Arthrex works to provide its surgeons the latest options in bone grafting to help treat their patients.&nbsp; The bone graft options consist of a variety of allograft products and a number of novel synthetic bone void fillers.

Knee

Product

The single use Bone Graft Harvester set consist of a minimally invasive 6, 8 or 10 mm diameter bone graft harvester, an impaction bar and a twist knob. It is ideal for harvesting autograft bone from the anterior/superior or posterior/superior iliac crest. The Bone Graft Harvester Set is an excellent option for any bone grafting procedure and can be performed through a small incision with minimal damage to cortical bone.

Bone Graft Harvester

Human

Child (D)

OSferion is an osteoconductive bone graft substitute and bone void filler consisting of 100% High Purity Beta-Tricalcium Phosphate (β-TCP). OSferion's micro and macro porous structure allows it to be resorbed and replaced by bone during the healing process when used in conjunction with rigid fixation devices. These revolutionary osteotomy wedges have an unprecedented compressive force of 15-20 MPa (2900 pounds/square inch), comparable to cortical bone, adding improved stability to the correction site. OSferion wedges can be used in conjunction with the Arthrex distal femoral and high tibial opening wedge osteotomy plates and screws. The chamfered wedge design of the implants corresponds to the shape of the open wedge correction performed with the Opening Wedge Osteotomy System. After insertion of the osteotomy plate, the appropriate size OSferion wedges are prepared in a sterile fashion using autogenous blood, or osteotomy site bone marrow and placed within the osteotomy site by hand. The OSferion wedges are placed on either side of the secured osteotomy plate within the osteotomy. They can be trimmed to size using a rongeur.

Orthobiologics

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iBalance® HTO System for Medial High Tibial Opening Wedge Osteotomy

OSferion Osteotomy Wedge

StimuBlast DBM provides osteoinduction and osteoconduction with optimal handling characteristics. The reverse-phase medium (RPM) carrier is biocompatible and allows the DBM to be molded and packed into any defect size or shape. Due to the RPM carrier, StimuBlast DBM thickens at body temperature and resists irrigation.

StimuBlast® Demineralized Bone Matrix

Features and Benefits:
Quickset calcium phosphate cement* is a macroporous, injectable, hardening and resorbable bone filler provided in an easy-to-use, closed mixing system.
Composition:
The mixing system is a dual-chambered syringe containing a powder and mixing liquid.
The powder chamber contains a mixture of calcium phosphates and an organic polysaccharide polymer; the polysaccharide is a highly biocompatible polymer that optimizes the viscosity, cohesiveness, and macroporosity.
The mixing liquid consists of a sodium phosphate solution that facilitates the setting time (crystallization) of the cement.
The end product is a calcium-deficient apatite very similar to the mineral phase of bone.
* Quickset is a trademark of Graftys, S.A.

Quickset™ Bone Cement - Injectable Macroporous Calcium Phosphate

video

Arthrex Quickset™ Calcium Phosphate Cement

Arthrex Quickset is a macroporous resorbable bone cement provided in an easy to use mixing syringe. Initiate mixing of Quickset by rotating the collar to the transfer position and using the push rod to advance the piston, so that the sodium phosphate liquid passes into the chamber containing calcium phosphate powder. Mix the two components for two minutes. The mixture of powder and liquid initiates the crystallization process, which will form a rigid matrix over time. Pull the mixing element back and bend it at its base until it breaks free. Rotate the collar to inject and insert the syringe into the gun with the markings on the syringe facing upwards. Compress the trigger in order to push the piston forward and dispense the resorbable bone cement paste through the provided cannula. When Quickset is used to fill an osseous defect, it will crystallize and form an interconnected porous structure that contains microporosity and macroporosity. Macropores are imperative for bone remodeling. These pores allow the larger osteoclasts to penetrate the bone cement and initiate the resorption process. After the osteoclasts resorb parts of the Quickset bone cement, the smaller osteoblasts can begin to lay down new bone matrix. Natural remodeling of the osseous matrix will occur throughout Quickset, ensuring complete cement resorption over time. When choosing a resorbable bone cement to fill osseous defects, consider Quickset as an optimal solution.

