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Das Allograft-OATS-Instrumentarium vereinfacht die Entnahme großer osteochondraler / hyaliner Knorpelzylinder aus Spenderknochen. Nach Platzierung des Kondylus in der Arbeitsstation wird der Kern mit dem Hohlmeißel (Donor) entnommen. Mit dem Hohlmeißel (Recipient) der entsprechenden Größe wird eine Fassung angelegt, die 0.5 mm kleiner (im Durchmesser) ist als der Spenderzylinder. Mit einer Tiefenskala wird die exakte Tiefe des Allografts ermittelt, damit es mit dem Empfängerloch übereinstimmt. Das Allograft wird an die richtige Größe und Neigung angeglichen. Durch Dilatation des Empfängerlochs kann nach Einsetzen des Allografts ein bündiger Abschluss erreicht werden. Das endgültige Einsetzen des Allografts erfolgt mit einem diametrisch größeren Stößel. Das Ergebnis ist ein plan abschließendes Transplantat, das dank der Press-Fit-Technik keine Fixierungsimplantate erforderlich macht.

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Allograft OATS® System for Articular Cartilage Restoration

S. Clifton Willimon, MD (Atlanta, GA), demonstrates the treatment of a capitellar osteochondral defect using the OATS® 2.0 system and a precut osteochondral allograft core. Dr. Willimon uses an anconeous approach to the defect and shares several technical pearls for achieving excellent fit and congruity with the surrounding articular cartilage.

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Capitellar OCD Treatment Using the OATS® 2.0 System

So for this demonstration, we're using an ingenious approach. It's a direct posterior approach to the capitellum. So this is a left upper extremity. We've positioned it to recreate the lateral decubitus positioning of a patient. So the hand is towards the bottom of the screen, the shoulder is towards the top and the patient's head would be to screen left. So for orientation we have the olecranon the lateral epicondyle and capitellum and Radiohead. The soft spot location for the soft spot portal, typically used for injections or arthroscopy would be here. And then the medial epicondyle and ulnar nerve. The anconeus splitting approach is critical for graft insertion. For the capitellum, because it allows for perpendicular approach to the articular surface of the capitellum. This is also a useful approach for fractures such as coronal shear fractures of the capitellum. For the same reason, it allows for excellent visualization of the articular surface, but also perpendicular approach to place fixation. The incision for the anconeus splitting approach is equidistant between the lateral epicondyle and the lateral border of the olecranon. As we flex the elbow, we can more clearly see the borders of the capitellum. Once the line is drawn, it's important to extend the elbow to make sure we have a linear incision. Once the capsulotomy is complete, we'll proceed with placing deep retractors so that we can flex the elbow to deliver the diseased portion of the capitellum into our operative field. A small Hohmann that is curved will be placed first laterally as we flex. We can begin to visualize the OCD. So now the elbow is hyper flexed, allowing the OCD to be fully visualized as well as perpendicular access to the articular surface. The Hohmann retractor is placed around the lateral edge of the distal humerus. We can place a small self retainer as well. Occasionally, additional exposure and access to the more medial portion of the trochlea is necessary, depending upon the medial extent of the OCD to provide additional access. The elbow and forearm can be supinated to cause the ulna to slightly subluxated at the level of the olecranon, providing additional exposure. With our retractors in place and the elbow in the flexed position, we have excellent exposure of the articular surface. We'll next begin with assessing the size of graph that is needed. This can also be estimated accurately from the preoperative MRI. First, a ten millimeter sizer can be used, and it seems that this may be a bit undersized given the size of the lesion moving up to the 12 millimeter sizer, this seems to provide adequate coverage to span entirely the OCD to normal chondral borders. Based on this, we're going to implant a 12 millimeter osteochondral allograft while holding the 12 millimeter alignment rod perfectly flush to the articular surface of the capitellum. My assistant will next insert the 2.4mm guide. Pin. With the guide pin in place. We'll proceed with the recipient site preparation. Next, we'll ream the recipient site using the eight millimeter deep, 12 millimeter diameter single use OATS reamer. The guide pin can next be removed. We'll lavage the recipient site removing the preparation reaming Readings from the field. To improve the biology and aid in GraftNet Corporation, it's helpful to use a small wire to drill the base of the recipient site. We can check the recipient site for any remaining bone debris or chondral flaps, just as shown here. After completing the recipient site preparation, we've measured and cut the graft to the appropriate length. We've lavage the graft to remove any remaining cellular elements, and we used a small arranger to bevel the leading edge of the bony portion of the graft to aid graft insertion. We will now proceed with implanting the graft. Once the graft is fully seated, we can take the elbow through a range of motion followed by lavage of the wound. Capsular and anconeus repair, and skin closure.

Riley J. Williams III, MD, (New York, NY) provides a cadaveric demonstration of a cartilage restoration procedure using 16 mm precut osteochondral allograft (OCA) cores. Dr. Williams highlights the single-use Allograft OATS® instrumentation to prepare the site for placement of the 16 mm core. Dr. Williams also shows a technique for implanting a second 16 mm OCA core next to the primary repair.

Allograft OATS® Technique Femoral Transplantation Using a Fresh, Precut 16 mm OCA Core

