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Microfracture in the Hip: a Matched-Control Study with Average 3-Year Follow-Up Parth Lodhia1, Chengcheng Gui1, Sivashankar Chandrasekaran1, Carlos Suarez-Ahedo1, S

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Microfracture in the Hip: a Matched-Control Study with Average 3-Year Follow-Up Parth Lodhia1, Chengcheng Gui1, Sivashankar Chandrasekaran1, Carlos Suarez-Ahedo1, S Journal of Hip Preservation Surgery Advance Access published December 10, 2015 Journal of Hip Preservation Surgery Vol. 0, No. 0, pp. 1–11 doi: 10.1093/jhps/hnv073 Research article Microfracture in the hip: a matched-control study with average 3-year follow-up Parth Lodhia1, Chengcheng Gui1, Sivashankar Chandrasekaran1, Carlos Suarez-Ahedo1, S. Pavan Vemula1 and Benjamin G. Domb1,2,* 1. Department of Orthopaedics, American Hip Institute, Westmont, IL, USA, 2. Hinsdale Orthopaedics, 1010 Executive Ct, Suite 250, Westmont, IL 60559 *Correspondence to: B. G. Domb, E-mail: [email protected] Downloaded from Submitted 19 December 2014; Revised 17 September 2015; revised version accepted 25 October 2015 ABSTRACT There is a paucity of literature regarding microfracture surgery in the hip. The purpose of this study was to compare http://jhps.oxfordjournals.org/ outcomes in patients undergoing hip arthroscopy predominantly for labral tears with focal full thickness chondral dam- age on the acetabulum or femoral head treated with microfracture and a matched control group that did not have focal full thickness chondral damage. A prospective matched-control study was performed examining four patient-reported outcome (PRO) scores: modified Harris Hip Score (mHHS), non-arthritic hip score, Hip Outcome Score—Activities of Daily Living (HOS-ADL), and Hip Outcome Score—Sports Specific Subscale (HOS-SSS) at minimum 2 years post-operatively between 35 patients undergoing microfracture for chondral defects during hip arthroscopy and 70 pa- tients in a control group that did not have chondral defects. The patients were matched based on gender, age within 7 years, Workman’s compensation claim, labral treatment and acetabular crossover percentage less than or greater than 20. There was no significant difference (P > 0.05) in PRO scores preoperatively between the groups. Both groups dem- by guest on December 11, 2015 onstrated significant improvement (P < 0.05) in all post-operative PRO scores at all time points. There was no statistic- ally significant difference (P > 0.05) in post-operative PRO scores between the microfracture and control groups, ex- cept for HOS-ADL and the visual analog scale (VAS) score, both of which were superior in the control group (P < 0.05). Patient satisfaction was 6.9 for the microfracture group and 7.7 for the control group (P > 0.05). Arthroscopic microfracture of the hip during treatment of labral tears results in favorable outcomes that are similar to the results arthroscopic treatment of labral tears in patients without full thickness chondral damage. INTRODUCTION years, there has been a focus on prevention of chondral dam- Management of articular cartilage injuries is a challenge [1]. age and managing pre-existing chondral injuries by extrapolat- Defects in the articular cartilage have a limited capacity to ing the technique and results of microfracture that has been heal regardless of the nature of injury [2]. Untreated lesions validated in the knee [4]. mayleadtoprogressionofarthritisandaddtopatientmor- Chondral injuries in the hip have been seen in associ- bidity [3]. Chondral injuries in the hip can occur in a variety ation with multiple hip conditions including labral tears, of hip disorders, can be atraumatic or traumatic, and can serve loose bodies and dysplasia. McCarthy and Lee [5] noted a as an obscure source of pain. The goal of microfracture is to 59% prevalence rate of chondral injuries in the anterior bring marrow cells and growth factors from the underlying acetabulum using arthroscopic evaluation. Furthermore, bone marrow into the affected chondral defect. By penetrat- 70% of these lesions were grades III and IV using the ing the subchondral bone, pluripotent marrow cells can de- Outerbridge classification system. The use of microfracture velop and form new fibrocartilage to fill the chondral defect. in treating chondral injuries of the hip has been docu- As the popularity of hip arthroscopy has increased in recent mented in various case series [6–8]. However, studies with VC The Author 2015. