Ortobiologicos

Conjunto de aloenxerto Meniscal Dovetail

O set de transplante Meniscal Dovetail utiliza uma técnica que enfatiza o aloenxerto do bloco do osso trapezoide para proporcionar um inter-bloqueio osso-osso sem necessidade de fixação adicional do enxerto. A instrumentação prepara, de forma rápida e consistente, a calha receptora do paciente e o formato trapezoide do bloco ósseo do aloenxerto.

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Orthobiologics - Next Generation in Biologics Technology

Knee

Thomas Carter, MD (Phoenix, AZ), presents 20-year clinical data of patients treated with meniscal allograft transplantation procedures. Dr. Carter reviews current indications for patient inclusion and exclusion, and describes several important factors in considering meniscal allograft transplantation.

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Meniscus Transplantation: 20-Year Survivorship and Outcomes

Hi, my name is Thomas Carter and I'm presenting on my 20 year outcome of meniscal transplantation. Isolated allografts have been performed for a long time and longer than most people think. It was 1980s or just beyond that. They were started in isolation. They initially were thought to be a salvage procedure before getting a total joint arthroplasty. A lot has been learned since that time, and I've had the experience for 20 plus years. And again, I'll present my 20 year follow up. The indications. The symptoms should be localized to the involved compartment that can be altered by a joint effusion. So there's more swelling in effect the whole knee. It is not indicated if it's asymptomatic. A lot of people recommend putting them in as soon as the meniscectomy, but there's a limited supply and there can be complications. So I highly recommend waiting until somebody starts having some symptoms. Make sure that their symptoms are due to the meniscus excision. So this is a perfect example. You can see the meniscus has been excised. The other one is still normal. It'd be a good candidate because of their symptoms. This is not a good candidate, one sent to me. And you can see this is avascular necrosis having pain. But if you put a meniscus in this the failure rate is going to be extremely high. So the degree of Malaysia. Unfortunately we have to deal with insurance companies. And most of them say it should be grade two or less. The clinical benefit most we see are grade two and three. The consensus is if it's a truly arthritic knee, do not put a meniscus in. People will do that, but the durability is very short and you may just get a few years of benefit. And again, there's only limited supply of the meniscus. So I always say use them wisely. You can have an isolated defect. It's not a contraindication since there are a lot of cartilage procedures. But again that isolated defect should not be surrounded by a lot of other articular damage indications. Ages 50 to 55. But you have to consider the physiologic age. If you have a 6065 year old that goes out and runs marathons, just because he's that age does not a contraindication. You have to make sure that the knee can be stabilized if it's unstable. You have to take into consideration the alignment and the condition of the cartilage. Highly recommend. It's not a substitute for arthroplasty and you have to have reasonable patient expectations. All too often they come in, they say, I want to have 100% knee. I want to go out and run marathons. Those are patients do not have reasonable expectations. So one thing about Osteotomies there's not uniform agreement. Some people say anytime the involvement the glove compartment you should do an osteotomy. Others say a few degrees or don't even bother. Most of us will say if there's more than 3 to 5 degrees toward the involved compartment, go ahead and do an osteotomy. Now, as far as surgical procedure, this is highly debated. You can either use no bone, you can use bone with plugs or a bridge. The bone procedure is a little bit more difficult, but you should use bone. And I'll go over why basic science studies say bone fixation is better. Many clinical studies say no difference. However, more critically this is a great study shows suture only fixation techniques leads to a higher degree of extrusion than when you have bony fixation. So if you can see the extrusion for soft tissues 36% bone fixation 26 and this is a more recent study that proves bone fixation is important in the long term. You can see in the short term five, six, seven years, there's really no difference in regard to the joint space. But if you get out to seven and eight, you can see there's a dramatic