classification and treatment of hip chondral lesions

Classification and Treatment of

Hip Chondral Lesions

Jorge Cruz de Melo

The Porto Hip Unit

PHM2015

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• Zonas • Articulación de la cadera • Compartimiento central • Compartimiento

periférico • Peritrocantérico • Sub-Glúteo • Isquio-femoral • Isquio-tibiales • Sacro-ilíaco • Sínfisis púbica

Introdução Grupo de entidades que cursam com dor peri-articular

“Boom” com estudos anatomofisiológicos sobre patologia da anca

Acesso a tratamento artroscópico / endoscópico

Patologias mais frequentes:1. GTPS

2. Anca de ressalto externa3. Anca de ressalto interna

4. Síndrome Piriforme5. Lesões Isquiotibiais

6. Fracturas/avulsoes apofisárias7. Hérnia Desportiva / Pubalgia

articular pathology presents as groin pain that may radiate to the knee. Pain located inthe thigh or buttocks, or pain that radiates distally below the knee, is likely to originatefrom the lumbar spine or buttock and proximal thigh musculature.7 Pain located in thelower abdomen and/or at the adductor tubercle can indicate athletic pubalgia. Painlocated around the greater trochanter and associated with snapping can be snappinghip syndrome. Identification of associated symptoms such as weakness or numbness,back pain, and exacerbation with coughing or sneezing, may indicate thoracolumbarpathology.8

Past medical and surgical history, as well as any developmental problemsshould be explored. Patients should specifically be asked about systemic illnessessuch as malignancy, coagulopathies, and inflammatory disorders. Various coagu-lation and metabolic disorders have been shown to impede vascular supply tothe femoral head.9 Social history should be reviewed to determine current or prioruse of alcohol, steroids, and tobacco, which might place the patient at risk forosteonecrosis.7

Recreational history and athletic participation should be probed, as certain sportsincluding soccer, rugby, martial arts, and long-distance running are associated withan increased incidence of degenerative hip disease when compared with the generalpopulation.10 Hip pain in elite athletes and patients sustaining low-energy trauma isoften caused by anterior labral tears and acetabular chondral defects.11 Patientswith clicking or locking are likely to have a mechanical cause, such as labral tearingor loose bodies. Traumatic or inflammatory conditions more frequently present withanterior groin pain and decreased range of motion.To help quantify the severity of symptoms, various hip-scoring systems have

been developed.12 Some quantify hip function into numeric value, whereas otherscategorize using descriptive terms such as excellent, good, fair, and poor.13 Themost frequently used functional scores include the Harris Hip Score, the CharnleyHip Score, the Hospital for Special Surgery Score, and the Merle d’Aubigne. Visualanalog pain score is frequently used because of its simplicity and ease of use.

Fig. 1. Intra-articular pathology presents as groin pain, diamond shape. Extra-articularpathology such as lower abdomen or at the adductor tubercle can indicate athletic pubal-gia, oval shape. Pain located around the greater trochanter and associated with snappingcan be snapping hip syndrome/trochanteric bursitis, rectangle shape.

Plante et al226

terça-feira, 20 de Maio de 2014

Classification and Treatment of Hip Chondral Lesions

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• Capas

• Osteocondral

• Inerte

• Contráctil

• Neuromecánica

inert, contractile, and neuromechanical relationships anddifferences, as they relate to normal osseous structure, os-seous overcoverage and osseous undercoverage, is what ledto the development of the Layer System. (Table 1)

Diagnostic testing for identifying osseous, inert and softtissue hip pathology has included x-ray, magnetic resonanceimaging (MRI), computed tomography (CT) Scan, delayedgadolinium-enhanced MRI of cartilage (dGEMRIC) studies,diagnostic injection and clinical special tests[9, 10]. Computernavigation surgical planning software, such as A2, can beused to confirm and model osseous impingements. X-rayviews of AP lateral and Dunn view can be used along with 3dimensional CTscans to identify osseous hip pathologies [11].

These studies provide structural blueprints for determiningalpha angles, beta angles and McKibbon indices [12]. dGEM-RIC studies can be used, when indicated, to determine thehealth of the cartilage[9]. Intra-articular injections have prov-en extremely reliable for differentiating between intra andextra articular hip pathology [13]. MRI has been diagnostical-ly sensitive to Layer II inert tissue (labrum, capsule, ligamentand ligamentum teres) pathology, as well as Layer III contrac-tile tissue direct involvement and indirect enthesiopathies.

