All right, we have a door closed, so I think we'll go ahead and get started. Welcome everybody, and thank you for joining us this early in the morning. Fortunate here to have an esteemed panel of folks. All of us are connected with the ROC group, and so we put together this ICL to hopefully give you some information, and hopefully in an organized manner, on the current thoughts about OCD, particularly within the ROC group. So this is our panel, and this is the plan for today. So we're going to start with Dr. Shea, and then we'll have Dr. Ganley. Dr. Ellerman, our colleague, unfortunately had a family event that came up fairly last minute that she couldn't get out of, so you're going to have to listen to me, I'm sorry. And then Dr. Perkins will give our last talk, and then we're hoping to spend the majority of our time kind of going through cases and save some time for questions. So Kevin, you're on. Thank you. Could you bring up my talk? Is there a moderator? Yeah. Let's see. Or is that something you do? Well, I don't know. Oh. It's got open there. Those aren't mine. Those are mine, though, so here. Great. Excellent. Very good. Thanks. Thanks, Mark. Good morning, everyone. It's great to be here and be part of this panel. I always learn a lot. Case discussions, the audience participation is the highlight of this, so here we go. I'll talk a little bit about the background of the ROC group, where we've been, kind of how we got started, and maybe a little bit about where we're going. So just a little background history. The group of us, about 2009, started talking about, hey, we weren't sure if there was enough research out there. There was the OCD guideline, which didn't identify a lot of evidence, so we kind of sat down and said, well, maybe we should start a research group and start at the academy's annual meeting and spend a little time kind of discussing what we might do and had a lot of great leadership from the guideline in terms of outlining what we need to do. I don't know if many of you have used the guidelines, but one of the nice things about the guidelines is not only do they outline clinical questions and clinical processes and approaches, but they do go through what the research is in the area. One of the nice things about this guideline in particular, it said, here's where the evidence is, here's where it isn't, and these are the unresolved research questions and areas that need further investigation, so it really created a roadmap for this research group, and we used that to kind of launch ourselves and also to outline our research questions. We also got a grant from the ORF to get the group started as well, thanks to Christy Weber. Some of the areas that were, I deem, most important by the guideline were inter- and inter-observer reliability studies for radiographs, MRI, and arthroscopy classification, because if you're ever going to form a multi-center study group, you have to make sure you can communicate consistently and classify consistently. Also, it was felt important that we need a prospective cohort to look at some of the independent predictors of healing and measure different outcomes, especially PROMs, and they felt that RCTs would be ideal as well, especially retroarticular versus transarticular drilling, so these are some of the kind of summer recommendations from the guideline. We started, you know, talked to really bright, talented people, and the first people we reached out to were Kurt Zmendler and Lynn Coker to get advice about what to do. As you know, they've been very involved with Mars and Moon, and one of the best piece of advice we got is we got connected with Jim Carey at the beginning from Kurt Zmendler. Jim is a statistician and really helped us a lot, and in particular, the lessons and tried to avoid maybe some of the mistakes early on with Moon. Rick Wright got involved early as well, and from the beginning has offered us amazing encouragement and attended many of our meetings early on. He's the one who helped us with the ROC acronym and also shared a lot of lessons they learned from the Multi-Center Mars or ACL revision group. First thing the group did is try and come up with an addition, and we had input from a lot of different people on this, lots of surgeons, obviously, but we got veterinarian researchers involved because OCD is quite common in the veterinary world, and also some radiologists, Dr. Ellermann, who couldn't be here today, but our definition was it's alteration of subchondral bone and its precursors with risk for instability and disruption of adjacent articular cartilage that may result in premature osteoarthritis. The ROC group's now got a little over 50 members, and it's a group of orthopedic surgeons, MSK radiologists, physical therapists, several veterinary researchers, and several PhDs. These are the classification reliability studies that have been done by the group and have been published already, including for arthroscopy, healing sequence, x-ray classification, and MRI, so that gives us some reasonable tools to use in a multi-center fashion. Currently we have 25 centers, and we're close to 1,800 patients in the cohort right now as of this year. We were able to get a randomized clinical trial done, which is incredibly difficult in orthopedics, but it basically compared transarticular, retroarticular drilling, and thanks to Ben Hayworth and the AOSSM who gave us a research grant for that, and it's been presented here and was published in AOSSM this last year. We've also looked at x-ray and MRI evaluation approaches with groups of surgeons and radiologists in particular that have been published. The veterinary research group has done some interesting work helping us better understand the etiology of OCD. We don't fully understand that yet, and there may be many paths to OCD, but one of the paths may actually be a vascular failure issue, and they've actually looked at humans and goats and pigs and done comparative anatomy. Humans and pigs are all prone to OCD in the same location. Goats have great blood vessel support of the fetal thermal condyle lateral aspect, but humans and pigs do not. We all have a deficit or watershed area there, so that does shed some insight from the veterinary world about the etiology. There's been some additional animal model work with several members of the ROT group looking at pigs in particular. They've not been able to induce it in goats yet, but looking at pigs in particular. Ted Ganley and others have looked at some of the genetic background and bases for OCD, including GWAS work and some population database work as well, both looking at canal loci as well as some genetic studies. We have four published epidemiology studies now from ROC members. The bottom one here is the largest one from our entire prospective cohorts, over 1,500 patients really helping us better outline and understand the location of this condition. There's lots of work remains to be done for sure. We're currently doing some work on our database using machine learning and artificial intelligence to help us predict healing. We've got a pretty accurate prediction algorithm for non-operative treatment of OCD. This was presented last summer here, and it was just accepted last week to OJSM. We're looking at some OCD fixation, some novel techniques. Ted has done some interesting work. He's working on suture bridges. We've learned that for some OCD fragments, this is a pretty good approach for securing tissue because it's too thin for screw fixation, and you don't want to have that prominent screw in the cartilage and bone. We're looking at some different patterns, and this is an example of an OCD fragment with anchors on the periphery and then sutures. We call it a Celtic cross pattern, trying to lock these down with absorbable or, in some cases, non-absorbable sutures. Some more biomechanical studies on this construct will be done this summer. The ROCCIT group, ET is for elbow and T eventually for talus. The ROCCIT group is out there. Don Bay and Carl Nesson have done a lot of the leadership work here, really trying to understand elbow OCD. I think they've got 450, 500 elbow OCDs already in the registry. Once again, lots of future questions. Our prospective cohort, I think, increasingly will take advantage of machine learning algorithms because as the database increases, you're better able to do that. Better understanding the biologic background and biological approaches to OCD and certain genetics will help us. Increasingly, Ted Ganley and others have looked at some of the socioeconomic determinants of outcomes of OCD, which actually there's some very important findings there. Once again, we still don't fully understand this and there may be several pathways, including repetitive loading, maybe vascular. I think we'll continue to look at surgical technique and development and biomechanics. I think one of the goals of our group also is to try to standardize treatment and reduce some of the existing treatment variation nationally and internationally. Thank you. Thank you, Kevin. Call up Ted. Thank you. So I'd like to thank Mark for organizing and really enjoy the new things that come up from this meeting. I'd like to thank AOSSM for this opportunity, and this is a collective effort with input from Kevin Chey, Mark Tompkins, and Kevin Landrum, who's a research coordinator with me. I tend not to sleep in Denver for whatever reason, so some of these slides are so hot off the press that they should be on fire, because I adjusted this based on some previews of Kevin's lecture, Crystal, and Mark's within the past 24 hours. So here we go. I have nothing directly relative to this talk. So we'll touch base on clinical studies. Kevin touched base on genetics, so I removed that portion, and trends in innovation. So when we think of OCD, Kevin had noted that OCD is considered an impact on the underlying subchondral bone and its cartilage precursors. So here's individual red blood cells at the lateral aspect of the medial femoral chondral traversing through the vessels, and that's what can be impacted, as well as the subchondral bone. And Kevin mentioned this clinical practice guidelines, which stated this is what you need to learn and do. And so I'll touch base on one 2015 AGSM reliability study, 45 OCD lesions, seven orthopedists at different institutions, interrelated reliability, and characterization of radiographic features. So we had to define certain things, including parent and progeny bone, and kind of come up with a bit of a nomenclature, if you will. And so this was the characterization. Based on size and location, the progeny bone, boundary, and the parent bone. So if you look at the term progeny, it's like the children, the small area bone, and characterized that fragmentation, including two or more pieces of bone shown there, displacement, which can be non-displaced, partially or fully displaced, and the contour, which can be convex, linear, or concave. The boundary at the interface, which is the density of the boundary that separates the progeny from the parent bone, is either indistinct or distinct. And then the parent bone density relative to the unaffected parent bone is either less, the same, or more dense. So it helps us have a common language about these. Arthroscopic nomenclature, as we showed also, was reliable in AJSM in 2016, using that same reliability study format. We created a prospective randomized controlled trial of trans versus retroarticular drilling. That was published in AJSM 2023. And I got Ben Hayworth to provide some of his slides from his talk at AOSSM. And the results of the anatomic features and treatment data, the transarticular drilling had a shorter, in terms of fluoroscopy time, that was statistically significantly lower. The K-wire size, you can see this is usually 0.45 or 0.62, which was used for those. And the tourniquet time was less for transarticular drilling. So transarticular drilling had a shorter tourniquet time, fluoroscopy time, bony healing six months, but they were the same later on, returned to sports a little earlier. Both were, however, safe and effective techniques for surgical management of stable OCD lesions. And this was one, at the time, one of only two prospective randomized controlled trials within all of orthopedics registered with the NIH. So both drilling techniques demonstrated consistent interval healing, high rates of clinical improvement, excellent PROs, and low rates of revision surgery. So both are considered safe and effective for surgical management of stable OCD lesions. A little technical tip. So I tend to use a core needle biopsy trocar, so that if you're doing transarticular drilling, you don't wrap up the fat pad. It