Dave, thanks for switching. I was taking a nap. I just figured you'd show up a little bit late, so I appreciate it. Thank you. So I'm going to cover over the next few minutes some thoughts and decision-making principles on cartilage repair. And like all of us, our disclosures can be found on the Academy website. So there's a number of factors related to decision-making and cartilage repair. And I think a couple of the basic principles are, obviously, it's multifactorial. We're not just dealing with a cartilage defect. Some of these athletes, most of them are with a very dense system with lots of other intangibles that relate to injury, taking time out to get treatment, whether it's non-surgical or surgical, and then timing to return to play, which has probably a lot more to do with other factors than just pain relief in terms of how they fit into their system. One thing that we've learned over time is that cartilage defects are incredibly common and that there really is a poor correlation between what we see by x-ray or MRI in terms of how people feel. And we have a very poor understanding of the natural history of these things. So in general, we're in the business of treating cartilage problems for today rather than what might happen tomorrow. Cartilage lesions in general are, as I say, very common. We do tend to see in our highest-level athletes an accelerated incidence. So if you take an athlete in his early 20s, say 20 to 25, and compare that competitive collision athlete to someone in their 30s and 40s who doesn't play a collision sport, they look a lot like them in terms of incidence. But as I said, there's a very poor correlation in terms of what you see. You look at that MRI there, and I showed you that little video. I didn't expect to see that amount of damage and delamination based upon that MRI, but clearly we knew there was a problem. So it can either over- or underestimate, but it's not the primary source of our decision-making. There is a very common question that's important to answer, and that's, will sports make it worse? Now that I know I have a cartilage problem, will I make it worse if I engage in sports? And I think, to me, this is really the most important understanding that we have to have with our athletes. There is very little data that shows that this condition will be made worse with sports. Yes, the prevalence is higher in our younger athletes, but there may be an uptick in symptoms, but we don't have a firm understanding of which defects will accelerate, for example. So that being said, it gives us a lot of room for nonsurgical treatment and pain management and counseling rather than immediate intervention to sort of obliterate the disease itself in the absence of any clear data that tells us it's going to get worse. This is a great quote by Voltaire. The art of medicine consists of musing the patient while nature cures the disease, right? This is pretty important in a situation where you understand that natural history is an important part. And since we know that patients can do fine for a long, extended period of time, maybe it's reassurance they need over active treatment. Now athletes have unique considerations, and we need to separate concern from disability. We need to separate their inability to perform, because does that make it unemployable or even worse, they can't get educated because of a scholarship. The treatment chosen can actually affect their asset value or their downstream options. Some people say, well, look, I don't want you to do marrow stimulation, because downstream if they fail, obligatorily they have to go to another type of treatment. So we have to think very carefully of what the downstream consequences of treatment in and of itself will have. Improved ADLs are predictable, but our ability to return to sport is less so. So the best athlete to take care of is the one who comes in and says, look, I not only have problems at my sport, I can't tolerate my performance as suffering, but I also have problems with activities of living, because we can achieve predictably good outcomes with the right indications in that scenario, but we can't always promise return to sport pain-free. We need to match the solution to the anticipated outcome in the time required. So sometimes debridement is just fine. It doesn't solve the problem, but it gets the athlete back with doing less, not more. One of the things as team physicians that we're often required to answer is what is the risk of an athlete who's actually had some procedure before? What can we tell the organization? And one of the things that I've learned is that if you can get a year of symptom relief for a challenging cartilage problem with a specific treatment, and they have no effusions and they have no pain, and you get a good solid year of performance after the recovery, that's often a pretty good predictor of that they may do well in the near term. And like it or not, the near term is often all that matters. When you look at the length of the average career or the college and so forth, that's acceptable. We're not looking for forever solutions. It's a different thinking sometimes in this population. So who gets what? Well, I think non-operative treatment is very good for the acute onset where their performance is maintained. Or maybe their performance is compromised, but they're playing for something. And we see that all the time when athletes have long money. Operative treatment where their performance is impaired and we've failed non-operative treatment. And maybe they're early in a long money contract experience. So the criteria and timing of surgery is a big factor here. And I will tell you that these athletes often will be subjected to non-surgical treatment because, again, we're not trying to stomp out disease. We don't have a firm understanding of the natural history. So if we can leave it alone and make those who have symptoms feel better, that in and of itself is effective treatment. So does it affect their performance? Do they have other pathologies and do we actually have to correct them? How many years do they have left to play? What time is it within the season? It's like a first time shoulder dislocation. Some of those same variables are taken into consideration when making a decision. What's the duration of a contract? That may have a real consideration as well. And what are the long-term expectations? So I'm not going to go into great detail about what the indications for all these procedures are because there's more than one way to get it right. These are all technically in contention. So typically