Quickset™ Calcium Phosphate Cement

The BoneSync synthetic bone void filler portfolio provides surgeons with synthetic bone repair products that provide excellent handling characteristics, all with an osteoconductive scaffold for a wide array of bone repair procedures.
The BoneSync portfolio includes:
<ul>
 <li>BoneSync calcium phosphate cement</li>
 <li>BoneSync putty</li>
 <li>BoneSync strips</li>
</ul>

This animation demonstrates BoneSync™ calcium phosphate cement for augmentation of poor-quality bone surrounding lateral-row anchors during a FiberTak® SpeedBridge™ rotator cuff repair.&nbsp;

BoneSync™ Calcium Phosphate Cement Animation

Bonesync calcium phosphate cement is a collagen enhanced bone void filler. This fast setting, fast remodeling biomimetic bone void filler uses a straightforward mixing system to deliver an injectable putty. The one cc size offering is optimal for instances where a small bone void needs augmentation, such as poor quality bone when placing the lateral SwiveLock anchors during a FiberTak SpeedBridge repair. When additional support to the surrounding poor quality bone is needed. Bonesync cement uses a mixing protocol that quickly results in an easily injectable cement. Draw 0.8ml of saline into a syringe. Remove the clear cap of the BoneSync powder syringe and thread the two syringes. Inject the saline into the BoneSync powder syringe and mix thoroughly for 60s. Move the mixed BoneSync cement to the delivery syringe. If excess air is present, pull back on the plunger, then press on the plunger to expel all the air in the syringe. After a punch is used to prepare a bone socket for the lateral row and bone quality has been assessed, insert an eight gauge open tip, jamshidi through the passport button cannula and into the prepared bone socket. Insert the delivery cannula 2 to 3mm into the socket. The inner trocar is removed and the BoneSync syringe is attached to the delivery cannula. The BoneSync syringe plunger is depressed, delivering the collagen infused calcium phosphate cement. The inner trocar is then reintroduced to clear the cannula and deliver all the material. The medial row sutures are passed through the eyelet of the SwiveLock anchor, which is then secured into the augmented bone socket, where the BoneSync cement interdigitate with the anchor threads. The same steps are completed for the second lateral row anchor. Adding BoneSync calcium phosphate cement to the construct can increase anchor fixation strength. The collagen component of the BoneSync cement brings unique handling characteristics, including stability, and helps to provide the macroporosity structure of the device. This macroporosity structure of the BoneSync cement allows for Osseointegration overall augmenting poor quality bone in the lateral row.

BoneSync™ Calcium Phosphate Cement


Spine

BoneSync™ Putty and Strips

BoneSync™ Synthetic Bone Void Fillers

The BioSurge™ cell and bone graft processing system combines the matrices of the AlloSync™ bone grafting solutions line with the Angel® system’s proprietary technology to prepare customized platelet-rich plasma concentrate (cPRP) from bone marrow aspirate (BMA). Hydrated AlloSync bone grafts provide the optimal scaffold for cPRP from BMA, which is a rich source of platelets and nucleated and progenitor cells.

BioSurge™ Cell and Bone Graft Processing System

Kirk A. McCullough, MD, (Leawood, KS) discusses the innovation behind the BioSurge™ system.

BioSurge™ Convenience Kit

Mollie Manley, MD, MS (Akron, OH), discusses a series of cases in which she treated scaphoid nonunions in young patients using the BioSurge™ cell and bone graft processing system. Dr. Manley also discusses the advantages of an arthroscopic approach and the grafting options available for these cases.

Arthroscopic Fixation of Scaphoid Nonunions Using BioSurge™ Cell and Bone Graft Processing System

