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The suction-activated GraftNet device is designed to collect autologous tissue for a multitude of applications. When connected to an arthroscopic shaver, the GraftNet device may be used to remove tissue debris from a surgical site. This recovered autologous tissue is collected in an easily accessed, sterile filtered chamber. The GraftNet autologous tissue collector makes gaining access to autograft tissue as simple as Resect and Collect™.

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GraftNet™ Autologous Tissue Collector

This animation shows the collection of autologous tissue for articular cartilage repair using the GraftNet™ device.

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Articular Cartilage Repair Using Autologous Tissue Collected With the GraftNet™ Device

The suction activated GraftNet device is designed to collect autologous tissue for a multitude of applications. When connected in-line to suction and an arthroscopic shaver, the GraftNet may be used to collect particulated autologous tissue into a sterile, filtered chamber to treat an articular cartilage defect. The GraftNet device may be used to collect autologous tissue from the defect site during preparation of the lesion, using a shaver on oscillate mode. Alternatively, autologous tissue may be collected from non-weight bearing aspects of the knee, such as the notch or lateral trochlea. The particulated autologous cartilage will collect in the GraftNet device, and the autologous tissue is readily accessible within the sterile field. When the plunger is withdrawn. The autologous tissue may then be mixed with autologous fluids. Then delivered to the surgical site in a single stage. Autologous chondrocyte implantation. The completed repair is then sealed with fibrin glue or autologous thrombin serum to stabilize the construct. The autologous tissue collected by GraftNet can also be used to repair chondral defects of the talus or acetabular cartilage defects in the hip. The GraftNet autologous tissue collector makes gaining access to autologous tissue as simple as resect and collect.

Michael Huang, MD, (Colorado Springs, CO) presents the latest techniques and innovations in arthroscopic hip joint preservation surgery. He discusses using the BioComposite Knotless Hip SutureTak® anchor for labral repair and reconstruction as well as the GraftNet™ autologous tissue collector for treating transitional zone cartilage defects.