keeps you, helps you stay perpendicular, and helps you create these perfect circles, if you will. And see if I can get that one to play. So that can, again, help you from skiving and help you get, again, these perfect circles. And there's a little video of the fat droplets you can elicit to show that you've reached below the non-viable bone into the dead. So what I tend to tell families is, you're asking me, what are you asking me to do for any OCD lesion is to go through non-viable, lesser viable, or non-viable bone. And I'll exaggerate to just say, you're asking me to bring dead bone to become living bone, and you're literally asking me to bring the dead back to life, which is historically considered to be a challenging thing to do. So this is, with those studies, we've already covered reliability studies and RCTs. And Mark can talk about how you address the optimal surgical approach in our discussion section. Our colleagues in Europe showed the high return to sport following management of OCD of the femoral trochlea, a systematic review, and said revision rates for operative protection was 9% over our return to sport. It was very high for treatment of the trochlear lesions. And that was 2024. In 2023, our colleagues, Dan Saris et al., showed there was no significant difference risk of failure based on fisial maturity as it pertains to internal fixation of unstable OCD lesions. Again, out of AJSM. Aaron Critch showed with internal fixation of OCDs to open growth plates, improve healing rates. And interestingly, skeletal immature and mature patients healed at comparable rates. And lateral femoral condyle lesions is an independent risk factor for failure. So they can be some more of the bad actors on the lateral femoral condyle. Really nice study by Aaron Critch also. If you have a full thickness defect, the palliative procedures or drilling et al. fared worse, as you can expect, relative to the restorative procedures in terms of progression to arthritis. And that was statistically significant relative to restorative groups, including MACI and other techniques. And then if you look with the prospective cohort, as Kevin mentioned, did an epidemiology study on the cohort when it was at 1,400 patients. That was published at AJSM January 2022. Interesting findings. I think it was kind of confirmed. Lesion location, medial femoral condyle was 66% in that group. And you can see the breakdown there. And most cases were involved in multisport athletes. And so that covers the other third box. It was kind of the gold standard of what was needed to do within this group. I would emphasize, based on this article, that we keep in mind alignment always with OCD lesions. The location of OCD correlated with leg alignment were significantly correlated, as you can imagine, medial femoral condyle with more varus than valgus. And lateral femoral condyle, more valgus than varus. That's intuitive, certainly. Pre-stage smoking, inactivity, and preceding trauma were predictive instability in OCD lesions. And that was, again, January 2024. So hopefully that's keeping us all up to date. The concept of suture bridge fixation, I sat with Phil Wilson. He forwarded me slides yesterday. This was out of our early article that we did on suture bridge. I'm sure Crystal will touch base on these. But the concept is that we create a net, if you will, over top. And this can be really helpful for some of these shallow OCDs with scant subchondral bone, as opposed to the deeper ones where screws work beautifully as well. And then again, I submit to you the excellent work by Phil Wilson and Henry Ellis et al. out of Texas, Scottish. That's a really nice article out of AJSM. They worked with OCD lesions as well as osteochondral fractures. We looked recently at patellofemoral osteochondral fractures and compared metallic screws versus bioabsorbables. And the objectives was to look at both of these. We didn't just say suture bridge only because we used some resorbable chondral darts and tacks, if you will. But good outcomes regardless of fixation technique. Two-thirds of metal screws required hard removal, as you can imagine. We don't like to keep hardware right at the surface in these scant subchondral patients. And future studies certainly need to evaluate the bioabsorbable more. We looked at social determinants of health impacting patients with OCD. And this was multi-center again across 17 sites across the U.S. And overall surgical and non-surgical cohorts. If you looked at, there was differences in the very low versus the very high groups in terms of number of providers seen and outcome scores including the PD-FAB score. And again, this is the difference between the very low and very high. We didn't see difference between the intermediate groups. But and noted that certainly the lower child opportunity index at the extremes impacted patient presentation. And so our goals is to strategies to minimize these gaps between patients. And this is all a collaborative effort. So I have an editorial in the American Journal of Sports Medicine on this collaboration and mentorship and highlighted our OCD group. We can certainly, as Kevin has stated, Margaret Mead said, Kevin, perhaps you can even give that quote better than I can. But the change is based on a small group. Yeah. Never underestimate the power of a small group of committed individuals to change the world. In fact, that's the only thing that ever has. Margaret Mead. So this is how I think a template for these collaborative groups. Certainly, we've learned from our Moon and Mars colleagues. And then that spread to multiple topics within Pediatric Orthopedics. So these are the patients that we're all treating. And that's why we're all here this week. But I think of ACL as more binary. It's either intact or ruptured, always occurs in the same spot. Whereas OCD is a spectrum of sizes, locations, and different features. So I'm really looking forward to the talks that Mark and Crystal have moving forward. Hopefully, we address our goals and objectives. And thank you for your time. Happy to answer any questions at the end. Thank you, Ted. Come on. All right. Well, as I mentioned, unfortunately, our colleague, Dr. Ellermann, couldn't be here today. So I'll try to hopefully still be able to keep this amazing radiology stuff sounding cool without a nice German accent from Jutta. So here is the stuff I want to make sure Jutta wants us to make sure we're going over. I think all of this is driven by radiology. But we would be remiss to also note that this is really a multidisciplinary effort. In particular, involving some of our veterinary colleagues. And in particular, people with histologic expertise. So all of this is kind of correlated between histology and radiology. Oh, sorry. There we go. Not sure why there was extra clicks there. So I think this is a really important concept. When we're trying to understand the basics and the pathophysiology of OCD, there's been some work by those of us in ROC suggesting maybe there's other pathways. But I think that the vast majority of OCDs occur in the pathway that we've sort of come to understand. And it's critical to understand that this concept of the growth cartilage in the epiphysis. So this is obviously different than the physis. But this cartilage is changing morphologically. And so it's growing. And also, obviously, importantly, it's changing from cartilage into bone. And so what we have come to understand is that at a young age, all throughout the articular epiphyseal cartilage complex, or AECC, that there is a nice vascular network that you can see on the right there. And we can look at that. Sorry. We can look at that vascular network through quantitative susceptibility mapping, or sometimes called susceptibility-weighted imaging. But basically, the idea is that the imaging allows you to show air or show a space. And so that's how we're able to map the vessels. What we know on a small histologic level is that the vessels do penetrate into this cartilage, much like you would imagine. And then we see this change over time. So this is from one month to eight years. And a number of studies looking at development in the pediatric distal femur, in particular, have suggested that there is a fairly clear, of course, it's not going to be for every child, but eight years is kind of an important point where a lot of the final anatomy, or at least shape of anatomy, is pretty well developed. So I think these different time points are important. If we look at the vessels on an even kind of more magnified level, what we see is that there's really vessels coming from three different directions. So from centrally, and then also from each side, medial and lateral. But you also get these watershed areas, and Kevin mentioned it when he was talking. And we think this is a really important concept. So I'm going to give even some more illustration here. If we put it into three dimensions, obviously it's important to then note that we have the vasculature reaching the entire area, but there are these watershed areas, and if we really highlight it, then you can see, I have no idea why Italy or Mexico colors instead of German colors, but we have, you can see the periphery, the lateral and medial in color, and the central in white. And if we do this over time, we can see that particularly centrally, that starts to go away. And so what we also note is that those watershed areas correlate very strongly with where the predilection sites are for OCD in the distal femur, at least in the femoral condyle. And possibly, actually, also in the trochlea, for what that's worth. But the lateral aspect of the medial femoral condyle is exactly where the watershed area is. So the thought process is that there's probably some injury to these vessels as they're receding, or maybe even before they recede, and then you get an area of necrosis of the cartilage. If that cartilage area of necrosis is large enough, then that, over time, can potentially become symptomatic OCD. That's the underlying principle for pathophysiology. So just to review, this is actually, as Kevin mentioned, this is a problem in some animals, pigs in particular. So it was first shown in pigs and horses. I don't know why that's going, sorry. And then we were able to show it, so this is where the histology comes in. We were able to show it through our pediatric cadaveric work, that we could find it. And interestingly, as I was pointing out, the ages. So we found a lot of precursor lesions in four-year-old, five-year-old patients. So again, thinking about how that AECC develops over time. I know this thing has a mind of its own. So the point here is that we think that this has given us a lot of insight into the pathophysiology of the overall osteochondrosis process, which ultimately leads to symptomatic osteochondritis dissecans. Dr. Ellerman and others have developed this idea of how we can follow the healing if we identify an OCD. So not only can we then take some of this information and understand how the vessels develop or change over time, but we can also get some understanding of what's happening at the distal femur as it's changing. Sorry, this thing is just walking its way through this. I think there's probably still some more work. I think we do see some variance of this, but this is important. So see this stage one, a couple variations at the top, and then stage two and three at the bottom. And then basically it either ends up going on to healing in stage four, or, sorry, or in stage five it becomes loose. One thing I would point out with stage five is one thing I think we need to fix on this illustration. That fragment usually doesn't look like the apparent bone. So usually there's different ossification of that fragment. You can get basically that AECC to catch up, and so you start getting ossification more superficial and right underneath the articular surface, but it's not normal bone. Over time, we hope that we can get ossification filling in. And so if you look here on the MRI, this is, you can see what it looks like as a stage one. So we see the OCD lesion. It's kind of hard to know at this point where it's going. This is stage two. We are already seeing some more changes. So you see the black line that's coming deep to the fragment. You can also see, by the way, on the T2 star mapping on the upper right corner. I should have mentioned too, these images in particular, the larger images are T2 star images. So that's another radiology technique that we have found to be extremely helpful for us. And then if we look at the stage three, this is where it's gonna decide, is that thing gonna become looser? Is that gonna heal? And then here's a couple stage