Hello, my name is Molly Manley. I practice at the Crystal Clinic Orthopedic Center in Akron, Ohio. And today I'm going to talk about arthroscopic fixation of the scaphoid nonunion with BioSurge bone grafting. So the scaphoid has poor bone supply and can lead to nonunion degenerative changes. Then can happen in 90 to 100% of patients in five years after injury leading to a snack or a scaphoid nonunion, advanced collapse wrist. These patients are typically young, which can create a great functional impairment. This can result in altered wrist kinematics, motion defects, and wrist osteoarthritis is likely to develop. The treatment of scaphoid. Nonunion can be open, which is a typical treatment. This has good success but can have large incisions, especially if taking bone graft from the same incision. However, this jeopardizes residual vascularity and can damage capsular and ligamentous structures surrounding the scaphoid and leading to further stiffness. There is a limited approach described in 2006 which bone grafting was inserted percutaneously. However, the amount of bone graft was limited and repeat bone grafting was required in 12% of patients and last is arthroscopic. Developed in 1997 and has shown faster union rates, there is an arthroscopic advantage. First, you can examine the joint treat can common injuries maintain blood supply and decrease the soft tissue trauma with faster recovery and better esthetics. The bone grafting options include autograft bone graft, which would be vascularized versus non vascularized. There's also allograft and BioSurge, which combines AlloSync with Angel PRP from the iliac crest. Bone marrow aspirate. This is a perfect mirroring of both biology plus scaffold and can be inserted arthroscopically. So next I'm going to talk about a variety of cases that I have performed this way. First is a 23 year old male. He's greater than three months post injury where you can clearly see reabsorption of the scaphoid at the fracture site. Intraoperative dry arthroscopy images show first the nonunion site. Next is debridement of the site. And last is once this has been debrided after inserting the BioSurge and a headless compression screw. These are his x rays at two weeks postoperatively where you can easily see the nonunion site. Just six weeks later, you can see cortical healing across the ulnar side of the scaphoid. The next patient is a teenage male that's over nine months post injury on his MRI. You can see AVN and Vascularity of the scaphoid on the imaging intraoperative photo, again showing the nonunion site. And after treating this with BioSurge and a headless compression screw, these are his x rays eight weeks out where the scaphoid remains vascular. There is no breakdown at the fracture site and it appears to be healing well. Last is a 31 year old male that is three months post injury, again with resorption across the scaphoid nonunion site. Intraoperative arthroscopy pictures showed debridement of the nonunion and then a probe showing the size of the nonunion, which is over two millimeters. Here's an intraoperative video showing insertion of the graft. So first we put the bone graft through a cannula which is in the midcarpal radial portal. The graft is inserted through a syringe into the nonunion site. After adequately packing the nonunion site, a blunt probe is then placed to pack the graft more boldly. Then the cannula is reinserted, and this is continued until the nonunion site is fully pacted with the bone graft. This is the gentleman two weeks post-op and last is six weeks later, again showing signs of cancellous and cortical healing of the fracture. Postoperatively. The patients are in a thumb spica splint for two weeks, then a removable WFO and they start range of motion. X-rays are then done at eight weeks and a CT scan at 12 weeks with full activity after bridging, callus is noted on the CT scan. In summary, scaphoid nonunion can be a bad problem if left untreated. Arthroscopic management has historically shown good results. A notable difference has been seen with BioSurge, and in my practice it has been a very cost effective alternative with the unique packaging of both the bone marrow aspirate and the AlloSync bone grafting to treat nonunions. Thank you.

Kirk A. McCullough, MD, (Kansas City, MO) demonstrates a percutaneous Jones fracture repair using an Arthrex Jones screw augmented with AlloSync™ Pure and Angel® cPRP from the BioSurge™ system.

BioSurge™ System for Percutaneous Jones Fracture Repair

This is Doctor Kirk McCullough from Kansas City. And what we're going to highlight today is the use of the BioSurge kit and the combination of the AlloSync allograft system, along with the Angel concentration system. So as you can see here in the box, as you open the BioSurge kit, this is the first thing you'll see. So this is the AlloSync matrix as it comes with this particular kit here. And then just beneath this you then see the Angel CRP system that is deep to that, that is provided with this system. And the important thing to realize about this is what we're trying to harness here is the ability of the patient's own osteoinductive potential that we can concentrate, along with the AlloSync osteoconductive nature of the allograft, to provide an overall triad of healing along with the cells signal and scaffold. All right. So you can see at this point we've already harvested a bone marrow aspirate, whether it's from the iliac crest, proximal tibia or the distal tibia or calcaneus. You can utilize any one of one of these sites for that. And then we will utilize the Angel system for a further spin down of this. And so as you can see here, we've already prepared where our screw insertion site will be proximal to the fifth metatarsal base. And then under fluoro I will identify the site of where the fracture is and make a small incision through which you can use a freer to then mobilize the periosteum. So I go deep and plantar as well as dorsal and medial to create a small little pocket subperiosteal that we're then going to use the BioSurge construct in the components, including both the spin down from the Angel as well as the DBM to then inject in that area. In addition to that, we will also under fluoro, go through the intramedullary space and then inject at the site of the fracture as well a small volume of that BioSurge product as well. And so what you can see here is this is the 2.5 cc's of AlloSyncPure. The important thing to understand about that is that is 100% bone without the need for a carrier. And realizing that also the ability of the cells and the product that we're able to isolate from the Angel spin down is able to bind with that and does not need, as compared to other competitive products, the need of a carrier for that to be able to stay with that graft. And what you can see here on the left is what we have as a yield from our Angel spin down three CCS of that concentrated PRP from the iliac crest in this case. And so what you'll do is you'll then combine those two and then ultimately have a yield similar to this that is now at least in this CC syringe, a flowable component that we will then through a Tuohy needle, advance both at the fracture site Subperiosteal as well as within the Intramedullary canal. So at this point, first I would inject into the intramedullary space. And so you can see where the fracture is that we've created. And then I will then advance the Tuohy needle to that site. And once you can see under fluoroscopy that you are at the site of the fracture, you can then connect your syringe with the BioSurge product. And so then under fluoro at that site, I will then advance and add some of the product into that intramedullary space, making sure that just distal at and just proximal to the fracture, I'm adding a small amount of graft. You do not want to add a whole lot of volume to this point, because obviously you still have to place your screw. And so similarly, what we'll do now in the subperiosteal space that we created previously, you can place the Tuohy needle in this spot and then remove the obturator. And then what you will do, similar to what we did in that intramedullary canal, you will then add graft subperiosteal all around the fracture site. And so you want to place that plant early laterally and dorsally. And then at this point we're ready to then advance the screw across the fracture. So at this point we're ready to then advance the screw into place. And so once your screw is then in place and able to then get the final shots of the construct.

