Progressive subluxation of the hip joint in a child with hereditary multiple exostosis

Functional Impairment of Hip Joint and Activities of Daily Living Failure in Patients with Multiple Hereditary Exostoses

OBJECTIVE

In this study, we focused on the hip joints and examined pain and functional impairment, and their relationship with anatomical characteristics in MHE patients.

METHODS

Patients with MHE followed up in our hospital from January 2020 to December 2020 were enrolled. Clinical hip functional outcomes were evaluated using the Japanese Orthopedic Association (JOA) hip score and hip range of motion (ROM). Proximal femur geometric measurements were evaluated using radiography.

RESULTS

A total of 39 patients (78 hips) with a median age of 25.6 years and average JOA score of 94.0 ± 10.5 were included. Eight patients felt pain in their hip joints. The average ROM score was 18.2 ± 2.5, and 47.4% of the patients with MHE had ROM limitation. The average score of ability to walk was 19.6 ± 1.8, and three patients had some problems with walking. The average ADL score was 18.2 ± 2.5, and 51.3% of patients with MHE had some failures in ADL. The hip flexion and internal rotation were markedly restricted compared with the normal values. When patients were grouped according to their ADL scores, we found that the ADL failure group had a significantly lower ROM score than the no ADL failure group (p < 0.0001), and there were significant differences between the groups in terms of femoral neck widening (p = 0.0001).

CONCLUSIONS

We found that half of MHE patients had some failures in their ADL due to hip functional impairment. The study results also suggest that femoral neck widening affected ADL failure and ROM limitation.

Intra-articular acetabular osteochondroma in patients with multiple hereditary exostoses

We report three additional cases of intra-articular acetabular osteochondroma in multiple hereditary exostoses patients in order to raise the awareness of this rare location, to prompt early diagnosis, and to present various treatment options according to the patient's condition. A 2.5-year-old boy presenting with an out-toeing gait had a large acetabular osteochondroma causing lateral displacement of the femoral head and acetabular dysplasia. Mass excision through hip subluxation via anterior approach and concomitant Dega osteotomy resulted in a congruent, well-developed, and well-covered hip joint at 11-year follow-up. A 10-year-old boy showing a pedunculated osteochondroma arising from the triradiate cartilage was successfully treated by arthroscopic excision. Normal development of the hip joint was observed at skeletal maturity. A 6-year-old boy presented with a painless limp. Acetabular osteochondroma could be confirmed by computed tomography scan, which was excised through hip subluxation by anterior approach. Persistent coxa valga and femoral head uncovering were addressed by femoral varization osteotomy at 9 years of age. A high index of suspicion is required to detect a lesion at this rare location. Various procedures may be considered according to the pathoanatomy. Acetabular dysplasia, coxa valga, and femoroacetabular impingement by femur neck mass, if associated, should be addressed in due time.

Reconstruction of the Hip in Multiple Hereditary Exostoses

The hip joint involvement in multiple hereditary exostoses (MHE) occurs in 30-90%, causing pain and limitation of motion by femoroacetabular impingement, coxa valga, acetabular dysplasia, hip joint subluxation, and osteoarthritis. The purpose of this study was to investigate the clinical and radiographic outcomes of ten hips in seven patients treated by surgical dislocation and corrective osteotomies between 2004 and 2009. Surgical dislocation and excision of the osteochondromas and varus intertrochanteric osteotomies were performed in all cases when the neck-shaft angle was > 150°. Common sites of osteochondromas were medial, posterior, and anterior neck of the femur. Neck-shaft angle of the femur was improved from a mean of 157° to 139°, postoperatively. On an average, the center-edge angle improved from 20° to 30° postoperatively. We believe that Ganz's safe surgical dislocation technique is the preferred treatment of MHE. This safeguards the circulation of the femoral head and the osteochondromas can be resected under direct vision. It can be combined with additional corrective osteotomies because the hip affected by MHE is frequently associated with dysplastic changes which can result in premature osteoarthritis.

Radiographic characteristics of the hip joint in skeletally mature patients with multiple hereditary exostoses

OBJECTIVE

To elucidate the radiological characteristics of the hips, especially in proximal femur, of skeletally mature patients with multiple hereditary exostoses (MHE).

