Advanced Hip Arthroscopymedia-ns.mghcpd.org.s3.amazonaws.com/sports2018/2018_injured_… · ~4 cc PRP + ~16 cc PPP aseptically drawn into a syringe. EVALUATION & TREATMENT OF THE

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

Advanced Hip ArthroscopyS C OT T D . M A R T I N , M D

D I R E C T O R , J O I N T P R E S E R V A T I O N

D I R E C T O R , M G H S P O R T S M E D I C I N E F E L L O W S H I P

A S S O C I A T E P R O F E S S O R O F O R T H O P A E D I C S


Disclosures “Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest

to disclose.”


FDA APPROVALFDA Approval 361

◦ Homologous tissue

◦ Includes bone marrow

◦ Minimal manipulation – cannot take outside the OR◦ Cannot expand cells


FAI & OSTEOARTHRITIS

FAI (2003, Ganz, et. al, CORR 2003)

Abnormal contact creates a labral tear◦ Pincer

◦ Cam

Articular cartilage defects

Narrowing of joint space

Degenerative Tear

Osteoarthritis


FAI: CAM IMPINGEMENT

◦ More common in males

CAM lesion

Nicole Wolf ©2018

Nicole Wolf ©2018


FAI: CAM IMPINGEMENTCauses chondrolabral damage & delamination

Type 1 Tear Wave Sign


FAI: PINCER IMPINGEMENTPincer

◦ More common in females

◦ Acetabular rim over-coverage

◦ Global acetabular over-coverage

Pincer lesion

Nicole Wolf ©2018

Nicole Wolf ©2018


FAI: PINCER IMPINGEMENTDamage usually confined

◦ labral tears

◦ Minimal chondral damage

Type II Tear

Posterior

Anterior


PRESERVING THE CHONDROLABRAL JUNCTION

Chondrolabraljunction

Nicole Wolf ©2018


CAM DECOMPRESSION


ACETABULOPLASTY


ANCHOR PLACEMENT


VERTICAL MATTRESS


LABRAL PRESERVATION


Shearing of

articular cartilage



CHONDRAL FLAPSViable Cells found in chondral flaps

◦ S Hariri et al. Biochemical and Cellular Assessment of Acetabular Chondral Flaps Identified During Hip Arthroscopy. Arthroscopy 31 (6), 1077-1083. 2015 Mar 05.



OSTEOARTHRITIS & THRArticular cartilage has limited healing capacity

Standard surgical intervention for end stage pathology

• McCormick, FM, MD, Nwachukwu, BU, Alpaugh, K, Martin, SD, MD. Predictors of Hip Arthroscopy Outcomes for Labral Tears at Minimum 2-year Follow-up: The Influence of Age and Arthritis. Arthroscopy, 2012.


PRESERVING THE NATIVE JOINTEarly Detection?

Get it right the first time

Preservation of the Chondrolabral Junction

Avoidance activities

Biologics


HISTOLOGY: CHONDROLABRAL JUNCTION

Majority of tissue is Type 1 Collagen

Elastic property likely due to relaxed/crimped collagen ratio◦ No elastin or laminin found in labrum

◦ Potentially lost with age

Fibrocartilage found in weight bearing area only

Increased substance P found close to labrum◦ Suggests mechanical stress area


HISTOLOGY: CHONDROLABRAL JUNCTION

(1) Cross section of the caprine acetabulum

(2a) Safranin-O stained chondrolabral junction at the anteroinferior zone and (2b) posterosuperior zone of the acetabulum demonstrating deep and shallow physiological cleft (black arrow), respectively

(3a) Substance-p expression (green; blue, DAPI-stained nuclei) seen in chondrocytes closer to and (3b) away from chondrolabral junction.

1

3a

2a 2b

3b


METABOLIC MARKERS

Articular cartilage damage of OA and FAI differ◦ Inflammatory cytokines greater in articular cartilage of FAI patients

◦ Earlier dx

◦ Preventitive measures?◦ Chinez, N., et al: Inflammation and Degeneration in Cartilage Samples from Patients with FAI. JBJS 2016


METABOLIC MARKERSDamaged Tissue (arrow) secretes cytokines

Cytokines1. regulatory proteinases that act as mediators to generate an immune

response attract donor stem cells

Donor Stem cells1. secrete proteins to stimulate stem cells

2. reduce inflammation

3. increase vascularity and blood flow


PARACRINE EFFECTParacrine Effect - inhibit and protect injured cells against death

a. Cells stimulate endogenous cells to repair tissue1. Donor cells emit factors that signal endogenous cells

2. Triggers patient's own cells to repair tissue

MSC - Mesenchymal stem cellsa. Bone Marrow

b. Adipose tissue

c. Umbilical cord

Stem Cellsa. Can directly replace diseased cells

b. Differentiate into required cell type◦ (Bone Marrow Transplant)


CARTILAGE REPAIRCurrent repair techniques span 20 yrs

Most done in knee

May not be applicable to the hip

Distinct differences◦ Constraint of joint

◦ Shear forces

◦ Morbidity


CELL-BASED THERAPIESIntroduce grafts to bridge defects

◦ mature cartilage

◦ undifferentiated stem cells

Autologous Chonrocyte Implantation (ACI)

