We'll do questions and then we'll get into some cases as well. So if anybody has questions, go right ahead. If nobody has questions, I can kind of, you know, you say what are these factors for healing? And sometimes I'm in a room with a patient and family and I'm standing and they'll say, are they going to heal? I can say, I can give you a simple method for who's going to heal. If they're this tall, everybody's going to heal. If they're this tall and they have a beard and a mustache, nobody's going to heal. If it's in between, everybody else is in between. The other thing I would say is when there was a discussion of OCD suture bridge fixation, you don't have, some of those anchors you can put in the cartilage just adjacent to the lesion. But sometimes at the intercollar notch, one of the anchors you can put within the notch so it's not through the cartilage. If it's far lateral, you can put it beyond the cartilage laterally. If it's proximal to the trochlea, I put a few proximal to the trochlea. And at the patella, that's a really valuable tool, I think, because you can drill through the patella and use some Keith needles to bring some vicral sutures through and then tie it off on the anterior aspect of the patella and you never have to go back for those. And that's a tremendous help because for some of these arthrotomies for patella, you have to evert the entire thing. So that can be helpful for those. I have a question to Crystal. So you kind of really stratified very nicely which intervention you are using. And I also have a question. When do you decide to intervene? How long do you wait? What are your tipping factors? Yeah, I think that's a great discussion. Crystal, you want to grab the mic? Oh, sure. We could probably have an entire hour-and-a-half long discussion about non-operative factors and who you treat. And I think it's very much family-dependent, and these are lengthy clinic visits, I would tell you. So I think there's a lot of OCD characteristics. You highlighted a lot of those kind of radiographic and MRI appearances. Lateral femoral condyle OCDs make me nervous. Kids with closing FICEs, right, so that the 10-year-old with an OCD, I can very reliably tell the family. It's going to heal great with appropriate activity modifications. When I start seeing subchondral cystic changes, I worry about those. When I see them taking up a large portion of the width of the femoral condyle, I worry about those as they get larger. So I think there's OCD characteristics that matter, and then I think there's kid, patient, and family characteristics that matter as well. And I really present the data to them both ways. We know that OCD drilling has greater than 90% success rates, somewhere in the four- to six-month healing timeframe. The healing of stable OCDs varies, and some reports 50% to 80% with appropriate compliance with activity modifications. So I try to steer them in a direction, more of what I think they're going to do, but I would say the closing FICEs, lateral femoral condyle, subchondral cystic changes, in my mind, are very quickly ones that I push in the direction of surgery, whereas kind of the small medial femoral condyle, OCD, open FICEs, small, are ones that initial non-operative management I think is very reasonable. Yes, sir. Go ahead. So for non-operative treatment, I think a couple of the speakers mentioned Neumobilizer for six weeks initially, and then progressed from there. And I have not had that tendency to do that. You know, if the athlete or the patient is asymptomatic with everyday activities, I have not immobilized them. And I was wondering if that was important to start the healing process to do that immobilization. I was just afraid of immobilizing them and having them get, you know, lose muscle strength and all. Just wondering your thoughts on that. So for those in the back, just to make sure everybody heard, the question is about bracing and non-operative management, particularly the initial management and the importance of bracing versus the potential risk for atrophy. Kevin can certainly comment on this. But I'd say there are certainly no wrong answers for non-operative treatment for OCD. So we've got over 1,000 patients in our database, but we don't have sufficient data. So if your protocol is bracing, if you use crutches, if it's non-weight-bearing, if it's unloader bracing, if it's a lock, brace, and extension, and a weight-bearer with a brace, lock, and extension for six weeks, and then they're non-weight-bearing, they're not in sports for six weeks and reimage at three months. So we could not have enough data to say there's any correct answer or there's any wrong answer. And having said that, Lyle Michele would say, go away for six months and come back, and we'll see how you do. So I would say there's a wide variation of non-operative treatments. There's no technically wrong answer. I think your comment on immobilization and atrophy, and not so much stiffness, don't see much of that, but certainly atrophy, I think you do. So I don't like casting and immobilization, but I will use unloader braces and try to do activity modification, but let the kids still be active to avoid some of the psychosocial impacts of taking them out of sports. I address the family and the kid a little bit, too, I would say. So my non-operative approach is not necessarily standard from kid to kid. So, you know, there's the incidental OCD that you find in a kid who has Osgood-Schlatter's, and that's where they hurt, and they