This is Doctor Riley Williams from the hospital for Special Surgery, demonstrating the technique involved with the placement of precut 16 millimeter osteochondral allograft cores. This is a right knee, and we will be doing a medial femoral condyle osteochondral allograft transplantation including the dissection. So here we have our right knee marked out here. I usually do a small patella incision starting from about the midpoint of the patella going down to the anterior aspect of the medial tibial plateau. So we make the cut incision wise at the skin. Come down here and then subsequently do a sub-q dissection to facilitate exposure like so. You can use a Mets or a knife for this as I'm doing here. I would suggest the first few times that you're doing this, you make your incision a little bit bigger as you get more comfortable with the instrumentation in the approach. You can progressively make it smaller. Here's our sub-q dissection. Patella is up here. And this is the soft tissue and the quad insertion here. So we basically just kind of come down as you would any other arthrotomy again down to the level of the tibial plateau. I will usually then right away excise whatever fat pad is existent, just deep to the arthrotomy to facilitate two things. Number one exposure. Number two, I am a big proponent of excising the fat pad because I do believe with these arthrotomy procedures there is the potential for scar formation, and that this tends to decrease the likelihood that that's going to occur. So we have our medial femoral condyle exposed here. As you can see in this position right here we have a what would be a typical full thickness articular cartilage defect of the weight bearing aspect of the medial femoral condyle. So this defect is going to size around 12 to 15mm. As you can see here from our interop measurements. Perfectly ideal for a 16 millimeter core and a single placement. So what I've done is to take the instrumentation from the set and mark it. So I've taken a purple marker and mark the circumference of the base of the death measurement portion of the multi-purpose tool from the 16mm set. In order to help me do my pre-drilling planning and we put that over the lesion like so, and it gives you a rough estimate of where your graft is going to be placed and whether or not it'll be sufficient to cover the affected area. So at this point you use the same tool and you place it over full thickness cartilage defect in this manner here. And then with the other hand place a pin through the center aperture. The main issue with this portion of the case is that you want to make sure the tool is placed flush in a perpendicular. On the. Articular surface, like so. Usually you would put that in approximately two centimeters. So this is the 16 millimeter three prong reamer as you can see. And it is equipped with the depth measurement. I would say the precut cores come anywhere from 10 to 12mm in length. I would recommend, before you do the reaming portion of this case, that you check that and verify the depth so that it corresponds to the host defect that you're going to create here. So I've already precut the cores here today to approximately ten millimeters in depth. I'm just verifying that circumferentially around the defect using the depth measurement here. So a little bit more grain. Okay. At this stage you can take the depth measurement off the alignment rod just to verify the depth of your defect. And again we were estimating a ten. And you can literally spin this around within the substance of the defect to verify your depth. So at this point you would remove the center guide pin. I would typically at this point in order to facilitate base of lesion Bleeding. Do a little bit. Of. Drilling here. This serves two purposes. Number one, if you're a little shallow with your defect, this allows some compaction of bone at the base of the host defect to allow you to get your graph flush. It also stimulates some base healing, especially if you're dealing with a situation that involves AVN or Osteochondritis. Dissecans. So for those of you who wish to do this Arthroscopically, this set does come with a tool that will facilitate placement of a graph through a more fine or smaller exposure, but this also serves to handle the graphs as well and facilitate placement. Whether or not you're doing the procedure open or arthroscopically with regards to approach. So here is our precut osteochondral dowel. Again, precut this to a ten. So then you would literally take the precut osteochondral graph and place it within the substance of this graph delivery tube. I would suggest that you extrude a small portion of the bone through the base of this prior to Prior to placement, then impact the graph partway into place, leaving it slightly proud. For fine tamping and tuning, I usually will displace my tamp halfway off the substance of the graft so that I don't over impact it into place. This is our final placement of the Osteochondral graft. The graft is flush inferiorly and superiorly. A small amount of superior displacement here, laterally or centrally, depending on how you want to describe it. Medially there is a small area of 2 to 3mm of non constraint over about a 10 to 20 degree portion of the circumference, which is fine. This is a nice stable graft which would then facilitate the appropriate rehab, which in my case usually means a one week toe touch weight bearing and then one week on crutches transitioning to full weight bearing by week three. So this is a continuation of a demonstration of placement It for the 16 millimeter precut osteochondral allograft cause. The majority of these ChondroGuard lesions, especially on the weight bearing aspects of both the medial and lateral femoral condyle, are more long than they are wide. So I say typically the use of two 60 millimeter cores can cover an area of up to 32 to 34mm, top to bottom, and obviously 16mm in width. A side to side placement of two such grafts should be able to handle the vast majority of these symptomatic lesions, in most cases in a symptomatic osteochondral defect in any given knee. So we've already placed here one graft as demonstrated earlier. So we're going to do another graft inferiorly to it here to demonstrate the technique. So the main technical point of placing two of these graphs is to leave approximately a one millimeter bridge between the two graphs in order to facilitate graft fixation and integrity. So you can see here we've placed one on the central aspect. And now we're going to place a separate graft inferiorly and repeat the technique which is to place the alignment guide into the appropriate position. Drill with a guide pin. We would then, after having already placed the first graft and place the second one. Depending on the convexity of the condyle, you may actually drill into a small amount of the base of your first graph. So I would recommend that you do just like you saw me here, which is to hold the graft in place during the remaining portion of the case. And much like before, then you take your depth measuring stop, put it in and measure it again. That comes out to roughly a ten. Most of these cores will be cut somewhere between 10 and 12. Just verify that before doing your host defect Creation and use. Arranger. Another fine guy to remove any excess cartilage that may be found around the rim. Again, we take our precut core, extrude a small amount of the bone out through the base of the core to facilitate placement, and this allows. Impaction of the core into the host defect. Once you've placed the inferior graft or the second graft, go back to your first graft and just again, make sure you're comfortable with the ultimate depth and placement of the graft. And here is the final placement of our two osteochondral grafts placed adjacently. Please note that there is no structural encroachment of one graft on the other. So again, with regards to planning the two, just be sure that there is a 1 to 2 millimeter bridge between the two marked areas of reaming. Once you've placed the first graft.

Brian J. Cole, MD, MBA (Chicago, IL), provides a demonstration of the Allograft OATS® instrumentation and disposable kit features and benefits. Several technical pearls are included, as well as an introduction to a new vice workstation and additional accessories provided in the instrument trays.

Advancements in Fresh OCA Techniques and Instrumentation

This is Doctor Brian Cole. I'm a professor in the department of orthopedics at Rush University Medical Center and Midwest Orthopedics at Rush. This video segment features a disposable osteochondral allograft system to be utilized for fresh osteochondral allograft transplantation. Historically, my treatment algorithm has evolved over the last 20 years. Most of us utilize cartilage restoration procedures in a demand match approach. We take into consideration several factors, including the activity level of the patient, their expectations, their meniscal status, alignment, and ligament status. Over the years, we've learned that osteochondral allograft transplantation is a procedure that can be performed at virtually any location along the femur and the patella. Historically, the femoral condyle was our location of choice for osteochondral allograft transplantation. Over the last 5 to 8 years, however, we've become very comfortable with the Osteoallograft as a primary treatment or revision treatment for the trochlea and the patella. I am pleased to provide an overview of the recent advancements in instrumentation to assist fresh osteochondral allograft procedures. While several techniques and technical pearls and steps are maintained from the legacy approach. There are important updates to the recipient as well as the donor side of the procedure. These updates include the launch of disposable kits to ensure sharp reamers and provided in every case, as well as the new instrumentation provided by Arthrex in the Arthrex Allograft OATS tray. As is typical with any fresh osteochondral allograft procedure, the use of allograft OATS sizer tubes remains the first key step. Typically, I use the allograft OATS sizers to measure the defect and donor allograft to ensure the appropriate plug or plugs may be recovered to treat the entire cartilage defect. Today, we will feature the components necessary to treat a 20mm donor site and corresponding plug to ensure sharpness and a perfect cut every time. New disposable kits are available to accommodate recovery and implantation of each size of the allograft. Oats plugs. These range from 15 to 35mm in diameter. Included in the kit are the following components a 2.4mm guide pin. An OATS harvester. The recipient size reamer with a new depth stop feature a 0.045in guide wire that may be useful for ensuring stability of the graft or to aid preparation of the OATS plug. Of specific note in this kit is the updated recipient site reamer and depth stop feature. Previously, one challenge we experienced in the past when preparing the recipient site was reaming to our desired and specific depth. Oftentimes, when the cortical surface was breached, the reamer would actually go to a depth that was undesirable. Now, with a depth stop, it's much more predictable in terms of determining the desired depth. Doctor Gamal, our research team and others have shown that the appropriate depth of the recipient site is ideally greater than five millimeters in depth, but certainly no more than 9 or 10mm in depth. Ideally, we try to use the least amount of bone to get a stable interferential fit to ensure we achieve our desired depth, as demanded by this recent literature, as well as by the amount of bone involvement. According to the MRI, the depth stop feature you see here dramatically improves our ability to control the depth of the recipient. Site. Preparation. The depth of the reaming cut can be selected by advancing the reamer beyond the depth stop feature to the desired depth. And as you see here, securing this wing nut assembly and tightening it appropriately when reaming over a 2.4mm guide pin. We now have the confidence that the resulting depth of the recipient site will closely match that of the defined depth of the reamer. Of course, it does remain important to confirm the depth of the recipient site. The new measuring tool provided in the instrument tray is a simple approach to do so, and is used in each quadrant of the recipient site to confirm the depth. I typically measure the depth at the north, east, south, and west aspects of the defects and have my surgical assistant take note of these measurements so we may later reference them when preparing the allograft plug. Moving over to the updated workstation, it's immediately apparent that significant changes have been implemented by moving to a Vice concept. Arthrex can better provide a workstation designed for malleting procedures, such as when creating the BioUni or the BioPatella implant, while also providing the necessary fixation of the allograft for standard OATS or cylindrical plug procedures. The legacy features of the boom arm and clamp assembly have been maintained. One important note, though, is that there are now several points of fixation of the boom arm to various positions on the vise workstation. Typically, I would secure my allograft in a stable position and then assemble the assemble the boom clamp as needed to achieve my desired approach. Today I'll assemble it in this position on the vise for demonstration. The vise workstation has additional features and benefits worth recognizing. For instance, knurled straight plates and Velox are provided in the instrument tray to accommodate a variety of allograft types and to ensure stable fixation. Additionally, one half inch spacers are provided to elevate the graft. When needed, these are available in both rectangular and square configurations. And to further ensure stability of the allograft, such as in the case of securing a telegraphed, a slot has been designed into the side of the workstation to allow a 0.045in guide pin from the disposable kit, or 0.062in guide pin from the allograft workstation tray to be driven into the graft and prevent any graft migration. Also, the workstation has flat features to accommodate a cutting plane when recovering allograft cores. One can see how quickly and easily graft fixation and recovery may be performed using the new and updated vise workstation. Once the desired allograft plug has been recovered, classically, we've been able to use the forceps to trim the plug to our desired depth. Of course, this option has been maintained in the in the updated system, but alternatively, the new instrument tray does offer several new components to provide an additional option. Leveraging the depth stop feature we observed being helpful for the recipient site preparation as well as the depth stop seat from the instrument tray. We can use these components to trim the height of the plug to a desired length. To do so, disassemble the depth stop feature and reassemble this with the depth stop seat. Then add the appropriate cartilage Protector pad from the instrument tray. By placing the allograft plug cartilage down and adjusting the assembly to the desired depth. We can then secure the assembly in the vise and then cut the plug to the specified length. This will incorporate the flat cutting plane shown here. The 0.045in guide pin from the disposable kit may also be used to fixate the allograft plug if desired. Alternatively, the allograft OATS sizers may be used to compress the graph down while trimming the allograft plug to the desired length. These updates and more are provided in the new Arthrex Allograft OATS instrumentation tray in disposable kits. Thank you.

