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REVIEW ARTICLE
Outcomes of cartilage repair techniques for chondral injuryin the hip—a systematic review
Naoki Nakano1& Chetan Gohal2 & Andrew Duong2
& Olufemi R. Ayeni2 & Vikas Khanduja1
Received: 20 December 2017 /Accepted: 21 February 2018 /Published online: 13 March 2018# The Author(s) 2018
AbstractObjective/purpose The aim of the study was to assess the options of treatment and their related outcomes for chondral injuries inthe hip based on the available evidence whilst highlighting new and innovative techniques.Methods A systematic review of the literature from PubMed (Medline), EMBASE, Google Scholar, British Nursing Index(BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Allied and Complementary MedicineDatabase (AMED) was undertaken from their inception to March 2017 using the Preferred Reporting Items for SystematicReviews and Meta-Analyses (PRISMA) guidelines. Clinical outcome studies, prospective/retrospective case series and casereports that described the outcome of cartilage repair technique for the chondral injury in the hip were included. Studies on totalhip replacement, animal studies, basic studies, trial protocols and review articles were excluded.Results The systematic review found 21 relevant papers with 596 hips. Over 80% of the included studies were published in orafter 2010. Most studies were case series or case reports (18 studies, 85.7%). Arthroscopy was used in 11 studies (52.4%). Theminimum follow-up period was six months. Mean age of the participants was 37.2 years; 93.5% of patients had cartilage injuriesof the acetabulum and 6.5% of them had injuries of the femoral head. Amongst the 11 techniques described in the systematicreview, autologous matrix-induced chondrogenesis, osteochondral autograft transplantation and microfracture were the threefrequently reported techniques.Conclusion Over ten different techniques are available for cartilage repair in the hip, and most of them have good short- tomedium-term outcomes. However, there are no robust comparative studies to assess superiority of one technique over another,and further research is required in this arena.
Keywords Cartilage repair . Hip . Chondral injury . Arthroscopy . Systematic review
Introduction
Isolated chondral and osteochondral defects within the hipjoint often present a technical challenge for the hip surgeon.Common causes of cartilage damage in the hip includefemoroacetabular impingement (FAI), developmental dyspla-sia, osteonecrosis, osteochondritis dissecans, loose bodies,
slipped capital femoral epiphysis, and trauma [1–5].Amongst them, FAI has increasingly gained recognition as amajor cause of chondral injury and subsequent developmentof arthritis in the hip joint [6–10]. In CAM FAI, the abnormalcontact between the aspherical femoral head-neck junctionand the acetabular rim results in a large amount of shear stressbeing transmitted to the labro-chondral junction. Over a peri-od of time, labral detachment and acetabular chondral damageensues [2, 11, 12]. On the other hand, the pincer FAI, in whicha deep or retroverted acetabulum makes contact with anormal-shaped femoral neck, has a recognised pattern of dam-age to the labrum, femoral head cartilage and a postero-medialacetabular countercoup lesion [13]. Furthermore, in imagingand surgical techniques like hip arthroscopy have led to in-creased recognition of chondral lesions. The incidence ofchondral lesions at hip arthroscopy for FAI has been reportedto be up to 67.3% of the patients in one series [14].
* Vikas [email protected]
1 Department of Trauma and Orthopaedics, Addenbrooke’s Hospital,Cambridge University Hospitals NHS Foundation Trust, Box 37,Hills Road, Cambridge CB2 0QQ, UK
2 Department of Orthopaedics, McMaster University, 1280 MainStreet West, Hamilton, ON L8S 4K1, Canada
International Orthopaedics (2018) 42:2309–2322https://doi.org/10.1007/s00264-018-3862-6
There is relatively little information about articular carti-lage restoration in the hip when compared with what is knownabout cartilage restoration in the knee. Currently, most carti-lage repair methods for the hip are based on basic science andstrategies that were developed for the knee. Awareness ofyoung adult hip disease has been increasing in recent years,and thus, the field of hip preservation continues to develop;several new innovative techniques have been performed anddescribed in the literature. They include microfracture, autol-ogous chondrocyte implantation (ACI), matrix-associatedchondrocyte implantation (MACI), autologous matrix-induced chondrogenesis (AMIC), osteochondral autograft/allograft transplantation, implantation of artificial plug, stick-ing down of chondral flaps with fibrin adhesive and an intra-articular injection of bone marrow mesenchymal stem cells(BM-MSCs).
Currently, there is a gap in information particularly regard-ing systematic reviews in the literature that provide hip sur-geons with evidence-based recommendations, therefore, ontreating cartilage injuries in the hip. The aim of this studywas to provide the reader with options of treatment and theirrelated outcomes for chondral injuries in the hip based on theavailable evidence whilst highlighting new and innovativetechniques involved in chondral repair.
Methods
Search strategy
Two reviewers (NN and CG) searched the online databases(PubMed (Medline), EMBASE, Google Scholar, BritishNursing Index (BNI), Cumulative Index to Nursing and AlliedHealth Literature (CINAHL) and Allied and ComplementaryMedicine Database (AMED) for literature describing the out-come of cartilage repair techniques for the chondral injury in thehip. The Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) guidelines were used for designingthis study. A detailed search strategy is described in theAppendix.
Study screening/data abstraction
The inclusion and exclusion criteria are shown in Table 1. Boththe reviewers independently abstracted the relevant study datafrom the final pool of included articles and recorded this dataon a spreadsheet designed a priori. Participant-specific demo-graphics extracted from each study included the number ofhips, gender distribution, mean age with range (years), lengthof follow-up, location of the cartilage injury (acetabulum orfemoral head), surgical approach (open dislocation, arthrosco-py or injection), cartilage restoration technique used in the
study, pre-operative condition of the damaged cartilage, finaloutcome and specific comments (if any).
Statistics
The abstracted evidence was collected and analysed usingMicrosoft Excel 2013 spread sheet. Statistical analysis in thisstudy focused on descriptive statistics.
Results
Flowchart of the literature search is shown in Fig. 1. The oldeststudy included in this review was published in 2003, and over80% of the included studies (17 out of 21 studies) were pub-lished in or after 2010. Study demographics are shown inTable 2. A total of 11 techniques were found from the system-atic review: AMIC (5 studies), osteochondral autograft trans-plantation (mosaicplasty) (5 studies), microfracture (4 studies),artificial plug (TruFit®) (2 studies), fibrin adhesive (2 studies),ACI (2 studies), debridement (1 study), MACI (1 study),osteochondral allograft transplantation (1 study), direct carti-lage suture repair (1 study) and intra-articular BM-MSC injec-tion (1 study). Three studies described two techniques and com-pared them to each other (microfracture and AMIC, 1 study;MACI and AMIC, 1 study; ACI and debridement, 1 study).
