Hip Cartilage Injury

Cartilage injury can occur on the ball (or femoral head) or socket (acetabulum). When the gliding cartilage is injured it can cause further problems in the hip as well as pain in the hip.    While it shares the common theme of cartilage injury with hip osteoarthritis, it is different. Hip osteoarthritis is a more widespread injury affecting the head and the ball associated with bone spurring while cartilage injury is more focal or isolated to one area of cartilage in the hip.

Symptoms

Symptoms of hip cartilage injury are not very specific.

1. Groin or Buttock Pain
2. Locking or catching sensation in the hip.
3. Pain with weight bearing or deep hip flexion

Causes

Femoracetabular Impingement (FAI)

Acetabular cartilage injuries are most commonly caused by Femoracetabular Impingement Syndrome (FAIS),  or commonly called hip impingement.  The cam shape initially causes tearing of the labrum.  After the labrum, repetivive contact of the cam deformity begins to cause shearing and impact injury of the adjacent hip gliding cartilage (chondrolabral junction).  This often causes fraying of the cartilage and delamination or separation injury of the gliding cartilage from the acetabulum bone.

This can also occur as a lever type injury seen with pincer type FAI but this is less common.

Trauma

Femoral head and acetabular cartilage can also be injured with trauma. Traumatic hip injuries such as hip dislocation/subluxation, femoral head fractures, and acetabular fractures can cause injury to the cartilage in the hip.

Iatrogenic

Previous hip arthroscopy or other hip procedures often performed by less experienced hip surgeons can cause cartilage scuffing or injury. This commonly is discovered on revision hip arthroscopy performed by Dr. Faucett.

Diagnosis

A history of hip trauma or previous hip surgery are commonly associated with cartilage injuries.

Dr. Faucett will perform a physical exam to determine if you have FAIS findings.  Some impaction tests and range of motion exams can also be helpful.

It is difficult to diagnosis a cartilage injury on physical exam as many of the symptoms and exam findings are also seen in other hip conditions such as FAI and labrum tears.

Imaging

X-rays are used to help screen for osteoarthritis and determine if there is irregularity in the bones around the hip joints.  It is also useful to diagnosis FAI syndrome.

MRI can better image the cartilage layers in the hip joint. It commonly underestimates the severity of the cartilage injury.  It can also be useful to find loose cartilage pieces in the joint.

Diagnostic Arthroscopy: A needle arthroscopy can be performed to directly look at the cartilage in the hip joint. This can be more accurate than doing a MRI as Dr. Faucett can directly view the cartilage rather than interpret the MRI results

Treatment

Active Modification

Limiting impact activities can lessen the injury to the cartilage. Avoiding hip impingement positions and activities will also limit the damage to the acetabular cartilage.

Injection

Dr. Faucett may discuss the role of hip injections to help manage the pain and cartilage injury. Injections can include:

• Cortisone –  This is a powerful anti-inflammatory and can lessen inflammation and pain in the hip.  It can also be helpful for diagnostic purposes to determine how much pain is coming from the hip joint.
• Viscosupplementation – There are many forms of hyaluronic acid which can be injected to treat cartilage injuries in the hip.  Dr. Faucett recommend which one would be the most helpful is for you.  These can be injected every 6 months if needed.
• Platelet Rich Plasma –  This is a technique to harvest the bodies own potential to heal itself.  It is considered an investigational treatment.  This also works to reduce inflammation and recruit the repair (stem cells) cells to an injury area to repair it.
• Stem cells –  Using bone marrow aspirate, bone marrow stem cells can be injected into the hip to encourage the damaged cartilage to heal itself.  This is an investigational treatment this time and there are not very many studies looking at the effectiveness or the durability of these biologic treatments.

Surgery

In cases where surgery is needed, the cartilage injury can be treated arthroscopically and in some cases using an open surgery.  The following are some repair techniques Dr. Faucett might use to treat cartilage injuries:

Chondroplasty

When the gliding cartilage is injured through damage from Femoracetabular impingement or trauma, it may need to be repaired. One technique to treat mildly damaged cartilage (less the 50% of its thickness) is chondroplasty. Chondroplasty is a method to remove or debride the damaged cartilage and leave the remaining cartilage.

Microfracture

When the cartilage damage is deeper (>50%) but of a small surface area, a technique called microfracture can be used to grow new scar type cartilage. This technique makes small holes in the acetabular bone to allow for the patient’s own stem cells to populate the cartilage defect and grow new cartilage.

Cartilage Transplant

In some cases when the deep defect (>50%) is a large surface area a cartilage/bone transplant can be performed. This is called an “osteochondral transplant.” Healthy intact cartilage is harvested earlier from someone who has donated their tissues after their death. After the cartilage is deemed to be free of any infection or communicable diseases and deemed the highest quality the cartilage can be transplanted into the patients defect and secured in place using a biologic glue.

Cartilage Repair

In some cases when the cartilage delaminates but is otherwise healthy looking, the cartilage can be “glued” back to the acetabular bone using a substance call fibrin glue. This is a collagen epoxy the starts as liquid and becomes a gel creating stability between the layers and a conduit for repair cells to repair the delamination.

Total Hip Replacement

In some cases, the cartilage damage by too extensive and a total hip replacement might be recommended.

Recovery

Patients undergoing these procedures typically need crutches for 6-8 weeks. Range of motion is important to help the cartilage heal. This is often performed with home circumduction exercises, continuous passive motion (CPM) machines, upright exercise bike. After 6 weeks, the patient is allowed increase weight bearing, as tolerated, and then to more aggressive strengthening exercises. The cartilage should be resilient enough to start impact exercises around 4-6 months.

Outcomes

Success rates range from 80% to 90%, with most studies showing good or excellent results beyond 2 years.

Prevention

The earlier the diagnosis is made, the higher the chance the patient can be successfully treated with hip arthroscopy. If the problem is recognized earlier, we can limit the amount and severity of the cartilage damage. The more severe the cartilage damage, the harder it is to achieve a better outcome after surgery.