McLean, Michael

Millar, Neal L.

Whyte, tony

English

Michael McLean

Tony Whyte

Neal L. Millar

Crossref

Annals of Translational Medicine

Outerbridge grade IV cartilage lesions in the hip identified at arthroscopy

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Page 1 of 4
© Annals of Translational Medicine. All rights reserved.   Ann Transl Med 2017;5(10):226atm.amegroups.com
Editorial
Outerbridge grade IV cartilage lesions in the hip identified at 
arthroscopy
Michael McLean, Tony Whyte, Neal L. Millar
Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences, University of Glasgow, UK
Correspondence to: Neal L. Millar. Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences, University 
of Glasgow, UK. Email: neal.millar@glasgow.ac.uk.
Provenance: This is a Guest Editorial commissioned by Section Editor Pengfei Lei, MD (Clinical research fellow at Department of Orthopedic 
Surgery Brigham and Women’s Hospital, Harvard University, Boston, MA, USA; Surgeon of Department of Orthopaedic Surgery, Central South 
University Xiangya Hospital, Changsha, China).
Comment on: Bhatia S, Nowak DD, Briggs KK, et al. Outerbridge Grade IV Cartilage Lesions in the Hip Identified at Arthroscopy. Arthroscopy 
2016;32:814-9. 
Submitted Jan 07, 2017. Accepted for publication Jan 21, 2017.
doi: 10.21037/atm.2017.03.58
View this article at: http://dx.doi.org/10.21037/atm.2017.03.58
Hip arthroscopy and chondral lesions
The utilization of hip arthroscopy continues to increase 
in both volume and scope within clinical practice (1) and 
can be used as a diagnostic or therapeutic intervention. 
Established indications for hip arthroscopy include but are 
not limited to diagnosis or treatment of; acetabular labral 
injuries, femoroacetabular impingement (FAI), chondral 
lesions, synovial pathologies including rheumatoid arthritis 
and synovial chondromatosis, removal of loose bodies, 
ligamentum teres tears and extra-articular pathologies such 
as trochanteric bursitis, gluteus medius/minimus tears and 
psoas tendinopathy (2). Importantly the evidence base to 
guide many if not all of these indications remains to be 
elucidated.
Chondral lesions/defects are typically described using 
the Outerbridge grading system (3) (Table 1). Grade I–
II are often termed mild to moderate and grades III–IV 
severe (4). But equally can be described as being acute, 
chronic or degenerative and full or partial thickness in 
the literature. They are considered to originate from 
both traumatic and atraumatic pathologies. Pathologies 
associated with chondral injuries include FAI, traumatic hip 
dislocation/instability, lateral hip impact injury, slipped-
capital femoral epiphysis, loose body formation in perthes 
and other chondrodysplasias, hip dysplasia and degenerative 
joint disease (2,5). 
In particular, FAI has been shown in several studies to 
be associated with predictable patterns of chondral injury 
Ganz (6-8) described FAI as being cam, pincer or mixed 
type. Cam impingement is thought to be due to increased 
shear forces created when an abnormally shaped femoral 
head-neck junction is brought into contact with a normal 
acetabulum as the hip flexes and internally rotates. This 
typically causes an anterosuperior acetabular grade IV 
chondral delamination, often with a concomitant labral 
tear. Pincer impingement involves either local anterior, or 
generalized acetabular over-coverage of a normal femoral 
head. Repeated impingement between femoral head-neck 
junction and acetabulum result in degenerative changes 
including ossification of the affected labrum. This leads to 
an anterior acetabular chondral defect of less depth but with 
increased circumference and a contre-coup posterior lesion 
as the head is levered or subluxated against the posterior 
acetabular wall (5,6).
 While chondral lesions will often be encountered 
