Arthroscopy Journal Podcast – Dr. Nuelle & Dr Cole discuss “Can Competitive Athletes Return to High Level Play after Osteochondral Allograft Transplantation of the Knee”
Clayton Nuelle: Welcome to the Arthroscopy Association’s Arthroscopy Journal podcast. The views expressed in this podcast do not necessary represent the views of the Arthroscopy Association or the Arthroscopy Journal.
Welcome everyone. I'm Dr. Clay Nuelle from the San Antonio Orthopedic Group in San Antonio, Texas. Today, I have the distinct privilege of speaking with someone who needs no introduction, long time team physician of the Chicago Bulls and White Sox, Dr. Brian Cole. Dr. Cole's from the Midwest Orthopedic Group at Rush, and was a senior author on a paper titled, Can Competitive Athletes Return to High Level Play after Osteochondral Allograft Transplantation of the Knee. Published in September 2017 in the Arthroscopy Journal. His co-authors included Drs. McCarthy, Meyer, Weber, Levy, Tilton, and Yanke Dr. Cole, thanks for joining me.
Dr. Brian Cole: Thank you for having me, and for furthering the mission of the Arthroscopy Journal.
Clayton Nuelle: Let's just start out, Dr. Cole. What is the number one thing you think in regards to this paper that will grab our readers and listeners attention, that they should definitely take away from this paper in particular?
Dr. Brian Cole: The important take home in my mind is that historically we would often do cartilage repair or restoration procedures in a setting where individuals, usually had issues of daily living, and lower levels of activity. We rarely wanted to enter into the situation where we would promise to deliver the ability to get back to high impact activities, which are associated with high loads, that might basically out strip the ability of the procedure to provide symptom relief. The thing about the Osteochondral Allograft is that it probably is perfectly capable of tolerating the loads of impact ballistic activities, cutting, pivoting, and so forth.
Dr. Brian Cole: The real issue with cartilage repair procedures is that generally speaking, the higher the loads, the more likely someone is to be symptomatic. So, the real question is, will the procedure endure high loads to keep symptoms low, to allow them to tolerate the things that individuals enjoy doing. Easier decision when some activities of daily living because those are generally low load situations that are the easiest to predicatively deliver to a patient, much more variable when we start to discuss the ability to deliver symptom free or less symptom, lower levels of symptoms when one is engaged in higher impact activities.
Clayton Nuelle: Absolutely. So, would you say that this paper, or along with some of the other work that you and your group has done quite a bit of, would you say that it's changed your practice or your approach to these particular type of patients with this pathology at all?
Dr. Brian Cole: It has. I would say that it wasn't long ago where we were fairly risk adverse, were worried about burning bridges, and/or catastrophic failure. Now, having done over 600 Osteochondral Allografts over 23 years, it is rare we see catastrophic failures. The issue is, once you go to an Osteochondral unit, then you can't go back. I get that, but we needed the history of doing these procedures before we would pull the trigger for earlier, maybe even first line, treatment. What we've also learned though, is that when I would typically perform micro-fracture or marrow stimulation, the population was often one that might have heterogenous pathology, might have some subchondral change, and so forth. I think one of the things we've learned over time is that, in the ideal candidate, micro-fracture could still be a good operation, but it still takes about the same amount of time to feel well as an Osteochondral Allograft.
Dr. Brian Cole: The challenge is that while it can deliver good pain relief, especially if comorbidities are respected, still much more variable and may have a decline over a period of time. I think the population you can treat is a little bit narrower with marrow stimulation compared to say an Osteochondral Allograft. What I've learned is that, maybe pulling the trigger earlier is not an unreasonable tenant in a highly active patient population, and that the graft itself can endure high levels of load without deterioration, once it's fully integrated. That was an important lesson that, A., I've learned over time, and B., I've learned as we've addressed the more active population, or I should say the population that really desires to be active and cannot accomplish that based upon their levels of symptoms, due to cartilage or an osteoarticular problem.
Clayton Nuelle: That makes sense. You mentioned the microfracture and certainly there's been, quite a bit of data coming out in terms, as you mentioned, the long term results maybe not being quite as good, particularity some of the larger lesions with microfractures. In your approach, especially in the high level athlete, or the athlete, is it more patient specific? Is it lesion size? Is it depth? Is it a little bit of each of those things? Describe your approach, or algorithm to it for us?
Dr. Brian Cole: Sure. I think there's some basic tenants, whether you do marrow stimulation or other techniques to restore the surface, or the osteoarticular unit, you still have to respect all comorbidities. One of the challenges with marrow stimulation is that it's easy to do but that's also its potential downside, because there's a tendency to maybe short circuit the rehabilitation, which for a weight bearing portion of the joint, tibiofemoral joint requires protective weight bearing. There's a tendency to particularly ignore comorbidities where we often wouldn't do that when we're dealing with higher level procedures, such as an osteoarticular graft. That's the first thing that should be important. Independent of procedure, one has to respect the rehab, respect the basic technical aspects of that procedure, and treat all patients in the same box, as far as identifying any of the comorbidities that need to be considered. With respect to where I fit it in, it's difficult to just look at an MRI, look at an X-ray, or even an arthroscopic picture and say, “This is what this patient should get.”
