So, first case, 20-year-old male, left knee pain for a long time. And he was diagnosed as a young teen with a discoid lateral meniscus and had undergone at that time a subtotal lateral meniscectomy. And these are his radiographs. Hey, Jack, do you see anything you want to point out? He's got some squaring of the lateral compartment. Joint space looks pretty good. We don't have magnification markers, but it looks close to normal. I have to compare it to the opposite side. MRI, Jack? Yep, no meniscus and marked chondral thinning. Okay. MRI, so subtotal, pretty much total lateral meniscectomy. The chondral defect was read as about 2.5. And more MRIs in terms of not a lot of marrow edema. And Andreas, these are his standing films, his mechanical access. Any comments on this? Well, he's in valgus. He's in valgus on both sides, which is a problem for lateral meniscal deficiency. So that's someone you think about in osteotomy. Is this 12 degrees anatomic or mechanical? Mechanical. It doesn't look 12 degrees mechanical, but it's definitely enough because it goes through that compartment. It's through that zone. Think about osteotomy. Christian, so the issues here, what are we thinking? And tell us a little bit just in terms of perspective, what stands out in your mind? The valgus malalignment, the subtotal or total lateral meniscal attrition, the defect, and the fact that he's got a little bit of joint breakdown in early osteophyte formation. What are you thinking? Yeah, so I'll start at the bottom. The early joint breakdown, that's a consequence of the above three. And what is the underlying problem here? I think the main underlying problem is two anatomic issues. One, the valgus malalignment. And secondly, the discoid meniscus that he has lost. If you undergo a lateral meniscectomy to that extent at that age, we know that is pretty much a recipe for disaster for that compartment. He has a fairly, what was that, 12 degrees, I believe, valgus? So that's fairly substantial. And those two factors will not allow for good homeostasis in that joint, even if you were to fix a secondary problem here, which is a lateral femoral condylar cartilage defect. So in order to address that, I think you have to address the underlying issues, which is the valgus malalignment. And you have to do something about that meniscus. And then you can decide, looking at it, whether that cartilage defect does or does not need to be filled. I think that's something that I would like to see. So this is a patient that I would definitely scope before I do anything else. So staging arthroscopy? Yeah. So he undergoes a staging arthroscopy. Bert, you're trying to sort this out. Are you just doing a staging arthroscopy, or are you going to do anything else at that time? Try to give us a sense of, we understand the list of problems, but what's your plan of attack? Well, first thing, before we get to this, I think it's important to look at a case like this. This is a patient that's 20. He's had seven years of knee pain. And maybe seven years ago, we'd let this kid go seven years. But I think at age 13 and 14, we should think and talk about how we would manage this particular patient because we've created a bigger problem by waiting seven years. So I think that's an issue we should discuss as well. Kevin. So he's 13. How would you change the natural history of this? You mean going back to Bert's point? I think now, potentially getting more aggressive with meniscal transplantation, if his growth plates are open, potentially changing that in terms of his alignment. So I think going back in time, there's some things you could have potentially done. This is a key point because I think in an audience in a group like this, we ought to think about that because in the past, we were too conservative early on. You could change the angular alignment over time that they wouldn't end up like this. And also, there may have not been that articular cartilage defect and that degree of degeneration at age 14. Some of the kids we take care of at Children's Hospital of Los Angeles do have that at 13 and 14. But again, we have to think in terms of being much more dynamic early on, much like we have changed in our approach to the first-time dislocator in the shoulder. Good point. This is out of the bag. This is the defect. Jack, more chondral than bony, does that change what you're thinking? Are you going to do a biopsy? Are you going to do something at that time? Staging arthroscopy. I think in my hands in this situation, both would do equally well. So I'm not really biased. So then you have to go back to the patient, what's the recovery time? What's their insurance? Are they going to allow me to do cell therapy? Are they going to allow me to do an osteochondralograph? What's his parents think? What's his whole team? So I'm going to probably be the low man on the totem pole making the decision. I'm just going to lead them down that they need to do all three. Read the moment. Andreas, are you going to try to, based on that, I think that's a good point about treating the patient and not what we want to do. Are you going to try to upload this a little differently and try getting some of this stuff done? Or are you going to stage it in a more protracted way? Yes. So in terms of staging, I think that depends on your personal comfort level with these. So we were mumbling on the table in terms