Hip Int 2014; 24 ( 5): 448-456 DOI: 10.5301/hipint.

5000144

ORIGINAL ARTICLE

Arthroscopic hip surgery with a microfracture procedure

of the hip: clinical outcomes with two-year follow-up
Benjamin G. Domb1, Youssef F. El Bitar2, Dror Lindner2, Timothy J. Jackson2, Christine E. Stake2
1
American Hip Institute, Hinsdale Orthopaedics, Loyola University Stritch School of Medicine, Westmont, Illinois - USA
2
American Hip Institute, Westmont, Illinois - USA

Background: Outcome studies assessing a cohort of patients receiving microfracture in the hip have
focused on second look arthroscopy and return to sport, which have shown favourable results in the
absence of osteoarthritis. Few studies exist focusing on clinical outcomes after microfracture in the
hip using patient reported outcome (PRO) scores. The purpose of this study is to evaluate two-year
clinical outcomes of a series of patients treated with microfracture during arthroscopic hip surgery
using PRO scores.
Methods: During the study period, all workers compensation (WC) and non-WC patients treated
with microfracture during arthroscopic hip surgery were included. Four PRO scores, pain scores and
satisfaction were used to assess clinical outcomes. Any revision surgeries or conversions to total hip
arthroplasty (THA) were noted. Location of microfracture procedure, lesion size and additional variables
assessed survivorship.
Results: Thirty-seven cases met the inclusion/exclusion criteria, of which 30 patients (30/37, 81%) were
available for minimum two-year follow-up. Twenty-six patients were classified as survivors. Preoperative
scores for patients with WC status were lower than non-WC patients and statistically significant (p<0.5)
for three of the PROs. However, changes in all four PRO measurements demonstrated statistically sig-
nificant improvements from preoperative to two-year follow-up for both compensation groups (p<0.05).
The amount of change in PRO scores for both compensation groups was similar and not statistically
significant. Two patients required THA and two patients required revision arthroscopy.
Conclusion: Our study demonstrates statistically significant clinical improvement in PROs after re-
ceiving microfracture during arthroscopic hip surgery at minimum two-year follow-up.

Keywords: Hip, Arthroscopy, Microfracture, Cartilage

Accepted: March 14, 2014

INTRODUCTION bring marrow cells and growth factors from the underlying
bone marrow into the affected chondral defect. By pen-
Articular cartilage damage is challenging for orthopedists etrating the subchondral bone, pluripotent marrow cells
to address because of its limited healing capacity (1). can emerge to form new fibrocartilage to fill the chondral
Advances in the field of hip arthroscopy, such as the use defect.
of microfracture in the hip, have broadened the spectrum Microfracture is a surgical procedure often described to
of surgical interventions available for management of in- treat chondral defects of the knee, with promising results
tra-articular pathology. The objective of microfracture is to (2-4). Research addressing the efficacy of microfracture

