We want everybody to engage because I'd like for this to be legitimately interactive so we all get something out of this. So if you can come and fill in so that we can disperse the faculty with the attendees so we have some meaningful discussion. If you see a table with some room, please come and sit there. And I think we have, because we only have one microphone really for the general audience so the closer you are, the better people will be able to hear too. Alright, so again, the goal of today is really to facilitate discussion, hopefully generate a little bit of controversy and different approaches to talking about the patellofemoral joint. We're not really going to talk much about instability that will come up within the context of the discussion, but we're really focusing on articular cartilage management in the patellofemoral joint and going all the way from, you know, chondroplasty up through arthroplasty. So we want to review each of these cases in light of those so that we hit all of the points as we go through. Sorry, there was a little bit of an adjustment there, but we want to talk about, well, non-surgical options, how do you get here? You know, these are all going to ultimately end up in surgical cases, but what we did on the front end. And then we'll talk about cell-based indications, perols for osteochondralographic transplant, TTOs, and then all the way up to patellofemoral arthroplasty. So when we look at these cases and we talk about these options, I really want you to consider each of these within the context of the case and why it may or may not be appropriate. So here are the course objectives as it was submitted for the ICL. And so we're going to start with a 28-year-old female with left knee pain. She shows up in the office with a large effusion, mild quadricep atrophy. She does have a positive J sign, a positive patella grind test. She has no instability on her examination. She had an MPFL construction nine years ago, but pain started to come two years ago and really got worse when she was going heavy on the Peloton during the pandemic. She had multiple cortisone injections over the course of that time before showing up in my office from an outside provider to manage that effusion. So here's her x-rays. And you can see that she does have an appropriately placed MPFL tunnel. She's stable on her exam, slightly narrow appearing on the lateral facet, but overall pretty central on that view. And here's her MRI. So what would you do? We'll start with this discussion here. What do you see on the MRI? I can't see names, so. Yeah, looks a little dysplastic. What do you think about the lateral facet of the patella? »» Yeah, it's pretentious. »» And then telethomocardial assistive formation of the lateral facet. »» So how concerning? This comes up a lot. If you're considering doing a cell-based treatment in the office, how much subchondral involvement can you tolerate? Is marrow edema okay? You're concerned about the subchondral plate? Right there, at Drew's table. Somebody comment. »» What was the question again? »» So when you're looking at it, here's your MRI and you're in the office and you're talking about options with the patient, how much subchondral involvement for a surface-based or cell-based treatment can you tolerate? »» That's a good question. In terms of percentage-wise, I don't actually have a firm number about how much involvement of the actual facet that could be involved. My gut feeling is that it's not a ton in terms of the involvement of that whole facet. In terms of the surface area, only like 20% or so, and it's not too deep. So I think that would be tolerated, but I don't have a good number. »» I don't think there is a number. »» I would worry maybe that's a sign of overload, even if you did a cell-based repair, then that would also fail just because of the pressure there. So having even that much demon might motivate me to try to unload that facet somehow. »» Yeah, I think that's excellent. »» How many steroid shots did she have? »» Oh, like five. »» I always think people minimize that impact on later biologic reconstructive procedures. And I know Christian's thinking osteoarthritis, osteoarthritis, osteoarthritis, and then I'm going to be mediators. And so I think if you look at that lateral facet, there's something there, but that's supposed to be double the thickness, that lateral facet. So there is something there, but it's missing a lot. So I would think that there's a lot of loss of the milieu inside that joint. It's an osteoarthritic process developing. So you've got to take that into account in your biologic healing process that you're trying to perform. »» Just one more point. Can you go back one x-ray, or to the x-ray? »» Hopefully. »» I think it's important to tell people how, I mean, this is why a plain x-ray is a bad way to judge what surgeries you should do. Because I mean, from a practical standpoint, outside of a little tilt, I mean, that looks pretty normal. And look at the trochlea there. So I think you can get very misled. And so, you know, one of my questions is whether or not the NPFL in the very beginning was the right surgery to do in the first place. And so it's an interesting question. You're dealing with a complication now of somebody who's having pain after an index surgery that maybe that wasn't the primary thing they should have done in the first place. »» She actually did have a patellar dislocation. And you could ask, because Christian did the original surgery nine years prior in this particular patient. But she did have a patellar dislocation at that time, too. So she was managed non-operatively and then had a second one. And then the patella. »» Central x-ray at