found it on x-ray, right? They don't otherwise have symptoms, and I just activity modify for them. And then there's the kid who hurts with everyday activities, and their means of, you know, walking around the house is like jumping off the stairs. And so they hurt all the time. Mom and dad can't slow them down. They're very frustrated. And so sometimes, for me, a use of a knee immobilizer brace is a helpful thing just to slow them down temporarily, but that's a rare minority of my patients that get that. So we'll take two more questions, and then we'll get into cases, and then if there's time at the end, we'll have some more. There was a question here and a question over there. Again, for those in the back, the question is about return to activity, lighter activity, cardiovascular activity, not necessarily impact activity, and the timing of that for the nonoperative patient. I think swimming and biking. You kind of have two populations of patients. You have the patients that are, like, high-level athletes, right? And then you have the 10-year-old who just has an OCD, and he likes to run, jump, and play just for fun all the time. So for the kids who are really concerned about kind of maintaining that, you know, I talked to them about cardio-wise, swimming, biking is my preference. But I think with elliptical, they're still putting some force and make them think they can do more. So I typically don't do that. And if I could just kind of – one thing that kind of has helped me, I think, if you think for OCD lesion discussions, sometimes families, they want to go in the morning, they want to get spark plugs changed at 9, go to the mall, get a sweater at 10, go 11 and get that OCD taken care of, and then go home. And so – and then discussing some of these nonoperative measures that they have to do and also surgery. Do you have to arthroscopic or open? Like, why are you doing this? If you follow Philadelphia sports, we've got some tough sports fans and we have some tough families asking us questions. So I get to the point where I said, if you – the concept of OCD is there's an area of lesser viable or non-viable bone. And we'll just say a little more extreme. There's dead bone you want me to make become living bone. So you are literally asking me to bring the dead back to life. And historically, if you ask any doctors, cardio doctors or heart, lung, liver, kidney doctors, that's considered a classic thing to do. Historically through it, the history of mankind bringing dead things back to life, whether it's medicine or religion, is challenging. And so therefore, you need to be prepared for perhaps a prolonged nonoperative course to get something to heal. Or if it's surgery, we have to put some viable bone or drill into that, like drilling for oil or physically put new bone. And you're going to need to be prepared for not just one surgery, but a surgery to put things in and then surgeries take things out. And we don't get – we don't get 100% muffler shop type guarantees for this. We're trying to save your cartilage so you can have that for a lifetime as opposed to putting cartilage from a dead person in there. So I think perhaps I started – I start now with every patient trying to set the expectations from the minute that they show up. Last question here. Yeah. Well, I was just going to go back to some of the comments you were making. You know, if you look at the Wilson test, you really captured the beast as you come up in the extension and you're shearing it. Shear forces – I do – I'm also an album guy. I'm really just doing a lot of how-to books. I've always thought that shear forces probably play a role. Takahara just recently, this year, posted a really great paper on the difference between casting, splinting, and active modifications versus splinting, active modifications, and active modifications. Why don't we – why don't we – why don't we – why don't we give her the shear force? Why don't we give her that tip? Instead of, as you come in extension, capture the beast? I can just – I'll just comment one thing and say just my two cents is that I actually will give patients a hinge brace locked in extension. We used to do cylinder casts like the late Dr. John Gregg in the 1970s, 80s, and 90s, but now we have more sturdy braces. Give them a hinge brace locked in extension. Give them the best of both worlds. Protection. Lock it out in extension. Let them wait. Bears. The philosophy is compression can stimulate healing. Allow them to work on their range of motion at home. We want them to do that. Then they can also remove that, take a bath and a shower, do that for six weeks. If it's an unloader brace and they have the means to get that, I don't mind. Again, your concept of shearing is involved there, but I'll – frequently I'll just lock them in extension. There's many logistics involved, but everybody can go to the cast room, get that hinge brace, six weeks of that, six weeks, go to physical therapy, get motion vaccine back in three months, and re-image. We actually use a very similar – we make a cast. It's a polyester material instead of a cast. It looks just like a cast, but it's open in front. We put them in a cast for eight weeks being a kid with lesion, but they can come in and out of it every day and take showers. The parents aren't prepared to let their kids in the cast. But we don't use range of motion braces because of the elbow. Unfortunately, I have the range of motion braces that don't stay where you put them. Yeah. I love it. It's