arthroscopic treatment for primary hip osteochondromatosis

2nd International Hip Meeting2nd International Hip MeetingHomburg Homburg 20062006

Arthroscopic treatment for primary hip osteochondromatosis.

Review andReview and Results Results about 147 casesabout 147 cases

T. Boyer, H. DorfmannParis

Hip Hip chondromatosischondromatosis

RareSynovial metaplasiaUnknown cause Variable durationAlways monoarticularCommonly benign• 5 cases of chondrosarcoma in literature

Synovial Synovial metaplasiametaplasia

ChondromasChondromasFreeFree PedunculatedPedunculated EmbeddedEmbedded

LiteratureLiteratureClinical Clinical datadata

Age: 20-40 Y.OMen > WomenSlow and unforseeable evolutionAsymptomatic at the beginingLate stiffness• Loose bodies ++• osteoarthritis

ImagingImaging

Plain X rays normal if chondroms (non ossified) 20%Opaque images if osteochondromsArthro CT scan or arthro MRI+++MRI ±

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TreatmentTreatment

Classicaly• Open synovectomy• Loose bodies removal (arthrotomy)

Arthroscopy

Materials and methodsMaterials and methods

Materials

Cohort of 111 primary(osteo)-chondromatosis

147 Arthroscopies

MethodsMethods

Retrospective studyWritten inquiry• Satifactory scale• VAS • Articular mobility

Follow-up Average 78.6 months (12-196)

ProcedureProcedure

Peripheral compartmentCombined Central

ProcedureProcedure

Choice of the technique

Peripheral Combined Central

Peripheral Peripheral techniquetechnique

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Procedure Procedure ((PeripheralPeripheral))

Succion by cannulaGraspersFragmentation

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Procedure Procedure ((PeripheralPeripheral))



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Procedure Procedure ((PeripheralPeripheral





Ilio femoral approachIlio femoral approach



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Iliofemoral Iliofemoral techniquetechnique

ProcedureProcedure



Classical central approach. 2 or 3 portalsDepends localization



MethodsMethodsAnalyse of Analyse of the resultsthe results

Excellent : >75% subjective improvementNo pain . Normal mobility

Good : > 50% subjective improvementLow pain. Normal mobility

Failure : < 50%, pain or loss of mobility



The cohortThe cohort1985 - 2002

CohortCohort

120 patients. 9 lost111 patientsSex ratio: 54 Men / 57 WomenRight Hip: 63 - Left: 48

Clinical Clinical patternspatterns

Age average: 40.9 YOAverage duration of symptoms before AS: 31 monthsProgressive : 70%Sudden: 23.3%Fortuitous discovery (Xrays) : 6.7%

PainPain

Type:Méchanic : 93%Inflammatory or mix : 7%

Rythm:Intermittent : 84%Continuous : 16%

Clinical presentationClinical presentation

Loss of motion : 51%Limping : 10%Normal: 39%

Imaging Imaging contributioncontribution((X rays,X rays,AgraphyAgraphy, , ACTscannACTscann, MRI), MRI)

Diagnosis + : 71/111 (56 osteochondromatosis)Suspected diagnosis: 32No diagnosis: 8

Type of Type of chondromaschondromas

Chondromas (Non-ossified) : 45%

Chondromas + OstéoCh : 26%

Osteochondromas : 23%

Intrasynovial (osteo)chondromas : 6%

Types of Types of ChondromasChondromas

Rice-like: 33%

Agglomerate mass : 30%



Wafer Wafer into the fossa into the fossa

« Wafers » : 5%

«« BagsBags »»

16 years old girl.YougsYougs. . Recurrent Recurrent ++++++

« Bags » : 3%

Particular Particular cases cases





V

Sometimes the jointis completely full ofchondromas

Particular Particular casescases

Re-arthroscopyModifications of chondromas

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1st arthroscopy 6 months later

Osteochondromas Osteochondromas ( 49%)( 49%)

Size• 2 to 25 mm

Location • Peripheral ++• Iliofemoral • Both• Psoas bursae QuickTime™ et un

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Only intrasynovial Only intrasynovial ((osteoosteo))chondromaschondromas

Milgram Milgram 11 : : 6%6%

Ossified : 5Non ossified : 1

Global Global resultsresultsMean FollowMean Follow--up up 78.6 78.6 mo mo ( 12 ( 12 -- 196 )196 )

Excellent result • Subjective> 75%• Normal motion • No pain

Improved• Subjective> 50% • Motion quite normal • No or low pain

Failure • Subjective< 50%• Loss of motion

Secondary surgery

ResultsResults

3 groups• 69 patients: only one arthroscopy• 24 patients : re-arthroscopies• 42 patients : secondary open surgery

• NB: total > 111 patients

Single Single arthroscopy arthroscopy 69/111 69/111 (62.2%)(62.2%)

Excellent results : 36%Improvement : 20.8%Failure : 5.4%

ReRe--arthroscopies arthroscopies 24/111 24/111 (21.6%)(21.6%)

No secondary open surgery : 17% (19 patients)• Excellent final result : 8%• Improvement : 8%• Failure : 1%

