Name: BioPatella™ OATS® Technique
Uploaded: 2020-10-30T00:00:00Z
Channel: Arthrex
Description: Thomas M. DeBerardino, MD (San Antonio, TX), introduces the BioPatella™ OATS ® surgical technique. The BioPatella instruments allow the preparation of oblong osteochondral allografts to treat large articular cartilage defects in the patella.

<p>Thomas M. DeBerardino, MD (San Antonio, TX), introduces the BioPatella™ OATS<sup>®</sup> surgical technique. The BioPatella instruments allow the preparation of oblong osteochondral allografts to treat large articular cartilage defects in the patella.</p>

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VID1-000781-en-US | A | BioPatella™ OATS® Technique

Thomas M. DeBerardino

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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BioPatella™ OATS® Technique

We're going to perform a fresh matched for size osteochondral allograft, oblong in nature or oval in shape to replace the cartilage in this right knee. So here we've done a midline straight anterior incision with a medial arthrotomy enough to allow us to flip the patella on axis. And in this case it sits nicely in the rotated view. And now we have easy access to the entire surface of the patella. You can see here we have generic large high grade patella. And in this case we do have a small trochlear lesion which we could manage. And these sometimes come up on you if it's 3 to 6 months out from this original diagnostic scope where we would classically scope the knee and then indicate the patient for cartilage restoration surgery. And in my hands, with the patella, it's almost always a match for size. Mega patella osteochondral allograft transplantation. So now we have a new set that's going to allow us to replace pretty much the entire biologic working functional surface of the patella with an oval graft instead of our standard round graft. And you can see on this patella there's equal medial facet central and lateral facet where. So it would be nice to put pretty much an 80% fill with a large oval osteochondral allograft instead of cheating toward the medial side or just doing the lateral side and leaving the medial side, there's a new set of instruments that allow us to fashion an oval graft on the recipient. We have three guides. The first size is a 20 by 30. You can see it's oval in shape. And that's going to be the downside on the patient's patella. And we simply use the best fit size to best fill the bulk of the patella lesion that's in front of us on the patient. So this is the small 20 by 30. The next size up is the 25 by 35. And you can see that that does a good job of basically filling the Incipient problem or high grade cartilage lesion. We can show you what a large size looks like. And again this is 27.5 by 37.5. And oftentimes it's just a little too big. But for the very large patient it's good to have this one. In this case I could actually maybe squeeze this one in. But then it goes down to the fact that you now have to also deal with the fact that you've matched for size a fresh patella. So you have to make sure that the donor plug is obtainable to match the recipient socket. And in this case, we're going to say that the biggest plug we can get from our donated patella is the 25 by 35. So we're going to make this work and center it up. Some patellas are more flat and some are more concave with a steep medial ridge. This one, as it sits here now because of advanced wear, is more like the flat patella over here on this diagram. We also have on the field already our donated patella. And this one actually is more on this Perspective more like a high ridge patella. So we know that in fact, when we replace the biggest plug that we can get, which is the 25 by 35 oval plug in this recipient socket that we're about to make, that this new patella is going to have perhaps a more normal ridge or central ridge. So it may be more prominent centrally at the 12 and 6:00 position. But that's okay because this will be functionally the new patella contained by the recipient socket, as we'll see in a couple of minutes. So with this offset guide, we can use these different little offset pins that screw in to offset to kind of make sure in the medial to lateral plane we get the right pitch and yaw. In this plane we've got good control here. This is pretty standard and not a lot of wear from top to bottom. It's that medial to lateral wear that we want coplanar with the axis or the equator of the patella. Now we're going to introduce the patella resection clamp. This has a base circle that's going to go on the back side of the patella, which is the back side of the the anterior part of the patella, the non-articular side. We have to dissect enough proximally and distally to get this clamp in. These sharp teeth are going to try and clamp it with the saw blade slot at the equator of the patella. So we get to, as the surgeon align it with this kind of role. And this a little bit of role to get it to match right along the equator of the patella. So that looks like a pretty good match. When I look at the equator of the patella from medial to lateral, I have matched the rotation in both planes, both proximal and distal and medial to lateral. This stylus here is adjustable through a click here, with a readout in millimeters through the small window here on the side. And this right now is set to. Nine millimeters. And we do that by taking the best looking central ridge highest part of the cartilage which is usually proximal and distal, and we set it off of that to know how much patella is left between the equator and the dome of the apex of the central ridge. So we clamp this in place with a good click, and that holds it. Now we have good control of the patella and it's not going to go anywhere. And it's its own separate platform. My system will hold the patella while I bring in the guide. And again we're using the 25 by 35. So we want this to match the plane of our clamp. So I can roll it lateral I can roll it medial. So it's just a visual check by the surgeon. We want to center it up. We're going to first mark with a marking pen. Our central ridge the 12:00 the highest point of the patella 12:00 and 6:00 noting that it's not truly like this plane because when we roll the patella, it always rolls off to the more proximal, lateral and distal more central. So that's the plane of our patella from proximal to distal 12:00 3:00 as we look at it, 6:00 and 9:00. And that will be important when we do we do our quadrant depth measurements. So we want to center this guide the 25 by 35 guide on the lesion. And we're just making note mentally of whether this central part, which has a little notch on it and a black laser mark is medial or lateral to the 12:00 position. In this particular patient I'm going to center it right up. So 12:00 is 12:00. And it's not offset medially or offset laterally. Its center of mass on the central ridge, which will be important. We'll match that on our donor patella on the back table. So now I'm going to use these guides to take off the the woggle. I bring this pin down. And when it touches the cartilage that gives me a stable platform through which now I can drill my