As an aftermath of an accident, 20-year old, state-level badminton player, Kunal Bhide was suffering from excruciating pain and stiffness in his right shoulder. During his treatment Kunal got an implant in his shoulder so that he could continue playing his favourite sport. However, after some time his right shoulder cartilage deteriorated due to the implant. He was later directed to Deenanath Mangeshkar Hospital, Pune where Dr Ashish Babhulkar, a Shoulder Specialist and Joint Replacement Surgeon conducted an Autologous Chondrocyte Implantation (ACI) to save his shoulder joint. After six to eight weeks of post-operative rehabilitation, Kunal has regained full range of motion and function. Dr Babhulkar explains this rare surgery case in conversation with Raelene Kambli
Congratulations on the success of the first shoulder regeneration case in India. Can you brief us on the complexity of this case?
| Dr Ashish Babhulkar |
The challenges were formidable for two reasons. First, the ball of shoulder joint is round unlike the knee joint. To pour a liquid graft on around eroded surface has its own challenges. Hence a silicone jacket was designed to retain the cell culture to help keep it snug and prevent spillage.
The other complexity, in Kunal’s case, was the presence of the protruding screws. If they were left in place the screws would scrape the fresh cartilage cover. So an arthroscopic removal of the screws was planned with an innovative technique. A special instrument – hollow mill was used to drill around the protruding screws and extricate them.
This was achieved with a minimally invasive arthroscopic procedure. Following this the joint was then opened up and the cartilage defect was freshened and the donor cartilage cell ulture was pasted over the defect within the silicone jacket.
After three years now, Kunal finally has a cartilage cover and along with that the hope that he would eventually have a functioning right shoulder.
Were there no shoulder joint related surgeries done before in India? Or this a rare type?
Shoulder surgery is now popular. I have been a shoulder specialist since 2001. However cutting edge arthroscopic surgery is rather high tech and we have very few training centres in India. Over the next few years major milestones will continue to be achieved. The ACI for the shoulder is arguably the first of its kind that we are aware of. There are no precedents for ACI in shoulder.
What is Autologous Chondrocyte Implantation (ACI)?
The idea of an ACI procedure is to take a few cartilage cells from the knee, grow them in the lab, and once millions of cells have been grown they are implanted into the area of cartilage damage. ACI is a two step procedure:
Step one: Arthroscopy: The first step of ACI is to perform an arthroscopic surgery to identify the area of cartilage damage, and determine if it is appropriate for an ACI procedure. During the arthroscopic procedure, cartilage cells are collected. These cells are sent to a cell expansion laboratory where they are multiplied by growing in a culture. Growing enough cells takes about four to six weeks. Once enough cells have been grown, they are sent to the surgeon, and the second surgery is scheduled.
Step two: Implantation: Once sufficient cartilage cells have been grown, a second surgery is scheduled. The cultured cells are implanted back into the defect site during this surgery.
Doctor you have done a lot of research in the area of shoulder and joint replacement. Tell us in which cases should ACI be used?
ACI is a landmark procedure. The recovery is lengthy, and patients must be prepared to participate with intensive physical therapy. ACI is only appropriate for patients with small areas of cartilage damage, not widespread wear of the cartilage characteristics of knee arthritis. Young patients with 1-4 cm cartilage defect rather than wear are deserving of ACI. However there are strict prerequisites that the patient has to fulfill. The joint should be without deformity and contractures. There should be no evidence of infection and prominent damaging hardware, like in our case, will have to be removed in advance.
Is there any age limit for patients to undergo an ACI?
As a norm, ACI is offered to younger patients who would maximally benefit from this procedure. Older patients beyond 50 years can easily be accommodated by a joint replacement surgery which has less demanding pre-requisites and the joint replacement burns bridges anyway.
Could you give us more scope on the use of ACI in India?
Awareness of ACI is progressively increasing, and can be applied to the major joints like knee, ankle, shoulder and elbow quite predictably and with reliable outcomes.
Is this a cost effective treatment method?
In the past, means for ACI were not available and was also prohibitively unaffordable. With more prolific use and production houses in India it is now within reach of the common man. Although not cheap you must understand that this is a revolutionary procedure that will restore the function of the arm.