Name: Cadaveric Demonstration of the Single Use Osteochondral Autograft Transfer System
Uploaded: 2007-09-10T00:00:00Z
Channel: Arthrex

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VCD-1056 | A | Cadaveric Demonstration of the Single Use Osteochondral Autograft Transfer System

Thomas R. Carter

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Cadaveric Demonstration of the Single Use Osteochondral Autograft Transfer System

[00:00:23] The treatment of articular cartilage injuries continues to be a very difficult problem facing orthopedic surgeons. There are very few options available to reproduce the fully formed articular cartilage. One of the more recently available is that of the Autogenous osteochondral transfer system, commonly known as OATS. The benefit is it takes a fully formed osteoarticular plug and places it in a less weight bearing to a more weight bearing area of articular cartilage. The benefits of the OATS system are many. One is it uses a fully formed hyaline articular cartilage system rather than fibrocartilage, and it uses one's own tissue. It is able to be performed at one setting, and typically can be performed in arthroscopic methods. It can be performed in a relatively inexpensive manner, rather than requiring that of allograft tissue or genetically or tissue engineered methods. One of the benefits of an OATS system is it can be performed at one arthroscopic procedure. Several methods. You have to be fully prepared before doing the resurfacing methods, such as that of an allograft, where the tissue is not readily available but has to be planned for the same thing when using ACI, in which point it's a staged procedure where you do an arthroscopy, take small pieces of articular cartilage, reproduce it in a lab, and then come back for a second procedure. The benefits of OATS. You can have the system available in your surgical suite. So if you find a defect in the weight bearing area of a large size, the rest of the articular cartilage has no notable arthritic changes, then you can perform it at that time. [00:01:54] For using OATS system, the most appropriate indications are that of having an OCD lesion osteochondritis dissecans where the where the surrounding articular cartilage is of good condition, where a post-traumatic defect where the articular cartilage is otherwise normal. If one has a small area of avascular necrosis, then it is a relative indication as well. If there is a large area of underlying subchondral bone that is avascular, or if there is articular changes due to, say, gout or pseudogout or rheumatoid arthritis, those are not candidates. And if somebody has generalized arthritis with maybe an isolated plug, then they're not a candidate for the OATS system either, because the articular cartilage is otherwise abnormal in the entire joint. We're performing a cadaveric demonstration of the Arthrex autogenous osteochondral transverse system. Because of the infrequency of definitely knowing when the procedure is to be undertaken. We're performing on a cadaveric specimen today, and thus the articular surfaces are not that of standard arthroscopic knee findings. The first step is identifying the size of the defect and whether or not it's an appropriate defect to use once it's been deemed appropriate for use the OATS you go ahead and determine the size of the plug needed to fill the defect. When determining the donor plug size, one can use a sizer as seen here to determine the proper diameter. And once that's determined, then you can correlate with that with the six, eight, and ten millimeter harvesters. One can then determine the proper angle for which to harvest the plug. So I routinely will go ahead. And make the standard portal. [00:03:24] Just away from the patellar tendon. And then by using a spinal needle, one can determine the proper orientation for which to make the lateral portal for harvesting of the graft. Routinely one harvest for larger plugs just above the sulcus terminalis along the lateral femoral condyle. If one wishes to harvest a smaller plug, that can be done so in the inner collar notch, as when one performs that of a notch. Plasty for an ACL reconstruction. Optimally, the portal should be 90 degrees to that of the articular cartilage. In this instance, you can see the sulcus terminalis, and by having your assistant flex and extend the knee. [00:03:59] You can confirm that this area is the one and less weight bearing as it is just below the patella, on full extension and on flexion is away from that of full weight bearing. So the optimal harvest site in this instance would be in the area above the sulcus terminalis and leaving a millimeter or two of the lateral wall intact. Thus, by coming 90 degrees to the articular cartilage and also 90 degrees to that of the knee, if there is any question in regard to the proper orientation, the surgeon can make a mini arthrotomy and harvest the plug under direct visualization. Once the portal is made, it behooves the surgeon to remove the fat pad, as this frequently will prevent proper visualization as it becomes edematous and gets in the way as one inserts the harvester. One of the. Benefits of this system that's. [00:04:43] Available is everything comes in a kit. Each set is available in six, eight, and ten millimeter sizes. Including this set or the. [00:04:50] Site specific donor and recipient harvester and alignment stick. Tap clear delivery tube as well as an optional screw in core extruder or graft deliverer used to deliver the graft. And you can go ahead and obtain the donor and recipient at one time, rather than having to do it in stage. Procedure. The important factors to note there are windows on all four quadrants for which to make certain that the plug is of proper height and orientation. Also, it is marked in stages