four, top being initial, bottom being once we see that it's actually healed, and you can see that bridging across. And I think you kind of get a sense. This is in a T2, obviously. It's a little bit harder to tell. In this case, you can see that it's healed, but you can definitely see the bone changes on this more easily than you can on the T2. And in particular here, then the T2 star bone windows, we can see. So if we want to follow this over time, here's what these plain x-rays, we can obviously see there's no CD, but is this thing healed or not? And so if we look at it on the T2 star over time, we can see that that does heal. And so one of the things we've learned is that we think this process, after injury to potential healing, is very much the same kind of process as endocondral osteogenesis. So here's the different stages that we have outlined for OCD. And so this is kind of what it looks like, putting those all together. Stage one through four, again, T2 star, as well as the mapping on the upper right. And then for our non-operative patients that heal, again, we can watch this happen. I actually, before we started doing this work, I wasn't 100% convinced that patients actually did heal. I thought they might become asymptomatic and we didn't necessarily need to treat them, but I wasn't sure that they had the capacity to heal, and they do. I think Ted pointed out, I'm not sure we know who that is. I don't actually personally think that it necessarily has direct correlation with skeletal maturity. I think that it's a correlation because of age. So I think that the injury happens probably early, somewhere in that four to eight range, most of the time. And the older the patient, the longer it's been there, the more likely it is not to heal. So it's not something with open physis necessarily, it's age-related things. All right, basically the point here is that the T2 star measures the progression of ossification, and which we can follow over time to see if it's gonna ossify or if we need to intervene. And over time, we're trying to learn more about which ones are we pretty sure, we don't need to watch for seven and a half months to decide if it's gonna heal. We know the likelihood is very low and we should intervene earlier. We're still working on that stuff. So in summary, again, I wanna emphasize the AECC, and then that during skeletal development, there are areas of vascular regression that probably there's some kind of an injury that occurs around those, either during the regression or at the watershed area. And so in many of these patients, this is a vascular origin, and then with these techniques, we can follow the osseous healing of OCD over time. And you just wanted to make sure to note that this is a multidisciplinary effort. Thank you. All right, Dr. Perkins. All right, so good morning. So we'll try to tie some of these concepts together and look at how this impacts some of our treatment. Maybe if it wants to click. I don't want to advance. It's going now. So I have no pertinent disclosures. So I think important is to reemphasize the definition of the OCD and understanding that this is really primarily, initially, a subchondral bone problem, secondarily causing, potentially, separation and fragmentation of the articular surface. And I think remembering that is important as we think about treatment for these. So kind of big overarching treatment principles when we think about this is what is its appearance at arthroscopy? And so we think about the stable or intact articular cartilage and then the unstable articular cartilage, and we'll touch on both of these and treatment options for those today. So starting with the immobile OCDs, treatment is most commonly drilling for these. So as we mentioned earlier, retroarticular versus transarticular, both reasonable techniques and a bit of physician preference. A couple of studies, including the RCT led by Dr. Hayworth, have shown similar long-term outcomes in healing at two years and similar PROs in both groups. My personal preference is retroarticular drilling, and so I'll just offer a few pearls related to that. So I use a patient supine using a leg holder. The one thing that's important, especially as you're drilling a medial femoral condyle, your CRM's coming in from your lateral side of the affected knee, you wanna maximally abduct the well leg so that the person that's doing the drilling has room to be able to stand. This particular three-by-three guide, there's several different guides similar to this, allows you to get nice parallel drill tracks, and then I typically use a 062K wire. Placing the first one with a goal being in a center-center position within the OCD. I think assessing your pin position, your initial pin position on both the AP and lateral is very helpful. I try to strive to be center with it on the AP initially and then directly perpendicular to it, so that's what that second image, flouroscomy image is showing. So on the lateral, being directly perpendicular to it so that as I march anterior and posterior, I'm truly covering the full span of the OCD as opposed to coming in oblique to it where you can scrutinize your post-op x-rays and notice sometimes you miss a portion of the OCD that you thought you were hitting. And typically keep a couple wires in place and then drill the remaining. I think some of us have trended over time to what we call more high-density drilling. So initially, certainly when I first started practice, some of my mentors were putting three or four K wires and then drilling a couple over top of those wires and instead now it's not uncommon for us to make 25, 30 drill passes into a large OCD K wire passes. And then we don't quite still have the answer yet in terms of what augments should we be using or can make a difference in ultimate healing. Often in our clinical practice, using bone marrow aspirate concentrate injected to try to augment healing, although we haven't definitively proven that to enhance the healing of the OCD itself. Using your post-operated graphs to scrutinize can be really helpful. Typically at the two to four week mark, you can really see nice drill paths into these. The drill paths reabsorb over time, but I think these early radiographs are helpful looking at did I truly cover, typically we easily cover on the AP projection, but did I fully get the posterior aspect of the OCD as I'm drilling. Typically make these patients touchdown weight bearing for the first six weeks. In a neomobilizer for the first four weeks, not because there's any problem with their motion, but really just to slow them down. The 12 year old boy doesn't slow down for much of anything, so everything we can do to slow them down. I would stress checking vitamin D levels. So I think vitamin D is kind of all the rage in orthopedics right now, and we hear lots of people talking about this. But I think we see startling low vitamin D levels in many orthopedic conditions, but particularly in OCDs. You have options in your supplements in terms of whether it's daily or typically for my adolescent teenage patients, I do 50,000 once a week, so I think it's a little more reliable than a daily dose. And then return to impact supports four to six months pending radiographic healing. And so this is just an example of following radiographic healing of this OCD, where you can see increasing ossification and ultimate successful healing. And then we move into the mobile OCDs, which are really a kind of totally different category, and our rock arthroscopy classification looks at these as kind of locked door, where you can put a probe down kind of in the edge in that area of injury of the cartilage, the trap door where you can really start to move that fragment, and then the crater where you have a loose body. And so I think this is where there's some kind of variation in how people may treat these. Debris minimera stimulation typically for OCDs itself does not have significant use in the treatment of this, and the reason being is that most of these OCDs are greater than two square centimeters, and so too large really to be effective in the long term for marrow stimulation. I've used this occasionally in OCDs that either I've drilled or repaired, and the majority of it's healed, and then a small area was still affected. So I think occasionally this can be utilized, but certainly not a main line treatment for these. Single stage cartilage restoration is very similar, and remembering this is a subchondral bone, and so typically isolated cartilage treatment alone is not ideal for these patients. You really want to be able to treat the subchondral bone. And so then when we think about treatment, it really comes down to is this cartilage that's disrupted, is this salvageable cartilage or not? So I'll show some case examples of this. This is a 15 year old elite level male soccer player who's got two months of knee pain, and this is kind of the knee we all cringe at when it walks into office. There's nothing good going on here. So you can see large kind of hole, lateral femoral condyle, OCD, as well as medial femoral condyle, OCD. And on his imaging, the lateral one looks like it may be intact and stable, as opposed to the medial side where there's some disruption of the articular cartilage surface. And so this is his appearance at arthroscopy. So this is the medial femoral condyle. The lateral femoral condyle was a cue ball. That side was drilled. But the medial femoral condyle here, you see large area of OCD. And there's a little bit of bone attached to this, but not a significant bony component to it. And so a decision was made to proceed with debridement bone grafting repair on the thought that this was a large piece of cartilage. The cartilage itself appeared salvageable and healthy. So the important part behind this is that you've gotta treat the subchondral bone, right? So we don't wanna ignore this interface at all. So as you lift that piece up, as you saw in the arthroscopic image, you have a lot of fibrous tissue back behind that. And so just taking screws or your fixation option of choice and just purely compressing that back down, you're not changing any of the biology behind that. So I think changing the biology is really important as we're treating these. So this is a distal femoral autograft harvested from the same knee. So after a complete debridement, you can use your arthroscope and kind of go inside that defect as well, be able to really see and make sure you've debrided that well, packing distal femoral autograft in. This particular case was very early in practice in using headless compression screws for that. I'll show you how that's kind of evolved over time. And then this is him at a two years post-op. They do not all turn out so perfectly, but this one turned out well. So healing, his screws had been removed. Lateral femoral condyle healed and he was back playing soccer at a high level. So as we think about fixation, you've heard us talk a little bit about suture bridge type fixation this morning. And I think this is an important concept because I think things have changed pretty quickly over time with regards to this. So metal headless compression screws, they're dependent on osseous structure. And so if you don't have osseous structure behind them, I think that's where we struggle to see the benefit and utility of those. They do require hardware removal, which is not such a bad thing in OCDs as it can be nice to get a second look at these. They can degrade MRI resolution. And certainly we worry, especially in the condyle fragments, even though you countersink these down, I think we've all seen these where they were countersunk. Clearly we're staring at them behind the cartilage and you go in to take them out and they've kind of worn a little bit of a trough as things kind of subside. Bioabsorbable implants, certainly still being used, but I think well-described concerns with them now, including loosening, synovitis, and some cyst formation. And so then what are our alternative strategies and what else can we do in a same kind of technique? So this is a 12-year-old male who has a stable lateral femoral condyle OCD, but then this unstable lateral trochlear OCD. And these, you know, another kind of bad knee, definitely bad biology. So at the time of scope I got in and you can see this large OCD of the trochlea. It covers really the entirety of the trochlea. The lateral half of it had already broken away as a free fragment was in the gutter. That's what I'm removing there. The medial half, you could stick your probe in and really just lift that whole fragment up. Given the size of this and his young age, felt that ideally trying to repair this would be optimal. And