Knee

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O aloenxerto osteocondral viável Cartiform* é composto de condrócitos viáveis, fatores de crescimento condrogênicos e proteínas da matriz extracelular. Mantendo uma estrutura de cartilagem intacta, a porção óssea do aloenxerto osteocondral viável Cartiform é reduzida e o enxerto é poroso para oferecer características de manuseio únicas e técnicas de fixação simples. O aloenxerto osteocondral viável Cartiform combina a segurança e o sucesso dos aloenxertos osteocondrais frescos com a facilidade de uso por ser aparável e flexível para corresponder a qualquer tamanho e contorno de lesão. O aloenxerto osteocondral viável Cartiform está prontamente disponível e é armazenado a -80°C.
*Cartiform é uma marca registrada da Osiris Therapeutics, Inc.

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Cartiform® Viable Osteochondral Allograft

The OrthoIllustrated® animation for cartilage repair of the knee is an educational tool to help patients better understand this treatment.

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Cartilage and bone defects in the knee can vary in shape, size, and severity. When the damaged area is small and shallow, a circular allograft from donor tissue called Cartiform viable osteochondral allograft, made of bone and cartilage may be used to regenerate tissue in the injured area. The graft is matched in size and secured to the affected area in the knee. Cartiform viable osteochondral allograft can be used for bone and cartilage injuries in the ankle. The restoration of tissue may reduce pain and improve function.

Advances in Allograft Treatment Using Cartiform® Viable Osteochondral Allograft

Hello, I'm Brian Cole, and I'm sitting with Jack Farrer, and he and I are going to discuss advances in allograft treatment, including heart reform. Brian, we've got a new option available to us many times, at least in my past, the availability of Osteochondral fresh allograft. It's there. We can we can get it on a routine basis, but we can't get it on a specific date. So now we have this new option of cryopreserved in the car deform technique. What what is car deform in your mind. Yeah. So the way I envision it having worked with it is it's a three dimensional sheet of articular cartilage now with a very, very microscopically thin layer of bone, which intuitively makes sense. So you could call it osteochondral allograft. Yeah. So you know, from the obvious, from a similarity perspective, it's just like an allograft. Except there's technical differences obviously. So this is more of a surface treatment. I like it because it works in surfaces that are concave or convex or or more complex, such as the Patellofemoral joint. Like you say from a timing perspective, it's very easy to use, but it has viable cells. We know that it interacts favorably with MSCs, and it's a three dimensional living graft that's cryopreserved, which if you think about the old data and cryopreservation, this probably has the best side of best cell viability that we've seen in any preservation technique other than fresh. Yeah. The laboratory data would suggest that approximately a 70% cell viability. Jimmy Cook had some recent data showing the viability of osteochondral grafting, and this was in an animal model, but still showed below 60% cell viability. The graphs didn't do as well as those with higher rates. So I think cells are certainly important for an osteochondral allograft. Right. So maybe just you could mention some of the advances with fixation and some a couple of the technical pearls that can help others. Well, we'll start. Off with the base then. We'd like to have a strong base. So we want to keep violation of the base. Minimal. Right now, they're still looking at the two arms of technique. One is some type of marrow stimulation. Whether it's drilling, as we've discussed earlier, or actually formal marrow stimulation, where I think people are leaning away from that. Some of the work that Lanny Johnson did showed that if done properly, a very superficial abrasion alloplasty can actually perform quite well. So I've sort of leaned towards that technique for preparation of the base. As far as fixation, we'd certainly like to have, because we're thinking about bone to bone fixation. We want to have rigid fixation. So I'm using suture anchors to rigidly bring this construct down to the basilar tissues. Yeah. So when it sits flat say in the patella, generally pretty easy to do. And you can use peripheral suture anchors, small suture tack I've used the knotless suture tack, especially when you're dealing with a concavity of the trochlea to try to hold this graft in position. And then we're working on some advances that will hopefully available soon to sort of almost stitch the graph down into place. The bottom line is you don't want it to dislodge. We're dependent upon retention of the graft. So whether you use sutures in the periphery, small suture anchors, small suture anchor in the center has to be done correctly. And you're trying to avoid any edge effects that the graph may be proud that could otherwise catch on an opposing surface. We're still working on our case series at the present time, but certainly early reports from multiple different surgeons have reported, you know, short term, medium term, good results. Certainly we have some post-operative MRI follow ups demonstrating. Phil, and what I mean by Phil is these constructs are only about 1.5, maybe to 2.5mm thick. And I'm putting them into a patella that's 5 to 6mm. And at a one year follow up MRI, it's re-expanded to that full thickness of the surrounding articular cartilage. So that's also supports the the potential use for this. Thank you.