of the, do you do osteotomies outpatient? I would say that the one criteria for doing things outpatient in a way, staged or non-stage, is how long it takes you to do them. I think at this point probably most of us would do it together to avoid having multiple rehab periods for the patient and to avoid going back again and again. But certainly if you are not that familiar with the DFO and it takes a little while, do the DFO at the time of the staging arthroscopy, let him heal, and then come back and do your intra-articular work. I would just say if you stage it, stage extra and intra-articular together so that you don't have to go into the joint multiple times. Okay. We're going to keep moving. We did the DFO. Christian, tell us in brief pros and cons of opening, wedge, lateral, medial closing, and what's your preference? Well, I mean, there's multiple things that you need to consider here. One is you need to find out where the actual deformity is, right? And if the deformity is truly in the distal femur, then typically an opening wedge osteotomy is not a bad idea. You know, there's technical aspects to it. An opening wedge osteotomy is probably technically for most of us here in the U.S. easier. I would say in Europe, they would probably say the exact opposite. And that's just a matter of familiarity. But it also requires a longer rehab time. You need to keep him on crutches longer because if you do a closing wedge osteotomy and up to 10 degrees, it probably doesn't matter. You're not obliquing joint lines too much doing that. You can weight bear them earlier, but technically, they are actually a little harder to do unless you do a lot of them. Because it is a biplanar osteotomy versus a lateral, it does not have to be a biplanar osteotomy. Panel, really quick, just yay or nay across the panel, opening wedge for this case, anybody closing wedge and why? Opening wedge, agreed? It's the same incision pretty much for opening while closing would be separate, unless you do a really big one. Okay. So how long do you wait, Kevin? Wait for what? For the healing. When do you get back in? Because basically, he's 20 years old and a year is 10 years. Sure. I would wait typically at least six weeks, but quite honestly, once he gets his range of motion back, because sometimes they'll get stiff, so I want to make sure he gets his range of motion back. So it wouldn't be unusual for me to wait three months or so. Okay. Wait a little bit longer. Then did the, at that second procedure, then did the lateral meniscus and did the Macy. Bert, from the standpoint of teaching us about the order of events, any issues here in terms of doing, I think Andreas hit it. Do the DFL at the time of the staging, do the extra-articular, get that going. Then come in and do both intra-articular procedures. Agree, disagree, why? Thinking. I think it's a nice, deliberate way of approaching it. I think it's safe, as Kevin said, getting the range of motion not too stiff. And lastly, sometimes I find that the osteocondylograft is a better, easier rehab on the last part of this to get them quicker on that part. The in-between, not so different, but in the last phase. Yeah. So great, great point. I was going to ask Andreas. So let's take the yin-yang. Would you have done an OCA on this with the lateral meniscus allograft and be done with it or are you going cell-based? More superficial, not a lot of bone disease. I think the bone disease would have forced the hand. Any thoughts? Andreas. Yeah. I don't think anyone can be really dogmatic. I think it's what you're more comfortable with. I mean, the one thing is if it's a larger defect, especially lateral femoral condyle is deep because it has thick cartilage and it may see you put at the bottom so you have edges and I feel sometimes they have more mechanical symptoms until that defect fills in. While with an OCA, you feel the defects sort of at time point zero and it's a little bit smoother. But I've done either and I can't really say I have a strong feeling about either. All right. This is a follow-up. Kevin. All right. So next case. So here's a 16-year-old male high-level basketball player for high school, two to three years of increasing activity-related pain, was actually told he had Osgood-Schlatter's previously and then sort of came to me after sort of an acute exacerbation of pain and swelling to the point where he could not play and he's getting recruited. So he's pretty good. So here's a 16-year-old high school high-level basketball player. Bert, what do you think? Just looking at these plain films. I think you've got a one-hour visit here. It was actually probably an hour and a half. It's a long clinic visit with coach and parents. Obviously first thing you want to do is get your mechanical access here and then head into your MRIs and really get into the weeds of this biconular OCD defect. Right. So have you, the whole panel, have you seen many? I mean, I personally, I've seen, we've all seen lots of patients who've had OCDs bilaterally. I've seen lots of patients who had a medial on one side and a lateral on the other side, but I have not seen too many with, you know, both medial and lateral. So unusual and they're symmetric. Right. So here's the MR. Christian, what do you think? Well, I mean, and there's, I don't think there's much to think. I mean, there's essentially a significant loss in the mid