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VPT1-00765-EN | A | BioUni® Osteochondral Allograft Transplant with iBalance® HTO

Jeffrey A. Macalena

Human

Surgeons presenting one or more clinical cases

Chirurg:innen präsentieren einen oder mehrere klinische Fälle

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BioUni® Osteochondral Allograft Transplant with iBalance® HTO

Hello, my name is Jeff Makalena. I'm an orthopedic surgeon at the University of Minnesota specializing in sports medicine. Case we're going to talk about today is that of a 36 year old female. She's had right knee pain for a number of years. She denied any specific inciting event and had no prior trauma or any previous surgeries. She was told by an outside surgeon that there was nothing to do about her knee pain, and that she would have to live with it. She was told that she was too young for an arthroplasty, and that she was going to have to just struggle to continue to get by. She was ultimately referred to my clinic. During our examination in my clinic, she showed medial joint line tenderness. She had a trace of fusion, but her knee range of motion was well maintained. Her ligaments were stable and she had an otherwise very benign appearing examination. Plain radiographs in my clinic showed maintained joint spaces on both the AP and the lateral radiograph, and an MRI was obtained. It showed no meniscus tears intact. Collateral and cruciate ligaments. Just a trace of bone marrow edema is noted on her medial femoral condyle, and subtle cartilage thinning is present. She was also found to have a large effusion, which was symptomatic. She went on to fail continued non-surgical management, including a course of physical therapy, anti-inflammatories and injection management, and ultimately I offered her an arthroscopic procedure at the time of her staging. Arthroscopy. We identified diffuse thinning of the medial femoral condyle cartilage. You can see on the arthroscopic images the cobblestoning on the medial femoral condyle and the diffuse thinning. Given the amount of thinning that the patient had, we felt that she'd be an excellent candidate for a BioUni to the medial femoral condyle. Standing alignment films demonstrated subtle varus malalignment of her lower extremity, with a subtle amount of joint space narrowing seen on these images here. Given this, we felt that she'd be an excellent candidate for an iBalance osteotomy to Osteotomy to unload the medial compartment. The iBalance osteotomy would be coupled with the BioUni for a bio plasty procedure. Our surgical technique was to first perform the BioUni. We do this through an open approach and a medial patellar arthrotomy. Here are open images. Demonstrate considerable wear of our medial femoral condyle that I think was subtly underappreciated at the time of arthroscopy. The BioUni jigs fit excellent and allowed excellent preparation of the recipient site. Here, preparation of our graft shows the healthy, viable cartilage from our fresh donor allograft. Implantation shows excellent fit and fill of the allograft. After completing the medial compartment BioUni, we closed our arthrotomy site and proceeded with the osteotomy. The osteotomy is done through an incision on the anteromedial tibia. One of the tips that I like to use is creation of a suture on the medial periosteum to allow retraction of the medial tissues and placement of our neurovascular guide. After applying the neurovascular guide and the cutting jig, the osteotomy is completed under radiographic control. Similarly, using the c-arm to confirm complete osteotomy to the hinge pin hole I think is useful. X-ray images here demonstrate that we've taken the osteotomy all the way to the hinge pin hole, to allow adequate flexing of the osteotomy site. When planning the surgical technique of a bioplastic procedure, including both intra articular cartilage work as well as an osteotomy, I recommend doing the intra articular cartilage work first. This allows hyperflexion of the knee, if needed, to get to a posterior base lesion without stressing the osteotomy site. After completion of the intra-articular work, you can then safely proceed with the osteotomy without concern for fracture along the tibia. One of the things that we can see on our radiographs is excellent union at the at the osteotomy site where the iBalance was completed. Further close inspection of the medial femoral condyle demonstrates good healing of our BioUni to the medial compartment and excellent contour of the subchondral bone. After progressing to Definitiv union at her osteotomy site, the patient has been able to return to all desired activities. I initially treated her with a course of limited weight bearing to protect both the osteotomy site as well as the allograft. We then allowed slow progressive motion at approximately the 4 to 6 week mark and began a full weight bearing process. By three months, the patient had reported an excellent improvement of her symptoms and was considerably improved from her pre-operative state. She was extremely happy with the progress that she has been made, and feels that we've given her a life back. I think that these options, including the osteotomy to unload the medial compartment as well as the BioUni, have been a great adjunct to allowing the treatment of this patient. Thank you for your attention.

BioUni® Osteochondral Allograft Transplant with iBalance® HTO

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