Focal chondral and chondrolabral injuries of the hip have become more commonly recognized lesions of hip joint pathology in the last decade, in part due to an increase in hip arthroscopy.1 Some hip morphologies, such as cam and pincer anatomy or dysplasia are predisposed to developing these lesions,2, 3, 4 while other lesions are sustained traumatically in patients with acetabular fractures, femoral head fractures, and native hip dislocations.5 Recent studies have also shown an increased risk in certain athletic populations (eg, dancers, figure skaters, cheerleaders, gymnasts, and martial arts practitioners;2,6, 7, 8 and higher-grade cartilage lesions in these athletes predicts the need for secondary procedures after initial hip arthroscopy.8

A growing body of literature demonstrates that the presence of these lesions is associated with worse clinical outcomes, risk of global degenerative disease, and future conversion to hip arthroplasty.9 Chahla et al.10 found that patients with full thickness chondral lesions were less likely to benefit from hip arthroscopy for femoroacetabular impingement and had worse patient reported outcomes than patients with partial thickness or no chondral lesions. Similarly, another study reported that severe acetabular cartilage damage and mild femoral head chondral lesions were both predictive of worse clinical outcomes following hip arthroscopy for labral preservation in borderline developmental hip dysplasia patients.11 These clinical findings are supported by computational data demonstrating that chondral and chondrolabral defects in cam impingement hips shift patterns of tensile and shear stress towards other areas of the hip joint, potentially increasing the risk of further disease progression.12,13 The presence of a chondral defect also increases tensile stresses to the labrum and chondrolabral junction following simulated labral repair, suggesting that there is a complex biomechanical interplay between cartilage and labral defects in the hip such that only addressing labral tears may not be sufficient for decreasing the risk of clinical disease progression in high-risk hip morphology.12

Given the negative impact of focal chondral and chondrolabral hip defects on patient outcomes, it is imperative that we understand effective treatment methods. Cartilage defects in the hip have been managed historically with joint resurfacing or total hip arthroplasty, but while these remain viable options with reliable outcomes, they have limited indications based on age and disease severity.14 Beyond arthroplasty, operative treatments for cartilage restoration in the hip can be divided into open and arthroscopic techniques. Recent advances in hip arthroscopy have improved the understanding of the efficacy and application of these various restoration techniques. It is crucial to review these procedures, discuss their outcomes, and provide future directions for research and development.

Options for surgical management include both open and arthroscopic procedures focusing on 3 general treatment goals: chondral flap stabilization (debridement with or without labral repair, acetabular rim resection), cartilage regeneration [microfracture marrow stimulation, autologous chondrocyte implantation (ACI), matrix-assisted ACI (MACI), Autologous Matrix-Induced Chondrogenesis (AMIC), Autologous Matrix-Enhanced Chondral Transplantation (AMECT), minced cartilage application], and cartilage restoration [mosaicplasty, osteochondral allograft transplantation (OCA)]. Orthobiologics have become increasingly popular, and these treatments can also be performed in isolation or in conjunction with the aforementioned procedures.

Treatment choice depends on lesion location, size, and depth. A basic algorithm for decision-making must consider if the chondral injury is located at or away from the chondrolabral junction and whether the chondrolabral junction is disrupted. Acetabular-based lesions can be found away from the chondrolabral junction, at the anterosuperior acetabulum with preserved chondrolabral junction, or at and involving the chondrolabral junction (Fig. 1). Isolated chondral lesions not at the chondrolabral junction can be addressed with debridement, cartilage restoration, and/or cartilage regeneration techniques. Those at the anterosuperior acetabulum with an intact chondrolabral junction can be addressed with an isolated labral repair followed by an osteochondroplasty to eliminate shear stresses in femoroacetabular impingement. This technique is effective as there is soft tissue continuity between the labrum and cartilage as part of the unique anatomy of the acetabular chondrolabral junction. Thus, stabilizing the labrum further stabilizes the chondrolabral junction and subsequently stabilizes a chondral flap at this location.15 A recent study reported superior patient reported outcomes in patients with the wave sign (anterosuperior cartilage separation from subchondral bone with intact chondrolabral junction) who were treated with labral repair and osteochondroplasty compared to osteochondroplasty alone.15 Finally, anterosuperior chondral lesions in the setting of a disrupted chondrolabral junction cannot be sufficiently stabilized with an isolated labral repair and therefore require debridement, cartilage restoration, and/or cartilage regeneration techniques (Fig. 2).