Hip Int 2010 ; 20 ( 01): 115 - 119

ORIGINAL ARTICLE

Arthroscopic repair of acetabular chondral delamination

with fibrin adhesive
Alexandros P. Tzaveas, Richard N. Villar

Richard Villar Practice, Wellington Hospital, London - UK

ABSTRACT. Acetabular chondral delamination is a frequent finding at hip arthroscopy. The cartilage is
macroscopically normal but disrupted from the subchondral bone. Excision of chondral flaps is the
usual procedure for this type of lesion. However, we report 19 consecutive patients in whom the
delaminated chondral flap was re-attached to the underlying subchondral bone with fibrin adhesive.
We used the modified Harris hip score for assessment of pain and function. Improvement in pain and
function was found to be statistically significant six months and one year after surgery. No local or
general complications were noted. Three patients underwent further surgery for unrelated reasons. In
each, the area of fibrin repair appeared intact and secure. Our results suggest that fibrin is a safe agent
to use for acetabular chondral delamination.

KEY WORDS. Cartilage damage, Chondral flap, Fibrin

Accepted: November 26, 2009

INTRODUCTION Fibrin adhesive is a biological substance, which has

Damage to articular cartilage is a common surgical finding,
both at arthroscopy and at open surgery. Many different tech-
niques have been described to deal with this problem (1-4).
However, one very common method is to excise an articular
cartilage flap and to undertake a microfracture of the under-
lying bone to encourage the development of fibrocartilage.
Perhaps the earliest stage in the formation of an articular
cartilage flap is delamination, or debonding (5), of the overly-
ing articular cartilage from the underlying subchondral bone.
To the hip arthroscopic surgeon this results in the so-called
wave sign (6), whereby pressure applied to the rim of the
acetabular labrum will cause bulging of the adjacent articular
cartilage (Fig. 1). Excising such an area of chondral instability
seems an unnecessary surgical manoeuvre, particularly if the
articular cartilage itself may contain a significant number of
viable chondrocytes (7, 8). This study shows the one-year re-
sults of the arthroscopic reattachment of unstable acetabular
articular cartilage by using fibrin adhesive.
been used in many specialties. Its haemostatic prop-
erties have been employed in neurosurgical (9), oph-
thalmological (10) and otolaryngological operations
(11) while its adhesive properties have been used in
general surgery (12) and orthopaedics (13). Evidence
shows that fibrin permits tissue fixation and stimulates
growth of fibroblasts (14). Fibrinogen is converted to
fibrin by the enzymatic reaction of thrombin at a rate
that is determined by the concentration of the latter.
Another ingredient, aprotinin, delays the fibrinolytic ac-
tion of plasmin (15).
We report 19 consecutive patients with defects of ac-
etabular articular cartilage who underwent arthroscopic
chondral repair with the use of fibrin adhesive. In this
prospective study, all patients were assessed pre-oper-
atively and post-operatively for up to one year. The aim
was to assess the post-operative level of pain and activ-
ity and ascertain the clinical efficacy of fibrin when used
in patients with acetabular chondral delamination.

2010 Wichtig Editore - ISSN 1120-7000 115

Chondral repair with fibrin adhesive

Fig. 1 - Delamination of the acetabular cartilage from the under- Fig. 2 - Instillation of the fibrin adhesive using a small-diame-
lying subchondral bone wave sign (arrows) (AAC, acetabular ter 17G needle (arrow) (AAC, acetabular articular cartilage; FH,
articular cartilage). femoral head).

