An evidence-based update on the management of articular cartilage defects in the hip

Osteochondral Allograft Transplantation for Large Osteochondral Lesions of the Femoral Head in Young Patients

INTRODUCTION

Osteochondral lesions of the femoral head in young patients are a rare but challenging clinical problem. Fresh osteochondral allograft (OCA) transplantation has been proposed as one potential treatment option that may improve function and delay hip arthroplasty. However, there is a paucity of published data. The purpose of this study was to assess allograft survivorship and patient-reported outcomes in patients undergoing OCA transplantation for osteochondral lesions of the femoral head.

METHODS

Sixteen patients (16 hips) who underwent femoral head OCA transplantation for the treatment of avascular necrosis between 1985 and 2021 were included. Mean age was 21.0±10.1 years (range: 11.6 to 43.5 y) and 56% were male. Mean allograft diameter was 26.9±4.2 mm (range: 20 to 35 mm) and mean thickness was 10.2±3.2 mm (range: 5 to 15 mm). We evaluated the frequency and type of further surgery, Hip Disability and Osteoarthritis Outcome Score (HOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), modified Harris Hip Score (mHHS), and UCLA function score. Clinical failure was defined as conversion to total hip arthroplasty.

RESULTS

Six of 16 hips (38%) experienced clinical failure (5 total hip arthroplasties and 1 resurfacing arthroplasty), with a mean time to failure of 3.6±2.6 years (range: 1.0 to 8.5 y). Allograft survivorship for patients under age 18 was 85.7% at 3 years and 42.9% at 5 years compared with patients over age 18 years who experienced a survivorship of 66.7% at 3 and 5 years (P=0.911). Of the remaining 10 hips, the mean follow-up duration was 4.1 years (range: 1.9 to 7.4 y). At the latest follow-up, mean HOOS was 74.5±20.2 (range: 48.6 to 100), mean WOMAC was 79.9±18.2 (range: 56.1 to 100), mean mHHS was 74.9±20.9 (range: 41 to 100.1), and mean UCLA score was 7.0±2.7 (range: 4 to 10).

CONCLUSIONS

Young patients with large chondral lesions of the femoral head may benefit from fresh OCA transplantation, but failure rates remain quite high for this challenging patient population. OCA can be considered as a useful treatment option that preserves function and delays the need for arthroplasty in young individuals with osteochondral lesions of the femoral head.

The Impact of Hip Arthroscopy on the Progression of Hip Osteoarthritis in Patients With Femoroacetabular Impingement Syndrome: A Systematic Review and Meta-analysis

Background

Hip arthroscopy (HA) for the surgical management of femoroacetabular impingement syndrome (FAIS) provides reliable improvements in pain and function; however, debate remains regarding the impact of HA on the progression of osteoarthritis (OA).

Purpose

To determine whether HA for FAIS reduces the progression of OA and the risk of conversion to total hip arthroplasty (THA).

Study Design

Systematic review; level of evidence, 4.

Methods

A systematic electronic search of articles in Medline, Embase, and ClinicalTrials.gov databases was performed under the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with 5046 articles remaining after duplicates were removed. All papers addressing HA for FAIS that reported radiographic progression of hip OA with a follow-up of ≥2 years were eligible for inclusion. Studies assessing labral reconstruction, revision HA, case reports, studies with <10 patients, and patients with hip dysplasia or rheumatoid arthritis were excluded. A total of 322 studies progressed to full text, and 16 studies were ultimately included in this review. Studies were divided based on short-term (ST) (2 to <5 years), mid-term (MT) (5 to <10 years), and long-term (LT) (>10 years) follow-ups. A meta-analysis of homogenous studies and outcomes was performed, otherwise, descriptive statistics were presented.

Results

Sixteen studies (2278 hips) with FAIS were included, in which 1196 hips underwent HA and 1082 hips were treated nonoperatively. There were 8 ST studies, 4 MT studies, and 4 LT studies. A meta-analysis of 2 comparative studies found 32% (P = .002) less risk of progression of radiographic OA (any increase in grading) with HA compared with nonoperative management. In addition, there was a nonsignificant 23% (P = .35) decreased risk of conversion to THA/hip resurfacing with HA. For all studies, there was a progression of hip OA ranging from 0% to 37.1% for ST studies, 11.5% to 23% for MT studies, and 4.3% to 28% for LT studies.

Conclusion

Our systematic review demonstrated that studies of patients undergoing HA for FAIS demonstrated increased radiographic progression of hip OA over time. Although significantly limited by only 2 retrospective cohort studies, subgroup analysis comparing operative versus nonoperative management demonstrated a 32% reduction in the radiographic progression of OA (any increase in grading) at the LT follow-up. However, there were no significant differences in the risk of THA/hip resurfacing. Future long-term, high-level controlled studies are needed to help further understand this important clinical question.

