Pie y tobillo

Aloinjerto osteocondral

Arthrex tiene amplia trayectoria asociado a los mejores bancos de tejido para proporcionar aloinjertos osteocondrales frescos (OCA) para usarse en procedimientos de restauración de articulaciones. Los OCA frescos permiten al cirujano transplantar cartílago hialino maduro con condrocitos viables y hueso subcondral en un solo procedimiento. Arthrex cuenta con la estación de trabajo OATS para aloinjerto que ofrece más flexibilidad en la preparación del OCA en la sala de operaciones.

Foot and Ankle

William D. Bugbee, MD (La Jolla, CA), discusses the role of fresh osteochondral allograft use in the talus and reviews the abundant clinical studies from the past 30 years available to support the procedure.

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Fresh Osteochondral Allografts for Osteochondral Lesions of the Talus

Hello, I'm doctor William Bugbee. I'm the chief of joint reconstruction and cartilage transplantation at Scripps Clinic in La Jolla, California. Today I'd like to talk about fresh osteochondral allografts for osteochondral lesion of the talus. Fundamental principles of Osteochondral disease are straightforward. Subchondral bone in the osteochondral unit are important to understand when you're doing allografts. This is an integrated organ system. It's very interdependent structure and function relationship. Therefore, an osteochondral lesion, which involves disease of bone and subsequently cartilage, is a prototypical osteochondral disease. What we understand is that these two tissues working together create an organ. And when you have a disease like an osteochondral lesion, that's essentially an organ failure. So replacing it with an intact organ makes complete sense. Osteochondral repair generally has many advantages. You transplant mature hyaline cartilage, so you require no cell or tissue differentiation. You invoke a bone healing paradigm by replacing abnormal subchondral bone and cartilage. Thus, you get the concept of the organ replacement that I mentioned earlier. Also, you get a faster and simpler simple rehabilitation because the structural integrity of the graft is normal at day one. The allograft paradigm also invokes the idea that cartilage is an ideal tissue for transplantation, its mature hyaline cartilage with viable chondrocytes, and you get a bone healing versus chondral tissue regeneration. And we understand bone healing much better than we understand chondral tissue regeneration. This makes grafting a perfect treatment for osteochondral lesions in the talus. So when do I use allografts in the talus? Well, of course for osteochondral lesions as I mentioned. And these would typically be the large volume cystic lesions that are not amenable to surgery, such as microfracture or surface treatments. We also use allografts when we have to salvage smaller lesions that have had previous treatment that just did not work. Additionally, occasional cases of osteonecrosis of the talus and traumatic defects are appropriate for grafting. And it should point out that fresh talus allografts are relatively easy to obtain, at least in North America. I want to mention a little bit about terminology. Many people would call a talus allograft a bulk allograft. Now, sure, it's bulk tissue, but I really prefer the term small fragment or shell allograft. You can see in these pictures that these partial talus grafts can be any size, but generally are not too bulky. But they basically restore a quarter to half of a of a talus. Let's talk about surgical techniques now, because there are a number of approaches that can be used for grafting of the talus. Of course, the medial or lateral malleolar osteotomies or the anterior approach through direct anterior without osteotomy and the use of joint distraction or external fixation can be useful to distract the tibia from the talus for access. What's clear from the literature is the type of approach does not appear to affect clinical outcome, but I would say that one would question the morbidity of an osteotomy if it's not always necessary. My preference for surgical technique involves utilizing an anterior approach, which is low morbidity. External fixation. For access to the talus joint distraction, we remove anterior tibial osteophytes of their present, and we do an onlay partial talus graft rather than a plug. This involves a freehand technique. However, I will tell you that instrumentation to make this easier is on the horizon. We usually fix the graph with either absorbable screws or pins or small metallic screws, and we invoke about 6 to 12 weeks of non-weight bearing prior to letting patients load the ankle and start doing functional rehabilitation. These images depict what I just mentioned in visual form. This is a large cystic osteochondral lesion of the talus. And you can see we've extracted the lesion, used it as a template for measuring the graph which has been resected from a whole talus allograft. We fit the graft into the resected area and we might have to do a couple of modifications. The graft is placed and then fixed with a single or two screws. And you can see the reconstruction here on the last photo. We have a series now of about 40 to 50 patients that have undergone this procedure. The average age of these patients is 34 years and equally medial and lateral lesions. And these, as I said, are pretty large lesions. So they're not small volume lesions. With a ten year follow up, we have documented 81% ten year survivorship and almost 90% satisfaction with this procedure. 100% of patients that have this procedure, again, which reflects the debility some of these people have with these talus lesions, there is a not insignificant re-operation rate. And we've had three failures that have required either revision, grafting or arthrodesis. There's a lot of research that has been done by various authors in the foot and ankle community, and generally every one of them have felt that this has been a reliable and effective procedure, successful and with high patient satisfaction. This, summarized in this review article about 200 patients have been published and again similar results. Significant clinical improvement 86% graft survivorship in about a 21% re-operation rate. Not always for failure, but sometimes hardware removal or arthroscopy for symptoms. So in summary, a fresh talus allograft is a great option for challenging osteochondral lesions when all else fails, or if the lesion is big or missing bone. A fresh talus osteochondral allograft, I believe is the best choice. Thank you.

