Microfracture of the hip in athletes

The Impact of Age on Clinical Outcomes of Acetabular Microfracture During FAI Surgery

BACKGROUND

Full-thickness acetabular cartilage lesions are common findings during primary surgical treatment of femoroacetabular impingement (FAI).

PURPOSE

To evaluate clinical outcomes after acetabular microfracture performed during FAI surgery in a prospective, multicenter cohort.

STUDY DESIGN

Cohort Study; Level of evidence, 3.

METHODS

Patients with FAI who had failed nonoperative management were prospectively enrolled in a multicenter cohort. Preoperative and postoperative (mean follow-up, 4.3 years) patient-reported outcome measures were obtained with a follow-up rate of 81.6% (621/761 hips), including 54 patients who underwent acetabular microfracture. Patient characteristics, radiographic parameters, intraoperative disease severity, and operative procedures were analyzed. Propensity matching using linear regression was used to match 54 hips with microfracture to 162 control hips (1:3) to control for confounding variables. Subanalyses of hips ≤35 and >35 years of age with propensity matching were also performed.

RESULTS

Patients who underwent acetabular microfracture were more likely to be male (81.8% vs 40.9%; P < .001), be older in age (35.0 vs 29.9 years; P = .001), have a higher body mass index (27.2 vs 25.0; P = .001), and have a greater alpha angle (69.6° vs 62.3°; P < .001) compared with the nonmicrofracture cohort (n = 533). After propensity matching to control for covariates, patients treated with microfracture displayed no differences in the modified Harris Hip Score or Hip Disability and Osteoarthritis Outcome Score (P = .22-.95) but were more likely to undergo total hip arthroplasty (THA) (13% [7/54] compared with 4% [6/162] in the control group; P = .002), and age >35 years was associated with conversion to THA after microfracture. Microfracture performed at or before 35 years of age portended good outcomes with no significant risk of conversion to THA at the most recent follow-up.

CONCLUSION

Microfracture of acetabular cartilage defects appears to be safe and associated with reliably improved short- to mid-term results in younger patients; modified expectations should be realized when full-thickness chondral lesions are identified in patients >35 years of age.

Injectable autologous chondrocyte implantation in acetabular cartilage defects: 2-year minimum clinical and MRI results

INTRODUCTION

Early results using injectable autologous chondrocyte implantation (ACI) for the treatment of full thickness acetabular cartilage defects have been promising. However, so far there is no information on radiological results after injectable ACI using spheroids. The purpose of this sturdy was to (1) investigate the quality of tissue repair on MRI and (2) investigate the correlation between the MRI results and clinical results at a minimum follow-up of 24 months after third generation ACI in full thickness acetabular cartilage defects. It was hypothesized that ACI shows good MRI results in patients with large full thickness acetabular cartilage defects 24 months after surgery. It was also hypothesized that there is a correlation between postoperative clinical and MRI morphological results at a minimum follow-up of 24 months.

STUDY DESIGN

Retrospective case series.

MATERIALS AND METHODS

Patients with ACI for full thickness acetabular cartilage defects > 2 cm² were evaluated by preoperative and postoperative clinical scoring tools including the modified Harris Hip Score (mHHS), the International Hip Outcome Tool (iHOT-33), and the Subjective Hip Value (SHV) as well as a high resolution indirect arthro-MRI 24 months after surgery utilizing an identical imaging protocol for all patients. The magnetic resonance observation of cartilage repair tissue (MOCART) scoring system was used to classify the repair tissue on MRI. Demographic patient data was evaluated for influencing factors for pre- and postoperative clinical as well as radiological results.

RESULTS

Thirty six consecutive patients (5 women/31 men, average age 32.9 years) had undergone two stage ACI procedure. The average size of the cartilage defect was 5.0 (2-6) cm². The average follow-up was 29.9 (24-42) months. Four patients were not available for the final follow-up (follow-up rate 89%). The postoperative average MOCART score was 82.2 (± 14.2). MOCART score showed medium correlation of the item defect fill and the postoperative mHHS (r = 0.384, p = 0.043). There was no correlation of the other items or the total score with postoperative results. The patients showed significant improvement in the outcome measurements between preoperative and postoperative in the mHHS, the iHOT-33, and the SHV.

CONCLUSIONS

Despite the large acetabular cartilage defects included in this study, ACI showed good MRI results with complete defect fill in 87.5% after a minimum 24-month follow-up. Statistically significant correlation of MRI and clinical results could only be seen with the item defect fill. Further research with longer follow-up is needed to evaluate the long-term results of ACI in acetabular cartilage defects.

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.

Intra-articular Damage and Patient Outcome Comparison Between Athletes and Nonathletes After Hip Arthroscopy

BACKGROUND

The body of literature comparing hip arthroscopy between athletes and nonathletes is relatively scarce. Analyzing these groups can help to shed light on the severity of intra-articular damage and end-stage osteoarthritis that may result from participation in strenuous activities.

PURPOSE

(1) To compare the intra-articular damage at the time of hip arthroscopy between athletes and nonathletes, and (2) to compare the pre- and postoperative outcomes between the groups.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were considered eligible for analysis if they had received a primary hip arthroscopy between August 2008 and June 2018, were participating in competitive athletics, and had preoperative baseline scores and minimum 2-year follow-up for the following patient-reported outcomes: modified Harris Hip Score, Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale, and visual analog scale. Propensity score matching was used to match eligible patients in a 1:1 ratio to patients who were not participating in any sports greater than a recreational level before surgery.

RESULTS

A total of 234 patients were included. There were no significant differences in the severity of labral tears, ligamentum teres tears, or cartilage damage (P > .05). The procedures performed between cohorts were similar (P > .05). The athlete population had higher preoperative means scores for the modified Harris Hip Score and NAHS (each P < .001). Likewise, the athlete population had higher postoperative means scores for the NAHS, Hip Outcome Score-Sports Specific Subscale, and visual analog scale (P = .031, P = .030, and P = .032, respectively). Additionally, the athlete cohort reported higher minimum 2-year outcomes than the nonathlete cohort for the 12-Item Short Form Health Survey (mental component; P = .003) and Veterans RAND 12-Item Health Survey (mental component, P = .032; physical component, P = .005).

CONCLUSION

At the time of hip arthroscopy, athletes demonstrate similar intra-articular damage to their nonathlete counterparts. Given their higher preoperative scores, it is possible that athletes better tolerate the damage to the hip joint. Despite their strenuous activities and potentially higher tolerance to pain, athletes should not necessarily be expected to have greater severity of intra-articular pathology.

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.

Predictors of Clinical Outcomes After Hip Arthroscopy: 5-Year Follow-up Analysis of 1038 Patients

BACKGROUND

Although hip arthroscopy has been shown to have favorable results, there is a paucity of literature describing predictive factors of 5-year clinical outcomes.

PURPOSE

To identify predictive factors of midterm outcomes after hip arthroscopy in a cohort of 1038 patients whose outcomes at minimum 2-year follow-up were previously reported. In addition, to provide a comparison of short- and midterm predictive factors in outcome measures after hip arthroscopy.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed on all patients undergoing hip arthroscopy between February 2008 and June 2012. Patients were included if they had minimum 5-year follow-up on 2 patient-reported outcomes: Nonarthritic Hip Score (NAHS) and modified Harris Hip Score. Patients were excluded if they had any previous ipsilateral hip conditions. Using bivariate and multivariate analyses, we analyzed the effect of 36 pre- and intraoperative variables on the NAHS, modified Harris Hip Score, and conversion to total hip arthroplasty.

RESULTS

A total of 1038 patients met the inclusion criteria for the 2-year study, and 860 met our listed inclusion criteria for the 5-year study. The mean follow-up time was 62.0 months (range, 60.0-120.0 months). The bivariate analysis identified 10 variables (4 categorical and 6 continuous) that were predictive of 5-year postoperative NAHS. For the multivariate analysis, 7 variables were identified as being significant: preoperative NAHS, body mass index (BMI), age, lateral joint space, alpha angle, revision hip arthroscopy, and acetabular microfracture. These 7 variables were also predictive in the bivariate analysis. Age, BMI, revision hip arthroscopy, Tönnis grade, sex, trochanteric bursectomy, femoral head cartilage damage, and acetabular inclination were significant predictors of conversion to total hip arthroplasty.

