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Use of Bone Marrow Aspirate Concentrate with Hip Labral Repair for the Management of Chondrolabral Junction Breakdown

February 10, 2018

Contributors: Scott David Martin, MD; John W Stelzer, MS; John W Stelzer, MS

Introduction: Femoroacetabular impingement is a known cause of damage to the acetabular labrum and chondrolabral junction, resulting in accelerated progression to osteoarthritis. Hip arthroscopy has been used to manage labral tears; however, strategies to mitigate or reverse chondrolabral junction damage do not exist. Cell-based therapies, including autologous chondrocyte implantation, osteochondral autograft transfer, microfracture, and bone marrow aspirate concentrate (BMAC) have been suggested to restore joint congruity and minimize additional chondral deterioration. Unfortunately, because of the technical constraints of the hip joint and morbidity of open procedures, autologous chondrocyte implantation and osteochondral autograft transfer have limited applications in the hip. In addition, microfracture may accelerate cartilage degeneration because of subchondral bone disruption. However, BMAC may augment healing of chondral defects without the use of multiple procedures, donor-site morbidity, and disruption of subchondral bone. BMAC involves the application of concentrated bone marrow–derived mesenchymal stem cells to the surface of chondral defects, allowing the progenitor cells to differentiate into mature cartilage. Recently, biologics such as BMAC have been used to aid cartilaginous healing in the knee; however, none have been successfully used to manage chondral defects in the hip. In this surgical technique video, we apply the studied benefits of BMAC to the chondrolabral surface of the hip without donor-site morbidity or increased labral repair time. Surgical Technique: During hip arthroscopy with a puncture capsulotomy, acetabular rim recession and labral repair are performed. Concurrently, a 60 cc solution of anticoagulated venous blood is prepared and centrifuged for separation of red blood cells, platelet rich plasma, and platelet poor plasma. A 20 cc mixture of 4 cc of platelet rich plasma and 16 cc of platelet poor plasma is withdrawn for later combination with concentrated stem cells. Using the established arthroscopy portals, the bone marrow–derived mesenchymal stem cells are harvested from the ilium proximal to the sourcil and the superior suture anchors and laterally adjacent to the reflected head of the rectus femoris. Next, the bone marrow aspirate needle is placed in the correct position on the bone, and fluoroscopy is used to confirm its location. The needle is driven with a mallet at 45° cephalad in the coronal plane so that the suture anchors are not compromised on needle insertion. After the cortex has been breached, the needle is advanced approximately 0.5 to 1 cm with constant pressure and simultaneous back and forth rotation. The tip of the needle's final position is confirmed via fluoroscopy. Approximately 25 cc of bone marrow is aspirated into four separate heparin-rinsed 60 mL syringes, resulting in a total of 100 cc of bone marrow aspirate. The bone marrow aspirate is then centrifuged to yield 3 cc of concentrated stem cells. The concentrated stem cells are added to the solution of previously collected platelet rich plasma and platelet poor plasma. Next, thrombin is added to the final stem cell solution, beginning the clotting cascade to form a megaclot. Between 3 and 5 minutes after thrombin introduction, the megaclot solution is then applied to the chondrolabral junction and labral repair site with the use of a bone marrow aspirate needle while the hip is in minimal traction. After traction is released, the megaclot and labral repair site are visualized while the patient’s hip is flexed from 0° to 45°. Conclusion: Within the technical constraints of the hip joint, BMAC is a feasible and potentially effective option for the management of chondral defects. In the senior author’s experience, no adverse events, such as bleeding, neurovascular injury, inadvertent needle placement, or heterotopic ossification, have been reported in 100 patients who underwent this BMAC technique. Outcomes data from patients who underwent BMAC treatment via this technique are currently being collected and are, thus far, favorable. Late-stage hip osteoarthritis is an indicator of poor prognosis for surgical and nonsurgical management of chondral defects. Therefore, preventing late-stage hip osteoarthritis is paramount to decrease poor outcomes and improve a patient’s quality of life. Early and effective management at the sites of chondral breakdown via techniques that afford patients little to no drawbacks, such as BMAC, are necessary to achieve these goals.

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