All right, welcome, everyone, to the happy hour. There are no drinks at this happy hour, but it is happy. All right, we're going to switch the PowerPoints back over. I'm Rachel Frank, joined by Aaron Kritsch and Brian Cole and Paul Caldwell, who has another engagement, but he is available for questions about all of these cases. At the end, I will hand his cell phone to everyone, and he's buying drinks for everyone tonight. So, how many of you, first time at ANA? Just curious. So, a lot of repeat offenders, great. How many attended this ICL last year? Okay, good. So we'll have a good mix of discussion. We welcome your feedback. ANA will collect surveys and feedback data for you, and they take that into account for ICLs for the subsequent years. So if you find this valuable, let ANA know, and if you'd like changes, of course, let ANA know. This is meant to be completely case-based. We'll go as long as you're still here, but if we end a little early, that's completely fine because we know it's happy hour o'clock, and we have the reception tonight, but we'll get started with some cases. And we designed this symposium, this ICL, for several years now to be strictly case-based, so no didactics. We're just going to get right into the cases, and we'll kind of go through the content as we go. We all have financial conflicts of interest, but none directly related to this presentation, but they're all available through the Academy and the ANA websites. So we have Dr. Cole, who's a mentor to many here and many around the world, but is my personal mentor, and I've gotten the opportunity to scrub some cartilage cases with him, and it's truly an honor to have him as part of this panel to share his wisdom through lots of different cartilage procedures that he's done. And we have, sorry, the mic or the battery's gone. We had Paul, but he had to leave for a different engagement, but he's been an expert and a mentor as well in cartilage restoration and repair for so many of us, and throughout many ANA courses and meetings at the OLC. So if you see him, pick his brain on cartilage. And then Aaron Critch, who's become, you know, he's been a mentor, but become a great friend over the years. We've gotten, we were just talking before this, gotten to travel internationally together and talk cartilage, meniscus, and all things sports medicine and knee surgery. And he's become, again, a great friend. So I feel lucky to be up here with these guys. So let's get started. I have a few introductory slides, and then we'll get right to the meat of the talk. So cartilage pathology is common, but I think the number one thing we would all tell you is that we treat very little of it. We see a lot of it, but treat very little of it because it's not very symptomatic in most patients, despite seeing cartilage defects in many patients that we scope. So the first answer is no, not all cartilage lesions need treatment. I showed this slide earlier yesterday, and I think it's important that we understand that whether it's meniscus, cartilage, rotator cuff instability or whatnot, the key for us is to manage expectations. I like to over-deliver under promise. And if you do it the opposite way, you're going to have some disappointed patients. You've got to be able to evaluate these patients. So for each of these cases, we're going to presume that all of this workup has been done, x-rays, weight-bearing x-rays, PA flexion views, alignment views, MRI, and then to really diagnose and understand a lesion, you can do arthroscopy or needle arthroscopy. You've got to consider the whole joint. Can't just treat cartilage and call it a win if they're malaligned. You can treat a malalignment problem with an osteotomy and call it a win, but you can't treat a malaligned plus cartilage problem with a cartilage solution and call it a win. So you've got to really treat the entire joint. We have a lot of options in our toolbox. This is how Dr. Cole trained me and so many others to think about it, kind of in these four buckets. And I still use this with my patients today. The simple scope, the palliative options, that's the scope, debridement, loose body removal, the reparative options, that's your marrow stimulation or marrow stimulation plus your reparative options. Those are your cellular treatments, either autograft or allograft. And then your reconstructive options. Those are your osteochondral solutions, autograft and allograft. How do we pick? And we're going to go through that in the cases. We use all of these factors here. And in particular, in the era of 2025, where we really have to think about cost, cost comes into play here as well. And then availability might not be the same internationally as it is here in the U.S. in terms of some of the techniques and technologies that we have available. I think one of the keys to understand, and I use this analogy to my patients all the time, is are we filling a pothole? I can pretty readily do that. Or are we repaving the road? And I can't really repave their road. So if they have a ton of arthritis, bipolar arthritis, that's a gravel road. I can't really fix that with the solutions other than osteotomy that we're going to talk about. But we can all fix potholes pretty easily. And that's where it becomes a lot of fun because we can figure out what is the right solution for that pothole. Don't forget about the non-operative treatment. We're going to talk surgery here today because we're at Anna, but non-operative treatment is a big part of what we all do and recommend. And it works for many, in particular weight loss, decreasing the load, changing the alignment with unloader bracing, and potentially biologic injections. So let's get to some cases. Actually before our panel, anything to add that I missed? And by panel, I mean the two gentlemen to my left. That was a great introduction. We're good to go. All warmed up. All warmed up. Ready for some cases. All right. Aaron, so this is a case of yours. And I think this is a great case to warm us up, get the cartilage juices flowing. So this 25-year-old woman presented to you with some mechanical symptoms, catching, no instability, failed non-surgical treatment. So coming to you for a definitive solution. Tell us what did you recognize here on the MRI? Well, first of all, before the MRI, I think, particularly with the patella femoral joint, but all cartilage patients, you really need to figure out those background factors as you talked about, particularly in the patella femoral joint. I spend much more time looking at their exam than I would their imaging, but obviously both are important. So here we can see, again, she's got this medial facet kind of lesion, which is kind of an odd location for a chondral defect on the patella. So first of all, you're just figuring out, gosh, did she have any previous instability? You ask her not twice, but like three times, are you sure you didn't have any instability? She didn't. She tracked well and had good mechanics overall. So you're kind of left with, gosh, what caused this? No trauma history. I think some of these might be kind of some OCD variants on the medial patellar facet, but those were all things that were going through my mind as I'm evaluating her. So before we get to what you did for the audience, you heard everything that Erin just mentioned. She's failed non-op, let's presume injection, physical therapy. She can do a nice single leg squat. This is not a quad inhibition patellofemoral pain type problem, and she's got this legit chondral defect bordering on an osteochondral defect. Who here is going in the audience to a simple scope alone, call it a day? Who here is going to definitive treatment in some, not definitive, a transplant of some sort, either autograft or allograft as a single stage? So going to surgery and doing some sort of definitive treatment for this cartilage lesion. So no one. I guess that's what we're here to learn. Nobody's doing anything. Everyone's ready for happy hour. I think this is such a simple case in terms of what Erin ended up doing, but I wanted to start with this case because we see this all the time, whether it's the patella, the femoral condyle, patients