Details of the 21 studies included are shown in Table 3.
Discussion
Our objective was to discuss the outcomes of the current strat-egies for restoration of focal chondral injuries in the hip. Thisstudy reviews all the cases of cartilage repair for the chondralinjuries in the hip (596 cases) reported in the English literatureand describes the outcomes of 11 techniques (includingdebridement).
Table 1 Inclusion and exclusion criteria applied to articles identified inthe literature
Inclusion criteria
1. All levels of evidence
2. Written in the English language
3. Studies on humans
4. Studies reporting the outcome of cartilage repair techniques forcartilage injuries in the hip
Exclusion criteria
1. Studies on other joints (e.g. knee)
2. Studies describing trial protocols without any results
3. Hip replacement surgery
4. Basic studies (e.g. cadaveric studies)
5. Reviews, systematic reviews
2310 International Orthopaedics (SICOT) (2018) 42:2309–2322
Cartilage injuries in the hip have been previously shown toresult in poor long-term outcomes, including pain and earlysecondary degenerative change followed by the subsequent de-velopment of osteoarthritis [15, 16]. The current trend is tofocused on treating isolated cartilage damage and underlyingmorphological pathology in younger patients in order to pre-vent progression to end-stage degeneration. Although a numberof procedures for the management of chondral lesions in otherlarge joints (e.g. knee) have been reported, there currently re-mains little information available for appropriate managementof these lesions in the hip [17]. All the techniques found in thesystematic review are described and discussed below.
Debridement
Debridement of a cartilage flap from a chondral injury mayallow symptoms to resolve and permit a return to activity orsports [6, 18]. Arthroscopy is essential for the diagnosis of anunstable flap if pre-operative imaging is unclear, and arthro-scopic debridement is often the definitive therapy. Fontanaet al.. [19] carried out a controlled retrospective study of 30patients (15 ACI, 15 arthroscopic debridements) affected by apost-traumatic hip chondropathy (Outerbridge classificationgrades 3–4, measuring 2 cm2 in area or more). The post-operative Harris Hip Scores (HHS) in the ACI group weresignificantly better than those in the debridement group.
Microfracture
Microfracture involves the use of an arthroscopic awl or drillto perforate exposed subchondral bone to create multiple holesand provide an entry portal for marrow-derived cells. Therationale of the technique is to recruit mesenchymal stem cells
into the cartilage defect to create fibrocartilage. Followingmicrofracture, a marrow clot forms and provides the idealenvironment for mesenchymal stem cells to differentiate intostable repair tissue [20]. The advantages of this technique arethat it is technically straightforward, can be performedarthroscopically, without donor site morbidity, and has a lowcost. The disadvantage compared with other cartilage repairtechniques is that it produces less type II cartilage and hasdifferent biomechanical properties than hyaline cartilage,which may raise questions of its resilience and longevity
Fig. 1 Flowchart of the literaturesearch
Table 2 Demographics of the study
Parameter
Studies analysed 21 studies
Levels of evidence
3b 3 studies (14.3%)
4 18 studies (85.7%)
Participants (hips) 596
Male 216 (56.1%)
Female 169 (43.9%)
Unclear 211
Range of follow-up time 6–74 months
Mean participant age (range) 37.2 (15–63) years
Surgical approach
Arthroscopy 11 studies (52.4%)
Open 9 studies (42.9%)
Injection 1 study (4.8%)
Location of cartilage defect (participants)
Acetabulum 534 (93.5%)
Femoral head 37 (6.5%)
Unclear 25
International Orthopaedics (SICOT) (2018) 42:2309–2322 2311
Table3
Detailsof
21studiesincluded
inthesystem
aticreview
.Studies
areorderedby
theyear
ofpublishing
(new
toold).A
geareshow
nin
years
Publication
year
Firstauthor
Levelof
evidence
Meanage(range)
Num
ber
ofcases
Male
Fem
ale
Acetabulum/
femoralhead
Follo
w-upperiod
Surgical
approach
Techniqueused
2016
Mardones[57]
451.8(39–60)
2910
10NA
24months
Injection
Intra-articular
BM-M
SCinjection
2016
Fontana[31]
436.4(18–50)
201
NA
NA
201/0
5years
Arthroscopy
AMIC
2015
Fontana[25]
3b39.2(18–55)
147
9156
147/0
5years
Arthroscopy
77MFx
,70AMIC
2014
Mancini
[28]
3b36.2(19–50)
5725
3257/0
Upto
5years
Arthroscopy
26MACI,31
AMIC
2012
Zaltz[24]
427
(16–31)
107
30/10
29months
Open
3AMIC,7
MFx
2012
Vundelinckx[59]
434
1NA
NA
0/1
6months
Arthroscopy
Artificialp
lug(TruFit®)
2012
Leunig[30]
422.7(15–31)
65
11/5
Minim
um1year
Open
AMIC
2012
Krych
[36]
422
(15–29)
21
10/2
4.3years
Open
Osteochondralautografttransfer
from
theipsilateralk
nee
(mosaicplasty)
2012
Karthikeyan
[23]
437
(17–54)
2016
420/0
17months
Arthroscopy
MFx
2012
Fontana[19]
3b41.5(20–53)
3012
1830/4
74months
Arthroscopy
15ACI,15
debridem
ent
2012
Emre
[34]
422
11
00/1
3years
Open
Osteochondralautografttransfer
from
theipsilateralk
nee
(mosaicplasty)
2011
Stafford
[50]
434.2(18–53)
4325
1843/0
28months
Arthroscopy
Fibrin
adhesive
2011
Krych
[40]
428
(24–32)
21
12/0
Minim
um24
months
Open
Osteochondralallograft
transplantation
2011
Girard[37]
418
(15–21)
107
30/10
29.2
months
Open
Osteochondralautografttransfer
from
theinferior
portionof
the
femoralhead
(mosaicplasty)
2011
Field[58]
448.6(31–63)
41
34/0
10months
Arthroscopy
Artificialp
lug(TruFit®)
2010
Tzaveas
[49]
436
(18–57)
195
1419/0
19months
Arthroscopy
Fibrin
adhesive
2010
Nam
[35]
418
(15–21)
22
00/2
Minim
um1year
Open
Osteochondralautografttransfer
from
(1)theipsilateralkneeand
(2)theinferior
portionof
the
femoralhead
(mosaicplasty)
2009
Sekiya
[42]
417
11
01/0
2years
Arthroscopy
Directcartilagesuture
repair
2008
Philippon
[22]
437.2(21–47)
95
49/0
20months
Arthroscopy
MFx
2008
Ellender
[27]
419
10
10/1
2years
Open
ACI(followingprevious
mosaicplasty)
2003
Hart[33]
428
11
00/1
6months
Open
Osteochondralautografttransfer
from
theipsilateralk
nee
(mosaicplasty)
Publication
year
Pre-operativ
econdition
Post-operativ
erehabilitationprotocol
Finaloutcom
eOther
comments
2016
Symptom
aticFA
Iandfocalchondral
delaminations
(Outerbridge
classification
grades
III–IV
)with
mild
tomoderateOA
(TӧnnisscaleII–III)
Walking
with
2crutches
andweightb
earing
astoleratedwas
allowed
onthefirst
post-operativ
eday.
