But before we start with our first case, any questions from the audience? Because we want to give you an opportunity, as I know at least one of our members has to leave right away. Yes, sir? Yes, on the notchplasty, I'll just speak, yes on the notchplasty, small, but yes on the notchplasty, pie crust, the MCL, usually it's about 10 millimeters of a bone plug. I'll just add, I do reverse notchplasty with a rasp pretty much routinely for medial transplants, pie crusting for sure. I'm using wide, like 9 or 10, by very thin bone plugs, if not even just a sliver of bone. So probably even 2, 3, you know, millimeters of bone these days. I actually do all soft tissue just because I went from these small bone blocks to bone slivers because the whole thing just kind of, and if you look at Rene Verdonk's stuff out of Europe, they have the same levels of extrusion, same clinical outcomes as using bone blocks, and I don't have to do reverse notchplasty. I can pie crust the MCL. If I'm doing an osteotomy, I'll actually do my osteotomy exposure first, which opens up the medial side, and you can deliver that meniscus pretty reliably. I've just found the bone blocks, by the time you're done, they're practically gone. I think the European data had more extrusion but same outcomes, but I think that the fixation was far inferior to our typical root fixation that we're using now, and I think that's likely going to pan out as we follow these patients. Other questions? Yep? What do you do for 1 to 2 centimeter defense? I mean, I know a lot of us are not doing micro fracturing more often. You know, the snowman techniques never really work out. It looks very pretty, and you can be hilarious if you're not doing it. What do you guys think about this? It depends on the context. I'll take this. You know, I still, for a lot of those patients, especially the younger ones, I'll do a single plug OCA, and I'll, you know, JRF does these plugs that are essentially prefabbed already, so they're 10 and 16 millimeters, and when I dictate it, since I do staging arthroscopy, they won't approve it for anything under 2 centimeters squared, so you have to be careful with how you dictate it. We also know that we underestimate the size of these lesions in MRI. We underestimate the size of these lesions in arthroscopy, so if it's a borderline case, I'll often in my dictation say, you know, measure 13 millimeters, but I suspect after debridement, it's going to be 15 by 15, which puts you over 2, and I'll just do like a 16 millimeter off-the-shelf plug if I've already scoped them, and I just think that that's a reliable operation. I think the burden is pretty low from a bony standpoint. It's instantly structural, and it just, it can be a slam dunk in that case, so I have a pretty low threshold to a small plug OCA. I don't know about you guys. Same here, single plug OCA. You can do it from a fresh graft, or you can do one of the ones that Armando was saying, kind of off-the-shelf from JRF. The one thing I encourage people to be cognizant of is that most of these pre-cuts come from the condyles, and if you're going to do something for the patella femoral joint, you might have a very significant bone to cartilage mismatch, so typically, I'm going to use patella for patella, and I'll just, I'll harvest right there. So, to add to that, I think, let's go down to the panel. When's the last time any of you have done a microfracture in the knee joint in the last two years? Only as part of a FDA clinical study. Okay. I haven't done one. And Mike? I think once. So, I've not done a single microfracture in practice in the knee joint. I have done a couple microfracture plus, so to speak, other than what Seth was saying as part of a trial, but I think for, it's interesting. When you look at the data around the country and around the world, microfracture remains 80% of all cartilage restoration procedures, at least per insurance databases, NISQIP databases, and ABOS database, but it's interesting when you talk to high-volume cartilage surgeons, that's almost 0% of their practice, and so you just have to be careful. It's easy to do, but you have to rehab a microfracture the same way that you rehab any other cartilage restoration. You can't just poke holes in a lesion and expect it to work. So, interesting, and I would echo what our panel said. For those, I like to use a fresh osteochondralograph for those small one to two centimeter defects. I have a very low threshold to do a snowman, especially if it's oblique or oblong, with a 16 and then another 16 or a smaller, if need be, if it's super small. There's a couple of pearls for using snowman technique, but they're very successful if you employ those pearls. I'm curious, from the people on the panel, how do you change your approach when there's people who have this, like, neonatal cartilage disease where it's almost a disease of the cartilage going in your face and they're kind of shooting off cartilage? Are you still doing localized transplants, or are you just doing those? Because I find you tend to change your approach a lot at this time. I think your time zero approach is probably, you know, going to be the same. You're going to do some staging arthroscopy. You're going to get quite aggressive. I've never refixed that cartilage that's delaminated off a bone. I don't think anyone else on the panel has that experience of considering that. But I think you want to leave the OR with stable edges, regardless of how large the size might be versus what it looked like. Initially, it might be a small blister, and then it actually delaminates to a large extent of your defect. So I think it's the same principles. I would debride pretty extensively, take inventory, measure, and then come back as needed for a secondary procedure. I think the key is that, does this work? Just push it once. Yeah. Oh, there we go. So I think the key is the given some time technique that, you know, Vidal was talking