MANAGEMENT OF CHONDRAL LESIONS OF THE HIPLeigh Brezenoff, MD

Litchfield Hills Orthopedic Associates

20th Annual Sports Medicine Symposium

Tuesday, August 4, 2015

BASIC ANATOMY OF THE HIP

The hip is a simple ball and socket joint

There are 3 compartments of the hip

Central : acetabular fossa ,lunate cartilage, ligamentum teres and the articular cartilage of the femoral head

Peripheral: femoral neck, outer acetabular rim, synovial membrane, and capsule

the labrum acts to separate these two

peritrochanteric: deep gluteal region

MORE ANATOMYThe femoral head represents approximately 2/3 of a sphere

Cartilage thickness decreases from center to periphery and is more developed in the superior aspect than the inferior

Vascular supply is mainly provided by the medial femoral circumflex artery (MFCA)

MORE ANATOMY

The acetabulum is a concave surface

Horseshoe-like articular surface

There are 4 types of morphology of the lunate cartilage

I: clover-leaf like form 60.62%

II: semicircular 28.76%

III and IV are rare exceptions

ANATOMY OF THE HIP

Primarily Type II Hyaline CartilageMost injuries occur

at the level of the

tidemark of calcified

cartilage

ETIOLOGYMany encountered chondral abnormalities are seen in the setting of hip pathomorphology

Structural impingement can be the result of

an aspherical femoral head neck junction

acetabular over coverage

Extra-articular hip impingement

Dysplasia is typically associated with more significant abnormalities of the hip

CAUSES OF CHONDRAL LESIONS To treat chondral lesions about the hip one

must first understand the cause of such lesions

Injury

Morphologic causes:

FAI

SCFE

Other:

fractures

AVN

metabolic

MECHANISMWe will only be discussing the chondral lesions associated with sports

The femoral head

Hip dislocation

Impaction injuries

Causing an osteochondral lesion

MECHANISMThe acetabulum

Lesions associated with FAI are typically due to increased shear forces

cam lesions lead to labral chondral separation

MECHANISM

Pincer type impingement leads to labral degeneration with “countercoupe” lesions in the posterior acetabulum

MECHANISM

The acetabulum

dysplasia causes lesions involving the anterosuperior acetabulum and femoral head

involving the superior weight bearing portion of the head

traumatic episode

lateral impaction injuries cause medial lesion

LOCATIONMcCarthy at al. reviewed their findings of 457 hip arthroscopies and found the anterior and superior acetabulum to be most prevalent, accounting for 73% of the cartilage lesions

HISTORY

Clinicians must inquire about traumatic etiology such as hip subluxations, dislocations and direct falls onto the lateral hip

It is more common to elicit an insidious onset of groin or deep lateral hip

Symptoms are often exacerbated by activities such as running, cutting and pivoting, getting in and out of a car, arising from a seated position and prolonged sitting

HISTORYMost chondral and labral lesions may be felt as anterior groin pain

They also may be referred to the trochanter and the buttock area and occasionally medially and along the adductor muscles

They may feel a pinch anteriorly with FAI

Popping or clunking may be perceived

Unlike snapping hip this will not occur 100% of the time nor be easily reproduced

PHYSICAL EXAMDuring an impingement test, consisting of flexion of the hip to 90° and rotation from external to internal the lesion may be mapped out

Articular flaps may be felt either more clockwise or counterclockwise depending on the direction of the flap

IMAGING

Radiographs:

A low AP of the pelvis with the coccyx seen to be less than 2 cm away from the symphysis

a frog lateral

CT scan:

Can map bony topography

MRI with or without arthrography

The use of gadolinium may enhance visualization of cartilage lesions

CLASSIFICATIONHead lesions:

HC0 = no damage

HC1 = softening

HC2 = fibrillation

HC3 = exposed bone

HC4 = any delamination

HTD = traumatic

CLASSIFICATION

Acetabular lesions

AC 0= no damage

AC 1= softening no wave sign

AC 1w = wave sign with intact labrocartilage junction

AC 1wTj = wave sign but torn labrocartilage junction

AC 1wD = intact junction with delamination

AC 1wTjD = torn junction with delamination

AC 2 = fibrillation

AC 2Tj = fibrillation with torn junction

AC 3 = exposed bone <1cm2

AC 4 = exposed bone >1 cm2

CONTRAINDICATIONS TO SURGICAL TREATMENT

Bipolar MRI with grade 3 and 4 chondral changes

Greater then 50% joint space narrowing

Less than 2 mm joint space remaining on radiographs

CONTRAINDICATIONS TO ARTHROSCOPIC TREATMENTRelative:

Significant structural instability/dysplasia

posteriorly based cam lesion

Absolute:

Associated superior and/or lateral subluxation

severe acetabular retroversion and severely deficient posterior rim

TREATMENTNon-operative treatment can be attempted for patients with FAI in an effort normalize soft tissue length, joint capsule mobility, strength.

Activity modification plays a large role in this approach. Most young athletes do not tolerate this.

Actual chondral lesions cannot be managed effectively without surgery

TREATMENT

HC 0 and HC1: little to no treatment

HC 2: debridement

HC 3: microfracture

HC 4:debridement with microfracture

HTD: excision of loose fragment

TREATMENTMicrofracture is still the first line treatment for exposed full-thickness chondral defects.

Loose chondral fragments and flaps are debrided

There must not be any contralateral lesion

In the setting of cam-type FAI and labral chondral separation with adjacent partial thickness or full-thickness delamination is frequently seen

the cartilage is dealt with either debridement or microfracture or a variety of newer techniques. Most importantly though the impingement is treated

POST OPERATIVE REHABILITATION

Early ROM is begun with well leg stationary cycling and/or CPM machine

Flatfoot or 30 pound weight bearing restrictions are recommended for 2 weeks when microfracture is not performed and continued for 4-8 weeks after microfracture

Core strengthening initiated postoperatively

At 6-8 weeks progressive unrestricted strengthening is allowed with sports specific drills beginning at 2-3 months which is delayed to 3-6 months if microfracture

OPEN TREATMENT

Open treatment for FAI is still the gold standard

this includes surgical dislocation of the femoral head

allows direct visualization of the cam and pincer lesions as well as the labral and chondral issues

although this is advantageous for significant deformity, there is significantly more trauma to the hip during the surgery

Most recent studies show minimal differences in 2 year followup

early recovery favors the arthroscopic approach

Chondral defect

Diffuse osteoarthritis partial thickness full thickness

Total hip chondroplastyfocal lesion <400mm2

Microfracture alternate

treatment

(OATS, hemiCAP)

THANK YOU