All right, good morning. Thank you for coming here on a Saturday morning. Usually the Friday night at ANNA can get a little busy, so we appreciate you all waking up and being here bright and early for the last day of ANNA and for this ICL. We have a great ICL. We've been doing this ICL, gosh, for probably the last five plus years. We mix it up a little bit each year, and ANNA collects your feedback, so please feel free to send in your feedback on how we can make this ICL or other ICLs better, and really this meeting is about you, so whatever you want to see, that's what we want to talk about. My name is Rachel Frank. I'm a sports medicine and shoulder surgeon at the University of Colorado in Utah. Wow, that's how early it is today. I don't even know why I said Utah, because none of our faculty is from Utah, and I don't see anyone specifically from Utah here, so I'm not sure where that is. Anyway, Colorado, we'd like to be skiing in Utah right now, and I'm joined by a terrific panel. All of us have some financial conflicts, but none are relevant to this presentation, but all can be found online, and so this amazing panel includes the doctors that you see here, Dr. Mike Alea, Seth Sherman, and Brian Cole, and these are all friends. As you can see here, Mike at his finest, Seth in his happy place, and Dr. Cole giving an interview in some capacity, talking about something that he has expertise in. Taking a step back, what do patients want to know? If you were here yesterday, this is a slide that I use in almost every joint preservation cartilage talk that I give, because I think it's the most important thing that we can talk to with each other and with patients, and that is that patients want to know, if you do something to them, will they get better? If you do nothing to them, will they get worse? If you do something to them, can they get back to their activity? That something could be PRP, it could be a steroid injection, it could be a surgery, it could be a brace. Whatever it might be, they just want to know what's going to happen, and you can't always predict that. I tell patients, I don't have a crystal ball, but the odds would suggest this, that, or the other, but the key is to manage expectations and remember that most cartilage defects are asymptomatic. Most meniscus tears are asymptomatic or don't require transplants, so it's important to remember that. What are our techniques for joint preservation when we're talking about surgery? We have cartilage restoration and transplantation, meniscus transplantation, osteotomies, and then biologics with or without surgery. What do we really know about these procedures? That's what we're going to learn about over the next hour. Please don't forget about non-surgical treatment. Most of us, if not all of us in the room, love to do surgery. That's how we make our income. That's what we are good at. That's what we love to do, and we're surgeons, we can fix problems, but many times non-surgical treatment can be just as effective without all of the risks if the patient's an appropriate candidate. Now, this is something we always teach our fellows, and even within my own practice, we have different perspectives on which of these options on this slide is the most valuable, but what I would say is you have to really treat the joint like an organ, and if you pay attention to the cartilage, but you don't respect the alignment, you're going to feel good leaving the OR, putting in a sexy cartilage transplant, and in a couple years, they're going to fail, and you might say, oh, well, sometimes cartilage transplants fail, but maybe if you did something with the alignment, they would have done better. Maybe if they had a stable knee, they would have done better. Maybe if they were meniscus protected instead of meniscus deficient, they would have done better. When you think about cartilage, we're going to hear about this in a little bit, but there's a lot of different options. The four buckets that I like to think about these in are really how Dr. Cole framed mine and so many other people's thinking about this. Simple surgery, that's your simple scope, debridement, loose body removal. That's the most common surgery that I do. Reparative, that's your marrow stimulation, marrow stimulation plus with a scaffold, et cetera. Restorative, this is your cellular transplantation, one stage or two stage, autograft or allograft. And then reconstructive, these are your osteochondral allografts and autografts. Don't forget about cartilage repair. It's a very powerful operation, particularly in the young athlete, but even in the older athlete in the right setting. Cartilage repair has become revolutionized over the last decade with suture anchor techniques, but certainly old-fashioned screws work very well. Whatever works well in your hands, have that available in your toolbox to repair cartilage. This is a kid, skeletally mature, but in his teenage years, who had a patella dislocation, we fixed a large osteochondral lesion, but mostly chondral of the distal lateral trochlea. I had the opportunity to come back, not because it was symptomatic, but I had never done this technique before with the all suture suture anchors. And I agree, or his father agreed to let me scope them. And we were able to see that these things work and this cartilage can heal. So if you can fix what they were born with, with what they were born with, I would try to do that before you restore it. But if you have to restore cartilage, there's a lot of different options. One of the most common questions I get both from patients and colleagues referring us patients is, how do you pick? And we use all of these different factors to pick which cartilage tool we're going to take out of our toolbox. For me, the biggest ones are defect size and location. And oftentimes, and I'm sure for many of you in the practice, if you're seeing someone who's had two, three, or four surgeries, you're limited with respect to what you can do. And many times those prior surgeries dictate what you must do. What about the meniscus? We've heard all about the meniscus this meeting. There's been a big push over the last decade to save every single meniscus tear. I will be very honest with you, I do not repair every single meniscus that I see, but I'm repairing more in 2025 than I ever have before because our tools and techniques have advanced to the point where I can repair things more safely than I ever have been able to. But you still have to have a good candidate. They can't have a ton of arthritis because otherwise, why are you saving the meniscus? They can't have a meniscus that's completely avascular. You're going to put stitches in something and have tears right through those implants. So you still have to have a meniscus that's worth saving. Sometimes you can't save it. And when you have meniscus deficiency, you need to consider meniscus transplantation depending on their symptoms. Remember, the vast majority of people with meniscus deficiency don't have symptoms. So you don't have to put a meniscus allograft in everyone who's had a meniscectomy. But in some, you may have to. And so you have to think about your options. And in the U.S. right now, the only option is meniscus transplantation. We don't have any substitutes available. That market will change in the coming years to decade. But right now it's transplant or nothing. With respect to transplantation, this is mostly for symptomatic patients. We don't know about the prophylactic transplant yet. My indications are patients with symptoms, meniscus deficiency, good or correctable alignment, good or correctable cartilage, good or correctable ligaments, and they have reasonable expectations. I do not do this prophylactically, especially for those discoid lateral meniscectomy patients yet. But I think about it more frequently now than I ever have because we know the devastating complications and downstream problems with those young patients who have been meniscectomized. Finally, what about osteotomy? So osteotomy in the U.S., you saw probably the osteotomy session yesterday here at the meeting. I thought 10 years ago there'd be an osteotomy session at an ANA meeting, an arthroscopy innovation meeting. But it's had a resurgence in the states in the last five to 10 years. I think we've recognized the power of osteotomy and we've been able to really customize our osteotomies to our patients, whether using an implant like this, which is 3D printed, or using a standard implant, but understanding our cuts better and being able to better align these patients with the concurrent procedures. You have to get patient-specific with your osteotomy. So osteoarthritis, we typically correct to the opposite downslope, tibial spine. So varus knee, we're going to the downslope of the lateral tibial spine, valgus knee, we're doing the opposite. But for joint preservation, which is why you're all here today, most of us do our osteotomies to get the patient to neutral, and we try not to alter slope unless we're trying to alter slope. I have definitely in my early years altered the slope not knowingly without even recognizing it, just based on where I put my plate or where I did my cut. Now I pay attention to slope more than ever, and we're starting to pay attention even to the axial alignment with what we do, the patellofemoral compartment with our coronal corrections. With respect to slope, certainly chronic ligament insufficiency, whether it's the ACL or PCL, can be a problem, and certainly the collaterals can be a problem. And so we can correct both ligament problems in the sagittal and coronal plane with a single cut osteotomy, or a single osteotomy with multiple cuts. So don't forget about slope. And the take-home point with osteotomies is you can't fix a malalignment problem with a cartilage or meniscus solution, but you can fix a cartilage or meniscus problem with an osteotomy solution. And in many times across the world, this is all that they have in their toolbox because they can't get the fancy allografts that we have here, or the expense is too much and not justified to the government or whatever might be paying for the health care. And so osteotomy is the most powerful tool that we have. So with that, that's a nice introduction, I think, to what we're going to talk about today over the next hour. We will have time for questions and cases. This is interactive, so if you have questions even while the speakers are speaking, feel free to raise your