Orthobiologics

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A técnica cirúrgica intraóssea BioPlasty (IOBP) se presta ao tratamento de patologias do osso resultantes de lesão aguda ou crônica, inclusive lesões da medula óssea associadas a fraturas por insuficiência, hematoma ósseo persistente, osteoartrite e necrose avascular nos estágios iniciais. A Arthrex oferece opções para o tratamento dessas patologias por intermédio de uma descompressão do núcleo da lesão e uma aplicação direta de um concentrado de plasma rico em plaquetas (cPRP) de aspirado de medula óssea (AMO) pelo sistema de processamento Arthrex Angel®. O procedimento IOBP™ é um tratamento biológico de lesões da medula óssea com técnicas que estimulam a remodelação e o reparo ósseos fisiológicos.

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IntraOsseous BioPlasty® Surgical Technique

The IntraOsseous BioPlasty® (IOBP) technique is the treatment used for bone pathologies resulting from acute or chronic injury, including bone marrow lesions and spontaneous osteonecrosis of the knee (SONK). The IOBP® technique is completed by performing a core decompression of the lesion, followed by direct application of concentrated bone marrow aspirate prepared using the Angel® concentrated platelet-rich plasma (cPRP) system.

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IntraOsseous BioPlasty® Technique for Bone Marrow Lesions of the Knee—Direct Approach

Intraosseous bioplastic is the treatment of bone pathologies resulting from acute or chronic injury, including bone marrow lesions and spontaneous osteonecrosis of the knee. Arthrex offers options for the treatment of these pathologies by performing a core decompression of the lesion and a direct application of concentrated bone marrow aspirate using the Arthrex Angel system. First position either the open tip or closed tip delivery cannula adjacent to the bone marrow lesion and according to the MRI. Insert the delivery cannula utilizing Fluoroscopic guidance to ensure the cannula is positioned appropriately into the subchondral bone, then remove the inner stylet to complete cord decompression to prepare the biologic graft to backfill the decompression site. The BMA is transferred into a separate sterile basin and drawn into a syringe. The BMA is transferred to the mixing and mixing and delivery syringe filled with AlloSyncPure using a female to female Luer adapter. Optionally, contrast may be utilized to aid in visualization of the graph during backfill of the cord. Decompression site. The female to female Luer adapter is removed and the Luer cap is secured to the mixing syringe. Unsnap the pushrod from the mixing element. Push and pull the mixing element back and forth until thoroughly mixed. Pull back on the mixing element and snap the pushrod back onto the mixing element. The BMA and AlloSyncPure mixture is then transferred to multiple one cc syringes. And then delivered directly into the lesion.

This animation shows the IntraOsseous BioPlasty® (IOBP) technique for treatment of bone marrow lesions of the talus. IOBP® is the biologic treatment used for bone pathologies resulting from acute or chronic injury, including bone marrow lesions and osteochondral lesions. The IOBP technique includes performing a core decompression of the lesion and direct application of concentrated platelet-rich plasma from bone marrow aspirate mixed with AlloSync™ Pure demineralized bone matrix.

IntraOsseous BioPlasty® (IOBP) Technique for Treatment of Bone Marrow Lesions of the Talus

Intraosseous bioplastic is the treatment of bone pathologies resulting from acute or chronic injury, including bone marrow lesions and osteonecrosis of the foot and ankle. Arthrex offers options for the treatment of these pathologies by performing a core decompression of the lesion and a direct application of concentrated bone marrow aspirate using the Arthrex Angel system. For a taller subchondral lesion with a cartilage defect, first debride the cartilage defect to achieve stable borders using a curette. Next, advance the delivery cannula according to the MRI, using Fluoroscopic guidance to ensure the 13 gauge cannulated delivery device is positioned appropriately into the subchondral bone, remove the inner stylet to complete the cord. Decompression of the subchondral lesion. Optionally, for a posteromedial lesion or when the articular cartilage is intact, a guide pin is driven through the lateral cartilage slightly anterior to the fibula towards the lesion. Slide the cannulated delivery device with the stylet removed over the guide pin, and twist it back and forth by hand until the desired depth is reached. To prepare the biologic graft to backfill the decompression site, the BMA is transferred into a separate sterile basin and drawn into a syringe. The BMA is transferred to the to the mixing and delivery syringe filled with AlloSyncPure using a female to female Luer adapter. Optionally, contrast may be utilized to aid in visualization of the graft during backfill of the cord. Decompression site. The female to female Luer adapter is removed and the Luer cap is secured to the mixing syringe. Unsnap the pushrod from the mixing element. Push and pull the mixing element back and forth until thoroughly mixed. Pull back on the mixing element and snap the pushrod back onto the mixing element. The BMA and AlloSyncPure mixture is then transferred to multiple one cc syringes. And delivered into the lesion by backfilling the tunnel created by the drill. After mixing the BioCartilage extracellular matrix with an autologous blood solution within the mixing syringe, apply the mixture into the defect with the ArthroPaddle delivery needle and smooth until flush with the cartilage surface. Use the dual lumen applicator to seal the BioCartilage with fibrin glue to complete the repair.

