Good evening. Thank you for joining us for the AOSSM Fellows webinar, Cartilage Restoration and Osteotomies, with faculty Drs. Michael Banfie, Connor Dorff, David Flanagan, and Seth Sherman. Thank you to Maricel for their support of this webinar. To submit a question on the GoToWebinar panel on your screen, click the Questions drop-down arrow on the right-hand side of the panel. This slide shows where you input your question and click Send. I will now turn this over to Dr. Flanagan to begin. All right. Well, welcome, everybody. Thank you for joining us to go through a really exciting topic. I'm excited to really have each and every one of you on here, and I really want to say thanks to AOSSM and also to Dr. Dugas, who chairs our fellowship committee, for setting this up. These times have been different, as we all have experienced with COVID, and I think it's really unique that our organization has really brought together some of the best minds across our country to really kind of provide this educational content. I also want to say thank you to our sponsor tonight, which is Veracel, who's been a leader, obviously, in some of this space and Carlos Restoration over the years. But I want to say thanks to you as well and congrats. I know you're about six weeks until you're done with fellowship, and it's been definitely a challenging one. I hope that it's been rewarding for you, and I really want to wish you a congratulations on your graduation and as your next venture in sports medicine. And finally, just an opening thought, I would just like to encourage every one of you to get involved in AOSSM. Unfortunately, with the COVID-19, we're not going to have our annual meeting, where it's a great time for all of us to meet all the fellows that have been out there and to really encourage you to be part of this great organization. It really is the leader in sports medicine in the country, and I do want to encourage you to be involved. We always need great minds like yours to further our association. Well, what are we going to be talking about tonight? Obviously, we're going to be talking about Carlos Restoration osteotomies, and our goal in talking amongst the faculty was really to kind of prepare you for practice. So I'm going to start very briefly talking about a working knowledge of the algorithm, but then we're going to kind of go through the tibial femoral defects, the patel femoral defects, and then finally, how to incorporate osteotomies in your practice as well. So here's our faculty. I've been a professor here at the Department of Orthopedics at Ohio State University. I'm the director of the Carlos Restoration program, also a fellowship director here. My practice is primarily knee and reconstruction and restoration. We also are joined by Dr. Michael Bamphy from Cedars-Sinai, Kirtland & Jobe. He's an associate professor there. He's also director of the Orthopedic Sports Medicine Fellowship and a team physician for the LA Dodgers and LA Rams. Dr. Seth Sherman joins us from Stanford, where he's an associate professor. He's also the fellowship director in Stanford Sports Medicine and head team physician for Stanford Football, and also has a significant interest in Carlos Restoration as well. And finally, we're joined by my partner, Dr. Robert E. Doerr. He's a complex knee surgeon in sports medicine, he's an assistant professor here at Ohio State. And his practice also has really unique focus in osteotomy. So I think we have a lot to learn from him and look forward to what he has to share with us. So as we start, I really want to kind of frame tonight's discussion with really our algorithm. I do like Dr. Cole's algorithm here, it's probably the best organized as far as thought process. But as you kind of approach this, a couple of key things I really want to highlight. A lot of our decision making is based on the size of lesion. And then we have a lot of things to consider. And I think the biggest take home point when you think through this algorithm is that we really need to individualize that treatment. There's not one treatment that's going to be the best for every one of our patients. And so as we frame tonight's discussion, it's really how do we make these decisions? How do we make that individualized decision for our patients? And in starting that, I really want to kind of challenge our thought process with that size portion. This has been an area of interest in my research, and we've looked at this in multiple different ways. And what we found is that if we think that MRI is great, unfortunately it's not. We typically are going to underestimate the size of cartilage defects based on what we see with our imaging. And I think this is really critical because you can't rely 100% on the MRI to make your decision. Some of that decision making process is going to have to be at the time of arthroscopy. But unfortunately, what we found in some of our other studies is that we're not always the best in arthroscopy either. This was a study that took a lot of my different partners here at Ohio State, and we looked at all different types of size lesions. And unfortunately, we all underestimate the size of our lesions too. And I want to frame this that we typically want to box things into being smaller lesions. So with this study, we looked at, is this really true? So I took some of my friends from across the country who are great cartilage experts, and we repeated this study, and we did it over and over again. Each of them did over 80 arthroscopies and sizing of defects in a single day. So it was quite a big study. We found out that even with great cartilage experts across the country, we still underestimate the size. We are consistent, and I really want to encourage you if this can be part of your practice is to find a tool. There's lots of commercially available tools that can help with your accuracy as far as measuring the actual defect. So again, framing tonight, we're going to kind of base this into different sections. Dr. Banfi is going to kind of cover this part to the left on the femoral condyle. Dr. Sherman is going to cover this portion on the right, looking at the patella femoral joint. As we always consider cartilage, it's a functional unit that really needs a lot of different pillars for it to be successful. And obviously, we can't go through all these in one short hour, so we're really going to kind of focus on this alignment and osteotomy portion, which Dr. Doerr is going to finish our discussion. As we go through this tonight, I've asked each of them to really kind of highlight pearls, pitfalls, and what are the true indications in their approach for these different types of patients. As they each present, please ask questions. I'm going to tabulate that here. I've also prepared some questions for the panel at the end, but we do have a good amount of time for some lively discussion and answer all your questions as possible. Again, I'm going to say thank you, and with this, I'm going to hand it over to Dr. Bamphy to start the formal presentations. All right, thank you, Dave, and thank you, AOSSM and Verisil for hosting this, this talk here. I'm going to be focusing on typical femoral lesions, and for time's sake, we're really just going to be focusing on pearls and pitfalls. This isn't really going to be a technique-based study or presentation, so I'm really going to try to keep this case-based and try to go through some of the principles of cartilage restoration in those cases, talk about our options within the tibia-femoral joint, and then we polled all of our fellows, and some of the questions that I had is, how do we obtain these graphs? What are the procedures behind that? Things that, you know, during your fellowship, the attendings probably did, you know, with their staff behind the scenes, there's always the insurance issues with cartilage that I'll touch base on a little bit, and I'll try to go through some pearls, you know, in my, really my decision-making process as we're doing this. So I'm going to start off here with patient Ann M. This is about five, six years ago. She's a 42-year-old, really high-level runner, marathon, Ironman runner, was having six months of right knee pain, but then had an acute pop that, you know, really increased her pain. Now she's having mechanical symptoms, pain on the medial aspect of her knee, and actually had an inability to fully extend. So we're thinking, you know, meniscus, you know, what the heck's going on here? But to otherwise normal alignment, and she was ligamentously stable, and if you look at her MRIs here, both on the sagittal views, as well as on the coronal views, you'll be able to see that on the medial joint line, she has a full thickness cartilage defect there. I'll pull up the coronal view here, too. So you can see that she's got a little bit of bony edema, she's got some cystic changes. It's not the biggest lesion in the world, but as Dr. Flanagan pointed out, you know, the MRI is not the best tool to really assess this. She's a high-level runner, and really wants to get back to running. So you know, we know that her menisci are okay, we know that her alignment is okay, ligaments are fine, and she does have those cystic changes in the bone, and I do worry about some of the bone issues, I'm thinking, you know, trying to go down a cellular-based path versus some other path. So her options could be, you know, continued non-operative therapy, which really isn't a choice for her. She's got mechanical symptoms, as well as the desire to continue what could be, you know, Olympic-level running. So we're going down the surgical route, and when you think about the surgical route, I think this is a great slide that I took from the Varicell slide deck, you know, you can think of this as palliation repair or restoration, palliation as being a debridement, repair being microfracture or some sort of microfracture augmentation with a scaffold, or cartilage restoration. And so when we're going through the different options, you know, this patient has a long-term goal of running, and we have to remember that although microfracture will put potentially a fibrocartilaginous layer, it probably doesn't have the longest durability. So I'm thinking somewhat of sort of a restorative procedure for a patient with athletic endeavors with these goals. And if you look at this study by Riley Williams and Aaron Critchback when he was at HSS, they did a big meta-analysis where they looked at the return to sport with these cartilage restoration procedures, and actually an OATS procedure, so an osteochondral autograft transfer, really has the highest return to sport in the quickest amount of time. So I think this is a great tool that you can utilize in the right patient. Now, that being said, I don't think there's lots of patients that OATS plugs work for because if the lesion is too large, you are, you know, robbing Peter to pay Paul for taking multiple plugs from the lateral medial trochlear region, but I think it's a good thing to have a discussion with the patient. So as we go into the surgery, we're saying, okay, well, we're going to go from a diagnostic arthroscopy, ideally perform an OATS procedure, but if we can't, then we have a different options. If it's a very large lesion, we consider cellular restoration, we have to be taking a biopsy. But at that point, we were not going down the road of the osteochondral autograft