Products within the comprehensive line of AlloSync bone grafting solutions are derived from human allograft bone and maintain optimal osteoconductive potential. Demineralized bone graft products also have osteoinductive properties. The comprehensive portfolio includes a wide selection of advanced demineralized bone matrix (DBM) graft options:
- AlloSync Pure demineralized bone matrix
- AlloSync Expand demineralized cortical fibers
- AlloSync demineralized cancellous sponges and cortical fibers
- AlloSync putty, gel, and paste 
 

- AlloSync wedges
AlloSync products provide excellent handling characteristics and can be combined with bioactive fluids, such as platelet-rich plasma (PRP) or cPRP from bone marrow aspirate (BMA).

AlloSync™ Bone Grafting Solutions

The AlloSync™ bone grafting solutions product line includes AlloSync Pure demineralized bone matrix and the AlloSync demineralized cancellous sponges and cortical fibers. These bone grafts are derived from 100% human allograft bone and can be hydrated with biologically active fluids.

Arthrex. Allosync is a comprehensive bone grafting solutions line derived from human allograft bone. The AlloSync grafts maintain optimal osteoinductive and osteoconductive potential while providing excellent handling characteristics for various orthopedic applications. Allosyncpure is an osteoinductive bone matrix derived from 100% human allograft bone with no extrinsic carriers. The AlloSync line also includes demineralized, cancellous, sponges, and cortical fibers, which are processed in a manner that optimizes the residual calcium level and osteoinductive. Allosyncpure is provided in a ready to use mixing jar and may be hydrated with PRP, BMC, or other biologic fluids to create the desired consistency during preparation. The compression of the graft mixture helps to incorporate the demineralized bone matrix with the bioactive fluid. Alternatively, AlloSyncPure can be prepared using the ABS 2000 mixing syringe. The graft and biologic fluid are added to the syringe and prepared with the internal mixing element until thoroughly mixed. The proprietary rice shaped fiber technology used to process AlloSyncPure allows the graph to resist irrigation and be used in a fluid environment when prepared as directed. Adding additional fluid to the graft allows the clinician to decrease the viscosity of the AlloSyncPure. For injectable applications such as iabp. The accelerated cellular ingrowth with AlloSyncPure has been histologically proven with in-vivo testing at 28 days post implantation. All five elements of bone formation, including new bone, bone marrow, osteocytes, chondrocytes, and cartilage are present. Allosync, demineralized, mineralized sponges and fibers are available in a variety of shapes and sizes, including cancellous strips, cubes, chips, and cortical fibers. These graphs maintain the natural bone architecture with interconnected porosity, providing an optimal scaffold for cellular attachment and proliferation while preserving native bone morphogenic proteins. The AlloSync de mineralized cancellous, sponges, and cortical fibers can be hydrated with bioactive fluids such as platelet rich plasma or bone marrow aspirate during hydration. The graft will naturally wick up and retain the surrounding fluid, making it an ideal scaffold for cells and growth factors. Once hydrated, the AlloSync sponges and fibers become compressible like a sponge, allowing for flexibility to fit in and around different types of bone defects. Allosync pliable handling characteristics facilitate minimally invasive surgical procedures with the incorporation of allograft bone. For fusion cases such as an ankle arthrodesis AlloSync demineralized. Sponges soaked in BMA can be placed at the fusion site for maximum biologic healing. Allosync mineralized sponges can also be interposed at the site of tendon bone repair in rotator cuff tears. The compressible nature of the grafts allows the sponge to be delivered and secured at the repair site arthroscopically. This construct has been shown to result in superior structural and biomechanical properties as compared to a standard of care repair. Histologically. Rotator cuff repairs with an interposed DBM strip have been shown to mimic normal rotator cuff tendon insertion to bone, compared to repairs without an interposition graft. Allosync bone grafts are processed sterile to device grade standards and stored at ambient temperature.