Orthobiologics

Knee

Thomas Carter, MD (Phoenix, AZ), provides an overview of the clinical rational and support for performing meniscal allograft transplantation (MAT) and osteochondral allograft (OCA) transplantation procedures. Dr. Carter includes a second-look image 14 years postoperative from a joint preservation procedure using both MAT and OCA transplants.

Clinical Applications of Meniscal and Osteochondral Allograft Transplantation

Hi, I'm Doctor Thomas Carter from Phoenix, Arizona. I'm here to present on meniscus and Osteochondral Allografts. When combined my practice with long term follow up. Second large scope case mis allograft indications are pretty well defined at this point. Symptomatic for meniscectomy the age of 50 to 55. Although older, you have to consider physiologic age, so that should not prevent you from being a candidate. You have to address other pathology. If the knee is ligamentous, laxity should be addressed. Limb alignment has to be evaluated and any cartilage lesions. Also, patient's expectations need to be reasonable if they expect the knee to be totally normal. That's not the case. It's indicated for Outerbridge grade two or less. There's clinical benefit with grade three and Kellgren-lawrence of grade two. It's not a substitute for arthroplasty. Isolated defects are not a contraindication either. Osteochondral allograft. Indications. Typically, a size lesion of two centimeters squared or greater depth of a defect. If there's bone loss, there are excellent substitute the cartilage condition overall. If the knee is degenerative, it should only be an isolated defect rather than diffuse. You have to address other pathology. Just as with meniscal allografts it has to be ligamentous stable. Consider the alignment and if the missus is absent, it should be replaced. For weeks you allow them a full range of motion and weight bearing progress, from four weeks to six to full weight bearing. There should be no high impact until 3 to 4 months. And many people say patients should be recreational activities rather than high impact full activities. Hypothetically at six months, but based on functional clearance rather than just time. So if you look at clinical outcomes by themselves, there's evidence that it provides pain relief and improves function. Ten year follow up studies show the grass survival rates of 70 to 80%. Radiographic results are encouraging as the slowing progression of arthritis but not fully confirmed osteochondral allografts by themselves also has evidence that it provides pain relief and improves function. Ten year graft survival rates are similar 70 to 80%. So when you look at patients that are candidates for osteochondral allograft meniscal allografts, you have to consider all variables. On the left this was treated with an osteochondral allograft. But you see there's no meniscus on the right. This was treated with osteochondral allograft no meniscus. And you can see the limb alignment is varus and knee deteriorated in a hastened pace. So when you're looking at limb alignment you have to take consider full length films. On the left you can see the mechanical axis his way to the middle compartment, and it should be over towards the middle of the knee. You do not have to change this in a case. If somebody has osteoarthritis the way over to the opposite side, but more midline on the right. You can see we did an opening wedge osteotomy of five millimeters to make a mechanical axis through the midline. Case example of one of my patients. He initially had surgery at 36 years of age, found to have an osteochondral lesion, a meniscus tear that was treated with plasty and partial meniscectomy. The patient continued to have problems with knee pain and swelling and presented to my office at two years post-op. I performed osteochondral allograft transplantation, allograft transplantation, and a high tibial osteotomy all at the same time. He returned to see me 14 years post-op because of having some discomfort, and we performed an arthroscopy. And this is what we found intraoperative. You can see the osteochondral allograft still with good integrity, the meniscus also with good integrity and no extrusion of the graft. Thank you.

