I'd like to thank you all for coming to this talk today. We're going to really be talking about determining stability of knee OCDs, really in the settings of radiographic findings, nonoperative management, as well as once you get in operatively, how we can better define stability. I have no specific disclosures to this talk. I am the board of directors of PRISM, as well as a committee chair for the PASNA Sports QSVI Committee. I want to thank ROC, the Research in Osteochondritis of the Knee, for their great work on this in the past and also in the future that's given us a lot of information about how to better treat these patients and this condition. There was an AOS clinical practice guideline that came out several years ago that really tried to help give us some information about how to treat these patients. And you can see it really came down to even recommendation number seven before any sort of consensus was even put together by this group. And this even starts with, in the absence of reliable evidence. As they continue on, you can see there's two more consensus style statements, but again, in absence of reliable evidence. So we know there's a lot of work to be done, how we can better improve our discussions, our conversations between each other, as well as outcomes from patients of this condition. Really you're going to have your patient who's going to come in, they're going to have their chief complaints, they're going to have their symptoms, and you're going to start with basic radiographic evaluation. This diagram to the left shows the different compartments of the knee that we break them down into. So we can all talk about the same location of these, because OCDs of the medial femoral condyle versus lateral femoral condyle, trochlea, and patella all act a little bit differently. When you're looking at your x-rays, you want to ask yourself some questions of what does the progeny bone look like? Is it fragmented? Is it sclerotic around the edges? Is it separating from the host partially or fully? Is it completely displaced? What does the contour of the articular side of the progeny fragment look like? Is it already fragmented, looking irregularity? What is the radio density in comparison? Is it very sclerotic? Does it look very osteopenic? Those are all things that can help tell you how acute, chronic, and potentially how stable these are on your radiographs, and are all going to be things you're going to use for determining if there's any healing presence after any sort of operative or non-operative treatment. The radiographic evaluation would make sure that you do this bilaterally, because we know 30% of OCDs present bilaterally and can be asymptomatic on that other side. So if you see one on one side, make sure and image the other side. Some of these risk factors being female, younger age, we know are associated with a contralateral OCD. When you find these on your radiographs, you're going to get your MRI, and that's really what we're going to use to try and help determine what stage this is. And hefty is the most classic stage that's used. And I think this one, stages one and two, where there's just a small amount of edema, no clear fragmentation or fluid behind it, those ones are pretty clear and obvious. And the fours and fives, I think, then are the next easier ones, where you have a very clear demarcation that this fragment is loose or it is completely displaced. And it's really those type threes where you're trying to decide, is this a type three? Is it a type two? What can we do for this? Really seeing any sort of chondral fissuring and identifying that at the very chondral edge and tracing that into the subchondral bone can help identify if there is a leak of intraarticular fluid through that subchondral bone. And then also, as we'll talk about in enormogram cysts that have formed, is that fluid that's come from the synovium and had through a breach in the cartilage, is that something that's there that could be a presence of instability? Obviously, once you see there's fluid completely surrounding these, we know these are very advanced and have a high degree of fragmentation and worsening. And obviously, the higher level of these, the more likely we are to pursue operative management. I would be remiss if I didn't mention, anytime you see these, of getting lower extremity alignment, that's something that can be easily correctable and can offer a lot of improvement in healing rates, and also making sure that you're assessing for any sort of skeletal maturity. You know, the pile atlas has been the classic way we've done this in PEDS Ortho, but there's now a great study out using knee MRIs, which you already have, to try and help determine what bone ages are, instead of having to have the book ready with you there in a clinic. So there's a couple of normograms I've taken a look at. What is the prognostic factors associated with healing? And I think you can think about these are, what are things that are more likely to be stable versus unstable? We think ones that are stable are more likely to go on to heal, versus ones that are unstable, more likely to go on to need operative management. So Wahl came out with their normogram. This is their treatment algorithm they had. And their normogram that they took a look at was looking at these major factors of what the length