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] 1 2 P. Lodhia et al. higher level of evidence and increased follow-up are Table I. Matching criteria needed to help understand the effects of this technique on Gender hip preservation. The purpose of this study was to compare outcomes in patients undergoing hip arthroscopy predom- Age within 7 years inantly for labral tears with full thickness chondral damage Crossover sign < 20% or 20% on the acetabulum or femoral head treated with microfrac- ture and a matched control group that did not have full Workman’s Compensation claim thickness chondral damage. The hypothesis of this study Labral treatment was that the patients undergoing microfracture would have similar outcomes to a matched control group of patients who did not have a microfracture. focal in nature [15], to either the femoral head or acetabu- lum. All patients who did not undergo microfracture had METHODS grade III or less Outerbridge changes in either their femoral The study period was between September 2008 and head or acetabulum. A wave sign, as described by Konan December 2011. The patient-reported outcome (PRO) et al. [16] was not considered equivalent to Outerbridge scores collected were the modified Harris Hip Score grade IV and thus was not treated with microfracture. Downloaded from (mHHS), the Non-Arthritic Hip Score (NAHS) [9], the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and the Hip Outcome Score-Sports Specific Subscale Surgical technique (HOS-SSS) [10]. These were collected preoperatively, at 3 All hip arthroscopies were performed by the senior author months and every successive year post-operatively for a min- (BGD). The indications for hip arthroscopy were predom- http://jhps.oxfordjournals.org/ imum of 2 years. All four questionnaires are used, as it has inantly labral tears with mechanical symptoms and failure been reported that there is no conclusive evidence for the of conservative treatment. The indications for revision hip use of a single PRO questionnaire for patients undergoing arthroscopy included reinjury, instability, peritrochanteric hip arthroscopy [11, 12]. Pain was estimated on a Visual pain, occult pain, heterotopic ossification and residual FAI Analog Scale (VAS) from 0 to 10 (10 being the worst). [17]. All surgeries were performed in the modified supine Satisfaction with surgery was measured with the question position using a minimum of two portals (standard antero- ‘How satisfied are you with your surgery results? (1 ¼ not at lateral and mid-anterior) [18–20]. Anterolateral and mid- all, 10 ¼ the best it could be).’ Institutional review board ap- anterior portals were established. A capsulotomy was by guest on December 11, 2015 proval was obtained for this study. performed with a beaver blade, incising the capsule parallel The inclusion criteria for this study were arthroscopic to the acetabular rim from 12 to 3 o’clock as described by microfracture during surgery for labral tear and/or femoroa- Domb et al. [21] A diagnostic arthroscopy was performed. cetabular impingement (FAI), with minimum 2-year follow- Bony pathology was corrected under fluoroscopic guid- up. Exclusion criteria were revision surgeries, To¨nnis grade ance. An acetabuloplasty was performed for pincer im- 2 and higher, and previous hip conditions such as Legg- pingement, and a femoral neck osteoplasty was performed Calves-Perthes disease, avascular necrosis and prior surgical for cam impingement. The cotyloid fossa was assessed for intervention. The matched pair control group was selected osteophytes and if present, a central acetabular decompres- on a 1:2 ratio to patients who underwent hip arthroscopy sion was performed as previously described by Gupta et al. for labral tear and/or FAI who did not undergo microfrac- [22] Labral tears were repaired when indicated or ture based on gender, age within 7 years, radiographic find- selectively debrided until a stable labrum was achieved ings, Workman’s compensation claim, and labral treatment. while preserving as much labrum as possible. If there was The radiographs were analysed, and the patients were full-thickness cartilage damage present, a microfracture was matched by acetabular crossover percentage <20 or >20. performed according to Steadman’s technique. The antero- Patients with To¨nnis grades 2 and above were excluded as lateral and mid-anterior portals were predominantly used. they have been shown to have poorer outcomes with hip Visualization was predominantly obtained from the antero- arthroscopy [13]. An acetabular crossover of 20% was used lateral portal with the mid-anterior portal being used for in- as a matching criterion since 20% has been shown to be a strument passage and performing the microfracture. For clinically relevant radiological sign of acetabular retroversion more superolateral lesions of the acetabulum, the portals in symptomatic patients with FAI [14]. The matching crite- were exchanged with the arthroscope placed in the mid- ria are shown in Table I. All patients who underwent micro- anterior portal visualizing laterally, while instruments were fracture had grade IV Outerbridge changes, which were passed through the anterolateral portal to perform the Microfracture in the hip 3 microfracture. Using an arthroscopic shaver, loose flaps of wearing the hip brace and restricted weight bearing was and portions of delaminated cartilage were removed. A carried out to 8 weeks. ring curette was then used to create stable borders and to remove the calcified layer. Chondro picks by Arthrex with Statistics 220-mm shaft and 40,60 and 90 tips were used perpen- An apriorianalysis was performed, and it was estimated a dicular to the subchondral bone and advanced with a mal- clinically significant difference between groups for mHHS let.
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