MATERIALS AND METHODS

We operated on 20 consecutive patients with chondral de-

lamination. One patient was lost to follow-up, so 19 were
included in this study. Of these, 14 were women and five
were men with a mean age of 36 years (18 to 57). All pa-
tients had endured persistent hip pain for a mean period
of 19 months (2 to 78). There were four who were high-
performance national-level athletes.
Arthroscopy was performed under general anaesthesia with
the patient in the lateral position, as originally described by
Glick et al (16). All procedures were performed by the same
surgeon (RNV), who is an experienced hip arthroscopist.
The single intra-operative criterion for the procedure was
the presence of acetabular articular cartilage delamina-
tion or debonding (Fig. 1), as described by Beck et al (5). Fig. 3 - The cartilage lamina is held in place until the fibrin clot is formed
(arrow) (AAC, acetabular articular cartilage; FH, femoral head).
This was identified as macroscopically sound cartilage, but
with loss of fixation to the subchondral bone and a carpet
phenomenon (5) or positive wave sign (6). Patients with
articular cartilage damage at a more advanced stage, or arthroscopic burr (Dyonics Power, abrader burr, Smith and
with diffuse osteoarthritis, were excluded from the study. Nephew, Inc. Andover, MA, USA).
A labral tear was found in 15 patients and a cam-type FAI Acetabular cartilage delamination was found adjacent to
lesion in 18. Additionally, four patients underwent a labral the anterior labrum in 16 patients and to the anterosupe-
repair and 11 a partial acetabular labrectomy. All patients rior area in three. Each chondral flap was carefully probed
with cam-type FAI had excision of their lesion with a radiof- to be certain that in all cases its articular surface was
requency ablator (Vulcan Saphyre II, bipolar ablation probe macroscopically sound, with no thinning, roughening or
suction, Smith and Nephew, Inc. Andover, MA, USA) and fibrillation. In order to prepare the bony surface for the ap-

