We can kind of catch up because this talk basically is this slide. So how durable is cartilage restoration surgery? It's not. Thank you very much. So we're going to talk a little bit about what has been done and what's more common, what has success and what doesn't. Contraplasty is probably the most commonly done surgery across all professional and high level athletes for cartilage defects. There was a study by Anderson, 53 patients undergoing isolated contraplasty. They all had significant improvement in their patient reported outcomes and a lot of them got back to play. The downside to this is that they all get arthritis later on in their careers. But if you stabilize the edges, you decrease the mechanical burden of the cartilage fragments that are floating around in the joint, they can do well. There was a study in 52 NFL football players who underwent contraplasty, 67% were able to return to football at about 8.2 months from their surgery. And this is kind of a common theme in pro athletes is if you can play with bad things, you can play with bad things, right. So if you were able to play more than 11 games the season before, you were 4.7 times more likely to get back to play than if you were someone that is on the shelf all the time. Microfracture has been around for a long time. There's a lot of different ways you can do it. You can augment it. You can just do a standard microfracture. There's about 13 Level 1 to 4 studies that described 821 athletes undergoing microfracture, mean follow-up about four years. Good to excellent results were only at about 67%. And between two to five years, a lot of the outcome scores deteriorated. So we know that the fibrocartilage that's created from a microfracture is not as durable as normal articular cartilage. OATS procedures, limited use based on lesion size. So there's some concerns about donor site morbidity. Ten studies with 610 patients undergoing OATS procedures, successful outcomes in better than microfracture at about 72%, but still not great. But the mean failure rate was 28% with mean revision surgery of about 20%. So all of these surgeries that you're going to hear about, they can get back, but they all have not great return to sport options. Several allograft transplantation studies in 149 knees, 142 of those were high-level athletes, mean follow-up six years, 71% excellent results, 79% able to return to a high level of activity according to their IKDC score. And 91% of athletes said they were satisfied, however 25.5% underwent revision surgery with conversion to either a revision OCA or arthroplasty. So again, there's a fairly high failure rate for these surgeries. MACI procedures, AJSM 2016, 130 patients in 32 different high-level sports treated with ACI, average follow-up about 5.3 years, 40% of those patients were able to return back to their pre-injury levels. So the cell-based technologies in high-level athletes may not be as good as the more structural allograft transplantations. Zach in 2012 looked at 44 athletes undergoing ACI, 54.3% returned to their pre-injury level of sport at their five-year follow-up. So again, slightly better than the other study, but still not very good. So what's old is new. So as we've looked at these outcome studies, people have started to talk about offloading osteotomies again. As our athletes are specializing in single sports at earlier ages, accelerated degeneration of their joints is increasing. And osteotomy is used to correct abnormal loads of the articular surface of the knee that are causing by deformity that puts stresses on the tibial-femoral axis, patellar maltracking, which is going to get talked about later by Dr. West, and then also for DDH in the hip. And one of the things that we wanted to focus on in this talk is as we sit at the NFL Combine and we see a lot more players coming in with osteotomy, it's something that you just want to be familiar with in your practice. So the first osteotomy was reported in 1958, six tibial-eight femoral osteotomies for deformity of the knee. We all know about the mechanical axis. It gives us an idea about where the primary weight is passing through the joint. And so the theory is that if you can correct that to some degree, you may be able to offload the compartment and then make any pathology in the compartment less significant. The biomechanics is really basically trying to offload and decrease stress from the compartment. So the goal of osteotomy, protect procedures for ligament reconstruction, protective procedures for meniscal and chondral surgery. So that's really what we're going to focus on at this part of the talk. You want to know what is their tobacco use history. And some of these guys aren't smoking, but they may be using other tobacco products with nicotine which may decrease their ability to heal. That can lead to nonunion or malunion. You want to make sure that they have a stable ligamentous exam, and you want to get standing alignment radiographs. This is a case example, 17-year-old, Division I, defensive lineman, recruit, injury, second game of his high school season, treated at an outside hospital where he comes from in southern Ohio with rehab and a brace, no MRI. Later on at the end of the season, they got an MRI, and he has this really pretty severe lateral meniscus tear that's completely radial and pretty split far apart. And he had this huge area of chondral delamination with significant marrow edema on his posterior lateral condyle. So he was into his lateral compartment, and we went through a lot of different scenarios with this patient. At some point, we felt he was probably going to need an offloading