with you my personal experience, and the only way I'm able to share it is basically on the hard work of lots and lots of people who have come through our institution, and many of them are here today. So I'm eternally grateful for the efforts that they put in to sort of help us understand where we are today. I think the first thing is you're hearing lots of options to manage articular cartilage problems, but this is an area that's perfect to consider this concept of skillful neglect. And this is, many of you have heard this, Voltaire, the art of medicine consists of amusing the patient while nature cures the disease. I don't think there's anything else in my practice that has more of this and that concept of most patients think they're broken. If you ignore them, they'll end up in a different place, and what we've learned is that reassurance goes a long way, and mostly what we're managing in the office is anxiety and uncertainty. But clearly, people are going to need help once you go through that, and the big question is why do they even hurt to begin with? We've paid a lot of attention to defect size, and defect size has largely driven the technology that we choose. This is a young woman who had a marrow stimulation technique but continued to hurt. If you just look at the size of her defect relative to the intact condyle, it's about more than 50%. The only thing that got her better was an osteocondyle allograft, even though her defect was 14 millimeters. Does size matter? Yes, it does matter. And what we've determined is that the defect size and the defect size ratio, in other words, the size of the defect relative to the femoral condyle, is directly proportional to the outcome. So it does have merit in the decision making. One of the things we really realized, and I think this largely came about from our management of failed procedures like from failed Macy, failed marrow stimulation, is at the end of the road, there's always the osteocondyle allograft. So it begs the question, when do we actually invoke osteocondyle allograft as primary treatment when we're using it as a salvage for all the other failed procedures? Very important, don't forget about the other stuff. The two things that we always have to keep in mind is the lowest hanging fruit, which is malalignment, and the second is if they're meniscal deficient. Ignoring one or the other generally cannot lead to as predictable of a result. So what really happens? So we have now over 800 osteocondyle allografts over 23 years. Where do they fit in? Debridement is still my number one treatment. It's either as a staging, as a way to render symptom reduction in about 65% of patients. The next one is osteocondyle allograft and meniscal transplants. Most of what we see now is that combined pathology, and this is a very predictable strategy for patients who have that combined disease. And then osteotomy. And yes, we of course have isolated osteocondyle allografts. So how are you going to decide when you hear all these individuals speak? I will tell you if you just think about debridement as a first-line, in-season individual, lower demand, marrow stimulation will work despite what Jack's going to tell you. Osteocondyle allografts is a dominant treatment strategy right now for the highest level athletes for small defects. You don't have to go to an osteocondyle allograft. And you've just heard a very nice lecture on Macy. But I will tell you that the osteocondyle allograft remains the most versatile and the easiest to implement in a variety of clinical situations, including virtually any joint in the body. Many of the people in this room have had excellent experience using it in the glenoid, using it on the humeral side, using it in the capitellum, using it in the talus, and of course the knee. It's procured aseptically. They have to be tested for bacteria and undergo PCR testing, which is why it takes 14 days to release them. And they are prolonged fresh. You just heard about storage time. We have indicated that current techniques of tissue banking need about 14 to 28 days. And beyond that, there's some decrement. Despite that, there are some emerging techniques that may render this discussion different. What about availability? We've now determined that you can actually get these grafts, but be a little bit open minded as to where you get them. You can, for example, use the lateral side for the medial side. There may be a surface match and a small osseous mismatch, which we don't fully understand the ramifications. But we know we can match the surface for lots of defects by going lateral to medial or right to left. It doesn't have to be the perfect graft. For sizing, it's very simple. We correct for magnification. We use the medial lateral tibia and the femoral condyle. When we handle these grafts, if you want to maximize cell viability, one of the things that we determine is that if you undergo gradual rewarming to 37 degrees, that's the way to maximally maintain the fitness of the graft, rather than taking it out of cold storage and just plopping it in room temperature