Knee

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Los sets de tubos para corte de donantes y receptores desechables del sistema de transferencia para autoinjerto osteocondral (OATS) facilitan la obtención de cilindros de cartílago osteocondral/hialino de diversos diámetros de un sitio donante superior y lateral a la muesca o por encima del surco terminal. Se crea un orificio receptor, de la profundidad adecuada, en el defecto condral para aceptar el injerto donante. El cilindro de hueso se inserta con un sistema de provisión de pins centradores para fijación de ajuste por presión. La obtención y la profundidad de inserción se controlan con marcas de 5 mm de profundidad. La colocación final del cilindro cosechado, al ras con el cartílago articular circundante, se logra con un medidor/nivelador de diámetro apenas más grande.

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Autograft OATS® 2.0 Set

Bert R. Mandelbaum, MD (Santa Monica, CA), demonstrates an autograft OATS® 2.0 procedure to treat an articular cartilage defect in the knee. Dr. Mandelbaum introduces the OATS 2.0 system and shares several technical pearls for the procedure. He also discusses how the OATS 2.0 procedure can be used for transplantation of precut osteochondral allograft cores for the primary implant or to backfill the donor site.

video

OATS® 2.0 Procedure for an Articular Cartilage Defect in the Knee

Hi, this is Bert Mandelbaum. And today we're going to talk about OATS 2.0. What we have here is the re Innovation 2.0. And the beauty of that, it's not only a system for autograft transplantation, but it's also good for precut allograft transplantation. So we're going to show you today the flexibility of how you do the harvest for the autograft, but also how you use it in the allograft situation. Now welcome to our cadaver. And for the sake of just looking at what and what we're doing, we can see the markings for our arthrotomy and also for harvesting our donor graft. But remember, this is a large incision here. And for the sake of educational purposes, we're going to make a large incision. But when we're talking about patients, all we need to do is make a small mini open procedure. You can do this, arthroscopically, but we'll really stress the need for perpendicularity in placing our grafts both on the donor and the recipient side. So today we're going to move from right to left and help you understand exactly what we're going to be doing in the operating room. So firstly this is now for the recipient site. You could see a pin through there. And actually a size. This is a ten millimeter guide that will help you with your perpendicularity accordingly. Number two you have some flexibility of depth. You can see here with a depth stop at 13mm and a depth stop here at eight millimeters. Now, another feature of the OATS 2.0 system is the fact that we have donor stops here. We have a 13 millimeter donor stop and an eight millimeter donor stop. And what these do is they are able to be placed directly into the donor system as such, and provides a stop to achieve the exact length of your graph from a donor perspective. You also have a transparent guide for which goes over the donor device, and you can deliver the graft accordingly down the cannula. If, in fact, when your graft is in your device, your donor device. As you can see, this is a ten millimeter device. It appears to be a millimeter or 2 or 3 long. You can appropriately cut it with either a Ranger or a blade for the sake of demonstration. Also, we have in front of us a fresh, precut osteochondral allograft. The other good feature to this is to understand that this particular allograft was harvested using the same instrumentation, so the sizes are exact for one another, and you could feel comfortable with that fact. And now we move to the surgery. And now we can see the articular cartilage defect of the medial femoral condyle. As you can see, it's grade for the 2.0 system has a great measurement device. As you can see it placed directly into the ten millimeter defect. Now most importantly, it's an imperative that at all times, you're perfectly perpendicular to the donor site. We can see here in the OATS 2.0 donor system. This is the harvester. And you can see it how it's metered for us to make decisions about length. Now we're going to bring it directly into position. And again, for the purposes of what we're doing today, we're going to take this to 13mm. And again the key is having it being perpendicular. And now about 13. Now the way the system is engineered is we want to take two clockwise turns with axial pressure okay. So I'm going to go one turn two turns. And then I'm going to give it a little jiggle. And it should come out. Voila the donut graph. And we can see the harvest site there. As we could see the donor graft is at about 13mm