Good morning, Mark, thanks again for putting this together. We'll talk a little bit about etiology, but we're going to talk maybe a little more broadly about sort of the history of the OCD study group and how these study groups sort of come together and try to solve some of the problems. This whole study group started with the discussion of the academy meeting in which myself, Ted, Rick Wall, and men, we were kind of talking about how we just didn't feel like we had a lot of good research articles to guide treatment, and not a lot had been published in the last 30, 40 years. It really changed our thinking. And so that led to a series of discussions, interesting, it lined up with the OCD clinical practice guideline, which the academy developed at the same time, and many of us served on that guideline committee. The downside of the guideline, it did come out, it did identify the really critical research questions for OCD and things that really needed research to be done, where the gaps were. But there was very little evidence, so our guideline wasn't very powerful because we just didn't have much evidence to outline or rely on. But once again, most of these guidelines provide a clear outline of future research for any topic where the gaps are. And so in essence, it created the platform for the OCD study group. We applied for an ORIF research grant. Thanks to Christy Weber, our past academy president, she suggested we apply for this based on what we'd done, and we got a grant to start this group. And some of the key recommendations that came from the clinical practice guideline were intra- and inter-observable reliability studies for both radiographs, MRI, and arthroscopy classification, which didn't exist at the time. We clearly needed a prospective database or a cohort to try to identify independent factors of healing, and importantly, to measure patient outcomes. And ideally, in some settings, we would like to do some randomized clinical trials. So these were some of the clear sort of guidelines that we were given about this is where you need to go as a research group. We had some really helpful input from the beginning. Kurt Spindler gave us remarkable recommendations advice about how to get this thing going based on his experience with Mars and Moon. He, Jim Carey, was doing MPH at the time, and he took this on as an MPH research project and then joined our group. And once again, we learned a lot from what Moon had done from Kurt Spindler. We also talked to Rick Wright, great encouragement, and he attended all of our meetings early on, and he helped us with the ROC acronym, Research on Osteochondritis Dissecants. And we also, once again, learned from Mars, what worked for Mars, what worked for Moon. That helped guide us and avoid some of our potential mistakes. We had some remarkable support from people outside of orthopedic human medicine. The veterinary world is filled with OCD problems, including Dr. Ellermann, who's here today. But we learned a lot from that group up there with the veterinarians up there, and Mark Tompkins really helped us a lot. And in particular, this group helped us to find what we think is a pretty good definition. OCD is a focal, idiopathic alteration of the sub-colonal bone and its precursors with risk for instability and disruption of adjacent articular cartilage that may result in secondary osteoarthritis. The ROC group, I think, is now about 67 members total. It's a group of surgeons, MSK radiologists, physical therapists, veterinarians, and some PhD researchers. These are some of the reliability studies that we started going back to about 2013, and they've all had wonderful support from AOSSM. And we've looked at both healing sequences, x-ray and MRI, arthroscopic classification, and quite good scores for the reliability for some of the domains. We launched our cohort in 2015. We got 34 patients in 15. Through the other 22, we had 1,600 patients. I think we're about 1,850 now, and we have 25 centers contributing data. I think one of the hardest things to do in any surgical field is a randomized clinical trial. Hats off to Ben Hayworth, who got this group together, and we actually did a randomized clinical trial comparing transarticular to retroarticular drilling. It's been presented at AOSSM and at PASNA, and was just published here a few months ago. So hats off to Ben for actually doing an RCT. We've had wonderful support from radiology partners, including Dr. Elliman and Dr. Zbiniewicz and Dr. Wall, but multiple studies looking at both x-ray and MRI imaging. Ted talked about a couple of those previously. The vascularity failure, trying to understand that etiology, it's beginning to look like some cases, not all, there's probably multiple pathways to AVN in the bone, but one of the pathways that we think may be a big part of it is some type of vascular failure phenomenon where the anatomy of vascular limitations may coincide pretty closely to where OCD develops in the human knee and, ironically, the pig knee. So we've learned a lot by partnering with a veterinary group doing that work. Some of our team has been doing some translational model work, including the group up in Colorado and also Eric Wall in, I'm sorry, the group up in Minnesota, and also Eric in Cincinnati. Ted has done a lot of work with his group on looking at some of the genetic backgrounds to OCD, including some GWAS studies, so I think a lot more to come on that. We've been fortunate, as the database has grown, we've been able to do some really interesting epidemiological work. Much of our early epidemiology data came from the Kaiser database in Los Angeles, because they had about 10 million patients in their large database to have access to. But Carl Nissen, last year, published our largest database study where we looked at the 1,600, 1,700 patients in our database and did a pretty nice job on better understanding of the epidemiology of OCD, so that's one of the power of setting up these prospective cohorts. I need to update this slide, but you can see that the number of publications, both independent ROC members as well as collaborative publications, we had, by the end of 2019, 75 collaborative publications in the group, so it's really done a nice job coming together. This tomorrow, in fact, this afternoon at 4.30, Tom Johnson, a data scientist from the Naval Academy, who's also a Stanford medical student, is going to present a healing algorithm, a machine learning, an artificial intelligence approach to predicting who heals with non-operative versus operative treatment. So I think there's going to be a lot of that coming forward as our