:30:11.000 And those senescent cells produce those factors that lead to degeneration of the tendon, causes inflammation, incredible amount of pain.

00:30:20.680 And it's hard to treat.

00:30:23.300 It's hard to reverse the process.

00:30:26.160 Now, if you knew it was happening before it started, would you be able to do anything?

00:30:31.480 We don't have that ability yet, but that's what we're trying to figure out, how to intervene before these injuries take place.

00:30:40.340 There's two things that jump into my mind here.

00:30:42.700 The first is the obvious need for, I hate to use the word physical therapy because that really gets misconstrued a lot,

00:30:50.300 but basically deliberate exercise that strengthens those muscles.

00:30:54.580 When I used to be a cyclist, one of the challenges of that versus any sport truly is you're sort of in one plane, one dimension, right?

00:31:02.200 So you get very, very strong quads, glutes, and hams.

00:31:06.660 Your glute, mead, and min do very little.

00:31:11.040 You're not really doing any abduction of the hip.

00:31:14.520 And as such, you get a very tight tensor fasciae latae.

00:31:17.520 A lot of cyclists get really bad IT band pain because they just lack that strength there.

00:31:22.760 And so an obvious way to fix this, which I was very lucky that I was able to fix this non-surgically

00:31:28.220 because I was having debilitating IT band pain, was simply doing a lot of strengthening for the abductors.

00:31:37.080 So that at least suggested to me that you could be preventive in some way.

00:31:42.020 If I had any muscle that needed to be worked on and I had to pick one muscle group, it would be that muscle group,

00:31:47.780 starting from early teens.

00:31:50.180 It is implicated in so many lower extremity injuries at the hip and the knee.

00:31:55.840 A weak gluteus medius, weak abductors can cause a lot of injury.

00:32:01.160 And I do believe that the stronger they are, it's almost like bones.

00:32:05.400 The higher the bone density you get early on.

00:32:09.080 The higher your glider, the longer it rides.

00:32:11.520 That's right.

00:32:11.920 Because it's going to degenerate.

00:32:14.080 It is just going to happen.

00:32:15.840 And so the stronger and healthier the tendon is at a starting point, this is sort of how I think about this.

00:32:23.640 First of all, not only are you likely to have less injury, and I'm talking about ACL injuries too.

00:32:28.920 I'm talking about...

00:32:30.520 Knee injury.

00:32:31.120 It holds back the valgus.

00:32:32.420 Yes.

00:32:32.540 Everything that we're going to talk about in the knee.

00:32:34.460 Exactly.

00:32:35.420 Hip fractures, which we started to talk about a little in the elderly, that too.

00:32:40.040 These muscles are incredibly strong.

00:32:42.140 And the hip flexors too.

00:32:43.520 There was a study done out of South Korea that looked...

00:32:46.500 It was an imperfect study, but it was pretty decent.

00:32:49.020 They took a group of...

00:32:51.460 It was retrospectively evaluated, but they took CAT scans of people who were in for a hip fracture,

00:32:58.000 femoral neck fracture, elderly population.

00:33:00.720 And they measured the volume of their psoas muscles.

00:33:05.640 So this is the psoas muscle, and this is the iliacus.

00:33:09.180 Together they make the iliopsoas muscle attaches here.

00:33:13.360 And this is what picks your leg up.

00:33:14.620 That's what lifts your leg up.

00:33:16.120 So if you stumble, you pick your leg up to save yourself.

00:33:19.240 Now, the volume of that muscle was significantly smaller than that of an aged matched control

00:33:27.900 group who were getting CAT scans for other reasons.

00:33:31.760 Now, we don't know why they were getting CAT scans.

00:33:33.960 So that's, you know, it's a little bit confounding.

00:33:36.340 But it showed that there was a significant decrease in volume in those patients who have

00:33:40.940 hip fractures.

00:33:41.520 So we know that hip muscle strength, so they're important to get the abductor strong, the hip

00:33:46.940 flexor strong.

00:33:48.140 The problem with the hip flexors is that we're always sitting.

00:33:51.460 Even if they're strong, they're often tight because we're always in this position.

00:33:55.720 So it's important to see how your hip flexors are, make sure that they're flexible because

00:34:00.940 an imbalance in the flexibility of that muscle group will also impact the antagonistic muscles

00:34:07.660 in the back, the gluteus maximus, which extend the hip, and the hamstrings, which also extend

00:34:14.540 the hip.

00:34:15.360 You know, it's fine balance.

00:34:16.660 But if I could work on anything to help prevent these things later, I think this is a good

00:34:21.420 place to start.

00:34:22.780 The other thing that I've really migrated to over the past decade as I've become very obsessed

00:34:27.720 with all of these muscles, in particular, those hip adductors, is the importance of training

00:34:34.460 them, not just in concentric phase, but also eccentrically.

00:34:38.740 So there are these exercises we do in a training, I don't know, for lack of a better word, philosophy,

00:34:44.000 dynamic neuromuscular stabilization, DNS.

00:34:46.640 There's a position called DNS star.

00:34:48.500 I was just doing it this morning.

00:34:49.640 So I'm doing this stuff most days.

00:34:52.300 And you're laying on your side.

00:34:54.740 So if I'm on my right side, you know, my right elbow is down.

00:34:57.620 It's sort of like a plank, but you're on the knee, and your hips are up, and you're

00:35:03.180 extending yourself forward as you're putting the hip back.

00:35:06.960 So you are eccentrically loading the adductor as you go back, and then you're concentrically

00:35:15.040 loading it as you bring yourself back up.

00:35:17.600 Now, for anybody who's done this, we've demonstrated these things in other exercise videos.

00:35:21.760 I mean, five reps of this slowly, you feel like someone is jamming an ice pick into those

00:35:29.800 muscles.

00:35:30.420 It is remarkable how difficult it is, but you don't need to do a lot.

00:35:35.040 Just doing a little bit of that stuff every day does so much in terms of lower body maintenance.

00:35:41.840 And looking at this picture, I think it's pretty clear why.

00:35:44.540 It's such small muscles that have such an unfavorable angle at their attachment, right?

00:35:52.340 In terms of like the contraction, you know, it has such an unfavorable lever arm for what

00:35:57.760 it needs to do.

00:35:58.760 So it really has to be strong.

00:36:01.060 Right.

00:36:01.340 Let's talk a little bit about fractures.

00:36:04.000 Put aside just, you know, the 25-year-old skiing accident, freak accident, you know, you're

00:36:09.340 going to see that all day long.

00:36:10.280 But let's talk about the more predictable and far more catastrophic fractures to quality

00:36:15.400 of life, which are these fractures of the femoral neck that are occurring in people due

00:36:20.400 to osteoporosis and osteopenia.

00:36:22.040 Now, I talk about these stats all the time and nobody believes them because they're so

00:36:25.960 absurd.

00:36:26.560 But if you're 65 or older and you fracture that hip, depending on the study, 15 to 30% one-year

00:36:34.880 mortality.

00:36:35.880 Right.

00:36:36.220 Can you explain why that is?

00:36:38.000 How do these people present to you and why is it so challenging to take care of that fracture?

00:36:42.560 A large percentage of those people, it's usually another disease that has overtaken their lives.

00:36:49.700 And so they may have advanced stage cancer.

00:36:53.540 They may have advanced renal disease.

00:36:56.980 And it's almost the last event.

00:36:59.580 The last straw.

00:36:59.920 It's the last straw.

00:37:00.760 The hospitalization alone is just catastrophic.

00:37:03.160 That's right.

00:37:04.040 And so, and it's very hard to, when you're elderly and if you don't, first of all, you

00:37:09.600 break your hip, you come to the hospital, there has to be some medical management to make sure

00:37:15.140 that it's safe to proceed with surgery.

00:37:16.680 And everybody who has a hip fracture needs surgery.

00:37:19.620 You can't treat this non-operatively.

00:37:21.320 It would be essentially a death sentence to do so because the goal is to mobilize as quickly

00:37:28.660 as possible.

00:37:29.760 Because for even the people who don't have, you know, the mortality of 20 to 30% within

00:37:35.520 the first year, you know, that's been a stable number for decades.

00:37:40.340 I mean, every time they look at it, that's a stable number and that's within one year.

00:37:44.060 So our goal is to get you up.

00:37:45.680 And Adam, how much of that is really acute?

00:37:47.760 It's pulmonary emboli, fat emboli, MI because of surgery versus, you know, two weeks out,

00:37:56.020 they're okay, but then they fail to thrive and they die within the year.

00:37:59.660 It's not so acute.

00:38:01.020 It really is spread out.

00:38:02.700 The management of these patients is very important early on.

00:38:05.880 So we'd like to get a full team on board, right?

00:38:10.000 A geriatric specialist.

00:38:11.820 You need a team approach because you need them medically optimized.

00:38:15.680 Before surgery so that they could safely go through the surgery.

00:38:18.500 How long can they take to get tuned up before surgery?

00:38:22.480 So it should be done within 48 hours.

00:38:25.200 Wow.

00:38:25.940 Before we had the medical management sort of model of hip fractures, you oftentimes were

00:38:33.420 able to get the surgery done quicker.

00:38:35.800 An orthopedist comes in and say, let's just do this right now.

00:38:38.820 Everybody signs off.

00:38:39.940 We have to do this.

00:38:41.140 Let's go.

00:38:41.640 So when we have sort of the team approach, the medical doctors are like, listen, we have

00:38:45.900 to get an ecto.

00:38:46.580 We have to do these other things.

00:38:48.020 We need to make sure the bloods are okay.

00:38:49.820 That has delayed the surgery slightly.

00:38:53.600 But probably gives better outcomes.

00:38:55.360 It does.

00:38:55.780 Very operatively.

00:38:56.380 It has, at least in the studies that I've seen, people are able to get discharged sooner,

00:39:01.920 which is a good thing.

00:39:03.360 But their long-term outcome is just...

00:39:04.800 It still seems to be about 20%.

00:39:06.860 Wow.

00:39:07.820 And part of the issue is, first of all, obviously you broke your hips.

00:39:10.940 There's a good chance you're weak.

00:39:13.140 You're now, you're NPO.

00:39:14.440 The first day you come in, they won't, no one will feed you anything, right?

00:39:18.100 You don't get a meal.

00:39:19.020 And then in bed for two days, we're having surgery.

00:39:22.200 In bed for a week.

00:39:22.820 Probably getting dehydrated and...

00:39:24.760 And then even for the people who don't pass away, who don't die, there's a decrease.

00:39:29.540 About 50% lose a level of function.

00:39:32.540 So if you were using a cane before, you're using a walker.

00:39:36.380 If you're using a walker before, you're now in a wheelchair.

00:39:39.260 If you were walking normally, you might be using a cane.

00:39:41.540 So there's a 50% of people that go down a level in performance.

00:39:45.140 I once had a patient who was early on in my career.

00:39:48.640 I was a junior attending and a resident calls me and says to me,

00:39:52.820 we have a patient with a femoral neck fracture.

00:39:55.580 And he says, so we'll tell me the story.

00:39:56.960 He says, well, he's 40 years old.

00:39:58.360 He was riding on the West Side Highway and he crashed and he broke his femoral neck.

00:40:03.120 I said, well, I'm coming in now.

00:40:04.180 Let's fix this right away.

00:40:05.500 I said, just go consent him for the surgery in which the resident was a junior resident.

00:40:09.680 He goes and talks to the patient about all the risks and benefits of the surgery.

00:40:13.340 I go in to see the patient and he's got this...

00:40:16.160 Obviously, I expect him to be miserable, but he really was like...

00:40:19.080 And I explain and he goes...

00:40:20.480 He said to me, he says, your resident just told me I have a 30% chance of dying this year.

00:40:26.480 He kind of forgot to age in just that.

00:40:28.400 Yeah.

00:40:28.660 I said, well, don't worry.

00:40:30.060 You're not going to die.

00:40:31.200 Somebody else is, but not you.

00:40:32.940 As you were talking earlier about the degeneration of the hip,

00:40:37.140 obviously the first thing that comes to my mind,

00:40:39.100 and I'm sure everybody's mind listening to this is,

00:40:41.620 where do stem cells play a role here?

00:40:43.960 Now, we're going to talk about stem cells through all of these joints,

00:40:47.960 but we might as well start here.

00:40:49.960 When I hear that the tendons of those muscles and those muscles themselves are going to weaken,

00:40:56.420 when I hear that my cartilage is going to weaken,

00:41:00.380 when I hear that the osseous structure of the bone is going to weaken,

00:41:04.540 all of these things make me wish I could just have newer and younger cells there.

00:41:10.020 So what do we know about the utility of stem cell therapy here?

00:41:15.500 What's the state of the art today?

00:41:17.160 This is a great conversation, and there's a lot of layers to this conversation

00:41:21.440 because there's the dark side and the bright side of this.

00:41:25.660 When we talk about orthobiologics or biologics in general,

00:41:29.880 basically biologics, it's a class of therapies that are using

00:41:34.440 your own natural resources to promote healing.

00:41:38.800 So you're using a biologic product to encourage healing of diseased or injured tissue.

00:41:45.560 So the most commonly used ones are blood, specifically platelets,

00:41:52.300 bone marrow, bone marrow aspirate concentrate is called, and also fat.

00:41:57.560 So if we sort of go through those three, just to start there,

00:42:01.740 for PRP, what are we doing?

00:42:04.340 Platelet-rich plasma.

00:42:05.720 Platelet-rich plasma.

00:42:06.820 We take your blood, we draw it, and we take it down the hall,

00:42:10.900 and we spin it in a centrifuge.

00:42:13.460 And the centrifuge machine will separate out the different elements of the blood

00:42:17.780 based on the density of those elements.

00:42:20.880 So after you're done spinning it, you have a layer called the plasma layer,

00:42:25.140 which is rich in plasma and platelets.

00:42:28.380 And it separates out the red blood cells and a lot of the white blood cells.

00:42:34.160 Now you could spin it twice.

00:42:36.160 You could do two-spin technique.

00:42:37.860 You can spin it so that you're keeping some of the white blood cells.

00:42:42.360 So we've categorized it into leukocyte-rich PRP and leukocyte-poor PRP.

00:42:48.700 And this is a very simplified way that we think about it right now.

00:42:52.120 And there's certainly, if we fast forward 10 years from now,

00:42:55.500 this will be a ridiculous conversation.

00:42:57.800 Because we just are sort of in our infancy of understanding what we're doing here.

00:43:02.900 So the principle is we take those platelets, which are involved in healing.

00:43:08.780 We know this because if you cut yourself,

00:43:11.040 the first thing that happens is the platelets come to the surface

00:43:13.900 to form a blood clot and to form a scar, and then you heal.

00:43:18.100 So platelets are associated with an incredible amount of growth factors

00:43:22.400 and healing factors, including the 800 to 1,000 proteins within the plasma.

00:43:27.760 And you inject that into tendon, a joint with arthritis, muscle, and see what happens.

00:43:36.960 The problem is that as a physician, you are allowed to do that procedure.

00:43:43.000 There's no rule that can't say that anybody comes in and they say,

00:43:46.340 I have this injury, can I have stem cells?

00:43:49.600 And you say, oh, sure, let me give you a PRP.

00:43:51.900 And I spin it and I inject it.

00:43:54.120 What does the actual science say about what's actually working?

00:43:58.160 And what we've learned is that it works for some things pretty decently

00:44:03.760 and other things not well at all.

00:44:05.880 And we can only go by our randomized controlled trials

00:44:09.340 and systematic reviews of randomized controlled trials

00:44:12.420 to find out what seems to work.

00:44:14.180 What are those best case scenarios?

00:44:15.460 So tennis elbow seems to work with PRP.

00:44:18.340 There's good data to suggest, like tier one data,

00:44:20.660 maybe tier two data that suggests that it works for tennis elbow.

00:44:23.980 It works pretty decently for gluteus medius tears.

00:44:28.160 And for tendons, that's about it.

00:44:30.920 Some will argue maybe in the hamstring tendon it works, but I'm not convinced.

00:44:35.140 And just to be sure, are you talking specifically about PRP

00:44:38.200 or are you talking about the broader umbrella of stem cells?

00:44:41.720 The broader umbrella of stem cells don't seem to work.

00:44:46.440 And I think it's important to bring up a very important part,

00:44:49.360 which is these aren't stem cells.

00:44:51.680 And I think that's one of the major problems is that there is no stem cell therapy anywhere.

00:44:58.820 When you go to Mexico and get stem cell therapy, what are you actually getting?

00:45:04.020 I don't know.

00:45:05.000 But they're not stem cells.

00:45:06.900 I mean, I can only speak what's happening in the United States,

00:45:09.720 but the only stem cell therapies approved in the United States are for blood disorders, blood diseases.

00:45:15.600 There is no stem cell.

00:45:17.180 In fact, the FDA has a big warning page with a video that explains there are no stem cells.

00:45:24.140 Stem cells implies that I'm going to inject cells into you,

00:45:28.000 and those cells are pluripotent.

00:45:31.300 They have the ability to become something else,

00:45:33.880 and those cells are now going to become your cartilage.

00:45:37.220 They're now going to become your tendon.

00:45:39.540 That doesn't happen.

00:45:41.280 In fact, right now, what seems to be happening...

00:45:43.680 What's the identity of the stem cell?

00:45:45.520 In other words, what is the signature that allows that doctor to know

00:45:50.420 or at least believe they have a stem cell?

00:45:53.020 Because these are not autologous typically at these clinics, right?

00:45:56.160 Aren't they...

00:45:56.800 Are we talking about Mexico or...?

00:45:58.780 I only say that because everybody I know is basically going abroad.

00:46:02.580 Although I know some people that have done this here.

00:46:04.380 You know, they tear the rotator cuff, you know,

00:46:06.260 and they go and get stem cells injected,

00:46:08.540 and six months later, the rotator cuff is fine without surgery.

00:46:11.860 Right.

00:46:12.060 So, first of all, it's illegal to actually give stem cells.

00:46:17.480 So, a few years ago, people were able to get products

00:46:21.140 that were manufactured by companies

00:46:22.940 who were selling umbilical cord blood

00:46:26.840 or some derivative of umbilical cord,

00:46:30.600 some umbilical product as stem cells,

00:46:33.780 Wharton's jelly, some of it's called,

00:46:36.100 exosomes, all these things are not allowed.

00:46:39.980 The FDA will not let you inject this into anybody.

00:46:44.760 What's the reason for that?

00:46:46.100 The FDA has a division that regulates the use of human cells,

00:46:50.540 tissues, and products.

00:46:51.900 Even if autologous?

00:46:53.580 Even if they're your own?

00:46:54.580 You can use your own as long as it's not manipulated

00:46:58.800 or what we considered minimally manipulated.

00:47:02.440 So, spinning is not a manipulation?

00:47:03.980 That's right.

00:47:05.160 So, you can take your bone marrow out of the pelvis,

00:47:08.960 and we get it from the pelvis, and you can concentrate that.

00:47:11.940 But you can't give any enzymes to it.

00:47:14.120 You can't digest it.

00:47:15.120 You can't make any changes to that product.

00:47:18.880 You can only give it as is.

00:47:20.840 Now, with fat, because fat has actually shown some promise

00:47:24.060 with osteoarthritis of the ankle,

00:47:26.280 very good studies on ankle osteoarthritis,

00:47:29.120 and fat injection, same with knee.

00:47:31.180 You can do that because you're minimally manipulating the fat.

00:47:36.680 You are taking it and making it into smaller fat particles,

00:47:40.320 but you are not essentially altering the fat itself.

00:47:44.980 I mean, you're basically breaking down adipose tissue

00:47:47.480 into individual fat cells?

00:47:49.860 It's micronized.

00:47:50.960 It's called micronized.

00:47:52.160 It's micronized fat.

00:47:53.060 And the idea is that micronized fat regrows as cartilage?

00:47:55.920 No.

00:47:56.480 What does it grow as?

00:47:57.240 So that's what we don't know.

00:47:58.780 So right now, our best understanding of biologics,

00:48:01.740 in reality, is that it reduces symptoms.

00:48:05.120 It is symptom-modifying treatment.

00:48:07.300 And it's a good symptom-modifying treatment when it works

00:48:10.200 because we don't have a lot for, let's say,

00:48:13.320 arthritis tendon problems.

00:48:15.880 Our toolbox of things to use

00:48:18.940 when someone comes in with knee arthritis

00:48:20.800 or hip arthritis are pretty pathetic.

00:48:23.900 You're going to go to PT

00:48:24.700 because that's been shown to help.

00:48:25.960 I'll give you a brace, maybe.

00:48:27.180 That might help.

00:48:28.340 Maybe take some COX-2 inhibitor anti-inflammatories

00:48:31.360 and some cream.

00:48:34.020 We don't have the repertoire of what I prescribe

00:48:36.800 is pretty pathetic.

00:48:37.540 Yeah, the non-surgical treatment for these things

00:48:39.660 is pretty weak.

00:48:40.440 So here's an opportunity with the ortho-biologic field

00:48:44.660 to reduce symptoms in a safer way

00:48:47.120 than, let's say, cortisone.

00:48:48.500 Because cortisone is quite effective and safe

00:48:51.600 as long as you're not injecting over and over again.

00:48:55.200 There's a space for this that is very reasonable.

00:48:58.140 And the randomized control trials show that

00:49:00.320 it works for knee arthritis probably better than anything.

00:49:05.440 If we're looking forward as to what this,

00:49:09.080 what we're going to do.

00:49:10.220 Why don't we have RCTs that can answer these questions definitively?

