Orthopedics

Case Reports 

Arthroscopic Repair of Delaminated Acetabular Articular Cartilage in Femoroacetabular Impingement

Jon K. Sekiya, MD; RobRoy L. Martin, PhD, PT, CSCS; Bryson P. Lesniak, MD

Abstract

Lesions to articular cartilage can be difficult to treat and directly impact surgical outcome in hip arthroscopy. This article describes a direct cartilage suture repair technique for a young, active individual with full-thickness acetabular cartilage delamination. Lesions of this type are commonly seen with femoroacetabular impingement.

A 17-year-old boy presented with bilateral hip pain greater in the right than left. Arthroscopic intervention for the right hip included direct cartilage repair for the cartilage lesion, osteoplasty for femoroacetabular impingement, repair for an anterior labral tear, capsular plication for iliofemoral ligament laxity, and psoas lengthening. Twelve weeks postoperatively, a standard capsular plication, osteoplasty, and chondroplasty were performed on the left hip. At follow-up, the patient reported feeling 95% normal. He noted that the right and left hips were essentially the same. Symptoms consisted of stiffness after prolonged sitting and mild pain following sports. The patient reported being pain free 90% of the time, with pain 2/10 at worst. He scored a 96 on the modified Harris Hip Score, 93 on the Hip Outcome Score Activities of Daily Living subscale, and 81 on the Hip Outcome Score Sports subscale. Overall, the patient was satisfied with the outcome. The direct cartilage repair, in addition to osteoplasty, anterior superior labral repair, iliofemoral capsular plication, and psoas lengthening, produced an excellent outcome in this young, active patient.

Lesions to the acetabular articular cartilage can be difficult to treat and directly impact surgical outcome in hip arthroscopy.1,2 Early intervention for a cartilage lesion is thought to be important for preventing or delaying degenerative hip arthritis.3 While microfracture and chondroplasty are surgical techniques commonly used to address small articular cartilage lesions, larger tears offer a more challenging situation. This article describes a case of a young, active adolescent who underwent arthroscopic surgery and was treated with direct suture repair for a delaminated acetabular cartilage tear associated with femoroacetabular impingement.

A 17-year-old boy presented with bilateral hip pain greater in the right than left. The pain was localized to the groin region and was aggravated with weight-bearing activities, particularly walking and climbing stairs. Symptoms began insidiously approximately 1 year prior to presentation and increased over the next 5 months. The patient’s activities included being a competitive high school wrestler. No previous treatment for this condition was rendered.

A comprehensive examination was performed. Significant findings for the right hip included limited passive range of motion (ROM) with 100° of hip flexion and 10° of internal rotation. These movements were limited by pain. The flexion–adduction–internal rotation impingement and flexion abduction external rotation (FABER) tests were both positive and reproduced pain. The log-roll test was also positive with increased external rotation at full extension. Standard plain radiographs, including standing anteroposterior pelvis and cross-table lateral views, revealed a cam impingement deformity. No acetabular dysplasia or joint space narrowing were seen. Conventional unilateral direct magnetic resonance imaging (MRI) arthrogram using gadolinium contrast and substituting saline with 6 cc of 1% lidocaine, 6 cc of 0.25% bupivacaine, and 80 mg of triamcinolone revealed a definite labral tear as defined by Czerny et al8 with a linear signal through >50% of the entire labrum on >2 views on the same MRI arthrogram sequence (Czerny stage IIA/B). With diagnostic injection, the patient reported 100% relief of symptoms. This relief was temporary as the symptoms gradually returned over subsequent days.

The patient was placed supine on a traction table, all bony prominences were well padded, and prophylactic antibiotics were given. The right extremity was secured in a traction boot and positioned in adduction and internal rotation as previously described.9 Traction was applied until adequate distraction of the hip…

Abstract

Lesions to articular cartilage can be difficult to treat and directly impact surgical outcome in hip arthroscopy. This article describes a direct cartilage suture repair technique for a young, active individual with full-thickness acetabular cartilage delamination. Lesions of this type are commonly seen with femoroacetabular impingement.

A 17-year-old boy presented with bilateral hip pain greater in the right than left. Arthroscopic intervention for the right hip included direct cartilage repair for the cartilage lesion, osteoplasty for femoroacetabular impingement, repair for an anterior labral tear, capsular plication for iliofemoral ligament laxity, and psoas lengthening. Twelve weeks postoperatively, a standard capsular plication, osteoplasty, and chondroplasty were performed on the left hip. At follow-up, the patient reported feeling 95% normal. He noted that the right and left hips were essentially the same. Symptoms consisted of stiffness after prolonged sitting and mild pain following sports. The patient reported being pain free 90% of the time, with pain 2/10 at worst. He scored a 96 on the modified Harris Hip Score, 93 on the Hip Outcome Score Activities of Daily Living subscale, and 81 on the Hip Outcome Score Sports subscale. Overall, the patient was satisfied with the outcome. The direct cartilage repair, in addition to osteoplasty, anterior superior labral repair, iliofemoral capsular plication, and psoas lengthening, produced an excellent outcome in this young, active patient.

