Purpose

Hip arthroscopy is becoming more advanced and commonly performed. However, significant controversy exists regarding whether high-grade acetabular cartilage lesions should be treated with debridement/abrasion or microfracture. The purpose of this study was to determine the mid-term patient-reported outcomes and failure rates of Grade 3 and 4 acetabulum labrum articular disruption (ALAD) lesions managed with debridement/abrasion or microfracture.

Methods and Materials

Primary arthroscopic labral repair cases at two centers from November 2008 to April 2016 were reviewed in patients aged <55 years with unipolar ALAD Grade 3/4 chondrolabral acetabular delamination. Patients undergoing microfracture and debridement/abrasion were compared using visual analog pain scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score–Sports Specific Subscale (HOS-SSS) to determine predictors of outcomes and failure.

Results

113 hips in 110 patients (66 M, 44 F, mean age 34.5±1.1) undergoing debridement/abrasion (n=82) or microfracture (n=31) were followed for a mean of 4.9 years (range 2.0–8.5). Lesion size was not statistically different between the debridement/abrasion (1.3±1.0 cm²) and microfracture cohorts (1.4±1.0 cm², p=0.47). Patients undergoing debridement/abrasion achieved 3.6 point mean improvements in VAS (p<0.01), 21.2 point improvements in mHHS (p<0.01), and 25.4 point improvements in HOS-SSS (p<0.01), which were statistically similar to that observed in microfracture patients (p≥0.20). Five-year survival free of revision surgery was 84.0% in the debridement/abrasion group and 85.0% in the microfracture group (p=0.78). Cartilage treatment technique was found not to be predictive of revision risk during both univariate (Hazards Ratio [HR]:1.01, p=0.98) and multivariate (HR:0.93, p=0.90) analysis accounting for patient age, lesion grade, and acetabular coverage.

Conclusion

Patients undergoing debridement/abrasion of high-grade unipolar acetabular cartilage lesions demonstrate similar outcome scores and revision rates compared to patients undergoing microfracture. These outcomes support the consideration of preferential debridement/abrasion at the discretion of the treating surgeon in order to optimize recovery while maintaining established positive outcomes following hip arthroscopy.

Purpose

The German Cartilage Registry (GCR) has been extended by the hip module in 2014. It represents a german- speaking cohort study (Germany, Switzerland and Austria) which has been introduced by the working group „tissue regeneration“ of the DGOU. In times of evidence-based medicine the GCR should provide a basis for long-term observational studies to represent the clinical reality of care and assess the effectiveness and efficiency of the therapies used

Methods and Materials

A total of 1019 patients with cartilage defects at the hip (inclusion period 10/2014 to 08/2018) were included. Data collection was performed using a web-based remote data entry (RDE) system. All data were provided by the attending physician at the time of surgery of the affected hip.

Results

A total number of 23 centers were involved in this multicenter study. Mean patient age was 37,0 ± 12,1y. In 55.9% (514/919) of the cases, cartilage damage ICRS grade 3 or higher was documented. In more than 91% of cases cartilage damage was associated with a corresponding labrum damage greater than 1/3. Previous hip surgery was rare with 4.6% (46/995). Femoroacetabular impingement represents in 79.1% the main pathology. The mean defect size was 1.7 +/- 1.0 cm². The most commonly used treatment was debridement (44.2%), in which 57.4% (218/405) of the cartilage defects were ICRS less than or equal to 2. In cartilage defect grade 3 and higher, debridement continued to be the most common surgical technique (34.6%, 176/508), but also BM techniques and ACI (30.1%, 163/508) as well as combination interventions (25.8%, 131/508) were used.

Conclusion

Over the last four years, the GCR has established itself as the benchmark for documenting and tracking patients with cartilage damage in the lower extremity. The present epidemiological analysis of the available data represents the current, mostly arthroscopic supply situation of cartilage damage in the hip area.

Purpose

To evaluate short-term clinical and radiological outcomes of patients treated arthroscopically with CarGel for acetabular chondral defects in conjunction with microfracture (MF) compared to lesions treated with MF alone.

