A Deep Dive into Cartilage Innovation with Dr. Brian Cole

Welcome to sports doc talk. I'm your host Will Sanchez joined as always by our orthopedic surgeon and sports medicine specialist. I'm so choked up. I'm already getting so excited. I know you're excited, Dr. Garcia. We've got a tremendous guest today. We're going to talk about one of the most exciting and evolving areas of sports medicine cartilage restoration joint preservation athletes. I can't I can't contain myself, Dr. Garcia. How are you? Tell me how you're how excited you are for our next guest. I'm super excited. This is we've had a number of podcasts. You've probably seen his picture too many times on my PowerPoints. We've talked his podcasts on the on the recent athletes, which we'll talk about as well have been huge hits and everyone's talking about it. Even today, I had a patient and meniscus transplant, Carlos transplant and they're like, Hey, what's that surgery like? And I'm like the ones with ball hat. They're like, Oh, OK, I got it. So they move on. Yeah, and we've got a lot of feedback from that. So we're really excited about our guests that's coming on. But first, let's talk about the great people over at the recovery shop, especially might be. Dr Garcia, tell us how you utilize recovery shop with your practice. Yeah, so big thanks them for sponsorship. Again, really key for me, especially with these complex surgeries, right? They offer these sort of aftermarket products, improved many machines, improved ice options. It's really great for me, especially nutrition and other recovery options that the patients can't get normally. So it's all one bundle there for the patients to access it and it works really great for these complicated surgeries. So thanks again, guys, and any surgeon interested, let us know. All right, listen, I normally introduce the guests, but this is your guest. This is your mentor. In fact, he should be he should be we should be giving him money because we brought up his name so many times in our shows. I mean, he may ask for a cut. Let's just make sure we're all right with that. Why don't you introduce our guest today. Yes, so I'm super excited introduced Dr Brian Cole. He is professor of orthopedics at Rush University where I went to fellowship and learned all the cartilage and meniscus and osteotomy surgeries. He's also managed to partner a rush. If I went through all the things that he does, we would have no more podcast time left. So thank you so much for being on the show. We're so excited to have you. Um, the will you give us? I know I don't want to get into, you know, all we have so many questions for you. Will you give everyone kind of the background as to what got you into this? I mean, there's so many things you do, but what got you into the cartilage stuff that's the meniscus surgeries, you know, you. These are now more mainstream, right, because we've learned them from you, but when you were doing them, they weren't really mainstream. So why do this like why go in this innovative sort of potentially risky options that no one was really doing a lot of? Sure, I mean, I think that's a good way to start start the narrative here and will and grant thanks for having me on the show. So look, when I was a resident in sort of the mid 1990s, we really only had two options. There was debris, men and male stimulation. And that was pretty much it. And that really wasn't that long ago when we think back one of the first publications of my stimulation by Dick Steadman was in the mid 1980s. So what typically would happen would would be that a high level individual would get an arthroscopy. And they would get transient relief. And then there would be really very little else that could be offered to that person when I came out of my fellowship after my residency. We really only had a couple more things. It was an Oster kind of autographed and it was ACI and we were starting to see. The introduction of Oster kind of hour ask for graft availability is real issue. And we really had no framework to have sort of that balance decision making and it was very little in the way of evidence based medicine. At that same time, there was a ton of new innovation happening. And we were starting to see laboratory studies started. She's a pretty clinical work. So it's very exciting area, but there was really no framework to make decisions on it. And that's why I found most interesting. I just felt like it was a huge white space to say, look, like to your point, Grant, it is risky when you, when you're, if you choose to be an early clinical adopter, because the outcomes are difficult to predict. And that in and of itself has inherent risks in terms of educating a patient and managing expectations. So when we started initially when I came to Chicago, I was recruited by also one of your mentors, Bernie Bach. There was really no one who had an organized infrastructure to manage, particular Carlos problems, most commonly than even other joints as well. So it was the opportunity, I think at the outset to say, how do we, how do we be proactive, do things prospectively collect every data point possible so that at some point that data becomes relevant. And we can start to make informed decisions. And that was really, that was really it was a challenge. It was an unmet need huge white space. And we really didn't know when to apply the limited solutions we had. And we were on the forefront of actually having a number of new solutions that we would have to start considering in terms of earlier delay clinical adoption. And do you think that this, I mean, one thing that we can talk about is we're going to show all the things you're involved in. And it's not like you did this interesting surgery. And then all of a sudden you were done, right? It's like the next thing you're the next thing you keep doing the early adoption. And you built up the background to that. So is that for you is the is the drive there just the continued early adoption or is there other drive that gets you going to do that stuff? Now, you know, to be honest, I, while the outside looking in you may say I'm an early adopter. And I guess relative to others I am because I'm exposed to new to new technologies. But my adoption has always actually been fairly measured and in a tempered way because the first thing is I always needed to feel that whatever I was going to do was going to be safe. And even if it wasn't proven as far as efficacy, I needed to know that was safe. So there were people around me, you know, pure groups and so forth were actually would jump on a new innovative solution even before I would. But I was I just need to know that it was safe if this is something we were going to do. And that even became more challenging as more options became available. And I think one of the difficult to start balancing innovation and research is that as you get more and more options when some of them start working. And then a new innovative option comes around the corner, you and I are no longer equal poise to say, hey, we're willing. We're we we acknowledge we have a problem with an existing solution balance against the patient who's not no longer equal poise in terms of making a decision. It gets harder and harder to introduce new options because we actually start to get things that work. So the balance is tough, but I would say that while it may be may have been perceived that I was early at the outset. I was actually I think pretty conservative, it just if things kind of came our way mainly because we were tracking prospective versus virtually everything we were doing. And we started to report our successes and failures early on. So we had a fertile ground of patients who actually needed these treatments, but this concept of echo poise is pretty evolutionary and gets it. It got more and more difficult as time went on as solutions started to prove themselves out because of the data that we were actually collecting if