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

Long-term outcome of total hip arthroplasty in patients with multiple hereditary exostosis

BACKGROUND

Multiple hereditary exostosis (MHE) is a rare autosomal dominant disorder characterized by multiple osteochondromas. There is a paucity of literature concerning total hip arthroplasty (THA) in patients with MHE. The aim of this study is to report long-term outcomes of THA in patients with MHE.

METHODS

Fourteen patients undergoing 15 THA's for the treatment of osteoarthritis in the presence of osteochondromas and proximal femoral deformity secondary to MHE were reviewed. Mean age at the time of surgery and follow-up was 56 and 12 years. Seven (47%) had uncemented femoral components. Eleven hips had coxa valga on preoperative imaging. Clinical outcomes were assessed with both Harris hip scores (HHS) and Musculoskeletal Tumor Society Scores (MSTS).

RESULTS

Following surgery, there was an improvement in the HHS (48-82, p < 0.01) and MSTS scores (41-70%, p < 0.01). Complications occurred in 5 patients leading to reoperation in 3 patients, of which 2 patients underwent a revision procedure at 19 and 20-years postoperative. The 10-year revision free survival was 100%.

CONCLUSIONS

THA in the setting of MHE reliably improves patient function. One in three patients will have a postoperative complication; however, the long-term incidence of revision is low.

Arthroscopic Removal of a Free-Floating Bullet From the Hip Joint

Gunshot injuries and bullet removal are extremely rare indications for hip arthroscopy. We present the case of a 22-year-old male with a free-floating bullet in the hip joint after a gunshot injury. A thorough imaging investigation was used to demonstrate the exact location of the foreign body. The bullet was removed by arthroscopic means under fluoroscopic guidance. The patient has been symptom-free for two years postoperatively. The tips and tricks of the technique are discussed. Hip arthroscopy is a minimally invasive technique to remove a free-floating bullet and avoid potential long-term complications like chondral injury and lead intoxication.

Surgical Hip Dislocation in Pediatric and Adolescent Patients

LEVEL OF EVIDENCE

V, Expert opinion.

Direct femoral head approach without surgical dislocation for femoral head chondroblastoma: a report of two cases

BACKGROUND

Chondroblastomas are rare, benign, locally aggressive lesions that appear in the epiphysis. Surgery for femoral head chondroblastoma (FHCB) is difficult. Conventional treatment with curettage via a drilled tunnel along the femoral neck can damage the growth plate and is associated with high local recurrence rates. The trapdoor procedure, which directly facilitates lesion access from the femoral head articular surface, can reduce local recurrence and avoid growth plate damage, although it requires surgical dislocation. Little is known about the long-term results of this direct articular surface approach, and there are no case reports on trapdoor procedures without dislocation.

CASE PRESENTATION

We report two cases (patients aged 12 and 15 years) of FHCB presented with coxalgia treated using the trapdoor procedure without surgical dislocation. Both surgeries were performed with patients in the semi-lateral position. The hip joint was exposed via an anterior approach, and a capsulotomy was performed at the superior rim of the acetabulum, followed by the external rotation of the hip joint. With a fine osteotome, a rectangular flap (trapdoor) was opened on the cartilage surface in the lateral non-weight-bearing area, and curettage of the lesion followed by bone and/or bone substitute grafting was performed. Subsequently, the trapdoor was replaced in its original position. There has been no local recurrence or femoral head aseptic necrosis after more than 6 and 12 years for patients 1 and 2, respectively. Both patients had musculoskeletal tumor society scores of 100% at follow-up and are enjoying a normal active life.

CONCLUSIONS

This direct femoral head approach without dislocation may be a simple treatment alternative for FHCB.

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.

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.

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.

Total Hip Arthroplasty for Secondary Coxarthrosis in Patients with Hereditary Multiple Exostoses: Minimum 5-Year Follow-up Results and Surgical Considerations

Background

Hereditary multiple exostoses (HME) is an autosomal dominant disorder. The lesion in the proximal femoral metaphysis can bring about hip dysplasia and subsequent degenerative arthritis. Due to its rare prevalence, there have been a few case reports of total hip arthroplasty (THA) for osteoarthritis secondary to HME. The aim of this study was to report mid- to long-term outcomes of THA in HME patients and discuss special considerations that should be taken into account during surgery.

Methods

We retrospectively evaluated the clinical and radiological results of THA for osteoarthritis secondary to HME in 11 hips of 9 patients after a minimum follow-up of 5 years (mean, 9.9 years). There were 3 men (3 hips) and 6 women (8 hips), with a mean age of 53.6 years (range, 46.8–58 years) at the index surgery in this study. Harris hip score (HHS) was used for clinical outcome assessment, and radiologically, implant stability, radiolucent lines, liner wear, and any sign of osteolysis or implant loosening were evaluated. Postoperative complications including infection, deep vein thrombosis, and dislocations were also investigated.