The
medianpre-operativemHHS,
WOMACand
VAIL
scores
were64.3,73and56.5,
respectiv
ely,andthey
increasedto
91,97and
83atfinalfollow-up(p<0.05).The
VAS
scorealso
improved
from
amedianof
6to
2.
Four
patientsreceived
aTHR(13%
ofthehips)
atthemedianof
9monthspost-intervention
(range
6–36
months);80mLof
bone
marrow
was
aspiratedfrom
theanterior
iliac
crest
during
hiparthroscopy.Eachpatient
received
3intra-articular
injections
of20
×10
6
BM-M
SCspost-operatively(4–6
weeks).
2312 International Orthopaedics (SICOT) (2018) 42:2309–2322
Tab
le3
(contin
ued)
Publication
year
Pre-operativ
econdition
Post-operativ
erehabilitationprotocol
Finaloutcom
eOther
comments
2016
Outerbridge
gradeIIIand/or
IVchondrallesions
locatedinthesuperior
area
oftheacetabulum
.Acetabularchondrallesion
size
was
between
2and4cm
2;radiologicalT
önnisdegree
ofosteoarthritiswas
≤2.The
meandefectsize
was
2.9±0.8cm
2.
Walking
was
allowed
with
theaidof
2crutches
with
partialw
eightb
earing
(30%
ofbody
weight)on
theoperated
legfor3weeks.
Pre-operativemHHShadameanscoreof
44.9±5.9.Significantimprovem
ent,as
measuredby
themHHS,
was
observed
at6monthsin
comparisonto
pre-operative
levels(80.3±8.3)
(p<0.001).C
ontinuous
improvem
entw
ithrespecttoeach
previous
evaluatio
ntim
epointw
asseen,reachingthe
highestimprovem
entlevelatthe3-year
follow-up(85.5±7.2).T
hemeanmHHS
improvem
entrecordedatthe5-yearfollow-up
comparedwith
pre-operativescores
was
39.1±5.9.
Nofailu
reresulting
inhiparthroplasty
was
detected
inanyof
thesepatientsduring
the
5-year
follow-up.Nopatient
hadapoor
post-operativ
emHHS(>
60).
2015
AcetabulargradeIIIandIV
chondrallesions
(Outerbridge
classificatio
n)measuring
between2and8cm
2.L
essthan
grade2
degenerativechangesradiologically
accordingto
theTӧnnisclassification
Non-w
eightb
earing
for4weeks.P
artialload
bearingup
to7weeks,afterwards
full.
The
meanmHHShadim
proved
significantly
inboth
groups
6monthspost-operatively(76.3
forMFx
(58to
98)and79.5forAMIC
(68to
96),p<0.001).A
tthistim
e,therewere
significantly
betterresults
intheAMIC
group
(p<0.025).D
ifferences
inoutcom
ebetween
the2groups
becamemoreapparent
1year
post-operatively,andthistrendcontinued
throughout
thesubsequent
follo
w-up.The
meanmHHSin
theMFx
groupwas
lowestat
between4and5years(72.4:
48to
92)
post-operatively.Conversely,the
improvem
entinmHHSseen
intheAMIC
groupwas
maintainedthroughout
the5-year
assessmentp
eriod.AMIC
grouphadbetter
andmoredurableim
provem
ent,particularly
inpatientswith
large(≥
4cm
2)lesions.The
outcom
ewas
significantly
betterintheAMIC
groupforboth
men
andwom
enat2,3,4and
5years,except
forwom
en5years
post-operatively.
Atotalo
f6patients(7.8%)in
theMFx
group
required
THRatameanof
3.2years(1
to5)
post-operativ
ely.Nonein
theAMIC
group
required
THR.
2014
Grade
IIIandIV
(Outerbridge
classificatio
n)acetabular
chondrallesions,mostly
locatedin
thesuperior
chondralacetabulum
.Patients
with
acetabularchondrallesion
size
between2
and4cm
2with
radiologicalTönnisdegree
<2.
Partialw
eightb
earing
(30%
ofbody
weight)on
theoperated
legfor3weeks.A
t4weeks
post-op,walking
with
theaidof
1crutch
oppositetotherecovering
legwas
allowed
for
7days,thennorm
alwalking
thereafter.
InboththeMACIandAMIC
groups,significant
hipscoreim
provem
entsweremeasuredover
baselin
elevelsat6monthspost-op
(81.2±8.4forMACI,80.3±8.3forAMIC,
both
p<0.001).S
tatistically
significant
differencesbetweenthegroups
werenot
observed.T
hemeanmHHSim
provem
entat
the5-year
follo
w-upwith
respectto
pre-operativelevelw
as37.8±5.9and
39.1±5.9in
patientswho
underw
entM
ACI
andAMIC,respectively(not
significant).
Nofailu
reresulting
inhiparthroplasty
was
detected
inanyof
thesepatientsduring
the
5-year
follow-up
2012
Full-thicknessparafovealchondrallesions
localised
anterolateraltothefoveaconfirmed
Patientswerelim
itedtotoe-touchweightbearing
forapproxim
ately6weeks.A
fter
6weeks
The
Tegner-Lysholm
scoreatlatestfollo
w-up
ranged
from
5to
9(m
ean,7.4).A
llpatients
International Orthopaedics (SICOT) (2018) 42:2309–2322 2313
Tab
le3
(contin
ued)
Publication
year
Pre-operativ
econdition
Post-operativ
erehabilitationprotocol
Finaloutcom
eOther
comments
atthetim
eof
surgicaldislocation.The
lesion
size
ranged
from
96to
513mm
2with
amean
of184mm
2.
andradiographicconfirmationof
trochanteric
union,progressiveweightb
earing
was
encouraged.
wereabletoreturn
totheirpre-operativelevel
offunctio
nwith
theexceptionof
patient
6whose
contralateralh
ipprecluded
participation.There
was
noobvious
asym
metricjointspace
narrow
ingvisibleon
anAPpelvisview
inanyof
thepatients.