concomitantly in the invest igation of  alternative 
pathologies presenting as a painful hip, in isolation 
they can be challenging to identify clinically. Common 
symptoms include progressive intermittent groin pain and 
mechanical locking, catching or clicking, with athletic 
activities, prolonged sitting or with hip flexion (6). 
Examination findings include pain on flexion, internal 
rotation and adduction (6). These findings are typical 
of FAI though and may not be specific to an isolated 
McLean et al. Chondral lesions of the hip identified at arthroscopy
© Annals of Translational Medicine. All rights reserved.   Ann Transl Med 2017;5(10):226atm.amegroups.com
Page 2 of 4
chondral injury, which can cause groin pain through 
synovial irritation alone, or be completely asymptomatic. 
Investigation includes standard imaging, including the 
AP pelvis and lateral hip X-ray. This may guide the 
physician to the potential of chondral injury through 
findings consistent with FAI or other associated hip 
pathologies, but it is not sensitive enough to show 
isolated intra-articular chondral pathology. Magnetic 
resonance imaging (MRI) arthrography has been shown 
to be relatively specific, but much less sensitive and with 
a low negative predictive value for identifying chondral 
lesions when compared to hip arthroscopy (9). Future 
use of gadolinium enhancement may improve this, but 
currently there is no adequate alternative to arthroscopy 
to reliably exclude chondral lesions, particularly if they 
are small (10).
Given the heterogeneity in the causes of chondral 
lesions of the hip, their variable symptomatology and 
unreliable non-surgical investigative identifiability, it 
is not surprising that their natural history has not been 
convincingly established in the literature (11). Current 
common treatments for chondral lesions of the hip include 
chondroplasty, microfracture and newer experimental 
autologous chondrocyte implantation techniques. Typically 
chondroplasty involves debridement of lower grade 
chondral lesions. Microfracture is a marrow stimulating 
technique applicable to focal, full thickness lesions usually 
between 1–4 cm in diameter (12). These techniques can 
be carried out either arthroscopically or as part of an 
open procedure and in isolation, or more commonly in 
addition to surgical management of separate or causative 
pathologies such as FAI correction, loose body removal or 
labral repair.
Outerbridge grade IV cartilage lesions in the hip 
identified at arthroscopy
In May 2016 Bhatia et al. (13) published the results of a level 
IV retrospective prognostic case series study with the aim of 
determining the pre-operative risk factors associated with 
grade IV cartilage defects in the hip, in patients undergoing 
hip arthroscopy with joint pain. They hypothesized that a 
larger alpha angle, increased body mass index (BMI), longer 
duration of symptoms, older age and decreased joint space 
would correlate with grade IV chondral lesions identified 
during hip arthroscopy. Surgery was performed between 
June 2006–2010 by a single surgeon at a single site specialist 
orthopaedic centre in Colorado, USA. Inclusion criteria 
included all patients undergoing primary hip arthroscopy 
aged older than seventeen years while exclusion criteria 
included prior hip surgery and incomplete data on chondral 
damage (size, location or grade). Of 1,693 hip arthroscopies 
carried out during the study period 596 were excluded; 
307 had prior hip surgery, 204 were carried out in patients 
under eighteen years and 85 had incomplete data. This 
resulted in 1,097 hip arthroscopies meting study inclusion. 
Pre-operative demographic characteristics (age, gender 
& BMI), measurements from standard AP pelvic, lateral 
hip and false profile radiographs (alpha angle, centre 