guide pins, which are 2.4 guide pins, one short and one long. We'll drill the short one first and then the long one. We're actually going to only drill one pin at a time, because the offset of these pins would interfere with each of the of the round drill holes that we'll use to communicate and thus create our oval socket. So we'll pin the short pin in first, and we go bicortical on this because we definitely want to get good purchase. So our first guide pins in place, we check it and make sure we're happy. We like what we've done. We take the guide off. So this is our depth stop or hard stop reamer. So it's got this wing nut that you can see I'm going to spin back. And now the depth stop is this outer ring. And I'm spinning it back. And you can see the blade start to deploy. So I'm going to set it by making the reading right on the blade. The blade has markings of five all the way up to more than ten. And usually these are no more than ten. And we don't want to over resect bone initially. We can always go back and take more. And then we hold the cylinder, the depth stop part and we tighten the wing nut. So now we load this calculated depth stop reamer under our pin. Making sure our assistant's holding that stable. That is our working base platform. And like all reamers, we want to come in like it's a lathe. You'd never start your lathe at full speed touching the the wood. And in this case, the patella. So we come in at high speed and we just tap down until we get a good solid. So now that we're at depth, we can take the reamer off the guide pin. The guide pin should stay in place because we use it now to offset our second guide pin, which we couldn't put it at first because it's going to be actually inset into the first reamed hole, which would have been impossible to do if the other pin were already placed. So before we take this pin out, we'll put the longer pin in and go bicortical again to capture that second cortex. So both pins are in place. Now we pull the first pin. The guide comes off and you can see that second pin is inside the first reamed socket or the first round circle. So that couldn't have been pre-placed only now. So now we use the same depth. Stop hard stop reamer. And that's down to good bone now. So that's nice. And that's a good depth. So there you can see our depth of the socket on the shallow side is a couple millimeters of bone. That's all we want. Here we have our donor patella. We're going to try and match our central ridge just as you're seeing it here in this shot. We're going to bring our guide in over to the side. So here we are using the patella resection clamp. Once again on our donor patella we have better access to the equatorial cut, which in a standard patellar arthroplasty would be the center line cut down the equator of the patella. So this instrument is key in this fashion, because remember when we said this is a particularly steep central ridge as opposed to a more flat patella due to wear and tear on a recipient or patient. So here we're going to still match our equatorial clamp so that we're going across medial to lateral and proximal to distal across the central midline equator of the patella. And now we have good three dimensional control of our patella as we bring our saw and make a sagittal cut across the patella. Now we're going to use what I would call a cookie cutter technique. We're going to take out a matched oval plug and cut away the ring. We're going to do that with a oblong cutter that matches the 25 by 35 oblong size that we made for made for our recipient socket. It's got a nice grommet in the center point so we can push our plug out as it will be. Press fit in this cookie cutting device. So we're going to bring this guide, this cutting guide in centralized on the central ridge as we discussed earlier not medial not lateral but centered up as best we can. And we're going to cut flush to the table because that's our predetermined planar cut to get the best graft to match the recipient socket. So we match it up in all planes, get a good solid, firm grip on it, and with the flat, firm surface of the plastic working table, we won't skid across it. I'll give it some light taps to get a good purchase, and then go in more robustly to cut through. Save the central oval plug and cut away the perimeter. So we're going to press fit out with that grommet using this screw in handle holding firmly and this will deliver out a traumatically our osteochondral oval plug. You can see it pushing out a traumatically through the plastic grommet. So approximately at the 12:00 position looks like it's right at one. So we're good there at the 9:00 position, we're supposed to be at seven, and we're right at seven. At the 6:00 position of the central ridge, we're right at one centimeter. So we're going to keep that. And then at the 3:00 position, we're supposed to be at five and we're at four. So this is an excellent opportunity to add a little bit of DBM as a bone void filler. Here we've used the PowerPick to make small RetroDrill holes. So here we use a PowerPick drills. As importantly in the donor plug. Now we're going to add our biologic autologous conditioned platelets or PRP by dripping it into the sockets. It'll reverse capillary action drip into the interstices of this plug, thus adding a nice biologic. Sometimes my preferred technique and really hard bone is to just use a little rongeur, just to curve the edge just a little bit, to get rid of that sharp edge that catches on the recipient cartilage. So now we've measured our plug. And remember this side at the 3:00 position is five. But on our plug it's only four. So we're going to remedy that by adding some bone void filler. And in this case it's going to be our demineralized bone matrix or DBM. We'll drip a little bit into most of it. But then at the 3:00 position we're going to add a little bone void filler again. And I'm going to just put a little smear of it. And then literally the best instrument here is the gloved finger. It just pushes it into the corner. And then this is going to layer out like a good putty laying down tile to give us just enough a little bit backside elevation to make our graph sit smoothly on the articular surface once we place it. So now matching 12:00 to 12:00, we're going to bring our plug up and we're going to get ready to press fit it. So there's two options here. We can key it in. Sometimes it's such a tight tolerance that we want to get it seated, usually at the 12 and 6:00 position to get a good hold on it. But then there's the lateral tilt. That's possible. So we like to hold it and see if it'll just wiggle in. In this case I think it's going to and I'll just use press fit technique. Take off any extraneous DBM that might come out like cookie dough. And here we have a very smooth articulation of our new patella in all planes. So what we do clinically now is we would rotate our patella back. We take two clamps and do our temporary arthrotomy closure and make sure we're not only tracking well, but that we have a good glide and smooth articulation between the patella and trochlea throughout an arc of passive motion.

BioPatella™ OATS® Technique

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