Methods and Materials

Patients who underwent hip arthroscopy and had MF +/- CarGel between 2012 and 2016 with a minimum clinicoradiological follow-up of 2 years were included. Intraoperative details and postoperative complications were analysed. Patients answered self-reported questionnaires, including the international Hip Outcome Tool (iHOT-33), Hip Outcome Score (HOS) pre-operatively and at 6 months, 1 year, and annually thereafter. Serial plain radiographs were assessed by two blinded observers independently for measurement of joint space and osteoarthritis grading utilizing the Kellgren-Lawrence scale. The number of failures, defined as a conversion to total hip arthroplasty (THA), was identified in both groups and correlated with the cartilage defect size at the time of surgery

Results

86 patients (53 Cargel, 33 MF) were evaluated with a mean age of 38.3 years at the time of the surgery. The average follow-up was 36 months. There were no statistically significant differences in iHOT-33 scores between the groups (p=0.85). 30% of MF cases progressed to THA while only 5% of Cargel cases did (p=0.0027). The mean defect size in the failure groups was significantly higher in the Cargel group compared to the MF group (8.8 cm² and 3.5cm², respectively; p=0.0002). Mean joint space reduction was 1.41mm and 0.21mm in the MF and Cargel groups, respectively, (p < 0.0001) denoting a significant decrease in the rate of progression to hip osteoarthritis in the CarGel group.

Conclusion

Arthroscopic treatment of chondral acetabular defects with CarGel demonstrated a significant decrease in progression to hip osteoarthritis and conversion to THA compared to MF alone. Short-term results are promising in this population of patients and this single-step, arthroscopic, cartilage repair technique does not burn any bridges.

Purpose

To determine if there any radiologic or demographic risk factors for labral reconstruction versus repair in primary hip arthroscopy.

Methods and Materials

This retrospective study draws from a prospectively and longitudinally maintained institutional database. Inclusion criteria were patients who underwent primary hip arthroscopy and received either labral reconstruction or simple labral repair by the senior author between October 2010 to November 2018. Exclusion criteria were patients with previous hip conditions. 14 radiographic measurements were reported.

Results

251 hips (237 patients) with primary labral reconstruction and 1147 hips with (1063 patients) primary labral repairs were identified from the institution’s database as having complete sets of radiographic measurements. Radiographically there was a greater prevalence of Tönnis 1 grade in the reconstruction group(0.37 vs 0.15). Patients who underwent reconstruction also had greater degree of acetabular coverage as measured by LCEA(33.25±7.31° vs 30.41±6.22°) and AI(3.45±5.26° vs 4.77±4.79°). Alpha angle(AA) was also higher(65.11±13.21° vs 59.45±12.21°). The average age of patients who underwent reconstruction was 40.99±11.74 years, while that of those who underwent repair was 34.98±13.57 years. The former cohort of patients had BMI of 27.4±5.42 kg/m^2, while that of the later was 25.69±5.04 kg/m². There was a greater proportion of males in the reconstructed group(0.36 vs 0.45). A final logistic regression selected age, BMI and three of the 14 predictive radiographical findings(Tönnis Grade, LCEA, AA). The odds of reconstruction were 2.52 times higher in those with Tönnis Grade 1 vs 0. Every additional degree in LCEA was associated with a 6% increase in the odds of reconstruction and 4% for each additional degree increase in alpha angle. The model accuracy is 70.5% with a ROC area = 0.74.

Conclusion

There is a direct proportional relation between the odds of primary labral reconstruction and age at surgery, BMI, gender, Tönnis grade, LCEA, and AA.

Purpose

The treatment of acetabular chondral lesions has the most significant impact on outcome in Femoroacetabular impingement. For large full-thickness cartilage defects arthroscopic matrix-associated autologous chondrocyte transplantation (MACT) using an injectable in situ crosslinking product is an option. Aim of the study was to evaluate clinical and MRI results 24 months after MACT of acetabular cartilage defects in FAI patients.

Methods and Materials

21 patients with a focal cartilage defect of the hip (2.97 ± 1.44 cm² (mean ± SD) caused by FAI were included. The treatment of associated pathologies and the harvesting of cartilage was performed in the first operation. After cultivation MACT was conducted arthroscopically. The results were assessed with patient-reported outcome measures (iHOT33, EQ-5D) pre- as well as postoperatively and by MRI using MOCART scoring system 6, 12 and 24 months post-operatively.

Results

The iHOT33 score improved from 52.9 ± 21.1 (mean ± SD) preoperative to 85.8 ± 14,8 (mean ± SD; p= 0.0012) 24 months postoperative. The change in the iHOT33 score at 24 months compared with preoperatively was with 33.6 ± 25.3 (MW ± SD); p <0.0001) points very high. Patients showed a significant improvement in quality of life after 24 months as measured by the EQ-5D-5L index (p = 0.0004) and EQ-5D VAS (p = 0.0006). In the 24-month MRI analysis, 11 out of 14 patients showed a complete filling of the defect area and in all 14 patients a complete healing of the graft, the MOCART score (maximum achievable score 85) improved from 62.5 ± 18.3 after 12 months to 72 , 9 ± 10.7 (MW ± SD) at 24 months.

