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Tissue Engineering and the Future of Hip Cartilage, Labrum and Ligamentum Teres Allston J

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Tissue Engineering and the Future of Hip Cartilage, Labrum and Ligamentum Teres Allston J Journal of Hip Preservation Surgery Vol. 3, No. 1, pp. 23–29 doi: 10.1093/jhps/hnv051 Advance Access Publication 12 August 2015 Review Article REVIEW ARTICLE Tissue engineering and the future of hip cartilage, labrum and ligamentum teres Allston J. Stubbs1,*, Elizabeth A. Howse2 and Sandeep Mannava1 1. Division of Sports Medicine, Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA 2. Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, 1425 S. Main St, Walnut Creek, CA, 94596, USA *Correspondence to: A. J. Stubbs. E-mail: [email protected] Submitted 30 March 2015; revised version accepted 27 June 2015 ABSTRACT As the field of hip arthroscopy continues to evolve, the biological understanding of orthopaedic tissues, namely articular cartilage, labral fibro-cartilage and the ligamentum teres continues to expand. Similarly, the need for biological solutions for the pre-arthritic and early arthritic hip continues to be a challenge for the sports medicine surgeon and hip arthroscopist. This article outlines existing biological and tissue-engineering technologies, some being used in clinical practice and other technologies being developed, and how these biological and tissue- engineering principals may one day influence the practice of hip arthroscopy. This review of hip literature is specific to emerging biological technologies for the treatment of chondral defects, labral tears and ligamentum teres deficiency. Of note, not all of the technologies described in this article have been approved by the United States Food and Drug Administration and some of the described uses of the approved technologies should be considered ‘off-label’ uses. INTRODUCTION developed, and how these biological and tissue-engineering Hip arthroscopy has evolved significantly since Burman’s principals may one day influence the practice of hip arthros- [1] first 1931 report of the arthroscopic appearance of copy. This article is a forward thinking and certainly not all in- intra-articular structures. As hip arthroscopy has rapidly clusive, as many of the technologies described have not been evolved, the specific instrumentation for performing the specifically tested in the hip joint; however, after review of the operations as well as the indications for surgery has ex- article, the reader will have a better understanding of recent panded [2]. As the field of hip arthroscopy continues to tissue-engineering and biological technologies that may influ- evolve, the biological understanding of orthopaedic tissues, ence clinical practice in the years to come. We conclude this namely articular cartilage, labral fibro-cartilage and the liga- article by briefly mentioning some of the techniques used at mentum teres, continues to expand. Similarly, the need for our institutes’ regenerative medicine laboratory, although not biological solutions for the pre-arthritic and early arthritic all of the techniques describedarebeinginvestigatedfor hip continues to be a challenge for the sports medicine sur- orthopaedic purposes, we do hope the mention of these tech- geon and hip arthroscopist. nologies will result in future orthopaedic and musculoskeletal This article will briefly review the native hip anatomy investigation. Of note, some of the described uses of the and common pathology encountered in patients undergo- approved technologies should be considered ‘off-label’ uses as ing hip arthroscopy. The focus will then shift to outlining not all of the technologies described in this article have been existing biological and tissue engineer technologies, some approved by the United States Food and Drug being used in clinical practice and other technologies being Administration to be used as described. VC The Author 2015. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 23 24 A. J. Stubbs et al. NATIVE HIP ANATOMY AND PATHOLOGY matrix components, including aggregans that are not ex- The hip is a weight-bearing ball and socket joint that is pressed optimally in the regenerated cartilage [21]. deeply seated and congruent, with a great deal of anatom- There are numerous reports in the literature that ical constraint, especially when compared with the shoul- demonstrate favourable clinical outcomes when perform- der joint. Two main forms of cartilage exist in the hip ing microfracture for the articular surface of the hip joint joint, articular hyaline cartilage, from innominate fusion of [15–18]. Philippon et al. [15] examined the percentage of osteochondral