00:49:15.380 Because there are a few things that I discuss with people in medicine

00:49:18.800 that create more sort of polarization around treatment

00:49:23.220 than the use of these biologic therapies

00:49:26.000 where the people who have had these procedures

00:49:28.600 will swear up and down by them when they work,

00:49:30.680 which is, you don't understand.

00:49:32.600 I couldn't move my arm and in six months I was fine.

00:49:35.000 Of course, we always fail to have the counterfactual here,

00:49:37.060 which is it's possible your arm was just going to get better on its own.

00:49:40.740 It's possible that the initial MRI showed something,

00:49:44.160 but the follow-up MRI didn't show something

00:49:45.720 or it just healed on its own because it was going to heal on its own.

00:49:48.000 So, you know, the only way you can ever escape that

00:49:50.360 is with randomized control trials.

00:49:52.640 Are they being done?

00:49:53.800 Yes.

00:49:54.300 And so to that point,

00:49:55.780 if we inject saline into somebody's joint,

00:49:58.680 a number of those patients are going to get better.

00:50:00.760 So that's sort of the standard we use.

00:50:02.720 How does PRP work in comparison to saline?

00:50:06.200 And there are a lot of studies.

00:50:08.180 There are dozens of studies,

00:50:10.900 randomized controlled trials looking at PRP.

00:50:14.080 And many of them have excellent results.

00:50:16.780 For example, tennis elbow?

00:50:18.260 For knee arthritis.

00:50:19.380 For knee arthritis, okay.

00:50:20.340 Of all the data, that's the tier one best data.

00:50:23.180 But, you know, we know so little about this

00:50:25.100 because it doesn't seem to work well in hip arthritis.

00:50:27.120 And why do you think that would be?

00:50:28.260 Is it just possible that the studies haven't been done correctly?

00:50:30.720 Maybe.

00:50:31.320 And I think this brings up a very important point.

00:50:33.560 When you do a randomized controlled trial,

00:50:35.880 let's say for a medicine, a hypertensive medication,

00:50:39.100 you know what dose you're giving.

00:50:40.720 And you're comparing it to some other treatment

00:50:43.000 where you know the dose.

00:50:45.080 Platelet-rich plasma.

00:50:46.340 I'm taking your platelets of unknown concentration.

00:50:49.580 Unknown quality.

00:50:50.600 Of unknown quality.

00:50:51.660 I'm spinning it in a machine,

00:50:53.280 either once or twice.

00:50:54.740 Different machines concentrate those platelets differently.

00:50:59.800 And so then I end up with a product

00:51:01.200 with a certain amount of platelets.

00:51:03.580 And then I inject it back into you.

00:51:05.180 I don't even know your disease process specifically.

00:51:09.120 So when you put people into these studies,

00:51:11.800 you get a lot of crappy data.

00:51:15.620 So what the future holds is,

00:51:18.880 and there's a push in our industry,

00:51:21.420 and there's a particular association

00:51:23.540 called the Biologic Association,

00:51:25.040 which is like an association of associations internationally

00:51:28.560 where they've formed something called the BARB,

00:51:32.280 which is a biologic association registry.

00:51:35.800 It's a bioregistry.

00:51:37.140 It's a registry and a bioregistry.

00:51:39.040 That is, they have lots of centers

00:51:41.320 and they want to know everything

00:51:43.100 about what you're injecting.

00:51:44.920 They want to know what's the concentration

00:51:46.320 of the blood of the patient you took.

00:51:48.000 What percentage of docs

00:51:48.700 who are regularly giving this therapy

00:51:50.720 are participating in the registry

00:51:52.540 to the point where we can generate information?

00:51:55.360 Compared to the total amount, very few.

00:51:57.800 But it's enough people

00:51:59.200 that we can get really good data

00:52:00.820 to find out what's the dose.

00:52:02.660 What's the critical dose of platelets

00:52:04.320 that we need to affect change?

00:52:06.460 And other things.

00:52:07.080 We can do a proteomic analysis

00:52:09.120 of the actual fluid itself.

00:52:11.400 And you match that with outcomes data

00:52:14.220 from the registry.

00:52:16.260 So you have a biorepository

00:52:17.820 and a registry combined.

00:52:19.640 Who did well and what did they get?

00:52:21.940 And they save samples of that still too.

00:52:24.220 But at best, this can only inform

00:52:25.980 what an RCT should do.

00:52:27.880 Those data by themselves

00:52:29.020 don't tell us anything, right?

00:52:30.520 Correct.

00:52:30.920 But this gives information

00:52:32.320 about to actually lead to the trial.

00:52:35.340 So you say, okay, it looks like this works.

00:52:39.740 Let's try this particular dose.

00:52:42.200 So right now, PRP looks more effective

00:52:45.000 at reducing symptoms

00:52:46.260 than cortisone in the knee for arthritis.

00:52:48.860 Is there any reason to believe

00:52:50.880 it can delay the requirement

00:52:53.720 for total knee replacement?

00:52:55.600 Maybe.

00:52:56.520 If we look over the course of a year,

00:52:58.940 because this is what those trials looked at,

00:53:01.520 cortisone works very well

00:53:02.760 in a short time frame.

00:53:04.220 It's pretty impressive.

00:53:05.440 The first couple of weeks,

00:53:06.280 you get one and it helps.

00:53:07.600 There are some people

00:53:08.320 who the pain comes right back.

00:53:09.960 So it doesn't have staying power.

00:53:11.740 When you compared steroids to PRP,

00:53:13.860 PRP, the PRP,

00:53:16.220 if you look out over a year,

00:53:18.040 they're doing better.

00:53:19.740 Hyaluronic acid,

00:53:20.640 which is another thing we inject,

00:53:22.640 also is doing better than cortisone

00:53:24.600 if you look out.

00:53:26.240 If you combine...

00:53:27.580 Isn't hyaluronic acid

00:53:28.720 considered biologic?

00:53:30.140 It's not.

00:53:31.180 Because it's an FDA approved product?

00:53:33.240 Yes.

00:53:33.600 And I don't even know

00:53:34.360 that it's a drug.

00:53:35.320 I think it's even classified

00:53:36.640 differently like a device,

00:53:38.060 but I'm not 100% clear on that.

00:53:40.680 So there's a number of studies,

00:53:42.200 or I don't know about a number of studies.

00:53:43.200 I know of a very well-done study

00:53:45.020 that looked at hyaluronic acid

00:53:46.860 and PRP together,

00:53:48.320 and that seemed to be more effective,

00:53:50.540 not astronomically more effective,

00:53:52.300 but more effective

00:53:53.100 than the treatments that we have.

00:53:55.040 It's more effective,

00:53:56.000 the combination of those two.

00:53:57.620 But is it disease-modifying?

00:53:59.980 And that's the big maybe,

00:54:01.040 because that's your question.

00:54:02.800 And there are studies that show

00:54:04.120 it may be pushing off knee replacements

00:54:06.660 for those patients.

00:54:07.740 But I think this is where

00:54:09.100 we still don't really know yet.

00:54:11.440 But there's so much deceitful behavior

00:54:14.880 out there with regards

00:54:16.880 to stem cell therapy

00:54:18.340 that the organizations involved

00:54:20.920 and the FDA

00:54:22.040 and the Federal Trade Commission

00:54:25.480 and CMS

00:54:26.720 are all trying to crack down

00:54:28.800 on the problem

00:54:29.680 of people advertising,

00:54:31.980 come onto my clinic,

00:54:33.540 I have stem cells,

00:54:34.720 I will inject it,

00:54:35.980 it's 100% guaranteed to help you,

00:54:38.260 I'm going to give you new cartilage.

00:54:40.100 One of my colleagues at NYU

00:54:41.960 did a study

00:54:42.780 where they looked at 1,000 websites

00:54:45.120 and 94% of those websites

00:54:48.520 who were promoting stem cell therapy

00:54:50.440 were making inaccurate statements.

00:54:53.880 And it just engenders distrust

00:54:55.940 between doctor and patient

00:54:57.500 when you're going for a treatment

00:54:58.760 and you think

00:54:59.420 they're telling you something that...

00:55:01.400 I had a friend,

00:55:02.460 I really,

00:55:02.760 like this is about two weeks ago,

00:55:04.000 my close friend from high school

00:55:05.600 sent me a brochure

00:55:07.540 because he wanted to get

00:55:08.740 an injection from his doctor

00:55:10.220 of something like

00:55:11.620 an umbilical cord

00:55:12.740 or Wharton's jelly injection,

00:55:14.300 which is not allowed.

00:55:15.740 And I look at the brochure,

00:55:16.980 I said,

00:55:17.300 send it to me.

00:55:18.300 You know,

00:55:18.600 I made the bigger

00:55:19.820 and I circled it

00:55:21.000 and on the brochure,

00:55:22.460 because it's from the company,

00:55:23.580 the company sells it to the doctor,

00:55:24.980 the doctor gives it to the patient.

00:55:26.380 On the brochure,

00:55:27.640 it said,

00:55:28.480 this is not intended

00:55:29.620 to treat any condition.

00:55:31.820 And I just circled it

00:55:32.960 and I sent it back

00:55:33.540 and he said,

00:55:33.880 never mind.

00:55:34.320 Before we leave the hip,

00:55:36.780 what is the role

00:55:37.560 of cortisone

00:55:38.640 as a treatment

00:55:39.880 to delay the need

00:55:42.260 for surgical intervention?

00:55:44.320 Is it particularly efficacious

00:55:46.060 or do you not muck around with it?

00:55:47.780 I don't love it

00:55:48.580 because we worry

00:55:50.100 about what it's doing

00:55:50.940 to the cartilage.

00:55:51.780 Listen,

00:55:52.120 I think because

00:55:53.040 it's such a successful operation,

00:55:55.680 I'm more apt

00:55:56.560 to push for

00:55:57.460 the hip replacement

00:55:58.420 in the appropriate patient

00:55:59.700 than a cortisone injection.

00:56:01.580 Because satisfaction rate,

00:56:03.220 90, 95%

00:56:04.680 for hip replacement surgery

00:56:06.220 with low complication rate.

00:56:08.120 That's not to say

00:56:08.800 that I don't do it

00:56:09.580 or I wouldn't do it

00:56:10.420 because there's certain

00:56:11.000 circumstances that I would.

00:56:12.720 I would give hyaluronic acid

00:56:14.220 in the hip also,

00:56:15.640 although it's not FDA approved.

00:56:18.280 It can be used off label

00:56:19.780 for that application.

00:56:20.720 There's some studies

00:56:21.400 to suggest that the gel can help.

00:56:23.860 We're still trying to find out,

00:56:24.820 figure out a better way.

00:56:25.840 But we also know

00:56:26.440 that if you give an injection

00:56:27.340 right before hip replacement,

00:56:28.540 there's an increased risk

00:56:29.360 of infection.

00:56:30.140 So we know that

00:56:30.800 there's something about this

00:56:31.880 that we need to be cautious about.

00:56:34.080 Anything else about the hip

00:56:35.220 before we move down to the knee?

00:56:37.100 No, because I think

00:56:37.880 even in the knee,

00:56:38.680 we're going to be talking

00:56:39.400 a little bit about the hip too.

00:56:41.280 So let's talk about the knee.

00:56:42.780 Again, I think most people

00:56:44.440 listening to this

00:56:45.220 can at least relate briefly

00:56:46.740 to some bout of knee pain.

00:56:49.000 So walk us through

00:56:50.560 the anatomy of the knee.

00:56:51.940 Sure.

00:56:52.580 So the knee is a bit different

00:56:54.120 than the hip joint.

00:56:55.180 It is more unstable

00:56:56.580 than the hip joint.

00:56:58.460 The hip joint is a true

00:56:59.780 ball and socket joint.

00:57:00.960 And the knee joint

00:57:02.520 is inherently more unstable.

00:57:04.520 So when we look at a knee,

00:57:05.840 what are we looking at?

00:57:06.820 If you look at the front

00:57:07.840 of your knee,

00:57:08.280 you often see that rounded

00:57:09.380 area in the front.

00:57:10.740 That's your kneecap

00:57:11.500 or patella.

00:57:12.600 The quadricep tendon

00:57:14.160 attaches to the top

00:57:15.760 of the patella

00:57:16.580 right here.

00:57:17.740 And then that tendon

00:57:18.980 continues on

00:57:19.980 as the patellar tendon

00:57:21.380 and attaches to the bone

00:57:23.100 here at the tibia.

00:57:25.180 If we were to

00:57:26.300 fold that over,

00:57:27.540 what we're looking at

00:57:28.380 is the undersurface

00:57:29.760 of the kneecap

00:57:30.700 and this is the patella

00:57:31.660 and this is the cartilage

00:57:33.120 on the patella

00:57:33.800 and all joints,

00:57:34.620 like we spoke about,

00:57:35.680 have cartilage.

00:57:36.580 All joints are made up

00:57:37.980 of cartilage.

00:57:38.660 So the end of all

00:57:39.520 of the bones

00:57:40.140 allow that to glide

00:57:41.940 smoothly on the surface.

00:57:43.840 So we're always interested

00:57:45.600 in maintaining the cartilage

00:57:47.360 because once that disappears,

00:57:50.120 we have trouble.

00:57:52.200 So if we were to

00:57:53.960 flex the knee

00:57:55.020 a little further,

00:57:56.000 what we can see

00:57:56.920 are ligaments

00:57:58.100 in the knee.

00:57:59.220 I don't know

00:57:59.480 if you could see that well,

00:58:00.380 but here's the anterior

00:58:01.340 cruciate ligament,

00:58:02.480 posterior cruciate ligament.

00:58:04.060 They're called

00:58:04.620 cruciate ligaments

00:58:05.420 because they cross.

00:58:07.020 And then we have

00:58:07.920 on the side

00:58:08.580 the collateral ligaments.

00:58:09.920 So this is the

00:58:10.900 medial collateral ligament.

00:58:12.500 This is a right knee

00:58:13.380 and this is the

00:58:14.080 lateral collateral ligament.

00:58:16.040 And then if we were

00:58:16.820 to fold it over

00:58:17.640 and you were to look

00:58:18.340 directly there,

00:58:19.520 you would see

00:58:20.160 two semicircular structures

00:58:22.100 that are called

00:58:23.320 the menisci.

00:58:24.300 And you have

00:58:24.860 two menisci,

00:58:25.700 medial and lateral menisci.

00:58:27.660 If I move the model away

00:58:29.380 and we look

00:58:29.780 at the picture here,

00:58:30.820 you can see

00:58:31.520 those cruciate ligaments

00:58:32.800 a little better.

00:58:33.960 This is the anterior

00:58:34.920 cruciate ligament,

00:58:36.040 posterior cruciate ligament,

00:58:37.540 and we see

00:58:38.240 the collaterals.

00:58:39.220 This picture

00:58:39.760 is without

00:58:40.520 the kneecap there.

00:58:42.020 You could also

00:58:42.900 see the menisci

00:58:44.720 or meniscus.

00:58:46.560 And the main role

00:58:48.260 of the meniscus

00:58:49.460 is to distribute

00:58:51.860 force across

00:58:53.260 that knee

00:58:53.800 and they're imperative

00:58:54.640 to maintain

00:58:55.480 the surface

00:58:56.600 of the joint,

00:58:57.280 the cartilage,

00:58:58.120 from wearing down.

00:58:59.520 And the ligaments

00:59:00.400 provide stability

00:59:01.540 to the joint

00:59:02.340 and the anterior

00:59:03.660 cruciate ligament

00:59:04.460 is a commonly

00:59:05.240 torn ligament.

00:59:07.360 And just again,

00:59:08.720 to orient people here,

00:59:09.980 you are looking

00:59:10.720 at the right leg.

00:59:12.420 Correct.

00:59:13.040 So the fibula

00:59:14.680 is that little

00:59:15.440 small bone

00:59:16.160 on the outside

00:59:16.840 and that's

00:59:18.360 where we see

00:59:19.120 both its attachment

00:59:20.180 to the tibia,

00:59:21.560 which is the platform

00:59:22.640 on which the knee sits,

00:59:24.340 and also you have

00:59:26.000 the lateral collateral

00:59:27.140 ligament attaching there,

00:59:28.540 yes?

00:59:28.940 Correct.

00:59:29.360 So the menisci

00:59:30.360 collectively make up

00:59:32.240 the bulk

00:59:32.920 of the cartilage surface

00:59:34.800 of the tibial plateau then?

00:59:36.580 The function of it

00:59:37.820 is to distribute stress

00:59:39.180 and it distributes

00:59:39.920 about 30%

00:59:40.920 of the load

00:59:41.620 of the knee

00:59:42.120 through the joint.

00:59:42.860 So without

00:59:43.280 that meniscus there,

00:59:44.940 you end up having

00:59:46.120 point loading

00:59:46.780 or edge loading

00:59:47.520 and it will

00:59:48.640 cause degeneration

00:59:50.040 of the cartilage

00:59:50.860 pretty rapidly

00:59:51.700 if it's removed.

00:59:53.780 I always hear people

00:59:54.420 talk about how

00:59:55.340 running and walking,

00:59:57.500 they amplify

00:59:58.460 forces at the knee.

00:59:59.980 So I've heard people

01:00:00.660 say when you're running,

01:00:02.040 you're experiencing

01:00:02.880 eight times

01:00:03.920 the force of your

01:00:05.280 body weight

01:00:05.860 at the knee.

01:00:06.840 A, am I remembering

01:00:07.660 people say that correctly?

01:00:08.620 And if so,

01:00:09.000 why is that the case?

01:00:10.200 So it depends

01:00:10.800 which joint

01:00:11.460 you're talking about.

01:00:12.280 So if we're talking

01:00:13.000 about the kneecap,

01:00:13.980 the amount of load

01:00:15.020 that the kneecap sees

01:00:16.500 with activities

01:00:17.640 like squatting

01:00:18.520 and lunging,

01:00:19.020 if you do not even

01:00:19.880 a deep squat,

01:00:20.520 just a regular squat,

01:00:21.980 the pressure behind

01:00:23.480 the kneecap

01:00:24.180 is about seven times

01:00:25.620 greater.

01:00:26.660 Than the weight

01:00:27.060 on your back.

01:00:27.940 That's right.

01:00:28.740 The cartilage

01:00:29.240 has an incredible

01:00:30.180 responsibility here.

01:00:32.000 One of the most

01:00:32.800 important conversations

01:00:33.840 that I have

01:00:34.480 with patients

01:00:34.920 because I get

01:00:35.440 the similar questions

01:00:36.640 often which is

01:00:37.740 things like

01:00:38.720 is running bad

01:00:39.600 for me?

01:00:40.440 Is this activity

01:00:41.360 good for my knee

01:00:42.380 or bad for my knee?

01:00:43.400 Because you'll read

01:00:44.760 a different report

01:00:45.780 in the news

01:00:46.360 all the time.

01:00:47.200 Running's good,

01:00:47.840 running's bad.

01:00:49.100 The truth is

01:00:50.040 we kind of know

01:00:50.960 the answer to this

01:00:52.080 in general.

01:00:53.460 That is,

01:00:54.300 no activity

01:00:55.120 is horrible

01:00:56.420 for cartilage.

01:00:57.560 If I put your leg

01:00:58.780 in a cast

01:00:59.460 and we then

01:01:00.780 look at your cartilage

01:01:02.020 in a couple weeks,

01:01:03.840 the content

01:01:04.780 of that matrix

01:01:05.920 is going to be

01:01:07.140 significantly

01:01:07.980 depressed.

01:01:09.640 Nothing's worse

01:01:10.440 for you

01:01:10.980 than inactivity.

01:01:12.000 Right.

01:01:12.380 But it's an

01:01:13.080 inverted U-shaped

01:01:14.260 curve.

01:01:15.300 But it's not

01:01:15.700 symmetric.

01:01:16.700 It's like that

01:01:18.000 where more and more

01:01:19.880 and more activity

01:01:20.540 probably better

01:01:21.260 and better

01:01:21.580 and better

01:01:21.960 but then you can

01:01:22.880 go too far

01:01:23.480 and it falls off.

01:01:24.240 It's not a perfect

01:01:25.140 U where it's

01:01:26.640 pure Goldilocks

01:01:27.600 where you want to

01:01:28.740 be right in the

01:01:29.380 middle of doing

01:01:29.940 nothing and doing

01:01:30.720 a lot.

01:01:31.260 Because we'll never

01:01:32.180 know because it's

01:01:33.020 dependent on a

01:01:33.760 particular individual

01:01:34.840 and so many factors.

01:01:36.900 So we know

01:01:37.740 that chondrocytes

01:01:40.060 respond to activity.

01:01:41.680 They feel the stress

01:01:43.900 and they make

01:01:44.660 more matrix.

01:01:45.600 They make all

01:01:46.240 of the proteins

01:01:46.980 within cartilage.

01:01:48.540 So a chondrocyte

01:01:49.980 that's being pressured

01:01:50.960 is happy.

01:01:52.340 A chondrocyte

01:01:53.300 that's not being

01:01:53.940 pressured isn't

01:01:54.780 going to do anything

01:01:55.560 and eventually

01:01:56.400 it's going to

01:01:57.000 break down.

01:01:57.900 And biomechanics

01:01:58.700 have to matter here.

01:01:59.880 They do.

01:02:00.280 In other words,

01:02:01.140 you watch

01:02:02.020 an Ethiopian runner,

01:02:03.980 you know,

01:02:04.280 you watch Kipchoge

01:02:05.380 running a marathon

01:02:06.240 and you realize

01:02:08.020 okay,

01:02:09.840 clearly there's

01:02:10.640 a lot of force

01:02:11.280 there based

01:02:11.800 on his velocity.

