Pathology and Management

The pathologies affecting the femoral head are:

Chondromalacia Chondrolysis Chondral defects Osteochondral defects Osteochondritis dissecans Degenerative joint disease Tumors


Global softening of the articular cartilage, chondromalacia coxae, similar to that in the knee, has been reported.6 It does

Avascular necrosis Ligamentum teres lesions Inflammatory disease Deformity Arthrofibrosis Fractures appear to be a definite clinical entity and is sometimes the cause of hip pain. The characteristic arthroscopic appearance of chondromalacia is the loss of the normal resistance or softness to probing (Figure 13.5A). It may affect large areas of the weightbearing surface of the femoral head and lead to fibrillation and fissuring (Figure 13.5B). No specific treatment is required for most early examples; however, symptomatic improvement can be seen after hip arthroscopy.


Chondrolysis is the global loss of healthy articular cartilage. It may be seen in the hip following sepsis, trauma, or slipped capital femoral epiphysis, and is occasionally idiopathic. Reduced joint space may be seen on a plain radiograph. It ap-

Figure 13.6. Chondrolysis: Irregular fluffy, thin cartilage.

Figure 13.6. Chondrolysis: Irregular fluffy, thin cartilage.

Contour Irregularity Femoral Head

pears as irregular, fluffy, opaque cartilage that is soft and thin to probing (Figure 13.6). Treatment options are few, although removal of any adhesions may improve the range of hip movements.

Chondral Defects

Localized chondral defects may be truly pathological or iatrogenic. Iatrogenic surface defects are caused by instrument or needle scuffing. Such injuries are best avoided by attention to surgical detail throughout the procedure, as well as judicious use of the guidewire during instrument and arthro-scope insertion. Scuff injuries usually appear as a smooth, linear trenchlike gouge with fluffy edges (Figure 13.7). Truly pathological defects are usually rounder, with vertical sides. Scuff lesions are usually no deeper than the superficial and middle layers of cartilage. No treatment is necessary for these lesions. Although they probably do not heal fully, it is felt that such superficial lesions are unlikely to lead subsequently to degenerative change. Deeper defects are clearly a risk to later degenerative change, and treatment of these using de-bridement or drilling should be considered. Chondral defects may be a result of trauma, such as hip dislocation or sports injury, but may also be an early stage of degenerative disease. The usual presentation is with nonspecific pain, but mechanical symptoms may be present secondary to unstable flaps, labral tears, or loose bodies. Outerbridge's grading7 of chon-dral disease, as used in other joints, may be applied to the hip. Grade I: Softening; 2: Fissuring; 3: Chondral flaps; 4: Ebur-nated bone. Treatment depends on the extent of the disease. Superficial lesions (grades I and II) should probably be left, whereas unstable flaps should be debrided, and consideration given to drilling exposed bony areas.

Osteochondritis Dissecans Hip
Figure 13.7. Scuff damage of the femoral head showing superficial fluffy disruption.
Osteochondritis Dissecans Hip

Figure 13.8. (A) Osteochondritis dissecans: A young lesion with a punched-out deficit on the femoral head and loose body. (B) Osteochondritis dissecans: A chronic lesion in which the sharp, punched-out edges have become smooth.

Osteochondral Defects

Osteochondral lesions may be localized (osteochondritis dissecans and posttraumatic) or part of a generalized joint disease such as osteoarthritis.

Osteochondritis dissecans of the hip tends to affect the femoral head. Symptoms are extremely variable, and radiographs are often normal or reveal only slight irregularity. In the classic case, as in other joints, there is a well-demarcated fragment of bone and overlying cartilage, which may be separated from the underlying surface. Although often on the weightbearing area, the site is variable. It frequently has a "punched-out" appearance (Figure 13.8A). Associated loose bodies are common, either lying in the defect or free. In more chronic lesions, the edges of the lesion are smoothed off (Figure 13.8B).