complexes, and labral fibrocartilage [3–5]. filled articular cartilage defect on the acetabular side of the The hip joint also contains the ligamentum teres, which hip joint after microfracture surgery as evaluated by se- does have an embryological and early developmental role cond-look revision hip arthroscopy. They report excellent in hip joint formation, yet the role in pathology remains of results of 95–100% coverage of the isolated acetabular some debate. The ligamentum teres may not simply repre- chondral lesions at an average of 20 months follow-up for sent vestigial anatomy, with some recent literature suggest- eight of their nine patients [15]. Similarly, Karthikeyan ing a more structural role [6–8]. The hip joint derives its et al. [16] demonstrated adequate macroscopic fill of vascularity from innominate fusion and much of the in- acetabular articular defects with associated femoral nervation of the joint is shared from surrounding layers acetabular impingement on second-look arthroscopy after and muscle-tendon units [5]. microfracture was performed an average of 17 months The challenge for the hip arthroscopist is to address prior. In addition, microscopic histological evaluation of various lesions of the articular cartilage, fibrocartilagenous the tissue demonstrated fibrocartilage in the region of the labrum and the ligamentum teres in a minimally invasive microfracture. In all, 19 of the 20 patients in the series manner. The pre-arthritic and early arthritic hip can be par- demonstrated mean fill of 96%. Domb et al. [17] studied ticularly challenging surgically because of its deep anatomic patient reported outcome measures and demonstrated location, and the relatively high physiological loads, forces significant clinical improvement after microfracture was and stresses seen by the joint. performed in their patient cohort at 2-year follow up. The outcome measures assessed were the modified Harris Hip Sore, the Non-Arthritic Hip Score (NAHS), the Hip HIP ARTICULAR CARTILAGE Outcome Score–Activities of Daily Living, and the For the hip arthroscopist, articular cartilage defects can be Hip Outcome Score—Sport Specific Subscale. These addressed in the pre-arthritic or early arthritic stage. The scores improved in their cohort; interestingly the improve- gold standard for end-stage hip arthritis is total hip arthro- ment occurred for both a workers’ compensation and a plasty; but there are many patients who have articular car- non-workers’ compensation cohort at 2 year follow up tilage wear that may not be significant enough to warrant when compared with pre-operative scores [17]. In elite total joint arthroplasty [9–11]. To date, there are several athletes who underwent hip arthroscopy with microfrac- articular cartilage strategies that have been employed to ture compared with elite athletes who underwent hip arth- help restore focal and larger cartilage defects in the active roscopy without microfracture, McDonald et al. [18] patient. Some of these articular cartilage strategies include demonstrated that the additional procedure of microfrac- autologous chondrocyte implantation , microfracture, com- ture surgery did not preclude the athlete from returning to posite grafting [e.g. synthetic TruFit bone graft substitute a high level of competition. (Smith & Nephew Inc., Andover, MA, USA)], osteochon- Other, more isolated case series have demonstrated dral autograft transfer system (Arthrex Inc., Naples, FL, some early success with mosaicplasty and autologous chon- USA) and fresh frozen allograft [12–20]. drocyte transplantation for the treatment of hip articular When examining cartilage, the ‘gold-standard’ is hyaline defects [19, 20]. Hart et al. [19] demonstrated the feasibil- cartilage, which is the native cartilage of the hip joint; ity of mosaicplasty of femoral head cartilage defects with mainly comprised of type II collagen and layers of func- autologous grafting from non-weight bearing portions of tional cells and extracellular matrix [12, 21, 22]. Marrow the knee in their case report. The authors of this report stimulation or microfracture technique has been utilized state that their experiences with mosaicplasty techniques in for hip articular cartilage restoration, with the goal of stim- the hip are limited but theoretically, in certain clinical situ- ulating pluripotent cells of the inner pelvic table and ations, may benefit the patient with a cartilage defect. proximal femur to restore focal areas of cartilage defects Fontana et al. [20] compared the results of autologous [15–18, 21, 22]. The microfractured cartilage that replaces chondrocyte transplantation (n ¼ 15 patients) versus the injured region of articular cartilage
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