01:02:12.980 For him to have

01:02:13.920 the stride length

01:02:15.000 that he has,

01:02:16.180 he is hitting

01:02:16.820 that ground so hard

01:02:18.040 and that ground

01:02:18.740 is hitting him

01:02:19.260 back so hard

01:02:20.080 and that's what's

01:02:20.520 allowing him to

01:02:21.020 stay in the air

01:02:21.600 long enough

01:02:22.160 to travel the

01:02:23.060 distance he travels.

01:02:24.840 And sure,

01:02:25.180 he's not the

01:02:25.620 heaviest guy in the

01:02:26.260 world.

01:02:26.420 He probably weighs

01:02:26.860 a buck twenty

01:02:27.520 soaking wet.

01:02:28.520 But again,

01:02:29.160 if he's feeling

01:02:29.920 eight times that,

01:02:31.340 we're close to

01:02:31.880 a thousand pounds

01:02:32.940 every time.

01:02:34.140 But his mechanics

01:02:35.320 are perfect.

01:02:37.180 I think it's all

01:02:37.960 mechanics.

01:02:38.760 I mean,

01:02:39.040 that's exaggeration.

01:02:40.320 But it's mostly

01:02:41.060 mechanics.

01:02:42.040 If you have

01:02:42.940 good mechanical

01:02:44.040 alignment,

01:02:44.880 we call it,

01:02:45.340 that is,

01:02:45.620 if we draw a line

01:02:46.480 from the center

01:02:47.100 of your hip

01:02:47.680 to the center

01:02:48.760 of your ankle

01:02:49.480 and we do this

01:02:50.380 regularly

01:02:50.860 and it goes

01:02:52.100 right through

01:02:52.540 the center

01:02:52.960 of the knee,

01:02:54.300 there's a good

01:02:54.800 chance you're

01:02:55.300 going to be okay.

01:02:56.320 Center of hip,

01:02:57.300 meaning where

01:02:58.420 the femoral head

01:03:00.320 meets the acetabulum.

01:03:01.980 Right.

01:03:02.240 The center of

01:03:02.900 the ball.

01:03:03.520 Center of the

01:03:03.940 ball.

01:03:04.380 You should be

01:03:04.820 able to drop

01:03:05.160 a plumb line

01:03:05.920 that cuts

01:03:06.940 the patellar

01:03:07.780 tendon and

01:03:08.640 the patellar

01:03:09.400 bone in half.

01:03:10.340 Correct.

01:03:11.060 And should land

01:03:11.720 where on the

01:03:12.220 foot?

01:03:12.620 Where in the

01:03:12.980 ankle?

01:03:13.620 You draw the

01:03:14.540 line from the

01:03:15.260 center and you

01:03:16.080 connect the

01:03:17.020 center of the

01:03:17.480 ankle.

01:03:17.900 To the center

01:03:18.340 of the ankle.

01:03:18.980 And then you

01:03:19.300 see where it

01:03:20.040 goes through

01:03:20.440 the knee.

01:03:20.980 If you go

01:03:21.580 dead center,

01:03:23.240 there's a good

01:03:23.740 chance you're

01:03:24.180 going to be

01:03:24.480 okay.

01:03:25.520 Sometimes even

01:03:26.360 if you have

01:03:27.320 other problems.

01:03:28.580 If you are

01:03:29.500 off to one

01:03:30.280 side or another,

01:03:31.300 and that's where

01:03:31.820 we have people

01:03:32.540 who have

01:03:33.100 knock-kneed or

01:03:34.160 bow-legged

01:03:34.700 knees, there is

01:03:36.360 an increased

01:03:36.920 amount of force

01:03:37.660 through one of

01:03:38.360 those compartments

01:03:39.160 of the knee and

01:03:40.700 you are at high

01:03:41.640 risk for

01:03:42.140 degeneration.

01:03:42.940 And then if you

01:03:43.440 get a meniscus

01:03:44.240 tear on top of

01:03:45.080 that and you

01:03:45.580 lose that surface

01:03:47.380 area of forced

01:03:49.040 diffusion, that

01:03:50.960 chondrocyte is no

01:03:52.160 longer going to be

01:03:52.880 happy.

01:03:53.940 So once the

01:03:55.260 knee is unstable,

01:03:56.320 just focusing on

01:03:57.280 the knee, let's

01:03:57.820 say you have an

01:03:58.340 ACL tear and

01:04:00.000 then you measure

01:04:00.680 the compressive

01:04:01.560 force of that

01:04:02.280 cartilage before

01:04:03.940 and after an

01:04:04.680 ACL tear, so

01:04:05.200 like a normal

01:04:05.860 knee and then

01:04:06.500 your contralateral

01:04:07.260 knee, the amount

01:04:08.700 that the cartilage

01:04:09.420 gets compressed in

01:04:10.640 an ACL deficient

01:04:11.980 knee is

01:04:12.840 substantially greater

01:04:13.940 than an ACL

01:04:14.920 intact knee.

01:04:16.780 If you

01:04:17.440 reconstruct that

01:04:18.580 ligament, it

01:04:19.720 still doesn't come

01:04:20.380 back to normal.

01:04:21.060 There's something

01:04:22.960 that happens once

01:04:24.040 the knee is

01:04:24.740 injured where the

01:04:26.160 loads through that

01:04:27.060 joint change and

01:04:28.380 sometimes permanently.

01:04:29.980 So is that why

01:04:30.700 if you have an ACL

01:04:32.000 injury, you do

01:04:32.960 increase your risk

01:04:33.620 of arthritis later

01:04:34.300 in life?

01:04:34.940 You do.

01:04:35.800 Is that partly why?

01:04:36.960 Because you never

01:04:37.720 fully get the

01:04:38.360 chondrocytes back?

01:04:39.780 Correct.

01:04:40.440 I think there are a

01:04:41.140 couple issues here

01:04:41.820 that obviously we

01:04:43.120 don't fully understand,

01:04:44.840 but the first thing

01:04:45.860 I'll say is that a

01:04:47.260 lot of it is baked

01:04:48.000 in the cake at that

01:04:48.820 injury.

01:04:49.260 And any injury where

01:04:50.280 there's sheer

01:04:50.820 stress on an

01:04:52.520 ACL, and I think

01:04:53.200 we should talk

01:04:53.680 about the

01:04:54.060 biomechanics of

01:04:54.740 the ACL injury,

01:04:55.700 but when you

01:04:56.220 have that event

01:04:57.120 on any joint,

01:04:58.720 the stats are

01:04:59.560 that in about

01:05:00.620 15 to 20

01:05:01.920 years, half

01:05:03.980 of the people

01:05:04.580 who have an

01:05:05.120 ACL tear,

01:05:06.660 whether it's

01:05:07.080 reconstructed or

01:05:07.840 not, have

01:05:08.900 signs of

01:05:09.440 arthritis.

01:05:10.380 No difference

01:05:11.100 if you

01:05:11.420 reconstruct or

01:05:12.080 not?

01:05:12.560 It's debatable.

01:05:13.440 There are some

01:05:13.940 studies that show

01:05:15.000 that if you've

01:05:16.080 had your ACL

01:05:16.920 reconstructed, you

01:05:18.220 have a greater

01:05:18.900 chance of

01:05:19.480 arthritis.

01:05:19.900 Those are the

01:05:20.360 literature I'm

01:05:20.860 sort of familiar

01:05:21.420 with.

01:05:21.920 And that's

01:05:22.460 because you're

01:05:24.120 active.

01:05:24.840 So you are now

01:05:25.580 able to do

01:05:26.500 things.

01:05:27.900 Very good point.

01:05:29.180 Because you're

01:05:29.900 knee stable.

01:05:30.860 So there haven't

01:05:31.300 been any RCTs

01:05:32.580 that have said

01:05:33.440 randomized to

01:05:34.560 repair, no

01:05:35.180 repair, and let's

01:05:36.100 see what happens.

01:05:36.620 No, it's too

01:05:37.260 hard to do.

01:05:37.780 There was a

01:05:38.280 FATE study, I

01:05:39.100 think in the

01:05:39.620 90s, where they

01:05:41.160 look at the fate of

01:05:42.000 doing ACL surgery,

01:05:43.200 not doing ACL

01:05:43.880 surgery, but you

01:05:44.540 can't randomize it.

01:05:45.820 That's where that

01:05:46.500 data comes from,

01:05:47.340 where that you may

01:05:48.440 end up having

01:05:48.940 more arthritis if

01:05:49.840 you have it

01:05:50.280 reconstructed.

01:05:50.960 I'm not necessarily

01:05:51.500 saying that you

01:05:52.180 shouldn't reconstruct

01:05:52.760 it by any means.

01:05:54.020 Why do we do

01:05:54.600 ACL surgery?

01:05:55.220 We do ACL surgery

01:05:56.180 because we want to

01:05:56.900 protect the meniscus

01:05:57.820 because if your

01:05:58.400 knee is flopping

01:05:59.020 around, your

01:06:00.000 meniscus is going

01:06:00.640 to tear.

01:06:01.900 If your knee is

01:06:02.980 flopping around,

01:06:03.820 you're not going to

01:06:04.220 be able to play the

01:06:04.800 sports you enjoy

01:06:05.480 doing.

01:06:06.380 So by all means,

01:06:07.920 it's worth the

01:06:08.700 risk of arthritis.

01:06:09.800 The other thing is,

01:06:10.380 it's not everybody

01:06:11.080 has an ACL tear.

01:06:12.380 Yeah, one in five.

01:06:13.420 Not everyone who

01:06:14.220 has a, right.

01:06:15.420 But to that point,

01:06:16.640 I mean, I'll just

01:06:17.160 use my own example.

01:06:18.120 When I was hit by a

01:06:19.000 car when I was 14

01:06:20.220 years old, I had an

01:06:22.260 ACL tear and a

01:06:24.260 meniscus tear.

01:06:25.440 This is the 80s.

01:06:26.600 I had knee surgery

01:06:27.500 that week, but nobody

01:06:29.000 did anything.

01:06:29.780 You just went in and

01:06:30.580 looked and I came out

01:06:32.260 and said...

01:06:33.660 What do you mean

01:06:33.960 they went in and

01:06:34.520 looked?

01:06:35.040 I had an

01:06:35.400 arthroscopic surgery

01:06:36.540 and only later they

01:06:37.820 were like, what did

01:06:38.280 we do?

01:06:38.760 They said, oh,

01:06:39.200 nothing.

01:06:39.500 They just said

01:06:40.000 they're going to

01:06:40.460 treat it non-operatively.

01:06:42.020 After the operation?

01:06:43.060 Yeah.

01:06:43.400 They didn't have MRI

01:06:44.160 that was high enough

01:06:45.020 resolution?

01:06:45.660 Well, I don't know.

01:06:46.260 You know, I was 14,

01:06:47.600 so it was like, I

01:06:48.640 just did what I was

01:06:49.600 supposed to do.

01:06:50.380 And they said after

01:06:51.580 the doctor was...

01:06:53.080 It's funny because he's

01:06:54.140 the reason I wanted to

01:06:54.940 be a doctor too.

01:06:56.120 You know, he came in,

01:06:57.100 he's talking to his

01:06:58.000 dictaphone.

01:06:58.760 He says, you know,

01:06:59.640 14-year-old male

01:07:00.560 injured his knee.

01:07:01.180 I was like, that's

01:07:01.700 cool.

01:07:02.480 That's what I wanted

01:07:03.040 to do.

01:07:03.500 Yeah, he gets a

01:07:04.100 dictaphone.

01:07:04.620 Exactly.

01:07:04.860 I mean, who doesn't

01:07:05.860 want to have one of

01:07:06.480 those?

01:07:06.900 Exactly.

01:07:08.020 So I didn't have the

01:07:09.040 surgery.

01:07:09.360 They said, we're going

01:07:09.860 to rehab it.

01:07:10.800 From the age of 15,

01:07:12.340 basically, to 30, I did

01:07:14.520 not have an ACL.

01:07:16.260 I had a bucket handle

01:07:17.620 tear of the meniscus,

01:07:18.560 which is a very severe

01:07:19.580 meniscus tear.

01:07:21.060 And only at age 30 did

01:07:22.920 I have the surgery done

01:07:23.900 after my fellowship was

01:07:25.320 over.

01:07:26.500 And I recently took

01:07:28.260 x-rays of my knee

01:07:29.020 because I was curious.

01:07:30.260 I did standing

01:07:31.000 alignment, center of

01:07:32.360 the head to the

01:07:33.400 ankle.

01:07:34.680 I have no arthritis

01:07:36.220 in my knee, but my

01:07:38.000 line is straight

01:07:38.840 through the center.

01:07:40.140 I don't think that

01:07:41.180 would have happened if

01:07:42.060 I had some mechanical

01:07:43.340 alignment issue.

01:07:44.860 So half people get

01:07:45.800 arthritis.

01:07:46.260 Half don't.

01:07:46.920 There's probably...

01:07:47.940 Oh, I thought it was

01:07:48.400 20%.

01:07:49.120 50%.

01:07:50.020 Oh, 50.

01:07:50.800 I'm sorry.

01:07:51.280 I misheard that.

01:07:52.340 50%.

01:07:52.740 Oh, it's within 15 to

01:07:53.920 20 years that you said

01:07:54.920 that.

01:07:55.100 That's right.

01:07:55.380 I get it.

01:07:55.980 And we also know, and

01:07:56.840 I know this from my own

01:07:57.640 practice because I do a

01:07:58.700 lot of ACL reconstructions,

01:07:59.960 is that some people

01:08:00.960 recover fairly well

01:08:02.660 after the surgery.

01:08:04.060 And there's a small

01:08:04.960 group of people who

01:08:05.820 stay inflamed.

01:08:07.300 We're identifying this

01:08:08.380 cohort of patients.

01:08:09.460 We call them an

01:08:10.380 inflamatite.

01:08:11.440 That is, if you take

01:08:12.440 out their fluid and you

01:08:13.280 look, analyze that

01:08:14.280 fluid, they have

01:08:15.340 elevated IL-1, IL-6,

01:08:18.280 inflammatory markers that

01:08:19.520 are not coming back

01:08:20.520 down to baseline.

01:08:22.300 In the synovial fluid,

01:08:23.580 you mean?

01:08:23.640 In the synovial fluid.

01:08:25.180 A lot of people recover

01:08:26.280 and then some people go

01:08:27.920 on to have sort of low

01:08:28.980 burn, chronic

01:08:29.900 inflammation.

01:08:31.220 And I don't think this

01:08:31.920 is just with ACL.

01:08:32.800 I think this is with a lot

01:08:33.740 of problems.

01:08:34.480 And this is also where

01:08:35.420 biologics may come in at

01:08:36.800 some point to push

01:08:38.280 someone from the

01:08:39.100 catabolic state back to

01:08:40.460 the anabolic state.

01:08:41.480 So let's talk a little

01:08:42.660 bit about how the

01:08:43.220 injury happens and then

01:08:44.300 I want to understand

01:08:44.920 kind of how it's

01:08:45.520 repaired.

01:08:46.640 In general, there's

01:08:47.700 ACL contact, ACL

01:08:49.440 injury and non-contact

01:08:50.780 ACL injuries.

01:08:51.780 And the majority are

01:08:52.540 non-contact.

01:08:54.020 Some are also

01:08:54.700 indirect contact.

01:08:55.960 We also categorize

01:08:56.920 them that way.

01:08:57.540 And women have a

01:08:58.260 higher risk.

01:08:59.600 Females have a higher

01:09:00.340 risk of ACL tear than

01:09:01.560 men.

01:09:02.360 And there's a lot of

01:09:03.260 factors.

01:09:04.060 Is it just the strength

01:09:04.700 difference?

01:09:05.520 That's one of the

01:09:06.360 reasons.

01:09:06.700 It's a neuromuscular

01:09:07.700 control.

01:09:08.300 So early in puberty,

01:09:10.600 boys tend to, during

01:09:12.380 the spurt, tend to

01:09:13.840 have testosterone and

01:09:15.260 that affects muscle

01:09:16.760 growth in females

01:09:18.360 that's delayed.

01:09:20.020 And if you look at

01:09:21.040 sort of the neuromuscular

01:09:22.600 control factors

01:09:23.500 specifically, we have

01:09:25.180 patients will, you

01:09:26.340 know, you jump off.

01:09:27.720 This is pre-injury just

01:09:29.120 so we evaluate why are

01:09:30.740 they greater risk.

01:09:32.340 You have them jump off

01:09:33.100 a box and see how they

01:09:34.160 land.

01:09:35.100 And in general, at

01:09:36.600 that age, females are

01:09:38.280 more likely to land

01:09:39.660 with a valgus knee

01:09:41.100 with an adducted

01:09:43.880 hip, right?

01:09:45.000 The leg goes in.

01:09:46.000 That is, you have

01:09:46.800 weak gluteus medius

01:09:48.400 in balance with the

01:09:50.040 adductors.

01:09:50.660 So they land with

01:09:51.420 their knees in valgus,

01:09:53.220 oftentimes with a

01:09:54.760 very straight,

01:09:56.120 extended leg,

01:09:57.440 slightly flexed,

01:09:58.840 and a little bit

01:09:59.520 pronated.

01:10:00.780 So one of the

01:10:02.000 programs we're trying

01:10:03.300 to implement,

01:10:04.520 which is incredibly

01:10:05.400 difficult to do,

01:10:06.340 are injury prevention

01:10:07.300 programs where we

01:10:08.200 can take individuals

01:10:09.880 and see risk,

01:10:11.220 stratify them based

01:10:12.120 on risk to see,

01:10:13.820 you know, we do

01:10:14.220 landing error scoring

01:10:15.680 system and see how

01:10:17.100 people, and we mark

01:10:18.240 them and say, okay,

01:10:18.900 you need special

01:10:19.880 neuromuscular training.

01:10:21.340 What percent, I know

01:10:22.500 that this answer can't

01:10:23.420 be known, but just to

01:10:24.360 speculate, what percent

01:10:25.760 of ACL tears do you

01:10:27.220 think could have been

01:10:28.380 prevented if the

01:10:29.240 individual was

01:10:30.500 maximally strong,

01:10:32.180 had the highest amount

01:10:33.180 of their genetic

01:10:33.860 potential for

01:10:34.520 neuromuscular control

01:10:35.620 going into it?

01:10:36.340 So even though

01:10:36.840 virtually all ACL

01:10:37.960 injuries, I assume,

01:10:38.840 are acute injuries,

01:10:40.240 how many of them do

01:10:41.640 you think are on top

01:10:43.140 of a chronic weakness?

01:10:45.120 The only thing I can

01:10:45.660 get close to sort of

01:10:46.580 answering that question

01:10:47.520 is there have been

01:10:49.080 studies that looked at

01:10:50.000 injury prevention

01:10:50.960 programs and then

01:10:52.880 followed those people.

01:10:54.760 And the number that

01:10:56.040 has come out of the

01:10:57.220 literature is that you

01:10:58.440 need to treat 90

01:10:59.760 people to save one ACL.

01:11:02.600 So the number needed

01:11:03.420 to treat, but I

01:11:04.620 think that also...

01:11:06.340 It probably speaks to

01:11:06.700 how hard it is to

01:11:07.400 treat, how hard it is

01:11:08.560 to prevent.

01:11:09.580 But it's potentially

01:11:10.460 also decreasing risks

01:11:12.640 of other injuries too.

01:11:14.060 So it's not just ACLs

01:11:15.380 when you strengthen

01:11:16.080 the glutes and you...

01:11:17.600 So let me show you

01:11:19.040 sort of the mechanism.

01:11:20.760 I'm going to move the

01:11:21.780 kneecap out of the way.

01:11:22.840 So this is a right knee.

01:11:24.000 So this is the outside

01:11:24.800 of a right knee.

01:11:26.060 What happens when you

01:11:27.180 land in a valgus position

01:11:29.060 is like this.

01:11:30.460 So you land with the

01:11:31.560 leg a little bit like

01:11:32.360 this.

01:11:34.200 What this does, we call

01:11:35.440 this condylar lift-off.

01:11:37.240 So that's why you

01:11:37.980 often see MCL tears

01:11:39.360 because this gets

01:11:40.100 stretched.

01:11:41.580 The condyle lifts

01:11:42.800 off of the surface

01:11:43.860 and that surface

01:11:45.200 on the inside of the

01:11:46.440 knee, this is called

01:11:47.240 the medial part of the

01:11:48.760 knee, is very

01:11:50.200 congruent.

01:11:50.780 It's the most

01:11:51.360 congruent part of the

01:11:52.400 knee.

01:11:53.400 The lateral side, the

01:11:55.140 surface of the tibia

01:11:56.140 is convex.

01:11:57.200 It's very unstable

01:11:58.580 in general.

01:12:00.200 So now you're only

01:12:01.480 bearing weight basically

01:12:02.440 on the unstable,

01:12:04.000 non-congruent part of

01:12:05.040 the knee.

01:12:06.040 When your foot lands

01:12:07.260 in pronation, by

01:12:09.340 nature, the tibia

01:12:10.580 internally rotates

01:12:11.540 slightly.

01:12:12.820 At the same time that

01:12:14.300 happens, the quadricep

01:12:16.060 pulls and then it

01:12:18.080 shifts out of place.

01:12:19.360 The only thing that

01:12:20.500 typically will help

01:12:21.420 that is that the

01:12:22.480 hamstring on the back

01:12:24.280 has the opposing

01:12:25.540 force.

