#264 ‒ Hip, knee, ankle, and foot: common injuries, prevention, and treatment options

28:41So this muscle is incredibly important. In fact, we consider this to be the rotator cuff of the hip. Just those two. Just those two. Correct. The gluteus, medius, and the gluteus minimus. And it has a very similar profile. And just as in the rotator cuff, it starts to degenerate after a certain age. Same thing happens in the hip. This will weakness of the gluteus medius is very difficult because it's incredibly painful, doesn't have great healing potential. We also see this in endurance athletes as well from the repetitive stress and we also see this in unstable patients because those muscles are trying to dynamically keep the ball in the socket so they are working harder.

29:24Ballet dancers in particular have incredibly large gluteus, medius, minimus powerful. Part of the reason is because they're asked to do a lot to stabilize the hip. So we see tears are all the time and we often approach that just like a rotator. So are most of the injuries you see here underuse or overuse? It sounds like they're mostly underuse. I don't think so. It depends. So the older we get, it doesn't necessarily matter whether it's overuse or underuse. These things will happen because that is just a normal trajectory of tendon problems, tendon pathology. The tendon cells over time started degenerate just like all of our cells, and they go through process of senescence like alt -issue, and those senescent cells produce those factors that lead to degeneration of the tendon causes inflammation, incredible amount of pain, and it's hard to treat.

30:23It's hard to reverse the process. Now if you knew what was happening before it started, would you be able to do anything? 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. There's two things that jump into my mind here. the first is the obvious need for, I hate to use the word physical therapy because it really gets misconstrued a lot, but basically deliberate exercise that strengthens those muscles. 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?

31:02So you get very, very strong quads, glutes and hams, your glute Mead and men do very little. You're not really doing any abduction of the hip. And as such, you get a very tight, tenser, fascial a lot of cyclists get really bad IT band pain because they just lack that strength there. And so, an obvious way to fix this, which I was very lucky to that I was able to fix this non -surgically because I was having debilitating IT band pain was simply doing a lot of strengthening for the abductors. So that at least suggested to me that you could be preventive in some way. 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, starting from early teens.

31:50It is implicated in so many lower extremity injuries at the hip and the knee, a week gluteus medius, weak abductors can cause a lot of injury. And I do believe that the stronger they are, it's almost like bones. The higher the bone density you get early on, the higher you're glider, the longer it grows. That's right. Because it's going to degenerate. It is just going to happen. And so the stronger and healthier the tendon is at a starting point, this is sort of how I think about this. First of all, not only are you likely to have less injury and I'm talking about it, ACL injuries too. I'm talking about knee injury.

32:30It holds back to valgus. Everything that we're going to talk about in the knee. Exactly. Hip fractures, which we started to talk about a little in the elderly. That too, these muscles are incredibly strong. And the hip flexors too. There was a study done at a South Korea that looked, it was an imperfect study, but it was pretty decent. They took a group of, it was retrospectively evaluated, but they took cat scans of people who were for a hip fracture, femoral neck fracture, elderly population. And they measured the volume of their sois muscles. So this is the sois muscle, and this is the iliacus, together to make the iliossois muscle, touches here.

33:13And this is what picks your leg up. That's what lifts your leg up. So if you stumble, you pick your leg up to save yourself. The volume of that muscle was significantly smaller than that of an aged matched control group who were getting cat scans for other reasons. Now, we don't know why they were getting cat scans, so that's, you know, it's a little bit confounding, but it shows that there was a significant decrease in volume in those patients who have hit fractures. So we know that hip muscle strength, so the important to get the abductor strong, the hip flexors strong, the problem with the hip flexors is that we're always sitting, even if they're strong, they're often tight, because we're always in this position.

33:56So it's important to see how your hip flexors are, make sure that they're flexible, because in imbalance and the flexibility of that muscle group will also impact the antagonistic muscles in the back, the gluteus maximus, which extend the hip, and the hamstrings, which also extend the hip. You know, it's fine balance, but if I could work on anything to help prevent these things later, I think this is a good place to start. The other thing that I've really migrated to over the past decade is I've become very obsessed with all of these muscles in particular those hip adductors is the importance of training them not just in concentric phase but also eccentricly.

34:38So there are these exercises we do in a training, I don't know, for the lack of better word philosophy, dynamic neuromuscular stabilization, DNS. There's a position called DNS Star. I was just doing it this morning. So I'm doing this stuff most days and you're laying on your side. So if I'm on my right side, you know, my right elbow is down. It's sort of like a plank, but you're on the knee and your hips are up and you're extending yourself forward as you're putting the hip back. So you are eccentricly loading the adductor as you go back and then you're concentrically loading it as you bring yourself back up.

35:17Now, for anybody who's done this, we've demonstrated these things in other exercise videos. I mean, five reps of this slowly, you feel like someone is jamming an ice pick into those muscles. It is remarkable how difficult it is, but you don't need to do a lot. Just doing a little bit of that stuff every day does so much in terms of lower body maintenance. And looking at this picture, I think it's pretty clear why it's such small muscles that have such an unfavorable angle at their attachment, right? In terms of like the contraction, you know, it has such an unfavorable lever arm for what it needs to do.

35:58So it really has to be strong. Right. Let's talk a little bit about fractures. Put aside just, you know, the 25 -year -old skiing accident, freak accident, you know, you're going to see it all day long. But let's talk about the more predictable and far more catastrophic fractures to quality of life, which are these fractures of the femoral neck that are occurring in people due to osteoporosis and osteopenia. And I talk about these stats all the time and nobody believes them because they're so absurd. But if you're 65 or older and you fracture that hip, depending on the study, 15 to 30 % one year mortality, can you explain why that is?

36:38How do these people present to you and why is it so challenging to take care of that fracture? A large percentage of those people, it's usually another disease that has overtaken their lives. And so they may have advanced stage cancer, they may have advanced renal disease, and it's almost the last event. The last drop. It's the last drop. The hospitalization alone is just catastrophic. That's right. And so, and it's very hard to, when you're elderly, and if you don't, first of all, you break your hip, you come to the hospital, there has to be some medical management to make sure that it's safe to perceive a surgery and everybody who has a hit fracture needs surgery, you can't treat this not operatively.

37:21It would be essentially a death sentence to do so because the goal is to mobilize as quickly as possible because for even the people who don't have you know the mortality of 20 to 30 percent within the first year, you know that's been a stable number for decades. I mean every time they look at it That's a stable number and that's within one year. So our goal is to get you up. And Adam, how much of that is really acute? It's pulmonary embolite, fat embolite, MI because of surgery versus, you know, two weeks out, they're okay, but then they fail to thrive and they die within the year. It's not so acute, it really is spread out.

38:02The management of these patients is very important early on. So we'd like to get a full team on board, right? a geriatric specialist, you need a team approach because you need them medically optimized before surgery so that they could safely go through. How long can they hate to get tuned up before surgery? So it should be done within 48 hours. Wow. Before we had the medical management sort of model of hit fractures, you oftentimes were able to get the surgery done quicker. In orthopedics comes in, say, let's just do this right now. Everybody signs off. We have to do this. Let's go. When we have sort of the team approach, the medical doctors like, listen, we have to get an echo.

38:46We have to do these other things. We need to make sure the blood's okay. That has delayed the surgery slightly. But probably gives better outcomes. It does operatively. It has, at least in the studies that I've seen, people are able to get discharge sooner, which is a good thing. But they're long -term outcomes. It still seems to be about 20%. Wow. And part of the issue is, first of all, obviously you broke your hips is a good chance you're weak. You now, your NPO, the first day you come in, they won't, no one will feed you anything, right? You don't get a meal. And then in bed for two days, we're have surgery, in bed for a week.

39:22Probably getting dehydrated. And then even for the people who don't pass away, who don't die, there's a decrease, about 50 % lose a level of function. So if you were using a cane before you're using a walker, if you're using a walker before you're now in a wheelchair. If you were walking normally you might be using a cane. So there's a 50 % of people that go down the level in performance. I once had a patient who was early on in my career. I was a junior attending and resident calls me and says to me, we have a patient with a femoral neck fracture and he says to a little Tom of the story says, well he's 40 years old.

39:58He was riding on the West Side Highway and he crashed and he broke his federal Mac. I said, well, I'm coming in now. Let's fix this right away. I said, just go consent him for the surgery in which the resident was a junior resident. He goes and talks to the patient about all the risks and benefits of the surgery. I go in to see the patient and he's got this. Obviously, I explained him to miserable, but he really was like, and I explained and he goes, he sent me, he says, your resident just told me I haven't 30 % chance of dying this year. He kind of forgot to age in just that. I said, well, don't worry.

40:30You're not gonna die. Somebody else's, but not you. As you were talking earlier about the degeneration of the hip, obviously the first thing that comes to my mind, and I'm sure everybody's mind listening to this is, where do stem cells play a role here? Now, we're gonna talk about stem cells through all of these joints, but we might as well start here. When I hear that the tendons of those muscles and those muscles themselves are going to weaken, when I hear that my cartilage is going to weaken, when I hear that the oceus structure of the bone is going to weaken, all of these things make me wish.

41:06I could just have newer and younger cells there. So, what do we know about the utility of stem cell therapy here? What's the state of the art today? This is a great conversation and there's a lot of layers to this conversation because there's the dark side and the bright side of this. You know, when we talk about ortho -biologics or biologics in general, basically biologics, it's a class of therapies that are using your own natural resources to promote healing. So you're using a biologic product to encourage healing of diseased or injured tissue. So the most commonly used ones are blood, specifically platelets, bone marrow, bone marrow our aspirate concentrate is called and also fat.