2012
Severe
osteochondrallesionwith
asubchondral
cyston
thefemoralhead
seen
onMRI.
Restrictedweightb
earing
during
4weeks
(walking
with
crutches
andplantartouch).
MRIscanning
at6monthsshow
edtheTruFit
plug
insitu,w
ithoutsubsidence,whilstthere
still
isan
irregularity
ontheborder
ofthe
articular
cartilage
surface.At6
months,the
righth
ipshow
edan
abductionof
35°,a
symmetricendorotatio
nandexorotationof
30°andan
adductionof
10°.Flexionwas
95°,
comparedto
110°
atthecontralateralside.
2012
Large
(>2cm
2)femoralhead
oracetabular
chondralor
osteochondrallesions.A
llwere
classified
asICRSgrade3or
4lesionsand
Tӧnnisgrade<2.
Not
mentioned
Post-operativeOxfordHip
Scores
ranged
from
13to
17,U
CLAActivity
Scores
ranged
from
5to
10andMOCARTscores
ranged
from
55to
75.
Twopatients(33%
)werelostto
follo
w-up.
2012
2cm
×5to8mmarea
ofosteochondraldefectin
patient
1and1×2cm
area
ofosteochondral
defectin
patient
2.Bothdefectswerein
the
anterosuperior
weight-bearingportionof
the
femoralhead.
Patientswerekept
partialw
eightb
earing
for
2monthsaftersurgeryandthen
were
gradually
returned
tofullweightb
earings.
MRIat6monthsshow
edcomplete
incorporationof
theosteochondralp
lugs
into
thefemoralhead.A
t4yearsfollow-up,
patient1hadmHHS96,H
OS100andpatient
2hadmHHS100,HOS100.
Radiographs
show
edheterotopicossificatio
npost-operativelyin
both
ofthepatients.
2012
Full-thicknessacetabular
chondraldefectsin
the
superior
andanterosuperior
zonesof
the
acetabulum
(average
154m
m2,range
48–300
mm
2)
Forthefirst6
weeks,onlyfoot-flatn
on-w
eight
bearingwas
allowed.F
ullw
eightbearing
was
achieved
over
thefollo
wing2weeks.
The
meanNAHSim
proved
from
55to
78.
Excluding
1patient
who
only
hada25%
fill,
19of
the20
patientshadameanfillof
96%
(range,75–100%
)with
macroscopicallygood
quality
(grade
1)repairtissueas
perBlevins
etal.’s
classificatio
n.2012
Post-traum
atichipchondropathy
ofgrade3or
4accordingto
theOuterbridge
classificatio
n,measuring
2cm
2in
area
ormore.The
mean
size
ofthedefectwas
2.6cm
2 .
Non-w
eightb
earing
for4weeks.P
artialload
was
allowed
after4weeks
ingroupA(A
CI)
andafter2weeks
ingroupB(debridement).
The
patientswho
underw
entA
CI(group
A)
improved
aftertheprocedurecomparedwith
thegroupthatunderw
entd
ebridementalone
(group
B).The
meanHHSpre-operatively
was
48.3(95%
confidence
interval,45.4to
51.2)in
groupAand46
(95%
CI,42.7to
49.3)in
groupB(nosignificantd
ifference).
The
finalH
HSwas
87.4(95%
CI,84.3to
90.5)in
groupAand56.3(95%
CI,54.4to
58.7)in
groupB(p<0.001).
2012
The
radiographsdisplayedachondraldefectin
thesuperolateralaspecto
fthefemoralhead.
Pre-operativeHHSwas
43.
Not
mentio
ned
mHHSim
proved
from
43to
96at24
weeks.A
ta3-yearfollo
w-up,thepatient
was
symptom
-freewith
near
complete
incorporationof
thegraftradiographically.
The
patient
hadpasthistoryof
Perthesdisease.
2011
Delam
inated
acetabular
articular
cartilage
(Apositiv
e‘w
avesign’atthechondrolabral
Toe-touchweightb
earing
with
crutches
isadvisedfor4weeks.
mHHSforp
ainim
proved
significantly
from
21.8
(95%
CI19.0to
24.7)pre-operativelyto
35.8
(95%
CI32.6to
38.9)post-operativ
ely
There
were3patientswho
required
further
arthroscopicinterventions
forpersistent
symptom
s,createdby
iliopsoas
irritatio
n.At
2314 International Orthopaedics (SICOT) (2018) 42:2309–2322
Tab
le3
(contin
ued)
Publication
year
Pre-operativ
econdition
Post-operativ
erehabilitationprotocol
Finaloutcom
eOther
comments
junctio
nindicateddelaminationof
articular
cartilage
from
thesubchondralb
one).
(p<0.0001).The
MHHSforfunctionalso
show
edsignificant,although
moremodest,
improvem
entsfrom
40.0(95%
CI37.7to
42.3)pre-operativelyto
43.6(95%
CI41.4to
45.8)post-operativ
ely(p=0.0006).There
were3patientswho
hadearly(w
ithin
12monthsof
theindexprocedure)
revision
arthroscopyforiliopsoas
pathology.
each
oftheseprocedures,the
previously
repaired
articularcartilage
was
seen
tobe
ingood
condition.
2011
18×18
mm
isolated
defectof
thesuperior
acetabular
domein
patient
1and12
mm
diam
eter×10
mm
deep
osteochondrald
efect
intheweight-bearingdomeof
thesuperior
acetabulum
inpatient
2
Eight
weeks
ofprotectedweightb
earing
AnMRIat18
monthsin
both
cases
demonstratedincorporationof
theallograft
bone
into
thehostacetabulum
.At2
4months
inpatient
1and42
monthsin
patient
2,radiographsshow
edno
progressivejoint
spacenarrow
ingcomparedto
pre-operative
radiographs.Patient
1hadim
provem
entin
mHHSfrom
75pre-operativelyto
97at
2yearsfollo
w-up.mHHSim
proved
from
79pre-operativelyto
100atthetim
eof
3years
follow-upin
patient
2.Bothpatients’HOS
subsetsforactivities
ofdaily
livingandsports
scorewere100pointseach.
Patient
2had2previous
open
hipoperations
for
fibrousdysplasia.
2011
Intra-operatively,themeanarea
ofcartilaginous
damageon
thefemoralhead
was
4.8cm
2
(3–9
cm2).
Patientswerekept
non-weightb
earing
for
6weeks
andthen
progressed
toweight
bearingas
tolerated.