come in, you know that there's a problem, they failed non-op, you're going to take them to surgery. And the question in our mind is one versus two surgeries. And that's, the patient's always going to want one. They're always going to ask you for one. Even if the one is the more definitive one and the more invasive one and the one that requires a longer rehab, and quite frankly, the less predictable outcome, that's typically what they want. And our job is to talk them through those options. I might take issue with that a little bit. Tell me about it. Only to the extent that there are patients who are okay coming back, and this has been the subject of a lot of work that we've done that you're familiar with, but there's so many different things that help them make a decision. And timelines are really important. And some people are willing to, a scope is a pretty easy thing. And in this instance, it's very likely to work based upon the subjective symptoms and location of that defect. So while many might have a reconstructive option for this out of the gates, patients might accept two. That's where I'm getting at. I think that if they understand what they're weighing one versus the other, I have patients frequently say, you know what, this, and I try to do it in a very unbiased way because sometimes I really don't have a strong preference. We use this analogy like we're waiters telling them what's on the menu, what they're likely to experience. Do you want to walk out of here a little bit hungry or do you want to be totally stuffed and postprandial? And a little scope as you're still hungry but satisfied versus a big, hitting with a stick of dynamite, which might solve the problem in the end. So I don't know. So what I thought I heard you say, and if I misheard you, was that most people would just want one surgery. Sure, ideally they would. But when you're weighing the magnitude of the surgery, they may actually choose something different. Would you agree with that? Yeah. I think a lot come in, especially if you're a second opinion, wanting that definitive treatment because they think that that's best to fix the problem. And you have to spend some time talking them through the menu options in terms of why the more simple appetizer might be enough to fill them up. I like this analogy. Yeah. I'm going to keep rolling with it. I like the analogy too. But I would say where we're at, we see all of these failures in cartilage and unfortunately you go back and you try to find their index MRI and you see things like this and you're like, man, if they just would have had a scope first, they might have been okay because a lot of people are dropping osteochondralografts and when those fail in the patella, it's a big deal obviously. So we kind of just talked through these options. I think that's more what I was thinking about is I see so many patients where they had a definitive transplant of some sort or even a microfracture and they're not doing well and you think, gosh, you probably could have had a non-surgical approach if they didn't try an injection or a simple scope. And now some bridges have been burned. So this is what you did, took them for a scope. Any pearls for a simple chondroplasty, any portal placement pearls, because again, this is the most common surgery that we do. Is there anything you do differently for these patella lesions versus ephemeral condylesion? Not really. I think you just have to be thorough. As with any cartilage procedure, you want to look at the synovium, you want to look at all the compartments carefully, the meniscus. Here this patient had a loose body in the back of the knee. So I think as cartilage surgeons, we're always being very thorough and really assessing that joint and we kind of get a sense of how this is going to go. I mean, if this joint has synovitis everywhere and there's multifocal cartilage defects, very different picture than this very bland looking knee with a loose body and a cartilage flap. Yeah. I would tell a patient this is probably going to be a minimum of 75% or probably higher based upon the subjective complaints. And this just shouldn't lead to a lot of anxiety or uncertainty. Nothing is certain, but it's about as certain as a transplant and someone who actually needs a transplant. So that's the definitive treatment. I think the patient did well as far as I know. And I think the take-home point from this case is a simple arthroscopy is enough for the vast majority of patients that we see. So despite us all wanting to talk about and do the sexy cartilage restoration, this is the most, at least in my practice, but I'm pretty sure in these guys' practice too, this is the most common cartilage surgery that we do. And it works in the vast majority of patients. How many of you in the room, how many of you in the room are surgeons and we're going to take your question? Okay. And then of those surgeons, raise your second hand if you routinely go posterior, medial, posterior, lateral as Gilquist described arthroscopically. Be honest. Okay. Is there anyone who doesn't do that routinely for cases like this? Yeah. You'd be surprised how much you'll find. Anytime you're dealing with a cartilage problem, I think just go to the back of the knee. You'd be surprised how frequently you find something because those things could be hiding there now and may not cause problems, but they can emerge and cause problems later on. And you can save patients a whole lot of headaches. So pretty easy to do and we can take it offline. But looking posterior, medial, posterior, lateral, switching your portal, that's the only time you really need to switch your portal is if you want to go posterior laterally, you'd want to put it on the medial side if you start laterally. It's a good thing to do. No, no, I didn't suggest posterior medial portal. So as Gilquist, so I think you don't need a 70 degree scope to do it. So you go from the front and if you're on the lateral portal with your camera, you go between the PCL and the medial femoral condyle with the knee and a little bit of flexion. And you can do it with the trocar and the sheath or sometimes just drive the camera back the way. If you can't get there, just take a shaver and clean up that space. And then similarly, if you want to go laterally, you put your camera in the medial portal and you go across and you skive against the condyle and you go against just by the ACL. And you can do that with a 30 degree. And then what I'll do is I'll just turn the suction on the shaver, I may turn the inflow off or keep the inflow on and turn the suction on to pull something towards me that I might not see. But I think I just hate changing things around, meaning changing a lens and I don't think you need a 70 to see everything you need to see back there if you're looking for a loose piece. That's the only thing that's really back there. Yeah. Yeah. Got it. So sorry. Yeah. Yeah. I want to make sure. Thank you for asking us to clarify. That's all right. I've never done that. Just making sure that TTTG is okay and is there any clinical instability? Yeah. I mean, he said that. Yeah. So for this patient, again, being patellofemoral, we have to spend a lot of time being careful about that, looking to see if they've had any instability, maltracking, et cetera, and she did not. But I don't think the... It's like people get alignment films on every patient. I mean, if a TTTG was through the roof, I'm not sure it would change any of our judgment in the absence of complaints of instability. Correct. We're not looking for anything more than this. We'll get to two questions, but two technical pearls. So if you're not routinely going into the back of the knee, the way Dr. Cole described I think is super efficient. For our younger surgeons and our fellows and residents who I'm often letting do the diagnostic scope before I get in there and I expect them to tell me about the back of the knee, but I don't trust them to get to the back of the knee. Agreed. I have the scope in the anterolateral portal. I take a switching stick from the medial portal and I just pop it right between the PCL and the condyle and then I put the