difference in the joint space when you start using bone versus no bone. So when you're talking about not using bone, think about how long that study is. Long term shows it is different. Now the way I do these are bone plugs. Technically it's a little more challenging, but the graphs show on the medial side there's a big difference between the anterior and posterior horn, probably about 2.5cm. So a bone plug seven eight millimeters back, ones in front. You can suture them similar to a meniscal tear in the back. I use press fit up in the front. And this is a dovetail technique. You can use a slot which basically it's easier to do, but it's a square and you have to augment the fixation with a screw or sutures. Dovetail is a press fit. Again, a little bit more technically challenging, but I would recommend using it. Rehab. That's something most surgeons never even think about. But you have to think about the patients. If they have a job where they got to get back sooner than later, consider that as far as treatment of them. So 0 to 4 weeks I have partial weight bearing. They don't have to be non-weight bearing partial weight bearing more according to how they feel. Range of motion. There's some debate on that, but I usually stop at 90 because on the lateral side, the meniscus moves approximately a centimeter from full extension to flexion. And on the medial side six millimeters or so. So if there's any concern of fixation in the back, say you have the capsule excised all the way. You want to get good healing before you push too hard. At four weeks I'll let them pull weight bearing, getting on a stationary bike and those decisions are healed. They can go swimming at 3 to 4 months. I hypothetically say they're running, but running. But as I said, don't push the envelope as far as activities and 5 to 6 full activities according to their core strength, balance and other parameters more functional. So the clinical outcomes, if you look at these, the evidence proves that it provides pain relief. Improved function ten year survival rate is 70 to 80% is pretty much uniformly agreed upon. The radiographic studies are encouraging of slowing progression, but it does not prevent arthritis. I've had the pleasure of having a ten year follow up. You can see the results of this 40 of my initial 47 recipients, so 85% follow up. I use cryopreserved grafts, 80% had symptoms improved, 82% had grafts. Survivorship. There were seven partial excisions and four after seven. So early on not to great failure. Going beyond about 7 or 10 year range, you start having to drop off now. More recently, I published in arthroscopy my 20 year follow up, the 48 of my of my initial 56 recipients, or 86% follow up, 27 of 48 patients had no additional surgeries. That correlates to a survivorship of 56.2%. At 20 years, I had eight that had joint arthroplasty average 14 years post-op. So again, with the ten year study, it does deteriorate with time. And these are patient activity levels. You can see for yourself from the graft. They have much improvement in the short term as you would expect. It does drop off. But the patients have been very happy, with only one stating that they would not have the surgery again. And the results? You can see that I had only 12 patients had radiographs in post-op at 20 years, but the patients were around the world very difficult to be able to get radiographs and have them proper to determine the joint space. But eight had two millimeters of joint space, four had only one millimeter of joint space. But that was maintained from pre-op. This is a study that obtained from a 22 follow up. And you can see that the arthritis progressed only a slight amount, and this is one from 22 year post op scope. The graph is not normal and we would not expect this to be totally normal, but there's still function and delayed some of the arthritic changes from the patient. And just so you know, the patient allowed the second look due to surgery on the other knee, which he had a torn meniscus. So in conclusion, you have to have stringent patient selection for success. If you're going to have a long term results, you're not expect to need to put in somebody that wants to go back and play heavy duty, high impact sports. It's not for the asymptomatic. It's not for the advanced arthritis. It's technically challenging and you have to be aware of that. It does take a learning curve quite a bit, but the significant improvement in clinical outcomes can be achieved. And that's what it's all about as far as making our patients happy. The ability to deter arthritis still needs further documentation. Thank you.

