OVT Video Demonstrates Camera-Assisted Intraosseous Excision Technique for Femoral Head Chondroblastoma

Editor’s note: The following article is a review of a video available via the AAOS Orthopaedic Video Theater (OVT). AAOS Now routinely reviews OVT Plus videos, which are vetted by topic experts and offer CME. For more information, visit aaos.org/OVT.

The treatment of periarticular bone tumors presents unique surgical challenges. Malignant lesions may require wide resection and reconstruction, whereas symptomatic benign bone tumors are addressed with more tissue-sparing techniques with or without intralesional adjuvants. Orthopaedic surgeons should attempt to avoid articular damage when surgically managing locally aggressive bone tumors, in addition to avoiding physeal injury in the pediatric population.

An OVT video by Tae Won Benjamin Kim, MD, FAAOS, published in February 2023, demonstrates an intraosseous excision of a femoral head chondroblastoma via a lateral proximal femur approach under camera visualization in a male, aged 19 years, with worsening chronic left hip pain. There was a large, well-circumscribed geographic lytic lesion in the femoral epiphysis on radiographs corresponding to a T2 bright marrow replacing mass with peritumoral edema on MRI. Diagnosis of chondroblastoma was suspected based on these characteristic imaging findings and later confirmed on histopathology via histone H3P3 and p.k36M mutations. Dr. Kim successfully excised the lesion without significant articular injury, and in this video he reports midterm follow-up. His technique is a compelling alternative to a large anterior intra-articular approach or a surgical hip dislocation and may be applied to other anatomical locations.

Operative technique
A lateral approach to the proximal femur with the patient in the lateral decubitus position was utilized. A guide pin was inserted from the lateral femoral cortex up through the femoral neck and into the epiphyseal lesion. The lateral cortex was opened with a bone scalpel, and a guidewire path was over-reamed with a trephine to create space for the scope and instruments. Intralesional position was confirmed on fluoroscopy prior to excision. Small pituitary rongeurs and curettes were used under direct visualization of a 30- or 70-degree scope until the entire lesion was excised on fluoroscopy (Fig. 1). Full excision is paramount, as local recurrence is seen in up to 15 percent of cases.

Omnipaque (Iohexol) was injected into the lesion to confirm with fluoroscopy that complete excision had occurred with no cortical or articular breakthrough. After this, the femoral head cavity was packed with autograft from the previously reamed tunnel, and the femoral neck was backfilled with bone substitute (Fig. 2). Finally, a prophylactic full cannulated screw was inserted in the superior femoral neck to stabilize the graft site.

The patient was kept non–weight bearing for 6 weeks followed by a gradual return to weight bearing for 6 weeks thereafter. He reportedly returned to his previous activity level, pain free, at 6 months postoperatively.

In summary, camera-assisted intraosseous excision of benign aggressive lesions such as chondroblastoma can be an effective and less morbid alternative to surgical hip dislocation, and the technique could possibly be employed for other sites and indications.

Andrew Moore, MD, is a second-year orthopaedic surgery resident at the University of South Florida/Florida Orthopaedic Institute.

Odion Binitie, MD, FAAOS, is an associate professor of orthopaedics and oncology at Moffitt Cancer Center and the University of South Florida College of Medicine in Tampa. He is on the Editorial Board of AAOS Now.

Video details

Title: Camera-Assisted Intraosseous Excision of Femoral Head Chondroblastoma
Authors: Tae Won Benjamin Kim, MD, FAAOS; Jigar Gandhi, MD, PharmD; Deep Patel; Rohan Paturu, BS
Published: Feb. 27, 2023
Time: 6:22
Tags: musculoskeletal oncology, benign tumors, reconstruction

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