a great idea. Yeah, you do. Go ahead. Quick question. So there was – I think I can just pick up. There was a recent paper which I read, a rock group was involved, that it depends also if you are an orthopedic surgeon or a sports medicine doctor if you choose to go to surgery or not. So there is kind of also quite a bit of personal – if you could comment on that, that I thought was very interesting. Kevin's great on the variability discussion. I'm not sure if I have much to offer there. I just think there's so much variation. And obviously, if you're a surgeon, you probably think a little bit more about surgical tools. But I do think one of the things about OCD, and Ted was alluding to it, is that I think when you first start meeting with the families, talk about the spectrum of the disease and the fact that this doesn't always heal, and you might end up with two or three or maybe four reconstructive surgeries over a three or four-year period, depending on how you do. And I think letting families know ahead of time this is a complex problem and that it doesn't always heal. If you tell them from the start, they're sort of prepared for that. If you tell them later, sometimes they're disappointed. And Jim Carrey likes to say the difference between an explanation and an excuse is timing when you tell them. If you tell them ahead of time that it might take a long time to get them to heal, whether it's a casting protocol or a surgery protocol or might require more than one surgery, they were expecting a complex pathway. And if you end up healing quicker or sooner, that's great. But I think getting that in front of the family, both the child and the patients ahead of time, parents ahead of time in particular, is really helpful just to prepare them for some of these cases are the worst-case outcomes and require multiple surgeries and end up with an osteochondrial graft. So I think that communication piece up front is very helpful. And I'll also tell them, if you carry an umbrella, it won't rain. If we describe these more challenging cases that can take many years to heal, you'll be the guy that'll heal in four months and you'll be set. Okay. I think we'll move into cases. So I'll have you guys kind of give your thoughts. And also, if you want to talk about some of the imaging findings, that would be great. I think it'll cover some of the stuff we've talked about. And then at the end, again, if there's more questions, happy to go over it. So the first case, this is an eight-year-old male. Patient presents with two years of bilateral knee pain, no precipitating injury. The pain was located supermedial and anteromedial, worse with activity, but bothered this patient even with walking and even sometimes at rest. Occasionally, the pain was severe enough that it would cause him to stop activity. So the only treatment he'd had was NSAIDs at that point. On exam, there was patellar crepitus bilaterally. Otherwise, basically, a normal exam, key findings, no tenderness throughout the knee and no effusion. So on MRI, because it was bilateral, we did get an MRI. Just to cut to the point, on the left side, there was no OCD found. But on the right knee, here is the imaging. Let me go through it and then you can comment if that will work. So these are the bone windows now that you presented. You can see the difference between what we see on T1 and T2 versus the bone window. I'll just go through that one more time. Okay, and then mapping as well. So Yuri, why don't you start and then ask these guys what they want to do. So let's go to the first T2 fat set, the first sequence, the sagittal. And just stop somewhere. Sagittal and stop somewhere where the lesion is. I'm not sure if I know how to stop it, Jutta. I'll keep trying. You keep talking. One, two, three. So there. You can stop it. That's fine. So we talked about the secondary physis. You see this white line here? And you see the white line is disrupted. That is the image. So there is an injury to the secondary physis. We see edema. I don't see any kind of osseous defect on this one. I just think it's bone marrow edema. And then there are secondary physis. The white line is disrupted. That is very important. So we have a lesion. And to me, that is a pretty innocent-looking lesion with bone marrow edema. But this edema, I'm concerned about juvenile osteochondritis dissonance lesion stage 1, not yet ossified. So when we look then at the so-called bone windows, we really realize how much bone defect we have, totally underestimated with the clinical imaging. We also see, like, this little bit of puzzle piece. There's some osseous fragments in there. Okay. Experts, what would you do? So this would be my eight years of age cut back on activities if they legitimately get any form of immobilization or cut back on their activities. See them back in three months, they should be healed. Yeah, kind of in addition to that, I typically get standing alignment x-rays of them unless I look at them clinically and they look completely approved. I don't have any concerns that they're in significant value. I get standing alignment x-rays. And then I check a vitamin D level. So I'm amazed at these kids that have a vitamin D level of 10, and I've seen some quite impressive healing. they've been followed on by somebody else in the community and vitamin D never checked, no big significant changes. You get them on vitamin D supplementation and you get really impressive healing. So that would be my additions to that. But yes, super