This animation demonstrates the treatment of a bone marrow lesion of the femoral head using the IntraOsseous BioPlasty® technique, including core decompression of the lesion and direct application of a platelet-rich plasma concentrate from bone marrow aspirate (cPRPBMA) using the Arthrex Angel® cPRP and bone marrow processing system.

IntraOsseous BioPlasty® (IOBP®) Surgical Technique for a Bone Marrow Lesion of the Hip

Intraosseous. Bioplastic is the treatment of bone pathologies resulting from acute or chronic injury, including bone marrow lesions and osteonecrosis of the hip. Arthrex offers options for the treatment of these pathologies by performing a core decompression of the lesion and a direct application of concentrated bone marrow aspirate using the Arthrex Angel system for a femoral head lesion. Advance the delivery cannula according to the MRI, using Fluoroscopic guidance to ensure the cannula is positioned appropriately into the subchondral bone. Remove the inner stylet. Then advance the 3.3mm guide pin to the desired decompression depth. The iabp decompression device is then advanced through the delivery cannula and to the depth of the desired decompression. Once drilling is initiated, the trigger mechanism is then engaged to flip the cutting feature. The seven millimeters decompression device is then pulled back to achieve the desired length of decompression. The trigger is then released and the device is withdrawn. To prepare the biologic graft to backfill the decompression site. The BMA is transferred into a separate sterile basin and drawn into a syringe. The BMA is transferred to the mixing and delivery syringe filled with AlloSyncPure, using a female to female Luer adapter. Optionally, contrast may be utilized to aid in visualization of the graft during backfill of the cord. Decompression site. The female to female Luer adapter is removed and the Luer cap is secured to the mixing syringe. Unsnap the push rod from the mixing element. Push and pull the mixing element back and forth until thoroughly mixed. Pull back on the mixing element and snap the push rod back onto the mixing element. The BMA and AlloSyncPure mixture is then transferred to multiple one cc syringes. And delivered into the lesion by backfilling the tunnels created by the drill and decompression devices. The iabp procedure may also be used to treat acetabular bone marrow lesions. When treating acetabular lesions, position the closed tip cannula towards the lesion according to the MRI. Drive the needle into the acetabulum under fluoroscopic guidance and direct the holes of the tip towards the lesion using the white arrow on the handle for reference. Remove the inner stylet to complete the cord. Decompression. And deliver the BMA and AlloSyncPure mixture directly into the lesion.

J. Lee Pace, MD (Farmington, CT), performs an IntraOsseous BioPlasty® technique with the new IOBP® decompression device. The updated device achieves a 7 mm decompression while maintaining the cortex for subsequent delivery of the biologic mixture during an IOBP procedure.