CONCLUSION

This study reports favorable midterm clinical outcomes in the largest cohort of hip arthroscopies with minimum 5-year follow-up in the literature to date. Seven variables were identified as being significant predictors of postoperative NAHS in the bivariate and multivariate analyses: preoperative NAHS, BMI, age, lateral joint space, alpha angle, revision hip arthroscopy, and acetabular microfracture. Of these, preoperative NAHS, BMI, age, and revision hip arthroscopy were predictive of 2- and 5-year postoperative NAHS. These predictive factors may prove useful to clinicians in determining indications for hip arthroscopy and counseling patients on its expected outcomes.

Sustained benefit of autologous matrix-induced chondrogenesis for hip cartilage repair in a recreational athletic population

PURPOSE

To investigate the clinical outcome of autologous matrix-induced chondrogenesis (AMIC) implementation for mid-sized chondral lesions of the acetabulum in young active patients, and assess their potential to resume an active lifestyle including return to recreational athletic activities.

METHODS

Sixty-two patients with full-thickness mid-sized acetabular chondral lesions were studied. All patients who underwent an arthroscopic AMIC procedure for reconstruction of chondral defects were assessed pre-operatively and at least 2 years post-operatively using the Hip disability and Osteoarthritis Outcome Score (HOOS), modified Harris Hip Score (mHHS) and Visual Analog Scale (VAS) for pain.

RESULTS

A significant improvement in all three scores at the time of follow-up was found. The mean HOOS improved from 58.8 ± 7.4 pre-operatively to 90.6 ± 7.1 at follow-up (p < 0.001) while the mean mHHS improved from 53.4 ± 6.6 to 82.4 ± 8.2 (p < 0.001). There was a significant decrease from 4.9 ± 1.1 pre-operatively to 1.1 ± 0.8 post-operatively (p < 0.001) in the VAS pain evaluation, indicating that the patients were satisfied with their relief of pain.

CONCLUSIONS

The AMIC procedure is an effective single-stage technique for the reconstruction of mid-size chondral defects of acetabulum in amateur athletes. This intervention enhanced the potential for patients to resume recreational athletic activities and the 2-year clinical outcome as evaluated by the HOOS, mHHS and VAS showed significant improvement over the pre-operative evaluations.

Management of Bone Marrow Lesions of the Hip With Subchondral Calcium Phosphate Injection: Surgical Technique and Tips

Bone marrow lesions (BMLs) are localized areas of edema within subchondral bone, which are often due to early chondromalacia changes, subchondral insufficiency stress or microfractures, and/or avascular necrosis. The presence of BMLs worsen outcomes after arthroscopy and arthroplasty, thus making their management important in the preservation of hip function. In recent years, the advent of Subchondroplasty (SCP; Zimmer Knee Creations Incorporated, Exton, PA)-a minimally invasive surgical technique that involves injecting an isothermic calcium phosphate solution to stabilize BMLs-has shown promising results in managing pain from osteoarthritis (OA). The SCP material (AccuFill Bone Substitute Material, Zimmer Knee Creations Incorporated) has a similar physical and chemical structure to native bone mineral. In this Technical Note, we discuss a surgical approach for managing acetabular and femoral head BMLs with SCP. We also review the prior clinical trials reporting on SCP for knee OA. SCP may be a promising technique as part of the treatment algorithm for managing hip OA, and clinical trial enrollment has begun for hip SCP. On the basis of these results, further investigations into this procedure may be warranted.

Identifying the Most Successful Procedures in Hip Arthroscopy

Hip arthroscopy for femoral and acetabular pathologies has increased dramatically. However, there is little literature analyzing procedures as predictors of revision arthroscopy or arthroplasty. From February 2008 to November 2015, patients undergoing hip arthroscopy for a labral tear with minimum 2-year follow-up and between 18 and 60 years old were retrospectively reviewed. Those with previous surgeries, Tönnis grade greater than 1, and previous hip conditions were excluded. Follow-up was obtained for 1118 patients (1249 hips; 81.7%) with a mean age of 38.7 years (range, 18.0-60.0 years), mean body mass index of 26.4 kg/m² (range, 16.3-48.9 kg/m²), and mean follow-up of 50.2 months (range, 24.0-111.9 months). A total of 122 (9.8%) patients converted to total hip arthroplasty (mean, 35.3 months; range, 1.4-95.2 months). Multivariate analysis for predictors of total hip arthroplasty found age at surgery (hazard ratio, 1.064/y; P<.05), body mass index (nonlinear; P<.05), labral debridement (HR, 1.558; P=.03), and notchplasty (HR, 2.128; P<.05), with trochanteric bursectomy (HR, 0.367; P<.05) identified as associated with higher survivorship. A total of 124 (9.9%) patients underwent revision hip arthroscopy at a mean of 21.7 months (range, 0.10-83.3 months). Multivariate analysis for predictors of revision surgery found workers' compensation (HR, 3.352; P<.05), capsular repair (HR, 1.950; P<.05), and femoral head microfracture (HR, 2.844; P=.04) to be significant, with age at date of surgery (HR, 0.973/y; P<.05) and femoral head chondroplasty (HR, 0.241; P=.05) associated with higher survivorship. Understanding risk factors for conversion to total hip arthroplasty or revision is paramount during discussions with patients. [Orthopedics. 2020;43(3):173-181.].

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)

Microfracture in Hip Arthroscopy. Keep It Simple!

Despite all the advances in hip arthroscopy, microfracture is still the workhorse for treating focal and full-thickness cartilage lesions. The success of this treatment is owed to its reliability and simplicity. Given the structure of the hip joint, however, there are challenges to this procedure using a conventional microfracture pick. This note presents our current and preferred microfracture technique using a curve drill guide and flexible drill. This method offers greater range of access to different regions of the joint with ease, thus ensuring a reproducible and quicker procedure with less risk.

Primary labral reconstruction in patients with femoroacetabular impingement, irreparable labral tears and severe acetabular chondral defects decreases the risk of conversion to total hip arthroplasty: a pair-matched study

In the presence of severe acetabular cartilage defects, the benefits of labral reconstruction (RECON) versus labral resection (RESEC) have not been determined. Prospectively collected data between October 2008 and December 2016 were retrospectively reviewed. Inclusion criteria were hip arthroscopy, acetabular Outerbridge grade III/IV, irreparable labral tears that underwent RECON or RESEC, and minimum 2-year postoperative measures for the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, International Hip Outcome Tool, Patient Satisfaction and Visual Analogue Scale for pain. Exclusion criteria included Tönnis grade >1, previous hip conditions or previous ipsilateral hip surgeries. A 1:1 matched-pair analysis was performed based on age ±5 years, sex, body mass index ±5 kg/m², Tönnis grade, acetabular microfracture, femoral Outerbridge grade (0 or I compared with II, III or IV). Relative risk (RR) and conversion rate to total hip arthroplasty (THA) were calculated. A total of 38 RECON hips were successfully matched. Both groups demonstrated significant improvements in patient-reported outcomes (PROs). THA conversion was 5.3% and 21.1% for the RECON and RESEC groups, respectively (P = 0.04). RECON was four times less likely to require THA conversion than the RESEC group (RR=4.0; 95% CI 0.91-17.63). In the setting of primary arthroscopic management of femoroacetabular impingement, irreparable labral tears and acetabular chondral lesions of Outerbridge III/IV, patients that underwent RECON and RESEC experienced significant improvement in PROs at minimum 2-year follow-up, and these functional scores were comparable when groups were matched. However, RR and rate to THA conversion were significantly higher in the RESEC group.

Subchondral drilling for chondral flaps reduces the risk of total hip arthroplasty in femoroacetabular impingement surgery at minimum five years follow-up

INTRODUCTION:

The best treatment of acetabular chondral flaps during surgery for femoroacetabular impingement (FAI) is unknown. We asked if subchondral drilling improves clinical and radiographic outcome and if there are factors predicting failure.

METHODS:

We treated 79 patients with symptomatic FAI and acetabular chondral flaps with surgical hip dislocation between January 2000 and December 2007. Exclusion of all patients with previous hip pathology or trauma resulted in 62 patients (80 hips). The chondral flap was slightly debrided in 43 patients/51 hips (control group). In 28 patients/29 hips (study group), additional osseous drilling was performed. 4 patients (5 hips, 6%) were lost to follow-up. Mean follow-up was 9 years (5-13 years). The groups did not differ in demographic data, radiographic parameters or follow-up. Clinical outcome was assessed with the Merle d'Aubigné score, modified Harris Hip Score and University of California Los Angeles activity score and progression of osteoarthritis with the Tönnis grade.

