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VID1-001801-en-US | A | AutoCart™ Procedure in the Hip: Applications and Technique With the GraftNet™ Collector

Travis Maak

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AutoCart™ Procedure in the Hip: Applications and Technique With the GraftNet™ Collector

My name is Travis Mack and I'll be presenting on AutoCart the procedure in the hip indications technique and the data behind it. Femoroacetabular impingement syndrome and chondral injuries are typically hand in hand problems. The landscape of the issue presumes primarily with surgery getting individuals back to approximately 74% return to sports at the same level, with some studies suggesting even higher. Over 90% of patients with chondrolabral injuries are identified at the time of surgery, despite many of these not being noted prior to surgery. Now, males and femoral acetabular impingement syndrome with sports can lead to an increased premature hip osteoarthritis problem. Injuries have been noted to have worse outcomes. Early interventions in the first 3 to 6 months in some studies have suggested that these outcomes can be improved if obtained earlier. Now, a case of mine represents this problem and highlights some of these issues that we're trying to treat currently to allow our athletes to return to sports and maintain these sports levels. This is a 20 year old male snowboarder who performed a jump in his terms. His left knee hit a tree. He was unable to stand after his accident and he had a posterior left hip dislocation reduced in the emergency room. Now he came to me four years post dislocation. He came into the clinic with significant pain with squatting and deep flexion. Typical FAI syndrome. He had groin pain for prolonged period of time and the pain was temporarily relieved with an intra-articular injection. X-rays demonstrate a Cam deformity with otherwise preserved joint space. Now what's the playing field? Well, Chondrolabral injury specifically suggests that condyle restoration techniques can result in improved outcomes. But how do we treat the cartilage? Some studies have suggested microfracture can help 89.6% or upwards success in these. However, worse outcomes score ADLs and Vasc scores versus controls Amick has suggested to be upwards of almost 100% success. That being said, 98.4% of athletes had acetabular cartilage lesions, and these can become disastrous over time. Other studies suggest that perhaps we're not quite as good as we think. 153 patients 50 years or older, 20% converted to total hip arthroplasty at three year follow up. That's not particularly good. Interestingly, a subset of these individuals had greater than two millimeters of joint space, 90% survivorship in those if they had less than two millimeters. Only 57% had survivorship at three years, suggesting that 43% of those subset of individuals converted to total hip arthroplasty not a return to sport protocol. That being said, other articles have suggested that maybe we're doing a little better than we think. There's insufficient evidence for an age cutoff. There are very high level athletes that are in the late population, in ages 50 or 60 years old, that still can be appropriate candidates for hip arthroscopy and chondral preservation as grade greater than one or a joint space less than two millimeters suggest worse outcomes, and this is consistent with the previous study. Now how do we identify these lesions? Pre-operatively. The answer is currently we're not very good at it. T1 rho MRI can can detect chondral injury in the hip. However these differ by gender. They also differ at medial to lateral with respect to the acetabular region. It has been promising results but also has variable outcomes. 3d dual echo steady state also shows early promise, but again these are these are very, very inconsistent as far as specific types of studies as well as the actual instrument by which the studies are performed. Here's an example of a T1 rho study in a patient of mine. We scoped the aforementioned patient in the following fashion a large chondral flap is identified. A deep acetabular defect is noted in this 24 year old gentleman who desires to return to cutting and pivoting sports, specifically skiing. Now, this spawned my interest in evaluating these lesions, so we performed a finite element analysis and modeling technique to look at what the results are with these defects. Interestingly, you have decreased contact stresses at the anterior hotspots, increased contact stresses at the medial hotspots. And the defect essentially removes that posterior hotspot, but results in subsequent damage areas throughout the acetabulum. This may allow us to understand why chondral defects result in subsequent joint degeneration. We further modeled this with an increased size, chondral defect, and delamination of the labrum, as well as the acetabular region. You can see the concentration of forces in a normal hip, but when a defect is loaded on the right, you can then see further concentration within the acetabulum, again suggesting that these defects are real and may cause problems down the road. This would suggest that perhaps not only should we treat labral tears because those have an effect, but we should also treat the acetabular defect. How do we do it? Well, there are many options. There's very little data in this area, at least conclusively. So. These are the following options as