The question is, what is the algorithm of using a TTO, or when do you put in a TTO when you address these patellofemoral lesions? Used to be that some of us have said every single patella-femoral ACI, for example, needs a TTO. I don't think that's necessarily true. So now I would say if the biomechanics of the. If someone has a large bipolar defect, then yes, I'd like to anteriorize them a little bit But I don't want anyone to think that you have to do a TTO for every single patellar femoral cartilage appear case Just look at your anatomy and you want to correct the anatomy to something that's normal I think the use of a TTO is a very powerful tool and the paper by Pierdano and Fulkerson actually shows you can have actually really good results with articular cartilage defects without any cartilage procedure if you're doing a TTO for the right kind of lesion. So antramedialization very effectively unloads the distal and lateral patella and also the lateral trochlea. You know, the pure anterization is something I've done much less frequently and I think is actually extremely technically difficult in many situations and so I've used that a lot less. All right, then what I would like to do now is I'll ask Nick Scoglione to come up and Nick and I, Brian you should be up here anyway, grab a chair Brian, if we could have the first slide and where's Patrick, is he here, Patrick are you in the audience anyway, and how about Eric Carson, you're supposed to be in on this too, all right, well welcome, Christian and I are going to tag team this, we're going to talk about some controversial things now that you know everything about everything as far as articular cartilage now we want to know what are we going to do in real life cases, we have an esteemed panel and we're going to do rapid fire, so what we'd like to do is get from all of you some quick witted crisp and brief answers, we have a few questions, so I'll take it. So first question is on meniscus root repair, Nick you're too fast for me, on meniscus root repair, this is a question to Andreas, after having done that when do you mobilize a patient? After I let them range of motion right away, but I limit them at about 90 and, do you let them weight bear right away, no, I keep them touchdown weight bearing for six weeks, for six weeks, yeah, Cassandra six weeks, eight weeks, two weeks, six weeks, six weeks, anybody else different, all right so six weeks, but you can let them range non weight bearing without consequences, so I let them go as tolerated progression of full range of motion, but then I don't allow that with weight bearing for six weeks, all right, anybody using unloader brace, yeah, I'm using unloader brace, I let them start weight bearing at four weeks, primarily just from some of the older population, I've just noticed it's really difficult for them to be limited weight bearing up to six weeks, so really try to progress them a little bit faster, all right, yeah, so this is obviously one of the hardest ones to keep our patients down, but it sounds like we still have to do that, even though the desire is big to abbreviate that, you know, that time point or time course, then we go to the next rapid fire case. So how about cartilage repair and indications as far as BMI, Paul Caldwell, particularly if you look to the right of the curve as you get into increasing morbidity and higher BMI, does that change your story? Definitely changes my outlook, I don't have a hard fast number to give you guys, but it definitely changes my outlook and I give the preoperative speech that the lighter we can get and the less load we put through this, the better chance we have, and I certainly have told people that we would keep them on the list until they get a little healthier to where we're ready. Cassandra, do you have anything active that you use to engage a patient that comes in with a high BMI and is symptomatic and you want to take care of the patient, they want you to take care of the patient, what do you do? Nutrition, do you kind of set them up, sort of like our arthroplasty colleagues, you know, how do you capture it? Pretty similar to the arthroplasty colleagues, I take advantage of like nutrition consults, we also have these counseling programs. Jason. So, they come back, they love you, it's six months later, and they have the same high BMI. Their effort to change their body habitus has failed. What do you do now? Are you going to operate? Thanks. I would operate on the right patient. One of the things is I think BMI itself can be a little misleading because you can have an actually very muscular athlete that has a high BMI. And so, I think what you're talking about is sort of overall, you know, obesity and fitness rather than, I think just looking at that one number can be misleading. You know, if you have, you know, because you got some pretty muscular men and women who are, haven't elevated, would fall into that, you know, overweight or obese category. Brian, would it be time to have a better algorithm, something that basically compares absolute weight against size