So just briefly, John, again, outstanding talk. You made really insightful comments that you're leaning toward oats for large lateral and open FICEs. So we think a lot about younger patients getting less invasive treatments, but your comment and also there's some really good work as yet unpublished out of AJSM was recently out of Asia that is coming out soon. So can you comment on why you theorize those patients with open FICEs don't do as well and need some more? So over my 30 years of managing osteochondritis in kids, I've seen a lot of kids with really complex lateral column dysplasia from having had debridement procedures or really any number of described procedures out there that didn't include trying to restore that lateral column. And the radial head will move proximally, become angulated, dysplastic, you get what's called biconcave dysplasia, they lose form supination pronation. And sometimes when they get to me, they really don't have much left to work with and it becomes a salvage procedure in a 13-year-old. And so my thought is if the growth plate's still open and I have something I can repair, I'll still repair those. And I've used every method out there except the only thing I have never done is the osteotomies. And I do think that if there's any bone at all behind the fragment, then it's worth fixing. The stuff he was just showing, I really have not had much confidence that I could make a piece of cartilage stick back down onto the bone, particularly when I'm having a graft beneath it. But we know we've always been treating the knee differently than we've been treating the elbow. And I'd love to see us come up with a better solution for that. But I do think that left to itself, if you let that go bad, you don't have a good bailout. Once that has become dysplastic, what do you do? So what is your thought on that? I completely agree. I think that's a fantastic insight. Rachel, Neil, and others beforehand had 30 years of insight in all of our discussions yesterday. I'm completely on board with that. There's really nice work coming out on that topic. And I think that's just a unique patient population that can use a little more, especially as a gymnast. Yeah. John, would you stage a UCO reconstruction and a pallet graft, or would you see them together? If I see them together, if I see them together, I've done them at the same time. In fact, my slide half there, I don't know if I kept it in this talk, I had, we had the baseball players, I had two that wanted to have a repair and wanted reconstruction in the most recent study. The rehab principles are pretty similar. Dr. Bradley. Yeah. John, you mentioned bone graft, I mean, in my experience, the ones I've been on, I don't get it, I don't need it, I don't have any problems with bone graft. Wait. Then, tell me about why you just don't need the bone screening. Yeah. So, many of the OCDs that we'll treat will not have a thickness of bone that you can necessarily make it flush with the sort of most superficial aspect of the subchondral bone. So, some of these end up, you know, half millimeter, millimeter before, or superficial to the subchondral bone. And at some point, the feeling is that they, you know, benefit from being removed. So, many can be removed if you place them deep to the surface of the subchondral bone, but you have to have a pretty favorable lesion with, you know, three to four millimeters minimum of bone on the fragment. So, if you have three or four millimeters, you're going to use a metal screw? I think that's a good option, yeah. And you're going to weaken it? I think the jury's out on what the implications of the joint over 30, 40 years are for an adolescent with a screw one millimeter into the subchondral bone surface. There's been research in other areas of pediatrics suggesting that subchondral implants may change the contact forces sooner than we'd like, but Jim Carey suggested that he leaves a lot in and people do okay, and I think if I can bury it, I'll leave it in. I'm not necessarily trying to take it out. There's just many that, you know, it's a game of millimeters, and I'm just putting it in enough, and even with 15 x-rays in the OR, I then discover in the clinic it's out by a millimeter, and I also find that it's a little bit of a dance with assessing healing, which is to say that the screws, it's very, if they start backing out, that happens just by millimeters, and so if you miss that and they start a contracoup, you know, issue on the tibial cartilage, you've got a big problem. So sometimes it's hard to assess those, and the MRI capacity of a bioabsorbable implant is a benefit there, but I hear you. They could probably be left in in the right cases. So we've crossed into bonus time, but this is, we're willing to stay. We always finish on time, but our panel is willing to add our extra time, so if you're energetic, we want you to know that we'll stay and answer additional questions, but our time is completed, but this is now bonus time. We have Dr. Bradley. We have Dr. Malewski. So if you'd like to stay, you're more than welcome to. I know, so, you didn't listen to me. No, so when I first started harvesting grass, so I actually, in the 90s, I, when oats stuff came out, I went over to the medical school and I harvested tons of stuff from one, from the knee and put them in the elbow, and I thought it was a great idea, and I looked everywhere, and then some good papers came out, but I couldn't convince insurance companies and private practice to let me use it until the late 2000s, and once I started doing it, I was just, I didn't want to have morbidity, and there were two papers in the, in the world out there on adults that had 29% morbidity harvesting cartilage from the trochlea, and so I said, well, I was going to do everything I could to prevent that, and