Name: IntraOsseous BioPlasty® Procedure: Case Presentation, Technique Pearls, and Early Outcomes
Uploaded: 2020-07-14T00:00:00Z
Channel: Arthrex
Description: Sam Akhavan, MD (Pittsburgh, PA), presents a case example using the IntraOsseous BioPlasty® procedure, provides technique pearls, and discusses outcomes using AlloSync™ Pure demineralized bone matrix mixed with bone marrow aspirate processed using the Angel® system.

<p>Sam Akhavan, MD (Pittsburgh, PA), presents a case example using the IntraOsseous BioPlasty® procedure, provides technique pearls, and discusses outcomes using AlloSync™ Pure demineralized bone matrix mixed with bone marrow aspirate processed using the Angel® system.</p>

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VID1-000847-en-US | B | IntraOsseous BioPlasty® Procedure: Case Presentation, Technique Pearls, and Early Outcomes

Sam Akhavan

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IntraOsseous BioPlasty® Procedure: Case Presentation, Technique Pearls, and Early Outcomes

Hello, Sam Akhavan from Pittsburgh. And today I'm going to be discussing a case for intraosseous bioplastic, as well as some of the early outcomes that we've had with this procedure. The case is one of a 36 year old male who presented to us for a second opinion for significant pain along the lateral joint line. The pain had been ongoing for three months. He may have had some trauma, although he's unsure if he remembers what the trauma actually was. He has at this point been through extensive conservative measures, including crutches Non-weight bearing for a period of 3 to 4 weeks. He has had a cortisone injection, physical therapy, as well as both regular bracing as well as on low to bracing. When we obtained his MRI, you can see that he's got a significant amount of bone marrow edema that can be seen along his lateral tibial plateau, and this side of edema correlated very well with his site of pain in his knee. Our options at this point were to either a continue conservative measures. We could proceed with another injection, more non-weight bearing or maybe a Maybe a series of hyaluronic acid. Potentially some biologics, such as PRP, inside the knee versus surgical options, which include a calcium phosphate injection within the bone to stabilize the lesion, or the intraosseous Bio-Post procedure. The reason I prefer an intraosseous bioplastic in this patient is this patient is 36 years old, and while calcium phosphate may actually make this patient better, the main use of calcium phosphate in bone marrow edema is to stabilize the lesion. No attempt is actually made to heal the lesion. Case in point. Here's a patient of mine. Two years after calcium phosphate stabilization of bone marrow edema lesion in his femoral condyle. And you can see that you can still see the drill holes. So to me what this says is that the day we did this procedure, a clock started towards the only revision option for this patient. In a 36 year old especially, this is not a good option for this patient. What intraosseous bioplastic provides is a novel method for the treatment of bone marrow edema, allowing biologic treatment of the lesion related to either trauma, stress or osteoarthritis. And unlike calcium phosphate, it actually allows for diversity in treatment in that we can use this in avascular necrosis. Some of the keys to this procedure is the cannulated drill and delivery device, which releases interosseous pressure within the subchondral bone. This is a 4.5mm cannulated drill with a Cannulation pulls out. This actually becomes your delivery device. You have the option of either an end delivery or a side delivery, depending on where your lesion is located. Does actually reducing intraosseous pressure matter? Well, multiple studies have shown us that it actually does. Patients with knee pain have been found dating back to as far as 1975, to have elevated intraosseous pressures that are commonly observed in patients with bone marrow edema have been also found to have 97% greater intraosseous pressure when compared to patients that do not have bone marrow edema. The second key to the intraosseous plasty procedure is the biologic injections. We have worked out the mixture that works best for flow through the cannula. This is an 8 to 9 cc mixture involving five cc's of AlloSyncPure demineralized bone matrix mixed in with 2 to 3 cc's of bone marrow aspirate and one cc of radiopaque dye. Our indications for the intraosseous plasty procedure include early stage bone marrow edema lesions where repair is still possible. Typically, this will include patients that are younger in age, ranging from 30 to about 55 years old. If you look at the pathophysiology of subchondral bone, essentially what we're doing is in cases of acute and chronic overload, you end up having an area of high bone turnover. Bone marrow edema develops when there is no healing, and a subchondral fracture or nonunion occurs at the site. Essentially, what we're trying to do is push that high bone marrow turnover to an area of actual healing and actually healing of the bone. The great thing about interosseous bioplastic is we have multiple revision options available. Due to the fact that this is a biologic. We can actually repeat an Intraosseous plasty at any point if the patient has had good success with the initial procedure. If we want to proceed with other options, we can then at this point proceed with either calcium phosphate or knee replacement as well. There are several key pearls to the Intraosseous bioplastic technique. One of the first things that I can tell you is when you're evaluating these patients with bone marrow edema, you always want to try conservative measures first. This typically for me includes either a cortisone injection, physical therapy, and or braces. I typically will hold off on hyaluronic acid if they're having significant bone pain. Part of the reason is patients, especially in my area, have a very high copay for some of their hyaluronic acid injections. And when you know it's not going to work, an intra-articular injections will not help with bone pain. I do not want to put them through the cost of hyaluronic acid injections if I know they're not going to be successful. The other thing that I want to make sure that everybody looks for is you have to make sure that these patients have bone pain. The first thing that I typically do when I walk into a room is I say, point with one finger where the knee hurts the most, and if they're pointing to the areas that correlates with the area of bone marrow edema on their MRI. This is someone that will actually do very well from a procedure to address their bone marrow edema lesion. I typically call this the jump off the chair sign, where