The following report is describing the case of a 14-year-old boy presenting for a limp secondary to two intra-articular hip osteochondroma lesions diagnosed on imaging. His symptoms were not responding to painkillers and interfering with his daily activity, which led to the decision to proceed with surgical excision. The traditional approach for these intraarticular lesions is either through an anterior or a posterior approach . These approaches will include the dislocation of the femoral head to allow for full access to the hip joint. In this case, we decided to proceed with two incisions to address this tumor: a medial approach and an anterior approach allowing for the full excision of the tumor with no need for dislocation. This permitted the safe excision and minimized the risk of avascular necrosis of the femoral head associated with dislocation . To our knowledge, this is the first case reporting excision of intra-articular osteochondroma utilizing two approaches. Given the benign nature of these lesions and their very low risk of malignancy transformation, they are managed conservatively . No medical treatment has been described to date to tackle this pathology, and surgical intervention is reserved only for cases with refractory symptoms.
Osteochondromas are benign cartilaginous tumors in children . There are only a few studies in the literature covering proximal femoral osteochondroma [5, 6]. Consequently, no consensus has been reached regarding the indications, outcomes, or optimal approaches for these lesions. Solitary lesions are diagnosed incidentally on imaging or by symptoms caused by the mass effect of the lesion . No medical treatment is available for these lesions. It is generally recommended to observe osteochondroma in the pediatric population as few cases of regression have been reported and given the inherent risk of surgical intervention . Surgery is considered only when symptoms caused by the mass effect of the tumor are interfering with daily life . The primary purpose of this study was to describe the successful excision of an interscapular synovial hip osteochondroma using a dual surgical approach with no hip dislocation tailored to this patient.
The main concern with proximal femoral excision in the pediatric population is the risk of vascular compromise to the femoral head leading to osteonecrosis . The femoral head receives its blood supply predominantly through the retinacular system of the medial femoral circumflex artery (MFCA) . The MFCA is a branch of the profunda femoris artery and less frequently the common femoral artery . It branches within the femoral triangle and crosses posteriorly behind the hip. This vascular system can be disturbed with deep dissection around the hip or dislocation to allow exposure . The surgical dislocation of the hip has been described commonly to allow full exposure around the femoral head and acetabulum . However, this technique, despite its excellent exposure, has been shown to cause disruption of the arterial supply to the femoral head and, hence, iatrogenic osteonecrosis . For these reasons, it was essential in this case to provide the necessary exposure with a limited compromise to vascularity. This was further achieved by avoiding the need for hip dislocation.
The anterior approach to the hip was first described by Carl Hueter and later adopted by Smith Petersen . It was initially adopted for the treatment of hip infections in children and then used for hip arthroplasty in adults. It is the only true internervous approach to the hip utilizing a muscle-splitting technique . The plane between the sartorius and the TFL is accessed first and the deep plane between the rectus femoris and the gluteus medius later. It keeps the posterior soft tissue cover and hip adductors unharmed, all while preserving the blood supply to the femoral head . This will allow for minimal blood loss, lower dislocation rates, earlier functional recovery, and better pain scores . It provides good access to the anterior aspect of the hip with acceptable lateral and medial exposure as well; however, no posterior exposure is achieved . Despite its numerous advantages, a few concerns remain regarding the anterior approach, especially the risk of injury to the lateral femoral cutaneous nerve (LFCN) . It is most frequently a neuropraxia injury with limited long-term functional constraints. Wound hematomas and wound breakdown can occur in the early postoperative course due to the closure of the TFL sheath layer allowing for deep bleeders to reach the wound . None of these complications was encountered in this case as careful dissection was done and thorough hemostasis and closure were achieved at the end of surgery.
The medial and posterior femoral neck are difficult areas to visualize through a traditional anterior approach and are probably not adequate for necessary access and instrumentation . To allow access to the medial aspect of the hip, a second surgical incision was utilized with no need for hip dislocation. The medial approach to the hip was first described by Ludloff but later modified by several authors, including Ferguson [21, 22]. It was initially adopted as a surgical procedure for open reduction of developmental dysplasia of the hip . The superficial intermuscular plane is first developed between the gracilis and the adductor longus, and then the deep plane is developed between the adductor brevis and magnus. This approach is carried out carefully while protecting the posterior division of the obturator nerve until the lesser trochanter is felt at the floor of the incision . Due to the possible endangerment of the medial circumflex vessel, many surgeons shy away from this approach due to lack of familiarity with the exposure . Therefore, careful dissection of the capsule with proper placement of the retractors is essential to avoid iatrogenic injury . The advantages of this modified approach are not limited to visualization but also include simplicity, minimal dissection of soft tissue, direct access to structures, and limited blood loss.
The utilization of this dual approach allowed the patient to start early ambulation with no limitations in hip range of motion. At 2 weeks follow-up, the patient was able to ambulate with minimal pain, and strengthening exercises were started. To our knowledge, this is the first description of a resection of a symptomatic pediatric proximal femoral osteochondroma, using dual medial and anterior approaches. In the context of the recent available literature on the topic, our opinion is that this surgical exposure was optimal for both the safety and accessibility of this unusual condition.