So, as Rachel mentioned, my name is Armando Vidal from the Sedmon Clinic in Vail, and my charge today is to talk to you about how you evaluate and make decisions for these cartilage lesions in the knee. My disclosures are in the Academy website and are really not relevant to this talk. Just picking up where Rachel left off, you know, our objectives today from my talk and from I think all of our talks is that, one, that you understand the prevalence of cartilage injuries in the knee, which I think Rachel elaborated on, which is they're common. We see them frequently at the time of arthroscopy. We know they coexist in high-level athletes, and the majority don't require treatment. I also want to give you a comprehensive toolkit for the evaluation and decision-making with these injuries, and oftentimes when I give this talk, I say, you know, if you're looking for a talk that gives you essentially an algorithmic approach to these injuries, like, you know, a two-centimeter lesion in this location requires this graft and a four-centimeter injury, and a patella requires this type of cartilage surgery, I'm not sure that this is the right talk. This is to give you a more conceptual gestalt of how you should approach it and the considerations, because I think as we present cases, you'll see that we all may have subtly different approaches to these injuries, and there are a lot of different options, but I think you'll see that our framework for how we approach them is going to be similar for all four of us, even though we have very different backgrounds and training. And then I want you to have a better understanding of where specific treatment strategies fit as you make this evaluation. So picking up where Rachel left off, again, the clinical evaluation, and Seth has a great way to think of the knee. So I think of it, you know, as this ecology, essentially, like a coral reef where everything's interacting. Seth describes it as an organ, and I think that's probably the best way to think of it. It's not just a joint, and it's a complex interaction, a composite, so to speak, of biomechanics, particularly the patellofemoral joint. There's skeletal anatomy, and you'll hear a lot of discussion today about varus and valgus and the role of osteotomy. Obviously, their articular cartilage status, which is why we're here today, their stability and their ligamentous injury, and their meniscus status. And this Venn diagram that Rachel showed earlier really characterizes every visit I have with a patient. And when I educate our fellows about this, I try to break down complex topics into manageable segments. I ask them every time, is there a stability problem? What's her meniscus status? What's her alignment? Is the subchondral bone involved? And it gives you a checklist-type approach to come up with a plan that's comprehensive and either addresses or accounts for every aspect of that patient's pathology. And I may be getting ahead of myself, but the reason this slide is so early is we're talking in this segment about the evaluation of these injuries. And Dr. Ranawat, when I was a resident, used to always say, the eye see what the mind knows. So you can't know what to look for when you're evaluating a patient or looking at imaging if you don't know what's important. And everything we're going to talk about today is going to be in the setting, in the lens of these four different aspects. So the history is pretty straightforward. I want to know, is it chronic? Is it acute? A lot of these patients have prior surgical intervention in the setting of ACL, meniscus. They may have had a previous microfracture or some other cartilage intervention. Do they get swelling? Is their pain localized to the compartment? So a patient comes in, they have a small medial femoral condylar defect, but they have global pan knee pain. I'm not sure that's a patient that I can help with an articular cartilage restorative procedure. Do they have mechanical symptoms? Is it something that maybe I could relieve with a chondroplasty where I can remove a flap or just a little meniscal debridement before I endeavor on one of these more complicated cases you're going to see here over the course of the next hour and a half. I like to do a physical exam, obviously. I think some of our mentors, like Dr. Fagan, really reinforced the importance and the lost art of the physical exam. But I want to see how they walk. This is a patient with a clear asymmetric valgus in their right knee. I want to look at their alignment. I want to know whether or not there's an effusion. Are they tender in the compartment that's involved? What's their motion like and what's their ligament stability? And again, you can see the components of that Venn diagram coming together as you assess them both on a history and physical exam. What's their alignment? What's their stability? Are their symptoms localized to the compartment that you're endeavoring on treating? X-rays are pretty standard orthopedic X-rays. Standing AP, flexion Rosenberg view, a lateral, which is particularly important for looking at patella femoral lesions, looking at patellar height, trochlear dysplasia. Some form of axial view, a merchant or sunrise view. And I think this is key too. You need to have a long alignment film. So everybody here is here because you are interested in doing articular cartilage procedures. You need to have this view. I can't tell you. We all have stories of patients that have been referred to us who've had a failed Macy or Osteocon or Allograft, maybe even a meniscus transplant, who have never had a long alignment film. And the clear cut reason why they failed is because they were malaligned into the compartment that was operated on. So I would stress that if you're here today and you're interested in cartilage work, one, you need to have a skillset in osteotomy, whether it's HTO, DFO, or TTO. And this needs to be part of your routine when evaluating these patients. MRI