hand, and we'll get to them as we go. It's meant to be interactive, and I'd love to hear from our experts. So we'll come back to this slide when we get back to the panel, but I think, Dr. Cole, you're going to be up next. And so thank you again for attending, and we'll get to Dr. Cole. Thank you. All right, good morning. Feeling like Groundhog Day? Okay, so this, it's interesting, we all speak about comorbidities, but this is, in 25 years, I think this might be the first talk I've ever given just on the value of comorbidities, so it really forced me to go to the literature and figure out, does it really matter? Because we speak, there's often a lot of dogma, yes, if they're maligned, you should do this, and then when you really challenge yourself, you start to think maybe less is more, and you don't know exactly when to pull that trigger, and I think Rachel sort of alluded to that, so my disclosures are online. All right, so this is the problem. The problem is often a focal defect, it may involve the subchondral region with edema, it can involve malalignment, they can be meniscal deficient, and these are the issues that we're typically dealing with, and we're sort of trying to determine what's really required to make the patient feel better, and then give them a sustainable result. Basic constructs on this are, look, we're treating patients for the here and now. One of the most important things that I still try to convey to my patient interaction, one of the first things I ask to say, I say, hey look, what would you really like to see happen? It's often very important to say, what are the previous surges in the response to treatment, what's their concomitant pathology, and are you going to think about this in a staged or combined, this is not my talk, this is the wrong talk. We might do, yeah, let me have one of the other guys go, because this is, this is truly Groundhog Day. I don't think, let me just see something, maybe there's modified, go, go back again, if you don't have anything else in there, is that true? Nothing, is there any, what's this titled? What? ITL 305. Go to the beginning. Let's just see. Let's try. Let me just see something. Some things are not looking the same. No, it's not. It's not. All right, you guys. Hang on, let me see something. No, it's not. Let's someone else go. I'll fix the problem. All right. Oh, that's Seth, that's the other guy. It's got kind of, it's going to be that kind of day, huh? I thought I was in good shape because I was, I thought I was in good shape just for being A and O times three this morning, but hell. Can we put up the Nexa, Alea? Mike Alea, superstar from NYU. So who's got the Knicks winning today, huh? How many, while we're getting that talk up, how many of you, nevermind, we got it. I was ready to start getting this going. Mike, take it away. All right, so this morning I'm gonna talk about technical pearls for doing these procedures in combination, and then you'll hear from Brian and Seth about some other topics as well. Disclosure on the AOS website. So as we know, these cases tend to be the perfect storm because we have to address the joints as an organ, and just doing the cartilage in the setting of a poorly aligned knee or a meniscus deficient knee or an unstable knee is gonna lead to failure. So we've got a lot of things that we have to think about in these patients, and if we're truly trying to preserve the joint long-term, not just preserve function for five years, but preserve the joint for the rest of their life, theoretically, then we have to think about doing these other procedures at the same time. And managing them can be a little bit tricky, a little bit dicey, and hopefully we can give you some technical pointers here. As Brian's gonna allude to, this is not a cookbook. These patients certainly are not just box checkers. Alignment, cartilage, you can't just go bing, bing, bing, and pick every single one because that's a lot of surgery. Sometimes less is more, sometimes more is more. You gotta be the one to determine what is right for each particular patient. So lesson number one is selecting the patient correctly. So the dude on the left, I'd probably just buy him a beer and not do his cartilage, but the rest of the people, maybe I'd do something different on, okay? But you gotta know how to select your patient at the right time and do the right procedure for them. You have to think about their comorbidities, right? Do they have medical issues? Are they smokers? What's their type of employment? When do they have to get back to work? Do they have a heavy lifting job? Are they a laborer? What's their support status? These patients need some help after surgery. It's not just a scope, bing, bang, boom, walking out of the same day. Can they get to PT? Do they have access to care? Because when we start thinking about osteotomies and ACLs, two-stage surgeries, not every single patient that we treat is an 18-year-old athlete who needs to get back on the field who's gonna have five sessions of physical therapy every single week. So the above may change the conversation completely. I always tell people this, never hesitate to scope first and ask questions later. I don't care if they've had no surgeries, have had five surgeries, getting in there with a camera and truly eliciting the pathology, doing a good examination under anesthesia, cannot be beat, all right? That is critical information and it costs the patient nothing. Costs the insurance companies a little bit, but the patient's nothing. Steps on the wall, right? If we're doing technically complex cases, everybody around you has gotta be in tune to what's going on. You as the surgeon might have a plan, but not everybody's got access to your brain or wants access to your brain. So you gotta think about what's going on and make sure that people are keyed in. So your scrub tech, your rep, your circulating nurse, make it the first case, understand exactly what's gonna happen, when it's gonna happen, why it's gonna happen, and how it's gonna happen. Patient positioning and prep is also very important because you need access to every part of the procedure. So are you gonna use a post? Are you gonna use a leg holder? Do you need to hyperflex the knee? Are you gonna have assistance? Where are they gonna be standing? Where's X-ray gonna come in from? You're gonna use a tourniquet, TXA, all these things are critically important. But then we get into the nitty gritty here is combining these surgeries. And the first thing we think about is whether or not these procedures need to be staged. Most of the time, I'm doing everything at the same time because I've got good help around me. But if you don't have a lot of good help around you, then maybe staging it is totally reasonable and totally fine. There is no right answer for this. You gotta do what you feel comfortable doing. Then the order of business is important, the surgical approach, as well as technical pearls. So when we think about cartilage work, joint preservation, this is a 30-year-old female who had a failed attempt at an osteochondral defect repair. She's in a little bit of valgus. So we gotta restore this cartilage somehow and hopefully correct the alignment of the knee. So in this particular case, does anything need to be staged? I don't think so, unless you're gonna just do a diagnostic arthroscopy first, there's really no reason to stage this. My order of business is that if I'm doing anything with cartilage, cell-based cartilage procedures, that always happens last. Because if you start mucking around with the knee and hyperflexing and taking the leg out of a leg holder after you've done a Macy or a DeNovo or an AutoCart, then you're gonna wind up screwing up your repair. So you have to be very delicate about that. So if I'm doing a Macy, I do everything else first, then I do the Macy last. But if I'm doing osteochondral allograft, I will do an osteotomy first because it takes the harder part of the procedure out of the way. You can get a nice extensile approach to these laterally based procedures, one incision, you can get to pretty much everything. What we typically do is make a very long incision, crossing the IT band, right? So see me crossing the LCL, you can make a big incision in the IT band, go all through the capsule there, you can see the arthroscopic fluid extravasating from the arthrotomy. But this gives you good access to everything, right? So I can get retractors in there, get around there into the notch and have access to the cartilage and I've got access to the proximal femur. So you can get everything through one laterally based incision, do your osteotomy and then do your cartilage work. When it's varus and cartilage, the same rules apply. I'm gonna do my osteotomy, then I'll do my osteochondral allograft, then I'll do the osteotomy. Any kind of osteotomy work or meniscus transplant happens before the MACE, make an extensile approach, you want easy access, don't make life hard on yourself, one big incision is perfectly fine. This is a 19 year old male who had a prior subtotal lateral meniscectomy, medial meniscectomy rather, displaced, I don't even know what it's, I am a A and O times one, I don't even know what's happening. So basically this is meniscus work with cartilage, okay? Should the procedure be staged, no need. Order of business, I'll typically do the medial meniscus transplant first or the lateral meniscus transplant first because it's more technically challenging, then I'll proceed with the cartilage, whether that be an osteochondral allograft or a cell-based procedure. My surgical approach tends to be a small arthrotomy, then we extend it for the cartilage portion of the procedure, we protect the transplant during the cartilage procedure, we wanna minimize our time hyperflexing after we do any kind of meniscus transplantation, but you can do these procedures very, very easily in the same context. These are just some pictures of what we can do with meniscus and cartilage, you can see the meniscus transplant followed by the osteochondral allograft, all in one setting, very, very simple to do. So now we talk about meniscus, 17-year-old female with a prior subtotal lateral meniscectomy, lateral femoral condyle lesion, should the procedure be staged? Maybe, lots of time, cartilage, meniscus, and malalignment, that's a lot of work, right? So osteotomy, meniscus transplant, cartilage, if you wanna stage it, by all means, go ahead, you can do the osteotomy