41:57So if we sort of go through those three, just to start there, for PRP, what are we doing? So we take your... Clay lit rich plasma. Clay lit rich plasma. We take your blood, we draw it, and we take it down the hall, and we spin it in a centrifuge. And the centrifuge machine will separate out the different elements of the blood based on the density of those elements. So after you're done spinning it, you have a layer called the plasma layer, which is rich in plasma and platelets. And it separates out the red blood cells and a lot of the white blood cells. Now you could spin it twice, you could do two spin technique, you can spin it so that you're keeping some of the white blood cells.

42:42So we've categorized it into leukocyte -rich PRP and leukocyte -poor PRP. And this is a very simplified way that we think about it right now. and there's certainly, if we fast forward 10 years from now, this will be a ridiculous conversation. Because we just are sort of in our infancy of understanding what we're doing here. So the principle is we take those platelets which are involved in healing. We know this because if you cut yourself, the first thing that happens is the platelets come to the surface to form a blood clot and to form a scar and then you heal. So platelets are associated with an incredible amount of growth factors and healing factors, including the 800 to a thousand proteins within the plasma.

43:28And you inject that into tendon, a joint with arthritis, muscle, and see what happens. The problem is that as a physician, you are allowed to do that procedure. There's no I have this injury, can I have stem cells? And you say, oh, sure, let me give you a PRP and I spin it and I inject it. What does the actual science say about what's actually working? And what we've learned is that it works for some things pretty decently and other things not well at all. And we can only go by our randomized controlled trials and systematic reviews of randomized controlled trials to find out what seems to be the best way to do it.

44:13to work. What are those best case scenarios? So tennis elbow seems to work with PRP. There's good data to suggest, like tier one data, maybe tier two data that suggests that it works for tennis elbow. It works pretty decently for gluteous, medius tears. And for tendons, that's about it. Some will argue maybe in the hamstring tendon it works, but I'm not convinced. And just to be sure, are you talking specifically about PRP or are you talking about the broader umbrella of stem cells? broader umbrella of stem cells don't seem to work. And I think it's important to bring up a very important part, which is these aren't stem cells.

44:51And I think that's one of the major problems is that there is no stem cell therapy anywhere. When you go to Mexico and get stem cell therapy, what are you actually getting? I don't know, but they're not stem cells. I mean, I can only speak what's happening in the United States, but the only stem cell therapies approved in the United States are for blood disorders, blood diseases. There is no stem cell. In fact, the FDA has a big warning page with a video that explains there are no stem cells. Stem cells implies that I'm going to inject cells into you, and those cells are pluripotent. They have the ability to become something else, and those cells are now going to become your cartilage.

45:37They're now going to become your tendon. That doesn't happen. In fact, right now, what seems to be happening. What's the identity of the stem cell? In other words, what is the signature that allows that doctor to know or at least believe they have a stem cell? Because these are not a tolligas, typically at these clinics, right? Aren't they? Are we talking about Mexico or? I only say that because everybody I know is basically going abroad. Although I know some people that have done this here. They tear the rotator cuff, you know, and they go and get stem cells injected and six months later the rotator cuff is fine without surgery.

46:11Right. So, first of all, it's illegal to actually give stem cells. So a few years ago, people were able to get products that were manufactured by companies who were selling umbilical cord blood or some derivative of umbilical cord, some umbilical product as stem cells, wardens, jelly, some of it's called exosomes. All these things are not allowed. The FDA will not let you inject this into anybody. What's the reason for that? The FDA has a division that regulates the use of human cells, tissues and products. Even if autologous, even if they're your own. You can use your own as long as it's not manipulated or what we considered minimally manipulated.

47:02So spinning is not a manipulation? That's right. So you can take your bone marrow out of the pelvis and we get it from the pelvis and you can concentrate that. But you can't give any enzymes to it, you can't digest it, you can't make any changes to that product. You can only give it as is. Now with fat, because fat has actually shown some promise with osteoarthritis of the ankle, very good studies on ankle osteoarthritis and fat injection, same with knee. You can do that because you're minimally manipulating the fat. You are taking it and making it into smaller fat particles, but you are not essentially altering the fat itself.

47:45I mean, you're basically breaking down adipose tissue into individual fat cells. It's micronized. It's called micronized. It's micronized fat. And the idea is that micronized fat regrows as cartilage? No. What does it grow as? So that's what we don't know. So right now our best understanding of biologics in reality is that it reduces symptoms. It is symptom modifying treatment. And it's a good symptom modifying treatment when it works because we don't have a lot for let's say arthritis tendon problems. Our toolbox of things to use when someone comes in with knee arthritis or hip arthritis are pretty pathetic.

48:23You're gonna go to PT because that's mentioned to help. I'll give you a brace maybe that might help. Maybe take some cox2 inhibitor and time flammatories and some cream. We don't have the repertoire of what I prescribe is pretty not a surgical treatment for these things this week. So here's an opportunity with the ortho -biologic field to reduce symptoms in a safer way than let's say cortisone. Because cortisone is quite effective and safe as long as you're not injecting over and over again, there's a space for this that is very reasonable. And the randomized control trials show that it works for me, arthritis, probably better than anything.

49:05If we're looking forward as to what this... Yeah, well, I don't really have bigger... Why don't we have RCTs that can answer these questions definitively? Because there are a few things that I discuss with people in medicine that create more sort of polarization around treatment than the use of these biologic therapies, where the people who have had these procedures will swear up and down by them when they work, which is, you don't understand. I couldn't move my arm, and in six months I was fine. Of course, it was failed to have the counterfactual here, which is, possible your arm was just going to get better on its own.

49:40It's possible that the initial MRI showed something, but the follow -up MRI didn't show something We're just healed on its own because it was quite healed on its own So you know the only way you can ever escape that is with randomized control trials. Are they being done? Yes, and so to that point if we inject saline into somebody's joint a number of those patients are gonna get better So that's sort of the standard we use how does PRP work in comparison to saline and there are a lot of studies There are dozens of studies randomized controlled trials looking at PRP. And many of them have excellent results.

50:16For example, tennis elbow. For knee arthritis. For knee arthritis, okay. Of all the data, that's the Tier 1 best data. But, you know, we know so little about this because it doesn't seem to work well in hip arthritis. And why do you think that would be? Is it just possible that the studies haven't been done correctly? Maybe. And I think this brings up a very important point. When you do a randomized controlled trial, let's say for a medicine of hypertensive medication, you know what dose you're giving, and you're comparing it to some other treatment where you know the dose. Platelet -rich plasma, I'm taking your platelets of unknown concentration, unknown quality.

50:50Of unknown quality, I'm spinning it in a machine, either once or twice, different machines, concentrate those platelets differently. And so then I end up with a product with a certain amount of platelets, and then I inject it back into you. I don't even know your disease process specifically. So when you put people into these studies, you get a lot of crappy data. So what the future holds is, and there is a push in our industry, and there's a particular association called the Biologic Association, which is like an association of associations internationally, where they form something called the barb, which is a biologic association, registry, it's a bio registry, it's a registry and a bio registry.

51:39That is they have lots of centers and they wanna know everything about what you're injecting. They wanna know what's the concentration of the blood of the patient, you know. Well, percentage of docs who are regularly giving this therapy are participating in the registry to the point where we can generate information. Oh, compared to the total amount, very few, but it's enough people that we can get really good data to find out what's the dose, what's the critical dose of platelets that we need to affect change. And other things, we can do a proteomic analysis of the actual fluid itself. And you match that with outcomes data from the registry.

52:16So you have a biorepository and a registry combined. Who did well and what did they get? And they save samples of that stuff too. But at best, this can only inform what an RCT should do. Those data by themselves don't tell us anything right? Correct. But this gives information about to actually lead to the trial. So you say, okay, it looks like this works. Let's try this particular dose. So right now, PRP looks more effective at reducing symptoms than cortisone in the knee for arthritis. Is there any reason to believe it can delay the requirement for a total knee replacement? Maybe if we look over the course of a year, because this is what those trials looked at, cortisone works very well in a short time frame.

53:04It's pretty impressive. The first couple of weeks you get one and it helps. There are some people who the pain comes right back. So it doesn't have staying power. When you compare steroids to PRP, the PRP, if you look out over a year, they're doing better. Hyaluronic acid, which is another thing we inject. also is doing better than cortisone if you look out. If you combine... Isn't how uroinoc acid considered biologic? It's not. Because it's an FDA -approved product? Yes, and I don't even know that it's a drug. I think it's even classified differently like a device, but I'm not 100 % clear on that.

53:40So there's a number of studies, or I don't know about a number study. I know of a very well -done study that looked at how uroinoc acid and PRP together, and that seemed to be more effective, not astronomically more effective, but more effective than the treatments that we have. It's more effective, the combination of those two. But is it disease modifying, and that's the big maybe, because that's your question. And there are studies that show it may be pushing off knee replacements for those patients. But I think this is where we still don't really know yet. But there's so much deceitful behavior out there with regards to stem cell therapy that The organization is involved and the FDA and the Federal Trade Commission and CMS are all trying to crack down on the problem of people advertising.

54:32Come on to my clinic. I have STEM cells. I will inject it. It's 100 % guaranteed to help you. I'm going to give you new cartilage. One of my colleagues at NYU did a study where they looked at a thousand websites and 94 % of those websites who were promoting STEM self -aeropathy were making inaccurate statements. And it just engenders distrust between doctor and patient when you're going for a treatment and you think they're telling you something that I had a friend, I really, like this is about two weeks ago, my close friend from high school sent me a brochure because he wanted to get an injection from his doctor of something like an umbilical cord or Wharton's Jelly injection, which is not allowed.

