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Dr. P here with surgeon,

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3 00:00:03,070 --> 00:00:04,930 wrist surgeon and hand surgeon, Dr. Peter Stern.

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5 00:00:04,930 --> 00:00:07,720 We're talking about a 31-year-old professional

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athlete who had a hyperextension valgus injury

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to both the thumb and the adjacent digit.

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We're going to ignore the adjacent digit right now.

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We've got a coronal, a proper coronal image

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through the radial and ulnar collateral

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ligament, and then a T1-weighted image.

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This is a 3D GRE.

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Uh, thin section, there's a T1 anatomic fat

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weighted image and on the right is a sagittal

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image, which we'll talk about, uh, towards the end.

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So in the coronal projection, just to get the

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audience oriented, you can see some swollen

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residual fibers of the UCL, but most of the UCL

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is torn off and you can actually see the gap,

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which is a few millimeters in its overall length.

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I could measure it, but I'm

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not going to do that right now.

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And you can see over the top of

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it is the adductor aponeurosis.

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So the lesion is not entrapped

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by the adductor aponeurosis.

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Here on the T1, it's kind of a fat, frayed UCL.

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Now in our experience, most people that

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have a UCL tear, we almost always see a

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contrecoup, if you will, proximal RCL.

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It's usually subclinical and asymptomatic.

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But I have seen cases where the imager latches

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onto this and completely overlooks that and then

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calls an RCL tear and the hand surgeon is pretty.

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pretty upset and loses confidence in the reader.

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So do be aware that this occurs in

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almost every UCL valgus-type injury,

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usually with some torque or twist.

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How do you manage this thing?

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Because this is kind of an in-between lesion.

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It's not a stentor, but it's not inconsequential.

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Uh, what are the tools that you use

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to decide what you're going to do?

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And when you do a stress view, how do you

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prevent from injuring the thumb, especially

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if there's a small fracture here?

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What are the steps you take?

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Well, uh, I actually, this case is, uh, my

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patient and, uh, was a very high-level athlete.

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So, uh, and, uh, in this case, the MRI was

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done, uh, immediately after plain films.

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And, uh, so, uh, I think, uh, I had all

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the information I needed to make a clinical

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decision, wouldn't do a stress view.

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However, uh, oftentimes this, or

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usually this is not the situation.

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So, very briefly, if I see a patient that I suspect

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a UCL injury, uh, UCL injury to the thumb and,

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uh, I will first examine the patient, look for

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asymmetric swelling and, uh, if it's a bad injury

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where there's a stentor lesion, uh, the alignment

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in the coronal plane will be off, the proximal

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phalanx will, uh, go in a radial direction.

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Um, the first thing I'll do after I've done the

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physical examination, that is tenderness, uh, overall

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alignment of the thumb, is I'll get plain radiographs.

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And if the plain radiographs show a fracture,

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I have to decide whether the fracture, uh,

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off the volar or base of the proximal

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phalanx is displaced or non-displaced.

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If it's non-displaced, I may go on and

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assume that the fracture will heal.

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If it's displaced, uh, then that's an indication in

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most people's hands, uh, for surgical intervention,

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certainly if it's more than a millimeter or two.

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If the plain X-rays are negative, then we will do

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stress radiographs, and I'll generally numb the thumb

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up, uh, with some lidocaine and, uh, do a stress view.

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If there's more than 15 to 20 degrees of angulation

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with the application of stress to the

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proximal phalanx in the radial direction, I would

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be inclined to consider surgical intervention.

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Uh, and we do that in flexion because

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the, uh, collateral, the head of the proximal

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phalanx, uh, is trapezoidal in shape.

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So, uh, collateral ligaments are under most

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tension, uh, with the joint in flexion,

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whether it's a thumb or a digit.

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How much flexion?

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Uh, as much as they'll tolerate.

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So in the thumb, the range of motion of

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the MP joint in the thumb is variable.

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In the fingers, it's always 90 degrees.