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Domb et al

in the hip joint is limited and indications for microfracture The inclusion criteria for this study were WC and non-WC
use in the hip is extrapolated from literature on the knee patients treated with microfracture for full thickness car-
(2-6). The advantages of microfracture include the abil- tilage defects performed during arthroscopic hip surgery.
ity to access a large surface area of the acetabulum and The indications for surgery were predominantly labral tears
femoral head, cost-effectiveness, minimal morbidity and is with mechanical symptoms and failure of conservative
straightforward to perform. Clinical outcomes of microfrac- treatment. Exclusion criteria were previous hip conditions
ture in the hip have been favourable in the absence of os- such as Legg-Calves-Perthes disease, avascular necrosis
teoarthritis (OA), with no significant complications reported (AVN), and Tnnis grade 2.
(5-9). Additional outcome studies in a cohort of patients
receiving microfracture in the hip have focused on second Surgical technique
look arthroscopy in revision surgeries and return to sport,
which have shown favourable results in the absence of OA The hip arthroscopies were performed by the senior
(5, 10). There are few previous studies focusing on clinical author (BGD) in a practice dedicated to hip preserva-
outcomes for patients receiving microfracture during ar- tion. All surgeries were performed in the modified supine
throscopic hip surgery, and use of several patient reported position using a minimum of two portals (standard an-
outcome (PRO) scores. terolateral and mid-anterior) (15-16). After establishment
The purpose of the study is to evaluate the clinical outcomes of portals and capsulotomy, a diagnostic arthroscopy
of a series of workers compensation (WC) and non-WC was performed and intraoperative data was document-
patients treated with microfracture during arthroscopic hip ed, including defects of the ligamentum teres, labrum,
surgery using PRO scores, with a minimum of two-year fol- synovium and articular cartilage. The ALAD classifica-
low-up. We hypothesise patients receiving microfracture to tion was used to classify articular cartilage damage (13).
treat chondral defects will demonstrate significant improve- Femoral and acetabular Outerbridge grade were also
ments with a minimum of two-year follow-up. recorded (14).
Bony pathology was corrected under fluoroscopic guid-
ance. Acetabuloplasty was performed for pincer impinge-
METHODS ment, and femoral neck osteoplasty was performed for cam
impingement. Labral tears were repaired when indicated
At our centre, clinical and outcomes data is prospectively or selectively debrided until a stable labrum was achieved
collected on all patients undergoing arthroscopic surgery while preserving as much labrum as possible. The full-
of the hip. The study period was between August 2008 thickness cartilage damage was then treated with micro-
and January 2011. PRO scores used included the modi- fracture, performed according to Steadmans technique
fied Harris Hip Score (mHHS), the Non-Arthritic Hip Score (17, 18). Using a shaver, loose cartilage was removed and
(NAHS), the Hip Outcome Score Activities of Daily Living portions of delaminated cartilage were removed with a ring
(HOS-ADL), and the Hip Outcome Score Sport Specific curette to create stable borders. The calcified layer was
Subscale (HOS-SSS). PRO scores were collected preop- also removed with the curette.
eratively and at three months, 12 months, and 24 months
follow-up. All four questionnaires were used, as it has Rehabilitation protocol
been reported that there is no conclusive evidence for the
use of a single PRO questionnaire for patients undergoing For the first two weeks, the patients were kept in a hip brace
hip arthroscopy (11, 12). Visual analogue scale (VAS) pain locked at 090 of flexion at all times. The patient was re-
scores and patient satisfaction rating were also collected. stricted to non weight-bearing status for the first eight
Any revision surgeries, complications, additional surgery weeks following surgery. Patients started physical therapy
or conversions to THA were noted. Location of microfrac- on the first postoperative day to initiate range of motion.
ture procedure, lesion size, acetabular labrum articular This was accomplished by four hours per day using a con-
disruption (ALAD) (13) and Outerbridge (14) classification tinuous passive motion (CPM) machine or on a stationary
systems were also recorded to help assess survivorship. bicycle for two hours a day. Two weeks postoperatively, the
Our institutional review board approved this study. brace was discontinued with continued emphasis on range

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Microfracture in the hip: clinical outcomes with a two-year follow-up

of motion. At eight weeks postoperatively, patients started

weight-bearing with gradual advancement to full weight-
bearing.

Statistical methods

For preoperative and postoperative mean comparisons,

scores were modeled using repeated measures analysis
of variance (ANOVA) as a function of group (workers com-
pensation yes or no) and time (preoperative, postopera-
tive) as the fixed main effects. Group x time was the fixed
interaction effect and person as the random effect, thus
taking into account that observations are not independent
across time (2 x 2 ANOVA). The normality assumption was
evaluated using the quantile-quantile plots of the residuals.
The constant variance assumption was evaluated by con-
structing plots of the residuals versus the predicted values
under the above ANOVA model. We confirmed that there Fig. 1 - Microfracture case series CONSORT flow diagram.
were no major violations of the normality and the constant
variance assumptions. TABLE I - CONCOMITANT SURGICAL PROCEDURES
Comparisons of variables between groups without failure
versus with failure used the Wilcoxon rank sum test with Procedure Type Number with Percentage
continuous/ordinal variables. Categorical variables were Procedure with
compared between groups using the Fishers test. Formal (n = 30) Procedure