55:16And I look at the brochure, I said, send it to me. You know, I made the bigger and I circled it and on the brochure, because it's from the company, the company sells it to the doctor, the doctor gives it the patient. On the brochure, it said, this is not intended to treat any condition. And I just circled it and I sent it back. Before we What is the role of Cortezone as a treatment to delay the need for surgical intervention? Is it particularly efficacious or do you not muck around with it? I don't love it because we worry about what it's doing to the cartilage. Listen, I think because it's such a successful operation, I'm more opt to push for the hip replacement in the appropriate patient than a cortisone injection.

56:01Because satisfaction rate, 90, 95 % for hip replacement surgery with low complication rate, that's not to say that I don't do it or I wouldn't do it because there's certain circumstances that I would. I would give hyaluronic acid in the hip also, although it's not FDA approved, it can be used off label for that application. There's some studies to suggest that the gel can help. We're still trying to find out, figure out a better way. But we also know that if you give an injection right before hip replacement, there's an increased risk of infection. So we know that there's something about this that we need to be cautious about.

56:34Anything else about the hip before we move down to the knee? No, because I think even in the knee, we're going to be talking a little bit about the hip too. So let's talk about the knee. Again, I think most people listening to this can at least relate briefly to some bout of knee pain. So walk us through the anatomy of the knee. Sure. So the knee is a bit different than the hip joint. It is more unstable than the hip joint. The hip joint is a true ball and socket joint, and the knee joint is inherently more unstable. So when we look at a knee, what are we looking at? If you look at the front of your knee, you often see that rounded area in the front.

57:10That's your kneecap or patella. The quadricep tendon attaches to the top of the patella, right here, and then that tendon continues on as the patella tendon and attaches to the bone here at the tibia. If we were to fold that over what we're looking at is the under surface of the kneecap and this is the patella and this is the cartilage on the patella and all joints like we spoke about have cartilage all joints are made up of cartilage so the end of all of the bones allow that to glide smoothly on the surface. So we're always interested in maintaining the cartilage because once that disappears, we have trouble.

57:52So if we were to flex the knee a little further, what we can see are ligaments in the knee. I don't know if you could see that well, but here's the anterior cruciate ligament, posterior cruciate ligament. They're called cruciate ligaments because they cross. And then we have on the side the collateral ligaments. So this is the medial collateral ligament. This is a right knee and this is the lateral collateral ligament. And then if we were to fold it over and you were to look directly there you would see two semi -circular structures That are called the menisci and you have two menisci, medial and lateral menisci If I move the model away and we look at the picture here You could see those cruciate ligaments a little better This is the anterior cruciate ligament post -ear cruciate ligament and we see the collaterals This picture is without the kneecap there you could also Also see the meniscus or meniscus.

58:46And the main role of the meniscus is to distribute force across that knee. And they're imperative to maintain the surface of the joint, the cartilage, from wearing down. And the ligaments provide stability to the joint and are the anterior cruciate ligament as a commonly torn ligament. And just again, to orient people here, you are looking at the right leg. Correct. So, the fibula is that little small bone on the outside and that's where we see both its attachment to the tibia, which is the platform on which the knee sits and also you have the lateral collateral ligament attaching there, yes? Correct.

59:29So, the menisci collectively make up the bulk of the cartilage surface of the tibial plateau then? The function of it is to distribute stress and it distributes about 30 % of the load of the knee through the joint. So without that meniscus there, you end up having point load or edge loading and it will cause degeneration of the cartilage pretty rapidly if it's removed. I always hear people talk about how running and walking, they amplify forces at the knee. So I've heard people say when you're running, you're experiencing eight times the force of your body weight at the knee. A. Am I remembering people say that correctly and if so, why is that the case?

1:00:10So it depends which joint you're talking about. So if we're talking about the knee cap, the amount of load that the knee cap sees with activities like squatting and lunging. If you do not even a deep squat, just a regular squat, the pressure behind the knee cap is about seven times greater. Then the weight on your back. That's right. The recartilage has an incredible responsibility here. One of the most important conversations that I have with patients because I get the similar questions often, which is, things like, is running bad for me? Is this activity good for me or bad for me? Because you'll read a different report in the news all the time.

1:00:47Running's good, running's bad. The truth is, we kind of know the answer to this in general. That is, no activity is horrible for cartilage. If I put your leg in a cast and we then look at your cartilage in a couple weeks, the The content of that matrix is going to be significantly depressed. Nothing's worse for you than inactivity. Right. But it's an inverted U -shaped curve. But it's not symmetric. It's like that. Where more and more and more activity, probably better and better and better. But then you can go too far and it falls off. It's not a perfect U where it's pure gold elocks where you want to be right in the middle of doing nothing and doing a lot.

1:01:31Because we'll never know because it's dependent on a particular individual and so many factors. So we know that congercites respond to activity. They feel the stress and they make more matrix. They make all of the proteins within cartilage. So a congercite that's being pressured is happy. A congercite that's not being pressured isn't going to do anything and eventually it's going to break down. And biomechanics have to matter here. They do. In other words, words, you watch an Ethiopian runner, you watch Kipchogi running a marathon and you realize, okay, clearly there's a lot of force there based on his velocity.

1:02:13For him to have the stride length that he has, he is hitting that ground so hard and that ground is hitting him back so hard and that's what's allowing him to stay in the air long enough to travel the distance he travels. And sure he's not the heaviest guy in the world, he probably weighs a buck 20 soaking wet, but again, if he's feeling eight times that, we're close to a thousand pounds every time. But his mechanics are perfect. I think it's all mechanics. I mean, that's exaggeration. But it's mostly mechanics. If you have good mechanical alignment, we call it, that is, if we draw a line from the center of your hip to the center of your ankle, and we do this regularly, and it goes right through the center of the knee, it's a good chance you're going to be okay.

1:02:55Center of hip meaning where the femoral head meets the acetabulum. Right. The center of the ball. Center of the ball. You should be able to drop a plumb line that cuts the patellar tendon and the patellar bone in half. Correct. And should land where on the foot, where in the ankle. You draw the line from the center and you connect the center of the ankle. To the center of the ankle. And then you see where it goes through the knee. If you go dead center, there's a good chance you're going to be okay. Sometimes even if you have other problem, if you are off to one side of another and that's where we have people who have knock knee or bolegan knees, there is an increased amount of force through one of those compartments of the knee and you are at high risk for degeneration.

1:03:42And then if you get a meniscus tear on top of that and you lose that surface area of forced diffusion, that conjure site is no longer going to be happy. So once the knee is unstable, just focusing on the knee, let's say you have an ACL tear. And then you measure the compressive force of that cartilage before and after an ACL tear. So like a normal knee and then your control lateral knee. The amount that the cartilage gets compressed in an ACL deficient knee is substantially greater than an ACL intact knee. If you reconstruct that ligament, it still doesn't come back to normal. There's something that happens once the knee is injured where the loads through that joint change and sometimes permanently.

1:04:29So is that why if you have an ACL injury, you do increase your risk of arthritis later in life? You do. Is that partly why? Because you never fully get the conned recites back? Correct. I think there are a couple of issues here that obviously we don't fully understand. but the first thing I'll say is that a lot of it is baked in the cake at that injury and any injury where there's sheer stress on an ACL and I think we should talk about the biomechanics of an ACL injury but when you have that event on any joint the stats are that in about 15 to 20 years half of the people who have an ACL tear whether it's reconstructed or not have signs of arthritis.

1:05:10No difference if you reconstruct or not. It's debatable. There are some studies that show that if you've had your ACL reconstructed, you have a greater chance of arthritis. Those are the literature I'm sort of familiar with. And that's because you're active. So you are now able to do things. Hmm, very good point. Because you're just needs stable. So there haven't been any RCTs that have said randomized to repair, no repair, and let's see what happens. It's too hard to do. There was a fate study, I think in the 90s, where they look at the fate of doing ACL surgery, you're not doing ACL surgery, but you can't randomize it.

1:05:45That's where that data comes from, where that you may end up having more arthritis if you have it reconstructed. I'm not necessarily saying that you shouldn't reconstruct it by any means. Why do we do ACL surgery? We do ACL surgery because we want to protect the meniscus because if your knee is flopping around, your meniscus is going to tear. If your knee is flopping around, you're not going to be able to play the sports you enjoy doing. So by all means, it's worth the risk of arthritis. The other thing is it's not everybody has an ACL tear. Yeah, one in five. Not everyone who has eight right.

1:06:15But to that point, I mean, I'll just use my own example. When I was hit by a car when I was 14 years old, I had an ACL tear and a miniscuous tear. This is the 80s. I had knee surgery that week, but nobody did anything. He just went in and looked and I came out and said, What do you mean they went in and looked? I had an arthroscopic surgery and only later, they're like, what did we do? It said, oh, nothing. They just said they're gonna treat it non -operatively. after the operation. Yeah. They didn't have MRI that was high enough resolution. Well, I don't know. You know, it was 14. So it was like, I just did what I was supposed to do.

1:06:50And they said after the doctor was, it's funny because he's the reason I wanted to be a doctor too. You know, he came in, he's talking to his dictaphone, he says, you know, 14 year old male, injured his knee, I was like, that's cool. That's what I wanted to do. Yeah, he gets addicted from it. Exactly. Who doesn't want to have one of those? Exactly. So I didn't have the surgery. They said we're going to rehab it. From the age of 15 basically to 30, I did not have an ACL. I had a bucket handle tear of the meniscus, which is a very severe meniscus tear. And only at age 30 did I have the surgery done after my fellowship was over.

