Osteochondral Allograft Transplantation of the Medial Femoral Condyle With Orthobiologic Augmentation and Graft-Recipient Microfracture Preparation  James Gwosdz, M.D., Alexander Rosinski, M.S., Moyukh Chakrabarti, M.B.B.S., Brittany M. Woodall, D.O., Nicholas Elena, M.D., Patrick J. McGahan, M.D., James L. Chen, M.D., M.P.H.  Arthroscopy Techniques  Volume 8, Issue 3, Pages e321-e329 (March 2019) DOI: 10.1016/j.eats.2018.11.008 Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 1 An osteochondritis dissecans (OCD) lesion of the right medial femoral condyle is seen on magnetic resonance imaging in the coronal and sagittal views. The lesion measures 1.8 cm mediolaterally by 0.8 cm superoinferiorly by 2.3 cm anteroposteriorly. Chondral thinning of the medial femoral condyle is seen posteriorly. The menisci, cruciate ligaments, collateral ligaments, and quadriceps and patellar tendons are intact. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 2 Arthroscopic view from the anterolateral portal showing the osteochondritis dissecans lesion on the surface of the right medial femoral condyle. A diagnostic arthroscopy is first performed to confirm the need for osteochondral transplantation before proceeding with a more invasive arthrotomy. The medial and lateral gutters are free of loose bodies and synovitis. The medial and femoral condyles and tibial plateau do not have any other cartilage defects. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 3 (A) Arthroscopic view from the anterolateral portal showing the guide pin drilled orthogonally at the femoral notch from the anteromedial portal. (B) Intraoperative photograph of the guide pin drilled arthroscopically from inferior to superior into the right knee femoral notch for bone marrow harvesting. The drill and guide pin are seen in the anteromedial portal, whereas the arthroscope is seen in the anterolateral portal. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 4 (A) Arthroscopic view from the anterolateral portal showing an 11-gauge bone marrow aspiration (Jamshidi) needle in the femoral notch of the right knee. The needle is tapped with a mallet until the bold line lies flush with the cortex. (B) Intraoperative photograph of the 11-gauge bone marrow aspiration (Jamshidi) needle placed through the anteromedial portal into a predrilled hole in the right knee. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 5 Intraoperative photograph of bone marrow suctioning through the anteromedial portal of the right knee with an 11-gauge bone marrow aspiration (Jamshidi) needle and a 30-mL syringe. Once the Jamshidi needle is tapped into place, its trocar stylet is removed and the syringe is connected. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 6 (A) Two 30-mL syringes containing a total of 60 mL of bone marrow aspirate collected from the right knee. (B) The harvested aspirate is centrifuged using the Arthrex Angel System while the rest of the procedure is continued. A total of 4 mL of platelet-rich plasma is produced from 60 mL of bone marrow aspirate. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 7 Intraoperative photograph of a right knee with a guide pin drilled through an Arthrex Cannulated OATS Sizer. Once the medial femoral condyle has been accessed with a medial parapatellar approach, an appropriately sized sizer is selected so that it covers the entire osteochondritis dissecans lesion. It is then positioned orthogonally on the articular surface, and a guide pin is drilled through the center. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 8 Intraoperative photograph of a right knee with a T-handle Recipient Harvester placed over a guide pin. The osteochondritis dissecans lesion is scored by rotating the T-handle clockwise and counterclockwise several times. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 9 Intraoperative photograph of a right knee showing a triple reamer being used to core out the osteochondritis dissecans lesion on the medial femoral condyle to a depth of approximately 10 mm. After coring out the lesion, the depth of the socket is measured precisely at the 12-, 3-, 6-, and 9-o’clock positions. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 10 Intraoperative photograph of the PowerPick used to microfracture the cored-out recipient site on the medial femoral condyle of the right knee. We use a PowerPick that produces holes measuring 1.5 mm in diameter and 4 mm deep (different sizes are available). A total of 7 holes are placed approximately 3 mm apart at the recipient site. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 11 Intraoperative photograph of a fresh right medial femoral condyle donor allograft secured to the Arthrex OATS Workstation. An Arthrex Cannulated OATS Sizer is positioned over the corresponding site on the allograft so that the donor plug will match the contour of the recipient's native articular surface. The sizer lies perpendicular to the allograft surface, and its borders are marked with a pen. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 12 Intraoperative photograph of the coring reamer used to harvest the right medial femoral condyle allograft plug. A donor harvesting reamer is placed through the Arthrex OATS bushing at the previously marked allograft donor site. The allograft is irrigated with normal saline solution using a bulb syringe. After reaming, the 12-o’clock position is marked on the allograft plug. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 13 (A) Intraoperative photograph of the harvested right medial femoral condyle allograft plug held with Arthrex graft-holding forceps while an oscillating saw is used to size the plug height so that it will lie flush with the recipient articular surface. (B) The plug is shaved until the height approximately measures the depth of the recipient socket at the 12-, 3-, 6-, and 9-o’clock positions. The plug is held in the forceps such that the articular side of the graft lies within the clamp and the cutting surface is level to the 12-, 3-, 6-, and 9-o’clock markings. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 14 (A) Intraoperative photograph of the PowerPick used to microfracture the harvested right medial femoral condyle donor allograft plug. (B) The donor plug is then soaked in the platelet-rich plasma prepared previously using the Arthrex Angel System. (BMC, bone marrow concentrate.) Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 15 Intraoperative photograph of a right knee showing an OATS Sizer and mallet used to tamp the donor allograft plug into the recipient socket in the medial femoral condyle. Half of the sizer is placed over the plug, whereas the other half lies over the recipient femoral condylar surface. Tapping the sizer with a mallet in this orientation prevents the plug from advancing unevenly into the recipient socket. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions

Fig 16 Intraoperative photograph of the donor allograft plug implanted flush with the articular surface of the right medial femoral condyle. A completed osteochondral allograft transplantation is shown. Arthroscopy Techniques 2019 8, e321-e329DOI: (10.1016/j.eats.2018.11.008) Copyright © 2019 Arthroscopy Association of North America Terms and Conditions