survivor analysis was performed using the Kaplan-Meier Osteoplasty 20 67%

method. Ligamentum Teres Debridement 18 60%
Acetabuloplasty 17 57%

RESULTS Labral Debridement 15 50%

Labral Repair 12 40%
Patient population Synovectomy 10 33%
Capsular Release 29 97%
A CONSORT flow diagram is presented in Figure 1. A to-
Chondroplasty 7 23%
tal of 37 cases met the inclusion/exclusion criteria and 30
Removal of Loose Body 6 20%
patients (30/37, 81%) were available for two-year follow-up
(mean 35 months 24-50). The study group consisted of 12 Capsular Plication 1 3%
females (12/30, 40%) and 18 males (18/30, 60%). The mean Femoroplasty 2 6%
age was 45 years (range 29.560). Twenty-eight patients Iliopsoas Release 2 6%
(28/30, 93%) had acetabular microfracture and the remain-
Trochanteric Bursectomy 2 6%
ing two (2/30, 7%) had femoral microfracture. Concomitant
Debridement of Acetabular 1 3%
surgical procedures are presented in Table I. The majority
Fossa
of patients (29/30, 97%) had a capsular release with one
Debridement of Trochanteric 1 3%
patient receiving capsular plication. Postoperative diagno-
Bursitis
ses are presented in Table II. No kissing lesions were re-
Labral Reconstruction with 1 3%
ported. Table III provides information per patient detailing if
Capsular Augmentation
femoroplasty or acetabuloplasy was performed, ALAD clas-
Removal of Os Acetabulum 1 3%
sification and acetabular and femoral Outerbridge grades.

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TABLE II - POSTOPERATIVE DIAGNOSES Based on our data, the standard deviation for the mHHS
paired mean difference from baseline to two years is
Diagnosis Number (N = 30) Percentage 16.9. We hypothesised that a mean change of ten points
Chondral Defect 30 100% would be considered clinically important. We determined
Labral Tear 27 90% 25 patients would be needed to detect this mean differ-
CAM Lesion 22 73% ence with 80% power at the usual p<0.05 level of signifi-
cance. Therefore, our sample size of 30 was adequate to
Ligamentum Teres Tear 16 53%
confirm the mean difference.
Pincer Lesion 16 53%
Two patients required conversion to THA after acetabular
Synovitis 7 23%
microfracture. The first was a 55-year-old male who was
Loose Body 6 20%
found during the initial procedure to have a grade 4 full thick-
Trochanteric Bursitis 3 10% ness defect on the acetabulum and two grade 3 lesions on
Os Acetabulum 1 3% the femoral head measuring 1 cm2 and .25 cm2. The second
Acetabular Notch 1 3% patient was a 61-year-old, obese female who was found to
Adhesive Capsulitis 1 3% have a grade 4 full-thickness, large chondral flap off the ac-
Capsular Stiffness 1 3% etabulum measuring 4.75 cm2, as well as grade 2 damage
Hip Flexor Tendonitis 1 3%
on the femoral head. THA was required because of increas-
ing pain and interference with activities of daily living along
Snapping Hip 1 3%
with failure of additional conservative therapies.
Two patients required revision surgery. One patient, a
Total cohort non-survivorship was four out of 30 (4/30). A 46-year-old female, required revision arthroscopy 11 months
total of two patients (2/30) in the study group, who had ac- subsequently because of persistent pain and recurrence of
etabular microfracture, required revision surgery. Out of the mechanical symptoms. The original injury was a high impact
28 patients who had acetabular microfracture, two required car to pedestrian motor vehicle accident. The revision ar-
subsequent THA (2/28). No patients required a THA after throscopy involved lysis of scar tissue in the capsular labral
femoral microfracture, for a two out of two survivorship. recess and debridement of hypertrophic fibrocartilage in the
At two-year follow-up, 26 patients (26/30, 87%) were de- area where microfracture was previously performed. Upon
fined as survivors, meaning they did not require THA or last follow-up, the patient reported notable improvement.
revision surgery after initial arthroscopy with a microfrac- The second patient required revision surgery 18 months after
ture procedure performed. All four PRO measurements the initial arthroscopic procedure with acetabular microfrac-
and pain scores demonstrated statistically significant im- ture due to recurrence of pain, which was confirmed with
provements for both groups from preoperative to two-year relief from intrarticular injection. MRA identified a re-tear of
follow-up (p<0.05). Preoperative scores for patients with the labrum. Intraoperative findings during the revision proce-
workers compensation (WC) status were lower than non- dure also identified a high-grade ligamentum teres tear, small
WC patients and statistically significant (p<0.5) for three pincer lesion and adhesive capsulitis.
of the PROs, mHHS, NAHS and HOS-ADL. Preoperative The following variables were compared in the four patients
pain and HOS-SSS scores were not statistically different requiring revision surgery or THA and compared to the 26
between groups, but trending lower for patient with WC survivors: lesion size, ALAD class, acetabular cartilage dam-
status (p = .08). PRO outcome means for both Non-WC age and femoral cartilage damage with the Outerbridge clas-
and WC are presented in Figure 2. When compared, the sification system. Results from each patient are presented in
amount of change in PRO scores for both groups was Table III with corresponding classification legends. None of
similar and not statistically significant. For two-year survi- these variables significantly varied between survivors and
vors (26/30, 87%) mean pain scores combined from both non-survivors. When assessing surgical procedures, the
compensation groups decreased significantly from 6.3 to only proportion that was significantly different (p = 0.018) be-
3.7 (p<0.001), and satisfaction had a mean of 7.25 for both tween the groups was removal of loose body. A total of three
compensation groups on a 110 scale, and were not sta- out of four non-survivors who required revision or subse-
tistically different. quent THA had removal of a loose body, compared to three

