Good morning, everyone. I'm Crystal Perkins from Children's Healthcare of Atlanta. So I'll give you an update on OCD treatment, and this is going to focus on surgical treatments. Of course, doesn't include a fair amount of non-operative treatment that many of us do for these. I have no pertinent disclosures. So Mark and colleagues put together this nice article that was published in JBJS last year, and it really highlights treatment algorithms for OCDs. And so I want to draw your attention to these two big boxes here, delineating between stable and unstable articular surfaces. And then for those that are unstable, whether this is salvageable and unsalvageable. And really, this will be kind of the focus of my talk today and how we've evolved in treating these. So again, immobile versus mobile, and the drilling techniques, I'll highlight some pearls for that in immobile lesions, and then mobile OCDs, talking more about kind of an evolving idea that we have on OCD repair, and then for unsalvageable, various graft options. So we'll start with the immobile OCDs. So the Rot Group, which I've had the fortune of participating in, has really done a great job of highlighting kind of how we define these OCDs and how that guides our treatment patterns. And so you can see these ranging from kind of cue ball, the perfect articular surface, to what we call a small wrinkle in the rug. So first, let's talk just a little bit about drilling, the ideas of retroarticular versus transarticular, and then we talk more and more now about the abilities of notch drilling as well. What our studies show us, and this is a systematic review that was published several years ago, but it looked at 12 studies, and really what they found is that whether you retroarticular drill, which people like because you don't violate the articular cartilage surface, or whether you transarticular drill, the healing rates are very similar at four to five months with comparable PROs. Notch drilling is a nice technique. I use it especially in the OCDs where I can really kind of see a little bit of a wrinkle or a shadow because arthroscopically I can easily visualize the OCD or the area of it. It's just another way to kind of get right in there at the subchondral bone, and I use that in conjunction for me with retroarticular drilling. Now drilling seems really simple in purpose, but I thought I'd just give you a few pearls today that I think kind of can make drilling more successful. So personally for me, I do the supine in a leg holder. I do that so I can maximally abduct the well leg and get it out of the way. You're going to be drilling the medial femoral condyle OCD, and so your other leg can easily get in the way of you. And then I use a mini C-arm that enters from the lateral side to be able to visualize, in the case of a medial femoral condyle OCD. I use this three-by-three drill guide, which allows me parallel drill paths. And my first K-wire, as you can see in the image on the right, is placed within the epiphysis to center-center within the OCD. And here's, I think, the part that kind of matters. And certainly as my practice has started to grow, I've evolved in my drilling technique. But on the lateral x-ray, I really try to get a K-wire that's entering directly perpendicular to the lesion. So you can see I put a K-wire parallel to the articular surface just against the skin. And this is because I think as you're drilling, if you're drilling anterior and posterior with your guide, if you're not perpendicular to the lesion, it's really easy to miss a portion of the OCD. And so as you scrutinize your x-rays, sometimes you'll see you miss the very anterior or the posterior aspect of it because of the obliquity of your drilling. I keep two K-wires in place all the time to secure the guide, then use my third to drill. Personally, I like to make a small incision to drill through because I think otherwise you do, it does generate some metal debris going through the guide, and you'll kind of tattoo the skin. In terms of biologics, we don't have great evidence specifically in the setting of OCD in kids yet. But personally, in my practice, I use BMACs. I harvest that before I do my drilling from the Ipsilaura Iliac Crest, and about 60 cc's of that for the system that I use generates about 6 to 8 cc's of BMAC, and then I'll inject that once I'm done. The other thing that I think has really evolved is perhaps the number of drill paths. Certainly when I was in fellowship and I watched Mike Bush do this, he would put kind of two K-wires down, he'd over-drill them, like a 3-millimeter drill, and then he'd put BMAC in and he'd be done. And now certainly in Atlanta, an OCD like this isn't unusual that gets 24 drill passes, or K-wire passes I should say, and so anecdotally we've seen improved healing from the kind of increase in K-wire passes. Your post-op radiographs can be really helpful. So these are two-week radiographs, and you can really nicely see all the drill paths that are done within the epiphysis. I've drawn on the yellow there just a line parallel to the articular surface, kind of looking, did I get directly perpendicular to the lesion and did I cover it? Post-operative plan really kind of protect their weight bearing initially as this begins to heal. Vitamin D supplementation I think is really important. There's certainly a lot of growing evidence of the association of vitamin D