We're gonna get started. First of all, I'd like to apologize to all our attendees, just in case you hear my young son out there yelling and screaming. It is directly related to Alabama basketball who is currently playing. I appreciate Ashley and the AOFAS team let me be involved in this. It's a simple topic. All we're talking about are cartilage lesions in the ankle. I think we have all the answers, right? This should go real quick. Fortunately, I was lucky enough to corral three really great panelists. So Kelly Hines from Washington University in St. Louis, Chris Gross at MUSC in South Carolina. Chris, I saw, I think, were you put on the nominating committee? I think I saw that. Congratulations. And then Tommy Haipmanik in the Stubman Clinic, a place near and dear to my heart in Vail, Colorado. So we're gonna start off with Chris. He's gonna talk about treatment of OCDs and adolescence. And then we're gonna move to Tommy and talk about some of the differing treatments in adults. And then finally finish with Kelly and some treatments for revision cases when these fail, which obviously they very rarely do. So, and then hopefully at the end of the webinar, we'll have plenty of time to ask some questions. And I hope everyone will feel free to throw in some questions in the chat. I'll try to follow along and get as many of those out there. So without further ado, Chris, fire away. Thank you much, Ashley, Norm. Thank you for inviting me. Can you all see this? So I once gave a talk on exactly consensus of treating adult Taylor OCDs. And you just switch over to adolescent and it's a completely different beast, but we still don't have any consensus on what to do. So we're gonna do our best. We're gonna provide a lot of evidence and you can make up your own mind. So OCDs are a spectrum of articular cartilage and specifically in juveniles and adolescents as subchondral bone pathology, incidence is not too high, but we know that the incidence increases in school children and in female adolescents. And in fact, for females, it's like 1.5 to 1.6 times the amount of males. We know that teenagers are significantly greater at risk than compared to children, six to 11 years old. So it's a unique situation because there may be some issues with the vascularity of the subchondral bone. It often is genetic. Oftentimes, there's not malalignment like we can see in adults, but it certainly can be the case here. And in juvenile idiopathic arthritis patients, these lesions are found to be 50 to 500 times more prevalent, which is just absurd. So 38% of the time, these things are an incidental diagnosis. I mean, my pediatric colleagues will be getting ankle x-rays and, uh-oh, now they have to explain something to the parents and especially someone, you know, someone that's not having any symptomatology. Oftentimes could be like adults, post-traumatic in origin. That's oftentimes the medial, but you'll see that the medial is most oftentimes the one that's represented. And lateral tends to be more of a vascular ideology. At least that's what the leading theories are with concomitant overuse. So symptoms are similar to adults. Activity-related pain and swelling, issues with sports, chronic ankle pain, just, you know, constant ow, ow, ow. And some of them will actually feel mechanical symptoms. And that's really if there's a loose body floating around in the joint or some kind of cartilage flap that keeps on getting caught with dorsiflexion or plantar flexion. Oftentimes it's not seen on an x-ray. And again, it could be an incidental finding. MRIs are very specific, are very useful in this situation. It's very sensitive, but they can't really predict the stability of the lesion. And in fact, and I'll go to another study that the accuracy rates of MR compared with an arthroscopic classification, they're not really that great. CT scans is helpful for looking at the subchondral bone and seeing any cystic changes, measuring the depth of the lesion, planning out if you need to bone graft and things like that. And you see that like when we compare MRI to CT arthrograms for grading it, CT arthrograms are significantly better at grading an osteochondral lesion. So similar to the last study, MRI and arthroscopic findings don't really correlate all too well. And that's unfortunate. So you really have to get in there and get your scope in there and find out. And a very useful classification, albeit I'm not a big classification person. I don't harp on my residents to learn classification schemes unless they're particularly helpful. However, with a Burton and Hardy radiographic classification it kind of bucks the trend here. And it's a really great way when reviewing the literature to actually have an idea of what they're referring to. And stage one is really a small area of compression of subchondral bone. And there's a little schematic of all of them here. One is partially detached. One is completely detached, but still in the crater bed. So it's really flapping back and forth. And stage four is a loose fragment. So this is something that's floating around in the joint. And when looking at radiographic parameters, a lot of data has been looked at, looking and look at the morphology of the foot itself and even of the talus to see if there's anything different between the juveniles with and without these osteochondral lesions. They found that the lesion size is moderately correlated with something called the deep deltoid attachment length. And for whatever reason, those that have higher pitch tend to not have osteochondral lesions. And those with like flatter feet tend to have osteochondral lesions. Another random radiographic study, looking at the length of trochlear talite arc, we know that that is now increasing patients with OCDs. But I mean, how often are we really comparing and contrasting this? I mean, yes, it's intellectual fodder to look at the ankle morphology, but does it really help us in a clinical setting? And it's really probably not. So treatment is beyond highly debated. And the reason being is because the case series are so heterogeneous. When you look at the adult literature, they're including adolescents or including teenagers. Rarely is there a strict cutoff for these definitions. So all of our information that we've been fed and taught, it's kind of fraught, especially when we're just solely focusing on adolescents. So it's really hard to predict who's gonna heal and resolve with conservative treatment. It's really fairly low. Now, for me, conservative treatment for the Burton-Hardy classification, because that's the best that we have really, is stage one, two, and three. We put them in a weight-bearing cast, and I changed my cast out at four weeks, but you wanna keep them in for six to eight weeks, following by a lace of ankle brace. And you wanna restrict, unfortunately restrict these kids for high impact for about six months. Old school thought was, you just leave the non-displaced acute lesions alone. However, some literature suggests being more aggressive is better, but the jury is still out on that. But you really wanna give it six months of solid conservative treatment. Now, there are specific predictors of failure, and we'll go over these two studies that really cite that, looking at a lot of these lesions, 61% of them failed conservative treatment. That's quite a high amount. And predictors for failure, at least in this study, is higher age, as well as Burton-Hardy grade three lesion. As we recall, that's the one that's kind of, it's a pre-loose body. So it's completely detached, but still in the crater bed. And those that had a worse functional outcome had a higher grade lesion. Here's something very similar, predictors of failure, older age, grade three lesion. Again, so this is a combination of 130 patients demonstrating older age and a completely detached, but undisplaced fragment are going to fail. So you may want to change the paradigm of conservative one, two, and three in an older patient with Burton-Hardy classification three. So the natural history of this is, it's quite bizarre. So looking at 12-year-olds, 31 patients, 77% of them continue to have persistent lesions on radiographs after six months. 