Good morning.

I'm Dr. Michael Steward,

or PTC surgeon and Mayo Clinic

chair, division of Sports Medicine.

Our first case today is

a collegiate hockey player, Division

one player who has a very

painful tibial tubercle Asacol.

He has a residual of Osgoode Slotter

disease, which was totally

asymptomatic till he was hit

by a puck last season

directly over the tibial tubercle.

He made it through the season after

multiple injections and now

with Off-Season training,

his very disabled by this persistent

pain directly over

the tibial tubercle or the patella

tendon attaches.

So our goal today is a very simple

surgical procedure.

That is to make a small incision,

split the protein on,

split the patellar tendon in line

with its fibers to

expose this large, painful icicle.

Well, then remove the icicle

and any sharp spikes of bone, which

are also causing symptoms

at his distal patella tendon

attachment with skating,

running and weight training.

He will be an outpatient surgical

procedure.

He can return immediately to weight.

Bearing is tolerated with full range

of motion.

And I expect we'll have him back

biking, running and training

within a couple of weeks.

Come on into the operating room.

Let's try to help this young hockey

player.

So I prefer never to make an

incision directly over the bony

prominence or over a tendon in case

we have any issues with wound

healing problems.

So we'll make our incision slightly

medial to the tubercle.

Then we'll raise a flap.

We can take our knife.

We probably don't need to use all

the incision.

So we'll start with

a little smaller one.

The finer layers, fifteen blade pick

up, so we'll dissect down

through the subcutaneous layer

and then I'll take an absent and a

cautery.

So if we lift up, we can define this

plane very nicely.

So it's always a full thickness skin

flap

to preserve skin blood flow.

And now we'll take our retractors

and expose the tibial tubercle.

And the distal portion of patellar

tendon.

OK. So here is the obstacle.

You can see it's mobile.

So we'll split the tendon in line

with its fibers, will take a 15

blade,

go through this little layer here.

Let's flex any up a little bit so I

can see the fibers, hold the leg

firmly. Don't pull it toward you.

Keep it towards.

Thank you.

We can see this pair of teen on

layer two were carefully going to

preserve and close at the

end of the procedure.

That's the layer covering the

patella tendon.

Seems trivial, but it is important

for tendon gliding.

So we always try to preserve it

and we close it as a separate layer.

It's very thin, but important.

Now you can see the patellar tendon

and the fibers will come a little

bit more distal.

Thank you.

Pair team on. Larry gets even more

thin and adherent as you get more

distal. So we can see the fragment,

we can see the fibers of the tendon

and I'm going to just split them

right down the middle,

right down to the bone.

Now we're going ETR sends back here

in a minute and we're right on the

bone fragment.

We're going to get a send retractor.

Chuck's going to retract the

medial tendon immediately.

So I'm staying right on this bone

fragment, doing a

search period, still dissection.

So let's have the sand now.

You're going to keep both hands.

You go.

That's a pretty big piece.

Very irritating.

His tendon.

As an elite hockey player.

I have a hold of the piece.

Now, sometimes it's in multiple

fragments.

Stay right on the bond to preserve

all the tendon

fibers which are being nicely

retracted away.

And there's our icicle.

I can feel around for any additional

ones. You did have a small cyst in

there. We don't want to detach

anymore of the tendon.

Then we have to

go back to an adult and there

is any scar tissue or

tendon fibres which are

scarred. We'll just remove those as

well.

Once we come out, we'll all retract.

There's not going to feel.

There's still a prominence.

But it feels very smooth.

Now the big piece is gone.

We could take on a little more in

here. We'll have our retractors

back. If you could grab the foot or

the knee, which would be great.

Question is, do we want to go more

distal here?

Don't really want to remove much

more tendon attachment here, but

you might want to grasp this.

Let me try Iran's.

You're a little flat rasp.

So there's a little bit of a

prominence here that will just

tear down a little bit.

And then I have a very small little

rasp, which I find very

helpful to make that

smooth.

Kids have little irrigation, please.

Well, irrigate on a little bone

debris.

You guys got a sucker by chance.

Feels much smoother now.

So now I look both ways to make sure

we're not missing any pieces.

That looks wonderful there.

So we'll get our protein out of the

way and we'll get a nice

full thickness bite of the 10.

Then we're just doing a real

proxima Asian issues,

simple sutures.

I don't want to shorten attention in

any way.

It's just a side to side closure

with a tool monarchial suture.

We didn't remove any tendon fibers.

He'll be able to do immediate

full range of motion and weight

bearing is tolerated.

And there's a little stretch there

from that piece being underneath it.

So close up, very

nice side to side.

And now we'll close our Parad teen

on with a three.

Oh, monarchial can typically do a

running stitch here.

So we'll come way to the top.

We'll find this nice thin layer.

Again, we'll give us good gliding

of the tendon.

No adhesions of the tendon to

the underlying skin.

It's a very fine monofilament

three oh suture.

And this is called a running stitch.

Very flimsy tissue

here. And there is just so right

back.

Now we're going to inject some local

anesthetic which will help with

post-operative thing control.

This is our real pivot cane.

So we'll be able to go home and just

hours. So I'll put a little

bit underneath the protein on here,

more towards Mario.

Next, we'll take three or

monarchial, please.

We're going to do subcutaneous and

then subcu tequila's sutures.

There were gravel damage, the skin

edges.

I always start in the middle of the

incision, so I make sure I don't

end up with a dog air either, and

you want to oppose it.

So I decide

now I'm going to do a subcu ticklers

suture. I personally don't like to

tie knots directly under the

skin. I think it causes

sometimes a little one break down.

So we'll need some tension there if

you want to just pin that.

Thank you.

And again, we try to be very careful

with the skin edges.

Come out right. Or Neith.

This is a running suture.

So we literally take these to the

skin. Then a week after surgery,

we just clip the ends

and the rest dissolves.

There's no stitches to take out.

And there's also no knot's

underneath the skin that can cause

problems.

Little compressed advantage, right?

So let's

take a little soft draw.

And we actually remove this bandage

before he goes home.

This just gives it a little bit of

pressure or

compression, and we can put a much

lighter one on.

Now, we have recovered steadily, so

we'll take the drapes down.

We'll use our Touby grip, which is a

plastic sleeve compressive wrap.

So this ring is very

handy. So grab this, please.

So we'll double add for compression.

The.