osteotomy. So our thoughts at the time of surgery were to debride the cartilage, biopsy it for Macy, do a lateral meniscus radial repair, and then do an offloading distal femoral osteotomy that was to put his weight-bearing surface more into the medial compartment. And so far, so good. We have the option now to go back. If the meniscus were to fail, you can do a meniscal allograft transplant or an OA graft to the lateral femoral condyle. But hopefully just by offloading the knee, this patient's going to do well with that. And it's certainly the more simple option for him. Outcomes of DFO in athletes, also not great. There was a mean return to sport rate in about 87.2% in this study. But only about 65% got back to the level that they were at prior to their injury. Another one, 86% were able to get back at a mean time frame of about 12 months back to the sport. 76% were able to get back at or above the level they were at prior. So this is maybe slightly better than some of the cartilage restorative surgeries that we were talking about. This one again, 70.6% back to sport at about 9 to 12 months. That's about what you're looking at for an osteotomy. How about proximal tibial osteotomies or HTOs? These are valgus-producing osteotomies. They're designed to offload the medial compartment. They can also correct for posterolateral insufficiency and thrust in the setting of a chronic ACL tear. It allows for multi-planar correction, less nerve risk to do a medial opening wedge. Return to sport in this study, case series 15 out of 17 patients returned to sport after an HTO. In this study, about 88% got back to sport by 7.5 months, but only 41% back to their pre-injury level of participation. So all these injuries, the theme is these cartilage injuries are devastating injuries for our high-level athletes. But with some of these things maybe in combination, they can be helpful. What about slope-altering osteotomy? I'm going to let Ashish talk a little bit more about that in the next talk for revision ACL. If your tibial slope is greater than 12 degrees, it's been demonstrated to have an increased risk for ACL graft failure. So in the revision setting, you want to look at the slope. They should be evaluated for this in players that fail in ACL. This is a 20-year-old active male, two-time failed ACL at an outside hospital down in southern Ohio. I feel bad about saying southern Ohio so much, but he presented to our institution after two failed ACLs right after his second washout because his graft got infected. We washed him out again, and this is what we see on his CT scan. He has a huge cavitary defect in the posterior aspect of his lateral femoral condyle and a big hole in his tibia. Did a washout there. This is what it looks like when you get in there. So his whole posterior wall of his condyle is missing. He's got a huge cavitary defect anteriorly to that, and then a big, big hole in his tibia. So what are you going to do with this? This is a case of James'. So what we decided to do is we took a chunk of his iliac crest. We used some tightrope fixation to pull that into the area where the defect was on the femoral side, and then we prayed to the god of skinny punks that it would actually heal, and it did. It came back. He also had increased tibial slope. So at his next operation, this is the follow-up surgery. Articular cartilage looks good. You can see the buttons from the previous fixation. You can see that that chunk has healed in nicely. So we just used a burr in there to get it down to a more normal shape, and we were able to drill into that area. You can see here that it recreated a back wall for us. We used a patellar tendon, autographed ipsilateral from the same side, also performed a slope altering osteotomy. He's not gotten infected again, so that's good, and we'll see how he does in the long-term. So this is what it looks like when it's all said and done. The other thing that I want to talk about a little bit, because it's near and dear to my heart and the hip always is kind of like the stepchild of all of sports medicine, is that you're going to see a lot more PAOs coming through. So I think people are recognizing hip instability and borderline dysplasia as something that is more common, and so a lot of these patients are getting treated concomitantly with a PAO and a hip scope. In fact, the anchor group showed that there's about almost a 200% increase in the amount of these things that are being seen in their recent studies. What's returned to sport of athletes after a borderline hip scope? It's only about 45% that get back to the same level of play, and only 3% at a higher rate. So I think these are ones that are important to think about doing some kind of, again, offloading or stabilizing osteotomy. Athletes undergoing a PAO and a scope, about 81.8% return to sport. So this is a much higher return to sport at the same level than if you do a scope alone. This is an example, 18-year-old Division I basketball player from the Detroit area, two years of left groin pain managed through high school with rehab and two corticosteroid injections, increasing pain in college and inability to play. So he's got a huge cam deformity there and dysplasia. So we treated him with a concomitant PAO and a hip arthroscopy. He did very well and has returned to sport six months after his surgery. So these are pretty quick recoveries, even with a PAO and a high-level athlete. And you're going to see some of these things coming through your offices. So thank you guys for your attention. Appreciate it.

surgical treatments

cartilage defects

contraplasty

microfracture

OATS procedures