Mosaicplasty for the treatment of femoral head defect after incorrect resorbable screw insertion

Outcomes of Osteochondral Allograft Transplantation for Femoral Head Cartilage Lesions: Minimum 2-Year Follow-Up

BACKGROUND

The surgical management of large osteochondral lesions of the femoral head in young, active patients remains controversial. Fresh osteochondral allograft (OCA) transplantation can be a highly effective treatment for these lesions in some patients. This study investigated survivorship as well as clinical and radiographic outcomes after fresh OCA transplantation at a minimum 2-year follow-up (mean, 6.6 years; range, 0.6 to 13.7 years).

METHODS

A retrospective review of 29 patients who underwent plug OCA transplantation for focal femoral head osteochondral lesions between 2008 and 2021 was performed. Patients were assessed clinically using the modified Harris Hip score (mHHS) preoperatively and at each follow-up visit. Postoperative radiographs were evaluated for graft integrity and osteoarthritis severity. Kaplan-Meier survivorship analyses with 95% confidence intervals (CIs) were performed for the endpoint of conversion to total hip arthroplasty (THA).

RESULTS

Overall graft survivorship for included patients was 78.4% (95% CI: 62.9 to 93.9) and 62.7% (95% CI: 39.6 to 85.8) at 5 and 10 years, respectively. There were ten patients (34.5%) who underwent conversion to THA. There was a significant difference using the log-rank test between survival for patients who had a preoperative diagnosis of osteonecrosis (ON) versus those who had other diagnoses (P = .002). The ten-year survival for those who had ON was 41.8% (95% CI: 4.8 to 78.8), and the ten-year survival for diagnoses other than ON was 85.7% (95% CI: 59.8 to 100). The mean mHHS score improved significantly (P < .001) from 48.9 (19 to 84) preoperatively to 77.4 (35 to 100) at the final follow-up. There were twenty patients (69.0%) who had mHHS ≥ 70 at the latest follow-up. Arthritic progression, indicated by an increase in the Kellgren and Lawrence grade, occurred in 7 hips (26.9%).

CONCLUSIONS

An OCA transplantation is a viable treatment option for osteochondral defects of the femoral head in young, active patients who have minimal preexisting joint deformity. It may delay the progression of arthritis and the need for THA. Patients who had a preoperative diagnosis of ON had worse clinical outcomes than those who had other diagnoses.

Modified osteochondral autograft transplantation for steroid-induced osteonecrosis of femoral head in idiopathic thrombocytopenic purpura: a case report and literature

Osteochondral autograft transplantation (OAT) has been commonly applied in the knee and ankle while the technique has not yet been a popularity in the femoral head. In this article, we present a 28-year-old female patient, who has a history of 1-year-use of glucocorticoid in the treatment of idiopathic thrombocytopenic purpura, with steroid-induced osteonecrosis of the femoral head (SONFH). She underwent surgical hip dislocation, osteochondroplasty, OAT, and internal fixation. Her Harris Hip Score improved from 64 to 82 in 36 months to follow-up. The case is valuable considering that a single, instead of several, 1.5 cm autograft was harvested from the non-bearing part of the same femoral head. This modification dispensed with the need of surgery for harvesting autograft from knee or ankle and reduced the structural vulnerability brought by the multihole donor part of the femoral head.

Surface repair of the femoral head using press-osteochondral autograft transfer

Aims

Hyaline cartilage has a low capacity for regeneration. Untreated osteochondral lesions of the femoral head can lead to progressive and symptomatic osteoarthritis of the hip. The purpose of this study is to analyze the clinical and radiological long-term outcome of patients treated with osteochondral autograft transfer. To our knowledge, this study represents a series of osteochondral autograft transfer of the hip with the longest follow-up.

Methods

We retrospectively evaluated 11 hips in 11 patients who underwent osteochondral autograft transfer in our institution between 1996 and 2012. The mean age at the time of surgery was 28.6 years (8 to 45). Outcome measurement included standardized scores and conventional radiographs. Kaplan-Meier survival curve was used to determine the failure of the procedures, with conversion to total hip arthroplasty (THA) defined as the endpoint.

Results

The mean follow-up of patients treated with osteochondral autograft transfer was 18.5 years (9.3 to 24.7). Six patients developed osteoarthritis and had a THA at a mean of 10.3 years (1.1 to 17.3). The cumulative survivorship of the native hips was 91% (95% confidence interval (CI) 74 to 100) at five years, 62% (95% CI 33 to 92) at ten years, and 37% (95% CI 6 to 70) at 20 years.

Conclusion

This is the first study analyzing the long-term results of osteochondral autograft transfer of the femoral head. Although most patients underwent conversion to THA in the long term, over half of them survived more than ten years. Osteochondral autograft transfer could be a time-saving procedure for young patients with devastating hip conditions who have virtually no other surgical options. A larger series or a similar matched cohort would be necessary to confirm these results which, in view of the heterogeneity of our series, seems difficult to achieve.

Mosaicplasty of the Femoral Head: A Systematic Review and Meta-Analysis of the Current Literature

Osteochondral lesions of the femoral head are rare. For the treatment of these lesions, various joint-preserving procedures, particularly in young, active patients, have been developed. Mosaicplasty is a well-established surgical procedure for the knee. However, there is little evidence that this method can also be used to treat osteochondral lesions in the hip. The indication for cartilage procedures continues to evolve for the knee, and a similar strategy may be adopted for the hip joint. Due to limited evidence and a lack of experience, mosaicplasty treatment of these lesions remains challenging, especially in young patients. This study shows that open and arthroscopic management using the knee and femoral head as donor sites yielded good to excellent short- to mid-term outcomes. For osteochondral lesions of the femoral head, mosaicplasty may be a new alternative treatment option, although this needs to be proven with longer follow-ups and in a larger sample of patients.

