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Osteochondral Defect of the Hip

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Other Names

  • Loose Body of the Hip Joint
  • Hip loose bodies
  • Osteochondral lesion of the hip
  • Hip OCD
  • Hip Chondral lesion
  • Acetabular osteochondritis dissecans

Background

  • This page refers to loose bodies and osteochondral defects of the Hip Joint

History

  • The first cases series was published by Goldman in 1976[1]

Epidemiology

  • Poorly described in the literature

Introduction

Illustration of some loose bodies in the hip joint

General

  • Under-recognized and under reported condition of the hip
  • Loose body may be osseous, chondral or osteochondral
  • Rarely exist as isolated pathology and typically present secondary to other conditions
  • If left untreated, can cause significant pain and impact ADLs
  • Generally treated surgically via hip arthroscopy

Pathophysiology

  • Pathogenesis
    • Complex interplay of mechanical, biomechanical and cellular factors
    • Often involves some form of trauma (i.e. sporting injury or sudden impact)
  • Acetabulum
    • Most common location of chondral lesions
    • One study estimated 88% of chondral defects found on anterosuperior acetabulum[2]
    • McCarthy found 59% occurred in anterior, 24% occurred in superior acetabulum[3]
  • Healing
    • Chondral lesions generally do not have self healing properties
    • Full thickness penetration into the bone does allow for some degree of healing

Etiology and Associated Conditions

  • Hip Dislocation
  • Hip Labral Tear
    • Commonly co-occur with chondral lesions
  • Femoroacetabular Impingement
    • Abnormal contact between the femoral head and acetabulum results in mechanical stress on the articular cartilage
  • Avascular Necrosis of the Hip
    • Weakened bone leads to microfractures and subsequent bony collapse, destruction
    • Disruption of the bone architecture involves the overlying cartilage
  • Developmental Dysplasia of the Hip
    • Shallow acetabulum fails to adequately cover and support the femoral head
    • Leads to increased stress concentration on weight-bearing regions of the articular cartilage
    • Joint instability further increases risk of damage
  • Acetabular osteochondritis dissecans
    • Very rare but can produce chondral and osteochondral lesions
    • Often due to repetitive microtrauma making the underlying bone and cartilage susceptible to damage
  • Insufficiency fractures
  • Slipped Capital Femoral Epiphysis (SCFE)
    • Altered biomechanics due to femoral head displacement alters stress/shear forces
    • These forces damage the articular cartilage, leading to chondral lesions
  • Legg Calve Perthes Disease (LCP)
    • Disrupted flow to the femoral head and AVN alters biomechanics
    • Abnormal contact pressures cause further cartilage damage and osteochondral lesions

History

  • 1974 Epstein believed that loose bodies were so common that he recommended that all fracture dislocations be treated with open debridement[4]
  • Advances in imaging, arthroscopy and fellowship opportunities has resulted in an increase in hip arthroscopy
  • Subsequently, diagnosis and treatment of chondral lesions has increased dramatically

Anatomy of the Hip Joint

Osteochondral Unit

  • Refers to relationship between articular cartilage and subchondral bone
  • Harmony of these is essential for both weight bearing and mobility of a joint
  • Preservation of the unit is necessary for joint health

Risk Factors

  • Male sex
  • Older age
  • Increased alpha angle (indicative of cam deformity)
  • Reduced joint space width

Differential Diagnosis

Differential Diagnosis Hip Pain

Differential Diagnosis Groin Pain

Clinical Features

History

  • Loose bodies rarely occur in isolation, so it is important to get a good history of athletic participation, previous trauma, childhood pathology, surgical interventions, etc
  • Patients typically report deep hip or groin pain
  • They may have mechanical symptoms such as clicking, popping, catching

Physical Exam: Physical Exam Hip

Special Tests

  • Special tests will be guided by hsitory

Evaluation

(A) Pelvic anteroposterior view showing a round radiolucent lesion (arrow) suggests an osteochondritis dissecans (OCD) lesion at the anterosuperior portion of the left femoral head. (B) CT also showing an OCD lesion (arrow) at the anterosuperior site of the femoral head. (C) Coronal magnetic resonance imaging view showing a high-intensity round lesion (arrow) at the anterosuperior portion of the femoral head[5]
Detached, non-displaced osteochondral lesion of the right femoral head with 'cystic' cavities.[6]

