So, for the panel, the case is a 21-year-old male D1 American football player, non-contact injury while running during a game, fell into a divot on the field, twisted, fell to pop, unable to walk, weight bare, reported pain and instability, unable to ambulate. Symptoms included some knee locking and mechanical symptoms soon after injury. And he was presented to me two weeks after injury. This guy was a defensive lineman, 6 foot 4, 330 pounds, BMI of 40, neutral alignment as measured on a long axis AP, hip, knee to ankle, minus 5 degrees extension, 120 degrees of flexion, 2 plus effusion, lateral joint line tenderness, and no overt patella findings. By my exam, I characterize it as a 2A Lachman, 2A anterior drawer, definitely an endpoint but increased excursion, along with a 2 plus pivot, no coronal plane or rotatory instability noted and normal neurovascular status, intact pulses, et cetera. So radiographs looked pretty good. Moved on to the MRI. And as you can see, some hint of an ACL injury, larger fusion. This osteochondral lesion on the anterior weight-bearing surface of the lateral femoral condyle, along with, on the slide mostly to the right, a radial split of the lateral meniscus. Just fat suppression images will just sort of show you guys the extent of the edema and lateral femoral condyle, as well as a loose piece kind of floating in the super patella space. So this is the case summing high-demand pivoting athlete, high BMI, possible ACL injury, radial split tear of the meniscus, acute lateral femoral condyle, articular cartilage. So who would like to apply? I'm going to start with you, Scott, just because you're the Giants guy. So if you would, for the audience, just kind of give us your gut feelings on approach and likelihood of a successful outcome. I would make every attempt, rather, to be pretty loud on this, because I've had a couple of people like this that are complete radial tear, right, it just cuts it in half. And in football, you know, the valgus loads, I would go to all extents to repair that. I've used often an inside-out approach, too, put sutures on femoral and tibial sides, a purse-string type of fashion. If that, on the contral side, I've used oats, you know, for a, if it's small, maybe you do nothing, you debride it. But if you really have a hole there, I'd rather use autograft tissue, but I would be aggressive trying to repair that meniscus. And that's hanging some crepe. That's tough on a big guy. Yeah. Come on. We'll keep coming down. Adam? No, that gives me hives looking at the scan, and it can be hard to repair, and the only other small addition is sometimes their lateral compartments can be very tight also, and it's technically difficult to repair, so I've done some outside-in also, but otherwise, exact same thoughts. You know, you both mentioned inside-out, which I don't disagree. Any thoughts about the extent of the procedure in this high-demand athlete with regard to adding an extra arthrotomy to the knee, infection risks, stiffness risks, things of that nature? Will that play into your decision-making? You know, honestly, not a lot. I mean, if I, you know, do an inside-out, I am doing a formal post-lateral exposure there. I'm not too worried about stiffness from that. Yeah, infection's always a risk, but I want to do a good job with that meniscus. And I would generally, frankly, use all-inside devices, but something like this, you want to get, one, with the all-inside device, it's a pretty big hole. You know, the nice inside-out, as you know, the nice small needles you can put on both femoral and tibial sides, I can do a better job sometimes to really, really get that secure. So I don't mind doing that. Christian? Yeah, so I would not be worried about doing an additional incision. The same thing, this is an inside-out or outside-in technique where you have an incision there anyway. Infection is really not my first concern here. My first concern is that I can get that lateral meniscus down. And to tell you the truth, sometimes you may even have to expose the actual lateral capsule from the outside to really get tissue to tie the meniscus down onto it, at least temporarily, because otherwise it can be extraordinarily hard to get these pieces to come together. I mean, you need ripstop sutures in there, you need to pull them together, and you have a guy with a BMI of 40 that eventually is going to walk on this. So, I mean, you know, belt suspenders and the kitchen sink. Yeah, I mean, that's a get-off-topic. My own personal, I'm primarily an NBA guy, and my gut is that meniscus repair doesn't work in these athletes. So that's how I was thinking when I was going through this. I don't disagree with anything anybody said, but that's like my gut. I'm certainly worried about it, but it wasn't like top of mind as the thing. So, Sabrina, comments? I mean, I think we need to talk a little bit more about his ACL, because I think the chances of this meniscal repair working, I agree with you, in