just because the lesion wasn't that large, and I thought we had a very good chance of getting an appropriate size OATS graft. So these are arthroscopic pictures. She has a little bit of wear and tear within the patellofemoral joint that we just abraded, but you can see the fairly large lesion within the, you know, from a condyle, and, you know, fortunately, I already was set up to do the OATS procedure. We have the plugs. The purple one is an eight millimeter lesion, and I felt as though that covered her defect well enough. So in this case, the MRI seemed to overestimate. So I prefer to take my plug from the lateral aspect of the trochlea, and the nice thing about this is you're going to have bone-to-bone healing. You already have K-line cartilage that covers the surface, and she'll be able to get back to running. You just want to make sure you don't have these grafts too proud. If anything, you want to recess them. I think that's also very important. And these are her x-rays actually about six years later. This is just right around January of this year. Her x-rays look good, no progression of osteoarthritis, but she did come to see me for some medial side of knee pain, so we did get an MRI, and you can actually see that her graft here looks quite good. So the cartilage surface looks very good, and if I back up a little bit, you can see her pain was coming from this parameniscal cyst, so she probably had a very small anterior horn meniscal tear, but we were able to treat that just with an aspiration, and she was able to get back to running. In fact, at this time, she was participating in the Olympic qualifier. So I think that those OATS plugs in the right patient are very useful and have great outcomes. So I'm going to transition over to another middle-aged female that's a high-level runner. This is not a marathon runner, this is an ultra-marathon runner. So this is someone that's running 100-mile races, which is crazy in and of itself. Progressive lateral-sided right knee pain, recurrent effusions, had tried therapy, had tried injections, unable to run, very unhappy. And we all know these patients, if they don't run, they're going to be unhappy. She's got a mild effusion, a bit of a flexion contracture, lateral joint-line tenderness, but she is ligamentously stable, sorry for that typo there. Her MRI does show that in her lateral compartment, she's got some significant chondral damage, even a little bit of edema in the bone. But you can see that she actually has significant chondral damage on the tibia plateau, which is a difficult thing to address. So she's got a kissing lesion on her femur as well as on her tibia. And then if we take a look at her axial views, you can see that she actually has a grade four lesion on her lateral patella facet. So this is a patient that's got multiple cartilage lesions. Now my partner actually had scoped her prior to this, and you can see that she's got that large grade four lesion on her patella. Now that being said, she did not have any anterior knee pain. Her trochlea actually looks quite good, particularly for the level of running she's doing. And then her tibia does not look so good. So she's got this grade three lesion on her condyle, not really visualized here, but this pretty bad grade four lesion on her tibia. And so this is an educated patient. And I think that, you know, as we talk about the individualization of these surgeries, this is very important because patients come with an idea of what they want. She happens to be my program coordinator. So she's very, knows these types of surgeries quite well. And she's got patellar tibial as well as femoral lesion. She was really looking for a restorative procedure to continue to run. And so our options here, from a surgical perspective, she could get away with an osteotomy alone. Just a femoral osteotomy, you can see that she does have valgus alignment there, a six degree correction would make her symmetric to the other side. We're going to talk about osteotomies a little bit later, so I'm not going to belabor that. But I think an osteotomy alone would be perfect. It could unload her lateral compartment. You also probably unload that patellar femoral joint, and Seth will probably touch on that. But you could incorporate MACI, you could do OATS plugs, you could do osteochondral allografts. The problem is really a paucity of literature. All there are are these case reports that talk about different things that you can do. Dr. Sherman and Dr. Bubby, you know, have a great Yellow Journal article on allografts. You know, you could put an entire tibial plateau in there. This is more for people who have massive bone loss or meniscal pathology. She really didn't have either of those. Rafi Mazarian has talked about utilizing plugs within the tibial plateau. So this is utilizing an old style retrograde reamer, creating this, you know, 10mm socket, and then placing the plug in an anterograde manner. The only problem about this is it is still a mosaoplasty. Because that space is so tight, you can't get any plugs that are any larger than 10mm. Brian Cole has talked about utilizing biocartilage, so performing a microfracture and then putting biocartilage over this. This is another option. The only thing about this is, again, it's a case report, you know, the study that he's looked at where he compared utilizing osteochondral allografts on the femur side with either a tibial debridement, tibial microfracture, or doing nothing, really all had the same outcome. So then it's like, well, shoot, should we even be doing anything? Phil Bugbee said that's his preference is to do nothing, and in fact, the second opinion that patient KL, the one we're talking about, got was from Bugbee, and his thought was just to do the DFO. Now, she really wanted Macy, and so we were going to go down that route. So I just throw these two papers up here. These are the papers from the summit trial. So as you guys go out into practice, you know, these are things you can talk about patients. Patients may like the idea of utilizing their own cells as opposed to utilizing an allograft. For me, I think that in her case with multiple lesions, Macy's a great option because you can address the patella. If you're in there, you can address the femur, and you can address the tibia, and these are studies looking at microfracture versus Macy at both two and five years and showing significantly improved patient-reported outcomes at the five-year mark, really attesting to the durability of the cartilages that's made with Macy compared to the fibrocartilage with microfracture. Macy now has these great tools, obviously on the femur, not on the tibia, but the thing I think from a technical standpoint is you just don't want to go through that calcific layer of bone and violate the bone to make a bleeding cortex. You want to go down to that calcific layer and to breathe that down so your cells can adhere but not violate the subchondral cortex. For this patient, our decision was to proceed with doing the DFO as well as Macy to all three lesions, but here's the problem. This is where insurance becomes involved. So we get this letter from Anthem, sorry, it's not medically indicated. So this is where you have to start doing some of the work. These are the things that you may not have seen yet in your fellowship. So I have to produce this letter talking about the medical indications. I have a reference list. Now the key here is your barosal reps can help you out with this. In fact, they can provide you with a lot of these references and really assist you on writing these letters because depending upon which market you're in, you may have more trouble than not. The other thing about barosal and utilizing Macy is that they utilize a third party that will actually assist you on getting insurance approval. And if insurance approval is attained, it's actually guaranteed, which is very important because you've grasped the cost of a car. And so if you're doing this at a surgery center and the insurance says they're going to pay for it, then all of a sudden they don't, that's a big cost to the surgery center. But with this third party guarantee, there really is no more worry. You know, the surgery center can do the case and the most expensive thing is the fiber and glue. So these are actually very lucrative cases now for the surgery centers. So for this patient, we went up doing the DFO, I used to utilize the Arthrex plate. I'm not a huge fan of this plate, actually. I don't think it sits very well. You can see how lateral, I'm not too pleased with that, but she actually did fantastic and got back to running, not full marathons or ultra marathons, but half marathons and is very happy and still to this day has no problems with her knees. You know, I think that the things to talk about this is that, you know, you could try to do this arthroscopically versus open. There are studies out there saying that there's less cell viability with arthroscopic. My preference is to do them open, but there's lots of studies out there showing that there are good outcomes doing them arthroscopically from a clinical standpoint. As far as the size of the lesions, she had three lesions, quite large. I agree with having a good tool you can utilize to measure these, particularly at that index arthroscopy where he took the biopsy. If you have lesions that equal out to being more than 16 and a half centimeters squared, you get two grafts. It costs the same to the patient, same to the insurance. So just have that be aware, if it's greater than 16.5 centimeters squared, you're going to get the two grafts. And then from a tendeal plateau standpoint, getting that graft in there, you know, I didn't have to take down the anterior horn of the meniscus, reflect that back to size and to place the graft down. But it's fine. You know, that area, that anterior aspect of the meniscus has a lot of blood supply, unlike the periphery with the anterior fat pad there. So that heals quite well just with some suture anchors. You know, sometimes if I'm doing a revision ACL and I'm doing a meniscal transplant, I'll actually just do a soft tissue repair in the front if I'm dealing with real estate regarding bone. And then I'll finish with this last case. This is patient CR. He's a 29-year-old male, nine-month history of left knee pain, locking and catching. When I saw him in the office, his physical exam was completely benign, but he has these x-rays. You can see he has this large cavitatious lesion on the medial conical of his left knee. His alignment shows that he's very varus bilaterally, so to get him out to neutral was about five degrees. These are his MRIs. You can see the large lesion with the bony edema. So he basically has had this OCD likely his whole life that has now become unstable. And so now we have to address how we're going to deal with this. CT scan again shows this cavitatious lesion. So there are a few ways to deal with this. I mean, this is quite a large lesion. You know, there are people that have different opinions on how to do this. One would be Macy again. You could do a bone grafting with Macy two layers. So it's called a sandwich technique. Tom Minus has talked about this a lot, and this has very good results. This is where, you know, originally we put the bone graft down. We'd place a layer down. We used to use something called BioGuide, place the cells