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

PLGA Conical Nail Fixation for Acetabular Chondrolabral Delamination in Femoroacetabular Impingement Promotes Cartilage and Labrum Regeneration in a Porcine Model

BACKGROUND

Acetabular chondrolabral delamination (ACD) is one of the most common hip cartilage injuries. However, there are very limited clinical treatments for this injury.

PURPOSE

To evaluate the effectiveness of poly (lactic-co-glycolic acid) (PLGA) conical nail fixation in the treatment of acute and chronic ACD in a porcine model.

STUDY DESIGN

Controlled laboratory study.

METHODS

In this study, 24 pigs underwent surgically induced delamination of the chondrolabral junction. Pigs were randomly divided into 3 groups: the control group (delaminated chondrolabral junction without treatment), ACD acute refixation (ACDA) group (delaminated chondrolabral junction fixed with a PLGA nail), and ACD chronic refixation (ACDC) group (placement of a nonabsorbable spacer at the stripped chondrolabral junction for 6 weeks before fixation with a PLGA nail). Porcine specimens underwent magnetic resonance imaging (MRI), hematoxylin and eosin staining, safranin O/fast green (SO/FG) staining, immunohistochemistry examination (collagen 1, collagen 2, and collagen 10), and immunofluorescence examination (SOX9 and aggrecan) to evaluate the chondrolabral regeneration at 6 and 12 weeks postoperatively.

RESULTS

MRI showed focal discontinuity of cartilage and fluid located between the acetabular cartilage and subchondral bone plate in the control group. The acetabular cartilage stained with SO/FG showed significantly more proteoglycan deposition at 12 weeks in the ACDA group than in the control group (P = .0109) and ACDC group (P = .0484). In accordance with the results of the SO/FG and collagen 10 staining, the aggrecan of the femoral head at 6 and 12 weeks was upregulated in the ACDA group (P < .0001) and downregulated in the ACDC group (P < .0001).

CONCLUSION

PLGA conical nail fixation achieved a good treatment outcome on MRI and histological evaluations. Early treatment upregulated the expression levels of SOX9 and aggrecan and promoted proteoglycan deposition.

CLINICAL RELEVANCE

The PLGA conical nail fixation technique may be a viable and effective treatment approach for patients with ACD in clinical practice.

Current understanding of articular cartilage lesions in femoroacetabular impingement syndrome

The concept of femoroacetabular impingement syndrome (FAIS) has received much attention over the past 20 years. Currently, it is believed that FAIS can lead to intra-articular pathologies such as labral tears and articular cartilage lesions, resulting in clinical symptoms and subsequent poor clinical outcomes. FAIS-related articular cartilage lesions are common but unique, and their natural course always leads to early osteoarthritis of the hip. However, despite these cartilage lesions having gradually gained considerable attention, limited consensus has been reached on key aspects, such as diagnosis, mechanisms, classification, and management strategies, which limits clinical and research advances. Hence, an intensive comprehensive overview based on the existing evidence is necessary. The purpose of this review was to introduce the general consensus, controversial issues, and recent advances in FAIS-related articular cartilage lesions.

Hip Arthroscopy Debridement Combined with Multiple Small-Diameter Fan-Shaped Low-Speed Drilling Decompression in the Treatment of Early and Middle Stage Osteonecrosis of the Femoral Head: 14 Years Follow-Up

OBJECTIVE

Osteonecrosis of the femoral head (ONFH) is a disease that occurs frequently in young and middle-aged people. Because of its high disability rate, it affects the ability to work, so the early treatment of this disease is particularly important. This retrospective study aimed to evaluate the clinical efficacy of hip arthroscopy combined with multiple small-diameter fan-shaped low-speed drilling decompression (MSFLD) in treating early-mid stage ONFH (ARCO II-IIIA) compared to MSFLD, with at least 10-year follow-up.

