Case Study from our Complex Cases Series

Atul F. Kamath, MD - Director, Center for Hip Preservation

Mr. J, a 25-year-old man, was referred to the Penn Center for Hip Preservation at Penn Medicine with structural deformity of the right hip, the result of a segmental fracture of the proximal femur at age four. His hip and leg were placed in a cast, and his fracture healed in a malaligned position. As a young adult, Mr. J had chronic, progressive and disabling pain (especially in the setting of his high-demand work as a manual laborer) that he managed with daily opioid medications. In the months prior to evaluation at Penn, he had extensive physical therapy and an intra-articular injection for pain control. He was unemployed for much of this time.

X-ray image of retrotorsinal femoral deformity of the hip
Figure 1: Pre-operative image of a 25-year-old male with retrotorsional femoral deformity and acetabular dysplasia and remodeling status post trauma as a child. He had combined instability and impingement of the hip, as well as an acetabular labral tear.
At Penn, Mr. J was deemed a candidate for hip preservation. Imaging determined that he had severe acetabular dysplasia, a tear of his acetabular labrum, a torsional deformity of the femur (45 degrees of retrotorsion) and FAI due to a cam lesion of the femoral head-neck junction (Fig. 1). Despite these abnormalities, however, there was no evidence of overt osteoarthritis at his hip. After discussion of the risks, benefits and treatment alternatives, Mr. J elected to have corrective surgery. Pre-procedural imaging and modeling were completed to ensure proper intra-operative alignment targets of the reoriented hip and femur.

A periacetabular osteotomy (PAO) was performed to correct the acetabular dysplasia. Nerve monitoring and fluoroscopic imaging were used to ensure safe and accurate surgery. Bone grafting was completed at the acetabular osteotomy sites, with autograft harvested from the pelvic osteotomy mobile fragment. A surgical hip dislocation was also performed, with careful preservation of the critical blood supply to the femoral head. To address the intra-articular sequelae of FAI, a labral repair and femoral head-neck osteochondroplasty were completed.

X-ray image of a patient demonstrating fixation of periacetabular osteotomy
Figure 2: Intra-operative and immediate post-surgical images of a 25-year-old patient demonstrating fixation after periacetabular osteotomy (PAO), surgical hip dislocation, labral repair, femoral head-neck osteochondroplasty, and subtrochanteric derotational femoral osteotomy. Bone grafting was performed at both the acetabular and femoral osteotomy sites.

Although Mr. J’s intra-articular causes of FAI were optimized, the extra-articular rotational deformity of the femur did not allow for adequate impingement-free range of motion. Therefore, a subtrochanteric derotational osteotomy with internal fixation was performed to bring the femur into normal rotational alignment. Bone autograft harvested from the greater trochanteric bed was used to supplement the osteotomy fixation (Fig. 2). Mr. J was on crutches the day after his procedure and was in the hospital for three days, where he received physical therapy, as well as a continuous passive motion machine. Partial weight-bearing was permitted on discharge. He was weaned from all pain medications by several months post-operatively. At six months, he was walking with no gait aids, and by seven months he had found full-time work.

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