Introduction
Methods
Search strategy
Study screening/data abstraction
Inclusion criteria |
1. All levels of evidence |
2. Written in the English language |
3. Studies on humans |
4. Studies reporting the outcome of cartilage repair techniques for cartilage injuries in the hip |
Exclusion criteria |
1. Studies on other joints (e.g. knee) |
2. Studies describing trial protocols without any results |
3. Hip replacement surgery |
4. Basic studies (e.g. cadaveric studies) |
5. Reviews, systematic reviews |
Statistics
Results
Parameter | |
---|---|
Studies analysed | 21 studies |
Levels of evidence | |
3b | 3 studies (14.3%) |
4 | 18 studies (85.7%) |
Participants (hips) | 596 |
Male | 216 (56.1%) |
Female | 169 (43.9%) |
Unclear | 211 |
Range of follow-up time | 6–74 months |
Mean participant age (range) | 37.2 (15–63) years |
Surgical approach | |
Arthroscopy | 11 studies (52.4%) |
Open | 9 studies (42.9%) |
Injection | 1 study (4.8%) |
Location of cartilage defect (participants) | |
Acetabulum | 534 (93.5%) |
Femoral head | 37 (6.5%) |
Unclear | 25 |
Publication year | First author | Level of evidence | Mean age (range) | Number of cases | Male | Female | Acetabulum/femoral head | Follow-up period | Surgical approach | Technique used | Pre-operative condition | Post-operative rehabilitation protocol | Final outcome | Other comments |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
2016 | Mardones [57] | 4 | 51.8 (39–60) | 29 | 10 | 10 | NA | 24 months | Injection | Intra-articular BM-MSC injection | Symptomatic FAI and focal chondral delaminations (Outerbridge classification grades III–IV) with mild to moderate OA (Tӧnnis scale II–III) | Walking with 2 crutches and weight bearing as tolerated was allowed on the first post-operative day. | The median pre-operative mHHS, WOMAC and VAIL scores were 64.3, 73 and 56.5, respectively, and they increased to 91, 97 and 83 at final follow-up (p < 0.05). The VAS score also improved from a median of 6 to 2. | Four patients received a THR (13% of the hips) at the median of 9 months post-intervention (range 6–36 months); 80 mL of bone marrow was aspirated from the anterior iliac crest during hip arthroscopy. Each patient received 3 intra-articular injections of 20 × 106 BM-MSCs post-operatively (4–6 weeks). |
2016 | Fontana [31] | 4 | 36.4 (18–50) | 201 | NA | NA | 201/0 | 5 years | Arthroscopy | AMIC | Outerbridge grade III and/or IV chondral lesions located in the superior area of the acetabulum. Acetabular chondral lesion size was between 2 and 4 cm2; radiological Tönnis degree of osteoarthritis was ≤ 2. The mean defect size was 2.9 ± 0.8 cm2. | Walking was allowed with the aid of 2 crutches with partial weight bearing (30% of body weight) on the operated leg for 3 weeks. | Pre-operative mHHS had a mean score of 44.9 ± 5.9. Significant improvement, as measured by the mHHS, was observed at 6 months in comparison to pre-operative 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 3-year follow-up (85.5 ± 7.2). The mean mHHS improvement recorded at the 5-year follow-up compared with pre-operative scores was 39.1 ± 5.9. | No failure resulting in hip arthroplasty was detected in any of these patients during the 5-year follow-up. No patient had a poor post-operative mHHS (> 60). |
2015 | Fontana [25] | 3b | 39.2 (18–55) | 147 | 91 | 56 | 147/0 | 5 years | Arthroscopy | 77 MFx, 70 AMIC | Acetabular grade III and IV chondral lesions (Outerbridge classification) measuring between 2 and 8 cm2. Less than grade 2 degenerative changes radiologically according to the Tӧnnis classification | Non-weight bearing for 4 weeks. Partial load bearing up to 7 weeks, afterwards full. | The mean mHHS had improved significantly in both groups 6 months post-operatively (76.3 for MFx (58 to 98) and 79.5 for AMIC (68 to 96), p < 0.001). At this time, there were significantly better results in the AMIC group (p < 0.025). Differences in outcome between the 2 groups became more apparent 1 year post-operatively, and this trend continued throughout the subsequent follow-up. The mean mHHS in the MFx group was lowest at between 4 and 5 years (72.4: 48 to 92) post-operatively. Conversely, the improvement in mHHS seen in the AMIC group was maintained throughout the 5-year assessment period. AMIC group had better and more durable improvement, particularly in patients with large (≥ 4 cm2) lesions. The outcome was significantly better in the AMIC group for both men and women at 2, 3, 4 and 5 years, except for women 5 years post-operatively. | A total of 6 patients (7.8%) in the MFx group required THR at a mean of 3.2 years (1 to 5) post-operatively. None in the AMIC group required THR. |