identified. So what about microfracture. It's fairly easy. It has a storied history. Many people have gone away from it. But I still think there is a reasonable role for this. However in the hip. Some studies would suggest that the addition of microfracture, although it can be done, is really not justified. What about saving the articular cartilage? Interestingly, this study suggests that in fact that chondral flap can be utilized, it can be taken and utilized and put back in because it still has chondral viability. Other studies using Act suggest you can actually take cartilage, grow it out, and then put it back in. This would suggest perhaps there are other options. That being said, this is a two stage procedure. What about bulk osteochondral allografts? Well, this can be done to this obviously has a significant morbidity requires surgical dislocation staging. Understanding the chondral defect is there and a significant return to sport delay. This brings us to our current technique. This is the AutoCart procedure. It has effectively all of the pluses with almost no of the minuses. This is a single stage implantation procedure where we at the index arthroscopic visualization procedure you identify the Chondral defect. Now, I already told you the chondral defects are largely identified at the time of arthroscopy, not preoperatively. So if you see your defect, you can treat it at the same time. Single stage. You take the cartilage from the femoral head. This allows harvesting from an area of very low injury. High viability. You harvest it combined with growth factors in the form of BioCartilage, then provided with either whole blood or other type of implantation procedures, and then re implant. A GraftNet offers a very easy method by which this cartilage can be harvested from the femoral head or acetabular flap, or both. And the promising results are preliminary, but very good. This is an example of confirmation of the concept here. In this case, I wanted to ensure that we were doing something that would actually benefit a patient. So we took the cartilage from the femoral head, used GraftNet to harvest it, spun it down and grew it. What we noticed is, interestingly, in a very heterogeneous cohort, both men and women of appropriate age group and appropriately BMI, 52% of the cartilage were viable. If you combine it with growth factors, such as those seen in BioCartilage that went upwards of 99% by two weeks, effectively taking the cartilage, combining it and implanting it in appropriate in vivo position results in 99% viability and a very good potential outcome for your patients. How's the setup? It's very simple. Attach the GraftNet to the back of your shaver. Harvester. You can harvest the cartilage very simply, just like you normally would on the femoral head prior to the osteochondral plasty. This can be combined again with whole blood or other type of biologic implantation procedure. It can then be combined in the syringe and then implanted. How is this done? Well, initially the defect has to be prepared. The flap can be removed, either harvested or taken away using a ring Curette. The The subchondral layer, calcified cartilage is removed. Punctate bleeding is performed. Notably, in this case, we are not doing microfracture, although that can be using a specific type of drilling procedure. The subchondral bone can be violated with a drill, but not a microfracture, all to preserve the subchondral bone. Then GraftNet is utilized, in this case with a forero shaver to harvest the cartilage from the femoral head, which again is something that's going to be removed anyway. Therefore, there is no morbidity to this procedure. Once the cartilage is harvested appropriately, the Cam deformity as in this case can be easily removed. Completing your osteochondral plasty like you normally would in a standard hip arthroscopy with a cam deformity. At this point, the joint is then removed from the irrigation. It is dried appropriately. The either a small sponge or gentle gauze can then be utilized to dry the defect. This provides an implantation bed. The combination of the BioCartilage with the AutoCart is then implanted through the appropriate position. Technique. This offers with a nice sled and then the palate. This can then can then be contoured to the defect, as you see in this case for your elevators also utilize to gently contour the surface so it's perfectly aligning with the subchondral bone and also the surrounding cartilage so that it's not proud. Once this is appropriately confirmed to be flush with the surrounding cartilage, it is then secured with either thrombin or a fibrin glue, depending on the surgeon preference. That's effectively all that it takes to implant AutoCart in a single stage procedure. My go to is this case, so most lesions greater than one centimeter AutoCart is the go to smaller partial thickness lesions. Those can be debrided appropriately, just like in the knee. Huge lesions. Consider other options. We know that in some cases scaffolds for those don't work quite as well. Remember microfracture can burn a bridge. Salvage requires open surgical dislocation. My go to is AutoCart. This is how you do it. And I suggest that this is something you can keep in your back pocket. For those cases which are very common, that you see cartilage defects and now you can treat them. Thank you so much for your time.

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