Raffy Mirzayan, MD, (Los Angeles, CA) treats a large osteochondral lesion of the glenoid with Cartiform®* viable osteochondral allograft. Technical pearls related to the preparation and fixation of the allograft are discussed, including the use of the Knotless SutureTak® anchor.
*Cartiform is a registered trademark of Osiris Therapeutics, Inc.

Cartiform® Osteochondral Allograft Glenoid Implant

All right. We have a right shoulder here and a lateral decubitus position. We're looking from the posterior portal. I've created an anterior superior portal with the Gemini cannula and a 5:00 GAP portal with the percutaneous kit using this metal cannula. We've created a defect, a substantial defect for this specimen size in the anterior glenoid. We can use these Cartiform templates to size our defect. Place it right down the cannula. And overlay onto the defect to get a rough estimation of the size of the defect. Alternatively, you can use the the arthroscopic measuring probe to size the defect. So the length here is approximately 20mm. And the width. Is ten millimeters. So we have a ten by 20 millimeter defect. I think it's important to also view the defect from the anterior superior portal. So what we've done is created nice perpendicular walls with the remaining cartilage around the defect. I use a ring curette to remove the calcified cartilage layer of the defect, and create perpendicular walls with the surrounding cartilage, in order to create a healing environment and stimulate biologic enhancement of the of the graft. Bone marrow vents are created, and in order to do that, you take out the clear cannula from the Gemini. This 45 degree. At very low rpm in the central center part of the defect. So the bone marrow vents are created and assist with the healing of the graft. At this point, we're ready for anchor placement. I'm starting with the with the 12:00 anchor. Go ahead. All right. So let's put a snap on that just to keep them all organized. Let's do the 3:00 anchor next. That's good. Yeah. You're in. You're okay. We've placed all four of our anchors here, as you can see. Suture management is critical to avoid tangling the sutures, which will make the graft passage more challenging. So at this point, we have to take out the center clear cannula, which has a dam out of the outer cannula, which will allow passage of the graft. So we're going to undo this. Undo the snaps. I'm going to each anchor and grabbing all the sutures and pulling them through and tagging them. So that's going to be our 6:00. Perfect. This this will ensure that the sutures won't get tangled when we're passing the graft. So here's. This is our 3:00. So as you can see, the all the sutures are individually passed. They're tagged and snapped. The central clear cannula is taken out, which makes the wings of the Gemini unstable. So it's very important, as we're passing sutures, that your assistant is holding the blue cannula in place so it doesn't come out. Okay. So at this point we're going to prepare the Cartiform and cut it down to size. We're going to put the template right over the Cartiform and draw the outline of it. Okay. Yeah. All right. Okay. We have a perfect match now. So it's it's not very clearly visible to the naked eye, but the undersurface of the Cartiform has a very thin layer of bone. So you want to make sure you keep that in mind. So this is going to be the superficial side right here. And this is going to be the undersurface, the bony side that's going to go down to the glenoid. So we can place a mark that this is going to be our 12:00. It will help us with orientation and make sure that the articular side is on the, on the, on the upper side of the graft. We want to pass the suture from the anchor, from the Nautilus SutureTak from the deep side towards the superficial side to create a mattress stitch. So our passing wire is going to go from superficial layer to deep in order to pull this through. And then from from the deep to the superficial. Notice that I pass it on the second hole from the edge of the graft and not the the holes nearest to the edge of the graft. And what we want to do is create a loop and place a probe so that as the sutures getting past the tension is placed on the on the switching stick or the probe and not the graft. We'll repeat these steps with all the other anchors at the 3:00, 6:00 and 9:00 positions of the graft. So prior to passing the sutures, I want to double check and make sure that these are free and not intertwined with the other suture limb. The stay suture is then passed in the loop of the shuttle stitch. And at this point we pass the stay stitch through the anchor. There you can see it coming down and going into the anchor. There we go. There we go. So from the my 5:00 cannula, I come in and I grab the suture limb that's passing, that's shuttling through this anchor, the stay suture and bring it out just for to make it easier for suture management and pulling the graft in. So we've already passed the stay suture from the 6:00 anchor through our 5:00 portal. And I'm going to grasp the stay suture from the 3:00 anchor as well. So we have our 3:00 and 6:00 stay sutures coming out of our TransFix GAP portal, which will make it easier to to pass the graft. So by sequentially pulling the stay sutures, we're essentially parachuting the graft in. So one way to relieve tension off the graft is to come in with a grasper grab the loop. So that way there's not there's no tension being placed on the graft There we go. So let's do the same with the others. As you can see, a lot of the suture gets bunched up under the graft. And what we do is come in with a atraumatic grasper put it, place it through the loop and lift it up and push and pull at the same time to make sure we take all the suture slack out from under the graft. That's looking really, really good. So once we've taken all the suture out from underneath the graft, we're going to do our final tensioning very, very gently. Now that we have sequentially secured each anchor the graft is nicely filling into the defect. So we're going to use our tensioner cutter. Go all the way down to the anchor and then cut the limb. There you go. We use a tensioner cutter on all four anchors. So we have our final fixation with the graft filling the defect. And this is our final view from the anterior-superior portal. The postoperative protocol is placing the patient in a immobilizer for the first three weeks, then begin carbon exercises at three weeks and allow for active and active range of motion at six weeks and strengthening at approximately three months after surgery.