RESULTS:

No patient underwent conversion to total hip arthroplasty (THA) in the drilling group compared to 7 patients (8 hips, 16%) in the control group ( p = 0.005); in the remaining hips, clinical scores and progression of Tönnis grade did not differ. Increased acetabular coverage, age and body mass index were univariate predictive factors for conversion to THA. No drilling was as an independent predictive factor for conversion to THA (hazard ratio 58.07, p = 0.009).

CONCLUSION:

Subchondral drilling under acetabular chondral flaps during surgical treatment of FAI is an effective procedure to reduce the rate of conversion to THA.

Effect of Cigarette Smoking on Patient-Reported Outcomes in Hip Arthroscopic Surgery: A Matched-Pair Controlled Study With a Minimum 2-Year Follow-up

Background

The rate of hip arthroscopic surgery has recently increased; however, there is limited literature examining patient-reported outcomes (PROs) in cigarette smokers.

Purpose/Hypothesis

The purpose of this study was to evaluate whether smoking status for patients undergoing hip arthroscopic surgery affects clinical findings and PRO scores. We hypothesized that patients who smoke and undergo primary hip arthroscopic surgery will have similar clinical examination findings and preoperative and postoperative PRO scores compared with nonsmoking patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

Data were collected on all patients who underwent primary hip arthroscopic surgery from February 2008 to July 2015. A retrospective analysis of the data was then conducted to identify patients who reported cigarette use at the time of the index procedure. Patients were matched 1:2 (smoking:nonsmoking) based on sex, age within 5 years, labral treatment (repair vs reconstruction vs debridement), workers' compensation status, and body mass index within 5 kg/m². All patients were assessed preoperatively and postoperatively using 4 PRO measures: the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12 (iHOT-12). Pain was estimated using a visual analog scale. Satisfaction was measured on a scale from 0 to 10. Significance was set at P < .05.

Results

A total of 75 hips were included in the smoking group, and 150 hips were included in the control group. Preoperatively, the smoking group had significantly lower PRO scores compared with the control group for the mHHS, NAHS, and HOS-SSS. Both groups demonstrated significant improvement from preoperative levels. A minimum 2-year follow-up was achieved, with a mean of 42.5 months for the smoking group and 47.6 months for the control group (P = .07). At the latest follow-up, the smoking group reported inferior results for all outcome measures compared with controls. The improvement in PRO scores and rates of treatment failure, revision arthroscopic surgery, and complications was not statistically different between the groups.

Conclusion

Patients who smoke had lower PRO scores preoperatively and at the latest follow-up compared with nonsmokers. Both groups demonstrated significant improvement in all PRO scores. These results show that while hip arthroscopic surgery may still yield clinical benefit in smokers, these patients may ultimately achieve an inferior functional status. To optimize results, physicians should advise patients to cease smoking before undergoing hip arthroscopic surgery.

Injectable autologous chondrocyte implantation (ACI) in acetabular cartilage defects-three-year results

To evaluate the clinical outcome after arthroscopic matrix-associated injectable autologous chondrocyte implantation (ACI) in patients with large full-thickness acetabular cartilage defects. ACI was performed in young patients with full-thickness acetabular cartilage defects ≥2 cm² in a two-step arthroscopic procedure. The patients were followed closely with clinical examinations and pre- and postoperative scores. The modified Harris Hip Score (mHHS), iHOT33 questionnaire (iHOT33) and the Subjective Hip Value (SHV) were surveyed. Demographic patient data was evaluated for influencing factors for the pre- and postoperative results. Thirty-two consecutive cases (4 female, 28 male, mean age 33 years) were included. The average defect size was 4.9 (range: 2–6) cm². They were followed at 6, 12, 24 and 36 months postoperatively. Patients had improved significantly from 64 to 91 points (P < 0.001) in the mHHS, from 44% to 86% (P < 0.001) in the iHOT33 and from 54% to 87% (P < 0.001) in the SHV. No surgery related complications were noted. Cell cultivation failed in two cases (7%) and the patients decided for a repeated harvesting of cartilage cylinders followed by a successful ACI. Patients age and size of the cartilage defect showed no significant correlation with the pre- or postoperative results. Injectable ACI is a reliable procedure treating full-thickness acetabular cartilage defects leading to promising results 3 years postoperatively with a significant increase in all scores despite large acetabular cartilage defects in the weight-bearing zone.

Acetabular microfracture in hip arthroscopy: clinical outcomes with minimum 5-year follow-up

INTRODUCTION

There is a paucity in the literature regarding mid-term results of microfracture in hip arthroscopy. We aim to assess 5-year outcomes of patients who underwent acetabular microfracture for full-thickness chondral lesions as a part of hip arthroscopy.

METHODS

Between August 2008 and September 2011, data were prospectively gathered for patients undergoing acetabular microfracture during hip arthroscopy with minimum 5-year follow-up. All patients were assessed pre- and postoperatively, with modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score - Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS). International Hip Outcome Tool (iHOT-12) and satisfaction were collected postoperatively. Exclusion criteria included previous hip conditions, or preoperative Tönnis grade ≥2.

RESULTS

Fifty three hips were eligible for this study. Of these, 43 (81.1%) hips in 42 patients had follow-up. The study group had a male majority (65.1%) and an average age of 44.4 ± 9.5 years. There was statistically significant improvement in all patient-reported outcomes (PROs) and VAS at follow-up. Patient satisfaction was 7.6 ± 2.6. A comparison of 2-year to minimum 5-year follow-up results identified no statistically significant deterioration in PROs, VAS, and patient satisfaction. Survivorship was 72.1% with 12 patients converted to total hip arthroplasty (THA). 4 patients (10.8%) underwent secondary arthroscopy.

CONCLUSIONS

In the mid-term, microfracture as a part of hip arthroscopy demonstrated favourable outcomes and 72% survivorship. Careful patient selection is warranted to limit the risk of conversion to THA.

Acetabular Chondral Lesions Associated With Femoroacetabular Impingement Treated by Autologous Matrix-Induced Chondrogenesis or Microfracture: A Comparative Study at 8-Year Follow-Up

PURPOSE

The aim of this retrospective study was to investigate, at 8 years, the clinical follow-up and failure rate (revision rate/conversion to arthroplasty) of patients with hip chondral lesions associated with femoroacetabular impingement and to compare over time the treatment by microfracture (MFx) and autologous matrix-induced chondrogenesis (AMIC).

METHODS

Patients aged between 18 and 55 years, with acetabular grade III and IV chondral lesions (Outerbridge), measuring 2 to 8 cm² operated on at least 8 years before enrollment. Exclusion criteria were rheumatoid arthritis, dysplasia, or axial deviation of the femoral head. There were no arthritic lesions, Tonnis < 2, or joint space of at least 2 mm. MFx was performed with an awl, and the Chondro-Gide membrane used for the AMIC procedure was placed without glue. Outcomes used modified Harris hip score (mHHS) at 6 months and yearly for 8 years and patient acceptable symptomatic state.

RESULTS

Among 130 patients, 109 fulfilled inclusion criteria. Fifty were treated by MFx and 59 by AMIC. The mHHS significantly improved in both groups from 46 ± 6.0 to 78 ± 8.8 for mHHS at 6-12 months, even for lesions > 4 cm². From 2 to 8 years, mHHS in the AMIC group was better than in the MFx group (P < .005). This mHHS improvement in the AMIC group was maintained through the 8-year follow-up period, whereas it deteriorated after 1 year in the MFx group (P < .005). Eleven patients (22%) in the MFx group required total hip arthroplasty (THA); none in the AMIC group did. Patient acceptable symptomatic state analysis confirmed similar short-term improvement, but a significant (P < .007) degradation after 2-8 years in MFx patients.

CONCLUSIONS

MFx and AMIC techniques led to marked clinical short-term improvement in patients with chondral defects resulting from femoroacetabular impingement in the first 2 years. However, AMIC gave significantly better results as measured by mHHS, which were maintained after 8 years, the results of MFx in the hip deteriorated over time with 22% of patients undergoing conversion to THA. No patient in the AMIC group was converted to THA; the results of AMIC appeared stable over time and independent of lesion size.

LEVEL OF EVIDENCE

III, retrospective patient group study.

Synovial Mesenchymal Stem Cells Derived From the Cotyloid Fossa Synovium Have Higher Self-renewal and Differentiation Potential Than Those From the Paralabral Synovium in the Hip Joint

BACKGROUND

Several studies have shown the relationship between poorer clinical outcomes of arthroscopic femoroacetabular impingement syndrome surgery and focal chondral defects or global chondromalacia/osteoarthritis. Although recent studies described good outcomes after the conjunctive application of synovial mesenchymal stem cells (MSCs), none demonstrated the application of synovial MSCs for cartilaginous hip injuries.

