Rodilla

Transplante osteocondral

El método Arthrex para los transplantes osteocondrales es&nbsp;<a href="https://www.arthrex.com/es/rodilla/oats-para-aloinjerto" title="OATS® para aloinjerto">OATS®&nbsp;para aloinjerto</a>; una familia de productos ortobiológicos que facilitan la obtención de cilindros de cartílago osteocondral/hialino de diámetro grande de un hueso para aloinjerto.&nbsp;

Knee

Product

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.

Orthobiologics

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Human

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.

A video recording of a panel discussion with a surgeon along with either a product manager, a medical education team member, or other surgeons.

Videoaufzeichnung einer Podiumsdiskussion mit einem Chirurgen oder Chirurgin zusammen mit entweder einem Produktmanager oder Produktmanagerin, einem Mitglied des Medical Education-Teams oder anderen Chirurg:innen.

Surgeon Segment Videos

Vídeo de um painel de discussão com um cirurgião, juntamente com um gerente de produto, um membro da equipe de educação médica ou outros cirurgiões.

Vídeos do segmento do cirurgião

Video de panel de discusión con un cirujano junto con un gerente de producto, un miembro del equipo de educación médica u otros cirujanos.

Videos de segmento de cirujanos

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

Child (D)

Procedure

La instrumentación OATS para aloinjerto facilita la obtención de cilindros de cartílago osteocondral/hialino de diámetro grande de un hueso de aloinjerto. El núcleo se forma colocando el cóndilo en la estación de trabajo y a partir de la toma de injerto. Se crea un orificio receptor de un tamaño 0,5 mm más pequeño, con el receptor del tamaño adecuado. La profundidad exacta para que el aloinjerto coincida con el orificio se obtiene con la guía de medición de profundidad y el aloinjerto se recorta a la misma profundidad y oblicuidad. La dilatación del orificio produce un calce exacto una vez que el aloinjerto donante es insertado en el orificio receptor. La fijación final del aloinjerto se logra con un nivelador sobredimensionado, que genera un injerto de calce a presión perfectamente al ras que no requiere implantes de fijación.

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.

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.

Transplante osteocondral

OATS^® para autoinjerto

Set de aloinjerto OATS^®, largo

Transplante osteocondral

OATS® para autoinjerto

Set de aloinjerto OATS®, largo

OATS^® para autoinjerto

Set de aloinjerto OATS^®, largo