A instrumentação Talus OATS® facilita a colheita de núcleos osteocondrais de cartilagem hialina de diâmetro pequeno de um aloenxerto osteocondral. Através de uma série de etapas precisas com instrumentação dedicada, o cirurgião pode substituir defeitos danificados da cartilagem articular por núcleo de tecido osteocondral fresco e saudável que corresponda ao contorno e à morfologia da cartilagem do local receptor. Existem poucas opções de tratamento para pacientes com lesões grandes e sintomáticas das superfícies osteoarticulares do tálus. Esta técnica fornece um resultado confiável ao restaurar a cartilagem articular.1
Referência
1. Bisicchia S, Rosso F, Amendola A. Osteochondral allograft of the talus. Iowa Orthop J. 2014;34:30-37.

Foot and Ankle

William D. Bugbee, MD (La Jolla, CA), discusses the role of fresh osteochondral allograft use in the talus and reviews the abundant clinical studies from the past 30 years available to support the procedure.

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Fresh Osteochondral Allografts for Osteochondral Lesions of the Talus

Hello, I'm doctor William Bugbee. I'm the chief of joint reconstruction and cartilage transplantation at Scripps Clinic in La Jolla, California. Today I'd like to talk about fresh osteochondral allografts for osteochondral lesion of the talus. Fundamental principles of Osteochondral disease are straightforward. Subchondral bone in the osteochondral unit are important to understand when you're doing allografts. This is an integrated organ system. It's very interdependent structure and function relationship. Therefore, an osteochondral lesion, which involves disease of bone and subsequently cartilage, is a prototypical osteochondral disease. What we understand is that these two tissues working together create an organ. And when you have a disease like an osteochondral lesion, that's essentially an organ failure. So replacing it with an intact organ makes complete sense. Osteochondral repair generally has many advantages. You transplant mature hyaline cartilage, so you require no cell or tissue differentiation. You invoke a bone healing paradigm by replacing abnormal subchondral bone and cartilage. Thus, you get the concept of the organ replacement that I mentioned earlier. Also, you get a faster and simpler simple rehabilitation because the structural integrity of the graft is normal at day one. The allograft paradigm also invokes the idea that cartilage is an ideal tissue for transplantation, its mature hyaline cartilage with viable chondrocytes, and you get a bone healing versus chondral tissue regeneration. And we understand bone healing much better than we understand chondral tissue regeneration. This makes grafting a perfect treatment for osteochondral lesions in the talus. So when do I use allografts in the talus? Well, of course for osteochondral lesions as I mentioned. And these would typically be the large volume cystic lesions that are not amenable to surgery, such as microfracture or surface treatments. We also use allografts when we have to salvage smaller lesions that have had previous treatment that just did not work. Additionally, occasional cases of osteonecrosis of the talus and traumatic defects are appropriate for grafting. And it should point out that fresh talus allografts are relatively easy to obtain, at least in North America. I want to mention a little bit about terminology. Many people would call a talus allograft a bulk allograft. Now, sure, it's bulk tissue, but I really prefer the term small fragment or shell allograft. You can see in these pictures that these partial talus grafts can be any size, but generally are not too bulky. But they basically restore a quarter to half of a of a talus. Let's talk about surgical techniques now, because there are a number of approaches that can be used for grafting of the talus. Of course, the medial or lateral malleolar osteotomies or the anterior approach through direct anterior without osteotomy and the use of joint distraction or external fixation can be useful to distract the tibia from the talus for access. What's clear from the literature is the type of approach does not appear to affect clinical outcome, but I would say that one would question the morbidity of an osteotomy if it's not always necessary. My preference for surgical technique involves utilizing an anterior approach, which is low morbidity. External fixation. For access to the talus joint distraction, we remove anterior tibial osteophytes of their present, and we do an onlay partial talus graft rather than a plug. This involves a freehand technique. However, I will tell you that instrumentation to make this easier is on the horizon. We usually fix the graph with either absorbable screws or pins or small metallic screws, and we invoke about 6 to 12 weeks of non-weight bearing prior to letting patients load the ankle and start doing functional rehabilitation. These images depict what I just mentioned in visual form. This is a large cystic osteochondral lesion of the talus. And you can see we've extracted the lesion, used it as a template for measuring the graph which has been resected from a whole talus allograft. We fit the graft into the resected area and we might have to do a couple of modifications. The graft is placed and then fixed with a single or two screws. And you can see the reconstruction here on the last photo. We have a series now of about 40 to 50 patients that have undergone this procedure. The average age of these patients is 34 years and equally medial and lateral lesions. And these, as I said, are pretty large lesions. So they're not small volume lesions. With a ten year follow up, we have documented 81% ten year survivorship and almost 90% satisfaction with this procedure. 100% of patients that have this procedure, again, which reflects the debility some of these people have with these talus lesions, there is a not insignificant re-operation rate. And we've had three failures that have required either revision, grafting or arthrodesis. There's a lot of research that has been done by various authors in the foot and ankle community, and generally every one of them have felt that this has been a reliable and effective procedure, successful and with high patient satisfaction. This, summarized in this review article about 200 patients have been published and again similar results. Significant clinical improvement 86% graft survivorship in about a 21% re-operation rate. Not always for failure, but sometimes hardware removal or arthroscopy for symptoms. So in summary, a fresh talus allograft is a great option for challenging osteochondral lesions when all else fails, or if the lesion is big or missing bone. A fresh talus osteochondral allograft, I believe is the best choice. Thank you.