Arthroscopic Hip Preservation

So I think it's important to kind of define what what we think preservation is. And, you know, I looked it up in the dictionary. It says to keep alive or in existence, make lasting to keep safe from harm or injury and to protect and spare. So when you start overlaying that into what we're doing in the hip, it's really important to ask whether or not we're making a difference. In my practice over the past 12 years, I think the indications for arthroscopic hip surgery in the hip preservation world has increased tremendously. These are just a few of the things that we are doing. I'm going to focus in this short period of time on labor repair and femoroacetabular impingement, and then highlight some new and interesting cartilage resurfacing techniques that I think will potentially make a long term difference in terms of preservation. Where we came from is not that long ago. It doesn't take much to look back and say, well, labor repair Arthroscopically and understanding of impingement came from the early 2000 or late 1990s. We all have Professor Gans to thank regarding the bony deformities and its association and knowledge base towards labral tear, so that's where we came from. Further studies have documented when the labral, when the labrum fails that we have increased articular compression, we have increased contact stress, loss of suction seal. And all of these things can predispose to early degeneration. And so these are the things that we're trying to treat. So if it started in the late 90s and early 2000, the question is, well, do we have any long term studies. And one of the longest term prospective minimum ten year follow ups is out of Vale. And Doctor Philippon certainly gets credit for this. But he compared 79 patients who underwent labral repair and also included 75 patients that underwent labral debridement. And out of that cohort over ten years, 34% of them went on to total hip and the predisposition factors were increased. Age obviously decreased joint space on presentation and the presence of microfracture, which will become a topic for later in this talk. What about the older patients? Well, minimum two year follow up. And patients over 60 actually did very well. So average age of 66 only about 12% failed and went on to additional surgery. And additional surgery was not always total hip. Actually three went on to total hip and two had revision hip arthroscopy, and at two years after hip arthroscopy, almost 90% of them were still doing well. So. So overall, we're seeing about a 66% improvement in preservation at the ten year time point between 2 and 5 years, depending on which cohort you're looking at. The results are still durable. I think this is because we've been advancing and we've advanced on lots of frontiers. We've advanced on patient selection criteria, and we've advanced in innovation in terms of techniques, and we've advanced in innovation on on some of the tools that have been given to us by companies like Arthrex. So patient selection and you followed this over time. We're much more diligent about who we are indicating. We're looking much more at dysplasia, coxa profunda, acetabular retroversion. We're starting to understand the relationships between the soft tissue damage and small Cam lesions versus large Cam lesions. And we're much better about predicting the soft tissue damage based on the bony deformity that we're seeing. So obviously, you know, this patient x ray, you know, is in a high degree of danger with significant dysplasia. And this is not a great arthroscopic candidate without a combined open procedure. On the other hand, this patient who has a long standing Cam lesion, very large Cam lesion, has been impacting and impinging long enough where the acetabulum has ossified. And that will change your treatment algorithm. And and 8 to 10 years ago you know, that type of sophistication was not in our playbook. But now it is. And we're looking much more critically at it. Advancements in technology have helped us quite a bit. Here's a classic, you know, delamination, injury on the acetabulum in the prior to a couple of years ago. We had, you know, straight straight resection. Now we have curved resection. And I love this hip length arthroscopic Torpedo. It leaves such a nice clean lesion debridement line. You know, I started using it in the knee and now it's available for the hip. So if you haven't seen that you should check that out. It does very well in the hip has the right angle for it which lets us treat it. Recently in the RF department, Arthrex has released the Hip 50 probe. This is also a favorite of mine. It's got 360 degree edge control which lets you ablate very carefully. The 50 degree angle lets you get to far reaching, far reaching places, and it does very well in terms of protecting the tissue that you want to protect while taking away tissue that you want to take away. The one characteristic about this probe that that most people don't talk about, it's the rigidity of the shaft. And this is important to us in the hip world because we need to lever on the on the capsule and you know, as it gets more posterior, you can really use this device to help you see better. And instead of switching out to a switching stick or something like that, this is just a quick video to show you how easy it is to kind of dissect through and around things. This is a loose body or acetabular rim fracture that's embedded in the labrum. So, you know, in this case we want to dissect the soft tissue around the loose body but protect and preserve the labral tissue. So the edge control really lets us do that. It does not seem to clog as much as the other standard hip ones that are available in the market, although no want to in and of itself is free from that type of issue. But this seems to do very well. Other technologies have been in the fixation world. You've heard all about Knotless fixation in the shoulder. Well, we have it in the hip as well, thanks to Arthrex. So the hip length Knotless SutureTak are out Throughout and the Knotless FiberTaks are also coming out. So this is a biocomposite. 3.0 Knotless SutureTak going in. I really like this technology because it. By eliminating the knot between the labrum and the capsule, I feel like there is less chance for postoperative adhesions, which can be very painful. Pretty straightforward passing. And then you'll see. And I think one of the presenters showed it yesterday. But we do the same. I do the same thing in the hip where you put in several of these and you get them a little snug, and then what you get to do is you get to position the tissue and dial in your tension. So one of the big things in hip, as you know, is we don't want to overly Evert the labrum. So here I have I've just placed it but now I want to go tension this one. This is the first one I put in. Now I'm going to kind of skip over that one. And I'm going to tension this one over here and tighten it down. And then I'm going to go back to the middle one. And then by by doing that you can kind of play with the tension. This has a lot of benefit when it comes to reconstruction. If any of you guys are doing that we can certainly talk through that. But the Knotless technology has helped my practice in terms of saving time, but also, I believe, has clinical applicability in terms of decreasing adhesions and appropriate tensioning. Capsular management has also been a hot topic over the last few years. We understand that