edge angle and joint space) and length of symptoms 
characterized as greater or less than 30 months were 
recorded. The location and Outerbridge grade of chondral 
lesions when present were then recorded in each case. 
Multivariate analysis using a binary logistic regression 
model was performed using the presence or absence of a 
grade IV chondral defect as the dependent variable. The 
relative risk of these various factors was then calculated.
The study identified grade IV lesions in 28% and non-
grade IV lesions in 72%. Of these non-grade IV lesions 
15% had no lesion identified. The average size of grade IV 
lesions was 158 mm (2). Of patients with a grade IV lesions 
80% had a lesion on one articular surface only, of which 
76% were acetabular and 95% of these anterosuperior with 
chondrolabral junctional pathology. Femoral lesions were 
more variable in distribution. Following regression analysis, 
they identified that: <2 mm joint space (RR =8, P=0.0001), 
age >45 years (RR =2.6, P=0.0001), male sex (RR =2.6, P= 0.001), 
Alpha angle >55° (RR =1.9, P=0.022) and symptom duration 
>30 months (RR =1.4, P=0.047) were factors associated with 
a higher relative risk of identifying a grade IV chondral 
lesion during hip arthroscopy.
Table 1 The Outerbridge classification for joint cartilage damage
Grade Outerbridge grading system (3,4)
Grade 0 Normal
Grade I Cartilage with softening and swelling
Grade II Partial-thickness defect with fissures on the surface 
that do not reach subchondral bone or exceed 1.5 cm 
in diameter
Grade III Fissuring to the level of subchondral bone in an area 
with a diameter more than 1.5 cm
Grade IV Exposed subchondral bone head
Annals of Translational Medicine, Vol 5, No 10 May 2017 Page 3 of 4
© Annals of Translational Medicine. All rights reserved.   Ann Transl Med 2017;5(10):226atm.amegroups.com
Where does this fit in?
One of the key strengths of this study is its large sample size 
and comprehensive pre and intra-operative data-collection. 
While the pre-operative assessment and referral of patients 
was made by different observers, the performance and 
recording of intra-operative data by an experienced single 
surgeon is likely to result in the reliable classification of 
the site and grade of chondral lesions (14). As they have 
acknowledged weaknesses of this study include the potential 
inherent bias in patient selection and the lack of MRI data 
for analysis.
Their findings characterizing the prevalence, anatomical 
distribution and relative grade of chondral lesion are broadly 
consistent with and supportive of the current literature. Of 
note, the confirmation of chondral lesions being a common 
phenomenon in the painful hip, around 25% being grade 
IV, acetabular lesions being more common than femoral 
and predominantly anterosuperior and the combined 
presence of chondrolabral dysfunction (15). Additionally 
their findings, support a previous study involving Philipon 
et al., where they found grade IV chondral lesions identifies 
during arthroscopy to be associated with patients with 
larger alpha angles on pre-operative X-rays (16).
Furthermore, rather than look at outcomes relative to 
either pre-operative or intra-operative findings, this study 
has utilized pre-operative demographics. The usefulness of 
their findings therefore hinges on the current understanding 
that patients with intra-operative evidence of grade III–IV 
chondral lesions have worse outcomes following hip 
arthroscopy (16). In that respect it supports established 
evidence, summarized in the systematic review by Ng et al. (17) 
that suggests patients with a pre-operative joint space 
<2 mm, age over 50 and increased alpha angle size all have 
worse outcomes. Where they differ in their results from 
the current field, as they themselves identify, is that they 