to posterior condyle on both sides. The good news is that it appears that the menisci and the tibia look still okay. It's interesting because, you know, if you go back to the initial x-rays in extension, he actually looks pretty good. So it's really more in mid-flexion to posterior where that comes into play. And I think that may be the saving grace for him, but I think he needs to have that plugged. He needs to have bone and cartilage in there. Right. And here's the other views. It's not going to add a whole lot. So would you get any additional studies or not before doing something? Andreas, would you do any, get any additional studies, CT or anything? Yeah. I mean, for OCD lesions, especially, I'm a big fan of CT arthrogram. This one is pretty clear that there's not really any significant bone on the fragment, but sometimes on MRI scan, it looks like there's bone, but you're not sure. And then a CT arthrogram just helps guide the discussion whether, hey, we go in and we repair this or we just go in, remove like the loose piece and then we come back to reconstruct it just in terms of logistics and how, what's going to happen timeline wise. Right. And that's what I actually did just in terms of discussion. I didn't think it was going to be salvageable, just placed on the plain films, but I sort of wanted to talk to the family. In fact, we talked about getting, had the whole discussion about getting just, you know, fresh OC allografts, I'm sorry, allografts to start versus waiting. And so I did do a CT scan just to get more information with them. The, and again, just to show you, the Jack, what do you think in terms of this? As everyone said, there's a long conversation with he and the family and, and, and certainly the coaches, but with he and his family, what what's sort of your conversation with them right now? What are you proposing? Sort of step one, what are you going to, what are you going to tell them, Jack? Well, step one, most insurance policies are not going to let you operate on this to a definitive procedure just based upon these studies. So you're going to have to be doing a staging scope and at the staging arthroscopy. I know it looks like it's would be impossible, but I've published and others have published that you can, especially in these people that are relatively young, his growth plates are still kind of around. It might be, at least on one side, might be salvageable to do bone grafting and do a repair. So you could do, you would, I think I would be talking with the parents about that. I kind of think that it's probably not going to be. So I'd lay the crepe on that. So that you're probably looking at doing the first stage, then doing, it's going to take, you know, quite a while to get this through insurance. And then once it's through, then I would be, you're going to do autograft bone grafting of the cysts, so you don't want a hugely deep, I'd like to at least maximize out at a 10 millimeter composite osteochondral allograft. Right. I'm going to check how tall, it looks pretty tall, how tall are his parents? Yeah, so he's 6'1", his dad's like 6'8", 6'9", and so you can see, look at his alignment, so Christian, you know, looking at his axis obviously is insignificant valgus, so what are you going to do? So obviously I think we're all considering doing step one like Jack talked about, anything else to consider or not? So I actually looked at him and I actually did a bone age, I actually did a ACL on a kid who was 6'5", and he turned out to be almost 7'2", so sometimes you have to look at, he's probably going to go in the NBA draft next year, so if you look at some of these kids, I think you do, it's important to look at their bone age as well, so I actually did wrist and hand x-rays and it turns out his bone age was about 14 and a half or so. So let me challenge you on that, so let's say his bone age came back 16.5 or 17 even, does that change your plan? It would. Is he mostly, where is he symptomatic, laterally, medially? Honestly when he came in his knee was just swollen, I mean he's been playing through this for a couple of years and everyone told me he does good sliders and finally got to the point where the parents brought him in, he had a big swollen knee, it hurt all over, so it really wasn't, I couldn't say medial or lateral. So just for the sake of time, so here's, you can see that right knee is in significant valgus. So for the sake of time, so like Jack suggested, I always like to try to fix the fragments if at all possible, I mean I was ready, we had the headless screws available, I was going to take autologous bone graft, but unfortunately both sides I just did not feel were salvageable, I was literally in five or six different pieces. So as much as I'd love to fix it, and I agree Jack, I just didn't think it was salvageable. Kevin, can I ask you a question, what criteria do you use, you showed this video with your bending it, what criteria do you use to decide whether this is salvageable or not? So we've actually published on fixing pure cartilage fragments back with bone grafting, with or without bone grafting, but that's when the bone, the subchondral bone is good, so my criteria is a little bit different. So for me, I like it to be in fairly one piece, I will take two if I think it'll heal, but it has to have some bone behind it, a little bit different than the pure chondral fracture