for kind of real-life cases here. So this is a 55-year-old female. She's a PA in our department who I've known for many years. And I have tried to nod on her for six months. She has worsening medial pain. We've done injections, we've done cortisone, we've done PRP, we've done viscoplasm PRP, we've done a motor brace, we've done six weeks of crutches, we've done PT, we've had her off work. She is absolutely miserable. And that arrow represents with one finger where she points her pain in. So you can see some early degenerative changes, but her alignment overall looks good. Here's her MRI. Again, medial pain. Andreas, what do you think? I think that's a little bit difficult because she has bipolar edema, so this is... And she points with one finger at the tibia there. So this is someone I would unload, I would consider, let's say, things like Fossamax, for example, if that, she doesn't respond to, then... She hasn't responded. Six months, she's miserable, she's limping around. You see her every day in the hallway. She just traveled from the Mayo Clinic to HSS to see you. I do send her to the PA clinic, and that's a BMAC injection for me, to the bone. So BMAC to the bone. Any other opinions? And then eventually I will do alignment x-rays, think about unloading osteotomy, but a 55-year-old female? If anything, she's in the degree of valgus. She's offloaded herself already. Concerning. Look at that meniscus starting to extrude. This is one of those, you touch it, you're gonna accelerate things, and you're gonna regret it. I'm concerned, and she's 55. She's getting away from insurance approval on anything we do. This is a tough one for all the reasons mentioned, but I think you have options here. There's many patients who are 55, have failed six months of non-operative treatment, come to see you as the surgeon, and there are no options. So you have options here. This, for me, if you've truly failed the non-operative approach, which you've alluded to, this is a problem in two regards. That meniscus, I think, is the issue more than anything else, and the bone marrow edema, not just posteriorly, but anteriorly, reflects that this is a compartment at risk despite her good alignment. That femoral condyle defect, I think, is tiny, but there is some bone marrow edema, and it's real. So this, for me, I think I'm prepping her for staging scope, possible treatment of that meniscus, possible meniscus repair, because the rest of the cartilage looks okay. My question, if you're gonna do that, is should you be prepared to do a cartilage transplant at the same time, since she's pointing to her, you said medial tibia, but I would say medial joint line, so that you can potentially limit weight-bearing only once, if you're going to do all that surgery. So I think those are a lot of questions. I'll give you some more information. So you asked for a staging scope. So the meniscus, you can see the post-debridement picture on the lower right there. It's, you know, it's not bad. She had a small little flap. Of course, you can see the small, full-thickness condyle defect of the femur that she picked up on, and then where she had that tibial edema, you know, in my experience, most of the time, you'll find a small little cartilage flap there. So now you're in the OR, you're left with that post-debridement picture. Is that enough? Are you gonna do anything else? Just to specify, BMAC injection to the medial tibia, not to the joint. And that, for edema, actually, I found that helpful. The problem with these patients is bipolar disease, and our cartilage repair options for the tibia are not great. So I mentioned you can do arthroscopic MAC for the tibia, but that's more you have a 20-year-old with a tibial lesion. This is early arthritis, and as Paul has said, you touch that, they will remember that your surgery made them worse. I think in this case, if you hadn't prepped her for any sort of cartilage restoration technique, and you said, I'm coming in to take a look, clean out that meniscus, see what we might do in the future at age 55, and it's all, my perspective being in Colorado has completely changed, because patients in their 60s, 70s, and 80s wanna stay skeen, and they have joints that look like this. They don't look like a bone-on-bone knee, even when they're in their 70s and 80s. And so your paradigm shifts a little bit in terms of what you might offer them, versus when I was in Chicago, that patients in their 70s and 80s, we don't really offer them these things. So even though she's in her 50s, that's an okay joint. It's not a great joint, but it's not horrible. She's got meniscus, she's got really good cartilage, other than the couple defects. I would probably, if this were me, I'd probably leave this alone, and make her kind of use the test of life, and see how she does, and if she does well, then fine. It was the mechanical nature of the cartilage flap and meniscus tear, and if not, you can talk to her about, you know, we can try restoration, but at your age, outcomes are limited, and blah, blah, blah. Yeah, I would add that I have a serious discussion with her on activity. I get down to, you know, are you power walking, are you running, you know, do you consider buying a Peloton? I mean, these are discussions I have to try to keep them away from something bigger. So we did talk to her, again, what swayed me to treating that tibial bone marrow was just, you know, it was that one finger test. She jumped off the table when you pressed that. The joint really didn't bother her. The other thing is that the injections didn't really help. So for me, that's sometimes a factor that helps me determine bone pain versus injured articular pain. And so you can see in this case, we decompressed that bony edema. I did come from the lateral side. It was just so peripheral medially, I was worried about violating that medial cortex. And then the technique we used here was demineralized bone matrix and PRP. So for her, this was instantaneous pain relief. She left the OR and she never had pain. I did keep her protected for four to six weeks. She sent me this picture. She's, you know, hunting, she walks six miles, hiking on uneven ground. She is absolutely 100% pain-free, delighted. I see her in the hallway every day. So the question is, you know, these bone marrow lesions, you know, can we have some success? There is some short-term limited data. For those of us that kind of live through the injectable calcium phosphates and things, really didn't see a lot of predictability with that. I have a more open mind. Hopefully this is more biologic. Certainly, as Andrea said, there's no fooling anyone here. You're treating arthritis, but you're trying to buy some time and symptom improvement. So I think something to keep in your armamentarium. Aaron, do you think in this case, it's more the decompression or the biologic that did the trick? You know, she left the OR, immediately had pain relief. So I have to think it's the decompression because I had her on crutches for a six-week period of time and that did not help. So it wasn't just the post-operative restrictions. I have to think it was probably the decompression, but we still protected her. You know, we wanted that bone to biologically heal. You can see follow-up here on the MRIs, you know, about 75% there's healing here. So something to think about. So we've only got about a minute left. I won't get into another case we'll run over, but any lingering questions from the audience? Sir. One of the slides showed, was it like a cartilage lesion, some bone that probably came from a dislocation. You didn't really talk about repair. Maybe it was just a sort of roll-off repair, or just a painful repair. Yeah, that's true. Yes, I can show you this case really quick here, omniscient here. So this is a 12-year-old that just sheared off a cartilage fragment from the panel. Raise your hand if you'd try to repair this. In a 12-year-old? In a 12-year-old. So this is one that, you know, in a very young patient, you know, we fix with chondral darts and does well. Maybe what you're also alluding to, newer technologies for chipped or, you know, kind of autographed cartilage that's minced. Anyone on the panel using autographed cartilage minced in this situation, would anyone mince it up and put it back in the defect? Not if you have a defect with that fragment like you had. I would give everything I had in my toolbox to try to fix it. And there's a lot of ways to do it. Yeah, I've transitioned to using a vicryl stitch and putting anchors on either side of that lesion, not to violate the cartilage, and had really good success thus far. Any other questions, sir? Yeah, so I think those are very good teaching principles. I always get a PA flexion, 30-degree view. I can tell you in that case, 100%, I X-rayed her about three times over six months, very thoroughly. Again, I saw her every day in the hallway. She would talk to me about her knee for about 10 minutes. And then in terms of the root tear, absolutely, if you see some extrusion, absolutely need to look for a root tear. This case, on her scope, the root was normal, but absolutely good.

medial pain

bone marrow edema

decompression

demineralized bone matrix

PRP