Chondral lesions in the hip: a review of relevant anatomy, imaging and treatment modalities

Save the subchondral bone plate: Debridement versus bone marrow stimulation in acetabular cartilage defects over 60 months of follow-up

PURPOSE

Bone marrow stimulation is a common treatment for full-thickness cartilage defects in the hip joint. However, common procedures may result in poor fibrous repair tissue and changes to the subchondral anatomy. This study investigated the clinical outcome of a cohort of International Cartilage Repair Society (ICRS) grades 3 and 4 cartilage defects treated with bone marrow stimulation compared to those who received simple debridement/chondroplasty.

METHODS

In this retrospective registry study, 236 patients with uni-focal acetabular chondral lesions of the hip up to 400 mm² (mean 177.4 ± 113.4 mm²) and of ICRS grade ≥3 with follow-up of at least 12 months (mean 33.2 ± 15.3 months) were included. Eighty-one patients underwent bone marrow stimulation (microfracture: n = 44, abrasion: n = 37) besides treatment of the underlying pathology, 155 patients underwent defect debridement/chondroplasty. The patient-reported outcome was measured using the International Hip Outcome Tool 33 (iHOT33) score and the Visual Analogue Scale (VAS) for pain.

RESULTS

iHOT33 and VAS both improved highly statistically significantly (p < 0.001) in the debridement group after 6, 12, 24, 36 and 60 months compared to the preoperative scores, whereas iHOT33 and VAS after microfracture or abrasion did not show statistically significant changes over time. Twenty-four and sixty months postsurgery the debridement group revealed significant higher scores in the iHOT33 compared to the bone marrow stimulation groups.

CONCLUSION

Patients with chondral lesions of the hip ≤400 mm2 sustainably benefit from arthroscopic debridement under preservation of the subchondral bone plate in terms of functional outcome and pain in contrast to patients treated with bone marrow stimulation. These findings discourage the currently recommended use of microfracture in the hip joint.

LEVEL OF EVIDENCE

Level III.

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.

The Use of Combined Hip Arthroscopy and Periacetabular Osteotomy for Hip Dysplasia Is Increasing and Has Low Complication Rates

Purpose

To analyze the annual use of hip arthroscopy (HA) and Bernese periacetabular osteotomy (PAO) for the treatment of hip dysplasia (HD), as well as postoperative outcomes, including ipsilateral reoperations.

Methods

International Classification of Diseases, Ninth and Tenth Revision, codes were used to query the PearlDiver Mariner database from January 2010 through January 2022 to identify patients aged 10 to 59 years who had a presenting diagnosis of HD and subsequently underwent (1) HA; (2) PAO; or (3) combined HA and PAO (HA-PAO, defined as PAO on the same day or within 28 days after HA). We analyzed annual rates for each treatment, as well as rates of postoperative emergency visits, readmissions, and 5-year ipsilateral secondary operations (determined via Kaplan-Meier analysis).

Results

There were 32,068 patients who underwent surgical treatment of HD. For HA, PAO, and HA-PAO, there were 29,700, 2,083, and 285 patients, respectively. All operations had the greatest percent-increase from 2015 to 2016. HA and HA-PAO peaked in 2021, whereas PAO peaked in 2019. For HA, PAO, and HA-PAO, most cases were performed in female patients and patients aged 30 to 49 years, 10 to 19 years, and 10 to 29 years, respectively. The 5-year incidence of ipsilateral secondary operations, which include revision HA, PAO, or conversion to total hip arthroplasty, was 9.2% (95% confidence interval 8.6%-9.8%) in the HA group and 6.5% (95% confidence interval 4.1%-8.8%) in the PAO group. Combining HA with PAO resulted in so few secondary operations that Kaplan-Meier analysis was infeasible. The PAO cohort had the greatest 30-day emergency visit and 90-day readmission rates, with infection as the most common cause for readmission.

Conclusions

HA is more frequently performed than PAO for hip dysplasia. HA-PAO is increasing at the greatest rate, demonstrating fewer complications and reoperations.

Level of Evidence

Level III, retrospective comparative trial.

Outcomes of Arthroscopic Joint Preservation Techniques for Chondral Lesions in the Hip: An Updated Systematic Review

PURPOSE

To systematically review outcomes of joint preservation procedures for chondral lesions of the hip through analysis of survival rates and patient-reported outcomes (PROs).