PURPOSE

To compare the characteristics of MSCs derived from the paralabral synovium and the cotyloid fossa synovium and determine which is the better source.

STUDY DESIGN

Controlled laboratory study.

METHODS

Synovium was harvested from 2 locations of the hip-paralabral and cotyloid fossa-from 18 donors. The number of cells, colony-forming units, viability, and differentiation capacities of adipose, bone, and cartilage were collected and compared between groups. In addition, real-time polymerase chain reaction was used to assess the differentiation capacity of adipose, bone, and cartilage tissue from both samples.

RESULTS

The number of colonies and yield obtained at passage 0 of synovium from the cotyloid fossa was significantly higher than that of the paralabral synovium ( P < .01). In adipogenesis experiments, the frequency of detecting oil red O-positive colonies was significantly higher in the cotyloid fossa than in the paralabral synovium ( P < .05). In osteogenesis experiments, the frequency of von Kossa and alkaline phosphatase positive colonies was higher in the cotyloid fossa synovium than in the paralabral synovium ( P < .05). In chondrogenic experiments, the chondrogenic pellet culture and the gene expressions of COL2a1 and SOX9 were higher in the cotyloid fossa synovium than in the paralabral synovium ( P < .05).

CONCLUSION

MSCs from the cotyloid fossa synovium have higher proliferation and differentiation potential than do those from the paralabral synovium and are therefore a better source.

CLINICAL RELEVANCE

Synovial cells from the cotyloid fossa synovium of patients with femoroacetabular impingement syndrome are more robust in vitro, suggesting that MSCs from this source may be strongly considered for stem cell therapy.

Predictors of Clinical Outcomes After Hip Arthroscopy: A Prospective Analysis of 1038 Patients With 2-Year Follow-up

BACKGROUND

As hip arthroscopy has expanded in popularity and volume, more information is needed about indications for the procedure and the predictive factors of clinical outcomes.

PURPOSE

To evaluate clinical outcomes of hip arthroscopy in a prospective study and to analyze the cohort to identify factors that are predictive of improvement.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were collected prospectively on all patients undergoing hip arthroscopy between February 2008 and June 2012. We included all patients undergoing hip arthroscopy who agreed to participate and who completed 4 patient-reported outcome (PRO) instruments at a minimum 2-year follow-up: the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale. The NAHS was selected as our primary outcome instrument. All patients with any previous hip conditions were excluded. We analyzed 34 preoperative and intraoperative variables using bivariate and multivariate analyses compared with NAHS.

RESULTS

The cohort consisted of 1038 patients with a mean follow-up of 30.1 months (range, 24.0-61.2 months). Mean age was 36.4 years (range, 13.2-76.4 years). All postoperative PRO scores showed significant improvement ( P < .001) at 2 years compared with preoperative scores. Bivariate analysis identified 15 variables (7 categorical and 8 continuous) and multivariate analysis identified 10 variables that were predictive of 2-year postoperative NAHS. Preoperative NAHS, preoperative HOS-ADL, preoperative mHHS, age, duration of symptoms, body mass index (BMI), and revision hip arthroscopy were identified as predictive factors in both bivariate and multivariate analyses. The predictive value of preoperative NAHS was accentuated for patients with higher BMI.

CONCLUSION

This study reports favorable clinical outcomes in the largest cohort of hip arthroscopies with a minimum 2-year follow-up in the literature to date. Factors identified as predictive in both bivariate and multivariate analyses included preoperative NAHS, HOS-ADL, and mHHS; age; duration of symptoms; BMI; and revision hip arthroscopy. These predictive factors may be useful to the clinician in determining prognosis and operative indications for hip arthroscopy.

Arthroscopic hip surgery with a microfracture procedure of acetabular full-thickness chondral damage. Cohort study with a 3-year follow-up

INTRODUCTION AND PURPOSE

Management of injuries to the articular cartilage is complex and challenging. Our purpose was to assess outcomes of a cohort of patients who underwent hip arthroscopy with full-thickness chondral damage treated with microfracture and compare these outcomes with those from a similar cohort of patients who did not.

MATERIAL AND METHODS

We prospectively gathered the data of 31 hips treated with microfracture from January 2009 to January 2016. In the cohort of hips without chondral damage there were 49 hips. All patients were assessed pre- and postoperatively with 4 patient-reported outcome instruments.

RESULTS

The mean follow-up was 36.2 months in the cohort of patients with full-thickness chondral damage, and 36.6 months in the cohort of patients without chondral damage. Both groups demonstrated significant improvement in all patient-reported outcome instruments between preoperative and final follow-up. There was no statistically significant difference between both cohorts at final follow-up.

DISCUSSION

This study showed that patients undergoing microfracture during hip arthroscopy had significant improvement in all patient-reported outcome instruments during follow-up. The greatest improvement was noted at 6 months postoperatively. Both groups showed no significant difference in final patient-reported outcome instruments scores.

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.

Outcomes of Femoral Head Marrow Stimulation Techniques at Minimum 2-Year Follow-up

This study compared patients who underwent femoral head microfracture with a control group of patients who did not require microfracture. Patients had more than 2 years of follow-up. The patient groups had similar demographic and radiographic features, including sex, age within 5 years, body mass index within 5 points, equal Tönnis grade, lateral center edge angle within 5°, labral treatment, and capsular closure vs release. Inclusion criteria were a minimum of 2 years of follow-up, Outerbridge grade IV cartilage damage, and femoral head marrow stimulation technique performed at the time of arthroscopy. Exclusion criteria were revision surgery, dysplasia, Tönnis grade of greater than 1, protrusio or profunda acetabuli, Perthes disease of the hip, slipped capital femoral epiphysis, abductor tear, and avascular necrosis of the hip. Patient-reported outcomes included modified Harris hip score, nonarthritic hip score, hip outcome score-activity of daily living subscale, hip outcome score-sports subscale, and visual analog scale score for pain. Fifteen patients had femoral head microfracture with more than 2 years of follow-up. Mean improvements in modified Harris hip score, nonarthritic hip score, hip outcome score-sports subscale, and visual analog scale score were 17.1, 19.4, 30.5, and 2.8, respectively, for the microfracture group compared with 11.8, 18.5, 22.2, and 3.0, respectively, for the control group. Both groups showed statistically significant improvement (P<.05) for all patient-reported outcomes, and no significant difference was found between the 2 patient groups at latest follow-up. Two patients in the microfracture group vs 3 patients in the control required hip arthroplasty. Femoral head microfracture is a technically difficult procedure, but when performed correctly, the results are similar to those of patients who do not require microfracture. Further study of femoral head microfracture is necessary to confirm these encouraging short-term outcomes. [Orthopedics. 2018; 41(1):e70-e76.].

Acetabular Chondral Lesions in Hip Arthroscopy: Relationships Between Grade, Topography, and Demographics

BACKGROUND

Hip pain remains a challenge given the multiple factors that can cause damage to the articular cartilage, such as traumatic injury, metabolic damage, and morphologic variations such as femoroacetabular impingement (FAI) and that can contribute to progression of osteoarthritis. However, a direct relationship between patient characteristics, the extent of acetabular chondral damage, and topologic characteristics of chondral lesions has not been established.

PURPOSE

To compare the grade of acetabular chondral damage, measured in terms of acetabular labrum articular disruption (ALAD) classification, to the size and position of the chondral lesions, matching patients' demographic factors such as age and body mass index (BMI).

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

This study included all hip arthroscopies performed by the corresponding author from August 7, 2008, to November 19, 2014, in which acetabular chondral lesions were intraoperatively identified and measured in terms of ALAD grade, clockface location, and size. Bivariate analyses and multiple logistic regression were used to identify the demographic factors, characteristics of the acetabular chondral lesion, and other anatomic characteristics that were related to the ALAD grade of the acetabular chondral lesion.

RESULTS

Acetabular chondral lesions were measured in 1502 patients during the study period. Multivariate analysis showed that higher ALAD grade of acetabular chondral damage was significantly related to male sex, more advanced age, the area of the acetabular chondral lesion, anterior extension of the acetabular chondral lesion within the anterosuperior quadrant, labral detachment from the acetabular cartilage, and posterior extension of the labral tear.

CONCLUSION

Higher grades of acetabular chondral damage were related to male sex, increased age, height, weight, BMI, and the size of the lesion. Chondral lesions were generally found in the anterosuperior region of the acetabulum, consistent with labral lesions and the weightbearing area of the acetabulum.