An evidence-based update on the management of articular cartilage defects in the hip

Objective

Articular cartilage defects in the hip joint pose a significant surgical challenge and remain one of the most important determinants of success following arthroscopic intervention of the hip. The aim of this literature review was to report on the best available evidence on the various treatment options utilised for articular cartilage defects in the hip.

Material and methods

A comprehensive literature search was performed on PubMed from its inception to October 2021 using the following search strategy: ((hip) and (cartilage or chondral) and (repair or regeneration or restoration or implantation or chondroplasty or chondrogenic)). Two reviewers (KHSK, MG) independently reviewed titles and abstracts to identify articles for the final analysis. Articles were included if they were original research studies (randomised control trials, cohort studies, case-control studies, or comparative studies) on treatment of hip cartilage defects in humans reporting on a minimum of 5 patients. A total of 1172 articles were identified from the initial literature search. Following a thorough selection process, 35 articles were included in the final analysis to synthesise the evidence.

Results

Debridement, microfracture, autologous chondocyte implanatation (ACI) and matrix-induced ACI (MACI) are shown to have good short-to medium-term results. Injectable ACI and MACI have been developed to enable these procedures to be performed via arthroscopic surgery to reduce the post-operative morbidity associated with surgery with promising early results. Large cartilage defects which involved the sub-chondral bone may need the use of osteochondral grafts either autograft or allograft. Newer biological solutions have been developed to potentially deliver a single-stage procedure for hip cartilage injuries but longer-term results are still awaited.

Conclusion

Accurate identification of the extent of the injury helps stratify the defect and plan appropriate treatment. Several surgical techniques have shown good short to medium-term outcomes with ACI, AMIC, mosaicplasty and microfracture. Recent advances have enabled the use of injectable MACI and bioscaffolds which show promising results but in the shorter term. However, one needs to be mindful of the techniques which can be used in their surgical setting with the available resources. In order to thoroughly evaluate the benefits of the different surgical techniques for hip cartilage defects, large scale prospective multi-centre studies are necessary. Perhaps inclusion of such procedures in registries may also yield meaningful and pragmatic results.

Why Does Hip Arthroscopy Fail? Indications and PEARLS for Revision Success

The surgical treatment of femoroacetabular impingement has been shown to have successful early and mid-term clinical outcomes. Despite these favorable clinical outcomes that have been published in the literature, there is a subgroup of patients that present with continued or recurrent symptoms after surgical treatment. Not only has there been an increase in the number of hip arthroscopy procedures, but also there has been a corresponding increase in the number of revision hip arthroscopy and hip preservation surgeries. Previous studies have reported residual deformity to be the most common reason for revision hip arthroscopy. However, chondral, labral, and capsular considerations also are important when addressing patients not only in the primary but also, the revision setting. In this review, we outline the evaluation and treatment of the patient that presents with continued hip and groin pain after undergoing a hip.

Osteochondral autograft transplantation of the femoral head in sequelae of developmental dysplasia of hip: A case report and review of the literature

Although osteochondral autograft transplantation (OAT) in the knee and ankle has gained much popularity on the other hand the technique has rarely been applied in the femoral head. In this article, we present a 15-year-old female patient with unstable chondral lesion on the right femoral head. She had a history of open reduction for developmental dysplasia which resulted in avascular necrosis. She had coxa magna, breva and trochanteric overgrowth along with an unstable chondral lesion on the superolateral part of the femoral head. She underwent OAT for chondral lesion, femoral head reshaping and relative neck lengthening. Her Harris Hip Score improved from 55 to 90 in the 18 months of follow-up. The case is unique in a way that the autografts were harvested from the anterior part of the same femoral head that was already intended to be removed during osteochondroplasty.

Promising outcomes of hip mosaicplasty by minimally invasive anterior approach using osteochondral autografts from the ipsilateral femoral head

PURPOSE

Recent studies demonstrated promising results of mosaicplasty for femoral head osteochondral lesions using posterior and lateral approaches. This study aimed to evaluate outcomes of mosaicplasty using ipsilateral femoral head autografts by minimally invasive anterior approach. The hypothesis was that this surgical technique would grant satisfactory clinical outcomes with considerable improvement of clinical scores.

METHODS

A consecutive series of 27 mosaicplasties, to treat osteochondral lesions of the femoral head measuring 1.6 ± 0.7 cm² (range 0.8-4.0) in patients aged 28.7 ± 7.4 years (range 19-44), was evaluated using the mHHS and WOMAC scores at minimum follow-up of 12 months. All patients were operated by minimally invasive anterior (Hueter) approach and osteochondral plugs were harvested from the non-weight-bearing portion of the femoral head. Adjuvant osteoplasty was necessary for some patients at the acetabulum (n = 3), femur (n = 14) or both (n = 2).

RESULTS

Three patients were excluded due to concomitant periacetabular osteotomies or shelf procedures, one patient could not be reached, and another was revised to THA. This left 22 patients for clinical assessment at 39.4 ± 23.2 months (12.0-90.2). Their mHHS improved from 56.3 ± 12.6 to 88.4 ± 9.9, and WOMAC improved from 45.1 ± 16.9 to 80.6 ± 13.0. Two patients (8.4%) underwent arthroscopy at 13 and 30 months to remove painful residual cam-type deformities. Regression analyses revealed that net improvement in WOMAC decreased with lesion size (p = 0.002) and increased with follow-up (p = 0.004).