METHODS

A literature search from 2018 to May 2023 was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in 3 databases: PubMed, Embase, and Google Scholar. Studies were included if they reported on outcomes of patients undergoing hip arthroscopy for the treatment of chondral lesions of the hip joint and if there were quantifiable postoperative outcome measures. Quality assessment was completed using the Methodological Index for Non-Randomized Studies criteria.

RESULTS

Twenty-seven studies were included, with 20 noncomparative and 7 comparative studies. Microfracture (MFx) was the most common procedure, reported in 17 studies. Other procedures include autologous chondrocyte transplantation (ACT) (5 studies), autologous matrix-induced chondrogenesis (AMIC) (3 studies), and MFx in conjunction with CarGel (3 studies). Seven other novel procedures were reported in individual separate studies. Survival rates, defined by no revision surgery or conversion to total hip arthroscopy (THA) at latest follow-up, for MFx (14 studies), AMIC (3 studies), and MFx in conjunction with CarGel (3 studies) ranged from 59.1% to 100%, 92.9% to 100%, and 94.4% to 95.7%, respectively. Survival rates of ACT, biological reconstruction, debridement and abrasion, microfragmented autologous adipose tissue transplantation, and ChondroFiller gel were all reported once in separate studies with rates of 100%, 100%, 85.4%, 100%, and 92.3%, respectively. All studies included PROs, most reporting statistically significant improvements (P < .05) at the latest follow-up.

CONCLUSIONS

Isolated MFx remained the most commonly performed technique, but with lower survival and higher conversion to THA rates than in studies before 2018. Novel techniques that were performed in conjunction with MFx or that avoided MFx altogether had higher overall survival rates despite being minimally performed. Most patients across all techniques demonstrated significant improvements in PROs.

LEVEL OF EVIDENCE

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

Osteochondral Allograft or Autograft Transplantation of the Femoral Head Leads to Improvement in Outcomes but Variable Survivorship: A Systematic Review

PURPOSE

To review patient-reported outcomes (PROs) and survivorship in patients undergoing osteochondral autograft or allograft transplantation (OAT) of the femoral head.

METHODS

PubMed, Cochrane Center for Register of Controlled Trials, and Scopus databases were searched in November 2022 with an updated search extending to December 2023 using criteria from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the following keywords: (hip OR femoral head) AND (mosaicplasty OR osteochondral allograft OR osteochondral autograft OR osteochondral lesion). Articles were included if they evaluated postoperative PROs in patients who underwent OAT of the femoral head and had a study size of 5 or more hips (n ≥ 5). Survivorship was defined as freedom from conversion to total hip arthroplasty. For PROs evaluated in 3 studies or more, forest plots were created and I2 was calculated.

RESULTS

Twelve studies were included in this review, with a total of 156 hips and a mean follow-up time ranging between 16.8 and 222 months. In total, 104 (66.7%) hips were male while 52 (33.3%) were female. Age of patients ranged from 17.0 to 35.4 years, while body mass index ranged from 23.3 to 28.1. Eight studies reported on osteochondral autograft transplantation and 4 studies on osteochondral allograft transplantation. Three studies reported significant improvement in at least 1 PRO. Survivorship ranged from 61.5% to 96% at minimum 2-year follow-up and from 57.1% to 91% at minimum 5-year follow-up. At a follow-up of less than 5 years, osteochondral allograft transplantation studies showed 70% to 87.5% survivorship, while autograft varied from 61.54% to 96%.

CONCLUSIONS

Patients with osteochondral lesions of the femoral head who underwent osteochondral autograft or allograft transplantation demonstrated improved PROs but variable survivorship rates.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Microfracture of Acetabular Chondral Lesions Is Not Superior to Other Cartilage Repair Techniques in Patients With Femoroacetabular Impingement Syndrome: A Systematic Review

PURPOSE

To perform a systematic review to compare clinical outcomes of hip arthroscopy patients undergoing microfracture (MFx) versus other cartilage repair procedures for chondral lesions of the acetabulum.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by searching PubMed, the Cochrane Library, and Embase to identify comparative studies that directly compared outcomes between MFx and other cartilage repair procedures for full-thickness chondral lesions of the acetabulum identified during hip arthroscopy. The search phrase used was: hip AND arthroscopy AND microfracture. Patients were evaluated based on reoperation rates and patient-reported outcomes.

