There we go. Welcome everyone. Thank you for sticking around. I know it's a long day, but thank you for being here at ANA24. This is one of our ICLs that we've done now for the last three or four years. And this is all based on feedback. So you guys all will get surveys. Please fill them out honestly. This has been one of the highest rated ICLs in the last several years. So that's why ANA keeps having it repeated. And so we're super excited about it. We have the first PowerPoint coming up. As we get that coming up, it's a true honor to be able to be up here with these incredible individuals who are world-renowned superstars in the world of joint preservation, cartilage restoration, osteotomies. They're each friends and colleagues and mentors for me, and I hope we all take away something from this ICL. The structure will be that we'll each kind of give a 10-minute spiel about something that we think is relevant to this topic, and you'll go through that. And then we have a bunch of cases. And then we all move on to the welcome reception and happy hour and all those good things. So we have three individuals who are outstanding in the fields of cartilage restoration, joint preservation, osteotomies. Michael Aya from NYU. This is what he really looks like in real life. Seth Sherman from Stanford. This is his real-life picture. This is what he'd rather be doing right now for sure. And Armando, who was my former partner, Armando Vidal from the Steadman Clinic, and he sometimes does push-ups, but if you look at him right now, you would not know that. I know, starting it out strong. Just kidding. He's a professional CrossFitter. Okay, taking a step back, when we think about joint preservation, what do we really want to know? Well, what do our patients really want to know? First, just in the audience here, how many of you have a knee that would potentially benefit from some sort of joint preserving treatment at this point in your life? Many. How many have metal in their knee? How many wish that they could have something besides metal if they could go back in time? So this is what joint preservation is about, and this is what patients really want to know. They want to know, if I have surgery, how long does it last? Can I get back to sport? And will things get worse if I do nothing? Meaning those people still who feel they need joint preservation but are waiting. And I'm a patient. I'm a professional patient. have been joint preserving surgeries, and I'm still searching for that holy grail that can make my knee 20 years old again. So one of the questions I'll always ask myself in my docs is, can I coexist with my current symptoms or do I need something done? We have to remember when we see cartilage lesions and meniscus lesions and malalignment that most of these problems are asymptomatic. So one of the things I teach our residents and fellows is just because we can doesn't mean that we should. Not every cartilage lesion needs a transplant. Not every meniscus deficiency patient needs a transplant. Not every malaligned patient needs or can tolerate an osteotomy. But if we find patients that are candidates for those procedures, these are the options we have. And certainly biologic augmentation is a major component to all of the surgical options that we have. The question we're going to hopefully answer over the next hour, but I think we'll all leave with more questions than answers just given the nature of this field, is what do we really know about these procedures? I would like to say, don't forget about non-surgical treatment options, particularly for our patients who have excessive load, be it overload from malalignment or overload from weight. Losing a little bit of weight or correcting alignment with a brace can potentially in a temporary fashion, and ideally a permanent fashion, improve the quality of lives of these patients. And they may not need any of the fancy surgeries that we all love to do, but they may not need that. And from a cost perspective, from a time off work or school perspective, they may not be able to tolerate rehabbing from a meniscus transplant. But if they lose 20 pounds, they might feel a ton better. So understanding the non-surgical treatment options is paramount. When we think about joint preservation, we do have to consider the joint as an organ, and it's looking at not just the cartilage, not just the meniscus, not just the stability via the ligaments, and not just the alignment, but the whole joint as an organ. If you have a malaligned patient with a juicy 2x2 full thickness, well-contained medial femoral condyle defect, and you just transplant the cartilage, you're going to feel great and the patient's going to feel great for two years. And then they're going to fail because their malalignment is likely what's contributing to their overload in the first place. And so if you don't treat the alignment, but you just treat the cartilage, you're going to have a failed outcome. And maybe the patient will move out of state by that time and they'll be treated with another surgeon. But that's still a failed outcome that you can expect to have if you look at the data. So we've got to treat the joint as an organ, look at the biology. When we have cartilage restoration patients, we have a lot of cartilage restoration options. And these really range into four categories. Palliative options, simple scope debridement. Restorative options, let's try to repair the cartilage back to what it was. Restorative options, these are more of our cellular procedures. And reconstructive options, these are our bulk osteochondral autografts and allografts. Now don't forget about cartilage repair. If you have a viable piece of articular cartilage, particularly in a young patient with or without bone, if you can repair it, I would recommend it. That's going to heal better than anything you can donate. So if you can heal their cartilage, if you have viable cartilage, try to repair it. And there's a lot of different tools and anchors that we can use in addition to standard screws that we've typically used in the past. And this is one example of a cartilage fragment in a young patient that probably would heal with anything you do because it's a young patient, but that healed with just two suture anchors. This is a second look scope that I begged the family to let me do so I could see this because I had never performed this technique before for this particular indication. And you can see that you can really get a lot of things to heal when it's young and healthy. When we think about how we're going to treat the cartilage, and our speakers here will get into the specifics, you have to consider all these things. Alignment is first and foremost. You cannot fix a malalignment problem with a cartilage solution. I think Armando is the first person who worded it like that to me, but it's something I tell my patients all the time when they come in for second, third, fourth opinions and they want a cartilage technique, they've never even been told about an osteotomy, and I think because a lot of surgeons don't like offering osteotomies when in fact that's the one procedure that they would have the most success with. And then all the other variables that you see here, you've got to really understand. Any particular cost, if you own your surgery center, an osteochondroallograft may not be the most cost effective solution for you, even though it's the best option for your patient. So you've got to think about where you might do that procedure and maybe switch from an ASC to a hospital so that you and your center can get reimbursed. Because at the end of the day you need to do what's best for your patient, but you also need to keep the lights on. So you've got to think about all these things as a surgeon. What about the meniscus? The meniscus is a big deal. We have tried to repair more menisci in the last 10 years than ever before. We do this because meniscus deficiency is bad. We know that meniscus deficiency leads to overload. What we don't know is when patients develop symptoms, particularly on the lateral side, and why certain patients develop symptoms but certain patients don't. Options for symptomatic meniscus deficiency include substitution, transplantation or watching and waiting. When we think about meniscus transplantation, which is the most commonly available technique in the U.S., we think about this for symptomatic meniscal deficiency, but not necessarily for the asymptomatic meniscus deficient knee. And when we think about those indications again, symptomatic meniscus deficiency typically after a prior meniscectomy, instability in the setting of a recurrent ACL tear, we know the medial meniscus provides a secondary restraint, concomitant cartilage restoration, don't put in a beautiful cartilage graft if you don't have meniscus to protect it, and I think something that's growing in curiosity and indications is the prophylactic meniscus transplant. The one patient that comes to mind is the 12 to 14-year-old patient who had a dyscoid and it got taken out for whatever reason. They have pristine cartilage, no symptoms, but we all know what's going to happen. The question is, is the morbidity of doing a transplant better than the morbidity of having no meniscus? I don't think we know the answer to that question yet, but I think those of us who do meniscus transplants would argue that potentially putting a meniscus in that young, healthy knee is better long-term than leaving it without any meniscus at all. Finally, what about osteotomy? Osteotomy has become, it's interesting, around the world osteotomy has been popular for decades. In the U.S. it's experienced a resurgence. I think this is due to, number one, recognition of the power of osteotomy, but also tools, implants, and industry has made osteotomy much easier. Wow, that's glitchy, and there we go. So this is, sorry that's so glitchy, I apologize, because it was great before. But anyway, you can imagine if you're doing, I'm going to just get rid of it because it's hurting my eyes to watch the glitch, but osteotomy is a powerful tool, and perhaps when we're thinking about joint preservation, the most powerful tool that we have, bone heals more predictably than soft tissue any day of the week. And so if I can find a reason to do an osteotomy, I'm going to do it. I feel confident that my patients will do well with that. We have to remember that when we do osteotomies, it's patient-specific, and again, technology and industry has really helped us dial in to within a millimeter or within a degree your correction in both a uniplanar and biplanar fashion. But you as a surgeon still have to make the decision. So if we're correcting for osteoarthritis, you're going to overcorrect, typically to the down slope of the opposite tibial spine, especially if they're in varus. If they're in valgus, you don't necessarily want to be too aggressive, thou shall not varus, but you do want to correct and overload the other side. If you're correcting for cartilage restoration or meniscus transplantation in a younger patient, I like to go to neutral, but I really customize that to the patient, and also if I'm doing a concurrent ligament reconstruction, it changes where my hinge axis is and how I do my osteotomy. Don't forget about tibial slopes. So we think of osteotomies from a cartilage perspective with respect to the coronal plane, but the sagittal plane is just as important for your chronic ACL and PCL