42% needed surgery, and 46% of them had no symptoms despite having these like weird lesions on radiographs. And only 16% had complete clinical and radiographic healing. So, you know, we just really don't know. Here's another study. I know it's only 13 patients, but they followed them for 24 years. And they found that there were abnormalities after 24 years. So maybe give it enough time and it resolves. They found that the abnormalities, like five out of these 13 pediatric patients, only three of them had mild symptoms that follow up. Another study looking at good clinical results in those that were able to have conservative treatment. So the operative indications when the person's walking into your room, and again, it's a very difficult conversation to have with the child and the teenager and the parents, but you're looking at symptomatic loose bodies, unstable, displaced acute fragments, Bernhardi stage four grade, and anything that's failed conservative management. So for the treatment options, you really have to consider that the underlying issue specifically in adolescents, we really wanna treat the bone and not just the cartilage itself. Again, we don't know what the best treatment option is because there's so many heterogeneous studies. So is there an ideal treatment algorithm? No. However, we do know that certain operative indications are better for different stages. So for low stage, we're thinking about arthroscopic treatment, microfracture, fragment fixation, and retrograde or anterograde drilling. Higher stages, we're going into the fancier realms that Tommy will likely get into and Kelly will get into, but we're thinking of cartilage replacement. So you wanna consider the size, location, and chronicity. And here are our options. Your repair, you're doing your microfracture or your retrograde drilling, that is marrow stimulation. You're doing your lift, drill, fill, and fix as popularized by Geno Kirchhoff's for large fragments, ACI, AMIC, and then replacing with autograft or allograft transfers. Now, we're gonna throw a lot of acronyms out at you and just look at this slide and realize that maybe you might need a legend for all the things that we're gonna be talking about because it really is an alphabet soup of all these treatments. In terms of cartilage repair, recognize that you're only allowing for fibrocartilage formation here. And arthroscopy is technically more challenging in younger patients, so remember that. So you may want to use a needle arthroscope for this. It could be helpful in revision open procedures. But as Tommy will tell you, nothing ruins outcomes like follow-up. Now, I'm purposely using heterogeneous data here, but results over time are not the greatest with just microfracture alone. We know that there is a cutoff for microfracture, and this is extrapolated from the adult data, so we're gonna kindly use it here, and that's 150 millimeters squared of your area or a 50-millimeter cutoff in any direction. In location and containment manners, we know that shoulder lesions do worse than contained lesions. So here's subchondral drilling. Again, you're recruiting bone marrow elements to repair cartilage lesions. You can do anti-grade, which is a lot more reproducible, or retrograde if they have intact cartilage. Again, you know once you stick your scope in there. But again, OCDs of the ankle in juveniles, the primary problem is subchondral bone. So if the overlying cartilage is intact of good quality, if you're a very good aimer, please do it retrograde so it doesn't violate the subchondral, I'm sorry, so it doesn't violate the chondral surface. And anti-grade, you want to, you know, if there is some cartilage lesion there, you wanna really kind of stimulate the vascularity of the subchondral fragment. Small series, again, a lot of these are just small series. So, you know, some of these will have, with transarticular drilling, three good and eight fair results according to radiographic criteria. That's not excellent, right? So that's all of them. Again, with Dr. Kirchhoff's in Amsterdam, the lift drill fill and fix, heterogeneous data, but we know that this restores the native architecture of the ossochondral layer. And the survival rate is quite high and probably higher in juveniles and adolescents. And your fixation options, you can do K-wires, absorbable pins, headless screws, all sorts of things, but why not just use something that is bioresorbable? So autologous chondrocyte implantation, a two-stage procedure. You know, you have your ACI and then your matrix-associated one. Again, this for failed microfractures or larger lesions. Your MACI is a matrix patch. And they actually do have a study looking at 13 patients with MACI and how well they did. They do know that there's a high rate of ankle arthritis on preoperative radiographs. And the good thing is only one of them converted to one grade worse. But overall, the functional subscales of the FAM went back to normal. So despite radiographically, it looks pretty good. Autologous matrix-induced chondrogenesis, it's microfracture plus collagen scaffold and other biologics like BMAC. It's a one-stage procedure. Here they did seven patients. Their VAS went to 0.4 at final follow-up, which is pretty darn good at about four years. And only 43% showed complete radiographic healing. This is a great study because it really combines a lot of patients. It's 109 ankles with 3.3 years. But look at this. Like the reoperation rate in these individuals is 27%. So we know that the reoperation rates are significantly higher in OCD lesions that look worse. Only 82% of these people were satisfied. So, and only 84% of them returned to sport. We know that female sex and BMI were significantly negative predictors, and it had no bearing whether or not they had an open physis or not. So lessons learned, support, salvage the lesion. Don't just excise it. So if the cartilage is good, do it. So when we're wrapping it all up, there's a really good systematic review done by Geno Kirchhoff's group. Looking at 381 lesions, and there's really only a pulled success rate in the conservative group of 44%. Bone marrow stimulation, 77%, with a return to sport rate of 86%. And then you see retrograde growing success rate, 95%. Lift, drill, fill, and fix, 79%. Osteoporosis autograft, 67%. So cartilage replacement, you have your problems with oats. Rarely are you going to be doing oats on kids. I mean, it's a significant burden on them, especially if you're going at the knee. But sometimes you really need to throw the kitchen sink at all of them. Again, heterogeneous data looking at 64 ankles, but they do have better outcomes when you kind of throw