1:07:26And I recently took X -rays of my knee because I was curious. I did standing alignment, center of the ankle. I have no arthritis in my knee. But my line is straight through the center. I don't think that would have happened if I had some mechanical alignment issue. So half people get arthritis, half don't. There's probably... Well, I thought it was 20%. 50%. Oh, 50, I'm sorry, I must have heard that. 50%. Oh, it's within 15 to 20 years that you said. That's right. And we also know, and I know this from my own practice, because I do a lot of ACL reconstructions, is that some people recover fairly well after the surgery, and there's a small group of people who stay inflamed, where identifying this cohort of patients, we call them an inflammatory type.

1:08:11That is, if you take out their fluid and you look, analyze that fluid, they have elevated IL -1, IL -6 inflammatory markers that are not coming back down to baseline. In the sonovial fluid. In the sonovial fluid. A lot of people recover and then some people go on to have sort of low burn, chronic inflammation. And I don't think this is just what they see. I think this is with a lot of problems. And this is also where biologics may come in at some point to push someone from the catabolic state back to the anabolic state. Let's talk a little bit about how the injury happens and then I want to understand kind of how it's repair.

1:08:46In general, there's ACL contact, ACL injury, and non -contact ACL injuries. And the majority are non -contact. Some are also indirect contact. We also categorize them that way. And women have a higher risk, females have a higher risk of ACL tear than men. And there's a lot of factors. Just the strength difference. That's one of the reasons it's a neuromuscular control. So early in puberty, boys tend to, during the spurt, tend to have testosterone and that affects muscle growth in females that's delayed. And if you look at sort of the neuromuscular control factors, specifically, we have patients will, you know, you jump off.

1:09:27This is pre -injury. just so we evaluate why are they greater risk. You have them jump off a box and see how they land. And in general, at that age, females are more likely to land with a valgus knee with an adducted hip, right? The leg goes in, that is you have weak glius medius, imbalance with the adductors. So they land with their knees and valgus, oftentimes with a very straight extended leg, slightly flexed, and a little bit pronated. So one of the programs we're trying to implement, which is incredibly difficult to do, are injury prevention programs where we could take individuals and see risk stratified them based on risk to see, we do landing error scoring system and see how people only mark them and say, okay, you need special neuromuscular training.

1:10:21What percent, I know that the sensor can't be known, but it just to speculate, what percent of ACL tears do you think could have been prevented if the individual was maximally strong. Had the highest amount of their genetic potential for neuromuscular control going into it. So even though virtually all ACL injuries, I assume are acute injuries, how many of them do you think are on top of a chronic weakness? The only thing I can get close to sort of answering that question is there have been studies that looked at injury prevention programs and then followed those people. And the number that has come out of the literature is that you need to treat 90 people to save one ACL.

1:11:02So the number needed to treat. But I think that also... Probably speaks to how hard it is to treat. How hard it is to prevent. But it's potentially also decreasing risks of other injuries too. So it's not just ACLs when you strengthen the glutes and you... So let me show you sort of the mechanism. I'm going to move the kneecap out of the way. So this is a right knee, so this is the outside of a right knee. What happens when you land in a valgus position is like this. So you land with the leg a little bit like this. What this does we call this condular lift off. So that's why you often see MCL tears, because this gets stretched.

1:11:41The conval lifts off of the surface, and that surface on the inside of the knee, This is called the medial part of the knee. It's very congruent. It's the most congruent part of the knee. The lateral side, the surface of the tibia is convex. It's very unstable in general. So now you're only bearing weight basically on the unstable, non -congruent part of the knee when your foot lands in pronation by nature, the tibia internally rotates slightly. At the same time that happens, the quadricep pulls and then it shifts out of place. The only thing that typically will help that is that the hamstring on the back has the opposing force.

1:12:26So if you land with a flex knee, it can help stabilize the knee. Did that make sense? Yeah. Unfortunately, this is going to be something where people listening to us on audio will have no idea what we're talking about. You really have to see the model in 3D. And the way you just described it, you could experience that if you fell, for example. Correct. Is that also what's happening in a ski injury? I just seem to see more people tearing their ACLs skiing than I can shake a stick at. It's hard to know because even when we have video analysis of skiing injuries or even basketball injuries, sometimes it's hard to get exactly that.

1:13:03It's probably a similar mechanism, but hyper extension of the knee will also have the same problem. The other problem is if your trunk is leaning over to one side at the same time, that's an extra amount of force pushing the knee that way. So we see football players get it all the time as soon as they plant if they're hit on their hip. Their body weight goes over that side, their foot struck, there's a lot of contact force, the quadricep contracts, the tibia internally rotates, it shifts out of place and it's ruptured. So, what is the typical cool down period you want on an ACL when a person is injured and are there various considerations as to how long you might wait versus operating right away?

1:13:52I prefer to wait until the knee is quiet. I'd like the initial inflammation to come down. My practice, I feel that if you go into the surgery with a quiet knee to the point where you almost feel like I don't even think anything's wrong. I think that's a good time to do surgery, but there are plenty of studies that show that you can do it right away. There's no adverse effect down the line, but I also like people to sort of prepare themselves and just sort of think about what's happening and get some prehab before the ACL reconstruction so that you know, we're all on the same page about what this means long term and how to prevent the other side and all the issues regarding recovery from the initial injury because they also retire.

1:14:35So we're doing a lot of revision ACL reconstructions. What are you typically using to repair the ACL? We have different categories, right? So autographed versus alligrafts. So the main autograph tendons that I use are patellar tendon and hamstring, although quadricep is being used a little bit more. So what part of the patellar tendon are you using there? We take the central third of the patellar tendon. So the width of the patellar tendon from meadial to lateral is about 30 millimeters. And so the central third. 1 centimeter. We take 1 centimeter or 10 millimeters of the central third of the patello tendon with a little bit of bone from the kneecap and bone from the tibial tuberosity and that becomes your new graph.

1:15:16So that you're doing bone to bone attachment. Bone to bone attachment, exactly. Is it always been that way? For patello tendon, yes. And if you did cate varic ACL, is that done anymore? Yes. And you're still going bone to bone. You can ask for different types of alligraphe, so you can get a B, We call it B -T -B bone, tendon bone, alligraft. Or you could do soft tissue alligraft. Bone to bone healing tends to be more predictable. Alligraft is really not a great idea in the younger cohort. There was a recent study that showed that you're safe with alligraft after the age of 34. That is, before 34, the risk of a re -re rupture is unnecessarily high if you use alligraft.

1:16:00Because alligraft tissue is somebody else's tissue and it takes longer for that tissue to mature and to get strong. And typically how old are the cadavers from which you're getting that? We hope that you're a young person. But do you get a say in this? Well, you do. You ask for a cue, I won't take it unless they're under this age and there are ways to make sure that you only are provided. So is the main incentive to do alligraft to avoid the patellar injury? There are a number of reasons why people want it. Number one, it's an easier surgery to recover from upfront. So people are busy, they work, they may not be skiers or play basketball.

1:16:37They may just do some recreational stuff occasionally like hiking and they're in their 40s and it's perfectly reasonable to use, alligraft. The rates are higher over erupture, but it's not as if, I mean, it's still being done because it's still a reasonable option. So that's why people are doing it. But if someone participates in high risk activities, high risk sports, level one sports, then it's not a great idea. The batteler is that much better? It's that much better. Yeah. And sometimes we compare, so the big question is what's better, the hamstring, the batteler tendon, the quad tendon, and the quad tendon, there's not enough research to say definitively that it's not in the game yet as far as...

1:17:18And which hamstring tendon are you taking? It depends. Some people take the semi -tendonosis along with the grisillas. Some people just take the semi -tendonose and again you can access that from the front because the tendons are attached right here in the front of the medial tibia and you make an incision in the front and you find the tendon and take it. So what happens to the rest of the hamstring? Great question. Tends to scarion but that is one of the reasons why people don't necessarily want to do hamstring because you do have weaker hamstrings after. Now you have the biceps femoris on the other side and you have the semi -memornosis that's not affected, which are the other components of the hamstring.

1:17:54But your hamstrings will be weaker and the hamstring is there also to protect you from an ACL injury because as the tibia moves forward, the hamstrings are pulling you back too. So it sounds to me like if you can handle the additional recovery and the pain of having your patellar tendon cranked open, that's the better operation. Right. The gold standard I think still is the patellar tendon and the downside of that is it's a little harder recovery early on and people do complain of kneeling pain because of the bone removed from the kneecap, the incision on the front of the knee. So people truly do complain about that.

1:18:35So if I have an individual who... So if you're Catholic. Correct. Or if you're If you garden all the time or you love yoga, I'm gonna say, listen, let's do the hamstring, hand it instead. So you can sort of tailor it to what seems to be more appropriate. So 50 % of people who get an ACL repair, or frankly just tear their ACL, it seems like there's no difference. 50 % of those people within 15 to 20 years are gonna need a total knee replacement. No. No, they're just gonna have arthritis. Right. And it doesn't even mean that's symptomatic. I see, okay. Again, X -ray tells a big story here. I've seen my knee on X -ray.

1:19:12I've got unfortunate, I don't have arthritis. So I've got a big clear space between the femoral condyle and the tibial plateau. How narrow does that need to be before you would make the diagnosis of arthritis and how correlated is the reduction in that space with symptoms? It's not correlated well. And even when I say arthritis, it's hard to define the way I think about it is there's arthritis and then they're symptomatic arthritis. So you can have cartilage loss and we consider that quote unquote arthritis but it very often isn't symptomatic and so when we really think about arthritis it's a whole joint disease.