METHODS

A total of 234 patients who underwent hip arthroscopy and MSFLD for ONFH from 1998 to 2012 were analyzed retrospectively. This study enrolled patients between 18 and 60 years old with ARCO stage II-III A, diagnosed clinically and through imaging, in accordance with the 2021 guidelines for the treatment of ONFH. Clinical data, including demographics, operation mode, BMI, pre- and postoperative Harris score, and femoral head survival rate, were collected. Patients were divided into hip arthroscopy + MSFLD and MSFLD groups based on the operation mode. The t-test was used to compare the postoperative efficacy, Harris scores, and survival rates of the femoral head between the two groups.

RESULTS

Among the 234 patients, 160 cases were followed up, including 92 cases in the hip arthroscopy + MSFLD group and 68 cases in MSFLD group, the follow-up rate was 68.38%, and the follow-up time was (10-22)14.11 ± 3.06 years. The Harris score (80.65 ± 6.29) in the hip arthroscopy + MSFLD group was significantly higher than that in the MSFLD group (p = 0.00), and the survival rate of femoral head (5-year survival rate was 84.78%, 10-year survival rate was 23.91%) was also higher than that in the MSFLD group (5-year survival rate was 63.24%, 10-year survival rate was 8.82%). The 5-year and 10-year survival rates of patients with ARCO II were 82.11% and 28.42%, which were better than 54% and 33% for ARCO III A. The femur head survival rate of alcoholic ONFH (5-year survival rate 61.54%, 10-year survival rate 9.23%) was significantly higher than that of other types of ONFH.

CONCLUSION

Clinical follow-up of at least 10 years suggests that hip arthroscopy combined with MSFLD is an effective treatment for early-mid stage ONFH, with good clinical effect and high survival rate of femoral head.

Biological Augments for Acetabular Chondral Defects in Hip Arthroscopy-A Scoping Review of the Current Clinical Evidence

PURPOSE OF REVIEW

A wide array of joint-preserving surgical techniques exists in the management of acetabular chondral defects (ACDs). The purpose of this review is to summarize the clinical outcomes of the recent biologics used to treat ACDs during hip arthroscopy.

RECENT FINDINGS

Increasing evidence is available for different biological solutions used in the hip. Studies have shown promising outcomes with minimal complications when using biologics as augmentation to microfracture (MF), including different scaffolds or stem cells, or to enhance autologous chondrocyte implantation (ACI). However, data so far is scarce, and more trials and longer follow-ups are needed to better delineate the appropriate indications and benefits for each technique. Presently, the level of evidence is low, but in general, biologics appear safe and trend toward beneficial compared to standard surgical techniques. Augmented MF is recommended for small to medium ACDs, and matrix-assisted ACI or three-dimensional ACI is recommended for medium to large defects.

Revision Hip Arthroscopy in the Native Hip: A Review of Contemporary Evaluation and Treatment Options

Hip arthroscopy is a reproducible and efficacious procedure for the treatment of femoroacetabular impingement syndrome (FAIS). Despite this efficacy, clinical failures are observed, clinical entities are challenging to treat, and revision hip arthroscopy may be required. The most common cause of symptom recurrence after a hip arthroscopy that leads to a revision arthroscopy is residual cam morphology as a result of inadequate femoral osteochondroplasty and restoration of head–neck offset, though several other revision etiologies including progressive chondral and labral pathologies also exist. In these cases, it is imperative to perform a comprehensive examination to identify the cause of a failed primary arthroscopy as to assess whether or not a revision hip arthroscopy procedure is indicated. When a secondary procedure is indicated, approaches may consist of revision labral repair, complete labral reconstruction, or labral augmentation depending on labral integrity. Gross instability or imaging-based evidence of microinstability may necessitate capsular augmentation or plication. If residual cam or pincer morphology is present, additional resection of the osseous abnormalities may be warranted. This review article discusses indications, the evaluation of patients with residual symptoms after primary hip arthroscopy, and the evaluation of outcomes following revision hip arthroscopy through an evidence-based discussion. We also present a case example of a revision hip arthroscopy procedure to highlight necessary intraoperative techniques during a revision hip arthroscopy.

