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Arthroscopic Treatment of Chondral Defects in the Hip: AMIC, MACI, Microfragmented Adipose Tissue Transplantation (MATT) and Other Options

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Arthroscopic Treatment of Chondral Defects in the Hip: AMIC, MACI, Microfragmented Adipose Tissue Transplantation (MATT) and Other Options This journal ar-.le%.ontains%lan1uage%that may%not fall%within%the%s.ope%of%78A%.learan.e%of%Lipo1ems%and%was%provided%by%Lipo1ems%to%the%requestor%in%response% to%an%unsoli.ited%request for%informa-on.%Some%authors%may%have%Anan.ial%interest or%re.eive%.ompensa-on%from%the%manufacturer.%The%Lipo1ems%System%is%a sterile%medi.al%devi.e%intended%for%the%.losed-loop%pro.essin1%of%lipoaspirate%-ssue%in%medi.al%pro.edures%involvin1%the%harves-n1,%.on.entra-n1%and%transferrin1% of%autolo1ous%adipose%-ssue%harvested%with%a le1ally%marDeted%lipoplasty%system.%The%devi.e%is%intended%for%use%in%the%followin1%sur1i.al%spe.ial-es%when%the% transfer%of%harvested%adipose%-ssue%is%desiredE%orthopedi.%sur1ery,%arthros.opi.%sur1ery,%and%other%spe.iAed%sur1i.al%dis.iplines. SICOT J 2017, 3, 43 Ó The Authors, published by EDP Sciences, 2017 DOI: 10.1051/sicotj/2017029 Available online at: www.sicot-j.org Special Issue: ‘‘Arthroscopic Treatment of Chondral Lesions of the Hip’’ Guest Editor: M. Tey Pons REVIEW ARTICLE OPEN ACCESS Arthroscopic treatment of chondral defects in the hip: AMIC, MACI, microfragmented adipose tissue transplantation (MATT) and other options Eugenio Jannelli1,* and Andrea Fontana2 1 Clinica Ortopedica e Traumatologica – IRCCS Policlinico San Matteo, Università degli Studi di Pavia, 27100 Pavia, Italy 2 Ortopedia 1, COF Lanzo Hospital, 22024 Lanzo d’Intelvi (CO), Italy Received 5 January 2017, Accepted 15 April 2017, Published online 7 June 2017 Abstract – Chondral lesions are currently considered in the hip as a consequence of trauma, osteonecrosis, dysplasia, labral tears, loose bodies, dislocation, previous slipped capital femoral epiphysis and Femoro-Acetabular-Impinge- ment (FAI). The management of chondral lesions is debated and several techniques are described. The physical exam- ination must be carefully performed, followed by radiographs and magnetic resonance imaging (MRI). Differential diagnosis with other pathologies must be considered. Debridement is indicated in patients younger than 50 years with a chondropathy of 1st or 2nd degree. Microfractures are indicated in patients younger than 50 years with a chondropa- thy of 3rd or 4th degree less than 2 cm2. Matrix-Induced Autologous Chondrocyte Implantation (MACI) and Autologous Matrix-Induced Chondrogenesis (AMIC) procedures are indicated in patients with full-thickness symptomatic 3rd–4th degree chondral defects, extended 2 cm2 or more. The AMIC procedure has the advantage of a one-step procedure and much less expense. Microfragmented adipose tissue transplantation (MATT) is indicated for the treatment of delamination and 1st and 2nd degree chondral lesions, regardless of the age of the patient. Chondral defects are effective when the joint space is not compromised. When the Tonnis classification is two or greater, treatment of chondral lesions should be considered ineffective. Key words: Chondral defects, Hip arthroscopy, Debridement, MACI, AMIC. Introduction to a separation of the cartilage from the subchondral bone. The cartilage is pulled and sheared with a ‘‘carpet-like’’ Chondral lesions are currently considered in the hip as a pattern, usually at the antero-superior acetabular region. consequence of other pathological features such as trauma, It was proposed that there is a continuum of damage, which osteonecrosis, dysplasia, labral tears, loose bodies, dislocation, starts with the chondrolabral lesion, then proceeds with the previous slipped capital femoral epiphysis and Femoro- cartilage delamination and finally labral detachment from the Acetabular-Impingement (FAI) [1, 2]. Recently, FAI has been subchondral bone [6]. indicated as a cause of progressive degenerative changes in The second type of FAI, the pincer type, is determined by the hip, leading to osteoarthritis [3, 4]. The altered morphology an altered acetabulum, usually as a slight acetabular retrover- of the femur and/or of the acetabulum leads to an abnormal sion or as an overcoverage of the acetabular wall. In this case, contact against the joint, thereby causing stress degeneration there is a large stress impact on the labrum which usually of the labrum and cartilage. degenerates, tears and sometimes ossifies. As a consequence Labral tears have been indicated as an adjunctive cause of of pincer deformity, the chondral acetabular lesion is a typical cartilage degeneration. Chondral damages have been described ‘‘counter-part’’ degeneration of the postero-inferior area, or a for up to 73% of the patients with