is obviously the workhorse in terms of three-dimensional imaging. We get multi-sequence 3T scans in our institution. These are non-contrast studies. And the things that are important to me, again, looking at that Venn diagram is what's the status and the health of that subchondral bone, that fourth pillar of that Venn diagram. Do they have bipolar change? What's the overall status of the joint? Is this a chondral lesion, or is this an early arthritic process? And those are the things that are important to me when I'm looking at imaging. So then they get to you, and you have to understand why they're there. Is this a patient who had an MRI for some reason, and somebody found an incidental cartilage lesion, and they were told, you need to have this fixed, or you're going to end up with a total knee, and they're completely asymptomatic? Well, clearly, as Rachel indicated, a lot of these athletes coexist with chondral injuries and don't even know it. And the natural history of those lesions is poorly understood. That's clearly not a patient you're going to discuss surgical intervention with. You want to know what they expect to get out of the procedure. I just, I'll give an example. A very close friend of mine came into the office this week. I've been treating him for several years. He's got a high-grade trochlear lesion. On MRI, it's nasty. It's got a ton of edema. It's got cystic change. It's progressed over the course of the past two or three years. He trains three to four hours a day. He has no effusions, no mechanical symptoms, and very minimal pain until the very limit of his envelope of function. I said, Tim, I can't make you better than that. I know I can, and frankly, I could probably, I have more chance to make you worse than better with a surgical intervention. And I don't know that going in prophylactically to treat that lesion is going to make you any better. So I would argue that our ability to treat marginal improvements in function is limited with these surgical interventions, meaning you'll have a patient that comes in. They say, gosh, I'm 90% of what I was before. I want to be at 95%. I don't think any of us can realistically say we can achieve that. You get some patients who are at 40%, and they used to be triathletes, and now they can barely go up and down the stairs without pain. Your opportunity for improvement, especially in their envelope of function, is pretty significant. So you need to be realistic with what you can achieve with surgery and what their expectations are. And you need to choose a path that matches their expectations with what you can realistically achieve with surgical intervention. Rachel touched on this. I think non-operative management for chondrolesions, especially chronic chondrolesions, is always, I would say, the first step for the majority. I think you can make an argument in certain cases where it may be more acute. Surgical intervention is key. And I like to teach our fellows there are three pillars to non-operative management for chondral injuries. There's metabolic optimization, and that can be diets, supplements, NSAIDs, injections, biologics. I think we could argue about the evidence behind some of these interventions, but I think we'd all agree that they're very low-risk interventions. And I think metabolic optimization should be part of your work, one of the pillars of your non-operative strategy. Neuro-optimization, PT, especially for the patellofemoral joint. The patellofemoral joint is PT, PT, PT before you ever consider surgery. Weight reduction and loader braces. And then it's that envelope of function discussion, right? If it's that patient that says, I can run 10 miles, but at mile 11 and 12, I start getting symptoms, that's the patient where you need to sit down and say, I'm not sure that surgery is going to get you to mile 11 or 12. You may need to reconsider your envelope of function and what is essentially, and oftentimes I talk about diversification of their fitness portfolio. So these are the three pillars, biomechanical, biologic, and then the envelope of function discussion. So when do we do surgery? This is obviously a surgical ICL. It's when they have failed non-operative management, when they have unacceptable symptoms coupled with realistic expectations, they can comply with the rehab, and you always need to be situationally aware. And what I mean by that in these last two bullet points is occasionally you have somebody that comes in, they say, I definitely want to have this fixed, I had this cartilage injury, I don't want to get a total knee when I'm 60. And then you talk to them about what a meniscus transplant and a cartilage repair and an osteotomy looks like and how long the recovery is and how long they're going to be non-weight bearing, and immediately they go back and they say, well, can we revisit some of those non-surgical options? Can we talk about stem cell? Can we talk about PRP? Because then they start to understand the complexity and what's involved. And you have to be situationally aware too. Is this like, I took care of college sports for the vast majority of my career, is this a kid who wants to go, you know, is Division I basketball and wants to go into the NBA? If you do a meniscal transplant and a cartilage graft on that kid, he's never going to get drafted, you're going to impact his career, you're going to impact his earning potential. So you need to be aware of where they are in their season and what their long-term goals are. And I often say these aren't first date conversations. Some patients already come in, especially in our practices that have had this discussion with multiple providers, you may be a second, third, or fourth opinion. But if this is the first time they're coming to you because they have knee pain and your first discussion is, I think you need an osteotomy, meniscus transplant, cartilage repair, that's a patient that's going to probably run out of your office. So