Hey, good morning, I think it's about time to get started. I really would like this to be interactive, so if you can at least shift maybe to this side of the room, these tables, spread out a little bit. Please, there are a couple of mics floating around. This is being recorded, so if you aren't near a mic and we can't hear you, please get to a mic. But we really wanna foster discussion, hopefully a little bit of controversy. And learn from these cases in the subsequent discussion. I'd like to thank all the faculty for taking time out of their busy schedules and joining us and lending us their expertise and leading this. We've got a great group. We were just talking that it's mixed backgrounds in terms of training, so hopefully you get some different perspectives and different practice patterns. So again, thank you all. We do have things to disclose. It's available on AOSSM app. Many of us do work in the cartilage space, and so we have various consulting relationships that are pertinent to this. But again, we'll stay away from the specifics. So we'll get going with the first case here. And this is a male soccer player. He's got right knee pain. It's spring. It's a 17-year-old male soccer, so this is spring. He's a rising senior now. And he's had chronic right anterior knee pain. It ebbs and flows for the past six years. Nothing really specific. It's worsened over the past three months, but not directly related to any trauma. He has never had any instability event. He hasn't had any effusions. No specific trauma that he can remember. And he continues to play at a high level. He's a high school star, rising senior, has aspirations and scouts looking at him from Europe. On his exam in the office, his knee exam's really unremarkable. There's no effusions, no instability. He's tight in his hamstrings, really tight in his hip flexors. He's got an entirely stable knee. So here's his radiographs at that time. Anybody see anything concerning? No, they're pretty normal. So at this point in the office, he was treated with therapy, mobility, brief course of non-steroidals, and he returned to play. Anybody find anything concerning about that? Would anybody have done anything differently at this point? Anybody at all? It's supposed to be case-based interactive. What part of the season is he in? So he is playing, it's like spring conditioning training. He's a rising senior, so he's got a senior season upcoming starting in August. This is in March or April. He's had no effusions? No effusions, nothing. He just shows up, his dad's there. He's still playing at a high level. He's had on and off pain. His exam is entirely normal outside of being pretty tight in both his hamstrings and his hip flexors. So Austin, you feel like it was intra-articular the source of it, or soft tissue, or patellar tendon, or? This I treated with the hamstring tightness and some chronic patellar tendonitis. He was tender at the inferior pole of his patella on his exam. So I did not have any suspicion intra-articularly right now. Again, no effusions and no discrete trauma. So he shows up in the season, six months after this visit, so it's early September. He's currently playing his senior season. Now he has atraumatic effusions. They just come, they go, they never fully resolve, but they ebb and flow in terms of its intensity. His anterior knee pain has worsened. Again, he has no history of patellar instability. The hamstring tightness and patellar tendonitis were gone. He was great over the summer. Now on today's exam, he has an effusion. It's not terrible, it's about one plus. He's got great range of motion. He's not tight any longer. Stable knee and no patellar instability. Who would get an MRI at this point? Most of our patients already would have demanded it. Right, right. So that's what happened, and this is what we're looking at. So you can see that there's some substantial delamination of the cartilage, but there's also some bone involvement. And he's been continuing to play. So his cartilage pathology is isolated to the trochlea. His TDDG is 16 millimeters. He doesn't have any history of patellar instability at all. This is a trochlear problem. Austin, can you go back to the x-rays? Mm-hmm. There must be something here that we missed. So if you're looking at that lateral, that actually does look a little funny there, doesn't it? Mm-hmm. You know, right in that area there that looks almost like there's, it looks almost like a little bit cystic. I wouldn't pick it up in the first go either, but retrospectively, I think it probably looked at us. Right, the proximal part of it, yeah. And this is one of the reasons I showed that case, because he didn't have any effusions. He didn't have any trauma. And he had no effusion. Yeah, and he'd seen one of my partners first, and then was subsequently referred, and like, ah, it's kind of lingering. Go see him. Wasn't tender in the trochlea at that point, though. Mm-mm. These are. So he's in season. His performance has decreased, but he's so gifted that he's still able to perform at the high school level at a high level in season right now. Devil's advocate. If the father comes in and says, listen, my son's gonna be the next greatest football player, would you get an MRI? No effusion? That X-ray? Really? In hindsight. In hindsight, you know. Because that's what happens in reality. The father comes in, or the uncle comes, somebody comes in, and they almost demand. The kid never had knee pain before. If you petition the insurance company, they say no. Yeah, I think one of the confounders for me was his on and off knee pain for six years, right? And he'd grown a ton, right? He was not far off. He was kind of a late-growth person, so he'd grown six inches the year prior. So. Austin, these are really important, because I saw one like this that was very similar where it was sent to me when it already got to this stage, but the person was very upset with the initial petition for a knee scan, and like, litiginously upset. But you can scrutinize them, like Christian's saying, and sometimes you pick them up, but the telethermal ones are much harder to find. And it is usually the lateral, but that piece was clearly not loose then. It's amazing how fragmented it seems on the scan now. Mm-hmm, absolutely. And the NOAA fusion was the thing that threw me. Like, if the guy had swelling, it's a no-brainer. Yeah, a lot of OCDs don't swell, but I agree with you. There wouldn't have been a red flag to scan them early. I mean, plus you had findings on your exam that were good enough to justify some pain. If you had a completely normal knee, your office might have thought of mitigating it. Mm-hmm. But if you had findings on your exam that you were able to justify, I mean, you were able to relieve it. At least in my practice, I have a super low threshold in kids, and I still consider him a kid, of scanning anybody who has any significant, if they had no trauma, I mean, if they hit another player head-on and they came in a week later and their exam was benign, I'd say it's probably just a contusion, a bone contusion. But no trauma, it's affecting his, I mean, it didn't sound like it was really affecting his play, but I think having a super low threshold, and I haven't had a problem getting these approved by insurance. I think it's also how you write your notes. I definitely write my note a little bit more catastrophically than the patient's story sometimes. I mean, unfortunately, that's a game we have to play, and that's true. You know, the interesting thing is, too, though, is that he didn't come back. Like, I gave him a dose back. Those are done in a week, and he went back and played for months and never came back, and he's local. It's not like he's far away. Now he's got this. It's a pretty devastating problem. So, now, this is the picture you have. It's September. He was planning on finishing and then going over to Europe at the end. He's gonna graduate from high school early, so he's planning on heading over there in January after this season. So, he still wants to play at an elite level, and he's continued to perform well despite having that MRI. So, what'd you do? Scope and debride? Did you jump immediately to something further? Thoughts? So, the first thing that I would do is, is you need to, obviously, explain to the family what the issue is, what the severity is, and what the consequences can be, right? And then, a scope and debridement is typically the first step that I would suggest here. I'm not expecting him to recover to the point where he can just go and play without any issues. But if you get to the point where he can, but if you get these in slightly different locations, sometimes you get surprised. They do actually a lot better than you think, but what is important is that you follow them very, very closely, because this can go to hell in a handbasket really quickly. I think for timing purposes, if he's truly functioning fine in season, and if this time is very important for him, and it's the wrong time for him to go through a recovery, that piece from those cuts you had up, at least, look pretty non-salvageable, and I try to fix any of these whenever possible. So, I don't think you lose anything by letting him finish the season if it's terribly important for him in his time of year and what he's planning. So, we had exactly those discussions, and we talked about, best case scenario, you're looking at 80% of people get back to some level of activity, regardless of how you treat this. He's got a cartilage knee, right? So, we had that conversation with the family. The senior season was not as important. It was the next steps that were important. That was their focus. And so, he was frank. He's pretty level-headed. And he said, I don't care if I can get to the next level. I don't care about the rest of this season. And that was the discussion that we had in the office at that point. Now, in light of that discussion, any additional thoughts? Yeah, I would definitely agree with Christian on scope to breathing. I would take a biopsy, and then I would follow closely, because I think Adam's right. The fragments look pretty disrupted there. And I've had poor success in later age groups of putting them back and trying to fix it. And that's gonna be a cluster, trying to follow that and letting them go back. What are you gonna do? But if you debride it, he might actually do okay. You can follow him closely. And if he doesn't, then you have this biopsy ready to go, and then I would do a Macy's sandwich if it went to hell in a handbasket. But you have a backup plan. It's interesting. He doesn't care about going to Europe, you