2014 | Mancini [28] | 3b | 36.2 (19–50) | 57 | 25 | 32 | 57/0 | Up to 5 years | Arthroscopy | 26 MACI, 31 AMIC | Grade III and IV (Outerbridge classification) acetabular chondral lesions, mostly located in the superior chondral acetabulum. Patients with acetabular chondral lesion size between 2 and 4 cm2 with radiological Tönnis degree < 2. | Partial weight bearing (30% of body weight) on the operated leg for 3 weeks. At 4 weeks post-op, walking with the aid of 1 crutch opposite to the recovering leg was allowed for 7 days, then normal walking thereafter. | In both the MACI and AMIC groups, significant hip score improvements were measured over baseline levels at 6 months post-op (81.2 ± 8.4 for MACI, 80.3 ± 8.3 for AMIC, both p < 0.001). Statistically significant differences between the groups were not observed. The mean mHHS improvement at the 5-year follow-up with respect to pre-operative level was 37.8 ± 5.9 and 39.1 ± 5.9 in patients who underwent MACI and AMIC, respectively (not significant). | No failure resulting in hip arthroplasty was detected in any of these patients during the 5-year follow-up |
2012 | Zaltz [24] | 4 | 27 (16–31) | 10 | 7 | 3 | 0/10 | 29 months | Open | 3 AMIC, 7 MFx | Full-thickness parafoveal chondral lesions localised anterolateral to the fovea confirmed at the time of surgical dislocation. The lesion size ranged from 96 to 513 mm2 with a mean of 184 mm2. | Patients were limited to toe-touch weight bearing for approximately 6 weeks. After 6 weeks and radiographic confirmation of trochanteric union, progressive weight bearing was encouraged. | The Tegner-Lysholm score at latest follow-up ranged from 5 to 9 (mean, 7.4). All patients were able to return to their pre-operative level of function with the exception of patient 6 whose contralateral hip precluded participation. There was no obvious asymmetric joint space narrowing visible on an AP pelvis view in any of the patients. | |
2012 | Vundelinckx [59] | 4 | 34 | 1 | NA | NA | 0/1 | 6 months | Arthroscopy | Artificial plug (TruFit®) | Severe osteochondral lesion with a subchondral cyst on the femoral head seen on MRI. | Restricted weight bearing during 4 weeks (walking with crutches and plantar touch). | MRI scanning at 6 months showed the TruFit plug in situ, without subsidence, whilst there still is an irregularity on the border of the articular cartilage surface. At 6 months, the right hip showed an abduction of 35°, a symmetric endorotation and exorotation of 30° and an adduction of 10°. Flexion was 95°, compared to 110° at the contralateral side. | |
2012 | Leunig [30] | 4 | 22.7 (15–31) | 6 | 5 | 1 | 1/5 | Minimum 1 year | Open | AMIC | Large (> 2 cm2) femoral head or acetabular chondral or osteochondral lesions. All were classified as ICRS grade 3 or 4 lesions and Tӧnnis grade < 2. | Not mentioned | Post-operative Oxford Hip Scores ranged from 13 to 17, UCLA Activity Scores ranged from 5 to 10 and MOCART scores ranged from 55 to 75. | Two patients (33%) were lost to follow-up. |
2012 | Krych [36] | 4 | 22 (15–29) | 2 | 1 | 1 | 0/2 | 4.3 years | Open | Osteochondral autograft transfer from the ipsilateral knee (mosaicplasty) | 2 cm × 5 to 8 mm area of osteochondral defect in patient 1 and 1 × 2 cm area of osteochondral defect in patient 2. Both defects were in the anterosuperior weight-bearing portion of the femoral head. | Patients were kept partial weight bearing for 2 months after surgery and then were gradually returned to full weight bearings. | MRI at 6 months showed complete incorporation of the osteochondral plugs into the femoral head. At 4 years follow-up, patient 1 had mHHS 96, HOS 100 and patient 2 had mHHS 100, HOS 100. | Radiographs showed heterotopic ossification post-operatively in both of the patients. |
