Microfracture cartilage repair is performed&nbsp;by creating tiny fractures in the underlying bone of an OCD lesion using Chondro Picks. The resulting blood clot initiates the development of fibrocartilage, which often will fill the defect site.

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Hip Next Generation in Soft-Tissue Repair and Reconstruction

Imaging and Resection

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CoolCut™ Specialty Series: Hip-Length Shaver Blades and Burrs

Orthobiologics

Brian D. Giordano, MD (Rochester, NY), presents a complex case in the hip in which he used various biologic and standard approaches to obtain a successful outcome. For the acetabular cyst, Dr. Giordano performed an IOBP® procedure augmented with autogenous bone collected using the GraftNet™ device. Dr. Giordano performed an AutoCart™ procedure to treat the articular cartilage defect, which includes mixing BioCartilage® matrix with autologous cartilage collected from the cam lesion using the GraftNet device. Labral preservation was performed using the innovative Knotless SutureTak® anchor, which provides tensionable advantage to the surgeon.

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Biologic Repair of Acetabular Cyst Using the IntraOsseous BioPlasty System and AutoCart™ Procedure

Hello. My name is Brian Giordano from the University of Rochester. I'm going to be discussing a case of biologic repair of an acetabular cyst using interosseous bioplastic, GraftNet and BioCartilage. The patient in question is a young, healthy female softball player who would unfortunately experience greater than six month duration worsening left hip pain. She had experienced a decline in her range of motion, function, strength, endurance and sport tolerance. She had pain that affected her quality of life, her ability to tolerate activities of daily living. The pain had begun to wake her from sleep, and she had begun to limp as a result of her symptoms. On her physical exam, she was mildly overweight. She walks with an antalgic gait, incorporating a shortened stride length for comfort. She walked with a slightly externally rotated posture through the lower extremity. She did not have any suprapubic inguinal or central core tenderness. She did have a globally restricted range of motion of her hip with significant Capsulitis range of motion was compromised on her. On her affected side, 90 degrees of degrees of flexion, with essentially zero internal rotation and mild external rotation before the point of pain. In comparison to her contralateral extremity, she also has positive provocative testing for femoroacetabular impingement, including positive Faber and Faber exams. On her plain radiographs, we essentially see a relatively normal congruent joint with a small area of lucency and the superior weight bearing surface of the acetabulum. And on more advanced diagnostic imaging, it's clear in the CT scan that you can see a large focus of subchondral cyst with significant surrounding bone marrow edema. The case in question presents a number of treatment challenges. Obviously, we're dealing with a young, physically active, patient, larger body habitus. We have to incorporate elements of treatment that are able to provide options for both the marrow edema, the biologically reactive lesion, the articular surface, the subchondral bone, and then of course, the surrounding labral pathology and synovitis. In this case, incorporating some elements of strategic rehabilitation are going to be important to optimize her post-operative care. So in considering options, we always start with start with conservative to the most invasive conservative options were not great for her because she had already failed exhaustive conservative management. Pain was affecting her quality of life. She was not able to do any more strenuous physical activities. Pharmacologic options should always be considered, including bisphosphonates elements like parathyroid hormone, but in this case they were not indicated. This lesion could potentially be accessed using interventional techniques. However, the labral OnControl pathology, the deep filling, could not be accomplished through a percutaneous technique. Open techniques could be considered but at the expense of significant patient morbidity, longer and more exhaustive rehabilitation process, and potential for other complications. Arthroscopic treatments have to incorporate the need for treating both the surface articular cartilage, the subchondral bone, and or potentially both. If you're going to consider biologic augmentation, we need to propose the idea of potentially using both allogenic or autogenous tissue and then, in addition, incorporating some biologically active vehicles such as autologous conditioned plasma, PRP or bone marrow. Maybe other useful adjuvants to this labral preservation, in order to incorporate a sufficient labral seal to protect and optimize the healing environment is important as well. This is the setup on our back table. You can see that obviously you have a very, very organized system. I think personally, it's very important to have a very well versed support rep in the room to make sure that when you're using a number of different biologic options, things are organized in a systematic fashion so that there's no unfortunate mistakes. So the selected approach that we used was arthroscopic to optimize the minimally invasive nature on entry into the joint. You can see a probe into the small nidus on the articular surface probing into a deeper cavity. There's a surrounding labor