All right, good morning. Last but not least, everyone gets a surprise at the end of this or the last session. So we'll go ahead and get started. This is the Solid as a Rock session, Make the Right Choices for OCD Management. We'll have four paper presentations. And the first will be Osteochondral Allograft Transplantation for Capitular Osteochondritis Descans, my partner, Dr. Crystal Perkins. Good morning. Thanks for hanging for the last session of the meeting. So on behalf of myself and my co-authors at Children's, thanks to the program committee for allowing us to present our work on OCD in the elbow and osteochondral allografts. If it wants to click. We have no disclosures pertinent to this study. So as we're aware, standard of care for treatment of OCD at the capitellum has typically been debridement and marrow stimulation. And although outcomes from that are generally good, we've seen that there's been suboptimal return to sport in up to about 25% of higher level athletes, as well as pain and high demand upper extremity athletes. And really the question becomes, is debridement and marrow stimulation truly the appropriate and ideal treatment for all of these patients? Or is there an evolving role for osteochondral allograft transplantation? And those indications have been for larger or unstable OCDs, as well as extension to lateral border of the capitellum where there may not be that same shoulder that would otherwise contain a central capitellar OCD. Fresh osteochondral allograft transplantation has the advantages of restoring subchondral bone and cartilage, while avoiding the donor site morbidity of autograft harvests. So the purpose of our study was to evaluate the outcomes of osteochondral allograft transplantation in pediatric patients with unstable OCDs of the capitellum greater than or equal to 10 millimeters in size. This was a prospect of cohort patients under the age of 19 with unstable capitellar OCDs. Again, 10 millimeters or greater. Treated primarily with fresh osteochondral allograft transplantations. There were no revisions for micro fractures in this group. All patients had minimum two year outcomes. We collected pre and post-operative patient reported outcome scores, as well as pre and post-operative imaging, including post-operative MRI, as well as surgical details. So this study included 26 elbows in 24 patients with an average age of 13. You can see about three quarters of the patients were represented either gymnasts or baseball and softball athletes, and the majority played their sport most months of the year at a competitive or travel level. Median symptom duration was three months. Most commonly, they presented with pain, mechanical symptoms, and loss of terminal elbow extension. Their pre-operative PROs are collected there, showing impacts on overall function of their elbow with daily activities, as well as with sports. Average size is about 11 millimeters in coronal plane width and 12 millimeters in sagittal plane width. The majority of these patients had a closed capitellar phisis. 35% of these were along the lateral margin of the capitellum, and most commonly on MRI, representing unstable OCDs with a breach or high signal fluid behind the lesion or a frank loose body. These patients underwent arthroscopy for loose body removal. Oftentimes, this loose body would be in the anterior aspect of the elbow, not able to be reached through the then ankyneous reflecting approach. So the ankyneous reflected off the ulna, and then exposing the capitellum with hyperflexion of the elbow, and then using pre-cut osteochondral allograft cores to treat this. The majority of these patients were treated with a single plug graft with a median plug sidus of 12 millimeters. A few of these patients did have larger OCDs treated with a snowman-type configuration with two cores. Mean follow-up was 40 months, ranging from two to five years. All patients were cleared for return to their primary sport between six and 12 months. Return to sport at one year was 81%. At two years, all but one patient had returned to sports. If you look at a subgroup of our gymnasts and baseball players, of the gymnasts, all but one returned to sports, but interestingly, only about half actually returned to gymnastics. And when you look at those patients, the six that chose a different sport reported it was unrelated to their elbow. Six baseball players, five of which returned, one chose a different sport, again, citing non-elbow-related reasons for choosing a different sport. Overall, PROs from pre-op, six months, one year, and two year are shown showing significantly improved outcomes with increases in the Oxford elbow score and decreases in the quick dash from preoperative to two years. MRI in these patients was obtained between five and eight months, and about 60% of patients had a postoperative MRI. The bogey score has been well-described by Don Bay and colleagues, and mean bogey score for these patients was 11, indicating high rates of incorporation without cystic change or loss of the overlying cartilage. In terms of complications, there were two patients who had reoperation, no other complications. Both of these were after full return to sport, arthrofibrosis in one, which was persistently symptomatic, and posterolateral synovial impingement in another. So in conclusion, osteochondroallograft transplantation of the capitellum for these large, unstable OCDs in our adolescent patients was associated with low rates of complication, excellent graft incorporation, high elbow function, patient satisfaction, and relatively high rates of return to sports at two years, even in some of our higher level athletes. Thank you. Thank you. Our next speaker will be Dr. Phil Wilson, return to sport and patient-reported outcomes of osteochondroallograft transplants for the capitellum. While he's walking up here, I would just encourage you guys to check in on the app, and if you have any questions, please put them through the app, or we can wait until after the speakers. But either way, app's available. Thanks, Cliff. Here? Yeah. Just advance here. But this is okay, too, right? Thank you. So I'd like to acknowledge our co-authors. Juno Ahn's one of our residents who you guys will be hearing from, and then several of our research coordinators. And then, as usual, Henry and I seem to be in lockstep with Cliff and Crystal and their group, and so happy to present this and maybe expand, or just a few different details that we can give you. Our disclosures are available. As Crystal said, there are multiple options, but I think the literature's pretty clear that for athletes, upper extremity athletes, osteochondral grafting is the preferred treatment. OCA is more sparsely reported. We have one series and then some technique articles, and so I think both of our institutions are interested to get this information to you. And of course, the allograft interest is driven by success in the knee, and donor site