everything at them, and I'm sure Kelly will go into this as well. So here's a nice summary side comparing the treatment methods, and the title is all there. No superior treatment for primary osteocondal defects of the talus. And this is kind of all the studies that they were looking at. And I just threw this slide up here just to show you how many studies there are, how they pooled the data, but really there's nothing that outshines the other one. Again, comparing treatment methods. A nice treatment algorithm is if your primary lesion's less than 1.5 centimeters squared, you just do some stimulation or some retrograde drilling. If it's larger than that, and it's not in the shoulder, you may want to consider ACI or MACI plus some bone graft. And if there is an acute fracture, obviously fix that. So there's a lot of level four evidence case series. There's a high variability in the characteristics of these OLTs, and then also the patients, so it makes it difficult to compare apples to apples. What I really like about the systematic reviews, they summarize their data nicely. Conservative treatment is successful in four out of 10 children. Surgical treatment options, if they need that, it's successful in seven out of 10 patients. And then you can give them fixation as clinically successful in eight out of 10 patients and radiographically nine out of 10 patients. So the authors summarize that fixation is the preferred surgical treatment modality. Thank you very much. Thank you, Chris. That was awesome. A lot of data. Very straightforward, right? I got a couple of questions, but we're gonna hold on to those till the end, just see what we can do with timing. Next up is Tommy Haydmanik from Vail, Colorado, and we'll let- All right, can you guys hear me? All right. Thanks, Norm, and the other panelists and the AOFAS for having me. That was a great start there, Chris, and we'll go over a lot of those things as well. I am in Vail, Colorado. Norm did his fellowship here two years before me, so thanks for keeping that Vail connection alive. These are my disclosures. I'm gonna talk about the osteocodral defect patient in the adult. For me, this always happens at 11.30 a.m. when I'm kind of sick of morning clinic, then I get the complex patient that involves a lot of talking when I'm sort of needing a coffee and some food. That's why I'm calling it the 10.30, or excuse me, 11.30 a.m. new patient. We've had some great academic talks lately. The Winter Meeting in Lake Louise, John Backus, my partner, gave a talk, and most recently at the AOFAS, AOSSM, Combined Specialty Day, Dr. Froekel gave a great talk a week or two ago. So I'm gonna try to do a little more bedside clinical-type take on this. We all know a lot of the things that Chris went over and these other guys went over recently. The 10-year data is not so great. We have 78% good to excellent outcomes. There are so many different things that I can't control here. The location matters. Uncontained lesions and shoulder lesions are worse, as Chris talked about, and larger lesions do worse. So, you know, this is a tough topic because there are so many things that are out of our control and they don't do all that well in the long run. So it can feel intimidating. Here's my daughter getting ready to do some ski racing and steamboat. It is intimidating, but you have a plan, you can attack it. And that's what I'll try to share with you a bit today. We're gonna follow the surgical principles, right? Whenever something's intimidating or you feel like you're lost, you always go from known to unknown. I like to use these slides from Dr. Galano who I had the opportunity to meet. Really neat guy who was from Spain who did beautiful dissections that you can use in talks. They're open access slides. But again, we all know the anatomy. That's why we're all here talking about this. So we're gonna go a bit from known to unknown as those surgical principles teach us. So we're gonna start with our physical exam. I always wanna know how long ago the injury was. If it was two weeks ago, I'm much less worried about it than if it was six months ago, 10 months ago. That's a bigger deal for me. Did they initially do well or did they not do well? That's a big thing I wanna talk to them about. Oh yeah, I was okay afterwards and it's slowly getting worse and worse and worse. That's gonna be a more chronic, more significant problem for me than somebody who's kind of had a problem all along. Maybe that's a loose body or something like that. Associated instability is important. A lot of these people are unstable. This actually can be helpful in getting to the lesion, technically when you're getting there, but that's something you wanna carefully assess for. And then I wanna talk a little bit about, is this just arthritis? So here are some of my, I guess, my soapbox about arthritis. I think osteochondral defects come on a continuum. Chris was talking a lot about what I would term true osteochondritis desiccans, which is really an adolescent blood flow problem. There are osteochondral defects, which is kind of what we're here to talk about. And then there is widespread osteochondral defects or problems with the bone and cartilage, and I would call that arthritis. So I mean, to think about this a little bit, I have a 46 year old male that comes into my clinic today and say he had a lesion that was this big. Well, to me, that's a pretty big lesion. If I was looking at that again, I have it just highlighted here, but this is approaching 150 millimeters squared. And that's basically our kind of mid-range lesions when we talk about adult osteochondral defects. So I would argue that maybe that is really just early arthritis. So this is what this 46 year old guy really had. I would argue this is probably not arthritis, but more of an osteochondral defect. But we need to use our heads. We need to interpret these studies and make medical decisions. That's why people come to see us. So talk to the patient, figure out how old they are, figure out how big this thing is. Are we treating it like an osteochondral defect or are we treating it like arthritis? Because I've certainly had people who come to my clinic and say, well, I have this cartilage problem in my ankle and they really have arthritis. They don't have an osteochondral defect. So we always want to get x-rays. We want to really check for joint space as we're talking about arthritis, fractures, or lift lesions, the lateral inter-articular fracture of the talus and associated deformity. If someone's in a bunch of areas and they have a medial sided problem, we may consider something like an osteotomy to straighten them out. MRIs are very helpful, as Chris alluded to, basically everything he showed was MRI, but it can overhaul the lesions a bit. In the bottom right there, I have a lesion showing you that's an acute one with a lot of bone marrow edema. CT is the best for bony architecture and cyst formation that may under call the lesion a little bit. And occasionally you do need to get all three. That can be hard to kind of figure out, right? Getting all of that done for a patient with cost and timing and all of those things, but they all give you different things. So I do want to talk a little bit about cysts again. Maybe this is my soapbox talk, sorry Norm. This is a very important factor to evaluate. So there was a consensus meeting that all of the big names really in the whole world went to in 2018 