osaicplasty for femoral osteochondritis dissecans

The authors describe a surgical mosaicplasty technique, with an anterior surgical dislocation approach without trochanterotomy, for osteochondritis dissecans of the hip. A graft was taken from the lateral ccepted 9 December 2015 eywords: steochondritis dissecans condyle of the knee. Two adolescents underwent this procedure with good results. No osteonecrosis was observed at the longest follow-up. Mosaicplasty is a useful treatment method for small osteochondritis dissecans (< 2 cm2). © 2016 Elsevier Masson SAS. All rights reserved. ip osaicplasty dolescent Osteochondritis dissecans (OCD) of the femoral head is rare 2% of all OCD cases) [1]. Its progression can be unfavorable [1,2]. ifferent treatments exist: perforations, stem cell implantation, llografting, femoral osteotomy, and mosaicplasty [1–3]. Few artiles have examined mosaicplasty in this location [3–7]. Surgical technique The patient is installed in dorsal decubitus, with a cushion under he homolateral buttock to expose the hip contours. Knee flexion acilitates harvesting the osteocartilaginous grafts from the condyar ramp of the femur. A Watson-Jones approach is used from the nterosuperior iliac crest to the top of the greater trochanter. The pace between the anterior edge of the gluteus medius and the tenor fasciae latae is opened with the finger, preserving the branch f the superior gluteal nerve above. The direct tendon of the rectus emoris muscle and the psoas tendon are cut to facilitate dislocaion and exposure. The lateral circumflex artery is not ligatured to islocate the hip because it is not found in the approach. External otation of the lower limb extends the capsule. The joint capsule s resected 1 cm with a scalpel along the acetabular rim (labrum). he capsule is opened in a T shape with an incision along the anteior acetabular labrum and an incision in the axis of the femoral eck. Two Kocher clamps are placed on either side of the incision o raise the capsule and allow cutting with scissors, with image uidance, obviating the risk of injuring the labrum or the femoral ead. The two upper and lower extremities of the capsule labrum re identified with sutures for closing. The lower limb is positioned ∗ Corresponding author at: Service d’orthopédie infantile, hôpital Lapeyronie, 4295 Montpellier cedex 5, France. E-mail address: d-louahemm sabah@chu-montpellier.fr (D. Louahem). http://dx.doi. org/10.1016/j.otsr. 2015.12. 013 877-0568/© 2016 Elsevier Masson SAS. All rights reserved. er Masson SAS. Tous droits réservés. Document téléchargé le 09/01/2019 Il est interdit et illégal de in complete external rotation, flexion, and adduction. A standard table (but not an orthopaedic table) allows this manoeuvre. The femoral head dislocates anteriorly. The ligament of the femoral head is resected, exposing the femoral head. Any necrosis is carefully excised 20 mm deep until properly vascularized subchondral bone is reached. This dislocation is temporarily reduced. To keep the patient in a single installation, with a sterile tourniquet and using specific ancillary instrumentation, osteochondral grafts are harvested on a non-bearing lateral condylar surface of the knee. Collagenous bone is also harvested. We prefer to use small grafts that are stable with this technique rather than a bone graft that requires fixation. The hip is dislocated again. The osteochondral grafts are impacted into the defect, with inter-allograft filling using cancellous bone to obtain optimal stability of the grafts and a uniform surface. Eighty percent of the refreshed surfaces are thus filled. The capsule is closed tightly to prevent repeated dislocation [8]. Direct tendon of the rectus femoris muscle is reinserted. The wound is closed with suction drainage in place. After surgery, dynamic traction of the lower limb (1/10th of the patient’s body weight) associated with mobilization assisted with a Merle d’Aubigné splint beginning the 1st day (then continued for 3 weeks in a rehabilitation center) prevented stiffness. Dynamic traction associated with mobilization is a safety measure against possible risk of secondary dislocation. Using crutches with no weight-bearing is authorized beginning the 4th week after surgery and with weight-bearing the 6th week.