injuries. And particularly if you're dealing with a patient who has a chronic PCL, it's actually a beautiful operation to go ahead and increase their slope. It's a much easier operation than trying to decrease slope, particularly if you're doing an opening wedge and restoring cartilage to the medial compartment. With respect to osteotomy, I've said it before but it's worth saying again, you can't fix a malalignment problem with a cartilage or meniscus solution as much as many surgeons try. You can fix a cartilage or meniscus problem, and often across the world in Europe, for example, where fresh tissue is not as readily available, you can fix those problems with an osteotomy solution. So before we get to the panel, I'd like to, or before we get to the panel's talks, I'd like to just go down the panel and when I say rapid fire, I mean rapid fire, gentlemen. Tell me what is your most common cartilage procedure for the femoral condyle? Mike. OCA. Patella. Armando, let's go back. OCA. OCA. Antrochlea. OCA. OCA. And a lot of people in the audience, potentially here, but certainly when I give other talks, do not like doing osteochondroallografts in the patella. They feel that it's hard. They feel that it's dangerous. And there's not a lot of salvage procedures, but I will tell you in my hands, and you just heard it in these three hands, these three sets of hands, that's what they do the most. That's because, at least for us, it's the most predictable, most reliable, and when it's done well, it's a home run. What's your preferred meniscus transplantation technique for medial? Bone plugs. Bone plugs. Very small bone plugs, so soft tissue-ish. So small bone plugs, and it's all soft tissue. Like you start with a bone plug, and then it doesn't quite get back, and then it's, oh, the bone plug, and it just didn't work. I dictated a very nice small bone plug. Good, good. Yeah, see, what we say versus what we do. Okay. You feel better about yourself like that? Armando, lateral. What do you do? I also do all soft tissue. I do the same operation, medial and lateral. Bridge and slot. Bridge and slot for me, lateral. I have done all soft tissue lateral. I have done bone plugs lateral. I find the anatomy of the lateral meniscus is so tricky to get perfect if your donor is not perfect. It's not always perfect with respect to size match for your donor versus your recipient, but if you have that anterior and posterior horn where they were supposed to be with the bridge and slot, I find it a lot easier. I started my practice doing medial bridge and slot, because that's how I was trained. And when you do your first one of those with an ACL, you will realize you will never want to do it. Why many people never want to do that again, although some people still do that. I agree. Sometimes my bone plugs convert to soft tissue. Surgical biologic of choice. Anything. PRP, if anything. BMAC. I do BMAC for my OCA's. I do PRP for the other stuff. Okay. So we'll hear a lot more about that from Seth. Lastly, preferred osteotomy technique. And this would have been a different question. We wouldn't have even had this slide five years ago, right? Five, ten years ago. But now with industry and technology, we've got the ability to do PSI, patient-specific instrumentation using 3D printing. And we're all conflicted because we all work with osteotomy companies and all of our disclosures are available online. So I think I know the answer for all of this. But tell the audience. Mike, what's your preferred osteotomy approach? The second one. PSI? Yep. I'll do PSI for tibia femoral and rotational, and then I'll do an instrumented TTO that's non-PSI. Where do you see TTO on there? I can't read so well. Seth has to talk about the patella femoral joint. It's okay. Let him have his joy. Let him have his joy. PSI. PSI. So if you're not familiar with PSI, we have companies in the exhibit hall that you can go talk to and learn about this, and you're going to hear about this today. It's revolutionized how I do my osteotomies. Well, obviously an easier option for more custom osteotomies where you have to correct in dual planes or bigger corrections or change your hinge point. For me, I do it for my simple ones as well because repetition matters, and the more you do, the more efficient you get, the faster you get. And from a cost-effectiveness perspective, the cost is awash in our surgery center due to negotiations. So I think this is a really powerful tool. So with that, we're going to start the next talk. We'll hear from our experts. And, again, thank you all so much for attending this. I'm glad we have so much diversity of opinion here on our panel. Honestly, we could have done that all ICL, and it would be awesome. I mean, that would have just rapid fire on these cases. All right, if you can pull up my talk. So my name is Armando Vidal. I'm at Sedmon Clinic in Vail, and my charge today was to talk about some of these technical pearls for combined cases. Order of operations, where you're going to find your pain points. No consensus on a lot of these things, and I think we do have differing opinions on this in terms of when we would stage and not stage, but that's what we're going to talk about today. So as Rachel indicated, joint preservation surgeries and procedures are becoming increasingly common. That's clearly evident in the marketing data, what you see at meetings, and what you see in the literature. As she indicated, this Venn diagram really informs every discussion we have when we have an ICL, an articular cartilage. It's this nexus of meniscal deficiency, instability, malalignment, and subchondral bony involvement that are going to influence our decision making. You need to have a plan that accounts for each of the components of a patient's disorder. And Seth often talks about the knee being an organ or an ecosystem, and I think that's something that's always resonated for me. You can't just think of it as an articular cartilage problem. You need to think about what's going on with that joint in a variety of different ways. Now this Venn diagram, a patient will present with a variety of different permutations of how this Venn diagram will present. I love Seth's checklist, and I make my fellows come out every time and have a checklist of is there meniscal deficiency, is there instability, is there malalignment, how are you going to account for those things. You have to have an individualized approach for every patient. It's not a one-size-fits-all. It's going to be influenced by what strategy you choose, your proficiency in the OR. Most of these are revision cases. They've had previous tunnels, previous incisions. All that can influence whether or not you're going to do it in one stage or two stage or what strategy you're going to take. So my goal today is not to be prescriptive. It's to give you a blueprint of how you should approach these, how you should think about these, and where you're going to have your pain points and where you should consider staging them. Your joint preservation toolbox really comes down to four things. So you have meniscal preservation or transplantation. You have ligament reconstructions. You have osteotomy. And then you have a variety of different articular cartilage procedures that I believe Seth and Mike are going to talk about. And that's what we're going to talk about is how these things can influence your surgical plan. And sometimes you get them all, right? Sometimes you get patients that need an osteotomy, an osteochondralograft, a root repair, all the things, ACL revision all in one case, and these can be very technically demanding. So as Rachel indicated, I would say joint preservation technology has really had huge advances in the last few years, and it's probably actually the use of PSI for osteotomy that has helped us, and this has allowed us and given us opportunities to do complicated procedures that were particularly challenging before. Now, these are still technically demanding operations, but it allows you to work around different tunnels, choose an osteotomy that may be more appropriate for a patient, and I think all of us have migrated to this. I started doing PSI for osteotomy in 2020 and really haven't looked back. I've been doing it for about four years, and we've built a pretty broad experience with these in a variety of different cases, revisions, sagittal plane corrections, axial plane corrections, and obviously coronal plane corrections. So the first question that comes up is do you need to stage or not stage, right? And I think the first question that comes up is do you need to do an osteotomy, because that probably drives my need to stage more than anything, and we disagree. Mike and I have presented cases where he's like, ah, I would have done that in one stage, and I'm like, I'm kind of a wimp. I'm going to do an osteotomy and come back and fight the fight another day. And that's totally reasonable, right? Like there's no, you know, you don't need to try to do it all in one day if you feel like you can't do it or it's going to be too long an operation or you're going to complicate your ACL fixation. But I would say osteotomy drives my need to stage more than any other intervention. If it's a cartilage problem alone, so this is going to be kind of the 35,000-foot view of the next several slides, and we're going to present several other cases. But if it's just cartilage alone, I don't think you have a problem. Like DFO, lateral femoral condylar OCD, medial femoral condylar OCD with an osteotomy, that's a pretty easy combination. You start adding ligament reconstructions to the mix, and that can get pretty tricky, right? Because you start to run out of real estate on the tibia if you do an HTO where you conflict with your femoral tunnel on an ACL and your DFO. So I have a pretty low threshold to stage those cases. You know, even when I do a slope correcting anterior closing wedge, I'll come back 12 weeks later, it's pretty healed, and do my revision ACL. But I know Mike will do that all in one stage. I think it's reasonable, but I will tend to stage them if I need to. If I'm doing a meniscal transplant on the lateral side, because most of those cases are DFOs, that's usually not a problem. If you're doing a medial one, it can be technically demanding, right? If you're doing drill holes, et cetera, through your osteotomy, not impossible, but things you need to account for. If you don't need an osteotomy, if you're doing an ACL, cartilage, meniscus transplant, pretty much all those combinations are easy to do in one stage. So for me, the driver of staging is going to be an osteotomy. Why would you stage? It's too much work in one setting, right? It's your first osteotomy, or your second osteotomy, your third meniscus transplant. You're like, this is a lot of work to do in one day, and I haven't done either or any of these individual procedures with much frequency. Just wait. Lay the foundation, bone graft tunnels, do your osteotomy, and come back. Your conflict with your osteotomy with other procedures, as I indicated before, so mainly tibial-sided surgery, like an HTL with meniscus transplant ACL, or a DFO with ACL, lateral femoral condylar OCA. And then the osteotomy serves as your staging procedure. Your MACI biopsy if you're a MACI surgeon. Your bone grafting for tunnels if it's a revision ACL. Lay the foundation bony-wise and then come back and do all your biologics. Just to keep in the interest of time, that's