Lesions to the acetabular articular cartilage can be difficult to treat and directly impact surgical outcome in hip arthroscopy.1,2 Early intervention for a cartilage lesion is thought to be important for preventing or delaying degenerative hip arthritis.3 While microfracture and chondroplasty are surgical techniques commonly used to address small articular cartilage lesions, larger tears offer a more challenging situation. This article describes a case of a young, active adolescent who underwent arthroscopic surgery and was treated with direct suture repair for a delaminated acetabular cartilage tear associated with femoroacetabular impingement.

Case Report

A 17-year-old boy presented with bilateral hip pain greater in the right than left. The pain was localized to the groin region and was aggravated with weight-bearing activities, particularly walking and climbing stairs. Symptoms began insidiously approximately 1 year prior to presentation and increased over the next 5 months. The patient’s activities included being a competitive high school wrestler. No previous treatment for this condition was rendered.

A comprehensive examination was performed. Significant findings for the right hip included limited passive range of motion (ROM) with 100° of hip flexion and 10° of internal rotation. These movements were limited by pain. The flexion–adduction–internal rotation impingement and flexion abduction external rotation (FABER) tests were both positive and reproduced pain. The log-roll test was also positive with increased external rotation at full extension. Standard plain radiographs, including standing anteroposterior pelvis and cross-table lateral views, revealed a cam impingement deformity. No acetabular dysplasia or joint space narrowing were seen. Conventional unilateral direct magnetic resonance imaging (MRI) arthrogram using gadolinium contrast and substituting saline with 6 cc of 1% lidocaine, 6 cc of 0.25% bupivacaine, and 80 mg of triamcinolone revealed a definite labral tear as defined by Czerny et al8 with a linear signal through >50% of the entire labrum on >2 views on the same MRI arthrogram sequence (Czerny stage IIA/B). With diagnostic injection, the patient reported 100% relief of symptoms. This relief was temporary as the symptoms gradually returned over subsequent days.

Surgical Technique

Figure 1: Anterior labral tear from 1 o'clock to 2 o'clock
Figure 1: Anterior labral tear from 1 o'clock to 2 o'clock.

The patient was placed supine on a traction table, all bony prominences were well padded, and prophylactic antibiotics were given. The right extremity was secured in a traction boot and positioned in adduction and internal rotation as previously described.9 Traction was applied until adequate distraction of the hip was confirmed with fluoroscopy. The right lower extremity was then prepped and draped. A lateral portal was established 1 cm anterior to the anterior aspect of the femoral trochanter. Fluoroscopy was used to confirm intra-articular placement of the needle prior to passing the nitinol wire. A skin incision was made around the wire, and a trochar was placed over the wire.

The arthroscope was placed through the lateral portal, and an anterior portal was established under direct visualization. The starting point was the confluence of the anterior superior iliac spine and the proximal tip of the greater trochanter. A nitinol wire was placed intra-articularly, and a 5.5-mm cannula was placed over the wire. This established the outflow portal. The diagnostic arthroscopy was then performed, with the femoral head being initially evaluated. The femoral head was found to be without chondral defects. The labrum was identified and evaluated. There was clear evidence of a labral tear from the 1 o’clock to 2 o’clock position peripherally (Figure 1). Also noted was peripheral acetabular articular cartilage delamination with chondral labral separation. This intact 1-cm delaminated articular cartilage flap (Outerbridge 010) was partially off the subchondral bone. The defect was probed and found to be unstable. Before this flap was addressed, a decision was made to repair the labral tear using suture anchors. A 45° Bird Beak (Arthrex, Naples, Florida) was used to pass the suture through the labrum and capsule. The knot was tied arthroscopically and found to be stable with gentle probing (Figure 2).

Figure 2: Anterior labral repair with a suture anchor Figure 3: Microfracture under the acetabular articular cartilage delamination

Figure 2: Anterior labral repair with a suture anchor. Note the chondrolabral separation (small arrow) and acetabular articular cartilage delamination (big arrow). Figure 3: Microfracture under the acetabular articular cartilage delamination.