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Thomas G. Harris, MD, (Pasadena, CA) performs an allograft OATS® technique to treat a talar osteochondral lesion. Several technique pearls are provided related to performing the osteotomy and to ensure the allograft implant is well contoured to fit the surrounding cartilage following implantation.

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Fresh Allograft OATS® Technique for Osteochondral Lesion of the Talus

We've drawn out our surgical site here, which is pretty well centered in the medial malleolus anterior. You have the saphenous nerve traveling here. We've got the posterior tibial tendon hugging the posterior aspect of the tibia. And then the neurovascular bundle there. So it's pretty much between these inter nervous planes. A pretty safe approach overall. We've made the incision perhaps a little longer than normal just for the sake of this demonstration. But this would be the approach to the medial malleolar osteotomy. And it's a similar approach that you would do as if you were doing a medial malleolar auf, and we'd carry that down to the level of the periosteum, free up the periosteum from it as well. The patient normally would be sitting supine. In this case, maybe not as far medial as that supine, with maybe a bump on the contralateral hip to externally rotate the leg ever so slightly. And then we'll take a K-wires placement here and just see how our cuts look in here. We'll take a fluoro after this. And just make sure that we've gone lateral enough so we can see the lesion. You can pre-drill before you've made the cut with a two over five drill, just to make sure that you're lined up your medial malleolus screws for the later fixation of the osteotomy. So, you know, once you've made these holes and confirmed them on fluoroscopy, a nice little tip is to make a mark in it with the pen so that you can find it later. Sometimes it's harder to find than you'd imagine later on. Okay, so now we've pre-drilled for our osteotomy, and then we can kind of mark out the osteotomy here with the apex being up at the top here. So we'll just come up above here and then kind of do a semi chevron type cut. So a little bit of a bend to it just makes it a little bit inherently more stable when you have a V chevron with the apex based approximately. Once you've kind of freed up the periosteum, you can see you're very close to the posterior tib tendon right there. So you want to put your home in underneath that, just hugging the bone so that you're pretty safe from all the neurovascular structures there. So anteriorly you're pretty safe as well. I don't always use a home in there, but posteriorly I would always recommend it just to help with the the safety and not making sure you're going into that tendon when you're making this cut. And then the cuts are always made with thorough irrigation, making sure you're not engendering any thermal necrosis in the bone. And then the first cuts are made. And then we'll check with fluoro in terms of our overall alignment, and that we're cutting in the right trajectory. Here's the the lesion right there. And we were measuring it and deciding on it's kind of between a ten or a 12. So here's the sizing guides, which blue is ten and the red is 12. And for really kind of measure it really the ten seems to fit nicely kind of centered in through that area. The 12 is just a little bit too wide from the standpoint. I just worry about blowing out that medial wall of the talus there. And I think the ten would really the main issue with the defect there would really be nice with the ten. There is this little peripheral lesion posteriorly here, this little offshoot like this, which is sometimes what you'll get. And you could always fill that area with BioCartilage just to lay there on top of it. And so this is A24 wide pin placed as tangentially to the lesion as possible. So here we got the reamer in in place. And we want to come down to about 8 to 10in terms of our depth. And preserving that medial cortex their medial Taylor wall. So we're about to ten there. Okay. And then we'll clean out the the lesion itself. So all quadrants are measuring between 10 to 11. We want to measure and kind of guide off what we took the lesion from, which was the medial central portion here. So this is the part we're trying to replicate. It really was near the top of the dome of the talus two. So we really kind of want to be in this area per se