Brian D. Giordano, MD, (Rochester, NY) outlines 2 different cases and his rationale for using various surgical techniques to treat cartilage defects of the femoral head. In this case presentation, he describes his reasoning for using biocompression screws to refixate the cartilage versus implanting an allograft femoral plug using the allograft OATS® system.

Allograft OATS® of the Femoral Head

Options for biologic resurfacing of the femoral head have grown in scope and capability over the last few years. In this case presentation, we're going to talk about a couple of representative cases that that highlight some of the options for femoral head lesions. The first case is a 16 year old soccer player with with more than five years of hip pain, largely activity related. He had previously undergone a hernia repair. He had been diagnosed by various providers over the years with a series of hip flexor strains. The athlete was having concomitant mechanical symptoms and catching and locking. He was unable to participate in more strenuous forms of physical activity, and his his love for soccer was precluded by his pain. Also present on an AP radiograph was associated acetabular dysplasia. So this patient had a combined series of pathologic abnormalities of both proximal femur and acetabulum that mandated treatment at our hip preservation program. We Program, we obtained some advanced imaging which documented evidence of evidence of deterioration of the articular cartilage of the femoral head with some subchondral bony changes. And you can see on these these imaging studies that there's evidence of, of avascular necrosis or osteonecrosis without collapse. Overall relative preservation of joint space and some associated labral tearing on CT scan. There was evidence of even more cortical irregularity. So the decision was made to proceed with vessel sparing surgical hip dislocation. Due to the size of the Legion and the need to geographically address all aspects of the femoral head on entry into the joint. There was evidence of a large focus of avascular necrosis, but with overall preservation of subchondral bone. This bone was found to be have good vascularity with with ample opportunity for healing, because the overlying articular cartilage was well bonded to the bone. The decision was made to proceed with open cannulated compression screw fixation. Station. So using Arthrex bio compression screw fixation strategy, a series of three pins were placed into the. Into the different geographic zones of the lesion, and three bio compression screws were placed into the femoral head. Applying excellent compression and opportunity for for healing because of the location of the lesion, the relative acetabular dysplasia decision was made to proceed with a pelvic osteotomy to protect the repair. This patient did very well, had an excellent surgical outcome, so the decision to proceed with osteotomy osteochondral repair or fixation is largely predicated on whether or not there is viable subchondral bleeding. And in this case, there was. Supported the contention and the strategy for primary fixation versus graft restoration. There needs to be a healthy articular cartilage surface, and the geographic lesion size is usually greater than two centimeters squared. In some cases, staging with arthroscopy can help to determine whether a graft should be available at the time of open surgical approach. The second similar case, approached with a very different strategy, was a 24 year old had experienced more than ten years of pain that was severely limiting ability to participate in recreational activities and many work endeavors that were required for employment. Interestingly, she had a strong family history of acetabular dysplasia and idiopathic osteoarthritis. Early hip replacements. She had significant physiological laxity, but also had evidence of significant capsulitis and restricted motion in the extremes. On her false profile radiographs, you see evidence of anterior undercoverage with some early degenerative changes and subchondral sclerosis, but overall joint space was well maintained. Advanced imaging and MRI, as well as CT scans were obtained documenting parafoveal lesion of osteonecrosis. This is documented in multiple multiple planes and on axial views. You can clearly see the location of the lesion. So with relative preservation of joint space associated acetabular dysplasia, early degenerative changes in her young age, and excellent physical and athletic health, the decision was made to proceed with surgical repair. So the patient in this case underwent osteoarticular allograft transplantation using the Arthrex allograft OATS set, as well as a acetabular osteotomy. So a surgical hip dislocation enabled us to achieve excellent geographic exposure of the femoral head that allowed excellent compression graft fit. No additional fixation was required, and because the graft showed evidence of of edge loading, pelvic osteotomy was used to to correct the underlying anatomic instability. So the decision to proceed with an allograft OATS in this case was predicated based on the lack of subchondral bleeding, the need for a large structural solution to to the lesion. The defect size was was large. There's obviously no donor site morbidity. The graft is available quite, quite readily because of the technical aspects of the Arthrex allograft OATS system. The graft is press fit and doesn't require any additional fixation. You retain a hyaline cartilage surface, and although the stakes are stakes are quite, quite high in margin for error low. This provides excellent contour to the femoral head. Excellent subchondral support. But be aware that the indication for the procedure may vary based on the the underlying morphology. If this is a steroid induced osteonecrosis, some small series have shown a higher failure rate than when the avascular necrosis is non steroid induced. These are typically done quickly, so once the graft is available, we usually call the patient within about five days to perform the procedure to retain as much cell viability as possible. So in brief the technique relies on a docking system for procurement of the donor graft. There's a sizing guide that is slightly different. Diameter. Some fixation pins are placed. A scoring reamer is used to achieve the preferential size of the graft. The femoral head is then cut, and we use a fresh femoral head allograft. Using different geographic sizing methods and points of orientation that are fixed and marked. The graft is cut to an appropriate depth that's going to match the recipient site. Once you have a nice plug that matches on all sides, you then turn your attention to the to the recipient aspect of the femoral head where the lesion is. Using a marker or an outline with a template to define the zone for the donor. This is then pinned. Scoring. Reamer is used to outline the borders, and then a hand driven coring reamer is used to core down to a base of bleeding subchondral bone, usually anywhere between 6mm to 10mm. With the pin in place, we usually microfracture or drill into the base of the bone for additional bleeding, and once we have a nice recipient cavity, the donor plug is inserted. It is gently tapped in place. Intraoperatively. The decision is made to proceed with additional adjunctive measures, such as BioCartilage, to enhance the biologic activity of the of the graft interface, and potentially provide a more favorable opportunity for for integration of the graft. Thank you.

Jeffrey Macalena, MD, (Minneapolis, MN) presents a case study on a patient treated with distal femoral osteotomy, meniscal allograft and fresh osteochondral allograft.