Open surgery (4.6%)• Arthroplasty : 2• Synovectomy and loose bodies : 3

ResultsResults: patients : patients with with a a secondary secondary open open surgery surgery

(37.8%)(37.8%)

• Total hip replacement : (17.1%)• Surgical synovectomy : 10.8%• Micellaneous : 9.9%

DiscussionDiscussion

Literature:• no arthroscopic series• Isolated cases: Elmali, Okada, Witwity,

Dienst, Gouin.Arthroscopy / Arthrotomy• Schoeniger : open synovectomy. 8 cases

Secondary arthroplasty: 25%

Summary Summary (1)(1)

Think chondromatosis in front of a painful hip with normal X raysGood sensibility of the imagingImaging indicates the procedureFrequency of the false positives

False positive synovitis / chondromatosis



V


Quite all the loose bodies can be removed

The intrasynovial chondromas can’t be removed

Synovectomy is difficult anduncomplete


In our cohort the arthroscopic treatment underwent 56.8% of excellent results or improvement with a single arthroscopy and72.8% with re-arthroscopy

17% of patients had a secondary arthroplasty

2ND International Hip Meeting2ND International Hip MeetingHomburg November Homburg November 20062006

Synovial pathologyPectineo-foveal impingement

Thierry BOYERParis

Synovial Synovial pathologypathology

•Rhumatoïd Arthritis•Pigmented villonodular synovitis•Osteoarthritis •Cysts

Synovial Synovial pathologypathology

Peripheral compartmentAnterolateral portals ++



OsteoarthritisOsteoarthritis





Villonodular synovitisVillonodular synovitisDiffuseDiffuse formform

Villonodular synovitisVillonodular synovitislocalized formlocalized form

Villonodular synovitisVillonodular synovitis





Rhumatoid arthritisRhumatoid arthritis

Synovitis is usely controledby medical treatment andinjections.



PeriPeri--labral cystslabral cysts



PectineoPectineo--foveal impingement foveal impingement (?)(?)

Pectineofoveal fold

Hypothesis: painful pathology of the pectineofoveal fold linked to a medial mechanical impingement of the hip

Pectineofoveal « impingement » (?)

1-Study on cadavers (contrast CT and MRI)

2-Results of arthroscopic resection of « pathological » pectineofoveal fold

Pectineofoveal fold: anatomy

Medial fold of the fémoral neck tight from the head-neck junction to the anterior trochanteric line

Cesare Amantini: 1889(Latarjet, Rouvière, Williams)

Rouvière

Rouvière

Pectinéofovéal fold: anatomyDissection of 10 unembaumed corpses: constant fold

Description on anatomical section ( O May CHU Lille)

Correlation corpes/ injected MRI and tomography

(Slides reconstructed according to axis of the femoral neck)

Pectinéofovéal fold: anatomy

Pectineofoveal fold

Arthroscopic resection: 12 cases

All patients underwent arthroscopy for unexplained pain

Groin pain in flexion-rotation

Preoperative imaging(Xrays, contrast CT sometimes contrast MRI)was either normal, or suspected a labral tear.

Pectineofoveal fold: peripheral approach

Peripheral arthroscopy: Thickening (fibrosis)

Femoral Neck

orbicularis zona

pectineofoveal fold

Synovitis

Pectineofoveal fold



Flexion

Pectineofoveal fold

Material and method

-Retrospective study (medical files, surgical reports)

-All patients were contacted to fill a questionnaire (sports/level, occupation, symptoms before and after surgery

-10 of 12 patients were consulted

Pectineofoveal fold: results

-7 women, 5 men, mean age 26.8 YO

Analysis : 2 groups

Pectineofoveal fold: results

GROUP 1 : homogeneous population (7)

Appeared during a sport practice, obliging to reduce or stop itNormal imaging

Mechanical hip pain in flexion-rotation movements

Arthroscopy :

• on average 20 months after the beginning of pain• ISOLATED « pathological » fold

Pectineofoveal fold: resultsGROUP 2 (5) No homogeneous population

No sportPain associated with-Snapping tendon-Labral tear-Dysplasia of the hip

Arthroscopy :• on average 4.8 years after the beginning of pain• “pathologic” pectineofoveal fold : not isolated

Pectineofoveal fold

Results

GROUP 1: Excellent and good results after arthroscopyAll patients returned to sport with the same level (1 professional)

GROUP 2: Poor resultsOnly one patient was transitorily improved

Pectineofoveal fold: discussion

- Hypothesis : impingement with medial soft tissus:

Orbicularis zona/ psoas tendon

Pectineofoveal fold: discussionAnatomic link between pectineofoveal

fold and psoas tendon via orbicularis zona

The fold could be rubbed down against the femoral neck due to intense practice of sports ?

Synovitis



Bursoscopy


- Probably rare

- Young sportmen

- Isolated hip pain

- Negative imaging


During arthroscopy for mechanical unexplained pain,the association:

Thick pectineofoveal fold

Synovitis

Normal exploration of the joint (cartilage, labrum)

should lead to arthroscopic resection of the pectineofoveal fold

To be confirmed

arthroscopic treatment for primary hip osteochondromatosis

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