you actually palpating along the area, and the patient actually will jump off the chair because you're causing pain. You want to make sure that your MRI is within three months of the surgery date. And part of the reason for this is the orthogonal planes on the MRI. So both your coronal and your sagittal picture are actually the picture that you're going to correlate when you're doing your fluoroscopy images. This is how you will locate your lesion and make sure that you drill in the appropriate place. As far as surgical equipment is concerned, the Intraosseous bioplastic Kit has essentially everything that you need. This includes your open tip, delivery, cannula, and drill. It also has the mixing syringe as well as the guide pin and low profile reamer. If you want to use an indirect technique to actually drill out the bones before placing your biologic injection, I typically will use additional one cc Syringes, because the smaller volume in the syringe for delivery actually makes flow through the cannula a little bit easier. You want to make sure that your fluoroscopy is present for the case, as you will need this to locate your lesion. I typically will have the machine come in from the opposite side of the lesion. For example, if I have a medial lesion in the right knee, I will be standing on that side of the patient. Therefore, I want the fluoroscopy to come in from the right, essentially coming from the lateral side of the knee opposite me. And then finally in terms of the bone graft, the pure allogeneic bone matrix, I typically will have five CCS of this available for each lesion. In terms of your bone marrow harvest, I typically will take this from the iliac crest before prepping the patient. This allows for spinning of the bone marrow aspirate while doing the rest of the case. Several tools that I have my scrubs have available for me prior to the case starting includes an 11 blade, a small snap to dissect down to the iliac crest, a jamshidi needle with a mallet, as well as closing sutures and needle driver, and a scissor If the patient is obese and you have problems reaching the iliac crest, which has happened on several occasions, I typically will take the bone marrow aspirate from the proximal tibia. If you're doing this during a case, I typically will still do this before the case. But if you decide to do it during the case, make sure you let down your tourniquet first in order to get good flow through the needle. I always will take a full 60 cc's every time, and then tell my perfusionist that I want about 6 to 8 cc's of bone marrow aspirate once concentrated. You also always want to scope the knee. First, you want to address any sort of meniscal pathologies that are present. You want to document the presence of any cartilage lesions. And then I actually will put the scope back in after the case is done prior to closing, just to make sure that there's no extravasation of any of the injectable inside the joint. There are several key aspects that you can do when drilling the lesions to make sure that you locate the lesion appropriately. I typically will start on an AP and place my drill against the knee at this point, obtain a picture and get my proximal to distal level. I actually make this mark across the knee, just to make sure that I'm at the right proximal distal level. I then will switch to a lateral position and actually get my anterior to posterior level, where those two lines cross is where X marks the spot. We'll make a small incision, use a snap to dissect down to the bone, and then in the lateral position, I will actually place my drill right against the bone. At this point, I will go ahead and switch back to an AP. I make sure that the drill is against the bone and obtain a shot. This shot will be moved to the opposite side of the actual screen. Prior to drilling, you then drill to the appropriate depth, but then compare the two pictures together and what you want to make sure is that the last hole is past the point where the tip of the drill was on the initial picture. This makes sure that you will not have any extravasation of the injectable into the soft tissue. When injecting the lesion, you want to make sure that you first have transferred your bone aspirate and bone marrow aspirate to one CC syringes. This will make it make it easier for you to inject. You want to make sure that you get a flu shot after every syringe. The main thing you're watching for is for extravasation within the soft tissue. But you also will be able to see that your injectable is actually going in the appropriate spot. The injection will always take the path of least resistance. The key to that is that you do not actually have to be in the lesion itself. You just have to point towards the lesion. The area of bone marrow edema will actually be weaker than the rest of the subchondral bone. And the injection will basically find its spot within the lesion itself. After injecting every 2 to 3 syringes, I will actually use the cannulated portion of the drill to actually clear the cannula prior to proceeding with the next injections. Postoperatively. One of the key aspects to doing an Intraosseous Bio-Post is that you have to remember that this is a biologic injection, unlike calcium phosphate. It actually has no strength to the injection itself. The point of this injection is to allow the lesion to heal, not to provide strength. Therefore, typically postoperatively we will ask will ask the patient to be non-weight bearing for a period of 3 to 4 weeks, followed by a course of therapy after their first post-op visit. Here's going back to that case. This is that 36 year old male that we presented at the beginning. This is his preoperative MRI. And you can see that six months post, the whole area has actually healed. There's actually no edema left within the lesion. And the drillhole has actually healed as well. We have just published our short term results of a prospective trial of 20 patients that had undergone intraosseous biopsy for the treatment of bone marrow edema lesions. This included 20 patients, all under the age of 65. All of them had bone marrow edema lesions associated with either osteoarthritis or avascular necrosis. Our average follow up for these patients was about 14.5 months. Overall, we had a significant reduction in both their pain scores as well as improvement in their function scores, including both the Icdc and the AOS.

IntraOsseous BioPlasty® Procedure: Case Presentation, Technique Pearls, and Early Outcomes

Verwandte Seiten

Orthobiologie

AlloSync™-Knochentransplantate

Produkt

Orthobiologie

Das Arthrex Angel™-System

Produkt

Orthobiologie

IntraOsseous BioPlasty® (IOBP)-Technik

Produkt

Knie

AlloSync™-Knochentransplantate

Produkt