Distal Femoral Osteotomy with Meniscal Allograft and Fresh Osteochondral Allograft Transplantation

Hi, my name is Jeff Mikulina from the University of Minnesota. I specialize in sports medicine. Today, I'd like to talk to you about a case of mine that I think brings up a couple of different interesting topics. It's that of a 32 year old male. He underwent an ACL reconstruction about ten years previously. And at that time, a large lateral meniscectomy was performed. He's done well in regards to stability of his knee and he has not had instability symptoms. He was referred to me to see if anything else could be done for his knee, as it certainly is affecting his desired activities. Plain radiographs show prior ACL tunnel in reasonable position without significant dilation of his tunnel. Lateral joint space narrowing is subtly appreciated in these plain films. An MRI shows an intact ACL graft. However, considerable wear of his lateral femoral condyle with subchondral edema and cyst formation is noted. Where are the cartilage surfaces on the lateral department is also present. Standing alignment films demonstrate subtle genu valgus, with the weight bearing axis falling lateral to the lateral tibial spine. In patients like this. With such complex histories, I frequently offer them staging arthroscopies to fully identify and understand the intra-articular components of their knee. Further, it allows for a detailed examination under anesthesia to check for his ACL graft function. Here, arthroscopic images show an intact ACL graft and his knee was stable on examination. His lateral compartment, though, shows profound wear of the distal femur with significant change in the normal contour. Note that the tibial plateau surface is largely maintained. The lateral meniscus is certainly deficient as seen in these arthroscopic images. Given this patient's profound amount of wear to the compartment and continued pain, we ultimately offered him surgical reconstruction and cartilage reconstruction in a technique of joint preservation. Our thoughts for this were to offer him a meniscal allograft transplant to improve the transfer of forces across the knee joint. We'd also plan to resurface his lateral femoral condyle with an osteochondral allograft at the same time. At the conclusion of those intra-articular procedures, we would then perform a distal femoral osteotomy to unload the lateral compartment. The next step is how to manage the timing of it during the procedure itself. And here's this process that I follow. I first perform an arthroscopy where we prepare the intra-articular structures for the meniscus transplant. To do this we use a FlipCutter. I use a seven millimeter FlipCutter to drill both the anterior and posterior root attachments, and we make a seven millimeter socket. I do this to about 20mm in depth. We then use number two FiberStick to place through these sockets to allow for placement of our graft. After preparation of the intra-articular structures for the transplant, I then perform an open arthrotomy of the knee and complete the osteochondral allograft. After the osteochondral allograft is in place. We then return and place the meniscus transplant and suture it in place with an with an inside out technique. At that point, we can close the arthrotomy and proceed with our distal femoral osteotomy. One of the techniques that I use for the distal femoral osteotomy is to preoperatively plan the size of the correction to help determine which contour lock plate we are going to use either the small or the large. The ContourLock plate with the cloverleaf design here is low profile in nature, and I think has left soft tissue irritation on the lateral side. After isolating our surgical incision, the ContourLock plate is then placed on the bone to help determine the level of the osteotomy. Two guide pins are then placed above and below the plate, and it's very important to ensure that these guide pins are collinear with the long axis of the femur, so as not to flex or extend the osteotomy. After the guide pins are placed across, the osteotomy is completed on the lateral cortex with an oscillating saw and then further with an osteotomy after opening and then final fixation. The radiographs show good position of our osteotomy plate and screw construct. Note the position of our osteochondral allograft on the lateral femoral condyle. Restoring the normal subchondral line. A final tip is to use an alignment rod intraoperatively to confirm the amount of correction. To do this, I take an AP X-ray of the hip end of the ankle with our long alignment rod centered over both these joints. Then, by transitioning to the knee joint, we can see where the alignment rod passes the knee joint, confirming the correction of the appropriate amount. This patient was admitted to the hospital and we did put them toe touch weight bearing for the first six weeks to protect both our allografts as well as our distal femoral osteotomy. At the six week mark, we will allow weight bearing as tolerated and a slow progressive range of motion. I think that this surgical technique and treatment of both the intra articular pathology, as well as the malalignment, is a way to potentially restore his desired activity level and get him back to doing the things that he wants to do.

Allograft-OATS®, groß

Child (D)

Das BioPatella-Instrumentenset ist der neue Standard für die Rekonstruktion der Gelenkfläche der Patella bei länglichen Knorpeldefekten, die einen erheblichen Anteil der Patella-Gelenkfläche umfassen. Mit einer Auswahl an präzise konstruierten Schneidinstrumenten kann der Operateur beschädigten Knorpel mit einem einzigen ovalen Stück vitalen hyalinen Knorpels ersetzen. Die BioPatella-Instrumente wurden entwickelt, um die natürliche Krümmung der Patella nachzuahmen und so die gesamte funktionelle Gelenkfläche zu rekonstruieren. Verschiedene Größen geben dem Operateur die Flexibilität, die Breite und Länge des Knorpeldefekts anzupassen und die richtige Rekonstruktion der Gelenkfläche mit einem einzigen osteochondralen Allograft zu erreichen.

BioPatella™ OATS® System

Thomas M. DeBerardino, MD (San Antonio, TX), introduces the BioPatella™ OATS® surgical technique. The BioPatella instruments allow the preparation of oblong osteochondral allografts to treat large articular cartilage defects in the patella.

