Case Report
Chondrolysis After Hip Arthroscopy Jesús Más Martínez, M.D., Javier Sanz Reig, M.D., Manuel Morales Santias, M.D., and David Bustamante Suarez de Puga, M.D.
Abstract: We report the case of a 58-year-old woman who presented with left hip pain and was diagnosed with femoroacetabular impingement. She underwent hip arthroscopy to repair a degenerative labral tear, as well as radiofrequency debridement and microfracture of the exposed chondral defect, and femoral osteoplasty. Two months after hip arthroscopy, hip pain and limping began. Hip radiography showed a concentric decrease of joint space and no signs of joint incongruity or osteophytosis. Revision surgery 4 months after hip arthroscopy showed that the cartilage of the femoral head was soft and separated from the subchondral bone.
M
ost hip arthroscopy complications have been recognized as minor and are related to traction and portal placement. There are rare but major catastrophic complications reported in the literature, such as hip dislocation, intra-abdominal and intrathoracic fluid extravasation, hypothermia, infection, thromboembolic phenomena, avascular necrosis, heterotopic ossification, femoral neck fracture, and death.1-3 We discuss the factors reported in the literature as potential contributors to the loss of articular cartilage. We report a case of chondrolysis of the hip in a 58-yearold woman after hip arthroscopy for femoroacetabular impingement. We discuss the factors predisposing chondrolysis occurrence. We believe the cause of chondrolysis in our patient may have been secondary to electrocautery or to an injury that occurred during the arthroscopic procedure. The patient agreed that the details of this case could be submitted for publication.
Case Report A 58-year-old woman came to us with left hip pain of 6 months’ duration. She had been taking oral analgesics with no improvement. Four years before, she had undergone operation for a hip resurfacing prosthesis on the right hip, with successful clinical and radiologic From Hip Unit, Department of Orthopaedic Surgery, Clínica Vistahermosa, Alicante, Spain. Received April 24, 2014; accepted June 23, 2014. Address correspondence to Jesús Más Martínez, M.D., Clínica Vistahermosa, Av de Dénia, 103, 03015 Alicante, Spain. E-mail: jmas@ traumavist.com Ó 2015 by the Arthroscopy Association of North America 0749-8063/14346/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.06.028
results, as can be seen in Figure 1. Her pain was located in the groin and was aggravated by squatting, crossing her legs, and sitting for long periods. On clinical examination, the range of hip motion was flexion, 100 ; internal rotation, 0 ; external rotation, 20 ; abduction, 30 ; and adduction, 30 . The impingement test result was positive. Initial plain radiographs showed loss of femoral head-neck offset and asphericity. The joint space was well maintained and there was no evidence of hip dysplasia (Fig 1A and B). Magnetic resonance imaging did not reveal avascular necrosis, a labrum tear, or evident chondral damage (Fig 1C and D). The patient was diagnosed with left hip femoroacetabular impingement, cam type, and was offered hip arthroscopy with decompression of the femoroacetabular impingement lesion. The Harris modified hip score preoperatively was 69.3 points. The procedure was performed using spinal anesthesia with the patient in the supine position on a fracture table for hip distraction. A large padded perineal post was used. Distraction was performed under fluoroscopic guidance. The hip joint was not aspirated or injected before distraction. We used a pressure- and flowcontrolled pump. The anterolateral and midanterior portals were set up under fluoroscopic and arthroscopic observation.4 A degenerative labral tear was identified in zones 2 and 3.5 It was repaired to the rim of the acetabulum using 2 suture anchors (PushLock, 2.9 mm; Arthrex, Naples, FL). An exposed bone chondral defect was also identified in the anterosuperior region of the acetabulum (Fig 2). It was debrided with radiofrequency ablation, and microfractures were performed. Traction was then released and the hip was flexed. A 5.5-mm bur was used to resect the cam lesion under fluoroscopic guidance and arthroscopic visualization. The capsule
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Fig 1. Preoperative images. A 58-yearold woman with left hip pain of 6 months’ duration. The impingement test result was positive, and her pain was located in the left groin. The joint space was well maintained and loss of femoral head-neck offset and asphericity (cam lesion) in the left hip are shown in the (A) anteroposterior pelvic and (B) axial hip views. Right hip resurfacing arthroplasty was performed, with a 4-year follow-up. No evidence of osteonecrosis of the left femoral head is seen in (C) coronal T1-weighted magnetic resonance images and (D) sagittal T2 magnetic resonance images.