1:19:53The cartilage starts to break down and inflammatory reaction happens. The synnovium which is on the inside of the meat also gets inflamed. The bone under the cartilage goes through changes. So the arthritis that you're worried about, that I'm worried about, is that whole joint arthritis. Not so worried about narrowing of the cartilage in isolation. It's the... It's much more systemic to the knee as a system. It's like a biologic process. We're really trying to avoid and I see them come in. They were perfectly normal. I see people with horrible looking knees who come into my office and say, my knee started hurting last week, I've never had a knee problem before.

1:20:34I get an X -Rate and there is no cartilage left. They won't believe me. They said, but I don't have arthritis. I know you didn't know you have arthritis, but now you do. So what tip that person over? Because clearly, if you took that X -Rate a year ago, it would look almost as bad if not the same. It's not the same. What flipped the switch? It's usually a traumatic event. It's usually a stumble. It's usually nothing. It's like, I lifted something heavy and twisted funny. I felt a little something. Maybe the meniscus tears a little more. It's a very slow process. The congercites have been not doing their thing.

1:21:08The carlogist's worn away, but it's been such a low burn that it hasn't tipped the scale into a very painful process. And then it goes overboard and it's hard to bring it back at that point, because there's not really any healthy cartilage left. That's very difficult. It's a very difficult problem. and those people get near -placements. Before we go to near -placements, let's talk about the meniscal tear. This is such a controversial area. I assume there have been sham surgery studies that have been done. What do we know about meniscal? Isolated meniscal tears. The principle is, if you have a meniscus tear and you don't have arthritis, you need to strongly consider fixing that meniscus because that's what's keeping us from getting arthritis.

1:21:53And the meniscus tear means separation from the tubule plateau, is that what the tear means, or is it a tear across the surface? Let me get a picture out. So here we have a cross section of the knee. This is the lateral meniscus here, and this is the medial meniscus here. So if we were to look at the model, that's what we would be looking at. So there are different types of meniscus tears. There are tears that are at the periphery where there's very good blood flow. And in those types of tears you can sew it back together and you should. There are tears that go all the way across. And then this piece can flip.

1:22:37It's called the bucket handle tear. And that often will lock the knee. The inner piece or the outer piece? The inner piece. The outer piece is connected to the capsule. There are tears that we call radial tears that go through here. Occasionally, if it's close enough to the rim, you could put sutures there, but sometimes you just need to trim it, where you take out the torn piece of meniscus and you just leave what remains. So that's the difference between a meniscus repair and a menisectomy. So when we talk about... In the bucket handle, you repair primarily. Yes, you put it back to where it is and you sew it back together.

1:23:15So all the controversy around meniscus surgery that is no better than a sham surgery is it based on a particular one of those or is it based on the fact that these studies didn't stratify for those? So it's a specific type of tear. In general, we want to save the meniscus when we can. So if you're young and you have a meniscus tear and you heard that sham surgeries no better than that's not you. you need to have your meniscus fixed if it can be fixed. If you have degeneration of the knee already, if you have arthritis, let's say you have advanced arthritis of the knee and your doctor gets you...

1:23:54And again, sort of interrupt, I want to come back to this point. No, sure. The diagnosis is made how of arthritis because it's clearly no longer just a radiographic diagnosis. Well, if it is even with a radiographic diagnosis because that's what the studies use to say this isn't effective. So you don't need inflammatory synovial fluid to make this diagnosis? No, but they are in flame because that's why they came to see you. The problem is we don't know, is there pain from the arthritis or is there pain from that new meniscus tear that they have? So I have a patient who has radiographic arthritis, evidence of arthritis, and they have pain and I get an MRI.

1:24:33I mean, often try not to get an MRI because I really just want to treat the arthritis, But let's say they come in with an MRI and they say, look, I have a meniscus tear. If they don't have normal cartilage and they have a meniscus tear, I want to do nothing. And really that's the population of patient where those studies really help us to say to our patients, listen, we do nothing. You're going to be just as fine as if we do surgery. And here's a study to show that. But those are just studies. And the truth is, it's easier for me to make a decision about a particular patient than to base it on some randomized control trial.

1:25:10It's a nice starting point to say, let's try. But I have untold numbers of patients who've had some arthritis, they have a new injury, a meniscus tear, try conservative treatment, not getting better, do the surgery later, and they do okay. Regardless of which of those tears they have. It depends on what kind of tear they have. There are certain types of tears where... You would always repair a bucket handle? It depends. If the person's 60 years old, they don't usually get bucket handle tears. It's more of a complete, complex, degenerative, just like the tendon and the cartilage, the meniscus, also goes through these changes with senescent cells and matrix that is unhealthy.

1:25:50And so those you can't repair, you put stitches in it's not repairing. So in those cases, you trim the piece. So the young person, the runner who comes in, they're 40 years old, they're having knee pain, it's new onset, they don't have radiographic arthritis. The MRI shows a meniscal tear. Any of those versions you would fix. I would try to, yes. This is assuming that their pain is from the meniscus and that's where this gets a little bit more like art than science because you can have some tiny tears that I'm not that worried about and their pain may be from patella femoral syndrome anterior knee pains.

1:26:28It depends where their pain is. If their pain correlates to the tear and it's significant, it's a good idea to try to address that, assuming that tear is a type of tear. So what are the things you need to rule out? How do you rule out the patella femoral syndrome? How do you rule out the MCL sprain which might not show up or other injuries? Those things usually happen with an injury. You know, you're not going to tear your MCL running unless you slipped in for. But a lot of my patients have patelli femoral pain which is basically overloading of the patelli femoral joint, right? So we talked about how if you squat at seven times bodyweight, well running is a similar type of problem with the force at the kneecap.

1:27:07And if you increase your duration of running, your mileage and the amount of times you've done it in a week, you're going to overload the cartilage in the kneecap and you're going to generate pain. But that has a very particular feel to it. An examination, you can tell the difference between patellar pain. In fact, on examination, patellar femoral pain, I can't find anything. I can't load it enough to generate the pain. I can bend your knee every which way. If you have a miniscule tear and I put some torsion into it, you're going to feel it. It's a different presentation with regards to injury.

1:27:37Also, miniscule tears, if there's no history of injury, I want to know why would this happen. So, if something twists and then they have a miniscule the pain happened after an accident, then I'm like, okay, I have to. What is the treatment for patella femoral syndrome? If they haven't been doing anything, if they haven't been very active, I send them to PT. I need to strengthen your quad. Yeah, so it's quad strengthening. But it also is difficult because I'm asking them to do an activity that increases the load on the kneecap as a quadricep strengthening for a problem that is causing pain. And the cause of their pain exactly is what?

1:28:13We don't always know in one particular situation. So this is a knee from the, this is a sagittal or a view from the side. And what we see here is this is the thigh bone or the femur and this is the leg bone or the tibia. And the kneecap is in the front on this image. So this is looking at the side of your knee. You see the quadriceps tendon and then you see the kneecap with its cartilage and the cartilage on the femur and the tibia and you also see the meniscus there as well. When you overload this part of the knee, your pain can be coming from the patellar tendon, the quad tendon, the cartilage, the bone, the fat pad, there's fat inside the knee, and that sometimes gets pinched and inflamed when you're running, and that will generate symptoms.

1:29:03So we don't always necessarily know. Well, we do know that strengthening the quadricep helps the kneecap to potentially glide better and can reduce symptoms. But I've had numbers of patients who go to PT and they have horse pain. We need to be creating... They may have bad mechanics. It seems to me that the recurring theme here is inactivity or poor mechanics is the root cause of most of these injuries. So this is where it's important. When I send in a PT, I may say, listen, I don't want you to do any quad strengthening this week, I want you to do hip strengthening. I want you to focus on the gluteus medius, because if your leg is adducting, you're pulling the kneecap outside, increasing the force on that area, and so I want to correct that without doing anything to this.

1:29:56And I'll also sometimes use, if I really need to work on the quad, I'll do blood flow restriction in those circumstances, because it's lower loads and provides a very similar amount of injury to the muscle as high load training would do. How long after ACL repair do you let patients do BFR? I send them to a place that does it a lot and as long as the swelling is down and they can tolerate it, I don't mind starting relatively quickly because you can titrate how much you're doing what percentage of blood flow you're decreasing and I think it's a great way to start that process early before letting more atrophy sit in.

1:30:36So what are the indications then for the total knee replacement? So if someone comes in and they have advanced arthritis that is all compartments of their knee, the medial compartment, the lateral compartment, the patella femal compartment, or really two severely degenerative compartments, and they failed conservative treatment, it's a conversation to have. What is failed conservative treatment? Have we tried PT? Have we tried injections? Have we tried a steroid, hyaluronic acid, potentially PRP if they're interested, bracing, and their quality of life is so poor that they want to have something done.

1:31:14We talk about neuroplacement. Do you have a sense of how often body weight is a driver of this arthritis? In other words, I don't know what the numbers are today, but it's roughly a third of the country would have a BMI over 30. Right. Many of those people don't have to be on my over 30 because they're overly muscled, although I'm not sure that the knee cares how much that weight is muscle versus fat. So just in terms of excess weight, how often is that driving the problem? It's driving it a lot, which is why I show them the chart of this is four times body weight when you do this. This is seven times body weight when you do this.