RESULTS

Six studies (all Level III evidence) met inclusion criteria, including a total of 202 patients undergoing microfracture (group A) and 327 patients undergoing another cartilage repair procedure (group B). Mean patient age ranged from 35.0 to 45.0 years. Mean follow-up time ranged from 12.0 to 72.0 months. Significantly better patient-reported outcomes (PROs) were found in patients undergoing treatment with bone marrow aspirate concentrate, microfragmented adipose tissue concentrate, autologous matrix-induced chondrogenesis, and a combination of autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate compared with MFx. No studies found significantly better postoperative PROs in group A. The reoperation rate ranged from 0% to 34.6% in group A and 0% to 15.9% in group B. Three of 5 studies reporting on reoperation rate found a significantly greater reoperation rate in group A, with no difference in the other 2 studies.

CONCLUSIONS

The literature on MFx of acetabular chondral lesions is limited and heterogeneous. Based on the available data, MFx alone results in a greater or equivalent reoperation rate and inferior or equivalent PROs compared with other cartilage repair procedures for acetabular chondral lesions in patients with femoroacetabular impingement syndrome.

LEVEL OF EVIDENCE

Level III, systematic review of level III studies.

Traction-related complications in hip arthroscopy for 26 years. A systematic review

The primary aim of the study is to determine the rate of traction-related complications in hip arthroscopy (HA) including perineal compression and distraction injuries, and the secondary objective is to report the incidence of complications in HA found on the studies selected by a systematic review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for data extraction from the PubMed and Cochrane databases obtained in February 2022. Reviewers extracted the title, author, date of publication, number of hips treated and number of complications describing the affected area, nerve and soft tissue injury related to traction. Studies on postless HA and HA combined with other procedures were excluded. Twenty-six years of HA literature was found in the search that included 35 studies and 8126 hips (89% Level IV) that reported the complications found during the procedure and described complications related to traction. A total of 623 hips (7.7%) had some sort of complications during HA, and complications related to traction were in 227 hips (36%). Injuries caused specifically by the perineal compression were in 144 hips (23%) that included the pudendal nerve and soft tissue injury of the groin area. Complications caused by the distraction were in 83 hips (13%) that included sciatic and peroneal nerve injury, numbness or pain of ankle and foot. HA complications occurred in 7.7% of hips treated, which is found in this systematic review. One-third of the complications are related to traction, 23% are caused by perineal compression and 13% are caused by distraction.

Parafoveal chondral lesion of the femoral head in patients with femoroacetabular impingement

Objective

To describe cases of parafoveal chondral lesion of the femoral head in patients with femoroacetabular impingement, correlating the clinical and imaging data.

Materials and Methods

This was a retrospective descriptive case series of parafoveal chondral lesion of the femoral head in 21 patients who underwent computed tomography and magnetic resonance arthrography scans of the hip, having then received an imaging-based diagnosis of femoroacetabular impingement.

Results

Of the 21 patients evaluated, 15 (71%) had cam-type femoroacetabular impingement, whereas five (24%) had mixed-type impingement, and one (5%) had pincer-type impingement. Twelve patients (57%) had a low frequency of physical activity, which was significantly associated with the presence of cam-type impingement (p = 0.015). Although the extent of the lesion correlated significantly with the acetabular coverage angle (p = 0.04), it did not correlate significantly with the alpha angle or femoral head-neck offset value (p = 0.08 and p = 0.06, respectively). We also found no correlation between the extent of the lesion and the other main parameters that define the femoroacetabular impingement types.

Conclusion

This was one of the largest case series of parafoveal chondral lesion of the femoral head in patients with imaging findings of femoroacetabular impingement. The extent of such lesions does not appear to correlate with the parameters of femoroacetabular impingement, with the exception of the acetabular coverage angle.