was not repaired. At no point during this procedure was there any abnormal bleeding. The portals were closed and a sterile dressing was applied. Platelet-rich plasma was infused. Intra-articular fluid pressure during the procedure remained between 40 and 65 mm Hg. The total operation time was 85 minutes, and the traction time was 45 minutes. The patient was discharged on the following day. She walked with walking aids over 4 weeks. One month after surgery she reported no pain and squatted and crossed her legs with no difficulty. However, 2 months after surgery, the patient began to experience groin pain, restriction of hip motion, and mild limping. She denied previous trauma. Conservative treatment with oral analgesics and noneweight bearing was prescribed, but the pain and limping increased. Laboratory test results showed a normal erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. Hip radiographs showed a concentric decrease of joint space and no signs of joint incongruity or osteophytosis (Fig 3). The Harris modified hip score was 39.6 points. We
recommended repeating magnetic resonance imaging, but the patient refused because it was not covered by her medical insurance. Because of the patient’s severe limitations, a diagnostic/therapeutic surgical procedure was prescribed. At surgery 4 months after hip arthroscopy, the cartilage of the femoral head was soft and separated from the subchondral bone (Fig 4). The exposed bone chondral defect in the anterosuperior region of the acetabulum was not covered by fibrous tissue. There were no signs of surgical infection. Macroscopic examination of the femoral head did not show evidence of osteonecrosis or subchondral collapse. Rim acetabular anchors had not damaged either the acetabulum or the femoral head cartilage. Because of the global fullthickness lesion of the articular femoral head cartilage, it was decided to proceed with hip resurfacing arthroplasty, following which the patient became pain free. Intraoperative culture results were negative. At 2-year follow-up, she was asymptomatic and the Harris hip score was 96 points (Fig 5).
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Fig 2. Arthroscopic view of the left hip through the anterolateral accessory portal. A chondrolabral lesion and exposed bone are visualized adjacent to the anterosuperior labrum. Radiofrequency ablation of acetabular articular cartilage was performed. (A, acetabulum; CL, chondrolabral lesion; EB, exposed bone; FH, femoral head; HC, hip capsule; L, labrum.)
Accordingly, with radiographic signs of a concentric decrease of the joint space and intraoperative findings, a diagnosis of chondrolysis caused by hip arthroscopy was established. Our case may represent a variant of chondrolysis given that there was a separation between the cartilage of the femoral head and the subchondral bone.
Discussion Chondrolysis of the hip includes a rapid progressive loss of joint space seen on radiographs and associated loss of clinical hip motion. Several factors are reported as potential contributors to the loss of articular cartilage: thermal causes (e.g., electrocautery, radiofrequency device), chemical causes (e.g., intra-articular infusion of local anesthetics, chlorhexidine, and gentian violet), mechanical causes (e.g., surgical insult or prominent hardware such as anchors, pins, or screws), or other causes (e.g., infection or a history of traumatic joint injury).6 A thermal source was implicated by the literature as a contributor to hip chondrolysis. Rand and Gaffey7 found that electrocautery produces temperatures of 400 C to 600 C when cutting the tissues, and this temperature generated thermal necrosis and cellular pyrolysis in one in vitro study.8 Additionally, when using thermal chondroplasty around cartilage, temperatures of 45 C to 50 C damage chondrocytes.9 Piper and Kim10 showed that intra-articular temperatures can reach a thermotoxic chondrocyte threshold, especially if inadequate fluid flow is present, and this thermal stress potentiates the chondrotoxic effects of bupivacaine in intact cartilage, leading to decreased chondrocyte viability compared with exposure to
Fig 3. Concentric loss of joint space in left hip is shown in (A) anteroposterior pelvic and (B) axial images 3 months after hip arthroscopy.
