Hip arthroscopy in hereditary multiple exostoses

Hip arthroscopy in hereditary multiple exostoses

Case Report Hip Arthroscopy in Hereditary Multiple Exostoses: A New Perspective of Treatment Franc¸ois Bonnomet, M.D., Philippe Clavert, M.D., Fadi Z...

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Case Report

Hip Arthroscopy in Hereditary Multiple Exostoses: A New Perspective of Treatment Franc¸ois Bonnomet, M.D., Philippe Clavert, M.D., Fadi Zen Abidine, M.D., Philippe Gicquel, M.D., Jean Michel Clavert, M.D., and Jean Franc¸ois Kempf, M.D.

Abstract: The cases of 2 children (9 and 11 years old) with hereditary multiple exostoses disease are presented. The lesions were located primarily in the acetabular fossa of the left hip and caused pain and limitation of range of motion. Hip arthroscopy was performed to remove the exostoses without damaging the articular surfaces and the Y cartilage. After the procedure, the pain disappeared and normal range of motion was recovered for both children. Conventional surgery would have required hip dislocation to access these lesions with an increased risk of femoral head necrosis. These cases constitute a new and interesting application of hip arthroscopy. Key Words: Hip arthroscopy— Multiple hereditary exostoses—Acetabular fossa.

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ultiple exostoses is a genetic disorder characterized by abundant duplication of solitary exostosis. It is responsible for several orthopaedic problems. The most severe complication is its malignant transformation into chondrosarcoma. The likelihood of such a transformation is not easily estimated1 but usually presents at the end of a person’s period of growth.2 The most common complications are functional because the proliferation and size of some exostoses can cause serious problems, such as reduction of osseous growth, deformation of joints, restricted motion of adjacent joints, and premature osteoarthritis. Excision of such lesions should be carried out as soon as possible to avoid these problems. Excision is technically difficult and can produce poor results. We report the cases of 2 adolescents who each had an exostosis in the acetabular fossa where its resection

From the Departments of Orthopaedic Traumatology and Pediatric Surgery (J.M.C.), Hoˆpital Hautepierre, Strasbourg, France. Address correspondence and reprint requests to Franc¸ois Bonnomet, M.D., De´partement d’Orthope´die Traumatologie, Hoˆpital Hautepierre, Avenue Molie`re, 67098 Strasbourg Cedex, France. © 2001 by the Arthroscopy Association of North America 1526-3231/01/1709-2821$35.00/0 doi:10.1053/jars.2001.22410

classically would have required an arthrotomy with hip dislocation leading to increased risk of avascular necrosis and early epiphysiodesis. We decided to perform this operation under arthroscopic guidance, which is far less invasive and is a new therapeutic solution.

CASE 1 J. G. was an 11-year-old boy referred to the pediatric surgery department to confirm the diagnosis of multiple exostoses and for therapeutic advice. Apart from several rib lesions (an unusual location) without involvement of the lungs, we found some in more usual locations, including (1) the left wrist at the level of the distal third of the ulna with radioulnar joint dislocation but no functional impairment; (2) the distal half of the second phalanx; (3) the proximal tibia with posterior exostoses blocking knee flexion with signs of nerve entrapment, also responsible for ankle axis deviation as a result of leg length discrepancy; and (4) the right distal femur without functional complications. There were also other locations in both the humerus and left femur, with femoral head displacement at this

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: E40

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level. We were unable to determine if the acetabular exostosis or the proximal femur exostosis was responsible for the femoral head subluxation. The physical examination of the left hip showed decreased range of motion (ROM) on the left side and limited flexion to 90° with no medial rotation. Lateral rotation and abduction were preserved. The ROM of the right hip was normal. A computed tomography scan of the left hip showed the lesion on the acetabular fossa (Fig 1). The patient was admitted for excision of this lesion under arthroscopic guidance. The postoperative course went well and he was able to walk the second day fully weight bearing with the aid of crutches. The patient was discharged the second day and the pain disappeared a few days later. The patient was seen 6 months later and he walked easily without pain. ROM was equal to the contralateral side. Another computed tomography scan of the left hip was obtained that showed sufficient excision of the exostosis with conservation of the Y cartilage and satisfactory articular congruence (Fig 2). The paFIGURE 2. Computed tomography scan 6 months after arthroscopy: the exostosis has been totally removed and the femoral head is centered again.

tient was followed-up for 3 years and there was no recurrence or growth problems. CASE 2

FIGURE 1. Preoperative computed tomography scan of the left hip showing the exostosis with the beginning of femoral head subluxation.