reliable, should heal, do great. Crystal, this patient was not in valgus, but if they were, what would be your indication for doing something about that? In an eight-year-old, if they're kind of zone one valgus on their mechanical axis, I'd probably just put them in an unloader brace at that point in time. And not much to add other than maybe activities. I think Crystal's comment earlier about, you know, what type of activities is this kid doing? And maybe swimming and cycling or sort of like Crystal's, those are my favorite diversion sports for kids when we're trying to unload them, if you will. Does the size of the lesion, the fact that it's a lateral femoral condyle worry you? It doesn't look as impressive on the T1 and T2, but when we have those bone windows, you can see how much is involved. Does that worry you and does that make you change your mind at all on treatment? Yeah, lateral lesions, as Crystal said earlier, lateral lesions, I think we all need to be a little more anxious about. I've seen a lot more failures with lateral. And so I always worry about lateral more. The edema is also a little bit concerning, location and edema. The age of the kid's helpful. Very young, as Ted says, he almost fits into this category. No beard or mustache yet. I tell families, lateral femoral condyle OCDs don't read the book. So they don't always behave exactly the same. Just turn the mic so they can hear. Try and say that again. Sure. I just tell families, lateral femoral condyle OCDs, they don't read the books. They don't follow exactly, necessarily, the sequential healing patterns that we see in medial femoral condyle OCDs. So I still think it'll do great. Okay, so for this patient, kind of like was outlined, we talked about avoiding impact activity and then follow up again in six weeks. At that follow up, the patient was having no pain with any daily activities and allowed to gradually return to regular activities. I don't know about everybody else's protocol, but particularly for these really young patients, if we have MRI evidence that there's an OCD that's not fully healed, I like them to come back. So the patient then returned 18 months after the initial presentation. At that point in time, fortunately, still no issues and had returned to all activities, including sports. So here is a MRI that we repeated at that time, 18 months. And so you can see the change in the presentation of the OCD lesion itself. May I have a challenging question? So bone healing needs activity, needs some kind of muscle, needs perfusion. Can it be that we do the wrong thing? In some cases, just restricting all activities, maybe they would heal this activity. You guys have to take that. We don't have a crystal ball. I mean, that's a great question, but I think just philosophically, we wanna allow compression to stimulate healing and then avoid shearing forces as was discussed previously. Yeah, I agree with that. So I don't know if everybody in the back heard. The question is, is it's the shearing forces and the forces that are keeping it from healing versus doing something to stimulate osseous healing? And unfortunately, I'm not sure we know what activity does what. And so at this point, it's not clearly defined. All right, and then Jutta provided some nice images. Actually, I think this was seen in your talk before, Jutta. So you can see the pre-op imaging on the left and the post-op imaging, or not post, but post-healing imaging on the right here. Crystal pointed out how important it is to have intact articular cartilage, that this is kind of a really decisive moment assessing. The images with the color show the articular cartilage, the red, that it is very much intact. And they are done with the same sequence. It's one stop shop. So again, here you can see the pre and post on all the different types of sequences. One more look at it. Okay, case number two. This is a 12-year-old male. One year history of right knee pain. The patient presented with anteromedial pain, and they noted that the pain had been worse over the winter. It initially started in the summer, fall, and worse over the winter because of indoor soccer. So they had discontinued soccer, which did help some, but the pain continued as soon as they started doing any kind of activity, even just light running. So at that point in time, then prior to presenting to me, they had been managed, as we had been discussing, for non-operative management in a very appropriate way with six weeks of non-weight bearing. And then medial unloader bracing after that. This did help to resolve the pain. Unfortunately, however, once the patient went back to activities after all of that, again, the pain returned. So the six weeks prior to presenting to me, there had been issues for long enough that the patient started to compensate, and now having issues on the other knee. On exam of the right knee, there was tenderness palpation with a medial femoral condyle, kind of the typical presentation. But otherwise, no effusion, no mechanical symptoms, and the remainder of the exam was non-impressive. So again, I think there's another one where the bone windows help to kind of define this a little bit better than what we see on the non-bone window imaging. Female Speaker So in my report, I would say very large lesion would identify the location, central aspect, medial femoral condyle. I would say the lesion, I always say the progeny is largely cartilaginous, to give you an idea. The interface does not reveal any fluid or cystic