IOBP® Decompression Device

I want to take a few minutes today to introduce everybody to the new Intraosseous bioplastic or Iabp decompression kit. The first thing we have here, this is the delivery device, which also acts as a guide for the decompression device. This is the guide pin here, which also has measurements on it so we can control the depth of our decompression. This is the actual decompression device which we'll explain a little bit more detail in just a second right here. This is our mixing syringe, which will be used to mix DBM with some sort of autologous fluid bone marrow aspirate for example. And then here these are all of the delivery syringes which will be used to take the mix material from here. And then inject it into the knee through the delivery device. So this is the decompression device here. And what's been done is a marriage of two different technologies. So at the tip. First thing to point out is the FlipCutter technology as you can you can see here. So we have the ability to flip the tip to create a cutting plane. The next technology here is the PowerPick technology with this handle here. And what this allows us to do is it allows us to basically open up the FlipCutter technology inside of bone. And the way this would work is that you could be drilling inside the knee. And while it's drilling, you can then open up the FlipCutter end while you're spinning to gradually remove bone up to a seven millimeter decompression. And then once you've got this opened up, you can keep spinning, and then you can start pulling back and you can perform your decompression just like that. Here we have our initial setup. So here's our delivery cannula. I want to point out that this has a pin driver connection. So this is very easy to assemble to take on and off. And you And you can actually deliver this or you can put this into bone. It's got a very sharp end. You can use your hand to put it in, or you can connect it to power to put it in. You can put this in either all the way to the depth that you would like because it is graduated. But you can also use this in conjunction with the guide pin here that is graduated, that has measurements on it to get down to the depth. So what we're going to show in this example is we're going to place this in about ten millimeters. We're going to remove the inner stylet. And then we're going to drill down to the depth that we want from there to create that initial socket. And then we're going to come in with the decompression device to the depth that we would like. And then we're going to ream back like that. We also want to highlight here that if you are working very close to the articular surface, it never hurts to have a NanoScope nearby so that you can look and make sure that you have not violated the articular surface. So this can be a nice double check. And we'll do that for demonstration purposes for this. So the way we're going to start this off is under Fluoroscopic guidance. The trajectory of the delivery guide is very important. So we're going to place this under Fluoroscopic guidance. And thus that will help us get our guide Pin and then subsequent decompression device into the area of interest. So you can see here with this fluoroscopic image that we are close to the joint. And we're aiming across to the lateral portion of the medial femoral condyle. So it looks like a pretty good trajectory there. So I can sort of advance this in like that. Again you can see that we're solidly in bone there. And we're going to get right down to that. You can see with that trajectory we'll get very close to the Subchondral border there at the most lateral aspect of the medial femoral condyle. So that should be a pretty good trajectory for us. So now we can take this off. We can pull that out. This comes out just like that. And then we can introduce our guide pin and we can place that under Fluoroscopic guidance. You can do some mild adjustments here. But we like how this looks on this AP so we can start advancing that across. And we can just follow that with fluoro. And you can see we're almost to but not quite to the lateral wall the medial femoral condyle. So we can advance that just a little bit more. You can see we're pretty much right at it there. So that's really good. That'll be a nice spot. We've given ourselves enough clearance here that we can do a seven millimeter decompression without violating the articular surface. So we've got that where we want it. We can take this off. We can measure our depth here. Now, remember, this is in about ten millimeters or so. So this is saying that that the guide pin is in about 15mm beyond the tip of this. So we're in about 25mm here. So we have that. We're confident we like how our x rays look. And so now what we can do is we can switch this out for the expandable reamer. And so we can pull this out. And then at any time that we want we can always go in Arthroscopically and take a look. But we'll take this out. So now we can just advance this and we'll just do it under fluoro. So just and again that's going pretty easily. You can see we've advanced it almost all the way across already just by just by pushing it. But if we want to just sort of finesse it in just a little bit more, we can do that. And there you can see we're at we're at the depth right there. We're at the very end of that. So now if we want to we can check it with the scope. So here we are inside the joint. You can see that we have not penetrated the cartilage. So that all looks great. And if you want to you can even just keep the nano in the joint while you're doing this. So if you've got enough hands you can do that. Now what we're going to do is do is we're where we want to be. So we're going to start spinning this. Now it's important, this thing. You see how this thing is mobile. Once you start opening this up, the FlipCutter component up, you've got to hold this. Because what will happen is it will engage and it will you know, it will get away from you. So you really want to have a firm grip on this. So. So what I'm going to start this spinning. So I'm spinning and then I'm going to start opening this up. [00:06:41] Get back on that track. And you can see that opening up just like that now. And you can see how now I'm going to stop it for a minute, just so you can see how it's partially opened up right there. So I'm going to keep it spinning. And now I've got it all the way. And now we can just start pulling back. You can see that we're just very safely under fantastic control Pulling back, and we're going to get right to the hub of the delivery sleeve. We've done a very controlled resection right there. Very easy to do. And then once we're done, you can just advance that in a little bit. Straighten out the FlipCutter and you can see that we've not touched the articular cartilage. We've had the NanoScope in the whole time. And then we can just take this out like that. And now we've got our delivery sleeve and we can now introduce our biologics. Now this is purposely radio opaque so that we can see how it fills the cavity. But this would this is representative of a DBM and autologous fluid slurry that we're then going to inject into through the delivery sleeve. So we'll just screw that in. Okay. And so that has we're going to put a little bit more of that in. And we can see it fill up that cavity very nicely. There. Look at that. So that looks great. You can see how, how very precisely we can fill in that cavity with that with those biologics right there. So that looks great. And then whatever's left in the in the in the sheath you can then you know, sort of complete that just by pushing that down. We've probably got plenty. You can see it's kind of oozing out the side here. Which means that we've got a we've done a full capacity delivery. Put that in and then we can just withdraw. We just take it out. And there we have it. The unique value of this kit in this device is that you can still do a seven millimeter decompression, similar to what is done with the legacy equipment, but you can do it in a minimally invasive fashion, with minimal amount of bone removal and maximizing as much intact cortex as possible.