Arthroscopy is extremely useful for diagnosis, assessment, and treatment. Loose bodies should be removed if possible. To do so requires tightly gripping forceps with sufficient bite to grasp each pole of a loose body effectively. Unstable flaps are debrided with rongeurs or a shaver. Drilling of the defect's base is sometimes undertaken to stimulate fibrocarti-lage formation. If access allows, it is sometimes possible to drill a defect in a retrograde manner, passing a long drill up the femoral neck under image intensifier control until the tip emerges from the base of the defect. Osteochondral grafting or chondrocyte implantation are options to consider for the future. To date, in the author's practice, such procedures have been undertaken as open operations.

Degenerative Joint Disease

Degenerative disease is the most common finding at hip ar-throscopy. Symptoms and radiographic appearances often bear no relation to arthroscopic findings. The earliest site on the femoral head is usually anterior, matching the common site of degenerative change seen in the acetabulum. Initially, the cartilage loses its glisten and assumes a yellowish matte appearance (Figure 13.9A) before fissuring, fragmentation, and eburnation occurs. (Figure 13.9B.)

At an early stage, cartilage degeneration is localized but later become more widespread and severe, involving both sides of the joint. (Figure 13.9C.) Osteophytes may form at the peripheral margins of the head, particularly posteriorly. These may cause impingement and impede instrument access. If localized and associated with otherwise reasonably healthy articular cartilage, it is worthwhile removing osteophytes. Range of motion can sometimes be improved dramatically.

Bony Eburnation

Figure 13.9. (A) Degenerative joint disease, early stages: The cartilage loses its glisten and has a yellowish appearance. (B) Degenerative joint disease, intermediate stage: Cartilage fibrillation. (C) Degenerative joint disease, late stage: Bony eburnation of the femoral head and adjacent acetabulum.

Figure 13.10. Chondrocalcinosis: Fluorescent sparkling deposits in the femoral head articular cartilage.

Chondrocalcinosis Arthroscopic

Figure 13.10. Chondrocalcinosis: Fluorescent sparkling deposits in the femoral head articular cartilage.

Arthroscopic surgery for generalized degenerative disease is unpredictable. In general, manual or powered debridement of unstable osteochondral flaps may be useful. As in the knee, an extensive washout is important. Consideration should also be given to a corticosteroid injection. It should be remembered, however, that it is possible to make a patient worse after hip arthroscopy for degenerative changes.

Inflammatory Arthropathy

Hip arthroscopy may be undertaken for inflammatory conditions such as rheumatoid arthritis, gout, psoriasis, and calcium phosphate arthropathy. The main findings are synovial hypertrophy and induration. Femoral head cartilage appearance is extremely variable, depending on the stage of the disease. In early stages, there is thinning, softening, and loss of the glisten, but surface continuity remains. Later, there is cartilage disruption and bony eburnation as in degenerative disease. Chondrocalcinosis has a characteristically striking appearance similar to that seen in the knee: sparkling fluorescent deposits are seen in the articular cartilage (Figure 3.10). Operative surgery is tailored to the extent of the disease, ranging from synovial biopsy to debridement and lavage.


Tumors within the femoral head are very uncommon. Osteoid osteoma and chondroblastoma are known to be characteristically associated with this site, though are most unlikely to be seen at arthroscopy. Arthroscopy may be helpful in diagnosis, however, if for no other reason than exclusion.

Avascular Necrosis

The etiology and pathogenesis of avascular necrosis (AVN) are still largely unknown. The common final pathway is thought to be vascular insufficiency of the subchondral bone by extra- or intravascular obstruction, resulting in necrosis, collapse, and subsequent deformity. The overlying articular cartilage loses support and becomes damaged and degenerates. (Figure 13.11.)

The arthroscopic appearance of avascular necrosis is variable. The spectrum is from complete normality, to cartilage softening with loss of support, to fragmentation and osteo-chondral flaps or loose bodies (similar to Figure 13.1).

Articular Cartilage Loss The Hip
Figure 13.11. Avascular necrosis of the femoral head: Overlying thinning and loss of articular cartilage.

