This instructional video, created by a team of Baptist Health orthopedic surgeons, illustrates the arthroscopic treatment of osteochondral lesions of the talus (OCLT) using particulated juvenile allograft cartilage.
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Hello everyone today I will be discussing our long term outcomes following an all arthroscopic technique for implantation of particularly juvenile telegraph. For difficult Austria contra lesions of the taylors. We have no relevant financial disclosures. No commercial support was received for this study and all reference devices and biologics used within this technique are approved by the FDA for the described purpose. Austria convolutions of the taylors are most commonly seen with traumatic ankle injuries, including ankle sprains and fractures. Patients may present with pain, swelling or mechanical symptoms like clicking and catching with ankle range of motion. In particular distal fibula fractures, complete deltoid ligament ruptures and chronic lateral ligament instability have the highest concomitant association with taylor legions, repetitive micro trauma degenerative joint arthropod the and metabolic dis arrangements also contribute to osteonecrosis and are all secondary ideologies of Austria, con religion of the taylors. These articular cartilage injuries can have a significant impact on patients occupation as well as the activities of daily living, which can lead to chronic pain and disability. Initially, patients can undergo a trial of non operative management with bracing, physical therapy and injections if patients continue to have pain or mechanical symptoms, then operative intervention is warranted. The lack of vascular city limits the ability for repair and articular cartilage cartilage also lacks undifferentiated cells that can migrate proliferate and participate in the repair response. Therefore initial operative management typically consists of arthroscopic removal of loose bodies and bone marrow stimulation techniques such as debridement microfracture abrasion, contra policy curettage and integrate or retrograde drilling. This leads to the formation of fiber cartilage with predominantly Type one collagen, which has demonstrated overall positive results, particularly for small lesions. However, the longevity is ultimately unpredictable compared to normal highland cartilage, larger allusions or those with underlying sub Condra bone involvement usually require either osteo condo holograph or autologous contraception implantation. Oates has been accepted as the primary method of treatment for these more difficult defects. However, complications such as pain at the donor site or healing of the aussie economy can occur. Therefore, we propose an alternative intervention for these large Astrakhan relations. We utilize an all arthroscopic technique to address these lesions. The lesion is adequately do greeted and prepared for placement of particularly juvenile articular cartilage. This articular cartilage telegraphed is obtained from young donors less than 13 years of age and so has two orders of magnitude higher levels of type two collagen when compared to adult cartilage. The graft is prepackaged and consists of viable contra sites, highland cartilage and more extra cellular matrix proteins. Standard disease screening is performed on each FDA approved donor tissue a lot and the cartilage is mechanically particulate id without chemicals or preservatives. Each package contains sufficient quantity of graft to treat a 2.5 square centimeter defect for cystic lesions. Additional Calcagno autographs can be used as well. This all arthroscopic technique restores the lesion with articular cartilage vs. Fiber cartilage and also avoids the risk of molecular gastronomy and donor site pain. A laboratory study from 2011 in the American Journal of Sports Medicine, noted the activity of juvenile and adult conversation. Juvenile contest sites have an increased reparative ability and production of extra cellular matrix. The addition of juvenile contradicts the adult suspension enhances the ability of the adult cells to produce type two collagen. Overall the cartilage fragments have been shown to be a valid source of cells, allowing for coverage of large cartilage defects without requiring the pre cultivation of cells. Our indications for this all arthroscopic technique can be expanded to patients with difficult to treat osteo Condra lesions. This includes patients with large lesions over 107 square millimeters shoulder lesions, failure of previous microfracture surgery, age over 40 or B. M. I. Over 25. These prior factors are usually risk for worsening progression of lesion or pretend a poor prognosis for surgical intervention. So this technique can provide an alternative method to treat these patients. Our goal is to restore highland cartilage by performing this surgery. It is important to obtain appropriate imaging to determine the size, location and shape of the lesion. Here we present a patient case of a 17 year old active female. She's been having left ankle pain for over two years now and has sustained multiple ankle sprains in the past. On examination, she has tender to palpitation along the medial ankle joint. Her preoperative M. R. I. Shows a large cystic osteo Condra lesion of the central post retailers along the medial shoulder. She has failed conservative treatment, including injections therapy and bracing at this time we discussed surgical intervention in the form of our all arthroscopic technique, she elects to proceed. The patient is initially seen in the preoperative holding area and we once again go over the risks, benefits and alternatives to surgical intervention. One surgical consent is verified. The correct extremities signed patients at this time may receive a regional block from the anesthesia service if available. Once completed, the patient is then transported