All right. Good morning, everybody. My name is Eric Strauss from NYU. Thanks for joining us bright and early. And for the next 10 minutes or so, I'm going to try and encourage you to be more aggressive about utilizing osteotomy whenever you're taking care of patients with cartilage pathology. So I have some disclosures. You can find them on the Academy app. So it's not uncommon that we'll see a young, active patient in the office who's presenting with symptoms from some permutation of cartilage injury, meniscus or ligament insufficiency, and or malalignment. And they can be a treatment challenge. While it's a good operation, the limitations of total knee arthroplasty have increased interest in procedures that are aimed at changing the natural history of degenerative disease, putting off the need for a total knee. In the last 10 to 15 years, I think we'd all agree that there's been significant progress made with respect to what we can do surgically for problems with the cartilage with respect to restoration, meniscus allograft transplantation, realigning osteotomies, and ligament reconstruction. But what I'm here to really kind of get across to you is when we can utilize combined procedures, mostly osteotomy and cartilage restoration, to change the natural history of that degenerative disease, especially in the young patient. So what's an example? So here's a 45-year-old male who comes into your office with one year of medial-sided knee pain and recurrent effusions that are significantly impacting his function. I think you look at those plain films, you'd agree there's a little bit of medial joint space narrowing. And when you look at these T2 images, both the coronal and sagittal, I think everyone would agree there's an osteochondral lesion of that medial femoral condyle in the central weight bearing region. Back home at NYU, any patient that I'm thinking about doing a cartilage procedure is going to get a set of long leg alignment films. I really want to understand where their mechanical axis is going. And in this patient, I think you'd see it's not terrible, but that mechanical axis is passing medial to the medial tibial spine. So I'm a frequent user of a diagnostic arthroscopy for any patient I'm considering a cartilage procedure on. So you see from these images from the patient, everything's looking pretty good. So the patellar articular surface is intact. It's centralized over an intact central trochlea. The medial meniscus looks good and stable to probing. The ACL is fine, and the lateral compartment is pristine. But then when we get to that medial femoral condyle, what we saw in the MRI is legit. So he's got this not small osteochondral lesion in the central weight bearing aspect of the medial femoral condyle. So now you're back in the office reviewing the images with him, and you're saying, well, what are the options? I think most of us would be hard pressed to think about a total knee replacement in a 45-year-old with an isolated lesion. But there are some folks out there that would consider a uni. Seth's going to talk about unloading osteotomy alone. But what I'm going to try and kind of really hammer home is that a combined joint preservation approach may be best for this 45-year-old to get him back doing the things he wants to do. So what did I do? I did a 22-and-a-half millimeter osteochondral allograft to that medial femoral condyle, and an 8-degree correction with a high tibial osteotomy. And as you see in the post-op alignment films on the right, I've corrected him to kind of the center of the knee right around the lateral tibial spine. I'm no longer over-correcting like we used to. So how about this one? A 46-year-old female, she comes in with 10 months of anterior knee pain, swelling, and mechanical symptoms, which she describes as catching. And the plain films look all right, but I think you guys will see on these T2-weighted images, there's a chondral lesion of that central trochlea. So once again, we've taken this patient for a diagnostic arthroscopy, and the remainder of the knee looks pretty good. The patellar articular surface is intact. The medial and lateral compartments look good. The cruciate ligaments are intact, but there's that central trochlear lesion, all right? Let's call it 12 by 15. So we took a cartilage biopsy just to keep our cell-based repair options open, and we go over things in the office with them. So the question is, is this a patient that you'd think about doing a cartilage restoration alone, whether it's cell-based in the form of MACI or an osteochondral allograft? Would you unload that central trochlear lesion alone with a TTO? Once again, I think it'd be a hard discussion to do a patellofemoral placement in a perfectly intact patellar articular surface, but it's on the list of options. But once again, I'm going to recommend a combined joint preservation approach. So here in