Does duration of symptoms affect clinical outcome after hip arthroscopy for labral tears? Analysis of prospectively collected outcomes with minimum 2-year follow-up

Limited research exists on the possible association between duration of symptoms and clinical outcomes following hip arthroscopy for labral tears. The purpose of this study was to evaluate whether duration of symptoms affected clinical and patient-reported outcome (PRO) scores following hip arthroscopy for labral tears. From 2008 to 2011, data were collected prospectively on all patients undergoing primary hip arthroscopy for labral tears. Workers' compensation cases, dysplasia cases and patients with previous ipsilateral hip surgeries were excluded. A total of 738 patients were identified with a minimum of 2-year follow-up, and clinical and PRO data were available for 680 patients. Uni- and multivariate analyses were performed to determine the relationship between duration of symptoms along with other variables and PROs. Overall, patients experienced significant improvements in all clinical and PRO scores. Results of univariate analysis revealed that all PROs were negatively associated with increasing Log₁₀ months of symptoms as were pain and satisfaction scores. During multivariate analyses, increasing Log₁₀ months of symptoms, age, body mass index and trauma were all negatively associated with PROs (P  < 0.05). Our study demonstrates that clinical and PRO scores were negatively associated with increasing duration of symptoms prior to hip arthroscopy for treatment of labral tears. Although this implies that delay in treatment may adversely affect outcome, conservative treatment remains the gold standard first line of treatment. Surgeons should incorporate this information into their treatment algorithm to maximize patient outcomes following treatment for labral tears. Level of evidence: Level IV, prospective case series.

Treatment of acetabular chondral lesions with microfracture technique

Introduction: Acetabular cartilage lesions are frequently found during hip arthroscopy. In the hip joint they mostly occur secondary to a mechanical overload resulting from a pre-existing deformity as hip dysplasia or femoroacetabular impingement (FAI). Lesions identified during arthroscopy can vary greatly from the earliest stages to the most advanced (full-thickness lesions). These lesions occur in the acetabulum in the early stages of joint damage. Microfractures are indicated in full-thickness chondral defects. Ideally, these lesions must be focal and contained.

Methods: The procedure begins debriding all the unstable chondral tissue of the lesion. The edges should have a net cut towards stable and healthy cartilage. It is recommended to make as many perforations as possible using arthroscopic awls. They should be ideally 4 mm deep and must have a vertical orientation to the surface. The suggested distance between perforations is of 3–4 mm. Once the treatment of the chondral lesion with the microfractures is complete, the labrum must be repaired. The repair of the labrum transforms in most of the cases the defect in a contained lesion containing better the clot in the lesion after the microfractures have been performed. It is also important to correct the bone deformity that has caused this lesion, which mostly corresponds to a “cam” deformity.

Conclusion: Clinical studies confirm good short- and medium-term results in full-thickness chondral lesions treated with microfractures in the absence of osteoarthritis. However, it is difficult to determine if these results are only due to the microfractures, as this treatment is always complemented with several other factors and surgical procedures, such as labrum repair, correction of underlying bone deformity or change in postoperative activity of operated patients.

Arthroscopic treatment of chondral defects in the hip: AMIC, MACI, microfragmented adipose tissue transplantation (MATT) and other options

Chondral lesions are currently considered in the hip as a consequence of trauma, osteonecrosis, dysplasia, labral tears, loose bodies, dislocation, previous slipped capital femoral epiphysis and Femoro-Acetabular-Impingement (FAI). The management of chondral lesions is debated and several techniques are described. The physical examination must be carefully performed, followed by radiographs and magnetic resonance imaging (MRI). Differential diagnosis with other pathologies must be considered. Debridement is indicated in patients younger than 50 years with a chondropathy of 1st or 2nd degree. Microfractures are indicated in patients younger than 50 years with a chondropathy of 3rd or 4th degree less than 2 cm2. Matrix-Induced Autologous Chondrocyte Implantation (MACI) and Autologous Matrix-Induced Chondrogenesis (AMIC) procedures are indicated in patients with full-thickness symptomatic 3rd-4th degree chondral defects, extended 2 cm2 or more. The AMIC procedure has the advantage of a one-step procedure and much less expense. Microfragmented adipose tissue transplantation (MATT) is indicated for the treatment of delamination and 1st and 2nd degree chondral lesions, regardless of the age of the patient. Chondral defects are effective when the joint space is not compromised. When the Tonnis classification is two or greater, treatment of chondral lesions should be considered ineffective.

Isolation and Characterization of Synovial Mesenchymal Stem Cell Derived from Hip Joints: A Comparative Analysis with a Matched Control Knee Group

Purpose. To determine the characteristics of MSCs from hip and compare them to MSCs from knee. Methods. Synovial tissues were obtained from both the knee and the hip joints in 8 patients who underwent both hip and knee arthroscopies on the same day. MSCs were isolated from the knee and hip synovial samples. The capacities of MSCs were compared between both groups. Results. The number of cells per unit weight at passage 0 of synovium from the knee was significantly higher than that from the hip (P < 0.05). While it was possible to observe the growth of colonies in all the knee synovial fluid samples, it was impossible to culture cells from any of the hip samples. In adipogenesis experiments, the frequency of Oil Red-O-positive colonies and the gene expression of adipsin were significantly higher in knee than in hip. In osteogenesis experiments, the expression of COL1A1 and ALPP was significantly less in the knee synovium than in the hip synovium. Conclusions. MSCs obtained from hip joint have self-renewal and multilineage differentiation potentials. However, in matched donors, adipogenesis and osteogenesis potentials of MSCs from the knees are superior to those from the hips. Knee synovium may be a better source of MSC for potential use in hip diseases.

Autologous Membrane Induced Chondrogenesis (AMIC) for the treatment of acetabular chondral defect

BACKGROUND

Acetabular chondral defect are very frequently associated to FAI. Treatment options are still questionable.

METHODS

Between 2008 and 2014, 201 patients over 583 have been arthroscopically treated with the AMIC procedure for grade III and/or IV acetabular chondral lesions. Patients age was between 18 and 50 years; acetabular chondral lesion size was between 2 and 4 cm²; radiological Tönnis degree of osteoarthritis was ≤ 2.

RESULTS

The mean follow up of the entire group of 201 patients was 5 years (from 8 to 2). Significant improvement, as measured by the mHHS, was observed at 6 months in comparison to preoperative levels (80.3 ± 8.3) (p<0.001). Continuous improvement with respect to each previous evaluation time point was seen, reaching the highest improvement level at the three year follow-up (85.5 ± 7.2). The mean mHHS improvement recorded at the five year follow-up compared with preoperative scores was 39.1 ± 5.9.

CONCLUSIONS

AMIC is a valid procedure to repair medium-sized chondral defects on the acetabular side of the hip found during treatment of FAI and lead to long-term favourable outcomes.

LEVEL OF EVIDENCE

IV.

Analysis of the Current Indications for Microfracture of Chondral Lesions in the Hip Joint

BACKGROUND

Data on the efficacy of microfracture for treatment of chondral defects in the hip are currently limited, and the recommended criteria for its use (minimal osteoarthritis; a focal, contained lesion <4 cm² in size) have been taken from those that were established for the knee.

PURPOSE

To determine if the current microfracture (ie, knee) criteria are appropriate for chondral lesions in the hip.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Seventy patients who had hip arthroscopy and 2 years of follow-up after treatment of labral tears and cam and pincer bony deformities, as well as microfracture of full-thickness chondral defects, are the basis of this study. The size and location of the chondral defects were recorded on each patient's "hip sheet" and operative note at the time of hip arthroscopy and were confirmed from intraoperative photographs. The chondral defects were debrided and microfractured regardless of their size. All hips were assessed with the 100-point modified Harris Hip Score (mHHS) before arthroscopy and at 3, 6, 12, and 24 months after surgery. Patients who had a total hip arthroplasty or repeat arthroscopy during their 2-year follow-up period were assigned poor results.

RESULTS

The average age of the 70 patients was 41 years, and the average size of the lesions microfractured was 143 mm². Outcomes, based on patients' 2-year mHHS or being assigned a poor result for revision surgery, were as follows: 32 excellent, 11 good, 6 fair, and 21 poor; overall, 43 patients (61%) had good and excellent results, and 27 (39%) had fair and poor results. The revision surgery rate was 24%. Seven of the 70 patients had chondral lesions greater than the recommended size for microfracture in the hip (>400 mm) and ranged from 430 to 750 mm². Their 2-year outcomes included 3 excellent, 1 good, 1 fair, and 1 poor result; the outcomes were the same as for the 8 patients with medium (200-400 mm²) and the 55 patients with smaller (<200 mm²) lesions (P = .25). There also was no difference in the 2-year outcomes of the older patients (age ≥50 years; P = .91).