saline. You already heard about insertion. These do have to be treated with respect. The current instrumentation has actually been modified to the extent that there's about a 250 micron difference. So most of these grafts can be impacted generally pretty easily without disrupting or harming the articular cartilage. So I'll show you a couple high-level individuals, mainly because if you can treat these people, we can treat virtually anyone, the masses that come to our office, with symptoms and signs of articular cartilage disease. So big person, known trochlear medial femoral condyle lesion, he gets a double graft, the trochlear and the medial femoral condyle, after serial debridements, marrow stimulation, and so forth. This is the only thing that got him well and got him back for two and a half more years in the NBA. Same thing. NHL player. Very tough place. People say, well, this is really difficult to match and so forth. It isn't that difficult. If you pay attention to details and measurements, this can be done even in a freehand technique with a plug to treat a trochlear defect. Same thing. Very, very good treatment. Patient had previous marrow stimulation and has failed. We're using it as a salvage, and it works 75% of the time. We have to start thinking, why not a primary treatment? We've also shown, a number of authors have shown, that return to sport, the highest level individual goes up to the level of 88%. Larger lesions can be treated, and there's been some interesting discussion now, should we, what we showed is that the unicondylar snowman graft, where you book them together, was slightly inferior to a single plug. Obviously, those are larger lesions. Multifocal grafts, different sites, look just like single grafts. So large degenerative lesions are a tough problem to solve. Maybe we can use this sort of bio-uni concept. But single focal defects, multiple defects, do as well, treat with single plugs, even if you have them in multiple compartments of the knee. So very versatile. OCD, the best success we've seen is in the primary treatment of OCD that's symptomatic, 90%, and that's juvenile and adolescent. Another example, when you're malaligned, this is a very high level individual, had valgus and isolated defect. It's kind of a chip shot, because you have the osteotomy that you can do. Same thing, 24-year-old, very big guy, NFL lineman. Multiple defect, he's in varus, and this guy was even medial meniscectomized. We decided to take the step, because he was malaligned, just do the realignment procedure, give him a graft and see how he does, because we were pretty certain he would torture his meniscal allograft, was able to get back to play. So obviously, if you can do it in this individual, why can't we do it in most of the people who come to our office? And what we've learned is that with osteotomy, the return to work in pretty tough, high level labor individuals is very predictable, 89% after an HTL or an osteocon allograft return to work. What about after a meniscectomy? It has demonstrated success in this population as well. Young woman undergoes a meniscal excision, six months later has joint space narrowing in this disease. We found that the survivorship, if you have to put it in a meniscus, with a meniscus is 85%. That mirrors the survivorship with an isolated osteocon allograft. What about obesity? Some of these procedures are very weight sensitive. An osteocon allograft has proven to be the least sensitive to BMI, and we showed, even in patients who have BMI up to 35 can still respond favorably. Similarly, we've seen a gender nonspecific, no differences, and even patients when properly selected over 40 can do very well. So overall, all of these authors on the bottom deserve to be considered and congratulated for what they've reported in the literature. We've seen a 75% survivorship at 10 to 15 years. That exceeds virtually any other procedure in the literature. We've also shown that even if you have to re-operate on them, 82% of them will still improve. So certainly a high re-operation rate, which is common in this population, up to a third for example, 82% of them still improve with a simple debridement. And finally, if they do fail, so what if this fails? We used to say if you fail the primary procedure, go to an OIGraft, and it was catastrophic if an osteocon allograft fails. If an osteocon allograft fails, you can do it again in some instances, and it still has an 89% survivorship. So what have I learned? Shallow grafts are probably key, 6 to 8 millimeters in depth. Correct the comorbidities, and it can be done in patients that are well-selected over the age of 40, even with BMIs up to 35. We've learned that patella-femoral plugs are as good as femoral condyle plugs. They rarely undergo catastrophic failure, and if they do, they can be revised. And survivorship at 10 years now is greater than 75%, even at 15 years. And return to sport exceeds 75%. Thank you very much. Thank you.

articular cartilage problems

skillful neglect

defect size

osteocondyle allografts

malalignment and meniscal deficiency