01:12:26.200 So if you land with

01:12:27.660 a flexed knee, it

01:12:28.620 can help stabilize

01:12:30.160 the knee.

01:12:30.900 Did that make sense?

01:12:32.340 Yeah.

01:12:32.680 Unfortunately, this is

01:12:33.540 going to be something

01:12:34.020 where people listening

01:12:35.260 to us on audio will

01:12:36.640 have no idea what

01:12:37.480 we're talking about.

01:12:38.400 You really have to

01:12:39.240 see the model in

01:12:40.560 3D.

01:12:42.060 And the way you just

01:12:43.180 described it, you

01:12:44.200 could experience that

01:12:45.100 if you fell, for

01:12:46.540 example.

01:12:47.200 Correct.

01:12:47.660 Is that also what's

01:12:48.860 happening in a ski

01:12:49.840 injury?

01:12:50.800 I just seem to see

01:12:51.840 more people tearing

01:12:52.660 their ACLs skiing than

01:12:53.920 I can shake a stick at.

01:12:55.220 And it's hard to know

01:12:56.400 because even when we

01:12:57.040 have video analysis of

01:12:58.980 skiing injuries or

01:12:59.960 even basketball injuries,

01:13:01.840 sometimes it's hard to

01:13:02.780 get exactly that.

01:13:03.840 It's probably a similar

01:13:04.780 mechanism, but

01:13:06.000 hyperextension of the

01:13:07.140 knee will also have

01:13:08.820 the same problem.

01:13:10.080 The other problem is

01:13:11.080 if your trunk is

01:13:12.680 leaning over to one

01:13:13.740 side at the same

01:13:14.960 time, that's an

01:13:16.200 extra amount of

01:13:17.540 force pushing the

01:13:19.220 knee that way.

01:13:19.780 So we see football

01:13:20.760 players get it all the

01:13:21.780 time.

01:13:22.540 As soon as they plant,

01:13:23.840 if they're hit,

01:13:25.220 on their hip,

01:13:26.600 their body weight

01:13:27.820 goes over to that

01:13:28.560 side, their foot

01:13:29.860 struck, there's a lot

01:13:30.920 of contact force,

01:13:32.560 the quadricep

01:13:33.300 contracts, the

01:13:35.160 tibia internally

01:13:36.000 rotates, it shifts

01:13:37.460 out of place, and

01:13:38.400 it's ruptured.

01:13:39.340 So what is the

01:13:41.400 typical cool-down

01:13:43.000 period you want on

01:13:44.340 an ACL when a

01:13:45.540 person is injured?

01:13:46.640 And are there

01:13:47.200 various considerations

01:13:48.380 as to how long you

01:13:50.520 might wait versus

01:13:51.320 operating right away?

01:13:52.980 I prefer to wait

01:13:54.300 until the knee is

01:13:55.660 quiet.

01:13:56.360 I'd like the initial

01:13:57.260 inflammation to come

01:13:58.160 down.

01:13:58.660 In my practice, I feel

01:13:59.800 that if you go into

01:14:01.100 the surgery with a

01:14:03.600 quiet knee to the

01:14:04.860 point where you

01:14:05.360 almost feel like, I

01:14:06.380 don't even think

01:14:06.940 anything's wrong.

01:14:07.880 I think that's a good

01:14:08.660 time to do surgery,

01:14:09.460 but there are plenty of

01:14:10.340 studies that show that

01:14:12.080 you can do it right

01:14:12.940 away.

01:14:13.440 There's no adverse

01:14:14.380 effect down the line,

01:14:15.560 but I also like people

01:14:17.500 to sort of prepare

01:14:18.300 themselves and just

01:14:19.180 sort of think about

01:14:19.880 what's happening and

01:14:20.680 get some prehab before

01:14:22.380 the ACL reconstruction

01:14:23.760 so that, you know,

01:14:25.200 we're all on the

01:14:25.660 same page about what

01:14:26.540 this means long-term

01:14:27.580 and how to prevent

01:14:28.640 the other side and

01:14:29.720 all the issues

01:14:30.600 regarding recovery

01:14:32.120 from the initial

01:14:32.880 injury because they

01:14:34.900 also re-tear.

01:14:35.900 So we're doing a lot

01:14:36.660 of revision ACL

01:14:37.580 reconstruction.

01:14:38.140 What are you

01:14:38.460 typically using to

01:14:39.740 repair the ACL?

01:14:42.000 We have different

01:14:42.600 categories, right?

01:14:43.520 So autographed

01:14:44.460 versus allograft.

01:14:45.420 So the main

01:14:45.940 autographed tendons

01:14:46.900 that I use are

01:14:48.160 patellar tendon and

01:14:49.440 hamstring, although

01:14:50.300 quadricep is being

01:14:51.440 used a little bit

01:14:52.140 more.

01:14:52.520 So what part of the

01:14:53.200 patellar tendon are

01:14:53.920 you using there?

01:14:55.040 We take the central

01:14:56.040 third of the patellar

01:14:57.160 tendon.

01:14:58.000 So the width of the

01:14:59.180 patellar tendon from

01:15:00.340 medial to lateral is

01:15:01.480 about 30 millimeters.

01:15:03.520 And so the central

01:15:04.260 third, one centimeter,

01:15:06.220 we take one centimeter

01:15:07.280 or 10 millimeters of

01:15:08.480 the central third of

01:15:09.460 the patellar tendon with

01:15:10.420 a little bit of bone

01:15:11.280 from the kneecap and

01:15:12.720 bone from the tibial

01:15:14.060 tuberosity.

01:15:15.000 And that becomes your

01:15:16.220 new graft.

01:15:16.800 So that you're doing

01:15:17.520 bone-to-bone

01:15:18.160 attachment?

01:15:18.660 Bone-to-bone

01:15:19.000 attachment, exactly.

01:15:19.920 Has it always been

01:15:20.560 that way?

01:15:21.500 For a patellar tendon,

01:15:22.440 yes.

01:15:22.920 And if you did

01:15:23.540 cadaveric ACL, is

01:15:25.400 that done anymore?

01:15:26.460 Yes.

01:15:27.080 And you're still going

01:15:27.840 bone-to-bone?

01:15:28.800 You can ask for

01:15:29.660 different types of

01:15:30.500 allografts.

01:15:30.980 So you can get a

01:15:31.860 B, we call it BTB,

01:15:33.480 bone-tendon-bone

01:15:34.640 allograft.

01:15:36.220 Or you could do

01:15:36.960 soft tissue

01:15:37.620 allograft.

01:15:38.700 Bone-to-bone

01:15:39.320 healing tends to be

01:15:40.280 more predictable.

01:15:42.060 Allograft is really

01:15:43.160 not a great idea

01:15:44.880 in the younger

01:15:47.080 cohort.

01:15:47.500 There was a recent

01:15:48.260 study that showed

01:15:48.800 that you're safe

01:15:49.640 with allograft

01:15:50.320 after the age of

01:15:51.200 34.

01:15:52.660 That is, before

01:15:53.860 34, the risk of a

01:15:55.340 re-rupture is

01:15:56.660 unnecessarily high

01:15:58.420 if you use

01:15:59.620 allograft.

01:16:00.600 Because allograft

01:16:01.440 tissue is somebody

01:16:02.200 else's tissue, and

01:16:03.220 it takes longer for

01:16:04.140 that tissue to

01:16:04.980 mature and to get

01:16:06.340 strong.

01:16:06.780 And typically, how

01:16:07.460 old are the

01:16:08.120 cadavers from which

01:16:09.040 you're getting that?

01:16:09.780 Hopefully, a young

01:16:11.260 person.

01:16:11.780 But do you get a

01:16:12.400 say in this?

01:16:12.960 Well, you do.

01:16:13.420 You ask first.

01:16:14.080 I won't take it

01:16:15.000 unless they're

01:16:15.580 under this age, and

01:16:16.440 there are ways to

01:16:17.200 make sure that you

01:16:17.960 only are provided

01:16:18.940 young lieutenant.

01:16:20.400 So, is the main

01:16:21.000 incentive to do

01:16:22.280 allograft to avoid

01:16:24.260 the patellar injury?

01:16:26.240 There are a number

01:16:27.060 of reasons why

01:16:27.680 people want it.

01:16:28.700 Number one, it's an

01:16:30.220 easier surgery to

01:16:31.320 recover from up

01:16:32.260 front.

01:16:32.720 So, people are

01:16:33.760 busy, they work,

01:16:34.680 they may not be

01:16:35.420 skiers or play

01:16:36.580 basketball, they may

01:16:37.460 just do some

01:16:39.120 recreational stuff

01:16:39.960 occasionally like

01:16:40.920 hiking, and they're

01:16:41.960 in their 40s, and

01:16:43.160 it's perfectly

01:16:44.280 reasonable to use

01:16:45.420 allograft.

01:16:46.680 The rates are

01:16:47.320 higher of re-rupture,

01:16:48.480 but it's not as

01:16:49.320 if, I mean, it's

01:16:50.060 still being done

01:16:50.620 because it's still

01:16:51.480 a reasonable

01:16:51.980 option.

01:16:52.980 So, that's why

01:16:53.600 people are doing

01:16:54.200 it.

01:16:54.520 But if someone

01:16:55.040 participates in

01:16:55.940 high-risk activities,

01:16:57.200 high-risk sports,

01:16:58.540 level one sports,

01:16:59.640 then it's not a

01:17:00.740 great idea.

01:17:01.720 The patellar is

01:17:02.200 that much better.

01:17:03.220 It's that much

01:17:03.760 better, yeah.

01:17:04.980 And sometimes we

01:17:05.780 compare, so the

01:17:06.560 big question is

01:17:07.320 what's better, the

01:17:08.020 hamstring, the

01:17:09.320 patellar tendon, the

01:17:10.980 quad tendon, and the

01:17:11.940 quad tendon, there's

01:17:12.840 not enough research

01:17:14.320 to say definitively

01:17:16.000 that it's not in

01:17:17.040 the game yet as

01:17:17.820 far as...

01:17:18.080 And which hamstring

01:17:18.880 tendon are you

01:17:19.500 taking?

01:17:20.120 It depends.

01:17:20.860 Some people take

01:17:21.480 the semitendinosis

01:17:22.540 along with the

01:17:23.580 gracilis, some

01:17:24.240 people just take

01:17:25.160 the semitendinosis,

01:17:26.180 and again, you can

01:17:26.920 access that from

01:17:27.960 the front because

01:17:28.600 the tendons attach

01:17:29.940 right here in the

01:17:31.080 front of the medial

01:17:32.020 tibia, and you

01:17:33.340 make an incision in

01:17:34.300 the front, and you

01:17:34.920 find the tendon and

01:17:35.680 take it.

01:17:36.160 So, what happens to

01:17:37.080 the rest of the

01:17:37.840 hamstring?

01:17:39.160 Great question.

01:17:40.100 Tends to scar in,

01:17:41.120 but that is one of

01:17:42.140 the reasons why

01:17:42.720 people don't

01:17:43.300 necessarily want to

01:17:44.120 do hamstring because

01:17:44.740 you do have weaker

01:17:45.620 hamstrings after.

01:17:46.580 Now, you have the

01:17:47.940 biceps femoris on the

01:17:49.100 other side, and you

01:17:49.860 have the

01:17:50.080 semimembranosus that's

01:17:51.280 not affected, which

01:17:52.600 are the other

01:17:53.080 components of the

01:17:54.040 hamstring, but your

01:17:55.180 hamstrings will be

01:17:56.140 weaker, and the

01:17:56.840 hamstring is there

01:17:57.820 also to protect you

01:17:59.660 from an ACL injury

01:18:00.660 because as the tibia

01:18:02.400 moves forward, the

01:18:03.520 hamstrings are

01:18:04.300 pulling you back

01:18:05.100 too.

01:18:06.020 So, it sounds to

01:18:07.020 me like if you can

01:18:07.940 handle the additional

01:18:09.580 recovery and the

01:18:10.520 pain of having your

01:18:11.720 patella tendon cranked

01:18:13.220 open, that's the

01:18:14.420 better operation.

01:18:15.180 Right.

01:18:15.680 The gold standard, I

01:18:16.700 think, still is the

01:18:17.800 patellar tendon, and

01:18:19.740 the downside of that

01:18:21.660 is it's a little

01:18:22.940 harder recovery early

01:18:24.200 on, and people do

01:18:25.580 complain of kneeling

01:18:26.860 pain because of the

01:18:28.700 bone removed from the

01:18:30.560 kneecap, the incision on

01:18:32.040 the front of the

01:18:32.560 knee, so people truly do

01:18:34.640 complain about that.

01:18:35.500 So, if I have an

01:18:37.040 individual who...

01:18:37.880 So, if you're

01:18:38.220 Catholic...

01:18:38.920 Correct.

01:18:39.400 Or, if you garden all

01:18:41.440 the time or you love

01:18:42.440 yoga, I'm going to say,

01:18:43.740 listen, let's do the

01:18:44.760 hamstring tendon instead.

01:18:46.520 So, you can sort of

01:18:47.920 tailor it to what seems

01:18:49.520 to be more appropriate.

01:18:51.220 So, 50% of people who

01:18:54.160 get an ACL repair, or

01:18:56.420 frankly, just tear their

01:18:57.400 ACL, it seems like

01:18:58.320 there's no difference,

01:18:59.380 50% of those people

01:19:00.480 within 15 to 20 years

01:19:02.000 are going to need a

01:19:02.620 total knee replacement.

01:19:03.800 No.

01:19:04.040 No, they're just

01:19:04.620 going to have

01:19:04.880 arthritis.

01:19:05.460 Right.

01:19:05.640 And it doesn't even

01:19:06.280 mean it's symptomatic.

01:19:07.340 I see.

01:19:07.760 Okay.

01:19:08.520 Again, x-ray tells a

01:19:09.920 big story here.

01:19:10.680 I've seen my knee on

01:19:11.560 x-ray.

01:19:12.100 I've got...

01:19:12.500 I'm fortunate I don't

01:19:13.200 have arthritis, so I've

01:19:14.060 got a big clear space

01:19:15.920 between the femoral

01:19:17.880 condyle and the tibial

01:19:18.960 plateau.

01:19:20.000 How narrow does that

01:19:21.280 need to be before you

01:19:23.120 would make the diagnosis

01:19:23.940 of arthritis, and how

01:19:25.320 correlated is the

01:19:26.820 reduction in that

01:19:27.480 space with symptoms?

01:19:29.000 It's not correlated

01:19:30.100 well.

01:19:31.240 And even when I say

01:19:32.760 arthritis,

01:19:33.340 arthritis, it's hard

01:19:34.760 to define...

01:19:35.880 The way I think about

01:19:36.600 it is there's

01:19:36.960 arthritis, and then

01:19:37.860 there's symptomatic

01:19:38.580 arthritis.

01:19:39.480 So you can have

01:19:40.360 cartilage loss, and we

01:19:41.800 consider that quote-unquote

01:19:43.260 arthritis, but it very

01:19:46.020 often isn't symptomatic.

01:19:47.660 And so when we really

01:19:49.620 think about arthritis,

01:19:51.240 it's a whole joint

01:19:52.500 disease.

01:19:53.680 The cartilage starts

01:19:54.560 to break down, an

01:19:56.000 inflammatory reaction

01:19:57.180 happens, the synovium,

01:19:58.900 which is on the inside

01:19:59.800 of the knee, also gets

01:20:01.000 inflamed.

01:20:01.540 And the bone under

01:20:03.000 the cartilage goes

01:20:03.900 through changes.

01:20:05.000 So the arthritis that

01:20:06.300 you're worried about, that

01:20:07.520 I'm worried about, is

01:20:09.020 that whole joint

01:20:10.080 arthritis.

01:20:11.060 Not so worried about

01:20:12.360 narrowing of the

01:20:14.000 cartilage in

01:20:15.260 isolation.

01:20:16.720 It's the...

01:20:17.300 It's much more

01:20:17.740 systemic to the knee

01:20:19.400 as a system.

01:20:19.960 It's like a biologic

01:20:20.980 process.

01:20:21.760 We're really trying to

01:20:22.760 avoid...

01:20:23.180 And I see them come in,

01:20:24.420 they were perfectly

01:20:25.100 normal.

01:20:25.540 I see people with

01:20:26.680 horrible-looking knees

01:20:28.420 who come into my

01:20:29.760 office, they say, my

01:20:30.720 knee started hurting

01:20:31.500 last week, I've never

01:20:33.000 had a knee problem

01:20:33.760 before, I get an x-ray

01:20:35.440 and there is no

01:20:36.460 cartilage left, they

01:20:38.040 won't believe me.

01:20:39.000 They said, but I don't

01:20:39.660 have arthritis.

01:20:41.060 I say, I know you

01:20:42.000 didn't know you have

01:20:42.860 arthritis, but now you

01:20:44.220 do.

01:20:44.840 So what tipped that

01:20:45.740 person over?

01:20:46.460 Because clearly, if you

01:20:48.280 took that x-ray a year

01:20:49.320 ago, it would look

01:20:50.140 almost as bad, if not

01:20:51.200 the same.

01:20:51.700 Exactly the same.

01:20:52.220 What flipped the

01:20:52.920 switch?

01:20:53.480 It's usually a traumatic

01:20:54.500 event.

01:20:55.060 It's usually a stumble.

01:20:56.200 It's usually nothing.

01:20:57.060 It's like, I lifted

01:20:58.220 something heavy and

01:20:59.080 twisted funny.

01:20:59.840 I felt a little

01:21:00.460 something.

01:21:01.260 Maybe the meniscus

01:21:02.160 tears a little more.

01:21:03.600 It's a very slow

01:21:04.520 process.

01:21:05.280 The chondrocytes have

01:21:06.140 been not doing their

01:21:07.160 thing.

01:21:08.080 The cartilage is worn

01:21:08.960 away, but it's been

01:21:09.980 such a low burn that it

01:21:12.360 hasn't tipped the scale

01:21:13.460 into a very painful

01:21:14.900 process.

01:21:15.620 And then it goes

01:21:16.380 overboard, and it's

01:21:18.880 hard to bring it back

01:21:19.920 at that point because

01:21:20.940 there's not really any

01:21:22.100 healthy cartilage left.

01:21:24.060 That's very difficult.

01:21:25.260 It's a very difficult

01:21:25.940 problem.

01:21:26.300 And those people get

01:21:27.040 knee replacements.

01:21:28.040 Before we go to knee

01:21:29.380 replacements, let's talk

01:21:30.180 about the meniscal tear.

01:21:31.420 This is such a

01:21:32.100 controversial area.

01:21:33.800 I assume there have

01:21:34.880 been sham surgery

01:21:36.400 studies that have been

01:21:37.360 done.

01:21:38.100 What do we know about

01:21:39.040 meniscal, isolated

01:21:39.980 meniscal tears?

01:21:41.120 The principle is, is if

01:21:42.660 you have a meniscus tear

01:21:44.220 and you don't have

01:21:45.160 arthritis, you need to

01:21:47.540 strongly consider fixing

01:21:48.920 that meniscus because

01:21:50.800 that's what's keeping us

01:21:52.640 from getting arthritis.

01:21:53.400 And the meniscal tear

01:21:55.440 means separation from

01:21:57.640 the tibial plateau?

01:21:58.640 Is that what the tear

01:21:59.240 means?

01:21:59.580 Or is it a tear across

01:22:01.560 the surface?

01:22:02.400 Let me get a picture

01:22:03.220 out.

01:22:03.940 So here we have a

01:22:05.500 cross section of the

01:22:06.480 knee.

01:22:06.940 This is the lateral

01:22:08.480 meniscus here, and this

01:22:10.060 is the medial meniscus

01:22:11.340 here.

01:22:11.860 So if we were to look at

01:22:13.140 the model, that's what

01:22:14.640 we would be looking at.

01:22:15.600 So there are different

01:22:17.700 types of meniscus tears.

01:22:19.600 There are tears that are

01:22:22.100 at the periphery where

01:22:23.360 there's very good blood

01:22:24.300 flow.

01:22:25.040 And in those types of

01:22:26.260 tears, you can sew it

01:22:27.580 back together and should.

01:22:29.520 There are tears that go

01:22:30.760 all the way across.

01:22:33.060 And then this piece can

01:22:35.900 flip.

01:22:37.240 That's called the bucket

01:22:38.300 handle tear.

01:22:39.200 And that often will lock

01:22:41.000 the knee.

01:22:41.660 The inner piece or the

01:22:42.740 outer piece?

01:22:43.240 The inner piece.

01:22:44.080 The outer piece is

01:22:45.400 connected to the capsule.

01:22:47.520 There are tears that we

01:22:48.700 call radial tears that go

01:22:50.240 through here.

01:22:51.680 Occasionally, if it's

01:22:52.540 close enough to the rim,

01:22:53.660 you could put sutures

01:22:54.620 there.

01:22:55.220 But sometimes you just

01:22:56.400 need to trim it, where

01:22:58.040 you take out the torn

01:22:59.060 piece of meniscus and you

01:23:00.720 just leave what remains.

01:23:02.240 So that's the difference

01:23:03.400 between a meniscus repair

01:23:04.980 and a meniscectomy.

01:23:07.220 So when we talk about...

01:23:08.460 In the bucket handle, you

01:23:09.760 repair primarily?

01:23:11.460 Yes.

01:23:11.740 You put it back to where

01:23:12.880 it is and you start

01:23:14.060 sew it back together.