in Pittsburgh. So they brought everybody together. And as Chris alluded to, there isn't great data on this. So the feeling was maybe if we create a consensus group, we can try to get some clarity for people around this. It was published as a supplement in FAI. And so it's all available. We all have FAI access. So I pulled the one that was talking about a microfracture specifically. And they recommend bone grafting for cysts that are larger than five millimeters. So I guess what I'm here to talk about a little bit tonight is I think that that might be a little bit too big, just like we're doing more posterior malleolus fractures. We're being more aggressive fixing those. I think we should be more aggressive fixing cysts. Here's one that I measured at 4.9 millimeters. Maybe I fudged it just a little bit, but the concept is that's a pretty big cyst to leave alone, fill with cartilage, to microfracture and not to bone graft. I would suggest we be more aggressive with bone grafting, which is my opinion. So when we get into staging, that's kind of the next phase to all of this. So my partner, John Backus, gave a great talk at the winter meeting in Lake Louise. Here he is ice skating with his wife. No, I'm just joking. That's just a stock image from the website. But here's one of his slides. So he said, unfortunately, staging rarely guides treatment because it does not account for lesion size. And we know that's very important. So Chris did a great job in sort of the pediatric adolescent population, but I would argue in the adult population, there's a lot of other things we're worried about. And so it's not a strict staging type problem. So I promised some cases. So let's talk about a 22 year old US track and field thrower. She had a twisting injury four months ago. So this is her MRI over on the right. She's unable to return to impact activities. She can't train, she can't throw, and she's having problems. Well, all right, here we go. 1130, she shows up, of course, right before lunch. So we got to kind of slog through this one, but she has a loose body in the anterior aspect of the ankle. I don't know if that's showing up for you guys or not. Sorry, I don't know if I can move my mouse there. So we take her to the operating room. I chose to do a small arthrotomy because I thought I was going to get this done in a little better fashion by looking right at it. That's what the defect looks like. Here's a loose body. I pulled it out. Well, a little bit of cartilage, a little bit of bone underneath. And I thought, well, you know what? There's some things that we can save here. So I pulled all of the cartilage off of the top of that loose fragment. It had been a couple of months, but it looked viable to me. Here's what the fragment looks like after I had ronjured all of that cartilage off and removed all of that stuff. I mixed that with the bone marrow aspirate concentrate that Chris alluded to can be very important in these cases, some of these biologic augments, and then I put it back. So here's what it looks like going back into that lesion. So that's basically an autograft mixed with bone marrow aspirate concentrate. And here it is with the Tissio Fiber Glue, which is what I choose to use there. The brand doesn't matter, but we're sealing that over to keep it in place. So that was cool, Tommy, but you can't always recycle, unfortunately. So what else can we do? Well, that's when we're thinking about this kind of Venn diagram, as it's called. I think Dr. Furkel coined this, and I've kind of showed you the high points here. We have the small lesions on the left. In general, those are less concerning ones. They do fairly well, whether you debride them or you microfracture them. Medium is kind of what we're here to talk mostly about, which is microfracture, maybe. Grafting, maybe. And oats is really getting a lot of talk these days. I think Kelly's gonna talk a little bit about the larger revision scenario, but that's on the far side. But there's, again, a continuum that runs in between all of these different injuries. So another example, 40-year-old female. Here we have some images. Here's her MRI. So, okay, maybe no big cystic formation, but certainly a problem with the cartilage there. And so we're gonna do this with bone marrow aspirate concentrate, and we're gonna mix it with a cartilage graft after our microfracture. And here it is going in and getting sealed. This was done all arthroscopically. But I'm showing this because she had continued pain for six months. This was kind of an interesting one when we talk about these. So we got an MRI, and then we got to do our repeat arthroscopy, which is always kind of exciting and makes you a little anxious as well. So here's some repeat imaging. I'd argue that's actually looking pretty good, maybe up in the shoulder. On the medial side, there's a little bit of fluid where there should be cartilage. But here it is after about six months. So pretty interesting to see that cartilage graft healing in quite a bit of vascularity. You can see both dorsally there. There's a tibial cyst or tibial osteochondral defect and also tailor on the bottom. So the tailor one is really pretty interesting looking to see. So what does the literature say? That's how I chose to treat this. And I'm sort of advocating here, I guess, for cartilage grafting, because it is what I do. The HSS crew looked at microfracture compared to extracellular matrix, which is this cartilage grafting with bone marrow aspirate concentrate. There were improved MOCART, which is sort of a cartilage score. So you get an MRI and you can grade the cartilage in terms of how much fill there is there. So they had better MOCART scores and a lower revision rate. Sorry, I'm gonna get that out of my way. And the patient reported outcome scores were similar. So, okay, is there something else that I should be thinking about? Well, OATS is getting some good press. AutoGraft is doing better than Allograft. The thing that I like about OATS theoretically is that you can deal with cysts and cartilage problems with one solution rather than having to bone graft and then put the cartilage graft over the top. It's really a one-stop shop, which I think is really nice. It can require an osteotomy to get perpendicular access. So that's a bit of a negative to me. But as we talked about, some of these patients are ligamentously lax. So you can really plantar flex them and get to a lot of the talus with a small arthrotomy. I don't personally have a whole lot of experience with this. I need to incorporate it into my practice. So I took a CARTIVA out here or a synthetic cartilage implant and put an OATS plug in there. That was the only picture I could find of my work. So that's why that's in there. So clearly I need to perhaps incorporate more of this into my practice, but this is really gaining a lot of popularity. So what does the literature say? Well, this is also the HSS group who's done a really great job following all this stuff. They compared the extracellular matrix, which is kind of what I presented a minute ago, to the OATS for a medium-sized lesion, which is where we're talking. The OATS had better MoCART scores even than the cartilage grafting, lower cysts, less post-operative injections, which is theoretically corticosteroid, and revisions, but there were no differences in the patient-reported outcome measures. Here we are harvesting. That is one that I put in, I believe, a