Results

Cemented stems and cementless cups with the conventional polyethylene liner were used in bilateral hips of a single patient. In the other cases, cementless implants were used with ceramic-on-ceramic bearings. The mean HHS improved from 34.8 preoperatively to 92.5 postoperatively. Polyethylene liner wear and osteolysis were observed in 1 patient with cemented stems. Radiolucent lines were observed in 2 different cases. However, the femoral stems remained stable. There were no surgery-related complications except heterotopic ossification during follow-up.

Conclusions

Despite the several surgical considerations, the mid- to long-term clinical and radiological outcomes of THA in HME patients were satisfactory. The abnormal, wide mediolateral diameter of the proximal metaphysis should be considered in selecting and inserting the stem with adequate anteversion. Leg length discrepancy was also common, so teleradiographs should be obtained before surgery. Intraoperative leg length evaluation might be difficult due to the morphologic changes in the proximal femur after mass excision and individual bone length differences.

Current Uses of the Transtrochanteric Approach to the Hip: A Systematic Review

BACKGROUND

The indications and technique for the transtrochanteric approach to the hip have evolved greatly since its initial popularization in the 1960s. The purpose of this systematic review was to assess current uses of this approach on the basis of indications, osteotomy technique, trochanteric fixation method, complications, and functional outcome.

METHODS

A comprehensive search of MEDLINE and Embase databases from January 2000 to July 2017 was performed in accordance with the PRISMA guidelines. Articles were divided into 3 major categories on the basis of the type of hip surgery performed: (1) primary arthroplasty, (2) revision arthroplasty, and (3) joint-preserving procedures. Patient data were then analyzed according to these 3 categories.

RESULTS

Seventy-six studies (5,028 hips), mainly of Level-IV evidence, were included. Four types of osteotomy were reported for a variety of indications. Rates of nonunion were 6.0% (303 of 5,028) across all studies, 4.2% (39 of 921) for primary arthroplasty, 6.7% (114 of 1,690) for revision arthroplasty, and 4.4% (56 of 1,278) for joint-preserving procedures. Rates of dislocation were 1.5% (14 of 921) for primary arthroplasty and 4.6% (77 of 1,690) for revision arthroplasty. The rate of osteonecrosis after joint-preserving procedures was 1.1% (14 of 1,278). Rates of deep infection were 1.1% (55 of 5,028) across all studies, 0.1% (1 of 921) for primary arthroplasty, 2.1% (36 of 1,690) for revision arthroplasty, and 0.6% (8 of 1,278) for joint-preserving procedures.

CONCLUSIONS

The transtrochanteric approach remains useful in cases requiring extensile exposure of the acetabulum or femoral medullary canal. However, trochanteric complications continue to pose a clinical challenge.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Labral reconstruction with tendon allograft: histological findings show revascularization at 8 weeks from implantation

This description shows the histological findings of a peroneus brevis tendon allograft used for labral reconstruction, implanted 8 weeks before being retrieved due to a postoperative complication unrelated to the graft. As far as we have knowledge this is the first description about revascularization of an allograft used for hip labral reconstruction. The histological report of the removed peroneus brevis tendon allograft shows evidence of vascular ingrowth represented by small vessels with a thin muscular wall in all layers of the graft and cellular migration mainly represented by mature fibroblasts.

The impact of hereditary multiple exostoses on quality of life, satisfaction, global health status, and pain

PURPOSE

The aim of the study was to evaluate quality of life (QOL), global health status, pain, and level of satisfaction in patients with hereditary multiple exostoses (HME), and to correlate the association between the severity of diseases and age, sex, number of surgical procedures, and number of exostoses.

METHODS

The data of 50 patients with HME were retrospectively evaluated and recorded. QOL was evaluated with the Short-Form Health Survey (SF-12) questionnaire, the 12-Item General Health Questionnaire (GHQ-12), and Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF); intensity of pain was measured using the visual analogue scale (VAS). The association of age, gender, pain, quality of life, number of exostoses, and number of surgical procedures were evaluated and correlated.

RESULTS

Mean number of exostoses in our patient's cohort resulted 18.12 ± 8.60, and every patient underwent to a mean of 5.62 ± 5.74 surgical procedures for the exostoses. Mean VAS resulted 5.16 ± 2.90. Considering SF-12, mental (MCS) and physical (PCS) component resulted, respectively, 45.36 ± 10.76 and 38.73 ± 11.09, while GHQ-12 and Q-LES-Q-SF were 15.48 ± 4.70 and 45.28 ± 9.55, respectively. We found a significant positive correlation between the number of exostoses and the number of surgical procedures (p < 0.001), a significant positive correlation between the number of surgical procedures and GHQ-12 (p = 0.422) and VAS (p = 0.0011), and a negative correlation between the number of surgical procedures and PCS (p = 0.0257) and between age and GHQ-12 (p = 0.0385).

CONCLUSIONS

We can conclude that HME impact on patient quality of life as measured by the MCS and PCS scores similar to the disability associated with osteoarthritis in the mental component and tumors or diabetes as regards the physical component. Moreover, we found no difference in patients' quality of life as regards number of exostoses, age, and surgical procedure, but we found that women have a worse response as regards the psychological side than men.