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Idiopathic Chondrolysis of the Hip

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Other Names

  • Idiopathic Chondrolysis of the Hip
  • Hip Chondrolysis

Background

History

  • First described by Waldenstrom in 1930 associated with SCFE[1]
  • Jones was the first to describe hip chondrolysis as idiopathic in 1971[2]

Epidemiology

  • Frequently seen in adolescence, ages 9 to 12[3]
  • More common in females than males, approximately 4:1[4]
  • 60% of cases are monoarticular, only 5% - 10% are bilateral[5]

Introduction

Radiograph of the pelvis with both hips. The blue arrow shows subtle contour irregularity of femoral epiphysis. The yellow arrow shows <3 mm concentric reduction in the left hip joint space. The note is made of mild pelvic tilt to the left side.[6]

General

  • Rare debilitating disease that results in articular cartilage loss in proximal femoral epiphysis and acetabulum
  • Seen in kids age 9-12, it is typically monoarticular and presents with painful hip and restricted movements
  • Much of the knowledge of ICH is limited to case reports and case series[7]

Etiology

  • Generally, it is not known or understood
  • Speculated to be an unidentified immune reaction[8]
    • Possibly in response to subclinical insults to the hip
  • Synovial biopsies demonstrate chronic, non-specific inflammation[9]
  • Some cases report minor trauma, overexertion or immobilization for another treatment[10]
    • This raises the question of whether mild exposures trigger development of ICH
  • Majority of reports lack any trauma or immobilization history

Four Stages of Disease

  • First stage
    • Patients present with hip pain, usually for weeks to months
    • Pain may also be referred to the knee
    • ROM is typically restricted at the time of presentation
    • Remains nearly normal under sedation in patients who undergo exams under anesthesia (EUA)/ surgery
  • Second stage
    • ROM deficits persist under anesthesia
    • Joint space narrowing becomes radiographically evident
    • Typically, patients develop a flexion-abduction deformity with apparent lengthening of the limb
    • This stage typically develops between three to nine months after symptom onset
  • Third Stage
    • ROM deficits remain fixed
    • Radiographs may demonstrate protrusio acetabuli
    • Patients may experience spontaneous resolution of their symptoms in stage 3
  • Fourth Stage
    • Progression becomes irreversible
    • Joint becomes stiff and ankylosed
  • Complete resolution/ fibrous ankylosis have been seen in both conservative and aggressive management[11]

Risk Factors

  • Unknown

Differential Diagnosis

Differential Diagnosis Hip Pain

Differential Diagnosis Groin Pain

Clinical Features

History

  • Progressively worsening pain and stiffness
  • Decreased active/ passive range of motion
  • Abnormal, painful gait
  • Worse with activity
  • Inability to participate in sports

Physical Exam

  • Tenderness to the gluteal muscles is reported in some cases
  • Abduction contracture of the affected limb from muscles spasms can be seen
  • Can lead to antalgic or apparently longer limb gait

Special Tests

  • Needs to be updated

Evaluation

Radiographic progression of idiopathic chondrolysis. A Stage I disease often presents as an abduction contracture with preserved joint space (right hip, white arrow). B Stage II is marked by joint space narrowing, particularly on the medial side, which worsens in Stage III (C). D Stage IV indicates fibrous ankylosis of the joint, global obliteration of the joint space, and cyst formation.[7]
Magnetic resonance imaging shows centrally located T2 hyperintensity (geographic enhancement) (white arrows) in the femoral head epiphysis of a patient with idiopathic chondrolysis in the coronal (left) and axial (right) planes[7]

Radiology

  • Standard Radiographs Hip
    • Generally reassuring/ unremarkable early on in the disease
    • Can exclude other causes of pediatric hip pain
  • Early potential findings
    • Osteoporosis/ osteopenia around the acetabulum[12]
    • Blurred subchondral lines
    • Joint space reduction
  • Late potential findings include
    • Early closure of trochanteric and capital epiphyses
    • Changes of osteoarthritis with secondary protrusio acetabuli
    • Fibrous or bony ankylosis

