Pearls
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First, before the skin incision, perform a diagnostic arthroscopy to check the extent of the chondral or osteochondral injury, locate and retrieve the loose fragment/s (if possible).
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Reshape and regularize the fragment so it can fit properly in the defect, taking into account that it typically increases its size in the synovial fluid environment in chronic scenarios.
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Debride the subchondral bone bed defect to remove unstable or necrotic tissue and to have a bleeding bone bed environment to favor healing.
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Before drilling, plan your repair, in terms of number and position of knotless anchors to have a reliable and equidistant stable construct repair.
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When drilling, ask the assistant to grab the spear with a perpendicular orientation to the defect surface in order to correctly position the anchors in the edges of the defect; the sutures will exit vertically between the fragment and the remaining healthy cartilage.
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Interconnect the repair sutures of each anchor with opposite anchors so that effective loops are created over the fragment/s.
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When tightening the sutures, ensure sound reduction and adequate compression.
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At the end of the procedure and before closing, cycle the knee to check the stability and the fixation quality of the osteochondral fracture repair.
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Pitfalls
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Avoid malposition and size mismatching of the fragment in the defect by evaluating and sizing both with a ruler.
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Be cautious about not damaging the cartilage fragment and drill before placing the fragment into the defect.
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Avoid suture trapping and tangling by creating large loops separated from each other before placing the fragment into the defect.
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Avoid fragment movement by applying finger pressure to the fragment when sliding the sutures for tightening.
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Avoid leaving suturing material into the joint by cutting the pulling ends of the sutures with a blade at the edges, without damaging the cartilage.
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In cases of comminuted or irregular non-contained fragments, provisional fixation with K-wires could be used to facilitate the procedure and allow the crossing sutures knotless fixation.
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