a patient, any high-level athlete and any patient with a BMI of 40 is probably less than 20 percent. I'm going to bring it back. Great point. What do you think of that image, that ACL image? I mean, he has kissing lesions. So, I mean, the ACL doesn't look that bad, but he must have translated. Yeah. This was a known, you know, Division I college. I don't think they sent the patient to me because they thought it was an ACL problem. They were focusing on the cartilage problem, and I focused immediately on the ACL as a potential issue, only thinking that this type of injury and injury mechanism, there was clearly some increased rotational force in that compartment. There had to be some abnormal translation to get all that injury, and we'll see from surgery. David? Yeah. I would be, based on the imaging, I'd definitely be concerned, based on your exam, that there is an ACL injury as well. But I would agree. I think the most predictive for this person doing poorly down the road is going to be that meniscus. And so, even though you might be a pessimist, I'd be an optimist in trying to repair this to give them the best chance for that knee in the long run. And there's techniques that you can do to help reduce that meniscus. There's lots of great suture passing devices that you can use as a traction suture to help reduce it so that you can then place your ripstop sutures in the appropriate orientation. Great. Great. All right. So, what was done? So, EUA, diagnostic arthroscopy, I did an ACL with a patellar tendon autograph. I did a arthroscopic lateral meniscus repair, but I wasn't quite sure if I was going to do that versus a menisectomy, just basing on tissue quality. And then I did an autograph to the condyle. So, I apologize. I probably put like four sutures, Scott. I had this just as one, like I did a crisscross across the top. I was actually kind of happy with the way it came together. And we'll see some post-MRIs. This is what the ACL looked like, what I would call your attention to. This robust ACL is pretty much just scarred down to the PCL. There's an empty wall sign there. So, I felt confident in my decision-making with regards to thinking we were going to have to do the ACL. So, patellar tendon autograph, which I think most of us would agree is a standard of care in this type of an athlete. But this is where things started going sideways. Now, I always know, just based on my historical experience, that these things are bigger. I was not expecting this. This was a 35-millimeter top-to-bottom, call it 20-across. And I had planned to do an autograph. So, I was really like perplexed, a little worried, and basically felt like ACL, I was good. A little meniscus I felt was adequate. I really was at a loss. So, panel, at this stage in the surgery, are you going to persist with an autograph? Do you pivot? If so, what do you pivot to? And do you stage it? Do you close it up, come back later? Just thoughts. We'll start down here this time, David. Yeah. So, this is all about pre-op discussion. I think, obviously, it looked like a small defect. And I would have gone in with the OATS plan. And I think if I had not had that, any other discussion, I would clean, debride, talk about the injury, and come back at another day. Perfectly reasonable. Sabrina? Well, absolutely, I agree. And it would be great if I just had an OCA sitting in the refrigerator. But typically, that's not the case. But certainly, I'd need to go back. I don't think there's anything I would do at the time of surgery besides debride it. Christian? Yeah. So, I think one thing that is a little bit of a giveaway, if you look back on that MRI, right, in the moment where you see a true step-off in the subchondral bone, in my experience, you can't cover that with an autograph, typically. They are always larger than you think. And I've had, in my career early on, when I started doing cartilage, I had a couple of cases that were basically catastrophic failures, right, because I completely didn't recognize that. And I think when you see that, you have to basically, your alarm go off, and then you have to have that discussion that Dave said. You need to talk to your patient up front and say, listen, if that's the case, we may have to come back and do that in a second step. First things first, ACL and meniscus, but you may have to address that articular cartilage lesion secondarily. If you're lucky and it's small enough, an autograph's a great idea, and you can always do it. But you've got to be prepared if you see this step-off. You see that on the sagittal better, and, you know, where really you see that indentation. Because what that means is basically it went in there and then basically ripped the rest off. And that, in the MRI, it can layer itself back down and looks normal, but it often is not. Yeah, I haven't done it, but it might be one of the only times I would have seen if two or three plugs of autographs could have filled it, you know, 80 percent and maybe