Orthobiologics

Product

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).

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Human

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.

video

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.

Spine

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.

Knee

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.

AlloSync™ Bone Grafts

Child (D)

Revision Bone Dowels offer surgeons a quick and effective solution for filling bone tunnels during staged ACL/PCL revision cases. The use of bone dowels provides an immediate structural and biologic architecture for stability and incorporation. Soaking the dowels in PRP or bone marrow concentrate provides an infusion of growth factors and cells to assist with the incorporation of the scaffold.
The Revision Bone Dowels were treated with the Allowash XG®* process to remove blood and bone marrow elements from the scaffold. The dowels are then preshaped with a tapered tip and cannulated for easier implantation. Treatment with Preservon®* technology allows for the Revision Bone Dowels to be stored in a prehydrated state for up to 5 years.
*Allowash XG and Preservon are a registered trademark of LifeNet Health.

Bone Dowel Revision Kit

Cannulated Revision Bone Dowels offer surgeons a quick and effective solution for filling the void left from a Cartiva®* implant, providing immediate structure and biologic architecture for stability and incorporation.
*Cartiva is a registered trademark of Wright Medical Group N.V.

Synthetic Cartilage Implant Revision Technique

The Arthrex Cannulated revision. Bone dowels offer surgeons a quick and effective solution for filling the bone void left in the metatarsal head, following the removal of a Cartiform implant. The cannulated bone dowels provide immediate structure and biologic architecture for stability and incorporation. Soaking the graft in biologic fluids prior to implantation allows for an infusion of growth factors and cells to assist with the integration of the bone graft. Initially, a 1.6mm guidewire is used to skewer the failed Cartiform implant and remove it from the metatarsal head. The same guidewire is placed centrally into the void left from the removed implant, and the appropriately sized reamer is placed over the guidewire to prepare the metatarsal head for the bone dowel. It is recommended to drill at least five millimeters past the original length drilled for the Cartiform implant. The cannulated bone dowel is then placed over the guidewire and tamped into place using the cannulated bone tamp and optional graft graph delivery tube. Note that the bone graft may be left a few millimeters proud. Place the metatarsal reamer over the guidewire to simultaneously prepare the metatarsal head for fusion, and contour the bone dowel until it is flush with the surrounding bone. It is important to remove all the original native cartilage from the metatarsal head as standard when preparing a joint for fusion. Insert a 1.6mm guidewire into the proximal phalanx, and use the phalangeal reamer to prepare the base of the phalanx. Place the joint in the correct position and temporarily fixate the MTP fusion plate with FiberTaks. From this point, continue following standard practices for fixating the MTP plate and completing the fusion.

Cannulated Revision Bone Dowels

AlloSync bone grafting solutions maintain optimal osteoconductive potential and can be combined with bioactive fluids like platelet-rich plasma (PRP) or Angel(r) concentrated PRP (cPRP) from bone marrow aspirate. AlloSync bone grafts are derived from human allograft bone and provide excellent handling characteristics in intraoperative settings.
 
The portfolio of AlloSync putty, strips, and chips includes a wide selection of advanced demineralized bone matrix (DBM) graft options:
<ul>
 <li>Demineralized cancellous sponges and cortical fibers</li>
 <li>Putty, gel, and paste</li>
 <li>Wedges</li>
</ul>

AlloSync™ Bone Grafting Solutions for Spine Procedures

Foot and Ankle

Thomas G. Harris, MD, (Pasadena, CA) presents a flatfoot procedure where he used AlloSync™ bone wedges for an Evans and Cotton osteotomy. Dr. Harris implanted a DynaNite® compression staple for additional stability and compression across the Evans osteotomy.