that makes sense. That does I will I knew this was going to do this. So if you so you're telling you at a great point there, which I was really I really want to hear more about this. We have solutions out really good that are time tested right want to macy cartilage transplants are some of the most studied studies and most of them are a lot of them are yours. But now you have we're going to show the slide in a second we have solutions that are newer that are still not fully time tested and maybe success rates are different. Pushes you to that direction and we are we can get there in a second. Is it that it no longer fits you have a new niche for it is that the idea is that's what's going to look like here or is it that sometimes. You know the patient indication I mean you're a different animal because you have such a busy practice and you have so many cartilage patients but for a newer surgeon. We're marketing is a big deal and you all of a sudden patients saying I saw online that this is the best surgery right and it's a pretty good surgery. Maybe it's not as good as the one you normally have. Do you ever deal with that or is it just not something you have to have an issue with. Yeah, I mean I think you know the concept of marketing is a is a dicey area and to be quite honest and you know we either have a presence by association and by our successes but you know truth be told these one patient gets another patient when you have a good outcome. And I think that when you start on the clinical adoption curve we all have to do it in a very measured way and there's it doesn't I would just say it doesn't provide an excuse to take a shortcut to try something new. What I am finding is if these new procedures are filling some white spaces you know I think we've done a pretty good job or sort of in the 75% predictability zone for when we properly indicate a patient and they undergo some type of joint preservation procedure where we can pretty much predict it will get some benefit not necessarily an off switch but some benefit that will be appreciated by them. We also now have identified that there's a growing group of people who are for example not good candidates for our class. They don't have sufficient joint space narrowing they may have they don't have the risk they don't want to assume the risk of high level activities which may lead to premature failure and frankly when you look at the response rate and those who meet the MC ID and so forth when it comes to our class. It isn't always as predictable and glamorous as people really have come to recognize. So even those who do near class is a primary surgical procedure would probably readily admit that outcomes can be tempered and they're most tempered in that mid zone that sort of gap patient which still has some joint space. Despite having arthritis for you and I see at the time of arthritis, it's actually joint space which predicts success or failure in many of these individuals. So they're not only young age or have an aversion to failure of a mechanical implant and then thus revision surgery. They actually don't do as well as those who have true foregone osteoarthritis that will otherwise respond to it. So that leaves an enormous white space, especially as people desire to remain active. And that's what I think some of the new technologies are leading us to is we're doing pretty well with localized Carlos defects, we've done much less well with early arthritis. And I think that's the area that I think we're going to see sort of the greatest improvements because that's a very large population that still is relatively untapped in terms of finding predictable solutions. I think that's excellent point. Will, can you bring up that slide? I think I think I want to do the two sides with Dr. Cole right now to show him that one's really good. So we've talked about a lot of these surgeries at nauseam, even briefly some of the last bits. Will you go through this briefly kind of your perspective because this is sort of this is your slide and it's a great discussion point that you just brought up. Yeah, it's just a way to sort of give you a high level to say where are we now? And the great news is the slide gets to be updated because we're in a place where we have some new solutions that have passed through the FDA process. They have proven to have clinical advocacy in the eyes of the FDA, which is probably the most difficult judge of all. They are the subject of level one studies. They are being compared to things that you and I would consider a maybe previously a standard to care for some challenging patients and you can see how it's expanding. The numbers that you see here are really the relative frequency of these procedures being performed and truth be told, we're sitting around the 3,000 mark for cell-based technologies such as Macy, formerly known as ACI, Ostercon Amographs are sort of in that 4,000 procedures per year range, but there's still a lot of agreements being done and it's worthy of discussion at some level because there even is a viable option to treat patients based upon their timelines and it's a very important one when you're dealing with high level athletes. And then we also have that sort of point of care opportunity, procedures such as medallion and adjunct and medallion. And then as you sort of move through the lineage, we start to see that we might actually have the ability to treat patients like I was just talking about who have Oster arthritis, but they're not sort of what we call Kelvorn Lawrence III and IVs where they're bone on bone, but they truly do have Oster arthritis, not vocalized effects. And that patient group is a very challenging group to offer some of these other solutions too to get a predictable outcome. So that's the one that's become very interesting because from an epidemiologic perspective, that's a big group. And we need to start finding solutions for those patients, which may not always be surgical by the way, but something that can be joined preserving without the need for medallion plastic that can yield a predictive result, something at or better than that 75% range. Well, I think this slide's really important too and I think you mentioned it, right? As much as these are sexy surgeries, we've seen them in marketing. As surgeons, we see these, I do cartilage, you know, obviously you learned it from you, but it's still not high volume, right? This is really not that high volume compared to the debreedment and the other things, right? So it's still, we're still in this learning phase for some of these surgeons. Would you agree with that or this? We're not. Yeah, I know. Yeah, I just speak to the fact that this is a niche area and there's, you know, as we make decisions, we get better, we learn more from our failures than our successes, but these are not high volume procedures. I mean, I've been doing this 26 years, over 26 years, we probably, you know, for, you know, my practice is sort of shoulder elbow knee, but my knee practice is either ligament or cartilage. And the cartilage practice, despite having a referral center, maybe we do 50 osteoconylographs a year, maybe 60, you know, I still probably do way more non-surgery and education and reassurance than surgery. Same thing for municipal algorithms, you know, over 26 years, we've accumulated about 1,500 osteoconylographs. Now that sounds like an enormous number, but that's 26 years. So you do the math. That's not a lot for a year, right? Well, for all the listeners, that's a lot for everyone else except for Dr. Cole. That's annoying. I mean, I think it's a big, I think it's a big number, but in the scheme, like when you think about things, compare that to 500,000 ACL surgeries a year, compared to 300,000 menacecondemies done a year, you know? So it's still relative niche area that, that, and the things in, and if we get outside the indications, then we've got real problems, so I think the things that we've