Cyx

FIGURE 11.24. Case 3. Anteroposterior (A) and lateral (B) radiographs of the left hip showing a big osseous body (large arrow) and a smaller body (small arrow) medial and posterior to the transition of the femoral neck and head.

appears most suitable. An instrument can be introduced reaching even up to the transverse ligament.

Case 3: Loose Body in the Peripheral Compartment

History and Preoperative Findings

A 35-year-old male patient was referred with a history of left hip pain for more than 5 years. He reported a persistent moderate aching in the groin that was aggravated with hip rotation and flexion. For example, when getting in or out of a car, he frequently complained of catching symptoms and giving-way episodes. On radiographs, a large ossified body about 3.5 by 2 by 2 cm medial to the transition of the femoral neck and head was found (Figure 11.24A,B). A smaller one was seen in projection on the femoral neck. A MR arthrogram was suspicious for osteochondromas within the peripheral compartment of the hip (Figure 11.25A,B). Even if arthroscopic removal appeared difficult with respect to the size and bony consistency of the large round body, we decided to start the procedure with an arthroscopic approach. Because radiographs and MRA only showed cartilage degeneration, without evidence of loose bodies within the central compartment of the hip, we preoperatively planned to perform HA without traction of the peripheral compartment only.

Hip Arthroscopy

A standard anterolateral portal to the peripheral compartment was established. The anterior and medial neck and head areas showed significant hypertrophy and inflammation of the synovium (Figure 11.26). An additional anterolateral portal in line with the femoral neck was placed and an electrocautery unit used to

FIGURE 11.25. Case 3. MR arthrograms of the right hip in coronal (A) and sagittal (B) orientation showing a large osseous body (arrows) medial to the transition of the femoral neck and head.

FIGURE 11.25. Case 3. MR arthrograms of the right hip in coronal (A) and sagittal (B) orientation showing a large osseous body (arrows) medial to the transition of the femoral neck and head.

FIGURE 11.26. Case 3. Synovitis (s) in the medial neck area between the femoral neck (fn) and anteromedial capsule (amc).

remove the inflamed synovium. After synovectomy within the anterior and medial neck and head area (Figure 11.27), the osseous body could be inspected and probed (Figures 11.28, 11.29). It was molded by the medial wall of the femoral neck and femoral head, bulging out the medial and anteromedial capsule. The body filled the complete medial neck and head area and reached up to the transverse ligament and the me

FIGURE 11.27. Case 3. Electrothermal synovectomy with progressive identification of the osseous body (b). Femoral neck (fn), head (fh), anterior capsule (ac).
FIGURE 11.28. Case 3. Identification of margins of the large body (b, arrows). Anteromedial capsule (amc), femoral head (fh).

dial and the anteromedial labrum. Subsequently, two more smaller loose bodies with a bony core were found and removed. Attempts to remove the large loose body with large threaded K-wires and pins failed because the body could not be mobilized. Thus, a large rongeur was taken from the spine set and piecemeal work was started (Figure 11.30). After 1 hour, the bony loose body was chopped up and removed. There was evi-

FIGURE 11.29. Case 3. Anterior proximal end of the large body (b). Femoral head (fh), anteromedial capsule (amc), anteromedial labrum (aml).

FIGURE 11.31. Case 3. Status post removal with the empty medial neck area, synovitis on the bottom (s), medial capsule (mc), femoral neck (fn), and head (fh).

FIGURE 11.32. Case 3. Chopped-up osseous body after removal.

FIGURE 11.30. Case 3: Removal of the osseous body (b) with a rongeur. Notice the kissing chondromalacic lesion (cm) of the femoral head (fh). Femoral neck (fn), anteromedial capsule (amc).

dence of a full-thickness erosion of the anteromedial cartilage of the femoral head. Arthroscopy and an intraoperative arthrogram revealed a complete removal (Figure 11.31). After surgery, the small pieces of the chopped-up specimen were photographed (Figure 11.32).

FIGURE 11.32. Case 3. Chopped-up osseous body after removal.

Results

Postoperative radiographs revealed complete loose body removal (Figure 11.33). The patient immediately described a significant improvement of the sharp catching pain and absence of giving-way episodes. This improvement was maintained at the 2-year follow-up.

Discussion

From the author's experience, the location of a large osseous loose body makes an open removal also difficult and time consuming. In addition, the arthroscopic

FIGURE 11.31. Case 3. Status post removal with the empty medial neck area, synovitis on the bottom (s), medial capsule (mc), femoral neck (fn), and head (fh).

FIGURE 11.33. Case 3. Postoperative anteroposterior radiograph indicating a complete removal.

procedure was minimally invasive and allowed direct full weight bearing and range of movement postoperatively. Contrary to the author's general recommendation to combine HA of the central with the peripheral compartment, in this case only the hip joint periphery was scoped without traction. Our decision was based on the preoperative radiologic findings and expectation that the removal would be time consuming.

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