repair. I place labor repair anchors adjacent to the cyst, so as not to incorporate the drill tunnel into the cyst itself, provide provisional stabilization of the labrum. The surface articular cartilage is quite unstable. You can see the the hole for the iabp needle. I'm using a bone cutting shaver right now to take autogenous cartilage from the femoral head. Harvesting it using a GraftNet, and then using a separate GraftNet to harvest femoral head bone for an autogenous bone graft, which can then be mixed with DBM to fill the cyst. As you can see, Afe decompression is being performed. A hip length IOP needle was utilized to deliver the bioactive substrate into the into the cyst. Biocartilage was delivered into the surface articular cartilage in order to provide bone grafting, both of a of a of a bone marrow constituent into the cyst, and then more of an articular cartilage matrix for the for the surface articular cartilage. After the, the dual grafting was complete and matured using fibrin glue, a knotless FiberTak was placed just above the drill tunnel from the IOP needle to create a central suspension in the labrum, further stabilizing the final repair construct. In this case, post-operative care was initiated immediately after surgery, with early range of motion hips in general providing an intense biologic healing response, but made even more aggressive by bioactive substrates, so early range of motion is extremely important. Protected weight bearing was utilized for the first six weeks of foot. Flat touchdown. Weight bearing. Skilled outpatient rehabilitation is crucial to ensuring an optimized outcome. This should be under the direction of a skilled hip rehabilitation team, avoiding specific psoas and abductor triggers, which tend to include open kinetic chain core fatigue based hip abduction. Retraining early. We often institute some aquatic therapy at about two weeks to reduce the postoperative infection risk and add myofascial based techniques. At six weeks in this case, we obtain a postoperative MRI at three months to evaluate healing of the repair construct and to ensure that no further progression was was occurring. We were excited to see at three months post-op that there was significant resolution in surrounding edema. Good incorporation of the graft material into the cyst. No progression of the lesion, and stabilization of the surface articular cartilage. Pearls of this case include extensive preoperative counseling. These patients really need to understand what will be involved in their pre and post-operative care. These can be painful procedures. Fortunately, in arthroscopic nature, this allows us to optimize the effectiveness and accomplish this in a in a method that is relatively pain free. It's mandatory that a skilled, experienced rehabilitation team with ancillary services are available to ensure that the patient does not become stiff. Post-operatively develop abnormal gait patterns or over utilized muscles which may not be prepared to rehabilitate at certain time frames. A milestone based approach is always used. Intraoperatively. It's extremely vital to have an experienced Arthrex biologics representative, both from the surgeon's perspective and also the perioperative surgical staff, to ensure that a smooth and efficient care flow is promoted. It's key to if you're using multiple biologics to have a very organized intraoperative setup, both from the standpoint of biologics, GraftNet and implants, these cases can become very confusing. So having these these out in an organized fashion ensures that substances are not are not mixed in an incorrect fashion or at wrong ratios. I typically perform the decompression early, both from the standpoint of of not wanting to have bone debris floating around the joint after a repair. You're at a point in the case where you do not want to to evacuate anything for fear of removing some of the graft material. The decompression, while vital to the pain resolution in that portion of the procedure, is also a technical step in procuring articular cartilage graft, as well as subchondral bone using GraftNet technology. I provisionally stabilize the labrum prior to grafting the the material both to, to ensure that the drill tunnels did not incorporate into the into the cyst pocket. Also, to ensure that the labrum was stable and was able to contain the BioCartilage graft in the surface, anchors need to be placed strategically. As I said, I stabilize the final element of the of the repair with with a FiberTak suture just above the introduction of the IOP needle for central stabilization. That worked well for this case with no further Other version. The double Knotless repair device allows a variable amount of tension so that you can. You can adjust how much tension is applied to to be able to place the labrum. Anatomically. A hip length iabp needle was used in this case because of the increased depth in the body habitus dimensions of the patient. This allowed for effective interosseous delivery of our bioactive substrate. We capped the articular cartilage to prevent egress. We did use an aqueous delivery into the cyst while the BioCartilage was delivered in a dry environment. Our preference is to use either an Ng tube to evacuate residual fluid from the joint, or to create a posterolateral portal with a suction based pledgets or simple suction equipment through the posterolateral portal. A 14 gauge spinal needle was introduced through a distal accessory portal using fibrin glue or autologous thrombin to mature the graft construct in this particular case.

