20-year-old woman with a femoral head osteochondral defect
Click Here to Manage Email Alerts
A 20-year-old woman presented with long-standing right groin pain that she first noticed during high school sports. She did not seek evaluation until beginning college athletics, when she noted increasing pain and functional limitations.
She was evaluated by a local orthopedic surgeon and diagnosed with a cam lesion, mild dysplasia and a lesion of the right femoral head considered suspicious for avascular necrosis by the outside surgeon (Figure 1).
The surgeon subsequently performed a right hip core decompression with injection of autologous iliac crest bone marrow aspirate concentrate into the lesion with backfilling of the drill tract with demineralized bone matrix and a fibula allograft.
Source: Ryan T. Conyer, MD; Xiao T. Chen, MD; Aaron J. Krych, MD; and Rafael J. Sierra, MD
Approximately 1 year postoperatively, her pain progressively returned. Imaging showed progression of cystic changes at the site of her lesion measuring approximately 2 cm in diameter and 0.7 cm in depth without collapse of the subchondral bone (Figures 2 and 3).
She was referred to our clinic for further evaluation and management. At the time of our visit, she was experiencing daily pain, which significantly limited her activity.
On exam, she ambulated with a normal gait. Hip flexion was 120° and extension was 0°. She had painful internal rotation to 20° with the hip flexed to 90°. Prone internal rotation was 70° bilaterally. She was neurovascularly intact with a well-healed lateral hip incision.
What are the best next steps in management of this patient?
See answer below.
Osteochondral allograft transplantation and femoral neck osteochondroplasty
After discussing total hip arthroplasty vs. hip preservation options, the patient was indicated for and elected to undergo an open femoral head osteochondral allograft transplantation (OCA) procedure via surgical hip dislocation. She also had a large cam deformity, so a concomitant femoral neck osteochondroplasty was indicated.
Surgical hip dislocation
The patient was placed in left lateral decubitus position. A 20-cm lateral skin incision was made and superficial dissection was carried down to the iliotibial band fascia, which was split longitudinally. The gluteus maximus was visualized proximally and bluntly peeled from the gluteus medius, exposing the posterior aspect of the greater trochanter. A vertical incision was made over the trochanteric bursal tissue, which was preserved for later closure.
At this point, a trigastric trochanteric flip osteotomy was performed with an oscillating saw, maintaining the tendinous insertions of the anterior gluteus medius, long head of the gluteus minimus and vastus lateralis on the greater trochanter. Distally, a subvastus approach to the femur was carried out, and the mobile trochanteric fragment was flipped anteriorly. The interval between the piriformis and gluteus minimus was identified to ensure preservation of the blood supply to the femoral head, including the anastomosis between the deep branch of the medial femoral circumflex artery and the inferior gluteal artery.
A Z-shaped capsulotomy was carried out, taking care to preserve the integrity of the labrum. The femoral head was subluxated anteriorly with a bone hook to allow transection of the ligamentum teres. The hip was then dislocated anteriorly with flexion and external rotation, allowing excellent access to the femoral head. The retinacular vessels at the posterior-superior femoral neck were visualized and carefully preserved.
OCA and osteochondroplasty
After the femoral head was exposed, visual inspection showed an osteochondral defect on the anterior-superior articular surface just superior to the fovea measuring more than 2 cm in diameter (Figure 4).
Significant cartilage loss was appreciated in the area. Using an allograft OATS system (Arthrex Inc.), a 22.5-mm osteochondral plug was planned. A 2.4-mm guide pin was placed perpendicular to the surface at the center of the lesion. Reaming was subsequently carried out to a depth of 7 mm. There was excellent bony bleeding without cystic changes at this depth (Figure 5).
We then turned our attention to preparation of the fresh right femoral head osteochondral allograft on the back table. A donor plug was created from a location on the donor femoral head complimentary to the location of the recipient site. The plug was trimmed to the exact dimensions as the recipient site. The marrow elements were expelled from the plug using compressed carbon dioxide, and autologous bone marrow aspirate from the stable trochanteric fragment was introduced onto the donor plug. Next, the osteochondral allograft was placed into the recipient site with excellent press-fit fixation. The interface was flush on all sides with excellent convexity matching (Figure 6).