Particularities on Anatomy and Normal Postsurgical Appearances of the Hip

Detailed knowledge of anatomy helps to understand pathologic processes. This article focuses on the anatomy and functionality of the hip, with emphasis on recently studied concepts and anatomic features that have an association with the development of symptoms. The most common anatomic variants posing a challenge for diagnosis and other common findings in asymptomatic patients are reviewed. Good understanding of the different surgical procedures helps in providing as much information as possible to guarantee a favorable outcome, improving prognosis. We review what are the commonly expected postsurgical appearances and the most common postsurgical complications.

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.

Patients with Small Acetabular Cartilage Defects Caused by Femoroacetabular Impingement Do Not Benefit from Microfracture

OBJECTIVE

According to current recommendations, large cartilage defects of the hip over 2 cm2 are suggested to undergo autologous chondrocyte transplantation (ACT), while small defects should be treated with microfracture. We investigated if patients with small chondral defects of the hip joint (≤100 mm2) actually benefit from microfracture.

DESIGN

In this retrospective multicenter cohort study 40 patients with focal acetabular cartilage defects smaller than 100 mm2 and of ICRS grade ≥2 caused by femoroacetabular impingement were included. Twenty-six unrandomized patients underwent microfracture besides treatment of the underlying pathology; in 14 patients cartilage lesions were left untreated during arthroscopy. Over a mean follow-up of 28.8 months patient-reported outcome was determined using the iHOT33 (international hip outcome tool) and the VAS (visual analog scale) for pain.

RESULTS

The untreated group showed a statistically significant improvement of the iHOT33 after 12 (p = 0.005), 24 (p = 0.019), and 36 months (p = 0.002) compared to the preoperative score, whereas iHOT33 in the microfracture group did not reveal statistically significant changes over time. There was no significant difference between both groups on any time point. Regarding pain both groups did not show a significant improvement over time in the VAS.

CONCLUSION

The subjective outcome of patients with small cartilage defects of the hip (≤100 mm2) improves 12 months after arthroscopic FAIS surgery without any cartilage treatment. However, no improvement could be seen after microfracture. Therefore, a reserved surgical treatment for small cartilage defects of the hip under preservation of the subchondral bone is recommended especially if a simultaneous impingement correction is performed.

Short-Term Results of Osteochondral Autologous Transfer and Femoral Neck Osteochondroplasty for the Treatment of Osteochondral Lesions of the Femoral Head and Concomitant Femoroacetabular Impingement Syndrome: A Case Series

This study aimed to analyse the initial results of five patients with symptomatic osteochondral lesions (OCL) and femoroacetabular impingement (FAI) who were treated successfully with osteochondral autologous transfer (OAT) and femoral neck osteochondroplasty (OCP) through surgical dislocation of the hip. Five patients with FAI and OCL of the femoral head who underwent surgery between 2015-2018 were studied retrospectively. All patients had a grade IV OCL, and the median defect size was 2 cm² (interquartile range [IQR], 2-2). At the final follow-up, the modified Harris hip score showed a median value of 94 (IQR, 91-95) (P=0.04). Pain evaluation using the visual analogue scale showed a median value of 1 (IQR, 1-2) (P=0.04). Adequate graft union and healthy formation of the chondral surface were observed by magnetic resonance imaging. Although the procedure is demanding, the combination of OAT and femoral neck OCP appears to be an effective alternative in young patients.

Photoactivated leucocyte-rich platelet-rich plasma treatment in reduction of bone marrow edema in hip osteoarthritis

Aim: To describe the successful treatment of bone marrow edema in the setting of hip osteoarthritis using ultrasound-guided injection of photoactivated leukocyte-rich platelet-rich plasma (LR-PRP). Setting: Outpatient clinic. Patient: 65-year old female with antalgic and listing gait. Case description: The patient presented with a 2-week history of left hip pain. Exam revealed restriction and pain at end range of motion. Imaging showed extensive bone marrow edema and hip effusion. The patient underwent four weekly photoactivated LR-PRP treatments. Results: The patient reported a significant reduction in pain with MRI showing an extensive resolution of bone marrow edema and complete pain relief at 2 and 6 months post-treatment, respectively. Conclusion: Photoactivated LR-PRP may be considered as a treatment option for patients with marrow edema in the setting of hip osteoarthritis.

