Thank you, Marty, my disclosure. So we want to get into this guy's head. So instead of being John Malkovich, we're going to be Andrea Scamal. So our five questions for you, sir, are treatment indications, is anything practical? Is microfracture dead? Why not osteotomies? And can you predict the future? Andreas, are you treating asymptomatic defects? I mean, the short of it is no. It's always hard to make a patient better if they already feel good. I would say the only caveat is, let's say you have a really young patient with a very large loose OCD lesion that was removed, lateral compartment, I just worry about what the meniscus does. But I think that's the only exception where I would talk to them and say, we've got to keep a close eye on this. So if you see a large defect with an ACL tear that's technically asymptomatic, are you leaving it alone? A lot has been said that cartilage doesn't matter in the setting of the ACL. Chilburn has done studies, many have done studies. I think we need to differentiate between the 90% of cartilage defects in the ACL setting or patella dislocation that actually don't matter. Those are the little defects or fissures that you can see. But if I see someone with a six square centimeter delamination, then yes, I would treat that. How deep, as we know about treating bone defects, particularly with osteochondral allografts, and you saw a case from Bryan Sennett that had a significant bony defect treated with ACI, how deep does a bone defect matter? And when do you bone graft? What's your threshold? So when I started life as an ACI almost only person, and I did sandwich ACI for anything that was deeper than about six, there are no real black and white thresholds. I think nowadays I usually would use an osteochondral allograft for combined osteochondral defects. If it's a shallow obesity lesion in a young patient, let's say five, six millimeters, that's still fine for just a primary ACI, for example. Why not just bone graft and leave it alone? So my ex-partner at the Brigham, Tom Minus, has done studies, initially insurance approval for ACI 20 years ago was extremely complicated, so he's done that actually quite a bit. Take the cartilage biopsy, bone graft, see if you need to come back, and the early results up to five years were actually really good in young patients. They formed nice fiber cartilage on top of the bone graft, but the majority of them failed over the five to 10 year. So let's take concurrent malalignment, a cartilage defect, and meniscal deficiency, concurrent pathology, in order, what counts? What's your priority? What's in your head? I'm always excited if someone is malaligned, because I think an osteotomy is probably the most powerful thing we can do in terms of biologics. So if someone is, let's say, if I had a medial meniscectomy, I had a varus knee, I would want just an HTO by itself. Okay, so what's number two? Between meniscus and cartilage? Cartilage, meniscus. Brian Cole showed basically leaving the meniscus deficient, but doing the osteotomy, doing the biorestoration of the articular cartilage. Do you agree or disagree? I agree. I think osteotomy is for life, and meniscus is for 10 years. Let's say you have to do all three, staging, concurrent, what's your order? If I have a strong feeling from the beginning that they need all three, I would just do one procedure, put them through one rehab. But I saw someone recently who had a partial lateral meniscectomy, as in valgus, but he still has some meniscus left, I think he'll be fine just with an osteotomy, and that's something where we just stage it, do the osteotomy, and see how they do. Let's be practical, Andreas. When is less more, and when is chondroplasty enough? We're not talking about two years on an NFL contract. Let's talk about somebody walks into your office, and maybe they own a grocery store. When is chondroplasty enough? If they have primarily mechanical symptoms, then I would primarily think about a chondroplasty. If they really have pain effusions and mechanical catching is not in the foreground, I might still consider a chondroplasty, but then my gut feeling is they probably will need more. What about delamination at the perimeter? Not fibrillation, but actually separation? Do you take those down if they're flapping a little bit? Is that part of your chondroplasty? I do, yeah. What about short-term goals? Patient is worried about short-term symptoms, patient's worried about short-term recovery. How does that fit into what to do practically versus what to do that is right in the long-term? That always leads to the biggest discussions, because on the one hand, you can look at the knee and you can make your treatment plan, and then it becomes the reality of life where you start talking to, are you a grocery store owner? Are you mid-season? Are you between seasons? That is the complicated part, and that's the longest part of the discussion that I really can't give you an answer, because every patient is totally different. What do you do about that insurance thing when it's not approved? What do you mean? De novo. You plan to do a de novo, or do you switch to another technique? If you do, and you switch to ACI, and it's still not approved, what do you do? Well, osteocondylograft and ACI, luckily, is on most insurance policies, so they've been pretty good. You just have to be careful for both, that when you document, you make sure you know what the medical policy requirements are in terms of how long being in pain, how big is the defect. Most insurance companies need to have this phrase that the patient is in disabling knee pain. There are other techniques that are new and sexy, and the problem is most of them, if you look at the medical policies, are specifically excluded. Now, you can pick up the phone and have a peer-to-peer review where you tell them specifically why you think this is better than what's covered. I sometimes use the particulate cartilage allograft together with osteocondylograft, for example, where I do the allograft for an osteocondylograft defect, but there's a second defect. This is an adjuvant, and then you get approved and paid for the allograft, but not for this. Should we be teaching our colleagues that some of these articular cartilage procedures should be regionalized, or should they be sent ... Should we be doing it in the community? Should they be sent to centers? Yeah, so it's this whole center of excellence idea, and that's true for everything, whether that's arthroplasty, complex spine. I think overall, 80% of these can be treated locally by every orthopedic surgeon. I think education should focus on recognizing the ones that need more for patellofemoral instability, for example, recognize when they might need a topioplasty, and that's a good example similar to a meniscus transplant. Not everyone has to or should do that. Yes or no, is microfracture dead? I would say microfracture is dead. Mirror stimulation, not so much. That might be subtlety, but overall, literature supports to go to drilling rather than microfracturing, and that's just you do less damage to the bone, and you serve the same purpose. Personally, I don't really do it very much, but my practice is such that I don't really get referrals for the small lesions where this would be indicated. I assume when you do it, you do it the way Jack Burt said. Is your rehab still limited to non-weight-bearing for six weeks? When you do it? Yeah. I do CPM. I do limited weight-bearing. Do you always do an osteotomy? More than three degrees metal alignment, yes. What if the patient doesn't want one, doesn't buy it? Then I pout and say, well, then I don't touch you. Ultimately, they are adults. I would give them, and we have pretty good data for both ACI in the patellofemoral joint and the medial condyle, that your success rate drops from 85% to about 45% if you leave them metal aligned. Ultimately, it's their decision. Parting comment, tell us, predict the future. What if I told you that if we followed all of these patients that we're doing this on at 20 years, they all have osteoarthritis, what would you say? I would expect that. Are we therefore then acknowledging, as you heard with the osteochondral allograft talk, that we're bridging, in fact? For sure. When I talk to young patients, I say, you have another 65 years to live. Let's map out a way to get you from here to there with the fewest number of operations and the highest function. Everyone wants to go home with one or two pearls. What is the next cool thing in your mind? I think there'll always be room for something minimally invasive, and whether that's mirror stimulation with some, you defined it, pixie dust to make microfracture plus. I think there's room for the small defects. There will be cell-based therapy for the larger multiple defects, and there will be an osteochondral, whether that's an off-the-shelf implant, or we just improve the current osteochondral allografts. It's never going to be just one solution. We thank you for your wisdom. Thank you very much.

knee injuries

cartilage defects

bone defects

osteotomy

chondroplasty