116
Tzaveas and Villar
A B
Fig. 4 - A) Area of delaminated articular cartilage. B) Nine months after treatment with fibrin: cartilage (white arrows) is stable and fixed onto
subchondral bone. This patient had revision arthroscopy because of iliopsoas tendonitis (AAC, acetabular articular cartilage; AL, acetabular
labrum; FH, femoral head).
plication of fibrin, a subchondral microfracture was per-
formed. Access to the subchondral region, or pocket,
was gained by making a small incision at the outer part
of the acetabular labrum, immediately at the acetabular
margin. An awl could then be passed through this incision
to the pocket and a microfracture performed. Before fi-
brin adhesive (Tisseel Kit, Baxter Healthcare Ltd, Norfolk,
UK) was instilled in the pocket all fluid was removed from
the hip joint, the procedure then being performed in air.
Once the pocket had been filled with fibrin adhesive (Fig.
2) the delaminated flap was held into position by a curved
arthroscopic punch (Fig. 3) until the adhesive had set, a
period of no more than two minutes.
Post-operatively, we instructed patients to touch weight-
bear for the first four weeks, with the use of crutches. Hip
flexion of more than 80 and extreme rotational move-
ments were also not allowed for this period. Isometric and
core exercises as well as swimming were allowed during
the first six post-operative weeks. Range-of-movement
exercises, stationary bicycle and cross-trainer were en-
couraged between six and 12 weeks after surgery. High-
impact exercises were not recommended until three
months after the procedure.
All patients were assessed pre-operatively and at six
weeks, six months and one year post-operatively. The
modified Harris hip score (MHHS) (17) was used for the
evaluation of pain and activity. A multiplier of 1.1 was used
to reach 100 as the maximum number of points. Pre- and
post-operative scores were compared for all examination
periods. A paired t-test was performed, using SPSS ver-
sion 14.0 (SPSS Inc., Chicago, Illinois) and p values < 0.05
were considered as significant.
RESULTS
Mean scores and standard deviations were obtained from
hip score questionnaires at different time points (Tab. I). All
comparisons between individual pre- and post-operative
scores were statistically significant, except for the total
MHHS six weeks post-operatively.
There were five patients who required a secondary interven-
tion because of persistent pain or disability; one received a
steroid and local anaesthetic injection to the affected hip;
two required revision hip arthroscopy because of persistent
pain, the first as a result of iliopsoas tendonitis and the sec-
ond for residual femoroacetabular and pectineofoveal im-
pingement, which were both excised. One patient received
a resurfacing arthroplasty because of rapidly destructive
osteoarthritis and another is scheduled to undergo revi-
sion arthroscopy in due course for persisting discomfort.
For those patients who underwent revision arthroscopy,
or subsequent arthrotomy, the area of chondral repair ap-
peared macroscopically intact and secure (Fig. 4).
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Chondral repair with fibrin adhesive
TABLE I - MEAN SCORES AND STANDARD DEVIATION (SD) FOR THE TOTAL MODIFIED HARRIS HIP SCORE (MHHS)
MULTIPLIED BY 1.1, AND SEPARATELY FOR QUESTIONS ON PAIN AND FUNCTION, AT VARIOUS TIME POINTS
Pain
Mean SD
Pre-operative 15.7 10.7
Six weeks 22.5 10.6
Six months 28.3 12.7
One year 28.9 16.0
DISCUSSION
Our results suggest that fibrin is a safe material to use for
chondral repair, with no patient demonstrating any local or
general complication, or immune response. Fibrin also ap-
pears to be efficient for the repair of the delamination-type
cartilage lesion as showed by the arthroscopic evidence
of healing of the previously delaminated area in the few
patients who underwent revision surgery.
Symptomatically and functionally, our data show a sta-
tistically significant improvement in pain and function by
six months and one year post-operatively. Data also sug-
gest that patients are functionally worse six weeks after
surgery, albeit with less pain, and are still continuing to
improve at one year. This is as expected, since patients
were on crutches for the first four weeks so their mobili-
sation did not improve during this period.
Our results agree with other published studies where fi-
brin has been used in osteochondral injuries, cartilage de-
fects or fractures. Shah, Ebert and Sanders (13) used fibrin
adhesive for a digital osteochondral injury. They reduced
and stabilised the osseo-cartilaginous fragment and had
excellent results by the three-month follow-up examina-
tion. Kaplonyi et al (18) used fibrin to fix chondral and os-
teochondral fragments of various sites, including femoral
condyles, patella and radial head in 28 patients. In some
instances they used fibrin as complementary treatment for
smaller cartilaginous fragments after stabilising the larger
ones with Kirchner wires. In this group, 26 patients were
followed up for six months to five years. Twelve of them
underwent arthroscopic examination six months post-
operatively and showed healing of the cartilage. Only two
patients had poor results. Arcalis Arce et al (19) treated
Mason type II fractures of the radial head with fibrin in 15
patients and followed them up for over two years. One pa-
118
Function MHHS x 1.1
Mean SD Mean SD
37.2 9.4 58.3 20.5
29.2 11.5 56.9 20.7
42.2 5.1 77.5 17.6
44.1 4.72 80.3 21.3
tient had significant and two had minor limitation of range
of movement. They had no other complications.
The use of fibrin adhesive as a scaffold for cartilage growth
is a relatively novel and promising technique, although this
property is not as yet completely understood. Brittberg et al
(20) used fibrin with and without growth hormone to repair
osteochondral defects in rabbits and found that both were
unsuitable as a scaffold to promote repair. However, Ahmed,
Dare and Hincke (21) suggested that fibrin alone, or in com-
bination with other materials, could be a biological scaffold
for stem or primary cells to regenerate adipose tissue, bone,
cardiac tissue, cartilage, liver, nervous tissue, ocular tissue,
skin, tendons and ligaments; as such, it is a versatile biopo-
lymer which shows great potential for tissue regeneration
and wound healing. Nehrer et al (22) published a prelimi-
nary clinical study in humans; they showed that fibrin with
harvested autologous chondrocytes and proprietary growth
factor had good clinical and MRI results at the one-year fol-
low-up. Shaban et al (23) studied in vitro chondrogenesis in
rabbit auricular chondrocytes and showed that fibrin / PLGA
(poly-lactic-co-glycolic acid) serves as a potential cell deliv-
ery vehicle and forms a structural basis for in vitro tissue-en-
gineered articular cartilage. Pelaez, Huang and Cheung (24)
performed an in vitro study and demonstrated the suitability
of fibrin gel for supporting the cyclical compression-induced
chondrogenesis of human mesenchymal stem cells.
We believe that fibrin is capable of firmly securing delaminated
articular cartilage to the underlying subchondral bone, which
in turn enables long-term stabilisation. We consider this to be
a far better alternative than the excision of an intra-articular
chondral flap which may itself contain large numbers of viable
chondrocytes. However, whether this technique has the abil-
ity to promote long-term recovery of the joint will depend on
larger and longer-term studies. Nevertheless, at one year the
results appear to be safe, reproducible and secure.
Tzaveas and Villar
Financial support: The authors received no financial support.
Conflict of interest statement: The authors had no proprietary interest
in this study.
Address for correspondence:
Alexandros P. Tzaveas, MD
Clinical Hip Fellow
The Wellington Hospital, St. Johns Wood
The Richard Villar Practice, 1st Floor,
South Building
London, NW8 9LE, UK
tzaveas@hotmail.com
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