morbidity is one of those things. As we look, we find it more and more. And so 8% in the literature, I think maybe even creeping up a little higher as we look a little bit more. The purpose was to see how OCAs did compared to maybe the literature that shows us that autograft is a good option. And so we had 47 elbows over about a 10-year period that we treated with this. When we screened it for a minimum of two-year follow-up, that left us exactly the same size cohort as Atlanta. We had 26 elbows in 23 patients. These graphs, we again had very similar technique. Most of them we harvested from the posterior aspect of a fresh lateral femoral condyle. That's the maximal apex of convexity posteriorly. We did use pre-cuts early in our series, and we'll talk a little bit about that. We collected data pre- and post-operatively, same as you've seen. Level of sport, exam, operative, imaging, and complication details. We looked at PROs, the quick dash Timbermen, and their activity level with the PD-FABs. Looking at our results, we had those 26 elbows in 23 patients. We had a minimum of two-year and up to 10-year follow-ups, so they had an average of five-year follow-up for this cohort. Age and percentage female, exactly the same as the series you just heard. Our amount of upper extremity athletes, very high, over two-thirds were upper extremity athletes, and the majority, 75%, were a very high-level select or elite level. At presentation, just under 50% had preoperative extension loss, and that averaged 16 degrees, and their arc of motion varied between 80 and full 155 degrees of motion. We had just at 50% present with a loose body, so these were pretty advanced lesions. We had one-third of them with concurrent radial head osteochondral lesions. When we look at our grafts, we had 17 of the lateral femoral condylar fresh grafts that we cut the graft ourselves, and then we had nine pre-cut cores, and there was a little historical bias. Those were more early in our series. When we had a single graft, they were usually eight to 10 millimeters mosaplasty. We usually used six and eight multiple plugs. You can see that our mean surface area of grafting was about 81 square millimeters, but went up to very large lesions with a large amount of grafting. The majority did have one graft, but 25% of our series had a mosaplasty. We looked at outcomes. We saw a significant increase in range of motion for the whole cohort, and we saw over 90% radiographic and MRI healing, as you saw Crystal's data, overall very good MRI outcomes in this allograft group. When we looked at the radial head osteochondral lesions, we saw that those correlated with a less post-operative range of motion, so both the post-operative arc as well as their terminal flexion was less when a radial head lesion was present. And looking at return to sport, of those patients who attempted to return to the same upper extremity sport, we had 18 of 20 for 90% return, and of those who did return, 100% returned to their same level, our average time to return to sport was eight months. What we found was if you had lesser lateral containment in this series, then that was predictive with less return to primary sport, and that mirrors the allograft, I'm sorry, the autograft literature. In the two patients who tried but couldn't return to their primary sport, they had less than two millimeters of lateral containment. We found that otherwise return to sport was not correlated with either the graft number or the graft source, and indeed, four out of the six mosaeoplasties did return to their primary sport and continued in their sport. We saw improved patient-reported outcomes. With their quick dash improved, they maintained a high PD-FABS activity level. When we looked at the Timmerman, interestingly, we found that our lateral femoral conular fresh grafts had a little bit better Timmerman outcome score than the pre-cut grafts. There were no other patient graft or graft area correlates with patient-reported outcomes. We had two elbows who had reoperation for graft complications, one who had incomplete incorporation and one that had graft dislodgement early in revision at five weeks. We had four additional reoperations for stiffness or posterior lateral mechanical symptoms. We found that a higher grafted surface area was predictive of reoperation, but no other correlates of all of the other things predictive of reoperation. So again, avoiding knee donor site morbidity we think is a significant advantage, and really, I think both of these series show that the return to sport levels are comparable to autograft, and this series is benefited by a relatively good intermediate follow-up term. We found that radial head lesions, larger grafted area, and lesser containment were all correlated with inferior outcomes, and we feel that we prefer a fresh lateral femoral conular graft source based on our series and those outcome measures. So in conclusion, we think this fresh osteochondral allograft treatment is a great option if healing rates are greater than 90 percent, improvement of clinical measures and patient-reported outcomes, and a high rate of return to the same level of sport and competition at intermediate follow-up. Thank you. I'll slave Cliff the steps for introducing me on this next one here. Henry Ellis from Dallas, Texas, and I'm here really representing the ROC group, Research on Osteochondritis Desiccans of the Knee. My interest was really looking at characteristics associated with unsalvageable lesions, and I'm going to tell you right now, unsalvageable means that the OCD was not salvaged. It wasn't retained, so it was either replaced with something else, and so sometimes that word can be a little confusing, but for this study, unsalvageable means the OCD was not salvaged and we had to replace it with something else. Disclosure can be found on the app, but it's pertinent just to mention that ROCK is supported by a varicell, osier, and allosource, but not pertinent to this talk at all. We all know the definition of osteochondritis desiccans of the knee, or OCD, and goals of treatment are really to address the subchondral bone, really, until before it affects the chondral surface, and treatment options really are intended to try to salvage, to try to get it to heal, but sometimes it doesn't heal, and when it doesn't heal at that point, we have to think about other options. So what is an unsalvageable lesion? When can we not salvage it? Well, some people have described that it can be fragmented, or it's just not congruent with the rest of the knee, perhaps that chondral surface is already completely deteriorated, or we've already tried to fix it and it didn't work. The reality is, is we have described techniques, both cell-based and structural-based, but the literature really doesn't tell us when, or how, or what is the right lesion in which to use these unsalvageable techniques. So my interest was really to look at, well, when do the ROC