Just to show you what it looks like for a non-op management and that we can actually get these to heal, I used to think, I felt like my first several years in practice, I didn't see a single patient who had non-operative management that healed, but it does actually happen. And I think, especially the fact that we have some nice MRI sequences now where we can really better define whether or not there is bony bridging, that can be helpful and we definitely have seen. I'm not sure, to be honest, I have any clue of who it is that is actually going to heal. If it's a grossly unstable lesion, we know that that is exceedingly unlikely. But if it's a stable lesion, which are gonna heal and which are not gonna heal, I think is something that we're still sorting out. So that'll lead me to this case, case number two, the 12-year-old male who had one year of right knee pain. In this case, localized pain right at the site of the OCD. Patient had discontinued soccer, but every time they started to come back to any kind of activity, even just light jogging, they would have pain. So these are all kind of typical presentations for a standard OCD patient. So we started for this patient with non-weight bearing for six weeks, including a medial unloader brace. This did resolve the pain, and fortunately, after they returned to daily activities, they started to have pain again. So on exam, there's tenderness palpation directly over, and I should actually say, over the anterior aspect of the medial femoral condyle and that lateral aspect of the medial femoral condyle. Sometimes you can find an effusion, and sometimes they'll report mechanical symptoms. In this case, this patient did not have that. So here's the MRI. So on the T2s, even, you can get a sense. This is one where we can very clearly see the OCD, but it's one of those kind of in between, is this a problem, is this not a problem, is it stable, is it not stable, hard to tell. I think one important thing, and Crystal nicely showed some of this in hers, is to understand that we've looked at our OCD patients, and the cartilage over the top, even if it's a little thickened, generally speaking, is pretty normal cartilage. So in this case, this is normal cartilage, which is good. Bone window, you can appreciate it better. All right, and here's the alignment film. So Crystal nicely pointed out that really important to understand what's going on with alignment. So hopefully this is gonna stop here. And so I wanna stop and ask the panel, what are you guys thinking, what would you do at this point? Maybe, Jutta, I'll start with you in terms of what you see on the imaging. Do you wanna use the mic there, so in the back they can hear? So it's hard to talk about images when the images are not there anymore, but I will quickly say what I saw. So on the T2-weighted images, for me, as a radiologist, it was unclear, is the lesion now cartilaginous, is it bone? So that is always the question in order to kind of predict at which stage of healing that lesion is. It was definitely stable. There was a lot of reactive bone marrow edema. If you can go back maybe two more. So let's just take the bone window, or the, yeah. So, okay, let's take this. Sorry, I take up too much bone window, yeah? Trying to get it to run. So on the bone window, you clearly saw that it was a cartilaginous lesion there. There we go. Okay, let's do this. So a lot of reactive bone marrow edema, and question, is this bone or cartilage? From the bone window next, we know it is a largely cartilaginous lesion, and it's a stage two lesion, and you will see early circumferential mineralization. Can you get this one image where it shows that there is circumferential mineralization? It's, yeah, it's a stage two lesion. It is largely cartilaginous, and has surrounding bone mineralization. All right, Ted, Crystal, Kevin, what's your, what are you thinking? What's your next plan? Okay, so at this age and degree of skeletal maturity, I tend to, I would say that I give them every opportunity to heal this on their own. I think it's not a bad thing to have a large stress reaction, and I tend to simplify things for patients. I think if you, patients, being from Philadelphia, I'm not sure if you've ever seen any sporting events. Our patients and their families can be direct and blunt, and sometimes mildly antagonistic. So I tend to say, to simplify things, I say if we wanted to think of healing potential for an OCD, if you're about this tall, everybody's gonna heal with non-operative measures. If you come in with a beard and a mustache, nobody's gonna heal, and if you're in between, some will and some won't. So I'm not gonna give you a muffler shop type guarantee. I'm also gonna tell you that this is an area of, I kind of simplify the process, say this is a lesser viable bone, but if this is, I'll exaggerate and say, if it's dead bone, you wanna make me, make dead bone become living bone. So what are you asking me to do? You're asking me to bring the dead back to life. That is historically considered in medical terms, and if you look in religion, a challenging thing to do. So you're asking a lot from me. I think it's important to set the expectations, whether it's non-operative or operative treatment. Yes, I typically, I agree with that. I think for skeletally immature patients, oftentimes, I discuss with them both non-operative and operative treatment for a stable OCD. I judge the family, I look at the MRI as well. This is a pretty large dimension on the sagittal image with a fair amount of bone marrow edema behind it. If we're gonna pursue non-operative management, I typically tell families you're buying at least three months of non-operative management, because I think it's important, although I'll see them back in a month or six weeks and we'll get new x-rays, I tell them, I don't anticipate we're gonna see significant changes on x-ray in that short window. So I think it's really important for them to understand, Johnny comes back in a month and we go back to seven days a week of