Flatfoot Reconstruction With AlloSync™ Wedges

Hi guys. My name is Tom Harris from Pasadena, California. I'd like to present a case to you regarding a flat foot reconstruction where we used some of the newer AlloSync wedges. This is a 31 year old male. He's had foot pain his entire life. He's had flat foot his entire life as well. And he's also had a history of arthritis, as you can see from those X-rays there on both the standing lateral and a-p views. So our surgical plan for this case was a medial displacement calcaneal osteotomy. We were going to use the system to perform that. We also talked about using a cotton osteotomy, a spring ligament repair, and an Evans osteotomy. His MRI preoperatively showed no evidence of a posterior tibial tendon pathology. Often in these younger patients, I think the spring ligament is the at risk structure more so than the posterior tibial tendon. So we do not plan an FTL transfer. The Mis technique for the medial displacement. Calcaneal osteotomy is nice, especially when doing a double osteotomy of the heel, because often there are some concerns for skin bridges, and making that smaller incision for the calcaneal osteotomy of the medial shift type is really helpful. It limits your skin risk of dehiscence. And so here is our miss approach to the calcaneus a certain system bring in for the miss set to make your calcaneal cut through a very small incision. And then we try to shift that about a centimeter medially. The. We then soaked the AlloSync wedges in the Angel BMC. So the bone marrow concentrate, the AlloSync wedges comes in a variety of sizes. And you can see there on the right that it's being soaked in the bone marrow concentrate to enhance the cell viability. And the AlloSync wedges are very strong and very dense. The here's another example of that being held. And you can see that it's completely soaked through often. We'll put a five 4K wire in that as a way to manipulate it a little easier. We'll also often pin the CC joint temporarily when we're doing our Evans osteotomy, just to prevent any superior subluxation of the cuboid during that. So we'll have a K-wires pinning the CC joint. We'll make our cut about 10 to 15mm proximal to the CC joint, and then be careful not to violate that medial cortex and then use the distractor. Here you can see the K-wires in place and the AlloSync wedge in place as well. It's fitting in there nicely. We're happy with our reduction. We've taken AP view of the foot to make sure that we are not having any Taylor navicular joint coverage, and we would do that with the sizers before we've actually picked a size to use. It's impacted gently into place, although very dense. You want to be careful with this step so it's not to disengage it or break it up. And then here you can mention the K-wires across that CC joint. And then in this case we used a DynaNite staple over the wedge just to make it a little stronger in that area. Sometimes that wedge will want to shift laterally or superiorly, so having some compression over it can be helpful. The. And here are some other examples of the staple in place. And then the DynaNite staple system is really nice from that standpoint, to be able to put that in over that. The one thing to be careful about here is that your staple distally is not too close to the CC joint, and that can be checked with x rays to make sure it does not violate the CC joint. In this case, we decided to use the 6.7mm screws, but having done this today, we would recommend the seven zero or the five zero headless compression screws, which have a less of a footprint there posteriorly and less chance for posterior heel pain. And you can see the staple having nice compression over Evans osteotomy. We then shifted over to the cotton osteotomy. Of note, we did do a spring ligament repair in this case as well with the internal brace. However, we did not need to do an FTL transfer, so the cotton osteotomy is done through a separate incision dorsally. And this is something you often have to fine tune on the table to help reduce that forefoot varus. And so you dorsiflex the foot up and you just put as much of a wedge in there as you need to get that forefoot varus reduced. It's usually around a 6.5 to 8.5 millimeter dorsal cotton osteotomy. Wedge in there. Now, again this is soaked in the bone marrow concentrate. And then that's impacted into place. Sometimes this distractor which is also in the set can be very helpful to get our diastasis in through that area. Another little helpful tip is I usually make my cut in the medial cuneiform right around the level of the second TMT joint. That kind of centers us in the medial cuneiform. And again, you want to make this cut but not complete the cut. You want to leave that plantar cortex intact so that you can have kind of the spring component to that cut. And then I don't usually use any fixation for this. However, a dorsal staple or a trans screw can be used if needed in through there. In this case we did not use any fixation and he really had a nice result at three months out. So there he is with a healed calcaneal osteotomies the Evans. Very hard to see. It's really incorporated in there nicely. And you can also see the cotton osteotomy which has healed in there nicely as well. The AP view here shows a nice coverage of the Taylor navicular. You can see the CC joints nicely reduced and that Evans osteotomy is healed well. So often in these younger patients with flat foot deformities, they'll often do this so-called triple osteotomy, be it a medial displacement calcaneal osteotomy and Evans osteotomy, as well as a cotton osteotomy. And often they'll need a spring ligament repair. So it's a little bit different than the older patients who come in with acquired flat foot. And that that's largely driven by the posterior tibial tendon. And in this case, I think this is more of a congenital thing and that their foot has always been flat. And so that's why the triple osteotomy in these cases are helpful. They're young. So you don't want to do a fusion if you can help it. So that's my thought process. When I see a younger patient who has a flat foot, I always keep an eye out for the spring ligament. But usually the posterior tibial tendon is okay in these patients. As you can see from the slide here. He's pain free. Ready for that. The other side. Done. And he was in a normal tennis shoe I think at about ten weeks out. So he really healed quickly and nicely from this. Thank you very much.