on this layer, and then place another membrane over it. It was called the sandwich technique. You can do this with Macy as well. The bottom layer has the cell side up, the top layer has the cell side down, and the outcomes are good. In fact, on this graph, you can see the survival curve, and compared to just bone grafting, the patient's survival rate is quite good, up to 15 years. But in my hands and in the United States, we have available osteochondralographs, and I think that this is a very, you know, functional option. I think that your weight-bearing status is a little bit easier, and originally you're putting haline cartilage in there. So particularly if there's bony involvement like that, I like utilizing an osteochondralograph. You can see from Dr. Cole's studies here, the survival is quite good too, up to 14 years. One question we had was, how do you measure this, and how do you get these? Well, fortunately, it's not something we have to do. We're just orthopedists. We can become glorified mechanics, but what the companies will do for us, they'll take the CDs. Typically, it's off of MRI. This shot was just one that had a magnification, so they're able to really assess the size of this, and they find a matched graph for it. So they'll send us these sheets. I usually will offer it out to a couple of different companies to have them compete. That way, you get them back faster, and if the patient wants to get done sooner, you can pick whichever graph you like better, whichever will come sooner, and if you like the graph, you can sign off on it. They usually will send you this picture that will show you the graph too, and that's how we get it. They'll give you this time window. There's a time period, usually of about two weeks, where they have to have testing after the patient has donated their tissue, and then there's an expiration date because, remember, these are fresh graphs. So there is a bit of a time window, which I think is really the only thing that can complicate us chondrolographs and getting them done for your patients. They have to realize that they need to be available when we have the graphs become available. Insurance for this is a little bit trickier than Macy, although insurance typically will cover this a little bit easier than Macy in some locations. I have had the circumstance where all of a sudden, they say they're going to pay it, we do the surgery, and then they don't want to pay it anymore. So what you'll see is that some of your surgery centers, they may want to take a deposit down from the patient for this. So when you're starting out, you may want to do some of these at the hospital, where we don't have to worry about those financial constraints. These are his arthroscopic pictures. You can see this large lesion here. One thing I like to do, particularly for one, I'm just going to press fit in there, is place a Vicryl down at the base of your post site before you put your graph in. That way, if you don't like the way the graph sits, you can just pull on that Vicryl and it'll pop it out, and we don't have to worry about it falling on the floor. I've seen it all. I've had my whole graph fly in the air and land on the floor. There are certain cleaning methods. Typically we'll use copious amounts of chlorhexidine, let it soak generally for about 15 minutes, and I've been able to use that graph. Fortunately, it's only happened once to me in my lifetime, hopefully not again. The other thing is condo darts. I don't believe I use condo darts on this patient, but if I'm doing a snowman in particular, I'll put one graph in, put some condo darts in so it won't spin, and then I'll do my secondary plug. Or if I have an uncontained lesion, I'll utilize the condo darts on that too. Usually two condo darts are enough to do it, and the orthotics people typically will have those for you. He also got a concomitant osteotomy just to protect that graph. I think he's about six months out now and also doing quite well. I've changed over just to utilizing regular trauma cell plates, but I'm looking forward to what Dr. Darr likes to use for these as well. That's all I have. What I'm going to do is just send this over to Dr. Sherman now to hear about the patella femoral issues. All right, guys. Can you hear me and see my screen? You can hear me? All right. Excellent. I'm really happy to be here. I'm going to be talking about patella femoral cartilage. I've talked to a lot of you in the past about osteotomy and other topics, so I tried to change this a bit to give you a little more philosophy of how we choose what we want to do in the operating room and beyond. My disclosures are easily accessible online. As you're seeing from both Dave and Mike, the cartilage repair landscape, and even in PF, can just be frankly confusing. I will submit if we're talking about small and focal lesions. There's a lot of different things we can choose from, and I neglect towards a lot of the procedures you've already heard about. However, if you want to simplify, and we're talking large, multifocal, or lesions of the patella femoral joint, then we're really talking about two right now, osteochondral allograft and MACI. We presented this at ICRS, just looking at the commercially available products by FDA regulatory pathway, and what we can see overwhelming evidence for MACI osteochondral allograft versus virtually everything else. So hopefully that'll help you guys going into practice. We've learned that not all cartilage patients are the same. There's differences with lesion size, depth, location, the joint, the limb, pre-arthritic, arthritic, perfectly normal x-rays, patient factors, and as Dave said, no one size fits all. We unfortunately have to use our brains before we use our brawn. This just happened. We sent this letter to the insurance companies from all of these centers, reminding them of the misconception that the patella is not weight-bearing, and saying that the patella is weight-bearing. So we're trying to fight this struggle with and for you guys, but it's an ongoing battle. This is a great article from a bunch of our colleagues, myself, that came out very recently. If you want to be in this space, I'd encourage you to read it, just to see where there's significant concordance and discord amongst us. For example, OCA and ACI are good treatments for large chondral defects of the patella and trochlea. The majority agree about that. We should treat alignment stability at the same time before or after we treat cartilage defects. Most of us would agree, but there's still significant discord over ACI versus OCA for things like central trochlear groove, medium patella ridge, multifocal defects. This is another study that came out this year that we put together, looking at 59 articles, all of the techniques, and basically, most of them had improved clinical outcomes, low rates of minor and major complications, and really no significant differences between them. We have to remember that most patella femoral defects are asymptomatic, and we must not over-treat. This is an NBA study, asymptomatic athletes. 82% had findings of some sort of abnormalities in their cartilage. We're not treating 82% of these athletes with cartilage restoration. We need to be careful not to barf or vomit, as Brian Cole has taught me and reiterated many times. We need to avoid iatrogenesis imperfecta by treating symptoms, and not the MRI or the scope findings. We can make things a lot worse, like this poor guy who had a microfracture of what might have been an incidental trochlear defect during a meniscus surgery. He comes to me debilitated with this large central cystic defect, and he needs to be converted through an open procedure to an osteochondral allograft to try to solve his problem. That could have been avoided. We need to know why is there a chondral lesion. Was it from patella dislocations? Was it from chronic maltracking? Is it post-traumatic? Is it an OCD? Or is this really the first site of genetically programmed osteoarthritis that's going to show up to burn you in all three compartments? We need to treat the joint as an organ. I think about stability and alignment way before I think about cartilage. I do that every time so I don't make any mistakes. What is driving my decision to treat cartilage? First, I say, can I fix the problem with alignment correction alone? If I can, I ask, do I need to add stability? And then lastly, do I need to add cartilage restoration in that order? We clearly need to understand patella femoral tracking and maltracking. We need to use that to our advantage to optimize the joint environment. We need to accurately measure alignment. We need to understand the relative thresholds, but take these values with a grain of salt. We can't say TTTG of 15 versus 18 or TTPCL or CD of 1.1 or de jure B and make those as definitive reasons to do or not do. We need to think about the whole patient and all of these factors together. We'll start in the toolbox with some non-operative pearls. So we clearly know what we might do non-surgically. I think the key point here is just to gauge patient's commitment, compliance, and their response to treatment to establish a rapport. Some of these surgeries that we might need to do are one or two stages. They're big. Things can go wrong. You want to be on the patient's team from the start. I strongly consider staging scopes for the reason that Dave outlined. It's a great opportunity to put it all together and to think. Some patients actually will respond to debridement alone, and I really want to know if patients are going to listen to me and be compliant before I do something bigger for them. Here's a person, 22-year-old female, seven years of painful effusions, imaging, MRI, fairly underwhelming. We get to staging arthroscopy. She has a huge shark bite in her joint. I'm not sure why our media is not playing, unfortunately, on this. I hope that doesn't burn us too much going forward. But anyway, she had a large defect. We make a problem list. I put that in my future plan, and then I have that going forward. When we think about concomitant procedures, these are the most common that we choose. Jack Farr and I just did an infographic where we really looked at the different ways we can use tibial tubercle osteotomies to our advantage. For this talk, it really comes down to cartilage mapping. So these distal lateral defects, we can unload them with a Fulkerson without cartilage restoration and get good or excellent results. Here's a 25-year-old, distal lateral chondrosis, painful effusions, mechanical symptoms, no instability, and frankly, an isolated AMZ, maybe with a lateral retinaculum lengthening, can get the job done. Alternatively, for these medial central or Pampatella defects, those are the ones with problems. Those are where we have to combine osteotomy with cartilage restoration to get our good to excellent outcomes. Osteotomy improves outcomes for cartilage repair. If you're on the fence about it, do it, especially when it comes to cell-based repairs you see here with and without osteotomy improving by about 50%. This is a study that our fellows put together looking at osteotomy, reducing the risk of reoperation for either ACI or OCA with a similar rate of complications and similar overall costs in the long term. When you're doing osteotomies, unfortunately and sadly, these videos aren't working, but this is an OKO video