MATERIALS AND METHODS

Fifty eligible patients (100 hips) were included in the study and assigned to the MHE group. The control group included age- and sex-matched individuals, and the radiographs of 100 hips were used as controls. We examined the anatomical characteristics of the acetabulum and the proximal femur, including the acetabular depth-width ratio (ADR), Sharp's angle, femoral neck-shaft angle (NSA), Wiberg's centre-edge angle (CEA), femoral neck axis length (FNAL), femoral head diameter, (FHD), femoral neck width (FNW), femoral shaft width (FSW), femoral neck-shaft angle (NSA), and femoral head-neck ratio (FHNR = FHD/FNW). p value < 0.05 was considered significant.

RESULTS

Osteochondroma was frequently observed in the medial femoral neck (79%), but it was rarely found in the femoral head (1%). ADR and Sharp's angle were not significantly different between the MHE and control groups (p = 0.2056, p = 0.5025). CEA was significantly different between the two groups (p < 0.0001). FNW was significantly larger in the MHE group than in the control group (p < 0.0001). FHNR was significantly different between the two groups (p < 0.0001). NSA was significantly larger than the MHE group (141.8° ± 9.7° vs 129.5° ± 5.6°, p < 0.0001).

CONCLUSIONS

Hip dysplasia in the pelvic side was not commonly observed in skeletally mature MHE patients. However, they showed femoral neck widening and coxa valga. The occurrence of osteochondroma around the femoral neck affects the degree of valgus deformity. These facts could be useful for orthopaedic surgeons treating MHE patients.

Surgical Hip Dislocation Using the Modified Hardinge Approach for Excision of Osteocartilaginous Lesions of the Acetabulum and Femoral Neck in an Adult: A Case Report

CASE

A 20-year-old woman presented with hip pain related to an osteocartilaginous lesion arising within the cotyloid fossa. She also had a lesion along the inferior femoral neck. Resection of both lesions was performed with surgical hip dislocation through a modified Hardinge approach.

CONCLUSIONS

This unusual location for an osteocartilaginous lesion can lead to substantial pain and disability. Surgical dislocation through a modified Hardinge approach is an excellent option to concurrently resect these benign lesions of the cotyloid fossa and femoral neck without the need for trochanteric osteotomy.

Arthroscopic Femoral Osteochondroplasty With Capsular Plication for Osteochondroma of the Femoral Neck

Osteochondromas of the femoral neck are a rare but challenging problem because of their distal location, which is difficult to access arthroscopically. Traditional methods of osteochondroma resection used invasive open approaches to manage these lesions. More recently, advances in hip arthroscopy have allowed expanded treatment of extra-articular hip conditions with a minimally invasive approach. Reports have described the use of hip arthroscopy for osteochondroma removal; however, surgical techniques for the procedure have yet to be described. We describe a technique for arthroscopic resection of a femoral neck osteochondroma using an extended capsulotomy and osteochondroplasty with subsequent capsular plication. This technique uses contemporary hip arthroscopic techniques and constitutes a safe and effective approach to addressing this rare intra-articular pathology of the hip.

One-stage surgical excision of a huge bilateral multiple osteochondroma of the hip: a case report

Osteochondroma or hereditary multiple exostoses is the most common benign bone tumor and is usually found in young patients. Osteochondromata of the proximal femur or hip have been reported in 30% to 90% of patients with hereditary multiple exostoses. This article presents a 25-year-old-male referred to our orthopedic clinic with a complaint of pain in both groins for the last four years which has deteriorated in the past 6 months by limitation of range of motion. Radiographic findings were consistent with huge hip osteochondroma and a histopathological report confirmed the diagnosis. This was a case of a huge bilateral osteochondroma of the hip originating from the posterior of the hips to the neck of the femur and hip joints and part of proximal of femur, that underwent one-stage surgical excision of the tumor with posterior approach and tumor resection. As we know, this case of bilateral huge hip osteochondromas has rarely been presented previously by someone who has undergone one-stage surgery treatment of a tumor this size. Bilateral hip osteochondroma is a rare condition and we showed that one-stage excision can be performed successfully.

Isolated acetabular osteochondroma of the hip

We present a case of isolated intra-acetabular osteochondroma in a 21 year-old male who presented with history of right hip pain for 5 years and difficulty in walking. Patient was managed with excision of intra-articular exostoses through surgical hip dislocation. Intra-articular hip osteochondromas can be a rare cause of hip pain in patients with unexplained etiology, and their diagnosis and management can be challenging.

