Hip Joint Cartilage Surgery

Hip Joint Cartilage and Focal Damage

The surfaces of the femoral head and acetabulum that make up the hip joint are covered with a special type of cartilage called hyaline cartilage. This cartilage:

• Provides nearly frictionless movement between the joint surfaces.
• Absorbs shocks generated during activities such as walking and running, and distributes the load.
• Protects the underlying bone tissue.

Focal Cartilage Damage vs. Widespread Osteoarthritis (Coxarthrosis): The condition discussed in this article differs from hip osteoarthritis (coxarthrosis), in which cartilage wears down and thins extensively over a wide area of the hip joint. Focal cartilage damage is full-thickness or near full-thickness cartilage loss in a limited area of a specific region of the joint (the femoral head or acetabulum), where the surrounding cartilage is generally intact. This damage is frequently found together with another underlying problem, particularly Femoroacetabular Impingement (FAI) and labral tears.

Purpose of Hip Cartilage Surgery:

• To create a smooth joint surface by repairing or regenerating the damaged cartilage area.
• To relieve pain and mechanical symptoms such as catching and locking.
• To improve the functions of the hip joint (range of motion, load-bearing capacity).
• To correct the underlying causes of cartilage damage (particularly FAI).
• To prevent or delay the development of osteoarthritis in the hip joint.

Why Does Hip Cartilage Damage Occur? Risk Factors

The main causes of focal cartilage damage in the hip joint are as follows:

• Femoroacetabular Impingement (FAI): The most commonly associated condition. Due to abnormal bone shapes (Cam or Pincer type), repetitive abnormal contact and impingement between the femoral head/neck and the acetabular rim during movement damages both the labrum and the adjacent cartilage (particularly at the anterosuperior rim of the acetabulum and the anterolateral surface of the femoral head).
• Trauma: Injuries that directly affect the joint surface, such as hip dislocation or subluxation, acetabular fractures, and femoral head fractures.
• Avascular Necrosis (AVN): Disruption of the blood supply to the femoral head causes the bone tissue to die and collapse, which also damages the cartilage above it.
• Developmental Dysplasia of the Hip: An insufficiently deep hip socket can disrupt load distribution in the joint, leading to premature cartilage wear.
• Osteochondritis Dissecans (OCD): Rarely seen in the hip; it involves separation of a fragment of the bone beneath the cartilage due to disrupted blood supply.
• History of Perthes Disease: Deformities that develop in the femoral head following childhood Perthes disease can lead to cartilage problems later in life.
• Intra-articular Loose Bodies: Bone or cartilage fragments floating within the joint can also damage the joint surfaces.

What Are the Symptoms of Hip Cartilage Damage?

Symptoms generally resemble those of labral tears and FAI, and they frequently occur together:

• Pain: Sharp or aching pain typically felt in the groin area (front of the hip). It may sometimes radiate to the side or back of the hip (buttock). It increases with activity, deep squatting, prolonged sitting, or certain hip movements.
• Mechanical Symptoms: Catching, locking, popping, or clicking in the hip during movement. These symptoms are particularly suggestive of cartilage damage or intra-articular loose bodies.
• Restricted Movement: Pain and restriction when fully flexing the hip or rotating it internally/externally.
• Feeling of Instability: Rarely, a sensation of the hip giving way.

How Is Hip Cartilage Damage Diagnosed?

The diagnosis is made through a combination of a detailed history, careful examination, and advanced imaging methods:

• Detailed History: The location, character, and onset of pain, triggering factors, mechanical symptoms, history of trauma, and activity level are questioned.
• Physical Examination: Hip range of motion (active and passive), painful movements, impingement tests suggestive of FAI (FADIR, FABER), crepitus (grinding sound), and muscle strength are evaluated.
• Imaging Methods:
  
  • X-ray: Taken to assess bone structures, FAI morphology, dysplasia, joint space (osteoarthritis?), loose bodies, and late findings of AVN. It generally does not show isolated cartilage damage.
  • Computed Tomography (CT): Shows bone details (FAI, fractures) better.
  • Magnetic Resonance (MR) Imaging or MR Arthrography (MRA): The most valuable method for diagnosing cartilage damage. It shows the location, size, and depth of the cartilage defect, the condition of the underlying bone (edema, cyst), and accompanying issues such as labral tears. MRA (contrast-enhanced MR) is frequently preferred, particularly to better visualize labral and cartilage details.
• Diagnostic Intra-articular Injection: An image-guided local anesthetic injection may be performed to confirm whether the source of the pain is intra-articular.

Hip Cartilage Surgery Options (Arthroscopic Approach)

Surgical treatment of focal hip cartilage damage is generally performed using arthroscopic (closed) methods and is frequently carried out together with labral repair and FAI correction in the same session. Although the techniques used are similar to those used in the knee, they are technically more challenging due to the anatomy of the hip, and the options may be more limited:

1. Arthroscopic Debridement / Chondroplasty: Involves shaving and cleaning up the loosened or frayed edges of the damaged cartilage. It may temporarily relieve symptoms but does not repair the cartilage. Usually performed for small, superficial damage or as an addition during other procedures.
2. Bone Marrow Stimulation Techniques (Microfracture / Nanofracture): Small holes are made in the bone beneath the damaged area to encourage bone marrow stem cells to reach the site and form a repair tissue (fibrocartilage). Generally applicable in young patients and in small (< 2 cm²), contained defects surrounded by healthy cartilage, on both the femoral head and the acetabulum. However, the resulting fibrocartilage is not as durable as the original hyaline cartilage, and its long-term outcomes in the hip are less predictable than in the knee.
3. AMIC (Autologous Matrix-Induced Chondrogenesis): A technique in which, after the holes are made, the damaged area is covered with a special collagen membrane (matrix) to enhance the effectiveness of the microfracture procedure. This membrane is thought to help keep the cells coming from the bone marrow contained within the defect and to promote the formation of a more organized repair tissue.
4. Osteochondral Autograft Transplantation (Mosaicplasty / OAT): Cartilage-bone cylinders (plugs) taken from the patient’s own knee or from a non-weight-bearing area of the hip are transplanted into the damaged area of the hip. Performing this arthroscopically in the hip joint is technically very difficult and is generally a limited option for small-to-medium-sized femoral head defects. Harvesting the graft from the knee carries the risk of an additional surgery and potential knee problems.
5. Osteochondral Allograft Transplantation: Involves using cadaveric cartilage-bone grafts of suitable size and shape obtained from a tissue bank. This is an important option, particularly for large focal defects (on both the femoral head and the acetabulum). It has the advantage of filling large areas with original hyaline cartilage in a single session, but the availability of the graft, its cost, and technical difficulty are disadvantages.
6. Autologous Chondrocyte Implantation / Transplantation (ACI / MACI): A two-stage method (biopsy, cell culture, transplantation). It is applied much less frequently in the hip than in the knee. It may generally be considered for large femoral head defects in young patients. It is technically very challenging, costly, and requires a long rehabilitation period.
7. Biological Augmentation: The use of PRP or bone marrow/adipose tissue-derived cell concentrates in addition to procedures such as microfracture is being investigated, but there is not yet sufficient evidence regarding its effectiveness.

With his experience in hip arthroscopy, Prof. Dr. Murat Bozkurt determines the most appropriate treatment strategy based on the characteristics of the patient and the cartilage damage.

Surgical Choice, Risks, Benefits, and the Long Recovery Process

• Factors Affecting Surgical Choice: The size, location (femoral head vs. acetabulum), and depth of the damage; the patient’s age and activity level; the presence and treatment of accompanying FAI and labral tears (very important!); bone quality; and the surgeon’s experience.
• Benefits: Relief of pain and mechanical symptoms such as catching, improvement of hip function, an increase in activity level, and the potential delay of the development of hip osteoarthritis.
• Risks: General surgical and anesthesia risks. Risks specific to hip arthroscopy (nerve injury – numbness in the groin/thigh, traction-related problems, infection, DVT/PE, joint stiffness). Risks specific to cartilage surgery (failure of the repair or graft, nonunion, persistence of symptoms, need for repeat surgery).
• Recovery Process: Recovery after hip cartilage surgery is a long, demanding process that requires full commitment to rehabilitation. It is similar to recovery from knee cartilage surgery, and can sometimes be even more restrictive.
  
  • Crutches and Non-Weight-Bearing: Depending on the procedure performed, it is usually necessary to avoid bearing weight—or to bear very little weight—on the leg while using crutches for generally 6 to 8 weeks or longer. This is essential to protect the repaired cartilage.
  • Movement Restrictions: Hip movements (particularly flexion and rotation) are restricted initially. A special brace may sometimes be used.
  • Intensive and Progressive Physical Therapy: Begins with passive movements started immediately after surgery, and progresses very slowly and in a controlled manner over months to active movements, followed by strengthening, balance, and functional exercises. Working with a physiotherapist experienced in hip arthroscopy is very important.
  • Timeline: Return to normal daily life takes months. Return to sports or strenuous activities generally takes 9 to 12 months or longer, and may not always be possible.

Hip Cartilage Surgery in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Focal cartilage damage in the hip joint, together with accompanying FAI/labral tears, are conditions that reduce quality of life—particularly in young and active individuals—but require specialized expertise for diagnosis and treatment. Prof. Dr. Murat Bozkurt applies current diagnostic and treatment methods in this field in Ankara:

• Expert Diagnosis: Accurately diagnoses cartilage damage as well as underlying FAI and labral pathologies using advanced imaging methods (particularly MR Arthrography) and detailed clinical evaluation.
• Comprehensive Surgical Treatment: When surgery is required, aims to treat the cartilage damage (with an appropriate technique – microfracture, AMIC, etc.), the labral tear (repair), and the bony impingement causing FAI (osteoplasty) all in the same session via hip arthroscopy. This comprehensive approach is important for long-term success.
• Technical Expertise: With his experience in hip arthroscopy and cartilage restoration techniques, he meticulously applies the most suitable and up-to-date surgical method for each patient.
• Focus on Rehabilitation: Guides and closely monitors the patient through the long and structured rehabilitation process, which is an indispensable part of post-surgical success.

Focal cartilage damage in the hip joint is a condition that can lead to pain and loss of function, but can be managed with early diagnosis and appropriate treatment. Simultaneously correcting underlying issues such as FAI with arthroscopic methods, in particular, increases the chance of long-term success. However, it should not be forgotten that the long and patience-requiring rehabilitation process following these surgeries is also an integral part of the treatment. You may consult the expertise of Prof. Dr. Murat Bozkurt in Ankara for your hip cartilage problems.

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt at 0312 502 70 74.