said? No, he doesn't care about his senior season. He cares about going to Europe. Yeah, that's what I thought. He's in the middle of his senior season, and he's leaving in January for Europe. Yeah, so debride him, and then let him see if he can recover. And possibly, platelets, plasma, stem cell, potentially try to get him through. No, it's hokey, but that's what you would do to try to get him to move forward in healing. And then if he gets through, great. If he doesn't, you've got the biopsy, and you pull the trigger at a time when he can take some time off and get fixed, which would be tough. That's the knock against Macy. But I've had some success in younger people with Macy, getting back at a relatively short period of time, at seven to eight months, in some cases, in young people. Bone grafting itself will fix a lot of that problem for you. I'm just curious, following from Dr. Latimer's comment, when you tell these parents how severe this is, the kid's been playing soccer, he's not had any serious injury, what do you tell the parents when they say, well, how come this has got so bad? What's the cause? Did they ask you that? Just curious whether you had to have that discussion with them, if you have to explain why this happened. Yeah, they did ask. They said, well, he was fine, and then he wasn't. And now this is a huge problem, right? You know, interestingly, fortunately, I'm not in a super litigious state. They didn't come out after me. The NIL thing wasn't trickling down to them yet. But the kid didn't come back ahead of time, right? So between March and September, I mean, was available, I said, come back, didn't, he was fine, he didn't have any pain, he didn't have any problems. So that was one of the confounding issues is that he was not having any major symptoms that would interfere with his play to the point where he would go back to the physician. I think with these large central lesions, I think it's, at least in my experience, pretty unlikely that he's going to be able to get back at his level. Somehow, when it sits perfectly in the defect, they can be completely asymptomatic. And when patients ask, like, what happened? You know, the piece got loose. I'm like, why did the piece get loose now? I have two patients in the last two weeks where the piece got loose in their 50s. I mean, most of the time, I think it gets loose, 17, 18, 19. It looks like his growth plates are still open, looks like it's maybe closing on the tibia. For these, I tend to take the piece out and just do an OCA. I think it's a faster recovery. I've got a number of those patients back to high-level sports. I think that's sort of the most reliable answer for these. And I would never consider fixing this. I mean, a fragmented avascular that's going to look like a piece of cartilage, you're not going to see any bone on that. Well, and that's one of the things, because you mentioned the ACI biopsy. You know, in looking at this MRI, and when we get to the arthroscopic pictures, I think it'll be a little bit more obvious. But to me, on the MRI, he had a lot more bone involvement than just surface-based, right? You see that. You mentioned bone grafting. And so, you know, for the panel and for the audience, what is your threshold for saying, okay, I know there's a little bit of bone involvement, but I'm still going to do a surface-based, or when are you now moving to OCA or surface-based with bone grafting, ACI with bone grafting sandwich? So if I start with that, so in the patellofemoral joint, typically my go-to technique is a cell-based procedure, such as the MACE. However, looking at this MRI, not having seen the scope pictures yet, I do agree this looks to me like there's substantial bone structural loss. And whenever I have a structural defect, particularly in what I would consider a high-loading zone, which is that entry of the trochlea, I would do what Sabrina does. I would rather go to a structural graft, which would be an allograft, simply because I'm concerned about the activity level. Now, that doesn't mean that in the long run, the OCA is going to survive this any better, but I think in a short run, there's a higher likelihood that they can do what they are going to do with it. If this was a 40-year-old, I would not have any issues with a cell-based procedure. My thoughts on that are kind of the opposite. I would say that a young person's gonna heal in their own cells and bone graft well, quickly, as I was saying, and if I put an osteochondroallograft in there, then I'm worried about what you're talking about, the bone incorporation issue. If it doesn't incorporate, then I'm in a worse situation. I agree they can get back more quickly, but then there's always that issue of bone incorporation, and are the symptoms now coming from the lack of bone incorporation, but you're gonna have limited bone incorporation at six months when he's trying to get after it, and what do you do? So I'd rather debride him, let him try it out, and then if it doesn't work, then a bone graft, say, look, we gotta take some time, let this heal. The kid will heal. As Sabrina was saying, his growth plates are open. He's gonna heal like gangbusters no matter what we do, but if you put an osteochondroallograft in there, bring in some other factors in that I don't really like. I like, I would say in the 40-year-old, I would go to osteochondroallograft because the growth plates are closed, doesn't work, then I go to patella from a replacement, I'm done, but I can't do that in this kid. I'd have to take that out, bone graft him at that point with an osteochondroallograft, which I've had to do, and then that's even bigger loss of time and conundrum for the patient and the family. And I think the MRI probably overestimates because his growth rates were not as open on the x-ray, and then this MRI was against, after his initial x-rays, six months later, and now we're a couple weeks after that, and it didn't fully tanner stage him, but he's more or less a four, so he's on the tail end. If there's any growth remaining, it's pretty minimal. And so, yeah, I had all those conversations with the family, like we talked about, and I said that my suspicion was that there was more structural involvement there than maybe even the MRI led, and so I offered that I would be open to taking a biopsy, but my suspicion was that he would be better served later, ultimately, with an osteochondroallograft, but first and foremost, we were gonna scope. So here's what you see when you get into his knee, and that first picture there hasn't been touched. This is what his trochlea looks like, and it's a huge lesion. I don't know if I put a taller picture in, but the rest of his knee is pristine. This is isolated to the trochlea, and this is delaminated around all of the edges there. You can see that he's got cartilage flex everywhere. All of that was evacuated, just sticking in the scope. And then got margins, but really, there was not a ton to do, because he had already delaminated virtually all of his trochlea, at least in the central portion. And it's a little easier when you're in there than these pictures justify. I apologize, I didn't have the video transfer properly, but there was bone involvement that was noticeable, and even though he was forming some of this fibrous tissue off of it, it was pretty difficult. So now what? And seeing this, you scoped it, loose cartilage is out, clean things up, stable vertical margins. The rest of his knee is pristine. What do you tell the kid? Do you let him play? Do you restrict his activity? Do you proceed to a next stage of surgery? Was he signed by somebody? He was not. So, and I don't know all of the ins and outs, because there's 230 leagues out there that are better than the MLS, right? Right, exactly. And you're looking at all these leagues, they all have different timelines and rules. He was going over in January for like, it was essentially a prelim, where they were training, evaluating, and the season started later in the year. So if you made it through the cuts in January, then you would be eligible to be on one of the league teams. But it was not like they were scouting from the US, you were going over to England for that. He was going over to London. I think you have to follow him functionally. I mean, once again, see how he's doing. If he's hitting a home run for some reason, it doesn't look like it's gonna be likely, then great, if he's having problems though, I think you'd pull the trigger and fix him. And tell him to bite the bullet, get it fixed. Yeah, I mean, I would agree. I think important here is that you are realistic with him, and basically say, listen, this is a big problem. I think you can let him play, and he will have to see that he can't do it. Otherwise, you'll never win any decision that you think is medically appropriate here with a family or with a kid, even if he's level-headed. He needs to understand that this is not working. The likelihood of him even getting recruited, I think, is close to zero. In any league where he is actually going to have a professional or semi-professional career, I don't think they would look at him. And I would be surprised if he can perform in that level. So to the comment earlier from Sabrina, I've seen people do really well with this type of lesion on their femoral condyles, but I have not seen people tolerate the patella-femoral joint quite as well. Has anybody had a different experience in terms of return to play, return to a higher level, even on the short term? If it's superior lateral trochlea, sometimes I think you can get away with taking out the piece. But I think this large central OCD is a, and I do think they tend to, you see patella wear pretty quickly and then obviously your options are significantly worse. I mean, I think if you wait, he's going to lose another year. So I mean, obviously, it's up to the patient. But I would lay a lot of crepe if he was going to try to play. Did you have something to add there? No, I think Chris was right, though. You want him to display that he can't function. Because you talk him into it, and then he never returns. And then it's all your fault. Look at you, what you did to my son kind of thing. So I get it. I mean, I agree. It looks like it's going to wear down the patella from a joint. But you've got to let them kind of come to that conclusion on their own in this situation, particularly when he's already set to go. And he was playing with a damaged knee anyway. So clearly, he takes pain. But follow him for effusion. Follow him for symptoms. And then closely follow him. That's what the mistake was, right? They didn't come back to you. And