Abstract
Background:
While there have been many advances in the treatment of labral pathology in the hip over the past decade, there are still questions regarding the treatment of chondral lesions in the hip. In this video, we highlight one such technique for harvesting and using bone marrow aspirate concentrate (BMAC) during hip arthroscopy.
Indications:
BMAC as supplementation is indicated for patients with hip chondrolabral pathology in the setting of femoroacetabular impingement. In this particular patient, there were magnetic resonance imaging findings that were suggestive of a possible chondral lesion, and these were visualized intraoperatively.
Technique Description:
Hip arthroscopy was performed supine on a postless traction table. Any labral or chondral pathology was identified during diagnostic arthroscopy. Bone marrow concentrate was harvested from the iliac crest 2 cm posterior to the anterosuperior iliac spine. This was taken for centrifugation, resulting in 7 cc of bone marrow concentrate. A T-capsulotomy and a femoroplasty were performed. The resection was started distally at the level of the “normal” native femoral neck and continued proximally to the articular surface. By starting at the distal femoral neck, distal cam lesions were not missed, and then this could be used as a template while reshaping the remainder of the neck during the resection. Capsular closure was performed, and before tying the interportal capsulotomy sutures, the hip was placed back into traction, and a spine needle was placed into the joint. All arthroscopic fluid was aspirated, and the BMAC was injected into the hip as it was taken out of traction.
Results:
This technique provides a safe and effective method for BMAC harvest and injection next to the intra-articular lesion during hip arthroscopy.
Discussion/Conclusion:
The literature has been increasing in support of the use of BMAC as a treatment or augmentation to other procedures for treating chondral wear, particularly in the hip. The technique demonstrated in this video is one such minimally invasive option.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Keywords
Video Transcript
This video details our technique for using bone marrow aspirate concentrate (BMAC) for the treatment of chondrolabral pathology in the hip.
These are our disclosures.
Background
Intra-articular chondral lesions in the hip are common in patients with femoroacetabular impingement (FAI) and can be seen in up to 88% of patients undergoing hip arthroscopy. 4 While there have been many advances in the treatment of labral pathology in the hip over the past decade, there are still questions regarding the treatment of chondral lesions in the hip. There has been increasing literature supporting the use of BMAC as treatment or augmentation to other procedures when treating chondral wear, particularly in the hip.
BMAC is composed of mesenchymal stromal cells, platelets, red and white blood cells, and hematopoietic precursor cells. These cells produce growth factors, cytokines, and chemokines, which aim to assist with tissue regeneration and have anti-inflammatory effects in higher concentrations compared to other biologics, including platelet-rich plasma. 1
Indications
The case we will be presenting today is a 34-year-old man who recently retired from military service and presents with a several-year history of progressive left hip pain that became worse during his active duty years. He currently has pain with activities of daily living and athletic activities. He is tender over the anterior hip, with examination findings consistent with FAI.
Radiographs of the left hip demonstrate no evidence of degenerative joint disease and advanced cam deformity with an α angle of 76°.
Magnetic resonance imaging (MRI) re-demonstrates the cam deformity with an anterosuperior labral tear with relative sparing of the cartilage.
There is also evidence of a small central femoral head subchondral cyst that is visible on the MRI.
He was indicated for left hip arthroscopy with labral repair, femoroplasty, and augmentation with bone marrow concentrate.
Technique Description
Hip arthroscopy was performed on a postless traction table using general anesthesia. The central compartment was accessed via the anterolateral and modified anterior portals. After an interportal capsulotomy, diagnostic arthroscopy was performed to assess the health of the labrum and cartilage. This patient had detachment of the labrum with early chondral delamination from the 12-o’clock to 3-o’clock position. The decision to use BMAC was based on the subchondral cyst that was visible on preoperative imaging, in addition to the chondral delamination visualized intra-operatively.
At this time, bone marrow concentrate harvest was performed. A Jamshidi needle was used to aspirate 60 mL of bone marrow using heparin-rinsed syringes. The bone marrow was obtained from the iliac wing approximately 2 cm posterior to the anterior superior iliac spine (ASIS) using anatomic landmarks. The needle was directed perpendicular to the ASIS, in line with the iliac crest, and inserted about 3 cm. After the first syringe, the needle could be redirected to a new location to obtain the second 30 mL of bone marrow. This was then taken to the back table for concentration. After centrifugation, this resulted in 7 cc of bone marrow concentrate, which had to be injected within 4 hours.