deficiency in many orthopedic problems in kids, and so I do check all of their levels, often intraoperatively or preoperatively if I've been managing them for a while, and supplement them, and then tell them kind of return to impact sports as pending healing four to six months. And you can see the nice radiographic changes. This is a kid over nine months out from his OCD drilling. So that kind of covers pearls for that stable OCD that you're drilling. The rest of this talk will really focus more on the mobile OCDs and treatment strategies, and you can see here there's a huge variability in these. So you can see the image on the left, the arthroscopic image there where again the cartilage is in good condition, but there's a lot of pathology back behind that, as opposed to the image on the right where you can see that's very different, a fragmented OCD, unhealthy cartilage, and so treatments vary for those. Just a kind of word of mention that I think is important, these are kind of treatment strategies we won't go into in detail. Debridement and marrow stimulation for the typical OCD, which is large, more than two square centimeters, is really not a great option. We know that temporarily it makes the kid feel better, you get the fragment out. But you're really not treating the deficient subchondral bone, and we know that the fibrocartilage that is produced there lacks the integrity of the hyaline cartilage. So I'd caution you not to plan a definitive treatment of a large OCD with debridement and marrow stimulation alone, although perhaps in partially healed OCDs it may have a role. Single-stage cartilage restoration, also typically not a great treatment option for these, and again because OCDs are associated with primary disease of subchondral bone, purely treating the cartilage injury is typically not what's necessary for these. So the rest of it will kind of be based on cases. So this is a 15-year-old male elite soccer player who has two months of knee pain, and this is a really long conversation in my office. So you see big medial and lateral femoral condyle, OCDs, open FICEs in this patient. And so you see his MRI here, his lateral femoral condyle OCD cartilage was thickened, but overall intact where you see impending instability. There are some cystic changes, but signs of an unstable OCD on the medial femoral condyle. So for brevity, I'll tell you his lateral femoral condyle cartilage was completely intact and we drilled that. For his medial femoral condyle, you can see his arthroscopic images here, so pretty good appearance of his overlying cartilage, but definitely significant disease and pathology behind it. And so this is an arthrotomy done. You can see this kind of loose body sitting in situ, and then maintaining some of the posterior hinge, which was intact to start to open this up. And my preference, and we'll kind of go into OCD repair here, when the overlying cartilage is good, I think the best thing these kids have is their own cartilage, right? If we can save that, I think that's hugely important. So I would tell you, please don't go in and take a huge piece of bone and cartilage out in a kid with overall good overlying cartilage. The ability for these to heal with repair is quite remarkable. So the key is you have to change the pathology behind it, right? So you look at that piece, and you're like, oh, I can put that piece back down. But if you don't treat the pathology behind it, which is the cause of the OCD to begin with, I think you really set yourself up likely for failure. So by hinging this down, trying to maintain a hinge, if we're able to in this case, debriding that out. I like to put the scope in through that little window, because I can see without having to take the whole piece down, and then debride everything behind that, make sure I have good bleeding cancellous bone, that I don't have fibrous tissue remaining. I harvest distal femoral autograft. It's within my same window. Just peel back the synovium, make sure, and if FISAS is open, that you're above FISAS, you can check that on C-ARM. And then harvest distal femoral autograft, pack that in. Now what I would tell you has evolved significantly in my practice, and perhaps many others, is what we use for fixation. So this is very early in practice, and I used headless compression screws, which ultimately in this kid worked nicely. This is his six-month scope pictures when we removed hardware. And these are his two-year post-op x-rays, which show healing of medial and lateral femoral conda OCDs, and he had returned to elite level soccer. What kind of fixation strategies, pros, cons, why are we evolving, and how we treat these. So I think a lot of these options work, but they certainly have some downsides. So metal headless compression screws, they do depend on good osseous structure. They're not good to treat pure chondral loose bodies. They require hardware removal. They can degrade your MRI resolution, and you can have potential adjacent chondral injury. I saw a case of this as a fellow where a kid was asymptomatic and came back and took these out, and there's a nice trough in the medial tibial plateau. And then bioabsorbable implants can also be associated with numerous complications, loosening, breakage, synovitis, cyst formation. Again, people still use these and use these successfully, but my practice has evolved away from those and instead to all