as we are evolving in terms of the the size of the capsulotomy or the type of capsulotomy versus inter portal versus t capsulotomy, we understand that we need to repair some of these on the way out. That used to be very long and tedious, part and very unrewarding part of the case. Now with things like the capsular Scorpion, it's pretty easy to just re approximate the capsular tissue and you can be done with the case. But and in the Velox young females where you really want to placate or actually do a shift of the tissue, then this makes it even easier to do that. So, so just another instrument where Arthrex has made our lives a lot easier. So that's on the labor repair and impingement side of things. What about chondral defects? So this is a big problem for us. These these lesions. Despite using three Tesla MRIs and MRI. Arthur Grams, we continue to miss Energel defects prior to surgery. We know that they will be there. We know that they are very prevalent. And usually at the time of surgery, you're stuck with basically debridement alone or debridement and microfracture. And we'll talk through some of the other options now. So the question is does microfracture work? Well, you heard on the ten year follow up by Philippon that one of the negative prognostic indicators for a hip scope repair, whether or not it's debridement alone of the labrum or labor repair. But microfracture in and of itself is an independent poor prognostic indicator. Ben Dohm has this paper with minimum five year follow up. And he said actually his patients, 53 patients had statistically significant improvement in his patient reported outcomes. But when you look at the survivorship it kind of mimics Philippon's data. 72% at minimum five years still had their hips. 12 of them went on to total hip, and four of them needed a conversion to revision. So, you know, the question then is, well, is microfracture enough for a large lesion like this? And those of you that are doing it understand it's very difficult to get to that area. And and although we can access good bone marrow, the question is well is it enough? So in my practice I went from debris alone to microfracture. Now, thanks to Arthrex, we have some a couple of other alternatives. If you haven't used BioCartilage in the knee, you should see it. It's very applicable to the hip. There are some hip dedicated length delivery devices, but here's a young patient who had full thickness flap tear, were performing a typical microfracture get good bleeding and then you have to dry out the joint, which is a little bit challenging in the hip. But then after that it's fairly straightforward. You can inject the BioCartilage. It sits on our shelf at our surgery center. It's not too expensive. We don't have to order a match, any osteochondral, allografts or anything like that. You do have to have some fibrin glue. And now we're very excited about the Thrombinator for that. But this was done about 2 or 3 years ago, so it gives you a nice coverage and potentially can improve the microfracture data, although the long term studies have not been done. You just heard about GraftNet. I just got this in my hands as well. They just released it. It's very interesting because again, as one of the other presenters discussed, it's on hand, it's cheap and you can use autologous cartilage. This is how it fits on the end of the shaver. We know based on right study published last year that the acetabular flap tear not just from a knee or from a shoulder, but the one from that we are talking about at the hip, has like 87% viability for the chondrocytes in that sample. So we know it's good tissue. So the question is can we use it. So this is another patient that we saw a couple weeks ago. It's a 16 year old male very large chondrolabral separation. You can see how it just pulls off the bone. You'll see in a second. Right in that area there's a full thickness defect. So we use our typical bone cutter and Torpedo shaver here to just debris this flap. Here you can see the how far in it goes. He had a very large cam lesion. So this is collecting the autologous cartilage. Here's the my favorite Torpedo. And then over time you see this the full thickness area right. Right there. So we prepare that performed the typical microfracture repair the labrum. And we get something that looks like this. So we've got the stitches behind it. We've closed down the the lesion slightly. Here's what we're getting in the GraftNet. This is all autologous cartilage from that flap. No bone. This is adding the ACP to it. And we don't add a lot. You just need enough to kind of make it a slurry. Mix it in and then we're using the same applicator. So this is the BioCartilage applicator. You can see that it's not quite as powdery. It's a little bit chunky. And I think that's based on the receptor that you use. And then same thing cover it over with fibrin. Now I was a little bit worried about the size of the lesions maybe being or size of the pieces of cartilage being easier to displace. So this is, you know, how stable the lesion is, a little snot pack that you get with the fibrin glue. But and I usually do this with BioCartilage as well. But I took a video of it. So while staying dry we let the traction off. And then we flex and extend the hip several times. You can see the seal that we've reestablished and then we rotate it. And this is just to test to see if the lesion was stable. And I'm always surprised at how stable this lesion can be. And the the fibrin glue. So you'll see us reapply traction here. And then we just take a sneak peek at it. And by reducing the head into this tablet, it actually flattens out the lesion quite nicely. You can see the graph and a little piece came out at the very medial inferior aspect. So we're just going to cut that and remove it. You can see that little piece right there. The fibrin glue is so strong that if you just went in and and pulled on that there's a risk that it actually pulls the whole fibrin cover off. So we just had to just cut it and then grasp it. And then there you go. So pretty excited about that technology. Stay tuned. In terms of whether or not it will make a significant clinical difference in terms of preservation. We had plenty of ACP left over, so we injected that at the end. And then this is this is how much was left in the tube after we were finished with the case. And you can see it just kind of comes out. There's a lot of differential sizes of the cartilage but a ton of ton of material to use. So pretty exciting. So in conclusion, I think in terms of preservation, the two topics we talked about were labor repair and defect. I think we've made a lot of progress on the labor repair side in terms of our fund of knowledge, our patient indications, our Arthrex has really helped us with a lot of the technical innovations, and we continue to look forward to the things that are coming up with. But that being said, at least based on minimum ten year follow up, we're still seeing a fairly high failure rate in terms of progression to other surgeries based on patient cohort defects is still an issue. I think microfracture may not be enough, and that's kind of borne out in the early data. I think some of the new innovations are very exciting. We need to keep a close eye on that. But certainly I think we need to improve in that area. So in terms of hip preservation, I think we're doing okay. But I think the next 10 to 15 years will be very exciting for us. Thank you.

