Hello, I'm Kevin Shea and we're going to talk about in-situ management of OCD lesions or letting the sleeping dogs lie. All my disclosures are up-to-date on both the Academy and AOSSM website and I have no relevant conflicts with regards to this talk. We're going to review stable versus unstable OCD lesions and also talk a little bit about the importance of a healthy bone bed. This is very important for in-situ fixation and also review some implant options and considerations. When I think of a stable OCD, I think of this as a minor apple bruise, if you will, that has intact skin and these overall have pretty good healing potential and here's an example of such. On the contrast though, if you have a larger lesion or things that involve break in the skin of the apple, if you will, these are lesions that are more unstable and I think have much worse or much poor healing potential. For example, this trochlear groove OCD which is delaminated. Operative treatment indications for non-healing stable OCD lesions, sub-colonal bone drilling is a very appropriate treatment but if lesions are less stable or have significant instability, you may have to do something. One, to ensure that the bone bed is healthy and not necrotic and you might need some bone grafting with or without drilling to help in these cases to get them to heal. So keep that in mind when you're doing in-situ fixation. Once again, the consideration of the cartilage quality is important. If you think your fixation of this fragment is going to provide at least 60 to 100% of coverage of the lesion, I think reusing that cartilage fragment makes sense. You want to make sure that that cartilage bone size is of adequate size and tissue quality to justify fixation because in some cases, the cartilage tissue has degenerated badly enough that you might think about another approach and you also have to make sure that the tissue that you're going to reattach will hold the fixation that you use. The Rock Group has developed what I think is a pretty helpful arthroscopy classification system including stable or immobile lesions and we call these the cue ball, the shadow, and the wrinkle in the rug. The other are the unstable or mobile lesions including lock door, trap door, and the crater. With regards to these stable and immobile lesions, isolated drilling will work in many of these cases, especially young patients who have significant growth remaining two, three, four years or more. If the patients are closer to skeletal maturity, you might have to consider drilling plus fixation and in some cases, bone grafting might be advantageous as well. Obviously, for more advanced lesions, drilling and isolation is not going to be enough and keep that in mind in older, more complex cases. The wrinkle in the rug classification is an unstable lesion so in some of these cases, fixation might be necessary. For these unstable lesions, fixation is almost always going to be necessary including lock door, trap door, and the crater type lesion. So here's an example of notch drilling technique for OCD. In addition to drilling through the lesion, you can actually drill off the side of the lesion through the notch to obtain additional subcontral bone stimulation and healing. Here's just the anatomy, the medial femoral condyle, there's the PCL organ and its fibers. And we'll just quickly show you a video of the OCD notch drilling with a marker pin. And you can see this drill here off the intercontal notch, just off the edge of the reticular cartilage, can be used to obtain additional drilling without traversing the reticular cartilage. This has advantages as it's more of a retroarticular drilling technique rather than transarticular drilling technique which may have some advantages. And you can frequently place these 3, 4, 5 millimeters apart to further stimulate that subcontral bone, try to create a fracture healing environment to produce healing of that subcontral bone to save the OCD. And once again a hole, a third drill hole is placed here sort of in a retroarticular, non-transarticular drilling fashion. And I think you'll find this a helpful trick. Typically use these 0.45 and occasionally 0.625 K wires which are a little bit stiffer. Fixation options, you can use metal including headless compression screws and these work great if you can put them deep below the subcontral cartilage or into the subcontral bone below the cartilage. There are some flat head screws that can be used for more superficial fixation which the thickness of the bone may be limited. And there are some bioabsorbable options that we use increasingly. There are different types of pins and suture anchor bridges and there are some bioabsorbable screws although many of the OCD study group members have abandoned the bioabsorbable screws because of reaction and cyst formation with some of these devices. So here's an example of blue, rather purple being the cartilage surface and orange being the bone. If you have cartilage with significant bone and you want to make sure you try to countersink the screws into this bone as possible, get them below the cartilage surface. These won't work with headless screws. If you just have cartilage or minimal bone on the cartilage, the screws will cut right through and they won't actually give you the purchase if you're trying to recess these more deeply. So you have to come up with an alternative. In addition to screws, there are also some implants, bioabsorbable pin type implants that have sort of a threaded barb that can also be used in a similar fashion. Once again, you want to make sure you've got cartilage and bone such that there's enough bone that you can countersink into the bone if possible. Once again, keep in mind that screw fixation may be better in cases in which you have significant bone just because the biomechanical strength of screw, especially headless screws, that have variable compression on the two different pitches of the screw. Once again, you have some bioabsorbable pin options and some people use these in cases where there's cartilage with no bone or minimal bone, but keep in mind that these minimal bone things probably give you a little better fixation than those with no bone at all when you're dealing with these bioabsorbable pins. A couple different companies provide these and we're not advocating for one or the other, but there are some reports of success, but there are also reports of these backing out, so keep that in mind. You probably need to get them recessed adequately to make sure they're not going to back out and create problems later on. In cases in which you want to use screws, and there are advantages and disadvantages of this, but there are some low-profile headed screws and they might be used in cartilage with no bone or minimal bone. These screws you can actually countersink into the surface. There's a small countersink device that