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Meniscal Allograft Transplantation Featuring Dovetail Meniscal Allograft

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Dovetail Technique for Lateral Meniscal Allograft Transplantation

The dovetail technique enables you to visualize the entire preparation of the bone, but at the same time, by having a dovetail orientation, it maintains the bone within the trough. The very first thing that's vitally important is proper position of your portals. You have to make the portal opposite that of the side of the meniscus first. You have as close to the patellar tendon, if not coming through the patellar tendon, so that that way you can see the posterior horn of the meniscus. Once that's been achieved, the contralateral side, you make sure that the posterior horn of the meniscus is directly aligned with your portal. After you've completed your portal site, the next step is to debris the remaining meniscus that is present. You have to make sure that there's excellent vascularity, otherwise you don't have a tissue to which the meniscus will heal subsequent to this. You go ahead and prepare the knee for accepting of the bone for the dovetail technique. You make certain that there's adequate space between the intercondylar notch and that of the horn attachment. So that way you're certain that the graph will fit to make sure that the graph fits easy and does not make the reduction difficult. The next step is the confirmation of communication from the anterior horn to posterior. So you can see that's straight on as we'd like. So if there's any question in regard to the height of this accommodating, you can take off a little portion of the tibial spine. So if you are going to do this completely through the arthroscope, you can use the Pin. Or you can put this in directly coming straight along the pin, or by looking through the arthroscope to see exactly where the blade is inserted. And this is a point that I will typically do it dry. You then can insert the osteotomy. Follow that by looking outside the knee. You can see the orientation from a sagittal plane. The marking tells you the height. The tibial slope is approximately ten degrees. If you come flat when you insert this, you can see that it's going to skive upward, and then you're not going to have the proper height for the insertion of the graft. So by doing it through the scope, you can see that the height is parallel to the articular cartilage. And by looking outside you can see can see that the angles ten degrees approximately, and by making certain that it does not rotate that way, you'll make sure when it goes in, it also is now 90 degrees to the articular cartilage. And typically you want to stop just a few millimeters away from the back wall. Your arthrotomy made the tourniquet up. You now take the guide off the osteotomy and just do it gently, even though it's embedded within the tibia. It should stay secure. This slides over the osteotomy and makes sure this fits flush with the tibia. After having this completed, you will use the first drill, which basically just takes off the top of the remaining bone so that you can see exactly where your tunnel is going to be and stop just short the posterior horn. You remove the initial guide for insertion of the drill. You then put the second one, which is below the level of the first, for depth preparation of the dovetail. The second one is an eight millimeter drill. It's two millimeters greater and obviously of lower depth when using the rasp where the final sizes, you need to make certain that your proper one one is on the right and one is on the left. Flat side is the one that follows the osteotomy. So when you turn these to insert them, make sure the flat side goes near the intercondylar notch. One can use inside out suturing technique, which is what I prefer to do. Other people use outside in, but as I frequently say, one needs to make the meniscus fit the knee, not vice versa. The next step is to go ahead and prepare the graft and do so on the back table. Here's the graft. The meniscus. When you first start, I'd recommend just gently, basically kind of roughing the edges from which to have the clot heal. So on the very first things that you do is to identify the posterior horn. And sometimes soft tissue will make it appear as if the horn is further back than it truly is. The horn is here, so you can make a cut first to mark the posterior horn in the same for the anterior horn, cut initially perpendicular to Perpendicular to the horn attachment. It makes it much easier to prepare the graph, so it is a true dovetail. Typically you do not have to make any adjustments in regards to the cuts. Cuts on the inner border. Since it already is perpendicular to the horns, the sizer actually is a dovetail. As you can see, you have perpendicular and a blank so that there is a little more than two millimeters difference between the top and the bottom, which helps the graph fit snugly within its trough. Go ahead and use this as a template for the marking of where you wish to cut the narrow portion on top. The greater portion on the bottom 90 degrees will be near the intercondylar notch, the greater will be at the bottom, the narrow at the top. And that gives you as a fairly good reference point for how you would like your graph to be prepared. So by using that template, you have a very good reference point for how to place the meniscus. It's obviously upside down. You make sure this is snug so it does not rotate. The nice thing about this system is we have three cutting devices and they're numbered. So you have cutting jig number one. And that is to make certain that your cut is exactly perpendicular to the meniscus. So if you do this properly, it should go straight up and down with the line in which you prepared. So one is more of a confirmation than anything. Cutting guide number two to cut the meniscus at the proper height for the dovetail. So this is exactly the same height as the height you wish to have the meniscus. Now it's important that you put this on proper orientation. If you come across this angle, you're not going to have it in the proper. It should be opposite from where you're perpendicular placement is. So the smooth edge of the bone, you put this on the same side. It's cut such that it's deeper on the bottom and narrower on the top. And once again I prefer to use a longer saw blade so that it goes all the way through and follows that all the way down. Obviously, you wish to keep the meniscus out of the way. You can either use a grasper or your hand. Once it's finished, you'll go ahead and place a reduction suture through the posterior horn of the meniscus and placing it in the knee with once again this being done through the arthrotomy, one can use inside out suturing technique, which is what I prefer to do. Other people use outside in, but as I frequently say, one needs to make the meniscus fit the knee, not vice versa. And by have direct visualization of where the meniscus should go, the inside out technique is a little easier to confirm this position. So here's the reduction. Here's all the way back. You can see it's all the way back here. The horns all the way back to the back wall. So here's our meniscus right here. That looks great. After I have two sutures placed in the posterior and medial side for exact position of the meniscus. Then under direct visualization, I'll repair the anterior horn using probably 2 or 3 sutures. Because there's such an excellent vascularity, I'll probably only use about a total of 6 to 8 sutures, and I've not had any problems whatsoever in healing because of the vascularity of the meniscal capsular rim, the arthrotomy is closed and then completion of the meniscus performed.

Zieldraht mit Bohrgewinde, 2.4 mm x 310.0 mm

Aguja guía con punta de broca, Ø 2.4 mm x 310 mm

Tibiales Zielinstrument für Dovetail-Technik

Dovetail Meniscal Allograft, Workstation

Basisplatte, für Dovetail-Meniskus-Allograft-Workstation

Dovetail Meniscal Allograft Workstation Base

Base de la unidad de preparación de aloinjertos de meniscoDovetail

Base da estação de trabalho de aloenxerto meniscal Dovetail

Dovetail Meniscal Allograft Instrumentation Case

Dovetail Meniskus Allograft Sterilisationscontainer

Caja para aloinjertos de menisco Dovetail

CAIXA PARA INSTRUMENTAL PARA ENCAIXE MENISCAL ALLOGRAFT

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Einsatzboden für Dovetail Meniskus Allograft Sterilisationscontainer