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.

Jason Scopp, MD, (Salisbury, MD) discusses treatment options for treating articular cartilage lesions in the hip and outlines his assessment protocols and surgical techniques when dealing with these defects. He discusses various treatment options rating from OATS®, BioCartilage® and Cartiform® and gives an overview of his experiences with each of these products and procedures.
Cartiform is a registered trademark of Osiris Therapeutics, Inc.

A video of a live presentation reviewing Arthrex products or techniques.

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Arthrex®  Cartilage Solutions in the Hip

The chondral defect management in the hip classically are being extrapolated from what we know in the knee. But what makes the hip more difficult to employ these techniques is the unique anatomy. And we all know with this prior, you know, the 90 degree microfracture, all as soon as you try to hit it perpendicular to the force, you're never going to get it. So the unique anatomy makes access difficult for these procedures. I was actually just here last week at the International Cartilage Repair Society meeting down the road, and there were a couple key points that I thought would be interesting just to present at the beginning of this talk, predictors of cartilage lesions and hips with phi of over 100 patients in Philippines group, 28% had grade four injuries, which I thought was very good demographics to understand. Three quarters of them are on the acetabulum, males greater than females, and they're more common with higher alpha angles. I think this is good information, just like curls study in knee arthroscopy. We've also seen an association between ligamentum teres injury and defects of the inferior acetabulum and apex of the femoral head. And then, as Ben has shown us both in the Arthroscopy Journal and last week, that does microfracture actually work in the hip and looking at patient reported outcomes at two years, showing that there is improvement. But we have yet to define the ideal size and location. So the big question really is, is can we extrapolate hip efficacy from knee data and that we're sort of in that process and we're now taking a niche procedure or a niche arthroscopy and a niche thing of cartilage repair, combining them to make a new niche within our current treatment recommendations. And the other day I got emailed this and I thought it was an interesting quote, but it makes sense for what we're doing with cartilage. If you don't know where you're going, you might end up someplace else. And Cells. And that's true especially with hip arthroscopy, because the we really don't know what we need to do, and we don't know if we can truly extrapolate the need data into the hip. But this is the way I think about a knee. And it can extrapolate to the hip as we begin to see our observations. And I call it the functional unit. Macroscopically, we know that the cartilage has to be supported by something. So it's important to understand the mechanics of the joint with the FAI and dysplastic hip, combined with the integrity of the labrum and then ultimately the joint stability. And that's the macroscopic component. Microscopically, the sites are supported by growth factors, scaffold and bone. And as we look at whatever procedure we decide to do, whether we observe the natural history of these, whether we do an operation or we just let it run on its own, we have to consider biologic boosters down the road. And whether or not we combine a cartilage procedure with ACP or a therapeutic procedure using either ACP or the Angel System. So our obstacle success really is, is in balancing that functional unit. Patient factors and doing the right operation in the wrong patient. And that's where we have to team with industry. Because industry provides us products. We provide the thought and we integrate right here at the middle. And that's where we guide together as a team as opposed to someone just saying, hey, put this in the joint because it's going to work. So as you're sitting there, this is actually a case I did yesterday. What would you do? And do we have an answer for that? And I bet if we went around the room and did a cross table like we just did, I bet we'd have ten different answers. And when we look at these, education, experience and environment avoids this way of thinking that we apply one technique to all cartilage lesions. Right now, microfracture is the easiest thing we can do. Let's look to. When Gerhard and I were fellows back in 2002. Microfracture, it was either microfracture OATS ASI was just coming into play. We only really had 1 or 2 tools in our quiver. Thankfully, Arthrex has been able to provide us in the NE world with a spectrum of cartilage management, and I thought of this one day when I gave a talk at the faculty forum for the NE component to this talk, where I was thinking, you know, it's kind of like staples. Yeah, we've got that, because when we look at the cartilage management spectrum, we really are provided by this company with management options in each lesion size, whether it's in