During the diagnostic process it may be helpful to cate-gorize the hip as structurally normal, structurally overcov-ered or structurally undercovered. A structurally normal hipwill have values that fall within a normal range for center

Table 1 The layer concept

Layer Name Structure Purpose Pathology

I Osteochondral Femur Joint congruence Developmental Dynamic

Acetabulum Arthrokinematicmovement

Dysplasia Cam Impingement

Innominate Femoral Version Rim Impingement

Acetabular Version Trochanteric Impingement

Delamination

Femoral Inclination Sub-spine impingement

Acetabular Profunda/Protrusio

II Inert Capsule Static Stability Labral Tear

Labrum Capsular Instability

Ligamentous Complex Ligamentum teres tear

Ligamentum Teres Adhesive capsulitis

III Contractile Musculature crossing hip Dynamic Stability Hemi-pelvic Pubalgia:

Lumbosacral muscles Anterior Enthesiopathy

Pelvic floor Hip flexor strain

Psoas impingement

Rectus femoris impingement

Medial Enthesiopathy

Adductor tendinopathy

Rectus abdominus tendinopathy

Posterior Enthesiopathy

Proximal hamstring strain

Lateral Enthesiopathy

Peri-trochanteric space

Gluteus medius tear

III Neuromechanical Thoroco-lumbar mechanics Communication, timingand sequencing of thekinematic chain

Neural Mechanical

Lower extremity mechanics Nerve entrapment Foot structure and mechanics

Neuro-vascular structuresreferring to and regionalto the hip

Referred Spinal Pathology Scoliosis

Regional mechanoreceptors Neuromuscular Dysfunction Pelvic posture over femur

Pain syndromes Osteitis Pubis

Pubic symphasis pathology

SI dysfunction

2 Curr Rev Musculoskelet Med (2012) 5:1–8


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A Articulação da anca é uma diartrose em que a cartilagem cobre a cabeça femoral e o acetábulo, permitindo o deslizamento entre ambos, com baixo atrito.

Células (Condrócitos) Matriz cartilagínea

Colagénio Proteoglicanos Hialuronato

Cartilagem hialina Camada superficial : 10 a 20% (Fibras orientadas de forma arqueada) Camada intermedia: 40 a 60% (fibras orientadas radialmente) Camada profunda: 30% (fibras orientação laminada)

A zona onde ocorrem a maior parte das lesões.


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Bordo anterior do acetábuloBordo posterior do acetábuloLinha ilio-isquiática

Ângulo CE (N: 25º a 40º)Ângulo acetabular (0 a 10º)

Off-Set (N >= 7 mm)Ângulo Alfa (N: < 50º)

!

•  Face bacia com ancas•  Ancas P, de Dunn ou Cross Table•  Ancas P de Lequesnne


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RM: Penetração, Ponderações, Cortes, Gadolinio. (Normal; artro-RM; dGEMRIC)

!


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Artro-RM da articulação coxo-femural direita revelando sinais de conflito femuro-acetabular misto de predomínio "CAM", com ângulo alfa

aumentado, onde coexiste patologia quística de herniação sinovial e alterações labrais e condrais importantes


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CFA Resulta em trauma de repetição ou agudo Lesão labral Lesao condral Cascata degenerativa não focal


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Hip Arthroscpy is an excellent way to evaluate, diagnose and treat chondral and labral lesions.

Hip Arthroscopy

Acetabulum Cartilage

Fovea Teres ligament

Labral-Cartilage junction

labrum Femoral Cartilage

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ANCA NORMAL

Normal Hip

Acetabular cartilage

Fovea

Labrum

Femoral Cartilage

Capsula

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Parece anormalCicatriz estrelada

Fossa supra-acetabular

Cicatriz da fise

Sulco condro-labral

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Parece normal, mas…

Cabeça&

Fovea&VI&

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Labrum

'

Car)lagem'

Sulco??'Rot.'CL??'

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“”Wave'lesion””'

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Labrum

'

Car)lagem'

Delaminação'

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Claramente anormal

Labrum'

Car)l.'Acetab.'

Fissuração'e+fragmentação+car2l.'

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Claramente anormal

Fovea&

Cabeça&femoral&

Labrum&

Acetabulo&Zona&3&

Lesao&car7laginea&&grau&V&de&Beck&Exposição&ossea&Delaminação&

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Claramente anormal

Acetábulo*Zona*4*

Labrum*

Lesão*condral*5po*V*de*Beck*Exposição*ossea*Fibrilação*

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Fovea&

Labrum

&

Fragmentação&Car2laginea&Exposição&ossea&

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Cabeça&

Erosão&car-laginea&

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Labrum

'

Cabeça'

Erosão&car)laginea&generalizada&

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OUTERBRIDGE classification (Acetabulo e femur) - 1961

0 - Normal cartilage Macroscopically sound cartilage

I - Malacia: Cartilage with softening and swelling

III- Parcial-thickness defect: That reach subchondral bone in an area that exceed 1,25 cm

IV - Exposed subchondral bone

II- Parcial-thickness defect: That do not reach subchondral bone or exceed 1,25 cm

Labrum'

Car)l.'Acetab.'

Fissuração'e+fragmentação+car2l.'