all? »» Yeah. So look at the x-ray, right? So if you look at that lateral, right? Adam, what would you say on the Dershow classification, where would you come in on that x-ray? »» Yeah. It's always the difficulty of one is the bump, a bump, and one is a small number. It's not going to cause that. So if the bump starts to get close to a B, there's not much of a problem. »» Yeah. So here's the thing, right? You know, if you look at that, this was done almost a decade ago, right? »» Yep. »» So back then, we were just starting to learn, basically, when is the right indication to do what. And I can tell you, because I remember this case extraordinarily well, because we just recently talked about it. We were just starting to learn, basically, when is the right indication to do what. I classified that back then as somewhere between an A and a B, actually. And you know, this is somebody who had a primary patellar dislocation, never had any previous instabilities and no other chondral loss. And this was not somebody, if you go to the MRI, this is not somebody where I felt primarily that a trochleoplasty, for example, here would be the right thing to do. Back then, we did this as a percutaneous MPFR reconstruction, right? There should be, do you have scope pictures from back then at all? »» Not from the original. »» So this was a time where I was trying to get a better idea, looking at the patellofemoral joint with an arthroscope to judge the supratrochlear bump. And I can tell you to this day, this is one of the hardest things to do. If you're looking at there with a scope and you try to identify is this a relevant bump or not, it's extraordinarily difficult to do. Today, if I see this and if I were to do something on the cartilage here, I would probably do a bumpectomy in conjunction with it, right, in order to get rid of that entry bump that she has without a doubt. But as I said, she had an MPFL, she was fine, it's ten years later now. And then, Watson, I'll let you go from here. »» Actually, I know this is not a teleheart stability talk, but can you put the x-ray back up one more time? The other thing about what you're saying, which I would agree with, is that this trophia is long. And so if you have an extension beyond the posterior condyle, most of that stuff proximal to that is probably not relevant, functional or physiologic. So that's where, but if that bump is distal and larger, then that's where bringing it down is the problem. »» Yeah, and that is exactly where it becomes complicated, because now you're going from an A or B into a C or D on the du jour classification. And to tell you the truth, this is really extraordinarily difficult to judge, right? You can do that much better if you have the joint wide open. But for a primary dislocator with risk factors where you wouldn't open the entire knee joint up to do just an MPFL, right? »» And she'd done very well for the decade. No instability and just more recent pain with increase in activity and probably loading the patellofemoral joint a little bit more because she probably had the seat too low on her peloton. That's the most common thing that people put their bike seats too low, right? So you're putting a lot of extra stress and it's repetitive. »» The comment about the bone is important because we certainly don't have that part all figured out. There is an assumption that if the bone's abnormal that we have to treat it, that a surface-based lesion's not going to work. And then you're also considering osteotomies in these patients, which we'll talk about. But I certainly have patients that have had MACE and a TTO and pre-op bone marrow lesions and then those are gone six months post-op. And so if you have a tire that's flat and the car's going out of alignment, if you put air back in the tire, you might be able to take pressure off and have some of that stuff calm down, similar to what an osteotomy is trying to perform. So I think it's important to know that the literature looking at the outcomes of microfracture, MACE and OA grafts with a setting of preoperative bone marrow lesions are particularly inconsistent. And it's not like all MACE does bad just because there's a bone marrow lesion deep to it. It's not that all OA grafts do perfect if there is a bone marrow lesion. So they all can still have issues. Sabrina. Yeah, I agree. And when we're talking about the subchondral bone, I look very critically at the subchondral plate. If there's subchondral plate involvement, surface-based treatments in my practice are out. But bone marrow edema is reactive until it gets to cystic change. But again, then you have plate involvement. So that's kind of one of the things that I take into consideration. There is no number or measurement. It's a gestalt. But I do critically evaluate the integrity of the surface that I will be putting that cell or surface-based treatment on. So show of hands, looking at this. She's in your office. She also happens to be an attorney in a family with a big donor to the hospital. So no pressure. You got to get it right. Who would automatically rule out a cell-based treatment? How many people would now start having this conversation of staged procedure, consideration for a tibial-tubercle osteotomy, and then some sort of cartilage restoration for this? Who would not consider doing an osteotomy? Yeah, I mean, so we pretty much universally recognize that this is a problem. She does have overload. And we're going to have to address that definitively for surgery. So we did talk about performing cell-based, planned on a bereavement scope. I tend to stage just about everything anyways. And so she's already done physical therapy. She's already had injections. In fact, she's