about. I would say for some of those delam cases on young people, you scope them, you debride them, and maybe 75, 80% of the time, you don't have to come back for anything. So those delaminated ones do really, really well when you just debride them and make a stable lesion. Chris, I actually have tried to repair a couple, so embarrassingly, and I've not had any success getting them to stick. And I've tried, you know, I haven't really used implants. I've tried, like, microfracturing under them and doing some TisSeal and trying to do something to get them to adhere, only to have them fail, and then either do a Macy or, more commonly, an OCA if they required some repeat intervention. But so I have had the experience of trying to get those to heal, and I've not been successful with those. Sir, because sometimes, you know, like, I find it, and the area you fixed does fine, but if you come back with a year's statement, and now I'm having a mechanical symptom, and a totally different area of the knee is now getting better. Those are challenging. I don't have a great way to predict those. I have had a few cases where I think you're catching them on this continuum, where for whatever reason, the knee is just going south in multiple compartments, but at the time that you saw them, it was a unique compartmental problem or pretty localized. And then, and I've had this experience even with osteotomies, where I've unloaded one compartment, and two or three years later, the whole knee is going south. I stress about those. I lose sleep about those, and I don't have a great way to predict them, but I do think those delamination injuries are unique, and they often have a really robust subcaudal bony response. It's not just that they're delaminated. Like, the subcaudal bone looks disproportionate to the injury that you're seeing at the time of arthroscopy, too, which, so I do think you're right. I think those are subtly different injuries than some of these degenerative injuries we see. For what it's worth in those patients, I typically will get a rheumatologic workup, just because it is, I know exactly what you're talking about in terms of, you kind of, it's almost as if you were doing an open procedure. You could take a freer and just slowly peel it off like the layers of an onion. I'm sure we've all seen that. When it's focal potholes, I have had some success with multifocal osteochondral allografts, but we have to remember, this is, as Armando was saying, a spectrum of arthritis, and in a young 20 to 30-year-old, or even up to 40-year-old with no other areas of arthritis and no other comorbidities, neutral alignment, why are they getting this? And that's where I do a full rheumatologic analysis. I'll send synovium for synovial analysis. I'll do the whole lab workup. Oftentimes, like Armando, it's very unsatisfying. You lose sleep, and it turns out nothing. But on rare occasions, you'll find a seronegative spondyloarthropathy or something else, and they end up going on a medical treatment as opposed to a surgical treatment that would likely have a poor outcome. I've seen that in some high-demand athletes, too, and it can be very unnerving. And then just on the cartilage front, we do actually fix cartilage-only OCDs, especially in skeletally immature. So it's not that we're not trying to refix cartilage ever. It's just these are different pathologies, the delaminating chondrolysis type versus the OCD cartilage-only fixation, which can work and has good evidence. I agree. Any role for autograft oats still? And do you have any tips or perms for how that might fit into this algorithm? I mean, autograft oats, I think, is still a really good operation and actually has really good outcomes and probably the highest return to play of any of the true cartilage restorative. If you look at microfracture, ACI, allograft, and autograft oats, probably has over 90% return to play in high-level athletes. So I think the challenge is the lesion size. I'm not a huge fan of mosaicplasty and multiple plugs like that was originally described. I often don't encounter lesions that are that small that also require advanced cartilage work. But I think it's a great operation in that it's a unicorn group of a symptomatic small lesion that fits the criteria and ideally would be like a one 8 to 10 millimeter plug that you would take probably from the lateral trochlea, assuming the patellofemoral joint's healthy. But we didn't talk about it in much detail. But I think it's still a very, very good operation. It's just a very niche group of patients. When's the last time you did an oat autograft? I did a live demo for an oats autograft at a course about four months ago. A non-cadaver one. I do them in the cadaver lab for demos pretty much every single time we go. And I have not had an oat autograft case. But as Armando said, the only other thing to add to that is the shortest return to sport times. But again, these are probably small defects, perfect patients. And I just am not seeing that. If you have one you want to send to me, I'm happy to do it. Well, we're at 830. We did have some great cases to show you. But hopefully we can do that next year at another time. I know all of the panelists are very approachable. If anyone has any questions, technique, tricks, or pearls that they want to share or ask about, feel free to contact any of us at any time. Thank you all so much for coming. When you get your evaluation form, please fill it out. We want to make this better. We've been doing this course now for close to five years. And it gets better every year because the techniques evolve. I feel like I learn something from our audience and our panelists each year. So let us know what you want to see and how you want to make it better. And again, thank you so much. And to our panelists, thank you all very much. Have a great day.

surgical techniques

knee cartilage restoration

notchplasty

bone plug size

soft tissue repairs