of five millimeters to determine the depth. The external diameter. [00:05:20] Of the donor harvester is actually one millimeter greater than, enabling thus to have an internal plug to place in a press fit fashion in the recipient site. It's important when inserting the donor harvester into the joint that one keeps the core extruder outward, for it is rounded for if you insert without it slightly proud, you run the risk of having the sharp edge on the harvester, cutting the articular cartilage. When inserting the donor harvester. The portal should be enlarged so that it slides in easily. If one forces it in, the sharp edge. Can cut the articular cartilage with this knee. The sulcus terminalis again is well delineated. One then comes 90 degrees to just above that for harvesting of the plug. There are four different quadrants marked, and one should maintain these as orientation for any obliquity that can occur with that of harvesting of the plug, and also the advantage of maintaining the orientation of the articular cartilage to match that of the recipient site by removing the soft tissue. You can see that you can get over top of the course, so you have one millimeter outer wall remaining. [00:06:21] There is any question as to the proper orientation. One can gently insert to the point at which they deem is appropriate, and then remove to see the outline of the plug to be harvested. An insertion initial insertion. You can make certain that the height is equal in all four quadrants. At this point, one can still make minor adjustments by angling. However, if one waits until it is inserted five millimeters or greater, any change in angulation can result in breaking of the plug to a much shorter length than desired. It's also very important that once the orientation is determined, one does not alter it once it is embedded in the bone, otherwise they run the risk of breaking the plug. As you can see as the harvester advance, there are five millimeter increments to show you show you the depth of the plug. Typically, one makes a 15 millimeter donor plug. Okay. So. Okay. Okay. Once the harvester is inserted, the 15mm is turned briskly, 90 degrees to the right and then to the left. And with this the plug is removed. In this situation you can. [00:07:21] See that it's 15mm around in proper orientation with a millimeter of lateral wall remaining. As you can see with the donor harvester, we have it flush to the end of the bone. In this case, you don't have to worry about making a difference in the depth. If by some chance it is broken or blight, then you need to push the graft out until the edge is flush, and then you read the depth, at which point that is what you should match the recipient site. You can take a look at all four quadrants to see if the plug has any areas of being proud in relationship to the other three quadrants, and this is useful in trying to match the donor site. If there is any alteration between the two sites in this situation, we have 15 millimeter depth in all four of the quadrants. When preparing the recipient plug. The same principles should. [00:08:04] Be used as that of the donor plug. Once you make the portal large enough so that the recipient harvester slides easily into the joint, and also to make sure there's no soft tissue entrapped, which can make visualization difficult for the recipient. Harvester one comes directly over that of the defect, with the goal of being 90 degrees perpendicular to that of the articular cartilage. If there's any question as to the appropriate size of the harvester, one can gently mark it and then remove it. And you can see in this situation, the six millimeter harvester is the appropriate size. Once again, one needs to make certain that the four quadrants are equal and symmetric. Just as with the donor plug. [00:08:42] It behooves you to be able to see all four quadrants and to make certain there's a few millimeters of the soft tissue away from the end of the plug. Remember, once it is engaged, only make minor adjustments and not large ones. Otherwise the bone can be broken free as it is harvested. The recipient harvester is advanced just beyond that of the ten millimeter line, stopping 2 to 3mm short of the donor plug. This prevents the subsidence of the plug, and also enables a true press fit of the plug at its base. When removing the recipient plug, one has to be careful not to toggle, as this can cause the plug to be broken at a shorter length and also can enlarge the opening, so it would not be a true press fit. Fashion. To confirm proper depth and orientation, an alignment stick is then used. Commonly the depth is 15mm. [00:09:29] However, the exact depth should be determined by the length of the donor plug. The donor harvester is then obtained and the screw in device is inserted. By using this method, it gradually pushes the plug out of the end and is less traumatic than if one taps it or hits it firm with a mallet. As you can see, just in this circumstance, when I'm turning it, you can see that it protrudes out the end of the harvester. The clear delivery tube is of great benefit. It helps keep all the soft tissue away so the visualization is readily achieved, and it also prevents the graft from being inserted too deeply within the tunnel. The clear delivery tube is. [00:10:06] Then placed over the defect and the donor plug then inserted by advancing the core extruder. If there's any difficulties or concerns of the pressure making it difficult to advance the core, the inflow can be stopped at this point. In addition, there is a tendency for. [00:10:22] The clear cannula to be pushed backwards as the core is inserted, and thus firm pressure needs to be applied as the plug goes in. With the delivery system. [00:10:31] Inserted fully, it leaves the plug approximately one