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Autograft OATS® Technique for the Talus

Osteochondral Autograft Transfer System (OATS) procedure is an effective treatment for small cartilage defects of the talus with associated subchondral bone damage. The Small Joint OATS™ instrumentation enables the harvesting of 6 mm, 8 mm, or 10 mm osteochondral cores containing autologous hyaline cartilage. These grafts are typically obtained from a non–weight-bearing donor site located anterior to the sulcus terminalis at the junction of the lateral trochlea or lateral femoral condyle.1
 
References&nbsp;
1. Rowland R, Colello M, Wyland DJ. Osteochondral autograft transfer procedure: arthroscopic technique and technical pearls. Arthrosc Tech. 2019;8(7):e713-e719. doi:10.1016/j.eats.2019.03.006

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Articular Cartilage Repair - Biologic Algorithm

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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.

Thomas G. Harris, MD, (Pasadena, CA) presents a case in which he treated an osteochondral lesion of the talus with a fresh allograft OATS® plug. Dr. Harris reviews the preoperative planning, intraoperative pearls including mixing with bone marrow concentrate from the Angel® system, as well as the fixation techniques of the osteotomy.

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Allograft OATS® Technique to Treat Osteochondral Lesion of the Talus

Hello, my name is Thomas Harris. I am a chief of foot and ankle at Harbor UCLA hospital out in Torrance, California, and the co-director of the Foot and Ankle Fellowship in Congress Orthopedics in Pasadena, California. I'd like to present a case to you that we recently did regarding a fresh talus transplantation using the OATS technique and technology we have here at Arthrex. This was a 33 year old female. She had previously had a arthroscopic microfracture about 13 months prior. She continued to have pain despite that prior microfracture, which was done completely arthroscopically on the MRI. The lesion measured ten by 19mm on MRI and was very cystic in nature. And you can see on that x ray there that you can see how that embodies the medial aspect of the talus of a pretty large lesion there. The MRI preoperatively was performed. And you can see the large cystic nature of that lesion, it does look like it's contained. However, our surgical plan for this case was to arthroscopically evaluate the lesion. We were going to use the Angel system and harvest bone marrow aspirate from the iliac crest. We also planned a medial malleolus osteotomy to gain access to the lesion. And we decided to use a chevron type of that and then proceed forward with an OATS technique using a fresh talus sagittal view. There you can see the large cystic nature of the lesion. And on the axial image to again the large nature of the lesion with surrounding edema as well as synovitis surrounding the entire joint there. But it's very significantly big lesion is the take home point from this case. So Intraoperatively we decided to size this somewhere between ten by ten and 15 by 15. The 15 by 15 seemed to take away too much bone when we got down to it. And the depth of this lesion was about 10 to 11mm as well. And there you can see a picture of the sizing guide for this lesion. So here's an image of the fresh talus. You can see that we took two plugs from this fresh talus. Because the first plug that we harvested seemed a little too shallow. We then soaked the appropriately sized plug in bone marrow concentrate solution for a period of time to let those cells interdigitate into the plug. We use the left talus in this case, even though the patient's lesion was on the right talus, because sometimes there's only one side available, which was the case here. So ideally you would match the side to the side of the lesion. However, sometimes that's just not plausible or possible with the constraints of getting fresh talus. The plug seemed to fit nicely with the similar slope to her native talus. I think that can be sometimes the hardest part of this case. It is important to to have some sort of system to match up your rotation, be it making clock marks on the graft to ensure the proper rotation when you're inserting it into place, so that the anterior part of the graft is going to match up with the anterior part of the defect, and that seems like it makes sense intuitively, but it's an important step to do. Just makes your life much easier. Intraoperatively. Here's an image, a photographic image of our graft in place. With these tamps of each graft, you have to be very cautious, and I would encourage you to tamp as less as possible, because that can cause some cellular damage to the cartilage as well. Here we have our final osteotomy construct. The medial malleolus osteotomy was fixed in this case with two solid screws. One was a partially threaded four screw and the other was a 3.5 cortical screw. We also used a medial third tubular plate applied in an anti glide type fashion. So there's a total of four screws and one plate in that x ray there. You can also see that the OATS plug seems to be fitting very nicely and is well contoured compared to the rest of the talus and doesn't seem to be sitting too proudly.

Autograft OATS® Technique for the Talus

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Allograft OATS® Technique to Treat Osteochondral Lesion of the Talus

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