found BMI not to be associated with grade IV lesions.
In summary, Bhatia et al. (13) have produced a large and 
informative study. It will give the assessing clinician more 
knowledge and power to predict intra-operative findings, 
that would hopefully translate to improved surgical 
outcomes. Given there is already good evidence for most 
if not all of the factors they have identified being relatively 
reliable markers for predicting patient outcomes, the 
impact on the field is limited and currently will be partly 
academic. It may continue to grow in importance however 
as arthroscopic treatment options grow and outcomes 
improve, particularly in relation to patients with non-
grade IV lesions. The field would benefit in the future, 
from large, high quality randomized controlled trials 
comparing treatment options and with lengthy follow up. 
This would help establish patients that would gain the 
most benefit out of preservative arthroscopic hip surgery. 
Acknowledgements
None.
Footnote
Conflicts of Interest: The authors have no conflicts of interest 
to declare.
References
1. Montgomery SR, Ngo SS, Hobson T, et al. Trends and 
demographics in hip arthroscopy in the United States. 
Arthroscopy 2013;29:661-5.
2. Shetty VD, Villar RN. Hip arthroscopy: current concepts 
and review of literature. Br J Sports Med 2007;41:64-8; 
discussion 68.
3. Outerbridge RE, Dunlop JA. The problem of 
chondromalacia patellae. Clin Orthop Relat Res 
1975;(110):177-96.
4. Femoroacetabular impingement syndrome. Available 
online: http://www.aaos.org/govern/federal/issues/UHCF
emoroacetabularImpingementSyndrome.pdf
5. Yen YM, Kocher MS. Chondral lesions of the hip: 
microfracture and chondroplasty. Sports Med Arthrosc 
2010;18:83-9.
6. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular 
impingement: a cause for osteoarthritis of the hip. Clin 
Orthop Relat Res 2003;(417):112-20.
7. Tannast M, Goricki D, Beck M, et al. Hip damage occurs 
at the zone of femoroacetabular impingement. Clin 
Orthop Relat Res 2008;466:273-80.
8. McCarthy JC, Lee JA. Acetabular dysplasia: a paradigm 
of arthroscopic examination of chondral injuries. Clin 
Orthop Relat Res 2002;(405):122-8.
9. McCarthy JC, Glassner PJ. Correlation of magnetic 
resonance arthrography with revision hip arthroscopy. 
Clin Orthop Relat Res 2013;471:4006-11.
10. Naraghi A, White LM. MRI of Labral and Chondral 
Lesions of the Hip. AJR Am J Roentgenol 2015;205:479-90.
11. Kuhns BD, Weber AE, Levy DM, et al. The Natural 
History of Femoroacetabular Impingement. Front Surg 
McLean et al. Chondral lesions of the hip identified at arthroscopy
© Annals of Translational Medicine. All rights reserved.   Ann Transl Med 2017;5(10):226atm.amegroups.com
Page 4 of 4
2015;2:58.
12. Sampson TG. Arthroscopic treatment for chondral lesions 
of the hip. Clin Sports Med 2011;30:331-48.
13. Bhatia S, Nowak DD, Briggs KK, et al. Outerbridge Grade 
IV Cartilage Lesions in the Hip Identified at Arthroscopy. 
Arthroscopy 2016;32:814-9.
14. Ilizaliturri VM Jr, Byrd JW, Sampson TG, et al. A 
geographic zone method to describe intra-articular 
pathology in hip arthroscopy: cadaveric study and 
preliminary report. Arthroscopy 2008;24:534-9.
15. McGill KC, Bush-Joseph CA, Nho SJ. Hip Microfracture: 
Indications, Technique, and Outcomes. Cartilage 
2010;1:127-36.
16. Johnston TL, Schenker ML, Briggs KK, et al. 
Relationship between offset angle alpha and hip chondral 
injury in femoroacetabular impingement. Arthroscopy 
2008;24:669-75.
17. Ng VY, Arora N, Best TM, et al. Efficacy of surgery for 
femoroacetabular impingement: a systematic review. Am J 
Sports Med 2010;38:2337-45.
Cite this article as: McLean M, Whyte T, Millar NL. 
Outerbridge grade IV cartilage lesions in the hip identified 
at arthroscopy. Ann Transl Med 2017;5(10):226. doi: 10.21037/
atm.2017.03.58