investigators, or the ROC contributors, when do they decide that an OCD can't be salvaged, and proceeding with an unsalvageable technique? I looked at the ROC prospective cohort from 2014 to 2022. All of the data is standardized, as it is a prospective cohort. This was the primary treatment of the ROC surgeons when the OCD was presented to the ROC surgeons. I excluded those that were older than the age of 20. These were just chondral lesions, so I excluded both patellar and trochlear lesions. And I'm just going to make a mention on previous surgical treatment. The original premise of this study, we looked at previous surgical treatment, which was so heavily, strongly in favor of an unsalvageable technique that I had excluded it for this analysis. Effectively, when we did a multiple regression analysis, it was statistically significant to have an odds ratio of 15.6 if it had previous treatment. So it's a very, very strong predictor, but I excluded it for this analysis so that we can look at characteristics of the OCD that determined whether it was unsalvageable or not. It's descriptive data, and I compared those unsalvageable to salvageable lesions, and I only looked at mobile lesions according to the arthroscopic classification that was described by ROC. This is just short of 1,300 OCDs. Following those exclusions, we looked at 186 mobile lesions. Of the entire core, 3% were unsalvageable, and it's about a fifth of the mobile lesions, majority of which underwent microfracture. But you can see OCA, cell-based MACI, and OATs were also used. This is a bit of a description of each one of these techniques. You can see microfracture, majority used OLLs, but going all the way over to OCA, you can see fairly large OCAs when they were used compared to the OATs, which were on average 10 millimeters. When you compared the salvageable to unsalvageable, these are the key characteristics. Again, we excluded those who had prior treatment. And you can see those unsalvageable were older, a little heavier, and they're more likely to be males. Characteristics of the OCD, rock surgeons, if they saw bone in the progeny, they felt like it was more amenable to salvage. So perhaps not having bone in the progeny may be an indicator to a rock surgeon not to perform a salvage technique. Looking at the density of the rim of the progeny when bone was present, and if there was higher density of the rim of the progeny, at that point, rock surgeons felt like it was more of an unsalvageable technique. And as expected, if it was displaced, it was more likely to undergo an unsalvageable technique. When I then, in this model, and I performed the multiple regression analysis, again, we found that male sex, age, and displacement were all associated with an unsalvageable technique according to the rock surgeons. You know, we need to learn more a little bit about when these are going to heal, when are some characteristics in which a salvage technique is not going to work, and we still need to look at that at the rock data, because this was just purely based on the surgeon's expertise and contributions to rock. So that certainly is a very, very strong limitation in this data set. So in conclusion, prior surgery is a very strong influential factor to rock surgeons when performing a unsalvageable technique. Older age, male sex, and displacement are factors of the lesion and the patient itself, but we still need future studies to understand when to use these techniques. Thank you. Thank you. And our last speaker, our colleague from Michigan, Dr. Michael Kluh, presenting on association mechanical access with OCD of the femoral condyle. I'm a PGY5 at the University of Michigan. Thank you to the committee for inviting us to present this work. We have no relevant disclosures for this talk, but the remainder can be found on the web page. A brief background, osteochondritis dissecans is characterized by an abnormal subchondral bone with the potential to progress to overlying cartilage disturbance. OCD lesions occur often in the knee with 70 to 85 percent of lateral aspect of the medial femoral condyle and 10 to 30 percent occurring bilaterally. These can progress to become unstable, as we just saw in the last talk, with subchondral bone fragmentation, which may contribute to early onset arthritis. Pathophysiology for etiology and underlying mechanism of OCD lesion development is not fully understood, but may include local subchondral bone ischemia, repetitive microtrauma, an abnormal ossification process, and also genetic contributions. Recently, mechanical access has been suggested as a potential contributing factor. So we sought out to determine the association of lower extremity mechanical access with femoral condyle OCD lesion location, and how this association is affected by physial status and lesion stability. We performed a retrospective case series from a single large academic center from 2009 to 2023. We categorized both OCD lesion location and mechanical access based on Cahill and Berg zones, which splits each condyle in half with zones one and two medially, four and five laterally, and zone three in the intercondylar notch. We then performed subgroup analysis to evaluate how this association with location access was affected by skeletal maturity, lesion stability based off MRI findings, and whether they were treated in non-operative surgery. We also measured the mechanical lateral distal femoral angle and medial proximal tibial angle to assess their contributions to mechanical access. We identified 86 patients, including seven with bilateral OCD lesions for a total of 95 knees that met our inclusion-exclusion criteria, 74% of patients were male, mean age was 21 years old, 65% had closed vises, 82% of OCD lesions were unstable on MRI, and 85% underwent a surgical procedure. This table here uses the Cahill and Berg zones to show OCD lesion location in relation to the mechanical access, 75% of our OCD lesions were located in zone two at that lateral aspect of the medial femoral condyle. Mechanical access was located in the same zone in 48% of the cases as marked with the blue arrows, and then within the same compartment 56% of the time. Further than 90% of lesions were located within plus or minus one zone of the mechanical access. Very few OCD lesions were located in the opposite compartment of the mechanical access as marked here at the red boxes. Our Spearman's correlation coefficient of .59 demonstrated a moderate positive correlation between OCD lesion location and mechanical access. We found no significant differences in this association in our subgroup analyses of location at the medial versus lateral femoral condyle, skeletal maturity, stability of the lesion, or treatment group. Given normal accepted values for mechanical lateral distal femoral angle and medial proximal tibial angle of 87 to 88 degrees, the varus alignment associated with medial femoral condyle lesions had about equal contributions from the femur