they should have been closely followed from the get-go. And they didn't come back. So what I hear a lot from colleagues in Europe who take care of professional soccer players, almost every soccer player has a chondral lesion and a trochlea. But the difference is they've had years and years and years to develop these. And they basically develop strategies, movement strategies, and also loading strategies around it where they can tolerate this. This kid has it exactly six months of adjustment here. And he's lost the entire trochlea. I think this is a different animal. So you can't treat that like many of the other trochlea defects that we see in professional athletes who are actually performing well with those. I don't think this patellofemoral joint will have the chance to adjust to that appropriately. So we had that conversation. And in fact, the conversation before surgery was that I actually intended to let him go back and see what he could do. And so he does. And he goes over and plays in January for the trials and the tryouts. The effusions and the pain are persistent. They're manageable. But he knows that this is not a long-term solution. Now he's back in the office. And so he's made it. He talked to the coaches over there. And they're like, you need to go get healthy. You're clearly not performing where you were. And so he's on board with that. So now what? He still wants to play. And he's continued to perform decently despite this. So if anyone's going to make it back, I think he's a good candidate. But there's obviously anything far from a guarantee. So we've already scoped into breed. So what any one of these or any combination of these would people do for this kid? So I think that it's a good conversation you guys were having about the MACI and the OA graft. And MACI sandwich technique kind of was a necessity. It's the mother of invention. It really came out of Europe because they don't have OA grafts. But if there's any situation that OA grafts have the most consistent outcomes, is in OCD lesions, actually. And I think for somebody like this that you want to know, you want to try to be definitive with whatever you're doing without over-treating them, I would do a TTO and an OCA to the trochlea. And with the etiology being an OCD, do you need the TTO? I think we all know that we don't really do preoperative measurements to know if that's really the case or not, when to really indicate it. But in this setting, I think if you do less and he has continued pain and the graft is still structurally normal, you'd probably be kicking yourself. So I would say OCA and TTO. How would you do your TTO? Do you do your eyes or anything? Yeah, so even though he's not patellar instability, I do look at TTTG to figure out if he's already medial or not. And when it's a central lesion, a lot of times I'll do a straight anteriorization, especially if they're pretty normal TTTG. So I'd say like a 60-degree cut at least. Then usually I use a tricortical wedge graft shaped like a doorstop at a centimeter. I just translate it. So I'd make an intraoperative decision, but it looks like it's smack dab in the middle to a little lateral, so maybe 60 or 90. And on that, we talked about in a previous ICL that you can make a contralateral cross-cut on your TTO so that you're not taking such a major, like a 60-degree cut. If you take that and you have a decent chunk of bone, that can get pretty deep on the tibia, so you can make a cross-cut. So you can selectively anteriorize a little bit more rather than doing intramedialization, like 45, like one-to-one ratio. And so that's a technique that has come up previously. Anybody going to do a sandwich technique? Because now they're really pressing me hard, too, because they want to know, they want numbers, right? I mean, we talked about numbers kind of globally, but now they're talking about the differences in the procedure, what are the numbers, what has the best, most reliable outcome in an athlete for return to play? Yeah, and I think that's a great point, because I think Adam brings up a great point. I like, when I look at the MRI, it looks deep. When I look at your scope pictures, it looks flat and really limited shoulders there. So I don't know how, if you started debriding, where the bleeding would stop and where the good bone would start. But I think that, in this case, I think OCA is not a bad idea. The TTO, I think, is a good idea, too, because it's not going to change your rehab anyway. I've used the KineMed system to anteriorize, because you don't take the lateral cortical wall down at all, the tibial bone. You leave the tib down alone, and it seems to be really well-tolerated by patients. You can anteriorize a reasonable amount without looking bad at all. It heals really quickly. So that's what I would use if I was going to do a TTO, and I would do an OCA and TTO probably, based on timing. If you look at timing, though, Macy and OCA, and if you look at Dave Flanagan's paper as well as Critch's paper, not significantly different in terms of return to play. Old ACI, definitely 16 months in Dave Flanagan's study, but if you look at Macy versus OCA versus OATS, OATS is definitely the best in terms of return, works most quickly, but then if you look at the Macy versus OCA, I don't know, it's not that big of a difference. And then the only one issue is if there is a bone that doesn't incorporate with the OCA, what's your backup then? So I would do the TTO if I'm going to do the OCA, because you want to do the full-court press if you're going to go that big, and you wouldn't want to do a TTO later. That would be an even worse move. So just do it all at once. And the other thing I think that you need to disclose here that there's really not very good data, all right? So this is a decision that you have to be making, and I disclose that to my patient. I say, listen, all the data that we have to answer that question is not in the trochlea, right? There's maybe single-digit cases in the published literature that show this kind of situation. So you have to make inferences. And with regards to the TTO, what you have to keep in mind is this is an OCD lesion. We know from the pediatric literature that OCD lesions today are considered overuse lesions. So this kid overused his trochlea during his formative years between 12 and 15, which ends up leading to something like that. So if you put an allograft or a Macy or whatever else magic in there, that will go exactly the same direction as his native knee unless you're changing something about it. And that's the case in point to make for the TTO. So anything you can do to protect that trochlea is necessary to do here. So I would never do any of this without a TTO. So I do 80 TTOs a year, and I wouldn't do a TTO for this. I think he's gonna have a much slower recovery because I'm gonna limit his weight bearing for the first four weeks. It's still only about 20% chance he has it in his other knee and we haven't even talked about that. But parents ask me all the time, should we image the other knee? And I pretty much just do whatever they want. The last thing I need to do is restrict. And in fact, I just had the exact same case in a 13-year-old this week. I took out the loose body and I did a Macy biopsy. I can't do an OCA. His birthplates are wide open and I would be drilling into the growth plate on his femur based on the location. But for him, whoever referred him to me had already got an MRI of the other side. And interestingly, he has a medial femoral condyle OCD on the other side that's asymptomatic. So we're watching it. But we haven't talked about the other knee, but I think that's worthwhile. I think a central trochlea, you're not gonna achieve that much unloading with the osteotomy, but that's just my two cents. And if I was going to do it, I would do it more like the KineMed system. I personally just freehand it, but I just wedge it up. And those do heal really quickly. So it's not that it's a big whack, but I think he'll get away with just an OCA and get back at four months. And we MRI them before we let them go back to running. So if we're talking about ACI and the patellofemoral joint, there's some series that say that they do better with a TTO. And I think that's to adjust loading mechanics. And we know from the more recent studies that traditional focus in osteotomy was all for lateral, but we can change some of the contact pressures across the patella now with a tibial tubercle osteotomy, depending on how you make your cut, et cetera. So is there a reason not to do it outside of, yes, it may delay his recovery, but these take a long time to get back to sport anyway. So that first six weeks where you're altering their weight bearing, protecting their rate bearing in a young, healthy athlete, do you think that that matters long-term? Right, that was my thought. So I guess I found myself hard pressed for a good reason not to do a TTL. And I really couldn't come up with one, which is what I did. So for him, I selected an OCA with the TTO. You can see that his trochlear involvement, it's pretty significant. And there are contour changes that are more obvious when you open it up. I have to say, I also like a TTO because I don't have to involve the quad or approximately as much as I can lever through that TTO. I mean, it just makes a very easy exposure. So I'm not insulting the VMO. I had considered going lateral just to make it so that I would even have a less likely chance of doing that. But I stuck with the medial because I didn't have to get up in the quad much at all. I preserve the fat pad as much as possible. I have a tendency to shell out just a little bit, almost total knee style of the patella. So I preserve that fat pad. I don't stress it as much. I think there is benefit there. It's got healthy cells. And then through that bone cut, I can get a little bit extra excursion. And so I did that for him. I was pleased with how the graft fit. I got a good match and I feel. At the thickest point, it was nine millimeters. And at the thinnest point, it was five. Yeah, so, you know, I mean, I did as little as I possibly could. It's interesting. He did some healing there, though. It looks like you kind of filled him over with that. Yeah, and this was after he went back to play, you know? I mean, he did go back. Also, it looks- Is it a high bone there? Yes. And so he did there. Normally, I don't like getting x-rays because the bone and the cartilage don't always match the native, but his looked pretty good. And this, we can talk as we go through here. I did that cross cut on him, though. I kind of semi freehand this. I use this cutting