allows you to recess these below the most superficial aspect of the cartilage surface, but not cut through that cartilage and still obtain adequate fixation in the bone. A technique that I've been using more and more recently is suture bridge fixation. Ted Ganley, Todd Lawrence, and others have described this and I'll just show you some diagrams. This is an example of a diagram. Assuming this is a femoral condyle, you can put four sutures or suture anchors on the periphery and then you can have a series of sutures pass through these suture anchors and there's various different constructs and I suggest you go into lab sometime and play with this. There are simple cruciform constructs and you can also cross limbs and basically combine what I call a crucifix with a diamond and you can also put a suture anchor in the center of these as well, but there's a lot of different constructs you can use. Here's an example of a cartilage lesion that we recently fixed with such a construct. In this case, we use zero-vicral sutures, obtaining quite good fixation for these cases. Here's another example of another cartilage case in which we used a series of sutures, including a central suture anchor to obtain good compression and good stability with dissolving sutures. Keep in mind about subchondral bone drilling. We typically do this if it's transarticular with a 0.045 inch K wire and put these at four to five intervals, four to five millimeter intervals, to help with healing and stimulating that subchondral bone. Orthoscopic placement of these screws is quite, you know, really a good option today. You don't necessarily need to do arthrotomies in many of these cases now if it's a relatively stable lesion and I'll just once again outline the anatomy here. Here's the medial formal condyle you can see that circumferential outline of the OCD lesion. It's been probed and determined to be a relatively stable lesion. These are the 0.45 inch K wire holes, about four to five millimeters apart. And here's actually the guide pin with a threaded tip that's used for a cannulated screw. So we'll just quickly play this video of placing this screw. And so you can hear we're going to advance the guide pin, the threaded guide pin. It's always good to advance these perhaps a little further than you think so that when you're drilling you don't back these guide wires out. And you can see the blood coming out of that adjacent hole indicating that you've drilled into the appropriate level of healthy bone to produce bleeding. Here's the use of a depth gauge measurement. We'll use these screws anywhere from 14, 16, sometimes as much as 22, 24 millimeters of length. Keep in mind you don't want to go too deep if you're going to be approaching the growth plate. Here we're drilling in partway, maybe only drilling in the first, you know, 10, 15 millimeters of screw. You don't necessarily need to drill this all the way because the subchondral bone is soft enough in most cases that it'll self tap as you advance the screw. And in this screw you have a different type pitch on the front edge of the screw and there's a different variable pitch on the other end of the screw so you actually get some sequential compression. This device also has an external collar that allows you to compress the lesion as you place it in. And so now it's actually compressing the lesion of the bone and this external collar is now threaded off the screw and you get additional fixation as you advance this screw because there's a difference in the pitch advancement on the proximal and distal screws. So it's very important to sink these screws into the cartilage and power actually past the cartilage through the cartilage into the subchondral bone to make sure they're not going to scratch adjacent cartilage surfaces. And you can go back and forth and kind of look at the depth of these screws. In this case you can see we now see subchondral bone so this screw is completely covered. Here's an example of three or four or five screws that you can place and you want to make sure kind of probing with the guide wire to ensure the screws are into the appropriate depth. Once again these screws are clearly below the cartilage level. One tip is I do recommend that you use subchondral screws that have a star driver especially if they're titanium. Titanium is more MR compatible than stainless steel screws. The allen head screws are more likely to strip so I strongly encourage that especially in these young patients with hard bone a star driver is much less likely to strip which is a real problem because you'd have to take that screw out if it's sitting proud. After putting the screws in we tend to get multiple CRM images just confirm that the screws are clearly recessed in the subchondral bone and these images basically confirm that for us quite clearly. Here's an example of progression of healing over six months. Patients are treated basically percutaneously. You have complete healing of that bone interface between the parent and progeny bone over that six month period. Just a little more detail on these screws. This is a hand set used for fixation of hand fractures and the screw diameters are quite remarkable. You have 1.0 1.3 1.5 2.0 and 2.4. This is a very low profile cruciform head much lower than you can get with an allen head screw and you can also countersink these. They do have a countersink tool and they're also made of titanium. Here's an example of these screws. I do typically remove these screws somewhere around four to six weeks because I do worry about them scratching the opposite surface so keep in mind you probably want to remove these if you don't use something that's dissolvable or absorbable or if you don't use a suture bridge construct. Here's an example of a 14 year old male who had a large condor delamination off the patella for a patella OCD and we use three screws to get very secure fixation. Currently I would probably do this with suture bridge instead of screws but screws are an option in some cases. So just to summarize that the cartilage and OCD fragment fixation is clearly possible. The healthy bone bed is really important and if you don't have a healthy bone bed you may need to do some debridement, bone grafting might be important in some cases. In some cases you can do that you know with a retroticular approach and a retroticular drilling device. Fixation options depend on the fixation of the bone and the cartilage. Make sure you've got adequate tissue of bone and cartilage delaminated piece that's actually going to be able to hold screws or sutures and there's several different options including metal, bioabsorbable and suture fixation options. And thanks for your attention. If you have any questions just send me an email at my gmail address listed below. Thank you.

OCD lesions

in-situ management

healthy bone bed

fixation techniques

treatment options