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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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.

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Paul Caldwell, MD (Richmond, VA), presents the process of placing orders for fresh osteochondral allografts.

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Fresh Osteochondral Allografts Ordering Process

Hi, my name is Paul Caldwell, and I'd like to talk to you about the process of ordering an osteochondral allograft and share with you some pearls to ensure a smooth and successful case. I hope you find this information helpful to avoid delays in locating a match for your patient. Even before the process can begin, surgeons must submit and receive prior authorization from the patient's insurance provider. Once prior authorization is obtained, the surgeon has multiple options for submitting a request for an osteochondral allograft. This process can easily be completed online using a computer, tablet, or smartphone via a HIPAA compliant website, or by emailing a scan request form to the tissue provider. Your Arthrex technology consultant is always available to assist you throughout this process to obtain the best size match for the patient. The tissue provider prefers an MRI or CT, which can be uploaded via a secure website. Alternatively, an X-ray with a with a magnification marker placed adjacent to the involved side of the joint may be used. Magnification markers are available upon request from the tissue provider. Once the application and imaging have been received, the tissue provider will place the patient on a waiting list and begin the search for an appropriate allograft. Although wait times may vary, they tend to be shorter for commonly procured allografts, such as a hemi condyle, talus, or distal tibia. Due to the varying demand, the typical wait time for distal tibias and talus is about a week, and lateral epicondyles is approximately two weeks. Now for medial epicondyles, which are in greater demand. The wait times are usually between 4 to 6 weeks, generally speaking. Less common grafts, which are referred to as specialty grafts, tend to have longer wait times. Example of a specialty graft would be a humeral head, femoral head, trochlea patella, distal femoral by compartmental and whole distal femoral graft. These specialty grafts can take anywhere from 8 to 16 weeks to obtain. Once a match is found, a formal offer and photo dissection sheet will be sent to the surgeon's office detailing the selected graft. As this is a very time sensitive process, the surgeon will promptly review the graft offer and, if approved, return the signed offer to the tissue provider. This process can be most efficiently completed electronically via e-signature, although faxing or emailing the offer is always an option. Osteochondral allografts are optimally implanted within 28 days from donor death, so this process must move very quickly and efficiently during the first 10 to 14 days. The allograft is recovered, processed, and undergoes strict testing and eligibility review to ensure it is safe for transplantation. Due to the tight time frame, the surgeon's office and patient must understand the importance of being flexible and available to be ready for surgery on short notice. The surgery date should only be confirmed once both parties are available, and the insurance company has been approved. Before the graph can be shipped to the tissue provider will supply the graph description part code graft ID, which is a lot number or serial number, and the price to the hospital or purchasing department. In turn, the hospital or purchasing department must then provide a purchase order number, more commonly known as a Po number, directly to the tissue provider for this process to move forward. Once final eligibility and testing of the graft has been completed and a Po number is received, the allograft may be shipped. Your Arthrex technology consultant can help track this process and ensure that the appropriate instrumentation is available for implantation. Your Arthrex technology consultant may also be present during the case to assist the surgical team. Maintaining the temperature of the graft is very important to preserve the living cartilage cells. Once the graft is received, it may certainly remain in the cooler that it was shipped in until the expiration date, which is written on the outside of the box, or the graph can be stored in a refrigerator at refrigerator at the facility between 1 and 10°C. If there are questions regarding graph storage, the ifu found inside the box outlines the storage and handling parameters specifically. It's extremely important to remember to never place a fresh osteochondral allograft in the freezer, and that all unused tissue should be discarded, according to hospital policy. To summarize, here are some of the pearls about ordering an osteochondral allograft. Ensure that the insurance approval is obtained prior to ordering the graft. Make sure that the surgeon, office, staff, and patient understand the flexibility and availability necessary to acquire the graft as quickly as possible. Utilize the online ordering process to submit your request forms, as well as MRIs or CT scans, to guarantee the quickest and most efficient response. Take care to handle the graft properly upon receipt to ensure successful implantation.

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.

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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Articular Cartilage Repair - Biologic Algorithm