block, kind of like you would for a total knee. I just put my saw on it, but I adjust my angle. So pretty steep angle coming in, but then I move contralaterally to make that cut so I'm not going so deep in the tibia. And then I can selectively anteriorize him more so than medialize him. I did bring him over a couple millimeters and bring that across, but I'd made my cross cut here on the other side of the tibia and pop it up. And it's very useful for bringing that over. I pre-drill it so I'm ready to go. So before I do anything, I put it where I want it. I pin it, I drill it, and then I leave it and continue on with my exposure there. And then I don't have to insult the vastus so much. I can lever through that. And again, release some of the fat pad along the inferior pole of the patella there. So preserving most of the fat pad, but getting that additional excursion and working around there. Again, a little bit total knee style. I don't remember how to do a total knee, but if I did. Now here, one thing I stole from Adam was marking the guide. So on this guide, I'll color the pin so that I can match it on the trochea and help line up my cut. I always score the cartilage. I know there's some debate, but for me, it just makes it a little bit more efficient. And I don't have to do so much cleaning up. It's really important to get all those cartilage flakes out of there. I don't typically biologically augment just because of the headaches in my hospital system. I think that there's rationale for that, but I do drill the base of the lesion to help encourage blood flow in there, clean that all up. And these videos always seem pretty quick when you're making them and then you're standing up here and they take forever. I do dilate the area. I think that makes it easier to get the graft in, chamfer the graft, and then ultimately go back and cut it. If I could figure out how to fast forward, I would. So there's a trochea. So again, I mark it on that sizer with the marking pen and you do ream through that. So my concerns about the toxicity of the blue dye are really minimal. Irrigate, make sure you're not burning the cartilage and then measure and cut. And I just really do this by holding this and then freehand it with a saw. I don't use any fancy graft holder. They tend to get in the way for me. Perhaps I'm just not that sophisticated, but I build a little towel for it so stuff doesn't hop off the table. So then measure it and get ready and implant it. Do you do any different preparation of the bone side or I see you're lavaging there? Yeah, I do pulse lavage. I've not gotten sophisticated like y'all and done CO2 lavage and all of that. Maybe it's in the pipeline, but haven't done that yet. Dr. Yankee, BMAC, yes or no? Yeah, I offer it to all of them. It's cash. I think I get 25% of people that go along with it, but I think for OCD, I would try to push them to do it. We just did a study looking at that BMAC versus just local BMAC, just taking a jam-sheeting needle into the distal femur and our MRIs at six months were exactly the same. So we just stopped and we hadn't been charging the patients. We'd just been eating it as a hospital. So we literally just stopped it. Do you think there's any role in soaking it in like whole blood or anything? I mean, do you think that that makes a bit of difference? Sort of what we're doing. You paid a bleeding bed. Well, that's what my thought was, but like, I don't know, you put more in there. I let it sit there. I come from the house that Microfracture built. You paid a bleeding bed. Well, well, well, well. What, now, if you wanna say, well, I'm gonna take a test tube and spit it down and put some of those growth factors in it. If you charge 15 bucks for that, that's okay. If you're gonna go charge a Dow, that's stupid. So why don't we hear from Adam, who has kind of sort of done the study that tries to disprove what Andreas and Sabrina has shown, that there's not much of a difference, and explain to us how you trade large for smaller cysts. Adam. Yeah, so the, good question. So the studies that exist now all have different time points that they use for their primary endpoint. They all have different imaging modalities. There's ones that are x-ray, CT, and MRI. They all get lumped together, saying there's no difference. And ours, we did a level one prospective randomized controlled trial, looking at it with CT as our primary outcome. And the main difference was the difference in small and large cyst formation. And you're more likely to have small cysts than large cysts if you use BMAC. And so it was potentially lessening some of that bioburden for the integration. People that had larger cysts were more likely to have second surgeries specifically related to graft failure issues, as opposed to continued pain with a structurally intact graft. So I think that there, I think all of us would probably agree there's some bioburden to the cancellous part of the bone there, that it still is not gonna get reached by pulse lavage. There's three different studies now that have looked at high pressure CO2 plus pulse lavage, showing that you get more marrow elements removed if you use the two of them together. And you definitely get more invagination or soaking essentially of whatever is gonna be there, whether it's the blood from the patient, BMAC doesn't matter, because otherwise it's oil and water and it won't come into the graft. So it definitely soaks it up more like a sponge. And I think Seth Sherman just did a study recently looking at the depth of penetration of application of biologics to OCAs and reiterated that. Adam, one question that I always have there is are you using a press fit system or an aligned fit system? They were all press fit with a millimeter of offset. Yeah, because I think this is also a little bit of a difference, even though I'm not sure if that totally makes sense with your data, but I'm always concerned if you do an inline fit, that you have a little bit more leakage around the edges because these grafts clearly are less stable when you put them in. In fact, actually, I feel they even rotate a little bit versus in a press fit where you really put them in and they are like rock solid. And sometimes you can also see how good you prepared everything when you push a little bit on the graft. And if you didn't do a perfect alignment, you actually see some fluid come off onto the side. Now, those are the ones where I would be a little bit concerned. And try to at least seal the edge a little bit so that you don't get any mechanical fluid going in and out, which could be one of the reasons for cyst formation. So, look where our discussion's gone. Exactly what I said was gonna happen. Did the bone incorporate? Is the bone gonna incorporate? We're gonna have a cyst. What are we gonna do to get it to incorporate? When I look at that picture on the left, it looked like the bone was limited involvement. You debrided down a little bit. You put your Macy in there. You do your TTO. You're probably in the same position with bone that's actually pretty good. So, I get the use of the osteochondrograph and return to play argument. But if it doesn't work, if all these issues you talked about just now do happen, then what? That's the problem I have with a young person. But the older person, once again, I'm good. And there was no problem with this kid. If it doesn't work out, I think you did a great job. It looks beautiful. I'm anxious to see. Do you got the result? Well, he's fine now. It's still pretty early. I didn't do this case very long ago. And there's nothing that ruins a good surgery like follow-up, right? Well, let's see. He had no problem getting his motion back. And I don't put any motion restrictions on him post-operatively. Would anybody restrict his motion? No. Good. And so, I do keep him touchdown weight-bearing for six weeks. Does anybody do less? I know. So, that brings up a good point. I have been using a patella from a loader brace that's on the market. Icarus brace. That's pretty nice. And transitioning him out of an immobilizer and into that at two to four weeks pretty quickly. And it allows for them to have more functional return of that hip flexor and the entire function of that leg. So, that's something to consider in this patient to get the ball rolling. And then they can transition out of that as they rehab, too. Stair climbing and all those things can be much easier without limitations. And it works really well. I've been very happy with that. or certainly advancing the match. So it wouldn't be unreasonable. I think it is Dave Wright, you're wanting him to be a little slower in terms of rehab, that's his own reason to make him not touch down weight bearing, assuming he's going to be partial or potentially weight bearer without crutches when no one's watching. Yeah, and he's a high school kid in Kentucky, so he doesn't listen, so make him... He's vested, but he's not that vested. That's where that brace can help. So weight bearing is tolerated, locked in extension. Yeah. There should be a hand one at the table. Oh, yeah. Yeah, I get the chance to operate on both sides of the Atlantic Ocean. And in Lake Tahoe, this kid would get an OCA. 100% of the time, they wouldn't consider a Macy with a sandwich procedure. It's too costly here, it's OCA. Return to play is really very good. And I think in my own life, it's a little bit better with OCA return to play than with a Macy sandwich. Now in Madrid, they get the Macy sandwich, and the kid would probably be about three or six months retarded from St. Kitts in Lake Tahoe with the Macy sandwich. His return to play would be about equal. And this is worse than level five, but I've got a lot of experience. And the thing is, though, if the kid with the Macy fails, then I get a chance to do my osteochondrolograph in Spain, which they don't really like to do. And then I have a good salvage. What's the salvage if your OCA fails? So there's both sides of the coin. The reality of this kid playing at the highest level, I would keep advising the parents, it's really not a realistic goal. I take care of two. Honestly, God, everybody that I see, I only, even if I see a garbage man in Madrid, he's like the best garbage man in this garbage man union. So we take care of these high-level athletes, and every kid that comes in is a potential, they're a superstar in high school, and the chance of getting back to the elite, elitist level is not there. They may get back to play recreational soccer, but he's trying it in the English league. Boy, they play a different game than we do here. Leave it at the table. So just to wrap up, so he's still in his