BioPatella™ OATS® Technique

We're going to perform a fresh matched for size osteochondral allograft, oblong in nature or oval in shape to replace the cartilage in this right knee. So here we've done a midline straight anterior incision with a medial arthrotomy enough to allow us to flip the patella on axis. And in this case it sits nicely in the rotated view. And now we have easy access to the entire surface of the patella. You can see here we have generic large high grade patella. And in this case we do have a small trochlear lesion which we could manage. And these sometimes come up on you if it's 3 to 6 months out from this original diagnostic scope where we would classically scope the knee and then indicate the patient for cartilage restoration surgery. And in my hands, with the patella, it's almost always a match for size. Mega patella osteochondral allograft transplantation. So now we have a new set that's going to allow us to replace pretty much the entire biologic working functional surface of the patella with an oval graft instead of our standard round graft. And you can see on this patella there's equal medial facet central and lateral facet where. So it would be nice to put pretty much an 80% fill with a large oval osteochondral allograft instead of cheating toward the medial side or just doing the lateral side and leaving the medial side, there's a new set of instruments that allow us to fashion an oval graft on the recipient. We have three guides. The first size is a 20 by 30. You can see it's oval in shape. And that's going to be the downside on the patient's patella. And we simply use the best fit size to best fill the bulk of the patella lesion that's in front of us on the patient. So this is the small 20 by 30. The next size up is the 25 by 35. And you can see that that does a good job of basically filling the Incipient problem or high grade cartilage lesion. We can show you what a large size looks like. And again this is 27.5 by 37.5. And oftentimes it's just a little too big. But for the very large patient it's good to have this one. In this case I could actually maybe squeeze this one in. But then it goes down to the fact that you now have to also deal with the fact that you've matched for size a fresh patella. So you have to make sure that the donor plug is obtainable to match the recipient socket. And in this case, we're going to say that the biggest plug we can get from our donated patella is the 25 by 35. So we're going to make this work and center it up. Some patellas are more flat and some are more concave with a steep medial ridge. This one, as it sits here now because of advanced wear, is more like the flat patella over here on this diagram. We also have on the field already our donated patella. And this one actually is more on this Perspective more like a high ridge patella. So we know that in fact, when we replace the biggest plug that we can get, which is the 25 by 35 oval plug in this recipient socket that we're about to make, that this new patella is going to have perhaps a more normal ridge or central ridge. So it may be more prominent centrally at the 12 and 6:00 position. But that's okay because this will be functionally the new patella contained by the recipient socket, as we'll see in a couple of minutes. So with this offset guide, we can use these different little offset pins that screw in to offset to kind of make sure in the medial to lateral plane we get the right pitch and yaw. In this plane we've got good control here. This is pretty standard and not a lot of wear from top to bottom. It's that medial to lateral wear that we want coplanar with the axis or the equator of the patella. Now we're going to introduce the patella resection clamp. This has a base circle that's going to go on the back side of the patella, which is the back side of the the anterior part of the patella, the non-articular side. We have to dissect enough proximally and distally to get this clamp in. These sharp teeth are going to try and clamp it with the saw blade slot at the equator of the patella. So we get to, as the surgeon align it with this kind of role. And this a little bit of role to get it to match right along the equator of the patella. So that looks like a pretty good match. When I look at the equator of the patella from medial to lateral, I have matched the rotation in both planes, both proximal and distal and medial to lateral. This stylus here is adjustable through a click here, with a readout in millimeters through the small window here on the side. And this right now is set to. Nine millimeters. And we do that by taking the best looking central ridge highest part of the cartilage which is usually proximal and distal, and we set it off of that to know how much patella is left between the equator and the dome of the apex of the central ridge. So we clamp this in place with a good click, and that holds it. Now we have good control of the patella and it's not going to go anywhere. And it's its own separate platform. My system will hold the patella while I bring in the guide. And again we're using the 25 by 35. So we want this to match the plane of our clamp. So I can roll it lateral I can roll it medial. So it's just a visual check by the surgeon. We want to center it up. We're going to first mark with a marking pen. Our central ridge the 12:00 the highest point of the patella 12:00 and 6:00 noting that it's not truly like this plane because when we roll the patella, it always rolls off to the more proximal, lateral and distal more central. So that's the plane of our patella from proximal to distal 12:00 3:00 as we look at it, 6:00 and 9:00. And that will be important when we do we do our quadrant depth measurements. So we want to center this guide the 25 by 35 guide on the lesion. And we're just making note mentally of whether this central part, which has a little notch on it and a black laser mark is medial or lateral to the 12:00 position. In this particular patient I'm going to center it right up. So 12:00 is 12:00. And it's not offset medially or offset laterally. Its center of mass on the central ridge, which will be important. We'll match that on our donor patella on the back table. So now I'm going to use these guides to take off the the woggle. I bring this pin down. And when it touches the cartilage that gives me a stable platform through which now I can drill my guide pins, which are 2.4 guide pins, one short and one long. We'll drill the short one first and then the long one. We're actually going to only drill one pin at a time, because the offset of these pins would interfere with each of the of the round drill holes that we'll use to communicate and thus create our oval socket. So we'll pin the short pin in first, and we go bicortical on this because we definitely want to get good purchase. So our first guide pins in place, we check it and make sure we're happy. We like what we've done. We take the guide off. So this is our depth stop or hard stop reamer. So it's got this wing nut that you can see I'm going to spin back. And now the depth stop is this outer ring. And I'm spinning it back. And you can see the blade start to deploy. So I'm going to set it by making the reading right on the blade. The blade has markings of five all the way up to more than ten. And usually these are no more than ten. And we don't want to over resect bone initially. We can always go back and take more. And then we hold the cylinder, the depth stop part and we tighten the wing nut. So now we load this calculated depth stop reamer under our pin. Making sure our assistant's holding that stable. That is our working base platform. And like all reamers, we want to come in like it's a lathe. You'd never start your lathe at full speed touching the the wood. And in this case, the patella. So we come in at high speed and we just tap down until we get a good solid. So now that we're at depth, we can take the reamer off the guide pin. The guide pin should stay in place because we use it now to offset our second guide pin, which we couldn't put it at first because it's going to be actually inset into the first reamed hole, which would have been impossible to do if the other pin were already placed. So before we take this pin out, we'll put the longer pin in and go bicortical again to capture that second cortex. So both pins are in place. Now we pull the first pin. The guide comes off and you can see that second pin is inside the first reamed socket or the first round circle. So that couldn't have been pre-placed only now. So now we use the same depth. Stop hard stop reamer. And that's down to good bone now. So that's nice. And that's a good depth. So there you can see our depth of the socket on the shallow side is a couple millimeters of bone. That's all we want. Here we have our donor patella. We're going to try and match our central ridge just as you're seeing it here in this shot. We're going to bring our guide in over to the side. So here we are using the patella resection clamp. Once again on our donor patella we have better access to the equatorial cut, which in a standard patellar arthroplasty would be the center line cut down the equator of the patella. So this instrument is key in this fashion, because remember when we said this is a particularly steep central ridge as opposed to a more flat patella due to wear and tear on a recipient or patient. So here we're going to still match our equatorial clamp so that we're going across medial to lateral and proximal to distal across the central midline equator of the patella. And now we have good three dimensional control of our patella as we bring our saw and make a sagittal cut across the patella. Now we're going to use what I would call a cookie cutter technique. We're going to take out a matched oval plug and cut away the ring. We're going to do that with a oblong cutter that matches the 25 by 35 oblong size that we made for made for our recipient socket. It's got a nice grommet in the center point so we can push our plug out as it will be. Press fit in this cookie cutting device. So we're going to bring this guide, this cutting guide in centralized on the central ridge as we discussed earlier not medial not lateral but centered up as best we can. And we're going to cut flush to the table because that's our predetermined planar cut to get the best graft to match the recipient socket. So we match it up in all planes, get a good solid, firm grip on it, and with the flat, firm surface of the plastic working table, we won't skid across it. I'll give it some light taps to get a good purchase, and then go in more robustly to cut through. Save the central oval plug and cut away the perimeter. So we're going to press fit out with that grommet using this screw in handle holding firmly and this will deliver out a traumatically our osteochondral oval plug. You can see it pushing out a traumatically through the plastic grommet. So approximately at the 12:00 position looks like it's right at one. So we're good there at the 9:00 position, we're supposed to be at seven, and we're right at seven. At the 6:00 position of the central ridge, we're right at one centimeter. So we're going to keep that. And then at the 3:00 position, we're supposed to be at five and we're at four. So this is an excellent opportunity to add a little bit of DBM as a bone void filler. Here we've used the PowerPick to make small RetroDrill holes. So here we use a PowerPick drills. As importantly in the donor plug. Now we're going to add our biologic autologous conditioned platelets or PRP by dripping it into the sockets. It'll reverse capillary action drip into the interstices of this plug, thus adding a nice biologic. Sometimes my preferred technique and really hard bone is to just use a little rongeur, just to curve the edge just a little bit, to get rid of that sharp edge that catches on the recipient cartilage. So now we've measured our plug. And remember this side at the 3:00 position is five. But on our plug it's only four. So we're going to remedy that by adding some bone void filler. And in this case it's going to be our demineralized bone matrix or DBM. We'll drip a little bit into most of it. But then at the 3:00 position we're going to add a little bone void filler again. And I'm going to just put a little smear of it. And then literally the best instrument here is the gloved finger. It just pushes it into the corner. And then this is going to layer out like a good putty laying down tile to give us just enough a little bit backside elevation to make our graph sit smoothly on the articular surface once we place it. So now matching 12:00 to 12:00, we're going to bring our plug up and we're going to get ready to press fit it. So there's two options here. We can key it in. Sometimes it's such a tight tolerance that we want to get it seated, usually at the 12 and 6:00 position to get a good hold on it. But then there's the lateral tilt. That's possible. So we like to hold it and see if it'll just wiggle in. In this case I think it's going to and I'll just use press fit technique. Take off any extraneous DBM that might come out like cookie dough. And here we have a very smooth articulation of our new patella in all planes. So what we do clinically now is we would rotate our patella back. We take two clamps and do our temporary arthrotomy closure and make sure we're not only tracking well, but that we have a good glide and smooth articulation between the patella and trochlea throughout an arc of passive motion.

Thomas M. DeBerardino, MD (San Antonio, TX), provides a technical overview of the BioPatella™ instrumentation and surgical technique.