Brian J. Cole, MD, MBA (Chicago, IL), discusses the benefits of using orthobiologic products during osteochondral allograft procedures to support graft incorporation with a goal of decreasing cystic changes.

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SpeedPearl: Osteochondral Allografts—Orthobiologic Application

After the Astrakhan allograft subchondral bone is deep cleaned. We then apply an ortho biologic. This may be ACP or concentrated bone marrow. We've shown that concentrated bone marrow, over time, using six month CT scans, demonstrates a reduction in the cyst formation from large to small cysts.

Trauma Lower Extremities

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Foot and Ankle: Next Generation in Foot and Ankle Technology 2023

S. Clifton Willimon, MD (Atlanta, GA), demonstrates the technique for downsizing a 16 mm precut osteochondral allograft to a 12 mm core, which can then be trimmed to the appropriate length. This technique provides surgeons who prefer using allograft to treat a primary defect or backfill a donor site an option that can be used with the autograft OATS® 2.0 system, which accommodates grafts up to 12 mm in diameter.

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Precut Osteochondral Allograft Sizing for Use With the Autograft OATS® 2.0 System

I would like to present a technique for downsizing a fresh osteochondral allograft plug size 16mm to 12mm from the 12mm. Single use OATS set two supplies are needed the 12mm graft delivery tube and the 12mm harvest device. From the 16mm. Single use OATS set the 16mm graft delivery tube and lastly a mallet. So the same principle for allograft implantation of perpendicular approach to the cartilage applies to downsizing from a 16 to a 12 millimeter allograft. It's critical that we have a perpendicular harvest approach. Otherwise we can create an oblique oriented graft. So we have our 16 millimeter allograft. And we're going to use the 16 millimeter graft delivery tube. The graft is loaded into the tube and we place it on our hard surface. Next we will use the 12 millimeter harvest device to downsize the 12 millimeter plug. So once loaded, we can bring in the 12 millimeter harvester. I find it's best to sit for this portion of the procedure so that you can see very well the orientation of the harvester as it approaches the cartilage. So we're now going to bring the harvester down to the articular surface, and we're firmly holding it in a perpendicular fashion to the articular surface. Next, my assistant will stabilize the top portion of the harvester, and we'll use a mallet to impact the harvester through the 16 millimeter plug. Once fully impacted, which is generally 15mm because that's the length of the cores that are processed, we can check the bottom portion. At this point, we've completed the downsizing and we're going to extrude the graft from the harvester. So my assistant will hold the graft as it's extruded so I can stabilize the device. So at this point we have our 12 millimeter plug that is downsized from the 16 millimeter pre-processed fresh allograft. Once the depth of the recipient site is known, this plug can be trimmed to the appropriate length.

A scientific report from the Arthrex Orthopedic Research Department stating an objective, methods and materials, results, and discussion and conclusion.

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White Papers

Relatório científico do Departamento de Pesquisa Ortopédica da Arthrex declarando um objetivo, métodos e materiais, resultados, discussão e conclusão.

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Metrics of Osteochondral Allografts (MOCA) Group Consensus Concerning the Use of Viable Osteochondral Allografts

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Precut Fresh Osteochondral Allograft Cores

Thomas G. Harris, MD, (Pasadena, CA) performs an allograft OATS® technique to treat a talar osteochondral lesion. Several technique pearls are provided related to performing the osteotomy and to ensure the allograft implant is well contoured to fit the surrounding cartilage following implantation.

