10 minutes for some cases. So can we get the remainder of the panel to come up and join us? So we should have, I think it was Craig Bennett, Brett's up here, we've got Aaron, and then Sachin Tipazvi from India, Maria Tuka from Chile, and Riley Williamson, US. Okay, so first case. Give you guys a little bit of time to settle in. Okay, so we're gonna be cartilage lesions in the athlete, what works and what doesn't. Let's see how many cases we can get through in 10 minutes. There we go, so. All right, so this is a 27-year-old male. He's in the military. He does jiu-jitsu, rock climbing, soccer. He's a very fit, active young guy. And he has a fairly innocuous injury, three-month history of having an acute locking episode. So not a significant traumatic issue. And he now presents with this issue with recurrent locking and complains of pain and swelling. He's got a five-degree flexion contracture. He's got a grade two effusion, stable knee. Otherwise, exam's pretty normal, and he's otherwise fit and healthy. I'm not gonna labor through this. I'm sure it's pretty obvious in the radiographs what we can see. Here he's got a large osteochondral lesion, medial form of condyle, presumably osteochondritis dissecans. Weight-bearing alignment films are neutral alignment. I'm gonna come to Brett. Brett, if these were his radiographs, so there's a different patient, but he's constitutional varus, does that change what you would do potentially in this case? Yeah, it does. I think that trying to get a soft tissue solution in a malaligned leg is gonna be less successful than proper alignment. If you're gonna do any type of regrowth procedure, you're gonna have a period of non-weight-bearing anyway. So really, the downside, it's slightly bigger surgery, but the limitation to the patient is minimal in terms of return to function, and the chance of optimal return to function is much higher. So yeah, I'd do an osteotomy in combination with the procedure. All right, so for sure we're thinking about alignment. Well, not in this case. We're not gonna think about alignment because we're in neutral alignment. Okay, so Craig. So here's the MRI scan. I've just given you a few select cuts. Hopefully you can see fairly large lesion, medial form of condyle. Do you rely purely on MR, or would you get any other imaging modality to try and understand the health of that particular fragment? I don't think there's ever a downside to getting a CT scan, particularly given that I'm gonna do some bony work as well. So CT scan shows the lesion, shows the bone defect, a little erosion in the femoral condyle as well. Cool, so Riley, you've got, he's a symptomatic guy. You've got this imaging. What's your plan of treatment here? So I've gotta restore bone and cartilage surface. So for me, osteochondralograft is probably my preference. Given you've got bone and cartilage wear. Other option would be to bone graft the site and do a resurfacing procedure like a sandwich technique, but osteochondralograft would be my preference for this. So Riley, if this guy comes into your office, are you gonna jump straight in with an OCA, or would you scope first, remove the fragment, try and repair? Is there a rule for repair in this scenario? I mean, the older I get, the less aggressive I am with osteochondralograft because they do fail. What they do in this population is relieve pain and enable activity, which ultimately leads to graft demise if you're objective about your results. So I really like the idea of autograft. I'm getting a sense of this. It looks like it's about a 25 by 20, 25, something like that. I mean, fairly substantive. I've really leaned into the bone grafting, and you can cover that with a collagen patch or fiber and glue, what have you, and I MRI every single cartilage case I do, and this one I would MRI it at three months, and in general, you're gonna find some sort of cartilage reproved on top of it. I've never had to go back, but I would urge caution with the use of fresh osteochondralografts in athletic population at this stage. Great, so Maria, do you have access to fresh osteochondralograft in Chile? We have access, but it's pretty expensive, so just as Riley said, I would probably prefer a transfer, and emphasizing what Brett said, we have to remember that even in a neutrally aligned knee for medial form of condyle, we know that most of the load, 60% is going through that compartment, so we have a really low threshold for adding an osteotomy to take into several bubbles. Brett, if you're going into this knee, would you consent the patient for a potential repair? Yeah, I would, I'd have a look at it, but it's failed probably from a biological reason. It's not a trauma that's knocked it off as much as it's most likely an unhealthy piece of bone, so the chance of that being successful, I think, is relatively low, Al. The other thing, the MACI technique, some of the best results were with these OCD lesions, surprisingly, so the bone graft in a MACI type on top, I think, is more suitable. It is a two-stage operation, though. That's the downside there, so for me, these things are always a balance between access to it, like osteochondral allografts and stuff we don't have much access to, and cost, what's covered by the insurer for the patient, and then, obviously, the best possible option biologically. Yeah, cool, so for me, it's a bit challenging to always go straight in with an OCA, so I actually did a staging scope, removed the fragments, debridement. He was still asymptomatic, and so this is his open procedure now, so significant lesion, and I think we've covered many, many of the options available to us in terms of whether or not we're bone grafting or not. I actually ended up doing an osteochondral allograft, and so far, so good, but I think it's very important to take Riley's point that these things do have a potential failure rate, so it's a bit of a concern. So I'm gonna come to Aaron. So this is a slightly different scenario, but similar sort of problem, 16-year-old male. He presents following playing basketball, complains of pain and swelling, occasional locking, no instability, again, low-grade effusion, full range of motion. He's got a stable knee, and he presents with these radiographs. He's got a large osteochondrosis, lateral thermal condyle, and he's in valgus. Not sure how well that is projecting for you guys, and we look at the MRI scan. It's a loose, loose fragment. Doesn't