HHSincreasedfrom
52.8(35–74)to79.5points
(65–93).The
OxfordHip
Score
decreased
indicatin
gfunctio
nim
provem
entfrom
34.5
points(22–48)to
19.2points(14–26).At
latestfollow-up,allautograftplugsappeared
tobe
wellincorporatedon
radiological
exam
ination.CT-arthrography
at6months
revealed
intactcartilage
over
theplugswith
smooth
interfaces
betweenthearticulating
bonesin
allcases.
NoTHRwas
required
bythetim
eof
thelast
follo
w-up.
2011
CTconfirmed
thepresence
ofsolitary
subchondralcystsin
theweight-bearing
portionof
theacetabulum
inall4
patients.
Patient
1was
also
foundto
have
subchondral
cystson
theopposing
surfaceof
thefemoral
head
andalabraltear.
Patientsweremobilised50%
weightb
earing
with
crutches
forthefirst6
weeks.T
hiswas
gradually
increasedto
fullweightb
earing
by8weeks.
The
meanNAHSim
proved
from
53.8(range
43.8to
70)pre-operatively,to
66.9(SD18.5,
range53.8to80)atthe
6-weektim
epointand
84.6(SD5.1,range78.8to87.5)at6
months.
Com
putedtomographyandmagnetic
resonanceim
agingat6monthsconfirmed
the
stability
oftheosteochondralp
lugs
and
on-going
healing.Noneof
thepatientshave
developedcollapseof
thefemoralhead
oravascularnecrosis.
MeanBMIwas
27.4.A
bone
tunnelwas
prepared
from
theregion
oftheiliac
crestto
theacetabular
articular
surface.Asynthetic
osteochondralp
lugwas
inserted
inan
antegradefashionandpositionedflushwith
thelunatearticularcartilage.Twopatientshad
undergoneprevious
hiparthroscopy.
2010
Acetabulararticular
cartilage
delaminationor
debonding,identifiedas
macroscopically
soundcartilage,butwith
lossof
fixatio
ntothe
subchondralboneanda‘carpetphenomenon’
orpositive‘w
ave’sign.A
cetabularcartilage
Patientswereinstructed
totouchweightb
earfor
thefirst4
weeks.
There
were5patientswho
required
asecondary
interventionbecauseof
persistent
pain
ordisability;
1received
asteroidandlocal
anaesthetic
injectionto
theaffected
hip;
2required
revision
hiparthroscopybecauseof
International Orthopaedics (SICOT) (2018) 42:2309–2322 2315
Tab
le3
(contin
ued)
Publication
year
Pre-operativ
econdition
Post-operativ
erehabilitationprotocol
Finaloutcom
eOther
comments
delaminationwas
foundadjacent
tothe
anterior
labrum
in16
patientsandto
the
anterosuperior
area
in3.
persistentpain,the
firstasaresultof
iliopsoas
tendonitisandthesecond
forresidual
femoroacetabularandpectineofoveal
impingem
ent,which
was
both
excised.One
patient
received
aresurfacingarthroplasty
becauseof
rapidlydestructiveosteoarthritis
andanotherisscheduledto
undergorevision
arthroscopyin
duecourse
forpersisting
discom
fort.F
orthosepatientswho
underw
ent
revision
arthroscopyor
subsequent
arthrotomy,thearea
ofchondralrepair
appeared
macroscopically
intactandsecure.
MeanmHHSscores
improved
pre-operatively
to1year
post-operativ
elyfrom
15.7to
28.9
forpain
and37.2to
44.1forfunction.
2010
(1)The
full-thicknesscartilage
defectin
the
anterior-superiorweight-bearingzone
ofthe
femoralhead
thatmeasuredapproxim
ately
2cm
inlength
andwas
tapereddownfrom
approxim
ately8to5mminwidth.(2)
Alarge
osteochondralfracturewas
appreciated
measuring
approxim
ately3×3cm
,which
hadbeen
displaceddistally
andsuperiorly.
There
was
also
afull-thicknesscartilaginous
injury
attheapex
ofthefracture,inthe
anterior-superiorweight-bearingzone
ofthe
femoralhead.T
hiszone
ofinjury
was
approxim
ately10
mm
insize.
Post-operatively,thepatientswerekept
non-weightb
earing
for6weeks
andthen
progressed
toweightb
earing
astolerated.
(1)AnMRIperformed
at24
weeks
post-operativ
elydemonstrated
well-incorporated
autograftp
lugs
andintact
cartilage
overtheplugswith
smoothinterfaces
with
theremaining
bone.A
t1yearfollo
w-up,
thepatient
hasno
complaintsof
pain,good
mechanics
with
ambulatio
nandhasreturned
torunningandphysicalactivity
with
out
difficulty.(2)
Radiographs
andan
MRI
performed
at1year
post-operativ
ely
demonstratedawell-incorporated
autograft
plug
with
minim
alfibrillationandno
evidence
ofosteonecrosis.Atover5
yearsoffollow-up,
thepatientcontinuestohave
nocomplaintsof
pain
andhasreturned
tohisbaselinephysical
activities
withoutd
ifficulty.
2009
Peripheralacetabular
articular
cartilage
delaminationwith
chondrallabralseparatio
n.Thisintact1-cm
delaminated
articular
cartilage
flap
(Outerbridge
grade0)
was
partially
offthesubchondralb
one.
Patient
was
allowed
30%
weightb
earing
with
crutches
for6
weeks,graduallyprogressingto
100%
over
thefollo
wing2weeks.
The
patient
reported
beingpain-free90%
ofthe
timewith
pain2/10
atworst.H
escored
96on
mHHS,
93on
HOSActivities
ofDailyLiving
subscaleand81
onHOSSp
ortssubscale.
2008
The
averageacetabular
chondrallesion
size
was
163mm
2.A
lllesionswerelocatedin
the
superior
acetabular
quadrant.
Weightb
earing
was
restricted
totoe-touchfor
8weeks.
The
averagepercentfill
oftheacetabular
chondrallesionsatsecond
look
was
91%
(range,25to
100%
).Eight
ofthe9patients
hadgrade1or
2repairproductatsecondlook
(grade
1was
norm
al-appearing
articular
cartilage,difficultto
discernbordersof
lesion
andnorm
alsurroundingcartilage;grade
2was
mild
fibrillation,discoloured,
softer-than-norm
alcartilage;grade
3was
deep
fissures
orcobblestonesurface,no
exposed
2316 International Orthopaedics (SICOT) (2018) 42:2309–2322
Tab
le3
(contin
ued)
Publication
year
Pre-operativ
econdition
Post-operativ
erehabilitationprotocol
Finaloutcom
eOther
comments
bone;and
grade4was
full-thicknesscartilage
loss
with
exposedsubchondralb
one).O
nepatient
who
haddiffuseosteoarthritisfailed,
with
only
25%
coverage
with
agrade4
appearance
oftherepairproduct1
0months
afterindexarthroscopyandrequired
totalh
iparthroplasty
66monthsaftertheindex
microfracture.