scope over the stick. If I see a loose body, I'll do what Dr. Cole said and turn the suction on water off. But sometimes that loose body is too big to come out. So then I know the loose body's there. I pull the scope out. The scope's now in the medial portal. I'm going to put the switching stick in the lateral portal, do the modified Gilquist, go between the ACL, excuse me, the PCL and the MFC to get into the posterior medial compartment. Do the same thing with the scope. Scope over the switching stick. I've now assessed both portals. What I'll then do is now my scope's back in that anterolateral portal. I'll take the Yankauer suction from like an open suction case, the ortho tip Yankauer suction. I shove that into the posterolateral portal where that loose body was and that has a bigger aperture than the scope trocar and I'll put the suction onto that and that usually avoids the need to make a posterior medial portal or posterolateral portal to get the loose body out. So that's just one little trick. Yeah, and I'll sometimes put a shaver blindly making sure you don't touch synovium. You've got to have a little faith and or I'll put the shaver down the camera sheath but if they're too big, like you can't because of Bernoulli's, you can't just open up your – turn off your inflow, turn on the suction on the shaver. It just doesn't work. You go back there and it's still swirling around. So that's a good technique. I like that. So you don't – it's nice not to have to make another portal if you can avoid it. Sometimes they're just too big and you have to. Would the patient complain? Probably not. Yeah. It's probably on the edge. Yeah. Patient will do great. Like these lesions with patella instability, they hardly, if someone who, that happens dramatically, they hardly ever come to pass to become symptomatic. I was kind of surprised, though, that it was an option, because I didn't think it was going to be that easy. That's a good question. Would that still be recommended to you, or do you just want to talk about it? Yeah, I would not, because I'm so confident this patient's going to do well, and I just don't like dragging varicella through a bunch of biopsy, no implants. So I just think this patient's, you know, it's just so, and this is not, I can't think of too many times in my life that I've ever treated that lesion with a cartilage procedure, you know? I mean, this patient had a, really looks like, like Aaron said, like an OCD neophyset, and it's almost non-weight-bearing, you know? Do you want to share your data on the biopsy? Oh, yeah. So we, there's a couple of studies like this. You have one, I think, too, right? Or is it ours? With you. With me. Okay, sorry. But we had 44%, we, biopsy people, no implant, 44% went on, never needed anything further. So early on, I used to do a lot of biopsies and started to get fine-tuned that, you know, it's 500 bucks for a kit. You don't get reimbursement for that. And you're clogging up, you know, from a varicella perspective. And they have a business model. They would like not to have a lot of these biopsy holds. So we try to do it responsibly. But 44% of our patients never came back for further treatment. And now we have, we have so much data now on debridement. Like, I can tell you, it's almost like AI. Like, I can tell you, if you give me these five independent variables, who is likely to do fine and not have to go on anything else, you know? So this is one that all of us are like, yeah, this is good. Let's put you on the schedule whenever we can get you on. Highly likely to be back within four weeks. I mean, this is just a feel-good case, you know, I think. And I would not plan for implantation. If you have to, you have to, but, you know. And of those 44% that didn't come back, of the ones that did come back, it's not always Macy. So there's other treatments. And so I think that taking a biopsy sometimes makes you think as a surgeon, I should just come back and do the implantation. And you're treating a lot of patients who would never have been symptomatic. So I think for that reason, you probably didn't take the biopsy because you didn't think they would need it. I understand the thought that you always have it, but for the reasons Dr. Cole mentioned, that's not necessarily fair. Not that we have to care about that per se to the company, but I also think it may bias your treatment decision a little bit, because you might feel compelled to go do the transplant and it might get in the patient's head as well. If this patient has significant bone marrow that's associated with that, really blew up that set, would that change your decision making? You mean for future treatment or for now? I'm just thinking about how she's gonna do it. No, not me. Not me. I mean, again, it depends on her symptoms. Like this one, I think what made Dr. Cole so confident was the catching was her primary issue. Like when she'd go up and down stairs or do a straight leg raise sort of thing, but really pain on level ground and things. Some of those other associated symptoms of bone marrow in the patella she didn't have. Let me ask both of you before we get onto the next case. I think a lot of people, at least in my community, are tempted to do what you did and then poke a few holes to stimulate the marrow. Not necessarily change the rehab. And for cartilage growth, we know rehab's really important. What do you guys think about that? Does it burn bridges? Is it something that, eh, if you do it, you do it. If you don't, you don't. What are your thoughts? Okay, so I'll be quick. So when patients have debridement of marrow stimulation of any sort, one of many things, but the two most common things are they get immediately better in the first four weeks, like this patient likely will, and they stay well. Or they're getting better and they have that trajectory, but they still continue to get better after four weeks. And the reason is that marrow stimulation doesn't make someone better in four weeks, right? But we had so many patients early on who had marrow stimulation that got better right away and were like, this is a great operation. It's because you debrided them. So if, what I tell patients, and this happens in a high-level athlete, I don't generally drill anymore. What I'll do is I will have no problem taking a curette. You can do a shaver, like Lanny Johnson described for abrasion arthritis, but just be careful because you can get all these on the leading edge and you can turn something on that wasn't meant to be turned on. So use a curette and get through, just let it pink up but do what Rachel said, just treat them like a debridement. And what can happen in that patient, they may say, I'm better in four weeks, but then they say, you know what? At six months, like I continue to get better. And that might have to do with fibrocartilage fill, okay? So I have no problem doing that as long as you're gentle. And I do that, I've had a number of pretty high-level athletes recently that were like, you know what? Let's just do, we're gonna get all the stuff out of there, but we'll be a little more aggressive. Not gonna, we're not gonna call it a microfracture marrow stimulation unfortunately that can condemn an athlete's value quite frankly, but they may actually get better on the second timeframe rather than just the first or they may, it may amplify their outcome after the first four to six weeks over time. Does that make sense? Yeah. And the great thing is you don't have to protect, you know, their rehabilitation is a knee scope. You know, you don't have to protect. Right, treat it like a knee scope. Okay, Dr. Cole, this is gonna be, nope, not your case yet, but you have a fun one coming up. This is a different case, 38-year-old male, right knee pain, swelling, catching for years, no prior surgeries, he's failed injections, he's failed bracing, symptoms are all localized to the medial joint line. He has a BMI of 24, subtle clinical varus bilaterally, so some might say physiologic varus. He's otherwise stable and his only provocative finding is some medial joint line tenderness to palpation. These are his radiographs, again, 38-year-old male, pretty