millimeter. Proud. The temp is one millimeter in diameter than the plug itself. To prevent over compression and insertion of the plug by using a tamp to insert the last millimeter. You can see that the plug can fit flush with that of the surrounding articular cartilage. In addition, with a press fit fashion, one can see that the concerns of early range of motion or accelerated rehab are less than if plugs are not in press fit fashion or when using fibrocartilage techniques. As with any surgical procedure, in particular arthroscopic procedures as they're developed. Obviously, there are several pitfalls or possible theoretical complications that can occur when harvesting a plug. One must. Pay very close attention. [00:11:15] To minor technical details, or it's very easy to harvest in a black plug, or to go ahead and come to lateral and break off of the bone. In addition, if one comes to medial near the inner collar notch, they leave a large rim of articular cartilage and start to get involved in more weight bearing area of the femoral condyle. If one cannot see the insertion because of fatty tissue, it is very difficult to truly determine the orientation in all four quadrants. Also, one cannot determine where they are in a medial lateral plane. Good. In this situation, it appears that there's only a very slight discrepancy in. [00:11:51] Regard to the insertion, and 1st May think that they can make adjustments for that when making the recipient site. It would behoove the surgeon to stop at this point and reorient the plug before it inserts too far. If one waits until it is inserted more than just a few millimeters. When they remove it to reorient it, it can break the plug off and have only a few millimeter length plug. To demonstrate such instance. [00:12:13] We will go ahead and obtain an oblique plug, and a blank plug in this instance can break out the wall, and as you go in further, there is more obliquity of the articular surface, which is very difficult to match properly in regard to the recipient site. You can see that it blows out the lateral wall, or even though one started in the proper orientation, because the obliquity, the lateral wall breaks free. And also, when looking at the plug, you can see the marked obliquity of the articular cartilage, which is going to make insertion of the plug to match that of the recipient very difficult. Typically, what will occur is one portion of the plug will be below the articular cartilage and thus not obtain proper stresses, while the other part will be a millimeter or two proud, which then can have. Shear stresses and. [00:12:58] Delaminate the articular cartilage. As was mentioned, it's very important that you have a 90 degree angle to the articular cartilage, but also that of your hand to the knee. In this situation. [00:13:09] It may look appropriately oriented, but on external you can see the marked obliquity which results in breakout of the lateral wall as the graft is harvested. The proper orientation, besides that of matching of the four quadrants seen on arthroscopy, is exterior. It should also be 90 degrees to the plane of the knee, which helps to prevent the improper angulation of harvesting of the articular cartilage. Another technical pitfall. [00:13:34] That can occur is if one starts to insert the plug and find that there is obliquity, and they wait until it's advanced too far to make any adjustments. Go ahead. Go ahead. The tendency to alter the orientation once the harvester is in more than just a few millimeters, results in the possibility of breaking the plug off and having a foreshortened plug of only a few millimeters of just over five millimeters, as seen in this case. One other thing that one has to keep in mind in regard to possible pitfalls. It's very important to try to have the graph flush with the surrounding articular cartilage. If it's countersunk approximately one millimeter, then forces are not applied to that, and the articular cartilage has a tendency to die. At the same token, if the plug is left proud. The millimeter or two, there's a tendency for the plug to shear and delaminate the articular cartilage. Post-operatively. One of the benefits of using an OATS procedure. It has much more accelerated rehabilitation than some of the other articular resurfacing methods. My own personal protocol is to have them on crutches for approximately four weeks, and then allow them weight bearing as they wish. [00:14:40] Studies have shown that Fibrocartilage fills in the donor site by approximately four weeks, and that's the reason for keeping on crutches during that time. After four weeks, I let them weight bear as they wish, but most patients are still using crutches for another week or two just due to the leg being somewhat weak. So typically they're fully off crutches by six weeks post-op. At six weeks, most patients are off their crutches fully and at that time can go can go ahead and ambulate as they wish. We typically do not have them do any real strenuous activities until 3 to 4 months post-op. And typically they can start jogging at 12 weeks following the surgery. My parameters for full activities are at four months. If they have 80% or greater of their leg strength compared to the contralateral side, they have full range of motion and have full functional stability, such as that of proprioception and neuromuscular function. Then they can return to activities without the specific restrictions. For information on. [00:15:33] The Arthrex surgical skills training programs, contact Arthrex at one 800 933 7001 or visit the Arthrex website at arthrex.com. This program was sponsored by an educational grant from Arthrex incorporated.

Cadaveric Demonstration of the Single Use Osteochondral Autograft Transfer System

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