gotten better at, because we have data, is actually understanding our failures actually more than our successes, and looking at large databases, this is where we can talk about it later, but this is really where AI is going to AI will have a role in terms of actually taking real data and helping us make decisions from a multivariate analysis that we couldn't really do before. So at any rate, you know, to your point, they are infrequent, not frequent procedures, and I think they'll probably remain that way, because it's on us to actually decide who is actually a good candidate, where we're going to do something to them and meet their expectations. Well, and you just brought this up, and I know Will wants to say something, but this is, we always get these good back and forth. The point you made that was really good, I had, you know, you brought this up on multiple times, I've had talks with you. But the number of patients that you see that have had a menacectomy, or that you do a menacectomy on that need menacecus transplant is actually quite uncommon. But the number of patients, at least in my office, that I do a menacectomy on that ask about menacecus transplant is far more common, or the patient that comes in saying, I think I need to have a menacecus replacement, and you're like, you're not even there, you have no pain, you have no other reason to have it, you know, and I learn that from you. I think that's really important that you keep saying that is like cartilage surgery actually is a vast majority of non-operative treatment for the right patient you need to do surgery for them. It's just that it's really sexy. So people ask about it all the time. Yeah, I mean, I, you know, I guess it's gotten less sexy over the years for me, it's becoming fairly routine, but I would say that cartilage surgery is for the here and now until we prove that we're disease modifying or being preventative in nature. It comes at a real cost to a patient. It comes with a high amount of variability in the outcomes, a degree of unpredictability, and timelines to get back to the routine things. It's not just back to sport, but just getting back to their life. So it's the decision making isn't to be taken lightly, which is why I think some lower-level procedures are gaining favor because you can actually achieve very good outcomes by doing less. I think that's really good. Will, you had a thing you were going to ask him. I mean, it was funny, I just listened to the conversation every time I was going to, you know, add something to it, you kind of, you talked about that, right? And you talked about, you know, that balance, right? And I think, you know, patients kind of want to hear that, that the balance between innovation and being on the cutting edge, but also being practical and making smart decisions, safe decisions. How does a young surgeon that has maybe doesn't have the confidence where they're at in their career, balance those decision making is? That just making sure that you're doing your homework, doing the practices, feeling confident on the procedures, or is there something else that you can kind of give advice, I guess on what I'm doing is tapping into your mentorship part of it, and what do you tell future surgeons on how to have that balance going forward? You know, the classic mindset of a young surgeon and just going back to what happens in training is that they want to do something, and they feel there's a need to do something. But when you really look at the human condition, when patients come to us in our practice, we don't always have to do something to actually meet their objectives. And I think that's, if you don't listen to that early in your career, it can take years for you to develop and understand that, but I would tell young surgeons that patients have concerns. They're concerned about the past, they're concerned about, how did they get there, they're concerned about the future, if they don't do something today, they will miss an option that they could otherwise enjoy today, that they won't be able to do later on, or they'll be pushed to a place where they'll never be able to be made better, right? So if you spend, you know, for young physicians, not just surgeons, spend time understanding what a patient really wants is probably the most important aspect of the physician-patient relationship. I will often ask a patient, look, on the way to your visit today, you know, what were you thinking if you, if you, if you, what would you most like, if you decide to treat, and that's a, that's a lever in and of itself, should you or shouldn't you treat? What would you most like to see happen? And based upon that answer, this is where young versus experience can be differentiated. Based upon their answer, you kind of have to know what you decide will deliver for that individual if you're going to meet their expectations. Now, in many ways I use this analogy, we're often like a waiter, you know, I've, I've never really liked the question when a waiter comes to table and I'm going to have to do eating dinner with someone, they say, well, what would you, what are you, what's your favorite thing? I mean, honestly, I don't really care what the favorite thing a waiter is, right? Because he might like, like, deliver him, like, liver makes me get, so the point is that a waiter should be able to describe the food, what they do well, and what you might experience if you order that and if what you order, consensually, if you will, in this instance, meet your, what you'd like to see happen, then that might be a good decision. So sometimes people say to, to Grants Point, look, I, I, I just have my meniscus taken and I'm I read something and I don't want to get arthritis or put one back in. Well, municipal transplant, five to seven or eight year or ten year maybe stent that goes in the knee that reduces pain generally speaking while it's there and functioning well enough. But very few people have shown that it will prevent the onset or progression of arthritis. Now, that is changing. We're starting to learn that, for example, and then this is transplant can be counter-protective. But to do it in an asymptomatic individual who is meniscus independent who can play and do every single sport. Now, worry about torturing a meniscus and then put something in there that they can now torture in a setting where they didn't have pain to begin with under the premise that you're going to protect in long term that's still a reach. So I think the summary of you asked a great question is provocative to be able to provide solutions to patients. But this is a marathon. It's not a sprint when we go into practice and I think the satisfaction of taking care of people is greatly enhanced when you start to think about each individual and not necessarily by their what they're finding is on their MRI at their time of arthroscopy or what they think they want. But rather getting inside their heads and understanding what their concerns are, you might come up with a very different solution set early in your career than you would otherwise just because you have a hand cream or a desire to sort of use the newestfangled thing or the newest thing that just got introduced, you know, to the FDA. Those are just in look, if you asked me at 15 years ago, I might have invited somebody to give me a different answer, but you know, that's a luxury at time. And this is where level five evidence comes in, you know, we discount level five, which is basically experiencing experiential because it didn't go through the rigors of a level one study. Look, a lot of level one studies are flawed. You know, randomized double black predator studies, a lot of them are flawed. Think about the people who choose to go into a clinical study. That's not a regular person, right? Especially if you're not, especially when if they're not, but I said, Epipodes, where the solutions are actually working, you know, they're thinking