Hip arthroscopy has evolved considerably over the past 15 years.  The surgical techniques and instruments have been refined to a point where skilled surgeons can accomplish a lot inside the hip in a relatively short period of time. Since the procedure is technically challenging, however, (requires a special 70 degree arthroscope, works in a deep part of the body in a narrow space, and requires joint distraction – which puts a time limit on the length of surgery) it is not ready for ‘mainstream’ practice – as most surgeons don’t have the opportunity to get specialized or advanced training in arthroscopy.   This reality, as well as the difficulty of reaching cartilage lesions deep on the femoral head or deep in the acetabular socket, has made treating cartilage lesions difficult.

We have decent strategies for cartilage repair/restoration in the knee, and less so in the ankle and shoulder, but in the hip the options are very limited. Converting to an ‘open’ surgery to transplant cartilage in the hip is much more impactful and difficult for the surgeon and the patient  as compared to the knee, for example.

Attached are a couple of pictures showing cartilage defects.  These could be repaired by microfracture technique or a cartilage transplantation procedure like Autologous Chondrocyte Implantation (ACI) or DeNovo NT. These latter two techniques are currently performed with open surgery, but Dr. Hyman is developing a technique to do the cartilage repair arthroscopically.

For more information on this, and other surgical techniques, see my website at www.hiparthroscopydoctor.com

MEDICAL DISCLAIMER:
Please be advised, we do not have established patient/physician relationship for medical care. If you need medical care or medical attention, please schedule an appointment with your physician in person, or go to an Emergency Room.

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33 Responses to Cartilage Repair in the Hip: Microfracture and …

  1. john says:

    I have a labral tear with a slight impingement in my left hip. I am a runner and do alot of external rotation of my hip doing pilates. Since November I have stopped running and continued Pilates and have had significant pain reduction. Almost 100%. However my doctor thinks I should do the hip arthoscopy surgery. My question is this, if I have no pain, what can happen if I don’t do surgery? I understand tear cannot heal, so will it cause problem in future? I’m 45 and active and so confused. If doing pilates and not running helps but I want to run, is surgery better?

    • JonHyman says:

      Not all labral tears require surgical treatment. If you can make your hip become pain-free without surgery it is likely that surgery is not necessary. No one truly knows the natural history of what comes of a label tear that becomes asymptomatic and goes on in definitely over the years.

      There is not a lot if significant evidence right now that suggests that you will definitely have problems later on simply because you have a torn labrum.That said, we do think the labrum serves an important role and in some patients it seems appropriate to fix it.

      Most surgeons I know would not recommend surgery on a labral tear that was not painful. Please discuss this carefully with your physician.

      Running may be well-tolerated even still in the future. One has to see on an individual basis what the possibilities are.

      While it is true that many labral tears are difficult to heal, I would not go so far as to say that the labrum is incapable of healing on its own.

  2. Megan Crump says:

    Hi! My name is Megan, I am a 35 y.o. very active female, full time counselor, wife, and mother. I had a hip arthroscopy on March 9th with a surgeon here in Springfield, Missouri. They indicated initially that I had a Labral tear in my hip (right side). I was told when I scheduled surgery that the surgery would be to repair the specific tear with one procedure before the surgery. I woke up to a different reality. They did a labral tear repair, with debridement, with a microfracture/chondroplasty to the femoral head. I am 40 days post op, still having significant pain, lack of mobility, and my surgeon has never followed up with with me. He has always had his physician’s assistant talk to me or see me. They STILL haven’t referred me to physical therapy. They did not prepare or educate me for the recovery and never discussed the additional procedures with me before the surgery. I have now missed several weeks of work, am still having to rely on one crutch and sometimes two, and the pain can be debilitating. They have given me no idea of how long this recovery will be, what the outcomes may be, or what I should or should not be doing. I am extremely concerned about what they have done. I am concerned this surgeon did a technique that he really knows little about, but just “tried” it on me. They have been neglectful in my aftercare, have minimized the overall surgery, and also never really discussed what can occur when putting my leg in traction during the surgery. I desperately need some guidance and don’t know what next step to take. My husband and I would greatly appreciate any information, direction, or guidance and what to do next. I just want to find a second opinion or specialist who can really help me from this point forward. Thanks so much!! Megan Crump

    • JonHyman says:

      Sorry to hear of your difficulty and frustration. Of course there is no substitution for an open, candid and honest conversation with your surgeon about all the issues you’ve raised.

