Surgical dislocation of the hip for excision of benign tumours

Surgical Hip Dislocation in Pediatric and Adolescent Patients

LEVEL OF EVIDENCE

V, Expert opinion.

Surgical Hip Dislocation for a Diagnostic Dilemma: Differentiating Synovial Chondromatosis and Pigmented Villonodular Synovitis

Pigmented villonodular synovitis (PVNS) and synovial chondromatosis (SC) of the hip are rare synovial diseases that can induce joint destruction without early diagnosis and treatment. The extent of surgical excision is critical given the high rates of recurrence. In the presented case, a 19-year-old female was referred to our institution with progressive left hip pain and radiologic evidence of an intra-articular mass that was consistent with PVNS versus SC. Her medical history was notable for a prior excision of a fibrous lesion at an outside hospital at age 13 with persistent pain. The patient underwent a surgical hip dislocation approach to obtain near-complete visualization of the femoroacetabular joint, ensuring complete evaluation and excision. The tumor was intraoperatively diagnosed as SC and excised accordingly, during an uneventful operation. Pathology confirmed the diagnosis. The essential diagnostic and surgical steps for the management of this pelvic tumor diagnostic dilemma are described. Level of Evidence: V.

Surgical hip dislocation for treatment of femoral head chondroblastoma: efficacy and safety

PURPOSE

Femoral head chondroblastoma poses a surgical challenge. Anatomical limitations may lead to increased risk of local recurrence, damage to the articular cartilage, growth disturbances, and/or avascular necrosis (AVN). We are presenting our results with surgical hip dislocation approach with the aim to evaluate its efficacy in preventing recurrence and its safety, preserving a functional hip joint and avoiding complications.

PATIENTS AND METHODS

Ten patients were managed using surgical hip dislocation with direct access to femoral head lesions, extended curettage through a modified trapdoor approach, and cement reconstruction. These were six males and four females, with a mean age of 17 ± 2.7 years (range: 14-20) and a mean follow-up of 34 ± 12 months (range: 17-57). The lesion extended into the neck in 60% of patients with the physis being either closed in seven or closing in three patients.

RESULTS

We had a single case (10%) of recurrence at the trochanters for which re-curettage was done. However, all patients had their hips preserved with good function at the latest follow-up, and no serious complications recorded. The Musculoskeletal Tumor Society score improved significantly from a pre-operative median of 23.5 (range: 16-28) to a post-operative median of 29 (range: 26-30) (P = 0.005).

CONCLUSION

This report describes a safe reproducible approach to effectively manage these locally aggressive lesions with good short-term results. This is done while maintaining the integrity of the articular surface, growth plate, as well as preserving the femoral head blood supply.

Surgical treatment of benign osteolytic lesions in the femoral head and neck: a systematic review

Background and objectives

Treatment of benign osteolytic lesions in the femoral head and neck can be extremely challenging, particularly in children with open physis or for aggressive tumors with pathological fracture. There remains the difficult management decision as to whether to perform complete excision of the involved area or only curettage. Moreover, there is no agreed consensus on the optimal approach to lesion access when performing curettage, which included the transcervical, open and direct approach. The current systematic review aims to provide guidance for selection of surgical methods in clinical practice by comparing the advantages and drawbacks of different procedures.

Methods

A comprehensive literature search of PubMed, Embase and Web of Science databases were executed for human studies restricted to the English language. The search was filtered to include studies published from January 1980 to January 2020.

Results

A total of 33 articles including 274 patients were enrolled in the final analysis. The most common diagnosis was chondroblastoma (CBT) (104, 38.0%), followed by giant cell tumor (GCT) (56, 20.4%). There were 57 (20.8%) patients with pathological fracture. Intralesional curettage was performed in 257 (93.8%) patients with the local recurrence of 12.5% at the mean follow-up of 51.5 months. The patients who were presented with open physis or curetted via transcervical approach developed higher local recurrence in patients with CBT (P < 0.001). The local recurrence rate of GCT is 33.3% after curettage, while 8 of 9 (88.9%) patients with fracture were treated successfully with joint preservation. Two of 45 (4.4%) patients developed avascular necrosis (AVN) of femoral head after surgical hip dislocation. The reported Musculoskeletal Tumor Society (MSTS) Score was comparable among patients with different approaches to curettage.