look too healthy, and so, Aaron, any comments to make about this particular case? Obviously, a different entity that we're dealing with here. Yeah, I would say, in general, these tend to be worse actors. It's a very large bone and cartilage surface, lateral thermal condyle. He's 16, so I don't expect he has much growth, but I would just check a bone age on him because he does have open growth plates on the X-rays, and he's in valgus, so if you could use this opportunity to use growth plate modulation to get him to neutral alignment, I think that would be helpful. And then these, I'm pushing the envelope in terms of repair. If there's a chance of repairing this at all, I'll definitely try to do that. I think that's the best outcome for these large structural lateral ones. Even if you have a small area that's fragmented, sometimes you can use a single autograft transfer plug, kind of a hybrid technique, but I would do anything you can to repair it, to restore alignment. If you're gonna take things out, then he's obviously in for a much bigger second stage operation. Great, Sachin, if you're gonna repair this lesion, let's say it is repairable, technique you're gonna use, are you using screws, metal, bioabsorbable? What's your go-to? So I think this will require open surgery. You need to curate out the base, drill all the subchondral bone that's sclerotic. Once that's been done, you may have to take some cancellous bone graft from the lateral femoral condyle, which is easily available, or from the proximal tibia, bone graft it, and then you want good compression. So compression here will either be with headless screws, or you can use bioabsorbable screws, but you need to have good compression if this has to heal. Okay, so I want a show of hands from the panel. Let's say we're fixing it. Who's using metal headless screws? Are you taking them out? When do you take them out? I would normally take them out around six to nine months. That's what I counsel all the parents. But then usually you'll find that only about 40% of them come back to have them removed. Okay, challenge. Okay, so same approach here. I did a scope, thinking, hoping to try and go in and repair this lateral femoral condyle. They're bad actors. This is what I find. And the fragment is not healthy. It's fragmented. It's a bit of a disaster. And so I debride the lesion, drill it, and he comes back, and these are now his radiographs. Notice, obviously, on the right-hand side, he's got exactly the same problem on the right-hand side, completely asymptomatic. And his left knee, so this is the treated knee, he's asymptomatic. He's back playing basketball, okay? What do you do now, Craig? 16-year-old kid, he doesn't want to talk too much. He's sitting there in the room with his mom, but I'm pushing him. Come on, you must be symptomatic. No, doc, no, I'm back on the basketball court, loving it. It's not a problem. So did you address the alignment on the first surgery? Nope. Okay, so I want to follow his alignment and follow his knee, follow him clinically on that left side. What's his effusion like? What's his range of motion? How is he coming along clinically? On that right side, that right side looks loose, and he's symptomatic on the right side now. No, he's asymptomatic. He's asymptomatic. I'm going to follow that, and he's going to need something done on that right side. It looks to be unstable, so repeat MRI and low threshold for an arthroscopy and compression fixation. I agreed with the treatment in terms of the bone graft before on that side. Riley, would you go in here and treat him? Asymptomatic knee, doing well, young kid? No. I mean, if you're doing cartilage surgery in general, you realize they're more akin to diabetics than the cure. So my practice is a surveillance practice. I probably would tell them, all right, three months, an MRI, and then maybe another one at a year just to see and keep track of kind of the bone structure because ultimately you deferred, which you probably would have done if they were skeletomatures, do the osteotomy straight away, which would have created a furtive environment for some regeneration and a relative asymptomatic state. I feel much more confident about that, so I probably would talk to them about that maybe in the future, but I don't see any reason to do anything now. Maria, anything to add? Yeah, I agree. Close follow-up, low threshold for doing something and attempting repair. Brad, final comment. Yeah, I agree, but be careful what I'm following up. It's hard to operate on them when they're asymptomatic. I don't think they'd want to have it. I'm not sure you're going to gain much. What's happening in the bone on the femoral side is already happening. Whether you intervene now or later, I don't think you're losing anything. What you can lose is meniscus and cartilage on the tibial side. So in terms of I'd follow them, the question becomes, well, what are you following them for? If they're coming back and they're still asymptomatic in six months for your follow-up MRI, is it symptoms that's going to drive your decision? If that's the case, there's probably not much point in seeing them at six months. The follow-up is come back when you're symptomatic. I think for me, it's about the meniscus and the cartilage on the tibial side. That's the bit that's still in good condition and it's the bit you want to save. And it's the bit, if I start to see changes, I'd much more likely push them to what will become an osteotomy with or without the biological side on the femoral side. I'm just going to have a hard time convincing any parents to operate on an asymptomatic kid. And to answer your question specifically, there are things you can look at. You can look at fascicular condition of the lateral meniscus. You can look at the presence of bone edema on either side to see if you have any sort of progressive wear or active biological processes. So the MRI in my life is very helpful because it helps predict. And then I can use that as a basis to go in and intervene and even if the patient isn't necessarily that symptomatic. But I don't want to wait for something to happen, potentially, that may be, like you suggested, may be more catastrophic. Perfect. Thanks very much, everyone. I think we should move on to the next session. So great discussion. Thank you. That's great. Thank you.

cartilage lesions

osteochondral lesion

osteotomy

bone grafting

headless screws