had way too many injections. I'm not comfortable with the number of injections. So in the back of my mind, I'm thinking, I hope she's not infected, right? I hope there's not an indolent infection. And so we have cartilage surface treatments and cartilage OCAs. Anything else that I didn't talk about that you'd consider for this patient? I guess one issue is if you get in there and you're doing a cell-based treatment and you find that there is a true cyst bone grafting, that issue could come up with that little cyst there. So that could expand, could be worse than you think when you get in there. And that has to be something you need to think about before you wander in for a cell-based procedure at least. If you were to bone graft, is where you're going to take the bone graft from? I usually get it from the iliac crest. There's a little eight millimeter trefine that I use that allows you to get a ton of bone grafts. So that's usually what I do. Why not go local? Because it's just so easy. It's one centimeter incision. The trefine is eight millimeters and people don't really have a problem with it. That's what I've been using. How do you plan for that? If you're in there, there are legs exposed where everything else is covered, right? That's booked preoperatively and prepped preoperatively. It's a prepped area. Okay. So you would prep in the crest? Yeah. If I'm going to go, I'm going to go in and tell them possibly we may need to bone graft. So in my experience, these kind of lesions, if you have bone loss issues there, it's actually a relatively low volume. So I think Adam, I think you do the same thing. If you do a TTO or plan to do a TTO anyway, or if you are in that general area up on the femur, you can just take the bone graft from the femur up on the tibia too. I mean, it's typically two carats full, so that's about the same as- I just wouldn't want to impact my TTO. I tend to bone graft those areas and then pack that back in. But I find that going to those areas- now if I do a medial femoral condyle, for example, I'll do a rectangular plane where I want to go down by the tibia. Let's see if the video plays. Looks like it might. All right. So here's her scope. I'll point out, look at that synovitis. That's significant, right? That's not a happy knee right now. But with this, debrided, I knew I was coming back. I did take the Macy biopsy. but I also was really concerned about that that synovitis. I did debride the synovium, ultimately had a synovial biopsy, but her first surgery went well, but she had recurrence of swelling. She had effusions come back for weeks and we managed this. We sent her to therapy, very aggressive about icing, compression, graduated return to activity, aspirated her knee, sent it off, cultured for everything, held for fungal, did a rheumatologic eval, all the blood work, perfectly clean. There is nothing there. So a dose pactor, the whole deal. So it took several months for her knee to normalize and for the effusions to go away. Now ultimately they did, but you know I was really nervous about the health of that knee. I knew that ultimately we would be doing an osteotomy, so we would be offloading that patella, and it's still planned to do the cell-based treatment, but I was not going to do it until we had established that there was at least a couple months of no effusion, no knee irritation, and it took a long time to get there. Austin, can you talk about how you debrided it and whether or not you use greater frequency cobalation, mechanical debridement? Yeah, so I overwhelmingly use mechanical debridement if it's a cartilage type thing. I will occasionally use cobalation in like an osteoarthritis type situation, but I use a mechanical debridement and I'll typically get a curette. And if I'm doing this, especially in a young person who's trying to get back to sport, I'll spend a lot of extra time making sure that those margins are perfectly vertical, which is a real hassle on the patella because it moves a lot. I think it's easier obviously on the trochlea or the femoral condyles, but a sharp curette makes a big difference in terms of the ability to get that. An open or closed curette, it's dealer's choice. Anything else to add about that? Yeah, I mean we could talk about it more, but I would just caution using heat around cartilage. Certainly a standard RF is probably not a great idea. Cobalation would be debatable. Anything that makes it smooth over and it looks better, it's denaturing collagen and it's sort of making it totally non-functional. It's just a matter of how deep that effect goes. And if it's not so deep, then maybe it's not a big deal. I have an elbow arthroscopy tray that I use that nobody else uses or knows about, so it stays real sharp. All those curettes are, they have really good angles and there's curettes as well as like elevators that look kind of like a bank card elevator. I find that it's like a pretty reliable way to do it compared to like a standard curette. It's pretty tough to do a good job, I think. I understand waiting to do the second stage until after your infection workup is done, you're really well, it's done. Why, if those are all negative, why do you care if she has, I mean those refusions can be reactive to her convalescent and to her, you know, presumed maltracking across the dysplasia? Why do you have to wait until that's gone before you go to the station? Well, you know, so the synovium is producing inflammatory factors, and so if you have an overproduction of synovial fluid, you have a very inflamed environment which is not going to be conducive to an anabolic reaction, which is what you're trying to get when you have a cartilage treatment, whether you're trying