and the tibia, whereas valgus alignment associated with lateral femoral condyle lesions had slightly greater contributions from valgus femoral alignment. For patients with unilateral medial femoral condyle OCD lesions, they were significantly more likely to have varus alignment in the affected extremity when compared to their contralateral extremity. This was not seen with lateral femoral condyle OCD lesions. Overall, our work adds to the growing evidence that mechanical access is related to OCD lesion location, and the hypothesis that focally increased contact pressures may be related to femoral condyle OCD lesion development and progression. However, at this point, more work is needed to better understand this intertwined relationship of deviation from a neutral alignment and pathologic development of an OCD lesion. The main limitations of our work was the retrospective design, which required inclusion of lower extremity alignment radiographs to have already been obtained. This may have selected for patients that were more likely to be symptomatic, potential surgical candidates, and patients with concern for malalignment on exam. We were also unable to determine if mechanical access deviation away from a neutral alignment preceded OCD lesion development or vice versa. In conclusion, we found a moderate relationship between femoral condyle OCD lesion location and mechanical access that was not affected by skeletal maturity or lesion stability. And we recommend that lower extremity alignment films should be part of the radiographic workup for femoral condyle OCD lesions, especially when considering surgical interventions. Thank you. Great job. Given the timing, all the speakers will stay on the stage. We have three technical spotlights, and then we'll have questions for the group. So our next speaker, the first technical spotlight is Paul Saliwan from the Cleveland Clinic, will be presenting on capitellar osteochondral transplantation. All right, thank you for having me here today. We'll talk to you about several techniques that we use to approach capitellar reconstruction specifically using osteochondral allografts. All right, and we are not advancing. There we go. You just want me to hit that one? Okay, very good. These are my disclosures. None are relevant to this discussion. A lot of you are aware of the Rocket Group. A lot of us are involved in it. If you're not involved with it yet, I'd encourage you to join. I think there's a great opportunity to glean a lot of knowledge from this multi-center approach, and we continue to work together. So I'd like to review a couple cases with you to illuminate how our approach has evolved. This is a 13-year-old pitcher, chronic pain, sticking, locking, and eventually progressed to arthroscopy and removal of loose bodies. He did well at the two-year mark. This is a gymnast, 17-year-old. Had a very large lateral condyle OCD. This was taken care of a while ago. Removed the large fragment, cleaned up the edges. She did well. She did not go back to gymnastics. She went back to track and ended up being a significant track star, because she's just a good all-around athlete. But really, are we doing any good for these kids by just removing and running? Well, early on, they do pretty well. Later on, as we're all aware, they tend to get radial head enlargement, arthritic changes, and other problems that are lifelong. So, do we need to be more aggressive with certain lesions? Which ones do we fix? Which ones do we debride? Which ones do we reconstruct? So, over time, this is something that I've developed in regard to my approach, and from all the literature that's out there, patients have a worse prognosis the larger the lesion, and the more laterally-based the lesion is. And so, with that in mind, we synthesized all of the data years ago, presented it here, shoot, about 14 years ago, 13 years ago, and this is how I approach these patients with these types of lesions. The type one lesions are the ones that are younger individual, open growth plate, some flattening, still remain with good elbow range of motion. Well, most of those heal well with some rest. Type two lesions, they might have closed growth plates, fragmentation, they might lose some motion, but then the majority of the lesion is medial to this radial head center line, and involves less than 50% of the capitellar width. In those situations, I'm very comfortable with debriding, and then moving forward with activities, because that lateral pillar is still intact, whereas when this lateral pillar's not intact, and the lesion is greater than 50% of the width of the capitellum, as well as focus mostly on the lateral aspect of that radial head center line, it's time to repair or reconstruct. So, as you've seen, some of these results with OCA are out there, and I was really happy to see Phil and Crystal's work today, and in support of the osteochondral allografts, because that's how I've evolved. Some of the members in the rocket group still are doing the osteochondral autografts, and they're very comfortable with that, and they get great results. So, this is just one way to approach this. So, I'm gonna share a couple of illuminating cases, and this is a 14-year-old cheerleader with a very large, unsalvageable lesion. You can see that this lesion has overgrown, and it's not sitting there well. So, even if you wanted to try and put this back, you wouldn't be able to. So, this is her at the time of arthroscopy with a very large, overgrown, unstable, and unsalvageable lesion, and this is the way the lesion looks, really with minimal bone. So, we removed it, and then one of the approaches we use for surgical fixation and reconstruction of this is the COCR approach. It's the interval between the ECU and the ankineus, and it's a good approach. It helps with some of the more anterior lesions that you'll see, and I've used this for years, and these are just some examples of how we kind of get down to capsule. You gotta be careful not to get too aggressive with takedown of the ligaments. You could end up with posterolateral rotatory instability if you're not repairing things at the end, but then this is a good example of how that fits, and it was very close to being an uncontained lesion, but this was stable, and she ultimately healed, did well, regained motion. That's what I would stress is early motion in these kids. This is another example of a different approach that I've evolved to over time, and I wish I could take credit for it, but I'll tell you who did. It's the, this is a 16-year-old baseball player, six months of lateral elbow pain. He's a high-level baseball player, and he was being sought after by many colleges. It's the size of the lesion, and you can see that it's still in situ. At the time of arthroscopy, you can see that it's a little kind of bulged up a bit, and you have the trampoline effect on it when you're pushing on it, because you know it's soft cartilage. It's not