changes, and there is, in the parent bone, a large area of edema. Thank you, Jutta. Okay, panel, what would you do? For me, I think this imaging shows several concerning findings, so when I'm starting my discussion, I certainly think non-operative and operative treatment are very real conversations with this family, but this is one that I probably trend pushing a little bit more towards considering a drilling procedure. For me, that's based on kind of both coronal and sagittal width. I think you're looking at an OCD that's probably more than 2.5 centimeters in the sagittal plane and almost the entire width of the condyle on the coronal plane, and I just worry if this starts to go bad, that's a big problem for a 12-year-old. So I would probably lean in the direction of check of vitamin D level, but planning to recommend retroarticular drilling in my hands with BMAC. Yeah, I agree with Crystal. He's had, I think, a pretty good run of non-operative treatment on loader brace and has failed, and to me, that's a pretty clear indication probably surgery is the next step. Yes, a shared decision-making process. There could be families that would elect for conservative slash non-operative treatment. The question is conservative. If things are getting worse, is conservative operative or conservative non-operative in that case? So sometimes I will say that word. I just use the terms non-operative versus operative rather than conservative or surgical. And then I always say, the good news is I don't see a crater. I don't see loose bodies. I don't see trap doors, but we always keep a winning game, always change a losing game. It has not improved. You could always try another round of conservative slash non-operative, but I have my doubts about that. Okay. Does that change your plan, to Crystal's point? It was his left knee? Yeah. They're both invarious. Yeah. So for me, that's beyond zone one. And so I think if I'm surgically treating an OCD and you've got a kid with wide-open vises, I'm going to use that, the abilities with guided growth. So at 12 years old, we have plenty of time. I'd probably do, I think you could take your pick whether you do a screw or whether you do a plate and screw construct, but he gets a hemi-epiphysiodesis for guided growth in conjunction with his drilling to unload the area. And I'd probably, since he has an unloader already, continue to use the unloader post-op until I saw that his mechanical alignment was neutral. I agree. The only comment is at 12, I think he's probably got four years of growth remaining. And I would worry a little bit about overcorrection, so I'd probably opt for a plate, just because the risk of closure with a plate is very low. I know there are some reports of premature closure. When you take the screws out, they stop growing. You can take the plates out, and they usually resume growth. And so I would be a little worried about overcorrection in this age group. If he was 14 and a half, 15, and closer to completing his growth, I think a screw is simpler, and I actually like doing the screws in that case. Does it matter that it's bilateral varus? Does that change it? There's no OCD on the other side, despite the fact that there's varus? I think talking to the family about the asymmetry you're going to produce with guided growth correction is always important. And so if they're comfortable with that, that's okay, but they may notice it. And so sometimes you might think about doing that later. If they're unhappy with it, tell them you can do a guided correction later on the opposite side. Great. Okay. So we discussed the possibility of guided growth for varus alignment. This family at this point wished to hold off, and so the plan at the time of surgery was to perform guided growth if the lesion was not healing after surgery. So this patient underwent arthroscopic transarticular retrograde. So Crystal nicely showed the two different, well, I'm showing the second option here. So antegrade or retrograde transarticular. And here's what things look like at surgery. These are just scope pictures, but you can see obviously cartilage looks great, but there is some softening. So we drill similar to what Crystal talked about. It's multiple passes. We change the flexion angle. We change the direction of the K-wire with each pass. So through the articular cartilage, these are small K-wires, one, two, one, six. And through the cartilage, it's only about four passes. But total, you get 20-plus passes across the lesion site, across the interface. I think that's the key, as Crystal nicely highlighted, is we're trying to change. And everybody's mentioned, we're trying to stimulate osseous healing at that site, and that's the goal with this approach. So post-op, saw the patient two weeks, non-weight-bearing. And at that point, no concerns. So the patient was allowed to be partial weight-bearing for the following two weeks, and then progressed to full weight-bearing. And with PT, they were basically just allowed to kind of go as the patient was doing. So at six weeks post-op, the patient was doing well, and at that point allowed to resume impact activities two weeks later, so around two months. And then at three months, was seen with a normal exam, and at that point allowed gradual return to activity. And then the patient was seen- Are you routinely using biologics in those cases, with lesions like that? Yeah, good question. I am not. Crystal highlighted, though, that she's using BMAC, and that that is helpful. I have