CONCLUSIONS

Hip mosaicplasty using autografts from the ipsilateral femoral head, performed by minimally invasive anterior approach, granted satisfactory outcomes and functional improvements. Caution is, however, advised for lesions > 2 cm² (diameter > 16 mm) which may be a threshold limit for this procedure.

LEVEL OF EVIDENCE

Level IV, Case series.

Micro-fragmented Adipose Tissue Transplantation (MATT) for the treatment of acetabular delamination. A two years follow up comparison study with microfractures

Background: Delamination of acetabular articular cartilage is a common progressive abnormality in hips with femoroacetabular impingement. The aim of this study is to compare the effectiveness of two different procedures for the arthroscopic treatment of acetabular delamination: microfractures (MFx) and micro-fragmented autologous adipose tissue transplantation (MATT) technique. Methods: We carried out a controlled retrospective study of 35 patients affected by an acetabular cartilage delamination in femoroacetabular impingement (FAI). In all the selected cases the size of the defect ranged from 1 to 2 cm², with a mean size of 1.9 cm² in MFx group and 1.6 cm² in MATT group (p=0.1). Of these, 18 patients were treated with MFx while 17 patients were treated with MATT. The two groups were similar in terms of clinical, functional and radiological aspects. All the patients were assessed before and after the procedure, for pain and function, with the modified Harris Hip Score (mHHS). The mean preoperative mHHS was 50±5 for MFx group and 53±6 for MATT group (p = 0.245). All the patients were followed-up for two years. Results: The final mHHS was 76±12 in MFx group and 97.1±3 in MATT group (p<0.001). In both groups neither a conversion to total hip arthroplasty nor a revision hip arthroscopy was observed. Conclusions: The results of this study provide proof that MATT technique improves clinical outcomes with a mHH scoring significantly higher than MFx group. (www.actabiomedica.it)

Fresh Osteochondral Allograft Transplantation for Treatment of Large Cartilage Defects of the Femoral Head: A Minimum Two-Year Follow-Up Study of Twenty-Two Patients

BACKGROUND

Controversy remains over the surgical management of large osteochondral lesions of the femoral head in young, active patients. The purpose of this study is to assess midterm clinical and radiographic outcomes after fresh osteochondral allograft transplantation (OAT) for large femoral head lesions at minimum 2-year follow-up.

METHODS

A retrospective review of prospectively collected data was performed for 22 patients under the age of 50 years with defined femoral head osteochondral lesions who underwent fresh OAT between 2008 and 2015. Patients were assessed clinically using the modified Harris Hip Score (mHHS) preoperatively and at each follow-up visit. Postoperative radiographs were evaluated for graft integrity and Kellgren & Lawrence Grade for osteoarthritis severity. Complications and reoperation were assessed by chart review. Kaplan-Meier survivorship analyses with 95% confidence intervals were performed for the end point of conversion to total hip arthroplasty.

RESULTS

At a mean follow-up of 68.8 months (26-113), the mean mHHS improved significantly (P < .001) from 48.9 (19-84) to 77.4 (35-98). Sixteen of 22 patients (72.7%) had an mHHS ≥70 at the latest follow-up. Arthritic progression, as indicated by an increase in the Kellgren & Lawrence Grade, occurred in 4 of 22 hips (18.2%). Five patients (22.7%) underwent conversion to total hip arthroplasty. Graft survivorship was 86.4 ± 7.3% at 2 years, 78.5 ± 10.0% at 5 years, and 67.3 ± 13.5% at 9 years.

CONCLUSION

Fresh OAT may be a viable treatment option for osteochondral defects of the femoral head in young, active patients with minimal preexisting joint deformity.

Outcomes of cartilage repair techniques for chondral injury in the hip-a systematic review

OBJECTIVE/PURPOSE

The aim of the study was to assess the options of treatment and their related outcomes for chondral injuries in the hip based on the available evidence whilst highlighting new and innovative techniques.

METHODS

A systematic review of the literature from PubMed (Medline), EMBASE, Google Scholar, British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Allied and Complementary Medicine Database (AMED) was undertaken from their inception to March 2017 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Clinical outcome studies, prospective/retrospective case series and case reports that described the outcome of cartilage repair technique for the chondral injury in the hip were included. Studies on total hip replacement, animal studies, basic studies, trial protocols and review articles were excluded.

RESULTS

The systematic review found 21 relevant papers with 596 hips. Over 80% of the included studies were published in or after 2010. Most studies were case series or case reports (18 studies, 85.7%). Arthroscopy was used in 11 studies (52.4%). The minimum follow-up period was six months. Mean age of the participants was 37.2 years; 93.5% of patients had cartilage injuries of the acetabulum and 6.5% of them had injuries of the femoral head. Amongst the 11 techniques described in the systematic review, autologous matrix-induced chondrogenesis, osteochondral autograft transplantation and microfracture were the three frequently reported techniques.

CONCLUSION

Over ten different techniques are available for cartilage repair in the hip, and most of them have good short- to medium-term outcomes. However, there are no robust comparative studies to assess superiority of one technique over another, and further research is required in this arena.