The unique long-strand geometry of AlloSync™ Expand 100% demineralized cortical fibers maximizes graft cohesion1 and provides a 3D interconnected matrix to promote cell migration across the bone void. AlloSync Expand fibers have demonstrated superior bone-forming capacity compared to standard particulate demineralized bone marrow.2 After hydration, the graft will expand to fill the void and create endplate-to-endplate contact in spinal fusion cases. AlloSync Expand fibers can be hydrated with biologic fluids, such as platelet-rich plasma or concentrated bone marrow aspirate.
References
1. Walsh WR, Lovric V, Russell N, Kim P, Larson MJ, Vizesi F, et al. Improved performance of SeaSpine demineralized bone fibers vs. three commercially available demineralized bone matrix products in an athymic rat posterolateral fusion model. IsoTis – Clinical Affairs. 2020.
2. Martin GJ, Boden SD, Titus L, Scarborough NL. New formulations of demineralized bone matrix as a more effective graft alternative in experimental posterolateral lumbar spine arthrodesis. Spine. 1999;24(7):637-645. doi:10.1097/00007632-199904010-00005.

AlloSync™ Expand Demineralized Cortical Fibers for Spinal Fusion Cases

Shoulder

Patrick A. Smith, MD (Columbia, MO), demonstrates a SpeedBridge™ rotator cuff repair augmented with interpositional AlloSync™ button (demineralized bone matrix) and Angel® system cPRP from BMA. He demonstrates using the Knotless SwiveLock® suture anchor, which has a tensionable knotless mechanism built into the eyelet that can be used to easily deliver the AlloSync button to the rotator cuff footprint.

SpeedBridge™ Rotator Cuff Repair With Knotless SwiveLock® Anchors and AlloSync™ Buttons