I can tell you that the lower demand resource intensity procedures like debridement and so forth and marrow stimulation, they deliver fibrous tissue. They have less predictable recovery times in terms of symptom relief. And then we move along this lineage. But the decision making is obviously very complex by defect location, defect size, what does the subchondral plate look like, and so forth. So there's no way to possibly teach what really is acquired with experience over time. And then critically looking at our outcomes to try to discern these intangibles. So I'll just try to give you some high-level thinking points that can help you contemplate this problem when you're working with your athletes and trying to make a decision. I really do believe that debridement is an acceptable form of treatment. We and others have stumbled upon this through various experiences. One of which was that we had a large group of patients who were biopsying for potential for ACI, or MACI now. And we looked at them and said, how do they do? And about 45% of them never needed further treatment. And we went in with the intent to treat, but they got better from debridement. Pretty simple, right? We also know that you don't have to fix the defect, but you can change it anatomically or geographically by, say, making vertical walls, where the defect itself doesn't experience direct load. So think about OCD and the lateral aspect of the medial femoral condyle. If you go as far as taking the piece out, those patients feel better. They're not walking on that loose pebble anymore. And that's a relatively low load area. Think about a 12-millimeter defect in a woman who has a femoral condyle that's very small. Female athletes who tend to have smaller femoral condyles. Put that in a male or a larger femoral condyle, they may experience very different symptoms. So we've learned that if you create vertical walls in a defect and don't do anything to the defect itself, that it reduces the load within the defect, and maybe that can shield them from having pain. So this is just a simple example. This is a player who had a cartilage defect in the patella. We put a little Voodoo and bone marrow concentrator in there afterwards. He was unable to play. And following just a simple debridement and getting rid of those flaps, got two years out when I last talked to him. He was doing extremely well, and he had no further complaints. That was it. All we did was a simple debridement. So you're currently a 20-year-old college student in a Division I school. This is another example. I just want to show you how we interview these patients. Two years ago, you had a really deep debridement for a patella cartilage defect, and you were able to get back to play pretty reliably and had no problems. Right. However, over the last three weeks, no injury you can cite. You've had right knee pain that's really inhibited your ability to play for more than two to three minutes before you get pain and swelling. Correct. You do not recall an injury? No. Where is the pain located? It's on the right side of my knee, and then kind of over here on the patella, and it's on the back. Okay. Since this started, have you limited your play, or are you just trying to push through it? I'm just trying to push through it. And have you been suffering for that in terms of discomfort? Yes. And has your performance been compromised? Yes. Okay. Your goal is to play how many more years? Two more years. Have you ever redshirted or taken a medical redshirt? No. You have a redshirt remaining now. Is that correct? Correct. How many more games could you play before that would be compromised? Six more games. If you played six more games, you would no longer have the option to take the medical redshirt. Correct. And then you might miss a year of school of play unless you got a medical redshirt, which is another way to get around it. Fair enough? Mm-hmm. Your desire is to play. Is that correct? Correct. All right. As you currently stand, do you believe your knee would allow you to play at any reasonable level? No. The more I play, the more it hurts. Okay. And the more it swells up. So, I'd like to show that little vignette because, you know, you think we're not even asking him about the defect or these other things. All the other variables that go into making a decision. What are you going to do for this guy? Are we going to just debride him? Depending on what we see, do we have to offer a longer-term solution? You saw the thermal condo lit up like a Christmas tree, right? And this is his defect. And it's a long, narrow defect, which I wouldn't do an OATS for. It was like four millimeters wide and maybe 20 millimeters long. So in this case, we did marrow stimulation and we drill it. So marrow stimulation has been very controversial on the podium. But truth be told, there's a number of studies that support that you can get an athlete back to play as long as you respect the rehabilitation principles afterwards. And I think that's a big part of it. I think a lot, and this is what Steadman would often say, a lot of the failures are because if you create a fracture, in this case we drill, which I think we think has some advantages. Once they load it immediately, they load the subchondral plate, they get sclerotic bone and so forth. So I think the rehab does play a big role, but we have to decide who's going to get better with simply cleaning it out versus actually drilling. I think the drilling is probably the way to go now. It's less traumatic. You get less of a fracture response, but achieve the same goal. We actually looked at our patients who drilled it versus who had an awl, and we found that our revision rates, if you look at the awl MRI on the left versus the drilling, the MRIs are much more quiet. We're trying to get access to the host MSCs, and what we found is our revision rates were much lower when we drilled versus using an awl, everything else being equal. There's some other options that are sort of low-cost options that we have in the United States. This is a relatively new procedure, collecting articular cartilage and mixing it with allogeneic collagen as a scaffold and using maybe PRP or bone marrow concentrate to provide growth factors. So this is an orthoscopic findings. We capture the cartilage from the inner column or notch, and we mix it. We do a marrow stimulation. We add the lyophilized collagen as a carrier, minced pieces of cartilage, PRP or bone marrow concentrate, and then fiber and glue to surface the defect. So new stuff, but some ways or evolutionary ways to think about an