So I'm flattered to be part of this pediatric session. I don't have any conflicts. So OCD presents very much the same for everybody. Pain, swelling, motion loss, catching, locking, deformity, loss of function and performance. In a paper out of Boston, they looked at the difference between the males and females. And the female athletes tend to present with earlier Nelson grades than the males. And this suggests to the authors that an earlier grade OCD lesion may result in greater functional limitations because of the demands of gymnastics. And I would submit to you that an intact, convex, biomechanically functionally subchondral plate in the lateral half of the capitalism is probably more important in the gymnast than the thrower. But that data has not really been defined. You can see in this case where it seems to have healed, this patient was still symptomatic with that lesion. Same study also showed that the males tend to present much older with older bone age or vice versa, the females much younger with younger bone age. But in this study, it's important to note that the treatment was dichotomized based upon an algorithm. And so some had drilling, some had fixation, some had oats. And if you look at many of the studies out there, it's one path only. And I think it's important for us to understand that that's a big problem with us understanding what we should be doing with these individuals. And whether it was the whole group or it was just the gymnast, it was a very similar split, except the gymnast had less fracture fixation. We did a similar study and presented it at Erudicus in 2018, looking at 49 elbows. And in our whole group, we had a similar split of procedures, drilling, fixation, oats, but we had less fixation in the gymnast, pretty much the same. We also saw that our gymnasts tended to come in at a really high level, level 8 or more in the great majority. The gymnasts were younger, shorter, lighter, had smaller OCDs and lower inclination angles. And so these were our numbers, 66 and 40 degrees, which were similar to the Kajiyama numbers, 57 and 28. But it's important to note there's a big difference in how these behave, and I think that needs to be considered as we make decisions for treating them. We also saw that in our group, the rock classification was really high in this. It was higher than we saw in the baseball players. And they were bilateral 37% of the time. This has been reported in a number of other articles, 25 to 40%. So always be aware if you see a gymnast, you need to look at the other side. So what are the evidence-based indications for nonoperative care? Less than 12, maybe a gymnast even less than 11, open lateral epicondyle physis, stable, small or central grade 1 lesions for sure. But stability is based on a number of things. And it's really hard to know when people say stable what they're talking about. But the cartilage subchondral plate fracture displacement needs to be minimal, and the pisces need to be open. No cystic-like lesions, no significant proximal radial head migration or radial head enlargement. And skeletal age is relatively similar. These are findings that have been defined as indications for conservative care. But even with this, another study out of Boston, only 50% to 60% of the stable lesions healed spontaneously with activity restriction alone. A really nice paper by Takahara just came out showing that casting plus splinting followed by activity restriction proposed a higher return to sport, shorter period of ossification, higher percent healing, and less time. So if you're going to be treating these nonoperatively, you probably should be using a cast to begin the process. A number of predictors for poor outcomes. Unstable lesions, older, longer duration, asymmetric skeletal maturity, closed lateral condyle phises, and of course higher grades on your X-rays and your MRIs. But also stable lesions that aren't healing. Those are all indications for surgeries. And these are the ones that tend to come to debridement, drilling, and fixation. But once you start talking about larger lateral lesions, especially those that are uncontained, you have to consider complex reconstruction procedures, particularly those with radial head capillary congruity, radial head hypertrophy, and radial head migration because these are the risk factors for osteoarthritis regardless of the method that you use. So it's still really controversial. What do we do? Debridement, drilling, fragment fixation, complex reconstruction? I don't think you pick one. I think you try to have an algorithm that you follow that allows you to come up with the best treatment for each individual patient. So for complex reconstruction procedures, the indications are probably large, unstable, lateral wall, open phises, asymmetric skeletal maturity. And particularly those who have radial head hypertrophy and migration. And even contralateral radial head physis that are open when the involved side is closed have been shown to have increased risk for proximal migration and osteoarthritis. So this is a group that you may want to consider also treating with complex procedures. And then finally, gymnasts and pitchers universally are the hardest to get back to sport. So does debridement work? Sure it does. It doesn't work all the time, though. But even if you look at the most recent studies, some of these are really mixed bag results. And if you look at the studies that support non-reconstructive surgical care, while they may report excellent outcomes, they'll still have subgroups that they say don't do as well. And the Rothman study that was just presented last year still had a 12% revision rate. And the Matsuhara study, while it had 87% return to sport, 20% of the pitchers were unable to return to sport. So it works for some, but it doesn't work for all. So you can't apply debridement to everybody. The TIST study showed very low return to sport. Lewin, 67% return, but with a lot of pain. Back skins, 