so kind of cleaned up the loose body fragment, elevated the more medial aspect of the cartilage fragment that was in place, debrised it behind it, took distal femoral autograft and repair. These are non-resorbable sutures. It's kind of a change or evolution in time. Initially we were using some vicral suture for this, using the same concepts as osteochondral fracture repair. Osteochondral fractures heal really rapidly of good vascularity to that area. And so we had good success, us and many centers around the country with using vicral suture for that. And then we were using vicral suture applying that same principle to OCDs and the biology is very different here and time to healing is longer. And so having a suture that's resorbed at four weeks and you lose that compression may be responsible for some of the failures that we saw with OCD repairs. So we've transitioned to using non-resorbable suture now. And so he was repaired. This is his follow-up MRI showing a good overall healing of his trochlea cartilage all intact. This is at five months and then went in to take out the non-resorbable suture which gives you a nice opportunity to be able to look at that cartilage surface. So I think OCD repair, we're still really trying to decide who the ideal candidates are for this but I would say those that you do really changing the biology behind it is important and then getting good compression across it. And then comes the unsalvageable cartilage cases, cartilage and subchondral bone. So this is a 17-year-old female, obese, who has bilateral medial femoral condyle, OCDs and then she is in varus. She's had several years of knee pain. I think looking at alignment is really important. We probably haven't discussed that enough today but looking at, I think we tend to look at alignment in all of our OCD patients, especially these younger kids and whether you're gonna consider guided growth to be able to correct them and unload that area or an unloader brace or whether in these skeletally mature patients you're considering osteotomies but definitely look at it not just by your naked eye because I think that misleads us oftentimes but truly getting good long-leg radiographs. So we started with her most symptomatic side. She had arthroscopy. The thought was, was this something repairable or not? You can see here overall poor cartilage quality, different from that before, fragmented and did not feel like this would do well. So cleaned up this piece and then planned for an osteochondral allograft for her. So osteochondral allografts are a nice treatment for OCDs as they restore both the subchondral bone and the cartilage in a single stage. We'll talk about another alternative technique as well but I think for OCDs, I oftentimes lean toward, for non-salvageable OCDs, I lean towards osteochondral allografts to be able to treat both of those problems. So through medial arthrotomy, this is a 25 millimeter osteochondral allograft plug and she got that in the same setting with a high tibial osteotomy to unload towards the base of her lateral tibial spine to unload that medial femoral condyle. So typically when we're doing any significant OCD treatment and the patient's mechanical axis passes through that compartment, either doing guided growth simultaneously if they're skeletally immature or an osteotomy in the setting of this reconstructive work. So this is her a year out. We staged these by six months and did her other side as well. Your other option to think about is autologous chondrocyte implants and kind of not being focused on any particular brand but if you're going to consider treatment with a cartilage-based product, you have to remember that you've got to treat the subchondral bone and so you really have kind of two main options with that which is a single stage approach where you can debride bone graft and then place your autologous chondrocytes over top of that or a two-stage technique where you at the initial arthroscopy debride everything, take your cartilage biopsy, bone graft that with autograft and then you can put fiber and glue over the top of that and then come back for your chondrocyte implantation and studies have not proven one to be superior to the other. I'll talk to families sometimes about both options of these. I think probably in our adolescent patients who perhaps push the limits of the activity restrictions we give them in the post-op protocols, I lean more towards an osteochondral allograft as opposed to placing a delicate sheet of cartilage cells in some of these patients but I think can be used as a technique especially for families who may feel strongly against use of an allograft. So in conclusion, drilling of that immobile OCD, you have to pay close attention to technique for complete coverage and similar long-term outcomes with both trans or retroarticular drilling so I'd say get comfortable with a technique you like and use that. OCD debridement, bone grafting, repair for the mobile OCD with salvageable cartilage. There's nothing better than being able to preserve native cartilage and try to avoid a second-stage procedure when we can, still working to decide in the long-term who the most ideal candidates are for that. And then when OCD fragment salvage isn't possible, chondral resurfacing as long as you're treating the subchondral bone is an option or osteochondral allograft transplantation. And then lastly, please get standing alignment radiographs routinely in the setting of OCDs and then consider guided growth or unloading osteotomies in the setting of resurfacing procedures. Thank you. Thank you. All right, thank you to all our speakers. Ted and Kevin, you guys wanna come back up? We'll get into cases. Okay, so our first case, this is an eight-year-old male, presents with two years of bilateral knee pain, no precipitating injury. Supramedial and antramedial pain is worse with activity, but can bother even with walking and even sometimes at rest that's obviously important so the pain is severe enough that it can cause him to stop activity No specific treatment. He does have to tell her crepitus bilaterally otherwise no tenderness to palpation in the knee No effusion and an otherwise normal exam On the MRI there was in the left knee no OCD found, but here's the right knee for you So I want to try to highlight in these Building on some of the radiology stuff that we were talking about so you can see in the t2 images here We can obviously see an OCD But it's a little hard to get an idea of really what's happening at the OCD And so the t2 star bone windows can really be beneficial in terms of trying to better delineate What it is that's happening so you can see the OCD here Much better than what we can see on the t2 alone The mapping can also be helpful. I think over time the mapping has become a little bit more of an academic Process I think the bone windows in particular are probably the most helpful things Panel with with those images, what's your first thoughts, and do you guys have a plan obviously it's fast-forwarded to this But do you guys have a thought on what you would do at this point? So I typically treat OCD cases at three-month intervals I describe to patients that my pediatric sports ABCs activity modification B is bracing C is Continued rehabilitation I can stretch their hamstrings and take a little stress off that his areas B is the bracing I'll do it either a hinge brace lock an extension They can work on take it off break room range of motion get a bath and shower or they can do an unloader bracing But I tend to reimage it at three months as opposed to six weeks Yes, I think a non-operative treatment would be my choice for this patient and Exactly what that entails I would say varies a little bit based on how the patient is feeling so when I have a patient come In that's hurting with daily activities walking around those are typically the patients that I Put on crutches and these younger patients I do typically put them in a neomobilizer initially and honestly that's a means to slow them down I mean these kids they jump off the stairs. They're all over the place. They're into everything Life is a sport when you're eight years old, so it's really just purely a means to slow them down And then I typically see them back in six weeks. I would love to just say come back in three months But I find parents not being too too exciting or accepting of that But I typically tell them that you're buying a three-month course of this that we're going to get some new x-rays in six or Eight weeks, but in reality. I think it often takes a three months to be able to really start to see some changes Not much more to offer than I think three month interval I don't know if I see much change earlier on sometimes families want to come earlier But three month is kind of my typical follow-up interval and slowing kids down crystal is spot-on It's like it's kind of like being a veterinarian sometime. It's almost impossible to stop your dogs from chewing out their sutures It's impossible to stop young kids from running and other things I try to say avoid impacts if you can cycle and you can swim and you can walk as much as possible But no running activities in the hopes that that slows them down a little bit But I think it's hard to slow kids down at this age Yeah, so I think you're hearing Three months is kind of it's not real well-defined in the literature But I think amongst folks who are seeing a lot of OCDs that has become a fairly common thing so at Minnesota Our protocol is also three months We will typically see the patients back at six weeks as well just to determine if we need to modify Excuse me. I thought I was gonna sneeze Just to determine if we need to modify a little bit So oftentimes we'll start on the more aggressive side if we feel we need to and then maybe lighten that a little bit at six Weeks and then see how they're doing at the three month mark so in this case we had the patient just avoid impact activity We didn't make them non weight-bearing. We didn't make do any bracing or offloading Work and then the six-week follow-up they presented with no pain with daily activities So at that point they were allowed to start gradually returning to regular activities So in that in that case we didn't even wait until three months But had they shown any kind of symptoms or concerns? I think in this case a situation where we had recommended they come back at three months But they were doing so well that they didn't even come back at three months But they did come back at 18 months And they had returned to all activities including sports So one of the things that we'll do until we demonstrate that the OCD is healed We'll recommend to our patients to have serial MRIs Usually at either six month or one year intervals with the t2 star bone windows so that we can actually see whether it's healing So at this point 18 months the patient returned and was back to sports and did not have any symptoms So here's what the MRI looked like at that point So in this case again, I mentioned before that I wasn't so sure that these heal But this is one of those situations where it doesn't so you can see the the before and after here on the bone windows These are a couple other cases just to show you the progression that a non-operative management can in fact Allow it to heal so a couple different cases here Okay We'll move on to case two so case two is a 12 year old male presents with one year history of right knee pain again No precipitating injury and remedial pain had become worse over the winter and this was during indoor soccer the patient Discontinued the soccer, but still with any kind of running they would have pain so initially they were managed with non weight-bearing for six weeks So more aggressive approach to a non-operative Management and had medial on loader bracing this did improve the pain in this patient And this is sort of what I was alluding to before for some patients I thought if we did this that we could make them asymptomatic, but we didn't necessarily have structural healing I think that's still probably true But we have to follow them and find out whether they either become asymptomatic or we or we definitely see some healing So in this case the patient presented when they did try to return to daily activities, and they continued to have pain So on exam there's tenderness over the medial femoral condyle the right knee no effusion no mechanical symptoms and then otherwise Normal exam so I think on the exam. It's particularly important to note whether there is tenderness directly over the Lesion site so we'll have a lot of patients present in our office who they have some tenderness to the knee if it's a medial OCD