Name: Arthroscopic Hip Preservation
Uploaded: 2019-10-08T00:00:00Z
Channel: Arthrex
Description: Michael Huang, MD, (Colorado Springs, CO) presents the latest techniques and innovations in arthroscopic hip joint preservation surgery. He discusses using the BioComposite Knotless Hip SutureTak ® anchor for labral repair and reconstruction as well as the GraftNet™ autologous tissue collector for treating transitional zone cartilage defects.

<p>Michael Huang, MD, (Colorado Springs, CO) presents the latest techniques and innovations in arthroscopic hip joint preservation surgery. He discusses using the BioComposite Knotless Hip SutureTak<sup>®</sup> anchor for labral repair and reconstruction as well as the GraftNet™ autologous tissue collector for treating transitional zone cartilage defects.</p>

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VID1-000400-en-US | A | Arthroscopic Hip Preservation

Michael Huang

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Arthroscopic Hip Preservation

So I think it's important to kind of define what what we think preservation is. And, you know, I looked it up in the dictionary. It says to keep alive or in existence, make lasting to keep safe from harm or injury and to protect and spare. So when you start overlaying that into what we're doing in the hip, it's really important to ask whether or not we're making a difference. In my practice over the past 12 years, I think the indications for arthroscopic hip surgery in the hip preservation world has increased tremendously. These are just a few of the things that we are doing. I'm going to focus in this short period of time on labor repair and femoroacetabular impingement, and then highlight some new and interesting cartilage resurfacing techniques that I think will potentially make a long term difference in terms of preservation. Where we came from is not that long ago. It doesn't take much to look back and say, well, labor repair Arthroscopically and understanding of impingement came from the early 2000 or late 1990s. We all have Professor Gans to thank regarding the bony deformities and its association and knowledge base towards labral tear, so that's where we came from. Further studies have documented when the labral, when the labrum fails that we have increased articular compression, we have increased contact stress, loss of suction seal. And all of these things can predispose to early degeneration. And so these are the things that we're trying to treat. So if it started in the late 90s and early 2000, the question is, well, do we have any long term studies. And one of the longest term prospective minimum ten year follow ups is out of Vale. And Doctor Philippon certainly gets credit for this. But he compared 79 patients who underwent labral repair and also included 75 patients that underwent labral debridement. And out of that cohort over ten years, 34% of them went on to total hip and the predisposition factors were increased. Age obviously decreased joint space on presentation and the presence of microfracture, which will become a topic for later in this talk. What about the older patients? Well, minimum two year follow up. And patients over 60 actually did very well. So average age of 66 only about 12% failed and went on to additional surgery. And additional surgery was not always total hip. Actually three went on to total hip and two had revision hip arthroscopy, and at two years after hip arthroscopy, almost 90% of them were still doing well. So. So overall, we're seeing about a 66% improvement in preservation at the ten year time point between 2 and 5 years, depending on which cohort you're looking at. The results are still durable. I think this is because we've been advancing and we've advanced on lots of frontiers. We've advanced on patient selection criteria, and we've advanced in innovation in terms of techniques, and we've advanced in innovation on on some of the tools that have been given to us by companies like Arthrex. So patient selection and you followed this over time. We're much more diligent about who we are indicating. We're looking much more at dysplasia, coxa profunda, acetabular retroversion. We're starting to understand the relationships between the soft tissue damage and small Cam lesions versus large Cam lesions. And we're much better about predicting the soft tissue damage based on the bony deformity that we're seeing. So obviously, you know, this patient x ray, you know, is in a high degree of danger with significant dysplasia. And this is not a great arthroscopic candidate without a combined open procedure. On the other hand, this patient who has a long standing Cam lesion, very large Cam lesion, has been impacting and impinging long enough where the acetabulum has ossified. And that will change your treatment algorithm. And and 8 to 10 years ago you know, that type of sophistication was not in our playbook. But now it is. And we're looking much more critically at it. Advancements in technology have helped us quite a bit. Here's a classic, you know, delamination, injury on the acetabulum in the prior to a couple of years ago. We had, you know, straight straight resection. Now we have curved resection. And I love this hip length arthroscopic Torpedo. It leaves such a nice clean lesion debridement line. You know, I started using it in the knee