normal, but it was still in situ, and so in this situation, I felt that this was something that was both repairable, as well as you can reconstruct as well, and this is something that actually Tony Mignacci showed me years ago. This was 25 years ago. He was doing osteochondral autographs into OCD lesions of the knee, keeping the lesion intact, but using these as stabilizing, biologic stabilizing factors, so this is a approach. It's a hyperflexion approach. Donald Bay has written about it, and it's basically just making a line in between the radial aspect of the ulnar border, and then the lateral epicondyle, and then going equidistant between those two, and then going through the ankineus and separating the muscle, and approaching it that way, and this works well for some of the most, the more posteriorly-based lesions, where you can get them into hyperflexion and do this, and this is a video of how we perform this in this baseball player, so we did the arthroscopy first, assessed the lesion, and then we approached by going through the fascia, and then after appropriate hemostasis, separating muscle, and slowly, sequentially just getting down to the lesion. Galpi usually works pretty well in this area. Your risk of neurovascular injury is fairly low with this approach, as opposed to a COCR, in which you can, if you go a little too distal, or if you're not pronated, you can run into the posterior interosseous, and so this is getting down the lesion, and that's actually the lesion, so if you palpate it, it will definitely trampoline and bounce around, but that's the approach, and then we used two osteoarticular allograft transplants here, fairly sizable, but we went one anterior to the other through the lesion, and before we put those in, I do not, this is anecdotal, but I irrigate the graft initially, and then I just let it sit in the patient's own PRP prior to implanting, and then this is the second graft that we placed, ultimately becoming flush. Post-operatively, we get them moving pretty quickly. We put them into a soft dressing, get them into physical therapy, start motion, I don't get radiographs for at least three months post-op, and return to light activities about six months, and weight-bearing torsional throwing activities at about nine to 12 months, so this has been a good technique, and very happy with how we can approach some of these lesions. The more posteriorly-based lesions, you'll see in the gymnasts, more so than the baseball players. I think this is a great opportunity for us to approach that, so thank you for your time. Thank you. Thanks, Paul. Our next video spotlight will be from Dr. Stephanie Meyer at the University of Colorado. She cannot be here in person, but she has narrated her video, so we'll start that in a moment. Good morning, everyone. I'm Stephanie Meyer from the University of Colorado, and we'll be talking about fixation of femoral condyle OCDs that are unstable. Those are my disclosures that can also be found in the program. Surgery is indicated for OCDs when they're unstable at initial presentation, or if they progress to being an unstable lesion despite your non-operative treatment. Fixation is indicated for unstable lesions with salvageable cartilage, and oftentimes I will combine it with transarticular drilling. Two of the main principles to remember during this procedure are to be sure that the screws obviously are countersunk below the articular cartilage surface, and to be prepared for multiple unconventional, sometimes C-arm use. For preoperative planning, the location of the lesion is very important to determine your portal location that you're expecting, the angle of knee flexion that you'll need to access the lesion, and then the planned trajectory of your screws. The size of the lesion will help you determine the size and number of screws that you will plan for, and overall, roughly the length of the screw that you'll need. I prefer metal screws over bioabsorbable screws, so the techniques I'll show you today will be cannulated headless compression screws. You can use mini-frag screws or headless compression screws, typically about a two to three millimeter size. I think the advantages of metal screws, in my opinion, are that they're a little bit sturdier during insertion, and then during the rehab process. Disadvantages, the need for removal around three months, plus or minus, but I would really overall consider this an advantage because you do get to see in person the healing of the lesion. As far as the operative technique goes, it's very important to have a stable limb, so I'll typically use a lateral post as well as a foot stop, and making sure that the assistant knows how to position the limb to be very stable. The K-wires we use for this procedure are pretty small and can definitely bend and break if you have any movement of the knee after they're in. Making sure that the foot stop is positioned so that the knee flexion is appropriate for accessing the OCD. I'll typically start with normal medial and lateral portals, but I almost always will include an accessory medial portal for a probe or a hemostat, both for visualization to kind of pull the fat pad back sometimes, and also sometimes to stabilize the K-wire or to help with screw removal during that stage of the case. As far as the K-wire insertion as the first step, it's really important to be perpendicular to the articular surface and also perpendicular to the lesion itself. Again, a probe can be helpful to pull the fat pad back out of the way through the accessory medial portal if you've made that. As you can see here, sometimes the fat pad will get sort of drug in with that K-wire. And then again, very important to keep position of the knee after that, so anyone you have in the room just needs to understand that they can't move the knee around trying to help when they might be bending the K-wire. After the K-wire insertion, you're gonna wanna check on fluoroscopic imaging to check both the trajectory and the depth. The lateral view is the easiest to get. Getting an AP view can be challenging because you have the knee flex at a certain angle. So using the Mini-CR, you can be creative with getting that AP view, but you're gonna be relying a lot on the lateral view during this portion. At this point, you'll use a depth gauge to measure your screw length. And then based on what your K-wire looks like on fluoroscopy, you might be going shorter or a little bit longer than what you need. I find that having the K-wire buried in a few millimeters past what you think your screw length is gonna be and your drill length is gonna be can help it stay inside the bone when you're removing those instruments. As far as drilling goes, this is in cumulative fashion over the K-wire. So being sure you're not drilling over the K-wire. So being sure you're very colinear with your K-wire is very important during this portion of the case. The K-wire definitely can back out as you remove the