      If you would like a second opinion, feel free to contact our office for instructions on submitting your records.

      That said, ‘some’ pain is not unusual at your stage of recovery, but how much would be appropriate for you specifically is not something I can discern in this manner. While PT is often well underway at this point, there may be reasons your physician has not prescribed it. I really couldn’t say.

      I am concerned about your hip and the impact this is all having on you. Please be persistent in communicating with your physician. We are open to helping, as I mentioned above.

  3. Nick says:

    Dear Dr Hyman,
    How are things coming with the Denovo/grafting process for chondral defects? I understand some other hip arthroscopists in the US may also be testing out the procedure?

    • JonHyman says:

      It’s progressing. We are doing it, though instruments are still being refined. The battle is in getting insurance companies to approve it.

  4. Dave says:

    I just had microfracture on my hip and had a question regarding timing for the rehab. I understand I should be on crutches for 6 weeks, but can I start deep mater walking in a pool now that I have gone 4 weeks post surgery with no pain? I am hopeful I can start to strengthen the leg so I can start walking normal at 6 weeks. Any thoughts you may have would be appreciated.

    • JonHyman says:

      Generally, the deep aquatics would be tolerated at this point, but it would depend upon what other work was done in your hip and WHERE the microfracture was done: ie on the femoral head, or acetabulum and how susceptible it was to load during weightbearing. Definitely something to get answered by your surgeon.

  5. Darko says:

    Dr. Hyman,

    I had a microfracutre surgery done for a small cartilage lesion on my acetabulum. This was about a year ago and I have recovered pretty well. However I still seem to have some discomfort when running but I do not have discomfort with things like weight training. Why do you think that is? Also I was wondering what your thoughts are on PRP injection to possibly give the hip more ability to recover.

    Thank you for your help!

    Darko

    • JonHyman says:

      Microfracture of acetabular cartilage is an area of ongoing interest and concern. The size of the lesion and the health of the adjacent cartilage can impact recovery, as well as genetics and activity level. PRP is this area is unproven but may merit consideration in difficult cases. DeNovo NT cartilage transplantation is something we are doing in isolated cases. Outcomes too early to really tell. The impact of running may be hitting the dome of the acetabulum, where most of these lesions occur, thus causing pain. Pushing through the pain after cartilage restoration may not be ideal.

  6. Lisa says:

    I am on day 8 after having a hip arthroscopy , labral debridement and micro fracture of the acetabulum on my right hip. Im doing good, pain isn’t too bad – more of a bad ache. I have had some nerve damage to my right foot – the surgeon said its because my foot was in traction for 2 hours – i cant flex my ankle and it feels slightly numb – is the feeling likely to come back? I am a bit worried about this – seeing my surgeon on 24th september – but wondered if you could share any light on this. I was also wondering what the average time is to go back to work? Im a teaching assistant. Im terrible at just sitting about doing nothing- theres only so much TV, and reading someone can do- ha!

    • JonHyman says:

      Feeling and function are concerning in this context. It is not uncommon to have slight numbness…but an inability to flex the ankle is much more concerning. The sensation would be expected to return within a few weeks of the surgery…and hopefully the flexion of the ankle will as well, but that is definitely something that needs to be followed carefully.

      Avg. time to return to work depends upon the type of work you have and the ability of the job to accommodate a ‘light duty’ work effort. Once you have a normal gait and have good range of motion and mechanics, your surgeon may clear you. Some patients are back at work in a week or two, others may take 6-8 weeks or longer. Again it all depends upon the demands of your job and your ability to perform them safely.

  7. Tim Megginson says:

    My Hyman

    Thank you for your blog. I had hip athroscopy 9 weeks ago. I underwent micrfracture treatment in my acetabulum, I had femoral acetabular impingement. The bony lump was cleared away from the femoral head.