first, come back three months later and do the rest of the work. So there's really, really no shame in doing that, but my order of business first, in this particular case, if I'm going to do everything at the same time, is I will do the meniscus transplant first because that's the most technically challenging portion of the procedure, and then I'll proceed with an osteochondral allograft and then my osteotomy last. So in this particular case, it's kind of easy to do it, but it is a lot of work. And there you can see some pictures afterwards. When you talk about ACL insufficiency with pain and malalignment, then you have to really talk about doing the osteotomy because they've got some pain issues, cartilage issues. This is a 27-year-old male who had a prior subtotal medial meniscectomy, medial compartment degenerative changes, varus malalignment, positive Lachman, positive pivot. There on the picture, you can see the classic cupola that's formed in the back of the knee when you get that chronic anterior tibial translation, cartilage defects in both the femur and the tibia. So you've got to do a lot on your plate. When you're going to do all of them, should the procedure be staged, there really is no need, but you have to know the implants that you're using because if you're going to make a lot of tunnels and you've got an osteotomy to do, you want to make sure that you're avoiding your tunnels and avoiding the screws because that can add another 20 to 40 minutes of pain in your procedure. So you really need to know where your implants are going to sit, how they're going to sit, and how you need to get around them. So my order of business for this particular case is I'll usually do the intraarticular work first, especially for the ACL. I will drill the femoral tunnel, typically off tourniquet. Then I'll do the high tibial osteotomy. Then I'll do the tibial tunnel last. My surgical approach is standard. It's a large HTO incision. It's go right through the scope portals. Like I said, technically, I'll give them TXA to avoid bleeding. I'll do all the intraarticular work off tourniquet first. That way you get things started. And then you also have to know how much tibial length you're going to need for your ACL, especially if you're doing a bone patella tendon bone, you want to avoid mismatch. If you're going to open that tibia up, you might not have that much room to work with. So you want to know the exact graph parameters that you're working with and how you can get good fixation of the ACL distally on the tibia. Sometimes you can't even do interferon fixation in these cases. You have to do suspensory fixation. You can go over a post and washer. You can use a knotless anchor, like a swivel lock or a footprint or something like that. If you really need to get fixation, but you have to know how you're going to fix it, when you're going to fix it. And you have to be prepared to have these issues arise in the operating room where you have to pivot. These are some cases. This is a picture of that exact case. We use quad tendon autograft. You've got tibial buttons in there, femoral button and the HTO. If you're doing an ACL with medial meniscus insufficiency, this is a 22 year old male who had a prior subtotal meniscectomy. Again, 2B Lachman pivot, normal alignment. Should the aspects of the procedure be staged, there really, really is no need. But if I'm doing a medial meniscus transplant with an ACL revision, I'm going to use bone plugs. I'm not going to use a bridge in slot because then you will hit your tunnels. If you hit your tunnels, then you're kind of just out of luck here. So you got to make sure you got room for your tunnels. I'll still use the bone plugs, intra-articular work first. Then I'll do the posterior medial meniscus tunnel. I'll pass and seat the bone plug and pass the meniscal sutures peripherally. Then I'll drill the tibial tunnel, pass the graft and fix it on the femoral side. Anterior tibial tunnel goes last, tie the meniscus sutures, then finally fix the tibial side of the ACL. So a lot of steps you have to be aware of, write them up on the board, make sure everybody's in tune. If you're going to think about medial work, pie crust the MCL, do it early, do it often. Don't struggle, especially with a medial meniscus transplant, multiple procedures, get it out of the way. You don't have a lot of time to work with in these cases, so just do it. These are some pictures and some videos showing an ACL reconstruction with medial meniscus insufficiency. Here you can see our retrograde reamer being passed, tunnel being drilled in the back, going ahead and retrieve it. Pass our bone plug, seat it. You can see that we pie crusted the MCL, so we have a lot of room to work with here. We can seat the graft. Once we seat the graft, we'll pass our meniscal sutures, fix everything like we discussed earlier, and then get on our way. When you're talking about sagittal malalignment, again, a lot of steps to go through. Tibial slope is becoming more and more important as we talk about posterior cruciate ligament insufficient knees, anterior cruciate ligament insufficient knees. So you have to know when to work and how to work. So if you're going to do a slope changing osteotomy, although we can use a plate to fix these, oftentimes I would recommend using staples, especially if you've got other issues to deal with, particularly for closing wedge osteotomies. Staples offer you the opportunity to close the wedge. You get great fixation, and then you have plenty of bone to work with. You don't have to worry about hitting screws, hitting tunnels, et cetera. Same thing holds true for PCL, but if you're going to do a lot of stuff like this, I would caution people to drill your tunnels last, but you got to make sure that you have a lot of room to work with. So if I'm doing an opening wedge osteotomy, I'm not using these plates anymore. I'm using a smaller plate that's pre-contoured using patient-specific instrumentation. That way I can actually dial in my posterior cruciate tunnel with regard to where the osteotomy is going to sit. So for patient-specific instrumentation in multiple procedures, I encourage everybody to use it because you can dial in meniscus root tunnels, ACL tunnels, PCL tunnels, and hopefully your screws will go far away from where your tunnels are going to be and rid yourself of any potential issues in the OR. So you can do that with a lot of things. Meniscus root, you can see one of the tunnels on the, you can see on the bottom right how that implant guide actually has a separate root tunnel dialed in for it. It avoids all the screws and avoids all the tunnels there that you drove for the HTO. So, you know, these things are very, very important. You can use them for slope-changing osteotomies plus ACL reconstruction. So in some, combining these procedures can be tricky. You got to have all the available options that are given to you to make sure that you can do these well. Carefully think through the procedural steps because a lot of them, choose the best approach, execute the plan. Thanks everybody for your time. Thank you. I can bring up Sherman. Perfect. Morning, everybody. My task here will be to go through biologic augments specific to surgery. So we'll talk about for joint preservation and also a touch on meniscus. My disclosures are online. Of all things, I think this is one of our hottest topics, how we can harness the power of biology to improve our results of these challenging situations. So first, of course, we must level set and understand what we're talking about. So anytime we're thinking about biologics, we're really looking at either anabolic or anti-catabolic molecules that can modify the joint environment. And so there are several out there that we can use and several in study, the autologous blood products, cell-based therapies, placental derived tissue, isolated growth factors, and others. And when we're looking at this and thinking about what our goals are with biologics, you can think about it this way. If you're adding things like growth factors, you're really just giving supplies to the environment. So basically, these can turn up the good and turn down the bad and really trying to manipulate the body's own intrinsic capacity to heal. One thing that we've learned from Arnie Kaplan and many others is about the MSC and about all the misconceptions our patients have about quote-unquote stem cells and how we basically can put these in and then they turn into different aspects of the joint organ system. And that's just not the way that this is working. Everything really is paracrine and we need to think of MSCs as medicinal signaling cells and we need to educate our patients about this concept. And so basically, that means that these activated MSCs, they respond to challenges or problems in the joint microenvironment. They secrete trophic, immune modulatory, antimicrobial, and other factors to help turn up the good and turn down the bad. And so when you're thinking about not just adding cytokines, growth factors, but also treating with cellular-based therapy, I think conceptually you can think about not just providing the supplies, but actually getting boots on the ground, getting those activated MSCs. And so you're basically getting the Red Cross in to help those in the local hot zone to do their thing. And so I think for patients, with that kind of an analogy, hopefully that helps you as it helps me. Biologics certainly are heavily regulated, evolving but imperfect evidence. Just going to give you some examples of where we might be using these in joint preservation. So ocealografts are obviously a great solution, a workhorse for us. And these can look really good at time zero. But there's absolutely no free lunch in joint preservation. And when you look at some of these and patients come back with pain at a year or two years, their subchondral edema changes, you can see that we really need to harness improvements in biology to get more consistent results. And so many have turned to bone marrow, aspirin, and concentrate. And the literature overall is a bit mixed. If you look at the radiographic integration out of Mizzou, then it was favorable. If you look at a few other studies of MRI findings of whether it helps or not, there's kind of a mixed bag or negative. The RUSH group, Brian's group, did a randomized study here, and it's more favorable as far as the types of cysts were smaller, the pain is reduced, and I think they're