Differences and Similarities between Hip and Knee Indications for the Arthroscopic Management of Chondral Defects Aman Sharma 1 , Alejandro Marquez-Lara 1 , T. David Luo 1 , Sandeep Mannava 1 , Austin V. Stone 1 , Elizabeth A. Howse 2 , Allston J. Stubbs 1 1. Wake Forest School of Medicine, Winston-Salem, NC, USA 2. Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, California, U.S.A.
Disclosures • Allston J. Stubbs MD, MBA – Consultant: Smith & Nephew – Stock: Johnson & Johnson – Research Support: Bauerfeind – Department Support: Smith & Nephew Endoscopy, Depuy, Mitek – Boards/Committees: AOSSM, ISHA, AANA • Austin V. Stone MD, PhD – Research Support: Smith & Nephew • Sandeep Mannava MD, PhD – US patent: Mannava et al. Tissues tensioning and related methods awarded January 2015 – Grant funding: American Board of Medical Specialties and the American Board of Orthopaedic Surgery – Boards/Committees: Arthroscopy Association of North America • Drs. Marquez-Lara, Howse, Luo., and Mr. Sharma – Nothing to disclose.
Introduction • Hip-specific indications for arthroscopic management of chondral defects are poorly defined in the literature. • The principles for treating these defects in the knee are currently applied in hip arthroscopy. • Fundamental differences in hip anatomy and biomechanics limit the applicability of cartilage preservation techniques used in the knee. • The purpose of the present study is to review the indications for current cartilage preservation techniques in the hip and the knee to better define efficacious strategies for cartilage preservation.
Methods Systematic Review of hip and knee arthroscopy 2004 and 2016 (n=8,154) Excluded cases* (n=6,805) * • Case Reports Study sample • Literature reviews (n=1,349) • Open procedures • Osteonecrosis Knee Autologous Hip Autologous Knee Microfractures Hip Microfracture Chondrocyte Transfer Chondrocyte Transfer (MF; n=476) (MF; n=279) (ACT; n=557) (ACT; n=37)
Methods • Sample size, patient demographics, BMI, defect location, Outerbridge severity grades, lesion size, and surgical technique were assessed. • Duration of symptoms, associated injuries, follow-up time, and outcome measures were also recorded. • Cohorts were grouped by surgical technique [MF vs. ACT and joint (hip vs. knee)]. • Statistical analysis was performed using Students t-test to compare means. • Regression analysis was utilized to assess the impact of patient- and lesion- specific characteristics.
Results - Frequency n = 557 600 n = 476 Number of patients 500 400 n = 279 300 200 100 n = 37 0 Knee MF Knee ACT Hip MF Hip ACT
Results – Arthroscopic MF • Significant differences were identified in gender, BMI, lesion size and mean follow-up time between hip and knee cohorts. Comparative measurements Hip Knee P-Value Number of studies 9 10 Number of patients 31.0±19.4 39.7±25.3 0.416 Mean age 35.1±7.0 36.1±3.8 0.722 77.0±20.4 56.5±13.3 0.017 % male patients 99.6±75.9 154.4±50.1 0.297 Duration of Symptoms (weeks) Body mass index (Kg/m 2 ) 24.0±0.0 25.6±0.49 0.008 Lesion size (mm 2 ) 149.5±20.7 279.3±87.2 0.015 22.2±3.9 48.2±34.2 0.039 Follow up time (months)
Results – Arthroscopic ACT • There were no differences identified in hip and knee patient parameters and chondral defects treated with ACT. Comparative measurements Hip Knee P-Value Number of studies 7 3 Number of patients 0.13 0 53.6±40.8 12.3±5.5 Mean age 0.537 33.6±2.8 35.2±4.8 60.4±10.1 % male patients 70.3±26.3 0.586 - 181.9±36.1 - Duration of Symptoms (weeks) Body mass index (Kg/m 2 )* 26 26.3±2.6 - Lesion size (mm 2 ) 357.3±96.0 425.4±58.1 0.194 0.832 Follow up time (months) 33.1±33.8 38.7±15.3 * Only one hip ACT study reported BMI and none reported duration of symptoms
Results – Arthroscopy Arthroscopy Procedure Odds Ratio 95% CI P-value Microfracture • Lesion size 0.15 0.03-0.72 0.018 ACT • Lesion size 6.6 1.4-31.2 0.018 • Regression analysis demonstrated that lesion size was a significant predictor for MF and ACT. • Patients with larger chondral lesions were more likley to undergo ACT while those with smaller lesions were more likely to undergo MF.
Discussion • Significant differences exist in patient- and lesion- specific characteristics between hip and knee chondral defects treated with MF. – Patients who underwent MF for hip chondral defects demonstrated smaller lesion size, lower BMI and a greater proportion of males compared to those treated with MF for knee defects. • No significant differences were identified in hip and knee patient parameters and chondral defects treated with ACT. • Regression analysis demonstrated that lesion size was a significant predictor for arthroscopic technique. – While the odds of undergoing MF decreased with increasing lesion size, the odds of undergoing ACT increased with greater lesion size.
Conclusions • In the hip, gender and lesion size may play a role in developing hip-specific indications for arthroscopic microfractures. • Ultimately, understanding the differences and similarities between joint-specific algorithms for the management of chondral defects will optimize hip preservation strategies.
References • Marquez-Lara A, Mannava S, Howse EA, Stone AV, Stubbs AJ. Arthroscopic Management of Hip Chondral Defects: A Systematic Review of the Literature. Arthroscopy. 2016 Jul;32(7):1435-43. doi: 10.1016/j.arthro.2016.01.058. Epub 2016 Apr 23. • Behery O, Siston RA, Harris JD, Flanigan DC. Treatment of cartilage defects of the knee: expanding on the existingalgorithm. Clin J Sport Med 2014;24:21-30. • Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up. J Bone Joint Surg Br 2009;91:16-23. 28. • Fontana A, Bistolfi A, Crova M, Rosso F, Massazza G. Arthroscopic treatment of hip chondral defects: Autologous chondrocyte transplantation versus simple debridementda pilot study. Arthroscopy 2012;28:322-329. • Steadman JR, Miller BS, Karas SG, Schlegel TF, Briggs KK, Hawkins RJ. The microfracture technique in the treatment of full-thickness chondral lesions of the knee in National Football League players. J Knee Surg 2003;16:83-86. • Karthikeyan S, Roberts S, Griffin D. Microfracture for acetabular chondral defects in patients with femo- roacetabular impingement: Results at second-look arthroscopic surgery. Am J Sports Med 2012;40:2725-2730. • Mithoefer K, Williams RJ 3rd, Warren RF, Potter HG, Spock CR, Jones EC, Wickiewicz TL, Marx RG. The microfracture technique for the treatment of articular cartilage lesions in the knee. A prospective cohort study. J Bone Joint Surg Am. 2005;87-1911-20 • Filardo G, Kon E, Berruto M, Di Martino A, Patella S, Marcheggiani Muccioli GM, Zaffagnini S, Marcacci M. Arthroscopic second generation autologous chondrocytes implantation associated with bone grafting for the treatment of knee osteochondritis dissecans- Results at 6 years. Knee. 2012 Oct. 19(5) 658-63. • Kon E, Filardo G, Berruto M, Benazzo F, Zanon G, Della Villa S, Marcacci M.– Articular cartilage treatment in high-level male soccer players: a prospective comparative study of arthroscopic second-generation autologous chondrocyte implantation versus microfracture. Am J Sports Med. 2011 Dec;39(12):2549-57. doi: 10.1177/0363546511420688. Epub 2011 Sep 7.
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