Arthroscopic Excision of a Solitary Acetabular Osteochondroma in an Adult: A Case Report

CASE

A 43-year-old woman presented with localized pain of the right hip 2 months after a trivial trauma. Physical examination revealed a positive Patrick (FABER [Flexion, Abduction, and External Rotation]) test. Radiographs showed a radiopaque lesion at the acetabular fossa, and magnetic resonance imaging revealed a mass with adjacent bone marrow edema. Arthroscopic excision of the lesion was performed; histopathologic examination demonstrated that it was an osteochondroma.

CONCLUSION

A solitary intra-articular osteochondroma is a possible cause of localized hip pain. Hip arthroscopy can be a good diagnostic and therapeutic option.

Surgical hip dislocation according to Ganz for excision of osteochondromas in patients with multiple hereditary exostoses

AIMS

We report a prospective cohort study of the midterm results of surgical dislocation of the hip (according to Ganz) to perform resection of osteochondromas involving the femoral neck in patients with multiple hereditary exostoses (MHE).

METHODS

Hip range of movement (ROM) was assessed pre- and post-operatively. Patients' judgment of post-operative reduction of pain, symptoms, the Rand 36-item Health Survey (RAND-36) and complications were analysed.

RESULTS

Symptomatic osteochondromas of the femoral neck were removed in 20 hips (17 patients) between 2007 and 2012. There were nine men and eight women with a mean age at the time of surgery of 29 years (11 to 47). Mean follow-up was 46 months (26 to 73). At latest follow-up, mean ROM was significantly increased in all directions. Post-operatively the pain associated with the lesion was either significantly decreased or non-existent. There was a significant improvement in seven RAND-36 sub-domains. Encountered complications in four patients were pseudoarthrosis of the trochanteric osteotomy, traumatic separation of the trochanteric osteotomy, a pertrochanteric femoral fracture and avasvular necrosis. Histological analysis revealed osteochondromas in all hips.

DISCUSSION

This study confirms the Ganz trochanteric flip osteotomy provided a reliable approach to osteochondromas of the femoral neck that are otherwise difficult to access for surgical resection. The procedure offered significant improvement in the quality of life, although one should be aware of the serious complications can arise despite the relatively safe procedure.

TAKE HOME MESSAGE

When daily function and activities are affected, resection of osteochondromas of the proximal femur according to Ganz is indicated to significantly improve quality of life.

Is hip dysplasia a common deformity in skeletally mature patients with hereditary multiple exostoses?

BACKGROUND

Various deformities appear in hereditary multiple exostoses (HMEs). Deformities around the knee or ankle joints are easy to detect in this disease because such deformities are visible in appearance. However, deformities in the hip joints of skeletally mature patients are not well understood because their tumors are invisible.

METHODS

To understand deformities around the hip joint in HMEs, we investigated 36 hip joints in 19 skeletally mature patients (12 males, 7 females). The mean age at last X-ray imaging investigation was 29.2 years (14.5-66.5 years). We evaluated the lesions of exostoses around the acetabulum and proximal femur, Wiberg's center-edge angle (CEA), neck-shaft angle (NSA), acetabular depth-width ratio (ADR), and Sharp's acetabular angle.

RESULTS

No exostoses were present in four hips of three cases. Thirty-one hip joints had exostoses on the medial side of the femoral neck. Exostoses existed on the lateral side of the femoral neck in 16 hips. None of the patients had acetabuluar tumors. One patient experienced pain because of impingement between the acetabular rim and medial tumors of the femoral neck. The increase in NSA, which is an index of proximal femoral deformity, was common with a mean NSA of 147.3 °. Two indices of acetabular deformity, Sharp's angle and ADR, were within normal limits with a mean Sharp's angle of 41.3 ° and mean ADR of 269. The average CEA was 29.9 °.

CONCLUSIONS

Hip dysplasia is not necessarily common in skeletally mature patients with HMEs. To determine the possibility of hip dysplasia in skeletally immature patients with HMEs, ADR may be a useful reference index.

Developmental pattern of the hip in patients with hereditary multiple exostoses

Background

Coxa valga is a common clinical feature of hereditary multiple exostoses (HME). The current study aimed to determine the unique developmental pattern of the hip in patients with HME and evaluate the factors that influence its progression.