toe. So that's harvesting from the knee we're showing there. So what else should I be thinking about? I was tasked with the adult problems, and so let's go to the larger stuff I shared with you. I don't have a whole lot of experience with OATS, but I do with bulk allograft. Here's a 35-year-old male with ankle pain. This is a pretty big one. You can see how the CT shows the bony architecture really well. So here we are, we're making a cut, and we are basically taking out the problematic portion of the talus. You can see this arthrotomy, and then that pin kind of helps guide me with some fluoroscopic images. Here's our donor talus on the back table. Here I am cutting it, and I'm rather nervous, because when this flips and goes onto the floor, you're in a lot of trouble. It's already been matched. So you're a little anxious as you're doing this, but we put it in, and I would say that looks pretty reasonable. The articular surface looks good. Maybe there's a little gap on the medial portion there, excuse me, the central portion there, and here's what it looks like clinically. So here it is four to six months later. I think that's looking pretty good, but he's having some pain, so we get a CT scan, and maybe there's an area where it healed, but there's actually a fracture in it. So these are tough cases. Sam Adams and the Duke team looked at 14 patients with a mean follow-up of 55 months, and they noted that these bulk allograft patients did have an improvement in BAS and AOFAS scores, but there were five revisions out of that 14, and two had pretty significant failures with cartilage delamination. Here's another example of one I did on the left through a medial malleolar osteotomy. So you kind of get to it however you need to get to it. I started to soak these in BMAC. I think that's a good idea to do, and I think that may help with the healing. They followed up this study. Again, same Duke guys, Sam Adams and the crew there in FAI in 2022. They were now 31 patients. Pretty good survival rate, almost 97%, but half of these patients required some type of other procedure. So these are tough cases. A lot of these are gonna go back to the operating room for something, but you gotta keep that in mind for large lesions. So one last thing, I have 26 seconds on my clock here. Sorry, Norm, I'm sure you're keeping track. Does weight bearing matter after these procedures? So after a microfracture, this is an interesting study. It was a meta-analysis, and there was no difference in patient reported outcomes up to 24 months. So that makes me a little nervous. I'm doing a lot of fancy work in there, and we really want this to heal for these patients and them not to fail. So what do I do? I split them for the first two weeks. Then I get them into a boot. Oh, that was my timer, sorry. I get them into a boot for the next four weeks. They can work on range of motion, but maintain non-weight bearing. So I'm a non-weight bearing out to six week kind of guy. We can talk more later or in the end. And then I start a two-week weight bearing progression followed by a two-week boot lean. So sorry for going over. These are the references. I think all these will get posted, and this is the Bell Valley. So thanks. Take it away, Kelly. Awesome, Tommy. Thanks. Kelly, you're up. Thanks, Curtis. Let me get this fully slideshow mode, and we'll get going. Here for the star, the revisions are the tough part. What do we do? Let it go. Yeah, for sure. So those are my disclosures. And really, it's obviously challenging the first time around. So you can imagine what I'm going to talk about. But some concepts about revisions and talking about some of the revision rates for the various procedures that we just went through, and then talking about what you do if you can't make it heal. So reasons for failure of these lesions are insufficient cartilage regeneration, the bone and the bone cyst doesn't heal, patients just have persistent pain, or there's progressive degeneration of the ankle joint. And there's a lot of challenges that arise in a patient's challenges that arise in a revision situation that's a little bit different than what we've been talking about. And we know that the lesion size increases after your index procedure, often because of poor bone and cartilage healing. And in order to do an appropriate debridement the first time you do tend to make the hole in the bone a little bit bigger. Cystic and uncontained lesions have poor outcomes after bone marrow stimulation. And it's sometimes hard to know what was done the first time if you're like me, and you get a lot of patients referred in, you really wanna know the patients did have a good first stage procedure, and sometimes that can be challenging. We know from the research that you've heard about that second look arthroscopy studies do show low quality and sometimes partially healed fibrocartilage when we go back in. And then again, teasing out, is this really a failed OCD or have we now finally moved into that kind of stage of secondary degenerative arthritis that Tommy was talking about? So some of the literature on revisions, we do rely fairly heavily on systematic reviews in OCL literature, just because of the smaller series that are out there. But this was a Rican study in JVGS last year looking at primary osteochondral lesions. And they looked at lesions less than 15 millimeters, 82% survival at 10 years. So probably not as bad as some of the previous literature would suggest, but that still leaves something like 20% of patients that are gonna need a revision surgery. And the literature is pretty consistent that the time to revision surgery is about two years, not just in this study, but among many. Just as one of the patient factors that increases the risk of revision is that higher BMI at the time of the primary surgery does increase that rate. So what do we do with that 20% of patients? There's been a little bit of work looking at what people do in systematic reviews in the literature. OATS is definitely used pretty heavily as a revision procedure. And then osteochondral allograft is more often a revision procedure than a primary procedure. But about 40% of revisions are done using some sort of cartilage regeneration technique, that kind of alphabet soup. And then there is some varied literature on doing partial metallic implants of the talus, which we'll talk about a bit later, along with a smaller proportion of cartilage repair. In summary, looking at all revisions of all OCLs across the literature, there's some consistent messages is that OATS do well. They seem to have pretty reasonably consistent outcomes and pain improvement for patients. This hemicap or partial tailor implant seems to be the worst performer across the board. So high failure rates, least pain improvement and high conversions to joint sacrificing procedure. And for all revisions, there's a very low return to sports at the pre-injury level, somewhere in the 50% range. So that's really important to know in counseling patients if they're coming back with a failed OCL. Kennedy and their group did a pretty nice systematic review a few years ago, looking at revision bone marrow stimulation. So, you know, we often do department micro fracture the first time around, especially for those small lesions. And they found that repeat bone marrow stimulation surgery was successful only about 60% of the time. That's pulled success across all studies with the