Advanced Hip Arthroscopy

Transcription

1 Advanced Hip Arthroscopy S 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

2 Disclosures Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose.

3 FDA APPROVAL FDA Approval 361 Homologous tissue Includes bone marrow Minimal manipulation cannot take outside the OR Cannot expand cells

4 FAI & OSTEOARTHRITIS FAI (2003, Ganz, et. al, CORR 2003) Abnormal contact creates a labral tear Pincer Cam Degenerative Tear Articular cartilage defects Narrowing of joint space Osteoarthritis

5 FAI: CAM IMPINGEMENT More common in males CAM lesion Nicole Wolf 2018 Nicole Wolf 2018

6 FAI: CAM IMPINGEMENT Causes chondrolabral damage & delamination Type 1 Tear Wave Sign

7 FAI: PINCER IMPINGEMENT Pincer More common in females Acetabular rim over-coverage Global acetabular over-coverage Pincer lesion Nicole Wolf 2018 Nicole Wolf 2018

8 FAI: PINCER IMPINGEMENT Damage usually confined labral tears Minimal chondral damage Anterior Posterior Type II Tear

9 PRESERVING THE CHONDROLABRAL JUNCTION Chondrolabral junction Nicole Wolf 2018

10 CAM DECOMPRESSION

11 ACETABULOPLASTY

12 ANCHOR PLACEMENT

13 VERTICAL MATTRESS

14 LABRAL PRESERVATION

15 Shearing of articular cartilage

16

17 CHONDRAL FLAPS Viable Cells found in chondral flaps S Hariri et al. Biochemical and Cellular Assessment of Acetabular Chondral Flaps Identified During Hip Arthroscopy. Arthroscopy 31 (6), Mar 05.

18

19 OSTEOARTHRITIS & THR Articular 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.

20 PRESERVING THE NATIVE JOINT Early Detection? Get it right the first time Preservation of the Chondrolabral Junction Avoidance activities Biologics

21 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

22 HISTOLOGY: CHONDROLABRAL JUNCTION 1 2a 2b 3a 3b (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.

23 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

24 METABOLIC MARKERS Damaged Tissue (arrow) secretes cytokines Cytokines 1. regulatory proteinases that act as mediators to generate an immune response attract donor stem cells Donor Stem cells 1. secrete proteins to stimulate stem cells 2. reduce inflammation 3. increase vascularity and blood flow

25 PARACRINE EFFECT Paracrine Effect - inhibit and protect injured cells against death a. Cells stimulate endogenous cells to repair tissue 1. Donor cells emit factors that signal endogenous cells 2. Triggers patient's own cells to repair tissue MSC - Mesenchymal stem cells a. Bone Marrow b. Adipose tissue c. Umbilical cord Stem Cells a. Can directly replace diseased cells b. Differentiate into required cell type (Bone Marrow Transplant)

26 CARTILAGE REPAIR Current repair techniques span 20 yrs Most done in knee May not be applicable to the hip Distinct differences Constraint of joint Shear forces Morbidity

27 CELL-BASED THERAPIES Introduce grafts to bridge defects mature cartilage undifferentiated stem cells Autologous Chonrocyte Implantation (ACI) Osteochondral Autograft Trasfer (OAT) Microfracture Bone Marrow Aspirate Concentrate (BMAC)

28 KNEE VS HIP: CARTILAGE MANAGEMENT CHALLENGES ACI OATS ACI OATS Technical Arthroscopic Limitations Isolated Microfracture Isolated Microfracture Unreliable outcomes Nicole Wolf 2018 AMIC MACI DeNovo Tissue Grafting Mesenchymal Stem Cells (BMAC) Nicole Wolf 2018 AMIC MACI DeNovo Tissue Grafting Mesenchymal Stem Cells (BMAC) Chahla J, Laprade RF, Mardones R, et al. Biological Therapies for Cartilage Lesions in the Hip: A New Horizon. Orthopedics. 2016;39(4):e 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): 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):

29 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): Paul JP. Biomechanics. The biomechanics of the hip-joint and its clinical relevance. Proceedings of the Royal Society of Medicine. 1966;59(10): 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: Adler KL, Cook PC, Yen YM, Giordano BD. Current Concepts in Hip Preservation Surgery: Part I. Sports Health. 2015;7(6):

30 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

31 MESENCHYMAL STEM CELLS BMAC 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

32 BMAC Can differentiate into BOTH Fibrocartilage hyaline cartilage Nicole Wolf 2018 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

33 Postero-superior zone LAB LAC LB LC Zone 1 Zone 4 Zone 2 Zone 3

34 Antero-inferior zone

35

36

37

38

39

40

41 % of cells expressing Sub-P Zone 1 Zone 2 Zone 3 Zone 4

42 Average fluorescence intensity per cell (A.U) Zone 1 Zone 2 Zone 3 Zone 4

43

44

45

46

47 SURGICAL TECHNIQUE Early 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

48 SURGICAL TECHNIQUE Labral Repair with Chondrolabral Preservation

49 CENTRAL ANTERIOR PORTAL

50 ILIUM ASPIRATE Nicole Wolf 2018

51 ILIUM ASPIRATE

52 BONE MARROW ASPIRATION ~20-25 cc into 3 separate 60 ml syringes Total: cc bone marrow aspirate

53 BONE MARROW PROCESSING Injected 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

54 MEGACLOT APPLICATION

55 MEGACLOT APPLICATION

56 MEGACLOT APPLICATION

57 MEGACLOT VISUALIZATION