Treatment of the Wave Sign With Femoral Osteoplasty With and Without Chondrolabral Stabilization Using Suture Anchors

PURPOSE

To discuss the surgical outcomes of patients identified to have the wave sign without an accompanying labral tear treated with and without stabilization of the chondrolabral junction in conjunction with femoral osteoplasty.

METHODS

A retrospective study was performed in patients with cartilage delamination (wave sign) treated with femoral osteoplasty alone (FO group) or femoral osteoplasty with chondrolabral stabilization (CLS group). Patient-reported outcomes including the modified Harris Hip Score, Hip Outcome Score (HOS)-Activities of Daily Living, and HOS-Sports-Specific Subscale were obtained at a minimum of 2 years postoperatively. Other outcomes included rates of revision hip arthroscopy and conversion to hip arthroplasty.

RESULTS

The study consisted of 47 patients in the FO group and 38 in the CLS group. Both groups showed significant increases in all patient-reported outcomes over the study period compared with preoperative values. The final modified Harris Hip Score was 72.8 ± 9.2 in the FO group and 79.9 ± 9.3 in the CLS group (P < .001). The HOS-Activities of Daily Living in the FO and CLS groups was 81.4 ± 10.3 and 87.2 ± 7.5, respectively (P < .001). There was no difference in the HOS-Sports-Specific Subscale between the FO group (74.4 ± 10.3) and the CLS group (78.0 ± 14.6) at final follow-up (P = .198). Revision hip arthroscopy was required in 5 patients in the FO group (13%) and 3 in the CLS group (6.3%). No patient in either group required conversion to hip arthroplasty throughout the study period.

CONCLUSIONS

Chondrolabral stabilization in conjunction with femoral osteoplasty is an effective treatment in patients with the wave sign without labral tears.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The 'wave sign' in hip arthroscopy: a systematic review of epidemiological factors, current diagnostic methods and treatment options

This study aims to present a systematic review and synthesized evidence on the epidemiological factors, diagnostic methods and treatment options available for this phenomenon. A multi-database search (OVID Medline, EMBASE and PubMed) was performed according to PRISMA guidelines on 18 June 2019. All studies of any study design discussing on the epidemiological factors, diagnostic methods, classification systems and treatment options of the wave sign were included. The Newcastle–Ottawa quality assessment tool was used to appraise articles. No quantitative analysis could be performed due to heterogeneous data reported; 11 studies with a total of 501 patients with the wave sign were included. Three studies examined risk factors for wave sign and concluded that cam lesions were most common. Other risk factors include alpha angle >65^° (OR=4.00, 95% CI: 1.26–12.71, P=0.02), male gender (OR 2.24, 95% CI: 1.09–4.62, P=0.03) and older age (OR=1.04, 95% CI: 1.01–1.07, P=0.03). Increased acetabular coverage in setting of concurrent cam lesions may be a protective factor. Wave signs most commonly occur at the anterior, superior and anterosuperior acetabulum. In terms of staging accuracy, the Haddad classification had the highest coefficients in intraclass correlation (k=0.81, 95% CI: 0.23–0.95, P=0.011), inter-observer reliability (k=0.88, 95% CI: 0.72–0.97, P<0.001) and internal validity (k=0.89). One study investigated the utility of quantitative magnetic imaging for wave sign, concluding that significant heterogeneity in T1_ρ and T2 values (P<0.05) of acetabular cartilage is indicative of acetabular debonding. Four studies reported treatment techniques, including bridging suture repair, reverse microfracture with bubble decompression and microfracture with fibrin adhesive glue, with the latter reporting statistically significant improvements in modified Harris hip scores at 6-months (MD=19.2, P<0.05), 12-months (MD=22.0, P<0.05) and 28-months (MD=17.5, P<0.001). No clinical studies were available for other treatment options. There is a scarcity of literature on the wave sign. Identifying at risk symptomatic patients is important to provide prompt diagnosis and treatment. Diagnostic techniques and operative options are still in early developmental stages. More research is needed to understand the natural history of wave sign lesions after arthroscopic surgery and whether intervention can improve long-term outcomes. Level IV, Systematic review of non-homogeneous studies.