Page 21 - ISAKOS 2020 Newsletter Volume 2

Case Corner Commentary
Young Patient with Femoral Head Limited Subchondral Collapse and Possible Impingement Symptoms
Aaron J. Krych, MD
Mayo Clinic
Rochester, Minnesota, UNITED STATES
Hajime Utsunomiya, MD, PhD
Wakamatsu Hospital of University of Occupational and Environmental Health Fukuoka, JAPAN
Rodrigo Mardones, MD
Medical Director; CDMA (Centro de cadera Dr. Mardones y Asociados) Santiago, CHILE
We thank Dr. Hetsroni for the very unusual case. This case is an example of one of the greatest challenges that orthopaedic sports surgeons and regenerative medicine doctors face today and will probably face in the future, namely, joint-preservation surgery for the treatment of chondral and subchondral disease in young active adults. We have provided 3 different perspectives, and, as is evident from the responses, there is no uniform consensus on the treatment options; as such, further research and clinical information about such cases in the future is needed and valuable.
Aaron J. Krych, MD
This case illustrates a very challenging problem. In this very young (15-year-old) female patient who is approaching skeletal maturity, the femoral head has developed osteonecrosis with subchondral collapse, resulting in secondary impingement issues and degenerative changes.
Current evidence indicates that small, asymptomatic lesions may be treated nonoperatively with close observation. So, if this patient is truly asymptomatic, such treatment may be an option. In contrast, core decompression is a viable option for a symptomatic patient without subchondral collapse.
Once subchondral collapse has occurred, as in this patient, then bone-grafting or hip arthroplasty may become more reproducible options.
In this patient, we would prefer to perform a biological joint-preservation procedure. At the Mayo Clinic, we have extensive experience with the use of fresh osteochondral allografts for the treatment of osteonecrosis of the knee, and the long-term results of such treatment for young patients with isolated lesions have been good to excellent. We are very fortunate to have access to fresh osteochondral grafts at our institution, so that would be our preferred option in this case.
For the procedure, we obtain a fresh osteochondral graft typically consisting of either a femoral head or, more commonly, a large lateral femoral condyle. Femoral heads are scarce, and the radius of curvature of the lateral femoral condyle seems to work well, so the latter is a common graft choice. The procedure is performed through an open surgical hip dislocation to preserve the remaining blood supply to the femoral head. Any concomitant femoral neck osteoplasty for the treatment of impingement can be performed at the same time. Such treatment would seem to be a good option for the patient presented here, who has impingement and symptoms.
We first remove the collapsed bone and dead cartilage from the defect. We then plan for multiple osteochondral dowels in a press-fit fashion. Figure 1 shows intraoperative photographs for a 15-year-old male patient with similar pathological findings to the patient described by Hetsroni.
01A–C
We ream to a depth of 6 – 8 mm and ensure good bleeding bone. If deeper bone is affected, then we usually remove the dead bone with a curet and insert local autograft bone from the trochanteric osteotomy. We prefer not to place a composite graft measuring >6 – 8 mm in thickness as doing so may lead to collapse of the graft over time. We then place the first dowel plug with use of a press- fit technique. In the sample case described here, the defect requires placement of a second allograft dowel in a “snowman” configuration. We temporarily pin the first plug, ream, and then place the second plug. In most cases, no addition fixation is required. We check range of motion to ensure that there is no residual impingement. We then fix the trochanteric osteotomy of the surgical hip dislocation. Postoperatively, the patient is kept non-weight-bearing for 6 – 8 weeks and then is allowed to progress to non-impact activities (while avoiding running and jumping) for the first 12 months after the procedure.
CURRENT CONCEPTS
ISAKOS NEWSLETTER 2020: VOLUME II 19