range from 32 to 88%, again, with a really low rate of return to pre-injury sport at 55%. But I think really important and what this talk is really focusing on is that 27% of revision bone marrow stimulation cases went on to a third surgery. So that's really what we're trying to avoid with exploring this topic. One of the higher quality studies in the systematic review by Yoon found 100% failure of revision bone marrow stimulation if the lesion is greater than 150 millimeters squared, which is what you'd expect since we're generally talking about doing bone marrow stimulation only in less than one centimeter to maybe 1.5, depending on what you read. So a second systematic review was done on this because one wasn't enough and Bodia and their group looked at some smaller studies as well as the ones that Kennedy looked at. And they felt in their summary that the outcomes really weren't that impressive. So the patient reported outcomes and pain scores were either at or below the MCID after revision bone marrow stimulation. So they're really cautioning against doing revision arthroscopic bone marrow stimulation. And they had 34% of patients going on to a third surgery. So this is obviously a challenging scenario. We talked a little bit about micronized cartilage and this is quoting the same Draco study that Tommy talked about, but really there's no studies on its use in revisions, but potentially lower revision rate than isolated bone marrow stimulation alone. Cartilage regeneration does not have a major role in revisions either, but just to include them here for completion, there has been a little bit of work done found that they're generally not recommended when the subchondral plate has been disrupted previously and they do have inferior outcomes with revision. So this is kind of not something I want to focus on. AMEC is an interesting thing. It's been very, very popular in Europe. They've been doing it for about 15 years over there. It's a single stage surgery. So it's got some advantages to the other cartilage regeneration surgeries. Really what they're doing is microfracturing and bone grafting if those cysts are greater than three millimeters. So Tommy, it seems like they're on board with grafting the cysts pretty aggressively, like you said, and then putting a collagen membrane over top and fixing it in place often with a glue or suture. And their revision rate for primary osteochondral lesions was only 7%, which is quite a bit better than that 18% I started with. And that's looking at kind of all the literature published over the last 10 years, but for revisions, not so hot. So we're looking at a 30 to 38% rate of revision and you'll see that's a pattern, right? The revision rate is somewhere in that 30% range for all of these kind of cartilage-based procedures. And this is Walden Spool specifically at revisions with AMIC and 28% of revisions and 14% of all patients had reoperation or for complications of fissuring and thinning of fibrocartilage. And most of those failures were with medial osteochondral lesions. They did revise them using Cancellus autograft and repeat AMIC, but they found smoking was an independent risk factor. So it is a consideration, but moving on to the big guns as we alluded to earlier. So odes or osteochondral allograft or autograft transplantation with autograft having better outcomes. These are used for symptomatic full thickness defects. They can be used in primary lesions that are larger as we talked about. And in all the literature, the long-term survival is about 78%. So on par with primary bone marrow stimulation for small lesions. Donor site morbidity is a primary concern with this and maybe what's limited is widespread use and adoption despite its good outcomes in the talus in that patients do have knee pain and the knee pain correlates with their outcomes. This does have better long-term results for revision though compared to doing repeat cartilage procedures or bone marrow stimulation. The challenge here though, is you can't do odes with plugs for uncontained lesions. So we need to have other options. There are very limited specific reports on odes, but Park did look at revisions versus primary and found there was really no difference in outcomes with about 50% of all odes cases in the literature having been done for revisions. So just as an example of how this is being used. There's not an insignificant rate of reoperation mostly for arthroscopic debridement, but patients also are found to have bone cyst after odes that don't incorporate. And then if you're doing a medial malleolar osteotomy, hardware removal is relatively frequent. This was an interesting study, I think really hammering home the fact that the autograft does much better than allograft. The rates are pretty dramatically different for rates of revision and rates of graft failure as you can see here. And then I'm not gonna harp on the technique of osteochondral bulk allograft, but there are a lot of small, very small series on this. There's studies on fresh, fresh frozen and preserved, but there really is consensus that fresh osteochondral allograft is best in terms of cell viability and healing. This is typically reserved for large uncontained lesions when odes is not possible, or there's very large cystic changes as you saw in the case we looked at earlier. But in general, these are more often used in revisions than primary unless you're being presented with one of those really large nasty primary lesions. And this is the same group, Duke group with that medium term outcome. So they did have pretty excellent graft survival, but that really high rate of additional surgery, including debridement and removal of hardware. I think just keep this in mind, you're replacing half the joint with allograft bone. You may have challenges when it comes to the revision for either total ankle replacement or arthrodesis, if that bone is not viable and then you're having to deal with significant bone defect at the time of a joint sacrificing procedure. So like I said, many small series with varying graft types, 20% revision. So 50% reoperation, but 20% revision. Revision being to a fusion typically or repeat grafting procedure. And just a couple notes on associated conditions. I'm glad Tommy brought this up, but it is really important to address instability, ideally at the time of primary surgery. But if someone's failed, really reassess to see if there's a chance that they have some clinical ligamentous instability that should be addressed at the time of revision to give them a better chance of healing. Because equivalent outcomes can be achieved with the primary OCL lesion if instability is treated concurrently. And then alignment, right? So there definitely are times when alignment may be overlooked or chosen not to be addressed at the time of primary surgery, especially in super young patients or athletes, but alignment needs to be addressed. So if there is hind foot malalignment persistent after a failed primary surgery, address it at the time of revision surgery. Not a lot of studies on it because this would be a small number of patients, but Lee and their group in, I believe it was Korea, did SMOs only for failed OATs and they didn't do any OATs procedure and had resolution of symptoms in all their patients. And then a note on medial malleolar osteotomies, because as you get into revision procedures, you often need more access or you need perpendicular