bupivacaine alone. Enochson et al.11 showed the in vitro effects of plasma-mediated bipolar radiofrequency ablation on human chondrocytes. They found it induced a well-defined margin of chondrocyte death. Rehan et al.12 reported one case of chondrolysis of the hip after excision of a torn acetabular labrum after an open approach with electrocautery. The authors speculated that the heat generated at that time may have been responsible for the subsequent chondrolysis. McCormick et al.13 recommended meticulous technique, intermittent use of electrocautery, good inflow and outflow, and pulsed lavage at frequent intervals to maintain intra-articular temperature at less than 50 C. In our patient, we used a conventional electrosurgical device to perform capsulotomy, so we
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Fig 4. Intraoperative photographs during hip resurfacing arthroplasty 4 months after initial hip arthroscopy. Articular cartilage of the femoral head was detached from the subchondral bone because there was a separation between them. No evidence of osteonecrosis or subchondral collapse was found.
know there were effects not only in target tissue but also in surrounding tissues. Also, we performed radiofrequency ablation of the acetabular articular cartilage. However, the labral tear was not excised and flow was controlled by a pressure pump. The infusion of local anesthetics through intraarticular pain pumps has been reported as a causative factor of chondrolysis in the shoulder14,15 and knee16 but not in the hip. Local anesthetics such as bupivacaine, lidocaine, and ropivacaine are chondrotoxic to human articular cartilage in vitro.17,18 We did not use the infusion of local anesthetics in the management of postoperative pain after hip arthroscopy in our patient. Surgical insult to the femoral head cartilage caused by the passage of hip arthroscopic instruments is another contributor to cartilage loss. It is probably underreported in the literature. Sampson considered it to be less than 1% in his series.19 In a review of 92 studies and more than 6,000 patients, Harris et al.20 reported
Fig 5. Hip resurfacing arthroplasty with a 2-year follow-up with no signs of loosening. Harris hip score was 96 points.
241 iatrogenic chondral injuries and 54 labral injuries. Other authors only mentioned it.21 Traction and distention enables adequate head-acetabular separation to avoid cartilage damage. It is recommended that there be at least 10 mm separating the femoral head and the acetabulum as measured by fluoroscopy. If this is not possible, access to the hip periphery should be performed first. In the same way, a cannula for instrument passage or portal exchange should always be used to prevent cartilage damage.22 In our patient, up to 10 mm of joint distraction was noted radiographically with fluoroscopy. A cannula was used during the procedure, and the hardware and rim anchors used did not injure the acetabular cartilage. Infection is another associated causative factor of chondrolysis in the hip. Hip arthroscopy is a minimally invasive procedure, and the incidence of infection is low. Chan et al.23 reported 2 cases in 236 hip arthroscopies. Harris et al. 20 reported 7 superficial infections and 1 deep infection in more than 6,000 patients undergoing surgery of the hip. In a patient with hip pain, there should be a high suspicion of postoperative infection when the patient is not bearing weight on the
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leg and is not moving the hip after hip arthroscopy and has elevated ESR and CRP levels. In our patient, ESR and CRP levels were normal, there were no signs of intraoperative infection, and intraoperative culture results were negative. Traction is necessary to view the central compartment of the hip, and inadequate traction can result in chondral damage. Traction force and duration should be attended to prevent complications caused by distraction. A mean distraction force between 15 and 30 kg or 200 to 400 N and duration no greater than 2 hours is recommended.19 We do not have a tensiometer to measure the traction force in the operating room, and adequate head-acetabular separation was determined using fluoroscopy. However, our traction time was 45 minutes. There is a risk of vascular injury related to hip arthroscopy. On the one hand, the portals should be used with care, especially the posterolateral portal for its proximity from the deep branch of the medial femoral circumflex artery.24 We used anterolateral and midanterior