a case that I had staged. So let's talk about specific cases. So HTL and ACL, you may want to consider staging. The order of operations if you do it in one stage is do all your arthroscopic work first. Do your femoral tunnel for the ACL, et cetera. Do your HTL second. I usually use 3D planning for this. As you see in this, that red circle is actually not where I would put my tibial tunnel. That's where the old tibial tunnel was. But you can plan that. If you notice, they move the screws around. So you can have the engineers move screw trajectory around to avoid a tunnel if you want to avoid a tunnel. You can have them just move a screw, just make it two screws that deviate. So you have quite a bit of flexibility with all this PSI and 3D rendering technology. I'll then complete my ACL, and then you have to consider tibial fixation, meaning if you're going to drill, you may have a really thin metaphysis above your osteotomy if it's an opening wedge. So how are you going to fix it? You're going to tie it over a post. You're going to do a short interference screw. A lot of different options. But you need to account for the fact that you're not going to have the typical bone stock that you would do if you're doing a primary ACL. How about if you're doing cartilage restoration and malalignment? As I indicated earlier, I don't think there's any need to stage in this particular setting. For me, the order of operations, I'm going to do an OC, if it's an osteochondral treatment, osteochondral allograft being the most frequent, I do that first. If it's a cell or surface-based treatment, I'm going to do my prep. I'm then going to do my osteotomy, and the most delicate part of my operation is going to be the final implant. So I will end with the final implant. And I'll choose a surgical approach that's extensile enough that allows me to do both procedures in one, as you see with this DFO, OC allograft. What if it's a meniscus transplant and an osteotomy on the medial side? As I indicated earlier, that's tricky. It's easier for those of us that do soft tissue because you can do the osteotomy and you just have little drill holes. It is technically demanding. I do worry a little bit about fracture risk because I've got a pretty thin area up top. And again, I do soft tissue medial meniscus transplant. I love to hear that that's what Seth does now because I've gotten so much crap from him over the years in the way I've done it. So it's nice to see that he's come to the dark side. If you're going to do this all in one setting, again, arthroscopic works first. I'll do my transplant second. I'll do my HDL, and then I will fix my roots at the very end in case I happen to inadvertently hit a suture. Actually, I'll put it in, and I won't pass the passing sutures to the root until after the osteotomy is complete just to make sure that I don't bag those sutures when I'm doing that. What if I'm doing cartilage restoration, meniscus transplant, and osteotomy on the medial side? So now we've added an articular cartilage work. Again, technically demanding. Consider staging. I'll do my scope work first, my transplant second. I actually leave the front open so I haven't fixed the anterior root. I'll do my OCA. I'll do my HTO, and then I'll fix my roots. And again, cell-based repairs are always the last thing I'm going to do if I'm going to consider MACI. How about on the lateral side? Technically easier because typically we're doing the lateral side with a femoral osteotomy. Not always. We do some medial closing wedge tibial osteotomies, but I'd say 80% or 90% of them are DFOs. So I'm going to do my scope work first, again, my meniscus transplant second, OCA, and then end with the osteotomy, and then I'll fix my roots at the very end. And again, cell-based procedures always are the last thing. ACL, articular cartilage meniscus transplant. Staging is pretty common, so I'll do my arthroscopic. So sorry, this is often done in one stage. I'll do my scope work first, my meniscus transplant, OCA. I'll then pass and tension my ACL, and then I'll do my final meniscus transplant fixation at the very end because, again, that's my most delicate part. If I'm doing an osteotomy with this combination, again, this is almost everything, right. This is everything. ACL, articular cartilage, meniscus transplant, and osteotomy. I would highly recommend you stage this, at least in my hands. These guys may do this all in one stage. But that's a big surgery. That's a lot of work. It's a lot of moving parts. The first stage, if I stage these, I'll do the osteotomy bone grafting if I need to bone graft any prep work. And then I'll just come back and do the ACL meniscus transplant and articular cartilage reconstruction at a later date. And that's actually a much simpler intervention, in my opinion, than having to try to do this all in one day. So in conclusion, these are challenging cases. There are various permutations, previous surgeries, previous incisions, different combination of work you're going to be doing. You should have a thoughtful plan. You should have a thoughtful approach. Don't hesitate to phone a friend. We all communicate a lot still. Like we text a lot, like weekly on different cases. You should walk through this mentally before the day of your surgery. I still do this. I do a lot of this work. I do probably at least, I don't know, 70, 80 osteotomies a year. And if I'm combining with these procedures, the day before I'm always walking my brain through that surgery. Where are my pain points going to be? What are the most delicate parts? Even though I've done these a lot. So these are challenging. They're super fun. Have a low threshold to stage, especially if you don't do this with as much frequency. And again, use your friends and colleagues as resources. Thank you. Applause. Excellent. Well, it's an honor to be here, and we'll try to keep this relatively brief so we can get back to the rapid-fire Q&A, because I think that's where we all learn the most from each other. My task from Rachel was to talk about biologics, and my disclosures are available online. This is obviously a very hot topic. We're just going to tease out some of the potential of cell signals and scaffolds, and so this is not a talk on some of our standard MACE, OCA, cartilage restoration techniques, but some of the things that are out there now and that we'll be seeing in the future. First, it's really important how we educate our patients. What are these orthobiologics? So this is what they are. They're bioactive, anabolic, and anti-catabolic molecules that can modify the arthritic or regenerative process, and so these come in many different flavors. You have the autologous blood products. You have cell-based therapies like BMAC and FAT. You have placental-derived from amnion and isolated growth factors. From a big-picture view, we need to explain this in layman's terms. You can think of these growth factors like an airdrop that's supplied by the Red Cross, and so that can turn up the good, and these are some of the good, and it can turn down the bad within the joint, and it can try to regain joint balance or homeostasis. We learned very much from a great mentor to all of us, Arnie Kaplan, who recently passed, about MSCs, and we know his classic lineages, but really, before he left us, he left us with a really important message that we have to continue to our patients. These are not, quote-unquote, stem cells that are going in and regrowing anything and changing the face of arthritis. These are truly medicinal-type signaling cells, not stem cells necessarily, and so what do these MSCs do? They do a lot of great things for joints, right? They're trophic, immune-modulatory, they have antimicrobial properties, and a host of other things that can really help us as doctors and surgeons to help our patients, and when we look at this as far as what the cell-based therapies are doing versus just supplying things like growth factors, I think you can start thinking not just airdropping supplies, but also having the Red Cross come in in a war zone or a danger zone, and helping to recruit and organize the local staff on the ground so that it leaves them with a template for the future, and I think that can be helpful analogies for the patients. Biologics are just heavily regulated. There's evolving but imperfect evidence, so we really all have to come to meetings and align with each other and make sure that we're not overstepping our bounds. The FDA is watching. They have pulled all of the amnion products off. We have one in a phase three FDA study now for osteoarthritis, which will get a true indication and label if it passes this test, hopefully in the next year or so, and that can be a real benefit to us all. So here's kind of an example. So this is a classic case for an osteochondral allograft, and we can make this look really excellent, and we can high-five, and then we can go about our day, but that's not the end of the story, because there's really no free lunch in cartilage restoration. There are tradeoffs. For things like Macy, we have to wait for the grass to grow and for it to remodel, and that takes some time. For osteochondral allograft, we have mature hyaline at time zero, but then we have to wait for the bone to remodel, and that creeping substitution can definitely take a lot of time. So we've all learned from Bill Bugbee and others to make these plugs very small, six to eight millimeters maximum, and I think we're all trying to harness biology to help, because there's nothing worse, as these guys can tell you, than a painful OCA at a year, and that's bad for our athletes, it's bad for us, it's bad for our middle-aged patients that we're trying to push the technologies on. And so things like CO2 and using BMAC is hopefully going to help us with this osseous integration. I won't ruin the punchline for my talk on Saturday, where we're presenting some of this Basin Science data, but it is quite intriguing. I will, however, in this session, tell us more about what the clinical summary is, because it's really not perfect. So if you look at the study from Mizzou, and they looked at x-rays, then you can say that, yes, there is a positive benefit for BMAC with our osteochondral allografts. However, when you look at the experience from our friend Andreas Gamal, and they looked more at MRIs, you can see a much more guarded message, and similarly, from the HSS experience, there was again a much more guarded message, so it really didn't pan out the same way that the first study did. Fortunately, the Rutsch group is looking at this, they've done a randomized study, and at least at this point, they did see significantly less pain in the BMAC group when they followed these out of the year. Interestingly, the BMAC group had more small cystic changes, whether that's a good or bad thing is up to debate. So I think just importantly, clinically, I think most of us, raise your hands if you do BMAC for your OCAs, so two out of the, or three out of the four of us do this, but the evidence is not perfect yet, and for me, at least, I'm not going to the hip and adding another area of morbidity, I'm taking from the knee for better or worse, maybe less cells, but still, those good growth factors, and at least, you know, I think it can be additive in these tough cases. And so here's one, a painful OCA, as I alluded to, I think, Mike, maybe for this one, so it's a year out, what's your treatment of choice biologically