using routinely as are many others, including myself, at this time. But it's still an imperfect solution to a tough problem. We're always looking for ways to make this better. Some of the research we highlighted last year at this meeting and published is looking at pressurized CO2. And you can see here when you kind of clean those pores out, then you can really load your biologic of choice into the osteochondral graft and get it there with much more consistency. And so here's kind of the study we looked at. The classic thing to do is to pulse lavage to get rid of those marrow elements. And that's okay, but that really doesn't weight-reduce your OCL graft and give you any room to soak up the biologics. Whereas if you do that first, then you cleanse with CO2, and then you look at how much weight you can gain with your biologic of choice, it's off the charts. And so that's helped me a lot, and I think we need to correlate that with clinical outcomes, redoing the same studies that we did, but hopefully with better results. This is a challenging problem, as I alluded to, the painful OCL graft at a year. They have subchondral edema irregularities. So what are we going to do for this kind of a patient? I think that brings us to the concept of the sick knee or the knee with subchondral insufficiency. And there's growing body of evidence for biologics to help this problem. Here you can see information on using bone marrow aspirate concentrate. So I think that there is sound literature support for drilling to decompress than using the BMAC. For osteonecrosis, similarly, there's good evidence and a strong rationale for using BMAC for these types of challenging cases. Here's a tibial lesion that was treated by Rachel. Her treatment of choice for this is targeting with subchondral drilling and then using a combination of bone marrow concentrate and allogeneic product to pack into that area to solve the problem. I think you'll hear later this morning in the innovation spotlight about other ways we might do this. So basically, mineralized rafting screws that we can put in just deep to the cartilage issue into the area of subchondral insufficiency. And those can help to heal the bone. And I think that's a really nice blend of biologics and biomechanics that we're studying carefully. We'll touch on a few things, cell signals and scaffolds, and the rationale for this as we went through previously to recruit MSCs, increase HA production, cell proliferation, decrease catabolism, increase anabolism. And so here's kind of one of those strategies in action that can be used for some of these smaller or medium lesions as a point of care. You can see harvesting autologous minced cells, combining them with a scaffold, getting a signal, perhaps PRP, making a nice mixture on the back table. And then in a single stage, you're able to offer this type of treatment to your patient. So I think that's been a really nice adjunct to my toolbox. Just want to highlight a few other things you might have seen or thought about as far as scaffolds or as far as next-generation cellular-type therapies. Here's a JILA-C. And so basically, this is made of C-coral or aragonite. You can see the differential porosity of the implant. So you basically have this bone phase, and you also have this cartilage phase up top. And so really, the way that this works is, again, trying to harness your body's own capacity to heal. These can actually act as a stem cell magnet. So they don't have cells, but they create a healthy bone environment and regenerate cartilage, not just above these relatively small plugs that are 7 millimeters, but also around them, which is quite remarkable. This is FDA-approved for use. This was a very large randomized study compared to both debridement and microfracture. So more real-world study with larger defects, older patients, little larger patients, patients with some degenerative meniscus issues. So a really interesting study. Here's one example of the type of lesion you might see. And you don't have to fill the entire defect, which is different than what Mike showed and Rachel with Macy and osteochondro-allograft. And what was remarkable for me, looking through the playbook, looking at the initial Q scores, these patients are tough ones. These are truly early osteoarthritics. And you can see Q scores that are really sealing out at two years. So quite remarkable. Even more differentiated when you have larger lesions. Even more differentiated when you looked at the subset of early osteoarthritis. So keep your eyes on agility and think about ways you might incorporate that for the tweener population in your practice. This is another one you'll hear about, the FDA Phase III studies coming. This will be the first allogeneic stem cell product for surgical treatment for knee osteoarthritis. So this is basically umbilical cord blood-derived MSCs with an HA scaffold for cartilage repair, randomized study shortly. Again, the themes are very consistent. This is paracrine. This is not quote-unquote stem cells to get in there and to regrow. This is really by the mechanisms we've talked about before, these cells help to organize the local microenvironment, inhibit cartilage degradation, promote cartilage regeneration, and suppress inflammation. So anti-catabolic, anabolic. Here's a case example, large or multiple defects. You can see basically making four millimeter by seven millimeter holes equally spaced within the bone, and then we basically pot the plant and the entire area with that mixture. And here you can see from Andreas Kamal in one of the earlier phase studies, the regenerate capacity. This has been around for a long time. The Koreans have over a decade of market experience, not just research experience. I think over 30,000 have been implanted, and we'll be doing this study starting hopefully next year. I'm just going to touch on a few concepts in meniscus. We know it's a problem. We know what the rates of meniscus healing are, 80% in isolation, 90% with ACL. But I think there's still a lot of room to improve. We think about the targets that we might utilize to improve. What are the cell sources? What's the vascularity? What's the tear patterns? Obviously this is major multifactorial, patient issues, repair, the activity demand. But the area where I think we can make the most impact, perhaps, is in biologic augmentation. And so conceptually, we have to think about the targets, vascular targets, cell recruitments, matrix deposition, inflammation control, combinations of all these. And so here's kind of the menu du jour, and I think just going through them. The simplest ones, of course, rasping and trephination, probably should do this on any and all, either transplants and repairs. There's sound support for this. It's not perfect, but you're basically stimulating vascularity and growth factors. Fibrin clots, I think we talk about these a lot. We want to be doing them more. It's still a little challenging to make it and then put it into the area of choice. But certainly, there's intriguing, albeit older data, obviously from Henning and some work from Arnosky, about utilizing fibrin clots for healing. I think newer information or newer times and targets, maybe putting it inside the pita bread sandwich of a horizontal cleavage tear, and then doing circumferential compression to try to get these types of degenerative tear patterns to heal so we're not doing meniscectomies. Whether we should be using bone marrow clots versus peripheral blood is unknown, and whether we should use these clots as vehicles for other cell-based targets is to be seen. I'd say my workhorse, and probably the others, is marrow venting. You can see here, as I've shown, I think previously, my trick for how I can really get that marrow very nicely to the meniscus repair site, so I'll teach you kind of how to do that offline. But I think there is a good amount of evidence to support this. If you do this, Leprod and others have shown, you really boost the healing rates closer to when you might have a combined ACL reconstruction. It's obviously cost-effective. It's very, very easy to do. I think we've talked about PRP and other targets. I'll just say that I don't routinely use PRP for every meniscus repair. Dave Flanagan and several others do use it for each repair. I think if you do combine it with ACLs, you do have a risk of stiffness. We did publish, as have others, where there is reduction in failure rates, as you see in this study here. When it's available, when patients can pay for it, when I have complex tears, isolated tears, I think it's a reasonable adjunct. And then just lastly, we looked into cell-based augments and won't belabor this in the interest of time, but I think I'm not using any of these routinely at this point for meniscus repair, for meniscus transplants. But I do think that this is where the science will be going. And I think we just need to really think more carefully about how and why and which patients. I think also potentially using adipose-derived cells, for example, for meniscus repair is intriguing as well. And so I'll just leave you with Arnie Kaplan's final thoughts. Now, a true stem cell that can be shown to differentiate into cartilage specific to a joint or tendon would be awesome. But we don't know scientifically how to do that. And so for all of us here, when you listen to this big menu, just practice evidence-based medicine, be a patient advocate, educate patients, be financially responsible, and always do the right thing. Thanks for your attention. Okay, we're going to switch over. So I'll try to tie it together in terms of what we have right now for cartilage without laboring it, because I want to minimize the redundancy, and then show you some of the literature that supports combining procedures, and then summarize that for you. And then we'll transition over to a couple of questions and cases. Okay, so we've already discussed the clinical problem. I think it's very clear at this point. Rachel highlighted how we have these existing options at this juncture, and this is sort of the frequency with which we have these options to treat these articular cartilage or articular cartilage and bone problems. And the further we go from left to right, we sort of get more mature constructs that can replace the entire osteocondyl unit. We've heard just now about things that are either available that are new that we're trying to squeeze into the algorithm, such as CardiHeal, which might