OATS and microfracture. As the lesions get bigger we have BioCartilage and Cartiform and then even larger we have allograft OATS. And marrow stimulation has been shown to have a high rate of pain in subsequent procedures, even though they might do well early on. Yet they still are the standard by which we have to compare all of our other procedures for FDA studies. And some of this will show the shortcomings of traditional microfracture. And this is from Brian Cole and Lisa Fortier showing these Micro-ct studies of what actually happens with a conical microfracture. And I think this one really shows nicely when the cone goes out. You're really creating a true fracture at that interface in this conical shape is what results in intralesional osteophyte formation, because your body truly thinks it's a fracture, even though you will get some subchondral marrow elements and stem cells. But we know access is challenging. Here is me, one of my first cases saying, well, how do I microfracture with this one? And how the hell do I microfracture with this one? And it's a struggle, even though we can try to make it look good in front of each other. We've all been there, we've skived and we've struggled. One option that I've found to be very helpful is the PowerPick. And the PowerPick eliminates the conical configuration. It minimizes the intralesional osteophyte formation. And I've seen subchondral edema decrease in post-operative MRIs. Even at six months. So when we look at these patients, who are the patients that we're supposed to microfracture and it's okay to profile, it's okay to say and come out and take a stance. And finally, some literature, at least with Microfractures come out in American Journal of Sports Medicine with Mithoefer saying that age less than 40 years old, lesion size less than four centimeters squared, we're now armed with some profile of what we can do and what does well, at least in the knee with microfracture. And then we ask ourselves, can microfracture plus can we add something to our microfracture to expand these indications and improve our results and make these patients better, more than just 2 to 3 years, but actually carry them on. And that's where BioCartilage comes into play. Microfracture. Plus what is BioCartilage? Well, BioCartilage is a dehydrated allograft. That's micronized. You have retention of extracellular matrix and growth factors. It's cost effective, costing less than $1,000. And it has a five year shelf life. So if you have it brought in, your surgery center is not going to be pissed off if you don't use it. It's provided in this little case with granules, and you mix it with ACP and it ends up in a syringe and it has a long Tuohy shaped needle and a straight needle. So you can do these procedures. Arthroscopically. The reason the original rationale for ACP or using PRP was we knew it had to be liquefied. What should we use? Well, saline is one thing. Why don't we use something a little bit more biologic? So thinking outside the box, adding ACP realizes that we've got decreased pain. We have an anti-inflammatory effect. It's enhancing matrix synthesis enhancing the microfracture ha synthesis. And it's actually recruiting stem cells. So there is some rationale behind using that. It can actually even be used in the hip. And thankfully, thanks to Mike Gerhart for providing me these slides. And I imagine we'll see some more videos on this in the later talks, but it looks great at time zero. I unfortunately or fortunately have the advantage of second looks on some of these patients in the knee. But I think it shows what the biology is at early and late second looks. And so this is a patient I did a patella. Obviously it looks great. Everyone says you did a great job in the O.R., but patient got stiff. But here this is eight weeks post-op. And if we look at the patella, what you're seeing actually already good incorporation. It's. I don't tend when I have to do second looks. I don't tend to really probe hard because I've done that before. And I've delaminated part of a patch doing an ACI. And I said I'll never do that again. So I'm very careful about palpating and probing these early lesions, but it really does begin to show macroscopically some good incorporation. But this is that patient's MRI six months post-op. And this is even more valuable because you're seeing regeneration of the lateral facet and six months post MRI. If any of you have ever gotten an MRI on a microfracture, you usually see a ton of subchondral edema. You don't really read much into it. But on this patient six months post-op and I assure you, this is the same patient six months post-op. You've got regeneration of that cartilage surface with no edema. I also had a patient who fell two weeks post-op two and a half weeks post-op, and we scoped her after she broke through a Fulkerson osteotomy. And what you see. And she had two. This was a two lesion implant. But what was impressive was the retention of the super clot. So the theory behind this early second look of mine was that the BioCartilage is basically a scaffold, just like we learned at Icrs last week, that a scaffold