I was telling somebody earlier with being in Zoom for so long, it's strange to be wearing pants giving a presentation, but that sounded weird, so I don't know if I'll use that. When I'm putting together this talk, it's amazing, a lot of the references and the papers that I'm looking at are all done by the esteemed faculty up here, so that's when you know you've got a rock star group in front of you when every paper you quote is about them. I'm going to take the easy route, I'm going to talk about bone involvement, this sexy topic they gave me, which is nice, they took the hard stuff, and I'm going to show you how we make it easy. Again, my disclosures are available within the final program as well as the app and the AOS website. So just as we've established, if you're going to scope knees, if you're going to take care of athletes, if you're going to do ACL reconstruction, you've got to be familiar with how to treat cartilage and you can't just have one particular way to treat cartilage. You've got to be able to handle all these topics that we've talked about and make a decision for different people and different athletes. If we look at Rachel's work, obviously, if we leave cartilage alone, typically it's more likely to progress, so that's the way I talk to patients and say, hey, it may not bother you that much now, but don't forget about it and let's check in and kind of monitor you down the road. To know where we're going, we've got to know where we've been. So just as we looked at the data from 2004, 2011, obviously cartilage procedures had an annual growth of about 5%, so it's on the up and up, so I'm glad you guys are here and willing to learn and kind of expand your horizons. And if you look at cartilage restoration 2010 to 2016, obviously this has been increasingly popular. If you look at kind of the linear growth, you can see that osteochondral allograft and autograft has kind of been on the up and up, and then where palliative treatments such as microfracture and chondroplasty has been kind of stagnant or even coming down, and I think if you listen to the prior talks, you'll understand that that's true, the way we're thinking about things. If you look at osteochondral allograft, you can see, wow, what an explosion, 2016 to 2019, you know, 52% increase. Obviously COVID put a damper on anybody wanting to touch anybody or harvest anything, but if you look at the forecast to the far right, you can see it's still forecasted to continue the same growth, so I think this is something you have to keep in mind and you have to consider when you talk to patients about cartilage restoration. And why has this become popular? Well, we've really realized that for cartilage restoration, you know, it's an osteochondral unit. It's not just a coating, as we talked about. This is really the foundation that we think about, and we know as orthopedists, we're really good at healing bone to bone. We do that from internship on, so we feel comfortable with that concept. We know we're not great at growing cartilage or getting cartilage to stick to bone. That's a topic that we can talk about, and certainly we're not great at growing articular cartilage inside the knee, so the bone to bone aspect is a little bit easier to understand and I think a little bit easier for us to digest, but that's one of the reasons. We know from Andreas' work that obviously you can't just judge what cartilage procedure you're going to do just on the MRI. We know that MRIs under-call and underestimate the size of the lesions, so it's very difficult and I tell patients all the time, I'm like, I can't tell you exactly what needs to be done. I know you've got a problem. We've identified that. We're going to work through this and we're going to get an idea of where we need to go. I love this algorithm. It's over 10 years old, but it still has a lot of the key proponents, from location to intrinsic factors to size to extrinsic factors, and even though some of the players have changed at the end, a lot of the same factors we look at are key, so keeping this in mind as you go through with patients is important, and don't worry, some of this is in the handout, so you don't have to worry about that. So judging lesions when you're in the knee, I think that's always tough, particularly as I talk to fellows and I always tell them, if you look at a dime, obviously, this is about 2.5 centimeters squared, and if you look at the average size of a medial formal condyle, it's about 32 millimeters squared, so it's a pretty big area. We think, though, a dime is kind of small, so that's always the tough part about judging lesions, and I always tell people, keep an arthroscopic ruler on your arthroscopic set. Anytime you're in a knee helps you document better, and I think it helps patients understand if you take pictures with the ruler there, so that's kind of key as well. As Aaron talked about, and we'll all emphasize throughout the talk, is really the larger the cartilage lesion, the more important the environment is, so if you look at everything we do from malalignment to meniscus to stability of the knee, that's always very important in considering what we're going to do with a cartilage lesion. So what are our options? As we talked about, there are a lot of options for cartilage lesions, and we're going to overwhelm you a little bit of information today, but obviously, hopefully, we're going to give you definition to go home with. What I look at, too, is there's a dividing line here. We've got fiber cartilage, and we've got hyaline and articular cartilage, and if most of us would take our pick, we'd want hyaline and articular cartilage for ourselves as well as our patients, so think about that when you're making decisions. So if you look at osteochondral autograft transfer, this is known as OATS. This is taking an area of healthy cartilage from a low weight bearing part of the knee and placing it in an area of damaged cartilage in the knee, and obviously, this is a single stage procedure, and the real limiting factor is really the size of the lesion. If you look at return to sports, obviously, after OATS, it's really great. I mean, if you look at it compared to certainly microfracture as well as ACI, it certainly beats them by a long shot. So if you're looking to get somebody back quickly, and they ask, how do I get back to my activities, this is certainly something to consider in a smaller lesion. Here's another study, obviously, looking at return to sports, and 93%, that's great. It's six months. If we could have everybody doing what we