that whatever is out there isn't sufficient. There's a strong belief that they want to have a successful outcome and entering in a clinical study is not real life. So level five is actually important. And as we accumulate level five year after year and seeing patients, if we have that intuition, we develop over time, which does take time. I think we all become better physicians over time. Do that level five experience. So I would, you know, I would say that while I'd say what I'm most proud of is that, you know, we'll see between eight and sometimes 10,000 visits a year with my turn. And while we may operate at 900 to 1000 people a year, if you look at the math, we're really doing more counseling and education and non-surgical care. And as I sort of alluded to, that gets actually more satisfying as you get through further on in your career. And as you filter out patients who really need surgery to get better, your success rate just get better and better. That is just a known for about conclusion. And I would say in order to do that, you can't do it. Like it's a cliche, but you can't do without a team. And the people you surround yourself with have to really be as passionate about these ideas as you are. And, and, and Greg, you remember when you were a fellow, like I, I love my team. Like the thing that will prevent me from retiring is because I really, I still love having clinics on Mondays. I love having clinics on Thursdays. I'm happy to show up in the morning. There's people who are eager. They're always asking excellent questions. They keep, they keep you honest. You feel like you're always at the forefront. And, you know, they, you know, they're not going to let things slide. And the quality and the ability to help many people is incredibly satisfying. And I would say the only way it gets done is by having a deep bench. And a deep bench of people who can actually ask or understand what do they want to get out of it. And they've got to be part of it. You know, people are not valued by salary. They're valued by the, the passion they have for the job and feeling valued for what they do. You know, there's, it's, there's a great book, this book, "Dribe," which I just started recently reading. And if you look over history, there's a lot of decisions people make that stay engaged. They have nothing to do with financial success or, or, um, compensation. There's a, we all have this intrinsic to goal, goal to do good. And when you think about it, when we go into medicine, most everyone goes into it initially because they want to make a difference in people's lives. And that's, at some point, it, it, it will become clear because if you're doing this for these days because of the bureaucracy and all the things that we're faced with and the, the, the decreasing decision making power and independence, so forth, physicians are going to get frustrated and they're not going to turn to, to medicine. So anyone who's currently going into medicine now really has to, I think, truly be in it for, you know, the intangibles that will give them a satisfying fulfilling career where it's not really considered a job. And the way to get it done is you surround yourself by like-minded people who in, in some instances are actually much better than you. And, um, making sure that their goals are also being fulfilled. Just like your goals, Grant, when you say, look, you know, what is satisfying to you, making a difference in someone's life, they too have those same, those same aspirations, same goals. And you got to have a deep punch. I'm really overcapitalized in FTEs. I, that's one area where I will not take a short cut because I want my patients to have access. And that means they have our, they have my email, they often have my cell phone. It's very rare that they abuse it. And they need to know that just because they don't have another scheduled office visit or they may have questions later on, they will have the opportunity to actually, to, to, to, to, to, to, to do that and close the loop because access to health care is one of the biggest problems right now. And I will say that my patients about the only complaint I get is they wait too long in the office. But they will uniformly say that the experience was good because they got their questions answered. And that's a really tough balance. I hate being behind in the office. You remember, it's like the most daunting thing during the day, you know. But I, and now I realize I got that from you as well. So now I'm just checking up all the boxes. You still have to, you still have to give them what they came for, you know, and they need to feel careful or they need to feel that we gave them, we satisfied the reason they're there in the first place. So at any rate, it's, it's a team approach. I know it's a cliche. People use it all the time, but it's true. And it's a, it's a reason that we, that concept gets brought up time and time again. It's pretty time-tested. Well, also, I would say, I mean, I, I don't want to bring up the, just the cards and meniscus because obviously, it's him approaches everything in medicine, but, but, but cartilage surgery, like when I started, I was like, I need to have a scheduler for cartilage transplants. And I need a schedule for my Macy's or my other cartilage surgeries because that's what you did. And that's how that works with that surgeries. You need even more help to be doing these really complicated ones, you know, extra insurance approvals and things like that. So the team is extremely important. And you, you don't have that, which, you know, you do a ton of talks. I do some talks and talk about this with other people, like you can't be successful in these challenging cases. It just doesn't work like that. The cartilage thing is a burden because you, like you pointed out, when the insurance process is, is very demanding. Although we're seeing peer reviews, unfortunately, every even, you know, simple procedures, you know, so that's just becoming the norm. And so the cost of delivering care is just going up exponentially because the insurance companies are putting this in this position because of the peer review process. But logistics of scheduling, especially, we're doing to common procedures, having a graph there on time, making sure the patient schedule fits the patient schedule. You know, this is a, in many cases, it's a gift of, of human life. And, and from human life, I should say, and you got to have your ducks in a row and everything lined up, because you can't have a graph show up in the patient, not be there, or not having insurance approval. So we have a big responsibility. If you're in the joint preservation business, if you will, there's a lot of boxes you got to check and you do need more infrastructure than routine things, although that's changing for virtually everything we do right now in healthcare, unfortunately, you kind of have to, the FTE problem, maybe it'll be South Parsley by AI, but it's still a very big issue. The HR problem in healthcare is not getting any easier. Well, I think it was going to bring us up to, but I want to know, like, what do you say when, you know, you, you have your fellows, right? And that's a different animal. I mean, obviously, they go through your rotation, they get your background information. Like, when I started practice, it was like, I have all my authorization letters from Cole's office. So I can hit the ground running. I mean, going into doing transplants, I mean, it's just transplants my first year in practice, is now is not a small feat after, you know, even from experiencing with you. But what do you say for some of these people? I mean, it's pretty daunting when someone's like, I want to come in and start doing these cartilage surgeries and they haven't had a strong fellowship. Like, how, how do you give them advice? Do you have people that ever come? I mean, I'm sure people ask you what these meetings and stuff. What's your advice