CONCLUSION

Microfracture in the hip should not be limited to the criteria of knee lesions (<400 mm²) or to younger patients (age <50 years). However, the results also indicate that patients with full-thickness cartilage defects can anticipate a high rate of conversion to total hip arthroplasty within 2 years of their microfracture surgery and that only 60% of them will have good/excellent results over that time period.

Arthroscopic Central Acetabular Decompression: Clinical Outcomes at Minimum 2-Year Follow-up Using a Matched-Pair Analysis

PURPOSE

To assess 2-year clinical outcomes of patients who underwent hip arthroscopy for central acetabular osteophytes (CAO) treated with central acetabular decompression (CAD), and to compare these outcomes with those of a matched control group.

METHODS

Data were prospectively gathered for patients undergoing CAD during hip arthroscopy from February 2008 to July 2012. All patients were assessed pre- and postoperatively at 3 months, 1 year, and 2 years with modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport-Specific Subscale, and visual analog scale (VAS) for pain. Patient satisfaction (0 to 10) was collected. A matched control group of patients without CAOs who did not undergo CAD was selected on a 1:3 ratio.

RESULTS

Forty-nine hips were included in the CAD group and 147 in the control group. The mean change in patient-reported outcome (PRO) scores at 2-year follow-up in the CAD group for modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport-Specific Subscale, Non-Arthritic Hip Score, and VAS was 11.0, 19.6, 15.2, 21.4, and -2, respectively. The mean change in PRO scores at 2-year follow-up in the control group was 17.0, 19.8, 24.0, 20.9, and -2.75, respectively. All improvements in PRO scores for both groups were statistically significant compared with the data collected preoperatively (P < .001). There was no statistically significant difference in postoperative PRO scores and VAS between the groups. Postoperative patient satisfaction at the latest follow-up was 7.14 and 7.60 for CAD and control groups, respectively.

CONCLUSIONS

This study showed that patients with a CAO treated with CAD during hip arthroscopy had favorable outcomes at minimum 2 years postoperatively. Furthermore, the study group showed similar PRO scores and VAS to the control group. We conclude that CAD is a viable treatment option for CAO, yielding clinical improvement at short-term follow-up.

LEVEL OF EVIDENCE

Level III, prospective comparative study.

Injectable autologous chondrocyte transplantation for full thickness acetabular cartilage defects: early clinical results

INTRODUCTION

Acetabular cartilage lesions are frequently seen in young patients with hip pain and have been identified as an important prognostic factor. New therapies have complemented abrasion and microfracture procedures. The aim of the study is to evaluate the early outcome of patients with arthroscopic injectable autologous chondrocyte transplantations (ACT) for full thickness acetabular cartilage defects.

METHODS

A two-step procedure ACT was performed in patients with full thickness acetabular cartilage defects measuring ≥2 cm(2). The patients were closely followed with clinical examination, pre- and postoperative scores until the latest available follow-up of 3, 6, 12, and 24 months.

RESULTS

20 consecutive cases (4 female, 16 male, mean age 33 years) were included. No patients were lost at final follow-up. The average defect size was 5.05 (range 2-6) cm(2). The average follow-up was 12.05 (range 6-24) months. Three months postoperatively the preoperative scores improved significantly from a mean mHHS of 63-81 points (p = 0.009), iHOT33 of 44-66 % (p = 0.028) and subjective hip assessment (Subjective Hip Value, SHV) of 60-87 % (p = 0.007). After 12 months the results improved significantly to a mean mHHS of 93 points (p = 0.017), an iHOT33 of 79 % (p = 0.007) and an SHV of 82 % (p = 0.048) compared with the preoperative scores.

DISCUSSION

The injectable matrix associated ACT is a reliable procedure, yielding promising early results with a significant increase of all scores evaluated in patients with full thickness acetabular cartilage defects.

Clinical Outcomes of Hip Arthroscopic Surgery: A Prospective Survival Analysis of Primary and Revision Surgeries in a Large Mixed Cohort

BACKGROUND

With the rapid increase in hip preservation procedures, revision hip arthroscopic surgery and conversion to total hip arthroplasty (THA) or hip resurfacing (HR) after primary hip arthroscopic surgery have become a large focus in the recent literature.

PURPOSE

The primary purpose was to perform a survival analysis in a large mixed cohort of patients undergoing hip arthroscopic surgery at a high-volume tertiary referral center for hip preservation with a minimum 2-year follow-up. The secondary purpose was to compare clinical outcomes of primary versus revision hip arthroscopic surgery.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

From February 2008 to June 2012, data were prospectively collected on all patients undergoing primary or revision hip arthroscopic surgery. Patients were assessed preoperatively and postoperatively with the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS). Pain was estimated on a visual analog scale (VAS). Patient satisfaction was measured with the question "How satisfied are you with your surgery results?" (1 = not at all, 10 = the best it could be).

RESULTS

There were a total of 1155 arthroscopic procedures performed, including 1040 primary arthroscopic procedures (926 patients) and 115 revision arthroscopic procedures (106 patients). Of these, 931 primary arthroscopic procedures (89.5%) in 824 patients (89.0%) and 107 revision arthroscopic procedures (93.0%) in 97 patients (91.5%) were available for follow-up and included in our study. The mean change in patient-reported outcome (PRO) scores at 2-year follow-up in the primary arthroscopic surgery group was 17.4 for the mHHS, 19.7 for the HOS-ADL, 23.8 for the HOS-SSS, 21.3 for the NAHS, and -3.0 for the VAS, and the mean change in the revision arthroscopic surgery group was 13.4, 10.9, 16.1, 15.4, and -2.7, respectively. All scores improved significantly compared with preoperatively (P < .001). PRO scores were higher at all time points for the primary group compared with the revision group (P < .05). Mean satisfaction was 7.7 and 7.2 for the primary and revision groups, respectively. Of 931 primary arthroscopic procedures, 52 (5.6%) converted to THA/HR. Of 107 revision arthroscopic procedures, 12 (11.2%) converted to THA/HR. The relative risk of THA/HR was 2.0 after revision procedures compared with primary procedures. The cumulative incidence of competing risks of conversion to THA/HR and revision hip arthroscopic surgery after primary hip arthroscopic surgery was 2.6% and 5.8%, respectively. The overall complication rate was 4.3%.

CONCLUSION

Patients showed significant improvement in all PRO, VAS, and satisfaction scores at 2 years after hip arthroscopic surgery. Patients who underwent primary arthroscopic surgery showed higher PRO scores and a trend toward greater improvement in the VAS score compared with patients who underwent revision arthroscopic surgery. The relative risk of THA/HR was 2.0 after revision procedures compared with primary procedures.

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.

Return to Play Following Hip Arthroscopy

Femoroacetabular impingement may be particularly disabling to the high-demand athlete, especially those with significant cutting and pivoting requirements. If nonoperative treatment fails to adequately alleviate symptoms or sufficiently restore function in the athlete, hip arthroscopy can lead to improved pain, improved range of motion, and high rates of return to play with proper postoperative rehabilitation. The rate of return to previous level of competition is also high with accurate diagnosis and well-executed correction of deformity. A clear understanding of the etiology, diagnosis, management, and outcomes is essential for clinicians to optimally help patients to return to play.

Mini-open approach for femoroacetabular impingement: 10 years experience and evolved indications

INTRODUCTION

Femoroacetabular impingement (FAI) has been proposed as a possible cause of early osteoarthritis of the hip. The treatment of this condition and its related lesions can be performed by 3 methods: surgical dislocation of the hip; pure arthroscopic; and anterior mini-open technique with or without arthroscopic assistance.

METHODS

We describe the anterior mini-open technique and report our experience over the last decade in the treatment of FAI and different associated pathologies of the hip.

RESULTS

This technique was found to be safe and reliable, allowing tissue preservation and providing a clinical improvement similar to the purely arthroscopic-treated patient, even in complex cases.

DISCUSSIONS

According to our experience there are several presentations of FAI and associated hip conditions, where other authors advocate surgical dislocation, which can be conducted through a mini-open approach when increased surgical skills are reached. Moreover, this technique was found to be useful as an additional tool to consider, even for surgeons involved in the arthroscopic learning curve.