suture-based repair. Really started doing this with osteochondral fractures or chondral big injuries associated with patellar dislocations. You know, there you don't have bone to be able to repair to, and so using a suture-based construct that's loaded through bioabsorbable implants that doesn't require hardware removal and provides great compression. So you see here with this OCD arthroscope, or I made a small arthrotomy. The kind of image from the left there is just showing that's my scope in, and I basically put my scope kind of on the bottom aspect of the OCD where it's kind of hinged open. And so I can see and I'm debriding back using either a burr or using a curette to nice bleeding cancellous bone, harvested distal femoral autograft, packed that in, and then repaired that back. So this is bicryl suture loaded through biocomposite anchors, which you get nice fixation with. And we've had great success with this and it's been a nice strategy for these as well as kind of chondral and osteochondral fractures as well. Some of our colleagues across the country have some presentations on this and outcomes at this meeting. So then what about the unsalvageable OCD? So this is a kid that has a huge lateral femoral condyle OCD that we can probably all guess by appearances on x-ray alone is going to be unstable. I would tell you getting alignment x-rays is really, really important. So especially if you're going to start to do work for OCD salvage and grafts, making sure you check alignment is really critical. So this is a kid with a lateral femoral condyle OCD who's in valgus. So at the time of a scope, he had a fragmented 20 millimeter loose body that wasn't salvageable. And so here's his kind of defect that he has. And so my conversation with the family typically when they're skeletally mature is our options if we can't repair are for grafts. So at osteochondral allograft typically as my workhorse, I find an autograft oats. Typically for OCDs, the area is quite large and so my preference is to use an allograft versus bone grafting and treating the bone problem and coming back for a cartilage substitute over the top. I generally push for osteochondral allografts most of the time because I think it treats in a single stage the bone and cartilage problem. But sometimes families have strong oppositions against allograft and this was one of those particular cases. Family said, no way. You're not taking anything from anybody else and putting it inside of me. And so we debrided and bone grafted this at the time of the arthroscopy. And then we came back and did, this is Macy over the top and a simultaneous distal femoral osteotomy to take them out of valgus. And so, not to be proprietary, but Macy if you want to think about how do you deal with a bone defect, right, this is very different than an isolated cartilage problem. Your options are to do what we did in that case at the time of your arthroscopy, debride, bone graft, treat the bone problem. Or alternatively, you can do what we call Macy sandwich, basically where you would do a single surgery with bone grafting and two membranes. So either is certainly possible. Keep in mind, you cannot do this in a skeletally immature. So don't take out a huge chondral piece in an 11-year-old and biopsy it because insurance won't approve for you to do a Macy. And then just to kind of wrap things up, looking at graphs, this is a 17-year-old female who had four to five years of knee pain. You can see it has very large, almost the entire width of the medial femoral condyle, OCDs, and of course is in varus. And so her MRIs show these. This is her kind of scope image, clearly, at least in my hands, not what I would consider to be a salvageable cartilage fragmented, frayed all around the periphery. And so you can see kind of her open image on the left, which shows this kind of cobblestone poor cartilage. And so she had a 25-millimeter osteochondral allograft, her medial femoral condyle, and a simultaneous high tibial osteotomy. She's actually having her other side done next week. So I kind of touched on this, OC allograft versus Macy, really it's a discussion with the family. For a kid, then I'm like, as I say sometimes, like a little bit of the knucklehead factor, less compliant. You need compliance with both, but I think that OC allograft's probably a little more tolerant as compared to a cartilage graft, but overall, similar return to sports. So kind of high-level conclusions, drilling of the immobile OCD can be very successful, but I think attention to some fine-detailed points is important to make sure you get full coverage. OCD debridement, bone grafting, and repair I think is really, in many of our practices, growing. So the ability to maintain their own cartilage I think is really important, and it avoids a second-stage procedure as well, and we've seen great success with it. When OCD fragment salvage is not possible, though, either chondral resurfacing in conjunction with treating of the subchondral bone problem or osteochondral allograft transplant are good options. And please, please, please get standing alignment radiographs routinely in the setting of OCDs, either in the skeletally immature considering simultaneous guided growth or unloading osteotomies in the setting of resurfacing procedures. Thank you.

OCD treatment

surgical treatments

treatment algorithms

drilling techniques

graft options