where do I get, how can I, what was available at the time when I started really was there on bone, but the best place for me to get it was either the femur or the tibia, and the tibia seemed to me to be the easiest, so I made a perfectly round hole, and then I sewed the little cortex back in there, connecting it to the periosteum, so basically, I just have a little circle of bone around a plug that's got to heal back in, and it's, it heals very rapidly, and because I'm harvesting it in that non-weight-bearing zone, on the medial, in the lower part of the medial trochlea, I let them bear weight on it right away, we tell the therapists to have them run ready by three months, and I feel that because I filled that hole in, and I pack it in with, and I use a big six millimeter curette, number six curette, so I get a solid piece of cancellous bone that I pack in there so it's not going to float out of there, and I pack it back in there with the sizers that come with the OAT system, and then, and when I, when you, and I have him ride a couple of these kids, all I'm really waiting to heal, I pack it right down to the subchondral plate, all I'm waiting for is a new subchondral plate and cartilage, and I feel like I'm not as worried about letting them be up and pounding around on this, because I expect that cancellous bone to heal in very rapidly in these kids, and so I feel better about moving them, so I have them start running by three months, and they're all running without problems by four and a half to six months, and I'd have, I have zero morbidity associated, I mean, yes, I've had some effusion, some hemarthrosis, but other than that, I've had zero morbidity associated with harvesting one or several plugs from the medial trochlea, and because it's worked for me, I haven't quit. Maybe I don't need to. You're right, Tim, but that's what I do. So we can keep going. You'll get an A-plus for enthusiasm. We've got, we've only lost three so far. We've got royalty here, and we've got Dr. Mike Saccotti, AOSSM president as well. We'll start with Matt, and then we'll go to the next question to the left. No, it was a great discussion. Dr. Bradley asked my question about the bone grafting, but my second question was, return to play with your gymnasts. Could you kind of, Dr. Conway, walk us through, you mentioned running at three months. When do you let them, after an OATs, when do you let them get on bars, when do you let them go to full? So yeah, we actually have a whole protocol that runs this pattern. We don't, we don't, we don't miss a day in the gym. They can go to the gym the next day or the day after. We do everything we can to preserve their aerobic capacity right away. I'll let them get on a stationary bike with the seat really high, just as soon as they're comfortable turning. I'll let them start jumping on a trampoline, just jumping up and down, usually by six weeks. And I'll let them, once they can do pushups, handstands, when they can do planks, pushups, and handstands, and then go up against the wall, do what I call a press handstand, not what they think of as a press up handstand. I'll let them tumble on the tumble track, this is if it's their dominant arm, and that's something people talk about, what not we're talking about, and I didn't put it in my talk because I've got to talk for 20 minutes on it, but in gymnastics you need to know whether or not they're right or left handed tumblers, whether or not they pirouette right, whether or not their blind changes is right or left, what their vault entry is, because it all changes the, what you can let them do as they, as they start. You need to know what level they are, because you don't pirouette until you're an eight, so there are a whole lot of things you have to know about what they're trying to get back to do. But then, we'll let them, you know, I don't have a, they're run ready by three months, but I don't mind them running on a trampoline before then, so they, if they are, if they can do pushups, handstands, press up handstands, I'll let them start tumbling on the tumble track as early as 10 weeks. They have to be able to at least run reasonably well to be able to run on the rod floor, so the rod floor, spring floor, competition floor, they get less and less springy, but most of them are doing at least some tumbling skills on the floor by 14 weeks. From bar skills, we'll let them hang just as soon, we'll let them hang usually by somewhere between eight and 10 weeks, but they have to have their extension back. And so, it's a little bit different than we manage their, the dislocation instability because of managing ligament problems, but in this group, they can usually hang within eight weeks, and once they can do pull-ups, toe to bar, core work, stuff like that, then we'll let them start to do, and they can do their pushups, handstand, press up, then they can start to kip, and when they can kip, they can cast, and some of them can kip and cast much more quickly than they can do tap swings, because sometimes they're really jerky on their tap swings, and when they're jerking their arms apart, because we just fixed those, we had to go through, pass their lateral ligaments. Most of them can do a high percentage of their skills by four and a half months. We don't let them start, we'll let them start doing vault entries by four and a half months, but not vault. The first time we'll let them hit a vault table is five months. I'll tell you a little more detail about that. Yeah, yeah. So, for a sense of, for a quick balance, I'm going to go to Ben real quick. So, can you give us an efficient discussion of, as your group demonstrated the degree of clavicle remodeling with non-operative treatment in the younger patients, are there any clavicle fractures in the adolescents that should get primary