fragment that kids and adolescents get that we published on previously. So real quick, why wouldn't you just, understood, but what, you know, what's, no harm, no foul, why wouldn't you try and put it back, just to play devil's advocate, and two, why wouldn't you just bone graft it autogenously, and just sort of, you're going to come back probably. So just the thought about getting the substrate in better shape. Well I think that, and you can see this as a result, so I think that we've actually had some success over 23 years with simply bone grafting OCDs, and amazing how well some have And it was back 23 years ago when we were involved in a lot of ACI projects, and for me, there were multiple, multiple cases, and I know a lot of people on the panel have had this experience where I was doing a staged ACI, and I just never had to go back, and I know people have published on, well then later on, some of them don't do as well, but I mean I've summed it, literally, I've summed it over 20 years out now, and so sometimes just doing that works to Nick's point. For this, in our conversation, if this didn't work, and if he was symptomatic, my first choice was going to be Osteochondroallografts in him, so, Andres. So that scope picture is actually why I'm scared of OCD lesions, to leave them empty, because you see how that engages in the posterior horn of the meniscus, so I have a kid who then shredded his meniscus, and all of a sudden it's a completely different thing, now it's not just, oh, you fill the hole, but the tibial plateau, and the meniscus, like Christian had said, is still good, all of a sudden, everything in that compartment is bad. So I always worry about letting these go, and just taking the piece out, and just see how they do. I'd love to fill that, and I think bone grafting is fine, it's just, this is a pretty shallow, I mean it's deep, but if you compare depth to size, it's sort of shallow, so it's hard to keep a bone graft in unless you suture a membrane over it, and there are all sorts of tricks. But one comment I wanted to make is, if you look at the lateral one, it's really posterior, so access for an Osteochondroallograft can be hard, because in some patients, you can't flex the knee enough to get perpendicular to the lesion, so sometimes, even though I might want to do an OCA, I end up doing a sandwich Macy, just for access purposes, but he's skinny, so he should be able to. That's exactly, this is a very difficult lesion to get to, and in some, people have done a tibial tubercle osteotomy, because you've got to go biconvallelly, and really flex this up, this is a very posterior lesion, which I find is, that's the other rareness to this, how posterior both lesions are. Right, I've actually had some cases previously where I've actually, to determine could I get there, did a lateral x-ray with having them hyperflexed, to see could I even get the angle, honestly. I think the other thing that you're showing here, which is great, is that you're using guided growth, right, because this is really the only true technique where you can literally dial in a neutral alignment over time, and I think this is really critical in this case, because if you overcorrect him in one direction or another, with any other technique, you're in trouble. Right. So, basically, this kid is now, he's only two and a half months out now, and right now, asymptomatic. So, that's always the question, what do you do now? All right, thanks, so now we have a 24-year-old female, chronic history of OCD. She had, basically, removal of loose bodies. I think it's reasonable, six months ago, comes in with this, again, more lateral compartment disease. Christian, any comments on this one? Well, in this, again, the lateral compartment, you see some early squaring, I don't see any major osteophytes yet. You see the lesion, obviously, this appears to me, and I would want to have that verified again, that she is involved with patellofemoral. I don't see any major issues there, it's maybe a little lateralized, and, yeah, I mean, that's pretty much what I would take out of this. Bert, anything about this? She had loose bodies, but she still has significant disease present. Again, same thing, you've got a broad, flat lateral femoral condyle, you've got cyst anteriorly, it's a very posterior lesion, and the same issues we had in the previous case are upon us. That's pretty far back on the lateral side. Andreas, anything more about the cyst formation? Again, you can do both techniques, OCA or MACI, but I think you need to fix the cyst, and I don't know about the rest of you, but I'm not really going to the ILLI crest, I'm just, in this case, probably would go GERDES tubicle and take local bone graft. Sometimes you can harvest that with an oats chisel, make a plug just to fill that. Yeah, I like going to the proximal tibia for autogenous, for fill, is the piece. So she has this, and then comes back six months later. So in essence, this was a repeat debridement, less is more, to try to kick the can down the road. Obviously, that didn't work. Seven on mechanical axis, Christian, and here's her arthroscopy. This is at the time of the second removal. So significant bony disease, which probably belies the extent of some of the bony disease based on where that cyst was. There was an incremental cyst, segmental cyst. So what are you thinking, Jack? Well, it looks