these are layered conversations and it takes a while for patients to really absorb the full extent of their injury and the intervention options that they have available to them. So we come back to this. So again, cartilage injuries are this nexus of a complex etiology and your plan needs to again be a comprehensive plan that accounts for or directly treats all aspects of their pathology. And as we go through cases, we're going to essentially, I guarantee all four of us are going to say, well, this patient is in stability, their meniscus is deficient, they're maligned, and this is how I'm going to approach all different aspects to that patient's injury. So how do I start? I'm a very strong advocate of staging arthroscopy. I think this could change over time as we get, as in-office arthroscopy becomes more prevalent, our ability to perform procedures in the office. But I think looking at the lesion directly is very helpful. And I tell all patients that there's a diagnostic and a therapeutic benefit to a staging scope. So one, I want to see how big the lesion is. Where is it? Is it contained? Is it not contained? What's a subchondral bone look like? And I'm trying to mentally fill out those different bubbles of that Venn diagram to understand this lesion better. I perform a debridement neurochondroplasty. Brian Cole has presented on this. Rachel and I are actually looking at a subset of our patients back when I was at CU. And I would estimate about 50 to 60% of patients, after the staging scope, feel well enough that they never go on to a more complicated cartilage discussion. So there is true therapeutic benefit from a chondroplasty. You can remove loose bodies, which may be creating mechanical symptoms, and it allows you to do any prep work or Macy biopsy if you're intending to do that. As I mentioned, a lot of these cases have instability. It allows you to do an exam under anesthesia. It may be a failed ACL. You can remove hardware. You can bone graft. And you're setting the stage for your next operation, if indicated or needed, which, again, in many cases is not needed. So as we break down these different aspects, and I don't want to spend too much time on malalignment, because both Seth and Mike are going to talk about this, is osteotomy is a very powerful unloader of the joint. And I think if you ask the question, does osteotomy, when indicated, enhance the outcomes of our articular cartilage procedures, the question is unequivocally yes. I think it actually becomes more interesting when we ask that question in reverse, is do our biologic surgeries, cartilage work, meniscus, et cetera, enhance the outcomes of our osteotomy as it becomes less clear? And I think the Europeans are certainly of a different philosophy, where they tend to unload first and only deal with the cartilage problems, typically, if they fail to respond to the unloading procedure in isolation. We tend to do everything as one surgery here, and you'll see a few cases of that. But the bottom line is unloading the joint is a very powerful procedure, and actually, when I look at this Venn diagram, we all present it like this. In my mind, it actually looks more like this. I don't think that these are equal circles in this Venn diagram, so I can't make enough plugs for having a toolkit that involves osteotomy. So breaking down meniscal deficiency, we know that even small meniscal resections can lead to significant decreases in contact area and increases in peak contact stress, and this is more prevalent on the lateral side. The lateral side is, and we're going to talk about this in a second, but the lateral side is very sensitive to lateral meniscus deficiency and may not respond as well as the medial side to unloading. So this is a paper that Dr. Frank and Dr. Preventer and the team at Rush did years ago, it's probably a decade ago now, looking at how do you protect a meniscal transplant with increasing degrees of valgus. And again, it's very clear that there's got a protective effect, but at the take-home point when you look at the center of this is that taking a knee that's in three degrees of valgus, even that's meniscus deficient, achieves contact profiles that are similar to a neutral knee that is meniscus intact. So in some cases on the medial side, I will use this data to avoid doing a meniscal transplant, which can be unpredictable, I think we'd all agree with that, to unload that joint, achieve pressure profiles that are similar to an intact state, and do my cartilage repair. So again, your strategy needs to either address or account for it, and I'll use this. Now, on the lateral side, that may not be the case. We're actually completing a study now at our institution doing this exact model on the lateral side, showing the lateral side may be more sensitive to it and may still require a meniscus transplant, even if it's adequately unloaded with an osteotomy. So the medial side and the lateral side may not behave in a similar fashion. So what about the actual treatment to the cartilage lesions? I think you have really four main categories. There are tons of subcategories, and this can be really dizzying when you look at it, but you have chondroplasty, and we talked about the role of a staging arthroscopy, and the fact that that in and of itself can be very effective for many of our athletes. It probably has the highest return to sport of any cartilage procedure in elite-level athletes. You have marrow stimulation techniques. This obviously has been around for decades, since the time of Pridey drilling and Dr. Sedman and his microfracture, and it's evolved into micro-drilling and a variety of ways to augment that. We know that microfracture in isolation creates fiber cartilage. The question is, can we entice these pluripotential cells to exhibit a phenotype that is more similar to highland cartilage with augmentation, either pharmacologic or with some surface treatment? There's cartilage regenerative