Fovea&

Labrum

&


ANCA NORMAL

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BECK classification (Acetábulo) - 2005

0 - Normal cartilage Macroscopically sound cartilage

I - Malacia: Cartilage with softening and swelling. Fibrillation.

III - Cleavage: Loss of fixation to the subchondral bone. Frayed edges, thinning of the cartilage, flap.

IV - Defect: Full-thicknes defect

II - Debonding: Loss of fixation to the subchondral bone. Macroscopically sound cartilage - CARPET LESION

ANCA NORMAL

“”Wave'lesion””'

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SAMPSON classification (Acetábulo) - 2011 AC 0 - Normal cartilage

Fovea&

Labrum

&


ANCA NORMAL

AC 1 - Softening no wave sign

AC 1w - Softening with wave sign, intact labrocartilage junction (CARPET LESION)

AC 1wTj - Softening with wave sign and torn labrocartilage junction

AC 1wD - Softening with wave sign, intact labrocartilage junction, with delimitation (DELAMINATION)

AC 1wTjD- Softening with wave sign and torn labrocartilage junction, with delimitation (DELAMINATION)

AC 2 - Fibrillation

AC 2Tj - Fibrillation with torn labrocartilage junction

AC 3 - Exposed bone small area < 1cm2

AC 4 - Exposed bone small area > 1cm2 Abbreviations: A, acetabulum; C, cartilage; D, lemamination; Tj, torn labrocartilage junction; W, wave sign

Labrum

'

Car)lagem'

Delaminação'

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SAMPSON classification (Femur) - 2011 HC 0 - Normal cartilage

ANCA NORMAL

HC 0T - Uniform Thinning (T)

HC 1 - Softening

HC D - Traumatic defect ( size in mm)

HC 2 - Fibrillation

HC 2T - Demarcation zone from FAI (Pincer)

HC 3 - Exposed bone

HC 4 - Any delamination

Abbreviations: HC, femoral head cartilage; T, thinning; TD, traumatic defect; DZ, demarcation zone

exposição)ossea)

Zona%de%demarcação%

Labrum%

Cabeça%

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SAMPSON classification - Modified by The Porto Hip Unit AC 0 - Normal cartilage AC 1 - Softening no wave sign AC 1w - Softening with wave sign, intact labrocartilage junction (CARPET LESION)

AC 1wTj - Softening with wave sign and torn labrocartilage junction AC 1wD - Softening with wave sign, intact labrocartilage junction, with delimitation (DELAMINATION) AC 1wTjD- Softening with wave sign and torn labrocartilage junction, with delimitation (DELAMINATION) AC 2 - Fibrillation AC 2Tj - Fibrillation with torn labrocartilage junction AC 3 - Exposed bone small area < 1cm2

AC 4 - Exposed bone small area > 1cm2

Abbreviations: A, acetabulum; C, cartilage; D, lemamination; Tj, torn labrocartilage junction; W, wave sign

AC 3D - Exposed bone small area < 1cm2, with delimitation (FLAP)

AC 4D - Exposed bone small area < 1cm2, with delimitation (FLAP)

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“Relógio”

“Zonas” Ilizaliturri VM Jr, Byrd JW, Sampson TG, et al. - 2008

Como na cabeça avaliamos A extensão da lesão,•  Periférica < 10%•  Lateral 1/3 periférico•  Mediana 1/3 intermédio•  Central 1/3 central

MAPEAMENTO CIRURGICO DAS LESÕES CONDRAIS!!


(Porto Hip Unit)

ip U

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“…. perante a lesão cartilagínea focal, o tratamento visa evitar a progressão, minimizar a lesão e reparar/regenerar a cartilagem articular…”

J. Cruz de Melo


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Opções de Tratamento:

1) O tipo e extensão da lesão cartilagínea2) As alterações morfologicas associadas 3) O labrum

Cartilage LesionShaving

Shaving micro-fractures

Shaving micro-fractures

cola fibrina

Enxertos …….

C. Pluripotentes

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Opções de Tratamento - Acetabular cartilage

1) O tipo e extensão da lesão cartilagínea2) As alterações morfologicas associadas 3) O labrum

Protocolo de tratamento de The Porto Hip Unit

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Opções de Tratamento - Acetabular cartilage

1) O tipo e extensão da lesão cartilagínea2) As alterações morfologicas associadas

Protocolo de tratamento de The Porto Hip Unit

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A lesão cartilagínea é de difícil caracterização na avaliação imagiológica, sendo a sua caraterização essencialmente

per-operatória.

Tratamento continua a ser um grande desafio.

Tratar sempre o fator causal (CFA, DDA, Corpos livres, etc )

Objectivo é minimizar a lesão, evitar a progressão,, tentar “restabelecer” a cartilagem ou fibrocartilagem cicatricial.

O DIAGNOSTICO PRECOCE E O TRATAMENTO ADEQUADO É O MELHOR FATOR PROGNOSTICO

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classification and treatment of hip chondral lesions

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