Conclusion

The majority of benign osteolytic lesions in the femoral head and neck can be treated with intralesional curettage with acceptable local tumor control and satisfactory function. The incidence of local recurrence might be decreased dramatically for lesion access under direct visualization. The native joint maintenance could be achieved even in patients with aggressive lesions presenting pathological fracture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04442-y.

Surgical hip dislocation for treatment of synovial chondromatosis of the hip

PURPOSE

In the present study, we aimed to evaluate the clinical outcomes of surgical hip dislocation in patients with synovial chondromatosis (SC) of the hip.

METHODS

Seven patients with primary SC of the hip treated with open synovectomy and removal of loose bodies by surgical hip dislocation from 2016 to 2019 were retrospectively reviewed. All patients had numerous and widespread loose bodies based on pre-operative images, including routine radiographs, CT, and MRI. The visual analog scale (VAS) score and Harris hip score (HHS) were collected and analyzed before and after surgery. The post-operative radiographs were reviewed to evaluate disease recurrence and osteoarthritis progression.

RESULTS

The mean operative time was 61 minutes (range, 42-75 min). An average of 33 loose bodies in each patient (range, 16-67) was removed, and extra-articular pathology was found in one patient. Patients were followed up for a mean duration of 30 months (range, 18-42 months). The average VAS scores were decreased from 3.7 (range, 2-6) pre-operatively to 0.9 (range, 0-2) at the last follow-up, and the HHS was improved from 60.1 (range, 50-73) to 90.1 (range, 82-95). All results demonstrated significant improvements (P < 0.05). Post-operative radiographs showed no recurrence, osteoarthritis progression, or osteonecrosis of the femoral head in all hips.

CONCLUSIONS

Surgical hip dislocation was a practical approach for managing both intra-articular and extra-articular pathologic lesions around the hip. It was an effective treatment for SC of the hip with short surgical time, good joint functions, a lower recurrence rate, and few complications.

Hip Arthroscopy for Diffuse Idiopathic Skeletal Hyperostosis Using a Capsulotomy-First Approach

Diffuse idiopathic skeletal hyperostosis (DISH) is a systematic disease of unknown etiology characterized by ossification at the site of spine and major joints entheses, including the hip. Ossified connective tissue may cause pain and joint stiffness, which may require surgical intervention. The purpose of this study was to investigate the clinical, radiographic, and arthroscopic presentation and surgical outcomes of patients with DISH involving the hips. Fourteen hips in 9 patients (mean±SD age, 63±14 years; range, 35-76 years) with overcoverage of the femoral head by DISH were retrospectively reviewed. For all joints, a transverse, capsulotomy-first approach was performed due to an inability to access the central compartment by traction of the lower extremity. After arthroscopic resection of the ossified lesion, labral reconstruction was performed with an iliotibial band autograft. For clinical evaluation, patient-reported outcome scores (modified Harris Hip Score [mHHS], Nonarthritic Hip Score [NAHS], International Hip Outcome Tool-12 [iHot-12], visual analog scale [VAS] pain score, and VAS satisfaction score) were obtained. Arthroscopically, circumferential labral damage with no or mild articular cartilage damage was observed. Mean NAHS, iHot-12 score, and VAS satisfaction score improved significantly (47 to 56, 43 to 71, and 21 to 72, respectively; P<.05). Mean mHHS and VAS pain score did not reach significance but did improve (65 to 92 and 45 to 78, respectively). Using a transverse, capsulotomy-first approach for arthroscopic hip surgery for patients with DISH yields successful outcomes in patient-reported outcome measures and satisfaction, despite minor gains in hip range of motion. [Orthopedics. 2020;43(5):e369-e377.].