01:23:15.680 So all the controversy

01:23:16.940 around meniscal surgery

01:23:19.080 that is no better than

01:23:20.980 sham surgery, is it

01:23:23.180 based on a particular

01:23:24.020 one of those or is it

01:23:25.580 based on the fact that

01:23:27.080 these studies didn't

01:23:28.880 stratify for those?

01:23:29.960 So it's a specific

01:23:32.060 type of tear.

01:23:33.360 In general, we want to

01:23:34.840 save the meniscus when

01:23:36.240 we can.

01:23:36.720 So if you're young and

01:23:37.620 you have a meniscus tear

01:23:38.560 and you heard that sham

01:23:39.700 surgery is no better than...

01:23:40.980 That's not you.

01:23:42.380 You need to have your

01:23:43.300 meniscus fixed if it can

01:23:44.460 be fixed.

01:23:45.860 If you have degeneration

01:23:48.000 of the knee already, if

01:23:49.280 you have arthritis, let's

01:23:51.280 say you have advanced

01:23:52.160 arthritis of the knee and

01:23:54.040 your doctor gets you...

01:23:54.920 And again, sorry to

01:23:55.720 interrupt, I want to come

01:23:56.320 back to this point.

01:23:56.840 No, sure.

01:23:57.320 The diagnosis is made how

01:23:59.620 of arthritis because it's

01:24:00.980 clearly no longer just a

01:24:02.220 radiographic diagnosis.

01:24:03.680 Well, if it is, even with

01:24:05.380 a radiographic diagnosis

01:24:06.880 because that's what the

01:24:08.140 studies use to say this

01:24:09.900 isn't effective.

01:24:10.820 So you don't need

01:24:11.780 inflammatory synovial fluid

01:24:13.500 to make this diagnosis.

01:24:14.700 No, but they are

01:24:15.620 inflamed because that's

01:24:16.620 why they came to see you.

01:24:18.440 The problem is we don't

01:24:19.260 know, is there pain from

01:24:20.580 the arthritis or is there

01:24:21.860 pain from that new

01:24:22.880 meniscus tear that they

01:24:23.920 have?

01:24:24.580 So I have a patient comes

01:24:25.620 in who has radiographic

01:24:27.140 arthritis, evidence of

01:24:28.720 arthritis, and they have

01:24:30.960 pain and I get an MRI.

01:24:33.700 I mean, I often try not

01:24:34.780 to get an MRI because I

01:24:36.440 really just want to treat

01:24:37.700 the arthritis.

01:24:38.280 But let's say they come

01:24:40.280 in with an MRI and they

01:24:41.340 say, look, I have a

01:24:42.180 meniscus tear.

01:24:43.380 If they don't have normal

01:24:45.020 cartilage and they have

01:24:46.500 a meniscus tear, I want to

01:24:47.560 do nothing.

01:24:48.400 And really, that's the

01:24:49.520 population of patients

01:24:50.580 where those studies really

01:24:51.920 help us to say to our

01:24:54.340 patients, listen, we do

01:24:56.080 nothing, you're going to

01:24:57.600 be just as fine as if we

01:24:58.660 do surgery.

01:24:59.400 And here's a study to

01:25:00.480 show that.

01:25:01.380 But those are just

01:25:02.640 studies.

01:25:03.720 And the truth is, it's

01:25:05.080 easier for me to make a

01:25:06.100 decision about a

01:25:06.940 particular patient than to

01:25:08.220 base it on some

01:25:09.380 randomized controlled

01:25:10.340 trial.

01:25:10.800 It's a nice starting

01:25:11.700 point to say, let's try.

01:25:13.480 But I have untold numbers

01:25:15.920 of patients who've had

01:25:17.140 some arthritis, they have

01:25:18.440 a new injury, a meniscus

01:25:19.820 tear, try conservative

01:25:22.360 treatment, not getting

01:25:23.620 better, do the surgery

01:25:25.100 later, and they do okay.

01:25:27.140 Regardless of which of

01:25:28.380 those tears they have?

01:25:29.460 It depends on what kind

01:25:30.620 of tear they have.

01:25:31.180 There are certain types of

01:25:32.200 tears where...

01:25:33.280 You would always repair a

01:25:34.260 bucket handle?

01:25:34.800 Well, it depends.

01:25:35.780 If the person's 60 years

01:25:36.940 old, they don't usually

01:25:37.580 get bucket handle tears.

01:25:38.680 It's more of a complete

01:25:39.940 complex degenerative, just

01:25:42.140 like the tendon and the

01:25:43.700 cartilage, the meniscus also

01:25:45.460 goes through these changes

01:25:46.840 with senescent cells and

01:25:48.220 matrix that is unhealthy.

01:25:50.680 And so those you can't

01:25:51.680 repair.

01:25:51.980 You put stitches in it, it's

01:25:53.160 not repairing.

01:25:54.440 So in those cases, you

01:25:55.900 trim the piece.

01:25:58.420 So the young person, the

01:25:59.900 runner who comes in, they're

01:26:01.220 40 years old, they're having

01:26:02.820 knee pain, it's new onset, they

01:26:05.620 don't have radiographic

01:26:07.100 arthritis, the MRI shows a

01:26:10.000 meniscal tear, any of those

01:26:11.480 versions you would fix?

01:26:13.280 I would try to, yes.

01:26:14.500 This is assuming that their

01:26:16.460 pain is from the meniscus, and

01:26:18.000 that's where this gets a little

01:26:19.040 bit more like art than science,

01:26:20.600 because you can have some tiny

01:26:22.340 tears that I'm not that worried

01:26:23.660 about, and their pain may be

01:26:25.440 from patellofemoral syndrome,

01:26:27.580 anterior knee pains.

01:26:28.740 It depends where their pain is.

01:26:30.340 If their pain correlates to the

01:26:32.040 tear and it's significant, it's

01:26:34.560 a good idea to try to address

01:26:36.620 that, assuming that tear is a

01:26:38.400 type of tear.

01:26:38.640 So what are the things you

01:26:39.640 need to rule out?

01:26:40.600 How do you rule out the

01:26:41.880 patellofemoral syndrome?

01:26:42.960 How do you rule out the MCL

01:26:45.200 sprain, which might not show

01:26:47.160 up, or other injuries?

01:26:48.480 Those things usually happen with

01:26:49.860 an injury.

01:26:50.600 You know, you're not going to

01:26:51.140 tear your MCL running unless

01:26:52.540 you slipped and fall.

01:26:54.020 But a lot of my patients have

01:26:55.420 patellofemoral pain, which is

01:26:56.880 basically overloading of the

01:26:58.520 patellofemoral joint, right?

01:26:59.920 So we talked about how if you

01:27:01.200 squat at seven times body

01:27:02.580 weight, well, running is a

01:27:04.040 similar type of problem with

01:27:05.500 the force at the kneecap.

01:27:07.140 And if you increase your

01:27:08.500 duration of running, your

01:27:09.760 mileage, and the amount of

01:27:11.620 times you've done it in a

01:27:12.640 week, you're going to

01:27:13.380 overload the cartilage in the

01:27:14.540 kneecap, and you're going to

01:27:15.400 generate pain.

01:27:16.420 But that has a very particular

01:27:17.900 feel to it.

01:27:19.160 On examination, you can tell

01:27:20.700 the difference between

01:27:21.580 patellofemoral pain.

01:27:22.880 In fact, on examination,

01:27:24.200 patellofemoral pain, I can't

01:27:25.360 find anything.

01:27:26.420 I can't load it enough to

01:27:27.640 generate the pain.

01:27:28.420 I can bend your knee every

01:27:29.900 which way.

01:27:30.640 If you have a meniscus tear

01:27:32.000 and I put some torsion into

01:27:33.420 it, you're going to feel it.

01:27:34.960 It's a different presentation

01:27:36.100 with regards to injury.

01:27:37.800 Also, meniscus tears, if

01:27:39.020 there's no history of injury,

01:27:40.420 I want to know why would this

01:27:42.080 happen.

01:27:42.520 And so if something twists

01:27:43.820 and then they have a

01:27:44.720 meniscus tear, the pain

01:27:45.640 happened after an accident,

01:27:47.120 then I'm like, okay, I

01:27:47.760 have to.

01:27:48.360 What is the treatment for

01:27:49.740 patellofemoral syndrome?

01:27:51.220 If they haven't been doing

01:27:52.120 anything, if they haven't been

01:27:53.640 very active, I send them to

01:27:55.480 PT.

01:27:56.220 You need to strengthen your

01:27:57.180 quad.

01:27:57.580 Yeah, so it's quad strengthening.

01:27:58.960 But it also is difficult

01:28:00.780 because I'm asking them to do

01:28:03.020 an activity that increases the

01:28:04.480 load on the kneecap as a

01:28:07.320 quadricep strengthening for a

01:28:08.940 problem that is causing pain.

01:28:10.720 And the cause of their pain

01:28:11.920 exactly is what?

01:28:13.620 We don't always know in one

01:28:15.400 particular situation.

01:28:17.180 So this is a knee from the,

01:28:19.200 this is a sagittal or a view

01:28:20.940 from the side.

01:28:21.860 And what we see here is this

01:28:24.500 is the thigh bone or the

01:28:25.580 femur, and this is the leg

01:28:26.760 bone or the tibia.

01:28:27.940 And the kneecap is in the

01:28:29.620 front on this image.

01:28:30.560 So this is looking at the

01:28:31.400 side of your knee.

01:28:32.280 You see the quadriceps

01:28:33.580 tendon, and then you see the

01:28:34.980 kneecap with its cartilage

01:28:36.280 and the cartilage on the

01:28:38.560 femur and the tibia, and you

01:28:39.720 also see the meniscus there

01:28:41.400 as well.

01:28:43.200 When you overload this part of

01:28:45.200 the knee, your pain can be

01:28:47.100 coming from the patellar

01:28:49.180 tendon, the quad tendon, the

01:28:51.640 cartilage, the bone, the fat

01:28:54.760 pad.

01:28:55.680 There's fat inside the knee,

01:28:57.400 and that sometimes gets

01:28:58.800 pinched and inflamed when

01:29:00.660 you're running, and that will

01:29:02.040 generate symptoms.

01:29:02.980 So we don't always necessarily

01:29:04.460 know.

01:29:05.460 Well, we do know that

01:29:06.500 strengthening the quadricep

01:29:08.240 helps the kneecap to

01:29:09.920 potentially glide better and

01:29:12.340 can reduce symptoms.

01:29:14.480 But I've had numbers of

01:29:16.260 patients who go to PT, and

01:29:19.160 they have worse pain.

01:29:20.660 We need to be creating...

01:29:21.860 And they may have bad

01:29:22.620 mechanics.

01:29:23.160 It seems to me that the

01:29:24.100 recurring theme here is

01:29:25.260 inactivity or poor mechanics

01:29:27.460 is the root cause of most

01:29:29.680 of these injuries.

01:29:30.820 So this is where it's

01:29:32.140 important.

01:29:32.720 When I send in a PT, I may

01:29:34.020 say, listen, I don't want

01:29:35.240 you to do any quad

01:29:36.920 strengthening this week.

01:29:38.380 I want you to do hip

01:29:39.500 strengthening.

01:29:40.260 I want you to focus on the

01:29:42.340 gluteus medius, because if

01:29:44.140 your leg is adducting, you're

01:29:46.940 pulling the kneecap

01:29:47.860 outside, increasing the

01:29:50.540 force on that area.

01:29:52.200 And so I want to correct

01:29:53.540 that without doing anything

01:29:55.880 to this.

01:29:56.480 And I'll also sometimes use...

01:29:58.600 If I really need to work on

01:30:00.440 the quad, I'll do blood flow

01:30:02.020 restriction in those

01:30:02.980 circumstances, because it's

01:30:05.020 lower loads and provides a

01:30:07.240 very similar amount of injury

01:30:08.920 to the muscle as high-load

01:30:10.840 training would do.

01:30:11.780 How long after ACL repair

01:30:14.500 do you let patients do BFR?

01:30:17.120 I send them to a place that

01:30:18.660 does it a lot.

01:30:19.540 And as long as the swelling

01:30:20.820 is down and they can

01:30:21.780 tolerate it, I don't mind

01:30:22.760 starting relatively quickly

01:30:23.980 because you can titrate how

01:30:25.740 much you're doing, what

01:30:26.620 percentage of blood flow

01:30:27.740 you're decreasing.

01:30:28.880 And I think it's a great way

01:30:30.540 to start that process early

01:30:32.480 before letting more atrophy

01:30:34.740 set in.

01:30:35.700 So what are the indications

01:30:37.320 then for the total knee

01:30:38.520 replacement?

01:30:39.000 So if someone comes in and

01:30:41.800 they have advanced arthritis,

01:30:42.980 that is all compartments of

01:30:45.180 their knee, the medial

01:30:46.340 compartment, the lateral

01:30:47.320 compartment, the patellofemoral

01:30:48.600 compartment, or really too

01:30:50.300 severely degenerative

01:30:52.280 compartments, and they've

01:30:53.760 failed conservative

01:30:54.600 treatment, it's a conversation

01:30:56.420 to have.

01:30:57.340 What is failed conservative

01:30:58.560 treatment?

01:30:59.520 Have we tried PT?

01:31:00.880 Have we tried injections?

01:31:02.500 Have we tried a steroid?

01:31:04.160 Hyaluronic acid?

01:31:05.980 Potentially PRP if they're

01:31:07.400 interested, bracing, and their

01:31:10.720 quality of life is so poor

01:31:12.280 that they want to have

01:31:14.120 something done, we talk

01:31:15.160 about knee replacement.

01:31:16.340 Do you have a sense of how

01:31:17.860 often body weight is a driver

01:31:19.920 of this arthritis?

01:31:21.580 In other words, you know, I

01:31:23.180 don't know what the numbers

01:31:23.860 are today, but it's roughly a

01:31:25.040 third of the country would have

01:31:26.580 a BMI over 30.

01:31:28.060 Right.

01:31:28.840 Many of those people don't

01:31:30.660 have a BMI over 30 because

01:31:31.740 they're overly muscled,

01:31:33.120 although I'm not sure that the

01:31:34.120 knee cares how much that weight

01:31:35.600 is muscle versus fat.

01:31:37.100 So just in terms of excess

01:31:38.640 weight, how often is that

01:31:40.100 driving the problem?

01:31:41.380 It's driving it a lot, which

01:31:42.480 is why I show them the chart

01:31:43.720 of this is four times body

01:31:45.440 weight when you do this.

01:31:46.620 This is seven times body

01:31:47.980 weight when you do this.

01:31:48.700 Just walking up the stairs

01:31:50.000 or down the stairs.

01:31:51.280 Down the stairs is even worse.

01:31:53.060 And I say, if you lose five

01:31:55.040 pounds, let's start small.

01:31:57.260 This is how much weight you're

01:31:58.780 taking off your knee if you

01:32:00.280 multiply that.

01:32:01.560 If you can lose this amount of

01:32:03.340 weight, you may not want

01:32:04.720 a knee replacement and you

01:32:06.020 may not need one.

01:32:07.520 And so I never tell someone

01:32:08.880 when it's time for them to

01:32:09.900 have a knee replacement.

01:32:10.700 They're going to tell me,

01:32:11.500 listen, I can't do this

01:32:12.380 anymore.

01:32:12.820 I want something.

01:32:13.620 And as long as they're healthy

01:32:14.580 enough to have the surgery,

01:32:15.680 it's reasonable.

01:32:17.080 But obviously, the satisfaction

01:32:19.020 rate after knee replacement

01:32:20.180 is different than hip

01:32:21.100 replacement.

01:32:21.520 And it's just an inherently

01:32:22.700 less stable joint.

01:32:24.160 And so it's harder to feel

01:32:25.820 like it's a normal knee.

01:32:26.880 People feel like it's a

01:32:27.820 normal hip, but they don't

01:32:28.880 feel like it's a normal knee

01:32:29.860 when it's replaced.

01:32:31.180 So this is probably a decent

01:32:32.420 diagram to show the

01:32:33.940 anatomy of the knee

01:32:34.780 replacement, huh?

01:32:35.760 I have a good model.

01:32:36.700 You have an even better one.

01:32:37.520 Okay, perfect.

01:32:38.540 So this is a model of

01:32:40.180 a replaced knee.

01:32:41.900 I'm going to take off

01:32:43.740 this portion, flex the knee.

01:32:45.980 And what we see here is

01:32:47.640 fake knee replacement,

01:32:49.400 but basically has three

01:32:51.320 components.

01:32:52.360 Before we put those

01:32:53.380 components on, we make cuts

01:32:55.020 in the surface of the

01:32:56.660 distal femur.

01:32:57.680 We make a cut on the surface

01:32:59.260 of the proximal tibia.

01:33:00.700 And that matches

01:33:02.320 an implant that fits

01:33:04.380 right on that surface.

01:33:05.760 And same with the tibial

01:33:08.200 surface.

01:33:09.220 And that is made of the

01:33:10.660 high molecular weight

01:33:11.780 polyethylene.

01:33:13.340 And then also occasionally

01:33:14.540 we also will replace

01:33:16.020 the surface of the kneecap

01:33:17.780 with a plastic button.

01:33:19.840 And that's your new knee.

01:33:21.880 Do you sometimes keep

01:33:22.780 the native patella

01:33:23.640 if it's fine?

01:33:25.180 Yeah, occasionally.

01:33:26.160 Sometimes, you know,

01:33:27.060 there's some people who

01:33:28.200 it's called resurfacing

01:33:29.660 the patella and some people

01:33:30.380 who don't resurface the

01:33:31.260 patella.

01:33:31.800 And the studies show

01:33:32.720 that there's probably

01:33:33.580 not a difference.

01:33:34.680 In Europe, I think they

01:33:35.640 hardly ever resurface the

01:33:36.880 patella.

01:33:37.300 It's more common in the

01:33:38.020 United States, but I know

01:33:38.960 a lot of surgeons who

01:33:39.780 don't.

01:33:40.040 And I do sometimes, I do

01:33:41.460 most of the time, but

01:33:42.820 sometimes I don't.

01:33:43.980 The reason I do it most

01:33:45.320 of the time is because

01:33:46.500 if there's significant

01:33:47.360 arthritis there and I'm

01:33:48.600 there, I'm too afraid

01:33:50.340 that they're going to

01:33:50.860 have pain after because a

01:33:52.080 lot of people after

01:33:52.700 knee replacement still are

01:33:53.860 85% satisfaction means

01:33:55.700 that 15% are

01:33:56.660 dissatisfied.

01:33:57.240 And if I haven't

01:33:57.900 replaced the patella, I'm

01:33:59.100 thinking to myself, maybe I

01:34:00.060 should have replaced the

01:34:00.800 patella too.

01:34:01.940 How long does this

01:34:02.520 operation take?

01:34:03.560 It depends, anywhere from

01:34:04.600 an hour to two hours,

01:34:05.820 depending on the complexity

01:34:06.860 of the surgery.

01:34:08.100 And how big is the

01:34:09.080 incision?

01:34:09.660 It's straight, it's a

01:34:10.340 midline incision?

01:34:11.120 It's a midline incision,

01:34:12.060 anywhere from 10

01:34:12.860 centimeters.

01:34:13.580 It depends on the knee.

01:34:14.560 It goes from here to

01:34:15.800 here.

01:34:16.760 And unlike the hip, which

01:34:18.600 we talked about earlier,

01:34:19.520 where the difference between

01:34:20.700 what happens today and 20

01:34:21.800 years ago is night and day,

01:34:23.040 and these patients are, they

01:34:24.600 just feel amazing.

01:34:25.820 These patients still

01:34:26.600 struggle post-operatively.

01:34:27.860 Yes, less so.

01:34:28.920 We learned a lot during

01:34:29.840 COVID that you can do

01:34:30.740 these outpatient very

01:34:31.760 safely.

01:34:32.720 The technology is

01:34:33.680 improving with total knee

01:34:34.920 replacements too, where

01:34:36.040 the incisions can be a

01:34:37.180 little smaller.

01:34:38.400 What's the dominant source

01:34:39.700 of pain?

01:34:40.240 Is it the incisional pain?

01:34:41.220 I assume it's much more

01:34:42.120 the bone pain of what

01:34:43.240 you've had to resurface.

01:34:44.060 Right, so none of that's

01:34:45.220 changed.

01:34:46.260 But the perioperative

01:34:48.160 management of the pain

01:34:49.260 has changed.

01:34:49.860 We give injections into

01:34:51.520 the capsule during the

01:34:52.740 surgery.

01:34:53.240 There's other nerve blocks

01:34:54.640 that are used.

01:34:55.260 We send them home with

01:34:56.040 pumps to get them through

01:34:57.840 that initial stage.

01:35:00.020 What is the time to

01:35:02.580 recovery for a motivated

01:35:04.220 patient who has a knee

01:35:05.840 replacement, and what are

01:35:07.820 the limitations?

01:35:08.860 I should have asked the

01:35:09.540 same question, by the way,

01:35:10.440 on the hip replacement, so

01:35:11.360 we can do that after.

01:35:12.380 But when a 50-year-old or a

01:35:14.580 60-year-old comes to you

01:35:15.920 at the end of the rope,

01:35:17.040 they have the knee

01:35:17.620 replacement, what are you

01:35:19.220 telling them is, this is

01:35:20.620 when you're going to feel

01:35:21.140 normal again, assuming

01:35:22.160 you're in that 85%,

01:35:23.300 and these are the

01:35:24.800 activities I don't want

01:35:25.780 you doing anymore?