Augustus D. Mazzocca, MD (Farmington, CT), discusses the role of the GraftNet™ autologous tissue collector to capture subacromial bursa as an augment to rotator cuff repair. Included are several key technical pearls as well as Dr. Mazzocca's early clinical results related to augmenting rotator cuff repair with bursal tissue.

Biologic Augmentation of Rotator Cuff Repair: The Subacromial Bursal Tissue

My name is Gus Mazak from the University of Connecticut. And today I'm going to talk about biologic augmentation of rotator cuff repair using the Subacromial Bursa tissue. And it's important to really recognize all the people that have done so much work over the years and where they have published this data. And today, I'm going to give you a compilation of the data that's been going on. The problem really arises from this middle article in 2011, where he found that 41% of all rotator cuff repairs failed. But the more important, or the more interesting fact about this paper was that they had determined that 80% of these failed within the first three months. And the way I interpreted that was that they never healed. The same is really true for arthroscopic revision rotator cuff repairs. And when we get to the tendon or the enthesis, it's really a highly organized structure. Whereas repaired tendon is disorganized. Scar and continuity. The thesis is really organized with bone calcified fibrocartilage, uncalcified fibrocartilage and then dense tendon connective tissue. We're also not as good as we think when it comes to evaluating rotator cuff tendon quality arthroscopically during repairs. We think we can judge good and poor tendon, but we can't. Paul Sethi did a great study where he attempted to analyze what he thought was good and poor tendon tissue. He then took a two millimeter biopsy and we analyzed this, blinded in our histological lab looking at the different scores. What we found that the degree of tendinopathy did not correlate with the gross appearance of the rotator cuff tendon. Patient outcome or rotator cuff healing in full thickness rotator cuff tears. So multiple animal studies have shown that tendon healing cells do not originate from the bone or the tendon, but the peritoneum. When we look for the for the peritoneum of the supraspinatus, we couldn't find it. All we found was the Bursa. And that's why we believe that the Bursa is the peritoneum of the rotator cuff, and that the cells needed to heal the rotator cuff can be contained in that Bursa. The subacromial Bursa may be an alternative source to assist with biologic augmentation and rotator cuff repairs. And really, as Doctor Rodeo has said in the past, stimulation of the intrinsic stem cell niche that exists in most tissue is a promising approach. Bursa is not a new idea. There are two distinct areas the Bursa above the tendon and the Bursa above the muscle. Bursal tissue contains large amounts of connective tissue progenitor cells. It demonstrates high proliferation potential regardless of patient demographics and rotator cuff tear characteristics, and there's no difference in biologic activity between primary and revision rotator cuff repairs, all of which we published on. As I've said, the history of Bursa really started with Butov in 1991. And really, as he points out, the burst of expansion during rotator cuff tears is a reparative response rather than a degenerative change. Bursa has two different areas anatomic and biologic activity. Bursa that is located above the muscle, more fat and vascular. And Bursa located above the tendon. More fibrous and less vascular. And these are examples of what it looks like as we extract it during the surgery. You need to break down this Bursa with a shaver into a slurry. Unprepped Bursa will not release its cells as we showed in this 2019 article, where you can see the chopped and the electron microscopy to the left compared to the whole tissue, there are more cells in the Bursa tissue over the tendon than the purse over the muscle and the cellular composition of Bursa is dominated by progenitor cells seen to the left, black bar being those over the tendon, white bar over the muscle, compared to fibroblasts and collagen as well as fat. We use multiple mouse models to confirm the mechanism of Bursa tissue and healing. Looking at both the biomechanics below grafts and the histologic analysis to the right. So for primary repairs that are large or, the provider feels that they have a biologic compromise diabetes, smoking, use of a walker arm dominance, then we think you can augment with Bursa, PRP and autologous