Working Diagnosis:
Osteochondral defects of the femoral head and acetabulum with associated early changes of osteoarthritis. Minimally displaced acetabular wall fracture.

Treatment:
Patient was initially given crutches and instructed to be partial weight bearing until one month follow-up appointment. At the one month follow-up appointment, his pain was improved but he continued to limp. Patient was referred to physical therapy for hip girdle strengthening and gait training for 6-8 week program. Tentative plan after completion of his physical therapy program if the patient did not see improvement in pain, or developed locking, buckling of hip, was to undergo evaluation for arthroscopy and removal of osteochondral fragments.

Outcome:
Patient was lost to follow-up after referral to physical therapy.

Author's Comments:
The femoral head is an uncommon location for an osteochondral lesion of the hip. (10%; Schmid MR, et al.) Osteochondral defects can share features of early avascular necrosis on MRI and plain film. Treatment and prognosis vary.
Osteochondral Lesions are due to torsional impaction, seen in young athletes, participating in sport involving wide ROM of hip. MRI shows focal wedge-shaped areas of low intensity on T1. The lesions typically do not affect the lateral aspect of the femoral head, where AVN extends to.


Treatment options (favor hip-preserving in young) include:
1. Microfracture: indicated for focal, < 2cm lesions
2. Autologous chondrocyte implantation: acetabular
defects
3. Osteochondral auto & allograft transplant
4. Autologous costal cartilage transplantation

Editor's Comments:
This case is illustrative of the typical presentation of an osteochondral defects (OCD) in younger individuals, albeit in an uncommon joint.. While the etiology is poorly known, OCD’s are primarily thought to occur due to damage of the subchondral bone due to frequent repetitive stress and more commonly present in the knee, elbow and ankle joints. While historically these lesions were referred to as osteochondritis dissecans, histology has not supported an inflammatory etiology to the condition and it is more commonly referred to as osteochondral defects (1,2). The frequency of OCD is thought to be in the range of 15-30/100,000 and affect boys more than girls, though the frequency in females is rising with increased youth sports participation (1). Most often patients present, as in this case, with chronic pain of the joint for weeks to months with or without proceeding trauma. Occasionally they are incidentally noted when imaging a joint for another unrelated injury (2). While plain films are the first diagnostic test, MRI is necessary to classify OCD lesions and assist in determining the stability of the fragments. Management is guided based on the stability of the lesion and skeletal maturity of the patient, with stable lesions in children being given a trial of conservative treatment for 3-6 months before surgical intervention (2). Unstable lesions, which are represented in this patient by the presence of loose bodies and subchondral cystic changes, most often will require surgical intervention. Unfortunately in this case the author was not able to provide long term feedback on the outcome of the case. There are multiple surgical options for repairing OCD lesions depending on the location and size of the fragment, including drilling, fixation, grafting, debridement, and autologous transplantation, (1,2).

References:
1 - Ghahremani S, Griggs R, Hall T, Motamedi K, Boechat MI. Osteochondral lesions in pediatric and adolescent patients. Semin Musculoskelet Radiol. 2014 Nov;18(5):505-12. doi: 10.1055/s-0034-1389268. Epub 2014 Oct 28. PMID: 25350829.
2 - Edmonds EW, Polousky J. A review of knowledge in osteochondritis dissecans: 123 years of minimal evolution from König to the ROCK study group. Clin Orthop Relat Res. 2013 Apr;471(4):1118-26. doi: 10.1007/s11999-012-2290-y. PMID: 22362466; PMCID: PMC3586043.

Return To The Case Studies List.