Arthroscopic Resection of Osteochondroma of Hip Joint … · 2015-04-10 · 45 Heung-Tae Jung et al. Arthroscopic Resection of Hip Joint Osteochondroma Associated with Internal Snapping

CASE REPORTHip Pelvis 27(1): 43-48, 2015http://dx.doi.org/10.5371/hp.2015.27.1.43

Copyright ⓒ 2015 by Korean Hip Society 43

Print ISSN 2287-3260Online ISSN 2287-3279

Osteochondroma is a benign tumor usually discoveredat knee, forearm, and ankle. But, osteochondroma of theproximal femur is relatively rare1). Clinical manifestationsby osteochondroma of the hip joint include trochantericbursitis, sciatic nerve compression2), an external snapping

hip3), femoroacetabular impingement (FAI)4,5) or fractureat the stalk of the tumor1,6). Internal snapping isuncommon pathology of the hip joint; however, it maymake the pain of the hip joint and disturbance of gait.As internal snapping hip is occurred by movement ofiliopsoas tendon, the bony lesion caught in iliopsoastendon can also make snapping phenomenon of the hipjoint. For treatment of intraarticular osteochondroma ofthe hip joint, open resection of the hip was usuallyperformed but the procedure may be somewhat invasive.So, arthroscopic resection for intraarticlular bony lesioncan be considered. However, if the bony tumor islocated at far distal portion of peripheral compartment,arthroscopic resection may be very difficult. Also, thereis no report about an osteochondroma related to internalsnapping hip, yet. The authors report the case thatunderwent arthroscopic resection of osteochondromarelated to internal snapping hip.

Arthroscopic Resection of Osteochondroma ofHip Joint Associated with Internal Snapping:

A Case ReportHeung-Tae Jung, MD, Deuk-Soo Hwang, MD*, Yoo-Sun Jeon, MD, Pil-Sung Kim, MD�

Department of Orthopedic Surgery, Busan Bumin Hospital, Busan, Korea,Department of Orthopedic Surgery, Chungnam National University School of Medicine, Daejeon, Korea*,

Department of Orthopedic Surgery, Seoul Bumin Hospital, Seoul, Korea�

A 16-year old male patient visited the hospital complaining of inguinal pain and internal snapping of right hip joint. Inphysical examination, the patient was presumed to be diagnosed femoroacetabular impingement (FAI) and acetabularlabral tear. In radiologic evaluation, FAI and acetabular labral tear were identified and bony tumor associated withinternal snapping was found on the posteromedial portion of the femoral neck. Despite of conservative treatment,there was no symptomatic improvement. So arthroscopic labral repair, osteoplasty and resection of bony tumor wereperformed. The tumor was pathologically diagnosed as osteochondroma through biopsy and all symptoms improvedafter surgery. There was no recurrence, complication or abnormal finding during 1 year follow up. Osteochondromalocated at posteromedial portion of femoral neck can be a cause of internal snapping hip and although technicaldemands are challenging, arthroscopic resection can be a good treatment option.

Key Words: Hip, Arthroscopy, Osteochondroma

Submitted: July 19, 2014 1st revision: November 17, 20142nd revision: February 3, 2015 3rd revision: February 17, 2015Final acceptance: February 23, 2015Address reprint request toPil-Sung Kim, MDDepartment of Orthopedic Surgery, Seoul Bumin Hospital, 389Gonghang-daero, Gangseo-gu, Seoul 157-930, KoreaTEL: +82-2-2620-0008 FAX: +82-2-2620-0167E-mail: [email protected]

This is an Open Access article distributed under the terms of the CreativeCommons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use,distribution, and reproduction in any medium, provided the original work isproperly cited.

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CASE REPORT

A 16-year old male patient visited the hospitalcomplaining of pain of right hip joint starting from 2years ago. The patient complained of inguinal pain andlimping. Visual analogue scale (VAS) pain score was 8.In physical examination, anterior hip impingement testand Patrick test were positive. When the leg of thepatient was rotated internally and extended distally, thesnapping movement happened in his hip joint. Plainradiograph showed pincer type of FAI which haspositive crossover sign of the acetabulum. On the frogleg lateral view, a bony protuberance was found atposteromedial portion of the femoral neck (Fig. 1).Computed tomography (CT) images showed craniallyretroverted acetabulum and a bony tumor which located

just above the lesser trochanter with a size of 1.7 cm by0.6 cm (Fig. 2). On magnetic resonance arthrographyimages, labral tear at the anterosuperior portion ofacetabulum and a bony tumor with cartilaginous cap atposteromedial area of femoral neck were demonstrated(Fig. 3). We observed snapping motion between iliopsoastendon and bony tumor at peripheral compartment inultrasonographic examination. Since the pain did notsubside even after conservative treatment using non-steroid anti-inflammatory drugs and physical therapy for6 weeks, arthroscopic management for FAI with labraltear and bony tumor was performed.