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In the thumb, it can be anywhere from zero,

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zero full extension to 30 degrees of flexion.

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flexion, depending on the geometry

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of the head of the metacarpal.

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Metacarpal heads in some people are quite

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square and they don't have as much MCP flexion.

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Others are more rounded or spherical and

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they'll flex, uh, say to 70 or 80 degrees.

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So I put them in maximal flexion and then

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uh, do a stress test.

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The other thing that you can do, which has been

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written about a fair amount, but I've not had a lot

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of success with, is that if the UCL is completely

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insufficient, you ought to be able to radially

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translate the proximal phalanx in the coronal plane.

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And any step-off more than, uh, if I recall,

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one to two millimeters can be a problem.

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So again, there are two ways

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you can stress the MCP joint.

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One would be, uh, flexing it and applying a

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radial force, and the other would be holding it in

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extension and then translating, uh, P1, the

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proximal phalanx, uh, in a radial direction.

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So basically, if I did it on myself,

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you'd basically be in extension,

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and you'd be pushing on this to see if

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yeah, you would, uh, you would, you would

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take the thumb, and you're translating it.

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I'm trying, yeah, you've got,

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you may need surgery, Steve.

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You're, we're I need brain surgery,

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but yeah, so, that's, there's, there's,

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he's got a little bit of laxity there.

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And then the other test would

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be putting the thumb in flexion.

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He's probably got a fairly spherical head.

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And then, uh, stressing again in a radial direction.

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He's completely stable.

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It's important also, you can get, uh, faked out,

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uh, you've got to stabilize the thumb metacarpals.

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So you, he's a little, he's a little loose here.

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He may need something surgically

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done, a little tightening procedure.

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Yeah, well that, that

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thumb's been abused for many years.

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So another question for you is this very weird,

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and I know we puzzled over this like 20 years ago.

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Right.

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We used to look at these lesions

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on MRI and see this very saggy.

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Uh, proximal phalanx.

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So here is the, uh, here's the metacarpal just

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to get the audience oriented and then look

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where, look where the base of, uh, P1 is.

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It looks like it's sagging this

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way into a palmar orientation.

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So what causes that?

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'Cause I remember initially we were wondering

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20 years ago about a, a plate injury.

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And the majority, majority of these

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don't have a plate rupture.

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So what causes this?

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So some of them do have a plate

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rupture, but you're dead on.

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The majority, I do not think, have it.

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But the orientation of the collateral

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ligament is such that it starts proximal

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and dorsal, and then it goes parallel.

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inserts again at the base, palmar

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base of the proximal phalanx.

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So collateral ligaments do two things.

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One is they stabilize the MCP joint in the coronal

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plane, and the other thing that they do is

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they suspend the proximal, uh, they suspend the

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proximal phalanx on the head of the metacarpal.

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So if the proximal, if the ulnar collateral ligament

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and the radial collateral ligament are both deficient,

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that will allow some palmar translation of the

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proximal phalanx and you get this sag effect

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which you talked about. I tend to look not

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so much at the mid portion in the lateral, but

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I look to see if the dorsal cortices of the

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proximal phalanx and the metacarpal are collinear.

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And in this case, it's very clear, uh, that the dorsal

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cortices of P1 and the metacarpal are non-collinear.

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Yeah, so here's one, and there's the other, and they,

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they should have lined up over here, and they don't.

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That's correct.

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So there's a fair amount of displacement here.

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Yeah.

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And, uh, we can see a little bit of

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the plate right here, proximally.

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Yeah, and then you can see the

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triangular plate condensation, distally.

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I think the plate was intact clinically on this case.

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Did this patient have a graft?

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No, this was, this was an acute injury and,

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uh, the ligament was reattached with a suture

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anchor and, uh, the patient made a full

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recovery and is back competitively playing.

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Well, the next one we'll look at, I think

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did have a graft, so let's move on. Dr. Stern and Dr. P out.