in length from the harvest site. And now we're ready for the next part of our procedure. A couple of important points. The first is the reamer. And you can see here we've chosen the eight millimeter reamer with a depth stop. This is to help us when we're delivering it so we know exactly the size. And again our donor graft is now inside, ready to be fine tuned when we're completing the recipient site here. And now we're ready to ream the recipient site. Here's our guide ten millimeters. We must place this in the defect in a perpendicular fashion. As you will see, we're going to put our pin in directly. And place it in about three centimeters. This comes off. And now we're ready to ream accordingly. Now as we ream the recipient site making sure that we Appropriately. Go to a step. Stop. At eight millimeters and stop. Now, for all those who are worried about the depth of the recipient site, the instrumentation provides an exact eight millimeters depth, so you do not have to measure it at this point in time. Now here we are on the back table with our donor Osteochondral graft. And many times it is very important. And we have it in this situation because it is a cadaver. It's a little bit shorter and incomplete. So a little lesson for the wise is take your graft a little bit longer if you want it. Eight take it to 10 or 11. You're just going to graft it anyway. So in this situation we've got this blue stop here to stop us at eight millimeters. And what we're going to do now is we're basically going to turn this in and we're going to push the graph. As you can see the graph moving. And it's going to be a hard stop when I get to eight millimeters. And now we basically turn this and we have a hard stop on our device that's going to take us directly to where we need to be. Right there. Hard stop. And as you can see, there's a certain amount of bone that we'll have to cut to make it exactly eight millimeters. Here we are actually using the device to exactly cut our graft. As you can see, it's right on that eight millimeter area and the bone has come off. And then here we have the perfect size of the graft. And now that our graft has been appropriately sized, you'll see me delivering it right here as I turn in a clockwise fashion and I bring the graft right to the edge. And you can see we've got a transparent guide that helps us. Again, I get to that perpendicularity. And we begin to start placing it accordingly. We get to the stop. And there is placement of our graft. We conclude that this is the Osteochondral Autograft transplantation system 2.0. This is our autograft intact. You can see that it is not recessed. Not proud exactly the way we like it. A great upgrade to the OATS system. There are many different ways of approaching Osteochondral autograft transplantation system, but one thing that we do quite commonly is we do biological augmentation utilizing sometimes ACP and sometimes using the Angel PRP system to enhance the integration for all those who like to use this as the Osteochondral Allograft Transplantation System 2.0, we have a precut ten millimeter allograft, and we would place it the same way we've done with the autograft directly into the recipient site. And now we're ready for the last step in the OATS 2.0. The donor site in this situation is something very important to graft, to make sure there's no functional limitations or pain. So the first thing you want to do is make sure that the donor site is set and hubbed to 13mm in this situation. And what we're doing now is we're exactly using the hand. But you could use power to achieve a hub that it is definitely 13mm, which it is in doing so, if you have any insecurity you could also add your device to impact this. But now we're ready to impact our precut osteochondral allograft to preserve exactly the appropriate depth and size that we need. As you can see, the cartilage is face up and we're just basically going to gingerly tap it in place. And we tap it into position perfectly. As you can see, we've completed osteochondral autograft transplantation to the graft that we see in the medial femoral condyle. And then we grafted the anterior portion of the trochlea with a precut ten millimeter osteochondral allograft. You can see it's not recessed and it's not proud.

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.

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.

Imaging and Resection

Jack Farr II, MD, (Indianapolis, IN) and Brian Cole, MD, MBA, (Chicago, IL) review the treatment options for small articular cartilage lesions. The available treatment options include debridement, marrow stimulation with the PowerPick™ instrument, Osteochondral Autograft Transplantation (OATS® technique) and BioCartilage® Cartilage Extracellular Matrix to augment a traditional microfracture or marrow stimulation procedure.