with myself and Brian Cole, and basically we can unhinge the tibial tubal osteotomy and leave it unhinged while we address that patellofemoral joint, and then after you're done with your OCA, your MACE, your other procedure, we can then fix the osteotomy and balance the soft tissues in that order. Here's a patient with recurrent dislocations, painful effusions between the episodes. You can see this large focal medial defect. They have a TTTG of 22, so you're worried that the TTO may load that medial lesion, but if you add cartilage restoration and soft tissue stabilization, treat the joint as an organ, we can get a good result. Here's a paper we did with Christian Latterman going through the technique for lateral retinaculum lengthening. This is a workhorse combined with TTO. We can access the patellofemoral joint nearly in its entirety. We can also fix pathologic tilt or patella subluxations. MPFL, we all know that this is for instability, and don't use it for pain, and don't use it to push or pull anything for alignment. We presented this abstract at the patellofemoral study group this past year, looking at our series of MPFLs with and without cartilage restoration. Basically, any symptomatic lesion that could not be unloaded by an osteotomy alone, so those medial central panpatellas were included in the cartilage restoration group. As you might expect, that group had a little older age group, and starting out, they had lower preoperative subjective outcome scores. However, using these principles we've discussed, we were able to get significant and similar improvement in both groups with no significant differences in their complications. So if we stick to the principles of alignment, stability, and then cartilage, we can get good outcomes. Just going through for the patellofemoral joint, these different options that we might have in our toolbox. First and foremost, you have a dislocation. You have a shear injury like this lateral femoral condyle. We should fix it, and when we fix it, as you see here, healed at one year follow-up. We also want to stabilize the soft tissue, so typically medial soft tissue stabilization for all internal fixation following a first time or other patella dislocation. Talking about marrow stimulation for the patella specifically, there's poor results. I don't do it. There's less cells. It's fibrocartilage. It's high shear environment. If you do it, you should do it mini open, because it's really hard to microfracture arthroscopically. What about microfracture plus? I'd say that it's compelling, but we need more data for the patellofemoral joint. OAT autograft has been discussed. I think it's time tested. It's available around the world. It's our good friend Diego Astor who wrote one of the major papers on it. We have good or excellent outcomes to support it in our literature. Mike went through the return to sports, so if you have these small focal defects, you can get great outcomes. However, the patella is really hard, so you want to drill. I worry about donor recipient cartilage mismatch, and I also worry about donor site morbidity. Taking more than one or two plugs, particularly for a patellofemoral lesion where you're taking from the PF joint, doesn't make much sense. These fresh pre-cut osteochondral allografts come in 10 to 16 millimeters, so 16 is about two centimeters squared. Here's kind of a 16 year old kid, direct blow to the patella, painful effusions, mechanical symptoms. You can see the osteochondral defects, superior medial, classic location. Unfortunately, again, these medias aren't playing, but you can see in this video there's good stability. Then we can see in size the cartilage defects. I use a tool, this probe. It has two millimeter increments, so I know 16 millimeters is two centimeters squared, and I go from there. Going through, you know, basically to cell-based repairs, it's a workhorse for the patellofemoral joint. The unique geometry makes it desirable, and frankly, technically easier. This is time-tested, bone stock preserving, hyaline-like, not necessarily hyaline cartilage. It's two-stage, and it is expensive, which are some drawbacks. However, multiple publications and favorable outcomes up to 20 years. There is outcomes for the patella that are good or excellent, similar for the trochlea. It was off label, but no longer for bipolar patellofemoral lesions. You can see the second generation. You can contour towards almost the entire patella and trochlea, and now with the approval of Macy, we have much easier ways to do this with uniform cell distribution and cell viability that we can actually know and tell our patients. This has expanded our indications, not just for femur, but for all parts of the joint, including patella. It's technically easy, and we can accelerate our rehabilitation processes. So, I do Macy and consider it for young patients with normal joint spaces and no osteophytes, particularly medium to large patella, trochlea, or bipolar cartilage defects that can't be unloaded alone. Multifocal cartilage lesions of the condyles in the patellofemoral joint when I have a normal or a corrected mechanical axis. And Macy has good support up to 12 years in our literature, as is referenced here. There's another study coming up, the NOVACARD study, that some of us will participate in. Also, an autogenous chondrocyte implant system. Touching on just a few of the single-stage options, if you're going to use these, you better be prepared or don't do it. Don't just go right to the cartilage and treat it. You want to treat stability and alignment and make sure that you're correcting these and optimizing the environment before choosing a cartilage repair strategy or you're going to get burned. Particulated juvenile is considered minimally manipulated, so there's a growing data set for this. These are some of the studies, but granted, it's small to medium defects, but there's good to excellent outcomes and good defect fill. This is a study specific for the patellofemoral joint with good outcomes, good MRI fill. However, fill did not correlate with their outcomes. This is from Alberto Gobi. It's intriguing, but we just don't use it. A hyaluronic acid membrane with bone marrow aspirate concentrate results similar to Macy, so we might think about this more in an American population. This study out of the Mayo Clinic, looking at allogeneic MSCs combined with particulated autograft, also intriguing, and I'm looking forward to their results. This is from Brian Cole, showing particulated autograft cartilage repair taken from the lateral aspect of the notch and then minced together with PRP and lyophilized cartilage. Limited data, but intriguing. Again, other things like cryopreserved or viable putties. Limited data. Keep your eyes open, but be skeptical. And then, as Mike touched on, we consider OCAs in older age, early osteophytes, and early narrowing. The results may not be as good with cell-based repair. If there's a compromised bone bed like an OCD, subchondral cystic changes, or prior marrow stimulation, my red flag and my guard is up. If it's uncontained, post-traumatic, AVN, yes, you can do some of those other techniques with Macy, sandwich techniques, or otherwise, but you might consider osteochondral allografts. And for PF, Bill Bugbee showed us that for unipolar lesions, the results are outstanding. However, even in the best of hands, for bipolar defects, the results are guarded with up to 40% survivorship problems at five years and 50% failures at final follow-up. So here's a patient who had a prior patella microfracture. We can convert them to an osteochondral allograft with soft tissue stabilization. Similarly, a patient with AVN following chemotherapy. Everything else was normal in this patient's joint, and we can use this specific oval osteochondral allograft to essentially recreate their whole lateral trochlea. The outcome for return to sport are also quite good for both Macy and osteochondral allograft. Takes a bit longer for Macy as expected. And then lastly, when we're going into the pre-OA or early OA space. So you have a 45-year-old laborer with lateral patellofemoral arthritis and malalignment. They're an active runner and a mountaineer. Here are kind of your options. You could do that bipolar OCA plus minus TTO. It's a big operation. It may produce stiffness, and in the best of hands, you have that 50% failure rate. Maybe not a perfect option for this age, maybe better for a 20-year-old. You could do a PFJ, which I think would be a little challenging for this person who's quite active. And so I think an unloading osteotomy alone is a very reasonable choice. This is another study I wanted to make you aware of. It's a phase III RCT. This is the agility implant, which basically is off the shelf. It has differential porosity in the bone part and the cartilage part. It's made of aragonite, so C-coral. This study, basically, when you look at this, it has a magnet effect, so it attracts your own cells to make bone and to make cartilage. When you look at the study that we've been doing, it's in real-world patients. So this is like a 35-year-old. They have a trochlea defect, medial femoral condyle. You can see the implants, which don't have to be stacked up together, different than osteochondralograft. You can actually space them. And when we follow them clinically and by MRI, it actually reconstitutes cartilage over and around the defects. And those KUS scores are just remarkable. And then lastly, I was going to show a video of a patient too much for cartilage restoration. So 45, instability, arthritis, dysplasia. For these patients, I basically just do patellofemoral arthroplasty. It solves the alignment issues, the bipolar cartilage issues. And then I just have to add soft tissue balance, which in most cases is actually just repairing the soft tissue sleeve. And so hopefully you've learned that these cartilage lesions are common and that most do not need to be treated. We want to stay low on that reconstructive pyramid with non-operative, benign neglect, and staging scopes. Choose the least morbid but effective option, and don't burn bridges because nothing lasts forever. First, we unload and stabilize, then decide if cartilage restoration is really necessary. And I think if you're going to do this, you need to love the patellofemoral joint, stay humble, and continue to learn. And so I thank you for your attention. I'm going to switch this over now to our final panelist, Rob, to talk about osteotomies. Thanks. Thank you, Seth. I want to thank Dr. Flanagan and the AOSSM for inviting me to speak today. Hopefully I can give you all a little bit different of a perspective as a young faculty member and some things to look out for as you start out in your practices in a few months. I think Dr. Bamfy made a good point when he talked about a lot of behind-the-scenes work that your faculty and their staff are doing for your insurance approval for some of these procedures. So there's a lot of behind-the-scenes work just for setting up your practice for osteotomies, getting your OR set, getting all your nurses and your OR tags and your x-ray tags all on the same page. And so you'll learn that pretty quickly when you start out in practice. So hopefully I'll give you a few tips as you're doing that. So my objectives here are to help you understand normal versus abnormal alignment, some of the