BioPatella™ Graft Technique Tips and Pearls

Hello, I'm Thomas Diberardino from San Antonio. Today our purpose is to go over the new BioPatella instrumentation and most importantly, to go over key pearls. We've learned to assist with the introduction of this new approach. It comes in three sizes. They're available in different disposable kits the 20 by 30, the 25 millimeter by 35 millimeter, and the largest 27.5mm by 37.5. That covers all the patella lesions that we've seen. The most commonly used sized will be the 25 by 35. In fact, this is an example of the small kit. Here we have our cutting saw the depth stop reamer. The oblong cutter with its already pre-positioned cartilage protecting grommet and its depth limit is 12mm due to the placement of that important grommet and then the short and long pins. So the surgeon's first order of business is to ask to have the allograft OATS harvester set opened. Within that set you'll find the three sizing guides the small, the medium, and large. And these correspond to the disposable kits. So once the surgeon decides what's the best fit guide, then the corresponding disposable kit is opened. Within that set also is the leveling pins. These help you maintain that horizon of the equator of the patella to kind of pivot and pitch and rotate and slant or angle perfectly the guide. So the surgeon's not holding the guide in space, they actually have a stable platform to begin the surgical process of pinning it in place. And then using the depth stop guide reamer. Also, within the allograft OATS harvester set, you will find the patella resection clamp. It's got sharp teeth on it, so be careful. It's got a cradle that holds the back side of the patella. Next, the surgeon will ask for the BioUni tray. From that tray they'll find the find the gold handle, the quick connect handle, the extractor pin which goes into the oblong cutter to help remove the plug of the donor cartilage safely through the grommet. Also within that tray will find the instrument to help remove debris and residual cartilage and bone from the base of the recipient socket and the cartilage curette to fine tune the edges of the recipient socket. The Quick Connect guide goes on to the sizing block. As any typical quick connect guide, a quick push and a release snaps in and it's ready for use. So here we have a right knee. So this is the perfect case for the oblong BioPatella graft. Here we've marked our center line the ridge line as we call it. And that's important. That's the reference point for everything for recipient and donor plug. So we've got our patella clamp. We've dissected off the soft tissue. So we own the equator medially and laterally to be able to bring in our guide. We slide it in. So in. So we freed up the soft tissue on the back side of the patella. And then we want to clamp it down slowly. And our depth stop guide is right there. So here we have the clamp in place. And we know our depth is the quad tendon in the patella tendon. But this kind of sets the platform for owning the patella as a stable base to now drill and ream. And here we have it clamped in place and we're ready to go. You can see we've pretty much recapitulated the horizon of this patella from medial across the ridge to lateral. And what we mean by that is that would be inappropriate if I clamped it like that. Just as that would be inappropriate. So we want to get it center center horizon to horizon. Remember, the purpose of this BioPatella is to basically be a total resurfacing in a sense of the functional articular aspect of the patella in the trochlea. So we're going to try the medium, which will be a better fit guide to maximally cover the cover the lesion and still have containment with the recipient. Patella rim of cartilage. And here we have that best fit. You can see the ridge line and I'm sliding along. It's hard to hold it into place. So now comes into play the all important leveling pins. So we're going to bring down the medial and lateral facet ones mostly. And notice I've centered it pretty much. This one is a good example of literally the guide is centered on the ridge line. You can see the blue marker below the guide as we bring down the leveling pins. And it negates the degree of freedom. So I don't have to hold this in place when we pin the pins right down the two center holes. So in this example of this right knee, you can see the marker for the center of the ridge line, absolutely coincident with the laser mark for the center of the oblong guide. So here we have our same patella in a right knee. And because it's kind of a centered lesion, I still think the rate limiting depth stop is going to be the lateral facet. So we're going to choose to put the short guide pin in the in the lateral hole first. All right. So with that pin in place now we take the guide off and we can see it's as planned. The lateral pin will obviously be lateral to the center line. But that's not the center of the oblong graph. So not to be fooled here we're going to remount initially to a seven and then incrementally go up because it's the rate limiting lateral of the set. Drill a little bit check drill a little bit more. Recheck. You may and not uncommonly drill three times for the rate limiting lateral facet in these cases. So here we'll remount to seven and then look in and check. And we'll use our little bone scraper and suction to remove the bony debris. All right. We're at depth now. And now we want to check with the bone scraper to get a good look in here. And we're looking at this depth here. And it's more of a visual check to see that I've got at least a millimeter or two of bone, so I think it's a millimeter and a half, it looks like. So we're going to step up just one. So you may go at a seven. And then gosh I should have just done an eight. Well you can't put bone back in. So it's always better to go seven and then eight. It takes an extra 30s as we're going to show here. So we're changing our guide to eight. We spin it back just one laser line from 7 to 8 and lock it down. And there we go. Very quick cut. And now we've got adequate bone. It's about two millimeters or just over two millimeters. And that's definitely adequate. So here's the cylindrical ruler that comes out of the allograft OATS workstation set. So we're using it to make sure this only gives you really the composite height. And that's five. So of that three is usually cartilage and two is bone. So this replicates what we talked about before. You want at least two millimeters of bone. And now I think we've obtained that. We've got two to 2.5mm of bone, and about five millimeters of total height is demonstrated by that first bold laser line. So we put our sizing guide back over the pin the lateral pin and the lateral hole. And you'll see here what happens. There's a little bit of wobble. So the pearl here is to adjust the lateral offset leveling pin down into the base. So conceptually we'll drop that pin down a full eight millimeters because that was the depth we just altered the height. So that gives it good stability. And now we place our second pin which is the long pin. And place this pin definitely before you take out the short pin. Because now everything is referenced off that first pin in our two circle plugs will be combined into the oblong recipient socket as the next step. So here we're putting our long pin in holding our position. And then we'll pull out the short pin. You can see why you can't replace both pins because of the shape and size. This guide pin certainly falls within the first circular ream socket, and that negates your ability to place both pins initially. That would be a mistake and it wouldn't let you proceed. So you'd have to pull it out. So now we're going to match our final reamed eight millimeters for the medial socket. And then they'll be at the same level. But we can do this all in one step. And there we go. We've got excellent containment. We've got just enough cortical bone over here and more than enough on the lateral side. We could go down one more millimeter together, but I don't think it's necessary in this plug. Here we are using the patellar resection clamp on the donor patella. So a couple key things. We've got the ridge line marked. Not so important here. It just lets you know where the distal and the proximal end is. This is the medial facet, which is how you'd approach the knee. So you want to clamp the patella both the recipient and the donor in the same fashion. This replicates the important aspect of clamping it at the horizon. And we'll have a best fit plug into the recipient socket if we stay true to the horizon. Now, an important discussion on the pearls of knowing and establishing that central ridge line on the patella. So the oblong cutter has three laser marks on it the center, the left of center, and the right of center. For descriptive purposes, because the key point for success is to make sure the ridge lines with regards to the center of this oblong graft are relatively the same. If it's center center, both the recipient and the donor plug need to be center center. So that takes us to the next problem potentially to overcome is make sure once the patella is exposed that you actually have the surgeon open the donor patella to make sure the planned placement of the cutter is tolerated, meaning we have enough cartilage real estate on the donor plug to match that relationship of Centerline to laser line relationship. That is critically important. So here we have an example of an extracted plug. And you can see the dot is the center of the oblong plug. So in harvesting this plug I can tell you that looking at it in retrospect this was a left leaning plug. So this is a center line. And most of the plug is from the lateral facet. So it more likely than not was tilted on extraction a little bit to the lateral side. Because if you look over here on the medial facet we've got only a millimeter or two of bone. This isn't seven millimeters of true thickness of cartilage because it's actually coming non-orthogonal to that surface. So it makes it look like an irregular patella, when in fact we probably harvested it with a little bit of lateral tilt, thus making us come up short with our bone extraction. On this particular example, in more than usual bone extraction on the lateral aspect, usually this is 2 to 3mm and this is 3 to 5, as opposed to this example where it appears to have been harvested more balanced. Again here's our center line. And our center point is probably right where my thumbnail is. And you can see now we've got less bone on the lateral facet and adequate to a little bit of bone on the medial facet. But it looks more balanced when you look at it from the side, as opposed to this one that has much more bone on the lateral side and minimal bone on the medial side. So that's why it's very important at the outset to get as orthogonal or perpendicular to the horizon as possible.