this patient, we did a 60-degree unloading tibial tubercle osteotomy to change the mechanical environment for our MACI. So there's our lesion. There's the cutting template. I like to mark the end of the cutting template to basically know what I've got to prepare. There's the implant, and there's our final product. And as you see, we've got the osteotomy fixed in the bottom right, and there's our defect treated in the central trochlea. So you may say, well, this guy seems pretty aggressive about this. And I'll acknowledge I am a little bit, but there's evidence to support this approach. In a paper that Dr. Meinitz and Andres put out a few years back, they looked at over 200 patients that had undergone autologous chondrocyte implantation. And these weren't small lesions. The mean lesion size was over 8 square centimeters. And what they found was that when ACI was performed with a concurrent osteotomy, the survival rate significantly improved. There was an 88% 15-year survival when those patients had a concomitant osteotomy versus 66% without it. Seth has a paper with his colleagues that looked at over 1,000 patients undergoing cartilage restoration procedures. As you see the breakdown, there was a little over 400 patients that had isolated ACI, 67 that had ACI with an osteotomy, over 550 had an isolated OCA, and then 92 had an OCA with an osteotomy. And at a mean follow-up of a little more than three years, when a concomitant osteotomy was performed, there was a significant reduction in the need for reoperations after the cartilage restoration procedure. Riley Williams and the folks at HSS had this paper. They looked at over 800 knees in a slightly older patient population with a mean age of 50 years. And at a mean follow-up of a little more than five years, there were significant improvements seen with respect to Leishman VS scores. But the reason I wanted to highlight this paper is only about 7% of this patient population ends up being converted to total knee arthroplasty five to 13 years following the index procedure. So this combined approach is really maybe doing its job with respect to joint preservation. In a more recent paper, David Flanagan and his colleagues looked at patellofemoral pathology. They had 366 patients with a mean age of just over 33 years, 78% of the patients had lesions of the patella with the remainder on the trochlea, and 23% of the cases included an unloading osteotomy with their cartilage restoration technique. And what the data from this study showed was that there were significantly greater improvements in all clinical outcome scores when that concomitant osteotomy was performed. And then I love this editorial by Robert Westerman in the Arthroscopy Journal. And he writes, although we appear to be pursuing more advanced cartilage restoration techniques, we cannot forget the basic principles inherent to the data that support these procedures, optimizing the biomechanical environment for joint preservation surgery. Addressing ligamentous deficiencies or pathologic malalignment is a foundation of cartilage restoration surgery. So please don't put down the osteotomy saw. So to pull it all together and stay in my 10 minutes, joint preservation surgery is definitely gaining popularity as we strive to not only improve patient outcomes, but we're hoping to change that natural history of disease and delay the need for total knee arthroplasty. What hopefully I got across is that optimizing the biomechanical environment in the setting of cartilage restoration is of paramount importance. So basically, please have a very low threshold to include a corrector or unloading osteotomy when treating patients with symptomatic cartilage lesions. Don't get overconfident because these aren't easy cases, but they're worth it. Preserve it and give your patients the best chance for functional improvement and joint preservation. Happy to take any questions. Oh, yes. The central trochlear lesion that you showed, do you ever use OCA for central trochlear lesions? And if you do, is your threshold of doing a competent TTO the same as with MACI, or does that change the equation? That's a great question. So when I'm giving a cartilage lecture to the residents, I got a couple sitting there. My algorithm used to not, it wasn't a tree, it was direct. If it was a patellofemoral lesion, it always got a TTO. That's changed a little bit, and I might be slightly less inclined to do an osteotomy if I'm doing an osteochondral allograft, just because it's healthy, mature adult tissue. But at the same time, the patient almost has to convince me not to do the osteotomy. I stick to what I'm trying to get across to you guys. I'm doing an osteotomy to unload that patellofemoral compartment pretty much every time. If they're hesitant, and I'm on the fence between a MACI or an osteochondral allograft, and they don't want an osteotomy, I'm going to do