2008
MRarthrogram
revealed
full-thicknessloss
ofthesurroundingarticular
cartilage
onthe
major
weight-bearingportionof
thefemoral
head.Intra-operativemeasuremento
fthe
chondraldefectmeasured4.0cm
by2.5cm
around
intactosteochondralp
lugs.
Progressiveweight-bearingactiv
itycanbeginas
earlyas
6weeks
butisusually
delayeduntil
8to
12weeks.
Twoyearslater,thepatient
remains
free
ofpain,
herpost-operativecontrast-enhancedMRI
demonstratesrepairtissuefillandradiographs
show
edanorm
aljointspace.
The
patienthadprogressionof
diseaseafterp
rior
autologous
osteochondralm
osaicplasty.
Fixatio
nof
themem
branewasperformed
with
theuseof
6.0Vicrylsuture.Fibrin
glue
was
used
tofurthersealthemem
brane.
2003
The
diam
eter
oftherounddefectwas
14mm,
andits
depthwas
16mm.
Partialw
eightb
earing
was
perm
itted
at6weeks
andfullweightb
earing
at10
weeks
afterthe
surgery.
HHSim
proved
from
69to
100points.A
t6monthspost-operativ
ely,thepatientshow
edthefullrangeof
painless
motionwith
nofurthercomplaintsof
restpain
orpain
related
toactiv
ities.
The
defectwas
caused
bypenetrated
resorbable
screwused
inthepastsurgicalfixationof
adisplacedlargesinglefragmento
fthe
posterioracetabular
rim.
FAIfem
oroacetabularim
pingem
ent,MFxmicrofracture,B
M-M
SCsbone
marrowmesenchym
alstem
cells,A
CIautologouschondrocyteim
plantatio
n,MACIm
atrix-associated
chondrocyteim
plantatio
n,AMIC
autologous
matrix-inducedchondrogenesis,(m)H
HS(m
odified)HarrisHipScore,VASvisualanalogue
scale,MOCARTmagnetic
resonanceobservationofcartilage
repairtissue,HOSHipOutcome
Score,N
AHSNon-A
rthriticHip
Score,B
MIbody
massindex,TH
Rtotalh
ipreplacem
ent
International Orthopaedics (SICOT) (2018) 42:2309–2322 2317
[20]. Also, the concentration of mesenchymal cells in the bonemarrow is relatively low and their chondrogenic potential de-clines with age [21]. Philippon et al. [22] reported the outcomeof microfracture in nine patients with a full-thickness chondraldefect of the acetabulum. The average percent fill of the ace-tabular chondral lesions at second-look arthroscopy was 91%,and eight of the nine patients had grade 1/2 repair product atsecond look. Karthikeyan et al. [23] described the outcome of20 patients who underwent arthroscopic surgery for FAI witha localised full-thickness acetabular chondral defect whichwere treated by microfracture. At an average follow-up of17 months, 19 of the 20 patients had a mean fill of 96% withmacroscopically good quality repair tissue. Zaltz and Leunig[24] reviewed ten patients with symptomatic FAI diagnosedwith parafoveal chondral defects confirmed at the time ofsurgical dislocation. Seven of the ten patients were treatedby microfracture (other 3 were treated by AMIC), and all thepatients were able to return to their pre-operative level offunction with the exception of one patient who had a problemin the contralateral hip. At the last follow-up, there was noobvious asymmetric joint space narrowing visible on an APpelvis view in any of the patients. Fontana et al. [25] comparedthe outcome of 77 patients who had a microfracture and 70patient who had AMIC for cartilage injuries in the hip.Although the outcome in both groups significantly improvedat six months and one year post-operatively, the outcome inthe microfracture group slowly deteriorated four years aftersurgery, whilst that in the AMIC group remained stable.
Autologous chondrocyte implantation
ACI includes the harvest of chondrocytes with growth andexpansion at an off-site facility, followed by reimplantationof the cells into the affected area. ACI is indicated for symp-tomatic, well-contained defects that are between 2 and 10 cm2
and with less than 6–8 mm of bone loss [26]. Most surgeonswho performACI regularly are now using a synthetic collagenmembrane to cover the implanted chondrocytes [19, 27].Ellender and Minas [27] presented a clinical case and de-scribed ACI for a femoral head chondral defect of 10 cm2 ina 19-year-old female college student who had progression ofdisease after prior mosaicplasty. Two years after ACI, sheremained free of pain. Her post-operative contrast-enhancedMRI demonstrated repair tissue fill and radiographs showed anormal joint space without any sign of change.
Matrix-associated chondrocyte implantation
MACI is a second-generation ACI technique that utilises ab-sorbable scaffolds to support the implanted chondrocytes dur-ing healing. Theoretically, it should restore hyaline cartilage atthe defect. Unfortunately, same as ACI, it is a two-stage pro-cedure where chondrocytes are harvested from the patient,
cultured and then returned to the patient via open surgicaldislocation of the hip which is a technically demanding surgi-cal approach. Mancini and Fontana [28] assessed and com-pared the clinical outcomes of arthroscopic MACI and AMICfor the treatment of acetabular chondral defects between 2 and4 cm2 consequent to FAI. In both groups, significant improve-ment in modified HHS (mHHS) was measured over baselinelevels at six months post-operation. It continued to improve upto three years post-operation and remained stable until fiveyears follow-up. There was no statistically significant differ-ence between the two groups.
Autologous matrix-induced chondrogenesis
AMIC is a novel single-step procedure in which themicrofracture technique has been enhanced by the use of acollagen matrix. The Chondro-Gide matrix is placed in thedefect and a porcine collagen I/III matrix is sewn over thelesion to stabilise the fragile blood clot that arises from themicrofracture to provide a stable infrastructure for the forma-tion of repair tissue [29]. No cells have to be harvested, cul-tured and re-implanted in AMIC. Therefore, there is no har-vest site morbidity, and the operation can be performed as asingle procedure. Moreover, AMIC does not require complexcell expansion techniques. Other than comparative studieswith microfracture [24, 25] or MACI [28] described above,Leunig et al. [30] reported six patients with AMIC using sur-gical dislocation of the hip. No complications occurred, andgood post-operative outcome scores were reported. Fontana[31] treated 201 patients with AMIC arthroscopically forOuterbridge grade III/IV chondral lesions of the acetabulum.Modified HHS improved significantly at six months post-operatively in comparison with pre-operative levels, reachingthe highest level of improvement at the three year follow-up.