for a surgeon that has very little experience they want to get into? Because it's, I mean, after seeing it with you, I was like, I think I might be able to do this and I had to practice in the lab more even after being in fellowship because they're not easy. So how do you tell that to the young people that don't have that type of experience? Yeah. So you asked me a good question. And I think, you know, one of the greatest blessings that we have is that we're always a student, you know, they're not too many people, if you think about your friends or do other things or private equity or best in banking or really say another, they probably wouldn't be able to say the same thing. And we never stop learning. So I think there's a lot of opportunities for mentorship. The hands-on experience comes to the, what the learning center through courses for Anna, for AOSSM. It comes from ICRS who has these courses, but it also comes from these traveling fellowships. So I think if you're interested, if an individual is interested in understanding the dynamic of heart and joint preservation, you will Do you have to be comfortable in the non-surgical management? You have to be comfortable in ortho-biologics where they play a role, where there's evidence or where you might want to use them, either in an office setting or as an adjunct operative care. You need to be absolutely comfortable with re-alignment procedures, osteotomies, meniscal alligrapes, and every college procedure because they just don't live in a vacuum where you have a carless defect. So that's the daunting part that you can learn it after if you're a good surgeon, you're a good orthostaticist, but you haven't learned joint preservation college repair. It's doable, but you know, look, I got better over time. I only had a few things I learned in my fellowship. What we've done, though, I will tell you is the field has gotten so advanced that it can put joint preservation in the hands of people who didn't get a fellowship in it. You know, miscal alligrap transplantation is an easier operation now because the instrumentation is much more streamlined. Osterkona alligrap transplantation is four simple steps. So will you tell me so one thing I know we talked about is traveling fellowship, learning it. But how do you feel? I mean, obviously, I don't want to be asking questions about myself, but part of the reason, you know, one thing that's really big deal for you is everywhere I go, it's like, okay, this person trained with coal, this person trained with coal. So like, how does that how does that motivate you as well? I mean, not only do you get to teach, but what everything you learn is now expanded massively, you know, it's just not that common. I mean, we all have people that we learned from, but for cartilage surgeries, especially these cargimniscus complex surgeries, the number of people that I can think of that I speak with on these podiums and talks that have worked with you is it's vastly overwhelming compared to many other different mentors. So and you're not many, but it's just what is that to you? Like, how does that how does that influence that changing thing you do or is it just really cool? Like, you know, what is that for you? Yeah, I mean, look, that's the greatest privilege of all is being able to be a mentor. Like, when you think about like, what's your legacy and what are you going to be one of the, what are some of the things you'll be most proud of is the people that I've had the opportunity to work with. Like, when I see you on a podium or we have these panel panels, like I, I, it's to the point now where the people I've trained 15 plus years ago are people I listened to and I'm like, well, what are you doing now? How are you managing this problem? So the coolest part of it is that, yeah, that may have set the foundation. They learned the decision making at the time that they were a fellow and then they also learned the techniques and then they practiced the techniques, which is one of the greatest things that we have is all these different learning environments we can, we can, you know, assume new skills. I'm still assuming new skills. I mean, there's things I do now that I didn't do even last year. So we're always a student. The greatest thing is seeing how you evolve in your career and you actually are an original thinker now. So I, I trust your judgment. I would ask you and I actually have second opinions together. You know, I saw, I saw Grant Garcia and I, you know, this is what he said. And I'll say, either I agree or I, this part I might think about differently. And there's room, you know, there's room to disagree, to agree to agree or agree to disagree because there's a lot of variability in terms of how we make decisions here and it doesn't mean it's, it doesn't mean it's improper or beyond the standard care. It just means it shows that this is still a bit of an art and there's a lot of level five behind it. So the, you know, the mentorship piece has been, has been, again, one of the most satisfying aspects of my career. And but look, there are other programs and there's other places where people learn Carlos. But because we talked about before, it's a low incidence problem. If you're really interested in your training and your resident and Carlos or joint preservation is something you would like to pursue and you're going to do a fellowship, you really should look to fellowship that have some volume because there are some, it is hard to teach and, and you don't get a ton of hands on experience in some places as a fellow, but you see a lot and then you get to do and you learn after you're out and we all get better as surgeons year after year. And there's plenty of different learning environments like when I learned something now, I actually go to a lab, you know, I mean, I didn't know 100%. Yeah, I didn't know how to do Misha, you know, I went to a lab and it took me two hours after I read it and I watched a video and I didn't know, a cardio has some, has some nuances to it that it's not like any other Carlos procedure. You got to learn these things, Macy, Artho Macy, like, you know, we have the greatest job ever because we do, we just keep learning new things in the Middle East and for us to stay on our game, you got, you got to be a student all the time. I think that's really important for people to hear that. I mean, you have you, expert at this stuff, still training, still learning new things, still going to the lab, you know, I'm doing something new, a new type of Minuscus transplant, I'm going to the lab in two months, try to figure out how to do it. Because I'm like, I'm not going to test on the patient, right? No matter what you do and it's just awesome to hear that, that's what, that's a drive, you know, as a younger surgeon saying, you know, we'll coals still doing the lab. So why would I ever not stop doing it, right? Like he's willing to learn still, like, I'm going to do it. So anyhow, I don't want to belabor that topic too much. I want to get to the last topic because obviously this is the one that's the sexiest, it's in the news. But very briefly, will you talk about how your carlage considerations change with the professional athletes that you take care of because not only are you carlage, Minuscus surgeon, but you also are carlage, Minuscus surgeon to professional athletes, which is extremely uncommon. Show that slide. We can show the two major athletes that you've been involved with to talk about that and pull that up. So this is actually from one of my PowerPoints, I gave a talk on this and showed these two players because they've been on our podcast, not the players, but the conversation in both times. We've talked extensively, but that, these come at my office all the time. I mean, these conversations for both these players, mainly lawns of ball. You don't have to go into too much detail, but maybe talk about the lawns of one a little bit more and kind