01:35:26.880 I will always tell them

01:35:28.020 all this is going to

01:35:28.840 take you a year of

01:35:30.240 recovery, because I

01:35:32.360 don't know who's going

01:35:33.120 to be shorter than

01:35:33.880 that, and there's a

01:35:35.360 number of people who

01:35:36.240 continue to improve up

01:35:37.900 to a year, and

01:35:38.640 sometimes even longer,

01:35:39.720 but I don't say more

01:35:40.440 than a year, because

01:35:41.520 it's just too painful to

01:35:43.100 even contemplate.

01:35:43.880 A year is pretty long.

01:35:45.180 But people are showing

01:35:46.280 improvements even beyond

01:35:47.600 a year.

01:35:48.200 And it's non-linear.

01:35:49.100 I mean, you know,

01:35:50.160 you're probably getting

01:35:50.920 80% better in six

01:35:52.600 months, and then...

01:35:53.520 How do I know how

01:35:54.420 people are doing?

01:35:55.060 Well, other than the

01:35:55.840 research and reading it,

01:35:56.900 but I see my patients at

01:35:58.120 regular intervals, and

01:35:59.340 it's always the same.

01:36:00.360 So, I see someone about

01:36:02.460 10 days after surgery, and

01:36:04.020 then I see them at two

01:36:04.880 months after surgery, and

01:36:05.940 I see them at six months

01:36:07.080 after surgery, and I

01:36:08.700 could tell you that

01:36:09.500 everybody's different.

01:36:10.960 I have people walking in

01:36:12.040 at 10 days who are

01:36:13.420 without a cane, walking

01:36:14.960 up and down the hallway,

01:36:16.700 doing very well.

01:36:18.340 They're not, you know,

01:36:19.400 jumping up and down, but

01:36:20.440 they're like, not as bad

01:36:21.400 as I thought.

01:36:22.300 And then I have patients

01:36:23.280 who are coming in at

01:36:24.380 their six-month visit, and

01:36:25.700 they're saying, I think

01:36:26.860 something's wrong.

01:36:27.640 My knee still hurts.

01:36:28.420 I'm still having trouble.

01:36:29.440 And I always have to

01:36:30.100 remind them, there's a

01:36:31.200 reason why I said it might

01:36:32.140 take a year.

01:36:32.960 What do you think

01:36:33.480 differentiates those two

01:36:34.420 patients?

01:36:35.020 I wish we knew.

01:36:36.320 Sometimes it has to do

01:36:37.440 with muscles, right?

01:36:39.380 Their strength of them,

01:36:40.400 their protoplasm before.

01:36:42.640 And then sometimes I think

01:36:44.560 it's sort of the similar

01:36:45.680 inflammatory type that I

01:36:47.120 mentioned with the ACL.

01:36:48.220 I just think that some

01:36:49.200 people show prolonged

01:36:50.840 inflammation after injury.

01:36:53.680 And I think we're still

01:36:54.640 trying to handle...

01:36:54.820 Have you ever looked at

01:36:55.960 sampling synovial fluid as

01:36:57.440 soon as you get in there,

01:36:58.620 seeing how well the

01:36:59.920 inflammatory milieu of that

01:37:02.020 correlates or corresponds

01:37:03.160 to the recovery?

01:37:04.620 So I know it's been done.

01:37:05.780 I don't know the data on

01:37:07.100 that.

01:37:07.480 It's been done in ACLs too,

01:37:09.100 where you check the

01:37:10.040 cytokine profile.

01:37:10.880 And this is how we know

01:37:11.680 that there are these types

01:37:12.580 of patients.

01:37:13.380 I don't know the details of

01:37:15.080 that, but it is done.

01:37:16.180 I mean, there's so much

01:37:17.260 to think about as far as

01:37:18.260 immune modulation as well.

01:37:20.100 I mean, to me, if I think

01:37:20.780 about like, how would you

01:37:21.720 advance this field?

01:37:23.380 That could be one way is

01:37:24.440 what if we utilized immune

01:37:26.120 modulators in a personalized

01:37:28.400 way based on that

01:37:30.680 inflammatory environment at

01:37:32.080 the time of surgery, given

01:37:33.020 that that's probably playing

01:37:34.180 a role in this?

01:37:35.100 So I think that the more

01:37:36.220 information we get from

01:37:37.860 the ACL injury will help

01:37:39.860 figure out the total knee

01:37:41.700 replacement.

01:37:42.060 The reason I say that is

01:37:42.860 nobody wants to put a

01:37:43.920 needle in a knee that

01:37:45.380 had a knee replacement

01:37:46.340 because it just slightly

01:37:48.660 increases the...

01:37:49.300 Oh, I'm thinking before

01:37:50.160 you...

01:37:50.860 I'm saying when you're

01:37:51.780 doing the incision.

01:37:53.440 So a lot of them have.

01:37:54.720 We know that.

01:37:55.720 IL-1, IL-6, tumor

01:37:57.160 necrosis factor.

01:37:58.040 It's...

01:37:59.000 We know what those look

01:38:00.200 like.

01:38:00.260 Presumably what's there

01:38:00.880 right before surgery is

01:38:01.920 right there after surgery.

01:38:02.980 It's not like you're

01:38:03.340 washing it away.

01:38:04.500 So yeah, you could sample

01:38:05.460 that before you do the

01:38:06.560 total knee.

01:38:07.420 That's probably been done.

01:38:08.920 So you're at the one-year

01:38:10.060 post-op appointment.

01:38:11.120 Patient says, Adam, God,

01:38:13.500 I feel amazing.

01:38:14.740 Anything I can't do?

01:38:16.540 So I let my patients do

01:38:18.160 the things that they enjoy

01:38:19.660 doing.

01:38:20.080 I have a patient right now

01:38:21.220 who ran a marathon with a

01:38:22.540 total knee replacement.

01:38:23.580 I mean, she's young.

01:38:24.300 So she's young and she knows

01:38:25.460 the risk.

01:38:26.000 It's more likely to...

01:38:27.040 How young?

01:38:27.660 50.

01:38:28.540 What led to the knee

01:38:29.400 replacement in her case?

01:38:30.780 Alignment, mechanical issues.

01:38:32.580 Are those mechanical issues

01:38:33.500 fixed now or is she just going

01:38:34.840 to need another knee

01:38:35.400 replacement in 10 years?

01:38:36.420 It's fixed.

01:38:36.940 When we do a knee

01:38:37.540 replacement, we make the cuts

01:38:38.820 to allow for better alignment.

01:38:41.480 Although not everybody does that.

01:38:43.220 There are different ways

01:38:43.860 to do a knee replacement

01:38:44.640 where people maintain

01:38:45.540 the alignment.

01:38:46.160 It's called a kinematic knee.

01:38:47.640 But the way I do a knee,

01:38:49.040 I align it.

01:38:49.680 You align it.

01:38:50.180 So you say, this is the hip

01:38:51.200 you got.

01:38:51.620 This is the foot you got.

01:38:52.760 I'm going to drop that plumb line

01:38:54.120 and I'm going to make the cuts

01:38:55.300 in those two surfaces

01:38:56.920 such that the hardware lines up.

01:38:59.160 And I use computer navigation

01:39:00.760 so I can really titrate

01:39:02.140 the exact amount

01:39:03.240 that I want to make the cut

01:39:05.040 so that the alignment

01:39:06.060 is as precise

01:39:07.140 as I can make it right now.

01:39:08.820 A lot of the newer technology

01:39:10.660 and software allows us

01:39:11.820 to be more precise

01:39:12.900 in our cuts

01:39:13.640 and the angles we want.

01:39:15.380 And sometimes you need

01:39:16.380 to do a little bit

01:39:17.720 of angulation

01:39:18.520 just so it fits properly.

01:39:20.520 But in general,

01:39:21.760 that's the principle.

01:39:23.060 And going back to the hip,

01:39:24.280 just for the sake

01:39:25.120 of completeness,

01:39:26.320 six months,

01:39:26.960 because these guys

01:39:27.440 heal so much quicker,

01:39:28.400 six months post

01:39:29.560 total hip replacement.

01:39:31.000 Hey, doc,

01:39:31.760 anything I can't do,

01:39:32.980 what are you saying?

01:39:33.680 And this is also with the knee.

01:39:34.840 I don't want any contact sports,

01:39:36.760 no contact sports.

01:39:38.060 Because you're

01:39:39.240 at high risk of traction.

01:39:40.120 Is skiing considered

01:39:41.060 a contact sport?

01:39:41.840 No.

01:39:42.520 I mean, it is,

01:39:43.240 but it's not part of the sport.

01:39:44.920 I mean, it is sort of.

01:39:46.080 But I let people ski

01:39:46.940 with total knee replacement,

01:39:47.900 total hip replacements.

01:39:48.780 They are allowed to ski.

01:39:50.360 It's called a stress riser.

01:39:51.920 Right above the metal

01:39:53.000 on the knee

01:39:53.500 is an area

01:39:54.340 where it can break easily.

01:39:56.060 And that is

01:39:56.720 a really devastating injury

01:39:59.100 to have a knee replacement

01:39:59.900 and then have it broken.

01:40:00.960 So I don't want anybody

01:40:01.820 doing any contact sports.

01:40:03.000 But I let them play tennis.

01:40:05.120 It used to be

01:40:05.680 we would say

01:40:06.240 only doubles tennis.

01:40:07.500 But, you know,

01:40:08.040 someone's doing really well.

01:40:09.560 I'll let them play.

01:40:10.580 But I tell them,

01:40:11.260 I said, listen,

01:40:11.700 the more you're on

01:40:12.600 this high molecular weight

01:40:13.840 polyethylene,

01:40:14.580 which isn't perfect,

01:40:16.020 it's going to wear out

01:40:17.000 because it's mechanical too.

01:40:18.780 That was my thesis

01:40:19.640 in engineering

01:40:20.500 was looking at

01:40:22.160 the axis of failure

01:40:23.660 in tibial plateaus.

01:40:25.000 I spent so much time

01:40:28.440 under a microscope

01:40:29.900 looking at failed

01:40:32.300 tibial plateaus

01:40:33.600 using a discipline

01:40:34.980 of mathematics

01:40:35.700 to map out

01:40:37.180 the planes of failure.

01:40:38.880 From polyethylene?

01:40:39.760 From exactly that.

01:40:40.500 Ultra molecular weight

01:40:41.240 polyethylene,

01:40:41.920 but just in the tibial plateaus.

01:40:44.040 So we talked a little bit

01:40:45.320 about the success rate

01:40:47.600 of PRP here potentially

01:40:49.180 and a greater appetite

01:40:50.580 for here than in the hip.

01:40:52.600 Any other knee pains

01:40:53.700 that you look at

01:40:54.980 that are quantifiably

01:40:56.780 not surgical

01:40:57.380 where you say,

01:40:58.440 boy, operating on you

01:40:59.800 would be a mistake?

01:41:01.300 So, you know,

01:41:01.680 in general,

01:41:02.300 it's injury dependent often.

01:41:04.400 There are some injuries

01:41:05.000 where there is,

01:41:05.780 there's no doubt about it

01:41:07.480 you have to have surgery.

01:41:08.320 If you rupture

01:41:09.100 your patellar tendon

01:41:10.180 or your quadriceps tendon,

01:41:12.260 the conservative treatment

01:41:13.520 is to do surgery

01:41:14.580 because your leg

01:41:15.900 will not work

01:41:16.620 unless we reconnect

01:41:17.520 the tendon.

01:41:18.300 Is the patellar tendon

01:41:19.200 typically ruptured

01:41:20.000 above or below the patella?

01:41:21.520 So this is

01:41:22.280 the quadriceps tendon.

01:41:23.700 Oh, the patellar tendon

01:41:24.760 is the below.

01:41:25.480 So if either one of these

01:41:26.600 is ruptured,

01:41:27.540 the patella will go

01:41:28.700 with the unruptured side.

01:41:30.460 They're not connected anymore.

01:41:31.760 You have to fix that.

01:41:32.820 Otherwise,

01:41:33.040 It's very hard to extend the knee.

01:41:33.960 You can't.

01:41:34.600 You can't do it.

01:41:35.240 I mean,

01:41:35.940 essentially you can't do it.

01:41:37.260 So that has to be fixed.

01:41:38.580 For a lot of problems,

01:41:40.160 you can try

01:41:40.980 conservative management.

01:41:42.420 Meniscus tears,

01:41:43.200 occasionally you could try

01:41:43.980 conservative management.

01:41:45.040 There are even people

01:41:45.920 who don't necessarily

01:41:46.860 need an ACL reconstruction.

01:41:48.980 There are people

01:41:49.720 who have ACL tears

01:41:50.940 who cope well

01:41:52.160 without reconstruction.

01:41:53.220 And we talk about

01:41:54.840 that possibility.

01:41:56.100 If someone does not

01:41:57.300 participate in level one sports,

01:41:59.300 they don't do pivoting

01:42:02.100 or rotational types

01:42:03.860 of activities,

01:42:04.800 you can bike

01:42:05.740 without an ACL tear.

01:42:07.000 You can run

01:42:07.840 without an ACL tear.

01:42:09.460 So even that potentially...

01:42:11.380 With an ACL tear.

01:42:12.140 With an ACL tear,

01:42:13.340 you can.

01:42:14.000 And there are a lot of people

01:42:14.720 who cope quite well.

01:42:15.860 I did from the age

01:42:16.560 of 15 to 30

01:42:17.440 and I was fairly active

01:42:18.820 with occasional swelling

01:42:20.440 here and there.

01:42:21.280 And during those 16 years

01:42:22.520 that you had the ACL tear

01:42:23.940 outside of the acute phase,

01:42:26.060 how many times

01:42:26.920 did you lose stability

01:42:28.500 or did your knee go out?

01:42:30.240 Dozens.

01:42:30.960 Were you causing more injury?

01:42:32.340 Were you increasing

01:42:32.880 the risk of arthritis

01:42:33.700 through that activity

01:42:34.940 through the instability?

01:42:36.080 Which is amazing

01:42:37.020 that I don't.

01:42:37.320 It's very similar

01:42:37.840 to the sublux shoulder, right?

01:42:39.600 Yes.

01:42:39.740 The more you sublux,

01:42:41.380 the more you increase

01:42:42.300 the risk of arthritis.

01:42:43.300 So you're tearing the labrum,

01:42:45.120 you're creating

01:42:45.520 more instability,

01:42:46.700 and if you wait too long,

01:42:48.340 yeah, you'll get it repaired,

01:42:49.480 but you might actually

01:42:50.300 start to have arthritis

01:42:51.220 at the clenohumeral joint.

01:42:53.260 The arthritis is not as common

01:42:55.280 in the shoulder

01:42:55.700 as the hip and knee.

01:42:57.420 And if you've had

01:42:59.280 a shoulder dislocation,

01:43:00.540 you're 10 to 20 times

01:43:01.820 more likely to get arthritis

01:43:03.420 of the shoulder

01:43:04.100 than someone

01:43:04.600 in the general population

01:43:05.680 without a shoulder dislocation.

01:43:08.000 So we know

01:43:08.940 it's that traumatic event.

01:43:10.800 And the same thing is true

01:43:11.840 for ankle sprains

01:43:12.840 and fractures around the ankle.

01:43:14.660 Because that joint

01:43:16.280 is so congruent,

01:43:18.600 that cartilage in the ankle

01:43:19.600 isn't even that thick.

01:43:21.340 It's so congruent

01:43:22.620 that if you don't have

01:43:25.560 an injury to the ankle,

01:43:28.100 that ankle can last you

01:43:29.660 quite a long time.

01:43:31.000 It doesn't have

01:43:31.740 the same incidence

01:43:32.480 as hip and knee arthritis.

01:43:34.320 And why is that

01:43:35.080 despite how thin it is?

01:43:36.060 It's just so engaging.

01:43:37.600 Because the surface-to-surface

01:43:38.940 level is so perfect.

01:43:40.440 Correct.

01:43:41.280 You don't have articulation

01:43:42.500 in the same way

01:43:43.480 where you have

01:43:44.000 more degree of motion.

01:43:45.380 Right.

01:43:45.800 Think about the hip

01:43:46.660 we talked about

01:43:47.380 where it's edge loading

01:43:49.140 in the developmental dysplasia.

01:43:51.480 It's not congruent.

01:43:52.760 That's who gets

01:43:53.340 the arthritis.

01:43:54.440 The patient

01:43:55.140 with the bump

01:43:55.900 on the side,

01:43:56.600 the acetabular impingement,

01:43:57.900 they get arthritis.

01:43:59.440 The knee,

01:44:00.320 which is in the middle,

01:44:01.900 that weight could go

01:44:02.840 through the inside

01:44:03.700 or the outside.

01:44:05.400 The ankle,

01:44:06.520 it's right down the center

01:44:07.680 because that's where

01:44:08.380 the plumb line goes.

01:44:09.640 So there's not a lot

01:44:11.280 of play

01:44:12.540 because it's closer

01:44:13.400 to the floor.

01:44:14.700 Does that make sense?

01:44:15.540 Yep.

01:44:15.920 Absolutely.

01:44:16.700 So that's why we see

01:44:18.280 it less in the ankle.

01:44:19.860 We see it a lot

01:44:21.000 in the knee.

01:44:21.560 And the hip,

01:44:22.180 we see it when there's

01:44:22.920 a mechanical problem.

01:44:24.480 Let's turn our attention

01:44:25.500 now over to the ankle.

01:44:27.700 The foot and ankle

01:44:28.420 are very complicated.

01:44:29.860 And the number of bones here

01:44:31.600 and the number of ligaments

01:44:33.500 is simply staggering.

01:44:35.720 Obviously,

01:44:36.160 we're not going to

01:44:37.360 provide a master's class

01:44:38.800 on this due to

01:44:39.480 the complexity of it.

01:44:40.700 But let's kind of focus

01:44:42.100 on the big picture here,

01:44:43.760 which is what part

01:44:44.980 of the anatomy

01:44:45.440 do we need to understand

01:44:46.460 to really get a sense

01:44:47.620 of where people

01:44:48.220 have pain here?

01:44:49.280 It depends, obviously,

01:44:50.220 on the population

01:44:51.460 we're talking about.

01:44:52.340 So if we just talk

01:44:53.160 about athletes for a second,

01:44:54.860 people who are very active

01:44:55.980 and, for example,

01:44:57.020 run a lot,

01:44:57.720 we're interested

01:44:58.320 in a number of things.

01:45:00.520 Let's focus

01:45:01.320 on the top picture here.

01:45:02.740 This is the heel bone

01:45:03.940 and this is where

01:45:04.560 the Achilles tendon

01:45:05.420 attaches to the bone.

01:45:06.800 And we do see

01:45:07.600 a lot of Achilles tendonitis.

01:45:09.700 That's a very difficult problem

01:45:11.140 because there are not

01:45:11.620 a lot of great

01:45:12.260 treatment options.

01:45:13.940 Surgery doesn't do great

01:45:15.000 with tendinopathy

01:45:16.360 of the Achilles tendon.

01:45:17.760 And only when it's ruptured

01:45:19.140 is there sort of

01:45:20.140 more of a plan

01:45:21.340 on how to address it.

01:45:23.440 Interestingly,

01:45:24.120 I don't think

01:45:24.780 there's an increased

01:45:25.680 incidence of tendon ruptures

01:45:27.140 in the setting

01:45:27.740 of tendinopathy.

01:45:29.300 We don't really see that.

01:45:30.180 So, tendinopathy

01:45:31.380 would just present

01:45:32.500 as pain there,

01:45:33.900 but that doesn't

01:45:34.860 necessarily increase

01:45:35.560 the risk of rupture.

01:45:37.620 My reading of the literature

01:45:39.300 up to date

01:45:39.940 and I don't do a lot

01:45:40.700 of foot and ankle surgery,

01:45:41.700 that's been my understanding.

01:45:43.280 And I've treated

01:45:43.800 lots of people

01:45:45.340 over the years

01:45:45.920 with Achilles tendonitis

01:45:46.980 and I don't remember

01:45:47.820 ever a case

01:45:48.440 where they came back,

01:45:49.180 oh, look at that,

01:45:50.080 I ruptured it.

01:45:51.180 Interesting.

01:45:51.640 While we're on the topic

01:45:52.320 of rupture,

01:45:53.580 how much of a concern

01:45:54.640 are fluoroquinolones?

01:45:55.700 Everybody asks me

01:45:56.440 this question,

01:45:57.180 I don't really know

01:45:57.820 the answer.

01:45:58.580 So, ciprofloxacin,

01:45:59.920 drugs, levoquin,

01:46:01.200 these antibiotics,

01:46:02.120 I know that,

01:46:02.720 you know,

01:46:02.900 we're told that they

01:46:03.600 slightly increase

01:46:04.880 the risk

01:46:05.340 of a subsequent rupture.

01:46:06.920 How big is that

01:46:07.540 increase in risk

01:46:08.160 and for how long

01:46:08.780 does it preside

01:46:09.640 after the antibiotic?

01:46:10.780 I don't know

01:46:11.200 the length

01:46:11.600 of how long

01:46:12.100 it presides,

01:46:12.620 but I do know

01:46:13.280 that mine is

01:46:14.100 sort of a sampling error

01:46:15.240 because I see it.

01:46:16.820 I see it more

01:46:17.680 than you do

01:46:18.220 because that's

01:46:19.240 who's coming in

01:46:20.020 and I've seen it

01:46:21.800 after one dose.

01:46:23.640 I don't know

01:46:23.900 how to guide people.

01:46:24.680 How long after a dose?

01:46:25.240 Someone has a dose

01:46:25.920 within a week or two

01:46:27.420 I've seen it.