We put the patient under general anesthesia and took asupine position on the fracture table for traction of thehip joint. We treated problems of central compartmentfirst, and the procedure for peripheral compartment wasexecuted later. Anterolateral and anterior portal wereestablished in ordinary manner. In whole procedure, 70。arthroscope was used only. After making two portals,we made transverse capsulotomy connecting anterior toanterolateral portal using arthroscopic knife. Forvisualization of bony tumor, transverse capsulotomywas more extended medially rather than usualcapsulotomy. In arthroscopic findings, labral displacedtear was found at anterosuperior aspect of theacetabulum. Acetabuloplasty was performed using a 4.5mm arthroscopic spherical burr (Conmed Linvatec,Largo, FL, USA) and acetabular labral repair using two2.7 mm absorbable suture anchor (Bioraptor; Smith &Nephew, Andover, MA, USA) was performed at anteriorand anterolateral portion of the acetabulum (Fig. 4).After the procedure of central compartment, thepatient’s hip was flexed to 60。and arthroscope was

FFiigg.. 11.. Frog-leg lateral view. The bony lesion was found atposteromedial portion of right femoral neck.

FFiigg.. 22.. (AA) Preoperative computed tomography (CT). Bony protuberance was located just above lesser trochanter. (BB) PreoperativeCT. Bony protuberance was located just above lesser trochanter.

A B

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Heung-Tae Jung et al. Arthroscopic Resection of Hip Joint Osteochondroma Associated with Internal Snapping

moved toward peripheral compartment, and additionalcapsulotomy using the hook type radiofrequency(Arthrocare; Arthrocare Corporation, Austin, TX, USA)was performed distally for easier access of arthroscopicinstruments to peripheral compartment. Afterfemoroplasty for decompression of FAI, we rotated thepatient’s leg externally and made his posture a frog legposition for arthroscopic visualization of medial portionwhere bony tumor was existent (Fig. 5). For resection ofthe tumor, we used anterior and anterolateral portal asworking portal and viewing portal, respectively. Weextracted bony specimens which contained cartilaginouscap and bony tissue for biopsy and remnant bonyprotuberance was removed completely usingarthroscopic spherical burr. To prevent femoral neckfracture that might occur after tumor resection, whole

procedure was performed under the guidance of thefluoroscopic image intensifier. Because of widenedcapsulotomy, arthroscopic capsular repair using 2-0Ethibond (Ethicon, Somerville, NJ, USA) was performedfor stabilization of the hip joint. Postoperative rehabilitationincluded continuous passive motion and pendulumexercise of the hip joint from postoperative 1 day and thepatient was permitted non-weight bearing for 6 weeksafter surgery.

Complete resection of osteochondroma was confirmedusing postoperative X-ray and CT images (Fig. 6) andosteochondroma was pathologically confirmed (Fig. 7).The VAS pain score was decreased from 8 preoperativelyto 1 postoperatively and the inguinal pain and internalsnapping were disappeared completely at postoperative 3month. At last follow up, modified Harris hip score wasimproved from 52 preoperatively to 90 postoperativelyand hip outcome score of activity of daily living andsport related activity were improved from 58 and 56preoperatively to 91 and 90 postoperatively, each. Theplain radiography and physical examination atpostoperative 1 year showed no recurrence of osteocho-ndroma and internal snapping hip (Fig. 8).

DISCUSSION

After FAI and acetabular labral tear have gainedattention as a cause of hip pain, arthroscopic treatmentfor lesions of the hip joint has improved remarkably eversince. Whereas arthroscopic treatment for the hip lesionsmainly focused on resolution for problems of the centralcompartment in the past, the operative indications areextended to pathologies of the peripheral compartment

FFiigg.. 33.. Intraarticular bony lesion was suggestive ofosteochondroma with cartilaginous cap in magneticresonance arthrography image.

FFiigg.. 44.. (AA) Arthroscopic finding of acetabular labral tear (arrow) at anterosuperior portion of acetabulum. Anterolateral andanterior portal were used as viewing and working portal, each. (BB) Acetabuloplasty using arthroscopic spherical burr(Linvatec, Largo, FL, USA) for correction of pincer femoroacetabular impingement. (CC) Acetabular labral repair with twobioabsorbable suture anchors (Bioraptor; Smith & Nephew, Andover, MA, USA).