This is the right shoulder. So we have our passports in place. Post your viewing portal first. Here's our tier. You can see anteriorly. Here's our biceps tendon posteriorly back through the infraspinatus. So muscle tendon junction right about here I like to prepare the footprint. And I've done some of this already. Removing the soft tissue I like to use a curette first to help remove all the soft tissue from the previous fibers that might be left over to get a nice little bleeding decorticated area. And then I also like the PoweRasp. So here's our PoweRasp. Just kind of like to touch it. So at this point we're going to first harvest some bone marrow concentrate. I've already made a portal just off the acromion. This will be our portal that we're going to use for our anchor placement as well. For our medial row we're going to come in here first with our jamshidi needle. We're going to come right into the proximal humerus for a harvest of our of our BMC. So there's our humerus right here. So kind of in the lateral extent of the footprints, we can come down the shaft. So here's a full 30 cc syringe and we get two of these. Next we're going to proceed with our cuff repair. We've prepared the footprint. We're getting our BMC spun in the Angel system. And so we're going to create our medial anchor placement. So first we're coming in with our SwiveLock punch. We're going to make our medial row anterior anchor placement first just behind the biceps tendon to restore the air of the anterior cable to SwiveLock. Now here's our knotless SwiveLock device coming in. And again this is preloaded with our FiberTape. So we bring the SwiveLock anchor down to our hole and insert. So first we're going to go ahead and pass our two tapes in a horizontal mattress fashion through the medial cuff. That way they'll be out of the way. When we utilize the knotless mechanism for the bow button, we're just going to grab our medial tape Anteromedial tape and brings them both out together. At this point, you have an option. You could either pass the two tapes together through a medial spot, anterior posterior, or. My preference is to cut the tape so I have two free ends. We'll take our first tape. So now we're going to come in here through the anterior aspect of this tear. Avoid the bicep. I can see the bicep right there. So this is my more anterior anchor placement. I just want to be just lateral to the muscle tendon junction by a couple of millimeters. So we'll grab now that pass through and bring it out the anterior portal. So it's out of our way. Here's our second pass now. So we'll retrieve that. As you can see, we've made our two passes here and we've left the mechanism free. And so the mechanism, the knotless mechanism is allow us to place our bio button right here at the footprint where we want it. So now you can see we've got our four passes of the tapes immediately through the cuff tissue, a couple of millimeters from the muscle tendon junction, which is where you want to be. Our two anchor placements immediately anterior and posterior. And you can see our two knotless mechanisms are separated. So now we're going to apply the bio button to our Knotless mechanism. So the bio button will lay at the footprint. And then we'll complete the double row repair over the top of the bio button to compress it to the tuberosity footprint. So here's our bio button. This is Demineralized Cancellous bone matrix. This specimen that we're using is three millimeters thick 12mm round. So here's the application of our BMC to the sponge. So we're just going to let it all soak in. So the soaking time recommended is five minutes here for the button in the BMC. So now we're going to come in through the percutaneous portal and grab the three anterior sutures from our To show that they're free from the posterior one. Just. There's no problem. So next thing we're going to retrieve through our lateral portal now, which is where we're going to pass a buy button. I'm going to retrieve my passing end of the repair suture and my shuttle suture. And so we're going to pull on the one we don't need which is posterior. So here we got the two that we need. So again this is the the looped end of the shuttle suture and the repair suture. So this is the SwiveLock passer. Now a repair sutures pass through the loop. And we're going to bring it back through the buy button. We've got the white tapered portion of the repair suture folded to the appropriate point. And now we're going to pass with our shuttle suture. So take a bit of slack out. Create the mechanism. At this point I want to insert the bio button. So here I'm going to insert the bio button through our passport. But I want to be careful with the sutures. So we're doing it Dramatically here. So now we're inserted and now we're going to bring the bow button down. With our shuttle suture. So at this point we can adjust our position. So we're right on the footprint. And the knotless mechanism is going to hold it in place. So this is ideally located. You can see we've covered the entire footprint and it's held in place here. This doesn't have to be super tight. I was able to manipulate with my probe to position it. Now I'm going to cut this suture as I don't need it anymore. So now we have our anterior bio button in position. So I'm going to come in through my lateral and bring out my repair suture and the looped end of the shuttle suture. We're going to repeat the process. This is for our second bio button. So we're going to fold it. This fixation does not have to be tight. This isn't for mechanical purposes. It's just for us to get our sponge for coverage of our footprints. So you can really see now the open pores of the graft and how that's going to help healing of this cuff back to bone. Remember, even though it looks as if the BMC is washed out, Doctor Maisaka has shown us that the stem cells are still there. So we've got complete coverage of the footprint, and we're going to bring the cuff repair of sutures over the top for compression. As you can see, just lateral viewing portal. Good reduction of tissue over the interposition of graft. So at the end of the procedure you can reload the interposition of graft with additional stem cells. With left over BMC. As you can see here adding additional growth factors here to the to the patch with the leftover BMC.

Chad D. Lavender, MD (Scott Depot, WV), demonstrates an all-inside ACL reconstruction augmented with bone marrow concentrate mixed with AlloSync™ Pure and autograft bone collected with the GraftNet™ device.

All-Inside ACL Reconstruction Using AlloSync™ Pure Implant and the GraftNet™ Device