wanted in six months with cartilage treatment, we'd have a line out the door of our office. So this is certainly something to consider for smaller lesions. Again, this is a great study out of UVA, and certainly, these are smaller lesions. Most of them were one plug, so keep that in mind. But they had athletes returning to sports in 83 days. I certainly don't advertise this, because I think you'll get a lot of disappointed people with this, but this is data to at least tell you. If you're taking healthy cartilage and bone from somewhere and plugging it in, it's almost like healing a fracture to an extent. So moving on to osteochondral allograft, this is a little bit different, because this is taking mature hyaline cartilage and bone from somebody who recently passed away, and this is bringing it into the knee to fill the defect. Obviously, you're establishing a new hyaline cartilage surface. This is typically for larger lesions, greater than 2.5 centimeters. I'm going to just show you a quick case, not to dwell on this, but to understand the process, just in case you haven't been exposed. 22-year-old soccer player, slide tackle injury, tried everything, not so good, and he came in with an outside MRI. You may look at these images and say, gosh, it's close to ultrasound. You don't really know what you're talking about. You can't base treatment on this, and I agree with you. You know there's a problem from looking at the bone edema, and you can see there's a cartilage issue, but yeah, I can't make my decisions on this. There's no doubt about it. I'm talking to a patient more about gathering other information prior to make a definitive treatment, and certainly a scope for me is that that's the next step. You can see, obviously, this gives me a lot more information. I can look at the meniscus. I can look at the ACL. I can look at the surrounding borders of this, so I can really make a decision, and that's when I start really planning ahead for these people, and this is basically getting magnification markers on my x-rays. This is getting alignment film. Thank goodness he was relatively in neutral here, which made my planning easy. Certainly I waited about six weeks for my graft to come in, which was nice. This is a lateral peripatelar approach, a little tougher than the medial peripatelar approach that we do, and we can obviously talk about that later. I'm looking at the lesion, and you can see even the surrounding cartilage doesn't look great at that point. I'm sizing the lesion to see how big it is. I'm basically looking at my allograft, and I'm basically trying to size that in the same area to get exactly the cartilage match as well as the osteochondral match that I want. This is preparation of taking my graft from the osteochondral allograft, and then I'm templating and sizing, which makes it easy, and a lot of these products are available out there. I'm preparing the recipient site to basically get a nice match for that right there, and then I'm implanting the cartilage, and I wish they were that quick. They're not, but that's a highlight version, kind of ESPN, of what you do with that, and it's a very powerful tool, and you feel really satisfied at the end of these cases because it really makes you feel like, hey, I've plugged a hole. I've done something different, and basically that patient has a chance to do well. Here's postoperative x-rays, and this is what you want to see. You want to see a subchondral bone match. They don't always look this good. A lot of times the cartilage looks good, but the subchondral bone looks different, but that's what you really want is not only a match of the cartilage, but also the subchondral bone, and I think that gives it the best chance to basically be successful long-term. So if you look at the advantages, I'm not going to go through all these. These are all in your handout. You say, well, gosh, this is great. Why don't I do this for every patient, but not so fast. This is something that you've got to really weigh the advantages and the disadvantages, and I would be remiss if I didn't mention those as well. This is the real tough part for most people. This is one of those things where you've got a two-week window for this. So as I talk to patients, you're on call for this. You're like a doctor on call. You're like anybody on call. You're on call for this kind of graft, and you've got to be ready. So there are a lot of disadvantages. You can look at cost. You can look at the wait list. You can look at the short time of implantation. There are a lot of possible risks that I don't always go through because knock on wood, those are becoming less and less as far as that goes, and it's a humbling procedure, and there's quite a bit of learning curve with these. So keep that in mind as you jump into that. You may want to do a couple in a lab or go do one at a course just to get an idea before you jump in on a patient. So if we look at outcomes, obviously Aaron's work here, great work, and this is 12.3 years. Who knows? Hopefully there's some 15-year data coming out soon. But anyway, you can see the survival rate up there. About 75% of patients, those are kind of the numbers that I kind of dwell on. Obviously patellofemoral lesions had a little higher reoperation rate, and if you look at patellofemoral lesions in general, they tend to do a little worse, and this is a very humbling procedure just as Andrea said. A lot of times we'll use some cell-based therapy in the patellofemoral joint just because these are difficult cases, mainly due to the topography really, and they can be humbling. Even if you're really good at osteochondroallograft, you can get in there and be like, wow, things just aren't matching like I like them to. So that's something to think about in the patellofemoral joint. If you look at obviously return to play with osteochondroallograft, again, about 77% return, so maybe three-fourths, and those are the kind of numbers that I quote to people, so I'm kind of giving you some take-home points here. Again, return to activity, somewhere around 88%, and then 75% to pre-injury full level, and this is about nine months. So I'm telling patients about nine months to a year with these kind of procedures, which is obviously tough to hear, but obviously I think they want to be realistic, and just as Rachel mentioned, you want to prepare these expectations as you go. If it's going to be a year, it's going to be a year. So knowing those numbers is important. Again, another return to sport, you look at it and say, gosh, it's in the mid-70s. So as