1:31:48Just walking up the stairs or down the stairs. Down the stairs is even worse. And I say if you lose five pounds, let's start small. This is how much weight you're taking off your knee if you multiply that. If you can lose this amount of weight, you may not want an ear placement and you may not need one. And so I never tell someone when it's time for them to have a near placement. They're going to tell me, listen, I can't do this anymore, I want something. And as long as they're healthy enough to have the surgery, it's reasonable. But obviously, the satisfaction right after a near placement is different than hip replacement.

1:32:21And it's just an inherently less stable joint. And so it's harder to feel like it's a normal need. People feel like it's a normal hip, but they don't feel like it's a normal knee when it's replaced. So this is probably a decent diagram to show the anatomy of the knee replacement, huh? I have a good model. You have a better one, okay? Yeah, perfect. So this is a model of a replaced knee. I'm going to take off this portion, flex the knee, and what we see here is fake knee replacement. But basically has three components. before we put those components on, we make cuts in the surface of the distal femur.

1:32:57We make a cut in the surface of the proximal tibia and that matches an implant that fits right on that surface and same with the tibial surface. And that is made of the high molecular weight polyethylene. And then also occasionally we also will replace the surface of the kneecap with a plastic button and that's your new knee. Do you sometimes keep the native patella if it's fine? Yeah, occasionally. Sometimes, you know, there's some people who, it's called resurfacing the patella and some who don't resurface the patella. And the studies show that there's probably not a difference in Europe, I think they hardly ever resurface the patella.

1:33:37It's more common in the United States, but I know a lot of surgeons who don't. And I do sometimes, I do most of the time, but sometimes I don't. The reason I do it most of the time is because if they're significant, our thread is there and I'm there, I'm too afraid that they're going to have pain after because a lot of people after knee replacement still are 85 % satisfaction means that 15 % are dissatisfied and if I haven't replaced the patella I'm thinking to myself maybe I should have replaced the patella too. How long does this operation take? Depends anywhere from an hour to two hours depending on the complexity of the surgery.

1:34:08And how big is the incision? It's a midline incision. It's a midline incision anywhere from 10 centimeters. It depends on the knee. It goes from here to here. And unlike the hip, which we talked about earlier, where the difference between what happens today and 20 years ago is night and day and these patients are, they just feel amazing. These patients still struggle postoperatively. Yes, less so. We learned a lot during COVID that you can do these outpatient very safely. The technology is improving with total near placements too, where the incisions can be a little smaller. I do - What's the dominant source of pain?

1:34:40Is it the incisional pain? I assume it's much more the bone pain of what you've had to research. None of that's changed, but the perioperative management of the pain has changed. We give injections into the capsule during the surgery. There's other nerve blocks that are used. We send them home with pumps to get them through that initial stage. What is the time to recovery for a motivated patient who has a knee replacement and what are the limitations? I should have asked the same question by the way on the hip replacement so we can do that after. But when a 50 -year -old or a 60 -year -old comes to you at the end of the rope, they have the knee replacement.

1:35:18What are you telling them is this is when you're going to feel normal again, assuming you're in that 85 percent. And these are the activities you're, I don't want you doing anymore. I will always tell them all this is going to take you a year of recovery. Because I don't know who's going to be shorter than that. And there's a number of people who continue to improve up to a year and sometimes even longer. but I don't say more than a year because it's just too painful to even contemplate. A year is pretty long, but people are showing improvements even beyond a year. And it's non -linear. I mean, correct.

1:35:50You know, you're probably getting 80 % better in six months and then... How do I know how people are doing? Well, other than the research and reading it, but I see my patients at regular intervals and it's always the same. So I see someone about 10 days after surgery and then I see them at two months after surgery and I see them at six months after surgery. And I could tell you that everybody's different. I have people walking in at 10 days who are without a cane walking up and down the hallway, doing very well. They're not jumping up and down, but they're like not as bad as I thought. And then I have patients who are coming in at their six month visit and they're saying, I think something's wrong.

1:36:27My knees still hurt, so I'm still having trouble. And I always have to remind them, there's a reason why I said it might take a year. What do you think differentiates those two patients? I wish we knew. Sometimes it has to do with muscles, right? The strength of them, their protoplasm before. And then sometimes I think it's sort of the similar inflammatory type that I mentioned with the ACL. I just think that some people show prolonged inflammation after injury. And I think we're still trying to... Have you ever looked at sampling synobial fluid as soon as you get in there, seeing how well the inflammatory milieu of that correlates or corresponds to the recovery?

1:37:04So I know it's been done. I don't know the data on that. It's been done in ACLs too, where you check the cytokine profile. And this is how we know that there are these types of patients. I don't know the details of that, but it is done. I mean, there's so much to think about as far as immune modulation as well. I mean, to me, if I think about like, how would you advance this field, that could be one way is what if we utilized immune modulators in a personalized way based on that inflammatory environment at the time of surgery, given that that's probably playing a role in this? So I think that the more information we get from the ACL injury will help figure out the total near -place and the reason I say that is nobody wants to put a needle in a knee that had a knee replacement because it just slightly increases the number.

1:37:49Oh, I'm thinking before you, I'm saying what you're doing, any incision. So a lot of them have, we know that IL -1, IL -6, 2 -minicosis factor. It's, we know what those are. But presumably what's there right before surgery is right there after surgery. Right. It's like you're washing it away. So yeah, you could sample that before you do this total name. It's just it's probably been done. So you're at the one year post -op appointment. Patients says, Adam, God, I feel amazing. Anything I can't do? So I let my patients do the things that they enjoy doing. I have a patient right right now, who ran a marathon with a total knee replacement.

1:38:23I mean, she's young. So she's young and she knows the risk. It's more likely to - How young? 50. What led to the knee replacement in her case? Alignment, mechanical issues. Are those mechanical issues fixed now or is she just going to need another knee replacement in 10 years? It's fixed. When we do a knee replacement, we make the cuts to allow for better alignment. Although not everybody does that. There are different ways to do a knee replacement where people maintain the alignment. It's called a kinematic knee. But the way I do a knee, I align it. You align it. So you say, this is the hip you got, this is the foot you got.

1:38:52I'm going to drop that plumb line and I'm going to make the cuts in those two surfaces such that the hardware lines up. And I use computer navigation so I can really titrate the exact amount that I want to make the cut so that the alignment is as precise as I can make it right now. A lot of the newer technology in software allows us to be more precise in our cuts and the angles we want. And sometimes you need to do a little bit of angulation just so it fits properly, but in general that's the principle. And going back to the hip just for the sake of completeness, six months because these guys heal so much quicker, six months, post total hip replacement, hey doc, anything I can't do, what are you saying?

1:39:33And this is also within me. I don't want any contact sports, no contact sports. Because you're at high risk of fraxking. Is skiing considered a contact sport? or no, I mean it is, but it's not part of the sport. I mean it is sort of, but I let people ski with total near place and total hyperplacens, they are allowed to ski. It's called a stress riser, right above the metal and the knee is an area where it can break easily and that is a really devastating injury to have a near place and then have it broken. So I don't want anybody doing any compact sports, but I let them play tennis. It used to be we would say only doubles tennis, but you know someone's doing really well, I'll let them play.

1:40:10But I tell them, I say, listen, the more you're on this high molecular way polyethylene, which isn't perfect, it's going to wear out because it's mechanical, too. That was my thesis in engineering, was looking at the axis of failure in tibial plateaus. I spent so much time under a microscope looking at failed tibial plateaus using a discipline of mathematics to map out the planes of failure. From polyethylene. from exactly that ultra -high -loveler -right polyethylene, but just in the tibial platose. So we talked a little bit about the success rate of PRP here potentially in a greater appetite for here than in the hip.

1:40:52Any other knee pains that you look at that are quantifiably not surgical, where you say boy operating on you would be a mistake. So you know in general, it's injury dependent often. There's some injuries where there is, there's no doubt about it, you have to have surgery. If you rupture your patellar tendon or your quadriceps tendon, the conservative treatment is to do surgery, because your leg will not work unless we reconnect the tendon. Is the patellar tendon typically ruptured above or below the patellar? So this is the quadriceps tendon? Oh, the patellar tendon is the below. So if either one of these is ruptured, the patellar will go with the unruptured side.

1:41:30They're not connected anymore. You have to fix that otherwise you can't. It's very hard to extend the knee. You can't do it. I mean, essentially, you can't do it. So that has to be fixed. For a lot of problems, you can try conservative management. Miniscuous tears occasionally you could try conservative management. There are even people who don't necessarily need an ACL reconstruction. There are people who have ACL tears who cope well without reconstruction. And we talk about that possibility. If someone does not participate in level one sports, they don't do pivoting or rotational types of activities.

1:42:04You can bike without an ACL tear. you can run without an ACL tear. So even that potentially - With an ACL tear. With an ACL tear, you can. And there are a lot of people who cope quite well. I did from the age of 15 to 30, and I was fairly active with occasional swelling here and there. And during those 16 years that you had the ACL tear outside of the acute phase, how many times did you lose stability or did your knee go out? Dozens. Were you causing more injury? Were you increasing the risk of arthritis through that activity through the instability? which is amazing. It's very similar to the sublux shoulder, right?

1:42:39The more you sublux, the more you increase the risk of arthritis. So you're tearing the labrum, you're creating more instability, and if you wait too long, yeah, you'll get it repaired, but you might actually start to have arthritis at the clenoking role joint. The arthritis is not as common in the shoulder as the hip and knee, and if you've had a shoulder dislocation, you're 10 to 20 times more likely to get arthritis of the shoulder than someone in the general population without a shoulder dislocation. So we know it's that traumatic event. And the same thing is true for ankle sprains and fractures around the ankle.