Brian D. Giordano, MD (Rochester, NY), presents a complex case in the hip in which he used various biologic and standard approaches to obtain a successful outcome. For the acetabular cyst, Dr. Giordano performed an IOBP® procedure augmented with autogenous bone collected using the GraftNet™ device. Dr. Giordano performed an AutoCart™ procedure to treat the articular cartilage defect, which includes mixing BioCartilage® matrix with autologous cartilage collected from the cam lesion using the GraftNet device. Labral preservation was performed using the innovative Knotless SutureTak® anchor, which provides tensionable advantage to the surgeon.

Biologic Repair of Acetabular Cyst Using the IntraOsseous BioPlasty System and AutoCart™ Procedure

Hello. My name is Brian Giordano from the University of Rochester. I'm going to be discussing a case of biologic repair of an acetabular cyst using interosseous bioplastic, GraftNet and BioCartilage. The patient in question is a young, healthy female softball player who would unfortunately experience greater than six month duration worsening left hip pain. She had experienced a decline in her range of motion, function, strength, endurance and sport tolerance. She had pain that affected her quality of life, her ability to tolerate activities of daily living. The pain had begun to wake her from sleep, and she had begun to limp as a result of her symptoms. On her physical exam, she was mildly overweight. She walks with an antalgic gait, incorporating a shortened stride length for comfort. She walked with a slightly externally rotated posture through the lower extremity. She did not have any suprapubic inguinal or central core tenderness. She did have a globally restricted range of motion of her hip with significant Capsulitis range of motion was compromised on her. On her affected side, 90 degrees of degrees of flexion, with essentially zero internal rotation and mild external rotation before the point of pain. In comparison to her contralateral extremity, she also has positive provocative testing for femoroacetabular impingement, including positive Faber and Faber exams. On her plain radiographs, we essentially see a relatively normal congruent joint with a small area of lucency and the superior weight bearing surface of the acetabulum. And on more advanced diagnostic imaging, it's clear in the CT scan that you can see a large focus of subchondral cyst with significant surrounding bone marrow edema. The case in question presents a number of treatment challenges. Obviously, we're dealing with a young, physically active, patient, larger body habitus. We have to incorporate elements of treatment that are able to provide options for both the marrow edema, the biologically reactive lesion, the articular surface, the subchondral bone, and then of course, the surrounding labral pathology and synovitis. In this case, incorporating some elements of strategic rehabilitation are going to be important to optimize her post-operative care. So in considering options, we always start with start with conservative to the most invasive conservative options were not great for her because she had already failed exhaustive conservative management. Pain was affecting her quality of life. She was not able to do any more strenuous physical activities. Pharmacologic options should always be considered, including bisphosphonates elements like parathyroid hormone, but in this case they were not indicated. This lesion could potentially be accessed using interventional techniques. However, the labral OnControl pathology, the deep filling, could not be accomplished through a percutaneous technique. Open techniques could be considered but at the expense of significant patient morbidity, longer and more exhaustive rehabilitation process, and potential for other complications. Arthroscopic treatments have to incorporate the need for treating both the surface articular cartilage, the subchondral bone, and or potentially both. If you're going to consider biologic augmentation, we need to propose the idea of potentially using both allogenic or autogenous tissue and then, in addition, incorporating some biologically active vehicles such as autologous conditioned plasma, PRP or bone marrow. Maybe other useful adjuvants to this labral preservation, in order to incorporate a sufficient labral seal to protect and optimize the healing environment is important as well. This is the setup on our back table. You can see that obviously you have a very, very organized system. I think personally, it's very important to have a very well versed support rep in the room to make sure that when you're using a number of different biologic options, things are organized in a systematic fashion so that there's no unfortunate mistakes. So the selected approach that we used was arthroscopic to optimize the minimally invasive nature on entry into the joint. You can see a probe into the small nidus on the articular surface probing into a deeper cavity. There's a surrounding labor repair. I place labor repair anchors adjacent to the cyst, so as not to incorporate the drill tunnel into the cyst itself, provide provisional stabilization of the labrum. The surface articular cartilage is quite unstable. You can see the the hole for the iabp needle. I'm using a bone cutting shaver right now to take