Resection-Induced Leveling of Elevated Plug Cartilage in Osteochondral Autologous Transplantation of the Knee Achieves Acceptable Clinical Results

BACKGROUND

Plug protuberance occasionally occurs in osteochondral autologous transplantation (OAT). The incongruity of plugs results in poor clinical outcomes, especially in cases of protuberance. However, a surgical procedure to deal with this problem has not been reported. Purpose/Hypothesis: The purpose was to evaluate the efficacy and safety of cartilage resection of elevated plugs, with the hypothesis that patients whose elevated plugs were resected and leveled would achieve clinical outcomes equivalent to those of patients with flush plugs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Cases (group P) included 22 patients who underwent OAT of the knee and whose plugs showed protuberance greater than 1 mm that was resected with a scalpel to obtain smooth congruity, while controls (group C) included 22 background-matched patients who did not require plug resection. The International Knee Documentation Committee (IKDC) subjective score, IKDC objective grade, and Japanese Orthopaedic Association score for knee osteoarthritis (JOA knee score) were used preoperatively and at the final follow-up (mean ± SD, 49.3 ± 18.1 months). International Cartilage Repair Society (ICRS) Cartilage Repair Assessment was used to evaluate lesion healing during the second-look arthroscopy.

RESULTS

IKDC subjective scores of group C (82.5 ± 11.8) and group P (82.1± 15.1) showed no difference at the final follow-up. On postoperative IKDC objective grading, 86% of group C and 82% of group P patients were graded as "nearly normal" or better ( P = .639). The mean JOA knee scores of group C (90.9 ± 8.9) and group P (90.1 ± 9.5) did not differ significantly ( P = .647). Nine second-look arthroscopies were performed in group C versus 8 in group P, and all patients had plugs that were graded as "nearly normal" or better by the ICRS Cartilage Repair Assessment. Larger plugs tended to be used in those patients who required resection.

CONCLUSION

Resection of the elevated plug surface did not negatively affect patient outcomes in the midterm follow-up period.

Indications for Hip Arthroscopy

CONTEXT

Hip arthroscopy is gaining popularity within the field of orthopaedic surgery. The development and innovation of hip-specific arthroscopic instrumentation and improved techniques has resulted in improved access to the hip joint and ability to treat various hip pathologies.

EVIDENCE ACQUISITION

Electronic databases, including PubMed and MEDLINE, were queried for articles relating to hip arthroscopy indications (1930-2017).

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Initially used as a technique for loose body removal, drainage/debridement of septic arthritis, and treatment of pediatric hip disorders, hip arthroscopy is currently used to treat various hip conditions. The recognition of femoroacetabular impingement (FAI) as a source of hip pain in young adults has rapidly expanded hip arthroscopy by applying the principles of osseous correction that were previously described and demonstrated via an open surgical dislocation approach. Hip pathologies can be divided into central compartment, peripheral compartment, peritrochanteric space, and subgluteal space disorders.

CONCLUSION

Although hip arthroscopy is a minimally invasive procedure that may offer decreased morbidity, diminished risk of neurovascular injury, and shorter recovery periods compared with traditional open exposures to the hip, it is important to understand the appropriate patient selection and indications.

Ipsilateral femoral head osteochondral transfers for osteochondral defects of the femoral head

Osteochondral defects of the femoral head are rare. Several treatment options have been described, though there is currently no consensus on the appropriate management of these lesions. Five patients underwent femoral head osteochondral autograft transfer for treatment of ipsilateral femoral head osteochondral defects via surgical hip dislocation between 2011 and 2014 at our institution. The mean age of the patients was 24.8 (16–37) years. There were four females and one male. Mean follow-up was 53.8 (30–64) months. Four patients reported complete resolution of preoperative pain, return to baseline activities and were satisfied with their results. Harris hip scores improved from a mean 60.8 (30–87) to 86.6 (44–100). There was no radiographic evidence of progression of the femoral head defects. There were no operative complications. Osteochondral autograft transfer from the ipsilateral femoral head using a surgical hip dislocation demonstrated good clinical and radiographic outcomes at midterm follow-up in our cohort and may be considered a suitable option for management of these lesions in select patients. Further research and follow-up is warranted to more clearly define the indications and outcomes of this procedure.

A Critical Review: Management and Surgical Options for Articular Defects in the Hip

Patients with articular cartilage lesions of the hip may present with pain and symptoms that may be vague in nature and onset. Therefore, a thorough history and physical examination should be performed for every patient presenting with hip pain and/or disability. The management may be operative or nonoperative. Nonoperative management includes a trial of rest and/or activity modification, along with anti-inflammatory medications, physical therapy, and biologic injections. Operative treatment in the form of arthroscopic techniques continues to decrease morbidity and offer innovative solutions and new applications for microfracture, ACT, and AMIC.

Osteochondral Autograft from the Ipsilateral Femoral Head by Surgical Dislocation for Treatment of Femoral Head Fracture Dislocation: A Case Report

As anatomical reduction of the articular surface of femoral head fractures and restoration of damaged cartilage are essential for good long-term results, many treatment options have been suggested, including fixation of the fracture using various surgical exposures and implants, as well as arthroscopic irrigation and debridement, bone marrow stimulating techniques, osteochondral allograft, autograft, and autogenous chondrocyte implantation. We report a case of osteochondral autograft harvested from its own femoral articular surface through surgical hip dislocation. The osteochondral graft was harvested from the inferior non-weight-bearing articular surface and grafted to the osteochondral defect. One year later, the clinical and radiological results were good, without the collapse of the femoral head or arthritic change. This procedure introduced in our case is considered convenient and able to lessen surgical time without morbidity of the donor site associated with the harvest.