and now it's available for the hip. So if you haven't seen that you should check that out. It does very well in the hip has the right angle for it which lets us treat it. Recently in the RF department, Arthrex has released the Hip 50 probe. This is also a favorite of mine. It's got 360 degree edge control which lets you ablate very carefully. The 50 degree angle lets you get to far reaching, far reaching places, and it does very well in terms of protecting the tissue that you want to protect while taking away tissue that you want to take away. The one characteristic about this probe that that most people don't talk about, it's the rigidity of the shaft. And this is important to us in the hip world because we need to lever on the on the capsule and you know, as it gets more posterior, you can really use this device to help you see better. And instead of switching out to a switching stick or something like that, this is just a quick video to show you how easy it is to kind of dissect through and around things. This is a loose body or acetabular rim fracture that's embedded in the labrum. So, you know, in this case we want to dissect the soft tissue around the loose body but protect and preserve the labral tissue. So the edge control really lets us do that. It does not seem to clog as much as the other standard hip ones that are available in the market, although no want to in and of itself is free from that type of issue. But this seems to do very well. Other technologies have been in the fixation world. You've heard all about Knotless fixation in the shoulder. Well, we have it in the hip as well, thanks to Arthrex. So the hip length Knotless SutureTak are out Throughout and the Knotless FiberTaks are also coming out. So this is a biocomposite. 3.0 Knotless SutureTak going in. I really like this technology because it. By eliminating the knot between the labrum and the capsule, I feel like there is less chance for postoperative adhesions, which can be very painful. Pretty straightforward passing. And then you'll see. And I think one of the presenters showed it yesterday. But we do the same. I do the same thing in the hip where you put in several of these and you get them a little snug, and then what you get to do is you get to position the tissue and dial in your tension. So one of the big things in hip, as you know, is we don't want to overly Evert the labrum. So here I have I've just placed it but now I want to go tension this one. This is the first one I put in. Now I'm going to kind of skip over that one. And I'm going to tension this one over here and tighten it down. And then I'm going to go back to the middle one. And then by by doing that you can kind of play with the tension. This has a lot of benefit when it comes to reconstruction. If any of you guys are doing that we can certainly talk through that. But the Knotless technology has helped my practice in terms of saving time, but also, I believe, has clinical applicability in terms of decreasing adhesions and appropriate tensioning. Capsular management has also been a hot topic over the last few years. We understand that as we are evolving in terms of the the size of the capsulotomy or the type of capsulotomy versus inter portal versus t capsulotomy, we understand that we need to repair some of these on the way out. That used to be very long and tedious, part and very unrewarding part of the case. Now with things like the capsular Scorpion, it's pretty easy to just re approximate the capsular tissue and you can be done with the case. But and in the Velox young females where you really want to placate or actually do a shift of the tissue, then this makes it even easier to do that. So, so just another instrument where Arthrex has made our lives a lot easier. So that's on the labor repair and impingement side of things. What about chondral defects? So this is a big problem for us. These these lesions. Despite using three Tesla MRIs and MRI. Arthur Grams, we continue to miss Energel defects prior to surgery. We know that they will be there. We know that they are very prevalent. And usually at the time of surgery, you're stuck with basically debridement alone or debridement and microfracture. And we'll talk through some of the other options now. So the question is does microfracture work? Well, you heard on the ten year follow up by Philippon that one of the negative prognostic indicators for a hip scope repair, whether or not it's debridement alone of the labrum or labor repair. But microfracture in and of itself is an independent poor prognostic indicator. Ben Dohm has this paper with minimum five year follow up. And he said actually his patients, 53 patients had statistically significant improvement in his patient reported outcomes. But when you look at the survivorship it kind of mimics Philippon's data. 72% at minimum five years still had their hips. 12 of them went on to total hip, and four of them needed a conversion to revision. So, you know, the question then is, well, is microfracture enough for a large lesion like this? And those of you that are doing it understand it's very difficult to get to that area. And and although we can access good bone marrow, the question is well is it enough? So in my practice I went from debris alone to microfracture. Now, thanks to Arthrex, we have some a couple of other