1. MANAGEMENT OF CHONDRAL LESIONS OF THE HIP Leigh Brezenoff, MD Litchfield Hills Orthopedic Associates 20 th Annual Sports Medicine Symposium Tuesday, August 4, 2015

2. 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

3. MORE ANATOMY The 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)

4. 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

5. ANATOMY OF THE HIP Primarily Type II Hyaline CartilageMost injuries occur at the level of the tidemark of calcified cartilage

6. ETIOLOGY Many 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

7. 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

8. MECHANISM We will only be discussing the chondral lesions associated with sports The femoral head Hip dislocation Impaction injuries Causing an osteochondral lesion

9. MECHANISM The acetabulum Lesions associated with FAI are typically due to increased shear forces cam lesions lead to labral chondral separation

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

11. 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

12. LOCATION McCarthy 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

13. 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

14. HISTORY Most 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

15. PHYSICAL EXAM During 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

16. 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

17. CLASSIFICATION Head lesions: HC0 = no damage HC1 = softening HC2 = fibrillation HC3 = exposed bone HC4 = any delamination HTD = traumatic

18. 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

19. 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

20. CONTRAINDICATIONS TO ARTHROSCOPIC TREATMENT Relative: Significant structural instability/dysplasia posteriorly based cam lesion Absolute: Associated superior and/or lateral subluxation severe acetabular retroversion and severely deficient posterior rim

21. TREATMENT Non-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

22. 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

23. TREATMENT Microfracture 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

26. 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

27. 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

28. Chondral defect Diffuse osteoarthritispartial thicknessfull thickness Total hipchondroplastyfocal lesion <400mm2 Microfracturealternate treatment (OATS, hemiCAP)

29. THANK YOU