BioPatella™-OATS®-Instrumentenset

Das BioUni-OATS-Instrumentenset ist der neue Standard für die Rekonstruktion der Gelenkfläche bei länglichen Knorpeldefekten im medialen Femurkondylus. Mit einer Auswahl an präzise konstruierten Schneidinstrumenten kann der Operateur beschädigten Knorpel mit einem einzigen ovalen Stück vitalen hyalinen Knorpels ersetzen.

Arthroplasty Knee

BioUni® OATS® System Surgical Technique

The BioUni® OATS® surgical technique is the new standard for restoring the articular surface of elongated cartilage defects in the femoral condyle. Through a series of precisely designed cutting instruments, surgeons can replace the damaged cartilage and bone with a single, oblong osteochondral allograft.

BioUni® OATS® Technique for Femoral Condyle Osteochondral Defect Restoration

The BioUni Osteochondral Allograft Transplant System provides a new and effective treatment option for elongated defects of the articular surface. Choose a sizer that fits best over the defect area, and mark the area to assist in identification of the restoration area. The sizer is then placed on the surface of a fresh osteochondral allograft, and advanced over the surface to locate and identify a flush fit. Once the harvest location has been identified and marked, the allograft is secured. In the allograft OATS workstation, an oblong cutter and insert are acquired from the instrument tray and assembled. These instruments are placed over the marked area on the allograft, and a Steinmann pin is advanced into the guide pin hole and through the allograft. The impactor handle is attached to the oblong cutter, and the assembly is advanced into the allograft cartilage and bone to the appropriate depth. The impactor handle is removed and the Steinmann pin may be removed. Alternatively, the pin may be utilized in the following steps to aid alignment when recovering the allograft. A distractor tool is tool is utilized to remove the oblong cutter from the allograft. The saw depth guide and sagittal saw guide are assembled and secured together with the impactor handle and placed into the previous cut made by the oblong cutter. This assembly is advanced until the guide is properly seated to the predetermined depth. A sagittal saw is advanced through the saw guide to create the final cut of the replacement cartilage. The new elliptically shaped cartilage allograft is recovered from the saw depth guide, and is placed into a donor trial to confirm the size and fit. The sizer is placed over the marked defect area and two drill pins are advanced through the guide holes. The sizer is removed and a scoring device is advanced over the two drill pins and tapped into the cartilage to create a perforation. An oblong socket is now created in the knee to match the dimensions of the allograft cartilage. This is made by placing a drill depth guide over one of the drill pins, and advanced firmly down against the surface. A reamer is placed over the opposite drill pin and advanced until the strike plate of the reamer hits the depth stop. A box cutter is attached to the impactor handle and is advanced over the drill pins until it stops at the bottom of the newly created socket. The remaining fragments of bone can be removed with a Howard elevator or a small rongeur. The recipient socket is dilated to compact the bone and prepare it for acceptance of the replacement allograft. The dilator will also mimic the fit of the allograft cartilage in the newly created socket. A PowerPick can be utilized to create a bleeding bed to assist with incorporation. Demineralized bone matrix, or DBM, should be utilized to fill in any bony gaps and to stimulate new bone formation. The replacement cartilage allograft is placed into the defect, and a tap is utilized to assist with properly seating the allograft. The BioUni OATS technique can be combined with an iBalance toe to correct for malalignment issues.

Osteochondral Allografts and the BioUni® OATS® Instrumentation

Jack Farr II, MD, (Indianapolis, IN) and Brian Cole, MD, MBA, (Chicago, IL) discuss various treatment options available for medium-sized articular cartilage lesions. Depending on lesion location, patient age and comorbidities, treatment options may range between BioCartilage® Cartilage Extracellular Matrix augmented marrow stimulation, Cartiform®* Viable Osteochondral Allograft and especially in revision procedures, Fresh Osteochondral Allograft. *Cartiform is a registered trademark of Osiris Therapeutics, Inc.

Treatment Options for Medium Articular Cartilage Lesions

Jason M. Scopp, MD, (Salisbury, MD) introduces his preoperative planning and intraoperative techniques when treating complex alignment and articular cartilage indications. By coordinating the surgical case date with the tissue bank prior to the procedure, Dr. Scopp has been able to expand his practice to include fresh osteochondral allografts and offer several joint preservation techniques to his patients, including the iBalance® HTO system and BioUni® OATS® osteochondral allograft instrumentation.

iBalance® HTO System with BioUni®  Osteochondral Allograft Transplant

Hi, I'm doctor Jason Skop. Today I'm going to present a challenging case that combines multiple concepts for joint preservation of the knee. This is a 36 year old male who was referred after acute onset of knee pain earlier in the year. He initially presented to the emergency room with a large swollen knee and was sent to me because they were concerned he had a tumor. During evaluation, he was found to have a large loose body in his knee, a large effusion and an OCD seen on his x rays. I sent him for an MRI and at the follow up visit, ordered alignment films x ray evaluation reveals an OCD in the classic location of the medial femoral condyle of the left knee. Hip to ankle alignment films were also obtained. As you'll note, the right knee does demonstrate medial mechanical axis deviation. This is also present on the symptomatic left knee. When I go into my pre-operative planning, I ignore the alignment of the Of the contralateral leg, because I do not want to let it skew my decision to make an osteotomy or not do an osteotomy on the operative side. Mri shows a large OCD. The medial femoral condyle. He has a healed OCD on the lateral side and that is currently asymptomatic. Subchondral edema and bone loss is also seen on these T2 fat suppressed images. My operative plan is based off of the concept of the functional unit in the knee. Articular cartilage cannot be treated without paying attention to limb alignment. Limb stability and meniscus integrity. As I was thinking about my treatment options for this patient, I had to ponder whether or not I wanted to do surface treatment or osteochondral treatment. I also had to take into consideration his alignment. His meniscus was fine and his ligament was stable, so I was left with looking at this functional unit manning an osteochondral problem and a limb alignment problem. I then indicated the patient for an iBalance high tibial osteotomy and an osteochondral BioUni. There are logistics that go into allograft using fresh Osteochondral allograft used to be very challenging for me. Most of these cases have multiple comorbidities and require several hours of surgical treatment. A phone call on a Monday with graft availability that must be used within two weeks makes very challenging logistics for the patient and for my schedule. Therefore, I wasn't using fresh Osteochondral allograft as part of my treatment algorithm. I therefore asked the company to provide a graft on a date that I confirm with them in the far future. I usually give them about 2 to 3 months of scheduling, and ask them to provide me a graph for that date. So far I have not had any problem getting an allograft. I do tell my patients that there's always a chance we won't have one, but they prefer the planning. So do I. This puts the pressure on the tissue bank to provide the graft, and hopefully decreases the amount of graphs that are wasted and increases our ability to plan for these challenging cases. Another thing when we talk about these challenging orthopedic cases that require multiple procedures, we talk about the techniques, but we don't always talk about how we're going to do the case. We don't necessarily focus on the order of the operation, the tools we use, or the positioning that we put the patient in. A high tibial osteotomy and a fresh osteochondral allograft transplantation requires two different types of setups on the patient. I began this case first by scoping the knee. This allowed me to have a full, comprehensive evaluation of all the compartments, as well as remove the loose body and any debris that I might not see when I perform the open part of the procedure. After performing the arthroscopy, I positioned the patient for the tibial osteotomy. I have found that it is very important to have the leg in full extension during this part of the procedure. I also don't like the leg moving. The iBalance guide requires during its placement to have the leg in a stable position. I therefore have a leg ramp that allows me to stabilize the leg, get AP and lateral projections without manipulating it at all. Therefore, I don't lose any rotation or alignment views. I have become very comfortable using the iBalance guide system. If you are comfortable with the free hand technique, you'll be comfortable with the iBalance guide. I have learned that if I put the guide where I think it needs to go, it requires very little manipulation. After I look and align up the hinge pin, as well as knowing where the joint line is and where I want my osteotomy. This case now is quite simple to do, based off of the experience that you have, simply by lining up the guide where visually it looks and then correlating it radiographically. After I complete the osteotomy, the leg needs to be repositioned to accommodate the accommodate the osteochondral allograft transplantation. The leg no longer needs to be an extension, but needs to be in Hyperflexion. I use a universal knee positioning device that allows me to extend, flex, and rotate the knee to expose the lesion. I also have an armamentarium of retractors that I like to use. Some go into notch and some go into the medial gutter or lateral gutter, depending on what compartment I'm transplanting. We then complete the cartilage portion of this procedure. The BioUni has modernized osteochondral allograft transplantation. Large osteochondral lesions have traditionally been treated with multiple plugs. These plugs look like a Mastercard or a snowman. While they approximated the joint surface. They never recreated the surface accurately. The BioUni Fresh Osteochondral allograft system allows us to be more accurate for joint surface reconstruction.