N. H., a 9-year-old girl, was referred to us from the pediatric surgery department for investigation and treatment of walking problems. She had a limp as a result of left hip pain with decreased ROM (flexion of 100° and medial rotation of 0°). Plain radiographs confirmed the diagnosis of multiple exostoses (familial type), with classical locations, including (1) the right clavicle, both humeri, radius, and ulna without functional impairment; (2) both hands with subungual locations at the level of the fifth finger; (3) the medial femoral condyles with bilateral axis deviation (valgus deformity); and (4) the proximal third of both femurs and left acetabular fossa with mild femoral head subluxation. The patient was hospitalized for excision of the acetabular exostosis by arthroscopic surgery. Postoperatively, she was fully weight bearing the second day using 2 crutches and was discharged. At 6 months, the patient was reviewed and the physical examination of

ARTHROSCOPIC EXCISION OF ACETUBULAR EXOSTOSES

FIGURE 3. Arthroscopic view: the acetabular fossa is covered by synovial tissue and the palpator is used to locate the exostosis.

the left hip was identical to the normal contralateral hip. The patient was followed-up for 2 years with stable and satisfactory results, i.e., a painless hip with normal ROM. A second surgical procedure was performed for partial epiphysiodesis of the ankles for limb axis correction. Three years after the arthroscopic surgery, no reoccurrence or acetabular growth problems were encountered. SURGICAL PROCEDURE Both procedures followed the same protocol. Under general anesthesia with the patient in supine position on an orthopaedic table, both feet were placed under traction with the operated hip in slight flexion to detract the hip capsule. The traction was less than 20 kg and the duration of the procedure was less than 1 hour to prevent nerve, vulva, and scrotal injuries. The traction followed an intra-articular injection of 15 mL of physiologic water to suppress the negative pressure of the hip joint. Two surgical approaches were used. The first was anterolateral according to Parisien.3 The second was slightly more lateral and very close to the lateral approach described by Glick.4 Irrigation was done using physiologic water (sodium chloride, 0.9% mg/L) without use of an arthropump. Adult-sized instrumentation was used (a 4-mm arthroscope at 30° angulation and 4-mm motorized instruments). In the first stage, the exploration permitted the repair of the anterior horn and the anterior portion of the posterior horn. The acetabular fossa, which was covered by synovial tissue, was palpated to locate the exostosis (Fig 3).

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FIGURE 4. Arthroscopic view: abrasion of the exostosis. The 3 parts are clearly visible: the superior part just above the motorized drill, the anterior part is to the left, and the posterior is to the right.

Using a basket and shaver, the synovial tissue was excised to uncover the lesion. The latter was composed of 3 lesions, each having developed over a branch of the Y cartilage. Abrasion of the exostosis was performed using a 4-mm motorized drill (Fig 4). We made sure to excise the whole exostosis without damaging the Y cartilage (not too much and not too little). At the end of the procedure, exploration and palpation of the acetabulum determined the quality of the excision in order to confirm a complete resection (Fig 5). The time taken for each of the procedures was

FIGURE 5.

Arthroscopic view after resection of the exostosis.

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about 50 minutes. The skin was closed using resorbable sutures. 3.

DISCUSSION Diagnostic and therapeutic arthroscopy is widely used in adults to treat some hip afflictions.5 Removal of foreign bodies in some cases of synovial chondromatosis,6,7 repair of acetabular labrum lesions,8-13 and articular debridement in septic arthritis14,15 are the major indications. In children and adolescents, arthroscopic surgery is used much less.16,17 Removal of osteochondral fragments of traumatic origin18 or resulting from Legg-Calv´ee-Perthes disease represent ideal indications for arthroscopic treatment in young patients.19-21 In the same way, acetabular labral tears are, as in adults, an excellent indication for arthroscopy.21-23 Recently, Kuklo et al.24 reported the arthroscopic debridement of an unusual epiphyseal ossification of the femoral head in a case of Legg-Calv´e-Perthes disease. Using a 4-mm burr, they reduced its prominence below the articular surface. However, as far as we know, there are no published reports on arthroscopic excision of an exostosis at the acetabular fossa. This location has been rarely described,25-27 even in the context of multiple exostoses. Exostoses in this location can cause progressive subluxation of the femoral head, making the risk of early articular damage even higher. In this case, surgical excision is justified. The anterior approach protects the posterior circumflex vessels but does not prevent aseptic necrosis of the femoral head because of the dislocation of the head in order to approach the acetabular fossa.28 Using arthroscopic techniques, the risk of iatrogenic damage to the femoral head is much lower if not rare. The capsular softness in both cases permitted remarkable hip distraction with only moderate traction that made exploration and resection of the exostosis easy and efficient. There was no recurrence in 3 years of follow-up and there was no epiphysiodesis because the Y cartilage had been preserved. We recommend this arthroscopic technique in the treatment of exostoses located in the acetabulum.

4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

21. 22. 23. 24. 25. 26.

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