drill. And so either having an instrument through the accessory portal to try to grab it before it comes all the way out of the joint or just to be ready to reinsert a K-wire through that portal can be helpful. As far as screw insertion goes, again, being colinear with the K-wire and just to try to ensure that the driver stays engaged with the screw throughout the process. Some of these are titanium screws and are somewhat easy to strip as you're inserting the screw. And as I said, inserting the screw until it's very below the articular cartilage is very important. So checking that on your visualization both arthroscopically and then on your fluoroscopy as in the next slide will be very important. When you get your fluoroscopic imaging, making sure that the trajectory and the depth of the screw is appropriate for both the lesion and the epiphysis. Typically the head of the screw will be right at the interface between the cartilage and the bone, sometimes even a little bit past that. And so as long as you're visually looking at it with your arthroscope and making sure that it's appropriate within the joint and having a view that you're gonna then take in clinic to compare to, you can at least know what to expect. I also think we employ transarticular drilling between the screws with a 4-5K wire. This technique has been shown to be very effective in healing stable OCD lesions and so perforating the lesion into the healthy bone in the epiphysis I think can only help with reestablishing blood supply to the OCD lesion now that it's stabilized and fixated. And hopefully this is what you see when you go back in for your second look arthroscopy for the removal of the hardware. A healthy cartilage surface, no step off. You can see the screws, they're still buried beneath the cartilage. When you do remove the hardware, you'll place a K-wire back through the screw. Sometimes utilizing fluoroscopy for this can be helpful if there's been a little bit of cartilage that's grown over the edge of the screw and then ensuring again that the screwdriver is very collinear with the K-wire so that you don't strip the screw as you're trying to remove it. As I said before, I think the accessory medial portal to place either a hemostat or another similar instrument to stabilize the screw with some back pressure against the screwdriver can be helpful. As the screw starts to come out and have less contact with the bone, there's not a lot to help it be pulled back towards the driver. You can also use a hemostat or another instrument once the screw is out of the bone and cartilage to just go back into that same portal and slide it along the K-wire to remove it. And hopefully your final imaging looks like this with a healed lesion. I do think that removing the screws probably provides another rush of blood supply into the lesion and helps to heal both the lesion and the cartilage surface. So again, I think that's another advantage rather than disadvantage personally. So thank you very much for your attention today and hope everyone has a great meeting. Great, and our last speaker, Dr. Kendall Bradley from Duke presenting on suture fixation of patellar OCDs. All right, thank you very much. So I'll be presenting on patellar OCD fixation with suture bridge fixation. All right, I have nothing to disclose. So I'm gonna start with a case presentation. Patellar OCDs are relatively uncommon, less than 2% of OCD lesions. But this is a 12-year-old female presented with several weeks of left knee pain and swelling. No specific knee injury, no mechanical symptoms, but had recurrent knee effusions. Her dad was a PA in our practice. And she was lacking about five degrees of hyperextension. So you can see here on her imaging this OCD lesion of her patella. An MRI was obtained here. You can see a OCD of the lateral patellar facet measuring about 13 by 10 millimeters and a moderate joint effusion. Otherwise, her TTG was 16. She did exhibit some amount of trochlear dysplasia. In terms of AOS consensus guidelines, a lot of variety here in terms of how to fix these and as we've kind of already stated earlier. So we did proceed to surgery. First performed a knee arthroscopy to make sure that this was something that we were gonna be able to salvage a little bit better. When I do these for MPFL, for osteochondral fractures in the setting of patellar instability, I do go ahead before I make an arthrotomy of going ahead and dissecting out my layers two and three, passing a stay suture there for easier passage of the MPFL at the end of the case. But in this case, we opened and this was her lesion. She still did have some relatively good cartilage overlying it. So we started by removing all the fibrous tissue from the bed and then we used proximal tibial bone graft harvested from the patient to place that. Then I used, in this case, I used three 4-5K wires to hold my reduction and create a pathway for Keith needles that I used afterwards. I used a Keith needle with a nitinol loop at the end. I used to go ahead and just place the number one vicrols directly through this but found that I had some breakage of the nitinol wire and so I used a 2-0 vicrol to help me pass these much larger number one vicrols. Depending on the lesion, you can do this three or four in order to create this configuration. So I'm passing both the two limbs to create that suture bridge fixation and then just tying this directly over the patella after dissecting off the soft tissue. And here you can see the final configuration here. That number one vicrol, tying that down and then occasionally, depending on the lesion, using some fiber and glue at the edges. Post-operatively, here were her radiographs showing good fill of that OCD lesion on the lateral view especially. For rehabilitation, I do keep these patients locked out on extension for ambulation but getting them going early in range of motion. The next week, I do use radiographic follow-up for fixation of lesions and considering MRI for OCD lesions if I have any concerns about healing. When you look at some of the literature, Phil Wilson, Henry Ellis had a nice paper that looked at, for osteocardial lesions, almost 90% union and return to sport around six and a half months. And for OCDs, 65% with full union and 35% with a stable union. I'd like to thank Ted Ganley, Henry Ellis, Phil Wilson who let me visit them after my fellowship in order to learn some of these techniques. Some nice papers on the topic here. And my take home was that strubridge fixation is an easy way to fix osteochondral lesions, both OCDs and fractures for the patella. Thank you very much. All right, so I'd just like to open it up for questions globally if anyone has any. No, I'm just kidding. It's all right, you don't have to call on me. Jay Albright from Denver. It's kind of for the whole panel, I think. So Dr. Myers, very nice video. One thing, that lesion was very nice and flush. What does a panel do when it's not flush and you're