of the joint or something? I don't know. I think a lot of us have looked at BMI in terms of our outcomes, our PROs and so forth. And it isn't, in fact, probably time for a new review article on it. But it's not, it isn't always a negative prognostic factor. That's the challenge. So, we've definitely had some patients who've had elevated BMIs, sometimes profoundly elevated because they just can't do it. And we can succeed, but it becomes part of the consensual decision making process in terms of what, because again, it's load, load, load, right? So, I always tell them it's five to seven pounds, every pound you carry above your knee, and I always say we, every pound we carry above our knee adds five to seven pounds at the level of the knee. So, let's, have you ever done it? Do you have a scale? Let's talk about it. You need to be armed with some resources. And if it's, as Nick's pointed out, if they come back six months later and nothing's happened, I'm willing to consider it because I think you can win. But obviously, and it isn't every study that has shown that it's a categorical negative prognostic factor. All right, next rapid fire. So, the next one is cartilage repair and OA. And this is, we'll start with Paul. How do you decide whether this is OA and you can do cartilage repair versus not? Yeah, I think that's a great point. And I think looking at the joint itself and seeing how diffuse this disease process is, whether it involves the meniscus or the tibia, I think we have much better outcomes with focal lesions, particularly on one side of the joint. And certainly looking at alignment is very important with this. So, Cassandra, if you have a case like this one here and you have, in the middle of this condyle you have a focal lesion, do you do a graft or what do you tell the patient? I think a lot of this, initially, it's the talk when you first meet the patient. So, having weight-bearing films, typically a lot of patients will come in with an MRI to my clinic. So, identifying that they have a symptomatic chondral lesion that I didn't find incidentally with the meniscus surgery, then there's counseling with regards to how do you want to approach this. I really try to get to know them in terms of what their expectations are, what their activity level is, and what they expect to do down the road. David, this patient has two degrees of varus and it's a medial femoral condyle. Do you do an osteotomy for him? Typically for two degrees, I would not. I would consider it only if they truly had cell-based. But two degrees is really a small amount to correct. And so, for two degrees, I would really do my treatment of choice for the defect if needed. Jason, what's your magic? So, a couple things are, I mean, I'd probably be more at five degrees. This patient in particular, I mean, it looks like there's just generalized chondropenia, the superficial tangential layers are clearly starting to be disrupted globally. I'm not sure, I don't think this is a focal condyle defect. I think this is a patient who is in the process of having a knee that is further degenerating. And we are, the tread is almost bald. This is exactly the problem, right? And these are the ones where we then put grafts in and come back two years later and the graft looks great and the rest looks absolutely horrible. So this is exactly why we asked this question. Yeah, next. Andreas, acute patella dislocation with a loose fragment. We heard from Brian about maybe less is more. Take it out, fix it, how do you fix it? And then if we're dealing with a medial facet lesion, what are we doing with the lateral femoral condyle? That's a lot of questions. Oh, one more. So if it's just inframedial patella facet, I think that's not really that involved in So if it's a smallish, inframedial facet that doesn't reach the median ridge, then I would just vote for debridement and focus on the instability. If it involves the median ridge or the lateral condyle, that's more real. So I would think about either fixing it, that piece that you said at the top right, to me that doesn't have much cartilage. So if this is someone with open growth plates, which this patient does not have, I'd fix it. With closed growth plates, if it's big enough, then I would just follow my normal cartilage repair algorithm. Bioabsorbable or metal? Or suture? I've started to use more suture. Okay. And how about that lateral femoral condyle? How much attention do you pay to that versus the facet? If it's the most peripheral, where it just really only articulates with the peripheral rim of the meniscus, then I would just do more of a wait and see. But if it goes into the central weight-bearing zone, then I think that's real, and I would fix that. Okay. Christian? Subchondral bone involvement. Clayton, if you have an image like that, you have a lesion like that, how do we go about this? Brian, sorry. What did you say? Who did you say? It's a little dense over at the end of the table. So I think the first thing is having a common vernacular so we can talk to each other similarly. And this is a sign of joint