Acellular Matrix-Induced Chondrogenesis Technique Improves the Results of Chondral Lesions Associated With Femoroacetabular Impingement

PURPOSE

The study's main objective was to evaluate, in the short-term, the result of the autologous acellular matrix-induced chondrogenesis (AMIC) technique in a selected group of patients with 2-4 cm² full-thickness chondral lesions, undergoing hip arthroscopy for femoroacetabular impingement (FAI).

METHODS

A retrospective single-center Level IV case series of 25 patients (28 hips) who underwent an arthroscopic hip surgery with a liquid acellular collagen matrix. Inclusion criteria for implantation were FAI diagnosis (cam or pincer type), grade IV chondral lesions (Outerbridge size 2-4 cm²); Tönnis stage 0-II, minimum follow-up of 24 months, and 1 year (12-15 months) evaluation with very high field 3-T MRI arthrography. Exclusion criteria were Tönnis III, joint space <2 mm, center-edge angle <20°, and <24 months of follow-up. Clinical assessments involved symptoms duration until surgery, changes in physical and work activity and range of motion, modified Harris Hip Score, reporting percentages of patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID), pain with a VAS, and level of satisfaction. Radiological assessments: Tönnis stage, articular space, alpha and lateral center edge angle (Wiberg), and generated tissue characteristics at 1 year (based on the MOCART score), through 3-T MRI.

RESULTS

25 patients (28 hips) treated; 19 men and 6 women (mean age: 40.5 years; range: 25-55). Two women underwent joint replacement surgery. Thus, 23 patients (26 hips) were analyzed. At 29 months following surgery (range: 24-48), a significant improvement was obtained in all parameters assessed, focusing on the characteristics of the generated tissue in the MRI (MOCART scores). 95% of the patients met the MCID (improvement >12 points in the modified Harris Hip Score), and 100% scored >74 points, achieving the PASS. Patients' satisfaction was 86.6% (SD 16.4). All patients who practiced sports resumed them.

CONCLUSIONS

The liquid AMIC is a safe technique that shows good clinical and radiological outcomes in a 2-year follow-up in patients with femoroacetabular impingement and grade IV acetabular 2-4 cm² chondral defects.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Comparison of the Effect of MFAT and MFAT + PRP on Treatment of Hip Osteoarthritis: An Observational, Intention-to-Treat Study at One Year

Hip osteoarthritis (OA) is a major contributor to reduced quality of life and concomitant disability associated with lost working life months. Intra-articular injection of various biological materials has shown promise in alleviating symptoms and potentially slowing down the degenerative process. Here, we compared the effects of treatment of a cohort of 147 patients suffering from grade 1–4 hip OA; with either micro-fragmented adipose tissue (MFAT), or a combination of MFAT with platelet-rich plasma (PRP). We found significant improvements in both the visual analogue score for pain (VAS) and Oxford hip score (OHS) that were similar for both treatments with over 60% having an improvement in the VAS score of 20 points or more. These results suggest a positive role for intra-articular injection of MFAT + PRP as a treatment for hip osteoarthritis which may be important particularly in low body mass index (BMI) patients where the difficulty in obtaining sufficient MFAT for treatment could be offset by using this combination of biologicals.

Treatment of Full-Thickness Acetabular Chondral Flaps During Hip Arthroscopy: Bone Marrow Aspirate Concentrate Versus Microfracture

Background:

The optimal treatment strategy for patients with full-thickness chondral flaps undergoing hip arthroscopy is controversial.

Purpose:

To compare functional outcomes of patients who underwent bone marrow aspirate concentrate (BMAC) application with those of patients who underwent microfracture.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This was a retrospective case series of prospectively collected data on patients who underwent arthroscopic acetabular labral repair by 1 surgeon between June 2014 and April 2020. The inclusion criteria for this study were age ≥18 years, preoperative radiographs of the pelvis, arthroscopic acetabular labral repair, exposed subchondral bone with overlying chondral flap seen at the time of hip arthroscopy, microfracture or BMAC to address this lesion, and completed patient-reported outcome measures (PROMs) (International Hip Outcome Tool–33 [iHOT-33], Hip Outcome Score–Activities of Daily Living [HOS-ADL], Hip Outcome Score–Sports Subscale [HOS-Sport], modified Harris Hip Score [mHHS], and visual analog scale [VAS] for pain) at enrollment and 12-month follow-up. Clinical outcomes were assessed using PROM scores.