BioUni® OATS® Instrumentenset

Die Gelenkallografts von Arthrex werden als frische Allotransplantate mit lebenden Chondrozyten bereitgestellt. Diese Transplantate werden im Rahmen von Eingriffen zur Rekonstruktion der Gelenkoberfläche an Knie, Schulter, Hüfte, Fuß oder Sprunggelenk eingesetzt. Um den Bedürfnissen der Patient/-innen und Operateur/-innen gerecht zu werden, hat Arthrex eine ganze Reihe frischer Gelenkallografts in seinem Sortiment.

Raffy Mirzayan, MD, (Los Angeles, CA) demonstrates an Osteochondral Allograft Transplantation procedure for resurfacing the damaged articular cartilage of the knee utilizing the Allograft OATS® Instrument Set. The set allows for precise cutting and placement of circular dowels to resurface the cartilage with either a single dowel or for the placement of overlapping dowels to cover the defect. The use of a fresh osteochondral allograft allows for restoration of the articular surface with a mature, hyaline cartilage scaffold that contains viable chondrocytes.

Femoral Condyle Allograft OATS® Technique

My name is Rafi Mirzaian from Los Angeles, California, and I'll be demonstrating a osteochondral allograft transplantation of the medial femoral condyle with a new allograft OATS instrumentation. So I always use the sizing guide to see what is the largest plug I can harvest from the graft before I create a socket in order to avoid a mismatch. 15 is the largest size that I'm going to be able to harvest from this portion of the graft, and more. Approximately 1818 would be the largest that I can harvest. So I make that determination before creating the socket in the patient. This can be checked by placing the sizing guide over the lesion, and making sure it's covered all the way around is placed perpendicular to the articular surface of the condyle and is held in place while the guide pin is drilled through the guide. The lesion is then scored and a triple reamer is then placed over the guide wire and reamed to approximately a depth of eight millimeters. The dilator is then introduced over the guide wire, and this new slap hammer and the slap hammer is then used to back out the dilator. The guide wire is then removed. 12:00 is seven, 9:00 is six, 6:00 is seven, and 3:00 is six. And we write the measurements that we've obtained on the board. So this is the new graph station. It has a boom that helps secure the arm. And it's one inch longer than the previous one. And it allows the arm to come in at much larger angles. The pin post has six different positions where the securing pin can come through and hold the the graft and secure the graft on all the posts. And that helps to avoid penetrating the cartilage of the of the graft and keeping it onto the bone. Only the white graft base can be placed either in this position or down. So for smaller grafts, I prefer to have it this way to just bump up and elevate the graft higher up. The new large securing bolt allows for the surgeon to tighten this arm. Once the proper position has been identified without using a wrench, a cheater bar can then be used to tighten this to its final position and make it very secure. So here we can see the graft. Place it over the white graft station, and the cheater bar can be used to determine the the pin height. Proper pin height placement to avoid penetration of the cartilage. The bolt pins are threaded and have a very sharp tip that helps secure the graft. So you can see that they're well below the articular surface on this side. So alternating tightening can be done to secure it. The advantage of advantage of this is you no longer have to place the cross pins to secure the graft. The 15 millimeter bushing is in place over the arm and use the sizing guide from the donor side. The thicker side through the bushing. I like to have the arm as close to the articular surface as possible, so there's less room or margin of error for the coring reamer to wiggle in the in the guide. This is what the side view looks like. So you have perfect contact all the way around with the sizing guide and the articular surface in a perpendicular orientation. Another advantage of the new system is that the surgeon can secure this entire system by himself or herself, without the aid of an assistant. So prior to coring and harvesting the graft, I mark my 12:00 position so that once it's harvested, we can easily identify the 12:00 position. So this is the coring reamer that we'll use to harvest the graft. Never forget. Never forget the plunger or or the collar must be inserted into the reamer prior to harvesting the graft. The reamer is then advanced. You want to start the power prior to making contact with the with the bone and cartilage. The cheater bar is then used to loosen it up, which will allow the arm to come out of the way and allow you access to the graft. At this point, you can either remove the graft from the workstation to remove the plug on the back table, or you can leave it in the workstation to harvest the plug. Once the cross cut has been made, you can remove the graft from the workstation and just by gently tapping. We can get the plug out of the condyle. So we're going to mark the depth of our plug based on our measurements. So I typically undercut by one millimeter. So if I measured seven I'm going to make a mark at six millimeters. This ensures that I'm not going to leave the plug proud. This is our 12:00 position. So we made a mark at six millimeters. Our 3:00 will be at five millimeters. At 6:00 we're going to be six millimeters. And our 9:00 will be five millimeters. At this point I connect the dots. So this is the new graft holding forceps. And regardless of the size of the opening the cutting surfaces remain flat, which is different from the previous one. And that is placed around the the plug, ensuring that the articular surface stays within the clamp. And we want this to be level all the way around with our markings. So our cutting surface needs to be flush with that blue line all the way around. So I'm going to make an make an adjustment here to level that off. And I use the the surface here of the forceps to help guide me. And make a nice flush cut. So at this point I confirmed the heights of my cut with my with my measurements. Again. Again keeping in mind that we undersize it by a millimeter. So at this point, I use a rongeur to bevel the edges or make the plug more bullet shaped at the end, and this allows the plug to enter the socket much more easier. Also, lavaging this plug to get rid of the bone marrow and bone marrow elements is absolutely critical. And then prior to placing the the plug into the socket, I add ACP to the plug. In animal studies, it's been shown to help with the incorporation of the plug with the with the host site. I place DBM to make up for that one millimeter discrepancy in the height that I measured and the plug that I cut. And I just impact it with my finger. The DBM holds growth factors which will help with the incorporation of the graft. And at this point the the plug is placed into the socket and making it bullet shaped gives me that initial press fit at that initial fixation to hold the plug in its place while I get the tamp and mallet it in. When I'm tamping, I typically have the tamp 50% of the tamp on the plug, and the other half of it is overhanging. So as soon as it makes contact with the surrounding cartilage of the of the patient, it acts as an internal block or brake to prevent it from over reduction of of the plug. That's a very nice flush placement of the graft.

Allograft OATS®

Allograft-OATS^®, groß

BioPatella™-OATS^®-Instrumentenset

BioUni® OATS® Instrumentenset

Frische osteochondrale Allografts