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Microfracture in the hip: clinical outcomes with a two-year follow-up

TABLE III - DIAGNOSTIC AND OPERATIVE DATA BY INDIVIDUAL PATIENTS

Patient WC ALAD Femoral Acetabuloplasty- Acetabular Femoral

Classification* Osteoplasty- Arthroscopic cartilage damage cartilage damage
Arthroscopic (Outerbridge grade) (Outerbridge grade)

1 No 2 No No 2 2
2 No 2 No Yes 2 3
3 No 0 No Yes 4 0
4 No 0 Yes Yes 3 3
5 No 4 Yes No 4 0
6 No 0 Yes Yes 4 4
7 No 0 Yes Yes 4 0
8 No 0 Yes Yes 4 3
9 No 0 Yes Yes 4 2
10 No 0 No No 4 2
11 No 0 No Yes 4 2
12 No 4 Yes No 4 3
13 No 4 Yes No 4 0
14 No 0 Yes No 4 0
15 No 4 Yes No 4 0
16 No 3 Yes No 0 4
17 No 4 Yes Yes 4 2
18 No 4 Yes Yes 4 0
19 No 0 Yes Yes 3 4
20 No 3 No No 3 2
21 No 3 Yes Yes 3 0
22 Yes 4 Yes Yes 4 0
23 Yes 4 Yes Yes 4 0
24 Yes 4 Yes No 4 0
25 Yes 2 No Yes 2 0
26 Yes 4 Yes Yes 4 0
27 Yes 4 Yes No 4 0
28 Yes 4 Yes No 4 0
29 Yes 3 Yes No 3 0
30 Yes 3 Yes Yes 4 0
* ALAD Classification System15: 0 = None, 1 = Softening of the adjacent cartilage, 2 = Early peal of the cartilage (carpet delamination), 3 = Large flap of the cartilage,
4 = Loss of cartilage.

Outerbridge Classification System16: 0 = Normal cartilage, 1 = Cartilage with softening and swelling, 2 = A partial- thickness defect that doesnt reach subchondral
bone, 3 = Fissuring to the level of subchondral bone with area greater than 1.5 cm, 4 = Exposed subchondral bone.

out of 26 for the survivors. We computed failure free prob- DISCUSSION

abilities over time using the Kaplan-Meier method. The fail-
ure free probabilities were 100% at 12 months, 93.3% at 18 The results of this study demonstrate statistically signifi-
months (95% CI: 84.4%100%), and 89.9% at 24 months cant improvement in PRO scores after receiving microfrac-
(95% CI: 79.9%100%), which are shown in Figure 3. ture during arthroscopic hip surgery at minimum two-year