Results:

A total of 81 hips with full-thickness chondral flaps were included in this study: 50 treated with BMAC and 31 treated with microfracture. There were no significant differences between groups in age, sex, body mass index, tear size, radiographic osteoarthritis, or radiographic femoroacetabular impingement. In the BMAC cohort, all PROM scores improved significantly from preoperatively to follow-up: 41.7 to 75.6 for iHOT-33, 67.6 to 91.0 for HOS-ADL, 41.5 to 72.3 for HOS-Sport, 59.4 to 87.2 for mHHS, and 6.2 to 2.2 for VAS pain (P < .001 for all). In the microfracture cohort, the score improvements were 48.0 to 65.1 for iHOT-33 (P = .001), 80.5 to 83.3 for HOS-ADL (P = .275), 59.2 to 62.4 for HOS-Sport (P = .568), 70.4 to 78.3 for mHHS (P = .028), and 4.9 to 3.6 for VAS pain (P = .036). Regarding clinically meaningful outcomes, 77.6% of the BMAC group and 50.0% of the microfracture group met the minimal clinically important difference for iHOT-33 at the 12-month follow-up (P = .013).

Conclusion:

Patients with full-thickness chondral flaps at the time of hip arthroscopy experienced greater improvements in functional outcome scores at the 12-month follow-up when treated with BMAC as opposed to microfracture.

Arthroscopic utilization of ChondroFiller gel for the treatment of hip articular cartilage defects: a cohort study with 12- to 60-month follow-up

ChondroFiller gel is an absorbable collagen implant. It serves as a protective cover for the cartilage defects, allowing chondrocyte migration into the lesion. The implant consists of collagen (Type I) and is derived from veterinary monitored rats. This study evaluates the use of ChondroFiller gel in the treatment of cartilage lesions during hip joint arthroscopy. A prospective study was conducted on a group of 26 adult patients. All patients had an existing femoroacetabular impingement together with acetabular cartilage lesions >2 cm². All patients underwent hip arthroscopic surgery and the lesions were treated using ChondroFiller gel. The cartilage tissue healing was evaluated postoperatively using MRI. A total of 26 patients, including 5 females and 21 males, all with articular cartilage lesions, were included in the study. Cartilage healing conditions were evaluated for all patients, and the difference between pre- and post-surgery conditions was statistically significant. The follow-up scores have been acquired from 21 out of initial 26 patients (2 were disqualified after receiving THR, 3 could not be reached by researchers) after 3, 4 and 5 years consecutively with 17/21 patients having good/excellent results. The use of ChondroFiller gel during arthroscopy of the hip for acetabular cartilage lesions is an effective treatment technique. Encouraging long-term results have been observed, but further research on larger group of patient is required to better assess the full value of this technique. Patients with pre-existing osteoarthritis (Tönnis 2–3) have poor results.

Patients With Symptomatic Sequelae of Slipped Capital Femoral Epiphysis Have Advanced Cartilage Wear at the Time of Surgical Intervention

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is a common hip problem in children. The resulting deformity can cause impingement similar to cam-type idiopathic femoroacetabular impingement (FAI). Although there are similarities between FAI and SCFE, deformity patterns, severity, and time of onset of symptoms varies, which may impact management. The purpose of this study was to describe patterns of articular cartilage damage in patients undergoing surgical hip dislocation for sequelae of SCFE in comparison to patients undergoing arthroscopic surgery for primary FAI.

METHODS

Patients were identified who underwent surgical treatment for hip pain due to primary FAI (cam type) or sequelae of SCFE. Clinical data and radiographic measurements were recorded. Cartilage was assessed intraoperatively. Severity was classified using the modified Beck classification, while location was classified into 6 sectors. Statistical analysis was performed to test for differences in demographic and radiographic characteristics between the SCFE and FAI patients. χ2 or Fisher exact tests were used to evaluate trends in patterns of acetabular and femoral cartilage wear between SCFE and FAI groups.