Dovetail Meniscal Allograft Case Tray Insert

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BANDEJA PARA CAIXA DOVETAIL MENISCAL ALLOGRAFT

Dovetail Meniscal Allograft Osteotome Blades

Osteotomie-Blades, Dovetail-Meniskus-Allograft

Dovetail Meniscal Allograft Osteotome Blades

Hojas de osteotomo para aloinjerto de menisco Dovetail

LAMINAS DE OSTEOTOMO DE ALOENXERTO DO MENISCO DOVETAIL

Dovetail Osteotomie Handgriff, Meniskus Allograft

Dovetail Meniscal Allograft Osteotome Handle

Mango de osteotomo para aloinjerto de menisco Dovetail

CABO DE OSTEOTOMO PARA ALOENXERTO DO MENISCO DOVETAIL

Dovetail Meniscal Allograft Alignment Rod

Dovetail Meniscal Allograft Alignment Rod

Barra de alineación para aloinjerto de menisco Dovetail

BASTAO DE ALINHAMENTO PARA ENCAIXE DE ALOENXERTO DE MENISCO

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Dovetail Meniscal Allograft Führungsstab

Guías de perforación para aloinjerto de menisco Dovetail

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Dilating Rasp, Slot, Meniscal Allograft

Dilatationsraspel, Meniskus-Allograft, geschlitzt

Raspador de dilatación, ranura, aloinjerto de menisco

RASPADOR PARA DILATACAO DE ABERTURA MENISCAL ALLOGRAFT

Dovetail Meniscal Allograft Dilating Rasp, Left

Dilatationsraspel, Dovetail-Meniskus-Allograft, links

Dovetail Meniscal Allograft Dilator, left

Dilatador para aloinjerto de menisco Dovetail, izquierda

RASPA DILATADORA PARA ALOENXERTOS DO MENISCO DOVETAIL ESQUERDA

Dovetail Meniscal Allograft Dilating Rasp, Right

Dilatationsraspel, Dovetail-Meniskus-Allograft, rechts

Dovetail Meniscal Allograft Dilating Rasp, right

Raspador de dilatación para aloinjerto de menisco Dovetail,derecha

RASPA DILATADORA PARA ALOENXERTOS DO MENISCO DOVETAIL DIREITA

Dovetail Meniscal Allograft Dilator, Left

Dilatator, Dovetail-Meniskus-Allograft, links

DILATADOR DE ALOENXERTO DO MENISCO DOVETAIL ESQUERDO

Dovetail Meniscal Allograft Dilator, Right

Dilatator, Dovetail-Meniskus-Allograft, rechts

Dovetail Meniscal Allograft Dilator, right

Dilatador para aloinjerto de menisco Dovetail, derecha

DILATADOR DE ALOENXERTO DO MENISCO DOVETAIL DIREITO

Impactador de aloinjerto de menisco Dovetail

Dovetail Meniscal Allograft Graft Sizing Block

Dovetail Meniskus Allograft Transplantatgrößen- Tester

Dovetail Meniscal Allograft Graft Sizing Block

Bloque de medición de aloinjerto de menisco Dovetail

BLOCO DE AJUSTE DE ALOENXERTO DO MENISCO DOVETAIL

Kirk Hammer, 650g, Dovetail Meniskus Allograft

Dovetail Meniscal Allograft Instrument Set

2.75 mm Mini Suture Retriever, Straight

Mini Suture Retriever, 15° Up Curve

MINI RECUPERADOR DE FIOS COM CURVATURA 15º PARA CIMA

Mini SutureTape, White/Blue, 0.9 mm Suture, VE12

2-0 Mini SutureTape Meniscus Repair Needles

SutureTape Meniskusrekonstruktionsnadeln mit 0.9 mm SutureTape und 2Nadeln

Mini SutureTape Meniscus Repair Needles with 0.9 mm SutureTape and twoNeedles, VE10

Agujas para reparación de menisco con SutureTape 0.9 mm

SUTURA SUTURETAPE MENISCUS REPAIR 0.9MM BRANCO/AZUL COM AGULHA

Conjunto de aloenxerto Meniscal Dovetail

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Apresentação vídeos (1)

Meniscus Transplantation: 20-Year Survivorship and Outcomes

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Orthobiologics - Next Generation in Biologics Technology

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Meniscal Allograft Transplantation Featuring Dovetail Meniscal Allograft

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Dovetail Technique for Lateral Meniscal Allograft Transplantation

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