maybe generally about the knee they have tenderness But we also have to remember that some of these patients will present with pretty significant Load issues, and they'll have significant bony edema And so they might be tender in multiple places because of other reasons and the OCD is actually more of an incidental finding So I think it's really important on exam to note that there is tenderness right at that site because those who are symptomatic In my experience pretty much always have tenderness right at the OCD site if you don't then I think You got to at least be thinking about other things, so here's what the MRI looks like on this patient Keep in mind 12 years old some of the principles that we were talking about before in terms of age and how that relates to lesion progression So again kind of highlighting what it looks like on t2, and then what it looks like on t2 star So we know there's an OCD pretty hard to say what is happening there is there bone on the fragment Is that something that's going to go on to heal is it unstable? I think all of that is more difficult to tell so I was talking to you before about the stages This is in a stage one lesion Showing up pretty bright over there and Then on the t2 star sometimes Mapping sometimes that can be helpful because if we see the dark blue in the OCD fragment then we know Even more conclusively there's bone in this case. There's not bone there yet, and then here are the standing alignment films, so Multiple people pointed out that alignment is very strongly Correlated and there's been there were a couple studies long ago, and then there's been several recent studies that have demonstrated An association with alignment And so alignment is very important, okay, so we'll stop there panel What would you guys recommend now for this patient? So typically So I tell families if we're started, so I think this looks like a stable OCD and a skeletally immature patient I tell them that you know if we're gonna start initially with non-operative treatment Which I don't think it's an unreasonable approach or buying a three-month course of that It sounds like we've gotten to three months here, and we're kind of pushing limits of activities and having pain again So I think operative treatment is certainly a reasonable option in this patient I would be thinking arthroscopy and then retroarticular drilling And then I would do Pets as my preferred technique for hemipipsy adhesis, and I would do that bilaterally So you know when it comes to healing I tend to try to simplify for families And I'll put my my hand up that like like waist high and I'll say everybody that this tall is gonna heal non-operatively Everybody that comes in with a beard and a mustache and is this tall is not gonna be really healing with conservative measures everybody else Is in between so this is kind of an in-between patient. It's an intact OCD lesion So I don't I wouldn't necessarily say I would mandate a hundred percent that they have to have guided growth or intervention From that standpoint so if they have a perfectly intact OCD lesion we've covered the issues of Trans articular versus retroarticular drilling it can be your dealers choice from that standpoint I think they could do very well, so I think you could do guided growth But I don't say it's a hundred percent mandatory in this particular lesion Couple comments with one is We learned from our non-operative sort of machine learning algorithm is that size matters and so bigger is worse And if you look especially on the AP dimension, this is a fairly large OCD So that's bad in terms of healing the second thing is it's a more weight-bearing lesion So size and more weight-bearing locations were two of our independent predictors for not healing for non-operative treatment So this kid I think has unfortunately two strikes against them maybe the only positive thing is this medial condyle versus lateral because lateral healing prognosis seems to be worse, but So size matters and location more weight-bearing matters as well I would probably lean towards guided growth in this because of the size of lesion I think it's not terrible Varus if you will, but there's enough deviation of the axis there that I think having some correction would be Ideal one of the dilemmas is always if you correct one because that's where it is You're gonna leave them with some asymmetry and some families don't care but I think a lot of families do and so it's a little bit odd to talk sometimes about doing guided growth on a Non-symptomatic or non OCD side, but in this kid with a lot of growth remaining They probably would notice that asymmetry and in barren Balcom my alignment. So doing both sides probably makes sense Make a good point, you know talking to some of these families about you know strikes against them are thinking about it Cuz you know, I have some families that are you know, listen, we'll do everything. He'll stop. He'll be out of soccer for a year We'll do anything we can to avoid surgery and other families are like we can't miss, you know Two months of soccer nonetheless, you know six months or a year So I think helping them understand, you know, what are those predictors of healing? and so I typically present both sides and then I oftentimes push them one direction or another slightly and And then other times, you know, they're willing to sit and wait six months. And if that's the case, I let them do that I'll even add if they're an in-between case and we're discussing surgery versus non-surgical I can say you can have identical twins one can be more sedentary non-operative can be the answer for you for them and one can be Some kids with ADD or just hyperactive just in general and surgery Could be the right answer or they're a level 9 gymnast and they just have to get back to activities things like that Yeah and mark if I get to maybe just ask a crystal question because I'm stepping into the the pets world as well where instead of using plates which are prominent and Symptomatic almost all patients as opposed to the pet screws, which are asymptomatic Do you have an age limit in which you think they're too young to do pets? Or do you feel comfortable with pets at just about any age? So it's interesting some of my limb deformity colleagues are like, oh my gosh You know you I would only do pets and a kid with you know a year maybe a year and a half of growth remaining because their concern is that are you damaging enough of the fices that you create a Longer term growth issue when you take the screw out, you know My concern with that concern is that we've learned from the ACL literature that putting a hole that size across the fices doesn't create a meaningful growth disturbance and so I've kind of adapted for my patellar instability patients that I prefer pets just so I'm not going back through the medial retinacular tissues again to come back and take a plate and So I've done that and pretty young, you know, eight nine ten-year-old kids and not had a problem with it so far So I have switched But I think there are definitely some concerns All right, so this is what we did for this patient Like has already been nicely illustrated. I would have a low threshold for for doing some type of guided growth for this patient Unfortunately, I failed to convince them. I'm not sure how because as you all know, it's it's not it's not adding a lot There are some concerns depending upon the way that you do it, but you know, the downside isn't huge I think their main concern was they didn't want to have another surgery if we potentially needed to take it out for fear of overcorrection So they elected to hold off on the guided growth But they did have transarticular Drilling which between Ted and crystal they nicely showed you the two options transarticular and retro articular Within the rock group. I think Kevin or Ted pointed out that we've had a study showing there's actually not any clear difference I think the key is and as crystal pointed out its biology, so we just have to make sure however we do it We have to make sure that we're crossing that threshold between the progeny fragments and the underlying normal bone we have to get biology in there to bridge that gap and to heal and then to start improving the ossification of the Progeny fragment of the OCD fragment itself. So the technique I use it and Ted nicely shows you how you could do it with a needle I Try to make it for most lesions that we think we're needing to do this for they're gonna be a little bit on the bigger Side, so usually it's about four or five holes in each hole. I'll actually drill about five passes so I'll have the knee I'll try to have it as Perpendicular to the articular surface as possible and then through the same hole I'll flex the knee and pass again extend the knee a little bit pass again also right to left So at each hole we get about five passes So I would say similar to what crystal was telling you we probably end up hopefully with 20 to 25 passes across that interface So again, we're trying to get biology going there and trying to get something to bridge that gap Keep in mind. This isn't a stable lesion. We think the this is a lesion that stable and so There's not any reason to try to put any fixation in there. It's gonna hold we just need to get healing across that threshold This might come in on that term. So we the term retrograde and antegrade It became a little confusing for people because it's a retrograde like a retrograde Femoral nail that you put in from distal to proximal or is a retrograde you're drilling behind the cartilage So some people had different interpretations So we we moved to the term transarticular and retroarticular rather than antegrade and retrograde for drilling Mark might even ask made the panel on you mark How many people are using some type of retroarticular bone grafting or bone marrow aspect concentration? I know Crystal and cliff and Mike Bush have been doing this for quite some time. I've had some pretty good Experience but any comments from maybe all three of you when and how or how often do you use it? Especially in a stable lesion like this one Um Yeah, so when we kind of pull all the right patients to look at it the struggle with looking at those who did get It versus who did not receive BMAC in that case was that We were also going through a transition over time from kind of low density to high density drilling And so at the end of the day, I think there were too many variables to kind of help delineate it You know, oftentimes I tell families I say it It's not going to hurt the healing and we hope that there's some augmentation that it may provide You know there we do it through just a jam sheeting needle up at the Iliac crest on the ipsilateral side You know by the time I see them back at two weeks. They have no complaints for them they're like, oh, what did you do to my hip and So in terms of which patients I use it for for those that I know I'm going to drill I do use it and I harvest first for those that I think may be an in-between case I have not harvested just not wanting to harvest and then potentially not use it And so I have some patients that I have and some that I haven't But I would say most often I am Without a specific algorithm or exact criteria if it looks like a bad Perthes lesion I'll tend to do some of the retrogated to a little more if it looks like this one here. I'll do a simple drilling. I Think that if we choose the patients correctly, I think if it's a stable lesion and we do drilling whether it's transarticular retrorticular I think they have a high chance of healing unpublished data But because we've been able to follow all these patients with the t2 star bone windows They heal nicely and don't don't need any augmentation. I think most of the time That's a little different than other other situations, but in this situation with a stable, and we're just drilling. I think it's Most the time not necessary So once I've done so I am a retroarticular driller So once I've drilled I basically pass a spinal needle back down one of my drill paths And so normally I harvest 60 cc's of bone marrow And then that concentrates down to around seven to eight cc's of bone marrow aspirate concentrate And so I typically choose kind of to Pass the spinal needle through two separate areas of the OCD so down one of my prior drill paths stop that short of the subchondral bone and then Inject about half of the BMAC there and then kind of move the spinal needle into another drill path more medial or lateral And put the other half there The concern a little bit is is that you know, where does that go? Does it sit and stay there? Does it move when you let down you know in those in