Dr. Andrea Spiker...: Welcome everyone to the Arthroscopy Association's Arthroscopy Journal Podcast. I'm Dr. Andrea Spiker from the University of Wisconsin, and today I am joined by Dr. Molly Day, who is a sports medicine and shoulder surgeon, also at the University of Wisconsin Madison and is head team orthopedic surgeon for the UW Badgers men's hockey team, men's and women's soccer, track and cross country teams. Dr. Day was the lead author of the article titled, Hip Arthroscopy With Bone Marrow Aspirate Injection For Patients With Symptomatic Labral Tears and Early Degenerative Changes Shows Similar Improvement Compared With Patients Undergoing Hip Arthroscopy With Symptomatic Labral Tears Without Arthritis, which was published in the June, 2023 edition of the Arthroscopy Journal. Dr. Day's co-authors were Kyle Hancock, Ryan Selley, Reena Olsen, Anil Ranawat, Benedict Nwachukwu, Bryan Kelly and Danyal Nawabi. Welcome Dr. Day and thanks so much for joining me.
Dr. Molly Day: Thank you so much Andrea. I appreciate you inviting me to do this and to talk about our study in this ongoing area of research.
Dr. Andrea Spiker...: So Molly, would you mind starting our conversation today by telling us a little bit about you and your current practice?
Dr. Molly Day: Yeah, absolutely. So I completed my sports medicine fellowship at Hospital for Special Surgery in 2021 and I am now currently in my second year of practice here at the University of Wisconsin in medicine. At the moment, my practice breakdown is about 50-50 shoulder and knee. So admittedly despite publishing this paper, hip arthroscopy is not currently part of my practice.
Dr. Andrea Spiker...: Well that's great. That's why we work so well together at UW.
Dr. Molly Day: Exactly.
Dr. Andrea Spiker...: This will lead to a great conversation here on this podcast. So can you give us some of the background as to why you and your study team wanted to ask this question about whether bone marrow aspirate concentrate or BMAC injection at the time of hip arthroscopy made a difference in outcomes? Did you consider any other biological adjuvants or any other sites of BMAC harvest, for example? And can you just give us a background into what questions you were trying to answer?
Dr. Molly Day: Yeah, absolutely and I think we're all well aware that pain and limitations because of arthritis and specifically here, hip arthritis, just significantly compromises quality of life for patients. And in the management of the young adult with early hip OA, I think presents a very unique set of challenges as symptoms may originate from a variety of underlying hip pathologies. I think we don't completely understand the role of hip arthroscopy in this specific cohort of patients and there's a lot to be learned, which prompted this specific group of patients. I think there's recently been an increased interest in interventions that might potentially improve outcomes in this middle cohort, which again are patients who are not candidates for a total hip replacement, don't have severe enough hip OA but have room for improvement in outcomes following hip arthroscopy. Hip arthroscopy over the last 10 or 20 years has changed dramatically and we know that treatment strategies have continued to evolve and there have been development of new and refined surgical techniques and a growing popularity of utilizing biologic agents.
So we sought to determine the role of an intraarticular injection of iliac crest derived bone marrow aspirate at the time of hip arthroscopy in these patients who have symptomatic labral tears and also have early degenerative changes. And I think we acknowledge that our paper has limitations and further rigorous study is needed to really grow this area of research. But the aim was to draw attention to the fact that there may be a role for biologic augmentation in hip arthroscopy in patients with these borderline indications, and I think serves as a good starting point for us and for others to really delve deeper into this area of research.
As to your question of did we consider other biologic adjuvants or other sites of harvest, I think specific to hip arthroscopy, the iliac crest is easily accessible, is prepped out at the time of surgery, so makes for a convenient method of harvesting bone marrow. I think this study could be repeated with PRP and other biologic agents, but the focus for this particular study was to look at bone marrow aspirate.
Dr. Andrea Spiker...: Yeah, that's excellent Molly, and I think you brought up a couple of great points in that discussion of how you approached this study question. You're right that over the past couple of decades, hip arthroscopy has really advanced and I would say as we think about bone marrow aspirate concentrate and other biologics as it's used in other joints, there's probably less published to date in the hip in part due to the fact that it is kind of the newer area in sports medicine. And so I think it's very interesting, as you said, to start spurring the conversation and demonstrating whether or not this is going to make a difference in our hip arthroscopy surgeries and population. So you mentioned it briefly, but just for the listeners, can you describe in those patients in the study who ended up getting bone marrow aspirate concentrate harvested and then injected into the hip, how exactly did this happen at the time of surgery, the order of harvest and the procedure itself in the event that somebody who's listening wants to try to replicate this process themselves?