is retaining and attracting the stem cells and keeping them there longer, as opposed to just a super clot provided by a microfracture. So the scaffold may ultimately require or may ultimately offer us increased durability and longer Longer incorporation of the stem cells into our lesion. This was just a brief demonstration. If any of you are ever interested in trying even an open treatment of a femoral head fracture. These bio compression screws. I've always wondered the fate of them. And I've used them extensively. And this was a patient who I saw for a separate injury to his knee. But two years post op, this is. I pieced together an osteochondral fracture. And this is a second look. And really those those bio compression screws incorporated. And you had BioCartilage over. So you don't need to be afraid to use those in the femoral head fracture. Which brings me to my next exciting product. I think that that Arthrex is is providing us, which is Cartiform. This is a case I did yesterday. I happen to have a great day for for a presentation yesterday because I did a couple cases that were relevant. What Cartiform is, is actually an osteochondral disc. It's an allograft. Osteochondral 27415. We don't have to fight for this because osteochondral allograft already exists. It's cryopreserved in a proprietary way that actually allows retention of chondrocytes on the surface even at two years. And they'll say seven, 70, over 70% of site viability, as you can see here in this slide. And because of that, it interested me to have a one step procedure for larger chondral defects. And this is the case I did yesterday was a knee. It was an OCD. And I actually as I was doing this, I started thinking about my talk today. I put these are SutureTak anchors which I put in. I bone grafted the lesion which you'll see here. And then this is the final product. But what made me think about the hip is the way I brought the graft down to the knee. So I had the anchors in position. I fed the sutures from the anchor through the holes or the fenestrations, and then pushed it down as if you're doing a cardiac valve. And I thought that if we're able to access the four corners of of a condo defect, either of a femoral head or acetabulum, most likely with more of a flexible anchor in system. We might be able to do this into the hip and provide a stable osteochondral support. This is just a summary of the comparison of of the other cartilage repair products, which really the most important thing as we're looking, a lot of patients who have had 3 or 4 operations are not interested in a fifth operation. So you can do a six operation. So some of these single stage operations are beginning to that are low cost, are beginning to prove exciting for the surgeon and for the patient. But as we know, there's nothing like long term follow up to ruin good results. Just briefly touch on the sows and I'm talking a little bit more about it tomorrow. But what sows does is empowers a an academic minded private practitioner like myself to critically look at my own work and to be able to compare it to your work if you're using it, and then even come up with an idea of this hip distractibility score and actually start putting some data behind it, and you can make some fancy looking graphs like this. This is just it's not really important what what I'm showing this is just comparing BioCartilage. It's part of a registry BioCartilage with traditional microfracture. But as we're beginning to gather this data, we're starting to actually just go from level five evidence to move up to, well, level three evidence, which is better than level five evidence, which is this is how I do it. So when we put it all together it's, it's important to think about this triangle of success. This is an industry sponsored meeting, but we are all presenting independent thought, and we're colleagues who are pushing the boundaries and we're trying to learn. But there's this triangle of success that exists. It's the surgeon. And we have to ask ourselves, can I do it? It's the patient where they say, you know, do you want this? And then it's the facility in the in the payer saying, can it be done? And there needs to be this interaction of all three of these players in order to have success. It's okay to start profiling. I want one day to be able to say, in a 40 year old male patient with an alpha angle of 50 degrees, with no degenerative changes and a two by two cartilage lesion of the acetabulum, that Cartiform is the ideal treatment. Or something else. And so begin profiling these patients so we can all learn from what we're all doing together. So Arthrex thankfully has offered us these cartilage solutions understanding the functional unit of the hip. Knowing that cartilage, just because you can put BioCartilage in a hip, it's not going to work unless you correct the osseous conflict, which we've been talking about. And this is a quote that Dan Serra said last week. And he didn't even realize he said it. But I ended my talk last week at Icrs with this. And I'm going to end this one is the patients who do well are the patients who are selected well.