be for individuals who have a little bit more advanced disease. So those can be KL2s and 3s who have more localized disease on the femur, for example, than the tibia. And then Novacart 3D, which is going through the FDA process, and maybe by next year we'll have that where we need it to be. I think one of the things you're also appreciating is that we're spending a little less time on cartilage and more time on the bone, and there's reason for that. If you think about virtually every solution we have available, whether it's living tissue or metal and plastic, those are all load-reducing procedures, and it even starts with non-surgical care that can lead to pain relief. So then we've also alluded to the fact that, you know, what else is there to do? It's not just an isolated cartilage problem. They rarely exist in isolation, and we're dealing with other issues such as meniscal deficiency, malalignment, and a ligament problem as well. In general, I've already alluded to this, but I think it's important to understand probably the best question you can ask your patients is what do you want to see happen, right? That's where you get your biggest cue, because you may walk into the room with some premonition of what you're going to offer them, and then they give you some crazy statement that says, look, I have no symptoms, I think I might have a cartilage problem, I just don't want a knee replacement in 40 years, so what do you got for me today? So you will have that in your office if you ask them, and I think honing in on what their concerns are and what their expectations are can rapidly change the course of action. The algorithm has gotten increasingly complex. It used to be based on size only and these overlapping diagrams and so forth, but as you can hear, we now are thinking about is it tibial femoral, is it patella femoral, is it primary revision, and then, of course, what's the status of these other structures that are in addition to the cartilage problem? But it does start with the cartilage, and it's been said by these authors that, look, no matter what you throw at them, you get about a 75% good and excellent result, and that's really not true. There's a tremendous amount of selection bias that goes into what we do today, and if you just want to sort of summarize and take home what's working, I would say an osteocondylautograph right now still is a treatment option for cartilage replacement for small symptomatic defects in the 10 to 11 millimeter range. That's sort of the general take-home. Certainly there are variants on that, and the variants often come by just geographical availability of some of the solutions we have or insurance availability, but this is a dominant treatment strategy for the very small symptomatic defect. It's just very rare. MACI still does provide in the literature, in our own experience, about a 75% return to sport rate, and I'll highlight return to sport throughout the talk, not because that's the common patient that comes into your office, but that's the most demanding patient, and if you can achieve that, then you can probably achieve the other more common factor, which is ADLs. Osteocondylautograph, same deal, really, 75% to 88% return to sport with this operation, and we now have significant experience, even the highest level athletes, whether they're D1 or competitive athletes, professionally, and it can achieve that outcome. Again, though, it doesn't afford the opportunity to skip the comorbidities. Losing your meniscus, this is uncommon, okay? In other words, developing early disease after a meniscectomy doesn't happen in every instance, but it will happen when it does. You've got to recognize it. It's typically associated with chondral loss and often early bipolar disease, like you see in this particular individual just six months out. But meniscal allografts in and of themselves actually do pretty darn well. Again, 75% to 85% return to sport, and it's similar to osteocondylautographs. We're finding that we can treat even the very highest level athlete, and that's something we may see more commonplace, but again, it doesn't afford the luxury to enjoy the other things. Osteotomy, we know, can actually also do very well, and even in isolation, and this is where I think it gets the trickiest when you're trying to make your decisions, because you're going to have instances with bipolar disease, maybe more in the femur than the tibia. Maybe it's peripheral rather than near the central pivot, where you may say osteotomy is a good thing to do. The flip side is you may have an OCD lesion near the central pivot with minor degrees of varus that you have to challenge yourself and say, look, do I really need to do a realignment procedure at the same time, despite them being in varus? So I think to follow the dogma that says, well, if they're malaligned, you must do this, is probably not in our best interest, but it's got to be under radar. So the philosophy of combination surgery, and it was covered in a bit, is when a patient really has skillful neglect, not as an option. In other words, ignoring them is no longer acceptable. They're still very dissatisfied. And in this instance, we're really treating the joint as an organ. We're not just thinking about it as a cartilage defect. And these operations can have synergistic benefits. In other words, you think about an operation in isolation, if you're dealing with a cartilage, you have to ask yourself, is that going to be enough, and or do you need this to provide an amplification of the outcome, or are you just doing it because you're trying to protect the problem that initially existed? So those are all the kinds of things that go through my mind when I'm trying to figure out, is this the right thing to do at the same time of dealing with the cartilage problem? And I'll just tell you from level five, okay, from my, you know, this is 25 years plus, and I think it does become relevant after a while. You know, we say from a literature perspective, it's low-level evidence, but all of you, the people who are older in the room and who have more gray hairs or no hair at all, think about it a little bit differently, because they have real-life experience, and that does matter, okay? So we do treat the symptomatic cartilage lesion in most, but not all instances. You got to contemplate how they complain of it, okay? So some patients will just say, look, I have load pain, and I don't effuse, I don't respond to barometric pressure change and things of that nature. That's a very different patient than someone who has sort of a wet synovitic knee with effusions that can predict when the weather's going to change, right? Doing a load procedure in that patient only may not be enough, right? They have a biologic problem that they're complaining of, they can't sleep at night, things of that nature. That's a very different entity. So just knowing their chief complaint might actually lead to a different decision when you're treating them. We do treat ligamentous insufficiency except for isolated osteotomy. So virtually every procedure you see that you would treat on the femur, you will likely want to make sure they have ligamentous integrity, okay? But that's not always true for osteotomy alone, okay? Things to think about. MAT when it's non-functional, but there are a few exceptions. There may be high-level individuals where you're saying, look, I think I can achieve enough by dealing with the alignment problem only. I think I can achieve enough by dealing with the cartilage problem only and maybe leaving the meniscus out of the equation. We generally, at least I think most of us would agree that people will say, well, when do you pull the trigger for an osteotomy for varus or valgus? I would say you gotta have enough of one or the other to say you're gonna do it, okay? And typically speaking, that's about five degrees. Now again, not dogma, but if it's two or three degrees that you think you need to correct, it's probably not worth the squeeze at that juncture. And then we also will correct sagittal alignment. I want to be very clear here. People say, well, I didn't do a typical osteotomy at the patella defect because they didn't have patella instability. These are unloading procedures that are not necessarily dealing with instability. So they say, well, they're in symmetrical varus, I don't need to do an osteotomy. Or there's no patella instability, never dislocated the patella, but they have a patella defect. The rationale is often less about the instability than it is about the opportunity to protect or augment or amplify the clinical outcome. Hopefully that makes sense. All right, so how do we sequence it? Well, in a simple setting, the osteotomy first and maybe only, it's durable and efficient, return to sport and other things you can possibly do later on. You can argue that an osteotomy can pretty much withstand virtually anything in terms of a high impact individual, and you can get them back to high level stuff at four months in many instances. So that's a consideration versus having to protect cartilage repair. Who would it be best for? Someone who has load pain without effusions, they don't ache, they don't hurt at night. That patient might respond to load reduction, they also might respond to weight loss in a brace as well. So just things to think about. But then there's the concomitant options, and essentially this is sort of the sequencing in my mind. If it's meniscus and cartilage, we do meniscus first, and then we do the cartilage restoration just because of the stress on the knee. If it's meniscus and they're malaligned, you do the meniscus first, grab all the bone you can from your meniscal preparation and use that for graft, and then you do your osteotomy. If it's cartilage restoration and you still need an osteotomy, do the cartilage repair and then do the osteotomy. If it's a meniscal transplant and you have an ACL problem, I will typically, although there's some nuances here, typically do the meniscus first and then do the ACL, but there's some nuances to that one. And then if you need the triple threat as we call it, I'll typically do the meniscus first, then the cartilage, and then the osteotomy. And there's reasons for all of that as you can probably imagine, but that seems to make the most sense. So I'll just give you a couple of cases to sort of challenge the decision making. And they're high level people, not again for the gee whiz phenomenon, but just to help you