right there. All right. So now we got this thing well secured. The fresh talus is where we want it. Then we go to a obtaining and acquiring the graft in this ten millimeter reamer. You'll see that there's a colored plug inside that just makes it a little easier to get your plug afterwards. And so that goes inside right here. So now we're ready to perform the reaming. We want to fill a defect that's between 10 and 11. But it's okay to over drill in this spot to go to 15 to 20, just so we have enough of a plug to place that can always be shortened. So here's our reaming that's going to begin. There's. Five. Normally we'd be doing it under thorough irrigation. Here's ten. Move down to 15. There you can still see the 20 is proud. So we'll come down to about 20. And then we'll come out with this. Somewhere between 15 and 20. We make a cut ten, 15. Somewhere like that. Here's our plug with the holder in place, which really holds it nicely. As our measurements we've already made there. And then here's the side view of that. And basically when we're measuring this plug from the very tip of the plug, it measures about 10 to 11 in through that area like that. If we measure from the bone measures about ten right in through this area. So really pretty good shape already. Another option here is to be cutting this to ten across the board. And then add a DBM to the base of this to even out any defects that may be present, rather than having to cut one side at ten and another side at 11. That can make the cut a little bit easier. And once you have the marks on either side one one nice tip is to kind of connect those marks to make your cut just a little bit easier here to go across that area. Now we have this held in place. And one one little tip is make sure that it's holding the cartilage side so that if when it does get cut, it doesn't go flying. So we want to make sure we hold on to the part that we want to keep. And then this guide itself can be helpful for a for a cutting guide and just place it right off the top of that. At this point, once you're happy with the the length of the plug, you would use a thorough irrigation or pulse lavage at this point to draw out some of the marrow elements of the allograft. Once we're happy with that and the irrigation has been completed, we'd put it in a small receptacle and then add the ACP. Another addition to the mixing can be a bone marrow concentrate, and that can be mixed with the ACP if so desired, before implantation of the plug. So we'll place DBM in the defect here at the base of the defect. Make sure it's going to the bottom with a free air or some sort of a smooth Curette can help fill in the base of that. And again, this is very soft. So it will compress with the. Once the plugs on top of it and just level out any defects that may be present. The tamping into place aspect of this is important in that you don't want to tamp it too hard and kill any of the the cells in place. And if you can tamp a little bit eccentrically, I think that would be helpful too. There we go. So we've got it in place now. And then maybe you can see it's still proud as to be expected. And then we would now gently. Gently impact into place and not too deep going. And it really seems like it's fitting in there pretty nicely. And finishes the defect really well. And so as you can see, there's still that little fragment posteriorly within that offshoot, which would be hard to fill and probably not worth putting in putting another plug right there. So you'd fill in any little surrounding defects with BioCartilage and through this at the same time to fill that in. Now this was just partial thickness. So it could be microfracture if you want to put a little pick there and then BioCartilage or just laying it in with BioCartilage. But the rest of it seems to be fitting really well moving moving smoothly through that area as well. So at the conclusion of this case, you can see that chevron type osteotomy fits in nicely there. What we usually do is place the two screws that we've already pre-drilled. And then a third tubular plate from the ankle fracture system would place two screws above the level of the osteotomy bicortical screws, three five screws here, and then one more up there. And then the plate would just contour itself in through this area here. And then we close the periosteum over that. And that provides good good fixation. So we can start early range of motion after these osteotomies.