1:43:15Because that joint is so congruent, that cartilage in the ankle isn't even that thick. It's so congruent that if you don't have an injury to the ankle, that ankle can last you quite a long time. It doesn't have the same incidence as hip and knee arthritis. And why is that despite how thin it is? It's just so ingrained. Because the surface to surface level is so perfect. Correct. You don't have articulation in the same way where you have more degree of motion. Right. Think about the hip we talked about where it's edge loading in the developmental dysplasia. It's not congruent. That's who gets the arthritis.

1:43:54The patient with the bump on the side, the acetypular impingement, they get arthritis. The knee, which is in the middle, that weight could go through the inside or the outside. The ankle, it's right down the center because that's where the plumbline goes. So there's not a lot of play because it's closer to the floor. Does that make sense? Yep, absolutely. So that's why we see it less than the ankle. We see it a lot in the knee and the hip. We see it when there's a mechanical problem. Let's turn our attention now over to the ankle. The foot and ankle are very complicated and the number of bones here and the number of ligaments is simply staggering.

1:44:35Obviously, we're not going to provide a master's class on this due to the complexity of it. But let's kind of focus on the big picture here, which is what part of the anatomy do we need to understand to really get a sense of where people have pain here? It depends, obviously, on the population we're talking about. So if we just talk about athletes for a second, people who are very active, and for example, run a lot. We're interested in a number of things. Let's focus on the top picture here. This is the heel bone and this is where the Achilles tendon attaches to the bone and we do see a lot of Achilles tendonitis.

1:45:09That's a very difficult problem because there are not a lot of great treatment options. Surgery doesn't do great with tendonopathy of the Achilles tendon and only when it's ruptured is there sort of more of a plan on how to address it. Interestingly, I don't think there's an that increase incidence of tendon ruptures in the setting of tendonopathy. We don't really see that. So tendonopathy would just present as pain there, but that doesn't necessarily increase the risk of rupture. My reading of the literature up to date, and I don't do a lot of foot and ankle surgery, that's been my understanding.

1:45:43And I've treated lots of people over the years with Achilles tendonized, and I don't remember ever a case where they came back up. I look at that, I rupture it. Interesting. While we're on the topic of rupture, how much of a concern or fluoroquin alone is everybody asking me this question. I don't really know the answer. So, superflax and drugs leave a quinn, these antibiotics. I know that, you know, we're told that they slightly increase the risk of a subsequent rupture. How big is that increase in risk and for how long does it preside after the antibiotic? I don't know the length of how long it presides, but I do know that mine is sort of a sampling error because I see it.

1:46:16I see it more than you do because that's who's coming in. and I've seen it after one dose. I don't know how to guide people. I've walked after a dose. Someone has a dose and then they... Within a week or two, I've seen it. So this is what I tell people. It's not a reason not to take the medication, but if you start to feel anything, you have to stop and rest because I feel like that is one of those situations. Are there warning signs to an Achilles rupture? They start to develop pain and that's when I stop. But it's not tendonopathy. So what's the pain? I don't know what the mechanism is for. that would, there is some sort of tendon inflammation that's happening, but I'm not sure.

1:46:51Okay, that's a little disconcerting. So what are we doing to prevent this? Because this is definitely the middle -aged person injury, right? The tendon apathy? Well, or just the rupture altogether, you know? It's the, I'm gonna go run around with my kids and lo and behold, I hear the loudest bang and your calf balls up and you're, next thing you know, you're in a boot for God knows how many weeks. I think maintaining muscle strength, with calf flexibility, making sure your gastrox and your soleus have good flexibility, both of those separately. I think that overtraining can be an issue in the circumstance, so just to proceed with care, you can't necessarily do everything you wanted to do when you're 20 and 30, because that tendon degeneration is a biologic event that affects all of us.

1:47:34And again, if you're staying healthy throughout your lifetime, it may or may not help you, but it's certainly possible that... I feel like such an important part of this is jumping. You know, literally just jumping rope, doing the types of activities like my warm up always sort of consists of, I have a particular jumping routine I always do and it's not super taxing. I'm not jumping, you know, onto 36 inch blocks or doing plyometric explosive stuff. I do it sometimes. But on a daily basis, I'm trying to make sure I'm putting some bounce in there. My belief is that that's a valuable way to maintain elasticity in that part of the body.

1:48:10I would agree, and I think it's penuro muscular training. The neuropart is just as important, because I think that's really what happens, is that it's always vulnerable when the tenetty generates, but there's a mismatch between the firing of the calf musculature and what you're actually doing at that moment. And so having more motor neurons and well -developed motor neurons may help prevent that, and just like it prevent ACL injuries, I think it's the same thing. There's no way that that's not helpful for all of lower extremity injuries is to be able to know where you are in space and to have good training in those dynamic situations because that's when people are injured.

1:48:49Nobody wanted to trip on the sidewalk. But what happens when you trip? Are you able to recover quickly or do you end up with an injury? Okay, so let's go over some of the bony structures here. Maybe it's easier to look at that model. So this is the ankle joint proper, which is this is the leg bone or the tibia. It joins here with the tailless, lulls along with the fibula. So these three bones make up the ankle joint. And the surface is coated in cartilage just like all the other joints we talked about. The tailless then articulates with the nevicular bone here. And then there are chenea forms, cuboid bone on the outside, the metatarsals, the phalanges.

1:49:33If we turn it to the side, this is the inner side of the ankle. This is the medial malealist and along this area is where the tendons that help to maintain your arch rest. So if we were to look at the tendons of the ankle, this on the bottom image is the medial aspect of the ankle and this is the posterior tibialis tendon which is incredibly important for maintaining your arch. And then we also have the flexor halus as long as here, which goes to the first toe. And these are the flexors for the digits as well. We look at the ligaments on the medial aspect of the ankle. We see here, this is the medial malealist.

1:50:15This broad ligament is the deltoid ligament. And then we have this spring ligament here. And this is the planar fascia as well, which helps to maintain your arch. and these are important structures to examine to make sure that the plants are fascia, which helps to maintain the arches competent, and that the posterior tibialis tendon is also working. So it's important to go through walking on your toes, walk on your heels, see how the gate progression is managed. Yeah, and all of these things will show in the exam, of course. On the outside of the ankle, the lateral part of the ankle, which is where the fibula is, this is where most ankle sprains happen.

1:50:53This is the main ligament that's injured. It's called the ATFL or anterior tailo -fibular ligament. And then we have the calcaneo -fibular ligament, posterior tailo -fibular ligament, which is not as often sprained. And then we have this ligament up here which connects the fibula to the tibia. And when people have high ankle sprains, this is often the ligament that's injured. Whenever someone Someone has an ankle sprain, it's conservative treatment, and most people get better, but not everybody. And is a sprain what degree of tear to that ligament? It could be any degree. If you have a sprain that is if your ankle twists and you have swelling, you've torn the ligament.

1:51:36The question is, is it a complete rupture of the ligament? And so we are, but surely, say this is a grade one, grade two, high ankle. They're all tearing of the ligament. The degree to which they're torn or which they heal will dictate the next step. It's very rare to have a severe ankle sprain without any dislocation of a joint that would require surgery except for some syndesmosis injuries up higher, those often will require surgery. But for the run of the mill, twist of my ankle playing basketball, the treatment is conservative, strengthening, strengthening, strengthen the perennial muscles.

1:52:15But doesn't necessarily mean everybody's going to recover because sometimes what happens is the cartilage gets injured. And just like we talked about in the shoulder and the knee and the hip, any mechanical trauma to the joint puts you at increased risk for arthritis of that joint. And which cartilage in particular, if you took the most common sprain, which would be the ATFL? ATFL, yeah. So the anterior telephabial ligament connects the fibula to the talus and when that rotates this way This does not rotate at all you will cause injury to the cartilage because it abuts in this area Uh -huh. Yep.

1:52:52Makes sense. So you will see what we call osteocondral bone and if you did an MRI Would you see bone adema there? Yeah, and that patient and so if someone is not recovering after an ankle spray And I get an MRI because I want to see what the cartilage looks like to see if they've injured the bone if they didn't have cartilage and if anything else needs to be done. And if there's a small fracture there, is it still conservative? Put them in a boot? Fracture here or fracture here? If there's a crack in the jar, depends if that piece is what we call stable or unstable. So you can have a crack in the cartilage and bone unit that is in place in situ and you can leave that alone, maybe give a boot if that piece is detached.

1:53:32That's unstable. And what about if you have a distal fibula fracture because the The sprain is so bad that when their foot went out, it actually broke the bone. Does that ever happen? The tail is a little break that tip of the fibula. So sometimes if this, the forefoot is externally rotated, this will hit the fibula and the fibula will break. And that doesn't necessarily need surgery. That can often heal without surgery. But if you've also at the same time torn the inner ligaments, the deltoid ligaments, then you now have instability on both sides of the ankle and then you go in and you fix the fibula and sometimes even the deltoid.

1:54:12So I'm guessing that the sprained ankle is hands down the most common injury to this part of the body. Yes. And obviously to your point, I can't imagine there are too many people listening to this who have never experienced a sprained ankle. They don't require surgery. What is the bread and butter of the foot and ankle surgeon? What is the type of surgery that is most commonly being done, acute or chronic injury. There are different types of practices. I mean, there's a lot of degenerative problems where you have arthritis of the ang. I'm not a foot and ankle surgeon. Once the foot collapses, the arch collapses and the posterior tibialis tendon is a trition to that.