Dr. Molly Day: Yeah, absolutely. So we started the procedure by taking the bone marrow aspirate and again we use that ipsilateral iliac crest through an incision that was approximately two centimeters just posterior to the anterior superior iliac spine. And we used one specific aspiration system, but there are a variety that are available for use. And the specific system that we used utilized a sharp trocar that had a hollow sleeve, which is then placed into the cancellous bone between the cortices. And then as the aspirate is collected, this sleeve is repositioned after each approximately one milliliter of aspiration. So we achieved final volume of bone marrow aspirate between three and seven milliliters. And then at the very end of the case, so that was then saved, hip arthroscopy procedures then were performed as per standard. And then at the end of the case, the aspirate was injected intraarticularly through a needle that was placed under arthroscopic visualization, but after the capsule was closed.
Dr. Andrea Spiker...: Excellent. So you know mentioned that at this point in your practice you're no longer doing hip arthroscopy yourself. So can you tell us a little bit about your own practice and the use of bone marrow aspirate concentrate in your surgeries and your decision process as to whether you're going to add bone marrow aspirate to a case and then how you might discuss that with patients?
Dr. Molly Day: Yeah, that's a really great question and brings up a really good topic because currently routine BMAC injection is not a part of my practice and that's really because right now there is no major insurance carrier that are covering stem cell therapies and it's all considered investigational. So definitely the cost will fall on the patient. I think because of that, the utilization is very limited and based on a conversation of the appropriateness specific to the patient, understanding the limitations based on insurance. So I do think that hopefully this will evolve and change in the future. And I think the more studies that are published and more data that are shown to demonstrate the advantages of bone marrow aspirate utilization, hopefully this is able to become more broadly utilized and have a bigger role in orthopedic practice.
Dr. Andrea Spiker...: Yeah, I agree with you Molly. And granted we're both at the same institution, so this might be different at various institutions and with different patient markets. For example, in New York City where you have more patients who are willing to pay out of pocket for certain adjuvants such as BMAC or PRP, this might be a different conversation. But certainly in our patient population in Wisconsin, I find that it's exactly as you said. It's not covered by insurance and because we don't yet have the data to back it in routine addition to our surgical procedures, there's not a big push by the patients to have this administered at the time of surgery. But I think that's where articles such as your own showing that it could potentially really make a difference are so important and will perhaps be a part of that change that we're going to see in the future and integrating these types of biologics into our practice.
So at this point, maybe as we keep referring back to this paper and discussing how the BMAC was injected into the hip, we should talk a little bit about the overarching findings of this study with BMAC in the hip arthroscopy patient population. Would you mind just taking us through a very broad overarching summary of what the end result of this study was and how that might in turn help us decide when to use BMAC in hip arthroscopy and potentially other sports medicine surgeries?
Dr. Molly Day: Yeah, absolutely. And I just wanted to add one more point that reminded me when you were talking and brought up about utilization. But I think it's interesting because more and more patients are asking about stem cells and bone marrow and PRP and I think it's something that they're hearing more and more about. And I think as a profession we sort of have an obligation to study this further because I think that it's certainly something that I talk more and more about with patients. But again, it's hard to offer these procedures when A, I think there's a lot yet for us to learn about the specific protocol harvest protocol, the appropriate concentrate, but also because they would have to pay for it. But I do think that there are other providers in medicine who are willing to offer these therapies that are not as controlled and they're not done with the expertise that we do as orthopedic surgeons. And I think we need to stay on the forefront of this evolving surgical techniques just so that we are the ones that have control and patients aren't seeking these therapies elsewhere.
Dr. Andrea Spiker...: That's an excellent point. Kind of our obligation to maintaining evidence-based medicine but also following and pursuing this potential avenue that might really help our patients in the future. So excellent points.