soccer and back to everything like normal. So I tell them, even with non-operative management, it's probably gonna be four months before, if it's healing and healed, then I'm gonna let you go back to impact activities. And it's probably at least a 12-week commitment to non-operative treatment and restrictions before we're gonna have an idea if this is healing. And so sometimes, families are very amenable. They would wait 26 weeks, if that's what it took, to get it treated non-operatively. And others are very adverse to waiting that long. And so if you can consider a drilling procedure, this kid's only six weeks out, but symptomatic again, he's in varus alignment. So I think, I tell them, drilling has higher rate, if we look at roughly maybe 80% healing in a skeletally immature patient with this stable OCD versus 90 to 95% with drilling, there's still some that may not heal. I would probably do an hemi-epiphyseal adhesis. At his age, I think you could do a plate or a trans-bicele screw, if I was going to drill and treat it. Great comments, just maybe a few things. We have learned from looking at our non-operative healing rates, is size matters. And this lesion is, I wouldn't call it massive, but it's on the bigger size. And so, especially as Dr. Perkins said, sagittal plane dimensions are concerning, and there is some edema there. There's no break in the cartilage, there aren't radial signs, but a little bit concerning. Absence of cartilage in there, as Dr. Elliman has pointed out, is an issue as well. So size matters, age matters. Age here is good, size here is bad. BMI seems to matter. This kid probably, I'm looking, it doesn't look like a heavy kid, but when I think of varus alignment, I sort of think of that as being a BMI multiplier. And so I would think that the alignment is a bad prognostic thing, the size is a bad prognostic thing, but age is a good prognostic thing. I think this is definitely a patient-centered, family-centered decision-making about the options. You saw one case, or someone, I think, Crystal, you saw one case of a very prolonged time for healing, 12 months, 14 months, maybe it was Ted, showed it 14 months before they finally had surgery to get it to heal. And I think for 14 months of a kid's athletic career, who might have an eight-year career in a sport they love, 14 months is a big chunk to give up. So this would be one I'd have that conversation with the family, but really, surgery might be a consideration, but if the family was opposed to that, I'd say, well, we've got unloader braces, activity restrictions, we've got things to help you with, but I think you wouldn't be faulted for going either way, depending on what the family wanted. One question I might direct back at Dr. Perkins is, you know, when I see a one-sided OCD, and I'm gonna do guided growth, which I do use from time to time, I also have to tell the families we might produce a little asymmetry in the alignment, and in a skinny kid, moms and dads might notice that. In a heavier kid, that may not be as noticeable. So in the South, I know, Crystal, you have a lot of bigger kids, and it may never be seen in a chunky kid, but in a slender female or slender male, if you do three or four degrees, five degrees of correction to unload that, and the other knee doesn't have OCD, and you'll have a little asymmetry, it's just something you gotta talk to families about, as well, but I don't know if, Crystal, if you have any thoughts about that asymmetric alignment you might produce with an unloading with a growth plate. Yeah, absolutely. I think, you know, guided growth is a, you know, it's very different than telling somebody you have to do an HTO or a DFO. And so, typically, if I have symmetric genu-valgum, or symmetric genu-verum, and we're unloading for an OCD, I typically go ahead and do it on both sides. You know, I tell the family, we don't have to do anything on the other side. But especially in the skinny kids, I mean, you correct that to unload it, you know, just beyond neutral, or to the lateral margin of neutral, they're gonna see a difference from leg to leg. And so, you know, especially with the transpysial screws now I think it's a relatively benign procedure, and so I give them the option. But more commonly than not, when it's symmetric, we'll correct both sides. Yeah, and maybe a question for you as well. Actually, Kevin, I'm gonna interrupt and keep going, because we're short on time, so that everybody can have questions at the end. So thank you, everybody, for the excellent comments. So in Minnesota, I think our patients are less mildly antagonistic than in Philadelphia, but they're very driven. So the discussion about should we wait, should we not, is very relevant. We had that discussion with the patients and the family, and they wanted to continue on, because we had tried some non-operative management, and that had not been successful. So in this case, because of the type of lesion, we did go ahead and drill. We did have a discussion with the family about guided growth. I don't remember the particulars in this discussion as to why they didn't want to do that, but they chose not to do that. So they just wanted the drilling. So here's what it looks like, some scope pictures. I think Crystal and maybe Ted showed some of this as well. So this is transarticular. You can also do nice retroarticular, as Crystal showed. All right, so post-operatively, the patient was non-weight-bearing for two weeks. At that visit, no problems. Then two weeks, partial weight-bearing. After that, followed by full weight-bearing. Doing great at six weeks. Allowed to resume impact activity at two months. Normal exam at three months post-op, and was seen at three years post-op for a separate issue and having no problems. Here's what the MRI looks like at three months. This is the three-month post, sorry. So you can see how it's starting to fill in. And then these are the before and after.

osteochondritis dissecans

non-operative treatment

MRI sequences

surgical intervention

healing