Following the labral repair, microfracture was performed under the mobile chondral flap. Care was taken not to detach the flap from its subchondral bone base (Figure 3). Once an adequate microfracture was performed, the chondral flap was then reassessed. Due to significant instability on probing, a decision was made to attempt suture repair. A spectrum device was used to pass a #1 polydioxanone monofilament suture (PDS; Ethicon, Inc, Somerville, New Jersey) through the labrum and the articular cartilage flap. After the suture was tied, the chondral flap was found to be stable and in good position (Figure 4). The polydioxanone monofilament suture was chosen specifically because it is absorbed in 6 weeks and therefore does not abrade the femoral head as weight bearing is advanced.

Figure 4A: Articular cartilage delamination repair Figure 4B: Articular cartilage delamination repair Figure 4C: Articular cartilage delamination repair

Figure 4: Articular cartilage delamination repair. Spectrum device used to pass #1 polydioxanone through delaminated cartilage (A). Articular cartilage repair viewed from lateral (B) and anterior (C) portals.

The iliopsoas was observed after the direct chondral repair was performed. Due to evidence of tendonitis, an iliopsoas lengthening was performed with a Beaver blade (Smith & Nephew, Andover, Massachusetts). Attention was then turned to the peripheral compartment. The patient was taken out of traction and the hip was moved through complete ROM to assess for femoroacetabular impingement. The presence of femoroacetabular impingement was confirmed, and a routine femoral neck osteoplasty was performed along a clear delamination between normal femoral head cartilage and abnormal cartilage (Figure 5). This osteoplasty was performed from the 6 o’clock to 12 o’clock positions. An impingement test confirmed that no bony impingement remained between the reshaped femoral head and repaired acetabular cartilage and labrum. Capsular laxity was identified and capsular plication of the iliofemoral ligament was performed in the peripheral compartment (Figure 6).9 Detailed descriptions have been previously reported for labral repair,11 osteoplasty,12 and capsular plication9 procedures. The cannulas were then removed after an intra-articular injection of neostigmine, meperidine, and 0.25% bupivacaine mixture.

Figure 5A: Arthroscopic treatment of femoroacetabular impingement cam impingement lesion Figure 5B: Arthroscopic treatment of femoroacetabular impingement cam impingement lesion

Figure 5: Arthroscopic treatment of femoroacetabular impingement cam impingement lesion. Note the evidence of cam impingement (arrows; A). Note that the femoral head no longer impinges on the labral repair or cartilage repair in this position of flexion, adduction, and internal rotation (B).


Figure 6A: Capsular plication of the iliofemoral ligament Figure 6B: The suture is tied arthroscopically, creating a capsular plication anteriorly

Figure 6: Capsular plication of the iliofemoral ligament. Polydioxanone suture passed through the medial and lateral limbs of the iliofemoral ligament in the peripheral compartment with the hip in 30° of flexion (A). After shuttling a #2 FiberWire (Arthrex) through the iliofemoral ligament, the suture is tied arthroscopically, creating a capsular plication anteriorly (B).

Postoperative Management

The rehabilitation protocol was protective to avoid excessive stress on the repaired cartilage and labrum as well as the femoral head–neck junction and plicated iliofemoral ligament. Therefore, the patient was allowed 30% weight bearing with crutches for 6 weeks, gradually progressing to 100% over the following 2 weeks. Gentle ROM and isometric strengthening were completed for 4 weeks with caution to avoid forced external rotation, hip extension, and hip abduction. Once full weight bearing was well tolerated, exercises were slowly advanced to progressive resistive weight-bearing exercises. This supervised rehabilitation program continued as outlined previously13 for 14 weeks with no significant complications.

At 12 weeks postoperatively, the patient’s right hip was progressing well as he reported feeling 90% normal. Range of motion and strength were good, and the patient tolerated activities of daily living with no problem. A decision was made to surgically address the left hip. A standard capsular placation, osteoplasty, and chondroplasty were performed. The patient continued with normal follow-up with no complications. Slow return to sports was allowed approximately 4 months after left hip surgery and over 7 months after right hip surgery.

At 2-year, 3-month and 2-year follow-up for the right and left hip, respectively, the patient reported feeling 95% normal. He noted the right and left hips were essentially the same. Symptoms consisted of stiffness after prolonged sitting and mild pain following sports. The patient reported being pain free 90% of the time with pain 2/10 at worst. The patient scored a 96 on the modified Harris Hip Score, 93 on the Hip Outcome Score Activities of Daily Living subscale, and 81 on the Hip Outcome Score Sports subscale. Overall, the patient was satisfied with the outcome of surgery.