RESULTS

The SCFE group had 28 hips compared with 304 in the FAI group. SCFE patients were younger (19 vs. 32, P<0.001), had higher body mass index (30±5.9 vs. 24±4.8, P<0.001), and were more often male (61% vs. 27%, P<0.001). Deformity severity based on α-angle was higher in the SCFE group [AP 74 vs. 55 (P=0.001) and Dunn 72 vs. 58 (P<0.001)]. There were no significant differences with regards to lateral center edge angle, anterior center edge angle, or Tonnis angle. In both groups the most common locations for cartilage lesions in both groups were the anterior peripheral and superolateral peripheral regions with fewer but more widely distributed femoral head lesions. The SCFE group had higher rates of femoral head and superolateral central cartilage lesions compared with the FAI group. There was no statistical difference between high-grade femoral or acetabular cartilage lesions between groups.

CONCLUSIONS

Patients with SCFE were younger at the time of surgery and presented with more severe deformity based on radiographic α-angle compared to patients with FAI. Our results suggest higher prevalence of femoral head lesions and more diffuse cartilage injury in patients with SCFE. This study can be used to support early surgical intervention in patients with symptomatic sequelae of SCFE due to risk of premature joint damage.

LEVEL OF EVIDENCE

Level III-prognostic study.

Managing Chondral Lesions: A Literature Review and Evidence-Based Clinical Guidelines

BACKGROUND

Articular cartilage lesions are becoming increasingly common. Optimum diagnosis and management of chondral defects cause a lot of dilemma. A number of surgical methods have been reported in the literature for treating focal cartilage defects. There is a lack of consensus on the most effective management strategy, with newer surgical and cell-based treatments being advocated regularly.

STUDY DESIGN AND METHODS

A clinical review is constructed by appraising the published literature about clinical evaluation and diagnostic modalities for articular cartilage defects and subsequent surgical procedures, management strategies employed for such lesions. Prominent available databases (PUBMED, EMBASE, Cochrane) were also searched for trials comparing functional outcomes following cartilage procedures. Synthesis of a practical management guideline is then attempted based on the evidence assessed.

RESULTS

Systematic examination and optimal use of diagnostic imaging are an important facet of cartilage defect management. Patient and lesion factors greatly influence the outcome of cartilage procedures and must be considered while planning management. Smaller lesions < 2 cm² respond well to all treatment modalities. Autologous osteochondral transplants (OATs) are effective in high activity individuals with intermediate lesions. For larger lesions > 4 cm², newer generation autologous chondrocyte implantation (ACI) has shown promising and durable results. Stem cells with scaffolds may provide an alternate option. Orthobiologics are a useful adjunct to the surgical procedures, but need further evaluation.

CONCLUSIONS

Most treatment modalities have their role in appropriate cases and management needs to be individualized for patients. The search for the perfect cartilage restoration procedure continues.

Capsular Management of the Hip During Arthroscopic Acetabular Chondral Resurfacing: Pearls, Pitfalls, and Optimal Surgical Technique

Treatment of hip joint chondral damage is a well-recognized aspect of the arthroscopic management of femoroacetabular impingement syndrome. Hip chondral resurfacing has evolved from microfracture to different forms of cartilage grafting, all with variable long-term outcomes. Recent literature has focused on techniques using different cartilage sources (native and synthetic products) that are available for clinicians to choose from during hip arthroscopy. None of the published reports on cartilage grafts have commented on hip joint capsular management as part of the procedure. This is likely because of the increased difficulty of capsular closure in the dry arthroscopic environment required for graft stabilization. However, potential iatrogenic hip instability induced by an unrepaired interportal capsulotomy can be detrimental to the existing joint architecture and possibly to the cartilage graft. This article presents a step-by-step approach, including tips and pearls, for capsular closure during arthroscopic acetabular chondral resurfacing with BioCartilage (Arthrex, Naples, FL). This method is a safe and reproducible way to close the joint capsule during chondral resurfacing in patients undergoing hip preservation that can potentially enhance the chances of a successful outcome.

Acetabular cartilage repair: state of the art in surgical treatment

Hip preservation has emerged as a developing surgical subspecialty with a variety of tools to address hip joint pain and dysfunction. Cartilage tears and delamination are caused by injury to the hip and can ultimately progress to osteoarthritis. It has been established that the acetabulum is particularly at risk of cartilage injury secondary to trauma, hip dysplasia and hip impingement. In spite of the high frequency of acetabular cartilage lesions based on our experience and the literature, there is no consensus as to the optimal treatment of these lesions. This review article highlights the challenges in treating cartilage injuries of the acetabulum with a particular emphasis on published studies and technical considerations in performing these procedures.

