Cyclist back on track after hip grafting procedure at UCH

Transplant of juvenile cartilage turns back the clock
May 11, 2016

David Rogers is 56, but he carries within him something far more youthful.

Sure, he’s young at heart, a necessary attribute of a guy who in middle age remains a competitive cyclist after nearly 30 years pushing the pedals. But more tangibly, Rogers carries a piece of youth in his right hip.

Cecilia Pascual-Garrido, MD
Cecilia Pascual-Garrido, MD, performed the state’s first repair of damaged hip cartilage using a tissue graft of juvenile cartilage cells.

The source is cells within minced pieces of cartilage from donors no more than eight years old. Orthopedic surgeon Cecilia Pascual-Garrido, MD, an expert in cartilage preservation, transplanted them into Rogers’ hip joint late last fall at University of Colorado Hospital.

About six months after the graft, Rogers has relief from nearly two years of intense hip pain caused in large part by severe cartilage damage. On April 23, he rode the 52-mile Clasica de Rio Grande bike race in Johnstown, Colo., finishing fifth in his classification and just 0.6 seconds off the winning time.

“I’m still not at 100 percent, but I’m progressing with a balance of cycling, cross training, strength work and stretching,” Rogers said in a phone interview. “I have the occasional twinge with a few movements but overall the hip is pain free and I’m riding with power on the right side.”

The craft of graft

The cartilage transplant procedure at UCH has helped David Rogers get back to the competitive biking he’s done most of his adult life. (Photo courtesy David Rogers.)
The procedure, dubbed the DeNovo NT Natural Tissue Graft, from Warsaw, Ind.-based Zimmer Biomet, is used to restore and repair damaged cartilage, most often in knees and ankles. Rogers is the first patient in Colorado to have the procedure on a hip, Pascual-Garrido said. She used it to treat a lesion in the labrum, the cartilage that cushions the ball-and-socket joint of the hip.

It’s an overuse injury, Pascual-Garrido said, that affects many cyclists, as well as hockey and soccer players. These athletes often have a cam impingement – a bony protrusion – that wears down the cartilage, she said.

For people younger than 40, Pascual-Garrido typically performs either micro-fracture or micro-drill surgeries. Both involve removing a tissue flap of cartilage and drilling holes in the socket bone of the joint. Bone marrow cells come through the holes and combine with blood to create a covering on the bone that eventually heals as new, protective tissue, Pascual-Garrido said.

However, those procedures are far less effective for people past the age range of 40 to 45, like Rogers, she added.

“As we become older, the capacity of healing after cartilage repair is greatly reduced,” she said. The DeNovo graft procedure can change the equation. That’s because the cells of juvenile cartilage “have a great capacity for regeneration,” Pascual-Garrido said. For someone like David Rogers, they can become a joint’s fountain of youth.

Cam Lesion
Pascual-Garrido used this image to identify the the cam (bump) lesion on Rogers’ right hip before surgery (shown on the far left in this shot). The lesion wore away cartilage in the joint.

The allograft procedure uses particles of natural cartilage with living cells packed in a small, sealed container. Unlike other repairs, it uses no water, which would wash the cells away, Pascual-Garrido said. Guided by arthroscopic imagery, she uses a catheter-like delivery device and miniature instruments to put fibrin glue in the lesion, followed by the cartilage cells, and then another layer of the glue to fix the cells in place “like a sandwich.” With time, new cartilage begins to grow.

The entire transplant procedure takes only about 30 minutes, Pascual-Garrido said. The standard post-surgical regimen calls for the patient to stay non-weight-bearing for six weeks. Rogers hit the three-month mark “doing great,” Pascual-Garrido said, although she confessed to worrying a bit about his aggressive efforts to get back to cycling.

Back to the bike

Rogers readily acknowledges that he’s pushed the recovery envelope. He said he’s now ridden 100 miles at a time, including stretches in the mountains, sprinted at his top bike speed, raced in a pack and plans to continue to ride competitively. He knows he’s walked a fine line, illustrated by the fact that he was at the gym the day after his procedure, exercising on a spinning bike.