indications, pre-op planning, and some of the pros and pitfalls for some of the techniques. These are my disclosures. So before you can understand osteotomies, you must first understand the basics. So this starts in the clinic with your preoperative x-rays. Especially early in your practice, you want to make sure that you control the things that you can control for. Patients should have a comfortable shoulder-width stance with feet facing forward, be fully weight-bearing, and with full knee extension. So talk to your x-ray techs about this. And you can even make a little printout to show patients where to stand and tape this on your floor. We have this at one of my clinics. Also talk to your other partners. See if they are already doing full-length x-rays. We get them on every single knee patient that comes through the door. It just makes it easier that way. And talk to your x-ray techs. If they already know how to do this, then it will make it a little bit easier for you. But if they don't, this x-ray on the right-hand screen is from one of my satellite offices. And they have to manually do this. They take an x-ray at the hips, x-ray at the knees, and x-ray at the ankles. And then they have to stitch it all together. And it takes about 20-30 minutes for them to do this. And it slows down the whole clinic day. And they all think that I'm a terrible doctor because I run 45 minutes behind for no fault of my own, but just because I'm waiting for x-rays. So we have stopped doing this at that clinic. But just talk to your x-ray techs. Make sure that everybody's on the same page. And communication is key. Make sure you're recognizing any joint laxity. You know, use some common sense. Repeat the x-rays if needed. So when we're evaluating lower extremity alignment and thinking about osteotomy, we're really looking at the mechanical axis or where the knee falls in relation to the center of the hip and the center of the ankle. Always measure both sides and look for asymmetry. And when we discuss the degrees of varus or valgus in our corrections, we're really talking about the hip-knee-ankle angle or the angle between the mechanical axis of the femur versus the mechanical axis of the tibia. So what is normal? This was a study where they looked at 500 healthy individual or 500 knees and 250 individuals. And they measured the hip-knee-ankle angle on full-length weight-bearing x-rays like I showed. And they found about 76 percent of patients were within three degrees of neutral. Only two percent of patients actually had a neutral mechanical axis. Males tend to be in a little bit more of varus. And females are closer to neutral, though still in a little bit of varus. And very few patients were more than three degrees of valgus, which is about what I see in my practice. I may see a little bit more valgus because I see a lot of osteotomy patients. So what are indications for osteotomy in patients undergoing cartilage restoration? So our goal is to create a mechanically favorable environment for biologic healing. I would say that ACI has a little bit lower tolerance for malalignment and may be a little bit more aggressive with osteotomies in these patients, whereas an osteochondral allograft is a little bit more durable of a restoration technique early on and perhaps can have a little bit higher tolerance for malalignment. As a general rule of thumb, patients who are between three and five degrees of malalignment are certainly at increased risk of failure with a primary cartilage restoration procedure. And I will certainly talk with them about an osteotomy, or Dr. Flanagan will send them to me to talk to them about an osteotomy. And anyone over five degrees, I would certainly recommend an osteotomy. And in patients who have had a previously failed cartilage procedure or have significant asymmetry, like more than five degrees of asymmetry or even more than three or four degrees of asymmetry, I would definitely recommend an osteotomy in those patients. And so several factors are important when considering a concurrent versus a staged approach. Also, keep in mind that this is a single reconstructive surgery. These patients are also going a initial staging arthroscopy, like Dr. Sherman discussed, and often may need taking cartilage biopsies if you're planning for an ACI. Some of the advantages of doing a concurrent reconstructive procedure are a little bit less time spent or maybe a lot less time spent in recuperation from a single surgery. There are some risks of doing this as a single procedure. Longer surgical time has been shown to increase risk of complications. Increased surgical trauma can lead to more stiffness. As opposed to a staged approach, the surgery itself is going to be shorter and perhaps an easier recovery. However, they're going to go through two surgeries or two major surgeries and two recoveries and a longer protective weight bearing and a longer rehab process. But generally, patient preference, surgeon experience, logistics, probably the logistics may be the biggest thing. Patients can't take off of work for two surgeries or something along those lines. And their clinical presentation really should be the main considerations when determining a single versus a staged technique. And so I know that this is a cartilage repair and restoration session, but it's important to think about osteotomies in our osteoarthritis patients. For every one cartilage repair patient, you'll probably see 20 OA patients in your clinic as you get started out in practice. So let's briefly touch on this. For HTOs, generally this is preferred in younger patients and those who wish to continue higher impact activities. Often we're considering osteotomy versus a partial knee replacement. UKAs are generally preferred in patients with higher grades of osteoarthritis and only up to about 10 degrees of varus malalignment. And generally, I would recommend low impact activities. And I recommend that they don't run, but I know patients do run with their unis. And I warn them that they may cause loosening and early failure. And larger studies have shown that partial knee arthroplasty does provide better pain relief and functional outcomes versus high tibial osteotomy, though this is an individual discussion to have with each patient. And I'll talk to them about the studies and make sure that they know that if they have grade four arthritis, they may still have a little bit of pain. We're not removing their arthritis, we're just unloading the arthritis. And I'll have that discussion with the patients and I'll be very upfront and frank with them. And I think they appreciate that. Along those same lines, proper patient selection is key and patient education is paramount to your success. If you're in a large academic, if you're in a large group or academic group and they're sending patients to you for an osteotomy, that makes your life a little bit easier. But if you're doing this as part of a general sports medicine practice, you'll want to have a good system in place in advance. You'll want to have informational handouts that you can hand to your patients. Maybe post-COVID, you want to put all these online. We can't really give patients handouts anymore, but make sure you have good educational materials to provide to patients after you have a 15 to 30 minute discussion with them. Give them the information to read about and learn more about it and then bring them back in for another visit before booking them for an osteotomy surgery. And I often will trial with an unloader brace, especially in my osteoarthritis patients, to see how they respond. If they have a great response with an unloader brace, I feel a little bit more confident that doing an osteotomy is the right thing. And you'll buy a little bit more time and they can think about things and think about the surgery. So prior to osteotomy, I will get an MRI on all my patients. Typically, they'll have one by the time they come to see us. I think it's important to evaluate the contralateral compartment or when planning any cartilage procedures, they're obviously going to have an MRI scan. And in your high tibial osteotomies, you'll always want to look for this aberrant anterior tibial artery. So I did fellowship with Dr. Minus. He's one of my mentors. He published this series of 1,100 patients and found a 2.1% prevalence of an aberrant anterior tibial artery. In the drawing, you can see how it branches deep to the popliteus muscle, right along the posterior cortex, right where you're going to be making your osteotomy cut. So I'll look for this on an axial MRI slice and you'll see it. You'll see it. You can follow the artery down. You can watch it branch right in front of the popliteus muscle and right down along that posterior cortex where you're going to be making your saw cut. And in my own practice, like I said, I look for this on every HTO patient. And I found this in two out of 30. So my prevalence currently is about 6.5%. And so now that we've decided we're going to do an osteotomy, how much are we going to correct in these patients? Fujisawa's point is one that's historically talked about. This was done for patients with osteoarthritis. In 1979, they published the results and had good results correcting them to a point at 62.5% across the width of the proximal tibia. Remember, this was 40A. Though when you're planning your correction, it is important to consider a multitude of factors. Your surgical indication is probably your most important factor or one of your most important factors. In osteoarthritis, maybe a slight overcorrection is recommended. Though in cartilage repair and meniscus transplant, I would typically go to neutral or, as Dr. Banfi mentioned, match their contralateral side if there's a big difference there. You'll want to know the status of their contralateral compartment. If they have a big lateral defect and you're doing a medial opening wedge osteotomy, you want to be more careful. Maybe only go, if they have a huge varus alignment, just go to neutral, maybe even a little less than neutral. You're trying to create a mechanically favorable environment for their knee. And as Dr. Sherman mentioned, think of their knee as an organ. And the presence of any laxity or they have a concomitant ACL rupture or post lateral corner injury and bad alignment, we'll consider osteotomy. So you just want to consider all of these things when you're planning how much to correct. This is a patient of mine. She had a failed ACL and you can see how much her lateral joint line is opening. And so when I'm measuring a correction on this x-ray, I want to take that into consideration. And various people I've talked to, we need to talk about a one millimeter of side-to-side difference on your x-rays. You're going to subtract one degree from your correction. This is a recent paper just published by Dr. Gamal and his series of patients. They looked at for focal medial femoral condyle defects. So they actually found that overcorrection into valgus or even patients who had a native valgus alignment actually did significantly worse in terms of survivorship with both osteochondral allograft and with ACI in their cohort. So pretty interesting for a medial defect. If they shifted them a little bit overcorrected into valgus, they actually did significantly worse, especially in that ACI group. So again, you know, the mechanical environment and the thinking