portals, so it is unlikely that direct vessel injury was caused. On the other hand, the most lateral aspect of the cam deformity is close to the area where the medial femoral circumflex artery enters the hip capsule behind the lateral synovial fold, and there is a risk of injury during femoral head-neck junction osteoplasty.22 We identified the deformity arthroscopically and through fluoroscopy to perform the osteoplasty. There was no abnormal bleeding during the procedure. A relation between hip intracapsular pressure and a decrease in local blood flow and venous occlusion is presumed. In vivo studies reported intracapsular pressure of at least 200 mm Hg maintained for 10 hours to observe osteonecrosis of the trabeculae.25,26 Other in vivo studies reported that tamponade of the hip reduced the mean oxygen partial pressure to 60% of its initial value, and traction in extension decreased the mean oxygen partial pressure to 35% of baseline.27 We used a pressure- and flow-controlled pump during the procedure, and pressure was kept between 45 and 65 mm Hg. We report a rare complication after hip arthroscopy. Our patient’s preoperative magnetic resonance image showed no evidence of chondral lesions or femoral head osteonecrosis. The patient had not sustained previous trauma. We were unable to record the exact amount of traction used on our traction table; however, our procedure lasted 85 minutes and traction time was 45 minutes. The arthroscopic portals used had no association with either the medial femoral circumflex or inferior gluteal arteries. We used electrocautery in our procedure and radiofrequency ablation of acetabular articular cartilage. Intra-articular fluid pressure was monitored and was less than 65 mm Hg during the procedure. No intra-articular pain pumps to manage
the postoperative pain were used. We confirmed the absence of postoperative infection. We believe the cause of chondrolysis in our patient may have been caused by electrocautery or to an injury that occurred during the arthroscopic procedure.
References 1. Griffiths EJ, Khanduja V. Hip arthroscopy: Evolution, current practice and future developments. Int Orthop 2012;36:1115-1121. 2. Ng VY, Arora N, Best TM, Pan X, Ellis TJ. Efficacy of surgery for femoroacetabular impingement: A systematic review. Am J Sports Med 2010;38:2337-2345. 3. Imam S, Khanduja V. Current concepts in the diagnosis and management of femoroacetabular impingement. Int Orthop 2011;35:1427-1435. 4. Robertson WJ, Kelly BT. The safe zone for hip arthroscopy: A cadaveric assessment of central, peripheral, and lateral compartment portal placement. Arthroscopy 2008;24:1019-1026. 5. Ilizaliturri VM, Byrd T, Sampson TG, et al. A geographic zone method to describe intra-articular pathology in hip arthroscopy: Cadaveric study and preliminary report. Arthroscopy 2008;24:534-539. 6. Provencher M, Navaie M, Solomon D, Smith J, Romeo A, Cole B. Chondrolysis. J Bone Joint Surg Am 2011;21: 2033-2044. 7. Rand JA, Gaffey TA. Effect of electrocautery on fresh human articular cartilage. Arthroscopy 1985;1:242-246. 8. Kaplan L, Uribe JW, Sasken H, Markarian G. The acute effects of radiofrequency energy in articular cartilage: An in vitro study. Arthroscopy 2000;16:2-5. 9. Voss JR, Lu Y, Edwards RB, Bogdanske JJ, Markel MD. Effects of thermal energy on chondrocyte viability. Am J Vet Res 2006;67:1708-1712. 10. Piper SL, Kim HT. Thermal stress potentiates bupivacaine chondrotoxicity. Arthroscopy 2012;28:1246-1254. 11. Enochson L, Sönnergren HH, Mandalia VI, Lindhal A. Bipolar radiofrequency plasma ablation induces proliferation and alters cytokine expression in human articular cartilage chondrocytes. Arthroscopy 2013;28:1275-1282. 12. Rehan UH, Yang HK, Park KS, Lee KB, Yoon TR. An unusual case of chondrolysis of the hip following excision of a torn acetabular labrum. Arch Orthop Trauma Surg 2010;130:65-70. 13. McCormick F, Alpaugh K, Nwachukwu BU, Xu S, Martin SD. Effect of radiofrequency use on hip arthroscopy irrigation fluid temperature. Arthroscopy 2013;29: 336-342. 14. Anderson SL, Buchko JZ, Taillon MR, Ernst MA. Chondrolysis of the glenohumeral joint after infusion of bupivacaine through an intra-articular pain pump catheter: A report of 18 cases. Arthroscopy 2010;25:451-461. 15. Busfield BT, Romero DM. Pain pump use after shoulder arthroscopy as a cause of glenohumeral chondrolysis. Arthroscopy 2009;25:647-652. 16. Fester EW, Noyes FR. Postoperative chondrolysis of the knee: 3 case reports and a review of the literature. Am J Sports Med 2009;37:1848-1855.