to get an osteochondralograft to heal one of the bone, or whether you're trying to have cells heal and grow in a cell-based or surface treatment. So, I do not want to add insult to injury. So, a small effusion, yes, you can have that reactive to cartilage, but larger effusions, there's generally something more going on, the joint's really inflamed, and I just don't think that that's a healthy environment biologically to put in a cartilage restoration treatment. You do, you do. I mean, in my experience, I haven't seen massive effusions after surgery, soft tissue swelling, you know, effusions, yes, but for cartilage restoration, and please jump in, differing opinions and experiences, but I'm very hesitant to implant anything into a inflamed reactive knee. I think there's a little bit of a spectrum, you know, so every once in a while, even just if you just do a biopsy, some patients respond very dramatically and get like massive effusions that can indeed take several weeks to calm down. Those are the ones where I would agree with that approach and say, let's wait until this calms down, because the other thing is, is it will inhibit your entire musculature around the thigh, particularly the VMO and the rest of the quad, and you need that in the early rehab to basically make sure you don't lose motion and stuff like that. If the quad doesn't kick in, these knees get stiff, right, but on the other hand, you know, if they continue with the synovitis, well, the reason for the synovitis is most likely the fact that they have continued cartilage wear, right, and if you don't stop that, that will continue on, so it's a little bit of a kind of a judgment call, and you can see both extremes. You can see those that recover and come back the next week, and you don't even send them to PT, and you know, they look like nothing ever happened, and then you can have those that react really dramatically. This is a bell-shaped curve, right? I think it's really important because there is such a thing as primarily synovial-based disease, but rheumatoid arthritis is causing the cartilage damage from the synovial inflammation, and you don't know which caused which. She obviously had instability, but her defect's not distal medial on the patella. It looks like it's more lateral, and so that could be from chronic lateral overload from the trophia of being anterior, but that's why, like, total knees can still have effusions post-op, and you've eliminated all the cartilage, so I think that when they have non-activity-based swelling, and it just, like, keeps coming back, I will inject them like crazy to try to calm that environment down for biologic benefit, but also symptomatic benefit, and I think that the chance of a patient improving from a debridement, which can help two-thirds of patients with polythermal cartilage defects, that has that type of synovium, it's really important. What would you inject? I do, I do use steroids for sure, like, I don't have any issues with one or two steroid injections. The clinical data that suggests that causes anything significant is pretty good. She's had five already. Yeah, well, that's, I'm just saying, I wouldn't have a problem with doing one or two, and I do three PRP combined in a series of three. Yeah. So, how long do you wait after an injection before going back into the knee? Six weeks. If you know you're coming back, if you know you're doing the osteotomy, why not do that initially to offload the patellofemoral joints and maybe prevent her effusions, like, in your initial procedure? Well, a couple reasons. Now, her, I did plan on coming back, but if I'm considering doing a cartilage restoration, but they're trying to get back to sport, or they just may get better, I mean, two-thirds do do get better. So, an osteotomy is six weeks of touchdown weight bearing, pretty extensive early recovery. I mean, you bounce back faster than a cartilage treatment, but still, that's a big surgery, and then if you're going to come back and do a cartilage treatment, then another joint violation. And also, it makes your surgical exposure easier if you do the osteotomy at the time of the implantation. So, it's both patient logistics, it's easy to recover from a knee scope, and they may be fine, maybe fine for a couple years, or the season, depending on what you're trying to do. And so, I don't commit them to that large procedure initially. Now, that varies in, like, an HTO or DFO, we may be having a different conversation, but for a TTO, it does make the exposure easier, and it's a pretty quick thing to add on. I mean, it only cost me about 15 minutes to do a TTO when I'm already doing a cartilage restoration. That is a really good question, because, you know, if you talk to our colleagues in Europe, for example, they will easily do this in two different procedures, right? But the problem is, if they just think about your patient, your patient, this is a 26-year-old who has a job, right? So, if she is out on crutches twice for four to six weeks, she may lose her job, right? In Europe, that's never a problem, because they are protected for a year and a half, right? So, this is where you have to sometimes, you know, if you read the literature also, you have to look at that, some of these things, when you're looking at how they are treating that, because there's different, you know, different societal norms, and that plays a role. So, this is why a lot of us in the U.S., particularly, go to basically do one small thing where they recover quickly, and then do the whole thing in one go. She was swelling before the surgery. She's clearly got overload on that side, and then you don't overload her, and she continues to swell. I recently had one of