early post-operative recovery. So how fast do you reintroduce cutting pivoting movements in these athletes? So the osteotomy's healed, you're four to six months down the line. What does your return to activity, return to play look like at that time frame? How quickly are you advancing them? When are you introducing plyometrics? How well do you sleep at night? So, you know, to tell you the truth, I would not recommend that, and I would make it absolutely clear that I would not recommend returning back to that same kind of level, and maybe be very, very slow on cutting pivoting movement, particularly in this mid-flexion area. This is a fairly large graft, right? And particularly in the trochlea, where the trochlea defines your patellar stability in that mid-flexion area, you will have rocking, and I would be concerned about that. You know, definitely not before six months to go back into cutting and pivoting activities if he really decides to go that. I think he can do strength training a lot earlier. And again, I would reiterate it that the recommendation is not to do that. Would anybody advance a higher impact before six months in this kid? I think you have to follow the physical therapist advancement protocol that you would for ACL, for example. You know, we check for a negative step-down test, and then progress. You know, once they have that hip flexor, rectus abdominis, and gluteal muscle on that side working, they can balance and hold the ability to start to jog. Then we start jogging, and then progress up. Alter-G would be something I would definitely implement in this case, and that patella form loader would be protecting me while I advance up. And then just follow how they're doing, and then follow the symptoms. I think Sabrina brought up a good point of the MRI as well at some point here to take a look at the graph, but I still don't know if it's gonna look bad on MRI six months out. So I would say negative step-down test, and then follow our standard ACL protocol, and follow their ability to balance on the leg by itself, run, sprint, and start cutting, and then start sport-specific training. I would let him, I mean, you do the procedures, I'd let him try to return to play, so you gotta give it a shot at the title. I mean, if it doesn't work out, it doesn't work out, and you've laid that, hopefully, at groundwork before you did the procedure. There's a possibility, a good possibility it won't return, but you gotta try it, I think. Well, a couple things we didn't mention. So first of all, I get these patients doing BFR a week or two weeks after surgery. I would let them wait there at four weeks if I did the osteotomy. We MRI everybody at six months, and occasionally when these kids are really chomping at the bit, we might get the MRI at five months, and what are we looking for? Because you're right, they never look normal, but once we started doing that on everyone, we sort of saw good, what looks good, and what looks not so good. And so we published last year just looking at bone edema. So if you look around the graft, not at the actual graft, because graft will still look bright for a while, but if you look at bone edema, if you have greater than 10 square centimeters, which you don't have to get your calculator out, but if you see a fair amount of edema around the graft, slow them way down, because we had a 50% failure rate in those patients. If we didn't have that, we had a 0% failure rate. So there are things that you can look at that can kind of dictate how you're gonna go forward. So if we see a lot of edema, we don't know if it works, but we put them on Fosamax, we slow them way down. If we don't, six months, we let them go, assuming, of course, that they're fully strong, and the physical therapist thinks they're ready to go. What time did they, the 50% that failed, what time point did they fail? By a year. A year. Yeah, it's a great point. We started scanning ours at six months and a year with MRI and CT for the same reasons, to routinely do it, to try to get information to help guide these conversations, because otherwise we were always having scans on people that were struggling, and we had no idea what the denominator was. So I do think that if you get something at six months and it's totally quiet, MRI looks pristine. If you get a CT and it shows no cysts, then, and it's very important for them to push, then that's like the one scenario where I'll do it. I'll restrict, in the patellofemoral joint, I'll restrict them for six months for higher loading activity. Strengthening's fine. I'm not a huge fan of open chain. Definitely keep them away from that in the patellofemoral joint. I'm allowing full weight bearing immediately with it locked out in extension, with my TTO cartilage procedure patients now, once again, transitioning to that unloader brace at two to four weeks. So I start immediate weight bearing. It's tolerated with the KineMet system. It's pretty stable, and I don't see any reason why not with the locked out in extension, that you can't do full weight bearing immediately, and then advance up. It's just, it's tolerated, you know, with crutches, but then advancing them off that touchdown weight bearing stash pretty quickly. That's a great point, though, because that system does leave more periphery of the cortex intact. So like, I think what I do is similar to what Austin does, which two-thirds of it's maybe intact, but you probably have 80% intact. So I think there is something functionally different there. The tibate muscle, I haven't taken it down at all. It's really tolerable by the patients. I like it. So you guys want to check it out, but I've been putting full weight on it, letting it go, and they're loving it. It's much, much easier for the patient to tolerate. Now, if this person were on the football linemen, for instance, like, would you change? You know, does body mass play any into that at all? Body mass would play into my use of an OCA, but in terms of weight bearing, no. With that system, I would be weight bearing, it's tolerated, locked in. I did one last week, and a guy who's 6'4", he's 260 pounds, it's fine, weight bearing. And it's much more tolerated by the patients. I've unfortunately been a patient myself, and keeping a leg locked out straight, toe-touch weight bearing is very tough to do. All right, so just to keep moving, we'll move through this next one a little bit faster, but I thought this was an interesting comparison. This is a 16-year-old mental soccer player, and he's not going to Europe. He's had a month of left knee pain, no discrete trauma, developed popping, swelling, and feelings of giving away. So this is a different picture from that last one. He's got swelling that comes and goes, and he's got some mechanical symptoms. No instability, no history of instability, no history of patellar trauma. And on his exam, he does have an effusion. He's limited by pain and apprehension in terms of deep flexion. He's got patellar crepitants with compression, and he's stable and doesn't have any signs or symptoms of patellar instability. And here's his X-ray. Thoughts, comments on his X-ray? Some proximal lateral fragment up there. It looks strange, but overall, it looks to be in decent shape with the exception of the lateral. And his mom is also one of my OR nurses, which is great. So... But this is OCD again, you know, Austin? I would say this is OCD again. Because you could see on that, it's just what you had on that other one, but less severe. Like again, what Christian was pointing out, there is like a ridge you can see in the bone right where that defect is that's deeper than the surface of the subchondral bone. So here's his MRI, a little different. Like I think his subchondral plate has a touch of involvement, but I don't see the same level of bony involvement here. And I don't really see a lot of subchondral edema. It appears more sheer for him on his MRI. And you could argue on that sagittal cut that you may have a little bit more, and you might see a little bit more edema there. So on him, what are the thoughts? He's far more acute. He's far more symptomatic than the other kid. Is there a recoverable piece in there somewhere? None obvious on the MRI. So the arthroscopy here in a second. He also is, so he's 16. He wants to play his senior year. And so we've got time to work with, but they don't want to wait around either. So they said, you know, I know I've got a cartilage problem. I know it's likely to get worse over time. I want this thing addressed so I can lose my junior year and get on with my life. You're saying he had one event with one effusion, or he has had no acute events with multiple effusions? He's had a month of increasing pain, and that's been associated with swelling and mechanical symptoms. No single event. No single event. Yeah, so like the other thing that I think is an important part of the conversation is that like when I have people that have that story, at some point that cartilage, you know, synovial fluid comes from the synovium. So like there's no other source for it. And the reason it makes the fluid is usually because it's pissed off. And the cartilage lesion is the assumption of why it's upset. And if you treat that, then maybe it calms down, but it doesn't always calm down. It can become two parallel processes. And sometimes you can treat that defect, but they'll still get swelling because the synovium hasn't restored itself. And so I use injections actually quite a bit, both pre-op and post-op for that reason, to try to help calm that environment down. So if he was in season and trying to get through it, I have no issues with injecting him. I also inject steroids, which I think could be a topic of debate. But, you know, but if it's not, then I think it's a similar algorithm to what we just saw in that last one. Yeah, in season, I use Depo-Medrol. So I do use steroids in season. And then I just, out of season, I'll do gel PRP combined series of three, if we can give them like a full three weeks of injection, six weeks of restriction. Any concern about cartilage procedures following steroid injections? That's my concern. I don't like that. So I would go with PRP if I was gonna do any injections. No concerns about doing steroid and then subsequently doing cartilage procedures? Yeah, no, I mean, it's one of these things that like, if you drink a thousand cans of Coke, you'll probably die. But the doses in the environments that we test these things in the lab are not always clinically relevant. And so I think that it's important to have a dose of, you know, concern that is, you know, it's reasonable to have, but I think extrapolating