thrombin. So why is the clot important and how is it designed to increase and promote cell growth and incorporation? Prp is really added to the clot secondary to its ability to normalize matrix metabolism, facilitate recruitment of mesenchymal cells, and it shows a two fold increase in proliferation compared to controls. Bpp contains high concentrations of fibrinogen, which creates the clot. Fibrin is a fibrous non globular protein involved in the clotting. It's formed by the action of the protease thrombin on fibrinogen, which is the soluble protein which causes polymerize. This polymerized fibrin, together with platelets forms the clot. As the fibrinogen is increased, so does the clot size and thickness. So simplifying an autologous bursal clot during surgery for rotator cuff repair. And this is our real time line that we've used as we go through the procedure. First we draw 53 seeds of whole blood with seven CCS of Acda which is anticoagulant citrate dextrose formula. A while we're setting up and up and prepping the patient. The reason why we have to use Acda and not heparin is because in the clotting cascade, heparin works by activating antithrombin, which in turn disables thrombin via factor ten. This then does not allow the external clock cascade to proceed with the PRP and the PRP. 40 cc's are placed into the centrifuge for the PRP in 20 cc's of whole blood for autologous thrombin extraction. This is then drawn from the centrifuge whole blood, and you can see it is easy to see the PRP, and it's withdrawn with a syringe. We use an arthroscopic shaver connected to the GraftNet, which is a faster and more reproducible method for preparing Bursa rather than mincing and chopping. We have compared the compared the various shavers with the cellular composition. After three weeks in culture, showing that the Torpedo and bone cutter shaver have similar results to chopping, which we felt was the gold standard. And really, you want to delay adding the autologous thrombin to right before you're going to implant the clot, because the thrombin can delay or decay over time. So this is just showing us placing everything together and then arthroscopically implanting it. There's various ways to implant the clot. 14 gauge metal jam sheeting ten inch pediatric chest tube or the Arthrex BioXpress. This is a video of the metal trocar implanting the clot both above and below the repair. This is video showing the ten inch French chest tube being inserted underneath with the anterolateral row anchor to close off after we finished implanting. And finally, this is video showing the BioXpress device with the final lateral anterolateral anchor. We implant the clot and then we close down the trap door with our final anchor post. Or excuse me, anterolateral. The size of the clot can easily be adjusted to make a small, medium or large clot, depending on what the surgeon would like. You keep the ratios the same. It's a 3 to 1 ratio. Some of our outcomes work. We've done 51 of these cases now since December 2018, with six failures or 12% failure rate. You can see the same scores to the right. This is an analysis of our six failures, two are doing quite well despite the failure to heal, and four have been revised. The colony forming unit number does not seem to have an effect on failure rate. The y axis here is the colony forming units, and the x axis has the patients and their ages, with the red being the failures. We then took this data and compared it to a randomized controlled study that we did in 2019 that had a 29% retail rate for the same size tendon in patient population, whereas the arthroscopic rotator cuff repair with Bursa had a 12% error rate. So take home points first is not a new idea. Two distinct areas. We start by arthroscopically taking the lateral or person above the tendon. This is less vascular, and most surgeons understand that this is relatively easy to take, but in an effort to get more, will go above the muscle. That's a distinct area as well. First, the tissue contains large amounts of connective tissue progenitor cells. It demonstrates high proliferation potential regardless of patient demographics and rotator cuff tear characteristics. There is no difference in biologic activity between primary and revision rotator cuff repairs, and the clot is really a reproducible method to form. You make a clot too tight and they die to loosen. It falls apart. So overall, I've tried to present a really reproducible, facile way to create Bursa autologous thrombin mixed with PRP to biologically augment rotator cuff repairs. Thank you.