1:54:50That's a very painful condition. You often have to fuse the small bones of the joint in order to better create a stable platform to land. Which bones are you fusing? So occasionally it's the midfoot, occasionally it's a sub -tailor joint, and then you can have an orthodesis even of the ankle itself. It's called a triple orthodesis. And that occurs when the person's arch is so weak that they lose their arch. There are stages. So there's early stage where you can treat it in a boot. Sometimes we just go in and address the tendon itself. More advanced stages, is you start to see changes in the ankle joints.

1:55:28So you would never do that. How is this occurring? I mean, why isn't this a problem that is fixed with foot exercises and PT? And why would we let a person get to the point where their arch completely collapses and the musculature becomes so compromised? Because some people have anatomy of their foot, their pronated flat feet that is not easily correctable, even with exercise, is just mechanically different. and that tendon itself wants it becomes so stretched. And these aren't people who would benefit, I mean, I'm not a huge fan of orthotic arches, but wouldn't these people benefit from that?

1:56:06Yes, and they are prescribed that. It doesn't mean the disease process won't progress. A lot of this is mechanical, we've talked about that. And a lot of this is biologics, too. We have decent ways of helping people, if they don't have a biologic problem, We have decent ways of helping people with mechanical problems, but it's all of this, all of these factors play into whether someone would benefit from exercise, right? But so there are things that can be done nonetheless. So you can give people rigid shoes to help with their feet and allow them to exercise other parts. Just because one area is deficient, you confuse the ankle so the pain goes away and still get on a plan to maintain the health of the rest of you.

1:56:50But if your foot kills with everything you do, you can't help any of the rest of it. So when people talk about an ankle fusion, normally they're talking about tibia to talus. That's the normal fusion. Now that was traditionally what's used. Now again, this is not my field, but there's also ankle replacements now too, which are becoming more popular because again the technology is improved but that's not the same patient necessarily. What are the other injuries to the ankle and foot that require surgical intervention? So this is the fifth metatarsal and you can have fractures of the proximal fifth metatarsal where there's a tendon attached here called the perineas tendon which pulls off that piece and that That rarely requires surgery and that tends to heal.

1:57:43If you fracture it right here, less than a centimeter higher up, that fracture is in an area where the blood supply is pretty deficient, called a watershed zone, and that often won't heal. So if you break it here, oh don't worry about it, you can wear whatever shoes you like as long as it doesn't hurt, if you break it here, oh you need to be in a cast or a boot for six weeks now weight bearing or surgery to put a screw in there. So there are certain types based on the blood supply to the bone. Certainly, an evicular stress fractures are another one of those fractures that are serious. Is that typically in a runner?

1:58:16Yes. What about the other metatarsals? You have stress fractures tend to heal. We see a commonly second and third metatarsal stress fractures. Do they have watershed zones as well? No, they heal. It's just the fifth one. But a lot of people have, I worry about the stress fractures because oftentimes, they'll see somebody, they have foot pain, they're a runner and then you find out they had three other stress fractures. So this is their third stress fracture. At the first visit, you have to have a conversation about relative energy deficiency. Why are you not healing? Do we need you to see an endocrinologist?

1:58:46Vitamin D? Find out. Yeah, you see this a lot. And I've seen this at least anecdotally, so much in female runners who are basically being put into eating disorders by running coaches. Right. They're way undernourished. We call it the female triad. and it's a risk of osteoporosis, stress fractures, and menstrual abnormalities. So what about bunion surgery? I guess show us what the bunion actually is and what the anatomy is that leads to the procedure. Well, some people develop an abnormality of the first ray where the metatarsal and the metatarsal phalangel joint. This will start to deviate where this portion, which we call the bunion, starts to be prominent on the inner aspect of the foot at the same time that can sometimes affect and crowd out the second toe and you'll get something called a hammer toe of that second digit.

1:59:39And so if it gets severe enough, as long as you're comfortable in your shoes and it's not painful, it's not necessarily something to do about, but if it starts to crowd out the toe and you start to develop pain, now we have to talk about correction. And osteotomies or cuts in the bone will be made to straighten out that area. And oftentimes you need to correct the hammer toes of the other digits if they're also affected. How do you correct those? Does moving the great toe over do it sufficiently or do you have to? No, because after a while what happens is the tendon length changes. And so you often have to cut the bone and just pin it to a shorter stump so that it no longer painful.

2:00:20and when you repair the great toe, there's a screw that runs along the metatarsal. There's different ways to do it. Some people use plates, some people use screws. And that can be quite a recovery. Yeah, that's hard. Why we don't recommend it unless you're starting to have pain. How much of that is driven by wearing super tight shoes, you know, being seen here. Oh, I wore dress shoes my whole life. And how much of it is that? How much of it is anatomic variation? It's a combination. I think it's a factor where some people are predisposed to develop it, but there's certainly a lot of cultures where tight shoes, you're gonna have more higher incidence of this problem.

2:00:56Anything else in the foot and ankle you wanna focus on? What about the calcanias? How often do we see injuries to that? Well, we see stress fractures of the calcanias as well. Also plantar fasciitis is very common, so it's important to recognize that this area of the foot, heel pain is its own animal, and sometimes it's a trition of the fascia or the ligament or the plantar fascia that attaches on the inner plant or surface of the bone. You could have stress fractures in this area. You can have insertional tendonitis where the Achilles attaches to. And sometimes you can have heel pain because a nerve is compressed, much like you have carpal tunnel syndrome.

2:01:31You could have tarsal tunnel syndrome. And sometimes people get just heel pain because they have a discreneation that's affecting S1 nerve root only presenting its heel pain. So it's one of those things where you sort of have to really take a close step by step approach to diagnosing that problem. So taking a step back from all of this, if someone watching this is sort of in the process of interacting with the medical community, specifically the orthopedic community, how can they pick a good surgeon? What are some of the tells that you're speaking with a good orthopedic surgeon versus someone who's a hack?

2:02:06It's a good question. I think you use the same judgment you have when you speak with anybody. Are they sitting down when they walk in the room? Are they sitting down? Are they looking at you in the eye? Are they talking to you? Do you feel like you're being rushed? I think that's a big sign. If you feel like you're being rushed, you probably are being rushed. And so just the ability to listen, to have someone that you're listening to you. You know, I hear a lot of people come and I've seen people all the time who they had surgery with someone and they're seeing me about three months after their surgery.

2:02:38And they say to me, I said, well, you really should ask that question of your surgeon. and because they know what they did for you and they're still in pain, for example. And they say to me, oh yeah, but he's just a surgeon. He just does the surgery. And so what? What do you think I am? I'm also just a surgeon. You can ask him these questions. You're entitled to have a conversation with somebody. You're not gonna know until you meet them. And some people, some people mesh well with people, other people don't. What are some questions that they can ask specifically to get a better sense of a person's competence, basically?

2:03:11That's a good question. I think just, again, the rapport you're having with the person, let's say, for example, they say, I think you need surgery. Just a simple question, are there alternatives? Or what are the alternatives? Or why do you think I need surgery now? And I can't do, are there any non -operative approaches to it? And just the answer, you know, right off the bat, you could get a good sense if they're defensive in their response. you know, that may not be someone who's right for you. Even if they're right and you do need surgery, it doesn't mean you're not allowed to ask the question about alternatives.

2:03:48If someone comes in with a ruptured patellar tendon and I'd say to them, you need surgery, even though that visit could be four seconds, I could say, oh, you ruptured your patellar tendon. I'm scheduling for surgery next week. I'll see you then. I'll be right in my assessment of what needs to be done, but that doesn't make me a good doctor or a good surgeon. You need to explain why that's the case, what to expect afterwards. So everybody deserves a conversation about these things. When I talk to people about this in general, especially with surgical procedures, I feel like when a surgeon can't give you a clear breakdown of what the complications are and what the probabilities are of those complications, especially in their hands.

2:04:29One thing to quote the literature, but I want to know what is your risk of wound infection? How many times do your patients get wound infections? How many times do your patients require re -operation? How many times do your patients still find themselves in pain a year out? All those little things. And then the other question is, what will we do if I'm still in pain in six months? What does your intuition tell you is going on and how will we work that up? In my experience, people who can't go through that thinking aren't very good at their job and you're playing a little bit with fire when you go under the knife from them.

2:05:06You might get a great outcome and you're fine, but if you don't, they're not going to be the ones to help you trouble shoot. That approach is also important. I've found even when you're not recommending surgery, for example, if I have someone coming with an ankle sprain and I say, oh, you just need to do PT and I don't explain to them what happened in three weeks. I could just say follow up with me in a month if you're not doing well. I need to go through the steps of them. Listen, here's the story. Not everybody with an ankle sprain is gonna get better. You're probably gonna get better, because most do, but you might not.

2:05:38So four or six weeks goes by, you're still having swelling pain. You don't feel like you're making improvements. I really need to see you because you may have an injury to the cartilage and we have to get an MRI. So I always give them the answer to what we are doing next if what I've just recommended isn't going to work. Well Adam, this has been super helpful. I've learned a ton. Again orthopedics is a little bit of a black box to me. I think it is probably even to a lot of doctors. We don't have enough of an overlap. It's such a subspecialty. There's so much you're learning. This will be very instructive for people, especially when paired with the exam videos that we'll do.

2:06:15So thank you very much for your time and for sharing all these insights. I appreciate the opportunity. Thank you Peter. Thank you for listening to this week's episode of The Drive. It's extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member -only content and benefits above and beyond what is available for free. So if you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of this subscription.

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