Colorado active. He does hiking, skiing, et cetera. He works a desk job and it's his right knee. I would say these radiographs look pretty normal. These are his standing alignment radiographs and this is his varus bilaterally. So before we get to his MRI, does this alignment make you, Aaron, concerned about anything with this patient? Or is this just this physiologic varus and call it a non-factor? I mean, it was physiologic varus and now it's varus in a symptomatic medial compartment. So yes, I worry about it and depending on, you know, the rest of the lesion characteristics and things, that's something you definitely have to take into account. How many in the audience get routine alignment films? Okay, good, about half. So if I were to go to this x-ray, Dr. Cole looking at his AP, does that look like significant varus to you? Would that be something you'd worry about if you didn't have an alignment x-ray? I'm not ready to worry about it, but I might worry about it based on how we move forward. So yeah. Okay, this is his MRI. So, and Dr. Cole, I'm always going to call you Dr. Cole, so I guess I'll call Aaron Dr. Cooch. She refuses to call me Brian, it's terrible. A-A-Ron. A-A-Ron, all right, perfect. So Dr. Cole, we've spent time over the years and I think philosophy on load and bone has evolved over the years. You know, he clearly has a chondral defect of the medial femoral condyle, but it's not that big and it's not that exciting, but he's got this load on his medial femoral condyle that you see on the MRI with a little bit of cystic change poster medially. What does this mean to you? And how does this factor into your next steps? Yeah, so I, you know, we kind of, it's not OCD. It's not likely AVN or SONC. And I don't think, and it may be all, like you say, Rachel, load or just some type of increased metabolic turnover in that area. So this is where I'd probably ask a lot of questions of the patient in terms of the timing of his symptoms and what he or she was doing when this started. I'd have to know a lot more about the patient because I would, and I'd like to know if the symptoms are more sort of bony. This is a hard one to get. This is where you synthesize a really important history with lots and lots of questions because I'm thinking surgery is, in this patient is gonna be somewhat involved and or unpredictable, at least for the first surgery. So I would love to figure out a way not to operate on that patient if we could. And I'm not sure, it doesn't swell. So I need, I would need, does the patient swell or have effusions? He can't tell if he swells. He's fairly thin. I know guys don't like to be called thin. He's svelte. He's fairly thin. Yeah, he's had it for years, medial knee pain, but now he only got 13 days of steam and it usually gets 33. So it's years of weight bearing, so it's like weight bearing load pain? And some mechanical symptoms. What he reports is catching, but who knows? His exam's pretty nonspecific and he had a PRP injection, got a little better, then no difference. Yeah, so you're thinking, sir, I don't think, yeah, you could try to brace him and things like that. He's just not a ton of errors. So I'm thinking surgery. I'm not sure I'd have anything non-op that's gonna reliably work with years of knee pain that's load related like this with those findings. So this is probably gonna be a stage one for me in terms of, hey, let's hold our breath, see what we can do. And the only thing I might add is to treat the bone. And this is where I would use this new procedure, this Osseo situation. I would think about that if I felt the bone was contributing to the pain. And that's using a sort of a mineral fiber implant that turns into bone that we use as a strut across it. It's another theme on subchondroplasty, if you will. Many people in the days of subchondroplasty, when it was very big, would probably, might be thinking subchondroplasty for this patient. But the edema is not a lesion, it's just a sign of a failing joint transferring to the bone. And none of us have any idea how long that's been there and when it became relevant, if it is even fully relevant. So this is a very hard case. So A.A. Ron, this patient, it's May. He just had a mediocre ski season because he only got 13 days in. He really wants to ski next year. He's someone who goes on opening day around Thanksgiving, but he's okay to wait until after the holidays. So we have kind of a six month window right now. And he's like, doc, I'm all yours. I'll be the most compliant patient, but I need to be skiing by New Year's. That's my goal. I have to be skiing. It has to happen. I will pay you cash to do whatever you need to do. I will get you a bottle of Screaming Eagle. Make me better. So at age 38, with this request from the patient, which doesn't mean you have to honor it, but I get these athletes all the time. You guys all get them, right? I got a season next year. I got skiing. I got a wedding. I have a vacation. Whatever it might be, they always have not enough time for you to do what you want to do. What are you doing with these three options? Yeah, the tough part for me, what makes this challenging is A, we don't know why the edema is there. And then B, I often struggle in this case to know what does the surface look like? So if I knew definitively what the surface looked like, for example, if the surface were not intact, well then any sort of kind of bone procedure alone is not gonna work. So then I'm probably leaning more towards an offloading osteotomy and ocealograft. If the surface is intact, then maybe under those circumstances, once a quicker rehab, maybe we try to do something to the bone alone first and see if it heals. That's relatively less invasive and you haven't bought the farm either, recognizing that the success rate is not 100%. Yeah, this is one I bet you're gonna needle scope in the office because Aaron's observation is accurate. I don't know if you can do that or not, but if you're not, this is one that might be a good place for that. So you don't all have the drama in the operating room. And his point is absolutely, I think, accurate. You can sometimes judge if they swell or not. And that's why I always ask about swelling. And if his primary complaint was mechanical, like if this is what you saw at surgery. Yeah, this one, look, discount it. I think this could get better by doing what you, I've had many people get better and you could decide to throw something on top of that or not. And I kind of like the idea of just add something to the bone too for this. And if you microfracture it or whatever, I don't think I, and then you'd come back. You're just trying to be one and done, it sounds like though. For me, this was a staging scope. So for the reasons you guys mentioned, I didn't know, his story doesn't really make sense. He's vaguely painful, still skied 13 days, even though it wasn't 30 days. I don't know, I told him a scope in my hands because I don't know, and maybe it'll get better. I didn't like the look of that cyst on the MRI. I didn't know why he had that. And I just, you do enough of these, as you guys know, probably that cartilage is not going to be normal, even if the MRI is not catching it. So for me, this was a staging scope. He got better with his mechanical symptoms, but continued to have pain. And that was important to me to understand. His catching, so to speak, went away, but continued to have medial pain with weight bearing. So now what? This is an OA graph with or without an HTO. OA graph for you, with or without HTO? I'm going to do both. Just one more point about the, that kind of unexplained bone marrow edema. This is a guy I would, you know, we have bone endocrinologists. I would probably send him for an evaluation. Sometimes you come up with some strange, like hyperparathyroidism, vitamin D issues, et cetera. But I would, for me, I would do the offloading osteotomy because of the diffuse edema pattern. That scares me a little bit with just putting dead bone back into kind of that dead bone state. So I'm going to offload him with an osteotomy. That's true. Would you guys have taken a biopsy at that staging scope? I wouldn't, given his