Osteochondritis dissecans of the femoral head

Seven patients with symptomatic osteochondritic lesions of the femoral head are presented. All were male with a mean age of 26 years (16 - 33 years). Two distinct morphologic appearances of the hip joint could be identified. Five patients presented with a coxa valga deformity, four of whom had signs of epiphyseal dysplasia. There were 2 patients whose hips appeared normal apart from the osteochondrontic lesions. In both cases an additional acetabular rim lesion due to a reproducible femoro-acetabular impingement was diagnosed at arthrotomy. This may have acted as the underlying cause of osteochondritis dissecans in these cases. All 7 patients underwent surgical treatment. An intertrochanteric osteotomy (I.O.) alone was performed in 2 patients. Follow-up of these patients at 6.5 and 8.5 years after surgery revealed that the osteochondritic lesions had not healed and one individual remained symptomatic. In the remaining 5 patients, treatment consisted of femoral head dislocation and screw fixation of the osteochondritic lesion. This was combined with an I.O. in two of these patients for coxa valga and osteoplasty of a broad femoral neck in 2 other patients. All lesions had healed at an average follow-up of 4.3 years (2 - 8.5 years). Three patients were asymptomatic and 2 patients had minor residual pain. No progressive osteoarthritic changes or signs of avascular necrosis of the femoral head were observed.

Surgical hip dislocation for osteochondral transplantation as a salvage procedure for a femoral head impaction fracture

Obturator anterior hip dislocation is very rare. Poor results are described in patients with additional large transchondral fractures and treatment of these injuries remains challenging. Appropriate treatment recommendations are missing in the literature. This case report introduces surgical hip dislocation for osteochondral autograft transplantation with graft harvest from the nonweightbearing area of the head-neck junction as a salvage procedure in a large femoral head defect. We report the treatment and outcome of a 48-year-old man who sustained an anterior dislocation of the left hip after a motorcycle accident. After initial closed reduction in the emergency room, imaging analysis revealed a large osteochondral defect of the femoral head within the weightbearing area (10 × 20 mm, depth: 5 mm). The hip was exposed with a surgical hip dislocation using a trochanteric osteotomy. An osteochondral autograft was harvested from a nonweightbearing area of the femoral head and transferred into the defect. The patient was prospectively examined clinically and radiologically. Two years postoperatively, the patient was free of pain and complaints. The function of the injured hip was comparable to that of the contralateral, healthy hip and showed satisfying radiologic results. Surgical hip dislocation with a trochanteric flip osteotomy is a simple, one-step technique that allows full inspection of the hip to treat osteochondral femoral defects by osteochondral transplantation. The presented technique, used as a salvage procedure in a large femoral head defect, yielded good clinical and satisfying radiologic outcomes at the midterm.

Surgical dislocation of the hip for a locked traumatic posterior dislocation with associated femoral neck and acetabular fractures

Traumatic posterior dislocation of the hip associated with a fracture of the posterior acetabular wall and of the neck of the femur is a rare injury. A 29-year-old man presented at a level 1 trauma centre with a locked posterior dislocation of the right hip, with fractures of the femoral neck and the posterior wall of the acetabulum after a bicycle accident. An attempted closed reduction had failed. This case report describes in detail the surgical management and the clinical and radiological outcome. Open reduction and fixation with preservation of the intact retinaculum was undertaken within five hours of injury with surgical dislocation of the hip and a trochanteric osteotomy. Two years after operation the function of the injured hip was good. Plain radiographs and MR scans showed early signs of osteoarthritis with some loss of joint space but no evidence of avascular necrosis. The patient had begun skiing and hiking again. The combination of fractures of the neck of the femur and of the posterior wall of the acetabulum hampers closed reduction of a posterior dislocation of the hip. Surgical dislocation of the hip with trochanteric flip osteotomy allows controlled open reduction of the fractures, with inspection of the hip joint and preservation of the vascular supply.

Treatment of slipped capital femoral epiphysis with a modified Dunn procedure

Surgical procedures with use of traditional techniques to reposition the proximal femoral epiphysis in the treatment of slipped capital femoral epiphysis are associated with a high rate of femoral head osteonecrosis. Therefore, most surgeons advocate in situ fixation of the slipped epiphysis with acceptance of any persistent deformity in the proximal part of the femur. This residual deformity can lead to secondary osteoarthritis resulting from femoroacetabular cam impingement.

Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC), after slipped capital femoral epiphysis

OBJECTIVE: The aim of this study was to assess the glycosaminoglycan (GAG) content in hip joint cartilage in mature hips with a history of slipped capital femoral epiphysis (SCFE) using delayed gadolinium-enhanced MRI of cartilage (dGEMRIC). METHODS: 28 young-adult subjects (32 hips) with a mean age of 23.8+/-4.0 years (range: 18.1-30.5 years) who were treated for mild or moderate SCFE in adolescence were included into the study. Hip function and clinical symptoms were evaluated with the Harris hip score (HHS) system at the time of MRI. Plain radiographic evaluation included Tonnis grading, measurement of the minimal joint space width (JSW) and alpha-angle measurement. The alpha-angle values were used to classify three sub-groups: group 1=subjects with normal femoral head-neck offset (alpha-angle <50 degrees ), group 2=subjects with mild offset decrease (alpha-angle 50 degrees -60 degrees ), and group 3=subjects with severe offset decrease (alpha-angle >60 degrees ). RESULTS: There was statistically significant difference noted for the T1(Gd) values, lateral and central, between group 1 and group 3 (p-values=0.038 and 0.041). The T1(Gd) values measured within the lateral portion were slightly lower compared with the T1(Gd) values measured within the central portion that was at a statistically significance level (p-value <0.001). HHS, Tonnis grades and JSW revealed no statistically significant difference. CONCLUSION: By using dGEMRIC in the mid-term follow-up of SCFE we were able to reveal degenerative changes even in the absence of joint space narrowing that seem to be related to the degree of offset pathology. The dGEMRIC technique may be a potential diagnostic modality in the follow-up evaluation of SCFE.

MRI morphometry, cartilage damage and impaired function in the follow-up after slipped capital femoral epiphysis

To assess rotation deficits, asphericity of the femoral head and localisation of cartilage damage in the follow-up after slipped capital femoral epiphysis (SCFE).

Algorithm for femoral and periacetabular osteotomies in complex hip deformities

Residual acetabular dysplasia of the hip in most patients can be corrected by periacetabular osteotomy. However, some patients have intraarticular abnormalities causing insufficient coverage, containment or congruency after periacetabular osteotomy, or extraarticular abnormalities that limit either acetabular correction or hip motion. For these patients, we believe an additional proximal femoral osteotomy can improve coverage, containment, congruency and/or motion.

Endovascular treatment of common femoral artery obstructions

To evaluate the clinical efficacy of endovascular therapy of symptomatic obstructions of the common femoral artery (CFA).