Osteochondral autograft transplantation(mosaicplasty)
Mosaicplasty involves transplanting healthy, mature cartilagefrom a non-weight-bearing part of the hip or knee to an artic-ular defect. The transplanted cartilage integrates with the ad-jacent host cartilage via fibrocartilage [32]. The inferior aspectof the femoral head, the femoral head-neck junction and theperiphery of the femoral trochlea of the knee can be the po-tential donor sites. Mosaicplasty offers many potential advan-tages, including the ability to transfer new mature hyalinecartilage into the defect in a single-stage procedure and theabsence of potential disease transmission, which can occur inallograft transplantation. On the contrary, owing to the autol-ogous nature of this technique, it is limited by donor sitemorbidity, graft availability and the potential for dead spacebetween the grafts [32]. Hart et al. [33] first reported the caseof an osteochondral defect of the femoral head and subsequent
2318 International Orthopaedics (SICOT) (2018) 42:2309–2322
treatment using mosaicplasty with open surgical dislocation ofthe hip. At six months following surgery, the patient had a fullrange of painless movement of the hip with no further com-plaints of pain related to activities. Emre et al. [34] also pre-sented a case where the defect of the femoral head was treatedwith surgical dislocation of the hip and mosaicplasty. Thepatient was symptom-free with nearly complete incorporationof the graft radiologically at three years after the operation.Nam et al. [35] reported two cases of a chondral defect on thefemoral head after a traumatic hip dislocation, treated withmosaicplasty from the ipsilateral knee, and the inferior femo-ral head, respectively. At 1 and five years of follow-up, MRIshowed good autograft incorporation with the maintenance ofarticular surface conformity. Krych et al. [36] reported twocases of post-traumatic osteochondral defects of the femoralhead. Both the patients were treated with mosaicplasty fromthe ipsilateral knee to the femoral head, with successful clin-ical and radiological results at a mean follow-up of 4.3 years.Girard et al. [37] treated 10 patients for femoral cartilage de-fects by mosaicplasty of the femoral head through a trochan-teric flip osteotomy with surgical dislocation of the hip. At themean follow-up of 29.2 months, clinical score and range ofmotion improved significantly. All radiological investigationsat the latest follow-up showed that the grafts were well-incorporated at the site of mosaicplasty with intact cartilageover them and smooth interfaces between articulating bonysurfaces.
Osteochondral allograft transplantation
Mosaicplasty has been shown to be a useful procedure, butthere can be donor site morbidity and there is a limit to thesize of the treatable defect. Allograft transplantation canalso be a successful solution for the treatment of cartilagedefects. It offers not only the potential advantages of trans-ferring immediate functional hyaline cartilage but also theability to resurface a large area without associated donor sitemorbidity. Potential allograft donor sources for defectswithin the acetabular side of the hip were a cadaveric ace-tabulum or medial tibial plateau. Cartilage is relativelyimmunoprivileged and avascular; thus, the host immunereaction is considered to be limited [38]. Allograft bonebecomes necrotic and is reabsorbed via creeping substitu-tion during the healing process. This provides a scaffold andsupports the articular surface as part of gradual incorpora-tion [39]. In the systematic review, Krych et al. [40] reportedthei r exper ience in two pat ients who underwentosteochondral allograft transplantation for the acetabularcartilage defects. MRI at 18 months in both cases demon-strated incorporation of the graft into the host acetabulum.Hip Outcome Scores (HOS) were 100 points each in bothpatients two years post-operatively.
Direct cartilage suture repair
Delamination is a full-thickness cartilage separation from theunderlying subchondral bone, which forms an unstable flap atrisk for complete detachment [41]. Our review found a casereport that presented direct cartilage repair as a possible tech-nique to treat large delaminated full-thickness acetabular carti-lage repairs. Sekiya et al. [42] described a case of a 17-year-oldboy presented with bilateral hip pain because of bilateral CAM-type FAI and a 1-cm delaminated unstable cartilage flap in theanterior-superior acetabulum. Arthroscopic microfracture un-derneath the flap of anterior-superior acetabular cartilage andan absorbable monofilament suture repair of the cartilage wasconducted. At two years post-operatively, the patient reported95% of normal function for both hips. Overall, the patient wassatisfied with the outcome including a score of 96 on themHHS, 93 on the HOS Activities of Daily Living subscaleand 81 on the HOS Sports subscale at the final follow-up.
Fibrin adhesive
The earliest stage in the formation of an articular cartilage flap isdelamination of the overlying articular cartilage from the un-derlying subchondral bone [43]. Particularly, if the articularcartilage itself may contain a significant number of viablechondrocytes, debriding such an area of chondral instabilityseems an unnecessary surgical procedure. Fibrin adhesive is abiological substance, which has already been used in generalsurgery, ophthalmology, neurosurgery, otolaryngology and or-thopaedics, thanks to its adhesive properties [44–48]. This pro-cedure involved creating an incision at the periphery of theacetabular labrum and passing an awl underneath to createmicrofracture. Fibrin glue was inserted between subchondralbone and delaminated cartilage, and the cartilage was presseddown until the adhesive had set. Tzaveas and Villar [49]analysed the efficacy of using fibrin adhesive for arthroscopicrepair of chondral delamination lesions with intact gross carti-lage structure in 19 patients. Mean mHHS was improved sig-nificantly after surgery, and in all five patients who underwentrevision arthroscopy at a later date, the chondral repair appearedintact. Stafford et al. [50] reported the results of 43 patients withFAI who have undergone fibrin adhesive technique for re-attachment of delaminated chondral flaps. Both mHHS for painand function improved significantly after the operation. In threepatients who required further arthroscopic interventions for per-sistent symptoms created by iliopsoas irritation, the previouslyrepaired articular cartilage was found in a good condition.
Intra-articular BM-MSC injection
Adult MSCs were originally believed to only differentiate intotissue-specific cells. However, these cells were recently proven tohave the ability to differentiate into a different tissue in response
International Orthopaedics (SICOT) (2018) 42:2309–2322 2319
to specific signals released by the site of injury, including carti-lage injury [51, 52]. Adding to animal studies, several authorsreported on intra-articular injection ofMSCs into the knee for thetreatment of cartilage defects and showed good results with re-gard to pain and clinical outcomes [53–56]. Injected MSCs wereincorporated into the articular cartilage of the injected joint. Theyintegrate into the surface of the cartilage and also the interior ofthe cartilage [52]. Mardones et al. [57] first reported the outcomeof intra-articular BM-MSC injection for the cartilage injury in thehip. Three intra-articular injections of 20 × 106 BM-MSCs wereconducted from four to six weeks post-operatively in 29 hips thatreceived hip arthroscopy for FAI and focal cartilage injuries.Clinical outcome scores and VAS improved significantly aftersurgery, and no major complications had been reported at thetime of the last follow-up.