do that. But it looks like it's probably too big for that. So, to a degree, I probably would just debride it, did everything else that you already accomplished, and then potentially stage it. I would think you'd have to stage it at that size is the concern. If you wait to see if he's going to do well, it's going to take so long to figure that out that now you're truly putting him through two recoveries. So, I think the timing part is obviously the hardest aspect. Scott? Well, I learned something from Christian. Christian made a good point. You know, because look at that middle view of that sagittal. I kind of look at that and go, that's a typical kind of lateral knot sign you see. You know, whereas in an HSSMR, I'm surprised to see that cartilage be that big. It's interesting. I kind of wouldn't have made as much of that, and obviously I should have. Yeah, it's tough. I would probably ‑‑ I'm thinking here, is there anything I can do off the shelf? You know, whether you want bio cartilage or cartomax if you had it there. I don't know if I'd do that. It's a thought for you. It's something you can't use allograft. You haven't consented in many ways. You don't have it. I might just debride it and see how he does. And a 21‑year‑old kid, frankly, sometimes you're surprised how well they kind of do, quite honestly. I mean, in the old days in the NFL, that's all the guys did, and they kind of got away with it. It's not great long term, admittedly. Might just clean the thing out and see how he does. You know, you may have to do something later. If you're going to go back, you're going to go back early. I don't like the idea of doing two operations right away on this kid, so that's tough, though. Yeah, there's clearly some reactive trauma to the bone that would suggest it would be a healing phenomenon. I agree. And some of the recommendations in and around ACL surgery would suggest that maybe you should wait and not treat these. That's unusual. It's like a fracture. That's just not a typical bone. Yeah, and again, remember, in the context of, you know, just to kind of keep it, you know, 100 percent above board, this kid was sent to me for a cartilage problem, and then, you know, I'm thinking I'm going to go and talk, and I get the MRI, do his exam, and I realize, okay, I need to understand what the mechanism of this is. And I think it was a translational injury, just a massive impaction fracture in this big man. Right. So there's some interesting work out of Germany. Andreas Emhoff published on that almost a decade ago where, you know, they don't have access to allograft tissue, and he will actually take the very posterior corner of the lateral condyle, and that you can get up to almost close to that size. That would be an autograft, but I think you have to have, you know, very big cojones to do that acutely. Well, I've been informed we're out of time, so I'll just tell you guys what I did. I did an autograft. I did five sixes, spaced them around, and then I did what I do all the time, which is to use the micronized dehydrated cartilage bio cartilage mixed with some bone marrow aspirate concentrate to fill in around the sides, and then top that off with fibrin groove. This is an illustrative case. Scott knows this case. He's a kicker for the Giants who had a lateral femoral condyle lesion, put in the two. These are two 10 millimeter plugs filled in with the bio cartilage around it, fibrin glued, and it was able to extend my autograft indication using that methodology, and I always MRI subsequently. The patient did well, and I'll skip right to the post-op MRIs. You can see here the ACL looking great at around nine months post-op, and then, you know, great feeling healing, quite frankly. My meniscus repair probably didn't work out all that well, but he got good autograft healing in the condyle with a massive decrease in subchondral bone edema, and he was able to play, and then he signed with the Denver Broncos this past rotation. Where'd you take them from, Riley? Your harvest site's notch and trochlea? Yeah, so he's big, so big notch. So I was able to take them all from the notch, which I was very happy about, and I was able to backfill with lesional bone. Six millimeters? Five six millimeter grafts. Six millimeter grafts, yeah, pretty much spaced out. You know, and for those of you who know me, like, I had this big phase of my career where I was doing osteochondral allografts in a lot of people, and, you know, nothing ruins a good surgery with follow-up. My intermediate follow-up of athletes is middling, you know, with a lot of reoperations. You know, I want to say about 40, 50 percent reoperation rate, so I pivoted probably about five or six years ago really trying to aggressively in these high-demand athletes to do, you know, autograft-based repairs whenever I can. Great. I think we'll finish there. Thanks for coming. Thank you.

non-contact knee injury

ACL injury

meniscus tear

osteochondral lesion

ACL reconstruction