understand how to make the decisions. This is a 20-year-old MLS forward, he had a lateral meniscectomy and did return to sport, then developed a cartilage defect, then was unable to play and is in valgus and has load pain and effusions. So got all the problems. So you have to ask yourself all these things, right? Did the cartilage defect occur because of the lateral meniscectomy? Is the pain related to the cartilage defect? Can you just fix the cartilage defect to get him better? Do you really need to do a DFO or is that in isolation or in combination? Do you need the meniscus transplant to get him better or just to protect the long-term aspect? And does long-term really matter if someone's just trying to get a couple years out of it? Will a meniscus transplant as such lead to incremental relief that you need that you otherwise wouldn't get? And will it actually survive in a challenging hostile environment? So in this instance, we did do all three and it was successful and he never came back for a meniscectomy, but you don't always get that lucky. This is just one example of, hey, we're going to deal with all of these things and see what happens and we'll pay the price later on if the meniscus fails. Another example, a 25-year-old who has malaligned with bipolar disease. Obviously, there's a BMI issue, but she has a dry knee with load-related pain. And you can see her compartment in the bottom left. So she wanted pain relief. She's relatively low-level active, but wants to be active to help with her BMI and her health. And an osteotomy alone, I will tell you, was categorically led to zero pain in this patient. She had load pain. She didn't have effusions necessarily and her knee was dry. And all we did was reduce her, correct her alignment. Here's another one. This is another individual who's in varus, who's meniscectomized, who has a cartilage defect. He's also about 275 pounds and he plays a collision sport. And in this instance, we decided to not do the meniscus, to do the alignment, and we said, what the hell, we'll throw in an OA graft because there's probably no consequence to doing that, okay? So we had to challenge ourselves and say, look, can you leave the meniscus out of the equation? Another one, 24-year-old guard, normal alignment, meniscectomized in pain, developed a cartilage defect and got worse pain, and then he had effusions. So can you do with or without the meniscus? Are you going to put in a basketball player? Yeah, I mean, that's a challenging thing to do. We went through a lot of consternation of what to do with this individual. Could we just do the articular cartilage, which we deemed as being the pain generator because we saw the transition, or do you got to put a meniscus in and that's what was done? Another one, a 24-year-old who has anterior knee pain and swelling, four prior scopes unable to play, has bipolar disease. Do you do a TTO? The patient has no history of instability. Yeah, I would say categorically, yes, because there's benefits of atypical tubal osteotomy to reducing the trochlear load as well as patella load, especially for central and inferolateral patella defects. And if you go back to Fulkerson's data, he actually had excellent results in patients with cartilage problems when cartilage restoration didn't even exist. So realignment of the tibial tubal is a very potent way to reduce patella-formal pain. So what are the results of all this stuff? I just want to tie this together now, okay? So meniscal transplants and cartilage repair. What we know is the following. Ignoring articular cartilage disease is associated with clinical failure for meniscal transplants. There is literature to support that. Combined MAT and OCA is basically the same or better than either one alone. That is also something you can glean from the literature. So just to sort of provide support. What about meniscus and osteotomy? Osteotomy improves peak pressures in all degrees of varus or valgus alignment. And one of the things that we showed in one of our tibial-formal contact studies is that 5 degrees of correction for a varus knee with a meniscal transplant, even if you bring them into just a little bit of valgus, is the most potent range to get them reductions in load. So even low degrees of osteotomy near the central pivot can be very effective when you have a meniscal transplant in place. What about valgus? Isolated DFOs are not enough to restore mechanics without a lateral meniscal transplant. And high return or support rates we see with DFOs and lateral meniscus with 88% satisfaction. So there's never been a randomized controlled study. But I'll tell you, the one thing we can generally agree on. If you have the opportunity for an osteotomy, you can often do it alone or together or do it in sequence if the osteotomy is not enough. What about cartilage repair and osteotomy, so we're not dealing with the meniscus? And basically, what I would tell you is that if you turn to the literature, it is highly supportive of the fact that you should do cartilage repair with osteotomy and this is in the setting where you have ligament stability and there's no deficient meniscus. So there's plenty of literature that says that it's an application of the outcome or it's a protection of the cartilage procedure. And what about with ACL reconstruction? This one is actually very controversial, okay? So I would just tell you that what we know is loss of the posterior horn of the medial meniscus is associated with increased tibial translation and graft strain in the ACL deficient knee. We know the medial meniscal deficiency is associated with increased clinical failure following ACL reconstruction and then development of secondary osteoarthritis. We also know that if you put a meniscus in, it'll restore ACL strain and it can reduce tibial translation and improve tibial frontal contact mechanics. So where are we today? I would just tell you this is, again, level five. Early on, when patients were ACL deficient and meniscal deficient and we had a failed ACL, we would often then add the meniscus even in the absence of pain. So Rachel, when you were with me, we'd probably do that pretty frequently. Now I will tell you that we don't necessarily do that. We look for other ways to improve the ACL reconstruction, whether it's a lateral extra articular procedure, looking at tibial slope and so forth. And I will not routinely do a meniscal allograft when an ACL fails. About the only time I do it is when they have pain immediately. So that's been a shift. So if you asked me 10 years ago, I would have said, yeah, we do it all the time. I don't do it any longer when they're just ACL recurrent and they have the absence of pain. There's lots of reasons for that because you then take a meniscal independent person, throw in a meniscal transplant to hopefully protect the ACL. And I would argue there's a lot of other ways to augment an ACL procedure to prevent failure. So what are the results overall? They're actually pretty good when you combine a meniscus with an ACL. Significant improvements in patient reported outcomes and high return to sport. The bottom line is I would say if you look at where we are, early meniscal transplant with acute ACL is not generally recommended. The most common indication is ACL failure in the meniscectomized knee with pain, okay? So I think that's the take home, all right? And then this is the final one. This is the triple threat, okay? And we'll finish up with this and then we'll have time for some questions. So the triple threat is cartilage repair, meniscal transplant, and osteotomy. And the procedure itself is actually pretty, I think he did a nice job showing you sort of the sequence of events. The procedure itself generally starts with the meniscus. Now he mentioned that you said use bone plugs because a slot gets in the way of the ACL. I think that's what I heard him say. So I'll just tell you my own experience has been that we've been doing slot technique on the medial side and lateral side with ACL reconstruction for a long time. And there are some technical challenges, but basically what we'll do is we will prepare the meniscal slot, then drill the femoral tunnel, then drill the tibial tunnel. We will introduce the meniscus, we'll introduce the ACL graft, fix it on the femur, hold off on the tibia, put your finger in or a device to push the ACL graft over, and then introduce the meniscal slot. And that's actually worked for us pretty well. It's not foolproof, but it's worked well. I don't like the tunnels because I'm always dodging tunnels from the ACL and so forth. So it's dealer's choice. I don't think there's a singular right answer. You do what you're comfortable with. This is already a stressful enough operation, so I'm not gonna land on dogma and say this is the way you gotta do it, okay? So in this instance, we do the meniscal slot first. We then come to, we repair the meniscus. We then do the arthrotomy because you wanna maintain a distension, right? We then repair the meniscus, excuse me, do the osteochondral graft in this instance. And the last thing we do is an osteotomy. And the tricks for osteotomy in this instance are make your osteotomy a little bit lower. And again, this is another reason why I like the slot because the slot allows you to stay upstream from where your osteotomy is. If you have tunnels for your meniscus, the obvious is you worry about running into those tunnels, although you can make short tunnels and still do the osteotomy below. So again, no dogma here. This is just my own personal preference, okay? We do meniscal repair for transplants with a vertical mattress on top and on bottom. And you only generally use eight to 10 sutures. It's not a ton of sutures like you typically see with a meniscal repair. And then we're commonly doing just a few all inside or all inside devices just from an expense perspective. But I never do a meniscal transplant with all inside devices. Seth did a great job on the biologics. I think the one area that we like biologics the most is when we're doing the osteochondral allograft. We have some data that suggests that it could be of benefit. So we hydrate it after deep cleaning with CO2 and it's generally put into position. And then again, the last thing, and we collect all that bone from the procedures. So if you do a meniscal transplant, you may get some bone graft. If you do a osteochondral allograft, you may get some more bone graft and use that. And we'll put that in