of the joint as an organ is important. So when you're planning your osteotomy, you'll want to make sure you have a systematic way of templating. This patient had a previous medial meniscectomy and is having some progressive breakdown of their medial compartment. So my goal was to correct him to about the lateral tibial spine, which is about an eight degree correction. And I'll typically measure about four centimeters down from the medial joint line. And it's important to have a general idea of wherever your implant is going to sit, whichever implant you use. This particular case, that implant is meant to be a little bit higher. And I now know that this is one of the first cases that I did. But it's important to have a general idea of where your implants are going to sit, and that's going to guide your templating. And so this will be your starting point. And then you're going to aim at a point about 2.5 centimeters below the lateral joint line. And I always try to preserve about a one centimeter lateral hinge. And I want this to end within that proximal tibiofibular joint. Because there's some strong ligaments around this proximal tibiofib joint. So if you do fracture out laterally, this will provide some stability there. And then you're going to measure an eight degree correction. And you're going to measure this point on the medial tibial cortex. And that's what the measurement that you're going to be using in NEOLA. So hopefully you guys have had an opportunity to template in your fellowships. You know, I can share these slides with you as well. But that's the way that I typically will do it. And then be familiar with your implants. So the implant on the top is one that I currently use. It provides very stable fixation. And you can allow early weight bearing. I like that it has a non-locking screw option. So you can compress through the plate with the osteotomy. And this is what I currently use. The plate on the bottom right, I previously used. And it's nice when you're first starting out. It has that pre-built wedge that you can get in a variety of different sizes. And that plate works very well, I think, for you know, the five to maybe 10 or 12 degree range. Bigger than that, I probably use the stronger top plate. And then for smaller patients or skinny, especially in females, I'll use that implant on the bottom. That's the iBalance, which goes all inside the bone. And really is a nice implant for your smaller patients with a smaller correction. Just know that there's some limitations with the sizes of that implant that are preset sizes. And you can only do certain corrections. So just talk to your rep about what those options are. And make sure that it's going to match your correction. I think in this case, you may be overcorrected a degree or two. And I think it's important to be familiar with all these plates and know different techniques and have a variety of options in your arsenal. So for DFO planning, in this case, I was planning for about a 12 degree correction to the medial tibial spine. And I'll measure, I'll start my measurement about 1.5 centimeters to the proximal to that lateral flare. And then I'll draw my line towards the adductor tubercle and again, preserve a one centimeter hinge. And then I'll measure the angle of correction about 12 degrees. And again, we'll measure this length at the lateral cortex. And in this case was about 15 millimeters of correction, which is a pretty big correction for a DFO, probably about the limit that I'll do for a DFO. And then your surgical setup. So this is probably one of the biggest things I took for granted coming out of fellowship. I was always asked, why don't you get the setup ready or make sure everything's all good. And I thought I knew what I was doing. And then when I went on to practice, I realized that I had no idea. But this is arguably one of the most important steps in the case, especially coming out of your guy's fellowship. You'll have a hundred other things on your mind and always want to make time to talk to your OR nurses or OR tech before any osteotomy or the beginning of the day and make sure that you're all on the same page and have the room all set up the correct way. So for your, make sure you have the correct OR table in the room. I think that's probably one of the biggest advice I can give you. The worst thing that could happen is you get in there, you're doing your osteotomy, everything's going great, you go to take your x-rays to check your alignment up at the hip and you can't get there because the patient's on a regular OR table and you never notice that. So don't ask me how I know that but that's a bad day. And for your high tibial osteotomies, you always want to position your foot holder below the mid-calf and so that'll keep the knee in an extended position and prevent you from flexing your osteotomy and increasing your tibial slope. You can see the difference between those two pictures and really appreciate that difference. Especially if you're doing some cartilage procedure where you want to hyperflex the knee, you're going to have that foot post higher up on the leg and so I'll put two posts in that case and put my distal post higher up so that'll keep my osteotomy hyperextended when I'm working. In the HTL, I'm working with the knee in extension and remember that we're working from the medial side so you'll want to make sure that the case card is set up on that side and you're going to bring in your c-arm from the opposite side. That's usually the opposite of what they're used to setting up so make sure that your OR techs and your team is available or aware of all that. And then for your distal femoral osteotomy, most of your work is going to be done in flexion so make sure that you're able to position the limb with your foot holder in a good position. I like about 50 to 60 degrees. You can see on my fluoro shot there that'll give you a nice view of the distal femur when you're putting in your guide wires and making your saw cuts and then you'll want to make sure that your leg is going to be stable when you swing through if you're lateral so you don't have to have an assistant holding the foot or holding the position. You can just put it up on your foot holders and your positioners and it's going to give you that perfect lateral x-ray and I'll check that before we prep and jape and I'll get those x-ray shots. And again, on the lateral osteotomy, you're working from the lateral side so your setup is going to be on the same side as the patient surgery leg and then your c-arm is going to be coming in from the opposite side. So just make sure that they know, you know, your tibial osteotomies are one way, your femoral osteotomies are the other way and just make sure everybody's on the same page at the beginning of your day. Tools for executing the osteotomy. When you start out, if you're lucky enough to have another surgeon who's been doing osteotomies, see if they already have an osteotomy tray set up at your hospital. Each implant company has their own trays and they'll charge you a lot to loan the tray to your hospital for a day to use it. So talk to your OR manager about potentially building a tray for you like this. You know, I'm not lucky enough to have this tray quite yet. It's been a two-year battle but I spent a week or so with Dr. Getgood and Litchfield up in Ontario and they had this beautiful tray for them for every one of their osteotomy cases. So as you get a little bit more established in your practice, hopefully you can have a tray like this. You'll want to have a nice thin flexible osteotome. I like this adjustable wedge from Arthrex. It's got this nice broad flat surface you can use for opening your osteotomy. You want to have some breakaway pins that come in some of the sets. I also like using the laminar spreader which comes in the Sinti's Tomofix set and you want to make sure you have a nice set of dull tip retractors. I can't tell you how hard it is for us to get some dull hoomans and they're opening up hip trays and trauma trays. So just make sure you have all this set up in advance and maybe it takes a few times for your OR team to get it right but you can see this tray there's only a handful of instruments here that you really need. And so some pearls for the high tibia osteotomy technique. Always completely release your MCL. You want to make sure that you're not increasing your joint pressure. I'll just completely transect it at the level of my osteotomy and that's the way that I do it. Starting out I'd use two K wires or a cutting guide when you're doing your your saw cut instead of making it freehand with just one pin. I think that helps you be a little bit more accurate. You always want to make your saw cut below the K wires. You don't want to drift proximally or make your saw cut above the K wire and drift towards the joint and then fracture into the joint. Again don't ask me how I know that. Always use a thin flexible osteotome to complete the cut under fluoro. I'll make my saw cut about halfway or two-thirds of the way across then I'll complete it with a thin osteotome. I like using stacked osteotomes or that adjustable wedge from Arthrex to open up my osteotomy. Do it slow. Make sure that you're not going to fracture across or fracture out laterally. If you're having trouble opening up the osteotomy you can get a small drill bit and actually drill across and poke a few holes through. Don't plunge deep into the nerve or anything but I think that's a pretty safe way to help open up the osteotomy. I prefer a biplanar technique. You can see here drawn out on the saw bone. If we have time I can show you the video. And then I always will measure intraoperatively and I'll get a view at the hip, ankle, and knee. There are some limitations to this so just beware of that but I use the intraoperative fluoro to really confirm that what we templated and what we're looking at in the OR is really what we're looking at and we're executing our plan appropriately. And I'd be remiss if I didn't mention the posterior tibial slope. I know you guys had a great talk from Dr. Gitgut and Dr. LaPrade last week and so this is also important for your medial opening wedge technique to maintain and monitor your tibial slope. You want to make sure you're opening it as a trapezoidal wedge. If you open it as a rectangular wedge you're going to actually increase your tibial slope. So you can see kind of the difference in those two if I go back and forth between those slides. When I first started out and I was doing a case in a patient who had an ACL deficiency I put a pin proximally and a pin distally so I could actually monitor the slope as we were doing the case. Maybe try that out when you first start out just to get a sense of what's happening with your tibial slope. You know make sure your posts are set up to keep you hyperextended. It just keeps, it just prevents you from having to worry about one more thing if you set everything up properly. Plan for intra-op complications, they'll happen. Plan for the worst case scenario and hope for the best. Hinge fractures will happen. Make sure you have some compressive bone staples available and in cases of 15 or more I'll actually prophylaxally put a staple and watch out for vascular injuries. Have your vascular surgeons on standby and if there is an aberrant tibial artery make sure that they're aware or on board or in the