autogenous cartilage from the femoral head. Harvesting it using a GraftNet, and then using a separate GraftNet to harvest femoral head bone for an autogenous bone graft, which can then be mixed with DBM to fill the cyst. As you can see, Afe decompression is being performed. A hip length IOP needle was utilized to deliver the bioactive substrate into the into the cyst. Biocartilage was delivered into the surface articular cartilage in order to provide bone grafting, both of a of a of a bone marrow constituent into the cyst, and then more of an articular cartilage matrix for the for the surface articular cartilage. After the, the dual grafting was complete and matured using fibrin glue, a knotless FiberTak was placed just above the drill tunnel from the IOP needle to create a central suspension in the labrum, further stabilizing the final repair construct. In this case, post-operative care was initiated immediately after surgery, with early range of motion hips in general providing an intense biologic healing response, but made even more aggressive by bioactive substrates, so early range of motion is extremely important. Protected weight bearing was utilized for the first six weeks of foot. Flat touchdown. Weight bearing. Skilled outpatient rehabilitation is crucial to ensuring an optimized outcome. This should be under the direction of a skilled hip rehabilitation team, avoiding specific psoas and abductor triggers, which tend to include open kinetic chain core fatigue based hip abduction. Retraining early. We often institute some aquatic therapy at about two weeks to reduce the postoperative infection risk and add myofascial based techniques. At six weeks in this case, we obtain a postoperative MRI at three months to evaluate healing of the repair construct and to ensure that no further progression was was occurring. We were excited to see at three months post-op that there was significant resolution in surrounding edema. Good incorporation of the graft material into the cyst. No progression of the lesion, and stabilization of the surface articular cartilage. Pearls of this case include extensive preoperative counseling. These patients really need to understand what will be involved in their pre and post-operative care. These can be painful procedures. Fortunately, in arthroscopic nature, this allows us to optimize the effectiveness and accomplish this in a in a method that is relatively pain free. It's mandatory that a skilled, experienced rehabilitation team with ancillary services are available to ensure that the patient does not become stiff. Post-operatively develop abnormal gait patterns or over utilized muscles which may not be prepared to rehabilitate at certain time frames. A milestone based approach is always used. Intraoperatively. It's extremely vital to have an experienced Arthrex biologics representative, both from the surgeon's perspective and also the perioperative surgical staff, to ensure that a smooth and efficient care flow is promoted. It's key to if you're using multiple biologics to have a very organized intraoperative setup, both from the standpoint of biologics, GraftNet and implants, these cases can become very confusing. So having these these out in an organized fashion ensures that substances are not are not mixed in an incorrect fashion or at wrong ratios. I typically perform the decompression early, both from the standpoint of of not wanting to have bone debris floating around the joint after a repair. You're at a point in the case where you do not want to to evacuate anything for fear of removing some of the graft material. The decompression, while vital to the pain resolution in that portion of the procedure, is also a technical step in procuring articular cartilage graft, as well as subchondral bone using GraftNet technology. I provisionally stabilize the labrum prior to grafting the the material both to, to ensure that the drill tunnels did not incorporate into the into the cyst pocket. Also, to ensure that the labrum was stable and was able to contain the BioCartilage graft in the surface, anchors need to be placed strategically. As I said, I stabilize the final element of the of the repair with with a FiberTak suture just above the introduction of the IOP needle for central stabilization. That worked well for this case with no further Other version. The double Knotless repair device allows a variable amount of tension so that you can. You can adjust how much tension is applied to to be able to place the labrum. Anatomically. A hip length iabp needle was used in this case because of the increased depth in the body habitus dimensions of the patient. This allowed for effective interosseous delivery of our bioactive substrate. We capped the articular cartilage to prevent egress. We did use an aqueous delivery into the cyst while the BioCartilage was delivered in a dry environment. Our preference is to use either an Ng tube to evacuate residual fluid from the joint, or to create a posterolateral portal with a suction based pledgets or simple suction equipment through the posterolateral portal. A 14 gauge spinal needle was introduced through a distal accessory portal using fibrin glue or autologous thrombin to mature the graft construct in this particular case.

Técnica intraóssea BioPlasty® (IOBP)

Técnica intraóssea BioPlasty® (IOBP)