Adolescent Patient With Severe Hip Deformity Undergoes Complex, Open Surgery: A Case Study

By Atul F. Kamath, MD

Presentation and diagnosis

A 16-year-old male was referred to Cleveland Clinic’s Center for Hip Preservation in early 2019 for right hip pain. The patient reported a continuous, aching pain in his right hip for 18 months. His pain was exacerbated by a range of daily living activities, from walking and managing stairs to sleeping and putting on his socks and shoes.

At the time of exam, the patient walked with a limp. His left leg measured approximately 2 centimeters longer than his right leg, and he had a severe external (outward) rotation deformity (Figure 1).

Figure 1. Severe external rotation deformity and shortening of the right leg due to retroversion deformity of the femoral head-neck junction.

Previously, physical therapy was prescribed as an intervention. However, the patient was unable to participate in physical therapy due to the significant deformity and pain associated with his condition. Radiographic images of the right hip showed residual deformity of the right hip (Figure 2), due to a chronic slipped capital femoral epiphysis (SCFE). This etiology led to the patient’s acquired deformity of the pelvis, leg length discrepancy, and inability to exercise with resulting obesity. He was dependent on crutches for ambulation.

Figure 2. Anteroposterior view of the right hip (A) and anteroposterior pelvis view (B), demonstrating severe retroversion deformity at the femoral head-neck junction as sequela of chronic SCFE.

SCFE is a condition that often develops in a still-growing adolescent population. In this deformity, the top of the ball of the femur slips backward off the neck of the remaining femoral neck bone. This slip is more likely to occur in overweight males. The condition tends to progress gradually over time, as was the case with our patient.

Advanced planning for a complex case

After discussion with the patient, we decided on an open approach, which was most appropriate to fully address the intra-articular pathology. This included labral repair, focal articular acetabular cartilage defect treatment and treatment of cam-type impingement areas. This severity of deformity could not be adequately addressed through an arthroscopic approach.

Because of the complex constellation of pathology, we decided that a surgical hip dislocation with a multi-planar closing wedge osteotomy of the head-neck junction would be most appropriate to correct the patient’s severe hip deformity. Due to the patient’s young age, expected high activity level, and preserved joint cartilage, hip preservation was deemed preferable to arthroplasty/hip resurfacing.

To address the complexity of the case, we decided that three-dimensional (3-D) planning would allow us to develop the best approach. With the patient’s consent, we used a low-dose 3-D computed tomography (CT) protocol, which enabled us to generate patient-specific modeling (Figure 3). By doing this, we could more closely evaluate the bony anatomy, including the femoral torsion and deformity in multiple planes.

Figure 3. Patient-specific osteotomy planning guide to perform accurate multi-planar head-neck osteotomy (A). The planned final appearance of the femoral head-neck region after osteotomy (B).

The procedure

A standard Gibson approach was utilized via a laterally-based skin incision. A trochanteric flip osteotomy was performed in accordance with a standard surgical dislocation approach in order to protect the femoral head blood supply (Figure 4). A complete capsular exposure was performed, including access anteriorly, superiorly and posteriorly. Range of motion to impingement and points of femoroacetabular conflict were again checked prior to femoral head dislocation. An extended retinacular flap was performed to safely identify the region of maximum head-neck deformity, and to afford later safe osteotomy of the femur. The hip was safely dislocated with flexion and external rotation and transection of the ligamentum teres.

Figure 4. In a landmark experimental study (A), Sevitt and Thompson showed that the lateral epiphyseal arteries were the most important blood supply to the femoral head; when the vessels were preserved, blood supply to nearly the entire femoral head occurred (Sevitt S, Thompson RG: The distribution and anastomoses of arteries supplying the head and neck of the femur. J Bone Joint Surg Br 47:560, 1965). More recent cadaveric study by Gautier, Ganz et al. (B) demonstrating the course of the deep branch of the medial femoral circumflex artery and its terminal epiphyseal branches, which are preserved with a retinacular flap (Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br 82:679, 2000).

Next, we conducted the femoral neck osteotomy. There was a severe malunion deformity due to the chronic SCFE. The patient-specific cutting guide was fitted to the bone, and the osteotomy was performed through the guide (Figure 5). The osteotomy was provisionally fixed with terminally threaded wires. The definitive cannulated screws were then placed and check visually and fluoroscopically (Figure 6A).

Figure 5. Intraoperative images depicting placement of the patient-specific osteotomy guide (A) and resection of the wedge osteotomy segment (B).

Figure 6A. Intraoperative fluoroscopic view of the right hip demonstrating osteotomy and satisfactory hardware placement.

Attention was then turned to the acetabulum. We found fraying of a hypertrophic labrum from 11-1:30 o’clock, with a breach of the chondrolabral junction at 12-1 o’clock. We repaired the labrum with anchors, which afforded a stable reconstruction. A rim trimming was performed at that position in order to further reduce the conflict, and a subspine decompression was performed.

Irrigation of the joint was carried out. The labrum was well-reduced and stable onto the bony rim after relocation of the femoral head into the socket. The capsulotomy was closed without undue tension, and the trochanteric flip osteotomy was reduced and fixed with screws. A greater trochanteric advancement was performed for relative head-neck lengthening. The patient tolerated the procedure without complication.

Outcomes

At three months post-operatively, the patient was recovering well. His femoral head-neck osteotomy demonstrated signs of healing, with no signs of avascular necrosis or hardware issue (Figure 6B). His hip pain had decreased, and he was walking with a stable gait. Notably, his hip flexion was 100 degrees and hip extension was 10 degrees, with 30 degrees of internal rotation and 50 degrees of external rotation. By eight months post-operatively, the patient was back to activities of daily living and recreation without issue.

Figure 6B. Postoperative radiograph of the right hip at three months.

About the author

Dr. Kamath is Director for the Center for Hip Preservation and staff surgeon in the Orthopedic and Rheumatologic Institute.