So, there is a way to ask questions through the app. A question for Ned. Would the data comparing the HTO and UNI more likely have favored HTO if they were done primarily as a medial opening versus a lateral closing? Well, that's a good question. That's been asked for a long time. I feel that way. I think the medial opening surgery has been an improvement from the previous, you know, closing wedge osteotomies. I learned as a closing wedge surgeon, and I've been doing opening wedge, I think the surgery is much more predictable. It's much more reproducible. I think the rehabilitation is much better. And then the, you know, the post-surgery revision to a knee arthroplasty, maybe we can ask the arthroplasty surgeon. I think it's much better following an opening wedge osteotomy where you have a lot of bone rather than a closing wedge where you have minimal bone. So, I don't know, Kevin, if you want to answer it. And by the way, you can just ask the questions, we're a small enough group, so just go to the microphones. Kevin, do you want to answer that? Did you hear what he asked? Yeah, I did. Yeah, I mean, my understanding of the literature is that the revision from an opening wedge is certainly easier. What's your experience? I'm tired of this literature stuff. Well, I mean, it is. Well, I'll say that also the revision of a uni to a total, should it be necessary, also is a pretty easy conversion as well. So, you know, that's another important point. So are you saying that you haven't revised any osteotomy? Come on. Come on. A little honesty on the stage. So if you sat in an arthroplasty session, if you go HSS or whatever, you would find most of the arthroplasty surgeons are concerned that they would say that the conversion for a uni to a total, first of all, or an HTO, is a revision, not a primary. You speak to a sports medicine doctor, they say the conversion from an HTO to a uni is a primary, and so it's perception, or it isn't perception, or maybe we get a different selection of patients. I just, I want to always just say it out there, because we need to do more things. That's why it's a delight to have you here, together, so we can really find the answers together. Questions? There's got to be questions. Biologics or Jorge, anyone? And in the meantime, if Dr. Strickland has a comment, or no. I can't see with a blinding light. I'm sorry. Is there someone? Okay. You want to come up to the mic? Can you just come up to the mic so we don't repeat it? I apologize. Just let them get through. Anyone else? If there is, just go up to the mics. We have about five minutes before we move to the, thank you for coming. So just let them get through, and then we'll get to you, I promise. Thank you for coming up. Is anybody using the biologics for the marrow-based lesions at this point, and is it successful? So go down the line, yes, no. And particularly, is the acute pain relief as good as with? Fair enough. One, you're going to answer, are you using biologics in the intraosseous lesion for an edema, starting down the line, yes or no, and is the pain relief good or not? And which one? Okay. Fair enough. And which one? So one, are you using it? Yes, no. Kevin? I haven't used it, no. Next person, are you using it? Who's, I can't see. I've not seen it used. Okay. Next, Armando. I haven't used it in isolation. I've used it as an adjunct in the setting of cartilage restoration where there's the bone marrow lesion behind what I'm resurfacing. Same as Armando. Adjunct. Adjunct. David, are you using it? Same as Armando. Same. Okay. No, I've not been using it. Sabrina? No, I use it, I mean, if I'm doing cartilage restoration procedure, I soak the allograft and BMAC, but I think it's been very effective mixed with, I personally mix it with graft on gel for isolated lesions. But I was looking, I think, I think you were asking if you injected intraosseous like a subchondroplasty, is that correct? I do a bioplasty. Yes. Yes. So the answer is, yes. And I don't think the result, I don't think the pain relief is as quick. I tell patients that they're going to be, it'll be more, more like three to six weeks till they feel better. But I've had excellent results, especially in the patella. Jorge, do you want to make a final comment since it was your presentation about intraosseous injection, not calcium phosphate, some type of biologic? You know, I try to find another solution that might be more mechanical. And in that regard, I feel if there's a big bone marrow lesion, I'm more inclined to do an osteotomy or something that will correct the axis, or if there's a root tear that might be causing that. So I always look for what's causing that bone marrow lesion, and not just treating what might be the consequence of something else going on. Thank you. Please. Yes, I