like the meniscus is starting to get beat up already. That's not a good sign. I guess when you said to try to kick the can down the road, this is a 24-year-old patient, is what you said? Yes. So I think we don't want to kick the can on this one. We want to get to work and try to normalize her, normalize alignment. I agree that deep cyst, I would like to have that filled. Probably I can't imagine it not communicating to the rest of the defect, so I would just find wherever that communication is and use that to lead my bone graft. And I would probably lean, once again, for OCA, and I would do it concomitantly with an osteotomy, depending upon what her alignment actually is. Seven degrees. Seven, I'd definitely do it. Andreas? Yeah. We already gave you a DFO, so I'm not trying to lead you down the path. No, I'd do the same. I think one of the big things that actually comes up a few times here is that the goal for these patients, well, we don't want to treat asymptomatic patients, but we're also worrying a 24-year-old what's going to happen in 5, 10, 15 years. And we have really, well, for OCDs, actually, we have pretty decent data that removal of loose bodies short-term works, but then they have a very high OA rate down the line. But like I said before, especially for lateral, small medial you can get away with because they don't really articulate with the posterior horn, but the lateral ones, since they're more central, the posterior horn of the lateral meniscus at some point can catch. And if that tears, it's a disaster. So Christian, to Jack's point, I'm concerned about the, or to your point, I'm concerned about the extent of bony disease, which is going to push me to an OCA. From the standpoint of correcting or improving her alignment, where are you going to take her? Are you going to take her to neutral? Are you going to take her to 1 degrees of varus? Where are you going to take her from 7 degrees? So with varus deformities, I'm a little careful. I do not overcorrect. For varus deformities, I sometimes do. So what does that mean in terms of numbers? Sorry? So what does that mean in terms of numbers? Neutral? I go to neutral. Okay. Anybody disagree? Jack? Bert? I would just say, if you're taking a female, take him to varus. Most of them are unhappy, especially if they have 7 degrees on the other side. Yeah. Kevin Bonner, does it bother you? What's the panel's thought about marking up the joint and the grafts? And the issue, the report of increased infection rate. Are you marking them up? When you say marking them up? Yeah. With the graft? Are you drawing on the graft and the joint? No, I do. Does it bother you? I don't do it quite like that, but I always mark them up. Hey, Jack, does that bother you? Do you draw on it? No. I'll make one dot at 12 o'clock just so I know my orientation. Like a little north mark. And then- So what bothers you? It turns out when you're putting it in, sometimes 12 o'clock isn't best at 12 o'clock. You need to rotate it, maybe put 12 o'clock at 3 o'clock, I mean, after you've done your fine-tuning. So I don't know what those other marks were for. Okay. Just the literature. I just think the work out of San Diego, that OCA treatment for these OCDs is optimal. Now this is the question. This is a technical question for everyone. How do you bone? You're using a four to six millimeter wafer. You're really trying to minimize your wafer. What's your trick for filling in the hole below it? And don't say that you're using the fresh cold stored bone, bad. So are you taking it from the proximal tibia, are you taking it from girdies, are you taking it? Where are you taking it? We didn't do a DFO, by the way, so. How do you kind of build the footing, if you will, that is going to seat your dowel graft on this extensive bone disease? This is the one, first off, that I would use BMAC as an enhancement. You know you have bone disease more proximally. We know that there's a smaller number of degenerative cells that are downregulated. So I would use BMAC to really activate the area proximal to that. I probably, as Jack said, Andrea said, take from the proximal tibia to bone graft assist as well. Anybody agree, disagree, or comment on building up all of the bone disease that you're placing your dowel on top of? So I would mitigate that a little bit. You know, we all, of course, want to ideally have a six millimeter graft, but if I can cover this with eight millimeters, I go for it, and I do not bone graft below it. If it is much deeper than that, then I may consider doing that, but the problem with bone grafting it is you can never compact it stable enough so that you are absolutely assured that your graft doesn't recess further. So that becomes technically a little bit harder to do. If I do it, I take it from the proximal tibia, I make it like a one centimeter window, take the cortex off and go inside and take it from there. I do not use BMAC. Kevin? I think we're done, actually. Okay. So I think it's in the sake of time, because I think there's a reception now. We have more cases, but I'm sure everybody would prefer to go to the reception. So we thank you for the session, and thanks for everybody's work on the panel. So thank you very much. I text Howard. Maybe we can meet him at the reception.

orthopedic surgeons

knee pain

osteochondral defects

treatment options

meniscus

osteotomy

alignment issues