Long-term follow-up of custom cross-pin fixation of 56 tumour endoprosthesis stems: a single-institution experience

AIMS

Aseptic loosening is a major cause of failure in cemented endoprosthetic reconstructions. This paper presents the long-term outcomes of a custom-designed cross-pin fixation construct designed to minimize rotational stress and subsequent aseptic loosening in selected patients. The paper will also examine the long-term survivorship and modes of failure when using this technique.

PATIENTS AND METHODS

A review of 658 consecutive, prospectively collected cemented endoprosthetic reconstructions for oncological diagnoses at a single centre between 1980 and 2017 was performed. A total of 51 patients were identified with 56 endoprosthetic implants with cross-pin fixation, 21 of which were implanted following primary resection of tumour. Locations included distal femoral (n = 36), proximal femoral (n = 7), intercalary (n = 6), proximal humeral (n = 3), proximal tibial (n = 3), and distal humeral (n = 1).

RESULTS

The median follow-up was 132 months (interquartile range (IQR) 44 to 189). In all, 20 stems required revision: eight for infection, five for structural failure, five for aseptic loosening, and two for tumour progression. Mechanical survivorship at five, ten, and 15 years was 84%, 78%, and 78%, respectively. Mechanical failure rate varied by location, with no mechanical failures of proximal femoral constructs and distal femoral survivorship of 82%, 77%, and 77% at five, ten, and 15 years. The survivorship of primary constructs at five years was 74%, with no failure after 40 months, while the survivorship for revision constructs was 89%, 80%, and 80% at five, ten, and 15 years.

CONCLUSION

The rate of mechanical survivorship in our series is similar to those reported for other methods of reconstruction for short diaphyseal segments, such as compressive osseointegration. The mechanical failure rate differed by location, while there was no substantial difference in long-term survival between primary and revision reconstructions. Overall, custom cross-pin fixation is a viable option for endoprosthetic reconstruction of short metaphyseal segments with an acceptable rate of mechanical failure. Cite this article: Bone Joint J 2019;101-B:724-731.

Modified trapdoor procedures by surgical dislocation approach to treat chondroblastoma of the femoral head

AIMS

The aim of this study was to evaluate the efficacy of the surgical dislocation approach and modified trapdoor procedure for the treatment of chondroblastoma of the femoral head.

PATIENTS AND METHODS

A total of 17 patients (ten boys, seven girls; mean age 16.4 years (11 to 26)) diagnosed with chondroblastoma of the femoral head who underwent surgical dislocation of the hip joint, modified trapdoor procedure, curettage, and bone grafting were enrolled in this study and were followed-up for a mean of 35.9 months (12 to 76). Healing and any local recurrence were assessed via clinical and radiological tests. Functional outcome was evaluated using the Musculoskeletal Tumour Society scoring system (MSTS). Patterns of bone destruction were evaluated using the Lodwick classification. Secondary osteoarthritis was classified via radiological analysis following the Kellgren-Lawrence grading system. Steinberg classification was used to evaluate osteonecrosis of the femoral head.

RESULTS

The epiphyseal plate was open, closing, and closed in five, five, and seven patients, respectively. In total, eight, six, and three patients were classified as having Lodwick classification IA, IB, and IC, respectively. Allogeneic and autogenous bone grafting was used in 13 and four patients, respectively. All patients had good bone healing and no local recurrence was observed. One patient developed osteonecrosis of the femoral head (Steinberg IA) and one developed secondary osteoarthritis of the hip joint (Kellgren-Lawrence Grade II). The mean postoperative MSTS functional score was 27.7 (24 to 30).

CONCLUSION

Surgical dislocation and modified trapdoor procedures are safe and effective techniques for treating chondroblastoma in the femoral head. Cite this article: Bone Joint J 2019;101-B:732-738.