not actually found it to be necessary. We have a case series of these that are evolving, and so far, our preliminary data is suggesting that we get pretty good healing with this. Our data about Atlanta that's not published showed no difference between- it was actually a project when I was a fellow, but it showed no difference, BMAC or no BMAC. So that being said, if it's really young kid, I don't, but if it's a 15-year-old who happens to be- cartilage is intact that I'm drilling, I do routinely do it, so I use a little bit of bias. The majority of my drillings get it. But clinically, I don't think I have great data. It definitely doesn't hurt, and we didn't find any complications associated with it, but I'm not sure that it has any greater benefit at this point. Just a technical question for Crystal. I appreciate your comment about the BMAC earlier. When Mike was putting pins and then drilling over a three-millimeter drill, obviously, it's pretty easy. You've got a little channel. You can put a syringe or a spinal needle and inject your BMAC through that, but in a setting when you just do multiple K-wires, how do you deliver your BMAC in that retroreticular space? Yeah, so when I finish doing all of my drilling, I basically pick centrally located K-wire passes in one more anterior, one more posterior, and then I refine that track again, and I just use a spinal needle to pass down that track, and then put half of it in the anterior aspect of the lesion, half in the posterior aspect of the lesion. I don't let the tourniquet down immediately because I think it just probably helps to wash it away. I would love to do a labeling study to look at exactly where all this goes, so we've discussed doing that, but I typically let the dressing be on, brace on, everything before I let the tourniquet down just to perhaps minimize some washout. Everybody able to hear that okay? Everybody got that? Okay, good. Ted? So, we will have published shortly transarticular versus retroreticular drilling. Study Ben Hayworth is the lead for that, and this is a rock group study, so I've done the transarticular and retroreticular drilling. I'm kind of neutral. I'm kind of like Switzerland on that. I think they're both great. One of the issues is they both got excellent healing. Retroreticular had longer time and higher, obviously, fluoroscopy because you have no fluoroscopy with transarticular, and if you're a biologics person and you want to have a large lesion and you want to add biologics to transarticular drilling, I'll drill a 4-5K wire for all the areas that are softened, but I'll take a few of those and I'll drill a 6-2K wire, then I'll take a 15-gauge corneal biopsy, and I'll just tap it into the proximal medial tibia about where you drill for your ACL tunnel, and then you take the stylet once you get past the cortical bone, take a cancellous bone biopsy, and you can put it into your 6-2 drilling site and you can plunge some local bone graft. I'm not saying that's earth-shattering biologics or a ton of bone graft, but I tell the family philosophically we are not just simply drilling for oil and bringing new bone, we are putting new bone in there. You have the gold standard, you're getting the gold standard of everything, and you show them little perfect circles, I take a picture of it, I'll take a picture of a little bit of bone graft, and so that's a way, if you're a transarticular person, so I've added things retrarticular and transarticular, but if you want something that's a little more efficient, you can do it in that way. So just to finish up on this one, here's what the patient looked like at three months post-op. So you can see that there is some bridging there. And then here's some final pictures. And there was an MRI later on for a separate issue that demonstrated even further integration of the lesion. The patient was doing well. Can I ask a quick question for you guys? So what's your standard return to impact activities? I do not routinely get follow-up MRIs unless I have some concerns based on radiographic healing. But I typically have not allowed progressive impact activities before the four-month mark, all based on radiographic healing. And you said starting earlier. So I'm just curious, are we holding these kids back once the healing started? Should we be letting them go sooner? And how do you make that decision? I think particularly in these kids, they can heal pretty quickly. And we've gotten some MRIs at two and three months and demonstrated healing for these smaller, more stable, well, not necessarily small, but earlier lesions, so more immobile lesions. And so we do routinely get an MRI follow-up to demonstrate osseous healing. And if it's healed, then they have no other symptoms. Even though X-rays may be lagging behind and not showing. Yeah, that's the problem, is that X-ray oftentimes is hard to tell what's going on. In many cases, you can actually get healing, and the X-ray still looks a little bit translucent in that area. And we can see bridging healing on MRI. We looked at just a small group of natural healing versus interventional healing. It is amazing how fast the healing takes place. If you're at a place that there's logistical issues with MRIs, our institutional philosophy has been to get plain film. So I always tell patients I want them to be physically, mentally, and emotionally prepared, that they don't return until six months. But I always see them back at three and a half months, and they have healing. Then I return