Brian Giordano, MD, (Rochester, NY) presents multiple techniques to treat chondral defects of the femoral head and gives an overview of the different options Arthrex® offers to repair these chondral lesions. Dr. Giordano discusses techniques ranging from autograft and allograft OATS®, microfracture with BioCartilage® augmentation and a variety of other commercially available options to treat these lesions.

Treating Chondral Lesions of the Femoral Head

Joe McCarthy had an interesting long term outcome study recently showing that femoral head wear was a significant predictor for the eventual progression and need for total hip. I was trying to think about how to present this. I think that looking at lesions, the femoral head can be broken up into based on etiology and etiology. I think plays a strong role in how these lesions should be addressed because they're they're usually part of a bigger global picture. So so they can be a traumatic. And a lot of what we see is actually an a traumatic cause or having significant biologic undertones, including things like avascular necrosis. Diseases of attrition or subchondral edema. You know, a traumatic causes can include mechanical where they can include instability. You know, a traumatic instability, not your macro you know, macro instability. And then then the traumatic cases, which are, you know, the low and the high energy mechanism of injury or the iatrogenic femoral head lesions that we will come across from time to time. So the biologic lesions, you know, because I think we have to consider all comers to be complete hip, you know, hip preservation, you know, practitioners subchondral edema. The femoral head may be related to pre collapsed state of avascular necrosis. You know it can be it can it can not be associated with AVN. It may just simply be transient osteoporosis or or rapidly progressive osteoarthritis. There's staging for AVN. We also need to consider things like the sequela of Perthes or Skiffy in the biologic classification of these these treatments. We all know the risk factors behind osteonecrosis and, you know, and this would be an example of sort of a pre collapse hip that's at a lot of risk for progression based on the size of the lesion and the location, the weight bearing dome of the of the femoral head. So when we get into solutions solutions could include arthroplasty. But we're here, you know, as hip preservation surgeons. And so we want to talk about the non arthroplasty techniques. We're you know we're in a we're in we're in a place in Rochester where we're heavily we have a very strong basic science lab. We have a very strong metabolic bone clinic. And we're using a lot of biologic pharmacologic agents to help slow the progression to, to, to harden or make the subchondral bone more, more rigid. There's obviously surgical interventions, including core decompression, which can be accomplished either open or arthroscopically assisted biologic resurfacing options, which can be, you know, a basket of different terms, including microfracture, ASI, OATS procedures or repair osteochondral repair, mosaic plasty or you know, articular cartilage repair. So for the we're generally considering biologic pharmacologic interventions for early stage pre-collapse lesions of the femoral head. The data on the use of bisphosphonates or alendronate is relatively mixed. But there have been some long term series looking at alendronate specifically to prevent the progression or the post collapse phase of AVN that's been promising. Some studies have shown almost a almost a 90% survivorship at ten years, as defined by lack of progression to total hip arthroplasty. We use a lot of forteo, which is the 134 peptide region of Teriparatide, which is the only one of the only osteoblastic osteoblastic agents on the market. We use this for patients who have AVN with a lot of surrounding edema. We also use it for, you know, femoral head edema to to stabilize that edema, to either prepare them for a core decompression or for an OATS procedure. And then there's a whole bunch of, there's a whole slew of other stuff in the, in the, you know, that has kind of anecdotal or small case series clinical outcomes that, you know, shock waves and the electromagnetic fields and but, you know, the form of, of, of this, of this, this type of program, you know, gives us the ability to talk about the whole spectrum of options. So core decompression is, is is generally has an associated risk factors for progression, including edema. So if there's bone marrow edema associated with