failure. So this is why we talk about load, because when the often, not always, sometimes this is an isolation, but I think the most common edema we see is when the surface is not functioning to absorb and shield the bone. That breaks down, then load gets transferred, and then we see edema. It's not a lesion, in my opinion. It's a sign of early joint failure. So it also speaks to all the measures we can do to make people feel better. So I don't attack this routinely with subchondroplasty and things of that nature. If I decide to do a surface-based treatment, I might add that to the equation. I think you can differentiate who has painful bone marrow edema and non-painful edema, too. Sometimes you do get patients with sort of cleanish joints who have bone pain. That, in my mind, is the ideal candidate for thinking about how to manage the bone. And that could be decompression. It could be putting DVM in. It could be putting some type of orthobiologic, you know, bottom line. And we don't know for sure if it's the drilling or what we're putting in, but you can do something to stimulate some healing. So I think if they have bone pain, you can pick that up in clinic. It's relevant. In this case, it's relevant only as a secondary sign that you've got a really big problem upstream from that. And think about load reduction maneuvers, osteotomy, osteochondral treatment, weight loss, modification of activities, what have you. But that's my thinking of these problems. Thank you. Brian Waterman, any role for an unloader brace here? Yeah, I think that's a good trial of initial management. That'll help to articulate whether this is truly the problem. I think you've taught me a lot about arthritis and progression. This is bipolar involvement. Probably reflects either meniscal insufficiency or post-meniscectomy syndrome, or you have a high index of suspicion for an untreated root tear in this scenario. So I think that would help to tease it out. Yeah, I think these are the ones where we have to just be really careful that we are not trying to basically, you know, work on the wrong end of things. And the cartilage is not the main problem here, right? It's a load issue, and we need to differentiate that, as you've heard. That's exactly the patient, though, that comes in and says, I have an MRI that says I have a torn meniscus. The doc fixed me, and why am I not going to be better in a week? Yeah. Organ disease. David Flanagan, do you treat asymptomatic lesion? Let's define that as an ACL with they knock off a piece of osteochondral. You can't repair it. No, because they're asymptomatic. Anyone else add to that? The only asymptomatic lesion that I might strongly consider is the lateral femoral condyle OCDs that go far lateral, the papateous hiatus involved, things of that nature. So I tend to ignore most asymptomatic lesions, but that is one that I've learned maybe has a strong predictor of a bad problem, that torches the lateral meniscus, torches the tibia. That's just my own thinking. Yeah. Cassandra, give us your algorithm, your brief algorithm, for biologic injections in osteoarthritis of the knee. What's your first line of treatment injection therapy-wise, and how do you progress? That's a really good question. I think a lot of it is trying to figure out what type of, if you're looking at a specific defect that's symptomatic, or if you're looking at more of diffuse arthritis. And I know folks over here have talked about what type of arthritis is it also. Is it a wet arthritis? Is it a dry arthritis? Is it a boggy synovitis type thing, or is it looking like more just kind of a pain generator? And then so that's how you kind of determine what biologics. I'm pretty limited where I'm at with the university, so I think only in my hands I have basically HA, cortisone, and very rarely do I use PRP. But that is just the patient population I have in my area. But I know folks who do a lot more of this, I know they're kind of teasing out when you would use a fat cell injection, like in terms of not quite necessarily the boggy arthritis, but more of the painful arthritis, and then something more that can be immunomodulatory for that kind of wet arthritis look. Okay. Let's go down the panel. Just yay or nay. Paul, office arthroscopy, yay or nay. I have no experience in that. Brian. I don't use it. David. Brian, why don't you give your opinion first? Other Brian. Sorry, those two Brian's up here. Sorry. Brian, do you have an opinion? What he said. Come on, guys. Go in order, all right? Sorry. Forgive me. David. I've only used needle arthroscopy in trials. Nothing really. Brian. I don't use it. Jason. Nope. Cassandra. I would love to use it, but there's no way I can use it. Andres. No. Let's go back. Andres. You use heat on cartilage. Yay or nay. Nay. Cassandra. No. Jason. Maybe a little at the hip. Oh. Oh. Jason, that's such a cop out. Oh, the maybe. Beware of the maybes. With hip arthroscopy, occasionally if it's a. Brian. I don't use it. David. Yes. When? I think with some of the newer technology, it's definitely some of the safety factors