Andrea said, that's tough, but we deal with the same factors in young patients with ACL as well as shoulder instability. So a lot of these numbers we don't like to admit being orthopedic surgeons because we always think we're really better than we are, but they're true and they're out there, and I think you've got to give those to patients to let them know. As far as outcomes with failed cartilage procedures, and I think if we went down the panel, everybody would say, hey, this is my bailout, you know, for any of these things that failed. It does pretty well, particularly revising a surface treatment with an osteochondrolograph, I always feel good about that as far as my outcomes. I don't feel like that compromises my outcomes, and certainly here, basically at 3.5 years, you've got a 90% graft survival rate. So always keep that in mind. We always, as orthopedists, like to have a backup plan. I think that's important with anything we do. People often ask, can you use a graft that's not perfectly matched? Can you use lateral for medial, particularly condyles? Well, yes, we have literature to show that, that obviously you can use that, and certainly if you get in a bad spot, it's tough to get a medial from a condyle sometimes, particularly, and accepting lateral is not bad. I would advocate going larger on your size, but I think that's reasonable to do. If you look at, you know, kind of supplementing your grafts, this is a little bit controversial. There's three or four papers out there. There's a little bit of literature that says basically, yeah, it helps early on to put some BMAC or some PRP in your graft. It may help incorporation a little bit, but really, that's still controversial. I still do that. You know, any advantage I can possibly gain from minimal risk and cost, I'm willing to take a stab at. I would be remiss if I didn't mention pre-cuts. The nice thing about pre-cuts, these are small allografts. They're always available, basically, because you don't have to really have waiting time for them. These are available in 10 and 12s. You can avoid the wait, you know. You can order it if you think you're going to need it. They're great to obviously use on the spot, and you can certainly cut them down if you need to. Thanks for your attention. Any questions? I had a question, Aaron, if the audience doesn't. Great talk. So, I think the oblong fresh osteochondrial graft has become very popular because it's super sexy. You know, you get those oblong defects. You don't really want to ream out a circular defect when you don't have to. I think all of us on the panel probably, I'm assuming, just due to the nature of our practices have seen those not go well and done some revisions and taken care of those patients. I have some thoughts as to why that might happen. But wondering if you have any pearls for technically executing that procedure well, or if there's ever a patient where you say I'm not going to do the oblong graft, I'm going to do two circular overlapping grafts in a snowman technique. Any thoughts on that? Yeah, I think that's a great question. And knock on wood, I've not seen many failures. I'm sure they're coming down the road because, as she said, technology's not been around. You know, I think some of the keys for me is I look at it, and even though we don't have the data, I'd much rather have one graft and one smooth surface than two grafts and the potential for, obviously, you know, fiber cartilage in between. But again, we don't know that. I'm just looking at it superficially. I think some of the pearls, obviously, are really taking your time, making the adjustments, particularly to the graft side, because you don't want to start making adjustments to the recipient side. That's where you get in trouble. Making sure your graft is about as perfect, and the instrumentation is very good. So that's why I advocate you go to a lab and do a couple of these, because there is a learning curve, and I've found over the years that it has become easier and easier. But there are a lot of tricks that aren't out there online and in the books. So go to a course and learn. The Learning Center is a great place to start with these. And... I would just caution, if you're just starting out doing osteochondralografts, I would not start with that. The one you did was perfect. It was... Exactly. Adam Yankie recently did an in vitro study looking at radius of curvature and trying to match. It is very specific to the host and the graft. So Andreas is just talking about he got an undersized graft. I don't know how many times I will order a specific graft, and I think the people in the labs are measuring it, oh, I can see a little cartilage here, and I can see a little cartilage here. Oh, this is a 35. I get in there, there's only 25 usable. So if you can have the chance to go out and talk to the people at the procurement arms, that's great. And get to know what they're doing. Because when they say we've got room for a 30, you don't. You got a 25. So I will always accept a graft larger than I've asked for. I don't want anything smaller, because I know it's going to be way too small. And I got lost initially in terms of measuring the size of the condyle itself, the length of the condyle. I think that's very subjective. I think what works really well is just tibial width. That puts you very much in the ballpark if you do tibial width and everyone can measure that. You can do that on x-ray MRI scan. If you do a lateral OCD lesion, always get a graft that's much, much larger. Just an experience. Lateral OCD lesions, their condyle looks different. It's larger. So never accept a medial, because yes, you can accept contralateral, but never accept a medial condyle for a lateral, vice versa is okay. Lateral condyles are bigger. The small, unless it's a small, small lesion. Yeah. If you need a 16 millimeter plug, you can accept anything. You can get that out of. Yeah. Great tips. I'm trying to figure out how to get sterile dimes in my ore pans. That's impressive. That was reimbursement here. So Jack Farr is going to talk to us about emerging cartilage options. And I think this is very relevant now. We're in a changing regulatory environment that Jack will talk about. And Jack, just thank you for teaching each and every one of us on the panel. We always look to you as the voice of wisdom and reason, having seen these things come and go. So we'll pay extra special attention. Thank you.

cartilage restoration procedures

knee conditions

osteochondral autograft transfer

osteochondral allograft

return to sports