Trends in Cartilage Repair Techniques for Chondral Defects in the Hip in Germany: An Epidemiological Analysis from 2006 to 2022

Cartilage repair techniques for chondral defects in the hip are crucial for treating conditions like femoroacetabular impingement, developmental dysplasia, and osteonecrosis, especially in young patients to delay the progression of osteoarthritis. This study aims to present age and sex distributions and trends in hip-preserving surgeries in Germany from 2006 to 2022, analyzing 116,179 procedures using the German OPS coding system. The procedures were categorized into three groups: debridement, refixation, and regeneration. Arthroscopy was more common than arthrotomy (98,916 vs. 17,263). Males underwent more procedures than females (63,771 vs. 52,408). Debridement had a monomodal age distribution peaking at 43.42 years, while refixation and regeneration exhibited bimodal patterns. Regenerative procedures were primarily performed on younger patients (average 27.73 years). A Joinpoint analysis showed an initial increase in procedures, peaking around 2013, followed by a decline. Arthroscopic procedures peaked at approximately 9000 in 2013, whereas arthrotomies peaked at around 1200 after 2014. The decline in procedures post-2013 may reflect refined surgical indications and a shift towards outpatient settings. These findings underscore the trend towards minimally invasive, scaffold-based treatments, with regenerative techniques showing promising outcomes in younger patients. Future research should focus on prospective comparative studies and cost-benefit analyses to guide clinical decision-making.

Outcomes of arthroscopy of the hip for femoroacetabular impingement based on intraoperative assessment using the Outerbridge classification

Aims

Hip arthroscopy (HA) has become the treatment of choice for femoroacetabular impingement (FAI). However, less favourable outcomes following arthroscopic surgery are expected in patients with severe chondral lesions. The aim of this study was to assess the outcomes of HA in patients with FAI and associated chondral lesions, classified according to the Outerbridge system.

Methods

A systematic search was performed on four databases. Studies which involved HA as the primary management of FAI and reported on chondral lesions as classified according to the Outerbridge classification were included. The study was registered on PROSPERO. Demographic data, patient-reported outcome measures (PROMs), complications, and rates of conversion to total hip arthroplasty (THA) were collected.

Results

A total of 24 studies were included with a total of 3,198 patients (3,233 hips). Patients had significantly less improvement in PROMs if they had Outerbridge grade III and IV lesions (p = 0.012). Compared with microfracture, autologous matrix-induced chondrogenesis (AMIC) resulted in significantly reduced rates of conversion to THA (p = 0.042) and of revision arthroscopy (p = 0.038). Chondral repair procedures in these patients also did not significantly reduce the rates of conversion to THA (p = 0.931), or of revision arthroscopy (p = 0.218). However, compared with microfracture, AMIC significantly reduced the rates of conversion to THA (p = 0.001) and of revision arthroscopy (p = 0.011) in these patients. Those with Outerbridge grade III and IV lesions also had significantly increased rates of conversion to THA (p = 0.029) and of revision arthroscopy (p = 0.023) if they had associated lesions of the acetabulum and femoral head. Those who underwent labral debridement had a significantly increased rate of conversion to THA compared with those who underwent labral repair (p = 0.015).

Conclusion

There is universal improvement in PROMs following HA in patients with FAI and associated chondral lesions. However, those with Outerbridge grade III and IV lesions had significantly less improvement in PROMs and a significantly increased rate of conversion to THA than those with Outerbridge grade I and II. This suggests that the outcome of HA in patients with FAI and severe articular cartilage damage may not be favourable.

Mosaicplasty of the Femoral Head: A Systematic Review and Meta-Analysis of the Current Literature

Osteochondral lesions of the femoral head are rare. For the treatment of these lesions, various joint-preserving procedures, particularly in young, active patients, have been developed. Mosaicplasty is a well-established surgical procedure for the knee. However, there is little evidence that this method can also be used to treat osteochondral lesions in the hip. The indication for cartilage procedures continues to evolve for the knee, and a similar strategy may be adopted for the hip joint. Due to limited evidence and a lack of experience, mosaicplasty treatment of these lesions remains challenging, especially in young patients. This study shows that open and arthroscopic management using the knee and femoral head as donor sites yielded good to excellent short- to mid-term outcomes. For osteochondral lesions of the femoral head, mosaicplasty may be a new alternative treatment option, although this needs to be proven with longer follow-ups and in a larger sample of patients.