the osteotomy site at the time of that correction. And the reason we do this last is because when you do your meniscal repair, you're pulling really hard. Last thing you wanna do is be pulling on your osteotomy, right? So that's sort of the take home. And we will use some of the bone that's left over, although we had a conversation yesterday at one of the ICLs. We'll use some of the bone as graft in front of and behind for the osteotomy taken from the osteochondral allograft bone. Okay, so what are the results of that? I would say in general, the results have been pretty good, but there's a high subsequent surgical procedure rate. So this operation in my hands has probably the highest subsequent surgical procedure rate, but we do see significant improvements in PROs. It is technically demanding. There is a positive clinical outcomes, but I would say consider osteotomy alone whenever possible when you're in this situation. I think that's okay, right? And you can help a lot of people with bipolar disease, early bipolar disease, femur more than tibia, by starting with osteotomy. So bottom line is you gotta manage your patient expectations. We speak about this all the time. There's not always off switches, but they can actually improve the way they feel, but perfection is not associated with zero pain. So these are the key takeaways. Treat the here and now. Knee preservation does require a comprehensive approach. We modify patient and now organ specific factors. You've heard now how we treat the entire knee, not just this isolated cartilage defect. We try to figure out first what do they need, and then we identify the solution. It can be something small. We'd manage their expectations, and I think just asking the patient just a really simple question. What would you think of as a success if you undergo treatment? What would you be satisfied with if you do anything at all, whether it's non-surgical or surgical? High demand patients can get a satisfying result. I mean, the patients I showed you were of the highest demand. That is not the most common patient. These are people that are just like you and me who come in with knee dysfunction and knee pain. The point is that if you can achieve it in the highest level person, we can do generally very well in the individual who just wants to remain active and maintain their health span. Thank you very much. All right. Well, thank you to all our speakers. We'll put that first PowerPoint back up, but before we get to some cases, I just want to say thank you to all our speakers. Any questions from the audience? Clear as mud? Okay. Yep. Oh, there you go. So in the whole concept of knee preservation, isn't it too late to put a meniscal transplant when the patient has symptoms of that? Because we're trying to preserve that knee. So most of the time I have that difficult conversation with the patient where if you start having pain with a meniscal deficiency knee, it might be too late in terms of preservation. So where do you fit that conversation with the patient? I think we all have our bias on this. I would say none of us want to, as Dr. Cole says, you don't want to make a patient who's not meniscus dependent, now meniscus dependent, and their pain can be due to a variety of things. Having personal experience as a patient with meniscus allograft and treating patients with meniscus allograft, I would never want to subject anyone to the rehab and potential change of lifestyle that you must do with a meniscus transplant if they didn't need it. And so to me, I don't think it's too late to try to preserve the joint. I think we want to treat the symptoms. But I'd be curious as to what the panel thinks. Yeah, I mean, all of these patients we're talking about were symptomatic and then were not symptomatic. The one thing I can tell a patient confidently is that you have a very high chance of having a reduction and maybe elimination of your symptoms if we do a meniscus transplant. What I cannot confidently tell them is that they will have a counterprotective procedure. So the estimates I see are between 500,000 and 750,000 meniscal surgeries a year in this country. I've probably done 20 meniscal transplants in my own meniscectomized patients. Every one of them is referred with knee pain that develops subsequent. Now, I've had plenty of patients showing up in the office with sutures in their knee from another physician saying, I was told I needed a new meniscus. I'm like, please just go home. Call me in four to six months if you have any symptoms, right? So your question is a good one. It's always a source of controversy. But these things are not lasting forever. There's stents, if you will, that are probably 7 to 10, 10 to 12 years. And if you cannot look yourself in the mirror and say, look, I know this will be counterprotective, this is the right thing to do, and then tell the patient they have to live a life of meniscal dependency, I wouldn't do it early. For me, the biggest point is the one that Brian made about these are space holders. These are bridging procedures. And they have definite failure rates and survival curves. And there is some emerging data, at least on the lateral side, that suggests meniscus transplant can be counterproductive. So I think that's intuitive. And I'm glad we're getting some of that information. But it's not game ready for me to go full on in prophylactic transplants without symptoms. The one exception I think we might all agree on is the valgus active female who is meniscectomized. If you don't go all in on osteotomy plus minus meniscus, at least watch them like a hawk. And symptoms for me in that patient are going to be biologic effusion, swelling, and other soft signs that might keep me following them closely and at least talking about it and potentially executing earlier than on the medial side. Yeah. And Seth just commented. I was just showing Seth a case that I have. There was a girl that I did a partial meniscectomy on two years ago. She was 12 years old. She had a discoid that was just kind of beat up. And it's one of those that you watch. You watch them like a hawk. But when they come in, and they've already developed that little lip osteophyte at age 14, and they're already sitting in a little bit of valgus, then you kind of wish that you maybe did a meniscus transplant two years ago when they weren't having very much symptoms. But I don't think that we're at that stage yet where we can do it. Yes, sir. Thanks. All the excellent lectures. I just want to follow up with a question that discoid meniscus subtotal lateral meniscectomy. Patient's 20 years old. It's already the lateral compartment is completely outrated. Is there any point to do an osteotomy plus a transplant or a meniscus transplant because it's too late to do any cartilage procedures if it's already full-blown arthritis? It's interesting. In young people, you afford a little bit of latitude that one of the things that we've recognized is that if they have tibial disease and you treat the other stuff, you can actually achieve a pretty decent outcome. The patients seem to be more femoral dependent in terms of pain than tibial dependent. We've broken out our patients now by saying, look, what's the extent of tibial disease? If you neglect the tibia, which we often do, and treat everything else, can you get a good result? The answer is yes. I showed you that one woman, that overweight woman who was like that. She was in her early 20s. Obviously, I elevated BMI. She had load pain. We just did osteotomy. Again, that's a net of one, but I have lots of those patients. If the patient's in valgus, that's the best thing that she has going for. Cartilage transplantation in the arthritic knee in a young patient, I'm not saying grade four. I'm saying grade two, threes. If the joint space is obliterated, I wouldn't do it. If you have some joint space, don't discount the potential benefit of putting something in there. Maybe a marrow stimulate to tibia. There's a couple things you can do to the tibia, but it isn't always necessary in my opinion. You can really still help that patient by doing the things you would do as if they didn't have much arthritis, but osteotomy for sure, and that's to her benefit. I think that PA flexion x-ray can be really helpful in guiding that decision because if they look standing neutral and they have some joint space, but they really collapse, a DFO is not necessarily going to fix that inflection, and so you might just squish the meniscus, and so there may be no salvage for that. But if they have some joint space, including on their PA flexion view, I think salvaging that joint with cartilage and meniscus, even if there's some bipolar disease, as Dr. Cole mentioned, is worth it. If they have that amount of joint space narrowing, not full bone-on-bone, but some clear narrowing, bipolar chondrosis, possible meniscus deficiency, for me, I'm going to do the staging scope combined with osteotomy and then possibly come back for the rest in that scenario, whereas if they had good joint space as well, I might do it all at the same time. Thank you. All right. Panel, we have a few minutes, so let's go quickly. Mike, we'll start with you. Most common cartilage procedure for the condyle, the patella, and the trochlea? Osteochondral allograft, for me, for the femoral condyle, for the patella, it's probably something cell-based, and for the trochlea, it's, again, probably osteochondral allograft. Seth? I think my patella is probably, at this point, 75-25 OCA, but it used to be 50-50, and the other two are mostly OCA. Dr. Cole? Debridement? No. Okay. That's fair. That's the most common. Good answer. Good answer. I use OAG for all three, no? Yeah. Most commonly. Most common. I like to put this up because I think a lot of people do not use osteochondral allografts in the patella femoral compartment. It's very difficult. It's technically very challenging. You have to get this right. The donor-to-recipient match is not always perfect in terms of cartilage thickness and bone thickness, but if you're not familiar with it or not comfortable with it, but you do osteochondral allografts, this is a great opportunity to get in the lab, play with the instrumentation, and not be afraid of that surgery. While cell-based transplants in the contour of the patella femoral compartment are technically easier, I find osteochondral allografts are much more predictable for a quicker recovery. I think cell-based transplants take two years for the