the peak patients we have enrolled, a big 6'11 basketball player, had a lateral condylesion, and had a massive effusion, which I found was way out of the ordinary. I was concerned. I scoped him. I did the synovectomy. It didn't go away fully prior to going forward with the MACE procedure. He enrolled in the MACE arm of the study, and it was amazing. The effusion went away. So, I think Christian is right. There's a balancing act there, you know. The cartilage lesion is obviously causing part of your problem. I think your workup is great. That's a great thought process. I don't know if I'd wait six months, though. I don't know if you get it. You waited for it to fully go away, or was it a little residual hanging around? Trace, but her knee was... When I aspirated her in the office, I took off 80 milliliters. Yeah, yeah. That's what this guy was. He was like, it was 120, and then 100, and it kept... I was like, I don't know. This may not work, but I put it in. It was amazing. The effusion went away with time. Compression, compression, compression, compression is a key with these, but... Well, and then also, once she felt better, she was like, well, maybe I'm going to wait until next summer. I've had enough, and then she went back to her activities and started to get a sore again, and we moved forward. Again, she didn't want to take too much time off work. She'd already been dealing with this, but then now that she felt better, she wanted to go on vacation with her husband, that type of deal. That was part of the delay, but I did not want to go in with a knee that was blowing up with 80 to 100 milliliters of synovial fluid. I did proceed with the Macy TTO. Like I said, I like to do this all at once. Do do the osteotomy. You're going to protect the patellar tendon, and I tend to... I pin the guy, but I freehand it. That's just mostly to protect skin and keep the saw blade good. Obviously, I was really trying to anteriorize her, so I did a little bit of a steeper cut and really leave that not only periosteal hinge intact, but I try and leave a good cortical hinge as well. I'll pin and drill it before finishing the patellar exposure, but I won't fix it. So everything's all set up so that I'm ready to go when I come back, but then I have the benefit of the osteotomy going through there. Now, I did lateral on her because she had a primary... or excuse me, previous MPFL, so I wasn't going to go medial, so I didn't want to do that. But I did lateral on her because I did a lateral parapatellar arthrotomy. When I do the cell-based treatment, I actually use this to speed it up because I can protect myself, and then I'll come back and I'll get nice, clean margins on hers. But again, large defect. She was not completely contained on the inferior pole. This is common. I find myself doing this on the patella almost always, sewing with 6-0 Vicryl to make sure that that inferior portion stays put, which is a big hassle. I don't like it, but it's necessary on most patellar cases. And then you put in the screws last, and I'm pretty careful and ginger with it then. 6-0 Vicryl suture is much easier than back in the day, though. You didn't live that life. I didn't have the patience for that. It doesn't need to be a watertight seal. And she did well. And I did send another synovial biopsy, and it was just some chronic inflammation. It never did show anything else. So we'll move a little bit quicker than this through this one because I want to make sure that we have good discussion about some of the other talking points. But this is a 43-year-old female. She had a couple-month history upon initial presentation of atraumatic right knee pain when she was walking several days. When she showed up in the office, she was getting ready for her busy season. She and her husband own a business, and what they actually do is they set up all the stuff for the Kentucky Derby in Keeneland for the horse races. So a lot of heavy lifting. She'd drive a forklift and whatever, but she's fit, she's active, and her job is she's self-employed. So if she's not doing it, she's not making money. And this knee pain is now really interfering with it, and it's about to be the spring meet in the Kentucky Derby, so she's got to keep moving. The pain, it's in the intramural knee. It's worse with activity, especially descending stairs. It's associated with some swelling and occasionally clicking. She's done physical therapy. She's done anti-inflammatories, dose pack, and she felt good on the dose pack, and then it came right back. So here is her exam. She's just got a trace effusion. She does have a J sign, but no history of instability, and slight lateral tracking, but stable knee. Comments, thoughts on these x-rays? You can see how on that lateral x-ray that there's not squaring off of the, on that one that you had before, like this was more sclerotic throughout the entirety of it, and then it was squared off proximal and distal, so the assumption is that that other one probably had more long-standing chronic cartilage problems, versus this one might have a shorter time course based on the x-ray findings. Just a sticking point, too. That's a pretty flexed lateral view, so you'd rather have a 30-degree angle on that view to get your true telephormal alto-daha measurements. Yeah, so overall she looks pretty good. She's not arthritic or anything. So right now it's busy season. What would you do? She's not feeling great, but she also doesn't really want to take weeks or months to recover right now because she's got to put food on the table. Who would just say go do more PT? Six to eight weeks by this point. What's your BMI? Just don't go normal. It's like 22.5, and she's muscular. Does she have