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17. Piper SL, Kramer JD, Kim HT, Feeley BT. Effects of local anesthetics on articular cartilage. Am J Sports Med 2011;39: 2245-2253. 18. Dragoo JL, Braun HJ, Kim HJ, Phan HD, Golish SR. The in vitro chondrotoxicity of single-dose local anesthetics. Am J Sports Med 2012;40:794-799. 19. Sampson TG. Complications of hip arthroscopy. Tech Orthop 2005;20:63-66. 20. Harris JD, McCormick FM, Abrams GD, et al. Complications and reoperations during and after hip arthroscopy: A systematic review of 92 studies and more than 6,000 patients. Arthroscopy 2013;29:589-595. 21. Clarke MT, Villar RN. Hip arthroscopy: Complications in 1054 cases. Clin Orthop Relat Res 2003;406:84-88. 22. Ilizaliturri VM Jr. Complications of arthroscopic femoroacetabular impingement treatment: A review. Clin Orthop Relat Res 2009;467:760-768. 23. Chan K, Farrokhyar F, Burrow S, Kowalczuk M, Bhandari M, Ayeni OR. Complications following hip
24.
25.
26.
27.
arthroscopy: A retrospective review of the McMaster experience (2009-2012). Can J Surg 2013;56: 422-426. Sussmann PS, Zumstein M, Hahn F, Dora C. The risk of vascular injury to the femoral head when using the posterolateral arthroscopy portal: Cadaveric investigation. Arthroscopy 2007;23:1112-1115. Kemp HB. Perthes’ disease: The influence of intracapsular tamponadeon the circulation in the hip joint of the dog. Clin Orthop Relat Res 1981;156:105-114. Vegter J, Lubsen CC. Fractional necrosis of the femoral head epiphysis after transient increase in joint pressure: An experimental study in juvenile rabbits. J Bone Joint Surg Br 1987;69:530-535. Svalastoga E, Kiaer T, Jensen PE. The effect of intracapsular pressure and extension of the hip on oxygenation of the juvenile femoral epiphysis: A study in the goat. J Bone Joint Surg Br 1989;71: 222-226.
Chondrolysis After Hip Arthroscopy Jesús Más Martínez, M.D., Javier Sanz Reig, M.D., Manuel Morales Santias, M.D., and David Bustamante Suarez de Puga, M.D.
Abstract: We report the case of a 58-year-old woman who presented with left hip pain and was diagnosed with femoroacetabular impingement. She underwent hip arthroscopy to repair a degenerative labral tear, as well as radiofrequency debridement and microfracture of the exposed chondral defect, and femoral osteoplasty. Two months after hip arthroscopy, hip pain and limping began. Hip radiography showed a concentric decrease of joint space and no signs of joint incongruity or osteophytosis. Revision surgery 4 months after hip arthroscopy showed that the cartilage of the femoral head was soft and separated from the subchondral bone.
M
ost hip arthroscopy complications have been recognized as minor and are related to traction and portal placement. There are rare but major catastrophic complications reported in the literature, such as hip dislocation, intra-abdominal and intrathoracic fluid extravasation, hypothermia, infection, thromboembolic phenomena, avascular necrosis, heterotopic ossification, femoral neck fracture, and death.1-3 We discuss the factors reported in the literature as potential contributors to the loss of articular cartilage. We report a case of chondrolysis of the hip in a 58-yearold woman after hip arthroscopy for femoroacetabular impingement. We discuss the factors predisposing chondrolysis occurrence. We believe the cause of chondrolysis in our patient may have been secondary to electrocautery or to an injury that occurred during the arthroscopic procedure. The patient agreed that the details of this case could be submitted for publication.