some of the basic science data, like the clinical data to support those kinds of decisions is really poor, you know, but I understand, you know, where your head's at with it. And, but I'm still currently okay with it. And I haven't seen some, you know, even the studies looking at like revision rates of rotator cuff repair with prior steroid injections, those are database studies. Like nobody's ever done like a good study on that. And we did a study in an abstracted and a couple of years ago looking at that exact problem. And the data got really muddy, which is why it never got fully published. We didn't find any significant differences once we accounted for all the co-founders. So, I mean, I'm still pretty skeptical myself. I've done it in season as well, but it does make me nervous in a knee where you're going back in and you're gonna be taking cells, putting in graphs, like you messed up that. I think it also matters who it is. Like if it's a kid going into his last year of college sport is a little different than a 16 year old who, I think if you tell this family that the right answer is to fix this, which is what I would say, I would say we're gonna scope it. I'm gonna look hard for a loose body. I would bet there's one somewhere. I think this is an OCD and I'm gonna get a Macy biopsy. And I think there's a perfect candidate for amaze. And this one may be an osteotomy because I think this is an unloadable defect, but I don't know what his TTTG is yet. Well, Christian, can you comment on your experience with acutely using steroids and the setting of ACL and hemarthrosis? Because if anything, it shows that it's beneficial, not detrimental. Yeah. So first of all, steroid injection, the actual component or the mechanism that steroids work, they work through a nuclear receptor inside cells. So once you have injected that, once the half-life is over, which is actually only within a week or so, and less than that, actually, it shouldn't have any effect on a graft that you're putting in there or anything else, right? Because it's an intranuclear receptor, it's gone, right? So it's not lingering around inside that joint doing something magical. And then the other thing that you have to consider is you have to know why you are doing this injection. You're not doing this injection to treat articular cartilage. You're doing this injection to calm down the synovial membrane. And what the synovial membrane does in this joint with the effusion, we have looked at that very carefully in ACL tears. This is a toxic soup that it's creating there. And that actually is much more detrimental to your cartilage or your cartilage repair than the cortisone would ever be, right? So if your main concern here is quite significant larger effusions, then I think a cortisone injection is the best thing you can do. There is recently some Pearl Diver data that is coming out that suggests increased infection rates. If you are injecting cortisone beforehand, I can tell you I've done these in hundreds of patients. To this day, knock on wood, I haven't had a single infection in any of these cases. So I'm not sure if this is maybe just a different animal. But it is not wrong to use this here if you're doing it for the right purpose. TDDG was 15. I'm sorry, I didn't actually put that up on the screen on him. So again, very similar to the other case, which is one of the reasons I liked it. So what would you do? I think just more physical therapy is not really going to help this kid. We talked about the use of injections. We talked about arthroscopy. We talked about moving forward. They are on a timeline where they want to get going. And so just to keep the day moving. What time in the season was it when he comes to you? Preseason of his 16th sophomore year. Sophomore year. Yeah, so he's willing to earn his junior year in an effort to get back to his senior year. You got plenty of time. Yeah, he's got a year and a half. He just wants to play his senior year. He's not looking to play in college necessarily. He's good and likes high school, and that's his goal right now. Cellular therapy works really, really well in this kid. What does? Cellular therapy. Cellular therapy. So unlike the other one I said, I think we've got a pretty good shot at doing an ACI. And so that was the plan going in. Again, his patella looks pristine. The interesting thing is that you saw the differences in the MRI appearance. The difference at the time of arthroscopy doesn't look radically different from that other kid. And so, you know, I mean, maybe I made the wrong decision than him. There were a few other factors, but yeah, that's that was my opinion. But you look at here and you're like, look at this. This doesn't look that different. But he does. He has a loose body. Oh, there's terrible problems. And his was actually just slightly bigger, too. I mean, five square centimeters just on the on the initial. You can see there's a hint of bone on the back of that cartilage, but there's not a salvageable piece. It's been floating and beat up. And also it doesn't. There's the lesions much larger than that. He had a snow globe appearance when I stuck the scope in. And so I did take the biopsy for him. So now, again, they're on a timeline. And so they said they just want to go. So we went ahead and authorized it. Who would do a TTO on this kid? So we're going to do an ACI. Who would do a TTO? Yeah. I would do the exact same procedure we did on the last one. Yeah. So. Oh, so you'd use an OCA on him. Yeah, this is an OCD. So like, well, I'm I use a lot of graphs in the patella femoral joint anyhow. So I have my own biases there of why I think they have more reliable outcomes. But we've all had our own experiences. But it's still this is still an OCD. It just doesn't have as large of a bony defect. I had a I had a patient with an OCD of the lateral trochlea that was a football player in his senior season. And I did an ACI TTO on him. And he played college ball the next season, freshman year. So you can get him back with that with that ACI procedure and Macy for sure. So I think one of the things we're kind of dealing with here is return to play issues people are worried about. But I think once again, you know, the fallback is, as we were saying, is, you know, I think it's an issue if you don't have it heal in. You have cystic formation. You have this zone of edema. She's talking about it six months. You know, it's a problem. It's a big problem. So I think, you know, yes, there's bone involvement. But bone involvement, it's a big issue. I know it's one we all talk about. But it's not necessarily a contraindication to using autologous contraceptive implantation. One thing we should just for compliance reasons, Macy is FDA approved 18 to 55. So this is a 16-year-old. I do disclose that to anybody under the age of 18. I don't think that that means it, but it's technically off-label. Yeah, so right now. He's 16. FDA approval for Macy is 18. So this is off-label. So even though this is in the U.S., this is off-label use. But, you know, I just want to remind you that in the original clinical trials data from, you know, the original Macy cohorts in Europe, the Macy does do very well in OCD defects, right? And, you know, while the majority of these defects reported in the literature there are in the femoral condyles, but there is also some trochlear defects included in that data. And the Macy is absolutely able to take care of that. I think the difference here is the location and the amount of loading that you're anticipating going forward here between somebody who is trying to go professional and somebody who just wants to have fun in the senior season. And I think that is in the location on the lateral side of that trochlear where you can actually really truly unload with the TTO. I think that that is, you know, the main consideration, whether cell-based is making sense or not. But for the audience, the Macy is absolutely an appropriate technique to use in an OCD situation. The newcomer in this field is really the osteochondral allograft, particularly in this age group, right? All the big osteochondral allograft data that also Adam refers to is done mostly out of Bill Buckby's and out of the Oregon group's data, but this is mostly in older patients, right? So you have to kind of sort of, you know, you're making inferences either way. And I think we are in the fortunate situation that we have two very powerful tools to deal with that. Can I just answer? Because I was just talking to Verisol, and he was saying in some states or some insurance will deny it based on open growth plates, but they get it approved 90% of the time on the peer-to-peer. So it's almost always if you go through the trouble of peer-to-peer, it will get approved. Really? The larger issue that I've had is because we're an academic center, we also see Medicaid, and they summarily deny these. And so that's where we get into a big issue is if I've got a Medicaid kid, they just won't approve it. I have had zero success. They default to OCA. And in our tri-state region, I've heard of zero successful appeals. And in my personal practice, I've had zero. But for this kid, just to keep moving because we want to get to the last couple cases, but I agree that it is an overuse injury, and therefore if I don't change the mechanics, I think I'm asking for trouble. So I did a TTO in this kid with the MACE. You can see it's a pretty large lesion. There was a millimeter or two areas of bone involvement. I don't know what the threshold really is. I don't graft that. I just do a surface treatment there. But perhaps it's the wrong answer. I don't know. Time will tell. What's your threshold when you get in there? What's your threshold of bone involvement for considering a sandwich technique, bone grafting? Yeah, I use a six-millimeter depth or larger to determine that. It looks pretty deep. I would debride it. In the peak study, it's interesting, at least from what I'm seeing, it works in any depth, MACE. So I don't know how far you have to go. I think Adam's right. This is an osteogenitis desiccans lesion. I mean, obviously, that's what you saw in that fragment. It had bone on it. But I would say it's six millimeters depth or larger or deeper. So similar. I want to go through this one quickly, and then I want to get to that tracheoplasty case. So this is a 25-year-old. She was a collegiate basketball player. She is now initially seen at the March of her senior season, so they're getting ready to go into playoffs. In February, she had a pop while she was playing, and she had immediate pain and swelling, so there was a traumatic event. This