age and the bone, I think there's a good explanation for the bone findings. I'm not worried about something else, but I respect that. I just, I think, I think, I think osteotomy is a good idea because this is such a load thing, but you're doing the osteo, you have to ask yourself why you're doing the osteotomy. This is, we can talk about this for an hour. We're not gonna, but you, are you doing it? Once you put an OA graph in there, he's likely to be better, in my opinion. So are you doing the osteotomy to protect the OA graft or to, because you don't think it'll get better if you don't do the osteotomy, you know what I mean? That's the kind of thinking I'm, because I don't know if it's definitive osteotomy with that degree of varus or not. I will say I use a minimum of five. If I can't get them to neutral with five, if they need less than that, I'm not wasting time with an osteotomy. My own, that's my own personal algorithm. So if five gets them, five or more gets them over, I'm good. But if it's just a little dinky thing, I'm not doing it. So why would you do, let's say, I know we all talk about it and I do a ton of them, but I'm asking you, why do you feel, what's the role of the osteotomy? Because that's the way to get them better or because you wanna protect your OA graft or both? I think both. What makes me a little uncomfortable, and maybe this is my insecurity in this case, is I can't explain why that bone edema is there. Like I can explain why the cartilage is bad because of the bone edema, but just, I mean, that bone edema is pretty diffuse. I know, but you would question it more if the cartilage was intact. I think the fact that the cartilage is not intact, that's a very good, like it is, I think it is, we've looked at a lot of bone marrow edema. I think it is very common to have a zone of edema that's bigger than the zone of injury in the knee. And I'm sure you've seen that. Like that is very common and you can't, I have no explanation on the fact that the joint has failed in load transfer or load sharing in a way that you and I can't appreciate why it's doing that. Does that make sense? Yeah. For the audience, yeah, go ahead. Yeah, sorry. Yeah, he just said at page 22. No, I don't use age as a criteria. I think if you really believe in osteotomy is needed for whatever reason, A, it's needed to get them better. B, it's needed to, as an amplification to the outcome that you would otherwise get if you just did an OA graft or whatever you're gonna do for it. Or if you, yeah. So I, or if you're just trying to protect the graft, which we've done that. We've had patients that have failed and we add an osteotomy later on. Sometimes mine, sometimes other people's patients. So yeah. Quick poll of the audience. Who would do an osteotomy with AA around here? And the wisdom of Dr. Cole, maybe not an osteotomy. Yeah, I didn't say I wouldn't do it. I'm still thinking. Okay. I'm honestly, I haven't decided. I'm going all in, osteotomy. I would ask him a lot of questions, but I don't have a problem doing osteotomy. What do you think I did? What do I think you did? I think you did the osteotomy. Yeah, I, what do I think you did? I just did this. I just did BMAC. You did? No. No. Let me think what you did. Just talk to us about background factors, Dr. Cole. I think you, I don't know. You gotta think. I don't know what the hell you did. Come on, get it. They both could work and we'll never know because you're going to do one solution. Tell me what I did. You did an osteotomy-away graft. Oh, I don't know. Did you have a question over there? Not the way this was delaminating. This is delaminating because of bone edema, at least in my opinion. I don't know, I might, I'm gonna say I don't know. Erin's smarter than I am. I just, here's what I know I don't see very often, is knee pain with isolated edema with intact cartilage. I can tell you that. Thousands and thousands and thousands of patients, 25 years, I have not, I definitely have seen isolated edema with intact cartilage, but it is not common. And this one was bone edema, small cyst, and cartilage delamination. So for me, that combination. That may be, yeah, that may be. That's a story you can put together. All right, so I took him for surgery. I did a little biologic here, little fresh osteochondral allograft. So for those who don't do this or are not familiar with this, you can order fresh plugs that are size 16, 20. There's gonna be some different options available. You can order a hemikondyle, which is the most common graft that's ordered, and that's what I ordered in this case. Multiple different companies available to help you do this. This company included that I'm using here has a tray system that you can actually use to steady the graft. I was trained by, again, Dr. Cole, who had a trustee, who has a trustee PA team who can hold the graft for him. I'm very lucky to have a PA who's willing to let me sacrifice his fingers for my patient's benefit. And so we do this freehand. So there's many different ways to do that. It's a bit more efficient, but you need a good assistant to do it freehand like this. But that's the way I learned, to be honest. If you haven't done it this way, I wouldn't try it. At least on the first patient, I would try it in the lab. Here we're using pulsatile lavage. Now we're using carbon dioxide gas to help clean the grafts and then soaking the graft in the biologic. We've done a little medial parapatellar arthrotomy, and you can think about your incision management for the future total knee that he might get for the osteotomy that I did at the time of the surgery. I see the incision line there for osteotomy, by the way. Yes, and then you can put the plug in. I put a piece of suture tape behind the plug when I'm planting it in. Try to use minimal force, little light taps, not big time taps, or just thumb pressure. And then you can slide that tape out. It always slides out. You don't have to be worried about that, but if you don't like your fit, you can use the two ends of the tape to pull the graft out without trying to lever it with a freer, et cetera. I find that really helpful on the patella especially, because that can be unforgiving, and I've learned that the hard way. And then I like to do my cartilage before my osteotomies, because you often have to hyperflex the knee to get access to the cartilage defect, to ream appropriately. And while I'd like to think that I'm an amazing osteotomy surgeon, and my plate construct is super sturdy, I don't always trust it. And so I don't wanna hyperflex that osteotomy in particular. If I'm doing an opening wedge, and I have an unseen fracture, which actually 33% of HTOs have some sort of non-displaced fracture that you can only pick up on CT, you wouldn't see it. So that's my order of events. And this is when I was using a peak implant for my osteotomies. Did a small correction. If you're not familiar with this implant, it's an all peak implant. The little black dots are the four screw holes, two up top, two down below, and then at the osteotomy site that marks the inner and outer portions of the implant. Aaron and Dr. Cole, sorry, Aaron, Dr. Cole, do you do that same order of events? Do you like to knock out the osteotomy first, because that's harder, get it out of the way? What are your thoughts? Go ahead, Aaron. Go ahead, please. I would do it exactly like this. Yeah, this is a really good workflow. It might work fine the other way, but I don't know why this makes sense. Yeah, so I'll save the bone from the reaming. So that's kind of fun. So you get a little extra bone graft. And then I will, the other thing we do differently now is we often will take the hemicondyle and put it under, say, I'm gonna give a talk tomorrow about like some translation stuff. So we'll take it and put it in the blue specimen cup, put a couple blue towels, and use the buffered solution that the graft comes in and submerge the graft completely. Adam and I did a study, Adam Yankee and I did a study looking at, you always think about thermal necrosis in the graft on the edges. So you irrigate the hell out of it while you're doing it. But the reality is we saw thermal