Thomas G. Harris, MD, (Pasadena, CA) presents a case in which he treated an osteochondral lesion of the talus with a fresh allograft OATS® plug. Dr. Harris reviews the preoperative planning, intraoperative pearls including mixing with bone marrow concentrate from the Angel® system, as well as the fixation techniques of the osteotomy.

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Allograft OATS® Technique to Treat Osteochondral Lesion of the Talus

Hello, my name is Thomas Harris. I am a chief of foot and ankle at Harbor UCLA hospital out in Torrance, California, and the co-director of the Foot and Ankle Fellowship in Congress Orthopedics in Pasadena, California. I'd like to present a case to you that we recently did regarding a fresh talus transplantation using the OATS technique and technology we have here at Arthrex. This was a 33 year old female. She had previously had a arthroscopic microfracture about 13 months prior. She continued to have pain despite that prior microfracture, which was done completely arthroscopically on the MRI. The lesion measured ten by 19mm on MRI and was very cystic in nature. And you can see on that x ray there that you can see how that embodies the medial aspect of the talus of a pretty large lesion there. The MRI preoperatively was performed. And you can see the large cystic nature of that lesion, it does look like it's contained. However, our surgical plan for this case was to arthroscopically evaluate the lesion. We were going to use the Angel system and harvest bone marrow aspirate from the iliac crest. We also planned a medial malleolus osteotomy to gain access to the lesion. And we decided to use a chevron type of that and then proceed forward with an OATS technique using a fresh talus sagittal view. There you can see the large cystic nature of the lesion. And on the axial image to again the large nature of the lesion with surrounding edema as well as synovitis surrounding the entire joint there. But it's very significantly big lesion is the take home point from this case. So Intraoperatively we decided to size this somewhere between ten by ten and 15 by 15. The 15 by 15 seemed to take away too much bone when we got down to it. And the depth of this lesion was about 10 to 11mm as well. And there you can see a picture of the sizing guide for this lesion. So here's an image of the fresh talus. You can see that we took two plugs from this fresh talus. Because the first plug that we harvested seemed a little too shallow. We then soaked the appropriately sized plug in bone marrow concentrate solution for a period of time to let those cells interdigitate into the plug. We use the left talus in this case, even though the patient's lesion was on the right talus, because sometimes there's only one side available, which was the case here. So ideally you would match the side to the side of the lesion. However, sometimes that's just not plausible or possible with the constraints of getting fresh talus. The plug seemed to fit nicely with the similar slope to her native talus. I think that can be sometimes the hardest part of this case. It is important to to have some sort of system to match up your rotation, be it making clock marks on the graft to ensure the proper rotation when you're inserting it into place, so that the anterior part of the graft is going to match up with the anterior part of the defect, and that seems like it makes sense intuitively, but it's an important step to do. Just makes your life much easier. Intraoperatively. Here's an image, a photographic image of our graft in place. With these tamps of each graft, you have to be very cautious, and I would encourage you to tamp as less as possible, because that can cause some cellular damage to the cartilage as well. Here we have our final osteotomy construct. The medial malleolus osteotomy was fixed in this case with two solid screws. One was a partially threaded four screw and the other was a 3.5 cortical screw. We also used a medial third tubular plate applied in an anti glide type fashion. So there's a total of four screws and one plate in that x ray there. You can also see that the OATS plug seems to be fitting very nicely and is well contoured compared to the rest of the talus and doesn't seem to be sitting too proudly.

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Allograft OATS® Technique to Treat Osteochondral Lesion of the Talus

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Fresh Allograft OATS® Technique for Osteochondral Lesion of the Talus

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