55% return to sport, 25% could not because of their elbow. And this is an important part for gymnastics. If a CT study looking at subchondral plate restoration showed that only 35% had good, not excellent, subchondral plate restoration, and 50% had fair, I think that's a problem in the gymnasts. So what about fracture fixation? Well, we're going to hear from Ben about the knee. They go to great lengths to try to fix all of those lesions. But in the elbow, they tend to just toss out the piece of cartilage. I fixed a lot of these in the 2000s. There's no question I've moved to some other options. It does work. Complex reconstruction works as well. But the systematic review by Westerman demonstrated that there was a lower return to play and a higher reoperation rate with debridement when compared to debridement notes. So we're probably not going to be fixing as many as we could, although there's some really nice suture techniques that have come along that we may be able to apply to this in the future. So if you're going to fix them, what can you do? Well, you can do autograft transplantation. You can do allograft transplantation. And there are a bunch of other options that are available that we don't have time to really run through. If you're going to harvest a graft from the patient, you can use medial trochlea or lateral trochlea, and there are good studies that support both. But Shube's paperwork shows that all the grafts tend to be a little bit thicker than the native tissue. This is a really important point, though. The Mexicans and Mozzarella's paper showed that when they do have donor site morbidity, it tends to be from harvesting from the lateral trochlea. So I tend to recommend that you use the medial trochlea for this. And if you're using pre-cut allograft, be aware that these come from various sites, and they may not be square, and they may have really thick cartilage. Systematic review is Westerman again reported that better with oats. CURS showed 94% successfully returned with oats procedure. Logely said oats produced reliably good outcomes and high return to play. But this is not a fair argument, and it's kind of biased in its presentation, because Sayana looked at a 35-year review of the literature and concluded that we really don't have sufficient evidence to support complex reconstructive techniques for high-grade lesions compared to microfractures or even lungs. So it's still controversial what we should be doing for these gymnasts. What about gymnasts? What data is out there? There's a lot of debridement studies, and there are a couple that look at fixation in oats. And so then you can kind of deep dive through some others, but some of the papers that do have done things that are looking at the difference between males and females but not really the outcomes. And so we don't really know the outcomes with gymnasts. Here's a couple of papers. Hastings 2012, 79% return despite lesion size. The Yalwe paper, 81% return, but this is only 50% follow-up. So we're really not sure statistically whether or not that's a fair assessment. And then the Bexican paper, 39% were able to return to the same or higher level, but 35% couldn't because of their elbow. And that's an important thing. We did a very similar look at this in the 2000s at 14 elite and level 9 to elite-level gymnasts, and only 41% could return to the same or higher level without restriction. A lot of the others could return with either limitations by cutting out vault or they had recurrences over the next two or three years and they had to reoperate on them. And 17% couldn't return because of their elbow. So this is an example of that. This looks like it's actually healed really well. It's a little young gymnast, but this is just a thin layer of cartilage. She had a loose body that was in the back, but her complaint was she couldn't bear weight. And so if you look at it, it looks like it's relatively firm, but she cannot bear weight on this. So we harvested a single-plug graft out of her medial trochlea, and we go in and take cancellous bone out of the tibia with a core reamer, and we put that little plug back in, and we do a trans-anchineous approach to this, so you can really get square. We try not to drill more than about 9 or 10 millimeters at most. Some of these little kids, their physis are pretty close. And you can get that done using the technologies out there, very simple, and usually be able to get a very square plug. And you can see here that we were able to restore the convex contour of the capitellum with a solid subchondral plate very easily. Some of our recommendations are using evidence-based, algorithm-based approach. I do think it seems more effective in position player and non-throwers than in pitchers or gymnasts. Cast plus splint plus activity restriction, and we use an activity cast, which is removal. It's made of polyester for young, premature, stable, small, central, short-duration lesions. Follow non-operative progress with flexed fuse. This gives a much better interpretation of whether or not it's healing. Non-contrast MRI plus OCD sequences plus bone windows and maybe mapping. Spontaneously healed OCD craters seem to heal better and do better in throwers. I think it's because the gymnast needs a solid lateral subchondral plate. Consider fixing the small, shallow, contained, unstable, in situ lesions in young individuals. Debride and derail the smaller, mature, contained craters without radial head pathology. Auto-OTs maybe. That's not really validated well in the literature, but I believe auto-OTs in the gymnast for the larger, lateral, uncontained, unstable lesions, particularly with radial head pathology. I recommend medial femoral trochlea and back fill with the cancerous bone. Allo-OTs may work. I don't know. And remember that 25 to 40 percent are bilateral. Thank you. Thank you, John. That was outstanding.

pediatric OCD

athletes

individualized treatment

surgical intervention

lesion characteristics