This document discusses the classification and treatment of chondral lesions of the hip. It begins by describing the layers and structures of the hip joint. It then reviews various classification systems for grading chondral lesions of the acetabulum and femoral head, including the Outerbridge, Beck, and Sampson systems. Diagnostic tools for evaluating hip pathology such as x-rays, MRI, and arthroscopy are also discussed. Finally, the document outlines treatment options for chondral lesions based on the type and size of the lesion and any associated morphological abnormalities, including debridement, microfracture, and various grafting techniques.

1. Classification and Treatment of
Hip Chondral Lesions
Jorge Cruz de Melo

2. The Porto Hip Unit
PHM2015

3. The Porto Hip Unit
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• Zonas
• Articulación de la cadera
• Compartimiento central
• Compartimiento
periférico
• Peritrocantérico
• Sub-Glúteo
• Isquio-femoral
• Isquio-tibiales
• Sacro-ilíaco
• Sínfisis púbica
4. Síndrome Piriforme
5. Lesões Isquiotibiais
6. Fracturas/avulsoes apofisárias
7. Hérnia Desportiva / Pubalgia
Fig. 1. Intra-articular pathology presents as groin pain, diamond sh
pathology such as lower abdomen or at the adductor tubercle can ind
Plante et al226
Classification and Treatment of Hip Chondral Lesions

4. The Porto Hip Unit
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Classification and Treatment of Hip Chondral Lesions

5. The Porto Hip Unit
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• Capas
• Osteocondral
• Inerte
• Contráctil
• Neuromecánica
differences, as they relate to normal osseous structure, os-
seous overcoverage and osseous undercoverage, is what led
to the development of the Layer System. (Table 1)
Diagnostic testing for identifying osseous, inert and soft
tissue hip pathology has included x-ray, magnetic resonance
imaging (MRI), computed tomography (CT) Scan, delayed
gadolinium-enhanced MRI of cartilage (dGEMRIC) studies,
diagnostic injection and clinical special tests[9, 10]. Computer
navigation surgical planning software, such as A2, can be
used to confirm and model osseous impingements. X-ray
views of AP lateral and Dunn view can be used along with 3
dimensional CTscans to identify osseous hip pathologies [11].
alpha angles, beta angles and McKibbon indices [12]. dGEM-
RIC studies can be used, when indicated, to determine the
health of the cartilage[9]. Intra-articular injections have prov-
en extremely reliable for differentiating between intra and
extra articular hip pathology [13]. MRI has been diagnostical-
ly sensitive to Layer II inert tissue (labrum, capsule, ligament
and 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 hip
will 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 Arthrokinematic
movement
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, timing
and sequencing of the
kinematic chain
Neural Mechanical
Lower extremity mechanics Nerve entrapment Foot structure and mechanics
Neuro-vascular structures
referring to and regional
to the hip
Referred Spinal Pathology Scoliosis
Regional mechanoreceptors Neuromuscular Dysfunction Pelvic posture over femur
Classification and Treatment of Hip Chondral Lesions

6. The Porto Hip Unit
PHM2015
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.
Classification and Treatment of Hip Chondral Lesions

7. The Porto Hip Unit
PHM2015
!
Bordo anterior do acetábulo
Bordo posterior do acetábulo
Linha 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
Classification and Treatment of Hip Chondral Lesions

8. The Porto Hip Unit
PHM2015
!
!
!
RM: Penetração, Ponderações, Cortes, Gadolinio. (Normal; artro-RM; dGEMRIC)
!
Classification and Treatment of Hip Chondral Lesions

9. The Porto Hip Unit
PHM2015
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
Classification and Treatment of Hip Chondral Lesions

10. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions

11. The Porto Hip Unit
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CFA Resulta em trauma de repetição ou agudo
Lesão labral
Lesao condral
Cascata degenerativa não focal
Classification and Treatment of Hip Chondral Lesions

12. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
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

13. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
ANCA NORMAL
Normal Hip
Acetabular
cartilage
Fovea
Labrum
Femoral
Cartilage
Capsula

14. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Parece anormal
Cicatriz estrelada
Fossa supra-acetabular
Cicatriz da fise
Sulco condro-labral

15. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Parece normal, mas…
Cabeça&
Fovea&
VI&

16. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Parece normal, mas…
Labrum'
Car)lagem'
Sulco??'
Rot.'CL??'

17. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Parece normal, mas…
“”Wave'lesion””'

18. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Parece normal, mas…
Labrum'
Car)lagem'
Delaminação'

19. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Claramente anormal
Labrum'
Car)l.'Acetab.'
Fissuração'e+fragmentação+car2l.'

20. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Claramente anormal
Fovea&
Cabeça&femoral&
Labrum&
Acetabulo&Zona&3&
Lesao&car7laginea&&
grau&V&de&Beck&
Exposição&ossea&
Delaminação&

21. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Claramente anormal
Acetábulo*
Zona*4*
Labrum*
Lesão*condral*5po*V*de*Beck*
Exposição*ossea*
Fibrilação*

22. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Fovea&
Labrum&
Fragmentação&Car2laginea&
Exposição&ossea&

23. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Cabeça&
Erosão&car-laginea&

24. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Labrum'
Cabeça'
Erosão&car)laginea&generalizada&

25. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
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&
Fragmentação&Car2laginea&
Exposição&ossea&
ANCA NORMAL

26. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
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””'

27. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
SAMPSON classification (Acetábulo) - 2011
AC 0 - Normal cartilage
Fovea&
Labrum&
Fragmentação&Car2laginea&
Exposição&ossea&
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'

28. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
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%

29. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
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)

30. The Porto Hip Unit
PHM2015
“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!
!
Classification and Treatment of Hip Chondral Lesions
(Porto Hip Unit)
ip U

31. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions

32. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions

33. The Porto Hip Unit
PHM2015
“…. perante a lesão cartilagínea focal, o tratamento
visa evitar a progressão, minimizar a lesão e reparar/
regenerar a cartilagem articular…”
J. Cruz de Melo
Classification and Treatment of Hip Chondral Lesions

34. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Opções de Tratamento:
1) O tipo e extensão da lesão cartilagínea
2) As alterações morfologicas associadas
3) O labrum
Cartilage
LesionShaving
Shaving
micro-fractures
Shaving
micro-fractures
cola fibrina
Enxertos
…….
C. Pluripotentes

35. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Opções de Tratamento - Acetabular cartilage
1) O tipo e extensão da lesão cartilagínea
2) As alterações morfologicas associadas
3) O labrum
Protocolo de tratamento de The Porto Hip Unit

36. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
Opções de Tratamento - Acetabular cartilage
1) O tipo e extensão da lesão cartilagínea
2) As alterações morfologicas associadas
Protocolo de tratamento de The Porto Hip Unit

37. The Porto Hip Unit
PHM2015
Classification and Treatment of Hip Chondral Lesions
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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www.portohipmeeting.com