James McWilliam, MD, (White Plains, NY) demonstrates the repair of a medial talar dome osteochondral lesion using Cartiform® Viable Osteochondral Allograft. Cartiform contains key components for articular cartilage repair, such as a structural extracellular matrix, viable chondrocytes, and chondrogenic proteins. The unique design of the product has excellent handling properties and flexibility to allow for the Cartiform to conform to the surface area of the defect site.
*Cartiform is a viable osteochondral allograft used for articular cartilage repair.
*Cartiform is a registered trademark of Osiris Therapeutics, Inc.

Cartiform® Talar Implant

In this cadaveric specimen. We're going to repair a medial Taylor dome osteochondral lesion using Cartiform, a medial malleolus osteotomy has been performed. In this case, we used simple sterile packaging from drill bits in order to create our template. Cartiform is stored at -80°C to thaw. The container is placed in room temperature sterile saline for approximately five minutes until the ice crystals are gone. Once thawed, the graft is removed from the container and placed in a sterile basin filled with room temperature sterile saline for at least one minute and up to two hours. The subchondral bone side is scored to aid in orientation. The implant is trimmed with scissors to match the template. In my patients, I will add bone marrow concentrate. Pilot holes are drilled for insertion of the 2.5mm PushLock anchor at the 12:00, 3:00, 6:00 and 9:00 positions. In this case, the PushLock anchor is preloaded with two vicryl suture and my patients I will use A40 vicryl monocryl or other rapidly absorbing suture. Once the anchors are placed, the sutures are passed through the fenestrations in the Cartiform implant Plant sequentially at the 12:00, 3:00, 6:00, and 9:00 positions. In this case, we're using a nitinol wire. Alternatively, a thin needle may be used. The Cartiform implant is gradually brought down to the joint surface. Care is taken to appropriately manage the sutures and avoid suture tangling. The sutures are tied securely to the top of the implant. Excellent stable fixation of the Cartiform is obtained with excellent restoration of the articular surface of the talus. Here we see anatomic congruity of the ankle joint restored by the Cartiform. The remainder of the bone marrow concentrate is placed into the joint. The medial malleolus osteotomy is fixed with a plate and screws. Patients are placed in a posterior splint or short leg cast for two weeks. At two weeks, they are placed in a long cam walker and are instructed in active and passive range of motion exercises. Weight bearing is begun at six weeks post-operatively. The patient continues cam Walker use until three months postoperatively. Patients are told to avoid impact cutting, contact or pivoting activities for six months. Postoperatively.