to the operating room. In the operating room, the patient is positioned supine after induction of general anesthesia. A thigh high tourniquet is applied and the ink was placed in a noninvasive ankle distracter. The lower extremities then prepped and draped in the standard sterile fashion. Surgeons are gowned and gloved and universal percussions are maintained. Once prepped and draped, a time out is performed to verify the identity of the patient as well as confirmed the procedure. Peri operative antibiotics and ensure there are no intra operative concerns small joint arthroscopy equipment utilizing a 2.7 millimeter camera is set up and ensured that it is properly functioning. White balanced and the pump is set at 30 to 35 millimeters of mercury. The extremities then elevated and exsanguination with the nash mark bandage and the tourniquet is inflated to 275 millimeters of mercury to perform ankle arthroscopy. We utilize the standard Antero medial and anterior lateral portals. We palpate immediately to the course of the tibial is anti-re attendant at the level of the joint and then insulate the joint with 5-10 mm of normal saline. The skin is then in size with an 11 blade medial to the tibial is anti attendant and away from the course of the superficial peroneal nerve for the anterior lateral portal. The incisions are then deepened bluntly with a small hemostat and then the tracker and operator are inserted into the anterior medial portal. The water is connected and the camera is then inserted. The procedure then begins with the diagnostic ankle arthroscopy using a 2.7 millimeter scope at 30 to 35 millimeters mercury water pressure. After diagnostic arthroscopy is complete and the defect is localized. We began arthroscopic debridement of the lesion. The location and size of the defect is noted and any concomitant pathologies are addressed in order to maximize visibility and accessibility. The ink was ranged, attraction is increased import replacement may be reevaluated and repositioned accordingly, lesion size is measured and then debridement of the lesion begins. The lesion is probed to remove the unhealthy Condra flat and if there is a cystic lesion. This is also degraded. Once the sub Condra bone is visualized, arthroscopic ring Tourette's are used to breed down a healthy vascular bone. A microfracture pick is introduced to incite some channels for bleeding and growth factors to lesions for healing due to the size of the cavity. We also plan on harvesting Falconio autographed with the leg maintained in the ankle distracter. A one centimeter incision is carefully made over the lateral Calacanis and dissection is done to avoid injuring the central nerve or perennial attendance once directly on bone. A cortical window is made and then cancels bone graft is harvested with a Keret. Alternatively, there are many other commercial products which can be used to harvest graft as well once enough graft has been harvested, then the void can be filled with gel foam and thrombin and the incision closed with nylon suture. After the bone graft is harvested, the water is stopped and the lesion is completely dried. Visualization initially may be difficult. The suction can be used while keeping a raised deck or sterile cotton swab in the cavity to keep the view intact and dry. To complete filling of the defect, A layer based repair is completed to fill the cavity, the bone graft and articulated juvenile articular cartilage are loaded, retrograde into separate ankle arthroscopic cannula. On the back table to assist for delivery here is a diagram of the overall repair. Once the lesion appears dried, vibrant blue is placed into the base of the lesion. Subsequently the bone graft and the particular juvenile articular cartilage is loaded into the lesion. The freer is then used to see the graph flush compared to the surrounding articular cartilage, then a final layer of fabric glue is delivered and allowed to dry. This is an arthroscopic image of the lesion. After the fiber glue has dried here, the bone graft is placed in the lesion, aiming to fill the defect to the level below the surrounding articular cartilage by using the arthroscopic cannula Stroker to carefully push the graft into the defect. After the bone graft has been placed into the defect, A freer elevator is then used to help impact the graft and seat the particles flush with the surrounding sub control bone. Once that has been completed, a layer of fiber and glue is then delivered over the graft before proceeding to the telegraph cartilage. Okay, the particularly juvenile articular cartilage is loaded retrograde into an ankle arthroscopic cannula. On the back table. The graft is provided as articulated pieces, each measuring approximately one cubic millimeter suspended in the preservation solution. Each package includes enough to cover a defect, measuring about 250 m mm. Multiple packages may need to be used for larger lesions. After delivering the bone graft and the layer of fire, one glue, the telegraph cartilage is in place in the lesion, aiming to fill the defect to the level of the surrounding articular cartilage by using the arthroscopic cannula to carefully push the autographed into the defect. Next, a freer elevator is then used to impact the graph to see the particles flush with the surrounding native articular cartilage, The final layer of fabric glue is then delivered over the draft with five minutes given to drop the portals of closing a standard fashion post operatively. The patient is initially placed in a short leg splint for two weeks and kept non weight bearing for a total of four weeks. Patients then transition to removable cam boot at two weeks and it started on active and passive range of motion exercises. Progressing the weight bearing is tolerated between 4 to 8 weeks. At eight weeks, the patient is allowed to begin strength exercises and light activity Weaning off the boot