The role of arthroscopy in the management of AVN is controversial.8,9 There are several reports of femoral head collapse shortly after hip arthroscopy, including several in our series.2,8 It is unclear if it is the natural history of the condition, the fluid pressure, or the distraction that is responsible.

The authors use arthroscopy primarily to establish whether or not any articular cartilage collapse is evident. Articular collapse in its early stages is not always seen by magnetic resonance scan. If present, it is believed that the chances of revas-cularization being effective are reduced. Unstable chondral or osteochondral flaps and loose bodies may be amenable to ar-throscopic surgery, as described for degenerative joint disease. Transient osteoporosis of the femoral head is uncommon and possibly related to avascular necrosis. We have no experience of arthroscopy in such a case.


Femoral head fractures are uncommon, though frequently associated with high-energy trauma and dislocation of the hip. The Pipkin classification10 may be used:

Type I: Small head fragment not attached to ligamentum teres. Type II: Large head fragment attached to ligamentum teres. Type III: Type I and II with femoral neck fracture. Type IV: Type I, II, or III associated with an acetabular fracture.

Following hip reduction, an assessment of fracture reduction may be made arthroscopically, and occasionally loose bodies that may be present can be removed. (Figure 13.12.) Arthroscopy of the freshly fractured or dislocated hip, however, is not always as easy as the operator might like. Bleeding and serous exudate, combined with bony fragmentation, can make disorientation a real problem. Such fractures or dislocations often lead to early femoral head degeneration and resultant symptoms, particularly in young people. In such cases arthroscopy is helpful in diagnosis, assessment, and management as described earlier.

Ligamentum Teres

The full function of the ligamentum teres is unknown, though several theories do exist. It is generally agreed that its contribution to the blood supply of the femoral head in the adult is small. It is perhaps related to hip stability. Three types of ligamentum teres lesions have been described:11

Type 1: A complete rupture after trauma of surgical distraction (Figure 13.13A). Type 2: Partial rupture (Figure 13.13B). Type 3: Degenerated and frayed (Figure 13.13C).

Type 1 lesions are unusual and often associated with high-energy trauma to the joint. There is often a clear symptom start date, with groin pain and stiffness. Loose bodies arising from the acetabular wall, or fossa fractures, are common. Type 2 lesions tend to present with a longer history of symptoms and are often diagnosed only at arthroscopy.

The degenerative Type 3 lesion is the most common and is often associated with clearly degenerative changes on the perifoveal and anterior regions of the head. Sixty percent have a clear history of previous significant joint pathology such as Legg-Calvé-Perthes disease.11 It is possible that a dysfunctional ligamentum teres plays an important early etiological role in the onset of degenerative joint disease. A lack of stability, similar to anterior cruciate ligament deficiency in the knee, may result in articular cartilage injury and accelerated degeneration.

Management at present is directed at removing loose flaps or frayed parts, which may cause impingement, using a power cutter.

Figure 13.12. Fracture: Acute fracture showing hemorrhage, fibrinous adhesions, and loose debris. The difficulties of arthroscopy are clearly obvious.

Slough Scalp Wound

Figure 13.12. Fracture: Acute fracture showing hemorrhage, fibrinous adhesions, and loose debris. The difficulties of arthroscopy are clearly obvious.

Arthritis Pathology
Figure 13.13. (A) Ligamentum teres, Type 1: A complete, acute rupture. (B) Ligamentum teres, Type 2: Partial rupture. (C) Ligamentum teres, Type 3: Degenerated and frayed appearance.


Arthrofibrosis is an uncommon finding characterized by numerous adhesions within the joint. It may occur spontaneously or following sepsis or trauma. The hip is usually stiff and difficult to access arthroscopically. Adhesions extend throughout the joint from head to acetabulum and capsule, obliterating the joint space. Chondromalacia or chondrolysis of the femoral head cartilage may be found. Treatment consists of removal of adhesions with both manual and power instruments.

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