are there. So when do I use it is for some of the cartilage. I just want to smooth the edges, especially in our older population. Brian Waterman. Despite the soothing sound I do not use it. And Paul. No. All right let's go back. Paul and let's keep this brief because we have some cases. Marrow stimulation just tell us yay nay and how. Not in years. Brian Waterman. Fine wire occasionally for the small lesions otherwise abrasion chondroplasty. David Flanagan. Low demand patients especially elderly population abrasion constancy or now with the small little drills. Brian Cole. On occasion for lesions I think won't respond to debridement that are small and I've gone more towards abrasion and little and if I do anything it'll be some some drilling and do an adjunct when I an inexpensive adjunct that I could use at that time like maybe autologous tissue if I'm gonna give them the same rehab anyway. Thanks. Small defects less than two centimeters I'll use a needle punch device often add an augment such as like a micronized cartilage particles and post-op non weight-bearing except in a patella thermal drain where weight bearing and extension. Cassandra. I don't really use microfracture anymore. And Andreas. Very rare acute traumatic focal femoral condyles young patients fine needle but very rarely. Less so I think less fairly less common. So we have the last point to in primary defects who uses primary osteochondral transplantation as opposed to a surface procedure. We know Paul Caldwell does. So I do for osteochondral defects so let's say an OCD lesion I would go with a primary OC transplantation. Cassandra. I think lesions where I see a lot of bone marrow edema again I guess when with Brian talking about like if we're talking about the same thing so I'm looking at something that where the bone is overloaded and I think the bone is stressed so I don't think of it as just a surface lesion by itself. Jason. Subchondral bone defects and then sometimes in the patella thermal joint given the high shear stresses. Brian. So we've heard that pretty much everybody does it in a significant subchondral bone involvement. Do you do it primarily just for articular cartilage. I do. Yeah I will. Especially for my highest demand people who need to feel better very quickly and multifocal lesions I may use surface treatments cell-based more frequently especially young people but single local lesions I love OA grafts for those. Yeah so what I'm finding for example if I combine it with a meniscus or so I like to have an allograft because I trust the structure a little bit more. David what do you think about that? Yeah I'm an agreement for me it's the manual laborers people who need to get on their feet right away they're gonna get a primary OC in my hands. And Brian do you see the problems with using an osteochondral allograft primarily for a chondral lesion? Outside of the context our debate I would agree that's a completely good first line option. But as Brian Cole has mentioned there's a lot of different inputs that play into this decision making it's really individualized and so I think to distill that into a sound bite it's tough. And I can see Paul almost sliding off the table. I think he just admitted defeat in the debate I'm pretty sure. Yeah. But yeah that's my workhorse. We'll do a case now. 43 year old law enforcement officer status post work related injury at a prior medial femoral condyle osteochondral defect and tear. A six months post-op comes in for another opinion. He did have what was reported in the op note to be marrow stimulation and a partial medial meniscectomy. He's unable to work and this is his exam and this is his plane radiographs. Andreas what are you thinking? So you mentioned varus. The question is how much varus? I think this is a patient I would be excited if they are in varus enough to do an HTO because his meniscus looks terrible. His tibia is not great. A lot of varus. So in my hand that probably would be an isolated HTO. HTO? Yeah. Cassandra this is the here's your work list this is what's going on bone marrow edema subchondral chondroplasty? No. I'm sorry so it's varus malalignment and you're looking at just subchondroplasty. No the answer is no. You have to address the varus malalignment and correct the physics of what's going on and then in the area of the prior micro fracture if there is a lot of subchondral edema I'm probably gonna be looking at an osteochondral allograft. Osteochondral allograft. Jason Koh here's some of your options. What about that unloader brace before the HTO? Yes? No? Might try it oftentimes patients don't tolerate them well I think they need it this guy needs an HTO and I might actually stage it so you do the HTO and see how he does and then otherwise you're looking at a combined cartilage and meniscus transplant. Brian at the time of his procedure this is what the scope looks like. Yeah. So and I will get ahead and tell you he's booked for an HTO but this is your scope. Do you scope and are you gonna do anything about this at the time that you unload them? You're doing the HTO? Yes