necrosis across the top of the graft, thinking we were irrigating it really well. So there's still quite a bit of heat that gets generated. So now we submerge the entire condyle. Not everyone's gonna be comfortable, like Rachel said, doing this, but the jig is also can be a little unpredictable too. I can't, I don't even, I'm like, don't even take it out of the thing. I don't wanna see the jig, but you gotta be, just be careful. You only get one hemikondyle, and you can get two grafts out of it, but you're not planning on getting two grafts out of it, probably the way you do it. So you're only gonna get one, if that makes sense. Because if you're planning on two, you have to do it differently. So at any rate, those are just some pros for that, but that's a good case. And we'll never know if you would do well. Let me ask you, why do the osteotomy? Because that's, it's dogma, but why did you do it besides dogma? I think because he continued to have pain after the scope without having the mechanical symptoms. I didn't re-MRI him, because I don't know the value of that, but I think that load to me with his varus meant that this condyle is not responding well to his physiologic load. So I wanna change his physiologic load to neutral. So I wanted to protect the cartilage and protect the bone. I just wanna say, because Dr. Cole talked about the reamings, you know, don't ever use graft, bone graft from your fresh graft. That bone is immunogenic. There are cells in there. You don't want that at your healing osteotomy site. And, you know, I do worry about infections with that as well. So I would not use the bone from your fresh graft for the osteotomy bone. I'll have to unwind about 20 patients then, because I've been doing that. So I pulse lavage it for whatever that's worth. It just, it saves like over a thousand dollars. And I just didn't, people have been using cortical grafts, they're frozen. So I take a wedge in front and back, and I use Kinsella's chips that are anhydrous. So your concern is infection. And what else? Well, that's, you know, it's just bone with alginate, you know, cells in it. Yeah, I mean, whatever it's worth for me. Yeah, they centrifuge, whatever it's worth, they centrifuge the graft, which has shown, but it's not high speed. So what the tissue bank does is not high speed centrifugation. So they centrifuge the graft, and that supposedly gets rid of some of the marrow elements. Then we pulse lavage it. So haven't paid, I don't think we've paid a price yet doing it. And so we did it for a cost thing, because I was always opening an iliac crest wedge, putting in front and back, and I recently thought it was the greatest idea ever. So I've done it for the last play 20. So maybe I shouldn't do it anymore. I don't know. Hope I didn't jinx you. Yeah. we've got data on that so essentially you never have to take this out you can do a primary knee through this like it's not there at all so it actually saves in our series metal and metal screws versus this metal plate and screws saved about a 50% hardware you know takeout rate so I like this implant for my corrections kind of under eight degrees and I've gone to using a different metal screw and plate construct for bigger corrections and really all of my corrections now just to have one company and one preference card for osteotomies a couple pearls incision management I think we have to stay humble and recognize even with ACL surgery that's probably not their last surgery so while before I was trying to get cute with two small incisions one for the cartilage one for the osteotomy I now make one midline incision if I'm doing combo cases and I just I make a big incision and that incision can be used for their future total knee the other pearl I was going to mention is with your graft while you size your graft and our tissue companies are pretty good at matching the donor X or the donor graph with the recipient x-rays when you size it or MRI I've been burned a couple times where I've gone to the cartilage and I've reamed out say a 22.5 circle and then I go to my donor and I can't really find a good spot let alone an anatomic spot to get a 22.5 and I really wish I had just reamed a 20 and so yeah check it first even if you know that you ordered the right graft and the tissue company told you the texts are just human the measurements are different and so I would say especially if you're gonna need to do a snowman with a double or triple or you're thinking about doing an oblong graft make sure that you can do what you're planning to do because the last thing in the world you want to have is a situation where you've reamed out a plug and you don't have a plug that you can fit in there ask me how I know about that the other thing I have on my pick list for these I rarely use them as metal headless compression screws so those are always on the back table if first or on the back in the back of the room if for some reason you think you're flush but you it's loose a little bit again not a situation you want to be caught in and you'd want to have some implants available to help secure that graft it's rare to do that but you don't you don't want to be without that what I mean what's top no don't don't first of all don't think you got to get rid of the edema like a lesion so you got to go deep like I've seen people excavate the edema put bone graft in and then put a plug on top of it okay I don't that's a no-no so we generally say the least amount of bone necessary to give you an inferential fit and most of us will like a total graft depth of somewhere of six to eight millimeters I mean it's not like an oats where you're doing ten to twelve to get stability those are usually smaller diameter plugs but the to Aaron's point that's where your antigenicity is that the bone is actually not it's it's not the most forgiving it's probably the least forgiving aspect of the operation and it's the area where we see the most problems not the cartilage you will see problems with the cartilage but it's not the most like I think you're gonna have a problem it's typically the bone you go all the way back to the tumor literature as well so and what's also interesting if you go back to retrieval studies sometimes the bone is not replaced by the host so so there's a lot of that we don't know enough about the bone but I'd say the general take-home is the least amount of bone necessary the only time I changed that a little bit is with the patella so the patella cartilage thickness can be six seven millimeters and you need to have a little bit of bone so you that the patella is the trickiest one to do I think although I think trochlea can be just as tricky but the cartilage thickness can be difficult there and sometimes my total graft thickness is thicker than six to eight simply because you need a little bone with that cartilage yeah yeah so Rachel said metal so I don't this is the one area I don't use metal I use a biocomposite screw which is a little bit of a misnomer because that takes at least a year to go away but I bury it and the reason is if the graft were ever to fail unbeknownst to you or me I don't want metal to be there so it's the same reason I always take metal out for OCD so biocomposite screws could be caustic too if they're if they're at the surface and you get any settling in OCD this graft is not likely to settle but if it ever did fill and you and I didn't know it there'd be metal so I use a biocomposite when it's when I'm not sure the the the pin you're talking about I think could be used as well I think that would be fine I I think metal gives you the best compression by far but I haven't been burned with like I cannot think of the last graft that I thought needed fixation that fell out or didn't heal like that was the risk early on we'd say don't burn a bridge but all of us do a graft so we just don't have a lot of you just don't see it if it fails it's not because a graft fell out or didn't you know heal sometimes they resorb sometimes you get you know but that's really rare it's it's usually something else for context I've had to use screws twice in my career one was a revision really bad bone and probably didn't need