Chad D. Lavender, MD (Scott Depot, WV), demonstrates an all-inside QuadLink™ ACL reconstruction with an InternalBrace™ augmentation after back filling the femoral and tibial tunnels with AlloSync™ Pure and autograft bone collected with the GraftNet™ device.

Augmentation of a Quad Tendon All-Inside ACL Reconstruction With Bone Marrow Concentrate Mixed With AlloSync™ Pure Demineralized Bone Matrix and Autograft Bone Collected With the GraftNet™ Device

Hello, this is Doctor Chad Lavender with Marshall University orthopedic sports medicine. And I'm going to present a case of augmentation of a quad tendon all-inside ACL reconstruction with bone marrow concentrate mixed with AlloSyncPure and autograft bone collected with the Arthrex GraftNet. This case is an 18 year old football player. He had a non-contact right knee injury, noticed a pop and an effusion, pain with weight bearing and he had a contralateral BTB ACL reconstruction I had performed one year prior to this. His exam showed 0 to 130 degrees. Range of motion. Positive. Lachman. Positive. Pivot shift. Moderate. Hemarthrosis. Here you can see his MRI showing the ACL rupture. So in this patient we elected to do an all-inside ACL reconstruction with quad tendon autograft augmented with bone marrow concentrate mixed with AlloSyncPure and autograft bone collected with the GraftNet device. Here you can see our technique video detailing this surgical technique. First, before the tourniquet is inflated, we aspirate 60 ccs of bone marrow aspiration from the From the proximal lateral tibia. Here's the quad tendon graft prepared on the back table. First, we will drill the femur in retrograde fashion with the FlipCutter. As you can see here, the GraftNet has been attached to the shaver which has been placed into the lateral portal. And as you can see, we are harvesting the reaming from the femoral tunnel using the GraftNet device. Here's the autograft bone within the GraftNet. Next, we will turn our attention to the tibial tunnel. A GraftNet attached to a shaver with suction has been placed through the medial portal. Here you can see the tibial tunnel reaming being taken up through the shaver and into the GraftNet there is the GraftNet with the bone graft within the GraftNet on the back table. In this case, we obtained four CCS of autograft bone using the GraftNet that was then mixed with five CCS of AlloSyncPure, which was mixed with five CCS of bone marrow concentrate. Next, the TightRope is then flipped on the femur. And here you can see delivery of the composite graft into the femur from the medial portal. We recommend fully filling the tunnel with the composite graft. Next, we will come from the lateral portal and deliver the composite graft into the tibia. We like to see slight fluid leak from the cannula, to allow us to know that we have properly impacted our composite graft into the tunnels. There is a view of the tibial tunnel completely grafted with our composite graft. Next, the femoral side of the ACL graft is delivered into the femur and the tibia is placed down into the tibial tunnel. We sequentially tighten the femur and then the tibia. And here you can see the final construct with an internal brace applied. Here are the patient's post-operative x rays. As you can see he's one year out on the opposite knee from a ACL reconstruction. He has obvious tibia and femoral tunnel widening. He's six weeks out on the fertilized ACL reconstruction. And you can see a significant improvement in his bone.

Bert R. Mandelbaum, MD (Santa Monica, CA), presents two cases of symptomatic cartilage defects of the knee treated with the AutoCart™ technique. Dr. Mandelbaum discusses his use of the GraftNet™ autologous tissue collector as part of this single-stage cartilage repair procedure and why, compared with earlier techniques, the AutoCart technique provides a simpler, more cost-effective option for treating articular cartilage defects.