Surgical Hip Dislocation and Fresh Osteochondral Allograft Transplantation for Femoroacetabular Impingement and Concomitant Chondral Lesion

Chondral lesions of the hip in young patients are frequently associated with additional articular pathology. Parafoveal osteochondral lesions have been reported to be a manifestation of cam lesions in the setting of femoroacetabular impingement (FAI). Although arthroscopic surgery is useful to treat intra- and extra-articular pathology, large lesions located in areas that are difficult to access represent a limitation of the technique. Open surgical dislocation and osteochondral allograft transplantation (OCA) allow treatment of larger surface areas and underlying morphologic abnormalities such as cam lesions. We present our technique for open surgical dislocation of the hip through a stepped trochanteric osteotomy, osteochondral transplantation of fresh-stored femoral head allograft, and osteoplasty of the head/neck junction.

Autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate compared with microfracture for arthroscopic treatment of femoroacetabular impingement and chondral lesions of the hip: bridging the osteoarthritis gap and facilitating enhanced recovery

In an attempt to bridge the osteoarthritis (OA) gap, this study compared biological reconstruction with traditional microfracture (MF) techniques in patients with femoroacetabular impingement and focal cartilage defects. Cohorts of two groups were investigated; age, gender and Tonnis grade matched comparison for outcomes between MF and newer biological reconstruction techniques hip arthroscopy surgery using autologous matrix-induced chondrogenesis and bone marrow aspirate combination. Outcomes investigated were pre-op and post-op mean iHOT-12 scores up to 18 months after surgery with a Kaplan–Meier survivorship analysis. Of 111 patients, 46 patients underwent MF and 65 biological reconstruction hip arthroscopy including cam/pincer osteoplasty and labral repair surgery. Age range was 20–69, mean age 45 years for both groups, Tonnis grading was as follows: Grade 0: 26% versus 30%, Grade 1: 52% versus 47% and Grade 2: 22% versus 23% in MF and biological reconstruction groups, respectively. The mean post-operative iHOT-12 score differences between MF and biological reconstruction were significant at 1-year minimum follow-up (P = 0.01, SD 2.8). Biological reconstruction allowed for an enhanced recovery protocol. The MF group had a 67.4% survivorship for conversion to hip replacement at 18 months (32.6% failure rate for any reason) and biological reconstruction had 100% survivorship at 18 months post-operatively with no failures for any reason. This study provides further support to the evidence base for biological reconstructive techniques as superior to MF in combination with joint preservation arthroscopic surgery, even in the face of focal cartilage defects and offers both surgeons and patients a potential bridging of the OA gap.

Findings on repaired full-thickness acetabular articular cartilage defects during revision hip arthroscopy allowing a second look

Full-thickness acetabular articular cartilage defects (FAACD) are found on most hips with femoroacetabular impingement (FAI) with a wave sign in the acetabulum. When not repaired it can produce pain and catching sensation. Multiple arthroscopic techniques for repairing this chondral lesion exist, but only few show the quality of the repair on a second look. The purpose of this study is to evaluate the quality of the repaired cartilage during revision hip arthroscopy (RHA) allowing a second look in patients treated of FAACD. A total of 13 hips with FAACD repaired in the past underwent RHA for ongoing pain. Signs of persistent chondral defects or the ability to elevate the articular cartilage from subchondral bone were evaluated by zones. Those with persistent defects were re-repaired. All patients had FAACD lesions in zones I, II and III diagnosed in the index hip arthroscopy. The most common finding at the RHA was the presence of bone growth or residual impingement. Before FAACD repair, 11 (85%) hips had the wave sign, while 2 (15%) hips had it in RHA. Five (38%) hips had residual delamination in the second look, these patients had residual FAI, were ≥58 years or waited >6 months to be revised. The wave sign was not observed in 85% of the revised hips, indicating the technique was successful in most cases and was not the principal cause of their ongoing pain. This technique achieved the stated goal of stabilizing the articular cartilage seen in the wave sign.