gonna fix the lesion? Just as a technique thing. Do you guys use similar technique? How many people do something different than what you saw there? So I think for me it depends a little bit on kind of the nature of the biology behind it. So I had one recently that was a large bony progeny fragment that really just needed compression. There wasn't much fluid signal behind it. And so I did not open the cartilage surface, it was intact. And so I just compressed through it. But I think the majority of these, you have to change the biology behind it. So I think many of us, if there's a wrinkle or a sign of instability, kind of elevating that through an open approach, debriding back behind it, bone grafting it, really bringing biology to that area and then repairing it is my typical approach. Yeah, I completely agree. I think using the rock classification, if it's a cue ball or a shadow, then maybe drilling an in situ fixation. I think the ones that are locked doors, I usually make them trap doors because most of the time those have that poor biology, as Crystal just said. There's the avascular zone or the Oreo cookie sign that shows that there's nothing there. And so open it up, aggressive debridement. I think if there's significant bone in the progeny, I think screws are a good option. I think when there's less bone in the progeny, we favored suture bridge a lot. But yeah, difficult lesions. Paul or Kendall? Yeah, I agree with all of that. And then I also think about the biology of the lesion itself and the chronicity that it has because the more chronic lesions will tend to overgrow. And then you're fitting a square piece into a round hole. And so at some point, you might consider that a replacement is better than trying to put this primary fragment back down. And so just ensure that there's not been, I think this is one of the historical questions you have to figure out ahead of time. If they've had four years of this and this has been most of their young life, then it's less likely you're gonna be trying to repair and much more likely you're gonna be replacing. So I think all these factors play in. My next question, unless somebody else has a question. I have a follow-up question. Go ahead. So when you're opening these, is anyone autograft versus allograft for bone grafting the base of the donor? My preference is distal femoral autograft. I think bringing the biology to the area is an important component. It's easy to access through a trap door through your same incision. Yeah, exactly the same. Either distal femoral proximal tibia in the same incision, same field. The other thing that I think that we've found anecdotally over time is being more aggressive with the parent bed. I think that sclerotic margin that we see on MRI and then we see in the OR can be much deeper than we realize. And so I think very aggressive debridement to a depth that may be at times a little bit frustrating that you feel like you're going so deep that it requires quite a bit of graft. So I think we've been more successful with that. So another question actually is switching to the elbow OCD. So I love OC allograft. First of all, that's what I use all the time because I don't like, as a knee surgeon too, I don't like violating the knee to do something to the elbow. But maybe have everybody comment on, we're using knee allograft cartilage, not lateral capillary cartilage. And so the radius of curvature of that is not quite the same. Anybody want to comment on sort of what's the next steps of how do we get actual capillary cartilage and osteochondral allograft so we can fit the radius of curvature for our kids? Yes, great question, Jay. I think in the one clinical case and then in the lab as well, trying to use a capillary donor, the subchondral bone is just not the same structural quality as the femoral condyle. And I think with an allograft and that difference in the cancellous interstices and the structural, I worry a little bit about that as a graft source, even though the radius of curvature is better. You know, going to that very central, far posterior lateral femoral condyle, if the grafts are eight and then sometimes 10, depending on the individual recipient, the radius of curvature is really close. With 12s, it's not gonna fit and many 10s don't. So I think it is a challenge. I'll tell you, sometimes we'll get a best fit in two or three quadrants and there may be one margin that's within a millimeter and I'll sharply debride that margin so that the, I think a sharp time zero chondroplasty to avoid point loading and transitional loading is better than intact allograft cartilage. And so I've really gone to trying to you know, kind of contour the edge just a little bit to avoid that point loading. But yeah, I think we just need more information about, and then of course you know the donor, availability of upper extremity allografts is very difficult, so. But I think some of those technical challenges may still be just as important as the availability, but that's in my opinion. Yeah, I think the other thing, I think most of our 10s and 12s, we in Atlanta have used pre-cut cores, get a pretty reasonable match of radius of curvature. I think if you're gonna go larger than that, we've been a little happier with using two plugs in a snowman type configuration to get a better radius of curvature as opposed to trying to take a larger single plug. Dr. Staliwan? Yeah, I agree with everything that's been said, once again, I don't think the radius of curvature is as much of a concern for those reasons that you just pointed out. We've never run into that. We did look at, and we published on this, I'd say probably about 12, 13 years ago in regard to which locations on the knee are best to harvest the appropriate thickness. I think if I recall correctly, we settled on posterior aspect lateral femoral condyle, or yeah, the lateral femoral condyle as the best spot. So I think you've got options. To Cliff's earlier question about when to use autograft versus allograft, we have stuck with, if I'm gonna use anything larger than a six to eight millimeter autograft, and if I'm just using, if I'm using one plug and it's six to eight, I'll do that as an autograft. If I have to use more than that, or a larger plug, I'm not going to the knee, I'm going to an allograft, because I do think it causes some donor site morbidity. What about for OCDs that you're salvaging with debridement and refixation? Dr. Bradley, do you use allograft to bone graft, the intervening space, or autograft? The question is, repeat that with the? If you have a lateral femoral condyle OCD that's a trap door that you open, debride the base, and then you're, what do you refill the debrided area with? Right, I typically just go to Gertie's Tubercle and just use some bone from there, just some cancellous bone. Make sure you curatage the base out pretty significantly, because even though it might not appear that sclerotic on an MRI, it's still the