these cases? I typically wait until I have a dressing embrace on before I put down the tourniquet just to avoid kind of immediate outflow From that, but I think there's a lot of unanswered questions No, they none of my OCD drilling patients take narcotics afterwards and We call and talk to them the next day and they'll say their hips a little bit sore But at two weeks when I ask them uniformly there, they're like, oh wait what? Not that I've noticed And similar experience to crystal I don't use narcotics for these I use BMAC pretty routinely, but I don't use narcotics they get Tylenol and ibuprofen only and Haven't had and it's very rare that a family calls with pain control issues, but try to do this without narcotics So here's what it look like at arthroscopy I think this is important to understand you can get in there and think where's the OCD in these stable lesions? So it's helpful to have x-ray and to also obviously be really diligent with evaluating your pre-op Imaging so, you know where this thing's gonna be and what degree of flexion you can expect So for these I don't actually always do non weight-bearing after the what we think are stable lesions But I kind of kind of base it on how active I think the kids gonna be as crystal was saying Life's a sport for some of these kids without actually participating in sports So in this case two weeks of non weight-bearing the two-week post-op was fine Then after that two weeks of partial weight-bearing advanced to full weight-bearing PT all the way throughout Patients doing well at six weeks and so at two months allowed to resume activities still normal exam at three months post-op So at that point they were allowed graduate return to all activity Our normal protocol is to get an MRI again around three to four months And if we see that the bone is healed and then Functionally in some of these kids, especially if they're athletes will actually have them undergo functional testing And so we make sure to try to check all of those boxes if all that looks good Then we'll let them go. So the three to four month range for this type of patient stable lesion Just drilling is is a pretty reasonable Range for most patients in this case. This patient was seen three years post-op for separate issue with no problems in the knee So here's that three month MRI So we can see that there's changes and there's bridging but you can still see there's areas where it's not fully ossified Which is pretty typical, but we were content that there was bridging And that this thing was Effectively healed and we could let them go. Here's what it looks like in comparison of pre and post Could I give you an in-between case So so for those you're trying to find that lesion, I'll let the light intensity down. That's one way to find those a little better Sometimes if you can see the the shadow if you will and then sometimes they're a little bit soft But they're significantly belottable And they have a trampoline effect that's that I feel is significant I'll add in those cases That's when I'll add in like resorbable Chondral darts or tacks or you're of choice and then I'll also in those cases I'll drill instead of a 4-5 K where I'll drill a 6-2 K wire And again, the ones that are Perthes looking will come from the back. But the transarticular I'll actually take 15 gauge Corneal biopsy, I'll go to the proximal tibia tamp that in get some cancellas bone from that location and I'll drill a 6-2 K wire And I'll add some transarticular bone grafting and then again So that's just one simple way of if I see it's more significantly Belottable I'll add a few extras All right, this is our third and last case and then hopefully we'll have some time for questions as well so this is 18 year old male pain began one year prior when Onset of pain was because he jumped into a shallow lake and kind of landed hard on that leg and at this point now He's describing loose body symptoms on exam. No effusion again tenderness over the lateral aspect of the medial femoral condyle And that probably should say anterior aspect as well. Otherwise, no pertinent findings. Here's the imaging So you can see that there's bone, clearly on OCD there is bone on that fragment. Best viewed by the T2 star bone windows. Okay, I'm trying not to show that. All right, let me see. Pause that. All right, hopefully you guys didn't see the thing. What would you guys do at this point in terms of management of this patient? Mark, I think, you know, trying to save the cartilage they have is always an ideal option and I think, you know, Crystal's comments earlier about looking at things arthroscopically and if the cartilage looks a little bit like crab meat, you probably have to think about a backup plan. But I think arthroscopically if that cartilage looks really good, even though the MRI and the fragmentation of the bone look a little bit concerning and even the signals in the cartilage on the MRI do look a little concerning. I always try to save cartilage if I can, but I'll tell families this is definitely a game day decision. Cartilage looks good. I'm going to do whatever I can to save it and all the principles that Crystal outlined earlier I would follow those, but sometimes these look pretty bad. So it's, to me, it's an arthroscopic decision about whether or not trying to do everything you can to save it with sutures, bone grafting, refreshing the base, suture bridge, whatever. Versus, hey, this is not going to work. We're going to have to have a secondary procedure. Yeah, before Crystal and Ted go, thanks for that segue. I think one really important thing to point out, we didn't have enough time in our radiology presentation to talk about some of the studies we've done looking at the cartilage. So, as Kevin noted when ROC first started, we thought this was a bone issue, but also that potentially the overlying articular cartilage was not normal. Sometimes it is thickened, but what we've seen in both our MRI and histology studies is that articular cartilage, both of the OCD, the adjacent cartilage in the femur in this case, the opposing cartilage in the tibia, it's all normal articular cartilage. And obviously there's nothing better that we're going to put in there for any type of cartilage procedure than the patient's own cartilage. So I want to just make sure to emphasize that. I completely agree with Kevin that any time we can, the vast majority of the time the cartilage is still okay. Although Crystal nicely showed a picture earlier where sometimes it is kind of crab meat and it's not so awesome. Then you got to think about other things. But most of the time, I think we should be thinking more about trying to preserve the patient's own cartilage than we have in the past where we've thought, okay, this doesn't look like a very healthy OCD. Even if the cartilage looks good, we're taking it out. I would encourage you to think differently. So these are the patients, you know, close growth plates, more severe lesion. They've sometimes been to other docs, other locations. They've been on the internet. And I tend to tell them at this point that like you can go from two clicks from dandruff to cancer, right? So, you know, there's, you probably potentially have looked at a lot of different options and they're throwing out different terms and different treatments. And so I will say, look, I'll simplify by saying we're going to fix what's fixable. If it's more like a cue ball, we do more to fix that. If it's more like a cotton ball, we will remove what's not fixable. And also say that for OCD lesion, I tend to quote, might be a misquote from Kevin, that bad OCD lesions can take two or three surgeries to address what you need. And sometimes Crystal showed a beautiful patient. They're probably going to live happily ever after, but some OCD lesions don't read our doctor books. So you're going to need to be prepared for these things in the future. Yeah, so I agree. This is a kind of game day decision. Typically, I post this as Nearthroscopy OCD debridement repair bone grafting versus OCD debridement. If we start, now that we've started to look critically at a lot of our OCD repair cases, I think we're starting to decide who is or isn't a good candidate for OCD repair. I would say, I'm not a fan of these notch adjacent, relatively small medial femoral condyle OCDs, and not super excited about the results when they've got fragmented progeny bone. So I, you know, I think this is a 18 year old patient, but this 18 year old patient is not thrilled when you repair something and it doesn't go well. So I would have a fairly, if it looks pristine, I wouldn't be opposed to trying OCD repair, but I would, this I think is a pretty slam dunk osteochondral allograft, plus or minus deformity correction, depending on their alignment, if I wasn't totally sold on a pristine piece of cartilage. And not to differ with Crystal at all, because I think that's a really good point, that that fragmentation and the age of the patient are really concerning. But if you are going to try and say these, both Crystal and Ted have done some nice work on suture bridges, I'd encourage all of you to read some of their articles and really become facile with that technique, because there's definitely some technical challenges with doing it. But if you get it right, it's a remarkable technique for trying to save cartilage. So that suture bridge thing has been a real, I'd say, last five years been the biggest game changer for me in terms of how to treat OCD more effectively compared to screws and bioabsorbable implants. Great discussion. All right, so this patient underwent curatage proximal tibial bone grafting in this case, which is the easiest to get to, and open reduction internal fixation with headless metal screws. Here's what it looked like at time of surgery. So you can see that looks pretty bad on MRI, but that cartilage looks quite good. And this is super common. And so I think, but this is what's really important. So this stuff here, actually, maybe I'll pause it. Let me go back. Oops. So Crystal mentioned before about biology. I think this is a critical concept, is that again we talked about the AECC and the fact that you have this area where there's cartilage necrosis that ultimately does not become normal bone. And so it becomes a structural problem and that's why you get the OCD lesion over the top of it. And you end up with this cartilage on log slash fibrous tissue, crummy tissue. It changes over time too if you get a break in the cartilage and you get fluid coming in there. But this is the stuff that's gonna keep it from healing. So you have to be aggressive with getting all of this stuff out, just like Crystal showed in her case. And then if you're aggressive enough, what should happen is that OCD lesion should subside, which you don't want. So then you need graft and you need it for two reasons. One is structurally to keep it from subsiding and number two, it helps with the healing process. If we do that, so it's really important to hear lots of different approaches, but that's what I was saying before. So in this situation, I would have, it would be very rare to think about an OCA. This is the type of patient that would always be trying to get to heal. If they don't heal, we can go back and do an OCA. But the good news is, is the vast majority of the time, if you think about biology and if you think about making sure that we're getting everything in a good, normal, articular surface and congruence, they can heal and be very effective. So this is what it looks like from the outside. Here's what the images look like. And I will also make the point, so I think there's lots of ways to do this, but at this point, I do like, sorry, I do like metal screws. I can't get this to stop. All right, we're gonna leave it there. But I think it's important to think, we typically, those screws are designed to be compression screws. I don't think that's what we get. I think what we need is, we need some type of more rigid fixation to hold it in place to allow the biology to run its course. So I've changed over time. I used to try to make those as short as I could just to bridge the gap. I think that's where you're more likely to get them to be loose and to come back and cause those troughs that Crystal was talking about. I think of it more of as an anchor. So I actually try to have it be pretty deep, obviously still taking into account the physis. I don't wanna cross the physis, although it's probably not the end of the world if we do. But you can still get a long, deep screw in there to kind of anchor everything in place and then let biology run its course. So for whatever that's worth, I think it's another way to think about