    I’m feeling quite good and re introducing some walking.

    I booked a holiday with some friends several months ago- and thought I would be OK to go. Do you think going on holiday is going to be OK?

    I walk OK, is too much walking a concern at this stage?

    I’m worried about the recovery

    • JonHyman says:

      Tim, unfortunately I can’t tell. It would depend upon your ROM, strength and how large your lesion was that was microfractured and how confident your surgeon is that it will heal. Generally, I would discourage microfracture patients from running, climbing or prolonged walks, especially with inclines, at this stage. It also depends upon what activities you plan to do on holiday. Please discuss with your surgeon and/or physio therapist. Glad you are doing well!

  8. Mario says:

    Dr. Hyman,

    First of all thank you very much for having this blog. Its tough to find knowledgable surgeons who are willing to take time to do something like this.

    I am 22 year old soccer player and I’ve had a hip scope for a labral tear and also microfracture in the acetabulum. My doctor said that the lesion was small and that the rest of the carilage is healthy around it. Its been about a year now and I am feeling pretty good, I have some minimal discomfort during higher levels of activity. My worry is that the region where the cartilage defect is will wear off again. How common is something like that? Also can the healthy cartilage around where the microfracure was done deteriorate faster because of that lesion there? And the last question I had, are there any supplements out there that have a good proven effect on cartilage support?

    Thanks again for your insight, it is much appreciated.

    -Mario

    • JonHyman says:

      We don’t know the natural progression of cartilage lesions in the acetabulum. We don’t know the long term outcomes of microfracture in the hip. No one does. The cartilage adjacent to the microfracture area is at risk because of rim/contact stress, especially if the microfracture area is large. There isn’t much we know of that one can do to prevent progression of the lesion. No proven supplements in this specific setting. All good questions, sorry our answers are so limited.

  9. Chris says:

    Hi there I had a laberal tear repaired bone shaved and micro fracture iny left hip 9 weeks ago. I have been off my crutches for 2 weeks and am walking ok. I am beginning to notice some pain in my glut near my ischium when I walk – what could be causing that

    • JonHyman says:

      That’s such a non-specific symptom that there are too many possibilities to mention them all. Hamstring tendonitis, compensation for altered gait, change in activity from sedentary to mobile, muscle deconditioning, bursitis, ischiofemoral impingement, nerve irritation, and on and on. Hopefully it will resolve once your ambulation normalizes.

  10. Dale says:

    Hi Doc,

    I am a 49 YO male and had arthroscopy on my right hip for a labral repair and microfractures on the femoral head one year ago. He also “cleaned things up a bit” he said. There was more arthritis than the MRI and arthrogram indicated. I am very active and in good shape. I was told to avoid any impacting activities and horseback riding. I am compliant. I was virtually pain free 6 months ago, but the symptoms are slowly returning and I get a lot of popping and tightness in the hip area. Stretching is very helpful though. Are the symptoms likely to continue to worsen or level out?

    • JonHyman says:

      It’s hard to tell. These types of symptoms are often progressive with advancing arthritis. However, the rate of deterioration is variable from one patient to the next. Your symptoms may decline and then plateau for a period of months or even years and then decline further. Unfortunately rapid progression is also sometimes observed.

  11. heather says:

    Dear Dr. Hyman,

    I was diagnosed almost 7 years ago with two hip labral tears (anterior and posterior) in my left hip. After being told by a surgeon that I was not a candidate for the minimally invasive labral repair and rather that my options at age 26 were either hip re-surfacing or hip replacement, I decided to do my best to manage my injury without surgery. I have had moderate success with aquatic therapy and reduced my physical activity dramatically (no more running, ultimate frisbee, carrying a backpack).

    Yet, recently, I have become frustrated by my limited mobility – my hip gets sore after only walking a short distance on hard surfaces and I long to be able to be as strong as I once was. I still am not willing to have my hip resurfaced or replaced.

    What would you recommend in terms of hip cartilage repair?

    Thanks!