Enlighten

Page 1 of 4© Annals of Translational Medicine. All rights reserved.   Ann Transl Med 2017;5(10):226atm.amegroups.comEditorialOuterbridge grade IV cartilage lesions in the hip identified at arthroscopyMichael McLean, Tony Whyte, Neal L. MillarInstitute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences, University of Glasgow, UKCorrespondence to: Neal L. Millar. Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences, University of Glasgow, UK. Email: neal.millar@glasgow.ac.uk.Provenance: This is a Guest Editorial commissioned by Section Editor Pengfei Lei, MD (Clinical research fellow at Department of Orthopedic Surgery Brigham and Women’s Hospital, Harvard University, Boston, MA, USA; Surgeon of Department of Orthopaedic Surgery, Central South University Xiangya Hospital, Changsha, China).Comment on: Bhatia S, Nowak DD, Briggs KK, et al. Outerbridge Grade IV Cartilage Lesions in the Hip Identified at Arthroscopy. Arthroscopy 2016;32:814-9. Submitted Jan 07, 2017. Accepted for publication Jan 21, 2017.doi: 10.21037/atm.2017.03.58View this article at: http://dx.doi.org/10.21037/atm.2017.03.58Hip arthroscopy and chondral lesionsThe utilization of hip arthroscopy continues to increase in both volume and scope within clinical practice (1) and can be used as a diagnostic or therapeutic intervention. Established indications for hip arthroscopy include but are not limited to diagnosis or treatment of; acetabular labral injuries, femoroacetabular impingement (FAI), chondral lesions, synovial pathologies including rheumatoid arthritis and synovial chondromatosis, removal of loose bodies, ligamentum teres tears and extra-articular pathologies such as trochanteric bursitis, gluteus medius/minimus tears and psoas tendinopathy (2). Importantly the evidence base to guide many if not all of these indications remains to be elucidated.Chondral lesions/defects are typically described using the Outerbridge grading system (3) (Table 1). Grade I–II are often termed mild to moderate and grades III–IV severe (4). But equally can be described as being acute, chronic or degenerative and full or partial thickness in the literature. They are considered to originate from both traumatic and atraumatic pathologies. Pathologies associated with chondral injuries include FAI, traumatic hip dislocation/instability, lateral hip impact injury, slipped-capital femoral epiphysis, loose body formation in perthes and other chondrodysplasias, hip dysplasia and degenerative joint disease (2,5). In particular, FAI has been shown in several studies to be associated with predictable patterns of chondral injury Ganz (6-8) described FAI as being cam, pincer or mixed type. Cam impingement is thought to be due to increased shear forces created when an abnormally shaped femoral head-neck junction is brought into contact with a normal acetabulum as the hip flexes and internally rotates. This typically causes an anterosuperior acetabular grade IV chondral delamination, often with a concomitant labral tear. Pincer impingement involves either local anterior, or generalized acetabular over-coverage of a normal femoral head. Repeated impingement between femoral head-neck junction and acetabulum result in degenerative changes including ossification of the affected labrum. This leads to an anterior acetabular chondral defect of less depth but with increased circumference and a contre-coup posterior lesion as the head is levered or subluxated against the posterior acetabular wall (5,6). While chondral lesions will often be encountered concomitantly in the invest igation of  alternative pathologies presenting as a painful hip, in isolation they can be challenging to identify clinically. Common symptoms include progressive intermittent groin pain and mechanical locking, catching or clicking, with athletic activities, prolonged sitting or with hip flexion (6). Examination findings include pain on flexion, internal rotation and adduction (6). These findings are typical of FAI though and may not be specific to an isolated McLean et al. Chondral lesions of the hip identified at arthroscopy© Annals of Translational Medicine. All rights reserved.   Ann Transl Med 2017;5(10):226atm.amegroups.comPage 2 of 4chondral injury, which can cause groin pain through synovial irritation alone, or be completely asymptomatic. Investigation includes standard imaging, including the AP pelvis and lateral hip X-ray. This may guide the physician to the potential of chondral injury through findings consistent with FAI or other associated hip pathologies, but it is not sensitive enough to show isolated intra-articular chondral pathology. Magnetic resonance imaging (MRI) arthrography has been shown to be relatively specific, but much less sensitive and with a low negative predictive value for identifying chondral lesions when compared to hip arthroscopy (9). Future use of gadolinium enhancement may improve this, but