it. So in this case, I do make the patient's non-weight-bearing because it is a rigid construct, but it's not a construct that's gonna tolerate a lot of stress when you're applying weight on it. So in this case, six weeks of non-weight-bearing. Patient was good at their two and six week post-op. After six weeks, we don't go zero to 60. We do two weeks of partial weight-bearing and then advance to full weight-bearing. So in this case, the patient was doing fine at three months. This again highlights, so at three months, it looks good. The screws don't show any sign of loosening or backing out. The lesion looks fine, but it still looks like a lesion. So is that thing healed? When is it gonna heal? So I always go back in and take the hardware out. So that's obviously a significant downside of using metal is that if you are worried about it causing damage to the adjacent cartilage, which I always am, or if you wanna do imaging, which we always do, you gotta take it back out. So that is one downside. So here's what it looks like at four months post-op after hardware removal. So you can see the screw track. You can see that there's bridging across the bone there, even in a fragmented OCD. It hasn't fully ossified, but you can see that there's bridging. And then it does change over time. At 1.5 years, you get even further ossification and more normal ossification of that OCD fragment. So the patient was clinically doing well, so they were allowed to return to all activities gradually following a complete PT course and that four-month MRI showing that it had healed. Since there was incomplete healing at the progeny site, so we did have them follow up with another MRI just to make sure that that had fully healed. And so here's what it looks like on this MRI at 1.5. So you can see how that's much more ossified and fully bridged. So from a structural standpoint, we're not worrying about that. Thoughts, comments, anybody? I did that same procedure just before heading out to this conference, but with suture bridge fixation, I would be very happy to have exactly the same outcome that you show. Questions? You guys wanna come to the mic if you have questions, that way everybody else can hear? Yeah, come on up. Anybody, come on up if you have questions. Great talks. How available is the T2 star MRI and are those covered by insurance or is that part of a research study in getting the time interval MRIs? Excellent question. I wish you were here for this because she has a better understanding of the broad, but my understanding is that it is supposed to be available, it's just that most places don't realize they have the ability to do it and they have to actually program their instrumentation to be able to do it. So it does take a little work on the front end, but my understanding is that it is supposed to be available. So if you're interested, it's worth talking to your radiologist and seeing if they can get it. Yeah, and I have experience. I have had to do it at two centers where I've worked over the last eight years. I was able to get it done and it's simply a software technique change that almost all MRI scanners can do. You probably have to talk to your radiology department. They don't want to do it on everything. So when I have an OCD patient, I'll put in the note to radiologist, please add T2 star sequence. It only adds a minute or two to the MRI time so it's not really consequential and there's no additional charge, at least in the two places I've worked, there's no additional charge for it. Yeah, it's covered. Thank you to the panel for the rock work. It's really invaluable. I have two questions. One is, do you guys have issues with getting MRIs on subtle situations, subtle presentations with patients that have a history of pain with activity but not necessarily as much with your examination? And my second question is, in a scenario where you have an 18 or 20 year old child like that last patient who has seen another physician before, had their loose body removed, felt great after removal of the loose body and was told they need a follow up and then you wind up seeing them three years later or four years later and they feel great, they feel great, but on your x-ray you see a shark bite out of their medial femoral condyle. How do you get them, or better yet, what is the data on the end game on that patient so that you can actually tell them, this is your future, so you can convince them to have a big operation? Excuse me. So first question, just to clarify, is do you have any trouble on a patient that's sort of in between, do you have any trouble getting an MRI? Correct. Is that the question? From an insurance standpoint. Yeah, so maybe I'll take that and then we'll do panel for the second one. No, at least not in my experience. And I would have a pretty low threshold. If you think, especially if you see anything funny on x-ray, x-ray oftentimes doesn't tell us everything, and there are, by the way, ossification variants, so it might look funny on x-ray and then you get the MRI and you say, okay, this probably isn't actually an OCD, it's just this kid's, it's the way this is ossifying, but that hopefully a radiologist can help you with. But yeah, I would have a low threshold for getting an MRI, and usually if you say suspect OCD, at least we haven't, I don't know if anybody else has had trouble getting an MRI for that. Authorization denials, it's kind of the, it's built into their hardware software and training for their staff now is basically to deny. And so I always have a sentence or two, sometimes a paragraph clearly describing why we need the MRI in this circumstance because of the concern of cartilage delamination and need for future major invasive surgery. And I try to put things there that sound like, and truthfully, that we're getting the MRI to try to make better decisions about the care, but if you just don't give a much detail, the person reviews your note that is routinely gonna deny the MRI. And I found that putting a couple sentences in there as to why we really need the MRI for the long-term health of the knee, reducing the need for future surgery, that seemed to have solved that automatic MRI authorization request problem. So I think Ted nicely, to move on to the second one, Ted nicely showed that study that demonstrates that leaving a pothole over time edge loads the adjacent cartilage and you run the risk of that wearing out earlier. So I think it's always important to have that conversation with the family. But Ted, 18-year-old presents with a pothole and then Crystal and then Kevin, what do you suggest to them? So- No, by the way, he nicely pointed out, they often come and say, I'm fine, I don't have any problems. So how do you handle that? Yeah, and Jim Carey has a nice study talking about arthritic changes over time with full thickness defects. So if it looks like it's filled in with something that's not too unreasonable, I'm not here to say that they have to have an intervention. If the knee is unhappy, the red knee, they're getting other changes in the knee, there's corresponding kissing lesions on the opposite side, then that's when I talk more about addressing that. Certainly there's a crystal covered variety of different measures to fill that. Osteochondral allograft is an excellent measure to fill a large lesion. I'm not as big a fan for OCDs as for Oates procedure autograft. You're taking another area that becomes a full thickness defect in an adjacent region in kids with sometimes smaller knees. But certainly autologous chondrocyte implantation is another. The minced cartilage is some other, there's lots of different proprietary things, but some of the gold standards for the much larger lesions are osteochondral allograft and autologous chondrocyte implantation. And alignment unloading, that area tend to repeat that every time. I think there's a small subset of patients who have those very far lateral, notch adjacent medial femoral condyle OCDs that are somewhat small, a centimeter, 15 millimeters or so. And so I've had a couple of those where we take the loose piece out, can't get ahold of the family, and then they kind of show up later and they're otherwise doing well. And I think some of those, those are really kind of non-weight bearing areas. Occasionally they're so far adjacent to the notch. And so I've occasionally, they fill in with fiber cartilage and I've let them be if they're asymptomatic with those. But I think once you're talking about a significant weight bearing area or a lateral femoral condyle for sure, I push pretty aggressively and quickly from loose body removal to salvage procedure. Agree, nothing more to add. For me, I would say this is a great example of shared decision making with the family. I mean I think you have to educate them on what you would worry about in the long run. If it were my knee though, or my child's knee, I would err more on the side of trying to fill the pothole because of what I think we know and my preference in this case is osteochondralograft for the reasons that Crystal pointed out. Yeah, two questions on the treatment of stable OCDs. Can you talk about the settings when you favor bracing versus weight bearing restriction and vice versa? And then the second one is if you have patients with bilateral stable OCDs that have failed conservative treatment, how do you feel about simultaneous drilling of both sides? So in terms of non-operative treatment, if they, oftentimes they've seen somebody before me, one of the non-operative people or something and so they've already shut them down from activities. If they come in and they're now completely asymptomatic or more commonly what I see is the kid that comes in who's got SLJ or Osgood, that's really where they heard, that's always where they've heard, that's where they heard on exam and we have an incidental OCD. I typically don't weight bearing restrict and brace those patients. I typically use weight bearing restrictions and a brace simultaneously as opposed to the kid who's hurting actively, walking around and then I typically package them together and I just tell families, if you're gonna take the time, energy and effort to use crutches for a period of time, I'm gonna put you in a brace too, mostly because I think you put them on crutches and then the crutches stay in the classroom, they're running around the hallways at school so I typically use them as a package and then I consider unloader braces in a non-operative treatment setting when the mechanical access passes through the affected compartment. So I find in the setting of bilateral intact OCD lesions, that's where unloader braces can be really helpful. I tend not to do restricted with non-weight bearing or crutches. I don't find that a 10 year old in crutches really work well after more than an hour and so I tend to do, and you can do a neomobilizer, they tend to break down pretty fast so every couple of weeks I'll put them in there but I tend to do a hinged brace, locked extension, I'll let them unlock the brace if they have car rides. But when it's up, I like to be acting like a cylinder cast when they're up and about. In general, so philosophy is compression can stimulate healing, we'll remove, but we can still remove it and work on range of motion. If they are so inclined, I fully support unloaded bracing for even individuals. It's a little bit more work for the family to get those, but you can get excellent results with those. We did some work with Minn Koker and showed that you get excellent outcomes with those as well. So for surgery for those, it takes a lot of work with the family just to make sure they are fully committed for that, to let them know that it's gonna be, and it's a perfectly intact legion so they can let them weight bear early on, but let them know that they will be walking a bit like the Tin Man from the Wizard of Oz for quite a bit, and they have to be working together. And maybe the last message to give the audience, there are some OCDs that are really gonna heal with a single drilling, transarticular, recto-tercoidal in the right patient, but there are so many that will not. And I think laying that out to patients ahead of time that it says there may be two or three operations sometimes to get this to heal really will help the families because if you fail after one thing, it's a little harder conversation, but if you told them from the start, hey, sometimes it takes two or three operations to get good results, psychologically, that's very helpful for them to hear that ahead of time. So just a tip to you when you're dealing with OCD patients, just let them know we might be having two or three operations over the next four to five years. I would