access to the joint to do things like OATs or osteochondroallograft. And there is a fairly high rate of symptomatic hardware, not such a high rate of non-union or other complications related to the medial malleolar osteotomy. I'll show you this thing. I've never put one in. And based on my very extensive recent update on the literature, I probably wouldn't recommend this. The outcomes are pretty miserable across the board in every study that I can find on this in every systematic review. I get it, you're trying to preserve the joint, but it seems like patients have a pretty significant amount of pain with this. And so when all else fails, we do have other options. Everything I talked about is in that young patient for whom a total ankle or arthrodesis really is not an ideal option for them. So you reserve these for obviously degenerative changes in their patients. And if they have associated tibial-sided defects, those patients typically do very poorly with joint salvage procedures that I talked about here. And so when you're having bipolar defects, you really do need to be looking at total ankle or fusion. So in summary, we're looking at survival rates for revision surgery, a bone marrow stimulation of about 50%, AMIC getting to about 65%, OATs and Alkammers at 78%, which is not specific to revisions, but about half of those are revisions. And then bulk allograft with great survival, but pretty technically challenging procedures, but also you need access to a fresh allograft matched helix, which is not necessarily feasible for folks in all locations. So failure rates higher for revisions, progressive degeneration, treat like arthritis and control what you can control, including smoking, stability and alignment. Hopefully that's helpful. Thanks. Thank you. Awesome job. Appreciate all you guys. We're gonna roll through a couple of questions that I have and hopefully wrap this up a minute or two early. So very straightforward, obviously, right? When you end your revision talk with here, here are four different ways to do it. It's a tough subject and that's no different, really ankle, knee, doesn't matter where we are. I did just see, I saw Chris answered this question. I'm not sure if our audience saw this, but one of the panelists did ask a question about where your typical bone graft harvest site is in these, he asked specifically about the calcaneus. Across the panel, where do y'all typically go? I know when I am doing a bone graft for these, I personally typically go to the iliac crust. And that's just through some of the older literature that says, maybe, maybe not. You may have some better, some of the progenitor cells, et cetera, may be a little better in the iliac crust, but certainly calcaneus, distal tibia, proximal tibia eruptions. What are you guys' thoughts on that? Yeah, I can kick it off. I do iliac crust as well. I think that's the best bone. I'm often taking bone marrow, like aspirate as well, to turn into bone marrow aspirate concentrate. So I'm up there anyway. Marty O'Malley talks about just using the jam sheeting needle and just like kind of jamming that down there to get a little bit of bone graft if you need it. I actually just use one of those commercial reamers. It goes down, the seven millimeter seems adequate. I take one or two passes with that. And it's an incision, maybe a centimeter and a half, and that's usually not been an issue for me. I do the same, and I strongly advocate for one of those harvesters because I think that the pain and morbidity of that is incredibly low compared to the old way of doing it. So I'm all about iliac crust. Well, I guess I'm the outlier here, but clearly you can do, I mean, do whatever you feel is best. I use distal tibia just because it's the surgical field. I know you're planning for it, but I certainly, if someone's having ankle pain, I don't want to give them hip pain as well. So that's my only thing. I think that's very fair. And I think there is, the good part is with some of the new commercial reamers, as we talked about, the morbidity is very small, and fortunately or unfortunately, we've definitely had instances in my clinic where we've forgotten to take the stitch out because the patient even forgets about it. And they call back and say, hey, were y'all supposed to take this stitch out of my hip? So I think that's a positive thing. We've had two questions that both came in on, on uncontained lesions. And that's certainly a challenge, right? We get in there, we look at the scope, we see that the lesion clearly has violated the shoulder of the talus, particularly most of the time on the medial side. Does that change what you're going to do? Let's say in the primary setting, when you see that there's a clear violation of the medial shoulder and that medial wall, does that change what you may do? Let's say you have that five centimeter deep lesion. Those are more difficult to bone graft when you don't have the medial wall. So how are you guys tackling this? Chris is going to give a great answer here. You know what? Thanks, Tommy. If it's a primary situation, I'm going to give the patient benefit of the doubt and tell them it's going to be a 50-50 chance that we're going to have to go back and say, I can either try this through a scope, it's minimal morbidity, and maybe 50% of the time you're going to be happy with it, or I'm going to take down your medial malleolus and put a nice slotted graft in there and just get rid of it all. And just a mini version of a hemitalialograft and just kind of slot it in or tap it in. The Amsterdam people are doing a periosteum for the iliac crest, so using the crest itself for that lesion area. And that's also great too. But I mean, there is a significant amount of morbidity breaking an ankle, right? Breaking it to fix it. It just, you know, it's unsettling. It's fun for us to do and it certainly has its roles and we need to do it. Yeah, Norm. I've had a non-union of a medial malleolus on a patient that had a great Oates procedure and that healed like a champ. So you get, you know, that colors you when you end up with a non-union and you try to do it technically perfect. And that's, you know, I don't live in a glass house, right? Or I do live in a glass house. I'm not going to throw stones. That'll color you when you do a medial malleolus and you get a non-union. Hey, you know, we broke your ankle, but now your ankles, you know, now your broken ankle's the problem even though everything else looks good. And that's a hard conversation to have. I didn't, hard prep, yeah. You got to really have a lot going on for me to do a medial malleolar osteotomy. I think to answer the question, those uncontained lesions are hard. I'm not happy, but I am kind of like packing the bone graft in there and then doing my cartilage graft and kind of making it look as good as I can. Because I do think there's some congruency in the ankle joint. I think that is the good part. I think it's not going to do as well. I'm not arguing that the literature is wrong, but I'm going to push a little bit with my primary techniques and hope that it does okay because the next step, as you're alluding to, is really big. So I think they're hard. I crossed my fingers a little bit and I don't think it's going to do as well, but I stick to the same techniques. I agree. Chris, I have a question for you because we've all seen this patient and we talk about the burnt and hardy classification