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Fresh Allograft OATS® Technique for Osteochondral Lesion of the Talus

We've drawn out our surgical site here, which is pretty well centered in the medial malleolus anterior. You have the saphenous nerve traveling here. We've got the posterior tibial tendon hugging the posterior aspect of the tibia. And then the neurovascular bundle there. So it's pretty much between these inter nervous planes. A pretty safe approach overall. We've made the incision perhaps a little longer than normal just for the sake of this demonstration. But this would be the approach to the medial malleolar osteotomy. And it's a similar approach that you would do as if you were doing a medial malleolar auf, and we'd carry that down to the level of the periosteum, free up the periosteum from it as well. The patient normally would be sitting supine. In this case, maybe not as far medial as that supine, with maybe a bump on the contralateral hip to externally rotate the leg ever so slightly. And then we'll take a K-wires placement here and just see how our cuts look in here. We'll take a fluoro after this. And just make sure that we've gone lateral enough so we can see the lesion. You can pre-drill before you've made the cut with a two over five drill, just to make sure that you're lined up your medial malleolus screws for the later fixation of the osteotomy. So, you know, once you've made these holes and confirmed them on fluoroscopy, a nice little tip is to make a mark in it with the pen so that you can find it later. Sometimes it's harder to find than you'd imagine later on. Okay, so now we've pre-drilled for our osteotomy, and then we can kind of mark out the osteotomy here with the apex being up at the top here. So we'll just come up above here and then kind of do a semi chevron type cut. So a little bit of a bend to it just makes it a little bit inherently more stable when you have a V chevron with the apex based approximately. Once you've kind of freed up the periosteum, you can see you're very close to the posterior tib tendon right there. So you want to put your home in underneath that, just hugging the bone so that you're pretty safe from all the neurovascular structures there. So anteriorly you're pretty safe as well. I don't always use a home in there, but posteriorly I would always recommend it just to help with the the safety and not making sure you're going into that tendon when you're making this cut. And then the cuts are always made with thorough irrigation, making sure you're not engendering any thermal necrosis in the bone. And then the first cuts are made. And then we'll check with fluoro in terms of our overall alignment, and that we're cutting in the right trajectory. Here's the the lesion right there. And we were measuring it and deciding on it's kind of between a ten or a 12. So here's the sizing guides, which blue is ten and the red is 12. And for really kind of measure it really the ten seems to fit nicely kind of centered in through that area. The 12 is just a little bit too wide from the standpoint. I just worry about blowing out that medial wall of the talus there. And I think the ten would really the main issue with the defect there would really be nice with the ten. There is this little peripheral lesion posteriorly here, this little offshoot like this, which is sometimes what you'll get. And you could always fill that area with BioCartilage just to lay there on top of it. And so this is A24 wide pin placed as tangentially to the lesion as possible. So here we got the reamer in in place. And we want to come down to about 8 to 10in terms of our depth. And preserving that medial cortex their medial Taylor wall. So we're about to ten there. Okay. And then we'll clean out the the lesion itself. So all quadrants are measuring between 10 to 11. We want to measure and kind of guide off what we took the lesion from, which was the medial central portion here. So this is the part we're trying to replicate. It really was near the top of the dome of the talus two. So we really kind of want to be in this area per se right there. All right. So now we got this thing well secured. The fresh talus is where we want it. Then we go to a obtaining and acquiring the graft in this ten millimeter reamer. You'll see that there's a colored plug inside that just makes it a little easier to get your plug afterwards. And so that goes inside right here. So now we're ready to perform the reaming. We want to fill a defect that's between 10 and 11. But it's okay to over drill in this spot to go to 15 to 20, just so we have enough of a plug to place that can always be shortened. So here's our reaming that's going to begin. There's. Five. Normally we'd be doing it under thorough irrigation. Here's ten. Move down to 15. There you can still see the 20 is proud. So we'll come down to about 20. And then we'll come out with this. Somewhere between 15 and 20. We make a cut ten, 15. Somewhere like that. Here's our plug with the holder in place, which really holds it nicely. As our measurements we've already made there. And then here's the side view of that. And basically when we're measuring this plug from the very tip of the plug, it measures about 10 to 11 in through that area like that. If we measure from the bone measures about ten right in through this area. So really pretty good shape already. Another option here is to be cutting this to ten across the board. And then add a DBM to the base of this to even out any defects that may be present, rather than having to cut one side at ten and another side at 11. That can make the cut a little bit easier. And once you have the marks on either side one one nice tip is to kind of connect those marks to make your cut just a little bit easier here to go across that area. Now we have this held in place. And one one little tip is make sure that it's holding the cartilage side so that if when it does get cut, it doesn't go flying. So we want to make sure we hold on to the part that we want to keep. And then this guide itself can be helpful for a for a cutting guide and just place it right off the top of that. At this point, once you're happy with the the length of the plug, you would use a thorough irrigation or pulse lavage at this point to draw out some of the marrow elements of the allograft. Once we're happy with that and the irrigation has been completed, we'd put it in a small receptacle and then add the ACP. Another addition to the mixing can be a bone marrow concentrate, and that can be mixed with the ACP if so desired, before implantation of the plug. So we'll place DBM in the defect here at the base of the defect. Make sure it's going to the bottom with a free air or some sort of a smooth Curette can help fill in the base of that. And again, this is very soft. So it will compress with the. Once the plugs on top of it and just level out any defects that may be present. The tamping into place aspect of this is important in that you don't want to tamp it too hard and kill any of the the cells in place. And if you can tamp a little bit eccentrically, I think that would be helpful too. There we go. So we've got it in place now. And then maybe you can see it's still proud as to be expected. And then we would now gently. Gently impact into place and not too deep going. And it really seems like it's fitting in there pretty nicely. And finishes the defect really well. And so as you can see, there's still that little fragment posteriorly within that offshoot, which would be hard to fill and probably not worth putting in putting another plug right there. So you'd fill in any little surrounding defects with BioCartilage and through this at the same time to fill that in. Now this was just partial thickness. So it could be microfracture if you want to put a little pick there and then BioCartilage or just laying it in with BioCartilage. But the rest of it seems to be fitting really well moving moving smoothly through that area as well. So at the conclusion of this case, you can see that chevron type osteotomy fits in nicely there. What we usually do is place the two screws that we've already pre-drilled. And then a third tubular plate from the ankle fracture system would place two screws above the level of the osteotomy bicortical screws, three five screws here, and then one more up there. And then the plate would just contour itself in through this area here. And then we close the periosteum over that. And that provides good good fixation. So we can start early range of motion after these osteotomies.