or no? Yes or no? Is that a yes or no question? Yeah. I feel like I'm an adept. So okay I obviously you know this is one you'd max out on non-surgical treatment so we're assuming it failed and then first line treatment I will debride not start with an HTO and then I'd love to see a flexion weight bearing view because I would you know that that's not a cartilage transplant patient based on a flexion weight bearing view before you even put the scope in. So I would scope, debride, pray and then if they do fine do nothing further and if they don't then I would come back for HTO most commonly so I might if they did great with an unloader brace go right to an HTO too. Okay. That's what they want. He had David. That's a big one. Flanagan. He had the HTO. Again foregone conclusion. Are you going to do anything with the joint other than debride it or are you going to leave it? The point being is the biomechanical treatment enough versus the surface treatment? Yeah based on what you showed with those arthroscopic pictures I don't think any of anything else the joints gonna really help this patient. This is truly the the treatment he needs is for this osteotomy to offload that and this will have good results in this patient. Okay. One more case. All right. Next case. 39 year old female teacher recreational tennis player and cyclist. One year increasing knee pain. No clear injury identifiable. Has pain during ADLs. Progressive swelling. Can no longer work out. Has now also increasing pain with stairs and loading. Failed NSAIDs. Interarticular cortisone injections. NPT. Classic cortifluor program. Next slide. The physical exam is relatively unremarkable. Has some mild crepitus. Normal ligament stability. Normal alignment. Both for patellofemoral as well as for axial alignment. No history or exam consistent with subluxation or patellofemoral instability. And then these are the arthroscopic. Next picture. These are the MRIs. You see that you know a relatively small lesion in the trochlea. Next picture. Next slide. And this is what you see arthroscopically. So why don't we start with the Brian Waterman. What do you think here? What do you do? I mean these are difficult because you have that central fissure. You know if you start picking away at it that it's really gonna end up being a very large area of defect. But I do think that there is some underlying delamination that's probably not well borne out on the surface. So I would do a diagnostic arthroscopy, debridement, harvest and then consideration or at least discussion about TTO depending on what the patient's symptoms are. Okay so next slide. So these are your dimensions. Next slide. And then she had no improvement after the arthroscope. It's actually now nine months later. And we go to the next slide. What are your options now? What do you do Andreas? So if you can get this approved by insurance and that's sort of the pragmatic aspect then yes you could do a MACE which I think would be great for this central trochlea. The surrounding cartilage is very deep. The patella looks intact. So I wouldn't combine this with a TTO unless there's something crazy about her anatomy that we haven't seen yet. You could also do PJAK. Probably wouldn't do an osteocondylalograft for this. Brian what about, this is Brian Cole, what about things like a coral plug or cartilage paste? I think there's a lot of ways to get this one better. So it's small enough that it could be responsive to like five things. So what would I do? I mean I, it's so small. I might, I might do a, it's small that I'm not sure I'd go right to MACE. So just given the resource and everything else because I think you get it right. So I wouldn't, I don't have coral plug available to me yet. And but and I probably wouldn't start with that. So I would probably do first line if I felt a ream wasn't gonna help him. I would have possibly done an abrasion type procedure and then added some cartilage autogenous tissue with some fiber and glue and see how that does. And if that failed I'd probably come back with a single plug. Probably a single plug. But I wouldn't argue with anything else that people would do here because I think you can get it right. I would probably start thinking about economics to be honest with you because I think I might go with something resource less intense for this one because I think you can get it right. Speaking about economics, what about an oats plug? Just basically moving. Yeah central oats. It's tough because this person has this propensity for the telephermal pain for such a small defect. So I but it might work. I mean yeah it I just worry about this now robbing Peter to pay Paul for this one because you're already in the telephermal joint with symptoms and why is it this patient may not tolerate further morbidity to that joint. So it wouldn't be my first line in my my hands. But I know in Europe it might and they made you fine. So one to resolve this case if you go to the next next slide Nick. So this is actually a case that we enrolled into a clinical trial and we used a coral plug here and you