them but I was nervous and one was a patella that the graft and my reaming and technique was not perfect and I needed something to salvage this situation so I use screws for that and thankfully she's doing well a couple years out and that's a that's a technical issue on my part that I think probably could have been avoided but you don't ream it perfectly you're gonna have a potential problem I would say so I don't know how many OA grafts I've done but two times in my career that I've used screws so it's very uncommon but you don't want to be caught without them whatever screw you use all right we might have time for one more case dr. Cole oh the slides look a little I tried to format it so do it on Mac or as PC I did it on a Mac and I for I tried to reformat it but tell us the gist of this case we got 10 minutes yeah just do it quick so this is it's a public high level athlete so people know about this one and it's kind of a it was a tough decision-making case so I thought I'd do it but it's not about gee whiz how sexy this is I mean this is where it got really hard and it was like five opinions involved so basically he's a guy he's a guard and he can't play any longer because of medial side of knee pain and he had a meniscectomy in 2018 when he was in college and did fine and then he's then he his symptoms began in like 22 ish and at the same time he started to get delamination of his femoral condyle so he was functionally metasectomized we knew that he actually had a scope two scopes by someone else to try to get him better he did get better from one complaint but then this complaint creeped in we had medial weight-bearing pain his alignment was fine it was medial and he had so that's his menis that's this meniscectomy he had before we were talking about transplants and his cartilage was a pretty decent shape and this is a revision meniscectomy from 2018 so right there hoping he would get better with this surgery and he didn't the tibia is in good shape I think the articular cartilage is a pretty decent shape then all right so then he says I still had soft tissue pain and he ended up coming back again he almost could leave this part out but then we injected him with a local anesthetic and he could dunk a basketball so that was all soft tissue pain so then we went back to the operating room try to get rid of the soft tissue on the medial side that's all right keep going yeah and did an open soft tissue excision and he got that actually made him better with the soft tissue pain I have no idea what was causing this but we just did this what we did is we hit with methylene blue took out the soft tissue pain and he actually got better and then like three to four months later he transitioned into medial joint pain which is when did what led to his transplant you can go this is not probably that important so then he has not much no his alignment was good we were comfortable with his alignment and then literally before our eyes we saw a delamination happening on the femoral condyle so if you look at the 922 versus 923 you see that he started to get progression it may be easier and yeah so he was definitely getting progression and this has nothing to do with any other treatment he got to our knowledge and then we were stuck because he's look I can't play and he's already been out a year you got rid of my soft tissue pain but now I got this and that edema has been stable since 2018 by the way all right so that's just to give you a sense we have a lot of natural history on edema so we injected into that now we're saying are we sure this is coming from this because we're about to you know unwrap you know holy hell on this guy does it are we sure it's coming from the joint so we inject the lidocaine into the joint just to make all of us feel better and then he got four or five opinions and he had he got relief with the lidocaine in the joint foot if you if you value that as a test okay so keep going so then he comes and he's gonna have surgery now he has tenderness immediately and yeah no you know he basically has a pretty normal looking exam doesn't swell very much so the challenge here was you have a meniscectomized athlete who's been meniscectomized since 2018 who now has delamination on the cartilage with the turning on of symptoms along the medial femoral condyle and he plays professional basketball so just put it in a it doesn't have to be a professional basketball player but there were some decision points that were hard which is namely I think all of us would probably agree on what to do with femoral condyle I'll tell you his alignment was accepted we weren't considering osteotomy so the only other issue was the meniscus so it's almost like why are we doing osteotomy do we think we needed to protect the OA graft or we think we needed to make someone better we had the same question here do you have to replace the meniscus because you're you'd be a little bit you'd be a little resident reticent because of what he does to put a meniscus in so I'm just curious what you guys think about how you first of all do you have any problem with the OA graft for the femoral condyle and a guy who says I can't otherwise play I'm willing to take the chance if it doesn't work I know I tried okay to have cartilage restorative procedure so you guys are good with the osteocondyle graft okay would you think about any other procedure for the cartilage are you good cartilage we're talking about okay so how how do you intellectualize the meniscus part this is this is the hardest part intellectually and again this is I know this is pretty high-level stuff it's not gonna fall in everyone's office but this stuff happens in regular people too because we ask ourselves do we really need to put a meniscus in someone when we think the problem turned on because of the cartilage yes the meniscectomy status let may have led to that right he's had a team all along and maybe the edema then led to the failure to your point that was a situation where the cartilage was intact with edema by the way okay well it was visually intact but maybe biomechanic wasn't normal so go ahead yeah cuz he was starting to get some subchondral delamination yes he did reaching the surface that's great he definitely started delamination that's when we caught him as being symptomatic too yeah so what do you how do you think about the meniscus I mean it looked like the bone edema developed after that last minute no in 2018 it's been it's been for years he's had it for five years stable he gets him right every year yeah I mean I mean that is tough I mean in a normal patient I wouldn't hesitate to write his transplant but obviously you know high-level basketball player you know as you've told us then you make a meniscal dependent but for me I just I feel the reason he has that edema there is you know loss of meniscal function and you know again you've got one opportunity right he's taking a lot of time out to recover this is it for his career he's either gonna make it or he's not and I think I would I would tend to go all-in recognizing that you know there just aren't athletes that play professional basketball with with a meniscus transplant but this is a very unique situation Rachel what about you well how would you how would you navigate that intellectually as far as the meniscus I think what Aaron said is spot-on I don't know that there's a right answer and he's 25 he's a primetime player for the team that he's with this is a multi-million dollar athlete who's got one shot so if I'm doing an osteochondralograph that's a year recovery for high-level impact basketball yeah if I'm adding a meniscus to that there's no addition necessarily to that time but it's gonna be a more difficult recovery in the first three months it's gonna be more quad shutdown etc that's just a difficult surgery to recover from there is data on meniscus transplants in high-level athletes but not necessarily in the NBA and so I think this is not just I would treat it all like you did but it's easy to say that in hindsight because yeah it's interesting I was planning on doing does anyone have any other thoughts just before I tell you just to tie it together but