Jeffrey Macalena, MD, (Minneapolis, MN) presents the case study of a young female who remained symptomatic following a tibial tubercle osteotomy. Rather than progressing to a patellofemoral joint arthroplasty, Dr. Macalena performed a cartilage transplant with Cartiform®* viable osteochondral allograft. He shares technical pearls and reports the 2‐year patient outcomes.
*Cartiform is a registered trademark of Osiris Therapeutics, Inc.

Patellofemoral Reconstruction with Cartiform® Viable Osteochondral Allograft

Hello, my name is Jeff Mikulina. I'm a sports medicine orthopedic surgeon at the University of Minnesota. And today, I wanted to share with you a case of mine that I think demonstrates some interesting principles regarding cartilage reconstruction. It's of a 38 year old female. She had a tibial tubercle osteotomy done a number of years previously, and has noted continued pain to the anterior aspect of her knee. She lives considerably far from our hospital system and has received her care in the Outstate area previously. She was ultimately referred to us at the university to see if anything could be done. She had previously been discussed the idea of a patellofemoral arthroplasty. This 38 year old female, though, was very active and has multiple young children and did not feel that she was mentally or physically ready for a knee replacement and was not interested in the potential limitations that come with an arthroplasty procedure. Ultimately, her exam showed a tenderness on both the medial and the lateral aspects of the patella, as well as a symptomatic effusion. I performed an MRI which showed diffuse cartilage wear to the posterior aspect of her patella, as well as some areas of areas of subchondral edema. The remainder of her exam was benign and the tibiofemoral compartments were well maintained. Plain radiographs demonstrated some early degenerative changes, and I performed a staging arthroscopy, which showed considerable areas of cartilage where she failed to see lasting improvement from our staging arthroscopy. And ultimately I offered her cartilage reconstruction. I did not feel that this patient needed a tibial tubercle osteotomy, as this had been done in the past. However, it should be noted that when considering cartilage reconstruction to the patella, the need for a tibial tubercle osteotomy should be performed. I discussed with her potential treatment options, and ultimately we elected to proceed with a Cartiform reconstruction to her patella. This large lesion of the patella, we felt, would require reconstruction with two two centimeter Cartiform discs. We used a snowman technique to provide appropriate coverage as seen here. We soaked the Cartiform discs in bone marrow aspiration concentrate to allow for biologic augmentation. One of the things that I have not been happy with in my clinical practice is the consequence of damage to the subchondral plate with microfracture. And I think that augmentation of the healing with bone marrow aspiration concentrate is a reasonable alternative. The 2.9mm short biocomposite PushLock were used in the periphery. One of the other techniques that I would encourage you to consider to use is to use the suture passing device of the PushLock, seen here in this open arthrotomy picture, as a way to shuttle the sutures through the Cartiform disk. After placement of the two Cartiform disks and getting secure fixation, the patella is again everted and the closure was performed in a layered fashion. Ultimately, we allowed this patient to weight bear as tolerated in extension right away, and we started a slow and progressive range of motion protocol using a CPM machine. I recently had a chance to see her again. She's a little out from two years from surgery. Now she's returned to doing the things that she wants to do, including playing some pick up volleyball with friends on nights and weekends. She's able to do the things that she wants in regards to her family and her responsibilities at home. She's quite happy with her reconstruction, and I think that this is a good technique that you should consider for your patients as well. Thanks for your attention.

Aloenxerto osteocondral viável Cartiform®

Aloenxerto osteocondral viável Cartiform®