Leigh Brezenoff, MD
Litchfield Hills Orthopedic Associates
20 th Annual Sports Medicine Symposium
Tuesday, August 4, 2015

The hip is a simple ball and socket joint
There are 3 compartments of the hip
Central : acetabular fossa ,lunate cartilage, ligamentum teres and the articular cartilage of the femoral head
Peripheral: femoral neck, outer acetabular rim, synovial membrane, and capsule the labrum acts to separate these two peritrochanteric: deep gluteal region

represents approximately 2/3 of a sphere
Cartilage thickness decreases from center to periphery and is more developed in the superior aspect than the inferior
Vascular supply is mainly provided by the medial femoral circumflex artery (MFCA)

is a concave surface
Horseshoe-like articular surface
There are 4 types of morphology of the lunate cartilage
I: clover-leaf like form 60.62%
II: semicircular 28.76%
III and IV are rare exceptions

Primarily Type II Hyaline Cartilage Most injuries occur at the level of the tidemark of calcified cartilage

Many encountered chondral abnormalities are seen in the setting of hip pathomorphology
Structural impingement can be the result of an aspherical femoral head neck junction acetabular over coverage
Extra-articular hip impingement
Dysplasia is typically associated with more significant abnormalities of the hip

Injury

To treat chondral lesions about the hip one must first understand the cause of such lesions Morphologic causes:
FAI
SCFE
Other: fractures
AVN metabolic

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

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

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

The acetabulum dysplasia causes lesions involving the anterosuperior acetabulum and femoral head involving the superior weight bearing portion of the head traumatic episode lateral impaction injuries cause medial lesion

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

Clinicians must inquire about traumatic etiology such as hip subluxations, dislocations and direct falls onto the lateral hip
It is more common to elicit an insidious onset of groin or deep lateral hip
Symptoms are often exacerbated by activities such as running, cutting and pivoting, getting in and out of a car, arising from a seated position and prolonged sitting

Most chondral and labral lesions may be felt as anterior groin pain
They also may be referred to the trochanter and the buttock area and occasionally medially and along the adductor muscles
They may feel a pinch anteriorly with FAI
Popping or clunking may be perceived
Unlike snapping hip this will not occur 100% of the time nor be easily reproduced

During an impingement test, consisting of flexion of the hip to
90° and rotation from external to internal the lesion may be mapped out
Articular flaps may be felt either more clockwise or counterclockwise depending on the direction of the flap

Radiographs:
A low AP of the pelvis with the coccyx seen to be less than 2 cm away from the symphysis a frog lateral
CT scan:
Can map bony topography
MRI with or without arthrography
The use of gadolinium may enhance visualization of cartilage lesions

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

Acetabular lesions
AC 0= no damage
AC 1= softening no wave sign
AC 1w = wave sign with intact labrocartilage junction
AC 1wTj = wave sign but torn labrocartilage junction
AC 1wD = intact junction with delamination
AC 1wTjD = torn junction with delamination
AC 2 = fibrillation
AC 2Tj = fibrillation with torn junction
AC 3 = exposed bone <1cm2
AC 4 = exposed bone >1 cm2

Bipolar MRI with grade 3 and 4 chondral changes
Greater then 50% joint space narrowing
Less than 2 mm joint space remaining on radiographs

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

Non-operative treatment can be attempted for patients with
FAI in an effort normalize soft tissue length, joint capsule mobility, strength.
Activity modification plays a large role in this approach. Most young athletes do not tolerate this.
Actual chondral lesions cannot be managed effectively without surgery

HC 0 and HC1: little to no treatment
HC 2: debridement
HC 3: microfracture
HC 4:debridement with microfracture
HTD: excision of loose fragment

Microfracture is still the first line treatment for exposed fullthickness chondral defects.
Loose chondral fragments and flaps are debrided
There must not be any contralateral lesion
In the setting of cam-type FAI and labral chondral separation with adjacent partial thickness or full-thickness delamination is frequently seen the cartilage is dealt with either debridement or microfracture or a variety of newer techniques. Most importantly though the impingement is treated

Early ROM is begun with well leg stationary cycling and/or
CPM machine
Flatfoot or 30 pound weight bearing restrictions are recommended for 2 weeks when microfracture is not performed and continued for 4-8 weeks after microfracture
Core strengthening initiated postoperatively
At 6-8 weeks progressive unrestricted strengthening is allowed with sports specific drills beginning at 2-3 months which is delayed to 3-6 months if microfracture

Open treatment for FAI is still the gold standard this includes surgical dislocation of the femoral head allows direct visualization of the cam and pincer lesions as well as the labral and chondral issues although this is advantageous for significant deformity, there is significantly more trauma to the hip during the surgery
Most recent studies show minimal differences in 2 year followup early recovery favors the arthroscopic approach

Chondral defect
Diffuse osteoarthritis
Total hip partial thickness full thickness chondroplasty focal lesion <400mm2
Microfracture alternate treatment
(OATS, hemiCAP)