for a painful OCA? So you think the cartilage is intact, you scope it, and in fact, it is intact, what are you doing then? I mean, you can do a bunch of things, first thing you do is check alignment and make sure you didn't miss any kind of mechanical malalignment, and then you've got subchondroplastic options out there, whether it's bone marrow concentrate, whether it's calcium phosphate options, there are options on the table. I don't know if any of them have really been shown to be 100% efficacious in this regard, but you have options, and I'm assuming this patient has painful symptoms, yeah? Yeah, I think they may not have the full efficacious data behind it for OCAs, but as I'll show you in a moment, briefly, you know, when we're talking about subchondral bone and these bone lesions, you know, I think that there is significant data for the bone marrow aspirate concentrate, so for example, this was an RCT for BMLs, and this was pitted up against totals, and it actually had, you know, quite compelling data, I'll show you also in a moment another study for osteonecrosis, where BMAC, you know, definitely did have favorable results, I think, for the painful OCA, at the very least, if the cartilage is intact, decompressing the lesion with drilling, and then considering some sort of biologic substrates to heal that subchondral bone. Here's one of Rachel's cases, a 55-year-old runner, had lateral pain, failed conservative treatments. Again, we go through that checklist, so they're neutral, they're stable, meniscus, you know, we can see, obviously, has issues, and the lateral subchondral changes, and so, for this kind of a patient, and you can see this online in the interest of time, so we can get to our cases, you know, she did a subchondral drilling solution, also combined with her biologic of choice, and this patient had an extremely excellent outcome as well, and so, I think the main point here, harnessing biologics, not only to treat the surface, but to look beneath the surface, and I think we're really understanding that the bone is implicated in a lot of the pathology that we're seeing. This is a study that, I think, was the brainchild of Brian Cole, that we're collaborating on, but these are mineralized-type materials that turn into bone, and so, some of us are using these to help fixate OCD lesions, or for osteochondral grafts that need fixation, and an interesting concept, like rafting screws for the subchondral bone, in those cases where they have significant subchondral insufficiency, and so, I think there'll be more to come on that. I'll pivot briefly just to some other things that are coming, conceptually, cells, signals, and scaffolds for cartilage repair. We can see here the power of cells, you see PRP on the left, and you can see how this stimulates recruitment of MFCs, increased HA production, increased cell proliferation, decreased catabolic proteins. This is all beneficial for joint homeostasis, and you can also envision that you can look for different cell sources combined with a scaffold and these signals to get the job done. So, in this particular example, that's minced autograft combined with lyophilized cartilage and PRP, but it doesn't just have to be that. It can be a whole host of different types of things, and I will also say that when we're talking about technologies like this, at least for me, I'm thinking about these more for those single stage, those smaller medium things, and not necessarily for everything Armando was talking about, where we have 20, 30-year data on things like MACI and osteochondral grafts, but these can definitely expand our armamentarium for some of the lesions that we're seeing day in and day out. And then lastly, I think we'll all hear more about the agility scaffold. So this is basically sea coral made of aragonite, and you can see what this implant looks like. These are interestingly small, 7.5 millimeter diameter and not very deep scaffolds that go into these areas of bone and or cartilage damage, and you don't have to fill the whole lesion like the osteochondral allografts. You basically can skip them within these larger lesions. And why this was so intriguing is that you have this kind of magnet effect, where basically it attracts your own cells to make bone and to also interestingly regenerate cartilage. And from the follow-up studies on these hundreds of patients and from the FDA clearances, this basically regenerates not only over the agility, but around it. And so this is a really interesting technology that bridges the gap for the early arthritic in my mind. So the tolerances in the study were basically up to eight degrees of varus malalignment, meniscus rim five millimeters, BMI up to 35, multifocal defects of the trochlea and the condyles. And so, you know, you can see how when you're scratching your head, man, I can't do an osteotomy or they won't tolerate it or, you know, I have to do three OCAs on this person or they have too much early osteophytes, early bone, you know, early narrowing. For Macy, I just don't get great results in that patient. I get much better results in young people with pristine x-rays for Macy. For example, this really comes into the armamentarium and frankly, if you look through the data and they'll present more at this meeting, lesions like this, treated like that, the KUS scores go through the roof and the MRIs show regenerate. And I've seen hundreds of these types of patients, the larger the lesions, the more the KL grade up to two and three, really the better the outcomes, the more disparate the outcomes were versus the standard of care, which was debridement and or microfracture. And so there's a lot more to unpack here. We'll probably get into the nuances with the decision-making and maybe some of the other ways we use biologics or other injections as adjuncts. For example, boggy synovitis post-op, you know, when things are not going well. But in the interest of time, I thank you for your attention. Look forward to some lively discussion. All right, great. Some great talks. My name is Mike Alea from NYU, and I'll be talking about HTO and the active population. So we're going to get more into the gist of meniscal transplants and osteochondral allograft MACE cartilage-based procedures as we discuss the cases, because if we wanted to talk about all that, this would probably take about another two hours. So we wanted to get into the meat of this, which is more of the case presentations. The other thing I want to say is that, you know, although we're up here talking about knowing what we're doing, I would like to tell everybody that we have been humbled a million times in our clinical practices, and we will continue to be humbled despite doing all these procedures. And we're still constantly trying to figure out what the best option for these patients are, because more often than not, as Seth and Armando and Rachel have alluded to, cartilage breakdown is very seldom traumatic and very often degenerative. And when it starts to be degenerative, then it's a disease of bone. It's a disease of the organs. So if you just address the cartilage, even if the bone looks perfect, you still might be cutting yourself short, because, again, this disease process has already started. So the idea of halting that disease process is hopefully the next step in what we're doing with restoration of the cartilage and joint preservation, but we're not quite there yet. But for me, I'm going to talk about high tibial osteotomy in the active population, which is a question that I get pretty much all the time from other people, from patients, et cetera. So here are some of the disclosures. I do want to say my first major disclosure is that I'm a metalhead, not just with my music but also with my hardware. I used to do an inset plate like this, and I've seen several cases, not just from myself but other patients as well and other people, where if there's a hinge fracture, you could actually convert the plate to the hinge, and if that happens, you're going to wind up having more varus than you started out with. I frankly got tired of seeing that, so I converted to only using metal for this. So we'll start with a case study. It's a 17-year-old female high school varsity basketball player with D1 interest. She's very, very good at multiple sports. She came in to me, referred by a friend, with severe lateral-sided joint pain and swelling. She had a loose body removal and a microfracture done by an outside physician. As you can see here, the microfracture wasn't going to do jack squat in this. This is diseased bone, a large osteochondritis desiccans lesion in the lateral compartment. Look at the MRI that corroborates that, and what you don't want to see, obviously, is this patient in a severe amount of valgus, which is certainly not helping her situation. You can see that the valgus in this particular patient is asymmetric in nature, which I'd like to point out. And then you're going to have your naysayers out there that say, oh, an osteotomy, her career is over. And, you know, well, is it? I mean, I don't think any of us really know the answer to that question. Most of the HTO and DFO patients that we have in the data, it's in older patients, maybe a little bit less active. We don't have good data in elite athletes, like your Tegener 10s, your Tegener 9s, because simply we don't do it very often because of the ramifications of their career. We do see postoperative decreases in the Tegener score from what they were originally, meaning if you have a Tegener 8, maybe after the surgery, they're a Tegener 7 or a Tegener 6, but when they were symptomatic, they were a Tegener 3. So you substantially helped them with their pain. Like I said, virtually there's no data in high-level athletes. You know, the pros of osteotomy, number one, these athletes have already probably tried everything, right? And if you've got a super elite athlete, we're going to do everything to get this to get better without surgical intervention. These are patients that have tried everything, whether it's PRP, BMAC, offloading, et cetera. So these patients really have nothing left to stand on. Fractures heal. Bones heal. You know, if you do a good osteotomy, just like any other fracture, it's going to heal. An HTO can't re-tear, all right? So you can't do, it's not like MACE or OCA, where everything wears away, an HTO is simply not going to re-tear. You're not going to have quad shutdown. We always talk about quad shutdown, ACL surgery, you're quad-dominant patients, you don't have to worry about that, and you're not violating the joint. The cons of HTO, number one, you're changing their alignment, right? If you have a patient with symmetric mild varus, let's say a soccer player, and you do an osteotomy on them, are they going to feel it? Will they notice the difference in their kinematics, their gait, their running, their kicking, et cetera? Also, are you going to have ramifications regarding changing the patella femoral compartment, whether it's patella or height? And these are questions that we have not answered. If you see any changes in leg length, will that alter their ability to play? What are the potential for complications, right? The other thing we do is complications, and that complication I showed of the failed HTO, that was my complication. Like I said, we've been humbled many times before, and we will continue to be humbled. Hardware prominence, which is a thing in HTOs, and