just wanted to ask the panelists if any of them have had an experience using Cool-Leaf in the management of their osteoarthritis patients. So I didn't hear. Cold-Relief. Cool-Leaf is the one, or Cool-Relief. It's a two-stage procedure, which I've done probably on 50 patients, and it gives them excellent results in the management of their, and I'm talking about bone-on-bone patients that don't want to have surgery in that. And it's a two-stage procedure paid by Medicare, and the first one you go to, in our area you have to go to a hospital, and they go to the pre-op holding area, they do lidocaine injections. The patients are instructed to keep an eight-hour criteria of how much it helped them. And if it's over 60%, then they're a candidate for Cool-Leaf. And they go back into the pre-op area, and they actually put them asleep for the procedure, which is where they do the stimulation to freeze the sensory nerves of the inside of the joint, which lasts anywhere from two to three years. And initially it was developed for people that had pain and post-op total knee replacements. Correct. And then they extended it for osteoarthritis of the knee, and now they're doing it in my area for shoulders and stuff like that, with quite good success. And supposedly, if at three years their pain comes back, you can repeat the procedure and Medicare pays for that. So the interventionalist radiologist, I was honored to participate in a consensus statement out of Emory. It was led for the infrapatellar branch of the saphenous nerve and ablation to it with the injections as well, with what you're talking about. Anyone on the panel, first of all, participating in any of the studies? Anyone in the audience also? So I'm sorry, please, any comment? A little louder, sorry. We are doing this procedure with Dr. Hackett and Dr. Weiss at Emory's Institute. And we see patients, not all of them are getting relief. Some of them, they get relief. Some of them, they don't. The procedure of getting that sentence for Medicaid is very complicated. They have to send a paper by mail, and then they have to get the acceptance letter. So it's also like some paperwork needs to be added to the procedure, but there's no satisfactory outcome of this procedure. Some patients, they get relief. Some patients, they don't get relief. Thank you. Thank you for sharing. Go down the line. You've got a tensex and blurb, OA in a young or middle-aged person. This is what we're here for, for this session. What's your final comments? Go for it. Go. I think the severity of the arthritis is going to predominantly dictate the treatment. Next. I agree with the severity of the arthritis and their willingness to undergo surgery and how much they would like to avoid any type of reconstructive procedure. I think don't undercount the role of non-operative intervention. I have three pillars for patients. It's biomechanical, biologic, and envelope of function optimization. If you view it through those three lenses, you can be successful. So weight reduction on loaders for biomechanical. Biologic is what Jorge just talked about. And then the envelope of function discussion of how can you keep them active and moving and still keep them minimally symptomatic. So I view it through those three. My lens is those three pillars, and I don't discount it in these patients. Tom. It's a shared decision process and a hybrid therapy almost on all of them. David. Shared decision-making process. I agree. And I think there's still a lot of options and options to come prior to surgery. Jorge. A staged procedure where you start with the minimally invasive stuff that you can do to get them through the pain or the flare-up that they might have and then move up the ladder if need be. Dr. Amendola. I think you should do an injection to relieve their pain. So either steroids or orthobiologics. But you should combine it with Kevin Wilk's plan to kind of do a shotgun approach. I think the most common mistake I see is people do an injection and then don't do anything else to make sure that the injection lasts for a long time. And last word. Dr. Strickland. And I don't necessarily agree with the degree of arthritis because we all see patients coming in with bone-on-bone arthritis who ran a 10K the weekend before. So I think it's all about their goals and their function. And I certainly start with injections, try to do limited PT because it's expensive and I want to save PT sessions for if I end up doing something more invasive. But I think a home program and getting the range of motion is incredibly important. And I'll throw a monkey wrench in it. High molecular HA sometimes does work and it helps patients even though the science may not.

osteotomy

knee osteoarthritis

opening wedge osteotomy

biologics

Cool-Leaf procedure