“It was a real morale boost to know going into this that cycling itself would be one of my primary modes of therapy and that I could be on a spin bike the day after to get the process started,” he said, adding that in the ensuing weeks he progressed to other activities and weight-bearing exercises.

“I have probably teetered at times on the side of being too motivated,” Rogers said. “I was diligent about progressing quickly, but I have a tendency to be overly aggressive.”

He knows, for example, that by pushing his recovery early, he increases the risk of the cartilage failing to knit properly. But he’s encouraged by the positive results he’s achieved thus far.

The price of pedaling

If he strains against limitations, perhaps it’s because he’s come so close to losing something he loves. By day, Rogers works a job in health care, but outside of work, he enjoys the experience of riding with friends, training and competing.

Cam Resection
During surgery, Pascual-Garrido transplanted new cartilage to Rogers’ hip joint, but also removed the cam lesion (shown at the far left of image A) to prevent the cartilage from wearing away again. Image B shows the repaired joint, minus the bump.

About two years ago, however, the physical toll caught up with him. It began with a popping sensation in his right hip that came and went. He raced a full season in 2014 and completed 23 events in 2015. But the pain worsened, and he had increasing difficulty flexing his right leg and even bringing it across the seat of the bike.

Rogers is no stranger to pain from injuries and chronic overuse. He carries a plate and screws in his left hip and femur from a fracture sustained in a cycling crash 10 years ago and has suffered many other injures. But the right-hip discomfort eventually led him to treatment with CU Sports Medicine orthopedist Omer Mei-Dan, MD. Mei-Dan administered two rounds of cortisone shots, and later injected platelet-rich plasma in the joint to promote healing.

The procedures gave Rogers relief from the pain, and they helped him to get through the 2015 season. By the end of it, though, the effects had started to wear off. He explored surgery to repair the damage with Pascual-Garrido, who defined the extent of the injury with imaging. It showed that Rogers had a severely torn labrum, the result of the large bump on the head of the femur that prevented the joint from moving smoothly – the last thing a cyclist wants.

Pascual-Garrido said she considered a micro-fracture procedure as an option when she began the surgery, but decided on the DeNovo graft because of the size of the lesion and Rogers’ age. She noted that while the surgery went very well, the wear-and-tear on the joint could eventually progress to osteoarthritis and possibly require hip replacement. But the DeNovo graft doesn’t close off any subsequent options for Rogers, including alternative stem cell procedures to rebuild cartilage.

“If it doesn’t work, we haven’t burned any bridges,” she said.

Toward the future

arthroscopic view of the minced juvenile cartilage
An arthroscopic view of the minced juvenile cartilage that Pascual-Garrido transplanted to Rogers’ hip.

For now, the DeNovo procedure is considered experimental for hip repair, but Pascual-Garrido, who learned the technique doing knee surgeries, said there is reason for optimism.

“There have been no adverse effects of this procedure on the knees,” she said.

Rogers is focused on the future, and he credits Pascual-Garrido, herself an accomplished marathoner, and her team for getting his bike and his life back on track.

“They are a great team, communicate very well, and graciously answered all my questions immediately,” Rogers said. “As a physician who is an elite athlete, Dr. Pascual-Garrido understands the mentality of another athlete. When you have a doctor who can relate to how you think and how you process good news and bad news and respond to adversity because they have been through it themselves, that makes the connection all the stronger,” he said.

“I’ve been very fortunate to have her in that regard,” Rogers added. “I’ve never been anywhere near the top end of this sport but I have been a fan and a participant since I was 12 years old. It truly is part of who I am so to have the opportunity to continue is a gift.”

About the author

Tyler Smith has been a health care writer, with a focus on hospitals, since 1996. He served as a writer and editor for the Marketing and Communications team at University of Colorado Hospital and UCHealth from 2007 to 2017. More recently, he has reported for and contributed stories to the University of Colorado School of Medicine, the Colorado School of Public Health and the Colorado Bioscience Association.