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Domb et al

we were able to use four different PRO scores, providing

a wider array of instruments than previous studies. Out of
30 patients who met established inclusion criteria, 26 were
categorised as survivors. Two patients required revision
surgery and two needed subsequent THAs, for a survivor-
ship of 26/30 (87%). Out of the two patients who required
subsequent THAs, both had diffuse degenerative changes
beyond the focal area of microfracture seen at time of ar-
throscopy. However, both patients presented with more
significant chondral defects and intra-articular pathology
during the first arthroscopic procedure than was revealed
through clinical or radiographic findings. Acetabular micro-
fracture had a 4/28 non-survivorship and femoral micro-
fracture had a 2/2 survivorship. Overall, the data presented
represents favorable results for patients receiving micro-
fracture during arthroscopic hip surgery for focal chondral
defects in the hip.
Steadman et al (18) contend advantages of microfrac-
ture include cost-effectiveness, technologically feasible,
and minimal risks, while leaving additional treatment op-
tions available to the patient. Microfracture does not rely
on replacing damaged tissue, but creating a marrow-
based strategy for tissue repair (18). Indications include
Fig. 2 - PRO scores pre-operatively and at two-year minimum fol- full-thickness cartilage defects and unstable cartilage flaps
low-up by compensation status. overlying subchondral bone. Contraindications include
patient unwillingness or inability to adhere to demanding
rehabilitation protocol, specifically weight bearing restric-
tions, and degenerative OA or systemic immune-mediated
disease. Age and size of lesion are not specific contraindi-
cations, but microfracture is generally preferred for smaller
lesions <4 cm2. Additional joint pathologies should also be
addressed when performing microfracture. Full benefits of
microfracture are usually not seen in knees for a minimum
of six to 12 months, with continued improvement lasting
for up to two years and then leveling off.
Knutsen et al conducted a randomised trial comparing au-
tologous chondrocyte implantation with microfracture in the
knee (4). In contrast to Steadman et al, this study excluded
acute injuries and included chronic and larger lesions. Forty
patients were randomised to receive autologous chondro-
cyte implantation and 40 received microfracture. Findings
Fig. 3 - Kaplan-Meier failure free probabilities.
at five years showed both groups demonstrated statistically
significant improvement in PRO scores, but there was no
follow-up. To our knowledge this is the largest prospective difference between the two treatment types. Similar to the
case series specifically evaluating patient reported out- Steadman study, younger patients had clinically better out-
comes with minimum two-year follow-up after receiving comes as compared to older patients. Both groups reported
microfracture during arthroscopic hip surgery. Additionally, a 23% failure rate. Additionally, five years post-treatment,

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Microfracture in the hip: clinical outcomes with a two-year follow-up