Artificial plug
The systematic review found two articles that used an artificialplug, and both of them utilise the TruFit cartilage/bone (CB) plug(Smith & Nephew). It is a resorbable polymer scaffold that canbe inserted into osteochondral defects, which acts as a scaffoldthat provides structural support. Also, native marrow elementscan migrate into the plug to promote bone in-growth as well asarticular cartilage regeneration. Field et al. [58] described the useof TruFit for the treatment of acetabular cystic cartilage lesions infour patients. Patients underwent hip arthroscopy followed by theantegrade insertion of a plug through the ilium until the surface ofthe plug coincided with the articular surface. At ten months fol-low-up, patients reported increased function and improvement inNon-Arthritic Hip Score (NAHS). CT and MRI showed incor-poration and continued healing of the plug six months post-op-eratively. Vundelinckx et al. [59] reported a case of a 34-year-oldemployee (gender was not described) who underwent TruFit foran osteochondral injury of the femoral head. MRI at six monthsshowed the TruFit was placed in situ whilst there was an irregu-larity on the border of the articular cartilage surface. They men-tioned it was very difficult to interpret early MRI images ofingrowth of TruFit plugs, as described by authors of past radio-graphic studies [60].
Of the 21 studies found in the systematic review, only 3 stud-ies are level IIIb (retrospective comparative study) and the restwere level IV (case series/report). Two studies described superi-ority of one cartilage repair method over another [19, 25], andone study showed there was no difference in clinical outcomebetween two methods [28]. Fontana’s study [19] was limited bythe reduced number of patients and the lack of an objectivemethod for the evaluation of the results. Other limitations arethe criteria for patient inclusion and selection bias in therandomisation process. Fontana’s study [25] andMancini’s study[28] were also limited by the lack of randomisation, and clinicaloutcomes were only assessed using the mHHS.
The strengths of this systematic review include the pursuit ofknowledge in an important novel area of investigation and arigorous methodological approach. Regarding the methodologi-cal approach, a broad-based and comprehensive literature searchof multiple databases with multiple reviewers allowed for a veryinclusive approach to capture the vast majority of existing liter-ature. Nonetheless, there are limitations which include the inclu-sion of English only studies and the overall low level of evidenceavailable in the included studies on this topic (mostly level IIIband IV studies). Retrospective designs are prone to data inaccu-racy as well as missing information, which subject them to se-lection and detection bias. Without a doubt, this diminishes theaccuracy of the data collected and, therefore, limits the quality ofa systematic review, whilst this current level of evidence reflectsthe novel and emerging nature of cartilage repair strategies in thehip joint. Additionally, our results include a wide spectrum ofpathologies and methods of treatment, which also made drawingconclusions and giving specific guidelines difficult. Furthermore,pre-operative condition and post-operative rehabilitation protocolwere different in each study, which made comparison amongstudies difficult as well. Future studies should address compara-tive effectiveness of the various treatment options, and long-termregistry-based studies that report patient reported outcomes andradiographic outcomes will help inform treatment decisions.
Conclusion
Although there are many different cartilage restoration tech-niques available, current best evidence does not support anyone surgical technique as a superior method for treating carti-lage injuries in the hip. Unfortunately there remains a paucityof randomised trials with long-term follow-up, which makes itdifficult to perform a meaningful assessment of the outcomeof each procedure. Of the 21 studies found in the systematicreview, AMIC, mosaicplasty and microfracture were relative-ly well-reported, though they were only described in verylimited case series. Also, only two studies described superior-ity of one cartilage repair method over another—one showedsuperiority of AMIC over microfracture [25] and anothershowed superiority of ACI over debridement [19], and onestudy showed that there was no statistically significant differ-ence between MACI and AMIC in terms of post-operativemHHS [28]. To make any specific recommendations for or-thopaedic surgeons with regards to treatment decisions, ade-quately powered long-term large-scale high-qualityrandomised-control trials focusing on two or three specificmethods of treatment need to be conducted in the future.
Contribution of authors VK takes responsibility for the integ-rity of the work as a whole, from inception to the finishedmanuscript. NN, CG, AD, OA and VK were responsible forthe conception and design; NN, CG and VK for the collection,
2320 International Orthopaedics (SICOT) (2018) 42:2309–2322
assembly, analysis and interpretation of data; NN, OA and VKfor drafting; and NN, CG, AD, OA and VK for the finalapproval of the manuscript and for the critical revision forimportant intellectual contents.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict ofinterest.
Ethical approval This article does not contain any studies with humanparticipants.
Appendix
Search strategy
Two reviewers (NN and CG) searched the online databases(PubMed (Medline), EMBASE, Google Scholar, BNI,CINAHL and AMED) for literature describing the outcome ofcartilage repair techniques for the chondral injury in the hip. ThePreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for designing thisstudy. Database search was conducted on 1st March 2017 andretrieved articles from database inception to the search date. Theresearch question and individual study eligibility criteria wereestablished a priori. We used medical subject headings includingthe following key search terms: hip, cartilage, chondral, repair,regeneration, restoration, refixation, implantation, chondroplastyand chondrogenic. Terms were connected by the Boolean oper-ators ‘AND’ and ‘OR’. Levels I, II, III, IV and V evidence (ac-cording to the Oxford Centre for Evidence-Based Medicine)English-language studies were eligible for inclusion in the sys-tematic review. The search also included the yet to be printedsearch results. Results were pooled, and duplicate searches wereexcluded by having two reviewers (NN and CG) independentlyreview all the titles and abstracts. Both of the reviewers had beentrained in a field of clinical research and had enough experienceat the stage of abstract screening and manuscript review. Anydiscrepancies at the title and abstract stage were resolved byautomatic inclusion to ensure thoroughness. The remainingsearch results were divided equally between two reviewers(NN and CG) and reviewed in duplicate applying the inclusionand exclusion criteria. Any discrepancies at the full-text stagewere resolved by consensus between the two reviewers. If aconsensus could not be reached, a third more senior reviewer(VK) was consulted to resolve the discrepancy. Also, for qualitycontrol, VK reviewed a 25% random sample of excluded studiesand all included title and abstracts.
Open Access This article is distributed under the terms of the CreativeCommons At t r ibut ion 4 .0 In te rna t ional License (h t tp : / /creativecommons.org/licenses/by/4.0/), which permits unrestricted use,distribution, and reproduction in any medium, provided you give appro-priate credit to the original author(s) and the source, provide a link to theCreative Commons license, and indicate if changes were made.
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