and the width of the lesion were, and then really what their symptom category are. And so this is something you can have in clinic with you. You can see this point system to give you your total points up on the top. And then once you use those total points, you come down to the probability that that's going to heal. Something that's more likely to heal is more likely to be stable. Something that's less likely to heal is probably more likely to be unstable. Similarly, following up with that, Krauss did a normogram. This is their treatment algorithm. And the big difference that they had was the cysts, and taking a look at cysts and how those are really a big factor in determining if these heal or not. And likely that's an indicator of instability, as I mentioned earlier, a crack in the chondral surface that can then leak into the dying subchondral bone, creating these cysts over time. Their normogram takes a look at this normalized lesion width, the cyst size, as well as the patient's age, and again, goes up towards the top. You take all of those different factors and give them a total point scale with the higher points leading towards a higher probability of healing. And again, likely the higher probability of healing, more likely related to ones that are more stable versus unstable. And you can see how that cyst size really makes a big difference in this normogram. We know that taking a look at these, you know, one study in one group can be hard to know if it's reliable, but they've been shown to be highly reliable amongst other people in their interim intra-observer reliability. Operative indications, we know it really are going to be failure of non-operative management or ones that we see all of these findings and have concerns for stability on their X-rays and MRIs. So once you get in there, you're going to be taking a look at this new arthroscopic classification of OCD, which is developed by that rock group. You can see it's brought into these more immobile lesions or stable lesions and the more mobile lesions on the bottom. This cue ball is a common thing you see where you get in there, their articular cartilage looks completely normal. Shadows where you can change the contrast of your camera and take a look with decreasing the light in your camera while potentially probing it to see these subtle margins and shadows around the periphery. And then these wrinkle in the rug where you actually have a visible wrinkle or fissure that you can see within the cartilage. Those are all going to be your immobile lesions. The mobile lesions you're going to see are these locked door where you can get the entire probe all the way down to subchondral bone and see that that fragment is loose just with a little wiggling within the probe in the chondral fissure. The trap door is when you can actually start to hinge it open and then the crater is equivalent to that hefty type five where you've got exposed bone and the fragment is completely detached. These are some different cues that you can use for determining which of these are, and especially with this classification, get familiar to using these in your transcriptions. And if you're doing any research in OCDs, these are critical to use. So confirming stability, once you get in there, kind of that trampoline sign people talk about, use the back end of your probe and see how does this feel? Do you feel a softening? Do you feel a give? Do you feel a bouncing in that lesion? I typically go and use my probe to define the borders, the anterior, posterior, and medial or lateral borders of these lesions so that I know where I'm going to be looking for that trampoline sign because often it can be very difficult to determine. Adjusting your light can be very helpful for looking at those contours on the edge of shadows that you may see, but that trampoline sign is going to be a sign of instability in these that otherwise look normal. Your pre-op planning is going to be really important if you are finding stability or instability and you're going to get talks about different articular drillings for these in treatments. But when you're going through your MRIs, defining your stability, take a look and see what the depth of that subchondral edema and then the depth to the physis because you want to make sure if you are going to pursue any sort of articular drilling that you don't go through the physis repeatedly. The integrate technique you're going to get a talk on, but these are brief visualization of going through the chondral surface. Retrograde technique, you'll get some pearls in another talk about how to do this, but involves a little bit more of a setup as well as fluoro, but the main key evaluation or improvement of this is the lack of penetration through the articular cartilage. The one I would make sure you always want to use is the intracondylar notch drilling. That's the freebies where you don't go through the articular cartilage and you can get a great stimulation of the subchondral bone and the subchondral healing. I want to thank everyone for coming to this talk and listening to this. Hopefully I've given you some pearls in order to evaluate on both radiographs as well as intraoperatively the knee osteochondritis desiccants.

knee osteochondritis dissecans

stability

radiographic evaluation

MRI evaluation

arthroscopic classification system