Conclusion

Injectable MACT is a promising minimally invasive treatment option for full-thickness cartilage defects of the hip caused by FAI. A significant improvement in function and quality of life despite large cartilage defects had been detected in the study population.

Purpose

The purpose of this abstract is to explain the process and delineate the consensus statements derived from this consensus meeting on the treatment of concomitant ankle instability and osteochondral lesions of the ankle.

Methods and Materials

43 national and international experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Experts were assigned to groups separated by topics, including ankle instability. Questions and statements were drafted within the groups and a comprehensive literature review was performed and, where possible, used to confirm or dispute the recommendations made. In addition, the available evidence for each statement was graded. Once the statements achieved majority vote within the working groups, a vote to the overall group was undertaken. The statements were then further edited on the basis of the discussion and votes within the entirety of the consensus group. A final vote then occurred, and the strength of consensus was characterized as follows: consensus: 51 - 74%; strong consensus: 75 - 99%; unanimous: 100%.

Results

12 statements addressing ankle instability in the presence of an osteochondral lesion reached consensus. There was a consensus that: [1] BMI, alignment, frequency/severity of sprains, history of prior ankle surgery and chronicity of symptoms should be considered prognostic factors. [2] Asymptomatic osteochondral lesions in the setting of symptomatic ankle instability do not require treatment. [3] Both a symptomatic osteochondral lesion and concomitant symptomatic ankle instability should be managed simultaneously. [4] Osteochondral lesions should be treated with the same repair/reconstruction technique with concomitant ankle instability as they would be in isolation. No statement achieved less than an 88% consensus following anonymous voting by the expert group.

Conclusion

This consensus derived from leaders in the field will assist clinicians in the treatment of ankle instability in the presence of an osteochondral lesion.

Purpose

Our study is a multicentric trial with the presentation of our series including 91 osteochondral lesions of the ankle joint. We try to determine the clinical and radiographic efficacy of three different scaffolds as BST-CarGel, Hyalofast and MaioRegen in patients with focal osteochondral lesion bigger than 1.5 cm² of the ankle joint.

Methods and Materials

Clinical data of 91 patients arthroscopically treated using either BST-CarGel scaffold (23 patients, Group 1) or Hyalofast scaffold (54 patients, Group 2) or MaioRegen scaffold (14 patients, Group 3) in combination with microfracture were retrospectively evaluated. Patients had ankle arthroscopy surgery due to osteochondral lesion of talus with our standard technique through standard lateral and medial portals.

After surgery neutral short leg cast was used for two weeks, patients were encouraged to partial weight bear at 4^th week and started our standard physiotherapy protocol. T2 relaxation time with use of standardized twelve-month posttreatment MRI scans and 12^th month AOFAS scores were calculated.

Results

Patient baseline characteristics were similar in the three groups. 91 patients with a mean age of 39.86 years (18-61) were included to this study. 36 (39.6 %) female and 55 (60.4 %) male were analyzed. Blinded quantitative magnetic resonance imaging analysis demonstrated that statistical superiority for lesion filling and more hyaline cartilage-like T2 values. Mean preoperative AOFAS score in whole groups is 70.13±9.52 (40-86) and mean postoperative AOFAS score is 82.98±8.52 (63-99); and improvement at clinical benefit is significant (p < 0.001). According to the between group analyze, improvement at the Hyalofast group was better than the other groups through the AOFAS scores.

Conclusion

At twelve months, scafold treatment for ankle osteochondral lesions resulted in greater lesion filling and superior repair tissue quality. Clinical benefit was better at hyalofast group although results were equivalent at magnetic resonance imaging in whole groups.

Purpose

Autologous transplantation has been shown to be a viable treatment option for large osteochondral lesions of the talus. However there is limited data regarding the management of large lesions in an athletic population, notably with regards to return to sport. Our investigation focussed on assessing both qualitative and quantitative outcomes in the high demand athlete with large (>150mm²) lesions.

Methods and Materials

The study population was limited to professional or amateur athletes (Tegner score >6) with a talar osteochondral lesion of size 150mm² or greater. The surgical intervention was autologous osteochondral transplantation with a donor site of the lateral femoral condyle. Outcomes include VAS and FAOS Scores, Tegner Score, and MRI evaluation using MOCART scores at 12 months post surgery.

