Minimally invasive bone grafting of cysts of the femoral head and acetabulum in femoroacetabular impingement: arthroscopic technique and case presentation

Hip arthroscopic management for treating a rhythmic gymnast with a large bone cyst at the femoral head in the setting of hip dysplasia—a case report

Recent literature lacks a clear understanding of how to manage bone cysts associated with hip dysplasia. This article aimed to report a case of hip dysplasia in a rhythmic gymnast surgically managed with arthroscopic retrograde bone grafting, labral repair, cam osteoplasty, double shoelace capsular closure and endoscopic shelf acetabuloplasty. A 20-year-old female college rhythmic gymnast presented complaining of right hip pain and discomfort for the past 2 months. This case report describes the use of the CROSSTRAC guide system to perform retrograde bone grafting to treat the bone cyst at the femoral head arthroscopically. Hip arthroscopic retrograde bone grafting, labral repair, cam osteoplasty, double shoelace capsular closure and endoscopic shelf acetabuloplasty are less invasive and beneficial for the treatment of bone cysts of the femoral head associated with hip dysplasia in symptomatic rhythmic gymnasts.

Arthroscopic Bone and Cartilage Grafting of Acetabular Cysts With Autologous Tissue

Repair of acetabular cysts and cartilage defects presents a challenge for the hip-preservation surgeon. Currently, most techniques involve allograft sources or open surgery. We present an arthroscopic technique using autologous graft sources for both bone and cartilage to repair subchondral acetabular cysts and the overlying cartilage defect. This technique uses new technology in combination with familiar arthroscopic instruments to decrease morbidity, hasten rehabilitation, and possibly improve the prognosis of these difficult to treat lesions.

Arthroscopic-Assisted Intraosseous Bioplasty of the Acetabulum

Intraosseous bioplasty (IOBP), has been previously described for arthroscopic-assisted treatment of subchondral bone cysts in the proximal tibia associated with early stages of knee osteoarthritis (OA). This technique entails combining bone marrow aspirate concentrate or concentrated platelet-rich plasma with demineralized bone matrix as a bone substitute before injecting into a subchondral bone defect under fluoroscopic guidance. The principles of IOBP as a procedure that combines core decompression with biologic bone substitute augmentation can be extended to treat subchondral bone marrow lesions such as acetabular and femoral cysts in degenerative hip OA. Intraosseous bioplasty of the hip, in particular the acetabulum, when done using this technique, is a useful alternative that can be beneficial in treating young patients with early hip arthritis to achieve successful outcomes while delaying more invasive procedures. The Technical Note described here presents a step-by-step approach, including tips and pearls for arthroscopic-assisted IOBP with decompression of the subchondral cyst in the acetabulum followed by bone substitute injection under fluoroscopic guidance. We believe this method is a safe and reproducible way to treat subchondral defects in young patients with signs of early osteoarthritis of the hip joint.

Prophylactic Fixation and Arthroscopic Bone Grafting of Large Femoral Neck Cyst During Hip Labral Repair and Femoral Osteochondroplasty: A Case Report

CASE

We describe a case of hip impingement in an 18-year-old woman in association with a large cyst at the femoral neck equal to a resection level of approximately 40%. There was great concern of femoral neck fracture. At the time of hip arthroscopy, this was prophylactically treated with cannulated screws in the femoral head and neck, and the cyst was arthroscopically bone grafted using a novel technique with instruments included in standard the arthroscopy trays.

CONCLUSION

Prophylactic femoral neck fixation with arthroscopic bone grafting of large bone cysts is a viable treatment option with minimal added morbidity.

The Hip Restoration Algorithm

BACKGROUND

Despite the rapid advancement of imaging and arthroscopic techniques about the hip joint, missed diagnoses are still common. As a deep joint and compared to the shoulder and knee joints, localization of hip symptoms is difficult. Hip pathology is not easily isolated and is often related to intra and extra-articular abnormalities. In light of these diagnostic challenges, we recommend an algorithmic approach to effectively diagnoses and treat hip pain.