any muscular deficit in that zone? Still a little bit of residual valgus collapse on a single-leg squat or dual-leg squat's good. But she can do it? Yeah, I mean she's lifting tables and chairs and everything routinely, so she's got pretty decent, you know, core. Not perfect. Her knee hurts. She does have a degree of arthrogenic muscle inhibition, but it's not bad. Does she have a positive grind? Equivocal. So another option that's not up there that's more recent is bracing. So there is patellofemoral offloading braces now that have different mechanisms, and they basically, all of them function to try to actively extend the leg and give some resistance to bending it, so it decreases your quad moment. And I found it pretty helpful in patients like this that just can't have surgery, or they, or diagnostically want to figure out, just like we use offloaders for normal plane surgery. So that's something that wouldn't have been on my slide in the past, but I would say bracing plays a role now. I think one thing with physical therapy too is including EFR, but there's some data that shows that that is beneficial in telephone problems, and especially with people like, well, I've tried six weeks. It just hurts. I can't make progress. It seems like you just push the quads forward and improve their strength. Yeah, absolutely. I think that there's a lot of that, and the arthrogenic muscle inhibition is a real thing, right? Your knee hurts, it shuts down the quad, it's a spinal efferent issue, and BFR can help overcome that and get some hypertrophy too. How many of you guys are doing routine using BFR for patients? I've also found that it helps patients buy in, too. It's a bit like, well, I did physical therapy. It's like, oh, no, this is totally different. You don't feel different. It's new and something. It's like, OK, I'll give it a shot. I recently did BFR myself. It works. Yeah, that's fine. And it's hard. You don't want to use, I mean, if you think you're going to end up, I think I did an MRI before. I at least did more physical therapy than this. Because if you're going to operate on this patient this year, at least in New York, they're going to run out of post-op, and I think those sessions are more important. I mean, I look very carefully at how they are doing on a single leg squat. So you said she had pretty good control, and she was pretty strong. And in those cases, I don't think more PT necessarily makes a big difference. But I used BFR in pretty much every post-op patient. Mm-hmm. And you brought up a very good point. She's self-employed. And in Kentucky, the way the insurance market is, they get shoved into, really, the Medicaid market when you're purchasing insurance. So she doesn't have much PT. And bracing, they don't cover some of the fancy stuff. So you really run into limitations, and you have to maximize your therapy visits, and you run out quickly. Brace is about $1,000. Mm-hmm. Hugely expensive. So we're going to start with a cortisone injection, patellar stabilization, not a true offloader, just to see, though, if we could make her, because she does have that J sign, a little bit more comfortable. And then she is continuing PT, but she's about to run out of visits anyways. But that's going to get her through at least the first couple months of her busy season. She followed back up a month later. The cortisone injection really didn't last that long. She was compliant with physical therapy. She's stronger. Her muscle control was much better. And so then we did get an MRI now, at this point, because of her continued pain. So thoughts on her MRI? Just a couple cuts. Full thickness medial facet lesion. One question I have. That's why I tend to get the MRI before I do the cortisone shot, that picture there. I mean, I don't like giving cortisone in that setting. You know, I think – you know, I've seen actual watched NFL players progress as cortisone injections are given during a season. I know they're putting a lot of load on it, but they feel good. They crank it out, and then it expands. It gets bigger and bigger and bigger. If I'm thinking about doing a biological reconstruction procedure, I am worried about putting cortisone in these people and setting up this process of further progression of that disease, inhibiting possibly. I know you say it's good, but I'm concerned about the healing potential once I've done steroid in people. If I'm going to do biologics, I'm thinking that biologics is even a candidate for it. I'll get the MRI first before I do the cortisone shot. They don't have the discussion. You know, if they want to go for the shot anyway, at least they know what they're dealing with. Absolutely, yeah. Typically, though, you have to have cortisone for insurance approval. I don't have to. That's not in our state. We can do hyaluronic acid if we want to. PRP, they've got to pay for. That's an option, too. They've got to pay for it. Yeah, I used to worry about that. I just fight that fight later on. Do the hyaluronic acid, then get after it later on. I mean, they seem to forget about it. That hasn't been a problem for me. Proliferation is much better than it used to be I tend to work with longer acting NDF limitories So I try to stay away from the straight forward COX-1 inhibitors I use something like Meloxicam or Celebrex if I can They work better on my hands But looking at this MRI I think this is a mechanical problem actually It looks to me that this is an unstable flap and that would make sense with her loading compliance So I could imagine, based on this MRI that a well done agreement here may actually be sufficient We talked about options and I was going to give her another month or two to get through it and she