of how, I mean, that was the first time, right, ever in an MBA that a player at how to Minuscus transplant. To my knowledge, yeah. Yeah. And so why, yeah, athletes are, you know, athletes propose a very unique decision-making process. Whether they, A, it's complex, there are a number of stakeholders, there are beyond the disease state itself, there are a number of aspects that are relevant, their age, their contract status, the position they play, the sport they play, roster changes. Like there's at least 15 independent variables that weigh into how we make a decision, which may not be the same thing for another wise active patient who's not a professional athlete. The most important determinant of an athlete deciding consensually to undergo a joint preservation procedure is the fact that without it, they cannot otherwise play their sport or play it at an acceptable level. If they can play in pain and play at an acceptable level for themselves with the organization, we're not discussing a procedure that might even make them worse or not deliver an outcome that they would otherwise not even need. So there's a go or no go when it comes to a professional athlete. And that's that, look, if you were told that you have permission to play in discomfort and that there is not concrete data that says that physiologically low is another will make this an exitly progress, that might or could, for sure, might or could elevate your symptoms. But if you could tolerate them and play your sport at an acceptable level, why are we talking about doing anything surgery whatsoever? So that's the first thing, because when you're dealing with procedures that have high variability, it's like, we do really well with activities that are living. But if you have a patient who comes in and says, "Look, I'm doing well with everything I do. I'm running a 340 when I do a marathon. I really need to do a 320, but I can't do it because I get pain. We can't squeeze that kind of margin out for the highest level individuals." So the best professional athlete is one who says, "I have problems with activities that are living who will say, "Yeah, I would see value in improving my quality of life, but I would see tremendous value in playing a sport that I otherwise cannot play." So that's the first thing. And then the next thing is, what is the least amount you can do to get them back? Because the less you do in a professional athlete, the less the variability will be due to the injury. If you take the variability of one operation, you multiply the variability of the next, all of a sudden you get a very big number in terms of standard deviations. So you've got to have your decision making as much tighter in a professional athlete is not always the same. If you look at the defect, the Minnesota Statistical Alignment, you can't plug those three things in and say you get the same output in a professional athlete that you would get with another 100% individual. So for example, Lonzo was a good example. It's publicly known that he had minuscule surgery in the past, right? So he was doing fine after a minuscule surgery. But then developed symptoms that were potentially related to that or potentially not. But the point is that our narrative is, whenever you have a minuscule deficiency and you have a cartilage problem, you replace the minuscule to replace the cartilage. But you can argument that that's not always true in a professional athlete. You would say, "Well, when you could do a graft, an osteocondrograph or whatever, and not do a minuscule transplant, and with the limitation being, it may not last as long." And that may be an acceptable outcome for someone who is in a sport that may not be any longer than five to ten years, for example. So they make a different decision than you and I may make being a high level recreational athlete. So I think the take home is that there's a lot of variability in these procedures. Like you said initially, it is very rare that a professional athlete would fall into this category. And when they do, because of the variability in the outcomes, it's not like an ACL, it's not like a shoulder stabilization. This is different, because the variability is so broad that the go or no go decision point it has to be that they cannot otherwise play their sport. acceptable level to them or the organization before they decided to embark on this because that any sport that is where an athlete is out for more than a year in terms of A being allowed to resume high levels of load and B to get their skills back, usually that's more than a year to get both those things, right? That is a tough, that's the onus of that timeline is, can't be underestimated because that in and of itself may be enough for an athlete never to get back to sport. So it's just their big decisions and their adult decisions that it's complicated by the fact that there's a lot of stakeholders. Dr. Coyne, sorry you go well. No, I was just going to say real quick. I saw the documentary a clean sheet with Gabriel Landscock and that journey from a freak accident from 2020 and his comeback trail, all from leading up to last year, when you have a player at that high level captain of his team, winner of the Stanley Cup, his team's dependent on him, there's been an investment and also quality of life, right? New parents and just trying to get back on, how difficult is it for you personally to see someone go through that and you're trying to balance, I'm trying to give you quality of life, I'm trying to get you back to the professional level and make sure that you can do everything possible to help this patient out. Yeah, I mean, you're hinting at the interpersonal side of it too because each of these professional athletes becomes a project in and of themselves because you tend to build a very close relationship with them because it's not about as I said before treating an MRI or a previous arthroscopy or what have you, you're treating it a human being whose career is at stake and again, I would say that virtually every high level athlete whether it's collegiate level or professional, they were treated because they otherwise were in labor on willing to do their sport and this was a go or no go decision. So that's a monumental thing. It'd be like someone telling me or grant that, you know, we're going to do this procedure, you're either never going to be a surgeon or a doctor again or you're going to be a surgeon or doctor again, like that's daunting. So, you know, with these individuals, like that's been one of the greatest privileges, like I'm not one of those sports nuts who can rattle off statistics and things like that and admittedly, I, you know, one of my PAs knows anything and everything about sports when I have an athlete come in sometime and I'm like, can you tell me who he is? You know, like Wells is dying. He loves this. I'm going to say we have no idea and Wells is like, I have much less of an idea than the average bird, you know, and it becomes, they really are just like every other patient, but the decision, the thing that's so fascinating and so captivating is the decision making part is really interesting and so multifactorial and there's just a lot of discussion that goes into it because the end of the day, if you're going to do something, you got to really understand the athlete's mentality and to make sure that they fully understand that what they're about to embark and may not deliver and they have to accept that. They also have to accept that it may not be perfect and that's still a good outcome. You know, a lot of things I use as an analogy, a lot of things we do are off switches. You are broken, you fix it and then you're good. Like that's the greatest thing about orthopedics. Like there are people say like, I never thought this would happen, I am perfect and they're hugging you and you, like that's why people do this and that's why it's so so so there's so much longevity in what we do