METHODS

In this review, hip pain is evaluated from diagnosis to treatment in a clear decision model. First we discuss emergency hip situations followed by the differentiation of intra and extra-articular causes of the hip pain. We differentiate the intra-articular hip as arthritic and non-arthritic and extra-articular pain as surrounding or remote tissue generated. Further, extra-articular hip pain is evaluated according to pain location. Finally we summarize the surgical treatment approach with an algorithmic diagram.

CONCLUSION

Diagnosis of hip pathology is difficult because the etiologies of pain may be various. An algorithmic approach to hip restoration from diagnosis to rehabilitation is crucial to successfully identify and manage hip pathologies. Level of evidence: V.

Hip arthroscopy for intra-capsular benign tumors: a case series

The purpose of this study is to demonstrate the assessment of intra-capsular femoral head and neck tumors, and to describe the arthroscopic surgical technique used to resect and fill the bone defects. Three cases of benign femoral head and neck lesions are presented. Two benign enchondromas and one benign osteochondroma were resected arthroscopically. Traction was used in one case. Modified Harris Hip Score improved in all three cases to scores of 95 or greater with an average improvement of 16 points with a minimum follow up of 15 months. Arthroscopic surgical resection of intra-capsular femoral hip lesions offers an effective alternative to open resection. This technique offered good outcomes in the limited cohort. We suggest that arthroscopic resection of intra-capsular femoral hip lesions be considered in relevant cases as an alternative to open resection.

Arthroscopic Bone Grafting of Deep Acetabular Cysts Using a Curved Delivery Device

Acetabular intraosseous cysts are frequently encountered in patients with dysplasia or femoroacetabular impingement. Small cysts are typically addressed by removing the cyst lining and stimulating healing via microfracture or abrasion chondroplasty. In contrast, larger cysts involving 1-3 cm(3) frequently require additional fortification with bone graft material to facilitate osseous ingrowth and cyst healing. Previous arthroscopic reports have described the use of rim trimming to access the extra-articular side of the cyst, with subsequent use of straight metal cannulas for delivery of bone graft material. The downsides of this technique include the requirement for rim trimming, which may be ill advised in patients with normal coverage or dysplasia, as well as the creation of a second breach in the cyst wall, precluding pressurization of the bone graft material. We describe an arthroscopic technique using a curved delivery device allowing for deeper penetration into the cyst cavity through the articular side and greater delivery of bone graft material.

Arthroscopic correction for concomitant cam impingement in a patient with idiopathic osteonecrosis of the femoral head: A case report

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It is important to accurately diagnose the status of idiopathic osteonecrosis of the femoral head and to consider another possible pathogenesis when a patient with idiopathic osteonecrosis of the femoral head has hip pain even without femoral-head collapse.

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Ignored or misdiagnosed concomitant femoroacetabular impingement in a patient with idiopathic osteonecrosis of the femoral head might leads to poor outcomes of surgical treatments such as bipolar hemiarthroplasty or osteotomies.

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In a patient with idiopathic osteonecrosis of the femoral head, it should be paid attention if concomitant femoroacetabular impingement exists or not.

A 53-year-old man presented with pain in the right hip. Radiological examination showed idiopathic osteonecrosis of the femoral head (ONFH) combined with a cam lesion. Findings on physical examination were consistent for femoroacetabular impingement. At surgery, we performed isolated arthroscopic correction for the cam lesion but did not use other treatment options such as hip arthroplasty or osteotomies for the ONFH. At the latest follow-up evaluation 3 years after surgery, findings indicted a satisfactory outcome, with a Harris hip score of 93.2 (compared with 76.4 before surgery), no joint-space narrowing, and no collapse of the femoral head. It is important to accurately diagnose the status of idiopathic ONFH and to consider another possible pathogenesis when a patient with idiopathic ONFH has hip pain even without femoral-head collapse.

The role of orthobiologics in hip preservation surgery

The potential regenerative role of different orthobiologics is becoming more recognized for the treatment of chronic and degenerative musculoskeletal conditions. Over the last few years there has been an increasing number of publications on cell therapy and other orthobiologics for the treatment of avascular necrosis of the femoral head and other hip conditions with promising short–term clinical results. In this article, we have used a systematic search of the literature to identify potentially relevant topics on orthobiologics and then selected those most applicable to hip preservation surgery. We identified several innovative strategies and present a summary of the currently available evidence on their potential role in hip preservation surgery. For many of these treatment strategies there was a lack of clinical evidence and therefore we suggest that there is a need for comparative studies in this field.