was not associated with a patellar instability event. She did not have any history of patellar instability and denies any symptoms now. She was told to play. They said that she had a meniscus tear and she had arthritis from her school surgeon, and she's currently trying to finish the season. So she comes to me. She's playing basketball down south but is originally from Lexington. So she comes. She's got an effusion. She's got a good range of motion. It's a little stiff just because of her effusion. She's got a pain around her patella. It's deep. That's where she describes it. She doesn't have any joint-line tenderness and no patellar abnormalities on her exam. Here are her images. They look like more valgus than she actually is clinically, and it's her right knee that's bothering her. Her left knee actually looks a little bit worse than her right. And she comes with this MRI. So she's got some wear on her patella. It's definitely present. TGG is 15 on her. But then if we start to look further down on the trochlea, it doesn't look terrible. So she has some articular wear on her trochlea. Excuse me, on her patella. There's some abnormalities on her trochlea. We do know that she has a cartilage problem here. The trochlear cartilage doesn't look so awful on the MRI. And so right now, she's in season. She's trying to play. She's getting ready for the tournament. Then she's done. She's had her, like, eight COVID years, whatever. She's going to go and get a job. I just don't understand the math. She's 25, and she's not out yet. I don't get it. She's still playing volleyball at 22. So what do you do? You're going to let her play. You're going to say, no, no, no. I've got to scope this. Your season's over. Your career's over. What are you going to do for this? Would anybody not treat her to get her through the season? Would anybody shut her down now? Okay, good. We can just move on. So she wants to finish. We dose packed her, gave her some anti-inflammatories, opted not to do an injection right off the bat. We wanted to see if these worked. And they worked well enough. She followed up after her season, did some more PT, kept strong. And she comes back. Now her effusions are worse. She had a lot of difficulty in the tournament. She played. She's done. But she's more symptomatic than she was a few months ago, now that she's done playing basketball. So now what are people going to do? Scope her? Give her more PT? Do something drastic right out of the gate? Raising the scope. Okay, good. I would inject her. All right, so one injection. I mean, her other knee is we deal with this all the time. Her other knee is structurally worse and asymptomatic. So the disease isn't always the reason for the pain and the swelling. But, Adam, you would not inject her and then be done with it. You would inject her and then proceed with a scope to treatment? Do I understand that right? No, I would see how she does. I mean, we all know that you can inject bone-on-bone knee arthritis and people can get a year or two of relief out of it. So, again, her other knee is worse than this if you've got a scan on it. Would you reimage her? Like a new MRI? No. I mean, how long ago was that other one? It was February. Her MRI was February. I saw her in March because she had already been seen. So her MRI was February. So now we're in May or June, right? Correct. And she's worse despite now having completed basketball. I've had patients that have been injected by, not by me, but repeatedly by other surgeons or physicians and allowed to participate and continue on. And it rapidly deteriorates in these kinds of situations. I mean, I think injection to get the synovitis down and get the effusion down with the continuing treatment plan is a good option. But I don't agree with the 25-year-old injecting and then letting this get after it because it's just going to wear down the bone. I mean, we know the natural history of that. That's going to happen. So, I mean, I would think that you would want to get after it a little bit unless you're going to write her knee off. And she's 25, so I would want to take my shot at the title now rather than letting her press further and have more damage to deal with. Yeah. What are you going to do with her other side that's worse then? Well, she's having more symptoms on this side. It looks worse on x-ray. Yeah, she's completely asymptomatic on her other knee. Yeah, she's asymptomatic. People can become asymptomatic with injections. Yeah, but she's not symptomatic, so I'm not going to touch that knee. I'm going to let that knee stay quiet so I can use it to help me recover from the other knee, the right knee surgeries. I would fix her right knee and get her right because she's probably going to have problems in the left knee as she progresses up. Get her right knee fixed and then move on. Get her to 28 with a reasonable chance to have a knee that's at 40. That's not going to need a total knee. Well, and I can't remember because what does what does done mean, though? I mean, 25, she's not done with anything, regardless of whether she gets quiet or not. She's going to have progression of this disease. I mean, that's pretty significant involvement. I don't agree with done. And we haven't even looked at the tropia yet, which was a real pleasant surprise. I don't remember if she got an injection in February or not by her team surgeon. I don't remember that. I saw her after the fact. Yeah. Jason Drago showed us that it's a small dosage. A corticosteroid, especially triamcinolone, isn't too bad. And at large doses, it really is chondrodestructive. So the one injection doesn't upset me at all and may solve a lot of problems. But if I'm going to operate and I know I'm going to do a cartilage procedure, I would try to avoid doing any type of injection first. And keep in mind, at this point, she's she's done. She's already finished her season. She she met all her objectives and now she's moving on with life. And I think that the big question here is and this is this is where where I think, you know, Adam is is sitting slightly on a different timescale here. The injection is not going to cure anything here. The injection is symptomatic treatment. So the question is, have you made the decision that symptomatic treatment is not going to be good enough because it's going to be coming back? The problem to face you in six months or maybe in a year from now or are you and the patient ready to tackle the problem now? Because we know there is a problem. Right. It always just boils down to what the expectations are between you and the patient, right? She's done with her athletic career. She's done with her basketball. She's done stressing out her knee. But if she's not quite ready to take on a fairly large procedure, this may not be the right time in her life. Then I think an injection singular injection is a good idea, but not necessarily something you're going to keep on repeating, repeating, because we all know where the natural history. She's 25. This is going to come back. The question is, when, when in her life is this something that she can tackle? Right. And she she is also a great surgical candidate. She's fit. She's, you know, ideal BMI. And she's ready. She's done being a high level athlete. She wants to get on with her life and be fit. But she's not trying to even play recreational basketball. She's over it. She's played for forever. So her patella actually looked somewhat similar to the MRI trying to get vertical margins. But the surprise for me was the extent of the disease in her trochlea. And so this is not something that I found quite evident on the MRI. A lot of this cartilage is delaminated and it's it's pretty involved. It unfortunately is right where she tracks. And so for her, just trying to trying to get the loose cartilage off, get the vertical margins and see how she does. I did end up taking a ACI biopsy. So this is bipolar disease. It's not what I said in my operative note because I'll never get it approved. But she's got pretty extensive disease. So what's what's your long term plan for her? That's that's OCA every day of the week for me. Both sides, patella and trochlea with the TTO. Anybody do, well, essentially a bipolar ACI? No problem. I would do large areas. That's hard to get right. And you're talking about patella, too. Well, I work in a private company. We have our own carbon bioreactor. So we make our own counter sites. And we've decided that we didn't want to spend $40,000 per one. We charge 11,000 euros, which is now $11,000. And it makes it more expensive than counter sites. So different places in the world. In Japan, you can't use counter sites, but you can use MSC. So different places in the world have different experience. But we do this all the time on our ACI. When we used to do ACI, the telephemeral was not allowed. Now we found out after our first Macy that it really works well. And we've got well over 100 patella femoral ACIs that I actually published in the Hisakos book on patella femoral lines based on our patella. So I think there's enough published data on cell-based repairs. Even if you have bipolar lesions, you have a slight deduction in the outcomes. And we know that. But this would be somebody where I think I would absolutely discuss the Macy. You know, you can do bipolar allografts. But to tell you the truth, the data on that is sketchy. And it's still not anywhere near in comparison to what we know about the Macy. Plus, in a 25-year-old, again, and this will be something where I would consider the aftermath is if the Macy fails, you still have the allograft as an option. If the allograft fails, then you are at a patella femoral replacement. Yeah, I mean, that was one thing that I felt strongly about with ACIs that you're not burning any bridges here. Yeah. My problem with the ACI in this one is where do you get your biopsy? Where's your good biopsy? I mean, that's one of the things you talk about is osteoarthritis. This is basically an osteoarthritic knee. If you look at it, she's 25, but she's been really pounding this thing. And so all these matrix from teloproteinases have been floating around. The cartilage that you get is, you know, you can biopsy, but I get concerned about the already the history of the knee already. And that's why I use the osteochondrology in this situation, because I think I can just get a more reproducible result than I have with bipolar massive lesions like that. I've done some bipolars, but that's large. That's very large. Bill Bugbee had published his longevity studies, and the worst are patella femoral and osteoarthritis when he does an OCA. So patella femoral was