During the graft preparation on the back table, a femoral neck osteochondroplasty was performed by the co-primary surgeon using a combination of osteotomes and a high-speed burr to correct the cam deformity. Following graft placement, the hip was reduced and carried through a range of motion. The labrum was well-reduced and stable on the acetabular rim.
Osteotomy fixation
The joint was irrigated with sterile saline, and the capsule was closed with 0 Vicryl sutures. The osteotomy was reduced and fixed with three 4.5-mm fully threaded screws, with two screws oriented from proximal to distal into the lesser trochanter, and one oriented lateral to medial toward the calcar (Figure 7). The trochanteric bursa was closed over the screw heads with 2-0 Monocryl suture (Ethicon Inc.), and the remaining wound was closed in a standard layered fashion.
Postoperative rehabilitation
The patient was placed on our institutional rehabilitation protocol for femoral head cartilage restoration with trochanteric osteotomy. This involves toe-touch weight-bearing for the first 6 weeks followed by a gradual progression to weight-bearing as tolerated. Range of motion is restricted to 0° to 90° for 4 weeks followed by progression to range of motion as tolerated.
Discussion
Osteochondral lesions of the femoral head in young, active patients are challenging to treat. While hip preservation is typically desired in this population, the surgical options for preservation are less predictable and carry a longer rehabilitation period and greater risk of continued pain compared with THA. However, hip preservation is especially important if the patient intends to return to competitive sports, as was the case with our patient.
Osteochondral lesions of the superior and medial femoral head require an open surgical exposure due to inadequate arthroscopic access to the area. The open exposure is frequently in the form of a surgical hip dislocation through a trochanteric flip osteotomy. This exposure is technically challenging and requires meticulous preservation of the blood supply to the femoral head, as well as preservation of the insertions of the abductors and vastus lateralis on the osteotomized greater trochanter. Preservation of the abductor insertion prevents postoperative gait abnormalities, and the vastus lateralis acts as a tether to help prevent superior migration of the trochanteric osteotomy.
While osteochondral autograft is widely used for osteochondral lesions of the knee, the femoral head presents challenges with obtaining a graft from an appropriate donor site. One possible site of autograft harvest is the non-weight-bearing inferior portion of the femoral head. However, osteochondral allograft eliminates the possibility of donor site morbidity and is taken from the exact area of the donor femoral head where the recipient lesion is located. This provides a highly congruent articular surface that closely matches the convexity of the removed osteochondral lesion and avoids replacing a weight-bearing portion of the femoral head with a non-weight-bearing portion of the femoral head.
Key points:
- Arthroscopic access to the superior-medial femoral head is inadequate for surgical treatment of osteochondral lesions in this area. Therefore, an open surgical hip dislocation is commonly required.
- The trochanteric flip osteotomy allows preservation of the vascular supply to the femoral head. Maintaining the abductor and vastus lateralis insertions on the greater trochanter is critical for protecting the fixation of the osteotomy and preserving postoperative abductor function.
- Fresh osteochondral allograft is an option that avoids the donor site morbidity associated with osteochondral autograft harvest and allows for highly congruent replacement of the removed osteochondral lesion.
- References:
- Daud A, et al. J Arthroplasty. 2024;doi:10.1016/j.arth.2024.06.030.
- Fong S, et al. Arthroscopy. 2024;doi:10.1016/j.arthro.2024.02.008.
- Johnson JD, et al. J Hip Preserv Surg. 2017;doi:10.1093/jhps/hnx022.
- Lazaro LE, et al. J Bone Joint Surg Am. 2013;doi:10.2106/JBJS.L.01185.
- Maldonado DR, et al. Arthrosc Tech. 2018;doi:10.1016/j.eats.2017.10.001.
- Massè A, et al. Clin Orthop Relat Res. 2015;doi:10.1007/s11999-015-4352-4.
- Trotzky Z, et al. Clin Orthop Relat Res. 2024;doi:.1097/CORR.0000000000003032.
- For more information:
- Xiao T. Chen, MD; Ryan T. Conyer, MD; Aaron J. Krych, MD; and Rafael J. Sierra, MD, can be reached at the department of orthopedic surgery at the Mayo Clinic in Rochester, Minnesota. Conyer’s email: conyer.ryan@mayo.edu.
Collapse
Read more about
Click Here to Manage Email Alerts