I would say like this one Brian the you know like if you look at meniscus transplant candidates this is like one of the ideals salvage 100% tibia is not involved it's focal there's no extrusion of the supporting ligament so this is what meniscus transplant that's going to do well if one's gonna do well that's fair yeah go ahead that's that is what I was thinking so that's actually what I was was thinking that I could probably just because of how we became painful and things changed and we caught it changing that if you just fix the bone and cartilage will go back to his menisectomy estate and hopefully get rid of this pain if you have to do something later when he's done with his career so you could argue that so that he got a number of opinions and and there was one most people actually agreed with me and I didn't steer it most people agreed that just do the OA graft and then one person said oh like Aaron said well obviously he's losing his but you got to do both you know that's what common teaching is that's the dogma but you're you make decisions sometimes differently based upon the situation of the patient and again it doesn't have to be an NBA player it could be anyone you know if for various reasons you might not choose the whole package the way that I came down to is sort of what Rachel said and I think Aaron alluded to it as well as you got nothing to lose because he's actually a good camp for this is transplant and if he doesn't get better you're gonna be kicking yourself to say if I had done that too maybe that would have made a difference and the worst thing that could happen as he tears his meniscus transplant and I'll tell you that having one thing in college repair is that 35% of these people at least in our series will have another operation in the first five years no matter who they are and if it's just a meniscal debridement or you have to take the damn thing out you know you tried like I know he's tortured gonna torture his meniscus and there's no I mean this was one of those things that was truly I would say a Hail Mary you know truly because there's no data and you're just saying look the decision is you can't play if you do nothing you got to do so if you want to do something and take that chance we could give this a go that's I mean it's it's kind of that simple of a conversation and then there has to be a little bit of trust that he's not gonna get worse and then the data in that one-third of patients who undergo a second look scope after cartilage or meniscus transplantation or both over 90% at five years are happy with their outcome so to me that's I don't mind having to do that second scope even if it's for a partial meniscectomy or in a complete meniscectomy for the reasons dr. Cole mentioned that data I mean I helped I helped with that initial data search and it really has impacted my practice because it's easy to talk to patients about the realities of what's going to happen one out of three of you will need a second surgery nine out of ten who get a second surgery are so happy they had the first surgery so it's very easy to talk to even high-level athletes when you have data to support that so I mean it was pretty so this point was straightforward I don't want to drag it out because I realize busing well we don't take these people but this is a decision-making thing that's that's important order of events just quickly yeah order of procedures so same thing as before so see like that wasn't there to scope not prior to that you know I mean and I you hardly ever catch this stuff but you have the opportunity to catch it if you're imaging these people so frequently you know but yeah so he gets a meniscal allograft we do all the things arthroscopic that we can possibly do I use abridged and slot techniques still because it maintains the anatomy of the anterior and posterior horns the way it's meant to be and I know it's healed when it's healed so if I do a tunnel I don't know it could pull out that's not gonna happen here if the bone is in place it's not gonna happen I also like slots because you can do osteotomies below it and not have any issues and I'm just used to it and it's easy you have to get rid of the medial eminence you got to cut that off because it can interfere with the notch and it's essentially it's largely not weight-bearing but not entirely and then we do a trans-patellar tendon approach in line with the anterior posterior horns it's a pretty efficient operation once you do enough of these and and and and then it's standard meniscal repair you actually use less meniscal sutures with a meniscal transplant you do in a meniscal repair I put a biocomposite anchor on the far side of the graft to push into the ipsilateral compartment and then sometimes I use an all inside posteriorly and yeah this I mean this case thankfully you know there's obviously a lot more anxiety with these things and you would have you know for some other patients but it went really well it felt good and then we make our we'd like to do all the things meniscal first because I like a closed system so I could do a meniscal repair I'm much better arthroscopic than I open with meniscal repairs and then we open it up and did a Osteochondralograft and you know I would I show the case if you didn't get back to sport yeah I would because I you know I gave it no more than 50-50 it was no more than a coin toss that he would have the pain relief necessary to play so that's the deal so anyway then we do the OIGraft much like Rachel showed and that's how we do it we're not that we'll do that like that just to minimize thermal necrosis across the top of the graft and he gets a six or seven millimeter graft and we post lavage it we deep we deep clean it with this is something that I'm Yankee came up with which is sort of to get more surface exposure I don't know if it makes a difference when you score like that and that's high-pressure co2 and then we use bone marrow concentrate which I do believe in as this is a good application we have pretty good data by CT scan that this might provide some benefit to reducing cyst formation at the level of the bone and then like Rachel said be very careful try to use your thumb to push it in and yeah and that one looked good yeah he got back but it was he got back and he's still back but for a wrist injury and he says he plays he says he has no knee pain which is amazing look I this is again I'm not doing this to be a gee whiz how great we are I mean anyone who does cartilage repair and transition could do that case but it's one of those things that when it works and you get this it's it's it's amazing but I it's not like I would prom this doesn't allow us to promise anything to future athletes because there's just we don't have it we have the zero data you know but I think the interesting part about this one was do a meniscus or not and I initially was not gonna do one and I sort of it took a lot of consternation and but you were happy as soon as you did that scope and saw the delamination yeah I was happy yeah I yeah I sort of knew we'd find that I just felt that look I'm not gonna hurt him by putting a meniscus in and if I have to take it out everyone knows that that's the most vulnerable part of the operation he's already meniscus deficient when you're doing the cartilage graft so if you have to take it out he's just going back to right and I still think he'd have good pain relief I've told him I said if you need another knee scope there's a good chance you'll feel better and the meniscus is not making a difference so anyway so it's gee whiz we are out of time this always happens with this ICL we have you know ten more cases to do I want to thank our panelists for being here because I know they're pulled in many different directions and same with you guys I mean we appreciate you spending happy hour with us I would encourage you to attend the presidential reception tonight honoring dr. Curtis and Anna and thank you all very much

cartilage restoration

non-operative treatments

arthroscopy

treatment decision-making

cartilage transplants

meniscus procedures

osteotomies

personalized treatment

cartilage pathology management