Case Report A 58-year-old woman came to us with left hip pain of 6 months’ duration. She had been taking oral analgesics with no improvement. Four years before, she had undergone operation for a hip resurfacing prosthesis on the right hip, with successful clinical and radiologic From Hip Unit, Department of Orthopaedic Surgery, Clínica Vistahermosa, Alicante, Spain. Received April 24, 2014; accepted June 23, 2014. Address correspondence to Jesús Más Martínez, M.D., Clínica Vistahermosa, Av de Dénia, 103, 03015 Alicante, Spain. E-mail: jmas@ traumavist.com Ó 2015 by the Arthroscopy Association of North America 0749-8063/14346/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.06.028
results, as can be seen in Figure 1. Her pain was located in the groin and was aggravated by squatting, crossing her legs, and sitting for long periods. On clinical examination, the range of hip motion was flexion, 100 ; internal rotation, 0 ; external rotation, 20 ; abduction, 30 ; and adduction, 30 . The impingement test result was positive. Initial plain radiographs showed loss of femoral head-neck offset and asphericity. The joint space was well maintained and there was no evidence of hip dysplasia (Fig 1A and B). Magnetic resonance imaging did not reveal avascular necrosis, a labrum tear, or evident chondral damage (Fig 1C and D). The patient was diagnosed with left hip femoroacetabular impingement, cam type, and was offered hip arthroscopy with decompression of the femoroacetabular impingement lesion. The Harris modified hip score preoperatively was 69.3 points. The procedure was performed using spinal anesthesia with the patient in the supine position on a fracture table for hip distraction. A large padded perineal post was used. Distraction was performed under fluoroscopic guidance. The hip joint was not aspirated or injected before distraction. We used a pressure- and flowcontrolled pump. The anterolateral and midanterior portals were set up under fluoroscopic and arthroscopic observation.4 A degenerative labral tear was identified in zones 2 and 3.5 It was repaired to the rim of the acetabulum using 2 suture anchors (PushLock, 2.9 mm; Arthrex, Naples, FL). An exposed bone chondral defect was also identified in the anterosuperior region of the acetabulum (Fig 2). It was debrided with radiofrequency ablation, and microfractures were performed. Traction was then released and the hip was flexed. A 5.5-mm bur was used to resect the cam lesion under fluoroscopic guidance and arthroscopic visualization. The capsule
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Fig 1. Preoperative images. A 58-yearold woman with left hip pain of 6 months’ duration. The impingement test result was positive, and her pain was located in the left groin. The joint space was well maintained and loss of femoral head-neck offset and asphericity (cam lesion) in the left hip are shown in the (A) anteroposterior pelvic and (B) axial hip views. Right hip resurfacing arthroplasty was performed, with a 4-year follow-up. No evidence of osteonecrosis of the left femoral head is seen in (C) coronal T1-weighted magnetic resonance images and (D) sagittal T2 magnetic resonance images.
was not repaired. At no point during this procedure was there any abnormal bleeding. The portals were closed and a sterile dressing was applied. Platelet-rich plasma was infused. Intra-articular fluid pressure during the procedure remained between 40 and 65 mm Hg. The total operation time was 85 minutes, and the traction time was 45 minutes. The patient was discharged on the following day. She walked with walking aids over 4 weeks. One month after surgery she reported no pain and squatted and crossed her legs with no difficulty. However, 2 months after surgery, the patient began to experience groin pain, restriction of hip motion, and mild limping. She denied previous trauma. Conservative treatment with oral analgesics and noneweight bearing was prescribed, but the pain and limping increased. Laboratory test results showed a normal erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. Hip radiographs showed a concentric decrease of joint space and no signs of joint incongruity or osteophytosis (Fig 3). The Harris modified hip score was 39.6 points. We
recommended repeating magnetic resonance imaging, but the patient refused because it was not covered by her medical insurance. Because of the patient’s severe limitations, a diagnostic/therapeutic surgical procedure was prescribed. At surgery 4 months after hip arthroscopy, the cartilage of the femoral head was soft and separated from the subchondral bone (Fig 4). The exposed bone chondral defect in the anterosuperior region of the acetabulum was not covered by fibrous tissue. There were no signs of surgical infection. Macroscopic examination of the femoral head did not show evidence of osteonecrosis or subchondral collapse. Rim acetabular anchors had not damaged either the acetabulum or the femoral head cartilage. Because of the global fullthickness lesion of the articular femoral head cartilage, it was decided to proceed with hip resurfacing arthroplasty, following which the patient became pain free. Intraoperative culture results were negative. At 2-year follow-up, she was asymptomatic and the Harris hip score was 96 points (Fig 5).