Zieldraht mit Bohrgewinde, 2.4 mm x 310.0 mm

Aguja guía con punta de broca, Ø 2.4 mm x 310 mm

Kleinfragment OATS Set, 10.0 mm, steril, SU

Small Joint OATS Set Autograft Diameter 10 mm

Juego OATS para pequeñas articulaciones, autoinjerto de Ø10 mm

Kleinfragment OATS Set, 8.0 mm, steril, SU

Small Joint OATS Set Autograft Diameter 8 mm

Juego OATS para pequeñas articulaciones, autoinjerto de Ø 8mm

Kleinfragment OATS Set, 6.0 mm, steril, SU

Small Joint OATS Set Autograft Diameter 6 mm

Juego OATS para pequeñas articulaciones, autoinjerto de Ø 6mm

Aloinjerto osteocondral

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Foot and Ankle: Next Generation in Foot and Ankle Technology 2023

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Precut Fresh Osteochondral Allograft Cores

SpeedPearls (1)

SpeedPearl: Osteochondral Allografts—Orthobiologic Application

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Fresh Osteochondral Allografts for Osteochondral Lesions of the Talus

Clinical Applications of Meniscal and Osteochondral Allograft Transplantation

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Precut Osteochondral Allograft Sizing for Use With the Autograft OATS® 2.0 System

Videos de técnicas quirúrgicas (1)

Fresh Allograft OATS® Technique for Osteochondral Lesion of the Talus

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Metrics of Osteochondral Allografts (MOCA) Group Consensus Concerning the Use of Viable Osteochondral Allografts

OATS para pequeñas articulaciones (3)

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