hospital or available. That's my two minute, one minute warning so I'll quickly go through my DFO pearls. I use a pretty small incision. You'll want to elevate your vastus lateralis again where you're aiming to the medial adductor tubercle. I'll actually do this in the OR. I'll use a Army Navy retractor here to measure perpendicular to the distal femur and I'll put my second k-wire in under flora looking at that. I like a biplanar technique for my distal femoral osteotomy as well. You want to make sure you have a nice big flange so you don't fracture through. I help, I think this helps you control your osteotomy of your distal femur a little bit better. Again this is showing the saw cut. Here's showing the biplanar technique. I'll use a thin osteotome to complete the osteotomy. I'll use my stacked osteotomes to open it up really slow and this measurement tool. This is my one of my favorite tools in orthopedics. It's very simple and very versatile. Just cut a paper ruler and you can use that to measure your opening and then again check your alignment intraoperatively again. So this is the the synthese plate. This is a nice robust plate. Again you can you can put a non-locking screw to compress and this is my preferred technique and then I'll do a percutaneous screws up more proximately. Post-operatively I'll do a progressive weight bearing program. I like to get them weight bearing early and moving early and I like those plates that are provide a lot of stability early on. And so to finish up again when you're building your practice educate your team, your x-ray techs, your OR techs, your OR nurse. Make sure everybody's on the same page. Talk to other surgeons in your community. I found actually that your OR reps are a good source of referrals. Let them know that you're doing osteotomies. They can let other surgeons know in the community that you're doing osteotomies. Attend an osteotomy course. The AOSSM and ISTCOS puts on a great course. Learn from your mentors or talk to your mentors and learn from your peers. Reach out to your mentors. You can always reach out to me if you have a case with questions and always remember to have a plan and stick to it. All right thank you and sorry for running over a little bit there. Thank you Dr. Doerr. I appreciate the wonderful discussion and thank you for my rest of my panelists. We do have some questions and I'd like to shift in a little bit of time to address some of the participant questions and some of them Dr. Doerr let's just start with you as far as osteotomies. A couple questions came out. Any use as far as patient-specific osteotomies or using navigation for osteotomies and what's the experience with that maybe with the panel here in their own practices? So I personally have not used any patient-specific or navigation yet. We are currently just applied for a grant for a project so hopefully we'll get funded for that but definitely an interest of mine maybe some of the other panelists have some experience with this. I can add in I think probably that's the next thing for me to implement in my joint preservation platform. I have not yet but I am actually speaking with companies and starting to integrate so it'll require in addition to MRI and x-rays a CT scan and then what's good is that our fellows alongside myself you know can actually help with the company representatives to pre-plan so that'll be exciting and I think it'll help us to really reiterate all the angles and corrections that you talked about. I'm going to specifically try to integrate it for complex corrections so two plain corrections changing slope changing coronal alignments and go from there. So I think you should have a broad portfolio stick with what you know to start. I wouldn't encourage you go out and just do that let the guys who do a lot of osteotomy do it first and work through pitfalls in America and publish on it and then but I think it's clearly something that is exciting. One more point I think for closing wedge techniques which I've started to do a lot more of which we didn't have time to go over today but I think that the patient specific or 3d printed guides would be really helpful in especially those types of cases. Just my two cents I agree completely with you guys. I actually think this is going to be the frontier for the next generation of sports related robotics. I think that a similarity with MAKO to do this just like doing a PAO with it too. I think that that's where we're really going to be going. What are your thoughts about double osteotomies and at the same time so if you had to do both a DFO and an HTO for whatever reason or TTO with HTO what are some of the complexities and issues that that may come across with those type of osteotomies? So fortunately I've not had to do that yet in any of my patients but talking with Dr. Getgood you know he certainly will do it if there's any cartilage procedures that they're going to need to do they will stage those. They'll do the osteotomies first. They'll try to do like a medial stay on the same side. You can combine a medial closing wedge or the femur with the tibia depending on what you're trying to correct. I think there's certainly a role for that. Maybe some of our other panelists have experienced themselves. I haven't had to do that fortunately as well. I think that you know with the DFO for example you can correct some patellar maltracting issues with that. So if you have a you know like in my case with the lateral patellar issue that we did ACI on as well as the the lateral compartment you know I think that the DFO corrected both of those compartments. But you know I think it's pretty rare to actually have to do that. I don't know Seth what do you think? I think it's very rare for me. I see incredible you know multiple osteotomies from my colleagues in Europe and elsewhere abroad and so it's clearly an option for patients. I worry about the morbidity of it. I tend to measure everything including version torsion and you know the whole limb axis and everything about the knee and then I choose which one I think is my biggest bang for the buck which is going to offload the cartilage which is going to really drive the success of my soft tissue balancing and my you know cartilage restoration. So I've not had to go to that and frankly if I did I'd talk to my colleagues in trauma who do trauma osteotomies or limb lengthening colleagues and and see what their thoughts are before just doing two levels. Well I think everyone can appreciate these cartilage and osteotomy patients are obviously quite complex and I think for our fellows to really simplify it as much as possible. Obviously don't chew off more than you can at one point. So that kind of comes into the question when do each of you stage things? When do you put it all together? What are some of those thought processes for you and what would you advise our fellows as they're kind of going into practice? So I mean I think it's the most important oftentimes ends up being the logistics for the patients like I mentioned in my talk. So I preference and the way I was trained is to do a single stage and Dr. Minus if you see any of his talks I'll show you some big procedures with multiple surfaces and osteotomy. I think the important is having a good post-operative plan. You get them in a CPM on day one. We'll admit them overnight, leave a drain in, do a lot of things to control their plane. We use a pericapsular injection to make sure you can get them moving early. As long as you have a good system I think you can do a lot of that in a single procedure. Rob just to point out though inherent to that since he's I assume doing cell based repair that the first stage was a simple staging scope to understand size, depth, location of cartilage, understand the ligaments and alignment and then coming back to execute all of it. So you know I think that that's a little nuance there. So there is just a staged component to it. Small surgery and big surgery in that regard. Right. What do you think? What you feel comfortable with. You know I tend to do everything all at once. If I for example if I've already done a scope and I know what I'm getting into but at the same time if you are unfamiliar with the procedure and it's going to take you a long time and you're worried about trying to get time probably your biggest bang for your buck is going to be your osteotomy. So then you'd stage it do that first and then you know proceed from there. Yeah I think for me I've looked at a lot of these complex cases and at the time of my staging arthroscopy where I'm kind of getting the lay of the land I think is a great opportunity sometimes just to get your osteotomy and in some of those people that maybe that's all that they need. Right. So I feel like it as you just point out it really doesn't burn any bridges. Some of that can be with their rehabilitation are going to have two potential rehabilitations but it is something that you're not taking too much at one time especially if you're starting in practice allows you to think through all the different issues and really give your best for each of those singular procedures. How about just a diagnostic arthroscopy when you're assessing cartilage lesions. How often is that used in your practice and how strong of a use is that for really deciding what's going to be the best treatment for your patient. I wouldn't say I'm using diagnostic arthroscopy per se. I mean you can talk about in office if any of you have experience but I don't. I would say that if they failed conservative management or they have mechanical symptoms and images that show that as well then for me it's both a therapeutic arthroscopy treating any inflammation within the joint also treating any unstable cartilage flap sizing the defects thinking about it making a future plan and seeing how they do in a lot of cases. So just going in to diagnose in and of itself you know I'm not typically doing that. Yeah I agree with Seth. I think that you know for the for the weight the I don't want to say weight bearing surfaces but for the typical femoral joint I generally have a pretty good plan of what we're going to do you know even before that first scope we've had a long discussion many ways to skin a cat these are the different things we can do so we're kind of going to it with a really good plan. I think that with the patella femoral joint you know I don't like scoping them. I think that I try to avoid you know scoping anterior knee pain at all costs you know but those are the ones probably that would be a little bit more diagnostic or they failed everything I'm going to go in there and then I see a significant cartilage lesion that could be treated say with with ACI that we would take the biopsy. I think that those are the ones that probably fit more in that category for me. So obviously these are complex patients and I think the biggest thing is who not to operate on right. We have a lot of experience here in the room but what who are the the big red flags that you would tell our fellows boy watch out don't don't operate on them. I mean we all have some experience. Dr. Banfi what's some of your experience with that? Well I mean I think pain out of proportion you know like some of that anterior knee pain like I was talking about you know is a red flag you know clearly if they've had on a prolonged narcotic use that's another big red flag. I