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Fig 2. Arthroscopic view of the left hip through the anterolateral accessory portal. A chondrolabral lesion and exposed bone are visualized adjacent to the anterosuperior labrum. Radiofrequency ablation of acetabular articular cartilage was performed. (A, acetabulum; CL, chondrolabral lesion; EB, exposed bone; FH, femoral head; HC, hip capsule; L, labrum.)
Accordingly, with radiographic signs of a concentric decrease of the joint space and intraoperative findings, a diagnosis of chondrolysis caused by hip arthroscopy was established. Our case may represent a variant of chondrolysis given that there was a separation between the cartilage of the femoral head and the subchondral bone.
Discussion Chondrolysis of the hip includes a rapid progressive loss of joint space seen on radiographs and associated loss of clinical hip motion. Several factors are reported as potential contributors to the loss of articular cartilage: thermal causes (e.g., electrocautery, radiofrequency device), chemical causes (e.g., intra-articular infusion of local anesthetics, chlorhexidine, and gentian violet), mechanical causes (e.g., surgical insult or prominent hardware such as anchors, pins, or screws), or other causes (e.g., infection or a history of traumatic joint injury).6 A thermal source was implicated by the literature as a contributor to hip chondrolysis. Rand and Gaffey7 found that electrocautery produces temperatures of 400 C to 600 C when cutting the tissues, and this temperature generated thermal necrosis and cellular pyrolysis in one in vitro study.8 Additionally, when using thermal chondroplasty around cartilage, temperatures of 45 C to 50 C damage chondrocytes.9 Piper and Kim10 showed that intra-articular temperatures can reach a thermotoxic chondrocyte threshold, especially if inadequate fluid flow is present, and this thermal stress potentiates the chondrotoxic effects of bupivacaine in intact cartilage, leading to decreased chondrocyte viability compared with exposure to
Fig 3. Concentric loss of joint space in left hip is shown in (A) anteroposterior pelvic and (B) axial images 3 months after hip arthroscopy.
bupivacaine alone. Enochson et al.11 showed the in vitro effects of plasma-mediated bipolar radiofrequency ablation on human chondrocytes. They found it induced a well-defined margin of chondrocyte death. Rehan et al.12 reported one case of chondrolysis of the hip after excision of a torn acetabular labrum after an open approach with electrocautery. The authors speculated that the heat generated at that time may have been responsible for the subsequent chondrolysis. McCormick et al.13 recommended meticulous technique, intermittent use of electrocautery, good inflow and outflow, and pulsed lavage at frequent intervals to maintain intra-articular temperature at less than 50 C. In our patient, we used a conventional electrosurgical device to perform capsulotomy, so we
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Fig 4. Intraoperative photographs during hip resurfacing arthroplasty 4 months after initial hip arthroscopy. Articular cartilage of the femoral head was detached from the subchondral bone because there was a separation between them. No evidence of osteonecrosis or subchondral collapse was found.
know there were effects not only in target tissue but also in surrounding tissues. Also, we performed radiofrequency ablation of the acetabular articular cartilage. However, the labral tear was not excised and flow was controlled by a pressure pump. The infusion of local anesthetics through intraarticular pain pumps has been reported as a causative factor of chondrolysis in the shoulder14,15 and knee16 but not in the hip. Local anesthetics such as bupivacaine, lidocaine, and ropivacaine are chondrotoxic to human articular cartilage in vitro.17,18 We did not use the infusion of local anesthetics in the management of postoperative pain after hip arthroscopy in our patient. Surgical insult to the femoral head cartilage caused by the passage of hip arthroscopic instruments is another contributor to cartilage loss. It is probably underreported in the literature. Sampson considered it to be less than 1% in his series.19 In a review of 92 studies and more than 6,000 patients, Harris et al.20 reported
Fig 5. Hip resurfacing arthroplasty with a 2-year follow-up with no signs of loosening. Harris hip score was 96 points.