Discussion

Delamination or peel-off tearing is full-thickness cartilage separation from the underlying subchondral bone. This lesion forms an unstable flap at risk for complete detachment, which would result in a defect and intra-articular loose body.4 Anterior superior acetabular cartilage delamination is commonly seen in patients with cam femoroacetabular impingement and often occurs concomitantly with anterior superior labral tears.4,5 The nonspherical femoral head associated with cam femoroacetabular impingement is thought to cause sheer forces, which lead to labral tearing and cartilage delamination.6 Irrespective of the origin of the articular cartilage injuries, these lesions can limit participation in activity and predispose individuals to progressive joint degeneration.

While joint preservation is important at any age, it may be more crucial in the young, active population. Controversy exists regarding how to address these delamination lesions. Treatment options include performing radiofrequency thermal treatment to the cartilage lesion in hopes that it will heal or removing the lesion to avoid further delamination and the potential for creating a loose body.7 Another option would be to simply leave it alone. Our case is novel because it involves a direct cartilage suture repair technique and provides 2-year outcome data for a young, active individual with full-thickness acetabular cartilage delamination commonly seen with femoroacetabular impingement.

Although advancements in hip arthroscopy have greatly increased over the past 5 to 10 years with instrumentation that allows chondral surfaces to be better visualized, large articular cartilage lesions continue to represent a potentially difficult situation. These large lesions may be particularly problematic in the young, active patient. Our case presents direct cartilage repair as a potential technique to address large delaminated full-thickness acetabular articular cartilage tears. The direct cartilage repair, in addition to osteoplasty, anterior superior labral repair, iliofemoral capsular plication, and psoas lengthening, produced an excellent 2-year outcome in this active, 17-year-old boy.

Articular cartilage lesions are commonly seen during arthroscopic evaluations.3,14-16 The type of peel-off delamination noted in our case reportedly occurs in approximately 40% of those surgically treated for femoroacetabular impingement.5,6 Microfracture is commonly used for an Outerbridge grade III or IV articular cartilage lesion if they are <4 cm2 in size.17 Microfracture involves resecting the unstable cartilage flap from the exposed bone and debriding the defect to allow the marrow clot to form more effectively.17 However, when the tear is large, the area of exposed bone may be too large for the fibrocartilaginous tissue to successfully cover. The technique described in our case, where the cartilage was directly repaired using absorbable sutures, may be an option for individuals with a delaminated full-thickness acetabular articular cartilage tear.

Outcome studies on hip arthroscopy have been encouraging. A review of the literature found 12 studies that investigated outcomes of the arthroscopic treatment of labral tears and femoroacetabular impingement.18 These studies noted 67% to 100% of patients were satisfied with their outcome.2,16,19-28 A recent 10-year follow-up study found favorable results with selective debridement of labral tears.29 Philippon et al14 reported 2-year outcome data on hip arthroscopy for femoroacetabular impingement and associated chondrolabral dysfunction. Overall patient satisfaction was high (median score, 9 out of 10) with an average improvement of 24 points on modified Harris Hip Score. This study also found those with labral repair had a better outcome than those with labral debridement.14 Overall, the outcome of hip arthroscopy in adults seems good; however, it is well documented that the presence of articular cartilage lesions, particularly findings of osteoarthritis, negatively impact surgical outcomes.1-3,14,18,26,29

While surgical procedures and outcomes have been described for adults, considerably less information is available for individuals younger than 20 years. A recently study reported short-term (1.36 year) outcome information for an adolescent population (mean age, 15 years; range, 11-16 years).30 The 16 patients in this study who were treated for primarily femoroacetabular impingement had excellent improvement and a high level of satisfaction. There were no complications associated with disruption of the perichondral ring (ie, slipped capital femoral epiphysis or arrest of the physis). It should be noted that these patients had no articular cartilage lesions that required treatment. Further research is needed to define the outcomes of hip arthroscopy in younger patients, particularly with the type of lesion and the techniques described in our case.

References

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Authors

Dr Sekiya is from MedSport, Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan; and Dr Martin is from Duquesne University and University of Pittsburgh Medical Center, Center for Sports Medicine, and Dr Lesniak is from the Department of Orthopedic Surgery, University of Pittsburgh, Pennsylvania.

Dr Sekiya is a consultant for and receives royalties from Arthrex and OrthoDynamix. Drs Martin and Lesniak have no relevant financial relationships to disclose.

Correspondence should be addressed to: Jon K. Sekiya, MD, MedSport, Department of Orthopedic Surgery, University of Michigan, 24 Frank Lloyd Wright Dr, PO Box 0391, Ann Arbor, MI 48106-0391.

DOI: 10.3928/01477447-20090728-44

10.3928/01477447-20090728-44

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