A 29-year-old male salesman complained of hip pain and limited range of motion (ROM) for 4 months in both hips. On July 10, 2019, insidious pain began in his left hip after walking, and the pain gradually subsided over 1 week without any treatment. At left hip pain relief after 1 month, the pain gradually started in both hips. The pain was alleviated after rest and aggravated with walking. No infectious contacts, such as tuberculosis, were found at his presentation. On primary physical examination, no warmth or swelling was noted in the patient's hip, nor was there any inguinal lymphadenopathy. X-rays of the pelvis showed osteoporosis of the femoral head on both sides (Figure 1A). The blood draw result was normal. He had an 11-year history of liquor intake in excess of 130 g per day and no history of glucocorticoid intake or trauma. No history of hereditary disease was found in his family. He was diagnosed with a synovitis of the hip and was managed with conservative methods such as the administration of non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and functional exercises.
Bilateral hip pain and loss of ROM were gradually exacerbated by non-operative measures. Subsequently, he was admitted to the Department of Orthopedic Surgery of the Affiliated Hospital of Zunyi Medical University. Physical examinations showed limitations in weight-bearing during walking, and pain was noted in all planes of the hip by 15 . Preoperative Harris hip scores (HHSs) were 58 and 61 for the left and right hip, respectively. The Visual Analogue Scores (VAS) were 8 and 7 for the left and right hip, respectively. The patient showed limited ability to perform daily activities (Table 1). Magnetic resonance imaging (MRI) revealed geographically aberrant signal intensity impairments with typical appearances of bilateral ONFH (Figures 2A,B). Computed tomography (CT) (Figures 2C-E) showed a mixed appearance, including sclerosis and cysts on the bilateral femoral heads without flattening or crescent signs. The preoperative x-ray showed cystic and sclerotic changes in the bilateral femoral heads (Figure 1A). Laboratory test results were normal. He was diagnosed with bilateral ONFH (stage II) according to the Ficat classification. An all-arthroscopic light bulb technique through outside-in fashion without distraction was recommended because no concomitant central compartment pathologies such as a labral tear, femoroacetabular impingement, and loose bodies were found on x-ray, CT, and MRI examinations.
Arthroscopy was performed on the patient's left hip under general anesthesia through the anterolateral (AL) portal, distal anterolateral accessory (DALA) portal, and mid-anterior (MA) portal in the supine position on the traction table without applying distraction. The all-arthroscopic light bulb technique to the hip was applied according to outside-in fashion and "touch method". The AL portal was made after making a vertical stab incision, and the subcutaneous and muscular layers were split by using a straight clamp. The straight clamp was directed medially, pointing in the direction of the femoral neck. When the tip of the straight clamp touched the bone, it was replaced with a blunt trocar and the femoral neck could be felt, and the tip of the trocar was situated extra-articularly at the femoral neck of the hip joint. The DALA portal was made after making the skin incision, and a straight clamp was introduced and directed toward the arthroscope trocar. When the straight clamp touched the trocar of the arthroscope, the trocar was used as a guide to travel medially in the direction of the femoral neck. The straight clamp must touch the arthroscope trocar until the straight clamp touches the bone, and an ablator or shaver was introduced. After the fatty tissue of the precapsule was removed with the shaver, the white structure of the joint capsule was shown. Then, an extra-articular longitudinal capsulotomy was performed from outside to inside. The necrotic site was located using a Kirschner pin under arthroscopic (Figure 3A) and radiographic (Figures 3B,C) visualization before managing ONFH. Then, the MA portal was established under direct visualization.
After the fluoroscopic image of the Kirschner pin location was obtained to find the center of the necrotic site at the femoral head, a cortical bone window with a diameter of approximately 1.5 cm was established at the femoral head-neck junction with a cannulated drill through the DALA portal, and the necrotic bone (Figure 3D) was removed using a rongeur and curette until bleeding or healthy bone (Figure 3E) was found. Then, an arthroscopic check was performed to ensure that the necrotic bone was removed. Furthermore, the femoral head and neck were percutaneously penetrated for improving blood circulation using a 2.0 mm Kirschner pin. Finally, the ipsilateral auto-iliac cancellous bone was harvested and was used to fill the cavity of the femoral head (Figure 3F) through the cannula after necrotic bone removal. The surgery lasted 136 min. Two weeks postoperatively, the same procedure was performed on his right hip. The patient was followed up at 1, 3, 6, and 12 months and annually thereafter.
Early core-strengthening exercises and closed-chain hip stabilization were carried out to optimize the joint ROM. Relative to the literature, in our institution, weight-bearing to prevent femoral head collapse is implemented with caution. For example, in the case under study, the patient was not allowed weight-bearing for the initial 3 months. Toe-touch weight-bearing using crutches was allowed for the second 3-month phase. The patient began full weight-bearing to prevent femoral head collapse when the grafted bone site fully healed. Three months after the procedure, the patient experienced no pain and had an improved VAS of 0. The VAS, HHSs, Hip Outcome Score Activities of Daily Living subscale (HOS ADL), International Hip Outcome Tool-12 (iHOT-12), and active ROM of the left hip and right side demonstrated consistent improvement at the 2-year postoperative follow-up (Table 1). This consistent improvement in outcomes showed that an all-arthroscopic light bulb technique through outside-in fashion without distraction could be a feasible method for the treatment of ONFH. The MRI (Figure 2I,J), CT (Figure 2F-H), and x-ray (Figures 1B-F) revealed a well-healed area of previous bone graft in the bilateral femoral heads, but there was radiological progress (slight collapse) on the left hip (Figures 1A-D). The patient was followed regularly and was strictly required to comply with the therapeutic plan. The patient presented that he was very satisfied at a follow-up visit 2 years after surgery. "As far as I know, ONFH is not always successful in hip-preserving procedure. The bilateral necrotic areas are healed, I am very lucky. The arthroscopic procedure is minimally invasive and aesthetically pleasing," the patient said. Also, he did not have any complications. The timeline for ONFH course and management response was presented in Figure 4.