currently there is no adequate alternative to arthroscopy to reliably exclude chondral lesions, particularly if they are small (10).Given the heterogeneity in the causes of chondral lesions of the hip, their variable symptomatology and unreliable non-surgical investigative identifiability, it is not surprising that their natural history has not been convincingly established in the literature (11). Current common treatments for chondral lesions of the hip include chondroplasty, microfracture and newer experimental autologous chondrocyte implantation techniques. Typically chondroplasty involves debridement of lower grade chondral lesions. Microfracture is a marrow stimulating technique applicable to focal, full thickness lesions usually between 1–4 cm in diameter (12). These techniques can be carried out either arthroscopically or as part of an open procedure and in isolation, or more commonly in addition to surgical management of separate or causative pathologies such as FAI correction, loose body removal or labral repair.Outerbridge grade IV cartilage lesions in the hip identified at arthroscopyIn May 2016 Bhatia et al. (13) published the results of a level IV retrospective prognostic case series study with the aim of determining the pre-operative risk factors associated with grade IV cartilage defects in the hip, in patients undergoing hip arthroscopy with joint pain. They hypothesized that a larger alpha angle, increased body mass index (BMI), longer duration of symptoms, older age and decreased joint space would correlate with grade IV chondral lesions identified during hip arthroscopy. Surgery was performed between June 2006–2010 by a single surgeon at a single site specialist orthopaedic centre in Colorado, USA. Inclusion criteria included all patients undergoing primary hip arthroscopy aged older than seventeen years while exclusion criteria included prior hip surgery and incomplete data on chondral damage (size, location or grade). Of 1,693 hip arthroscopies carried out during the study period 596 were excluded; 307 had prior hip surgery, 204 were carried out in patients under eighteen years and 85 had incomplete data. This resulted in 1,097 hip arthroscopies meting study inclusion. Pre-operative demographic characteristics (age, gender & BMI), measurements from standard AP pelvic, lateral hip and false profile radiographs (alpha angle, centre edge angle and joint space) and length of symptoms characterized as greater or less than 30 months were recorded. The location and Outerbridge grade of chondral lesions when present were then recorded in each case. Multivariate analysis using a binary logistic regression model was performed using the presence or absence of a grade IV chondral defect as the dependent variable. The relative risk of these various factors was then calculated.The study identified grade IV lesions in 28% and non-grade IV lesions in 72%. Of these non-grade IV lesions 15% had no lesion identified. The average size of grade IV lesions was 158 mm (2). Of patients with a grade IV lesions 80% had a lesion on one articular surface only, of which 76% were acetabular and 95% of these anterosuperior with chondrolabral junctional pathology. Femoral lesions were more variable in distribution. Following regression analysis, they identified that: <2 mm joint space (RR =8, P=0.0001), age >45 years (RR =2.6, P=0.0001), male sex (RR =2.6, P= 0.001), Alpha angle >55° (RR =1.9, P=0.022) and symptom duration >30 months (RR =1.4, P=0.047) were factors associated with a higher relative risk of identifying a grade IV chondral lesion during hip arthroscopy.Table 1 The Outerbridge classification for joint cartilage damageGrade Outerbridge grading system (3,4)Grade 0 NormalGrade I Cartilage with softening and swellingGrade II Partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameterGrade III Fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cmGrade IV Exposed subchondral bone headAnnals of Translational Medicine, Vol 5, No 10 May 2017 Page 3 of 4© Annals of Translational Medicine. All rights reserved.   Ann Transl Med 2017;5(10):226atm.amegroups.comWhere does this fit in?One of the key strengths of this study is its large sample size and comprehensive pre and intra-operative data-collection. While the pre-operative assessment and referral of patients was made by different observers, the performance and recording of intra-operative data by an experienced single surgeon is likely to result in the reliable classification of the site and grade of chondral lesions (14). As they have acknowledged weaknesses of this study include the potential inherent bias in patient selection and the lack of MRI data for analysis.Their findings characterizing the prevalence, anatomical distribution and relative grade of chondral lesion are broadly consistent with and supportive of the current literature. Of note, the confirmation of chondral lesions being a common phenomenon