just add to that comment, though, and say I definitely think it's important to lay crepe, but in the back of your mind, hopefully you're thinking this is the operation, this is all we're gonna do. And if you think you need to be more aggressive, you probably do, is what I would say. So err on the side of being more aggressive so you don't have to come back for another time. Question on how quick to go to treatment on a stable, symptomatic lesion in an older patient. I see a lot of 16, 17-year-old wrestlers, and good wrestlers, they wanna get back right away, so if I wait three months, then tell them it's failed, then I fix them, now. So in that specific patient, nearly closed growth plates, how does it affect the prognosis of non-operative management? And again, how quickly do I say, okay, it's not working, let's not wait the three months, let's just wait six weeks and then go to treatment? So I typically lay out for them predictors of healing, and so I say the kind of Kevin strikes against you kind of model, so medial femoral condyle versus lateral femoral condyle, closed versus open FICEs, cystic change, significant hemicondyle edema, vitamin D levels are all kind of things that I put into the conversation, and then I say, all right, in the setting of, you have a large medial femoral condyle, OCD stable with cystic change behind it, and you're skeletally mature, I think your likelihood of success with non-operative management is probably pretty low. We can certainly try that, I don't think you have any harm in trying it other than time, but in my hands, I tell them, if we're pursuing non-operative treatment, you're buying a three month course of non-operative treatment. And so what I don't want them to expect is in four weeks, we then decide it hasn't worked and we move on to something else. So three months, or you do not opt in for three months? I do, yes, I just don't think you need to, I don't think you see radiographic changes fast enough at that point in time, and they all feel better, and so I make sure they understand, just because we stop things that hurt and at four weeks you feel better does not mean that at four weeks I'm gonna let you go back to doing what you were doing. Great question and a great scenario of a very difficult patient population. Timing matters, they're skeletally mature, they're super aggressive year-round athletes. We eventually hope to have an algorithm on the website where you can plug in probably five or six X-ray radiographic age features, size and location, and it can give you a healing prediction algorithm and it'll say this has a 22% chance of healing in three to six months, this has an 84% chance, and you can just show that number to the family and say, what do you wanna do? And if it's 28% is not acceptable to them, do surgery. If 84% is not, then do surgery, but you can maybe have a more educated discussion with them in the future. So hopefully in about a year and a half, two years maybe we'll have that on the website and you can just plug the numbers in and give the family a prediction healing. I tend to tell wrestlers and level nine gymnasts you're a whole different kettle of fish and that you're gonna be, typically there's some level nine gymnasts that yesterday surgery is not soon enough for those guys. And then I'll sometimes say I'm gonna be like a teacher, your alignment gets an A plus, your quad strength, your dedication, they get A pluses. Your activity restriction as a wrestler is gonna be hovering around a C minus D and your cystic changes. I'll give them a rating, but say those guys are gonna be surgically, they're heavily leaning towards surgical and getting back to activities. I would answer your question from an in-season perspective if I understood the question correctly. And you said sort of a stable lesion, right? I would even say, let's talk about an unstable lesion where you're more worried about it coming out of place. I think it's just important to counsel the patients that I basically will let them do whatever they want to. I'll let them play or wrestle if they want to and then just counsel them that does obviously put more stresses on this area, increasing the chance of this thing being symptomatic or even potentially coming out of place. But the worst case scenario is that it comes out of place. If it does, then I tell them, I counsel them on what to be watching for from a symptom standpoint. But as I said before, the cartilage is generally still good. And even if it comes out of place, I'm gonna put it back. So they're gonna decide what happens because if they're able to keep wrestling fine and then we can address it at the end of the season. If they're not, if it comes out of place, then they're not probably gonna wanna wrestle anyway and they're back in my office and we can proceed with what I thought we were gonna have to do anyway. So I leave it up to them basically, if that helps. We might be on bonus time here. Yeah, we're on bonus time. But if people have, if any of you guys need to go, but if any of you, please keep asking questions. We're here for as long as anybody wants. Yeah. I have a 30-year-old who just presented for the first time. He has an MRI that shows a two-by-one centimeter lesion, a kind of weight-bearing and posterior aspect of the lateral aspect of the medial femoral condyle. Anterior portion seems stable, but the posterior portion has fluid behind it and is intermittently symptomatic with activity. Is there an upper age limit to some of the techniques that you're talking about for like allograft? The fact is that's a bit of a hybrid. I think that's crystallizes the issue of like ACLs, like binary, like ones and zeros intact, or it's ruptured, always the same location. As long as it's not partial ACLs, we're talking about the same surgery at the same spot, whereas all these can be unique and different. Encouraged by the fact that you said a portion of that is intact, but then, so that makes me think that the other portion you could get to heal. And so I think those same principles would apply. And then some of that is gonna be dictated by the quality of the cartilage. And then is it look like a real sclerotic fragment of bone? You might be able to need to open that up and take a look at it. And then if a portion of it is healed, and you said, well, you might be losing a centimeter, but it's a contained lesion, it's a discrete pothole, then you can do some marrow stimulation for that small segment. So I tend not to give them kind of the guarantees, but I think I could be encouraged that they could potentially heal the same principles. Did I understand, so you're saying that there is a progeny fragment in place, it's just in the back, it's unstable? Is that what you, that I would say actually is like a great corollary to the last case that we showed. I think that's likely a patient, especially if they keep coming back with symptoms, it's likely they're gonna continue to be symptomatic, but it's also likely a patient that you could get that to heal. And so that would be my first approach. And probably pretty aggressive at this point, because they're continuing to be symptomatic. Ben. What construct have you found to be most reliable for your suture bridge repairs, as far as suture size, flat or round, anchors, biocomposite, peak, all suture, knotless, push lock type, three millimeter anchors. Just curious what you found to kind of be the most reliable construct. So I credit Kevin with the biomechanical analyses and his creative cell to cross configuration. For, I started out in that UPOJ article was three, five anchors. If, you know, it's your anchor of, manufacturer of choice, certainly. Now I'm using smaller anchors, 2.9 millimeter, and I'll use an all suture anchor. So for that construct there, all suture anchors proximally, and then some of these resorbable anchors with bony and growth properties that can be pushed into the knee more distally, because they'll lock that in. I did this before getting on an airplane, but I didn't in that same configuration, but I didn't put, that was at the trochlea, that lesion there, so I put one in the center. So again, that kind of mirrors Kevin's cell to cross. Each individual lesion can be unique. So if it's by the lateral trochlea and it goes over the edge, I'll run some sutures from left to right to engage some other areas. That might mean another anchor, but sometimes the anchor doesn't have to be on the articular cartilage. It can be off at the intercolonal notch or it can be at another location. So each, sometimes each one will have a little bigger configuration. I run it this way because those sutures generally run in the direction of range of motion, and then I'll come back again, like Crystal said, between five or six months and take out, if it's an acute fracture, it's resorbable sutures. If it's not, and I'll use suture tape now rather than meniscal tape sutures, rather than round for, and I don't know the answer, but that's what I'm using. I welcome thoughts of these guys because they're doing a lot as well, every one of them. I agree, I use the same. I use flat suture through small anchors, two nines typically, typically small peak anchors. And I think the pattern is a little bit challenging. If they were all perfectly round, we could probably come up with a standard pattern that worked every time. The problem is a lot of times they're not round, they're oblique, oblong, they may have irregular edges. And sometimes I think if it's got some irregularity to it, you need something to catch the edges. And so you have to think about your anchor placement that might allow you to grow directly across the near equator of the lesion, but also an anchor that'll allow you to have another suture that catches the edge of the lesion. So it's a lot of creativity sometimes with these. The other comment I make is that sometimes you have to tie knots. And I tend to do these really small incisions with a Z retractor in the notch, so I don't have a very big incision, I don't dislocate the patella. And so tying knots can be challenging sometimes. And so I've been using, I'll do a mixture of some with and without lack of a push lock, because if you use a push lock at the end, you don't have to tie a knot on your last limb of suture, so it just makes it technically a little bit easier. But you have to be creative. I don't know if there's a perfect pattern for every one. Any other questions? And if we're allowed to say manufacture, I'm not sure if we're beyond our time and we can say manufacture or whatever, but basically he used the term push lock, right? But all suture-based smaller anchors, which are made by the different companies, Arthrex and Stryker and all, you know. But the small joint ones for sure, because a lot of companies have small joint, medium joint, large joint, the small ones for sure are the ones you wanna pick. Yeah, please just try to minimize cartilage damage, obviously, as we all know. That's the only thing I've had conversations with these guys about. Only thing I would say that bothers me about this is we're having to put stuff in the adjacent cartilage that's otherwise normal. So whatever you can do to minimize cartilage damage, that's why you're there in the first place. It's more just a practical question. Most of these kids are obviously involved in regimented year-round sports. A lot of the kids you see with these lesions. And so the first question you probably all get is, you know, what can they do during a period of non-operative protective weight-bearing treatment? So the question is, do you allow them some type of exercise, like swimming, for instance? I mean, some of these kids consider themselves future college professional athletes, obviously, and the families do, of course. So they're always thinking, what can we do to stay in shape and stay active? And I know you've seen the look on their faces when you tell them they're not gonna do anything for six, eight weeks. So do you allow them some type of either cycling, elliptical, low impact, or swimming, at least? This is a practical approach. Yeah, I mean, I'll let them swim, I'll do flutter kick, but no flip turns, no crashing surf, no surfing, no pool basketball, no pool volleyball. There's a lot of nos in there. And I'll say swimming, walking, I think our time is up. But I'll let them do some basic, and any upper extremity exercises, and so yeah. All right, thank you, everybody, appreciate it.

Osteochondritis Dissecans

ROC group

Dr. Shea

Dr. Ganley

Dr. Ellerman

Dr. Perkins

clinical guidelines

RCTs

transarticular drilling

retroarticular drilling

T2 star imaging

osseous healing

osteochondral allograft

individualized patient care