This is an all inside ACL reconstruction, where we augment the tunnels with bone marrow concentrate mixed with AlloSyncPure. And in this case, we're also going to add in autograft bone that's going to be harvested with the Arthrex GraftNet. So first we're going to take a look at our GraftLink construct on the back table. There are several things I'd like to highlight, one of which is we've lengthened the femoral sided TightRope to a longer construct that's going to give us more space intra-articular so that we can deliver our composite graft, which is the BMC, the AlloSyncPure, and the autograft bone. Okay. So we're going to begin by cleaning off the lateral intercondylar notch here with the ACL remnant to get down to bone okay. So we're going to begin our notch plasty. And we've attached the GraftNet to the bur. And this will begin our autograft bone collection process. So here you can see we're doing a standard notch plasty beginning at the top of the notch. It's okay if you get a little cartilage in this step. The goal is we just want to collect as much as we can from our notch plasty into the GraftNet. The more, the better. Okay. So just to orient you here, we have our FlipCutter in place in the lateral femur. And we have coming in from the lateral portal, the shaver which is attached, as you can see, to the GraftNet device. So we're going to retrograde ream our femoral socket and collect the bone. Ream means into the GraftNet. You want to use oscillate on the GraftNet. Okay. So you can see here the GraftNet with the autograft bone remains collected. And we're going to place those into a cup. It is recommended to go ahead and remove the graft that you obtain after the femur before pursuing the tibia, because that GraftNet will fill up with bone remains. We have a nicely reamed tunnel and have obtained nearly all of the autograft bone from that tunnel. All right. You can see we placed our FlipCutter up into the joint. We're going to flip the FlipCutter. Okay. And now we're going to take the shaver through the medial portal right above where you're going to be reaming out your tunnel like this. Okay. Now we're going to retrograde ream our tibial tunnel. Through. So as you can see here, we placed a passport canyon in the medial portal. And we're going to bring both passing sutures out that medial cannula. I do that to prevent a SutureBridge. The femoral side is brought superiorly and the tibial side is brought inferiorly. Okay. So you can see here we've obtained about two and a half cc's of autograft bone reaming from our femur and tibia combined. And we're going to take that solid consistency of that bone graft and add it with our AlloSyncPure. And then that's going to be combined with the bone marrow concentrate. We like a ratio of three CCS bone marrow concentrate to five CCS of the solid bone graft, or AlloSyncPure. So we're getting ready to pass this button up through the femur. Okay. We're going to pass the femoral sutures of the graft. So here you can see we've flipped our button on the lateral cortex of the femur. And you can see that our graft sits outside the joint right now. And this is very important when we talk about delivering our composite graft into the femur. Remember at the beginning of the case we lengthen our construct. And that's why we lengthen the construct so that we didn't get in the way of our graft composite delivery. So you can see here this is our composite graft. And I should mention that before the tourniquet is inflated we aspirate bone marrow from the proximal lateral tibia that's concentrated down into bone marrow concentrate and mixed with our solid autograft bone and AlloSyncPure. So to deliver our composite graft we're going to use the BioXpress delivery device. So I like to go ahead and fill some of the BioXpress delivery device before placing this into the joint. I think that that's less tedious. And again, I'll point out that your graph mainly is outside of the joint to give room for our delivery device. So once we have answered this first plunger that we sequentially press each plunger and deliver the graft. I will say a lot of the questions are how much to put into each tunnel. I recommend filling the tunnel completely, and I have never had an issue with bottoming out our soft tissue or bone block grafts. Here you can see the composite graft is delivered into the femur. We sequentially go to the next plunger and you want to see fluid leak around the cannula device. And that's how you know that you're compressing the graft into the tunnel. So you can see the completely filled femoral tunnel there with the composite graft completely filling that tunnel. So for the tibia, I do think it's helpful to slightly hyper flex the knee. And then you can see here's the tibial tunnel. And we're going to eject down into the tibia. The tibia will accommodate a substantial more amount of the composite graft. So this is the way I want my tibia to look. You cannot see the edges of the tibial tunnel. And if it weren't for the suture that you can see coming down through the tibia, you would not even realize that you have a tunnel, and that's the way you want it to look. And then you can see the femur as well, completely filled tunnels. This is what we consider the fertilized ACL portion of this procedure. Here you can see we're delivering the femoral side of the graft into the femur. So we deliver about 10 to 15 of that. Here you can see we're delivering our tibial tails down through the tibia. So you can see here we've dunked our tibia side. Now we're going to sequentially tension on the femur then the tibia. And then we're going to also tension our internal brace as you can see running along our graph there. So we're going to bring another 5 to 10mm of graft up into the femur. You can also place a stitch in the center of your graft. That's going to let you know that you're at a good place. And as you can see, there's no composite graph that leaked into the joint. Completely clean joint. And the tension is very excellent on that graft. And we'll tension with a button on the tibia. And then the internal brace goes through a swivel lock on the tibia as well.

Paul R. Fleissner, MD (Akron, OH), presents a case in which he performed a high tibial osteotomy (HTO) using a tibial opening wedge osteotomy plate. The osteotomy was augmented with AlloSync™ Pure demineralized bone matrix and Angel® concentrated platelet-rich plasma from bone marrow aspirate.