Dr. Molly Day: And then the outcome of our study, and we may get into it a little bit further in other conversation, but we found that in these challenging patients with symptomatic labral tears and Tönnis one to two grade radiographic degenerative changes, hip arthroscopy with added bone marrow aspirin injection did result in improvement in patient reported outcomes that were comparable to a group of non-arthritic patients at the same and thus I think could be considered in this group. That comes with a caveat that there were a small proportion of patients that went on to early conversion to total hip within two years. So I do think that appropriate counseling is necessary when talking to these patients about hip arthroscopy and the both short and longer term outcomes.
Dr. Andrea Spiker...: And I think for the listeners too, the results basically help us draw the conclusion that this might be a method in which we can level the playing field. So we know that those patients with more advanced degenerative changes at the time of hip arthroscopy specifically typically don't have as good of outcomes after surgery as those who have pristine cartilage in their hip joints. And so here you've introduced this possible means which is relatively minimally invasive using autologous BMAC harvested at the time of the hip arthroscopy surgery with just a minimal additional incision and really no additional prep and drape, that might help our patients who might otherwise have poor outcomes really reach the pinnacle of their outcomes after surgery as if we had reached them before their cartilage was damaged. So really an impactful finding and again spurs the continued interest in whether or not we can really help our patients with this relatively minimal intervention.
Dr. Molly Day: Yes, exactly.
Dr. Andrea Spiker...: Now speaking of this patient cohort, the patients who are arthritic but not arthritic enough that it makes sense to put in a total joint replacement, this group really tends to be one of the most challenging groups of patients that we see in clinic. And I'd like to just hear your approach to this type of patient and we don't have to focus specifically on the hip, but you can talk also about these patients regarding the knee and the shoulder. When they come to your clinic and they have some degree of arthritis which you think may impact their outcome of other joint preserving surgeries or tendon surgeries, and can you take us through a little bit of your thought process, how you approach this with patients and how you end up ultimately treating these patients?
Dr. Molly Day: Yeah, absolutely. I think the patient that walks in the door with early OA and is a young adult I think are the hardest and have the longest conversations because there are a lot of options and often really weighing the pros and cons of the various interventions, both surgical and non-surgical that we can offer. So I think that this specific patient cohort has been the target of really research and innovations and treatment techniques because I think we have the potential to make the biggest impact in quality of life, especially like I said, this middle cohort of patients. I think specific to this particular paper, Andrea, like you alluded to, we know that for hip arthroscopy when arthritis is advanced, specifically patients with Tönnis grade greater than two radiographic changes or patients who have full thickness cartilage defects preoperatively, caution should really be used because these patients generally historically don't do as well falling hip arthroscopy.
I think in this particular patient cohort then more non-operative management should be considered until arthroplasty is desired or discussed. I think when there's a structural deformity present, and again you can speak of this specifically about the role of open procedures for the treatment of complex FAI or dysplasia then can be discussed given their underlying, again, structural abnormalities. Again, we showed that in patients with symptomatic labral tears, early radiographic degenerative changes, hip arthroscopy I think has a potential role with the adjunct of bone marrow aspirate. And as you said really well, kind of leveled the playing field and we found that these patients in the short term had very similar outcomes compared to the non-arthritic patients. So I think with short-term follow-up these patients do really, really well. And again in this population really having appropriate counseling of pros and cons and what to expect in the short and long term, and again the possibility of conversion to total hip arthroplasty should definitely be part of that conversation.
I think one of the advantages and probably why the hip is a harder joint to treat in this case is for the knee, I think there's an advantage that in early arthritis, especially specific to one affected compartment, there are surgical techniques to kind of unload that particular part of the joint. So whether it's a distal femoral osteotomy or high tibial osteotomy or even tibial [inaudible] for patella femoral OA, I think that those procedures can be considered that kind of unload the affected arthritic part of the knee, but then you have relatively preserved other compartments that can take over as the main weight-bearing source for that joint. And I think that's more unique to the knee and maybe not entirely the same for the hip, although again, there's a rule in a PAO, again if there's underlying dysplasia where that could be applicable. But I think that makes the conversation a little bit easier for the knee.
But I still have the conversation of joint preserving versus joint replacing procedures and the specific age cutoff and the degree or amount of arthritis I think is something that is based on each individual patient and a conversation specific to the goals and desires of that particular person.
