Hip Labral Tears Benefiting from Lessons Learned with Shoulder Tears
By BECKY GILLETTE
Improved treatments include OATS, meniscus transplants and platelet rich plasma
Improvements in surgical and rehabilitation techniques used in sports medicine are allowing athletes to recover faster and get back in the game.
"A big thing in sports medicine is improvements in arthroscopic surgery for labral tears," said Lawrence (Larry) O'Malley, MD, a sports medicine specialist with the University of Arkansas for Medical Sciences (UAMS) Orthopedic Clinic in Little Rock and Conway. "Internal impingement can cause labral tears and also cartilage injuries. We have been doing arthroscopic surgery for labral tears in the shoulder for multiple years. Now we are also seeing a lot of success fixing labral tears in the hips. Arthroscopy for labral tears is a large portion of my practice. We are able to perform more repairs than we could previously."
In terms of cartilage restoration, there is now a whole gamut of options including the Osteoarticular Transfer System (OATS), osteochondral allografts or MACI, where a surgical procedure is used to transplant cartilage from either a cadaver or from a non-weight bearing, undamaged area of the joint to the damaged area of the joint.
"You can also transplant knee meniscus from someone else," O'Malley said. "Associated with that are alignment procedures - making sure there are no alignment issues affecting the cartilage wear. We try to preserve the knee so the patient won't need a replacement. These are for people with isolated defects versus someone with global arthritis, and global cartilage loss. It is important to pick the right patients who have isolated lesions. These are many younger patients, often 45 and under."
Another option is Platelet Rich Plasma (PRP), which uses the patient's own blood to stimulate growth in injured tissues. Evidence is increasing that PRP may be effective in managing pain associated with knee osteoarthritis.
"Studies have shown PRP can be helpful, but that is not growing new cartilage," said O'Malley, who is also an assistant professor in the UAMS College of Medicine's Department of Orthopaedic Surgery. "The best way to replace cartilage is to transplant cartilage from someone else or the patients themselves."
Anterior Cruciate Ligament (ACL) injuries in athletes are very common, and for years orthopedic surgeons have been doing reconstruction using a graft to replace the ligament. O'Malley said that a quadriceps tendon graft is an excellent option instead of doing a hamstring or patella tendon graft.
"There is also Anterolateral Ligament Reconstruction where an extra articular ligament is used to supplement for someone who has had an ACL reconstruction that has failed," O'Malley said. "We are adding the ALL to protect the rotation forces on the ACL. Hopefully, it is a way to reduce the risk of ACL re-tears. It is a newer procedure we are doing more often. We are still trying to study it to see who needs it and who doesn't need it. I will do it depending on the patient's needs."
In terms of rehab, some therapy centers in the state, including those at UAMS, are using an anti-gravity device originally developed using NASA technology called the AlterG® Anti-Gravity Treadmill. This is used to reduce body weight to 20 percent so patients can get up walking and running earlier after knee and hip surgeries.
"It is a great option that allows us to get patients back to health more quickly," he said. "Another great tool is blood flow restriction. A special blood pressure cuff is used to provide 80 percent constriction so the patient works at 20 percent of normal mass. For example: they used to leg press 200 pounds. With blood flow restriction, they now leg press 40 pounds, but get the results of 200 pounds. This rebuilds muscle in areas that have previously been injured.
"The NBA has used it the past four or five years to help athletes recover while building muscle. A lot of the therapy clinics around the state have been getting these machines and it is really helping patients get back to functioning quicker. After you take that tourniquet off, you get a rush of blood that enhances tissue growth."
Wearable telematic devices are increasingly being used as prices have come down. O'Malley said these are useful for determining an athlete's performance before and after treatments. Are they back to baseline or are they still having issues?
"Out on the field, the athlete may not be as good as we expect, or may be better than expected," O'Malley said. "This information can help decide how much to allow the athlete to practice. The problem is the cost; not everyone can afford these. But they can be extremely helpful in terms of monitoring athletes and getting them back to full activity.
O'Malley said he loves working with athletes, who are usually very motivated to get well so they can get back playing the game they love.
"What I like about my job is most of the time you fix them, and they are back to where they were and are able to meet their goals and aspirations," O'Malley said. "That is something I really enjoy seeing. Unfortunately, with ACL, recovery can take 6 to 12 months."
While the surgeries take only a short period of time, O'Malley's job is not done after the surgery.
"The great part of my job is the encouragement aspect of getting them back to their previous level of competition or perhaps even getting them better than they were before," he said.
The UAMS Sports Medicine Clinic takes care of athletes at the University of Arkansas Little Rock, Philander Smith College, Arkansas Baptist College, and the University of Arkansas Monticello. O'Malley takes care of athletes at North Little Rock High School. "As of this point, we continue to expand taking care of more and more colleges," he said. "It takes time to develop those relationships."