often, like I said, and Seth and Armando and Rachel have alluded to, these are often combined with other intra-articular procedures. So this is an ACL insufficient patient with malalignment. He's 24 years old. He had a triple varus knee. He's pretty much tried everything. He has instability. He has pain. This is a patient who's very, very active, very, very athletic, probably like a Tegner 7 or a Tegner 8, and this patient ultimately needed an HTO, right? So I can change the slope a little bit with patient-specific instrumentation, change their hinge axis, make sure their hinge is appropriate, correct their varus, correct their slope, and hopefully lead them to having a successful outcome. This is a 24-year-old female with three ACL failures. Meniscus was intact. She has normal coronals, normal collaterals, and we can do a simple slope-reducing osteotomy, and these patients can go back to a very high quality of living. If you have a patient—excuse me, this is our final post-operative x-ray, and these are patients that will text you and tell you how good they're doing, and then you can see no ACLs were torn this weekend, and naturally, out of my sarcastic, cynical self, I say thanks be to God. Well, what does the data say about all this, right? We're all focused about data, right? We can sit up here and tell anecdotal stories about how great our patients are doing. We look like all-stars, heroes, et cetera, but what does the data really say, okay? We've got several studies out there in OJSM, AJSM, which do show that patients with higher baseline activity scores do better with high tibial osteotomy as opposed to unicompartmental arthroplasty, right? So if you get a patient who's 250 pounds, doesn't really do much, has a desk job, that patient might have a much more realistic and reliable outcome with a unicompartmental arthroplasty as opposed to an HTO. But your patients that are super active, the data is out there, and it really does confirm that HTOs give those patients a higher Tegner score and a higher return to activity than arthroplasty. Our friends out in Europe, Matt Olivier's group has shown quicker return to professional activity with osteotomy as compared to uni, higher CUS sub-scores, quicker return to sport, particularly impact sports, with much tighter standard deviations, so a much more accurate, reliable way to get your patients back to sports. Other articles as well has shown patients with a little bit higher age with good return to sport, 75% return to sport from HTOs, and a lot of these patients did undergo high-impact sports like running, marathon, volleyball, mixed martial arts, soccer, boxing, et cetera. So you can do it reliably. Looking at our data at NYU, and we're going to present this at the AOSSM this year, we have a cohort that we combined, and we're soon to be combining with other cohorts as well, and we looked at 80 of our own patients, and these are younger patients, right? These aren't your over-50 patients. 60 HTOs and 20 DFOs at an average of about six years of follow-up. The pre-injury Tegner score on these patients was 6.6, meaning before they got hurt, they were pretty active, right? When they developed their symptoms, they went down to about 3.1, and then post-operatively, we did well, but we didn't do perfect. We got them on average to about 4.6 on the Tegner. We found a 46% return to sport. Of that, 65% of the patients did return to their peak level of sport, so we certainly got a lot of people back to where they wanted to be, and 76% of those patients who were pretty much elite athletes would elect to have the surgery again. 86% of them met pass. We found no difference in outcomes regarding the indications, whether it's for arthritis, instability, et cetera. So you can certainly improve a patient's quality of life and give them the chance to go back to the sports that they love. You cannot guarantee it, but you can guarantee that you will give them a chance. This is something we talk about all the time, hardware prominence, right? This is a patient that had bilateral high tibial osteotomies performed by me. You could see the inset plate that the patient healed uneventfully from, and then this is sort of after I made the switch, and then you could see a metal plate there, but these metal plates come with problems, whether it be hardware removal, secondary procedures, et cetera. This was a nice Pearl Diver study by Drew Lansdown, who's over at UCSF. At two years, they found that HTO patients had about a 25% rate of a second surgery. DFO patients, again, about 25% needed a second surgery. And hardware removal is certainly not a small issue, right? A lot of patients are going to require hardware removal, so counsel them on that. Make sure they understand it. In terms of some general observations regarding high-level athletes, we know for certain that high-level athletes do not tolerate overcorrection very well. We want to keep the angles within about five degrees of normal. So your distal lateral angle, your proximal medial angle, you want that roughly within five degrees of the normal mechanical axis. Ideal patients for these surgeries are going to have asymmetry, meaning that they've been either falling into varus or falling into valgus on that one side. When we look at the joint line, we want to keep the joint line congruent, and we want to keep the joint line perpendicular to the ground. Once they start developing obliquity of the joint line, then you increase the shear forces on those compartments. Those patients ultimately develop more pain, more issues. And as with everything, counseling, counseling, counseling when it comes to the treatment of any high-level athlete that you're considering an osteotomy on. Why do we care about joint line obliquity? And I just mentioned this. This was a nice study looking at peak pressures from KSSTA of 2018. As you can see, if the joint line becomes more and more oblique, the joint forces change. They become focused in a different spot with increased peak pressures at different parts of the joint that you don't want to see. When we look at our outcomes, this is a study out of Asia, found that patients with increased joint line obliquity, which you can see from this x-ray that is part of the paper, that's an oblique joint line of about 6 degrees. Those patients will develop lateral-sided pain because of the shear forces that you have on that compartment. So again, the importance of keeping the joint line perpendicular to the ground cannot be overstated. And then we get into things like double-level osteotomies, right? You've got a patient here with a clear valgus deformity. If we're going to do a distal femoral osteotomy on this patient in isolation, that's about a 13-degree cut. And you can see what happens to the joint line. It becomes quite perpendicular. Your lateral distal femoral angle is now 96, which we don't want. That's more than 7 degrees out from where we are target. So that's really not what we want to see. So you have the option to do dual-level osteotomies. And again, you can do this in a high-level athlete. It's been done. It will continue to be done. But if you achieve perpendicularity to the floor, which you can see on this patient, that's when you're going to have a good outcome. The future, and most of us agree about it, is patient-specific osteotomies. They're certainly becoming more and more popular. The ease of the procedures is there. The accessibility to these procedures are there. They are more accurate to the traditional freehand technique. This was a paper that we did in a cadaver study. Myself, Armando, Anil Ranawat, a few other people went down to Phoenix and did a cadaveric study, and we found that PSI patients only had 0.5 millimeters off from the correction that we wanted, compared to about 3 millimeters of a difference with a standard freehand osteotomy. And as you would expect, there was substantially less radiation in the patients that underwent patient-specific osteotomies. We looked at our own data at NYU. Myself, Ian Elliott, Laith Jhazraoui, Anil Ranawat helped with this paper as well. We looked at cost-effectiveness. So a lot of times people will have a hard time getting patient-specific instrumentation into their hospital systems. So I've been offering to send our data to other people. If anybody's having problems in the audience with that, I'm more than happy to send you our article, which is going to be presented tomorrow. But overall, the cost is the exact same after the learning curve hit. So if you're going to have, let's say, $26,000 worth of cost for your osteotomy from your freehand, you're probably going to have about $26,000 worth of cost from your patient-specific instrumentation, but it will save you time. And ORs like when you save time because that means you can do more cases. The beauty of PSI is that you can dial in your hinge pin and your hinge axis, right? A lot of times we want to change slope to give you either less instability or let's say you're doing some sort of ACL revision, et cetera, or a PCL case. You can dial in your hinge axis using a series of drill bits for this particular case, and there are other different products out there that allow you to do similar things. You can also dial in other procedures as well. This is a case that had a meniscus root guide dialed into the implant as well, and it's quite accurate. You can see it's coming out exactly where you want it to be. Going back to our case, this is an ideal patient, young, super active, healthy, asymmetric varus deformity with a large lateral femoral condyle osteochondral injury. Here you can see the intraoperative pictures. Like Armando, I like to do a very big extensile approach, jump over the LCL and do your arthrotomy right over that. You can see it looks like she's got two notches. She's got that big notch in her lateral femoral condyle and then her notch where the Z retractor is. This is a patient that ultimately went distal femoral osteotomy trying to keep the joint line as perpendicular to the ground as possible. We have a snowman-based osteochondral allograft, and you can see here I fractured the hinge. This is a hinge fracture. Hinge fractures happen. They happen much more commonly in distal femoral osteotomies as compared to high tibial osteotomies, but the beauty of using a rigid plate that's a locking plate is that allows for very little micromotion, and most of these hinge fractures, if not all of these hinge fractures, will heal simply by doing nothing. So that's the beauty of rigid fixation. Here you can see our correction pretty much straight down the path. We don't want to overcorrect this patient and put her into varus because she will not tolerate that very well, and she ultimately went on to do very well returning to full sports, and next year she's going to be a D1 athlete in the Northeast. So getting a little bit tired of hearing the age-old adage, if you do an osteotomy and an elite or professional athlete, they are no longer an elite or a professional athlete. I truly believe that that is not a correct statement. I think that it is appropriate, but it is not correct. In reality, these patients have tried everything, and they cannot play, and they cannot get back to doing the things that they love. So we owe it to ourselves. We owe it to our patients to at least give them a chance at success, improve their life, improve their morale, and get them going. So osteotomy can be done in the right patient for