2012 | Karthikeyan [23] | 4 | 37 (17–54) | 20 | 16 | 4 | 20/0 | 17 months | Arthroscopy | MFx | Full-thickness acetabular chondral defects in the superior and anterosuperior zones of the acetabulum (average 154mm2, range 48–300 mm2) | For the first 6 weeks, only foot-flat non-weight bearing was allowed. Full weight bearing was achieved over the following 2 weeks. | The mean NAHS improved from 55 to 78. Excluding 1 patient who only had a 25% fill, 19 of the 20 patients had a mean fill of 96% (range, 75–100%) with macroscopically good quality (grade 1) repair tissue as per Blevins et al.’s classification. | |
2012 | Fontana [19] | 3b | 41.5 (20–53) | 30 | 12 | 18 | 30/4 | 74 months | Arthroscopy | 15 ACI, 15 debridement | Post-traumatic hip chondropathy of grade 3 or 4 according to the Outerbridge classification, measuring 2 cm2 in area or more. The mean size of the defect was 2.6 cm2. | Non-weight bearing for 4 weeks. Partial load was allowed after 4 weeks in group A (ACI) and after 2 weeks in group B (debridement). | The patients who underwent ACI (group A) improved after the procedure compared with the group that underwent debridement alone (group B). The mean HHS pre-operatively was 48.3 (95% confidence interval, 45.4 to 51.2) in group A and 46 (95% CI, 42.7 to 49.3) in group B (no significant difference). The final HHS was 87.4 (95% CI, 84.3 to 90.5) in group A and 56.3 (95% CI, 54.4 to 58.7) in group B (p < 0.001). | |
2012 | Emre [34] | 4 | 22 | 1 | 1 | 0 | 0/1 | 3 years | Open | Osteochondral autograft transfer from the ipsilateral knee (mosaicplasty) | The radiographs displayed a chondral defect in the superolateral aspect of the femoral head. Pre-operative HHS was 43. | Not mentioned | mHHS improved from 43 to 96 at 24 weeks. At a 3-year follow-up, the patient was symptom-free with near complete incorporation of the graft radiographically. | The patient had past history of Perthes disease. |
2011 | Stafford [50] | 4 | 34.2 (18–53) | 43 | 25 | 18 | 43/0 | 28 months | Arthroscopy | Fibrin adhesive | Delaminated acetabular articular cartilage (A positive ‘wave sign’ at the chondrolabral junction indicated delamination of articular cartilage from the subchondral bone). | Toe-touch weight bearing with crutches is advised for 4 weeks. | mHHS for pain improved significantly from 21.8 (95% CI 19.0 to 24.7) pre-operatively to 35.8 (95% CI 32.6 to 38.9) post-operatively (p < 0.0001). The MHHS for function also showed significant, although more modest, improvements from 40.0 (95% CI 37.7 to 42.3) pre-operatively to 43.6 (95% CI 41.4 to 45.8) post-operatively (p = 0.0006). There were 3 patients who had early (within 12 months of the index procedure) revision arthroscopy for iliopsoas pathology. | There were 3 patients who required further arthroscopic interventions for persistent symptoms, created by iliopsoas irritation. At each of these procedures, the previously repaired articular cartilage was seen to be in good condition. |
2011 | Krych [40] | 4 | 28 (24–32) | 2 | 1 | 1 | 2/0 | Minimum 24 months | Open | Osteochondral allograft transplantation | 18 × 18 mm isolated defect of the superior acetabular dome in patient 1 and 12 mm diameter × 10 mm deep osteochondral defect in the weight-bearing dome of the superior acetabulum in patient 2 | Eight weeks of protected weight bearing | An MRI at 18 months in both cases demonstrated incorporation of the allograft bone into the host acetabulum. At 24 months in patient 1 and 42 months in patient 2, radiographs showed no progressive joint space narrowing compared to pre-operative radiographs. Patient 1 had improvement in mHHS from 75 pre-operatively to 97 at 2 years follow-up. mHHS improved from 79 pre-operatively to 100 at the time of 3 years follow-up in patient 2. Both patients’ HOS subsets for activities of daily living and sports score were 100 points each. | Patient 2 had 2 previous open hip operations for fibrous dysplasia. |