in the painful hip, around 25% being grade IV, acetabular lesions being more common than femoral and predominantly anterosuperior and the combined presence of chondrolabral dysfunction (15). Additionally their findings, support a previous study involving Philipon et al., where they found grade IV chondral lesions identifies during arthroscopy to be associated with patients with larger alpha angles on pre-operative X-rays (16).Furthermore, rather than look at outcomes relative to either pre-operative or intra-operative findings, this study has utilized pre-operative demographics. The usefulness of their findings therefore hinges on the current understanding that patients with intra-operative evidence of grade III–IV chondral lesions have worse outcomes following hip arthroscopy (16). In that respect it supports established evidence, summarized in the systematic review by Ng et al. (17) that suggests patients with a pre-operative joint space <2 mm, age over 50 and increased alpha angle size all have worse outcomes. Where they differ in their results from the current field, as they themselves identify, is that they found BMI not to be associated with grade IV lesions.In summary, Bhatia et al. (13) have produced a large and informative study. It will give the assessing clinician more knowledge and power to predict intra-operative findings, that would hopefully translate to improved surgical outcomes. Given there is already good evidence for most if not all of the factors they have identified being relatively reliable markers for predicting patient outcomes, the impact on the field is limited and currently will be partly academic. It may continue to grow in importance however as arthroscopic treatment options grow and outcomes improve, particularly in relation to patients with non-grade IV lesions. The field would benefit in the future, from large, high quality randomized controlled trials comparing treatment options and with lengthy follow up. This would help establish patients that would gain the most benefit out of preservative arthroscopic hip surgery. AcknowledgementsNone.FootnoteConflicts of Interest: The authors have no conflicts of interest to declare.References1. Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy 2013;29:661-5.2. Shetty VD, Villar RN. Hip arthroscopy: current concepts and review of literature. Br J Sports Med 2007;41:64-8; discussion 68.3. Outerbridge RE, Dunlop JA. The problem of chondromalacia patellae. Clin Orthop Relat Res 1975;(110):177-96.4. Femoroacetabular impingement syndrome. Available online: http://www.aaos.org/govern/federal/issues/UHCFemoroacetabularImpingementSyndrome.pdf5. Yen YM, Kocher MS. Chondral lesions of the hip: microfracture and chondroplasty. Sports Med Arthrosc 2010;18:83-9.6. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003;(417):112-20.7. Tannast M, Goricki D, Beck M, et al. Hip damage occurs at the zone of femoroacetabular impingement. Clin Orthop Relat Res 2008;466:273-80.8. McCarthy JC, Lee JA. Acetabular dysplasia: a paradigm of arthroscopic examination of chondral injuries. Clin Orthop Relat Res 2002;(405):122-8.9. McCarthy JC, Glassner PJ. Correlation of magnetic resonance arthrography with revision hip arthroscopy. Clin Orthop Relat Res 2013;471:4006-11.10. Naraghi A, White LM. MRI of Labral and Chondral Lesions of the Hip. AJR Am J Roentgenol 2015;205:479-90.11. Kuhns BD, Weber AE, Levy DM, et al. The Natural History of Femoroacetabular Impingement. Front Surg McLean et al. Chondral lesions of the hip identified at arthroscopy© Annals of Translational Medicine. All rights reserved.   Ann Transl Med 2017;5(10):226atm.amegroups.comPage 4 of 42015;2:58.12. Sampson TG. Arthroscopic treatment for chondral lesions of the hip. Clin Sports Med 2011;30:331-48.13. Bhatia S, Nowak DD, Briggs KK, et al. Outerbridge Grade IV Cartilage Lesions in the Hip Identified at Arthroscopy. Arthroscopy 2016;32:814-9.14. Ilizaliturri VM Jr, Byrd JW, Sampson TG, et al. A geographic zone method to describe intra-articular pathology in hip arthroscopy: cadaveric study and preliminary report. Arthroscopy 2008;24:534-9.15. McGill KC, Bush-Joseph CA, Nho SJ. Hip Microfracture: Indications, Technique, and Outcomes. Cartilage 2010;1:127-36.16. Johnston TL, Schenker ML, Briggs KK, et al. Relationship between offset angle alpha and hip chondral injury in femoroacetabular impingement. Arthroscopy 2008;24:669-75.17. Ng VY, Arora N, Best TM, et al. Efficacy of surgery for femoroacetabular impingement: a systematic review. Am J Sports Med 2010;38:2337-45.Cite this article as: McLean M, Whyte T, Millar NL. Outerbridge grade IV cartilage lesions in the hip identified at arthroscopy. Ann Transl Med 2017;5(10):226. doi: 10.21037/atm.2017.03.58

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Outerbridge grade IV cartilage lesions in the hip identified at arthroscopy

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