labral pathology [5–7]. chondral lesion on the anterior and superior area of the In the FAI cam type, the bone deformity located at the acetabulum, consequent to shear forces concentrating on the femoral head-neck junction, when forced into the joint, leads chondrolabral junction. to increased friction on the cartilage and on the labral Chondropathies of the acetabulum and the femoral head structures. The labrum is pushed up and the stress forces are a frequent cause of pain and functional limitation. concentrate at the level of the chondrolabral junction leading Moreover, if cartilage defects in the hip are not adequately repaired, then progression of the damage and arthritic changes *Corresponding author: [email protected] may occur [3, 4]. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 E. Jannelli and A. Fontana: SICOT J 2017, 3, 43 Patient selection and examination The technique is based on the penetration of the subchondral bone plate and the consequent outflow of bone Candidate patients for hip arthroscopy must be carefully marrow blood, containing mesenchymal stem cells (MSCs). selected [7], particularly when chondral damages are The underlying mechanism is the differentiation of the mes- suspected. They should have mechanical symptoms or persis- enchymal stem cells (MSCs) in fibrochondrocytes which can tent pain despite conservative therapy. The physical examina- produce type I, II and III collagen [18]. Therefore the forma- tion must be carefully performed with all the known signs tion of a fibrocartilaginous tissue is expected, with reduced and tests, and then followed by radiographs and MRI, and mechanical properties compared to hyaline cartilage. eventually by computed tomography (CT) and ultrasonography The subchondral bone is penetrated for approximately [3, 8–10], while the differential diagnosis with other patholo- 2–4 mm with an arthroscopic awl (30° and 45° are preferable gies must be considered [11]. because of the sphericity of the hip) to create V-shaped holes of The degree of arthritis can be defined by the Tonnis 1.5–2 mm diameter. The distance between the holes must be classification [12] and is usually accompanied with the about 3 mm. It is usually suggested to begin the microfracture measurement of the radiographic signs such as the alpha angle at the periphery and to proceed towards the centre. In addition, [6], the cross-over sign, the coverage of the femoral head and it is important to penetrate the subchondral bone perpendicu- estimation of the joint space [13]. larly. This can be particularly difficult in the hip, specifically MRI without contrast often fails in the identification of in the supero-anterior areas of the acetabulum. Bone marrow 2 chondral defects of small dimension (less than 1 cm ). bleeding from the holes must be checked reducing the water Therefore, an MRI arthrogram is usually suggested [2]. pressure or removing the arthroscopic fluid. Nevertheless, MRI arthrograms can be over-interpreted, partic- The indications for microfracture in the hip are similar to ularly those concerning labral tears and, in selected cases, an the knee and include focal and contained lesions, typically intra-articular injection of 10 cc carbocaine 2% can become 2 cm2 in size. useful in determining whether the source of pain is intra- or extraarticular (hip injection test) [13, 14]. In addition, a high Matrix-induced autologous chondrocyte percentage of false negatives has been reported for plain radio- implantation (MACI) graphy, scintigraphy, CT, and MRI [2]. Matrix-Induced Autologous Chondrocyte Implantation (MACI) is a technique described for the treatment of chondral Surgical treatment defects of the knee, where it has given good clinical results [19]. This technique requires two surgical steps: the biopsy of Debridement cartilage for chondrocyte culture and expansion followed by their direct culture in a membrane used as a scaffold; and a Regardless of the type of treatment of chondral lesions, the second operation where the seeded membrane is inserted into first step is an accurate articular debridement. the joint and applied to cover the chondral defect. Four steps have been indicated for a correct debride- Several materials have been proposed as matrices: protein- ment [15]: abundant washing of the joint, removal of loose based polymers (collagen types I and III, fibrin, gelatin, etc), bodies, removal of mechanically irritating cartilage and carbohydrate polymers (hyaluronic acid, polylactic acid, polyg- synovia, limited chondroplasty. lycolic acid, alginate) and artificial polymers [20–23]. Articular washing could be effective for immediate but Indications for MACI are: full-thickness symptomatic not lasting pain relief in an inflamed joint, therefore debride- chondral defects, in general of 3rd–4th degree, extended ment must be
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