Long-term result of mosaicplasty for femoral head osteochondral lesion: a case report with 8 years follow-up

PURPOSE

Treatment of the chondral lesions of the hip joint is problematic due to its deep anatomy and complex biomechanical demands. The purpose of the study is to present the long-term result of a deep, large femoral head cartilage defect treated successfully with surgical safe dislocation of the hip and autologous osteochondral grafting.

METHODS

A 27-year-old male patient was admitted to our clinic with left hip pain. On assessment, a large femoral head osteochondral defect was detected in his left hip. An open safe hip dislocation and autologous osteochondral grafting was performed due to the large size of the lesion and subchondral bone involvement.

RESULTS

Using a Kocher-Langenbeck incision, the hip was dislocated after a trochanteric flip osteotomy. The defect was reconstructed with 3 x 13 mm and 1 x 11 mm osteochondral plug from the ipsilateral knee. We have not encountered any complication at the postoperative period. After 8 years follow-up his left hip range of motion was preserved and The Harris Hip Score was qualified as excellent with 96 points.

CONCLUSIONS

Chondral defects of the femoral head are still a challenging problem in orthopaedic practice. Mosaicplasty of the femoral head is a demanding procedure with safe dislocation of the hip. However, if successful it can provide satisfactory functional and radiological results in the long-term.

Arthroscopic Management of Hip Chondral Defects: A Systematic Review of the Literature

PURPOSE

To critically evaluate the evidence for arthroscopic management of chondral defects in the hip through a systematic literature review.

METHODS

A systematic literature review was performed to identify all articles addressing the arthroscopic management of chondral defects about the hip. Case reports, open techniques, and those associated with osteonecrosis were excluded. Articles were assessed for sample size, location, severity, and size of chondral defects, and the surgical technique. Associated injuries, follow-up duration (months), and functional outcomes were recorded. Study cohorts were defined by a surgical technique (debridement v microfracture v autologous chondrocyte transplantation [ACT]). Statistical analysis was performed with a χ(2) test and analysis of variance with post hoc pairwise analysis for categorical and continuous data, respectively, with significance defined as P < .05.

RESULTS

The literature search identified 269 articles, of which 12 clinical studies met inclusion criteria for this analysis. After pooling the data, there were 579 (64.7%) debridements, 279 (31.2%) microfracture, and 37 (4.1%) ACT performed. Patients were followed for an average of 27.1 months (range: 5 to 72 months). All lesions treated with either a microfracture or ACT were high grade (Outerbridge 3 to 4). However, lesion size was significantly larger in ACT-treated patients compared with those who underwent microfracture (357.3 ± 96.0 mm(2)v 149.5 ± 20.7 mm(2); P = .020). All cohorts showed significant improvement in functional outcomes after hip arthroscopy (P < .001).

CONCLUSIONS

This systematic review showed that arthroscopic debridement, microfracture, and ACT are associated with equivalent improvement in clinical outcomes in patients with high-grade chondral defects in the hip in the short- and midterm follow-up. In addition, although there were no differences in patient characteristics and demographics based on the surgical technique, we confirmed the hypothesis that lesion size varied significantly between arthroscopic techniques, and that the decision to use one technique over another may be determined by the size of the defect. Therefore, lesion size is likely to influence the development of hip- and technique-specific indications, and may also represent a useful metric for success of surgical intervention. LEVEL OF

EVIDENCE

Level IV, systematic review of Level III and IV studies.

Biological Therapies for Cartilage Lesions in the Hip: A New Horizon

Treatment of hip cartilage disease is challenging, and there is no clear algorithm to address this entity. Biomarkers are arising as promising diagnostic tools because they could play a role in the early assessment of the prearthritic joint and as a prognostic factor before and after treatment. The potential effect of biomarkers may be used to categorize individuals at risk of evolving to severe osteoarthritis, to develop new measures for clinical progression of the disease, and to develop new treatment options for the prevention of osteoarthritis progression. A trend toward a less invasive biological treatment will usher in a new treatment era. With the growth of surgical skills in hip arthroscopy, cartilage restoration techniques are evolving in a fast and exponential manner. Biological and surgical treatments have been proposed to treat these pathologies. Biological treatments include platelet-rich plasma, stem cells or bone marrow aspirate concentration, hyaluronic acid, losartan, and fish oil. Surgical treatments include microfracture alone or augmented, direct repair, autologous chondrocyte implantation, matrix-induced chondrocyte implantation, autologous matrix-induced chondrogenesis, mosaicplasty, osteochondral allograft transplantation, and stem cells implanted in matrix (stem cells in membranes/expanded stem cells). This article reviews new evidence available on treatment options for chondral lesions and early osteoarthritis of the hip. [Orthopedics. 2016; 39(4):e715-e723.].

Chondral Lesions of the Hip

The treatment of chondral hip injuries is challenging. However, for young patients with hip disorders, orthopedic surgeons now have the opportunity to intervene early in the development of debilitating joint disease. As understanding of the hip joint continues to evolve, more effective treatment strategies are emerging. There are several reportedly successful options for surgical treatment. This article reviews the clinical presentation of chondral injuries and the surgical modalities, arthroscopic and open, available to treat them.

Mosaicplasty for femoral osteochondritis dissecans

The authors describe a surgical mosaicplasty technique, with an anterior surgical dislocation approach without trochanterotomy, for osteochondritis dissecans of the hip. A graft was taken from the lateral condyle of the knee. Two adolescents underwent this procedure with good results. No osteonecrosis was observed at the longest follow-up. Mosaicplasty is a useful treatment method for small osteochondritis dissecans (<2cm(2)).