Methods

Thirty patients (57 hips) with HME were divided into two groups according to the Hilgenreiner epiphyseal angle (HEA). Twenty-two patients (44 hips) including 13 men and 9 women were assigned to group 1 (HEA <25°), and 8 patients (13 hips) including 3 men and 5 women were assigned to group 2 (HEA ≥25°). The mean age at the initial presentation was 6.0 (4–12) years with 6.8 (4–11) years of follow-up in group 1, and 10.4 (8–13) years with 5.4 (2–9) years of follow-up in group 2. We measured the HEA, neck-shaft angle (NSA), acetabular index (AI), center-edge angle (CEA), and migration percentage (MP) for radiographic evaluation.

Results

Among the hips, 50 (87.7%) hips had coxa valga and 27 (47.4%) hips had abnormal MP (42.1% were borderline and 5.3% were subluxated). There was a significant difference in the HEA and NSA between the groups (p < 0.001 and p < 0.05, respectively). The HEA significantly correlated with the development of the NSA and no correlation was found between the HEA and AI, CEA, and MP.

Conclusions

There was a significant relationship between the HEA at the initial presentation and the NSA at skeletal maturity. We should consider guided growth for patients with lower HEA to prevent significant coxa valga deformity with close follow-up.

Hip joint osteochondroma: systematic review of the literature and report of three further cases

The aim of this study is to systematically review the literature with regards to surgical treatment of patients with hip joint osteochondromas, and to report our surgical management of three paediatric patients who had femoral neck or acetabular osteochondromas in association with acetabular dysplasia. We performed a systematic review using PubMed and Embase databases for all studies that reported surgical treatments for patients with peritrochanteric or acetabular osteochondroma with or without acetabular dysplasia. We also retrospectively reviewed three patients who were diagnosed with a hip osteochondroma in association with actetabular dysplasia. These patients were known to have hereditary multiple exostoses (HME). The systematic review revealed 21 studies that met our inclusion criteria. All studies were case reports and retrospective in nature and failed to conclude a uniform treatment plan. The three reported cases illustrate successful excision of hip osteochondromas and treatment of acetabular dysplasia. Early excision of hip osteochondromas might prevent acetabular dysplasia in HME patients. Routine radiographic pelvic survey at the time of diagnosis of HME is recommended for early detection of hip osteochondromas and acetabular dysplasia in these children.

BICIPITAL TUBEROSITY OSTEOCHONDROMA CAUSING PAINFUL CLICKING AROUND THE WRIST: CASE REPORT AND LITERATURE REVIEW

Osteochondromatas of bicipital tuberosity are rare, most commonly occurring as metaphyseal benign tumours of the long bones. The usual presenting symptoms are pain and reduced rotation of the elbow. A painful clunk in the wrist as a presenting symptom has not been described before.

We present a young lady with a two-year history of a painful clunk in her wrist. Her case presented a diagnostic challenge, as the pain and the click originated from her elbow and radiated down her forearm to the wrist. She underwent several radiological studies, and examination under anaesthesia confirmed the diagnosis. Excision was performed resulting in complete resolution of her symptoms.

Along with painful clunk in the wrist originating from the elbow, an enlarged radial tuberosity should raise a high index of suspicion, and MRI scans and examination under image intensification can aid in the diagnosis of radial tuberosity osteochondroma.

Operative treatment of femoral neck osteochondroma through a digastric approach in a pediatric patient: a case report and review of the literature

A digastric approach has been used successfully to treat adult patients with femoral neck osteochondromas; however, to our knowledge, this has not been described in pediatric patients with open proximal femur growth plates. A case of femoral neck osteochondroma in an 11-year-old boy is presented and treatment using a digastric approach is described. No intraoperative femoral neck fracture or postoperative avascular necrosis occurred. There is no recurrence of the tumor at the 7-year follow-up. Surgical hip dislocation through a digastric approach provides adequate exposure of the femoral neck for osteochondroma resection and this technique should be considered for such circumstances.

Surgical hip dislocation for removal of intraarticular exostoses: report of two cases

Exostoses or osteochondromas are the most common benign bone tumors in children. The proximal femur is affected in approximately 30% of individuals and may lead to growth disturbances, acetabular dysplasia, and possible subluxation. Intraarticular lesions may also occur but are rarer. We present 2 cases of intraarticular exostoses that were successfully treated by surgical dislocation of the hip and complete excision of the lesion. However, despite successful excision, both hips are still abnormal because of the long standing inherent growth disturbance and residual acetabular dysplasia and may still require further surgery.