because it's like gasoline. People come in and they're like, they're hugging you, they're bringing you cupcakes, they're you know, they're you change their lives, you have impact on someone that you cannot put a price tag on. That decision is with Carlos repairs a little different because it's more like a light reostat. It may be a down regulation where they have less pain and could do a whole lot more than they could otherwise do and that too is successful outcome, right? Not as compelling as someone where it's an off switch where like, I am perfect and sometimes they are, but you never go into it with that into this with that expectation. And with Lonzo, you know, the ESPN that what they said was, I think they quoted me, I said, this is a Hail Mary. Yeah, it was a Hail Mary. It's like, I can't, I was unable to say what is going to happen or what is like that happen. I was only, it's never been done before. Yeah, and I've never been done before. Yeah, what you can say is there's a 100% chance that you will not get better and you cannot play if you do nothing. So we've already proven that with an extended period of time and lots of things that just haven't worked. So now you're faced with this, it might work and I don't have any percentages to share with you like I do in other areas. And the problem with percentages is it's binomial. It's either zero or one. You and I are just like, yeah, you got a 75% chance of doing well with this, right? That's meaningless to the patient who's either it's going to be or it's not going to be. It's binomial for that. It's either it is or it isn't. So we do population and data statistics, but they're just like an end of one and it's either going to work or not going to work. So it's a really fascinating area, but you can't, I guess, and you can't really over communicate, you know, and the privilege of meeting a guy like Gabe or working with a guy like Lonzo and some of you know, I've worked with tennis players and professional soccer players and female professional athletes like they're like they're the bomb like they they play with they'll play with anything some of the female women athletes that I take care of, you know, and yet there's times where they just can't go. And yeah, so a lot of this is the psychological aspect of how they deal with their disease. I'd say that that's probably, honestly, 50% of it because we can do a great job, but if they don't have the mindset and I can tell you to the end of his, we're talking about had the mindset and the mental capacity and the fortitude to go through the rehab and not sort of for lack of a bit of term crap out along the way because of frustration or lack of progress. So that part is really the most fascinating and it's again, that's a privilege to get to know some of these people to figure out how the soft stuff weighs into a successful outcome. I wanted to just bring up one point on both these athletes that's subtle and unless you're a carless surgeon, you wouldn't pick up on it. But both of the surges you did, you did in skimp, you did meniscus and cartilage, TTO and battella. And like what you talked about before, is that sometimes you just do the simplest thing, you know, in my opinion, those two, the simplest thing was battella or the cartilage. So what made you, I mean, I know there's indications, right? But we're not following the indications of facial athletes. We're doing our best job forward. You went all in on both. Yeah, even with them being riskier because you felt like it was the right thing to do. So mentality wise, what were you thinking? You just went, you're like, we're going to give this the best shot. The basic thing I was thinking is what is the least amount I need to do to make them better. And if I don't do that, they're not going to get my, in my judgment, level five or even level one or level three, they are less likely to succeed. And the additional offerings have acceptable levels of risk. Okay. So you could argue cartilage defect, patella, fix that, should be fine. What if it's not? God added a TTO because there's a fair amount of data for specific defect locations that it's complicating. That'll amplify the outcome. What's the cost of that? And what's the relative risk? And is it worth it? And again, this is a little visceral. And it's a little level five. And it's a bit of an art. But like five years from now, we'll be able to plug that in and actually get numbers, you know, based on data. So yeah. So that's the, I think the harder one honestly was, do you or do not do a meniscus transplant in a setting where cartilage defect becomes symptomatic? And it's easy to stand on a podium and say, you should always put a meniscus in when the meniscus deficient, they have a cartilage defect, right? But there is no always. And I could create a very similar narrative to say, leave the meniscus out and just do the cartilage graph. But you say, well, what if the meniscus fails, which is probably the most likely thing that will always fail the point of her inability, what's the cost of that? Well, the cost is you do a scope and a cleanup and they may do just fine. So barring no complications from the incremental procedure you add, which is, as I say, lots of variability, you multiply those percentages, you start to get a big number, you got to take that into consideration. The heart of that decision is, I've got to believe that that is what that person likely needs to get better if you're going to drag them through this. And to stack rehab and timelines is not an option often in a professional athlete. Kind of have one shot to do to offer a big operation because stacking it together pushes them to two years to three years. And that becomes a really big bar for any high level athlete to get back historically, once you're out of your sport for any extended period of time. I think that's excellent point for the listeners to hear that, you know, again, it's all or nothing. You did the right thing. And, but I'll you know, but great, to date to your point, I'll never know what if I didn't do a TTO? What if I didn't do a Mrs. Transplant? You know, they could have kind of good result without either one. Well, I will never know because we used our cumulative knowledge to make in our judgment, which is not always perfect, and our judgment to make the best, most informed decision. Well, I, I, by asking the question, I thought that those two were the best decision, but the, the answer is that you could do, because you saw a good outcome, but you know, I will never know what, what have happened if we didn't do it, you know, 100%. And support for the listeners to know that, right? You know, I'm sure they had an opinion, maybe not in your case, because they went straight to you and they were happy with it, but these pro athletes, guys had three or four opinions and they, we didn't all align. You know, I'm sure, one of these, that's the other thing we should mention is that I will never offer it on a professional athlete who hasn't had at least one second opinion in this situation, you know, and that's perfect. That's a perfect thing for all to hear that because we walk through the, we walk through all those opinions and where we agree to agree, I'll say, and if I don't agree, I'll say this is where I think I, we differ here and it's not about, it's not about cast and shade or other, it's literally saying this is why I think this is, this will work, this is maybe less likely to work. Remember, there's lots of ways to get something right, you know? Well, I think the point you made up too is that the opinions second opinion is really important. Like, that was one thing in your office, despite how many surgeries we do and non-surgical things we do, second opinion is still something that you, if someone wants it, you get it, so you feel more comfortable with the surgery or you encourage it. Exactly, which is really not, not all doctors do that. So seeing that, I'm