as tolerated. Return to sport or more strenuous activity is allowed as tolerated after 4-6 months. Regarding our patient example, here's a 17 year old active female who presented with the left media tailor Austria convolution of the taylors. She underwent the all arthroscopic technique utilizing bone graft and particularly juvenile articular cartilage. After failing non operative treatment, Her post operative Maria two years has showed great integration of the graphs and her symptoms have significantly subsided as well. Prior to our prospective analysis, previous studies have been completed analyzing results of treatment of osteo con religions of the taylors with particularly juvenile articular cartilage. These two studies, from foot and ankle. International in particular analyze short to mid term outcomes of the procedure. The first study is a case series analyzing a cohort of 24 ankles to collect outcomes of pain function and activity levels. The analysis involves six surgeons at five different centers and all patients had at least one year of follow up. The average follow up was about 16 months And patients on average for 35 years old with lesion sizes of 125 sq mm. Unfortunately, data was collected retrospectively. So there was limited data on preoperative outcome scores in their cohort. They showed that 92% of patients with moderate sized lesions between 10 and 15 millimeter lengths had a ofA scores demonstrating good to excellent scores, While only 50% 6% of those with larger lesions did well. Additionally, one patient had partial graph delamination and six of the patients require further surgery to remove the symptomatic hardware or correct anterior impingement. Overall, the study showed that there is promise in the use of particularly juvenile articular cartilage and moderate sized lesions. However, further follow up is needed. The second study is a retrospective case series which sought to evaluate clinical and functional outcomes and 15 ankles triggered by two surgeons at a single center. All of these patients had at least one year of follow and the goal was to identify any patient or lesion attributes that could be influencing the outcome. The average follow up was about 34-35 months. An average age of the patient was about 32 years. The mean size of the legion was about 143 sq mm and a retrospective analysis shows that 60% of these patients did well, while 20% required further surgery and the other 20% did not have further improvement in terms of lesion attributes. Preoperative lesion size on MRI or inter operative size tended to portend a worser outcome. However, age be my ideology and location of lesion did not impact outcomes. The clinical successes tend to have better functional outcomes scores and were able to return to impact activities when compared to the clinical failures. Overall, this study also helps show the promising utility of particularly juvenile articular cartilage. However, the lesion size can decrease the rate of success. The role of particulate in juvenile telegraphed articular cartilage implantation is not well elucidated in reference to long term patient outcomes. We therefore performed a single surgeon analysis to determine the long term quality of life outcomes of patients treated with articulated juvenile telegraph cartilage implantation for difficult to treat. Social contributions, details 13 patients of which six had additional bone grafting were evaluated prospectively at six weeks, 12 weeks, six months and additionally long term at two years, four years and eight years patient reported outcomes including visual analog, score, foot and equal ability measures A. F. A. S. Scores. SF 36 physical and mental component scores were completed. The study population consisted of 13 patients of which six required additional bone grafting. Average follow up was about 97.8 months. A touch above eight years. There were eight males in the population and the average age at the time of surgery was around 46, 10 of the patients reported previous traumatic injury to their ankles and the main lesion size was about 151 sq mm. Four of the patients had previous surgery consisting mainly of arthroscopy and micro fracture, but continued to have persistent symptoms Across the board. Patient reported outcome measures improved significantly from pre operatively to their most recent follow. 11 of the 13 patients reached the minimum clinically important difference by their final follow up Between postoperative evaluation dates. There was no significant difference in patient centered survey scores using the numbers available, except for SF 36 physical and mental component scores from the two year to the four and eight year follow ups, which showed improvement. There were no intra operative or peri operative complications observed. One patient did show postoperative complications with persistent pain within the first year, requiring second look arthroscopy with debridement. Upon examination, the patient was noted to have partial delamination on the graph as shown here, large taylor usher con relations remain a challenging clinical entity to treat successfully, as is evident by the multitude of modalities used to manage this pathology, although many surgical management options exist are small cohort Studies showed the use of arthroscopic assisted implantation or particularly juvenile articular cartilage to tailor osteo Condra lesions as an effective single procedure treatment modality for the treatment of difficult to treat lesions, primarily moderate sized lesions or patients who feel microfracture. These results demonstrate clinically positive long term outcomes for a cohort of patients followed over the coast course of 6-8 years, as assessed by patient reported survey outcomes. It is a safe and reliable treatment option for patients with taylor astrakhan relations and should be a part of the Orthopedics Armamentarium. Thank you.