Mosaicplasty for the treatment of a large traumatic osteochondral femoral head lesion: a case report with 2 year follow-up and review of the literature

Different joint-preserving techniques have been described for the treatment of traumatic osteochondral lesions of the femoral head especially in young active patients. Mosaicplasty with autologous transplantation of osteochondral cylinders is an established surgical technique in the knee. Little evidence, however, exists for the treatment of osteochondral lesions in the hip using this technique. Here, we report on the result of treatment of a traumatic 5 cm(2) osteochondral lesion of the femoral head in a young patient treated with mosaicplasty. Grafts were taken from the ipsilateral knee. After 2 years, the outcome was satisfactory with partial return to previous activity level.

Steroid-induced femoral head osteonecrosis in immune thrombocytopenia treatment with osteochondral autograft transplantation

Osteonecrosis of the femoral head is a devastating complication of steroid administration and has rarely been observed in the treatment of immune thrombocytopenia. The treatment of osteochondral defects in advanced stages of avascular necrosis (AVN), characterized by collapse of the subchondral bone, remains an unsolved burden in orthopedic surgery. In this report, we present a case of a 19-year-old female that was admitted in the Emergency Department with walking disability and painful hip joint movement due to steroid-induced femoral head osteonecrosis. Two years before she was diagnosed with immune thrombocytopenia, for which she received pulse steroid therapy with high dose of dexamethasone and underwent a splenectomy. This case report is the first to describe the use of osteochondral autograft transplantation as a treatment of steroid-induced AVN of the femoral head due to immune thrombocytopenia at the age of 19 years with very good clinical and radiological results 3 years postoperatively.

The role of orthobiologics in hip preservation surgery

The potential regenerative role of different orthobiologics is becoming more recognized for the treatment of chronic and degenerative musculoskeletal conditions. Over the last few years there has been an increasing number of publications on cell therapy and other orthobiologics for the treatment of avascular necrosis of the femoral head and other hip conditions with promising short–term clinical results. In this article, we have used a systematic search of the literature to identify potentially relevant topics on orthobiologics and then selected those most applicable to hip preservation surgery. We identified several innovative strategies and present a summary of the currently available evidence on their potential role in hip preservation surgery. For many of these treatment strategies there was a lack of clinical evidence and therefore we suggest that there is a need for comparative studies in this field.

Tissue engineering and the future of hip cartilage, labrum and ligamentum teres

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.

Fixation of femoral head fractures with autologous osteochondral transfer (mosaicplasty)

Posterior fracture dislocation of the femoral head is a rare entity usually requiring open reduction and internal fixation. Results of different fixation methods have been reported, including countersinking screws, headless screws, and bioabsorbable implants. Osteochondral autologous transfer (mosaicplasty) is an established method of treatment of full thickness cartilage defects of the knee, ankle, and elbow. At our institution, posterior fracture-dislocations of the femoral head were treated with femoral head fragment fixation using osteochondral autografts through surgical hip dislocation. Osteochondral plugs were harvested from the non-weight-bearing area of the lateral femoral condyle of the knee and used for fixation of the reduced fragment. This article details the technique and its application.

Arthroscopic retrograde osteochondral autologous transplantation to chondral lesion in femoral head

This report describes the treatment of 2 cases of full-thickness cartilage defect of the femoral head. The authors performed osteochondral autologous transplantation with a different technique that has not been reported to date. One patient was 37 years old, and the other was 42 years old. Both presented with hip pain. In both patients, radiograph and magnetic resonance imaging scan showed a focal chondral defect on the weight-bearing area of the femoral head and acetabular impingement. A retrograde osteochondral autologous transplantation technique combined with hip arthroscopy and arthroscopic impingement treatment was performed. After a 2-month recovery period, the symptoms were resolved. In the first year of follow-up, Harris Hip scores improved significantly (case 1, 56.6 to 87.6; case 2, 58.6 to 90). The technique described yielded good short- and midterm clinical and radiologic outcomes. To the authors' knowledge, this report is the first to describe a retrograde osteochondral transplantation technique performed with hip arthroscopy in the femoral head.

Joint-preserving surgical options for management of chondral injuries of the hip

Management of injuries to the articular cartilage is complex and challenging; it becomes especially problematic in weight-bearing joints such as the hip. Several causes of articular cartilage damage have been described, including trauma, labral tears, and femoroacetabular impingement, among others. Because articular cartilage has little capacity for healing, nonsurgical management options are limited. Surgical options include total hip arthroplasty, microfracture, articular cartilage repair, autologous chondrocyte implantation, mosaicplasty, and osteochondral allograft transplantation. Advances in hip arthroscopy have broadened the spectrum of tools available for diagnosis and management of chondral damage. However, the literature is still not sufficiently robust to draw firm conclusions regarding best practices for chondral defects. Additional research is needed to expand our knowledge of and develop guidelines for management of chondral injuries of the hip.