the right reasons with good results, but in the end, just like everything that we do, it's all about counseling. So thank you very much for your time. All right. If we can put up that last perfect. So what you guys just heard was 35 minutes of really high-level, complicated stuff made very easy, I think, very simple. So before we get to cases, what I'd love to see is if anyone in the audience has any questions, any specific questions that we can answer or try to answer before we get on to some of these cases. Because often times we get right to the end, it's 5 o'clock, it's happy hour, we're always happy to stay, but no one's going to want to stay. Yeah? Now, you know, this is a last chance saloon for a lot of these patients. You know, if they come to me and they haven't really had much treatment, I mean, you can certainly offer a surgical, like, debridement, arthroscopic debridement, there's nothing wrong with that, burns no bridges. You can inject anything from hell to high water, whether it's BMAC or PRP, et cetera. I mean, I don't offer it right away, I will never do that, and I think that's a bad adage and a bad precedent to set because that is certainly not what we're trying to come across here with right here. We're just trying to say that for the right patient at the right time, it's a good procedure. I would just add to that. We know there are some bad actors and the bad actors are lateral and, you know, we alluded to that discoid that loses the meniscus. They're often in varus and you watch them go to neutral, then you watch them lose some cartilage and then you have to do a bunch of things to them, so that's one group. But I also see as taking care of D1, you know, the valgus active female who's meniscectomized at 16 and she's effusing before she even started to practice and we're not quick to jump to osteotomy for that one either and that's probably the solution and we know how to do it and we can tackle it, but until we have, how many do we need, all of us to pull it and get five or ten that went back to sport at two years to get that confidence up, if you have that complication in that one person, we're in trouble, right? I mean, I agree with everything Seth just said. I mean, that's a bad actor, that failed discoid, that discoid that's now falling into valgus. No, that's an early intervention for me every day of the week. I don't think there's good data on that. There was some data out of the Mizzou lab that I didn't put here that showed that PRP or I think it was saline was inferior to the BMAC. However, I think just conceptually and drawing off of those other level one studies for other bone problems, that's why a lot of us went to BMAC. We're starting an RCT looking at exactly this because cost for concentrated bone marrow aspirate is just, it's cost prohibitive for many of our patients to electively do it. We've gone to bone marrow aspirate in those patients. Andreas Kamal has shown some data out of HSS with that. There is no data to support or negate the use of PRP, but I think most of us feel more comfortable soaking an allograft in something autologous versus nothing. But the bottom line is the data is just not there. So we're doing a nice funded study looking at this. It's going to be multicenter, which is great. But even then, I think the number needed to treat versus results that we're going to see with respect to radiographic healing, and then how does radiographic healing correlate to clinical symptoms and clinical outcomes? I mean, with osteochondrialografts, we just don't know. That's why most of us don't routinely, and this is something I learned from Brian Cole, don't image what you don't want to see. So if a patient's doing amazing, I don't want to see the MRI. I have no interest in what that MRI looks like. Because if it looks bad, it's now in my head and the patient's head. So I don't want to see unless it's for research purposes. So the question is, what are we really treating? Yeah, and something no one's really talked about up here is the fact that we don't know what the antigenicity is of osteochondrialografts as well. I mean, we soak them, we debride them, we use CarboGED, et cetera. But ultimately speaking, and again, we don't know the answer, if you've got a 4 foot 5 patient from Asia and you put in an female patient from Asia and you put in an osteochondrialograft from a 6 foot 7 guy from, let's just say, Morocco, is that going to be different? Is that going to cause you a problem? And we don't know the answers. That's something that BMAC probably can't solve. You're referring to like a bio-uni, essentially? Yes. It's funny. We were just talking about this yesterday. I still do some. I mean, I think some of these lesions are certainly longer than they are wide. I think we all are worried about the bony burden, because it's a pretty big, especially centrally. I think they're footsie. So I like them. I still do them. I was talking yesterday. I don't think I've had a failure, as far as I know, in one of those. I do Socom and BMAC. I actually supplement them with fixation, because sometimes, if you're not perfect, they're not biomechanically stable. I seal the perimeter reticule, too, because I worry about intrusion of synovial fluid at that interface. A lot of intra-articular fractures don't heal because of that. So I do certain things in that particular case. But I like them. But I think we are all worried about the bony burden centrally. Just to add to that, Adam Yanke from Rush did a finite element analysis, and he favors the snowman approach. But then Bill Bugbee and John Grant dissected out a large number of the bio-unis, the oblong grafts, and they demonstrated superior contour versus snowman. So I think it's a mixed bag. My biggest issue is the thickness of bone. It's also very destructive to the grafts, I think, if you're doing that. So if you have multiple plugs, like if you're doing a medial femoral condyle, maybe trochlea, it is pretty destructive when you take it out. So you just got to be mindful of, and you only get one shot. You don't get two shots at harvesting that graft. Tommy? I have a question about the past eight years, we've been doing the trifecta, retro-drilling, pulse lavage, and then PRPs, because it's cheaper. I don't know which of those three is the most important. So I refuse to pull one out and not do the other three. Retro-drilling, like into the lesion itself? Retro-drilling the plug. The plug. You put a light and you see Xenon. Not through the cartilage. Since I'm not sure how many of us are going to endure it until Saturday afternoon, when I was running our scientific session, the punchline that I have for us, pulse lavage gets rid of very little fluid. I mean, it's to get rid of the marrow elements, but you actually gain a little bit of saline weight. And then when you try to absorb something like BMAC, it doesn't really do it. Whereas, if you do pulse lavage and then you add the pressurized CO2, you basically see what we see clinically, that there's much increased porosity, and then it increases up to 100% of your ability to take in a thing like BMAC. So, basically loading that plug, I think, will be a big benefit, and probably that preparation helps. Who in the audience have used carbon dioxide flow to try and decrease the marrow? Not a lot. Yeah, I mean, I would strongly recommend trying it, because you will see the difference in your plugs. You will see just how porous it becomes. And for those who do joint replacement, that's a reasonable thing that they've done for quite some time, my understanding, for cement pressurization. All right, we'll get on to some cases. Just a final answer, the snowman versus oblong. I'm a big snowman fan. If I have to take more than two millimeters of healthy cartilage, in terms of one circular plug versus two snowmen, or if I just did a three snowman and an 18-year-old college football athlete, I will do multiple snowman plugs to try to violate as little of the cartilage as possible. What I will say is I order a whole distal femur for those, so not just a hemicondyle, so I can really match radius of curvature. My big problem with the oblong graft is not only the bony burden, as mentioned, but also the radius of curvature from the donor to recipient is almost impossible to match with an oblong, versus with circular plugs, you can finesse it. So for me, in my practice, I have revised several of the oblong plugs, and so that's dissuaded me. But it is sexy. It looks good. Look, the pictures look awesome, until you have to revise it. So that's just my bias with that. So we're going to go fast through the cases, because I want to get to quite a few of these. So speakers, fast. And if someone says something, no need to repeat it, because we all basically have the same opinions on everything it seems. Okay. 23-year-old male, left lateral knee pain, mechanical symptoms, prior surgeries, lateral femoral condyle microfracture, a partial lateral meniscectomy by another surgeon. Then he had a washout. I love when they say, oh, I had this other surgery for infection. I'm like, oh great, I'm vomiting. So he had some sort of washout for drainage. And he had tried all the non-ops. So non-op is not an option for him. MMI is 26. His knee looks dry. There's not a huge effusion. Good range of motion, tender laterally, all the things you want to see. He's pointing to the spot where it hurts, where he says he has problems. These are his x-rays. It's the left knee that's involved. We can start to see that that lateral compartment, while still good joint space remaining, you can start to see some squaring of the condyle if you really look and you compare it to the opposite knee. Here's his standing alignment x-rays. Armando, does this amount of valgus, his asymmetric valgus, make you happy, make you underwhelmed, as the kids would say these days? Is this like a mid-level of valgus? Did I say it right? This makes me super happy. Super happy. Yeah, because I like the idea that I'm probably going to have an osteotomy as an option. And that's such a powerful driver of outcome. So I actually get more worried when they're embarrassed because of like, oh, I've lost my extra articular volume. But just this much. How many docs in the audience here are thinking, oh, that's not that much. It's asymmetric. But just be honest. How many are thinking, I wouldn't even think about correcting this? How many are thinking, I'm excited. I want to correct this? Okay. I like it. I like it. All right. So asymmetric. So this is his MRI. He has an MRI. I'm going to let it, I have a few slides here. We see, what, a focal chondral defect of the weight-bearing surface of the lateral femoral condyle. Here's some MRI videos for you. Lateral meniscus. There's some there. Small effusion. Ligaments are fine. Medial compartment's fine. Okay, Mike, what's the next step? Non-op's not an option. He feels better in an unloader. All the things you want to hear. What's next step? Well, first of all, I want to go back to your last conversation. I don't think we can, I think it's inappropriate that you call it a snowman. It should be a snowperson at this point. I stand corrected. Let's keep going. I'm running for the HeForShe award for next year. What if they don't identify as a person? No, this is intervention. This is going to be an intervention. Okay, what's the intervention? Last one or the last, last one? Diagnostic staging scope or are you going right to doing all the