2011 | Girard [37] | 4 | 18 (15–21) | 10 | 7 | 3 | 0/10 | 29.2 months | Open | Osteochondral autograft transfer from the inferior portion of the femoral head (mosaicplasty) | Intra-operatively, the mean area of cartilaginous damage on the femoral head was 4.8 cm2 (3–9 cm2). | Patients were kept non-weight bearing for 6 weeks and then progressed to weight bearing as tolerated. | HHS increased from 52.8 (35–74) to 79.5 points (65–93). The Oxford Hip Score decreased indicating function improvement from 34.5 points (22–48) to 19.2 points (14–26). At latest follow-up, all autograft plugs appeared to be well incorporated on radiological examination. CT-arthrography at 6 months revealed intact cartilage over the plugs with smooth interfaces between the articulating bones in all cases. | No THR was required by the time of the last follow-up. |
2011 | Field [58] | 4 | 48.6 (31–63) | 4 | 1 | 3 | 4/0 | 10 months | Arthroscopy | Artificial plug (TruFit®) | CT confirmed the presence of solitary subchondral cysts in the weight-bearing portion of the acetabulum in all 4 patients. Patient 1 was also found to have subchondral cysts on the opposing surface of the femoral head and a labral tear. | Patients were mobilised 50% weight bearing with crutches for the first 6 weeks. This was gradually increased to full weight bearing by 8 weeks. | The mean NAHS improved from 53.8 (range 43.8 to 70) pre-operatively, to 66.9 (SD 18.5, range 53.8 to 80) at the 6-week time point and 84.6 (SD 5.1, range 78.8 to 87.5) at 6 months. Computed tomography and magnetic resonance imaging at 6 months confirmed the stability of the osteochondral plugs and on-going healing. None of the patients have developed collapse of the femoral head or avascular necrosis. | Mean BMI was 27.4. A bone tunnel was prepared from the region of the iliac crest to the acetabular articular surface. A synthetic osteochondral plug was inserted in an antegrade fashion and positioned flush with the lunate articular cartilage. Two patients had undergone previous hip arthroscopy. |
2010 | Tzaveas [49] | 4 | 36 (18–57) | 19 | 5 | 14 | 19/0 | 19 months | Arthroscopy | Fibrin adhesive | Acetabular articular cartilage delamination or debonding, identified as macroscopically sound cartilage, but with loss of fixation to the subchondral bone and a ‘carpet phenomenon’ or positive ‘wave’ sign. Acetabular cartilage delamination was found adjacent to the anterior labrum in 16 patients and to the anterosuperior area in 3. | Patients were instructed to touch weight bear for the first 4 weeks. | There were 5 patients who required a secondary intervention because of persistent pain or disability; 1 received a steroid and local anaesthetic injection to the affected hip; 2 required revision hip arthroscopy because of persistent pain, the first as a result of iliopsoas tendonitis and the second for residual femoroacetabular and pectineofoveal impingement, which was both excised. One patient received a resurfacing arthroplasty because of rapidly destructive osteoarthritis and another is scheduled to undergo revision arthroscopy in due course for persisting discomfort. For those patients who underwent revision arthroscopy or subsequent arthrotomy, the area of chondral repair appeared macroscopically intact and secure. Mean mHHS scores improved pre-operatively to 1 year post-operatively from 15.7 to 28.9 for pain and 37.2 to 44.1 for function. | |