Treatment Options for Small Articular Cartilage Lesions

Hi, I'm Jack Farr. I'm here with Brian Cole. We're going to talk about how we've changed our thought process on cartilage algorithms over the past 20 years. Brian, I want to start off about small lesions. Have things changed much? I think they have, because. Well, the first thing that's interesting is that if you look at sort of clinical adoption, small lesions are often not treated that aggressively. So the good news is I think that people tolerate small lesions, small lesions incredibly well. So what do we define small to to us small is a little different. So yeah. So I think the thing that's interesting is that we talk about size. But size is often dictated by how relevant they are and often by the technology that we have available to us. So we've typically tried to say, well, these are 1 to 2cm². That's sort of our small range. 2 to 4cm² is our intermediate range and greater than four is our large range. Embedded in that concept though is our outcomes. In other words small lesions. If they do hurt, they are often amenable to sometimes very simple things. Even debridement can remedy some of these individuals to be less or asymptomatic for periods of time, whereas that may not be effective for for intermediate sized lesions and intermediate sized lesions. As you approach say, 4 to 6 may not do as well with neural stimulation and so forth. So it's very difficult to just drop them into buckets. But suffice it to say, if we want to have an overview to help guide people on how to think about managing these lesions, I think we can at least use that as a discussion point. Small, medium and large. I think something we've been talking about for the last ten years is size. Absolute size is important, but relative size and how much of the actual condyle? For example, if you have a ballerina with a size one femur and you have me with a size six, right, ten millimeter lesion is going to be much different on her. Yeah, absolutely. And that and we have some really interesting research that looks at how these can be load shielded small lesion relative to a small condyle as you're saying is a lot different than a large lesion relative to the same size condyle, which is why they tolerate it. And we basically see the more normal cartilage they have remaining relative to the size of the defect. That may manifest in how load bearing leads to the onset of symptoms or the absence of symptoms. So I think for for me, a small lesion, I have to respect them. And if I find it incidentally, then I think to treat it as somewhat overly aggressive in most cases. So most of those small lesions so maybe less than 1.5cm I'm going to evaluate them, stabilize the margins, take away anything that could be a mechanical irritant. But then basically just measure it and grade it and observe the patient. Many of these people will become asymptomatic with short duration. I would agree so that so what you alluded to is the relatively asymptomatic or incidental lesion that may have a very innocuous natural history. Most of us who see a number of these patients will tend to just stabilize them and and watch them going forward, sort of benign neglect. So those that do become symptomatic, say 1.5 to 2cm. What's your. Personal. Algorithm? So I think there are several options. And and obviously there's other nuances Athletes in season and so forth. Mechanical symptoms. You know, if you have that rare patient, that one, you can still treat the same way you just described and render them less or asymptomatic. But definitive treatment, I think, ranges from either an autographed maybe in our more higher demand level patient, which has excellent outcomes when you look at return to sport versus microfracture or marrow stimulation. And I think advances that we've had there allow us to treat those lesions pretty predictably. And I'll typically use as an adjunct anything bigger than 1.5cm². I'll typically add bio cartilage to that as well. But I would suffice to say the buckets for small lesions, if I'm not going to simply to breed them, will either be for their intermediate to high level patient stimulation, adjunct bio cartilage with ACP or Osteochondral Autograft. If it's a very high level individual who has an 11 millimeter defect or smaller in in circumference, because I prefer to use a small number, maybe just one osteochondral autograph plug. I think the literature looks fantastic for osteochondral autograft for the small lesions, the return to sport, the early return to sport. But for me, it's hard to find those small lesions that are symptomatic. I agree. I think you touched on another point on an in-season athlete, or maybe they're trying to get ready for next year. The Andrews group came out and they showed their results much better with just simple stabilization control compared to. I mean, you generally don't get long term if they have been symptomatic once, they often will become symptomatic again if they remain highly active. But it fits within the confines of getting an athlete back to play within their timeline horizon, whether it's a contract or what have you. So it's a great option that doesn't take them out of the sport for any prolonged period of time. Just can't forget about it as a good option. Well, I think that pretty well summarizes my thoughts on small lesions. Do you have anything to add? Very good. Brian, that was great. Thank you. Thank you.

OATS® para autoinjerto

OATS® para autoinjerto