things? I'm going right to doing all the things. Seth? I'm going to do a staging scope with a, probably a small correction, tibia closing wedge, and then I'm going to come back as needed for meniscus and cartilage. Okay, so you're going big with an osteotomy at the first go, but no joint preservation with biology. I haven't been in there. I think that meniscus looks diminutive at best, and MRI underestimates cartilage, so I'm not going to start doing three things when I could possibly solve it with one and wait there early. Armando? I'm going to do a staging scope. I think that it informs your plan better. I think you're more thoughtful with what you're going to choose, and I think there is a meaningful therapeutic benefit for some patients, which we published on, Rachel. Mike, you said you're doing it all. What is it all? Quick. This is going to be an osteochondral allograft and an osteotomy. What about his lateral meniscus? I wasn't too convinced. Let me go back to it. No, no, no. You saw it. I actually wasn't looking. I was too busy making fun of you. You weren't looking. Audience, who's doing a staging scope alone? Audience, who's doing osteotomy alone? Who's doing osteotomy with cartilage alone? And who's doing osteotomy with cartilage and meniscus allograft? Second stage. So this is what I did, and I'm biased. At Rush, you really learn to do diagnostic scopes unless you're absolutely sure. Now, this guy was in his late 30s, early 40s, different scenario. He's 23. So if I'm going to do a surgery, I want to do one. I want one period of non-weight bearing, one period of misery with the knee. I will say doing all three, osteotomy, lateral meniscus transplant, lateral femoral condyle cartilage, is miserable for the patient, more miserable than doing all three on the medial side, at least in my experience. So I do a staging scope. So let's see what Mike thinks now of the staging scopes. Mike, you ordered the fresh graft, and you're planning for the osteotomy, and this is what you see. Okay. Here's the meniscus. It's not so good at that level right there. It's not so good. It's not so good. But this is a very real scenario. It's not so good. Are you going to put in the cartilage graft? I am. And do the osteotomy? I am. And what are you going to tell them? I'm going to tell them that they're probably going to do very well. I mean, we have data to show that osteochondral allografts, without doing a meniscus transplant, if you do change the alignment, they actually do really, really well. Meniscus transplants are not the easiest surgery in the world, and they have morbidity. And if anyone's done one, they know that there's a fudge factor with there. It's like a suture crisis sometimes, and getting the graft in can be an issue. This is not like a trivial thing. It's like, oh, a meniscus transplant. Oh, osteochondral allograft. Mike, can I ask you a question? Is that data on the lateral side as well? I can't remember. Because I think the medial side and the lateral side are different, right? And I think that the medial side, you know, Rachel, that paper of medial compartment pressures with osteotomy, you can achieve pressure profiles similar to an intact knee with an intact meniscus. The lateral side is more meniscus sensitive. So, like, this makes me nervous about just doing osteotomy. Now, maybe a tibial osteotomy like Seth recommended is better because you offload the entire range of motion. These are posterior lesions, right? They're posterior. But I get a little bit more nervous about not protecting the lateral side. I just wonder if you had a difference in your data because I'm not sure the compartments behave similarly. To be fair, I actually don't remember if there was a difference between the compartments. This is an active patient with bipolar chondrosis, meniscus deficiency, and asymmetric malalignment. I mean, that's screaming osteotomy as a dominant treatment strategy. Osteotomy is a dominant treatment strategy. And the other things, I mean, this is a 23-year-old, and none of those things are going to last forever. And the transplant, we're not going to necessarily go back to sport, you know. So you have challenges all around. But to me, this is the hedge bet that will lead to the easiest rehab, one stage, and, you know, not burn bridges for the future. You could also make the case to do a meniscus transplant and leave the cartilage alone, right? You can make that case. I wouldn't do that. I wouldn't do it either, but you can make the case. You'd lose. You could fail. Yeah, you'd fail. But, I mean, you know, if somebody was presenting that at the oral boards, if somebody was presenting oral boards, I certainly wouldn't fail them for that. I mean, if they didn't do an osteotomy, yeah, I'd probably be a little bit pissed off at them. But, I mean, you know, the other stuff is dealer's choice. All right. So I think the take-home message is there's a lot of different ways to treat this. I think you do not treat this with just cartilage or just meniscus or just cartilage and meniscus. You need to add some sort of osteotomy. This is before I was using PSI, and so I just did this probably a little bit naively in terms of understanding deformity on the femoral side versus the tibial side. But I did a lateral opening wedge distal femoral osteotomy. I did do two plugs, and that somewhat turned into soft tissue for this meniscus transplant, just like my colleagues have described. And I think for the sake of time, I'll try to get to the final pictures. But this is the osteochondrial graft snowman. Here, as you see here, no supplemental fixation. So don't need screws for this. There's a lot of different strategies. Variable depths is how I get around snowman. Usually drill the first plug a little deeper, 9 to 10. The second plug a little more superficial, 6 to 7. And that variable depth can be very helpful. And then this is the osteotomy, and you can see a good appearance of his snowman. If you look at the lateral, you can really see that contour. And he healed and did well. But I will tell you these take a year minimum for their knee to start to feel even remotely normal. They feel what I like to call woody. Their knee feels thick and leathery. They don't feel good. And I tell all of my joint preservation patients, and the literature supports this, there's a one-third chance you're going to need a second scope in the first two years. But if you get a second scope in the first two years, the data would show that over 90% of patients do well. So you have to counsel them ahead of time that the second surgery is likely coming so that if the second surgery comes, that you failed or that they failed. It was just part of the process. Hey, Rachel, can we just go down the line real quick and just what everybody's definitive treatment in this panel would have been after that staging scope? Yes, I would have done what I did. Yeah, so for me, that would be an osteotomy. I'd plan it. If I could find a tibial option like Seth, which is probably 20%, I would choose a tibial option. But I would do osteotomy alone and not do the cartilage work if it was my patient. Okay. Same. But if you staged it and then were coming back, is what he's asking. I would probably do osteotomy alone. They're all lying. 100% all of them would do the cartilage and meniscus. I made a convincing argument. If this was your 23-year-old son or brother, 100% you would offer the biology. But then there's the tibial lesion on the cartilage, too. That's what the osteotomy's for. Yeah, I know. They are all lying. I think it's reasonable to only do the osteotomy, like you're saying, if you're consenting. But for me, if I feel comfortable doing it all at once, I'm going to stage them. And if I want to do the cartilage and meniscus, I'm bringing them back because I want one rehab. I think one more take-home, and I want everyone to leave here, if you're going to leave here with one take-home point, and I'm sure no one does this, but you never order a fresh graft as a possible. So a fresh graft is a definite. So you either, and I have a case that I'm not going to show because we're not going to get to it, but a graft was ordered by a partner of mine that I was asked to scrub in to help, and alignment wasn't considered in the pre-op discussion, and we had a fresh graft. And so I felt real conflicted. So we did the fresh graft because we had the graft, and then we took them back to do an osteotomy later because I wasn't going to do an osteotomy and cut his leg open without having consented him for that. But that, if you order a graft, you're using the graft. Now meniscus is frozen, so for some reason you decide not to use it, which again, I feel if you order a graft, you should use it. That is a shelf life. But you're not ordering a fresh graft. Not only is it an expense, but that's a precious resource. And there is much more demand than supply. So we are not wasting those grafts for sure. All right, this is a new case. This is a 21-year-old female. She's an avid volleyball player. She is a collegiate volleyball player, and she plays recreational volleyball now. Anterior knee pain without instability for years now. We did not cover patella femoral in this, but this is part of what we're doing here. Exam is fairly nonspecific. She's got that trace effusion, a little bit of anterior knee pain, mild patella femoral click with extension, and no apprehension. So this is a cartilage case, right? This is not an apprehension instability case. These are her radiographs. You can see we have some osteophyte over the lateral aspect of the patella. We have a little bit of tilt. We have relatively neutral alignment, slight valgus, otherwise some patella alta. Nothing else exciting. Maybe a little dysplasia. Seth's getting excited, but this is not a patella femoral lecture. So slight valgus and slight patella alta. This is her MRI. So we can see a cartilage defect over the lateral aspect of the trochlea. And we can see a corresponding cartilage defect over the entire lateral aspect of the patella. And the TTTG was measured at about 11. All right, next steps. Let's go down the line. She's failed all the non-op. She's done injection. She's done therapy. She's done bracing. She has a good quad. She can do a single leg raise. She's compliant. She is your golden patient to have surgery on. She's insured, so she can have it done in veil. »» Okay, perfect. Okay. Check, check, check. I think, I mean, I would still start with the staging scope. But I would reinforce that the core to floor rehab. These are rehab, rehab, rehab, plan A, B, and C for patella femoral lesions before you get to the OR. »» Seth, biopsy during the staging scope or no? »» No disease like that. 28, probably not. I'm probably going to staging scope and offload her. »» Staging scope with a TTO at that time in the staging scope? »» I think for this one, I'm skeptical on your TTTG measures, but we won't go into that. She definitely has ALTA. I could definitely anterize and distalize and potentially offload both of those cartilage lesions to good cartilage and that would be my preference. »» Seth, this is a cartilage ICL. »» I'm treating the cartilage. »» Okay. »» Actively. »» Loading new cartilage. »» Better cartilage. »» Michael? »» Yes. »» Yes, you're taking a biopsy. »» Yes. »» What would you do? »» Yes. »» This is staging scope for me. I like to stage with tell femoral lesions, not just to get more information, but I like to lay crepe