was coming back We talked about scoping, we talked about debridement We talked about stage procedures She's 43 healthy, everything else in her knee looks good So we talked about the potential for a cell base or a cartilage restoration Insurance doesn't cover cell base for her She can't afford it So that's out the window I talked about just doing a TTO with a scope Again, reasonable because a TTO will still offload the medial facet There's biomechanical data to suggest that that's very effective for that And so we laid out all those options Also, I have an ongoing study where she can get the graft for free So I offered a surface based treatment as well And that's a single stage procedure for a surface based treatment for that lesion And you can measure off the MRI and get the graft in or order a couple And so ultimately, she and her husband decided that she would do that So she's got neutral alignment There's no problems, you can see she's fit So historically, maybe somebody might have considered microfracture But in my practice, I don't use that at all any longer It was very narrow indications And now I've completely abandoned it So I don't think that that's a viable option OATs for the patella I've actually never done that Usually, the lesions are much larger and I just don't see a symptomatic less than one centimeter lesion in the patella We talked about ACI for her It's not really an option due to cost Osteochondralograft could be But she had no bone involvement there And then obviously, I don't think that arthroplasty is where we want to be for her So measuring off the MRI I looked at about 12 by 16 She wants one operation and done She doesn't want a scope It bothers her And so I didn't do an osteochondralograft, I did a TTO And the allograft is a surface-based So I chose the cryopreserved fresh osteochondralograft She gets a graft for free, so it works out with insurance because she's participating in the study And the laser etching on the back is actually the bone So it's thin, it's flexible It's very easy to put on the patella When I've used these in the patellas the patients have done well It's really straightforward because the sizers are disposable You only open one set of instruments And so that's what I did for her And when you go in there And I don't think on this particular one I put in anything You can see that that cartilage is just really macerated And if you press around it the extent of that counter-malacia is obviously much bigger MRIs consistently underestimate the degree of cartilage pathology when you're actually in the knee The TTO, you can see how easy the exposure is when you can lever through the TTO It's just really simple and straightforward And so then put in that graft for her And that's just, you know, real quickly how to do it It's really straightforward, the sizers are there You use the reamer on the patella because the bone is complex curvature You always have to finish with curettes to make sure that you get that calcified layer off And then once you do you can implant the graft after drilling You can use a very small K-wire for the marrow vending But do drill about 7mm into the bone to ensure that you get it out And so far on my two-year follow-up MRIs these incorporate really well So Something else You know, I mean this is obviously a good outcome and this is one of the more products on your market I'm a little troubled because I'm not hearing anything about measurements Right, so, I mean there's two questions that I have First of all, does any cartilage procedure in a patella-femoral joint automatically mean you do a tibial-tubicle osteotomy and particularly in a medial-based defect you know I assume that you are measuring TDDGs and those kind of things to understand where you have to move the tubicle, right? Or are you just anterior-rising in these cases? It's primarily, I mean there's a degree of medialization because you can't just bring it straight out very easily You actually can, but most of us don't, right? Yes, technically it is possible but it is harder and you don't get the compression So her TDDG was 17 So I medialized her a couple millimeters but had a steep cut and primarily anterior-rised her to offload that So not everybody gets a osteotomy I have become more personally aggressive with it because I've regretted not doing it a few times and so that's definitely a discussion. Now there's some people you know, like for instance one of the gymnasts who had a patellar dislocation with associated cartilage, she did not want to risk having asymptomatic screws or problems with the osteotomy and so did Macy and PFL on her because she was concerned about the impact on her knee because she depends on her knee quite a bit So there are those types of conversations that you have to have where you understand that you may not be offloading them as well as you could, but it's a risk-benefit conversation I think this is important because I think there are some differences between the instructors in the room and I know Andreas, for example, thinks differently I don't know about you, Sabrina In my hands, almost everybody gets a tubercle transfer just for the anteriorization effect because if I can unload the patellar femoral joint by about 15-20% which biomechanically has been shown that you can, why would I not do that if at the same time it also actually improves my approach and the complication rate, even though the literature talks about 25 or 30% complication rates of the tubercles, that's absolutely not what I'm seeing. But I know that, you know, Andreas and you Sabrina, I think you may think differently about that, right? I think we could go around the room and say what we would do as far as