Osteochondral Autograft Trasfer (OAT)

Microfracture

Bone Marrow Aspirate Concentrate (BMAC)


KNEE VS HIP: CARTILAGE MANAGEMENT CHALLENGES

ACI

OATS

Isolated Microfracture

AMIC

MACI

DeNovo Tissue Grafting

Mesenchymal Stem Cells (BMAC)

ACI

OATS

Isolated Microfracture

AMIC

MACI

DeNovo Tissue Grafting

Mesenchymal Stem Cells (BMAC)

Technical Arthroscopic Limitations

Unreliable outcomes

• Chahla J, Laprade RF, Mardones R, et al. Biological Therapies for Cartilage Lesions in the Hip: A New Horizon. Orthopedics. 2016;39(4):e715-23.• Kraeutler MJ, Chahla J, Laprade RF, Pascual-garrido C. Biologic Options for Articular Cartilage Wear (Platelet-Rich Plasma, Stem Cells, Bone Marrow Aspirate Concentrate). Clin Sports Med. 2017;36(3):457-468.• Goyal D, Keyhani S, Lee EH, Hui JH. Evidence-based status of microfracture technique: a systematic review of level I and II studies. Arthroscopy. 2013;29(9):1579-88.

Nicole Wolf ©2018Nicole Wolf ©2018


HIP BIOMECHANICS & CARTILAGE MANAGEMENT

Increased shear force◦ near peripheral aspect of femoral head and acetabulum

Pericapsular muscle weakness ◦ increases stressors & shear forces upon articular cartilage

Dysfunctional joint kinematics and force coupling around the joint◦ lead to accelerated cartilage degeneration

◦ (i.e. increased forces on damaged cartilage yields further damage)

Snowball Effect◦ Cartilage damage & dysfunctional kinematics

• Correa TA, Crossley KM, Kim HJ, Pandy MG. Contributions of individual muscles to hip joint contact force in normal walking. J Biomech. 2010;43(8):1618-22.• Paul JP. Biomechanics. The biomechanics of the hip-joint and its clinical relevance. Proceedings of the Royal Society of Medicine. 1966;59(10):943-948.• Ecker TM, Tannast M, Puls M, Siebenrock KA, Murphy SB. Pathomorphologic alterations predict presence or absence of hip osteoarthrosis. Clin Orthop Relat Res. 2007;465:46-52.• Adler KL, Cook PC, Yen YM, Giordano BD. Current Concepts in Hip Preservation Surgery: Part I. Sports Health. 2015;7(6):518-26.


MESENCHYMAL STEM CELLS

Microfracture◦ Disrupts subcortical bone

◦ Mesenchymal stem cells within blood clot along chondral defects

◦ Effective in small patient populations in the knee

◦ Limitations ◦ Could accelerate cartilage degeneration

◦ Bone cyst formation

◦ Quicker progression to THR?

Nicole Wolf ©2018


MESENCHYMAL STEM CELLSBMAC

◦ Augment healing of chondral defects

◦ Single procedure

◦ No additional donor-site morbidity

◦ No disruption of subchondral bone

Previous early treatments mitigated symptoms◦ not the disease process


BMACCan differentiate into BOTH

◦ Fibrocartilage

◦ hyaline cartilage

Important for chondrolabral junction healing

Samples analyzed from 10 patients (Ilium) showed◦ CFUs visible within 24 hrs

◦ Number & activity highest seen in lab

Nicole Wolf ©2018

Nicole Wolf ©2018


Postero-superior zone

LAB

LB

LAC

LC

Zone 4

Zone 3

Zone 1

Zone 2


Antero-inferior zone








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SURGICAL TECHNIQUEEarly in Operation

◦ 51 cc venous whole blood drawn from median cubital vein

◦ Anticoagulant added

60 cc injected into processing centrifuge◦ Separation of:

◦ RBCs

◦ PRP

◦ PPP

~4 cc PRP + ~16 cc PPP aseptically drawn into a syringe


SURGICAL TECHNIQUELabral Repair with ChondrolabralPreservation


CENTRAL ANTERIOR PORTAL


ILIUM ASPIRATE

Nicole Wolf ©2018


ILIUM ASPIRATE


BONE MARROW ASPIRATION~20-25 cc into 3 separate 60 mL syringes

◦ Total: 60-75 cc bone marrow aspirate


BONE MARROW PROCESSINGInjected into centrifuge

Concurrent with final stages of surgery◦ No increased traction time

3 cc BMAC combined with 20 cc PRP/PPP

Thrombin added 3-5 mins prior to application◦ Formation of “Megaclot”


MEGACLOT APPLICATION






MEGACLOT VISUALIZATION

Documents

Advanced Hip Arthroscopymedia-ns.mghcpd.org.s3.amazonaws.com/sports2018/2018_injured_… · ~4 cc PRP + ~16 cc PPP aseptically drawn into a syringe. EVALUATION & TREATMENT OF THE