Results

38 athletes including 11 professional athletes were assessed. Mean follow-up was 46 months. Mean lesion size was 249mm². Visual analogue scores improved from 4.53 pre-operatively to 0.63 post-operatively (p=0.002). FAOS Scores improved significantly in all domains (p<0.001). 33 patients returned to sport at their previous level, 4 at a lower level compared with pre-injury, and 1 did not return to sport. 2 patients developed knee donor site pain and both had 3 osteochondral plugs harvested. Univariant analysis demonstrated no association between pre-operative patient or lesion characteristics and ability to return to sport. However there was a strong correlation between MOCART scores and ability to return to sport (AUC=0.89).

Conclusion

Autologous transplantation for large osteochondral talar lesions is a procedure that yields excellent outcomes in the athletic population, with favourable return to sport levels, patient satisfaction, and FAOS/VAS scores. The ability to return to sport is predicated upon good graft incorporation and further research is required to optimise this technique. Our data also suggests that patients should be aware of the increased risk of developing knee donor site pain when 3 osteochondral plugs are harvested.

Purpose

We used CS-SENSE, a combination of compressed sense and parallel imaging, to accelerate a standard ankle MRI protocol with Dixon imaging and T2 mapping without losing image quality.

Methods and Materials

We scanned twenty healthy volunteers on a clinical 3.0T MRI scanner (Ingenia), equipped with a CS-SENSE software prototype extension (Philips Healthcare, Best, the Netherlands).

All CS-SENSE images were compared to standard SENSE images. The images were randomized, presented on two diagnostic monitors and evaluated by three blinded readers. To standardize the assessment, we used a five-point Likert scale consisting of 25 anatomical regions. Every answer on the Likert scale contributed one point in favor of the preferred type of scan. For the quantitative T2 mapping scans, we performed a pixel-wise comparison of T2 relaxometry measurements with accelerations of 1.5×, 1.7×, 1.8× and 1.9× faster than the normal acquisition time with SENSE.

Results

The readers found the quality of the Dixon images of SENSE and CS-SENSE comparable in 88.7% of the scorings as illustrated in figure 1. With CS-SENSE we were able to reduce the total acquisition time of the ankle Dixon scans by 45% from 13’38” to 7’37”.

The T2 relaxometry measurements on cartilage were highly dependent on the signal-to-noise ratios in the T2-mapping sequence. We found an acceleration of 1.8× faster than the SENSE scan to be the optimal acceleration factor based on the acquisition time and comparability with the SENSE scan. The spread in T2 values illustrated in the Bland-Altman plot (Figure 2a) was acceptable and the T2 values in talar and tibial cartilage using SENSE and CS-SENSE had a good correlation of ρ = 0.65 (figure 2b).

Conclusion

In conclusion, CS-SENSE could accelerate qualitative Dixon images and quantitative T2-mapping images by 45% with comparable image quality and T2 relaxometry measurements of the ankle.

Purpose

Two-year follow-up to assess efficacy and safety of High-Density Autologous Chondrocyte Implantation (HD-ACI) in patients with cartilage lesions in the ankle treated in our hospital from 2010 to 2016

Methods and Materials

Twenty-four consecutive patients (14 men and 10 female) with ICRS grade III-IV cartilage lesions of the ankle were included. The patients’ median age was 31 (minimum – maximum: 18 – 59). Five million chondrocytes per cm2 of lesion were implanted using a type I/III collagen membrane as a carrier and treatment effectiveness was assessed by evaluating pain with the Visual Analogical Scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at baseline, 12 and 24 months follow-up, together with dorsal and plantar flexion. Magnetic resonance observation for cartilage repair tissue (MOCART) score was used to evaluate cartilage healing. Histological study was possible in 5 cases

Results

Median VAS score was 8 (5 – 10) at baseline, 1.5 (0 – 8) at 12-month follow-up and 2 (0 – 5) at 24-month follow-up (p<0.001). Median AOFAS score was 39.5 (29 – 48) at baseline, 90 (38 – 100) at 12-month follow-up and 90 (40 – 100) at 24-month follow-up (p<0.001). Complete dorsal flexion significantly increased at 12 (16/24: 66.7%) and 24 months (17/24: 70.8%) with respect to baseline (13/24: 54.2%) (p=0.002). MOCART at 12- and 24-month follow-ups were 73.71 ± 15.99 and 72.33 ± 16.21. Histological study confirmed that neo-synthetized tissue was cartilage with hyaline extracellular matrix and numerous viable chondrocytes

Conclusion

HD-ACI is a safe and effective technique to treat osteochondral lesions in the talus, providing good clinical and histological results at short- and mid-term follow-ups.