masteotomy or not so Andreas is my husband, he's not here but I would say both of us would do masteotomy with its case so for BLT subpatients, we might do a straight anteriorization, but we likely would not do an AMZ we have over the past maybe 3 or 4 years started measuring tubercle height or set tilt CTG, and so one of the things we know I think there's not three studies published, one of ours it's not published, it's getting it's imminent, but where we looked where when people looked at cartilage lesions in the patella, and in our case we looked at medial patella lesions, essentially all of those patients were posterior, so it certainly makes sense to anteriorize them but at least for me I have a revision patellofemoral practice, and I do see a lot of patients who had a masteotomy and come in unhappy now potentially all of them are over-medialized but certainly some were just medialized and with their AMZ and now are visible, which is good, that did not improve the outcome, but I think as cell base for this type of treatment is perfect for this lesion, so I understand I know you can't do cell base, but this product is what was the name of this product? This one is Prochondrix, which is a cryopreserved with a high cell viability, and so I mean, you know, she's part of the study, right, so graft is free because insurance companies don't reliably cover this. I would just add I'm just wondering, does the does it matter what side of the joint is part of the staff on the TTOs, patella versus the trochlea I know you're talking patella, but does that drive you if it's a patella lesion more to a TTO versus a trochlear lesion, or what's the staff or the faculty's thought on that? Maybe what I was going to say might have to do with that a little bit, and then I'll add more but the, you know, the just like Sabrina's saying, and Drew helped us with some of the sagittal TTTG stuff and the, you know, the how much you anteriorize the tibial tubercle is one of the only osteotomies in orthopedics that doesn't have a preoperative measurement for indication, and so we're still relying on historical studies of where lesions were based and whether or not people benefited from doing an AMZ which was kind of uniform and not dialed in based on a lesion location and so we look at TTTG primarily for some reasons because we don't want to over medialize people so if you see this defect, it's lateral you want to primarily medialize and it turns out their TTTG was 12 I have seen people develop reverse J signs and be over medialized and there's just certainly more to it that we're all trying to understand, so if you have somebody that has a J sign they have lateral maltracking, they have a significantly lateral TTTG and they have a distal medial defect if you centralize that patient which is medializing them, you're offloading the medial lesion because the medial lesion now is sitting on the lateral femur and has a lot of pressure on it, and if you centralize it which is technically medializing it you're offloading a medial lesion in that setting so there you want to kind of bring it over a lot you could bring it anterior too, but you really want to bring it over I think it depends on the situation where it is the biomechanics data is trochlea you offload about 30%, so it's a little bit less than the patellar joint, distal and lateral are the historical parts of the patella that you offload the most with an anterior medialization, but that's where I think that we just have to keep getting better at having really clear indications just like all the other osteotomies that we do She did, but a normal TTTG, and that's one of the reasons I glossed over that, because I wasn't going to focus on that, but I think it's important to recognize that and I do measure in the OR how much I'm moving them over based on my preoperative measurement, so I'm not trying to medialize something I'm trying to centralize, which is far better terminology If you've got straight anteriorization, it's basically putting a little 6mm wedge underneath the tubal fragment of the way to do it and then popping it back down, that's the method if you want to know that's how to do it, leave the hinge distal pop it up, put a 6mm bottom wedge underneath, it's a technique not to do a global K anteriorization it's ridiculous, you're going to have to be crazy just a little bit She's got a J sign, she has a normal TTTG, if you look at the rotation profiles I have done that in her case, I did not but the part of that too can be a little bit of quad control more of a functional J sign it was not profound, but I wasn't too concerned about that I have done derotational osteotomies before, but it's pretty uncommon in my practice you have the entire spectrum when you're talking about osteotomy a simple test is basically look at when they are walking into the room and have them walk in shorts if they come in with what they call the squinting knee caps where they look at each other then check rotation a very easy clue is just basically check rotation in the hip and if it's asymmetric for example, then you should probably look into rotation and that's a patient where you should probably get a CT scan or an MRI whatever your poison of choice is in order to determine that but I don't think everybody up front really needs to have that full 100 million dollar workup if there's no kind of alarm sign, so I think this is something that you need to keep in the back of your mind, but it's actually relatively rare

articular cartilage management

patellofemoral joint

chondroplasty

cell-based treatments

osteochondral grafting

tibial tubercle osteotomy

MPFL reconstruction

MRI findings

cryopreserved osteochondral allograft