    • JonHyman says:

      If you weren’t a scope candidate 7 yrs ago, at age 26, you must have really bad arthritis/DJD. That is unusual at such a young age. In any event, cartilage repair options are almost nil in this setting, assuming the above us correct. Managing pain w occasional injections of cortisone or visco gels, along w flexibility non impact exercises is about all we’ve got at present.

  12. Crystal says:

    Hello! So I am 25 years old. I had a labral debridement at the age of 21 for a tear..at the age of 22 I had another surgery because they thought I still has pain because I had a “sport hernia”..(which I did not end up having but they repaired me as having one anyways..) Then at the age of 23 or 24 I finally found a great doctor..I had my labral tear “repaired” and it was also discovered that I had FAI. After that surgery I was also informed that I had arthritis in that area and I am now bone on bone..I did very well for quite a while after that surgery..now I am finding myself in the same previous pain as before..but the doctor never mentioned anything about this microfracture treatment..I of course now am 25 and I’m fearing that before Im 30 I’ll end up needing a hip replacement! Is it too late in the game to try this treatment..will it help??

    • JonHyman says:

      Crystal, sorry to hear of your troubles. If you are in fact ‘bone on bone’ then microfracture is highly unlikely to help you. You might try talking to your doctor about viscosupplement injections, eg. Gel One, Synvisc One.

      • Crystal says:

        thank you..I’ll have to mention that to him last week..I had an MRI last week which unfortunatly revealed yet another tear ..now it’s a “chondrolabral junction tear of the anterosuperior labrum” also have “fissuring and spurring” on the acetabulum…and I havn’t done anything to cause it..I work and go to school..it’s all getting very frustrating..so who knows what the game plan would be now..

  13. Gary says:

    I am 56 yrs old and I had labral tear repair surgery with microfracture 8 weeks ago on my right hip. I can’t walk without crutches…..sometimes I can get by with one crutch….but there is always pain. I had the surgery done in Sept so I could be off crutches before the snow gets bad here in Buffalo, NY…now that doesn’t look possible. I had bad arthritis in the hip as it turns out too. Should I have even had this operation? In hind sight, I’m feeling I maybe should have had a full hip replacement. My left hip as all the same symptoms, including arthritis. I’m thinking when the time is right, I should not have another labral tear surgery but will go with hip replacement in the left hip. The length of recovery and recurring pain with my labral repaired hip is more than I would want to go thru again on the other side. What do you think? My fear now is I’ll always walk with a limp….thnx.

    • JonHyman says:

      Sorry for your ongoing troubles. It depends upon why you needed the microfracture and how big the lesion was and where it was. If you had bad arthritis, your prognosis is poor. It sounds like hip replacement may be a better option for you. Hip arthroscopy can be attempted as a salvage, but when arthritis is bad, or worse than anticipated, unfortunately, many patients have to go on to have their hips replaced.

  14. bernard breton says:

    Bonjour,
    j’ai été opérer il y a 4 semaines pour une hip cartilage delamination acetabulum micro frature et déchirure du labrum et je ne peut mettre de poids sur ma jambe pendant 6 semaine ,j’ai pris des antiinflamatoire pendant 10 jours après l’opération j’ai arrêter pendant 3 jours puis suite a une chute que j’ai fait il y a deux semaine (écartillement de la jambe) j’ai recommencer a avoir de la douleur dans laine depuis ce temps je suis obliger de reprenre les antiinflamatoire une fois pas jour.Cependant l’antiinflamatoire réagit pendant 24 heures presque sans douleur dans l’aine
    Donc ma question est ce que cette chute peut avoir occasioner de nouveau une déchirure du labrum et refait des dommage aux processus de réfection du cartilage suite a la microfracture ou bien cette chute repousseras un peu la guérison?Merci

  15. batya says:

    Hello Dr Hyman,
    Im scheduled to have hip arthroscopic surgery for torn labrum, torn articular cartilage and iliopsoas tear in ten days and I’ve been reading up on all the different recovery timings and physical therapy starting times as well as hip immobilizers and cpm machines. Some drs insist in three weeks of no weight bearing and some say walk all you want so long as pain free.
    My question is why are the surgeons so different in their approach and why is one better than another.
    Thank you in advance