Steve M. Douthett, DPM (Eugene, OR), presents two cases in which he used AlloSync™ anatomic reconstruction wedges and Arthrex compression screws to repair large bone deficits in subtalar bone block arthrodesis procedures.&nbsp;

Bone Block Subtalar Arthrodesis With AlloSync™ Anatomic Reconstruction Wedge

My name is Steve Douthat. I'm a foot and ankle surgeon based out of Eugene, Oregon. Today I'm going to present two cases with Bone block Subtalar joint Arthrodesis using an Allo sync reconstruction wedge. For my first case, it was a 68 year old gentleman that complained of left hind foot and ankle pain with walking. He was an airborne veteran. He had been a paratrooper. Multiple jumps and he injured his heel at one point in time. The patient had injections and bracing, but they failed to provide adequate relief. When he came to my office on exam, the x rays showed arthritic posterior facet of the subtalar joint with loss of height. He had no significant deformity. He did have crepitus with pain on range of motion of the subtalar joint. My plan for this patient was to do a subtalar joint arthrodesis in order to regain height. I planned on using an async reconstruction wedge for bony incorporation. My plan was angel BMC pulverized Calcaneal autograft and expand for fixation. I was going to use 6.7 and 4.5mm screws. The reconstruction wedge is made out of dense cancellous bone. It comes pre hydrated, but you can soak it in BMC or ACP for cell signaling. The instrument tray set has trial sizes and in this case I use an Evans specific wedge. This is a interoperative image showing the wedge. It was a size 18 by 18 by eight. I used an Evans wedge for this particular case and it was soaked in BMC for cell signaling. In these images you can see the aliasing expand along with the pulverized calcaneal autograft. On the left I hydrated the yellow sink, expand with BMC, and on the right you can see the yellow sink. Expand in the injection syringe. For fixation, I use 6.7mm screws posterior and a 4.5mm screw anterior. You can see my intraoperative fluoroscopy images showing the fixation and alignment. Here you can see a post-operative comparison x ray with the regaining of Taylor height after insertion of the bone graft at the patient's six month follow up, he was walking pain free. The x rays showed incorporation of graft and we have clinical photos also showing the skin calcaneal height. Significant subtalar joint arthritis. Her foot was in a rectus position. She didn't have any varus deformity. She had subluxation peroneal tendons from the lateral calcaneal blowout. She had an Aquinas contracture. I was able to hear her lateral calcaneal artery on Doppler. This is an x ray showing the loss of calcaneal height. You can see a decreased bohler's angle and an increased angle of gaskin. My plan for this patient once again is Subtalar joint arthrodesis for the Aquinas contracture. I was going to do a percutaneous Achilles tendon lengthening for the subluxation peroneal tendons. I had to do an x ostectomy of the lateral calcaneal wall, possible groove deepening and possible peroneal tenodesis for the loss of calcaneal height. Once again, I was going to use an Evans reconstruction wedge for bony incorporation. My plan was for angel BMC and expand, and for fixation. I planned on using 6.5 and 4.3mm headless screws. This is an image showing the wedge which was hydrating in BMC. For this case, I used size 20 by 20 by ten. I also hydrated my aloe sink expand with BMC. For this case, I did a lateral approach so I could address both the peroneal tendons and the subtalar joint fusion. Through one incision, you can see the Evans wedge placed into the subtalar joint. Fluoroscopic and clinically, and you can appreciate the subluxated peroneal longus tendon. At this point in time, I put the perineal longus back into position. I deepen the groove. I did a perineal tenodesis both proximally and distally, and then I packed expand around my bone graft. I use headless compression screws posteriorly and anteriorly for fixation on this. You can see the pre and post operative comparison showing increased height of the patient's hindfoot. At two month follow up, the patient began weight bearing. She was pain free. She didn't develop a lateral wound. And you can see our post-operative x rays here. So in summary these are two cases that I used alongside reconstruction wedges for large bone deficits. Wedges are made out of dense cancellous bone. You can hydrate them with BMC or ACP like I did in this case. Allison expand is demineralized cortical fibers which are great for filling deficits. In this case I use BMC to hydrate. I also highlighted the use of arthrex screws, both headed and headless compression screws in this case. Thank you.

AlloSync™ Strips, Chips, Fibers, and Cubes

AlloSync™ Pure DBM is an osteoinductive demineralized bone matrix (DBM) derived from 100% human allograft bone. With zero extrinsic carriers, AlloSync Pure DBM maintains exceptional handling characteristics and can hold its shape in arthroscopic fluid environments. In addition to preserving the native bone's morphogenetic proteins and growth factors during the demineralization process, AlloSync Pure DBM can be hydrated with bioactive fluids like platelet-rich plasma (PRP) and concentrated PRP (cPRP) from bone marrow aspirate (BMA) for maximum bone grafting potential.

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.

Allograft Bone

AlloSync™ Bone Grafts

Cannulated Revision Bone Dowels

AlloSync™ Strips, Chips, Fibers, and Cubes

AlloSync™ Pure Demineralized Bone Matrix