High Tibial Osteotomy Augmented With AlloSync™ Pure and Angel® cPRP From BMA

Hi, I'm Paul Fleissner from Akron, Ohio. I'm here today to discuss the use of biologics in a high tibial osteotomy case. Our patient is a 21 year old college female basketball player who presented to me one year status post left ACL reconstruction. All reconstruction and partial medial meniscectomy. She presented with medial knee pain and swelling. Her past medical history was pertinent for her previous primary left ACL repair and medial meniscus repair, followed by a partial medial meniscectomy, first as a weight bearing film of the left knee showing some mild medial compartment narrowing and osteophyte formation. She then had a long standing film to show that she had seven degrees of varus deformity in the left knee. An MRI was obtained and revealed mild medial and patellofemoral joint osteoarthritis. I felt at this time her treatment options included either a high tibial osteotomy or a unicompartmental knee arthroplasty. However, because of her young age and high activity level, I felt that she would do much better with the high tibial osteotomy. It gave her a much better chance of an active lifestyle and did not burn bridges for the future. For her, the high tibial osteotomy has been successfully used to treat arthritis of the of the knee in symptomatic patients with varus deformity for many years. It was initially popularized by Coventry as a lateral closing wedge osteotomy. The current standard for high tibial osteotomies is a medial opening wedge osteotomy, and this is because the deformity is considered to be a proximal tibia and you have the ability to modify your correction. There are, however, some drawbacks. There is a higher risk of nonunion because the osteotomy is performed under tension and distraction, and we all know that osteotomies heal better under compression. There is also the possibility of loss of correction when the patient begins weight bearing. The loss of correction can be dealt with by using plates with spacers, which are more reliable in maintaining that correction. And that is why I use this. The Arthrex high tibial osteotomy plate. It has many sizes available in the set that allow you to achieve the desired correction you would like, and this is a side view of it showing the spacer that is there. And they come by one millimeter increments to give you the ability to fine tune your osteotomy. The medial osteotomy can be augmented by bone grafts, synthetic bone substitutes, PRP growth factors, and bone marrow concentrate. There are early encouraging results with PRP Growth factors in bone marrow aspirate concentrate with bone grafting and bone substitute augmentation. The surgical treatment of this patient involved an initial diagnostic arthroscopy, which revealed grade 1 to 2 changes of the medial femoral condyle, medial tibial plateau, as well as evidence of her partial medial meniscectomy. The patellofemoral joint showed some early changes of the trochlear groove. The ACL and lateral compartment were normal, therefore finding no contraindication to a tibial osteotomy. She underwent a high tibial osteotomy using the Arthrex high tibial osteotomy plate. I used an 11 degree plate because of the fact that she had seven degrees of varus to start with, and I like my patients to wind up with 3 to 6 degrees of valgus after correction. The osteotomy was augmented by using the Arthrex product BioSurge, which is a combination of bone marrow aspirate concentrate from the Angel system, and AlloSyncPure, which is a mineralized bone matrix, and these are initial post op films showing in the AP and lateral plane total filling of the osteotomy site. Tamayo et al. In 2010 reported on a series of 20 patients who had underwent a medial opening wedge high tibial osteotomy with an average eight year follow up. He used DBM in DBM. Intracortical iliac crest allograft as this augmentation. He found the average time to full weight bearing was 11.4 weeks, with one patient actually taking 32 weeks to heal, enough to begin weight bearing. By using BioSurge in this case, I felt that I took advantage of the bone marrow, stem cells and AlloSyncPure properties. It gives you all the potential of autograft without the morbidity or time consumption. Seven weeks Postoperatively. You can see on this radiograph she has complete healing of this osteotomy. She started on full weight bearing and progressive strengthening. And at three months she still had maintenance of her correction and was well on her way to returning to full activities. In this case, combining bone marrow aspirate concentrate, which provides a rich supply of stem cells, platelets and growth factors with AlloSyncPure and its Osteoinductive matrix, creates a regenerative matrix for the patient. Thus, achieving complete and rapid healing allows faster initiation of therapy and quicker return to life. So keep in mind, when treating any situation with delayed healing or the potential for it to consider using bone marrow aspirate concentrate and AlloSyncPure in your patient.

Bone Void Fillers

Bone Graft Harvester

OSferion Osteotomy Wedge

StimuBlast^® Demineralized Bone Matrix

Quickset™ Calcium Phosphate Cement

BoneSync™ Synthetic Bone Void Fillers

BioSurge™ Cell and Bone Graft Processing System

AlloSync™ Bone Grafts