them back sooner. So we have five minutes. I'm going to go through the whole case. And then if you guys have comments at the end, you can say. So this is an 18-year-old male. Pain began a year prior. And it started with jumping into a shallow lake and landing flat, basically, and started to have pain. And then eventually started to describe loose body or started to have what he described as loose body symptoms. On presentation, there was no effusion. There was tenorine palpation over the lateral aspects of the medial femoral condyle. No other pertinent findings. And the patient had no other treatment to date. So if I would write a report, I would say there is a partially ossified progeny lesion at the interface. I see fluid. I am worried about the so-called omen sign, which you pointed out. And I would alert my orthopedic surgeon that this could be an unstable lesion. So that's what we felt. The patient underwent very important, I think, what Crystal was saying before. Not just open fixation, but important that we got in there, pried the lesion open, likewise always try to keep a hinge if possible. Most of the time, these are connected to the PCL, and so you end up hinging it towards the notch. It's super important to get in there, clean out any of that cartilage on logger that's left behind that never fully became bone, as Jutta nicely illustrated. Sometimes there's sclerotic bone. You need to get rid of that. It's a good bleeding bone in the base. And then bone grafting from somewhere, Crystal illustrated, you can use distal femur. In this case, I just used proximal tibia because it's right there as well. Just make sure if it's a patient who's not done growing that we're avoiding the growth plate. That serves two purposes. One, it's a structural graft to keep the fragment from subsiding, and so it keeps the fragment flush. It also is osteoinductive, so it helps with the healing itself. And then fix it, and there's a lot of different ways to do it, as Crystal nicely outlined. I typically will still use the headless screws, so you can see what it looked like at the time of surgery. So you can see all that junk. You get some fibrous stuff. Some of that's, again, that cartilage on logger. Both on the fragment side and on deep, it's important to kind of curet all of that out. So here's what it looks like after it's fixed through an open approach. Here's post-op films. Or sorry, these are actually intra-op films. So post-op relief patient, six weeks of non-weight-bearing. When they were seen at two and six-week post-op there were no issues. Two weeks of partial weight-bearing at that point in time, so a total of eight weeks of restricted weight-bearing and then progressed to full weight-bearing. Patient was doing well at three months post-op, and here's what the post-op image is. So this highlights kind of what Crystal was talking about. You can see here on that OCD lesion there's definitely still some translucency in that lesion. So what does that mean? Is it healed? Is it stable? What do we do about that, particularly from an advancement of activity standpoint? So what we like to do is then go back in and take the hardware out. So this patient underwent hardware removal at four months. And here's what the MRI. So we then send them back to get an MRI, as you were asking about, Crystal. And here's what you can see. So not complete ossification yet at this point, but good bridging at the interface. And you can see the difference. I put this in there so it's a little difficult to tell in the T2 what exactly is happening at the bone, but you can see the cartilage nicely. So the cartilage has remained in good condition. Obviously there's some puncturing through the cartilage at the screw site, but apart from that, the cartilage is in good condition. So patient was clinically doing well at four months, and the MRI looked good. So the patient was allowed to gradually return to all activities. But since there wasn't full ossification at that point, we did have the patient come back, I think it was supposed to be a year, came back something like one and a half to two years later. Fortunately at that point, there was no symptoms and the patient had returned to all activities. So here's what their MRI looked like at that time. You can see further ossification, further integration. Here's some images from UTA, just showing the contrasting pre and post. And the MRI at the bottom, that's the early MRI, not the late MRI. Thank you all very much. Any comments you guys want to make? I think in particular with that case, it emphasized the importance to scope these and assess it. I saw a kid has a second opinion recently who had seen somebody else in town, and the recommendation was just plan for an OATS, that this is going to be an unstable lesion, it wasn't repairable. And I told the family, I said, that could be the case, you're 18, I certainly worry about it. I don't know how long this has been here, but we should scope it first and look at it. It looked identical to that, and so we repaired it. So just an important thought with understanding that some of these lesions look better arthroscopically in terms of cartilage than we might suspect. One question in the back. Quick question. Can you comment on whether you're fixing arthroscopically any of these, so rather than doing a low approach? I'll comment. I am not, because I think it's super important to get in there and clean that out. I think that's a big change that's happened in my practice from what it