34% of patients had radiographic evidence of early OA de- microfracture patients were the only patients to return to
spite this being an excluding factor at the beginning of the greater than simple activities of daily living such as martial
study. However, the authors attribute this finding to their arts and horseback riding. The authors report these pa-
patient cohort and corresponding demographics and con- tients continue to demonstrate satisfactory function five
founding variables. The authors recommend microfracture years postoperatively.
as first-line procedure for cartilage defects in the knee while Haviv et al assessed outcomes related to femoral osteo-
autologous chondrocyte implantation may be most benefi- chondroplasty to treat cam lesions and acetabular chondral
cial as a second-line treatment for larger chondral defects. lesions (20). Patients with additional intra-articular hip pa-
Phillipon et al advocated that microfracture principles can thology were excluded. Out of 170 hips, 29 (17%) patients
also be applied to the hip (5). The authors reported on a received microfracture, for which criteria included grade 2
series of nine patients who previously underwent micro- or 3 lesions <300 mm2. The authors reported a significantly
fracture for acetabular chondral defects and underwent better NAHS in this patient group. The authors theorise the
second look hip arthroscopy for a variety of reasons (5). improved NAHS scores reflect improvement in the ability to
The mean percent fill of the defects was 91%, with good perform higher demand activities.
quality cartilage at a mean of 20 months. The authors con- Microfracture has been more specifically studied as an in-
cluded microfracture is an effective treatment strategy for dependent variable in the athletic population. McDonald et
chondral lesions in appropriately selected patients such as al conducted a study in elite athletes assessing return to
patients without diffuse OA and those able to adhere to the play between those who did and did not receive microfrac-
strict rehabilitation protocol. ture (10). Sports played included football, soccer, hockey,
Many additional authors support the use of microfracture baseball, tennis, and golf. Thirty nine patients (39 hips) re-
in the hip as an option to promote cartilage healing without ceived microfracture, compared to 81 patients (94 hips) in
adding significant risk or morbidity. Byrd et al (9) reported the control group. No significant differences were found
on the arthroscopic management of cam-type FAI in 207 between the two groups for rate of return to play, however
hips. Microfracture was performed in 58 hips based on sur- the microfracture group did have a 1.6 times higher risk
geon assessment, which included grade 4 chondral defects, of not returning. Additionally, there was no statistical dif-
intact subchondral plate and healthy surrounding cartilage. ference between the number of seasons played postop-
For patients who received microfracture, their mHHS score eratively between the two groups. The authors concluded
improved a mean of 20 points, from 65 preoperatively to microfracture can be used in an athletic population to help
85 postoperatively. Karthikeyan et al published a series of increase levels of return to play.
20 patients who underwent hip arthroscopy for FAI and In contrast to other studies, Philippon et al (21) conducted
underwent microfracture for acetabular chondral defects a study reporting two-year outcomes after hip arthroscopy
(19). These patients subsequently underwent a second look for the treatment of femoroacetabular impingement (FAI)
arthroscopy for various reasons. The mean time interval and related labral and chondral pathology where patients
between the primary and revision surgeries was 17 11 receiving microfracture showed no significant difference in
months. The mean percent fill was 93% 17%, with mac- postoperative mHHS score when compared to patients not
roscopically good quality cartilage. The Non-Arthritic Hip receiving microfracture. Of the 122 patients who met the
Score (NAHS) mean was 54.5 points before both primary inclusion criteria, 47 (38.5%) received microfracture, eight
and revision surgeries. The score improved to an average on the femoral head, 30 on the acetabular surface and
78 points at a mean follow-up of 21 months. nine on both. The authors reported patients who received
Byrd et al published their series of nine patients who were both types of microfracture were statistically more likely
found to have an inverted labrum as a possible cause of (p = 0.0001) to receive THA.
hip OA (8). All nine patients concomitantly presented with Many authors discuss the importance of patient selection
grade 4 acetabular chondral lesions. Out of the nine pa- and diagnostic criteria for selecting patients to undergo mi-
tients, only four demonstrated mHHS score improvement crofracture. Horisberger et al (22) conducted a study assess-
of at least 10 points, however of those four, three were pa- ing short-term results for patients treated concurrently for
tients who received microfracture and had a mean mHHS FAI and labral and chondral damage, who also were found
score improvement of 36 points. Additionally, the three to have severe cartilage lesions or damage intraoperatively.

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Domb et al

Out of 20 patients included in the study, 15 (75%) received Future use of a matched-pair control group would provide
microfracture. Of the original 20 patients, 50% required additional insight into the outcomes related to microfrac-
conversion to THA at point of last follow-up, at a mean of ture in the hip.
three years. However, a large percentage of the patients
(55%) had Tnnis grades >2, which at our centre is a rela-
tive contraindication for arthroscopic intervention. The au- CONCLUSION
thors do report in their study that patients with higher Tnnis
grades were statistically more likely to need THA (p = 0.03). The results of this study demonstrate patients reported
Additionally, the authors advocate arthroscopic treatment statistically significant clinical improvement in PROs after
in FAI addressing degenerative lesions is contraindicated in receiving microfracture during arthroscopic hip surgery at
patients with Tnnis grades >3. minimum two-year follow-up. A high survivorship was not-
ed, and those patients who were not survivors had diffuse
Strengths/limitations degenerative changes. We conclude that the presence of
diffuse degeneration may be a negative prognostic factor,
The greatest strength of our study was the dedicated pro- but results of microfracture in focal chondral defects of the
spective assessment of clinical outcomes of microfracture hip are favourable.
using four PRO scores. Many previous microfracture stud-
Financial Support: General research support from Arthrex, Inc.,
ies have evaluated microfracture as a subgroup within a
Florida, USA.
larger cohort, or in very specific populations such as elite
athletes or patients requiring second look or revision pro- Conflict of Interest: None.
cedures. Additionally, no previous study of microfracture
has assessed outcomes using four different PRO mea- Address for correspondence:
Benjamin Domb
sures. A limitation of our study is the small sample size. As American Hip Institute, Hinsdale Orthopaedics
in other studies, concomitant procedures were performed Loyola University Stritch School of Medicine
in all cases, creating a challenge in isolating the outcomes 1010 Executive Court
Suite 250
of the microfracture itself. Our cohort is quite heterog- Westmont, IL 60559, USA
enous and numerous variables may influence outcomes. [email protected]

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