think those are the main ones on the flip side you know mechanical symptoms an acute issue you know young athlete those are those are the home runs. Those are the ones you know you're really going to be able to help. For me for the osteotomies patients cannot smoke or use any tobacco you know I didn't mention that and so that's a big one. They'll have to quit. I'll cotinine test them. They'll come for a pre-op visit. We'll cotinine test them then. We'll cotinine test them on day of surgery and they got to quit smoking. I think that's a big one and then the unloaded brace trial I think weeds out some people. They're like oh I don't want to wear this silly brace or I don't want to do any PT. That's not going to work. Well how are you going to go through this big osteotomy procedure where you know we're changing the mechanical alignment of your lower extremity and I think that's where you really want to try to weed out patients who I think are looking for a quick fix and osteotomy is not a quick fix and they have you have to get a good buy-in from them and you want to have a good patient doctor relationship with these patients because they're going to be your patients for forever and especially these ones you put an osteotomy on and I didn't mention you know you're going to about half the time especially with that synthes tomofix plate or even more than half the time you may have to go back in there for another surgery a year later to take that plate out. So these patients you're going to be seeing a lot of so make sure that they're happy and they have realistic expectations. Dr. Sherrill, how about yourself? I completely agree. I will often try things like sleeves, unloaded braces. I will clearly make them not you know smoke before osteotomy. I will try to get them to understand that they need to learn different ways to lose weight not necessarily through exercise through different diet choices and you know just get them on board with the whole paradigm. Anything we can do outside the OR can help our outcomes that we you know do in the operating room and so getting these patients on board when things go wrong starts in the beginning and you know rushing into surgeries or not having that half hour or longer one or two conversations before you cut their bones or do these procedures or give them false expectations about what you can deliver with these types of procedures just makes your life much worse. I find myself talking longer with them sitting back you know making eye contact stopping and saying what can I answer for you and waiting you know and like just seeing where their brains at. I've used primary docs or psychology on occasion particularly with the PF patients that Mike's going to now send them all down to me. You know I just need other resources. These patients have been debilitated with two to five surgeries over two decades and they're 30 and they can't you know play with their kids. I mean it's a problem so if you don't if you think you're going to just fix that with your hands I think you're delusional. Yeah I think those are some key points. I mean one pain out of proportion these are not the right patients to get them to go to this. You know two they have to be in the right mindset and I agree the psychological mindset of your patient is so key. What type of resources do they have? Who's going to help them? These are big procedures but you have to make sure that you're doing it for the right reason and if they you have to kind of prove that it's the cartilage that's the main issue and so they need to fail some sort of conservative measures for a good time that you are convinced they're convinced that this is the right procedure and cannot overestimate this is going to be a patient you need to spend more time with. I think you've heard that from all the panelists that these are these are unique patients and they need to be on board. You need to have those right expectations so that you are not leading yourself nor the patient towards failure because it can be really a nasty failure if you haven't thought through this appropriately and had those discussions with them. I know we don't have too much time left but there's one other question from some of our participants on insurance and I know this was covered a little bit Dr. Banfield in your talk but obviously it's something that's important. What are some of these pearls as far as getting things approved? What are some of those kind of cutoffs that insurance companies are looking for and how can you help yourself from the get-go to get as much approval as possible without having to go through those timely letters that we often have to send to insurance companies if we have to appeal? Well I think that I can give the Southern California experience pretty well but I think that it probably is going to be somewhat regional on what people are looking for. I know that there's going to be different pre-operative requirements for different insurance companies and what they want the trials to be for example. All of them are going to want to have physical therapy done but some may actually insist that you have a trial of some sort of injection therapy as well. Then with regard to the demographics of the patient, for ACI for example currently it's only FDA approved for adults so from 18 to 55. So if you have an insurance reviewer look at the strict definitions and you have someone that's 17 and a half you still could have a problem with that and you may need to explain that to them and they may need to wait six more months before we actually get this approved. So criteria like that and also lesion size. Another example with ACI it's got to be two centimeters squared or larger and so you need to have really good documentation and you need to make sure you have that in your operative report just as you were saying with regard to your measurement tool. Be very familiar with that and utilize it on every lesion you're looking at and treating just so you have that documentation in there. I think those are the things that really come to mind and then also once you have you know taken that biopsy for example and you're seeing them post-operatively and you're trying to see like well shoot did this osteotomy work? Maybe it didn't. Maybe they're having some persistent pain. You need to reiterate that in your note. You need to reiterate the entire story because that that's the note that's going to be submitted to insurance from your surgical scheduler or your MA or whoever does it and you're going to have some person that's probably not even an orthopedic surgeon reviewing this and looking at some criteria. So you really got to try to make it easy for them to get this approved. Dr. Sherman, other advice on this end? I think it's frustrating. I think you need to lean heavily on the company representative teams in your region to help you get the form letters, get the evidence, make these letters, give it to your surgical scheduling team so that you know you have a process in place. You know I think the patient also needs to really understand the process and you need to communicate with them through denial and appeal and time frames and expectations because they can get fired up you know quite quickly and I think you know you have to at least be a little bit flexible and have the opportunity to pivot if things don't go well and it's taking too long or you know you are finally rejected. So you know I think we're trying to do the legwork to get these other you know just because something's FDA approved is a good point. It doesn't mean it's insurance approved. That's the next barrier. So we stick to evidence. We're good doctors and still it's rejected because the policies haven't changed yet. So that's frustrating. That's not going away. I don't know anything different Dave that you think? Yeah so I you know I think in line of what Dr. Doerr was saying in his talk but setting up your practice this is something that from the get-go having that information using your reps I think is really important. Obviously we talked about Veracell and the my cartilage care and everything else that they have set up but a lot of the other Osteochondrolographs has information as well that can be utilized. But get to know in your state your insurance carriers because each of them are going to have nuances as far as what they are going to cover, what size are the lesions that you need to and I know for myself I set up in my EMR specific templates for all the different companies so that basically if I have a cartilage procedure I put that dot phrase of that insurance carrier. I know exactly what they're looking for. It's a checklist and that really has streamlined my ability to get most things approved pretty quickly. Osteochondrolographs there's some that are required to be two square centimeters there's other ones that are two and a half square centimeters. So again knowing what your insurance carrier is asking is going to be really helpful to kind of streamline that process and once you start practice it's usually a little bit slower. It's a good time to set all those things up so you can set yourself up for success for sure. I just had one pearl maybe a slightly different topic but I know time's getting short you know if we're going to try to build a complex salvage and revision like a cartilage you know practice I think it's really important for you guys you know never throw the other doctors under the bus. I mean you know just understand what they've done tell patients about the biology the biomechanics the graph choices the literature you can say those things in a very nice way and then talk about you know where we're going to go from here onward and you know I think the doctors will respect that the patient will respect that you know it's not a blame game and then you'll get more referrals I think because of that. And then similarly and lastly if you don't know which you know there's controversy here I think in this space we all really like each other and you know we're all mentors and we're close-knit and we're available to you so I call up my friends and get opinions and you guys can do the same so I'd encourage you to do that. Yeah well I know we've gone way over so I want to thank everyone for their attention and ability to be part of this webinar. I'm going to turn this over to Meredith but I want to say thanks to Dr. Sherman, Dr. Banfield, Dr. Doerr for a really just a great lively discussion and thanks again AOSSM and Varisel specifically for sponsoring this one tonight. Meredith. Thank you to our panelists, to Drs. Banfield, Doerr, Flanagan, and Sherman for your time and preparation for tonight's educational webinar. Thank you again to Varisel for supporting this webinar. Listed here are resources for the attendees. Varisel is hosting a virtual fellows program on June 30th. The informational link is on this slide. This program takes place immediately prior to the final AOSSM Fellows webinar of the series. Next week's webinar will discuss the program folder with featured panelists, AOSSM President Dr. James Bradley including Dr. John Conway and moderated by Dr. Jack Dugas. Thank you and good night. Thanks guys.

cartilage restoration

osteotomies

webinar

Dr. Michael Banfie

Dr. Connor Dorff

Dr. David Flanagan

Dr. Seth Sherman

Maricel

patella femoral defects

individualized treatment

lesion size

location

patient factors