know that was I felt almost I felt it was almost a little aggressive to do that. But interesting enough you know this is actually a perfect indication for this implant. Yeah. As we have learned through the trial and if you go to the next slide the resolution I just saw her the other day. She's three years out now. She's happy as a clam has zero pain and has a completely normal knee joint functionally. So this can work and this is basically a playing field for a lot of technology. We have a little bit time a couple of minutes for questions from the audience. Is there are there any questions to the panel up here? I'd actually jump in and ask a question about that coral plug. So the idea is that the trochlea can be a little bit daunting and if you're thinking about putting an osteochondral plug just because of the contours and trying to get that to match up. So are there any tips or tricks that you've learned with this coral plug now that it's FDA approved? It goes a little bit against what we kind of sort of generally learn because this plug is actually sitting at the level of the subchondral bone. So it's not actually trying to resurface the articular cartilage and the subchondral bone in that area is not shaped like the articular cartilage. It's actually relatively flat in the center. So it fits in there pretty well. The the key is that you do not leave it proud. This is an implant if that starts cracking or fracturing that leads to significant synovitis in the joint. So this needs to be engineered really well. The tools are good for that and it's it's a different concept because it relies upon basically sucking in mesenchymal cells that then will start covering the defect and you know there's good basic science data to show that. It's a different concept for all of us who like to fill up the lesions. You want to repeat? Did you hear it? Anyone do tibial plateau? Yeah, Ryan. Yeah, I have quite a few isolated tibial plateaus. And the good news is they actually are way more responsive than you might think. And that's good because if they fail first line treatment, there's not a lot of great things to treat it with. So there is like two retrograde oats trays in the country, I think, don't know if they know where they are, but very hard to get to even with that technology to do a retrograde oats. So I will use, this is perfect in my mind to use particulate cartilage. You could actually do a Macy too now with the technique, but I use a marrow, this is where I will use marrow stimulation with a particular autogenous tissue, fiber and glue with some bone marrow aspirate. And that has done as well or better than just marrow stimulation alone. I think it's a great place for it. And we've done very, thankfully really well, because if they fail, I have no idea what to do next. Seth. So three to three to five four just let you Three the question is what do you all do for borderline malalignment? Let's say three to four degrees of varus with ipsilateral lesion. Are you pushing it? Are you tolerating it? Are you debating it? Andreas So osteoclonal Procedures are more forgiving to minor malalignment than cell based And then also just depends on what the rest of the joint looks like So if it's let's say it's an OCD lesion, then I would be more forgiving because OCD lesions are more central They're less affected. I think by malalignment and meniscus and tibia are okay But if someone has a more chronic defect because they had a partial medial meniscectomy a while ago Then it would be a little bit more aggressive. I Think one thing said that's important here is also look at who the patient is, right? If you have additional factors that you're concerned about like for example size weight Activity etc. I think you have to basically go to the maximum you can achieve here in order to optimize the environment versus if it is really kind of like a Relatively low demand patient or so. You may have different options here. I think this is a very individualized decision Yes about you just repeat that again sorry Yeah, so regarding HA, initially they started out doing that, but for the trial they actually did not use it. So there's no HA in these plugs. And the mechanism of action, you know, Susan Chubinskaya looked at that very carefully, you know, on a cell-based level, and there is migration through the actual, physical migration actually, through the actual plug. Why exactly the e-chondrocytes end up deciding to make cartilage there, I don't think I know that. And I'm not sure anybody does, but phenomenologically, if you look at the trial pictures, and they show them to you readily if you talk to them, this looks about as good as any of our other cartilage repair procedures. Was HA used in Europe during the trial? No, it was not. Okay, we're going to, sorry, we can take your questions offline, but we're going to keep the program on time. Thanks so much for coming. Thanks to Christian and the panel. Thank you.

patellofemoral lesions

TTO

anatomy evaluation

articular cartilage defects

meniscus root repair

biologic injections

coral plugs