AVM, there's a very high rate for progression to full collapse and need for total hip replacement. The size of the lesion also matters. And this can be quantified. There's a specific method looking looking at an angle on a, on a, on a sagittal plane image. Lower angle, smaller, less weight bearing. Involvement of the femoral head. Less risk of collapse. But obviously the natural history is dependent on the size of the lesion and some of the data that's looked at core decompression, both in meta analysis and systematic review. And some of the larger case series has shown, has shown sort of equivocal results. Core decompression is generally indicated for early stage osteonecrosis, the goal being to reduce interosseous pressure, improving pain, restore the biologic milieu for for a healing environment. This can be supplemented with a lot of different agents. We have you can you can use bioabsorbable screw material. You can use allograft nonstructural autograft. You can, you can, you know, get in there through different techniques with a core tract or a lateral entry or a trap door or light bulb technique. It can be arthroscopically assisted as well to identify the location of the lesion, to make sure your guidewire is going into a pinpoint location. It can then be used as a, as a tract for backfill, including stem cells and PRP, bone marrow elements, calcium substrates. And a variety of other agents. So again, these outcomes are relatively mixed. But there has been some promise in the use of arthroscopy to augment or to facilitate this type of treatment. Vascularized bone transport, the most popular of which is free vascularized fibular grafting. Very technically demanding procedure. Probably. Probably probably confined mainly to large institutions where you have microvascular surgeon. Initial initially a lot of promise. The principle makes makes a lot of sense, but the long term outcomes have not really stacked up to this. And we find now that, you know, 5 to 10 years out, we're doing a lot of revisions for for eventual failed vascularized fibular FibuLock graphs. So on to the mechanical causes. So mechanical abrasion can be from a lot of things. You know theoretically suture material anchors that are placed in a in a slightly non anatomic location into a subchondral subchondral position where they're exposed intra-articular loose bodies, severe impingement morphologies, a lot of the extra articular impingement morphologies like the severe type three sub spine impingement. These can be addressed arthroscopically. And you know, we have a great number of talks that that are being presented to to go through these in more detail. Instability can cause femoral head, where there's obviously an increased shear and translational vector through the soft tissue. Increased soft tissue attenuation. The correction for this is is you know we've seen some some data from Ben saying we can we can at least partially correct this with capsular. If your capsular volume reduction in our practice we I think if you have an instability situation and you have the availability of a of an of an open, hip, open, hip preservation person that's going to do femoral or rotational osteotomies and pose. I think we're more inclined to use a more powerful correction tool like that. This is an example of a young person who had a prior osteotomy done, done elsewhere, who had sort of an overcorrection where the Ise was brought very far inferior into a location where it was scraping against the femoral head, and it created basically a big gopher hole across the top of the femoral head. She had huge, unaddressed intra-articular disease just because she had an isolated POW without any arthrotomy dislocation or arthroscopy, so made the decision to to augment the microfracture of the femoral head with BioCartilage which I thought could kind of help restore the surface, the overall integrity relatively easy. Technically, the biggest thing is to just make sure the surface is nice and dry, which you can you can use a pledget do it at the end of the of the case. Microfracture. You know, we know this is an extrapolation of the literature. It's a it's a reproducible technique. It's relatively easy. We have some new tools coming out to improve the angle and make it a drilling vector versus a, a tapping or a, you know, that kind of a mirror stimulation mechanical vector which tends to skive, the skive, the articular surface of the acetabulum. This has to be a contained lesion, relatively small. It has to be geographic. So if in the presence of a labral