A B C

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such as cam type FAI, synovial osteochondromatosis,loose bodies, internal snapping hip, etc7). Recently,arthroscopic treatment for extraarticular hip lesions suchas gluteus tendon tear, greater trochanteric painsyndrome, piriformis syndrome, external snapping hip,etc is being attempted. Although some cases aboutosteochondroma in the hip joint involved FAI andacetabular labral tear were reported4,5), there is not anyreport about that which occurred internal snapping hip.As the location of tumor was the posteromedial area ofthe femoral neck, that is superior portion to lesser

trochanter, arthroscopic approach for resection ofosteochondroma is difficult more than other cases8). Themain problems of this case were acetabular labral tearand internal snapping hip. For treatment of pathologiesof central compartment such as acetabular labral tearand pincer type FAI, we performed arthroscopicacetabuloplasty and labral repair with two bioabsorbablesuture anchors (Bioraptor). Arthroscopic treatment forinternal snapping hip by iliopsoas tendinopathy isusually performed around femoral head-neck junction.But, because snapping phenomenon of this case wasoccurred by bony tumor, resection of osteochondromawas needed for resolution of this pathology. Authorsusually used ordinary anterior and anterolateral portal,but as classic transverse capsulotomy is not enough tosecure the space for resection of tumor in the peripheralcompartment, T-shaped capsulotomy forward peripheralcompartment was performed for widening of operativefield. Lee et al.9) have reported the results of arthroscopictreatment by medial approach using medial portal andthe site of medial portal is close to the passing route ofobturator nerve and artery. So, risk of neurovascularinjury can be not excluded, completely. In this reason,arthroscopic resection of bony tumor of far distalportion of peripheral compartment through widened T-shaped capsulotomy was attempt and we obtainedsuccessful result.

Complications of arthroscopic treatment of the hipjoint include neurovascular injury and avascular necrosisof femoral head by long traction time, femoral neckfracture or hip joint instability after excessive

FFiigg.. 55.. Arthroscopic finding of osteochondroma withcartilaginous cap (arrow) at posteromedial portion offemoral neck. FN: femoral neck, OC: osteochondroma.

FFiigg.. 66.. (AA) Postoperative simple radiography. The bony mass was removed successfully. (BB) Postoperative 3 dimensionalcomputed tomography image. Complete resection of osteochondroma was identified and degree of osteoplasty wasevaluated postoperatively.

A B

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Heung-Tae Jung et al. Arthroscopic Resection of Hip Joint Osteochondroma Associated with Internal Snapping

osteoplasty, lateral femoral cutaneous nerve injury andextraarticular leakage of arthroscopic fluid. Arthroscopicprocedure in far distal portion of peripheral compartmentlike this case may have an occurring chance of avascularnecrosis of femoral head because this procedure needwidened T-shaped capsulotomy which may make injuryof medial femoral circumflex artery. So, we used smallsize osteotome for resection of stalk of osteochondromaand collection of biopsy specimen and removed remnanttumor using only arthroscopic burr. For preventingprobable other complications, we used a plastic cannulafor protecting neurovascular structure and performedfemoroplasty under a fluoroscopic image intensifier.Though there was small amount of extraarticular leakageof the arthroscopic fluid and air bubbles along the

FFiigg.. 77.. The cartilagious cap was identified in biopsy and thecap has a smooth round surface of a pathologic finding ofosteochondroma (hematoxylin and eosin stain, ×40).

FFiigg.. 88.. (AA) Hip anteroposterior simple radiopraphy at postoperative 1 year. Posteromedial cortex of the femoral neck wasreformed and any bony recurrence was not shown. (BB) Hip frog leg lateral radiography at postoperative 1 year.

A B

FFiigg.. 99.. (AA) In postoperative axial image, leakage of arthroscopic fluid and air bubbles were shown around iliopsoas muscle.(BB) In coronal computed tomography image, air bubbles were found along iliopsoas muscle.

A B

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iliopsoas muscle in postoperative CT images, that leakagedid not make any symptom or complication (Fig. 9).

This case suggests that arthroscopic resection ofintraarticular bony lesion of the hip joint can be applieddepending on clinical situation. The patient neededarthroscopic treatment for FAI, acetabular labral tear andresection of osteochondroma and all procedures wereperformed simultaneously. When the operator have aplan for resection of intraarticular bony lesion, they mustconsider and find other intraarticular pathologies throughpreoperative evaluation. Arthroscopic management forcoexistent problems must be performed for resolution ofclinical symptoms of the patient.

Osteochondroma located in posteromedial portion offemoral neck can make a pathology of internal snappinghip and although technical demands are challenging,arthroscopic resection can be a good treatment option.

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