  16. Ben says:

    I am an active 35 year old who has had arthroscopic labral repair surgery on both hips, most recently the left hip in January 2012. I had been pain free on that side for 18 months unil 2 months ago, when I started developing pain in the joint which is steady and has grown over time. An MRI was negative for a labral retear and my surgeon speculated the pain may be due to delaminating cartilage. The cartilage in the left hip appears to be in decent shape and I have only very early-stage arthritis. I would like greatly to avoid a second surgery on that hip, and I have spoken with several doctors who have varyingly recommended a gel injection or a PRP injection to try and reduce the pain. Do you have advice on which route to take? Thanks.

    • JonHyman says:

      We have recently been inundated with requests from patients for explanations and insights into their hip pain after surgery. Most patients have had hip arthroscopy and are having persistent pain, though many have had hip replacement surgery and are having persistent pain. The sheer volume of these inquiries strongly suggests a few observations are valid:
      1. Pain after surgery is not an uncommon phenomenon.
      2. Many patients do not have adequate communication and correspondence with their operating surgeon.
      3. Patients are seeking information online without adequately being able to share all of the salient and relevant points that could help illicit a qualified response.

      There are many reasons why your pain may be persisting after surgery. I thought I would list some of the more common reasons so that you may consider these and discuss them with your surgeon in detail.
      1. Technical errors or complications during surgery. These will be hard to discern and will require integrity and honesty on the part of your surgeon.
      2. Realizing that the healing process is an extended one. For example, after a labral repair, it is common to still feel the symptoms of a labral tear for a few months after the surgery because the labrum has not healed yet and sometimes takes 3, even 4, months to heal fully after surgery. Therefore, since there is still technically a labral tear after surgery, although it is sutured, it is not fully healed and therefore one should not necessarily expect the pain of the labral tear to be gone until after it is fully healed. Cartilage, ligament, bone, muscle, tendon, synovial membrane, etc, all heal at different rates and will likely cause different symptoms along the postoperative recovery process.
      3. Possible infection. This is a rare complication, but it is at least one worth discussing.
      4. Tendonitis or bursitis from over zealous rehabilitation or physical therapy. This could be due to over exertion on the part of the therapist, or due to over exertion on part of the patient.
      5. Too rapid a return to exercise or activity. Many patients don’t have adequate guidance as to when they can return to certain types of activities and they may be premature in doing so, thus aggravating their hip or condition, and causing recurrent inflammation or persistent problems.
      6. Physiology and metabolism. Obviously, we are not all the same, and some people heal at slower rates or to varying degrees. Your diet, your metabolism, your genetics that you inherited from Mom and Dad, your immune system, possibly your stress level and attitude and perspective, can all have an influence on your experience of your pain.
      7. The pain generator or source of pain may not have been fully identified or addressed. Many patients have more pathology or problems than just the hip joint and if those other things are still active after surgery, there can be persistent pain. These things might include but are not limited to:
      1. Low back dysfunction
      2. Cartilage, ligament, or capsule dysfunction
      3. Persistent impingement or bony irregularity, muscle, tendon tightness or inflammation
      4. Scar tissue, like a keloid scar that some people form, but internally
      5. Neuromechanical dysfunction with nerve irritation from traction, pressure, stress, or a hyper sensitive nervous system.
      8. Recurrent synovitis, which is redness or inflammation in the joint. This could respond, as could tendonitis or bursitis, to a short course of non-steroidal anti-inflammatories, or a Medrol Dose Pack or two, or a cortisone injection in the inflamed tissue area or in the joint. You would need to discuss which medications, if any, were appropriate, with your physician.
      9. Re-injury
      10. Failure of repair or anchor fixation. Loose anchors or sutures.
      11. Muscle imbalance, asymmetry, or weakness.
      12. Leg length discrepancy
      13. Traction issues or problems that were not detected before surgery that are worsened after surgery due to the use of crutches or abnormal walking for extended periods of time in the postoperative phase.

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