01:46:28.560 So, this is what

01:46:29.260 I tell people,

01:46:29.880 it's not a reason

01:46:30.440 not to take the medication,

01:46:31.660 but if you start

01:46:32.280 to feel anything,

01:46:33.120 you have to stop

01:46:33.840 and rest

01:46:34.400 because I feel like

01:46:35.880 that is one of those

01:46:36.640 situations.

01:46:37.060 Are there warning signs

01:46:38.180 to an Achilles rupture?

01:46:39.440 They start to develop pain

01:46:40.580 and that's when I stop.

01:46:42.360 But it's not tendinopathy.

01:46:43.800 So, what's the pain?

01:46:44.980 I don't know

01:46:45.380 what the mechanism

01:46:46.140 is for it.

01:46:47.020 There is some sort

01:46:48.900 of tendon inflammation

01:46:49.920 that's happening,

01:46:50.640 but I'm not sure.

01:46:52.100 Okay,

01:46:52.360 that's a little disconcerting.

01:46:53.500 So, what are we doing

01:46:54.920 to prevent this?

01:46:55.680 Because this is definitely

01:46:56.480 the middle-aged person injury,

01:46:58.380 right?

01:46:59.020 The tendinopathy?

01:47:00.340 Well, or just the rupture

01:47:01.320 altogether, you know.

01:47:02.360 It's the,

01:47:02.860 I'm going to go run around

01:47:03.520 with my kids

01:47:04.180 and lo and behold,

01:47:05.320 I hear the loudest bang

01:47:07.880 and your calf balls up

01:47:09.440 and you're,

01:47:10.080 next thing you know,

01:47:10.560 you're in a boot

01:47:11.020 for God knows how many weeks.

01:47:12.500 I think maintaining

01:47:13.380 muscle strength,

01:47:14.500 calf flexibility,

01:47:15.520 making sure your gastrocs

01:47:17.020 and your soleus

01:47:17.760 have good flexibility,

01:47:19.040 both of those separately.

01:47:20.020 I think that overtraining

01:47:22.180 can be an issue

01:47:23.020 in this circumstance.

01:47:23.860 So, just to proceed

01:47:25.760 with care,

01:47:26.660 you can't necessarily

01:47:27.660 do everything you wanted

01:47:28.960 to do when you're 20 and 30

01:47:30.140 because that tendon degeneration

01:47:31.660 is a biologic event

01:47:33.080 that affects all of us.

01:47:34.620 And again,

01:47:35.160 if you're staying healthy

01:47:36.100 throughout your lifetime,

01:47:37.200 it may or may not help you,

01:47:39.300 but it's certainly possible

01:47:40.880 that maintaining-

01:47:42.080 I feel like such an important

01:47:42.880 part of this is jumping,

01:47:44.620 you know,

01:47:44.840 literally just jumping rope,

01:47:46.640 doing the types of activities.

01:47:48.260 Like, my warm-up always

01:47:49.460 sort of consists of-

01:47:51.280 I have a particular

01:47:52.200 jumping routine I always do

01:47:53.760 and it's not super taxing.

01:47:55.240 I'm not jumping,

01:47:56.400 you know,

01:47:56.740 onto 36-inch blocks

01:47:58.120 or doing plyometric

01:47:59.420 explosive stuff.

01:48:00.640 I do it sometimes,

01:48:01.780 but on a daily basis,

01:48:02.980 I'm trying to make sure

01:48:03.720 I'm putting some bounce

01:48:04.900 in there.

01:48:05.740 My belief is that

01:48:06.720 that's a valuable way

01:48:08.120 to maintain elasticity

01:48:09.500 in that part of the body.

01:48:10.920 I would agree

01:48:11.440 and I think it's

01:48:12.180 the neuromuscular training.

01:48:13.580 The neural part

01:48:14.120 is just as important

01:48:15.080 because I think

01:48:15.740 that's really what happens

01:48:16.740 is that it's always

01:48:17.540 vulnerable when

01:48:18.560 the tendon degenerates,

01:48:20.040 but there's a mismatch

01:48:21.620 between the firing

01:48:22.520 of the calf musculature

01:48:24.000 and what you're actually

01:48:25.320 doing at that moment.

01:48:26.820 And so,

01:48:27.860 having more motor neurons

01:48:29.860 and well-developed

01:48:30.880 motor neurons

01:48:31.560 may help prevent that.

01:48:33.040 And just like

01:48:33.520 it prevents ACL injuries,

01:48:34.920 I think it's the same thing.

01:48:36.640 There's no way

01:48:37.420 that that's not helpful

01:48:38.600 for all of

01:48:40.400 lower extremity injuries

01:48:41.460 is to be able

01:48:42.540 to know where you are

01:48:43.440 in space

01:48:44.060 and to have

01:48:45.360 good training

01:48:46.060 in those dynamic

01:48:47.560 situations

01:48:48.180 because that's

01:48:48.900 when people are injured.

01:48:49.740 Nobody wanted

01:48:50.340 to trip on the sidewalk,

01:48:52.000 but what happens

01:48:52.880 when you trip?

01:48:53.580 Are you able

01:48:54.040 to recover quickly

01:48:55.180 or do you end up

01:48:56.240 with an injury?

01:48:58.520 Okay,

01:48:58.840 so let's go over

01:48:59.800 some of the

01:49:00.720 bony structures here.

01:49:02.400 Maybe it's easier

01:49:03.040 to look at that model.

01:49:04.600 So this is

01:49:05.240 the ankle joint proper,

01:49:06.700 which is

01:49:07.160 this is the leg bone

01:49:08.500 or the tibia.

01:49:09.180 It joins here

01:49:10.360 with the talus,

01:49:12.680 also along

01:49:13.360 with the fibula.

01:49:14.120 So these three bones

01:49:14.920 make up the ankle joint

01:49:16.200 and the surface

01:49:17.640 is coated in cartilage

01:49:19.000 just like all the other

01:49:19.900 joints we talked about.

01:49:21.600 The talus then

01:49:22.980 articulates

01:49:23.680 with the navicular

01:49:24.560 bone here

01:49:25.900 and then their

01:49:26.840 cuneiforms,

01:49:28.560 cuboid bone

01:49:29.340 on the outside,

01:49:30.760 the metatarsals,

01:49:31.920 the phalanges.

01:49:33.340 If we turn it

01:49:34.320 to the side,

01:49:35.200 this is the inner side

01:49:36.240 of the ankle.

01:49:37.600 This is the

01:49:38.280 medial malleolus

01:49:39.580 and along

01:49:40.600 this area

01:49:41.960 is where the tendons

01:49:42.880 that help to

01:49:43.940 maintain your arch

01:49:44.960 rest.

01:49:46.260 So

01:49:46.600 if we were to look

01:49:48.140 at the tendons

01:49:48.800 of the ankle,

01:49:50.660 this on the bottom image

01:49:51.960 is the medial aspect

01:49:53.280 of the ankle

01:49:53.880 and this is the

01:49:55.340 posterior tibialis tendon,

01:49:57.000 which is incredibly

01:49:57.760 important for maintaining

01:49:59.060 your arch.

01:50:00.420 And then we also have

01:50:01.260 the flexor halluses

01:50:02.360 longest here,

01:50:03.160 which goes to the

01:50:03.880 first toe

01:50:04.380 and these are the flexors

01:50:05.900 for the digits

01:50:06.840 as well.

01:50:08.280 We look at the ligaments

01:50:09.580 on the medial aspect

01:50:10.740 of the ankle.

01:50:12.240 We see here,

01:50:13.880 this is the medial

01:50:14.560 malleolus,

01:50:15.200 this broad ligament

01:50:16.980 is the deltoid ligament

01:50:18.160 and then we have

01:50:19.080 this spring ligament

01:50:20.160 here.

01:50:21.480 And this is the

01:50:22.120 plantar fascia as well,

01:50:23.280 which helps to maintain

01:50:24.320 your arch.

01:50:26.040 And these are

01:50:26.980 important structures

01:50:27.820 to examine

01:50:28.600 to make sure that

01:50:29.700 the plantar fascia,

01:50:30.920 which helps to maintain

01:50:31.740 the arch,

01:50:32.220 is competent

01:50:32.760 and that the posterior

01:50:34.160 tibialis tendon

01:50:35.000 is also working.

01:50:36.080 So it's important

01:50:36.820 to go through

01:50:37.460 walking on your toes,

01:50:39.160 walk on your heels,

01:50:40.040 see how the gait

01:50:41.140 progression is managed.

01:50:43.440 Yeah,

01:50:43.580 and all of these things

01:50:44.300 will show in the exam,

01:50:45.660 of course.

01:50:46.920 On the outside

01:50:47.600 of the ankle

01:50:48.060 or the lateral

01:50:48.580 part of the ankle,

01:50:49.920 this is where

01:50:50.400 the fibula is,

01:50:51.440 this is where

01:50:51.940 most ankle sprains

01:50:53.000 happen.

01:50:53.940 This is the main

01:50:54.800 ligament that's injured.

01:50:55.880 It's called the

01:50:56.400 ATFL

01:50:57.300 or anterior

01:50:58.200 talofibular ligament.

01:51:00.580 And then we have

01:51:01.400 the calcaneofibular

01:51:02.540 ligament,

01:51:03.820 posterior talofibular

01:51:04.960 ligament,

01:51:05.280 which is not

01:51:05.980 as often sprained.

01:51:07.800 And then we have

01:51:08.380 this ligament up here

01:51:09.280 which connects

01:51:09.820 the fibula

01:51:10.420 to the tibia.

01:51:11.760 And when people

01:51:12.520 have high ankle

01:51:13.300 sprains,

01:51:13.740 this is often

01:51:14.500 the ligament

01:51:15.180 that's injured.

01:51:16.620 Whenever someone

01:51:17.340 has an ankle

01:51:18.640 sprain,

01:51:19.740 it's conservative

01:51:21.040 treatment,

01:51:21.920 and most people

01:51:22.720 get better,

01:51:23.300 but not everybody.

01:51:24.620 And is a sprain

01:51:26.140 what degree of

01:51:27.380 tear to that

01:51:28.260 ligament?

01:51:28.700 It could be

01:51:29.300 any degree.

01:51:30.460 If you have a

01:51:31.380 sprain,

01:51:31.860 that is if your

01:51:32.620 ankle twists

01:51:33.460 and you have

01:51:34.120 swelling,

01:51:34.720 you've torn

01:51:35.320 the ligament.

01:51:36.300 The question is,

01:51:37.360 is it a complete

01:51:38.180 rupture of the

01:51:39.000 ligament?

01:51:39.740 And so we

01:51:40.420 arbitrarily say

01:51:41.900 this is a grade

01:51:42.540 one, grade two,

01:51:43.520 high ankle.

01:51:44.640 They're all

01:51:45.240 tearing of the

01:51:46.160 ligament.

01:51:47.100 The degree to

01:51:47.840 which they're

01:51:48.380 torn or which

01:51:49.080 they heal

01:51:49.680 will dictate

01:51:50.820 the next step.

01:51:52.180 It's very rare

01:51:52.740 to have a

01:51:53.440 severe ankle

01:51:54.000 sprain

01:51:54.440 without any

01:51:55.900 dislocation of

01:51:57.560 a joint that

01:51:58.180 would require

01:51:58.980 surgery,

01:51:59.740 except for

01:52:01.100 some syndesmosis

01:52:02.340 injuries up

01:52:03.060 higher.

01:52:03.580 Those often

01:52:04.340 will require

01:52:04.920 surgery.

01:52:06.060 But for the

01:52:07.280 run-of-the-mill

01:52:07.880 twist of my

01:52:08.480 ankle playing

01:52:08.940 basketball,

01:52:10.200 the treatment

01:52:10.720 is conservative,

01:52:11.820 strengthening,

01:52:12.980 strengthen the

01:52:13.560 perineal muscles.

01:52:15.060 But it doesn't

01:52:15.620 necessarily mean

01:52:16.160 everybody's going

01:52:16.980 to recover because

01:52:17.760 sometimes what

01:52:18.480 happens is the

01:52:19.140 cartilage gets

01:52:19.800 injured.

01:52:20.440 And just like we

01:52:21.400 talked about in

01:52:22.040 the shoulder and

01:52:23.000 the knee and

01:52:23.700 the hip,

01:52:24.520 any mechanical

01:52:25.240 trauma to the

01:52:26.120 joint puts you

01:52:26.900 at increased

01:52:27.420 risk for

01:52:28.200 arthritis of that

01:52:29.220 joint.

01:52:29.740 And which

01:52:30.600 cartilage in

01:52:31.200 particular,

01:52:32.320 if you took

01:52:32.680 the most

01:52:33.200 common sprain,

01:52:35.440 which would

01:52:35.920 be the...

01:52:37.260 ATFL.

01:52:38.180 ATFL,

01:52:38.800 yeah.

01:52:39.280 So the

01:52:39.760 anterior

01:52:40.180 talofibrilligamic

01:52:41.040 connects the

01:52:42.040 fibula to the

01:52:42.820 talus.

01:52:43.760 And when that

01:52:44.440 rotates this

01:52:45.560 way, this does

01:52:46.300 not rotate at

01:52:47.120 all, you will

01:52:48.300 cause injury to

01:52:49.480 the cartilage

01:52:50.100 because it abuts

01:52:50.960 in this area.

01:52:52.100 Yep, makes

01:52:53.000 sense.

01:52:53.500 So you will see

01:52:54.400 what we call

01:52:54.960 osteochondral

01:52:56.220 bone...

01:52:56.460 And if you

01:52:56.640 did an MRI,

01:52:57.600 would you

01:52:57.880 see bone

01:52:58.460 edema there

01:52:59.340 in that

01:52:59.880 patient?

01:53:00.880 And so if

01:53:01.360 someone is

01:53:01.780 not recovering

01:53:02.560 after an

01:53:03.040 ankle sprain,

01:53:03.620 I get an

01:53:04.040 MRI because I

01:53:05.280 want to see

01:53:05.680 what the

01:53:05.980 cartilage looks

01:53:06.680 like to see

01:53:07.700 if they've

01:53:08.040 injured the

01:53:08.460 bone, if

01:53:08.860 they're in

01:53:09.160 their cartilage

01:53:09.660 and if

01:53:09.900 anything else

01:53:10.480 needs to be

01:53:11.060 done.

01:53:11.860 And if

01:53:12.600 there's a

01:53:12.940 small fracture

01:53:13.580 there, is it

01:53:14.280 still conservative?

01:53:15.180 Put them in a

01:53:15.580 boot?

01:53:16.260 Fracture here or

01:53:17.140 fracture here.

01:53:17.780 If there's a

01:53:18.100 crack in the

01:53:18.580 cartilage...

01:53:18.780 There's a crack

01:53:18.980 there.

01:53:19.280 Depends if that

01:53:19.840 piece is what

01:53:20.440 we call stable or

01:53:21.560 unstable.

01:53:26.220 is in

01:53:26.840 place in

01:53:27.460 situ and you

01:53:28.160 can leave that

01:53:28.680 alone, maybe

01:53:29.240 give a boot.

01:53:30.320 If that piece

01:53:31.260 is detached,

01:53:32.540 that's unstable.

01:53:33.120 And what about

01:53:33.540 if you have a

01:53:34.820 distal fibula

01:53:36.000 fracture because

01:53:36.880 the sprain is

01:53:38.460 so bad that

01:53:39.420 when their foot

01:53:40.180 went out, it

01:53:40.740 actually broke

01:53:41.280 the bone?

01:53:42.080 Does that ever

01:53:42.540 happen?

01:53:42.880 The talus will

01:53:43.460 break that tip

01:53:44.400 of the fibula?

01:53:45.400 So sometimes

01:53:46.100 if the forefoot

01:53:47.720 is externally

01:53:48.520 rotated, this

01:53:49.900 will hit the

01:53:50.620 fibula and the

01:53:51.860 fibula will

01:53:52.380 break.

01:53:53.300 And that

01:53:53.820 doesn't necessarily

01:53:54.640 need surgery.

01:53:55.360 That can often

01:53:56.460 heal without

01:53:56.940 surgery.

01:53:57.640 But if you've

01:53:58.360 also at the

01:53:59.040 same time torn

01:54:00.480 the inner

01:54:01.320 ligaments, the

01:54:02.120 deltoid ligaments,

01:54:02.980 then you now have

01:54:04.060 instability on both

01:54:05.540 sides of the

01:54:06.000 ankle and then

01:54:07.080 you go in and

01:54:07.900 you fix the

01:54:09.240 fibula and

01:54:10.220 sometimes even

01:54:10.840 the deltoid.

01:54:12.440 So I'm guessing

01:54:13.580 that the sprained

01:54:14.720 ankle is hands

01:54:15.760 down the most

01:54:16.260 common injury to

01:54:17.920 this part of the

01:54:18.540 body?

01:54:19.000 Yes.

01:54:19.700 And obviously

01:54:20.240 to your point,

01:54:21.220 I can't imagine

01:54:21.940 there are too

01:54:22.280 many people listening

01:54:22.960 to this who have

01:54:23.640 never experienced a

01:54:24.760 sprained ankle.

01:54:25.740 They don't

01:54:26.120 require surgery.

01:54:27.520 What is the

01:54:28.440 bread and butter

01:54:29.060 of the foot and

01:54:30.220 ankle surgeon?

01:54:31.280 What is the

01:54:31.740 type of surgery

01:54:32.500 that is most

01:54:33.500 commonly being

01:54:34.220 done, acute

01:54:35.440 or chronic

01:54:35.940 injury?

01:54:36.580 There are

01:54:36.840 different types

01:54:37.560 of practices.

01:54:38.760 I mean,

01:54:38.940 there's a lot

01:54:39.380 of degenerative

01:54:40.220 problems where

01:54:41.060 you have arthritis

01:54:41.820 of the ankle.

01:54:42.520 I'm not a foot

01:54:43.100 and ankle surgeon.

01:54:44.680 Once the foot

01:54:45.500 collapses, the

01:54:46.380 arch collapses,

01:54:47.380 and the posterior

01:54:48.060 tibialis tendon

01:54:49.020 is attrition

01:54:49.980 to that, that's a

01:54:51.300 very painful

01:54:51.880 condition.

01:54:52.500 You often have

01:54:53.080 to fuse the

01:54:53.840 small bones of

01:54:54.780 the joint in

01:54:55.700 order to better

01:54:56.700 create a stable

01:54:57.760 platform to land.

01:54:58.720 Which bones are

01:54:59.120 you fusing?

01:54:59.700 So occasionally

01:55:00.280 it's the midfoot,

01:55:01.760 occasionally it's

01:55:02.300 a subtalar joint,

01:55:03.500 and then you can

01:55:04.360 have an arthrodesis

01:55:05.240 even of the

01:55:05.960 ankle itself.

01:55:07.540 It's called a

01:55:08.020 triple arthrodesis.

01:55:08.980 And that occurs

01:55:10.700 when the person's

01:55:12.160 arch is so weak

01:55:13.760 that they lose

01:55:14.880 their arch.

01:55:15.860 There's stages.

01:55:16.840 So there's

01:55:17.840 early stage

01:55:18.740 where you can

01:55:19.180 treat it in a

01:55:19.920 boot.

01:55:20.560 Sometimes we just

01:55:21.380 go in and

01:55:22.120 address the tendon

01:55:23.040 itself.

01:55:24.080 More advanced

01:55:24.780 stages, you start

01:55:25.640 to see changes

01:55:26.420 in the ankle

01:55:27.460 joints.

01:55:28.000 So you would

01:55:28.440 never do...

01:55:29.020 How is this

01:55:29.500 occurring?

01:55:30.040 I mean, why

01:55:30.480 isn't this a

01:55:31.020 problem that is

01:55:31.680 fixed with foot

01:55:32.840 exercises and PT?

01:55:34.500 And why would

01:55:35.560 we let a

01:55:36.560 person get to

01:55:37.160 the point where

01:55:37.740 their arch

01:55:38.700 completely collapses

01:55:39.760 and the musculature

01:55:41.480 becomes so

01:55:42.860 compromised?

01:55:43.540 Because some

01:55:44.020 people have

01:55:44.460 anatomy of their

01:55:45.280 foot, they're

01:55:46.280 pronated, flat

01:55:47.360 feet that is not

01:55:48.620 easily correctable,

01:55:50.340 even with exercise,

01:55:52.080 it's just

01:55:52.540 mechanically

01:55:53.240 different, and

01:55:54.840 that tendon

01:55:55.620 itself, once it

01:55:57.100 becomes...

01:55:58.260 So stretched.

01:55:59.740 And these aren't

01:56:00.280 people who would

01:56:00.860 benefit...

01:56:01.320 I mean, I'm not

01:56:01.820 a huge fan of

01:56:02.880 orthotic arches,

01:56:03.860 but wouldn't

01:56:04.460 these people

01:56:04.900 benefit from

01:56:05.580 that?

01:56:05.980 Yes, and they

01:56:06.600 are prescribed

01:56:07.100 that.

01:56:07.860 It doesn't mean

01:56:08.680 the disease process

01:56:10.060 won't progress.

01:56:11.100 A lot of this

01:56:11.920 is mechanical,

01:56:12.720 we've talked

01:56:13.140 about that, and

01:56:14.060 a lot of this

01:56:14.580 is biologic,

01:56:15.500 too.

01:56:16.220 We have decent

01:56:17.240 ways of helping

01:56:18.000 people if they

01:56:19.340 don't have a

01:56:19.820 biologic problem.