like, I'm the same way now, like with you, I'm like, you want to get another opinion, I want to make sure you're comfortable with whoever decision you make. And we've had that conversation on this show, we've, we've mentioned in numerous times, get a second opinion. And I, it just, it seems to me, just we're talking with someone like you and other people that we've had on, good doctors are always going to recommend, get a second opinion, you know, especially you want someone that's going to feel comfortable about the decision making, they've explored all options, they didn't just rely on Google.com to give them suggestions. So that's been a very important point. If you let as a physician, if we let ego get in the way, we have problems, you know, there's always another patient to treat. So when you're dealing with, especially these types of athletes, you know, it can be challenging. You're never a fan in this instance, you're there to give you, do the best possible service for that individual. This is really important stuff for that person and their family and their livelihood. So ego is absolutely not part of it. And a second opinion is the, the greatest way to sort of cast that aside. Awesome. So I know it's getting late, you've been such a, been so awesome having you on. One big question for you, and I know it's, you don't can just do as brief as you want. Are you talked about the AI stuff? What do you see as kind of this future of cartilage, meniscus, kind of the work you're doing? Like what do you think kind of the most innovative, interesting thing coming down the pipeline? And again, you don't be, you know, quick, quick, you know, quick take home sound bites, you know, I think that we've spent a lot of our time and energy focusing on cartilage, but what we're realizing is that most cartilage problems are really load problems, and they're more likely than not bone problems. So by the time patients get to us, it's less about the fact that they're missing cartilage, but more about it than the osteocondromal load problem. And the, the, the basis of that opinion is when you think about all things we do, knee replacement, you could put a dead piece of bone in cartilage, you could put a frozen piece in, losing weight, changing alignment, putting a shock absorber on the inner side of the knee. Those are actually load reducing procedures and may have nothing to do with biology. So I think paying closer attention to the bone and load is part of our near term future. I think that determining where we can use responsibly sort of orthobiologic as an adjunct to improve things, that's an obvious one. I think that a focus on allogeneic solutions, rather than auto-genic, that can be used off the shelf. I think a focus on less invasive things that are injectable or injectable with smaller operations, rather than larger operations will be including office space procedures that might be beneficial. I think that disease modification is still aspirational. I think we love to talk about it, but we're still a long ways away. So I'm kind of comfortable treating still for the here and now, but if we find something that's disease modifying, that's going to be awesome. The problem is our healthcare system doesn't yet value disease modification and the FDA makes it very, very difficult to be designated as a disease modifying agent. So still a battle we got to take. As far as AI, I would say that AI is important. I think all of us are going to be, it's not going to replace us, but we will all be working and we currently are working with AI in situations where it's unbeknownst to us. The place where I think AI will be important is how we, you and I will leverage the databases that we've been spending all this time and energy, the registries and so forth, taking that data and using generative machine learning models to then make informed decisions on how a patient will do based upon, you know, what if you could plug in, you know, Lonzo Ball, 28 years old, three years of knee pain, two previous procedures, no kids, body weight this, loves, you know, I'm not saying this is true, you know, loves to play chess, you could plug all of these things in if you collected that data and then use that as a predictor for an outcome. That's what AI will, I, for, it's already happening in other industries, that's how AI will help me and you, Grant, is will take, will, will be able to leverage all that data we're collecting to make an informed decision better than we can do by doing multivariate regression analysis, right? That is tedious and fraught with tons of potential errors and type two and type, type one to type two errors and so forth. With AI used responsibly, I think we're going to actually be able to do some really cool things and it's already being done, but that's why we have to keep collecting data, like, and you got to collect collect the right data and make sure that you're compliant, like make sure you're getting it at times zero, get it at six months, make sure they're filling that stuff out of one year, 18 months, two years in longer term. So we can go back retrospectively to look at prospectively collected data and use some engine, some machine learning model to get us there. That's cool. That's going to make a difference. We got plenty of soundbites from that one. That is awesome. Thank you so much. Yeah. Will anything closing? Yeah, just real quick, you know, we've talked about mentorship and inspiration throughout all of this, along with all of this plethora of information. I read somewhere, and most young people will know them as Professor Proton or Papa Elf, but some of us that are a little bit older may remember the Bob Newhart show. That's one of my favorite shows. That was one of my favorite shows. Wait, I read somewhere that they, you've got some inspiration from that show that kind of set you on your pathway to where you're at right now. Can you elaborate that, or am I? Sure, we have some young viewers, you know. Bob was a clinical psychologist, but so he's dealing with a lot of like, you know, DPC to psychological issues, but the guy was funny as hell, and so he blended humor in a way that also really helped people. And it's interesting. If you look at physicians who are actually sued less, they are more likely to use humor in the office setting than those who are not. There's like a whole litany of literature that discusses litigation and health care, and those who can actually engage patients with a appropriate level of humor, are far more effective in their ability to sort of meet a patient's expectations and leave them in the end of day satisfied. So Bob Newar was just an easy show to watch and was, yeah, it was a long time ago, you know, but your listeners are, you know, you and I, I'm probably older than you are, but the, that was a great show. And that's what he did, and he combined humor and had a huge impact on people. Thank you, Dr. Cole. Thank you for taking time to spend with us. Dr. Garcia is absolutely giddy. He's going to be talking about this forever. Dr. Garcia, say good-bye to Dr. Cole. Thank you very much for coming on. We're looking forward to this. Yeah, Greg, thanks. Keep up the great work. I'm proud of you, and you're one of my legacies, so I'm really happy with what you've accomplished, and you're thoughtful and you're forward thinking and just keep doing a great job and taking care of people. Thank you. Dr. Brian Cole, spending time with us today, we want to just really thank him for his time. Just absolutely amazing. Dr. Garcia, some final thoughts on it before we, before we say a do to everything else. No, stay tuned. This is going to be an awesome people are going to enjoy his episode, more great guests, and listen to it. If you want to be a guest, let us know. We've had tons of requests, but you know, it's going to be hard to top this one. So that's all right. Thank you very much. It was a great show. I'll see you later, Dr. Garcia.