We next proceeded with placing 2 knotless all-suture anchors at the 12:30-o’clock and 2-o’clock positions. The sutures from these anchors were looped around the labrum and tightened down for a 2-anchor labral repair.
A chondroplasty of the chondral delamination was also performed.
Once this was complete, based on surgeon preference, a T-capsulotomy was performed to expose the entirety of the proximal femur using an arthroscopic blade to create clean capsule edges for later repair. Traction sutures were placed on the medial and lateral sides of the horizontal limb of the “T” using a suture passer for increased visualization. The suture through the lateral or superior capsular leaflet could be brought out of the anterolateral portal, and the suture through the medial/inferior capsular leaflet could be brought out through the distal anterolateral accessory or DALA portal. These sutures were then held by an assistant to aid in visualizing the femoral neck during the femoroplasty. The cam lesion was then fully outlined using an arthroscopic ablator. A round burr was then used to perform a recontouring femoroplasty.
The resection was started distally at the level of the “normal” native femoral neck and continued proximally to the articular surface that had been previously defined. By starting at the distal femoral neck, distal cam lesions were not missed, and then this could be used as a template while reshaping the remainder of the neck during the resection. If more resection was needed, it was started distally again and then carried proximally to avoid over-resection.
Fluoroscopic views were then performed to confirm adequate resection of the cam lesion.
We then proceeded with capsular repair using two No. 2 nonabsorbable sutures placed in site a side-to-side fashion to close the bottom portion of the T-capsulotomy, and these sutures were tied down with the hip in about 20° of flexion. The remainder of our interportal capsulotomy was examined.
Next, 2 additional sutures were placed from distal to proximal in the interportal capsulotomy but not tied.
The hip was then placed back into traction, and a spinal needle was placed into the central compartment. All arthroscopic fluid was then suctioned out of the joint using the arthroscopic shaver. Then, 7 cc of bone marrow concentrate was placed adjacent to the chondral-labral injury. As the BMAC was being injected, the hip was then taken out of traction into the capsule closure position, and the sutures were tied. All arthroscopic equipment was removed. The platelet-poor plasma resulting from the concentration process was then also injected above the capsule after closure of the skin.
Technical pearls for this case include anticipating chondral lesions based on patient imaging (MRI) and age. BMAC can be harvested from the anterior iliac crest without the use of fluoroscopy. BMAC should also be harvested, and the aspirate should be concentrated during the hip arthroscopy procedure to avoid additional operative time. Place the operative hip back into traction before final capsular closure to facilitate the placement of the BMAC into the joint. Lastly, take the hip out of traction when injecting BMAC into the joint so that it stays next to the intra-articular lesion.
Results
The postoperative protocol includes 2 weeks of 20 pounds of foot-flat weightbearing with no brace and does not vary from the isolated hip arthroscopy protocol. Patients are started on a stationary bike on postoperative day 1, and active hip flexor strengthening is avoided. Weightbearing is then progressed at week 3 with running progression at 3 months and return-to-sport training at 4 months. The senior author (C.S.M.) has been increasingly using BMAC in his practice for patients with chondral damage or preoperative mild degenerative changes with clinical success.
Discussion/Conclusion
Martin et al 5 published a prospective cohort study of 62 patients with isolated labral repair and 62 patients with labral repair with BMAC augmentation and found that in patients with moderate cartilage damage (Outerbridge 2 or 3), those patients who had labral repair supplemented with BMAC had greater mean patient-reported outcomes and greater score improvements at 12 and 24 months postoperatively.
Day et al 2 published a case-control study of 35 patients with Tönnis grade 1 and 2 changes undergoing arthroscopic hip procedures, using an age- and sex-matched control group without any arthritic changes. They found that there was no statistically significant difference in outcome scores up to 2 years postoperatively between the cohort and control groups.
Lastly, a study from 2021 demonstrated that in treating full-thickness acetabular chondral flaps during hip arthroscopy with a 1-year follow-up, there was significantly greater improvement in patient-reported outcomes in patients treated with BMAC compared to those treated with microfracture. 3
Thank you for your attention.
Footnotes
One or more of the authors has declared the following potential conflict of interest or source of funding: J.W.A. and C.S.M. receive support from Arthrex that makes an instrument system featured in the video for BMAC harvest/concentration. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