Dr. Brian Cole: It's important to not only demand match, procedure to patient, but also to understand the dynamics of the patient. If a high level individual, especially in a system that has many different players in the decision making, let's say it's a collegiate or professional athlete, where you've got agents, you've got athletic directors, you've got family, you've got coaches, you've got strength and conditioning, you've got athletic trainers, you know, you've got an entire network of individuals who weigh in on the decisions making, that may be a lot different than the patient who has everything else the same, but doesn't have that system around them. That all has to be taken into consideration. What year the contract is, if they're a red shirt remaining how much time they've missed, how old they are, how do they factor into the team, those may be variables that you have to take into consideration, that you may not have weighing in on the decision making for patients that have just an isolated defect that don't have that same system in place.
Dr. Brian Cole: It's not only about size and what the MRI shows, and so forth, it's a comprehensive derision based upon all these variables. That being said, marrow stimulation I think is still a good option for first line treatment, but I think one can't even forget about debridement as a good option. If someone has mechanical symptoms, effusions, relative nuance that symptoms, debridement can offer symptom relief, and that may be just fine for individuals who are in the midst of season or contract, or so forth. However, if you're looking for a long term solution, maybe because other short term solutions have failed, then the decision making gets a little more complex, and I think the easiest one to grab onto is, if there's an osteochondral problem, of any surface, that independent of what the previous treatment was, I would argue that maybe the best option is an Osteochondral graft, over isolated marrow stimulation.
Dr. Brian Cole: Obviously, there's going to be exceptions to that, and also very small defects, maybe those that are just outstrip the size that would be amenable to an Osteochondral Autograft, which would be say a 10, 11 millimeter defect, maybe not big enough that you want to go towards an Allograft, which is our cut off, but we'll say two to three square centimeters, and clean subchondral bone, still could be, all things respected, a marrow stimulation candidate. But you have to do it properly under power, vertical walls, get rid of the calcified layer, respective rehab, so forth. The flip side is the easier patients who make the decisions, previous treatment, osteochondral signal, maybe even a previous marrow stimulation, that's often an excellent candidate to then indicate for us and Osteochondral Allograft.
Clayton Nuelle: Makes sense. Do you think that the, does your rehab protocol or weight bearing status change for the high level athlete? Obviously, in a professional setting their rehab is going to be much, much different than our recreational athlete or weekend warrior. But, in terms of your particular rehab protocol or weight bearing status in particular, when you do go with the Osteochondral Allograft, does it change in any way or is it pretty set and straight forward?
Dr. Brian Cole: No. No, it really doesn't. It really doesn't. I think that I would say that marrow stimulation is an incredibly rehab sensitive procedure.
Clayton Nuelle: Right.
Dr. Brian Cole: In contrast, I think that an Osteochondral Allograft is probably much more tolerant of earlier weight bearing, and loading activities. I do use continuous passive motion when it's covered, whether it makes a difference or not on an Allograft, I honestly don't know. I don't think anyone has really looked at it with that granularity. Certainly doesn't hurt the joint, it's great to have early motion, but the motion may have less of an effect on the biology of the graft than it would, for example, when someone is trying to develop fibrocartilage repair after marrow stimulation. I think you have to abide by the basic principles, which is a shallow graft. It can be done on any surface, but I always protect the weight bearing post-op.
Dr. Brian Cole: You like to load them as early as you can, because I think load is good for the joint. Keep in mind, the patella femoral lesions can be weight bearing as tolerated as long as you haven't done a tibial tubercle osteotomy. You can weight bear them in extension, but tibiofemoral lesions, those lesions actually will protect for about six weeks with heel touch weight bearing. Really, don't even need a brace. Then the real issue is when do you allow them to get back to high level ballistic, high energy activities, I think that that's generally, we say six to eight months, not a ton of data on the biology of why we make that decision, except that there's a revascularization and an incorporation phenomenon that we'd like to respect. I think that six to eight months period largely will cover it, depending on the sport.
Clayton Nuelle: That's great. Dr. Cole's article, the title, “Can Competitive Athletes Return to High Level Play After an Osteochondral Allograft Transplantation of the Knee?” can be viewed in the September 2017 issue of the Arthroscopy Journal, or online at www.arthroscopyjournal.org. Dr. Cole, thank you for joining me today.
Dr. Brian Cole: Thank you.
Clayton Nuelle: I'm Dr. Clay Nuelle, and that concludes this edition of the Arthroscopy Journal podcast. Have a great day.