Dr. Andrea Spiker...: And Molly, maybe you and I can meet in the middle at the knee because I do hip surgery and knee surgery in my practice and gave up shoulder surgery many years ago. But you make some really pertinent points about how the joints themselves are quite different. And so this conversation with those patients that have some early arthritis can be very different. And I think if you think about the knee arthroscopy in the slightly arthritic knee compared to a hip arthroscopy in a slightly arthritic knee, there's much more acceptance to perform that knee arthroscopy to do a clean out surgery for example, or get rid of some of the loose cartilage and frayed edges of meniscal. Whereas in the hip this is much less of an acceptable practice. And we could go into what reasons there are for that outside of the literature showing that patients with hip arthritis do worse, but also the cost of the procedure, the length of the procedure, the technical difficulty of the procedure when you compare hip to knee.
And so I'm curious, just when you think about shoulder versus knee, you've talked about ways in which you can potentially alter the course of a patient's early knee arthritis. What are you talking about with shoulder patients and what are you thinking about in that shoulder patient who has early arthritis but is not quite yet ready for an arthroplasty?
Dr. Molly Day: Yeah, that's a really great point. And I think between the shoulder and the knee, the difference in the joints are knees are obviously weightbearing and people walk on two legs and generally don't walk on their arms. So I think the people tend to ... Some patients tend to have more success with non-operative management of early shoulder arthritis just for that fact alone. But when it comes down to the shoulder, I think beyond the non-operative treatments that we offer every patient with early OA, I think there is some role in looking specifically at is there an involved structure that seems to be more symptomatic that can be addressed, a symptomatic biceps tendon or some impingement or in that case, I think trying to hone in on what specifically might be causing the majority of the symptoms. And I think there could be a role in addressing those few structural symptomatic structures, shy of doing a full shoulder replacement, but tends to not be one to offer just kind of clean up procedures for the shoulder either and will generally speak of the roles of all non-operative management.
And if there's a surgical indication, we'll discuss it. But really I think in these patients it's important when indicating patients for surgery to really understand the benefit and limitations to best minimize the number of failed procedures. Because I think worst case scenario is you indicate for someone for surgery and their expectation is they're going to walk out of the OR with a completely asymptomatic shoulder or completely asymptomatic hip or knee, and that's just not the reality. So I think that's the most important piece of this is having a very honest conversation with patients about what to expect.
Dr. Andrea Spiker...: It's very interesting to think about the nuances and differences between each of these joints because in general terms, we often think about them in the same terms, but really there are so many very nuanced differences that play into how we treat patients, how we consult patients, and then ultimately how our patients do. So thanks for that. So to finish our conversation tonight, I just want to touch on thinking back on the BMAC question, injecting into hip arthroscopy procedures or even more broadly, injecting into shoulder or knee procedures. What research questions do you think we should continue to focus on to really help us understand how best to treat this group of patients that are somewhat arthritic but not arthritic enough for arthroplasty? Where do you think we should be focusing on the future? As we just spoke, it's very important for us to take the reins of this research and try to lead the conversation, but where should we go next?
Dr. Molly Day: Yeah, absolutely. And that's already something that my co-authors have been discussing after publishing this paper is what is the next step? And I think the next step is to really refine our approach and design a prospective randomized clinical trial in this group of patients with more robust methodology, including analyzing the bone marrow aspirate to really assess the composition and biologic activity to not only help better define the role, but then also to counsel and help others be able to reproduce and duplicate our methods to have some consistency in the literature. Because I think important for having and allowing this to be approved by insurance companies and seeing where this goes in the future will be to have consistent and reproducible methods of both harvesting and knowing what the composition of this bone marrow aspirate is to better define its role.
Dr. Andrea Spiker...: Yeah, that would be very interesting information to know and will be very helpful for us in the future. So thank you so much, Molly, again for joining us and it's been a real pleasure speaking to you about this paper. I look forward to seeing you in the OR probably tomorrow.
Dr. Molly Day: Thank you so much, Andrea.
Dr. Andrea Spiker...: Dr. Day’s article titled, Hip Arthroscopy With Bone Marrow Aspirate Injection For Patients With Symptomatic Labral Tears And Early Degenerative Changes Shows Similar Improvement Compared With Patients Undergoing Hip Arthroscopy With Symptomatic Labral Tears Without Arthritis can be found online at www.arthroscopyjournal.org. This concludes our episode of the Arthroscopy Journal Podcast. Thank you for joining us. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal.
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