patient to really feel better, especially if they're a contact or collision athlete, and I just have more predictability with a plug than a cellular transplant, even in that compartment. All right. Let's go down the line. We'll start with Dr. Cole, because I think your answer is the same, but preferred meniscus transplant technique. Yeah, I'm still doing slots on both sides. Seth? So, on both sides, I'm doing, I would say at this point, very small bone plugs or almost soft tissue. What he means is soft tissue. Mike? Yeah. Lateral, I'm doing a slot technique, and medial, I'm doing small bone plugs. So, my evolution was bridge and slot on both medial and lateral, and then bone plugs. If you've ever done bone plugs, they sometimes become more of a bone sliver or like a splinter or a wood chip, and then they just become all soft tissue. We have no data to show that any technique is better than another from a clinical perspective. There is biomechanical data to suggest that bone heals to bone better, and thus, extrusion might be better with bone to bone, but no clinical data. So, for me, these are technically complicated enough. I'd rather make it simple. We are going to put out our data, unfortunately. It does show that the soft tissue ones have a higher failure rate. Yes. Yeah, but which surgeons? Which surgeons? I don't do soft tissue, so I don't know. So, maybe it's surgeon-dependent. So, did you do a systematic review or what? No, it was our own data at NYU. Strausser? Strauss doesn't do, Strauss does not do all soft tissue. Okay, I look forward to seeing that. But we know they have higher extrusion rates, right? Yeah. So, I think if you're going to do soft tissue or close to it, then you really want to pay particular additional attention to meniscotibial and other fixation strategies, centralization type strategies. But again, we need data to support that. It has to work. This is conceptual. Yeah, I mean, think about how, like, it is conceptual. I mean, look, time-zero data shows that it's better to have bone, but that's not relevant. So, think about, like, how this, I think, I believe Verdonk's step, but Verdonk has the largest experience. He has a very large experience, and he's very trustworthy. So, I think he's doing as well as we are. But then, to your point, Rich, you end up with this little piece of bone, and then you can't tell when it fails. And think about how uncomfortable we are, most of us, with early weight-bearing after a root repair. It really is just a root repair. So, it's just so satisfying to have. That's why I like the slot, because a bone plug could just fail, just like a root repair in theory, and you're just dependent upon that suture. That being said, if you give them the protected weight-bearing phase, you're probably fine as long as things don't toggle away. And through cyclic loading, too, that's the other thing is, depending on how you fix that, the anterior and posterior horns, like, what are you guys doing for your bone plug fixation or your soft tissue fixation at the horns? What do you guys use? Sutures? So, I use an all-suture-based device for the posterior horn. So, like, what you do for your root, you're using that device? Correct. And then a couple all-insides in the back, above and below, to help secure it to the capsule. Inside-out for the body, I use a suture anchor anteriorly to secure it to the tibial plateau, plus a capsular-based repair outside-in. So, I think the biggest advantage to soft tissues is the inherent technical ease. And I'm just not as good of a surgeon as Mike or the rest of the guys here, so the bridge and slot and bone plugs are just tougher for me. But I think as we learn more about centralization, especially on the medial side, our papers are going to become less relevant because the techniques, just like anything we do in medicine, are changing. And so, centralization, potentially almost an internal brace-type suture along the periphery of the meniscus, at least on the medial side, may become an evolving technique to help minimize those failure rates with all soft tissue. I also think graft mismatches is a major issue, and it's harder to manage that if you're doing a trough taking. You're kind of married to some of that. And for me, one of my sockets will be a bit longer, and I do actually suspensory fixation on one of the roots. And so, I can manage that mismatch in real time, and I can actually fixate and kind of retention, bring the meniscus back under, on top of the tibial plateau. So, I have a little modularity there. It's all, again, theoretical. Yeah, I think the big thing is not too big, but when it's too small. And you end up with this, like, especially when it's a tight, you have a tight radius of curvature on the donor, the front is away from the front. And having the ability to do a plug anteriorly is, in theory, something that would be helpful. I will say, if I, now I'm remembering, I used to only do, I used to do plugs medially, routinely, and then slots laterally. And then we just got comfortable, after we did some biomechanics, saying, yeah, it's probably okay to take away that middle cartilage and bone and the notch, and we did slots medially. But, look, like you said, Rachel, we don't know for sure. Do what you do best for now. With the emergence of PSI, patient-specific instrumentation for osteotomy, it's definitely changed my practice. Panel, what are you guys doing for osteotomies routinely? This is DFO and HTO. So, for me, I mean, I'm using PSI for almost every osteotomy now, unless I have to do it quickly for some reason, for an insurance reason, and I don't have a month to wait to get the plan teed up. I don't love the concept of doing freehand osteotomies. I mean, they're easy. I used to do freehand cuts all the time, put a tomofix on it, and then you're done. But I think our accuracy, and we have papers to prove it, is so much more refined using the patient-specific stuff, and that it's just completely obliterated the need for me to do freehand cuts at this point. Because, you know, using a bovie cord as a guide as to, like, how you're making your cut, it makes, you know, for me, I'm like, we got better options. If my total joint surgeons are doing makos on everything, I'm using a bovie cord, then maybe there's something wrong here. And I have one of my own patients has a failure of mine recently. Like, I did a freehand cut. I did not correct him enough. I kept him in a little bit of varus, then he developed a lateral hinge fracture. If you got a lateral hinge fracture and the patient's in varus, guess what? That hinge fracture is always going to be under tension. It's always going to want to expand a little bit, and that's not going to heal. So, you know, for me, I've pivoted. What's up? Yeah, I'll just add. I do PSI for all of these. I think it's opened my toolbox towards thinking about femur versus tibia or both, and single or two-plane corrections, and opening versus closing wedge, and pros and cons, and just things that I wasn't facile at and, you know, frankly, couldn't incorporate into my practice safely before these tools. That's cool. Yeah, I guess I don't call it freehand, but I guess I know what you're implying. I just don't use the bovie cord. That's how I get around it. All the planning is pre-op, and I'm still doing the standard instrumentation, and it's interesting. I've been talking to Adam Yankee, my partner. He's seeing some more complications that, you know, maybe I wish he was here to defend himself, but he's seeing more complications with the patient-specific instrumentation without getting into specifics. So I think it's going to be – I think it seems like the right direction to go, and maybe I can do better than I'm currently doing with my osteotomies, but it's – like you said, it's still very easy to do, and to date, our complication rate is really, really low, and it's very easy to protect neurovascular structures because these guys can get in the way. As I understand it, they can get in the way of some of your either pins or cuts or what have you, and I don't know if that's true or not, but that's some of the comments that Adam's been giving me, and Adam's pretty progressive. So it's interesting how he's starting to maybe flip back to the other way. Yep. I think we're not going to have time for cases because I don't want to keep you guys from the break. We just have one more minute. I would make one final comment on the PSI versus freehand because PSI is new, and as Mike was saying, there's a lot of our colleagues using robots and other technology to enhance our accuracy with surgery. Like anything that we do in medicine, there's no free lunch, and you have to know the cost. You have to know the value. Certainly for me, my osteotomy incisions are much bigger with the PSI because you need a bigger exposure to get the guide on. The various companies are working on that to try to reduce the size of those guides. In addition, if you use a company that comes with a 3D printed plate, you've bought that plate, and you cannot pivot intraoperatively from that plate, so you better be good as a surgeon first. And the last thing I'll mention is we had a case in my OR not too long ago where expecting a guide and sterility became an issue with the tray, and you still have to be a good surgeon. You still have to know how to do cuts freehand. You still have to know the principles of osteotomy surgery. If you're going to take on an osteotomy case, just like our total joint surgeons need to know how to put in a total joint without a robot because the robot or technology may fail at some point. At the end of the day, we're surgeons. We're not robots, and we still have to be able to execute the surgery. Yeah, I can't agree with that statement more. You have to understand the principles of what you're doing first before you actually do the surgery. And just like with MAKOs, osteotomies, PSI, you get yourself into a lot of trouble if you don't know how to do a total knee and you think a robot's going to do it perfectly for you. So, you know, understand what you're doing first and then execute. All right, guys. I want to thank our panel. These are world-class surgeons. Thank you all, and enjoy the rest of the meeting.

Arthroscopy Association of North America

joint preservation

sports medicine

surgical techniques

Dr. Rachel Frank

osteotomies

cartilage repair

meniscus transplants

biologic augmentations

patient-specific instrumentation

PRP therapies