Radiographs

  • Standard Radiographs Hip
    • Should be obtained on all patients
    • May demonstrate loose bodies
    • Stigmata of arthritis: subchondral sclerosis, subchondral cysts, osteophytes, etc
  • Dunn View
    • Used to evaluate the sphericity of the femoral head in patients suspected of having FAI[7]

CT

  • Indications are unclear
  • Provides a good osseous evaluation
  • Nishii et al accuracy diagnosing chondral lesions with CT arthrography[8]
    • Sensitivity: 49-79%
    • Specificity: 76-94%

MRI

  • Gold standard for evaluating chondral lesions
  • Smith et al pooled findings[9]
    • Sensitivity: 59%
    • Specificity: 94%
  • MR Arthrography[10]
    • Sensitivity: 47-79%
    • 77-89%

Biomarkers

  • Bedi et al looked at Cartilage Oligomeric Matrix Protein (COMP) and C-reactive protein (CRP)[11]
    • They found COMP increased by 24%, CRP by 276% in patients with FAI
  • Fibronectin-aggrecan complex (FAC)[12]
    • Cytokine and cartilage breakdown product measured in the synovial fluid
  • Higher concentration in those undergoing microfracture without radiographic evidence of OA

Diagnostic Arthroscopy

  • Rarely performed but considered superior to the less invasive MRI

Classification

Chondral lesion classification systems[13]

Buckwalter Classification

  • Based on the severity of tissue damage and repair response[14]
  • Type I injury
    • Damage to the cartilage matrix not apparent by visual inspection or by clinical imaging methods
    • Possible injury to the subchondral bone may be visualized by scintigraphy or MRI.
    • Represents elastic deformation of the cartilage, possible bone marrow edema which may cause pain
    • The basic matrix structure remains intact
    • Repair response is synthesis of new matrix macromolecules
  • Type II injury
    • Defined as cartilage disruption limited to the articular cartilage
    • Represents plastic deformation of cartilage such as chondral fractures or ruptures which may cause mechanical symptoms, joint effusions, synovitis and pain
    • Repair response results in synthesis of new matrix macromolecules, cell proliferation
    • There is no fibrin clot formation, no inflammation and no cartilage defect filling by new tissue
    • May progress to cartilage degeneration
  • Type III injury
    • Defined as mechanical disruption of both the articular cartilage and subchondral bone
    • May cause mechanical symptoms, joint effusions, synovitis and pain
    • Repair response to cartilage, bone disruption results in fibrin clot formation, inflammation, new cells invading the lesion, and production of new fibrocartilage and osseous tissue
    • May progress to cartilage degeneration, which is dependent on the stability and alignment of the joint as well as the location and size of the lesion

Management

Summary of the biological treatment methods for chondral/osteochondral lesions in the hip[15]

Nonoperative

  • Indications
    • Unclear, generally considered a surgical problem
    • Certain patients who are not good surgical candidates
    • Possibly cases of mild to moderate symptoms, stable and small lesions, absence of mechanical symptoms, and when the patient prefers nonsurgical options[16]
  • Patient education
  • Symptom control with NSAIDS
  • Activity modification
    • Identifying and avoiding provocative activities can help reduce stress on the joint
  • Physical Therapy
  • Dynamic Stabilization

Procedures

Operative

  • Indications
    • Vast majority of patients
  • Technique
    • Hip arthroscopy
    • Open excision
  • Chondral Lesions
    • Chondroplasty
    • Microfracture
    • Cartilage transplants (osteochondral autograft transfer, mosaicplasty, Osteochondral allograft transplantation)
    • Incorporation of orthobiologics

Rehab and Return to Play

Rehabilitation

  • Largely depends on the surgery, surgeons preference and underlying pathology
  • Microfracture surgery
    • Non weightbearing from 2-8 weeks with gradual weight bearing
  • Many other techniques
    • 6 weeks of toe touch weight bearing, followed by 6 weeks of partial weight bearing

Return to Play/ Work

  • General[19]
    • Timeline varies widely based on surgery, pathology, sport, level of competition
    • Most athletes return to sport in 3 to 6 months
    • Elite athletes often return to competition at an average of 6.8 months