adjunct to marrow stimulation. Osteoconal autografts, I think, in an athlete is a dominant treatment strategy. So the thing is, you don't see a lot of 10, 11 millimeter defects that are symptomatic, but if you're fortunate enough to see one, this is a dominant treatment strategy over marrow stimulation any day. This is a young woman who had a lateral formoconal defect that was treated with debridement and didn't do well. It's only one centimeter. To me, this is a chip shot, and this is one that you can get back in four months with an osteoconal autograft, and then she also had some tibial changes as well. But I think if the athlete's unfortunate enough to have enough symptoms, despite having a small defect, this is a dominant treatment strategy. Now, ACI, I think, is an option in a high-level athlete. I will be honest. While I've done a lot of ACIs, patella-femoral joint and multifocal defects with no subcontinal changes, and there is data in soccer players in the United States where they have good or excellent outcomes, it's a long recovery, in my experience, to actually say they feel better. So this is not, for me, a dominant treatment strategy for our highest-level athletes, even though I use it in other patients. This right now is the go-to, the osteoconal autograft, by far. If you have graft availability, all things being equal, for large defects that don't respond to debridement, this is becoming closer, not a first-line treatment, but becoming closer to a first-line treatment. And the return to sports, I think, supports this technology. I think we have to be very careful about what we learn in the literature with return to sport because it may have less to do with the defect we're treating than the system the athlete's in. You know, we know it can take two years for an athlete to get back when there's a roster change or they're off contract. So you can't really rely on the literature to tell us, but this is what you see in the literature itself. This is an NHL player with a large butterfly-shaped trochlear defect, which historically was really difficult to manage with an allograft. But I think, given current instrumentation, it can be done and you can match it, the topography with a standard allograft sizing. So sort of finishing up, I think, as I alluded to in my first slide, it is multifactorial. It is not just the fact that they have a cartilage defect. They may be malaligned. They may have instability. They may be meniscal deficient. In fact, my number one transplant now is a meniscal transplant with an osteochondral allograft. So it is much more common for them to be symptomatic because they have other problems. And if we just look at the literature overall, I know that was one of the emphases, was return to sport after meniscal allografts. This is what's reported, 75 to 85 percent. And I had a struggle early on allowing patients to go back to play because of the concern, look, you tore your own meniscus, you're probably more likely to tear a meniscal allograft. And arguably, we've been surprised at how infrequent our high-level athletes, when they do go back, will tear their meniscus. And you could argue, look, it's just another scope and a clean-out and so forth because these are never going to be permanent solutions, but we're dealing with these higher-level individuals. Again, the best one who has problems with ADLs, and oh, by the way, would like to get back to the sport with less pain. If the only problem is trying to play their sport, it's very tough sometimes to squeeze out that marginal improvement. Osteotomies. You know, I've heard people say, look, you can't do an osteotomy in an NFL player because they never do well. I think they never do well because it's an awful problem and the osteotomy just doesn't solve it. I don't think the osteotomy, if done correctly, will create an additional problem that will prevent that athlete from getting back. Most pain with cartilage problems is due to overload, and the osteotomy can, in some individuals, reduce that load enough that they can feel better. So all things being equal, if I can pick an extra-articular solution without hurting the athlete, I don't have a problem doing an osteotomy in this population, and there is pretty good data in the military and other normal sports that osteotomy can alleviate symptoms enough, even absent of treating the cartilage, and get a player back with sufficient pain relief. This is one of the first NFL alignment we did, and I had two over a short period of time, and I understand, you know, I don't take care of an NFL team, and I can certainly understand the reluctance of an NFL team physician of doing osteotomy on their player. They would probably much rather refer it to someone who doesn't have an interest in it, because, you know, you say this has got to be no better than 50-50, but it's an osteotomy with an osteochondralograft, and can successfully get a player back, even some of our bigger players. So finally, I think it's important to understand the literature and your own experience. I think that what I've learned over the last 25 years is I've tried to figure out who can do well with non-operative treatment, and maximize that, because you know what you get, and if we don't think the natural history is necessarily bad, why not just find some way to make them feel better? But if you can't, then hone in on what really yields a successful outcome, and I will tell you we've been paying more attention to our poor outcomes than our successful outcomes. I will tell you that about 30 percent of our athletes require re-operation after having any cartilage procedure. I don't think that's a sign of failure, it just shows that we're not doing as well as we wish, but it is just another scope, and in the scheme of things, maybe that's not so bad in a setting where they otherwise couldn't play. Using orthobiologics. I would say that, you know, when price doesn't matter, we're using them all the time, but I think we have to be conscientious and use them judiciously. We had a full day of the Biological Association the other day with some really good science, but still, there is a paucity of high-quality studies, and while we always say the preliminary results are encouraging, we really do not have enough data to say that it will routinely make a difference. But when money doesn't matter, if it's an athlete, and we're not going to hurt him, then I think we often use it. So I'm going to stop there, and thank you for your time and attention.

cartilage repair

treatment

athletes

decision-making principles

nonsurgical treatments