alternatives. If you haven't used BioCartilage in the knee, you should see it. It's very applicable to the hip. There are some hip dedicated length delivery devices, but here's a young patient who had full thickness flap tear, were performing a typical microfracture get good bleeding and then you have to dry out the joint, which is a little bit challenging in the hip. But then after that it's fairly straightforward. You can inject the BioCartilage. It sits on our shelf at our surgery center. It's not too expensive. We don't have to order a match, any osteochondral, allografts or anything like that. You do have to have some fibrin glue. And now we're very excited about the Thrombinator for that. But this was done about 2 or 3 years ago, so it gives you a nice coverage and potentially can improve the microfracture data, although the long term studies have not been done. You just heard about GraftNet. I just got this in my hands as well. They just released it. It's very interesting because again, as one of the other presenters discussed, it's on hand, it's cheap and you can use autologous cartilage. This is how it fits on the end of the shaver. We know based on right study published last year that the acetabular flap tear not just from a knee or from a shoulder, but the one from that we are talking about at the hip, has like 87% viability for the chondrocytes in that sample. So we know it's good tissue. So the question is can we use it. So this is another patient that we saw a couple weeks ago. It's a 16 year old male very large chondrolabral separation. You can see how it just pulls off the bone. You'll see in a second. Right in that area there's a full thickness defect. So we use our typical bone cutter and Torpedo shaver here to just debris this flap. Here you can see the how far in it goes. He had a very large cam lesion. So this is collecting the autologous cartilage. Here's the my favorite Torpedo. And then over time you see this the full thickness area right. Right there. So we prepare that performed the typical microfracture repair the labrum. And we get something that looks like this. So we've got the stitches behind it. We've closed down the the lesion slightly. Here's what we're getting in the GraftNet. This is all autologous cartilage from that flap. No bone. This is adding the ACP to it. And we don't add a lot. You just need enough to kind of make it a slurry. Mix it in and then we're using the same applicator. So this is the BioCartilage applicator. You can see that it's not quite as powdery. It's a little bit chunky. And I think that's based on the receptor that you use. And then same thing cover it over with fibrin. Now I was a little bit worried about the size of the lesions maybe being or size of the pieces of cartilage being easier to displace. So this is, you know, how stable the lesion is, a little snot pack that you get with the fibrin glue. But and I usually do this with BioCartilage as well. But I took a video of it. So while staying dry we let the traction off. And then we flex and extend the hip several times. You can see the seal that we've reestablished and then we rotate it. And this is just to test to see if the lesion was stable. And I'm always surprised at how stable this lesion can be. And the the fibrin glue. So you'll see us reapply traction here. And then we just take a sneak peek at it. And by reducing the head into this tablet, it actually flattens out the lesion quite nicely. You can see the graph and a little piece came out at the very medial inferior aspect. So we're just going to cut that and remove it. You can see that little piece right there. The fibrin glue is so strong that if you just went in and and pulled on that there's a risk that it actually pulls the whole fibrin cover off. So we just had to just cut it and then grasp it. And then there you go. So pretty excited about that technology. Stay tuned. In terms of whether or not it will make a significant clinical difference in terms of preservation. We had plenty of ACP left over, so we injected that at the end. And then this is this is how much was left in the tube after we were finished with the case. And you can see it just kind of comes out. There's a lot of differential sizes of the cartilage but a ton of ton of material to use. So pretty exciting. So in conclusion, I think in terms of preservation, the two topics we talked about were labor repair and defect. I think we've made a lot of progress on the labor repair side in terms of our fund of knowledge, our patient indications, our Arthrex has really helped us with a lot of the technical innovations, and we continue to look forward to the things that are coming up with. But that being said, at least based on minimum ten year follow up, we're still seeing a fairly high failure rate in terms of progression to other surgeries based on patient cohort defects is still an issue. I think microfracture may not be enough, and that's kind of borne out in the early data. I think some of the new innovations are very exciting. We need to keep a close eye on that. But certainly I think we need to improve in that area. So in terms of hip preservation, I think we're doing okay. But I think the next 10 to 15 years will be very exciting for us. Thank you.

Arthroscopic Hip Preservation

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