Prognosis and Complications

Prognosis

  • Return to play[19]
    • Generally athletes do well, with RTP rates ranging from 84 to 94%
    • Elite athletes have a higher return to play rate than recreational athletes

Complications

See Also

References

  1. ↑ Goldman, Amy Beth, et al. "Osteochondritis Dissecans Complicating Legg-Perthes Disease: A Report of Four Cases." Radiology 121.3 (1976): 561-566.
  2. ↑ Schmid, Marius R., et al. "Cartilage lesions in the hip: diagnostic effectiveness of MR arthrography." Radiology 226.2 (2003): 382-386.
  3. ↑ McCarthy, Joseph C., and Jo-Ann Lee. "Arthroscopic intervention in early hip disease." Clinical Orthopaedics and Related Research (1976-2007) 429 (2004): 157-162.
  4. ↑ EPSTEIN, HERMAN C. "Posterior fracture-dislocations of the hip: long-term follow-up." JBJS 56.6 (1974): 1103-1127.
  5. ↑ Kubo, Takanori, et al. "Hip arthroscopic osteochondral autologous transplantation for treating osteochondritis dissecans of the femoral head." Arthroscopy techniques 4.6 (2015): e675-e680.
  6. ↑ Case courtesy of Liz Silverstone, Radiopaedia.org, rID: 97241
  7. ↑ Maupin, Jeremiah J., Garrett Steinmetz, and Rishi Thakral. "Management of femoroacetabular impingement syndrome: current insights." Orthopedic Research and Reviews (2019): 99-108.
  8. ↑ Nishii, Takashi, et al. "Fat-suppressed 3D spoiled gradient-echo MRI and MDCT arthrography of articular cartilage in patients with hip dysplasia." American Journal of Roentgenology 185.2 (2005): 379-385.
  9. ↑ Mont, Michael A., et al. "Osteonecrosis of the knee and related conditions." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 19.8 (2011): 482-494.
  10. ↑ Smith, Toby O., et al. "The diagnostic test accuracy of magnetic resonance imaging, magnetic resonance arthrography and computer tomography in the detection of chondral lesions of the hip." European Journal of Orthopaedic Surgery & Traumatology 23 (2013): 335-344.
  11. ↑ Bedi, Asheesh, et al. "Elevation in circulating biomarkers of cartilage damage and inflammation in athletes with femoroacetabular impingement." The American journal of sports medicine 41.11 (2013): 2585-2590.
  12. ↑ Abrams, Geoffrey D., et al. "Fibronectin–aggrecan complex as a marker for cartilage degradation in non-arthritic hips." Knee Surgery, Sports Traumatology, Arthroscopy 22 (2014): 768-773.
  13. ↑ Dallich, Alison A., et al. "Chondral lesions in the hip: a review of relevant anatomy, imaging and treatment modalities." Journal of hip preservation surgery 6.1 (2019): 3-15.
  14. ↑ Buckwalter, Joseph A. "Articular cartilage: injuries and potential for healing." Journal of Orthopaedic & Sports Physical Therapy 28.4 (1998): 192-202.
  15. ↑ Itha, Rajesh, et al. "Management of chondral and osteochondral lesions of the hip: A comprehensive review." Die Orthopädie 53.1 (2024): 23-38.
  16. ↑ McGovern, Ryan P., et al. "Non-operative management of individuals with non-arthritic hip pain: a literature review." International journal of sports physical therapy 14.1 (2019): 135.
  17. ↑ Gobbi, Alberto, et al. "One-step cartilage repair with bone marrow aspirate concentrated cells and collagen matrix in full-thickness knee cartilage lesions: results at 2-year follow-up." Cartilage 2.3 (2011): 286-299.
  18. ↑ Centeno, Christopher J., et al. "A dose response analysis of a specific bone marrow concentrate treatment protocol for knee osteoarthritis." BMC Musculoskeletal Disorders 16 (2015): 1-8.
  19. ↑ 19.0 19.1 McDonald, John E., Mackenzie M. Herzog, and Marc J. Philippon. "Performance outcomes in professional hockey players following arthroscopic treatment of FAI and microfracture of the hip." Knee Surgery, Sports Traumatology, Arthroscopy 22 (2014): 915-919.
Created by:
John Kiel on 8 May 2025 18:37:00
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Last edited:
8 May 2025 20:35:20
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