an osteochondral allograft for that trochlear lesion. Seth. That patient's a hard one because there's no measurable malalignment. It looked like the trochlea morphology was okay, and the patella height was okay, and the TTTG might have been normal. Let's call it like 11. Yeah. In those cases, it's the conversation about anticipation or not. It's not AMZ. It's not AMZ plus distalization. I have, I guess, a higher threshold to just do an OCA and maybe not do an osteotomy, like you said. Totally fair. But at the same time, like I said, I think that with these patients, many times you have one good shot to really do this joint preservation approach. With that 60 degree tibial tubercle or AMZ, you're getting the most bang for your buck. You're getting a fair amount of anteriorization for not all that much medialization. I have tried this direct anteriorization. I'm not a fan, to be honest with you. For those kinds of cases, trochlea, basically lateral patella facet in the absence of instability, I'm going to do a 60 degree. Dr. Bugbee. How many TTOs does a surgeon need to do a year to be confident and pull it off well in time and again? These are all good ideas, but I think the execution matters too. That's a great point. I don't know if that has an answer. I think Andre is going to talk about complications. It doesn't matter. I do a fair number. Listen, stuff happens. We all have complications. I wish I had a number for you. I still sometimes get a little bit of the willy before some of these complicated cases. I'm doing a fair number of these combined cases a year. I just think you got to be prepared, just like everything else. Have your operative plan, stick to it. Not to pitch it, but I have a decent video out there you can click on. We always need the clicks. Basically, you got to get comfortable. The more you do, the better it will be. Once again, it's all about preparation and that shared decision making. Yeah, so on that point, back at NYU, and the residents will attest to, we very frequently will do cases with partners. These complex cases, the more experienced hands you have in there, the better it is. First of all, it's more enjoyable. It's more efficient. I think it's better for the patient. My question is, are you using any system with jigs, or are you free-handing the osteotomy? I don't free-hand those osteopaths. He uses the system. Because I think that makes it very reproducible, and it'll get your comfort level right up relatively quickly. If you know the system, you don't need to go out there and tell them how to use the system. You're probably good enough at it. Fair. Fair, fair. Seth? When you commented for cartilage restoration, meniscus transplants, you were putting it to the lateral spine now. I might be moving it just centrally, and then going to lateral spine, or 62%, as I was showing. For arthritis? Just curious about the other panelists. Are you guys going to do that? Yeah. I'm going to be moving it just centrally, and then going to lateral spine, or 62%, as I was showing. For arthritis? Just curious about the other panelists. Are you guys going dead center, or are you going to lateral spine when you're correcting Cards? Same. Yes, so I think that what we're getting at here is, you know, the old school approach here was to go to, you know, that Dugdale's point, that 62.5% almost every time. In cartilage restoration, I think we're basically just saying, get it to neutral. For me, like I said, I might go just to the spine, but I'm not overcorrecting the way we used to. Yeah. What's your role for the unloading place in preparation for this? That's a great question. I'm a very frequent user of an unloader. It also depends on like kind of the patient's ability to have a definitive procedure. If there's any inclination that they're not going to be able to do the procedure quickly, I'm going to put them in an unloader brace. First of all, I think it's going to make them feel better, and two, it's going to give me a little bit of a window into what things are going to be like after they're unloaded. So we're pretty frequent users of unloader braces. And I'm also curious to hear the rest of the panelists. I've been using unloader braces postoperatively for a lot of these patients to almost protect the work that we've done. If I have an athlete that I did an osteochondral allograft on or a meniscus transplant on, I've been using an unloader brace to kind of protect my work. It's sometimes a little bit bulky, but they'll get used to it. I think, once again, as is true with everything we're talking about, you've got to optimize the likelihood of success, and if it means that they're going to be in an unloader brace when they play ball, I think it's worth it. All right. I think I'm going to hand off. Thank you, guys.

osteotomy

cartilage pathology

joint preservation

total knee arthroplasty

cartilage restoration