Arthroscopic internal fixation of osteochondritis dissecans of the femoral head

Osteochondritis dessicans of the femoral head is an uncommon problem. Limited literature reports the incidence of osteochondritis dessicans and its treatment. The surgical technique used and outcomes for a 40-year-old man with symptomatic femoral head osteochonditis dissecans who was treated 11 years previously with retrograde drilling and hip arthroscopy are discussed.Despite temporary symptomatic improvement without subchondral collapse after his index procedure, increasing pain a decade later was thought to be caused by a large apical osteochondritic fragment and chondrolabral dysfunction from femoroacetabular impingement. Acetabuloplasty of acetabular overcoverage permitted arthroscopic internal fixation of the bone fragment by improving screw trajectory. Labral refixation and femoroplasty were subsequently performed. At 18-month follow-up, his nonarthritic hip score improved from 53 to 76 and his osteochondritic lesion had healed radiographically.Although clinical improvement with radiographic union has been reported following open screw fixation of femoral head osteochondritis dissecans, to the authors' knowledge this is the first published case with a similar outcome using arthroscopic techniques. Clinical improvement and union of even long-standing osteochondritis dissecans of the femoral head may occur with arthroscopic fragment fixation. Hip arthroscopy may play significant therapeutic and diagnostic roles in the treatment of this condition while offering a less invasive alternative to open osteosynthesis.

Fresh-stored osteochondral allografts for the treatment of femoral head defects: surgical technique and preliminary results

PURPOSE

The purpose of this study was to present the preliminary clinical and radiographic outcomes of the treatment of femoral head osteochondral defects in eight consecutive symptomatic patients with fresh-stored osteochondral allografts via a trochanteric osteotomy.

METHODS

This study included all consecutive patients treated in our department between 2008 and 2010 for worsening pain and mechanical symptoms of femoral head osteochondral defects. Each patient had preoperative routine hip radiographs and a preoperative magnetic resonance imaging study that determined and recorded the defect size and femoral head diameters. Allograft donors were identified through the Multiple Organ Retrieval and Exchange program (Ontario, Canada).

RESULTS

The osteochondral defects were secondary to osteochondritis dissecans in four patients, avascular necrosis in three and femoral head fracture without dislocation in one. The patients' average age at surgery was 23.7 (range 17-42), and the average follow-up was 41 months (range 24-54). Follow-up included clinical and radiographic examinations at standard intervals. The average Harris hip scores improved from 57.7 (range 50-65) points preoperatively to 83.9 (range 72-94) points at latest follow-up. Five patients had good-to-excellent clinical outcomes, and one had a fair outcome. One patient was converted to a total hip arthroplasty due to progression of arthritis. Another patient's graft subsided and he underwent a successful repeat transplantation. An additional patient required the removal of the screws transfixing her trochanter due to persistent irritation.

CONCLUSIONS

These findings indicate that fresh-stored osteochondral allograft transplantation using a trochanteric slide and surgical dislocation is a viable treatment option for femoral head defects in young patients.

Surgical technique: Second-generation bone marrow stimulation via surgical dislocation to treat hip cartilage lesions

BACKGROUND

Compared to knees, hips have more bony constraint and soft tissue coverage. Thus, repair of focal cartilage defects in hips requires more invasive and technically complex surgeries than simple arthroscopy or arthrotomy. Autologous matrix-induced chondrogenesis (AMIC) is a second-generation bone marrow stimulation technique. Improvement in Tegner, Lysholm, International Cartilage Repair Society (ICRS), and Cincinnati scores has been reported at 1 and 2 years after AMIC in knees. AMIC is potentially useful to repair defects in hips, but it is unknown whether it relieves symptoms or results in a durable construct.

DESCRIPTION OF TECHNIQUE

A surgical hip dislocation is used to access the defect. This is débrided to stable cartilage shoulders, necrotic bone is removed, and the lesion base is drilled. Autogenous bone graft is used for lesions with bony defects to create a level surface. Fibrin gel and a collagen membrane are placed to stabilize the superclot for fibrocartilage formation.

METHODS

We treated six patients with AMIC in the hip between 2009 and 2010. We obtained Oxford Hip and UCLA Activity Scores. Repair quality was assessed on 6-month postoperative MRI using the modified magnetic resonance observation of cartilage repair tissue (MOCART) system. Minimum 1-year followup data were available for four patients (range, 1-2.5 years).

RESULTS

Postoperative Oxford Hip Scores ranged from 13 to 17, UCLA Activity Scores ranged from 5 to 10, and MOCART scores ranged from 55 to 75. No complications occurred.

CONCLUSIONS

We describe AMIC in the hip. Although these patients had pain relief and improved function, long-term followup is necessary to assess the duration of improvement, durability of repair, and potential for arthrosis.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Operative treatment of chondral defects in the hip joint: a systematic review

Young patients with cartilage defects in the hip present a complex problem for the treating physician with limited treatment modalities available. Cartilage repair/replacement techniques have shown promising results in other joints, however, the literature regarding the hip joint is limited. The purpose of the current study is to conduct a systematic review of clinical outcomes following various treatments for chondral lesions of the hip and define the techniques for the treatment of these cartilage defects. The full manuscripts of 15 studies were reviewed for this systematic review including case studies, case series, and clinical studies. A variety of techniques have been reported for the treatment of symptomatic chondral lesions in the hip. Microfracture, cartilage repair, autologous chondrocyte implantation, mosaicplasty, and osteochondral allografting have all been used in very limited case series. Although good results have been reported, most studies lack both a control group and a large number of patients. However, the reported results in this article do provide a good foundation for treatments and stimulant for further study in an inherently difficult to treat young patient population with articular cartilage defects in the hip.