AutoCart™ Procedure in the Knee Using the GraftNet™ Device

I'm Doctor Bert Mandelbaum, and I'm here to talk to you about the AutoCart technique and give you some case presentations, how we use it in the clinical situation. Now, before we get started, I want to connect the AutoCart, the present technique to what we have previously called articulated autologous cartilage implantation, or the Pasi technique that we started using between 2000 and 5 and published on it in 2011. Now let me introduce you to one of my patients. This is a 48 year old male. He had one year history of right knee pain, no trauma. Pain was localized to the anterior aspect of the knee, and pain was exacerbated by stairs running, squatting and biking. His past medical history, surgical history, allergic history are all unremarkable with respect to gait. He can bear weight on the injured extremity, the right knee pain. There were no other issues going on. No atrophy in a mild effusion. Diffusion. There was some tenderness on the lateral and medial aspect of the knee. Its strength of five over five plus and did have patellofemoral crepitus. As you can see, his x rays show no dysplasia and no other bony abnormalities. Furthermore, his MRI, as you can see in the axial view, indicated Osteochondral defect in the lateral facet of the patella. So what do we have? We've got a 48 year old male with osteochondritis dissecans of the lateral patella facet. What do we do about this? Well we look at the options and after informed consent we proceed. And this we felt that this was indicated for pacing or what we now call the AutoCart procedure plus or minus autologous bone grafting. In this situation with CRx arthroscopically, we could look up and see the patella cartilage defect on the lower left corner. We could see our harvest site. And in the lower right we could see our cartilage defect, which measured 1.5cm by 1.5cm. As you can see, it's a grade four defect. How do we manage this? You can see my medicine cup, the arthroscope and a 5.5 shaver. And what we're doing now is we could see the saline coming into the medicine cup. The shaver is now taking the cartilage fragments from the notch and then mincing them accordingly. You can now see the GraftNet, which lies proximal to the shaver, and as suction pulls the fragments into the GraftNet, we can then see how this works. Basically, the cartilage or bone fragments get segregated there for later use. Here is the later use. We can see the GraftNet easily opened up as we could see here. Now let's turn our attention to the cartilage defect. There's a joystick for retraction. This is a lateral arthrotomy and the cartilage defect is in full view. We're now taking our graft and placing it directly into the cartilage defect. And you can see us packing it as such. At this point, the cartilage defect is filled with our AutoCart graft, and we're now ready for the use of fibrin glue. You can see here in a droplet fashion. We then place the fibrin glue onto the graft and over a 6 to 10 minute period it can dry, giving the cartilage graft full resilience in preparation for relocation. Here you can see the final result the fibrin glue in place, the graft in place, and now the incision is ready to be closed. Let's go to our next case. This is a 19 year old Division one collegiate basketball player who had right knee pain after a patellar dislocation. He could not play or train. The MRI on the right reveals a significant effusion and a cartilage defect measuring 1.5 by 1.8cm and a loose fragment off of the medial facet of the patella. You can now see arthroscopically, the cartilage defect. Again, you can see it's size 1.5 by 1.8cm. And it is truly a grade four defect. We use the fragments at this point from the loose body, and we begin to prepare our AutoCart graft. We also did, as you can see, a microfracture with a drill creating those channels accordingly. And the lower two photos on the left and on the right, the cartilage defect has been filled, fibrin glue placed and dried, and now the procedure has been completed. Let's take a look at the MRI. First, the baseline MRI on your left and the three month MRI on the right. Note the Note the significant changes in fill of the cartilage defect with full integration basally and laterally. And again, all these situations are best when we have clinical outcome in this situation as an athlete. We can see here that he has no inability to dribble and dunk the basketball, jumping on and off the left and right knee. So we present two cases today about the use of AutoCart for cartilage defect transplantation. Now this procedure has been around and we could see our publication from 2011 by Brian Cole and others really showing the outcomes based after a single stage cell based cartilage mince repair. We're excited about AutoCart procedure, and we look forward to more patients and more results with this great technique. Thank you.