for the patients also. When they see the pictures, they kind of know how bad their knee is when they go into their second stage. »» All right. Here's the staging scope. »» Yeah. It doesn't look good. »» This to me is not a biopsy. I put possible biopsy in all the consents, but I'm never going to treat this with a procedure that a biopsy produces just based on both the MRI findings and these arthroscopic findings. And while, yes, you can always take a biopsy and say I did it and I can maybe use it later, why do that if you don't feel like you're going to do it, right? So I don't even want that in the patient's head as a possible option because then when we have to come back and have the surgical discussion, they say, well, I have this biopsy, doc. Why can't you just use my own cartilage? And then I have to say, well, I don't think it's a good option. Well, then why did you take the biopsy to begin with? So I don't take it just to take it. I only take it if I feel like Macy's going to be my treatment of choice or could be my treatment of choice. And for these lesions, bipolar, even though the trochlea one's kind of dinky, it still potentially could be symptomatic. She's got that huge cyst on the MRI that you saw, so she's certainly seen load. »» This is a degenerative lesion from most likely maltracking. This is not a trauma issue. So that's another thing you have to think about, whether these lesions are traumatic, whether osteochondritis desiccans, or whether they're degenerative. Because we all know that the degenerative ones have a worse long-term outcome than your traumatics or your OCD lesions. »» So shockingly, Mike, this scope did not make her better. So what are you doing next? »» I'm going to do a bipolar osteochondral allograft with an offloading TTO on this. »» How are you going to get a bipolar osteochondral allograft approved by insurance? What do you say when they come back and say this is denied? »» They don't deny me. »» Okay. New York is different than Colorado. »» I got to tell you, osteochondral allografts hardly ever get denied anymore. Because you know why? And they'd much rather deny Macy than osteochondral allograft. So my rates of denial for even a bipolar, it's like almost zero. »» Okay. Bipolar with TTOAMZ, distalizing or no? »» I'm not going to distalize this one. »» Okay. Seth? What's your treatment? »» I mean, if I had central medial panpatellar type disease, then I'll treat the cartilage. I know. It's lateral and bipolar. I'm going to offload it. »» But are you doing anything in this 28-year-old to the cartilage? »» I don't know. »» Rachel, why are you being so aggressive with us? »» Because I want answers. I want the truth. »» Order the code red. Order the code red. »» If I was going to treat the cartilage, it would be an osteochondral solution. But I don't think it's necessary in this case. »» All right. So 28, in all seriousness, 28 with those focal defects, even though they're bipolar, you're going to do TTOAMZ alone? »» Yes. »» Distalize or no? »» That's what I would do. »» Me too. »» I'm going to distalize because that will normalize the forces and I'll enterize, that will reduce contact. »» But she has pain. So you're going to normalize the forces, but she has full thickness cartilage defects and pain. »» Well, they're not going to load anymore. »» But what's the downside? But they're not going to heal. »» Well, Bugbee's bipolar OCA data is not awesome. And Jack Farr's wasn't awesome either. And she's pretty young. She's going to need other things in the future. So I don't know. »» And the results of isolated AMZ for this particular pattern is pretty good. »» Fulkerson's classic data is really good. »» Pretty good. But focal defects with an effusion, to me, I think you need the alignment no matter what. »» How could you not offload this? Because this is a loading issue. This is a maltracking issue. »» I'm not disagreeing with you. »» No, I'm talking about you and you. You clown. »» We're going to offload it. »» No, we're only offloading it. »» Oh, yeah. »» We're only offloading it. »» Pay attention. Pay attention. »» Let me go to the people. To the people. Who in the audience is doing a TTO alone? Who's doing TTO with some sort of cartilage technique to either the patella or the chest? So about 50-50. Okay. So to me, this is all patient specific. If they're arthritic and they're overloading, that's a different story. This is not arthritis. This is focal cartilage defects. And they're actually very isolated. That's the value of a staging scope. So to me, when that lateral patella defect does not cross the midline of the patella, even if it does, but especially when it doesn't, and that trochlea defect is isolated, this is where I want to restore. Now, to me, that trochlea defect was very small. I did not feel it was worth the donor to order the whole trochlea or distal femur. So I elected for a cellular procedure for that and a patella osteochondral allograft for the patella, TTO, AMZ, and some bone marrow. I'm going to show this case. So you're mixing and matching different cartilage strategies here? Yeah. But I think they're different lesions. So that patella- Just like my kids. They wear different color socks. So there's that patella. That's trochlea lesion small. It's less than one by one. I don't think I could make that necessarily better, although it'd be fun to do with a trochlear plug. I think I can make it just as good with an autologous solution. So here is a single stage autologous solution. The trade name or proprietary name is AutoCart, which is just a technique. But essentially, you can use your shaver and you can shave healthy, viable articular cartilage from the notch or the lateral trochlea, which I would not take in this case because we're treating the lateral trochlea, but the non-articulating portions. Get viable, healthy, autologous cartilage. And then you can prepare that with either a matrix on the back table with a possible biologic or not. In this case, we're also doing a patella osteochondral allograft. I think that was the main portion. You guys saw that patella. I think even if you offload or I just don't think- That's not just a lateral. So if I saw a pan patella like this looks like, then I agree with you 100%. You saw the staging scope. I showed you the pictures. It looked lateral. MRI looked just lateral. But that is the value of the staging scope right there, right? Because you get a peak. And so here I'm prepping my autologous cartilage solution. You're essentially hydrating this to the point where you want to make it a putty. And that putty is going to sit into that defect. In this case, we'll take the tourniquet down if you use a tourniquet. And then you will go ahead and make sure that that bleeding base is dry, just like many other cartilage techniques such as Macy, et cetera. And you'll go ahead and basically do artwork and sculpt that in. And then there's some debate between the Europeans and the Americans about this technique in terms of if you marrow stimulate the base or not. The Europeans say no. Many in the U.S. say yes. And then we all cover this with fiber and glue. Fiber and glue is not just there to protect it, but it's also chondrogenic. So you can get some fiber and glue to help hopefully seal that up and get some cartilage growth. So here's the fiber and glue. You can see the offloading tibial tubercle osteotomy. And to me, in this 28-year-old, if this were my kid's knee or my sister's, I'm a little young to have a 28-year-old. If this were my family member's knee, this would not be something that I feel comfortable just treating with realignment. I don't think it's wrong, but I think we can do more to preserve the joint. So I don't disagree with my colleagues, but I think we can do more. And so that's why I elected for that in this case. And you can see that patella looks cruddy. I restored just really the lateral aspect of it, but the medial side doesn't look great either. These are her radiographs. You can see everything looks a little bit better. She's actually done really well, but not perfect. And so we got through two of the 10 cases that I put together. Did you move this down at all or just keep it where it was? No, it looks like I moved it down, but I didn't. So I don't know why that looks like that. Just a better alignment. I think there's a proximal attachment inside. No, I didn't distillize her. I thought about it, but decided not to. Once you distillize and you get a bad healing situation, if you don't have to distillize, you don't want to distillize. Not that I would ever know that. So final questions, thoughts? Yes, sir. A couple I know you don't want to share names, but how can we find out more about the patient's symptoms and conditions? Yeah, I think so. It's 5.05, so we're off the CME clock. So we can say names. So there's two systems that are available in the U.S. right now, to my knowledge, two and only two, BodyCAD, which all four of us do some work with and consulting with. So that is our transparent disclosure for the room. But none of us, to my knowledge, have royalties. So if you use it, we're not going to make money off that. If you guys do, great for you, though. And then the other one is Nuclip. And they both do it a little bit different. And there's some advantages and disadvantages to both systems. I know BodyCAD has a booth here. I don't know if Nuclip does. But both worth looking into, and we're happy to connect you with the teams if need be. And I would say what you do when you're using that system is basically you get a hip-to-ankle x-ray bilateral, and then a CT scan of either the whole leg, which is what we do because our radiologists feel that it's easier. But all BodyCAD needs is the hip, knee, and ankle. You submit that to the software system, and then they will render a plan. And then you either accept the plan or ask to modify the plan. And you can actually work directly with their engineers to customize what you want for your patient. Then they will send you a 3D-printed cutting guide plate. It's actually printed to that patient. So I will say the one downside of this system, and I recently shared this with Armando, actually Mike too, but Seth, now you're hearing too, recently we just had a patient where we got all this printed. This is only going on this patient, and patient canceled literally three days before surgery. So we're now making patients sign self-pay contracts that if they cancel after the plate is printed, they will be liable. Now if we can collect on that, I have no idea. But that is the one downside of the current system for 3D printing. You weren't upset about that at all. I was not upset about that. I don't even own my surgery center, so it's not money out of my pocket, but just the system and the principle. It's very annoying. I heard you say words that I've never heard come out of your mouth. All right. Other questions? Because we're off the clock now, but we could talk about this all day. We love talking about this stuff. All right. With that, please fill out your ratings. Thank you so much. We are starting bright and early tomorrow. Thank you.

orthopedic conference

joint preservation techniques

osteotomies

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meniscus transplants

biologic augmentations

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cell-based therapies

high tibial osteotomy

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cartilage defects