surgery? Second question is, you've shown that patients up to 18 do well with non-operative treatment, the clavicle's still ossifying patients up to 25. How would you like us to think about patients 18 to 25? So, talk to us about that category. I think with the adolescents, mid-shafts, we're slowly looking at different subsets, including the older adolescent athletes, you know, we presented last year, and all with significant or completely displaced with significant shortening or comminution, and those were no difference between operative and non-operative. We've looked at the Z-fracture types, and those were no different between operative and non-operative. The sort of final two cohorts, we're going to look at the severely shortened, like 30 millimeters or greater, and see, as well as overhead throwing athletes, so like the throwers on the dominant side, that might be the last one to not show a difference, just because those people often want to get back to normal biomechanics, so severe shortening in a throwing athlete on their dominant side, I would consider fixation, but there's, so far from our research, there's just no subset or cohort that we've shown that does better with surgery yet, in terms of the 18 to 25. But we're going to say Z-fracture, and a thrower, and 30 millimeters, you're going to fix that, right? No. The Z-fractures showed no difference, so just because there's a Z-fracture, that does not mean that they do not have normal PROs. In a thrower, how short do they have to be until you fix them? Yeah, again, I think you might throw off their biomechanics on the short term. I think remodeling takes care of the long term. If the stakes are high, and a 17-year-old pitcher is getting looked at, in six weeks it can restore their biomechanics. I think that might be a one subset in whom I would do a clavicle fracture fixation. But one centimeter you're not doing, two centimeters you're not doing. I think, yeah, I think that would be a discussion. It would have to be severely shortened. But the 18 to 25-year-olds, I think that warrants additional prospective study with collaboration with OTA members, et cetera, because we certainly see those folks, but they see a lot of them as well, and those are all getting fixed. If our 15 to 18-year-old group is doing just as well with no surgery, it's worth a look. Thank you for waiting. I apologize. I'm bringing us back to cartilage for two questions. One, in terms of the capitellar, when I do a capitellar oats, I don't use any type of fixation, but I have used metal screws for a capitellar shear fracture, and I did notice some metal screws in your presentation. Do you take those out on a capitellum? Because I've left mine, but do I need to is, I guess, my question. So in the first 20 years of my career, I couldn't do oats, and so I had really big lesions. Sometimes I was forced to come up with a way to fix something, and on a gymnast, I would put screws in, and I hate putting screws in a capitellar OCD. I do use screws for capitellar shear fractures, and the truth is, we can't usually go get those because they're often pieced together, and there's really no access back to it. Yeah, I was just making sure that was okay. My second question then is, in terms of fixation, I didn't hear anybody talk about using any type of knotless anchor, so I see a ton of patellar instability where there's a little wafer of bone on that cartilage piece, and I've had the same problem with the little screw heads popping off on the bioabsorbable screws, and it's a little bit too superficial to use metal. So has anybody used knotless anchors or done kind of like a little cargo net to restore that cartilage, and what has been your experience with that? Yeah, so suture bridge techniques are certainly growing in popularity for cartilage fixation, osteochondral fractures, OCD. Phil has presented at PRISM and PASNA on his and Henry Ellis' series with really good results. I think Aaron Critch has some work on that, and so I think prospective comparative analyses are seeing, and then longer-term studies to see what the implications are of those large vicrols or potentially even some nonabsorbable that some people are using, the implications of that on the cartilage long-term are warranted before widespread use, but any comments, Phil? I think it's an option. I can show you a technique publication afterwards if you want to help us. I think it's a great technique, particularly for the thin pieces, the ones that may be a little bit comminuted. I think the benefits are it's excellent compression and pretty widespread compression as opposed to single-point fixation, and with almost all of, whether it be a pure chondral fracture or the osteochondral fractures, the vicrol in our series worked 90% of the time to get them healed for radiographic and MRI union, and the vicrol's not there very long, so I think the other benefit is if you do have a lesion, and we have used them in OCDs with some success, the imaging is much better than screws, as Ben was saying. It's a big challenge, and so I think there's a lot of things that we need to look at, certainly the effects, physical effects of the suture and the second surface and all of those things and how long the suture stays, all of those kind of things we need to look at quite a bit, but I think we've been optimistic so far. So thank you, everyone. We had outstanding studies, didactic, the cases, the questions. Thank you to our esteemed colleagues that have come to enjoy this session, and we will be standing here, Phil and I can answer any questions for anyone, any of our residents, they're heading into fellowship, we're happy to stay and chat, but thank you. This concludes our session. Have a great meeting.

orthopedics

oats

cartilage repair

osteochondritis

fixation techniques