MRI

  • Diagnostic gold standard
  • Early findings
    • Wedge-shaped/T2 hyperintense, T1 hypointense marrow edema involving the middle third of the proximal femoral head epiphysis[13]
    • May also see ill defined marrow in the iliac and ischial bones
    • Geographic enhancement is pathognomonic[14]
  • Contrasted MRI
    • Will usually show enhancement of the lesion and the synovium
    • Central femoral head epiphysis cartilage loss
    • Bone remodeling
    • Marrow edema involving the head and neck of the femur and acetabulum
  • Late findings
    • Joint space reduction
    • Acetabular changes
    • Changes of osteoarthritis with secondary protrusio acetabuli
    • Fibrous or bony ankylosis

Laboratory

  • Typically unrevealing
  • Rheumatologic and infectious workup do not identify anything
  • In patients suspected of ICH, some patients have been HLA-B27 positive[15] or had elevated ESR[16]

Biopsy Findings

  • Not necessary in diagnosing ICH, findings are too inconsistent
  • Common histological findings include[17]
    • Chronic inflammatory changes
    • Articular cartilage thinning
    • Synovial membrane thickening, hyperemia

Classification

Herman MRI Classification[18]

  • Stage 0
    • Normal imaging
  • Stage 1
    • Variable reduction in the hip joint space
    • Focal wedge-shaped area of marrow edema located in the middle one-third of the femoral head (earliest and characteristic finding in MRI)
    • Mild synovial thickening and joint effusion.
  • Stage 2
    • Stage 1 PLUS
    • Marrow edema involves superomedial aspect of the acetabulum with protrusio acetabuli
  • Stage 3
    • Increased extent of marrow edema in the proximal femoral epiphysis
    • Femoral head collapse
    • Wide involvement of acetabulum
    • Osteoporotic and degenerative changes (fibrous ankylosis)
    • Possibly, overgrowing femoral head on the neck (“buttress” sign).

Management

Algorithm for evaluation and treatment of idiopathic chondrolysis[7]

Nonoperative: First Line

Nonoperative: Second Line

  • Methotrexate[7]
    • Has not demonstrated improvement in late 2nd or 3rd stage of ICH
    • Some improvement pain/ROM in early 2nd stage
  • Etanercept[19]
    • Has been utilized along with NSAIDS in a few case reports
    • Showed benefit in some case reports and case series
  • Hip Joint Injection
  • Botulinum Toxin
    • Two case reports noted significant improvement in pain and range of motion at six month follow up[20]

Operative

  • Indications
    • Failure of conservative management
  • Technique
    • Manipulation under general anesthesia
    • Soft tissue release/ capsulectomy
    • Arthroscopic exploration
    • Osteochondroplasty
    • Total hip arthroplasty (THA)
    • Arthrodesis

Rehab and Return to Play

Rehabilitation

  • There is no agreed upon rehabilitation program for ICH
  • All surgical and non-surgical approaches require intensive physical therapy
  • Major emphasis is on active and passive ROM

Return to Play/ Work

  • There are no agreed upon RTP guidelines for ICH
  • Highly varied depending on age, sport and competition level
  • Athletes should
    • Have strength in the affected hip at least 90% of the unaffected limb
    • Be able to perform sport specific exercises

Prognosis and Complications

Prognosis: Conservative Treatment

  • About 60% of patients have resolution of symptoms with early conservative treatment[9]

Prognosis: Surgical Treatment

  • Patwardhan et al case series combined intra-articular corticosteroids and manipulation under anesthesia[21]
    • Complete resolution of symptoms in 62% of patients
    • 24% still had painful, stiff hip at final follow up but had significant improvement at 2 year follow up
  • Hinged external fixator arthrodiastasis
    • Improvement in pain and range of motion in one case series[22]