Outcomes of Revision Hip Arthroscopy: 2-Year Clinical Follow-up

PURPOSE

To evaluate clinical outcomes, pain, and patient satisfaction following revision hip arthroscopy with a minimum 2-year follow-up.

METHODS

From April 2008 to October 2011, data were prospectively collected on all patients undergoing revision hip arthroscopy. All patients were assessed pre- and postoperatively with 4 patient-reported outcome (PRO) measures: the modified Harris hip score (mHHS), nonarthritic hip score (NAHS), hip outcome score-activities of daily living (HOS-ADL), and hip outcome score-sport-specific subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS). Patient satisfaction was measured on a scale from 0 to 10. The number of patients who underwent subsequent revision arthroscopy or total hip arthroplasty during the study period is also reported.

RESULTS

Eighty-seven patients underwent revision hip arthroscopy during the study period. Seventy (80.5%) patients were included in our study. Average follow-up time was 28 months (range, 20 to 47.4 months). In terms of residual femoroacetabular impingement morphology, 45.7% of patients had preoperative alpha angles ≥ 55°, and 7.14% of patients had a lateral center-edge angle ≥ 40°. The score improvement from preoperative to 2-year follow-up was 57.84 to 73.65 for mHHS, 62.79 to 83.04 for HOS-ADL, 37.33 to 54.93 for HOS-SSS, and 55.65 to 70.79 for NAHS. VAS decreased from 6.72 to 4.08. All scores demonstrated statistically significant improvement (P < .001). Overall patient satisfaction was 7.67. Our success rate was 74.58%. Ten (14.29%) patients underwent total hip arthroplasty during the study period. Our hip survivorship was 85.7%. Five (7.14%) patients underwent secondary revision hip arthroscopy during the study period. We found an overall minor complication rate of 10%.

CONCLUSIONS

Revision hip arthroscopy for all procedures performed on aggregate has improved clinical outcomes for all PROs, high survivorship, and high patient satisfaction scores at short-term follow-up. Patients should be counseled regarding the potential progression of degenerative change leading to arthroplasty and the potential for revision surgery.

LEVEL OF EVIDENCE

Level IV retrospective case series.

Reconstruction of Focal Femoral Head Cartilage Defects With a Chitin-Based Scaffold

It is well known that articular cartilage defects have little capability to heal. For grade III or IV cartilage defects, surgical intervention may be required for symptomatic patients. Microfracture is a commonly used surgical technique to address these injuries. However, microfracture has drawbacks, which include the risk of ossification of the newly formed tissue, as well as the imperfect and fragile nature of the fibrous cartilage. Given the challenges associated with microfracture, BST-CarGel (Piramal Healthcare, Laval, Quebec, Canada) has been developed to stabilize and support the nascent clot. This chitin-based polymer is mixed with the patient's own blood and inserted onto the microfractured defect. The polymer allows normal clot formation and provides a matrix to strengthen the clot, prevent retraction, and increase its adhesiveness to the natural tissue. We present, with a video example, a detailed arthroscopic technique for using BST-CarGel to fill a focal femoral head cartilage defect.

Indications and Outcomes for Microfracture as an Adjunct to Hip Arthroscopy for Treatment of Chondral Defects in Patients With Femoroacetabular Impingement: A Systematic Review

PURPOSE

To evaluate the indications, preoperative workup outcomes, and postoperative rehabilitation of patients with femoroacetabular impingement (FAI) receiving microfracture as an adjunct to hip arthroscopy for chondral defects.

METHODS

The electronic databases MEDLINE, EMBASE, and PubMed were searched and screened in duplicate for studies involving patients with FAI treated arthroscopically with microfracture of the hip for chondral defects either solely or as an adjunct to hip arthroscopy. Data regarding indications, investigations, outcomes, and postoperative rehabilitation were abstracted from eligible studies. The references of included studies were additionally searched, and descriptive statistics are provided.

RESULTS

There were 12 studies included in this review, involving 267 patients. With the exception of a single, one-patient case report, 11 of the 12 studies reported positive outcomes after hip arthroscopy with microfracture. Only 0.7% of the total patients experienced a complication, and 1.1% required further surgery on the basis of outcomes evaluated at a mean follow-up of 29.5 (range, 4 to 60) months across the studies. Eight of 12 studies discussed the preoperative workup of these patients, with X-rays and magnetic resonance imaging being the most common preoperative imaging used. There was little reported on weight-bearing status during postoperative rehabilitation.

CONCLUSIONS

The outcomes reported in the literature after hip arthroscopy with microfracture for chondral defects are, in general, positive, with a very low percentage of patients requiring further surgery or experiencing complications. The most common indication used in the literature for microfracture is a full-thickness, focal chondral defect (Outerbridge grade IV). The vast majority of literature recommends limited weight bearing after microfracture; however, there was significant variation among the specific rehabilitation protocols used. More research is needed to explore what indications and postoperative rehabilitation result in the best outcomes for patients.

LEVEL OF EVIDENCE

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

Does Primary Hip Arthroscopy Result in Improved Clinical Outcomes?: 2-Year Clinical Follow-up on a Mixed Group of 738 Consecutive Primary Hip Arthroscopies Performed at a High-Volume Referral Center

BACKGROUND

Hip arthroscopy has gained increasing popularity over the past decade. The need to develop metrics to evaluate success and complications in primary hip arthroscopy is an important goal.

PURPOSE

To evaluate 2-year patient-related outcome (PRO) scores and patient satisfaction scores for a single surgeon at a high-volume referral center for all primary hip arthroscopy procedures performed.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

During the study period between April 2008 and October 2011, data were collected on all patients who underwent primary hip arthroscopy. All patients were assessed pre- and postoperatively with 4 PRO measures: the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS). Pain was estimated on the visual analog scale (VAS), and satisfaction was measured on a scale from 0 to 10. The number of patients who underwent revision arthroscopy, total hip arthroplasty (THA), or a resurfacing procedure during the study period was also reported.

RESULTS

A total of 595 patients were included in the study. The score improvement from preoperative to 2-year follow-up was 61.29 to 82.02 for mHHS, 62.79 to 83.05 for HOS-ADL, 40.96 to 70.07 for HOS-SSS, 57.97 to 80.41 for NAHS, and 5.86 to 2.97 for VAS. All scores were statistically significantly different (P < .0001). Overall patient satisfaction was 7.86 ± 2.3 (range, 1-10). Forty-seven (7.7%) patients underwent revision hip arthroscopy, and 54 (9.1%) patients underwent either THA or the hip resurfacing procedure during the study period. The multivariate regression analysis showed that increased age at time of surgery was a significant risk factor for conversion to THA, revision arthroscopy, and change in NAHS <10 points. Acute injury, acetabuloplasty, iliopsoas release, and patient sex were significant for 2 of these 3 types of failure.

CONCLUSION

Primary hip arthroscopy for all procedures performed in aggregate had excellent clinical outcomes and patient satisfaction scores at short-term follow-up in this study. More studies must be conducted to determine the definition of a successful outcome. There was a 6.1% minor complication rate, which was consistent with previous studies. Patients should be counseled regarding the potential progression of degenerative change leading to arthroplasty as well as the potential for revision surgery.

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.

Arthroscopic correction for concomitant cam impingement in a patient with idiopathic osteonecrosis of the femoral head: A case report

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It is important to accurately diagnose the status of idiopathic osteonecrosis of the femoral head and to consider another possible pathogenesis when a patient with idiopathic osteonecrosis of the femoral head has hip pain even without femoral-head collapse.

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Ignored or misdiagnosed concomitant femoroacetabular impingement in a patient with idiopathic osteonecrosis of the femoral head might leads to poor outcomes of surgical treatments such as bipolar hemiarthroplasty or osteotomies.

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In a patient with idiopathic osteonecrosis of the femoral head, it should be paid attention if concomitant femoroacetabular impingement exists or not.

A 53-year-old man presented with pain in the right hip. Radiological examination showed idiopathic osteonecrosis of the femoral head (ONFH) combined with a cam lesion. Findings on physical examination were consistent for femoroacetabular impingement. At surgery, we performed isolated arthroscopic correction for the cam lesion but did not use other treatment options such as hip arthroplasty or osteotomies for the ONFH. At the latest follow-up evaluation 3 years after surgery, findings indicted a satisfactory outcome, with a Harris hip score of 93.2 (compared with 76.4 before surgery), no joint-space narrowing, and no collapse of the femoral head. It is important to accurately diagnose the status of idiopathic ONFH and to consider another possible pathogenesis when a patient with idiopathic ONFH has hip pain even without femoral-head collapse.