01:56:21.140 We have decent

01:56:21.960 ways of helping

01:56:22.780 people with

01:56:23.400 mechanical problems,

01:56:24.660 but it's all of

01:56:26.020 this, all of

01:56:26.620 these factors play

01:56:28.000 into whether

01:56:28.580 someone would

01:56:29.860 benefit from

01:56:30.640 exercise, right?

01:56:31.720 But so there

01:56:32.780 are things that

01:56:33.300 can be done

01:56:33.800 nonetheless.

01:56:34.560 So you can

01:56:35.120 give people

01:56:35.780 rigid shoes to

01:56:37.240 help with their

01:56:37.760 feet and allow

01:56:38.860 them to exercise

01:56:40.100 other parts.

01:56:41.360 Just because one

01:56:42.440 area is deficient,

01:56:43.580 you can fuse the

01:56:44.440 ankle so the pain

01:56:45.280 goes away and

01:56:46.560 still get on a

01:56:47.480 plan to maintain

01:56:48.920 the health of the

01:56:49.800 rest of you.

01:56:50.460 But if your foot

01:56:51.460 kills with

01:56:53.100 everything you do,

01:56:54.840 you can't help

01:56:55.620 any of the rest

01:56:56.840 of it.

01:56:57.660 So when people

01:56:58.580 talk about an

01:56:59.140 ankle fusion,

01:57:00.320 normally they're

01:57:00.940 talking about

01:57:02.020 tibia to

01:57:03.000 talus.

01:57:03.780 That's the

01:57:04.280 normal fusion.

01:57:05.460 Now that was

01:57:06.320 traditionally what's

01:57:07.100 used.

01:57:07.380 Now, again,

01:57:08.800 this is not my

01:57:09.320 field, but there's

01:57:11.380 also ankle

01:57:11.860 replacements now

01:57:12.740 too, which are

01:57:13.520 becoming more

01:57:14.120 popular because,

01:57:15.000 again, the

01:57:15.320 technology is

01:57:16.420 improved.

01:57:17.060 But that's not

01:57:18.100 the same patient

01:57:19.000 necessarily.

01:57:20.860 What are the

01:57:21.240 other injuries to

01:57:22.920 the ankle and

01:57:23.880 foot that require

01:57:25.280 surgical intervention?

01:57:26.600 So this is the

01:57:28.700 fifth metatarsal, and

01:57:30.720 you can have

01:57:31.480 fractures of the

01:57:32.560 proximal fifth

01:57:33.520 metatarsal where

01:57:34.560 there's a tendon

01:57:35.580 attached here called

01:57:36.520 the peroneus tendon

01:57:37.580 which pulls off

01:57:39.100 that piece, and

01:57:39.940 that rarely requires

01:57:41.360 surgery, and that

01:57:42.120 tends to heal.

01:57:43.060 If you fracture it

01:57:44.300 right here, less

01:57:45.920 than a centimeter

01:57:46.560 higher up, that

01:57:48.240 fracture is in an

01:57:49.480 area where the

01:57:50.180 blood supply is

01:57:51.200 pretty deficient.

01:57:52.460 We call it a

01:57:52.940 watershed zone, and

01:57:54.660 that often won't

01:57:56.040 heal.

01:57:56.820 So you break it

01:57:57.720 here, oh, don't

01:57:58.360 worry about it, you

01:57:59.060 can wear whatever

01:57:59.640 shoes you like as

01:58:00.400 long as it doesn't

01:58:00.940 hurt.

01:58:01.520 You break it here, oh,

01:58:02.560 you need to be in a

01:58:03.260 cast or a boot for

01:58:04.240 six weeks, not

01:58:04.960 weight-bearing or

01:58:05.700 surgery to put a

01:58:06.600 screw in there.

01:58:07.420 So there are certain

01:58:08.120 types based on the

01:58:09.100 blood supply to the

01:58:10.060 bone.

01:58:11.080 Certainly, navicular

01:58:12.220 stress fractures are

01:58:13.200 another one of those

01:58:13.940 fractures that are

01:58:14.680 serious.

01:58:15.040 Is that typically in

01:58:15.620 a runner?

01:58:16.260 Yes.

01:58:16.940 What about the

01:58:17.480 other metatarsals?

01:58:18.780 You have stress

01:58:19.420 fractures tend to

01:58:20.160 heal.

01:58:20.600 You know, we see

01:58:21.220 it commonly

01:58:21.580 second and third

01:58:22.300 metatarsal stress

01:58:23.240 fractures.

01:58:23.540 Do they have

01:58:24.040 watershed zones as

01:58:25.000 well?

01:58:25.160 No, they heal.

01:58:25.860 It's just the fifth

01:58:26.540 one.

01:58:27.100 But, you know, a lot

01:58:27.760 of people have, I

01:58:28.780 worry about the

01:58:29.500 stress fractures because

01:58:30.320 oftentimes you'll see

01:58:31.120 somebody, they have

01:58:32.320 foot pain, they're a

01:58:33.040 runner, and then you

01:58:33.680 find out they had

01:58:34.320 three other stress

01:58:35.080 fractures.

01:58:35.640 So this is their

01:58:36.300 third stress fracture.

01:58:37.760 At the first visit,

01:58:38.760 you have to have a

01:58:39.240 conversation about

01:58:40.340 relative energy

01:58:41.920 deficiency, right?

01:58:42.920 Why are you not

01:58:43.540 healing?

01:58:44.060 Do we need you to

01:58:44.840 see an endocrinologist,

01:58:46.040 vitamin D, find out?

01:58:47.500 Yeah, you see this a

01:58:48.420 lot in, I've seen

01:58:49.920 this at least

01:58:50.520 anecdotally so much

01:58:51.660 in female runners who

01:58:53.040 are basically being

01:58:54.640 put into eating

01:58:55.680 disorders by, you

01:58:57.080 know, running

01:58:57.360 coaches.

01:58:58.200 Right.

01:58:58.560 They're way

01:58:59.240 undernourished.

01:59:00.280 We call it the

01:59:00.980 female triad, and

01:59:02.360 it's a risk of

01:59:03.460 osteoporosis, stress

01:59:04.880 fractures, and

01:59:06.240 menstrual abnormalities.

01:59:07.980 So what about

01:59:08.960 bunion surgery?

01:59:10.340 I guess, show us

01:59:10.920 what the bunion

01:59:11.580 actually is and what

01:59:12.740 the anatomy is that

01:59:14.060 leads to the

01:59:15.060 procedure.

01:59:15.780 Well, some people

01:59:16.560 develop an abnormality

01:59:17.860 of the first ray where

01:59:19.160 the metatarsal and

01:59:21.660 the metatarsal

01:59:22.520 phalangeal joint, this

01:59:23.720 will start to

01:59:24.280 deviate where this

01:59:26.440 portion, which we

01:59:27.280 call the bunion, starts

01:59:28.280 to be prominent on the

01:59:29.440 inner aspect of the

01:59:30.400 foot.

01:59:30.920 At the same time, that

01:59:32.400 can sometimes affect and

01:59:33.880 crowd out the second

01:59:35.000 toe, and you'll get

01:59:36.240 something called a

01:59:37.200 hammer toe of that

01:59:38.180 second digit.

01:59:39.520 And so if it gets

01:59:40.420 severe enough, as long

01:59:41.880 as you're comfortable in

01:59:42.760 your shoes and it's not

01:59:43.760 painful, it's not

01:59:44.700 necessarily something to

01:59:45.700 do about, but if it

01:59:48.020 starts to crowd out the

01:59:48.880 toe and you start to

01:59:49.600 develop pain, now we

01:59:51.940 have to talk about

01:59:52.640 correction.

01:59:53.580 And osteotomies or

01:59:55.300 cuts in the bone will

01:59:56.220 be made to straighten

01:59:57.520 out that area, and

01:59:58.580 oftentimes you need to

01:59:59.680 correct the hammer

02:00:00.980 toes of the other

02:00:01.840 digits if they're also

02:00:02.880 affected.

02:00:03.520 How do you correct

02:00:04.160 those?

02:00:04.820 Does moving the great

02:00:06.420 toe over do it

02:00:07.640 sufficiently, or do you

02:00:08.480 have to?

02:00:08.960 No, because after a

02:00:10.000 while what happens is

02:00:10.960 the tendon length

02:00:12.000 changes, and so you

02:00:12.960 often have to cut the

02:00:14.120 bone and just pin it to

02:00:16.520 a shorter stump.

02:00:18.460 So that it's no

02:00:19.880 longer painful.

02:00:21.480 And when you repair

02:00:22.800 the great toe, there's

02:00:23.900 a screw that runs

02:00:25.140 along the metatarsal?

02:00:28.080 There's different ways

02:00:28.960 to do it.

02:00:29.480 Some people use plates,

02:00:30.740 some people use

02:00:31.320 screws.

02:00:31.980 And that can be quite

02:00:32.700 a recovery.

02:00:33.580 Yeah, that's hard.

02:00:34.520 This is why we don't

02:00:35.260 recommend it unless

02:00:36.120 you're starting to have

02:00:37.220 pain.

02:00:37.980 How much of that is

02:00:38.700 driven by wearing

02:00:39.420 super tight shoes,

02:00:40.660 you know, being so you

02:00:41.320 hear, oh, I wear

02:00:42.160 dress shoes my whole

02:00:42.940 life, and how much of

02:00:44.300 it is that?

02:00:44.700 How much of it is

02:00:45.140 anatomic variation?

02:00:46.640 It's a combination.

02:00:47.360 I think it's a

02:00:48.200 factor where some

02:00:48.840 people are predisposed

02:00:49.680 to develop it, but

02:00:50.540 there's certainly a lot

02:00:51.960 of cultures where

02:00:52.580 tight shoes, you're

02:00:53.540 going to have a higher

02:00:54.560 incidence of this

02:00:55.340 problem.

02:00:56.300 Anything else on the

02:00:56.980 foot and ankle you

02:00:57.700 want to focus on?

02:00:58.400 What about the

02:00:58.880 calcaneus?

02:00:59.620 How often do we see

02:01:00.600 injuries to that?

02:01:01.560 Well, we see stress

02:01:02.340 fractures of the

02:01:02.960 calcaneus as well.

02:01:04.500 Also, plantar fasciitis

02:01:05.740 is very common, so it's

02:01:07.180 important to recognize

02:01:08.240 that this area of the

02:01:09.380 foot, heel pain is

02:01:10.880 its own animal, and

02:01:12.600 sometimes it's

02:01:13.380 attrition of the

02:01:14.220 fascia or the

02:01:15.100 ligament, the

02:01:15.780 plantar fascia that

02:01:16.840 attaches on the inner

02:01:18.440 plantar surface of the

02:01:19.880 bone.

02:01:20.660 You can have stress

02:01:21.440 fractures in this area,

02:01:22.900 you can have insertional

02:01:24.280 tendinitis where the

02:01:25.240 Achilles attaches to,

02:01:26.700 and sometimes you can

02:01:27.700 have heel pain because

02:01:28.840 a nerve is compressed,

02:01:30.100 much like you have

02:01:30.780 carpal tunnel syndrome,

02:01:31.860 you can have tarsal

02:01:32.540 tunnel syndrome, and

02:01:33.780 sometimes people get

02:01:34.480 just heel pain because

02:01:35.340 they have a disc

02:01:36.060 herniation that's

02:01:36.900 affecting S1 nerve

02:01:38.340 root, only presenting

02:01:39.840 as heel pain.

02:01:40.680 So it's one of those

02:01:42.140 things where you

02:01:42.640 sort of have to

02:01:43.140 really take a close

02:01:44.580 step-by-step approach

02:01:45.940 to diagnosing that

02:01:47.780 problem.

02:01:49.060 So taking a step

02:01:49.660 back from all of

02:01:50.300 this, if someone

02:01:51.160 watching this is sort

02:01:52.100 of in the process of

02:01:53.260 interacting with the

02:01:54.540 medical community,

02:01:55.560 specifically the

02:01:56.140 orthopedic community,

02:01:57.360 how can they pick a

02:01:58.780 good surgeon?

02:01:59.480 What are some of the

02:02:00.100 tells that you're

02:02:01.380 speaking with a good

02:02:02.460 orthopedic surgeon

02:02:03.300 versus someone who's

02:02:05.580 a hack?

02:02:06.620 It's a good question.

02:02:07.740 I think you use the

02:02:08.600 same judgment you have

02:02:09.740 when you speak with

02:02:10.420 anybody.

02:02:10.960 Are they sitting down

02:02:11.940 when they walk in the

02:02:13.000 room?

02:02:13.240 Are they sitting down?

02:02:14.040 Are they looking at

02:02:14.620 you in the eye?

02:02:15.080 Are they talking to

02:02:15.880 you?

02:02:16.600 Do you feel like you're

02:02:17.660 being rushed?

02:02:18.480 I think that's a big

02:02:19.320 sign.

02:02:20.160 If you feel like you're

02:02:20.960 being rushed, you

02:02:21.600 probably are being

02:02:22.420 rushed.

02:02:23.600 And so just the

02:02:24.600 ability to listen, to

02:02:25.940 have someone that

02:02:26.580 is listening to you.

02:02:28.720 You know, I hear a lot

02:02:29.420 of people come and I've

02:02:30.480 seen people all the

02:02:31.720 time who they had

02:02:33.460 surgery with someone

02:02:34.600 and they're seeing me

02:02:36.280 about three months

02:02:36.940 after their surgery

02:02:38.020 and they say,

02:02:39.740 to me, I said,

02:02:40.960 well, you really

02:02:41.620 should ask that

02:02:42.200 question of your

02:02:43.120 surgeon because they

02:02:44.260 know what they did

02:02:45.160 for you and they're

02:02:46.140 still in pain, for

02:02:46.880 example.

02:02:47.620 And they say to me,

02:02:48.560 oh, yeah, but he's

02:02:49.160 just a surgeon.

02:02:49.820 He just does the

02:02:50.580 surgery.

02:02:51.560 I said, well, what do

02:02:52.480 you think I am?

02:02:53.260 I'm also just a

02:02:54.220 surgeon.

02:02:55.020 You know, you can ask

02:02:55.860 them these questions.

02:02:56.840 You're entitled to have

02:02:57.880 a conversation with

02:02:58.780 somebody.

02:02:59.360 You're not going to

02:03:00.040 know until you meet

02:03:00.720 them.

02:03:01.020 And some people, some

02:03:02.280 people mesh well with

02:03:03.300 people.

02:03:03.620 Other people don't.

02:03:04.400 What are some

02:03:04.940 questions that they

02:03:05.760 can ask specifically

02:03:06.780 to get a better

02:03:07.860 sense of, you know,

02:03:09.280 a person's competence,

02:03:10.880 basically?

02:03:11.940 That's a good

02:03:12.600 question.

02:03:13.180 I think just, again,

02:03:14.700 the rapport you're

02:03:15.560 having with the

02:03:16.300 person, let's say,

02:03:17.620 for example, they

02:03:19.100 say, I think you

02:03:20.440 need surgery.

02:03:21.300 Just a simple

02:03:22.080 question.

02:03:22.620 Are there

02:03:22.940 alternatives?

02:03:24.340 Or what are the

02:03:25.780 alternatives?

02:03:26.540 Or why do you think

02:03:27.640 I need surgery now

02:03:28.600 and I can't do

02:03:29.400 non-operative approaches

02:03:31.600 to it?

02:03:32.700 And just the answer,

02:03:34.200 you know, right off

02:03:34.640 the bat, you could get

02:03:35.380 a good sense.

02:03:36.340 If they're defensive

02:03:37.460 in their response,

02:03:38.960 you know, that may not

02:03:39.800 be someone who's right

02:03:40.780 for you.

02:03:41.480 Even if they're right

02:03:42.780 and you do need

02:03:44.000 surgery, it doesn't

02:03:44.720 mean you're not

02:03:45.240 allowed to ask the

02:03:46.100 question about

02:03:47.200 alternatives.

02:03:48.240 If someone comes in

02:03:49.320 with a ruptured

02:03:50.060 patellar tendon and

02:03:51.000 I'd say to them,

02:03:51.780 you need surgery,

02:03:53.000 even though that

02:03:54.040 visit could be four

02:03:55.340 seconds, I could say,

02:03:56.420 oh, you ruptured

02:03:57.060 your patellar tendon.

02:03:58.260 I'm scheduling you

02:03:59.120 for surgery next

02:03:59.900 week.

02:04:00.400 I'll see you then.

02:04:01.700 I'll be right in my

02:04:02.840 assessment of what

02:04:03.560 needs to be done,

02:04:04.420 but that doesn't

02:04:05.100 make me a good

02:04:06.160 doctor or a good

02:04:06.960 surgeon.

02:04:07.760 You need to explain

02:04:08.480 why that's the

02:04:09.260 case, what to

02:04:09.920 expect afterwards.

02:04:11.140 So everybody

02:04:12.120 deserves a

02:04:12.780 conversation about

02:04:13.680 these things.

02:04:15.140 When I talk to

02:04:15.620 people about this

02:04:16.260 in general,

02:04:17.160 especially with

02:04:17.660 surgical procedures,

02:04:18.480 I feel like when

02:04:20.180 a surgeon can't

02:04:21.420 give you a clear

02:04:22.660 breakdown of what

02:04:23.980 the complications are

02:04:25.120 and what the

02:04:25.840 probabilities are of

02:04:26.960 those complications,

02:04:27.940 especially in their

02:04:28.740 hands.

02:04:29.260 One thing to quote

02:04:29.880 the literature, but I

02:04:30.700 want to know what is

02:04:31.720 your risk of wound

02:04:32.800 infection?

02:04:33.740 How many times do

02:04:34.460 your patients get

02:04:35.100 wound infections?

02:04:36.220 How many times do

02:04:37.480 your patients require

02:04:38.780 re-operation?

02:04:39.640 How many times do

02:04:40.280 your patients still

02:04:41.620 find themselves in

02:04:42.400 pain a year out?

02:04:43.080 All of those little

02:04:43.900 things.

02:04:44.320 And then the other

02:04:45.000 question is, what

02:04:46.800 will we do if?

02:04:48.680 If I'm still in pain

02:04:49.980 in six months, what

02:04:51.360 does your intuition

02:04:52.540 tell you is going on

02:04:53.600 and how will we work

02:04:54.340 that up?

02:04:54.600 In my experience,

02:04:55.940 surgeons who can't

02:04:58.520 go through that

02:04:59.320 thinking aren't very

02:05:00.960 good at their job

02:05:02.140 and you're playing a

02:05:03.800 little bit with fire

02:05:04.560 when you go under

02:05:05.920 the knife from them.

02:05:06.660 You might get a

02:05:07.080 great outcome and

02:05:07.700 you're fine, but if

02:05:08.800 you don't, they're not

02:05:09.700 going to be the ones

02:05:10.220 to help you

02:05:10.620 troubleshoot.

02:05:11.700 That approach is also

02:05:13.000 important, I've found,

02:05:14.520 even when you're not

02:05:15.480 recommending surgery.

02:05:16.500 For example, if I

02:05:17.680 have someone come in

02:05:18.440 with an ankle sprain

02:05:19.360 and I say, oh, you

02:05:20.080 just need to do PT

02:05:20.940 and I don't explain

02:05:22.820 to them what happened

02:05:24.540 in three weeks, I

02:05:25.700 could just say, follow

02:05:26.480 up with me in a month

02:05:27.240 if you're not doing

02:05:28.360 well.

02:05:28.960 I need to go through

02:05:29.880 the steps with them.

02:05:30.640 Listen, here's the

02:05:31.440 story.

02:05:32.000 Not everybody with an

02:05:33.080 ankle sprain is going

02:05:34.360 to get better.

02:05:34.980 You're probably going

02:05:35.640 to get better because

02:05:36.280 most do, but you

02:05:37.620 might not.

02:05:38.420 So if four or six

02:05:39.540 weeks goes by, you're

02:05:40.420 still having swelling

02:05:41.300 pain, you don't feel

02:05:42.680 like you're making

02:05:43.100 improvements, I really

02:05:44.020 need to see you because

02:05:45.220 you may have an injury

02:05:46.700 to the cartilage and

02:05:47.500 we have to get an MRI.

02:05:48.600 So I always give them

02:05:50.180 the answer to what we

02:05:51.540 are doing next if what

02:05:53.640 I've just recommended

02:05:54.740 isn't going to work.

02:05:56.860 Well, Adam, this has

02:05:57.480 been super helpful.

02:05:59.120 I've learned a ton.

02:06:00.120 Again, orthopedics is a

02:06:01.140 little bit of a black

02:06:01.780 box to me.

02:06:02.760 I think it is probably

02:06:03.500 even to a lot of

02:06:04.200 doctors.

02:06:04.660 We don't have enough

02:06:05.760 of an overlap.

02:06:06.400 It's such a subspecialty.

02:06:07.700 There's so much you're

02:06:08.440 learning.

02:06:09.520 This will be very

02:06:10.380 instructive for people,

02:06:11.640 especially when paired

02:06:12.820 with the exam videos

02:06:14.260 that we'll do.

02:06:15.240 So thank you very much

02:06:16.080 for your time and for

02:06:17.540 sharing all these

02:06:18.140 insights.

02:06:18.600 I appreciate the

02:06:19.260 opportunity.

02:06:19.740 Thank you, Peter.

02:06:21.040 Thank you for listening

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The Peter Attia Drive - July 31, 2023

#264 ‒ Hip, knee, ankle, and foot： common injuries, prevention, and treatment options

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Sentence Count

Misogynist Sentences

Hate Speech Sentences

Summary

Transcript