Complications

See Also

References

  1. ↑ Waldenström, Henning. "On necrosis of the joint cartilage by epiphyseolysis capitis femoris." Acta Chir Scandinav 67 (1930): 936-946.
  2. ↑ Jones, B. S. "Adolescent chondrolysis of the hip joint." South African Medical Journal 45.2 (1971): 196-202.
  3. ↑ Johnson, Karl, et al. "Childhood idiopathic chondrolysis of the hip: MRI features." Pediatric radiology 33 (2003): 194-199.
  4. ↑ Nema, Sandeep Kumar, et al. "MRI features and treatment for idiopathic chondrolysis of the hip (ICH) in children: outcomes of a systematic review." Indian Journal of Orthopaedics 56.9 (2022): 1491-1505.
  5. ↑ Millis, Michael B., and Ira Zaltz. "Current perspectives on the pediatric hip: selected topics in hip dysplasia, Perthes disease, and chondrolysis: synopsis of the hip subspecialty session at the POSNA Annual Meeting, May 1, 2013, Toronto." Journal of Pediatric Orthopaedics 34 (2014): S36-S43.
  6. ↑ Krishnagopal, R. "Idiopathic chondrolysis of hip: a case report." International Surgery Journal 2.3 (2015): 402.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Kebeh, Martha, et al. "Idiopathic Chondrolysis of the Hip in Adolescents: Updated Evidence for Clinical Management." Journal of the Pediatric Orthopaedic Society of North America (2025): 100187.
  8. ↑ Madhuri, Vrisha, Noel Malcolm Walter, and Jyoti Panwar. "Idiopathic Chondrolysis of the Hip." The Pediatric and Adolescent Hip: Essentials and Evidence (2019): 375-390.
  9. ↑ 9.0 9.1 Segaren, Neil, et al. "Idiopathic chondrolysis of the hip: presentation, natural history and treatment options." Journal of Pediatric Orthopaedics B 23.2 (2014): 112-116.
  10. ↑ Kampani, Khaled T., et al. "Idiopathic hip chondrolysis: a case report of a Caucasian HLA-B27 positive adolescent with a history of long walking." Rheumatology International 39 (2019): 751-755.
  11. ↑ Patwardhan, Sandeep, et al. "Minimally invasive treatment for idiopathic chondrolysis of the hip: analysis of forty-one cases." International Orthopaedics 48.6 (2024): 1627-1634.
  12. ↑ Picazo, David Ruiz, et al. "An unusual case of chondrolysis of the hip: a possible etiology for a rare condition–a case report." Journal of Pediatric Orthopaedics B 25.6 (2016): 533-538.
  13. ↑ Bleck, EUGENE E. "Idiopathic chondrolysis of the hip." JBJS 65.9 (1983): 1266-1275.
  14. ↑ Johnson, Karl, et al. "Childhood idiopathic chondrolysis of the hip: MRI features." Pediatric radiology 33 (2003): 194-199.
  15. ↑ Patwardhan, Sandeep, et al. "Minimally invasive treatment for idiopathic chondrolysis of the hip: analysis of forty-one cases." International Orthopaedics 48.6 (2024): 1627-1634.
  16. ↑ Appleyard, Deborah V., et al. "Idiopathic chondrolysis treated with etanercept." Orthopedics 32.3 (2009): 1-5.
  17. ↑ Rowe, L. J., and Eric K. Ho. "Idiopathic chondrolysis of the hip." Skeletal radiology 25 (1996): 178-182.
  18. ↑ Herman, J. H., et al. "Idiopathic chondrolysis--an immunopathologic study." The Journal of Rheumatology 7.5 (1980): 694-705.
  19. ↑ Megremis, Panos K., Orestis P. Megremis, and Rodanthi Margariti. "Case Report: Total hip replacement in a 12-year-old girl with protrusio acetabuli and disabling joint degeneration, secondary to femoral head idiopathic chondrolysis—Six-year follow-up." SN Comprehensive Clinical Medicine 3.1 (2021): 411-418.
  20. ↑ Khoshhal, Khalid I., Yasser Awaad, and Alshahid A. Abbak. "Botulinum neurotoxin-A in idiopathic chondrolysis: a report of two cases." Journal of Pediatric Orthopaedics B 23.5 (2014): 441-446.
  21. ↑ Patwardhan, Sandeep, et al. "Minimally invasive treatment for idiopathic chondrolysis of the hip: analysis of forty-one cases." International Orthopaedics 48.6 (2024): 1627-1634.
  22. ↑ Thacker, Mihir M., et al. "Hinged distraction of the adolescent arthritic hip." Journal of Pediatric Orthopaedics 25.2 (2005): 178-182.
Created by:
John Kiel on 12 May 2025 18:51:56
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Last edited:
14 May 2025 13:48:19
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