right there with osteoarthritis for about seven or eight years with good results. And then they tend to fail. Mm hmm. And yeah, some of those studies, too. Sorry. I don't mean I don't know if I cut somebody off. Sorry. The some of the studies, too, though, you know, you have to look at techniques. You know, the I know you use the word sketchy, Christian, but it's just poor quality data that doesn't show that they're necessarily bad. But the Dr. Bugbee has pretty good data. I'm just saying the Macy data is the quality of data for Macy's very high. So like there's just higher quality literature and larger series. But the you know, we looked at Jack Farr's shell graphs versus our plug graphs for patients with bipolar patella femoral disease. And the shell graphs did very poorly. But a lot of times that'll just get lumped into bipolar patella femoral OA graphs. So I think that the details really matter. And I would do the same. I would do bipolar graft detail. Do you have any concerns about the size here? And this is I mean, so I use allografts fairly readily in a patella femoral joint, typically not for bipolar lesions. But I get nervous if we are talking about grafts in the vicinity of 25 millimeters diameter or larger. And part of that has to do with that I've actually had to revise quite a few out of neighboring states where that was done very deliberately. But it's very large graphs, particularly in the patella. And you know, this is why I'm a little cautious about that. Yeah, it's interesting, Christian. Those were large plugs that were in the patella. Sorry, the ones that you were revising that you saw a lot of was more plugs in the patella. Yeah. And the revision was for cysts and delamination. Or what was the mechanism? Basically, fragmentation of the grafts. Yeah, pretty interesting. I don't know. You know, I don't know who did that or how the technique is, but like the in the patella for OA grafts, they're very especially if you use the ones that have a millimeter of offset, they're very difficult to put in. And I have like a no impact rule in our OR. And so I hit the crap out of the dilator to get that in multiple times. But all of them are press fit. And, you know, we have a series of about 50 we're looking at now. We had zero fragmentation. So I don't know if there's technique differences that matter. I don't know. But there there used to be this catastrophic failure concern of like 30% in the older literature. But I do feel like with more modern approaches, I feel like we're not seeing it. But I don't know. But you are. So I'm I'm open to listening. Do you worry about a size mismatch between the patella and the femur if you're putting plugs in? Because I plug the patella in and it doesn't really match with the femur. And the same thing I've done on the femur. And it's not really the way God made the patella femoral drain. Is there any special sizing that you do or you just get the best whatever the company gives you? Yeah, the companies don't want to restrict those grafts because they're already hard to get. And they'll give you three measurements, you know, at most. And those have been debated between Sabrina, Andreas and I and others. And so I don't think we know for sure. But like trochlear width on MRI is kind of the one that I feel like I need the most reliably. You know, if you can get a sulcus angle, that's great. But a lot of times you're not going to get that information. So and it'll never match perfectly. But the ones that I get are from the same donor. So the patella and the trochlea at least match. We just published a case report on a guy who was a fifth degree black belt that we did a large bulk allograft of the trochlea on. We used BMP seven to incorporate the graft along with fixation. And and so one of the things that that you can employ in these in these trochlear areas is fixation if you need to. I mean, screws are not a bad idea to get compression. And in the same thing with the patella, getting compression of the graft in the patella, I don't we use these minimally these minimally invasive screws, acumen screws, titanium screws. They compress that graft. And I've been impressed with how it incorporates. But but I think it's it's it is hard to contour. But you can you can recreate the contour of the patella pretty well with the with the osteochondral to my hands. And I've been happy with them, too. And I've done quite a few bipolar lesions in the patella from a joint. So we may need to put those together because I got I got a large series, too. Yeah. So the question is, are you going to do a TTO on her? But if you get her 10 years, she's 35. And if you do a osteochondral graft, she's thirty five with a failed bipolar osteochondral graft in the patella from a joint, then it's committed a metal implant. But it's but it's interesting. We've had a 17 year old with a car with a contra graft. And you guys want to put the OCA in the kid is 17. Now we're talking about 25 year old with bipolar disease. She's finished playing. And we and we're not going to say this the same issue. Right. Why did we do it in that kid? But not I don't get that. That's the that's the part I don't get. It's kind of it's so funny how we decide these things. And so I wonder why we decided in the 17 year old to go with OCA. And everybody's all over it. And this one now we're all doing Macy on a bipolar lesion. 25 year old with that. Oh, my God. And the same issues there. Yeah. Bone incorporation is an issue for sure. Well, it is the bipolar, in my opinion, kind of changes it because you could revise that trochlear OCA. Hopefully don't need to, but you could because we tell us fine. And your revision would be a removal of autologous bone grafting and a Macy procedure in the 17 year old, correct? Yes. All right. Austin, Austin, real quick. The other thing is that the I think that a lot of us have that in our mind of like the cat, what we view as catastrophic failure of graphs. But like, by and large, that doesn't happen. And it's the failure mechanism is either continued pain, which is a nonstructural failure mechanism, delamination of the graft, which puts you exactly back to where you started or structural failure. And structural failure can be treated with revision OCA, which is getting into rare air in the patella femoral joint. But it doesn't have to be metal and plastic. So I get the concern, but I think it's actually not as large of a concern as it seems in our heads because it seems like such a bad outcome. Adam, I might disagree with it. Back to where you started with delamination. Now you have dead bone under there. Yeah, it's got some dead bone in it. For sure it does. You think that you think the delamination in the graft that looks bad and MRI doesn't have any bad bone, it's bad. It's worse bone than it was when you started before you drilled into it. Assuming it wasn't an OCD at the beginning, it's worse. I mean, I think it's bad bone. That's my my thoughts on that. That's the problem. But when you ream it out, you know, if you put in a five millimeter graft, yeah, as long as it's bleeding. So maybe I go to a six. I mean, it's been pretty rare. I've only had one delamination that I know of. And it. One delamination out of all your osteofendolysis? OCA's, yeah. And I didn't really believe it till I saw it. I thought the bone would look crappy and the bone actually looked completely normal bone. I still reamed maybe six millimeters just to make sure it was good bleeding bone. But maybe I went up a millimeter to an OCA. We've had we have had some patients where we did an OCA after they'd had like a smart nail fixation of an OCD where I think it does it can disrupt the blood supply. And so where you get part of the OCA healing in and part of it not. And then you fix that part with a sandwich macy. And it would have a sandwich macy have done well in those cases, primarily with some bone graft, maybe. Those are the ones that are a little tricky, where they've had something done to the bone in the past where it's not normal bone to begin with because it's an OCD. And then it's not normal bone because somebody has put screws or something absorbable in there. Yeah, I just on OCD fixation, I'm a little bit off topic, but I really concerned about the bioabsorbable screws. With one exception, there's one new to the market that I think may be very promising. But the ones that break down into CO2 and lactate, I mean, you're to me, you're creating an acidic environment never made any sense to me. I don't use any bioabsorbable from that. There is one new screw that's coming onto the market that may be more promising. It breaks down a completely different matter to bone. And so we'll see on that. But, you know, back to your comment about some of the insurance authorization. So this person, unfortunately, she's off the school insurance now. She's no longer there. Their school insurance was crummy anyways. And she's working for her mother, who is self-employed. In the state of Kentucky, you are forced into the marketplace. And so she now has Medicaid. So she's working to get a new job so she can get this approved. But, you know, at least for the first couple of months after she had that debridement scope, when we got the loose flaps of cartilage out, she feels very good. Her effusions are gone. She's quiet. She's happy. We'll see. We know it's going to get worse. It's not going to get better. So we'll see. We'll see when she gets insurance, what we do next. But that's to be determined maybe some other year. And next year, if we get this, we'll have to lead with your trochleoplasty case because two years in a row we haven't gotten there. Well, actually, since we have one minute or one point about the trochleoplasty was sort of what what was brought up on a bipolar OCA is that, you know, one of the things that we really worry about with trochleoplasty is that you're not doing a patelloplasty, although David Dujour says occasionally he does do a wedge, takes a wedge out of the patella to change the shape of the patella, which seems awfully scary. But, you know, that's a real, real worry with trochleoplasty because assuming everything heals, it's kind of like a bipolar OCA. All right. Well, thank you. Any last minute questions? Wrapping up on time. Wonderful. Thanks so much for attending. Appreciate it.

medical case studies

knee pain

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cartilage damage

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arthroscopic debridement

osteochondral allografts

Autologous Chondrocyte Implantation

osteochondritis dissecans

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