best practice to curatage that. And then I even take a fine wire, a fine smooth K wire, and drill at the base of that as well. So we really go the full effort to create a biologic environment that'll allow that healing to occur, because you only got one shot at this. And if it's an extra large lesion, I get worried about trying to repair those with metallic fixation or absorbable fixation. I'm more inclined to bail out to a biologic fixation of that. Once again, a lot of this is anecdotal, right? That's why we've got our group working on this together to try and figure this all out. Dr. Bradley? Yeah, I do the exact same thing. I like autograft, it's right there, and then I feel like from a biology standpoint, this gives me the best chance at healing those lesions. And same thing, I curate that out and use a K wire to poke some holes at the base of that bed, just to try to bring as much blood to that area to help aid in healing. Great, and then a follow-up for you, Dr. Bradley. I'm a huge proponent of suture-based fixation for OCDs, because these are typically thin fragments and it's hard to get compression and fixation with screws in many cases. When are you using absorbable or non-absorbable suture? Yeah, I think that's something that's kind of evolving for me early in practice. I love absorbable fixation just from the standpoint you don't have to go back. But I think especially for our older kids and adults, so you have these lesions, I worry about those absorbing too quickly. So I think it's great for fracture, I think it's great for the younger kid, and I'm still trying to decide when I need to switch more to a permanent suture. I think we need further investigation as to when that's appropriate, and then you probably need to go back and potentially cut those sutures, so it's gonna be a second look as well. We have a few immoderate questions and they're actually directed to me, so I'm gonna go and answer them. The, they both were related to the unsalvageable data set, and so I'm just gonna kind of answer it globally, and I hope that I answer y'all's question. When you, one of the biggest challenges when you look at a big multicenter database is you just don't always know why people make a decision. It's not like your own decision for unsalvageable. So number one, I would say that the series that I presented was at the index procedure. So about 44 cases were previous surgeries, and I excluded those. So of those that we studied, it was at their index surgery, not their second surgery. So they underwent unsalvageable techniques first time they went to surgery. So, which is really important because that's what I was trying to learn from the data is when I look at an OCD, I need to know, is this worth fixing and saving, or is it not? And so this data set should be able to help us understand that, and this is just a preliminary look at it. The second question was about the high rate of microfracture, and I'll tell you, I was a bit surprised by that, and it's another part of a large data set, multiple institutions, multiple surgeons doing microfractures. You know, it has always been my belief that an OCD by nature is a bone problem. It's not a cartilage problem, and microfracture is commonly treated for a chondral problem. And so, although there are some continued indications for a microfracture, in this series, the ones that underwent microfracture were thinner, and they were smaller. And so I don't always know why that, but I would also express some caution on perceiving that microfracture is a solution for OCD, unless perhaps it's a small, shallow lesion in which you may be able to mimic that subchondral bone. But again, your subchondral bone is usually diseased tissue, so I would continue to express caution, and I can't really comment on why the surgeons chose to do that. Dr. Salih, one follow-up comment? Yeah, in support of that statement, I think there's a big difference. Sorry, I'm losing my voice here. I think there's a big difference between a microfracture of an elbow, a capitellar OCD, versus an EOCD. I don't think the capitellar OCDs do as well with microfracture of that area, especially if it's a more lateral-based lesion. I do think the forces then actually accelerate deterioration, even if you do the mildest of microfracture techniques. I still think if you don't have that lateral pillar intact, then you can create more problems than good. So I think be very judicious with that approach. I agree with Henry's assessment in that way, and I've pretty much abandoned microfracture in a lot of different aspects of what we're doing. It's interesting, I was just talking about the OCD of the tailless now, and that's the next frontier, right? Because a lot of people are, because it's just such a pain to do the osteotomy, get in and get access, and so a lot of people do debridement and microfracture of that area. So I think we have an opportunity in that realm as well with, I guess, more minimally incisional approaches to these lesions and better approaches on how to try and reconstruct. I ramble on, though, so this is good stuff. So one more, for the treatment of capitellar OCDs with transplants, I think one of the challenges is if you're using allografts, working with your graft non-profit source to make sure that those plugs are harvested perpendicular to the articular surface, and I suspect that may be what helped your transition to using lateral femoral condyle allografts. When you're ordering lateral femoral condyle allografts, since you're not size matching for a knee graft, what are your tips on ordering it so that you're getting grafts quickly and you're not playing the waiting game that you might play in the knee? Yeah, I think the time that we have to wait on grafts is probably one of the bigger issues that we really haven't addressed with the allograft, but I think what we've done typically is we ask them for a small, non-size-matched graft in someone less than 25 years old, typically 20. But because the lateral femoral condyle is not nearly as commonly needed as medial and we're asking for the smallest grafts that they have, we've generally gotten grafts fairly quickly. I would say that when we compare that to the other things that we're looking for in the knee, our wait times have been generally much less. So that's just the way we've worked with our distributorship and ordered them is non-size-matched, small, young, and we've been fairly successful. Great. Any other questions? Thank you to all the speakers and thank you to the audience for attending. Safe travels. Thank you.

S. Clifton Willimon, MD

Henry B. Ellis, MD

Crystal A. Perkins, MD

Philip L. Wilson, MD

Michael Klueh, MD

Paul M. Saluan, MD

Stephanie W. Mayer, MD

Kendall Bradley, MD

Osteochondritis Dissecans

OCD management

elbow joints

knee joints

osteochondral allograft transplantation

capitellar OCD

femoral condyle

surgical techniques

mechanical axis deviation

radiographic workup