I appreciate the opportunity to be a part of this great faculty and to talk a little bit about osteochondral and chondral acute injuries in kids. What can we get away with? So we know that preservation of our particular cartilage is very important, but our challenges are achieving osseous union or osteochondral union, minimizing implant related injury and eliminating the need for reoperation. Here's a typical lesion. This is a large chondral shear injury from lateral femoral condyle that occurred during a patellar instability event and obviously a big portion of the articular cartilage in the weight bearing zone and a big difficulty if salvage is not employed. So what are our options? We can use headed screws, flat headed screws from a hand reconstruction set has been advocated and employed in the past, bioabsorbable tacks and screws made of polylactic acid have been utilized with success and absorbable sutures have been utilized in the past and recently as our implants continue to improve, maybe coming under renewed interest. So here's an example of a lesion fixed with those flat headed screws. You can see, again, this is another patellar instability lesion. You see the lesion bed there at arthroscopy, the subchondral plate exposed and the chondral flap near there in the lateral gutter, small infrapatellar lateral arthrotomy, a comminuted lesion and the headed screws were chosen due to the comminution and the desire for compression across the lesion in this case. You can see there the radiographs, you can see how the screws pleat down within the cartilage just slightly. So if you rub your hand over that, it's relatively smooth but certainly no prominence of the implants. Following six weeks, a secondary procedure with arthroscopic implant removal and then you can see there in the far right lower image the meniscal and tibial surfaces as well as the surface of that lesion. Another technique which has been well described by some of our colleagues who are with us today which is using bioabsorbable implants. Here's an example, a figure from their article showing a trochlear lesion. Again, you can see arthroscopic images there on the top and a subsequent open image. You can see those bioabsorbable polylactic acid chondral darts, some interval imaging and then a second look arthroscopy. And then the suture bridge concept, again some of our colleagues, Todd Lawrence, Ted Ganley wrote about this over a decade ago, has been subsequently described by others for both patellar and femoral conular techniques. So that technique generally at this point is being employed with 2.5 or 2.9 bioabsorbable headless anchors. They are usually placed at the margin of the lesion or outside the lesion with multiple strands. For these acute lesions, we can either do this open or arthroscopically if there's a lesion that is unstable in site to versus a displaced lesion. And number one, vicryl seems to have excellent compression and the bioabsorbable nature seems to fit these acute lesions as we'll talk about slightly later. Here you can see a lesion example there again, here's an open technique for fixation of this with a suture bridge and you can see a four-month MRI here demonstrating healing. So the postoperative protocol is without clear evidence, so usually all of these techniques are utilized with six weeks of toe-touch weight bearing or non-weight bearing and about three months prior to full activity. Here's just a little bit of look at the suture bridge. We recently presented a series on this. You can see we had 26 consecutive lesions, five of which were all chondral. I'd note here that all of these techniques, the osteochondral lesions are certainly somewhat easier to fix with acute bony fragments, but just demonstrating or showing the chondral techniques today because certainly these techniques can then be maybe even somewhat easier employed to the osteochondral techniques. So in this particular series that we presented, we had 26 consecutive lesions. We had 89 and a half of those with a full union and two with stable, just slightly incomplete union by imaging, but very stable, none ununited. There were two re-operations in an entire series with no additional complications, marginal chondroplasty was employed. So the technique may have benefits, certainly the bioabsorbable nature. Some of the other absorbable implants have worked excellently in series, but we do know that secondary body wear or debris from occasional loosening of metallic or as what's been mentioned here, the nonmetallic bioabsorbable screw and tacks. The outcomes of these lesion techniques in adolescents, we certainly have a lot to learn. Lesion chronicity limit, how long can these be there and you put them back, we don't know. We've had anecdotal success up to a month and a half old lesions and certainly some lesion hypertrophy occurs in these more chronic lesions and you have to trim them to get them to fit. The long-term cartilage survival again is unclear. How much apoptosis, how much denaturing of the cartilage occurs and what the longer term outcomes are will certainly require further study. So we have a lot to learn, but these techniques are encouraging and I would encourage you to employ them for salvage of these lesions. Thanks very much.

osteochondral acute injuries

chondral acute injuries

union between bone and cartilage

implant-related injuries

reoperation