was when I was trained. And I would emphasize that, actually. I think that is why we're changing how these are healing, because we're getting in there and cleaning all that stuff out that you saw in that picture. And actually, I'm pretty aggressive with saving the patient's progeny, even if it's fragmented, even if it doesn't look like there's any good bone in the progeny, because we've done some good studies showing that that cartilage is effectively normal. Sometimes it looks thickened on T1 and T2 MRI, but most of that thickening is because of the AECC that Yuta talked about that just never fully ossified. The articular cartilage, for the most part, is normal. There's nothing better than the patient's own articular cartilage. So anything you can do to stimulate the biologic healing between progeny and base bone and keep the patient's own cartilage, I think, is where we're going. I think that's a good point, and I think historically we've been trained about the mechanical importance of fixation, which is still important, but I think increasingly we're looking at the biological aspects, debris in the bed, getting bone graft in there, and maybe eventually some type of pharmaceutical complements to that or VMAC or other things, but I think the biological element of this is critical for getting healing. Yeah, and maybe we can figure out ways to do that arthroscopically, but getting in there and cleaning all that stuff out is critical. And I agree with all of that philosophically, but there are times when you'll have a lesion that is a trap door that you can curette and get appropriate bone, and then you curette the back. And even that fragment that you flipped back, that has sometimes been growing, so it's actually more prominent. So you curette the bottom of that and you have appropriate surfaces. You can put pins and headless compression screws on top of that. I have a case example out on my computer if anybody wants to see it. So I don't philosophically, I just tell the families, anything that's fixable arthroscopically gets fixed, anything that's not fixable arthroscopically gets opened. And for this case, it was done with screws, and the disadvantage of screws sometimes is you have to go back, but sometimes the advantage is you can get a second look at those things. But I'll do a lot of suture bridge fixations for those, but again, the principles don't change on what you do. The treatment of the underlying bone, the bed, the fibrous tissue, the sclerotic bone, all of those things. So I think we all agree on that. So if you type, this is not a PR thing, but Ganley University of Pennsylvania Orthopedic Journal, I have a description. It's like 10 years ago, but it shows an X, which goes over the defect. And I can pull it up, even when it showed up, I can text it to you a bit or something. And it shows, for that I used four anchors. It was perfectly round. And that was done arthroscopically, by the way. That was an acute injury, so that didn't require a lot. And then two longitudinal. Now if you have it open, and you have one, and there's an extra bit, and you want to add another one, you can put one at the intercollar notch or elsewhere. And I can pull up a few images on my phone of some different shaped size lesions. But basically, I create an X and then two longitudinal. And you can, since you have those anchors, you can run more than one suture through when you have it open. So it's just basically like shoulder principles, basically. Yes. Mm-hmm. There are times, however, I hedged my bets recently on an OCD, and I had two of the longitudinal sutures I had non-resorbable, and I had the others as resorbable. But for the most part, they're all vicryl. So I've been using the .9 millimeter meniscal tape if it's non-resorbable. If it's resorbable, if it's the vicryl, I'll just use a O, or depending on the size of it, I'll use it as slightly larger. So it depends on kind of the lesion itself, how large I pick the suture. What size anchor did you use? I was using 3.5, so now I'm using 2.9. And sometimes, if you're right at an interface that has a little bit of space, you can put the anchor right at the interface. If there's some space there anyway, you can put it there. You don't have to put it on the cartilage, on the quote-unquote normal cartilage adjacent to it. Ted, do you worry about braided versus non-braided suture? You're using braided. Yeah. I used PDS originally at the patella, but I had a girl who really, the number of knots that I put, the knots themselves became problematic. She got a little bursa on the front, so I had to go back. I didn't have to go back to the cartilage, but I had to go back to take out the PDS sutures. So I have used PDS in the past. I've just been using Vicryl, because they've been using those for trochleoplasties and all over. That's probably why I was asking, Ted, because I use PDS for trochleoplasty, which is nice, because it's just not braided, so it's just pretty even pressure. Yeah. So, I mean, you can make an argument for both. Yeah. Excellent. Any other questions? One final. Yeah. And if you guys need to go, feel free to go. Quick question. Could you imagine a place with a distraction hinge, where it actually creates joint separation over a certain range of motion? Would that be useful? I love it. Yeah. I don't have one, but yeah. Yeah. Yeah. Great. We can talk later. Great. Excellent. All right. Thank you very much, everyone. Have a good day.

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