strategies. I would say MACI is the frontrunner. It's been around for decades and has a long track record, and then you have cartilage replacement or restorative options. So breaking these down, for me, the decisions can be based on the location, the size, the involvement of the subchondral bone. I think we'd all agree this is a huge OCD lesion. The subchondral bone is completely involved in this situation. This is going to be an ocealograft in my hands. You could argue for a sandwich technique MACI, but I think the vast majority of us would favor a large mega-oats in this case, and is it a revision or not a revision? So very quickly breaking these down, marrow stimulation has a very limited role in my practice. I actually can't think of the last microfracture or micro-drilling that I've done. It's ideal for smaller lesions. The problem is most of the lesions I treat are not this small. I would say that they're ideal for lesions under a centimeter squared. You could argue maybe up to two centimeters squared, but we know that the results with lesion size diminish. We know that they do not create a repair tissue quality that is highland cartilage in nature. It's more fiber cartilage, and as such, the durability of this tissue can be limited. And again, you're doing this typically in younger patients. But I do think that there's still a role, and I think that people continue to explore the role of scaffolds to, again, try to get these cells to exhibit a phenotype that is more similar to highland cartilage, so I don't think we need to completely throw out marrow stimulation yet. It is still the most common cartilage procedure performed in this country. You have regenerative options like MACI. I'm a big fan of MACI, especially the patellofemoral joint. It is much easier than it was for those of you guys that have been around for more than 10 years where we had to take periosteal patches or suture bio-guide patches to the femur with 6-O-Vicryl. It's now a patch. They have these pre-cut cutting guides. It's probably the easiest cartilage procedure that I do, and actually has a very long track record with very high levels of success, and I would argue pretty similar outcomes to Ocealograft. There are a variety of other scaffold-based options. This is an example of a DeNovo or a Prochondrix, so there are a couple different options. I think these are ideal for larger, multiple lesions. I think MACI is particularly well-suited for multiple lesions, especially areas of the joint that have unique surface anatomy. As I mentioned, I really do like MACI in the patellofemoral joint, especially if the subchondral bone is preserved, because it's difficult to match the anatomy of that trochlea and that patella. I would say my workhorse, though, is Ocealograft. It's probably 80% of my cartilage cases. It's ideally suited. I'd say it's the gold standard, even though most things are compared to microfracture. It's instantly structural. It is instantly high-end cartilage. It has a very long track record with a high level of success and over 30 years of data at this point. It can be used for extensive lesions such as this, multiple lesions, lesions with subchondral bone, and I would say it's really the ideal treatment strategy for revisions. Obviously, in places like our institutions where we have readily access to these grafts, it's easier to perform, but I think these companies are coming out with ways to, one, optimize the amount of tissue we get from each donor, and two, to create plugs that may be available, not necessarily off the shelf, but very quickly, readily available so it's more accessible to the community as a whole, and I would say that, in my practice, it's probably 80% Ocealograft and 20% Macy at the current time in 2021. So how do I make decisions? In the patella-femoral joint, it's almost always going to be Macy or Ocealograft. I don't like microfracture in the patella-femoral joint. The architecture is too unique. The bone is too dense. It's just I don't think it works particularly well in the patella-femoral joint. If it's a revision case or bone loss case, it's always an OCA. If it's a high-demand individual, it's going to be an OCA or Macy, and I would reserve microfracture, and I always augment it for smaller lesions and, ideally, lower-demand parts of the knee or lower-demand individuals. So in summary, always address alignment. In fact, sometimes that's all you need to do, and I think the Europeans would argue that. If there's meniscus deficiency or tear, you need to have a strategy that accounts for or addresses it. If it's a radial split like this, you should try to repair it. I would argue you should augment it with biologics, either marrow venting or PRP. This is a case of mine. I was just showing these guys. This is the zebra, the unicorn. This is lateral meniscus deficiency, not arthritic yet. That's a very beautiful cartilage coat on that femur. She's had multiple surgeries. You can see she's got some damage in the posterolateral plateau. You see our meniscus transplant, a variety of different techniques for that, and this is her one-year MRI that we actually just got before I left to come here to Nashville, and she clinically is doing very well. This is the optimized, obviously, case. This is a really, really perfect outcome clinically and radiographically. So in conclusion, cartilage repair is challenging. You should think of the knee as an organ, as Seth likes to say, and you should have a checklist of contributing factors based on that Venn diagram of instability, meniscus deficiency, alignment, and subcaudal bone. Those four things should be part of the checklist on every case. Don't underestimate the role of nonoperative management. Consider a staging scope, both for its diagnostic and therapeutic role, and choose a strategy that doesn't burn bridges. So thanks, guys. Thank you.

cartilage lesions

evaluation process

decision-making

knee injuries

treatment options