Surgical hip dislocation through a direct lateral approach: A cadaveric study of vascular danger zones

OBJECTIVE

There is limited information on the potential danger to the vascularity of the femoral head during surgical dislocation of the hip using the direct lateral approach. The objective of this study was to investigate the topographical anatomy of the medial femoral circumflex artery (MFCA), the primary source of blood supply to the femoral head, in relationship to the direct lateral approach.

METHODS

Seven unembalmed cadaver hips had dye injection into either the profunda femoris artery or the MFCA. Surgical hip dislocation was then performed through a direct lateral approach, noting the danger zones to the MFCA branches during each step of the exposure.

RESULTS

None of the MFCA branches were found to cross the anterior surgical field superficial to the capsule. The deep (main) branch of the MFCA pierced the inferior capsule at the level of the lesser trochanter after emerging posterior to iliopsoas tendon. Ascending branches up the medial femoral neck were identified at this level. The deep branch then coursed posteriorly terminating in a variable number of vessels ascending the posterior femoral neck. Dislocation of the femoral head did not stretch or alter the course of the deep branch of the MFCA.

CONCLUSION

Safe surgical hip dislocation preserving the MFCA can be performed though a direct lateral approach as long as the inferomedial portion of the anterior capsule is preserved (main branch of the MFCA pierces the capsule at this level). Extracapsular injury is possible from inadvertent dissection at the level of the lesser trochanter or aggressive retraction on the iliopsoas. The posterior capsule should be left intact and instrumentation around the posterior neck should be avoided.

Surgical dislocation of the hip without trochanteric osteotomy

BACKGROUND

Surgical dislocation of the hip remains an important alternative in hip preservation surgery, especially when a dynamic access to the hip is needed and arthroscopy is not a suitable option. We describe a novel technique for operative dislocation of the hip without trochanteric osteotomy and the clinical results of our patients.

METHODS

Surgical dislocation of the hip without trochanteric osteotomy was done through a modified lateral approach in all of the cases. A review of demographic, clinical, and radiological data was done in all of the patients operated with this technique between 2010 and 2015. Complications, walking aids, weight-bearing status, and modified Harris Hip Score (mHHS) were also recorded.

RESULTS

Six surgical dislocations of the hip were carried out. Indications were tumor resection in five and bulletectomy in one hip. There were two women (four hips) and two men. Mean age was 19 ± 3.8 years. Median follow-up was 2.5 years (range 2-4.5 years). Median mHHS was 92 (90-96). There were no intraoperative nor postoperative complications.

CONCLUSIONS

Surgical dislocation of the hip without trochanteric osteotomy through a modified lateral approach appears to be a safe, simpler, and effective alternative.

Surgical hip dislocation for removal of retained intra-articular bullets

INTRODUCTION

Surgical hip dislocation with trochanteric osteotomy was introduced for the treatment of femoroacetabular impingement and other intra-articular pathologies of the hip. We expanded the indications to include removal of retained bullets in the hip joint as an alternative to hip arthroscopy.

PATIENTS AND METHODS

We present a prospective case series of ten patients that were treated with a surgical hip dislocation for removal of retained bullets in the hip joint between January 2014 and October 2015 in a Level 1 trauma centre. The main outcome measurements were successful bullet removal, blood loss, surgical time and intraoperative complications.

RESULTS

There were 8 males and 2 females with a mean age of mean age 27.3 years (range 20-32). All patients had one whole retained bullet for removal (right side: 8; left side: 2). In all cases the bullet could be removed in its entirety. The average surgical time was 73min (range 55-125) and the average blood loss 255ml (range 200-420).

CONCLUSIONS

Surgical hip dislocation provides an unlimited view of the acetabulum and femoral head and neck and it therefore allows for easy removal of retained bullets. Osteocartilaginous lesions and concomitant fractures of the femoral head can be simultaneously evaluated and treated.