database grows. Another project that's being looked at is how do you decide which ones are unstable? Can you use arthroscopic features, I'm sorry, MRI features to confirm whether or not it's going to be unstable arthroscopically, and Matt's going to present that tomorrow, Matt Malusky, one of our partners. We've got an upcoming biomechanical project looking at when you're trying to stabilize some OCDs, you can't use screws all the time, so Ted's done some really nice work on suture rig fixation, where you may use dissolving sutures. The terms use suture bridges, and once again, if you don't have enough bone or cartilage thickness to use screws, suture bridges may be an alternative to this, and it prevents having that prominent screw head in the cartilage, which may cause damage to the counter-facing surface. We're going to be looking at the biomechanics of this this summer, and typically we use zero-vicral sutures or small tapes, but if you can imagine, that's an OCD lesion, and you put your anchors around the lesion, and then you connect sutures, so here's sort of the diamond part of the construct that gets the edges, keeps the edges down, and then we put a center cruciform, or what I call a Celtic cross, where you have a diamond and a cross, where you get the center and you also get the peripheral edges with dissolving sutures, so we're going to be looking at that in the lab later this summer. The prospective cohort, some other interesting projects, Henry Ellis and Phil Wilson are looking at some of the psychosocial impact on young athletes. We all know this has a big impact on the emotional health of these developing adolescents, and Jeff has got a really nice project going with the rest of the group, looking at unstable OCD outcomes, how these patients do, and we've got 200-plus data-dated patients that's going to be the foundation for that study. The ROC group is expanding into the ROCKIT group, that's going to include Elbow and Talus, and Don Bay and Carl Nelson are really leading that work, and we've had a wonderful opportunity to partner with Masa Masahura, who does a lot of work, ultrasound evaluation, and OCD is remarkably common in Japan, and so he's done a lot of work there, and we're partnering with him. A lot more for our future, I think the prospective cohort outcome studies are really going to be the key for our future, and I do think integration of artificial intelligence and machine learning really is going to be the next step for any large database, and as our database gets larger, this will be even more powerful for us. I don't know if we've really taken advantage of some of the biologics yet, a lot of us are playing around with different things for biologics, but I do think there's a healing problem with OCD, we essentially have a non-union, if you will, and I think biologics will be part of that in the future. Clearly genetics, Ted's group at Philadelphia is doing a lot of work here, still trying to understand the etiology, got some work to do there, Mark, Yuta, and other people in Minnesota are doing some nice work there, but vascular etiology as well as mechanical loading may be two of the most critical things, and I hope we're going to continue to sort of refine and improve and develop new surgical techniques, and then back that up with some biomechanical testing and outcome studies in the future. I think a final goal of the group is we'd like to create more standard approaches to certain stages of disease in which we're not trying to tell everyone to do it the exact same way, but there's an awful lot of variation in how we treat many things in orthopedics, and trying to standardize that across the ROC group I think will be really valuable and powerful, and also make us more value and cost-conscious in the future. A couple final comments about working with organizations, one of the great things about ROC is it's really had a mission and I think a very powerful culture, and Eric Wall kind of said, hey, what do we want to do? We want to cure this condition over the next 25 years. John has said that ROC has been the best thing that's ever happened to him professionally, and Ted says, hey, you get to know people in an amazing way, both friendship, leadership, and creativity, so I think that's been a big part of the mission and the culture of the group. For those of you guys who don't know Jim Carey, Jim actually was a, tried to be a semi-professional tennis player, didn't make it too far, but also tried to be a ROC musician, and he said even as he failed as a ROC musician, he finally gets to be part of a real ROC group, so he's really happy to be part of this group. Jim's not only our MPH and statistician, but he's also a comedian, and any time you're part of a research group, you need a comedian, for sure, just to keep the group moving ahead. Carl, one of our senior members, he's described this as the most invigorating and enjoyable aspect of his professional life, and what really makes him happy is that we've had very little attrition from the group, which is, you know, a lot to say about the organization, and the group tries to be very welcoming and supportive and try to keep people involved and engaged, and we continue to, we still don't add a lot of members, we occasionally add younger members, but we're really looking out for those younger members and their future and their careers. Last couple comments, I think those of you who haven't read this book, Give and Take by Adam Grant, it really talks about successful organizations, and if you have organizations that are filled with people that are givers and matchers, you're going to be more likely to be successful, and helping other people be successful is critical for personal and I think organizational, not only success, but also happiness. And to conclude, Margaret Reid's wonderful quote about never doubt that a small group of thoughtful, committed citizens can change the world, indeed, it's the only thing it ever has, and I think ROC has tried to follow that recommendation from Margaret Reid. And I'd like to just conclude by calling out a couple people that we've lost along the way. Alan Anderson, many of you know, a remarkable leader, died in a tragic accident a few years ago, and what an amazing friend, mentor, and colleague he was to all of us in ROC. And we also lost Lucas Murnahan to cancer a few years ago at a very young age, and so we got a long way because of those two individuals, and we're grateful for their support. That's it, thank you.

OCD study group

research articles

OCD clinical practice guideline

surgical techniques

randomized clinical trials