and it's one of the few times where I do really will use a classification. You mentioned that I'm not a big classification guy, but when we see a 14-year-old who has a grade three, it doesn't look good. They come in, they're really symptomatic. They try to play it off. The odds are this is not going to go well with non-operative treatment, but every book you read says treat it non-operatively. Are you treating that non-operatively and making them non-weight-bearing every time? This is a conversation to have, like one of those come-to-Jesus talks with the parents and you really need to throw some numbers out at them and then make them understand, like it's almost like a mini statistics class that you're trying to teach the parents at the same time. I would say, based on the literature, like 40% of people are not going to need surgery, right? And that's not a lot. I'm sorry, it's a high amount of people that are gonna need surgery. So we can either stop wasting everyone's time and like really do it, or if the kid's like just playing video games for his athletic career, I would be a little bit more apt to try a conservative route. But if the kid's active and playing sports and enjoying the outdoors, I think I'll be a little bit more aggressive with talking statistics regarding this is probably not going to work and probably waste a lot of everyone's time. Yeah, I always find that a really hard conversation because a lot of the book answers are non-operative treatment and frankly, a lot of times I like to try to make them fail that, but six weeks of non-weight bearing in the face of doing it again is a really hard thing to tell a 14-year-old. I've got a 15-year-old and a 12-year-old running around. And if I knew that they would be facing three months of non-weight bearing in the face, that's a hard one too from the flip side. And I've always found that a really challenging discussion from really both sides of the fence. And I think you put all those numbers out there really well. And I think you kind of got to read the room a little bit. I think that's important. I think Norm also questioning, because we all go in and kind of chat quickly with the family, but getting a good history, because a lot of these kids have done something before. Now they might not have done CAST and six weeks of non-weight bearing, but they've often done something. And so you can kind of tease that out. Oh yeah, we had a boot and some crutches for a little while. And that kind of helps you a little bit with the decision-making and the family knowing what they're getting themselves into with the non-weight bearing. Kelly, I have a question for you. I've always said, I always tell patients, you know, one in five fail, okay? So, which is that 20% number. You know, one in five fail, four in five work. And they always say, well, what do we do if it fails? And I say, well, you know, there are other options out there and essentially the numbers are the same. One in five fail. Is that an accurate statement? Is that fair? I know you presented those numbers, but I always say the second round is it's about the same because that's always what they harp on. Cause it's a tough decision. Do you think that's a fair way for me to put it? That's what I was taught. Close, right? If you add all those different techniques together and try and summate what the failure of revisions is, it's probably higher if you're not doing oats or osteochondrolograph realistically. It's probably more like 30 to 35%, but you're not way out of the ballpark and probably your kind of way of describing it for a patient's pretty practical. I think that's fair. So for the panelists, we've got a couple of questions up here that I do want to get to, but to me, you have the patient that you've done, let's say you've used one of those extracellular matrix or you bone grafted it. They've had some discomfort. You've injected them, it helped, but didn't get them over the hump. They had probably a little over, let's say a 1.2 centimeter, 12 millimeter lesion. You get in there and 80 to 90% of it's healed and they have this little small flap. What are you doing? That's a great case. I'm debriding that flap and telling them they're going to be awesome. You're just debriding it and letting it go. You're not doing anything else. For sure, for sure. I saw that guy yesterday and I'm getting a CT, but I'm pretty hopeful that that's all I'm going to have to do, so I agree. Yeah, that CT scan is extremely helpful. A CT scan and maximum plantar flexion preoperatively, because I do all of mine supine without any leg distractor. And MRI is going to show you a little cartilage flap and then that CT scan is going to tell you if that thing tunnels, right? And so if that thing tunnels, then that's a different conversation you're going to have with the patient. If you see some chondral cysts and still an intact cartilage layer, but still something poking out, you're going to have to dig that whole thing out. Got asked a question that I think is very interesting. You know, it said, one of our participants asked, in patients with an OCD and ankle instability, are there any situations where you would ever leave that OCD untreated and address only the instability? Even in the case where, you know, there may be, you know, it's not a big lesion, it's small. You look in there, the cartilage doesn't look bad, but you know, there may not be some support there. Are you going to address that OCD every time? That's a great question. Because once you fix the stability, are you going to help the OCD lesion? I specifically have a single appointment just for the OCD. All the appointments have been up to that date for the instability. They have one appointment for an OCD. And I want to just do a lidocaine, marcaine injection into the ankle and see what percentage of their pain gets better. If it's more than 0%, I'll address it. But oftentimes I am beyond surprised. There are so many asymptomatic OCDs floating around, and I think we're opening a big can of worms by microfracturing them all. I agree. And one thing we do know is that OCDs in patients with instability, because we're working all these patients up with MRIs, are smaller than OCDs in patients without instability, right? So like Chris said, a lot of them are likely incidental or aggravations from the instability itself. So I'm scoping them like most of us are in the setting of instability, but if the cartilage is intact, I'm not going after it. Yeah, there can be a scenario where you leave it. Guys, we've run a little bit over time, so I appreciate all of y'all. Great talks. I hope everybody, you know, really our goal from these is to give some people some pearls to think about when we walk away, certainly on a topic like this, that is such a big topic that, you know, we hope to get better and better at over time, but the answers still are clear as mud. But the numbers and good research come out of places that all you guys work at are really critical to making it better for our patients. Fantastic talks. Thanks for doing this. I really do appreciate y'all, and thanks everybody for joining tonight. It means a lot to us, and hopefully we gave y'all some pearls to think about that will help you guys in your practice. So thank y'all. Thank you.

cartilage lesions

ankle

osteochondral defects

OCDs

treatment strategies

Chris Gross

Tommy Haydmanik

Kelly Hines

revision surgeries

personalized treatment