Surgical hip dislocation for osteochondral transplantation as a salvage procedure for a femoral head impaction fracture

Obturator anterior hip dislocation is very rare. Poor results are described in patients with additional large transchondral fractures and treatment of these injuries remains challenging. Appropriate treatment recommendations are missing in the literature. This case report introduces surgical hip dislocation for osteochondral autograft transplantation with graft harvest from the nonweightbearing area of the head-neck junction as a salvage procedure in a large femoral head defect. We report the treatment and outcome of a 48-year-old man who sustained an anterior dislocation of the left hip after a motorcycle accident. After initial closed reduction in the emergency room, imaging analysis revealed a large osteochondral defect of the femoral head within the weightbearing area (10 × 20 mm, depth: 5 mm). The hip was exposed with a surgical hip dislocation using a trochanteric osteotomy. An osteochondral autograft was harvested from a nonweightbearing area of the femoral head and transferred into the defect. The patient was prospectively examined clinically and radiologically. Two years postoperatively, the patient was free of pain and complaints. The function of the injured hip was comparable to that of the contralateral, healthy hip and showed satisfying radiologic results. Surgical hip dislocation with a trochanteric flip osteotomy is a simple, one-step technique that allows full inspection of the hip to treat osteochondral femoral defects by osteochondral transplantation. The presented technique, used as a salvage procedure in a large femoral head defect, yielded good clinical and satisfying radiologic outcomes at the midterm.

Traumatic osteochondral injury of the femoral head treated by mosaicplasty: a report of two cases

The increased risk of symptomatic progression towards osteoarthritis after chondral damage has led to the development of multiple treatment options for cartilage repair. These procedures have evolved from arthroscopic lavage and debridement, to marrow stimulation techniques, and more recently, to osteochondral autograft and allograft transplants, and autogenous chondrocyte implantation. The success of mosaicplasty procedures in the knee has led to its application to other surfaces, including the talus, tibial plateau, patella, and humeral capitellum. In this report, we present two cases of a chondral defect to the femoral head after a traumatic hip dislocation, treated with an osteochondral autograft (OATS) from the ipsilateral knee, and the inferior femoral head, respectively, combined with a surgical dislocation of the hip. At greater than 1 year and greater than 5 years of follow-up, MRI studies have demonstrated good autograft incorporation with maintenance of articular surface conformity, and both patients clinically continue to have no pain and full active range of motion of their respective hips. In our opinion, treatment of osteochondral defects in the femoral head surface using a surgical dislocation combined with an OATS procedure is a promising approach, as full exposure of the femoral head can be obtained while preserving its vasculature, thus enabling adequate restoration of the articular cartilage surface.

A clinically relevant review of hip biomechanics

The hip is a complex anatomic structure composed of osseous, ligamentous, and muscular structures responsible for transferring the weight of the body from the axial skeleton into the lower extremities. This must be accomplished while allowing for dynamic loading during activities such as gait and balance. The evaluation of hip pain and periarticular pathology can be challenging because of the complex local anatomy and broad differential diagnosis. Recent advancements in the evaluation and surgical treatment of hip pathology have led to a renewed interest in the management of these disorders. An understanding of the basic biomechanical and kinematic function of the hip and the consequences of associated pathology can greatly assist the orthopaedic surgeon in appropriately diagnosing and treating these problems. In this review we discuss the basic biomechanical concepts of the native hip and surrounding structures and the changes experienced as a result of various pathologies including dysplasia, femoroacetabular impingement, labral injury, capsular laxity, hip instability, and articular cartilage injury. We will also discuss the clinical implications and surgical management of these pathologies and their role in restoring or preserving the native function of the hip joint.

Case report: Fresh-stored osteochondral allograft for treatment of osteochondritis dissecans the femoral head

Osteochondral defects of the femoral head are exceedingly rare, with limited treatment options. Restoration procedures for similar defects involving the knee and ankle have been well described. In this report, we present a young patient who had a symptomatic osteochondral defect of the femoral head develop secondary to trauma and underwent subsequent treatment using a fresh-stored osteochondral allograft via a trochanteric osteotomy. At the 1-year followup, the patient was symptom free with near-complete incorporation of the graft radiographically. Our observations in this case suggest osteoarticular implantation may be an appropriate alternative to consider when treating osteochondral defects of the femoral head.

Autogenous osteochondral transfer in the femoral head after osteonecrosis

Osteonecrosis of the femoral head is a major problem, especially in younger patients. Most of them need a total hip replacement. This article presents a case of a successful autologous osteochondral transfer.

Fixation with poly-L-lactide screws in hip osteotomies

The purpose of our study was to investigate the bone union rates and complication rates, including breakage of screws, infection, and osteolysis, in hip osteotomies using poly-L-lactic screws. We prospectively followed up 111 hips in 100 patients using conventional radiography, in which 81 rotational acetabular osteotomies, 26 Chiari pelvic osteotomies, and four Sugioka's transtrochanteric osteotomies were performed. The mean age of the patients at the time of surgery was 34 years, and the mean followup was 5.4 years. Eighty-one osteotomized acetabula and 98 osteotomized greater trochanters were fixed using poly-L-lactic screws. These hips were compared with 64 hips in 58 patients using metallic screws. Bone union was achieved in 80 of the 81 acetabular osteotomies, except in one hip with postoperative deep infection. Proximal displacement of the greater trochanter because of poly-L-lactic screw breakage occurred in six (6%) hips. None of the metallic screws broke. Osteolysis occurred in one hip with a trochanteric osteotomy using poly-L-lactic screws. Poly-L-lactic screws are suitable to transfix the osteotomized acetabulum, but there is some risk of fracture when used to reattach an osteotomized greater trochanter. Complete bone ingrowth in the screw channels cannot be expected for several years after insertion. Osteolysis is a possible complication.

LEVEL OF EVIDENCE

Therapeutic study, Level II (prospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.