Arthroscopic Treatment of Subchondral Bony Cyst in Early Osteoarthritis of the Hip Joint Using Allogeneic Bone Graft: A Report of Two Cases

Subchondral bony cyst, large solitary or multiple cysts in acetabular dome usually exacerbate progression to degenerative osteoarthritis in the hip joint. But it can be treated through arthroscopic intervention. We report two cases that treated by arthroscopic curettage and bone graft for subchondral bony cysts in early osteoarthritis of the hip joint, and it may delay progression to moderate osteoarthritis.

Femoroacetabular impingement: current concepts in diagnosis and treatment

As a result of reading this article, physicians should be able to: 1. Identify the etiology of femoroacetabular impingement. 2. Assess femoroacetabular impingement on physical examination. 3. Recognize femoroacetabular impingement on imaging studies. 4. Discuss modern techniques to effectively treat femoroacetabular impingement, both open and arthroscopic. Femoroacetabular impingement (FAI) is a recently proposed concept describing abnormal anatomic relationships within the hip joint that may lead to articular damage. Impingement is caused by bony deformities or spatial malorientation of the femoral head-neck junction and/or the acetabulum. These abnormalities lead to pathologic contact and shearing forces at the acetabular labrum and cartilage during physiological hip motion. There is an increasing body of evidence that these forces lead to cartilage wear and eventual osteoarthritis. Treatment options for FAI are evolving rapidly. Although the gold standard remains open hip dislocation, arthroscopic techniques have shown significant promise. It is possible that early recognition and treatment of subtle deformity about the hip may reduce the rate of hip osteoarthritis in the future.

Management of incarcerating pincer-type femoroacetabular impingement with hip arthroscopy

This report describes the arthroscopic management of a case of incarcerating pincer-type femoroacetabular impingement. The hip joint had a marked restriction of range of motion and secondary pain as a result of osteophytes wrapping around the femoral head down the femoral neck. The patient was treated with staged bilateral hip arthroscopy. The procedures were initially performed through the peripheral compartment to remove the incarcerating acetabular rim, followed by arthroscopy of the central compartment with acetabuloplasty and femoral head osteochondroplasty. The patient's treatment has led to an excellent clinical and radiographic result at 24 months' follow-up despite an unrelated pelvic fracture sustained in the postoperative period. This technique emphasizes the capabilities of hip arthroscopy in advanced cases of femoroacetabular impingement as an alternative to arthroplasty for patients with healthy articular cartilage.

MR imaging of the hip: pathologies and morphologies of the hip joint, what the surgeon wants to know

MR imaging of the hip is frequently used in symptomatic patients before hip preservation surgery; it is used as a decision-making tool and as a planning tool. The MRI can confirm the preliminary working diagnosis, identify other possible sources of pain, and highlight anatomic areas that are not routinely viewed during surgery. In addition, MR imaging is capable of illustrating normal and abnormal bony morphology of the femur and pelvis; and in the case that arthrography is used, diagnostic injection can be administrated concurrently. This article highlights a surgeon's perspective on the use of MR imaging in the patient with nonarthritic hip pain.

Subchondral bone regenerative effect of two different biomaterials in the same patient

This case report aims at highlighting the different effects on subchondral bone regeneration of two different biomaterials in the same patient, in addition to bone marrow derived cell transplantation (BMDCT) in ankle. A 15-year-old boy underwent a first BMDCT on a hyaluronate membrane to treat a deep osteochondral lesion (8 mm). The procedure failed: subchondral bone was still present at MRI. Two years after the first operation, the same procedure was performed on a collagen membrane with DBM filling the defect. After one year, AOFAS score was 100 points, and MRI showed a complete filling of the defect. The T2 mapping MRI after one year showed chondral tissue with values in the range of hyaline cartilage. In this case, DBM and the collagen membrane were demonstrated to be good biomaterials to restore subchondral bone: this is a critical step towards the regeneration of a healthy hyaline cartilage.