complete labral destruction, labral reconstruction can help provide that buffer to contain the the elements that are going to come from the microfracture. I think I've been back on cases where I've done, I've basically done achondroplastic and I've, and I've freshened the edges of, of a, of a large full thickness lesion treated the I, I've been backing on the case and the, and the region has been completely filled in without any sort of microfracture whatsoever. So I think, I think the hip is a unique joint because we do so much bony decompression it, and we have so much stem cell and sort of PRP free PRP release. I think a lot of these lesions will heal in naturally during the bone work. Repair. I think repair osteochondral repair needs a viable bleeding subchondral surface. It needs a chunk of bone that is going to be big enough that supports some form of screw fixation, whether it's a, a recessed, you know, bio, you know, biologic interference screw relatively relatively larger lesion. And you want to consider staging this with an arthroscopic procedure. He had both coexistent DDH as well as a large large osteochondral defect of the femoral head. And so since we weren't sure if he needed a graft, we did a staged arthroscopy first. He had a relatively large lesion that did have a nice foundation of bone. You can you can microfracture this intraoperatively to see if there's bleeding. In this case there was good bleeding, and there was a stable base which looked like it would be amenable to fixation. So he was converted to a surgical dislocation. And you can see kind of a large osseous base to this in a couple of different fragments. Guide pins and then bioabsorbable bioabsorbable screws were used to secure this lesion. He then had a POW on top of that. So it was a big, big operation for him. But you know, he's a few years out now. He's doing very well. And he he hasn't had any collapse of that of that lesion. You can use you can use dowels. So you can, you can take OATS, as you know, from lateral trochlea of the knee as little dowels to secure fixation and sort of augment, augment osteochondral repair that's been reported. And then mosaic plasty. Mosaic Plasty again, an autograft solution for larger, well contained lesions. Its advantages or its, its highland cartilage. It's a single stage. You know, there's a lot of different donor sites. You can take it from the non articulating part of the femoral head, and it's shown a high, a high rate of success over a over 44 to 8 year period. So OATS OATS is generally our go to for for Post-collapse AVN and it's for, you know, for large femoral head lesions. We, we, we generally do a surgical dislocation. We plan this out ahead of time. We, we we have a graft donor within five days of, of procurement. So these are relatively viable cells. It's kind of a high stakes case. And the graphs are pretty expensive, about 6 to $10,000 per graft. And you can usually only get one plug out of out of a size match. Age matched femoral head. So if you drop it, you're you're in big trouble. And the thing to know though with these are that there's about a 50% failure risk in the, in the, in the historical literature associated with AVN. That's steroid induced but a relatively high success rate with non steroid induced AVN. And you can use larger bulk structural allografts as well. Oats can also be performed arthroscopically assisted. And there's some some data on that. And I think a couple of special considerations to to think about are these parafoveal lesions the ones that you just can't get to with your microfracture tool? These are largely attrition or traction injuries from the ligamentum teres. The edema can be backfilled sometimes with things like the subchondral plasty technology or some of the the bioactive substrates. And then the femoral head lesions with associated dysplasia. I think treating these you know, what we will do usually is we'll do an OATS procedure. We'll reduce the hip and we'll see if the graft is edge loaded. If it is, then generally we believe there's a higher rate of higher rate of graft failure because it's it's edge loaded and it's and it's placing unbalanced stresses on the graft. So in that case we would perform a POW simultaneously. Rotational osteotomy has some has some basis in the historical literature. You know, into, you know, in order to off offset and offload some of these lesions. Another option we're thinking about if you have an open, hip preservation faculty partner.

Microfracture

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