Outcomes After Labral Repair in Patients With Femoroacetabular Impingement and Borderline Dysplasia

PURPOSE

To determine outcomes after labral repair in patients with borderline dysplasia and femoroacetabular impingement (FAI).

METHODS

Patients with dysplasia treated between June 2005 and March 2009 were identified. The study included only patients aged 18 years or older (mean, 35 years; range, 18 to 69 years) whose affected hip had a Wiberg center-edge angle of 20° to 25° and who underwent primary hip arthroscopy performed by the senior author.

RESULTS

One hundred two hips (100 patients, comprising 50 women and 50 men) underwent hip arthroscopy with labral repair with correction of FAI and capsular closure. Five hips were converted to total hip arthroplasty, and 7 required revision arthroscopy. Of 95 patients (representing 100 hips, 5 of which underwent total hip arthroplasty), 80 were monitored for a minimum of 2 years. At a mean follow-up point of 40 months, the preoperative modified Harris Hip Score had improved from a mean of 63.5 points (range, 20 to 98 points) to a mean of 84.9 points (range, 45 to 100 points) by the latest follow-up (P < .001). The mean score on the Western Ontario and McMaster Universities Arthritis Index improved from 25.3 (range, 0 to 60) to 9.7 (range, 0 to 59) (P < .001). The 12-Item Short Form Health Survey Physical Component Summary score also significantly improved (from 42.5 to 50.9, P = .001), whereas the 12-Item Short Form Health Survey Mental Health Component Summary score showed an insignificant improvement (from 52.4 to 54.1).

CONCLUSIONS

This study showed that FAI and labral pathology can be successfully managed using hip arthroscopy, with capsular management, in patients with borderline dysplasia. Patients showed significant improvements in outcomes and high levels of satisfaction after hip arthroscopy. The need for subsequent procedures was similar to that in patients with just FAI and labral repair.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Arthroscopy of the hip for patients with mild to moderate developmental dysplasia of the hip and femoroacetabular impingement

The purpose of this study was to determine patient-reported outcomes of patients with mild to moderate developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI) undergoing arthroscopy of the hip in the treatment of chondrolabral pathology. A total of 28 patients with a centre-edge angle between 15° and 19° were identified from an institutional database. Their mean age was 34 years (18 to 53), with 12 female and 16 male patients. All underwent labral treatment and concomitant correction of FAI. There were nine reoperations, with two patients requiring revision arthroscopy, two requiring periacetabular osteotomy and five needing total hip arthroplasty.

Patients who required further major surgery were more likely to be older, male, and to have more severe DDH with a larger alpha angle and decreased joint space.

At a mean follow-up of 42 months (24 to 89), the mean modified Harris hip score improved from 59 (20 to 98) to 82 (45 to 100; p < 0.001). The mean Western Ontario and McMaster Universities Osteoarthritis Index score improved from 30 (1 to 61) to 16 (0 to 43; p < 0.001). Median patient satisfaction was 9.0/10 (1 to 10). Patients reported excellent improvement in function following arthroscopy of the hip.

This study shows that with proper patient selection, arthroscopy of the hip can be successful in the young patient with mild to moderate DDH and FAI.

Cite this article: Bone Joint J 2015;97-B:1316–21.

Microfracture in the Hip: Results of a Matched-Cohort Controlled Study With 2-Year Follow-up

BACKGROUND

Microfracture in hip preservation surgery has demonstrated favorable outcomes, but studies with a higher level of evidence assessing microfracture are warranted.

PURPOSE

To assess 2-year outcomes of patients who underwent hip arthroscopy with full-thickness chondral damage treated with microfracture and compare these outcomes with those of a control group from a similar cohort of patients who did not have full-thickness chondral damage and who were not treated with microfracture.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between February 2008 and May 2012, prospectively gathered data for patients undergoing microfracture during hip arthroscopy with a 2-year follow-up were reviewed. All patients were assessed pre- and postoperatively at 3 months, 1 year, and 2 years with 4 patient-reported outcome (PRO) instruments. A matched cohort of patients who did not have full-thickness chondral damage and hence did not receive microfracture was selected on a 1:2 ratio. Matching criteria were sex, age within 6 years, workers' compensation status, concomitant labral treatment, and radiographic parameters. Statistical analyses were performed to compare the change in PROs in both groups.

RESULTS

A total of 79 hips were included in the microfracture group and 158 in the control group. There was no significant difference in PRO scores preoperatively between the groups. Both groups demonstrated significant improvement in all postoperative PRO scores at all time points. There was no statistically significant difference in postoperative PRO scores between the microfracture and control groups, except for the visual analog scale (VAS) score at 2 years, which was higher (P = .02) in the microfracture group (mean ± SD, 3.63 ± 2.50) than in the control group (2.82 ± 2.76). Patient satisfaction was 7.2 for the microfracture group and 8.04 for the control group, which was statistically different (P < .05). The mean change in all PRO scores was similar between groups at 3 months and 1 year postoperatively but significantly lower in the microfracture group at 2 years postoperatively. The greatest improvement in both groups was noted at 3 months postoperatively.

CONCLUSION

This study showed that patients undergoing microfracture during hip arthroscopy had equivalent PRO scores compared with the control group at 2 years postoperatively. The change in PRO scores from preoperatively to 2 years postoperatively was significantly lower in the microfracture group compared with the control group. The VAS scores and satisfaction were inferior by 0.81 and 0.84 units, respectively, in the microfracture group compared with the control group, likely due to lack of full-thickness chondral defects in the latter. However, both groups showed significant improvement in all PRO scores after surgery, with no significant difference in final PRO scores.

Arthroscopic hip surgery with a microfracture procedure of the hip: clinical outcomes with two-year follow-up

BACKGROUND

Outcome studies assessing a cohort of patients receiving microfracture in the hip have focused on second look arthroscopy and return to sport, which have shown favourable results in the absence of osteoarthritis. Few studies exist focusing on clinical outcomes after microfracture in the hip using patient reported outcome (PRO) scores. The purpose of this study is to evaluate two-year clinical outcomes of a series of patients treated with microfracture during arthroscopic hip surgery using PRO scores.

METHODS

During the study period, all workers' compensation (WC) and non-WC patients treated with microfracture during arthroscopic hip surgery were included. Four PRO scores, pain scores and satisfaction were used to assess clinical outcomes. Any revision surgeries or conversions to total hip arthroplasty (THA) were noted. Location of microfracture procedure, lesion size and additional variables assessed survivorship.

RESULTS

Thirty-seven cases met the inclusion/exclusion criteria, of which 30 patients (30/37, 81%) were available for minimum two-year follow-up. Twenty-six patients were classified as survivors. Preoperative scores for patients with WC status were lower than non-WC patients and statistically significant (p<0.5) for three of the PROs. However, changes in all four PRO measurements demonstrated statistically significant improvements from preoperative to two-year follow-up for both compensation groups (p<0.05). The amount of change in PRO scores for both compensation groups was similar and not statistically significant. Two patients required THA and two patients required revision arthroscopy.

CONCLUSION

Our study demonstrates statistically significant clinical improvement in PRO's after receiving microfracture during arthroscopic hip surgery at minimum two-year follow-up.

Sustained five-year benefit of autologous matrix-induced chondrogenesis for femoral acetabular impingement-induced chondral lesions compared with microfracture treatment

The repair of chondral lesions associated with femoroacetabular impingement requires specific treatment in addition to that of the impingement. In this single-centre retrospective analysis of a consecutive series of patients we compared treatment with microfracture (MFx) with a technique of enhanced microfracture autologous matrix-induced chondrogenesis (AMIC).

Acetabular grade III and IV chondral lesions measuring between 2 cm2 and 8 cm2 in 147 patients were treated by MFx in 77 and AMIC in 70. The outcome was assessed using the modified Harris hip score at six months and one, two, three, four and five years post-operatively. The outcome in both groups was significantly improved at six months and one year post-operatively. During the subsequent four years the outcome in the MFx group slowly deteriorated, whereas that in the AMIC group remained stable. Six patients in the MFx group subsequently required total hip arthroplasty, compared with none in the AMIC group

We conclude that the short-term clinical outcome improves in patients with acetabular chondral damage following both MFx and AMIC. However, the AMIC group had better and more durable improvement, particularly in patients with large (≥ 4 cm2) lesions.

Cite this article: Bone Joint J 2015; 97-B:628–35.