241 iatrogenic chondral injuries and 54 labral injuries. Other authors only mentioned it.21 Traction and distention enables adequate head-acetabular separation to avoid cartilage damage. It is recommended that there be at least 10 mm separating the femoral head and the acetabulum as measured by fluoroscopy. If this is not possible, access to the hip periphery should be performed first. In the same way, a cannula for instrument passage or portal exchange should always be used to prevent cartilage damage.22 In our patient, up to 10 mm of joint distraction was noted radiographically with fluoroscopy. A cannula was used during the procedure, and the hardware and rim anchors used did not injure the acetabular cartilage. Infection is another associated causative factor of chondrolysis in the hip. Hip arthroscopy is a minimally invasive procedure, and the incidence of infection is low. Chan et al.23 reported 2 cases in 236 hip arthroscopies. Harris et al. 20 reported 7 superficial infections and 1 deep infection in more than 6,000 patients undergoing surgery of the hip. In a patient with hip pain, there should be a high suspicion of postoperative infection when the patient is not bearing weight on the
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leg and is not moving the hip after hip arthroscopy and has elevated ESR and CRP levels. In our patient, ESR and CRP levels were normal, there were no signs of intraoperative infection, and intraoperative culture results were negative. Traction is necessary to view the central compartment of the hip, and inadequate traction can result in chondral damage. Traction force and duration should be attended to prevent complications caused by distraction. A mean distraction force between 15 and 30 kg or 200 to 400 N and duration no greater than 2 hours is recommended.19 We do not have a tensiometer to measure the traction force in the operating room, and adequate head-acetabular separation was determined using fluoroscopy. However, our traction time was 45 minutes. There is a risk of vascular injury related to hip arthroscopy. On the one hand, the portals should be used with care, especially the posterolateral portal for its proximity from the deep branch of the medial femoral circumflex artery.24 We used anterolateral and midanterior portals, so it is unlikely that direct vessel injury was caused. On the other hand, the most lateral aspect of the cam deformity is close to the area where the medial femoral circumflex artery enters the hip capsule behind the lateral synovial fold, and there is a risk of injury during femoral head-neck junction osteoplasty.22 We identified the deformity arthroscopically and through fluoroscopy to perform the osteoplasty. There was no abnormal bleeding during the procedure. A relation between hip intracapsular pressure and a decrease in local blood flow and venous occlusion is presumed. In vivo studies reported intracapsular pressure of at least 200 mm Hg maintained for 10 hours to observe osteonecrosis of the trabeculae.25,26 Other in vivo studies reported that tamponade of the hip reduced the mean oxygen partial pressure to 60% of its initial value, and traction in extension decreased the mean oxygen partial pressure to 35% of baseline.27 We used a pressure- and flow-controlled pump during the procedure, and pressure was kept between 45 and 65 mm Hg. We report a rare complication after hip arthroscopy. Our patient’s preoperative magnetic resonance image showed no evidence of chondral lesions or femoral head osteonecrosis. The patient had not sustained previous trauma. We were unable to record the exact amount of traction used on our traction table; however, our procedure lasted 85 minutes and traction time was 45 minutes. The arthroscopic portals used had no association with either the medial femoral circumflex or inferior gluteal arteries. We used electrocautery in our procedure and radiofrequency ablation of acetabular articular cartilage. Intra-articular fluid pressure was monitored and was less than 65 mm Hg during the procedure. No intra-articular pain pumps to manage
the postoperative pain were used. We confirmed the absence of postoperative infection. We believe the cause of chondrolysis in our patient may have been caused by electrocautery or to an injury that occurred during the arthroscopic procedure.
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