2010 | Nam [35] | 4 | 18 (15–21) | 2 | 2 | 0 | 0/2 | Minimum 1 year | Open | Osteochondral autograft transfer from (1) the ipsilateral knee and (2) the inferior portion of the femoral head (mosaicplasty) | (1) The full-thickness cartilage defect in the anterior-superior weight-bearing zone of the femoral head that measured approximately 2 cm in length and was tapered down from approximately 8 to 5 mm in width. (2) A large osteochondral fracture was appreciated measuring approximately 3 × 3 cm, which had been displaced distally and superiorly. There was also a full-thickness cartilaginous injury at the apex of the fracture, in the anterior-superior weight-bearing zone of the femoral head. This zone of injury was approximately 10 mm in size. | Post-operatively, the patients were kept non-weight bearing for 6 weeks and then progressed to weight bearing as tolerated. | (1) An MRI performed at 24 weeks post-operatively demonstrated well-incorporated autograft plugs and intact cartilage over the plugs with smooth interfaces with the remaining bone. At 1 year follow-up, the patient has no complaints of pain, good mechanics with ambulation and has returned to running and physical activity without difficulty. (2) Radiographs and an MRI performed at 1 year post-operatively demonstrated a well-incorporated autograft plug with minimal fibrillation and no evidence of osteonecrosis. At over 5 years of follow-up, the patient continues to have no complaints of pain and has returned to his baseline physical activities without difficulty. | |
2009 | Sekiya [42] | 4 | 17 | 1 | 1 | 0 | 1/0 | 2 years | Arthroscopy | Direct cartilage suture repair | Peripheral acetabular articular cartilage delamination with chondral labral separation. This intact 1-cm delaminated articular cartilage flap (Outerbridge grade 0) was partially off the subchondral bone. | Patient was allowed 30% weight bearing with crutches for 6 weeks, gradually progressing to 100% over the following 2 weeks. | The patient reported being pain-free 90% of the time with pain 2/10 at worst. He scored 96 on mHHS, 93 on HOS Activities of Daily Living subscale and 81 on HOS Sports subscale. | |
2008 | Philippon [22] | 4 | 37.2 (21–47) | 9 | 5 | 4 | 9/0 | 20 months | Arthroscopy | MFx | The average acetabular chondral lesion size was 163 mm2. All lesions were located in the superior acetabular quadrant. | Weight bearing was restricted to toe-touch for 8 weeks. | The average percent fill of the acetabular chondral lesions at second look was 91% (range, 25 to 100%). Eight of the 9 patients had grade 1 or 2 repair product at second look (grade 1 was normal-appearing articular cartilage, difficult to discern borders of lesion and normal surrounding cartilage; grade 2 was mild fibrillation, discoloured, softer-than-normal cartilage; grade 3 was deep fissures or cobblestone surface, no exposed bone; and grade 4 was full-thickness cartilage loss with exposed subchondral bone). One patient who had diffuse osteoarthritis failed, with only 25% coverage with a grade 4 appearance of the repair product 10 months after index arthroscopy and required total hip arthroplasty 66 months after the index microfracture. | |
2008 | Ellender [27] | 4 | 19 | 1 | 0 | 1 | 0/1 | 2 years | Open | ACI (following previous mosaicplasty) | MR arthrogram revealed full-thickness loss of the surrounding articular cartilage on the major weight-bearing portion of the femoral head. Intra-operative measurement of the chondral defect measured 4.0 cm by 2.5 cm around intact osteochondral plugs. | Progressive weight-bearing activity can begin as early as 6 weeks but is usually delayed until 8 to 12 weeks. | Two years later, the patient remains free of pain, her post-operative contrast-enhanced MRI demonstrates repair tissue fill and radiographs showed a normal joint space. | The patient had progression of disease after prior autologous osteochondral mosaicplasty. Fixation of the membrane was performed with the use of 6.0 Vicryl suture. Fibrin glue was used to further seal the membrane. |
2003 | Hart [33] | 4 | 28 | 1 | 1 | 0 | 0/1 | 6 months | Open | Osteochondral autograft transfer from the ipsilateral knee (mosaicplasty) | The diameter of the round defect was 14 mm, and its depth was 16 mm. | Partial weight bearing was permitted at 6 weeks and full weight bearing at 10 weeks after the surgery. | HHS improved from 69 to 100 points. At 6 months post-operatively, the patient showed the full range of painless motion with no further complaints of rest pain or pain related to activities. | The defect was caused by penetrated resorbable screw used in the past surgical fixation of a displaced large single fragment of the posterior acetabular rim. |