Arthroscopy of the hip in children and adolescents

Hip Arthroscopy for Sequelae of Legg-Calve-Perthes Disease: A Systematic Review

There is no clear evidence on indications and outcomes of hip arthroscopy in sequelae of Legg-Calve-Perthes disease (LCPD). The aim of the current study was to evaluate current literature on the role and outcome of hip arthroscopy in LCPD. A literature search using four databases was conducted in April 2020, focusing on the role of hip arthroscopy in sequelae of LCPD. A systematic search was carried out in confirmation with the Cochrane Collaboration, Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of nine studies were included in the systematic review. The total number of hip arthroscopies performed for LCPD was 109. The mean age of included patients was 34.8±7.88 years (7-58 years). Recalcitrant hip pain was the main indication for surgery, followed by pain and stiffness. The most common finding in arthroscopy was labral tears, followed by osteochondral lesions of femoral head or acetabulum and intra-articular loose bodies. Consequently, debridement of labrum tears chondroplasty for cartilage defects and osteoplasty for impingement from deformed femoral head (hinged abduction) were commonly performed. A significant improvement in hip function was seen in all studies. Pooled data of Harris hip score showed significant improvement after surgery was conducted. Hip arthroscopy may be beneficial in patients having symptoms of impingement secondary to changes in labrum, femoral head or acetabulum. Limited evidence shows improved function and range of motion after surgery. This treatment has been found to be safe in terms of complication rates and improvement may persist for years.

A case report of an unrecognized osteoid osteoma of the proximal femur

We present the case of a 59-year-old male patient with unrecognized osteoid osteoma in radiography as well as in magnetic resonance imaging. Computed tomography revealed osteoid osteoma that was successfully treated with percutaneous computed tomography guided radiofrequency ablation. The osseous pathology was underestimated on magnetic resonance imaging in the presented case and bone marrow edema led to incorrect diagnosis. The particular case emphasizes the value of computed tomography scans diagnosing an osteoid osteoma.

Arthroscopic Treatment of a Posterior Labral Interposition after a Pediatric Hip Dislocation-A Case Report

We report the case of a 13-year-old boy, who suffered a posterior hip dislocation from playing soccer. Closed reduction was performed urgently. Because of a nonconcentric hip after closed reduction, further imaging was done. An intra-articular bony fragment was identified. Arthroscopic treatment was performed. Through an anterior portal we were able to locate the intra-articular bony fragment, which was located within the region of the fovea. After lifting of the caudal enfolded labral complex, we were able to remove the fragment. Evidence of a grade 3 cartilage defect was present at the femoral head. We were able to reduce the enfolded posterior labral complex, which was stable afterwards without the necessity of additional suture fixations. The concentric hip reduction was confirmed on an anteroposterior view of the hip postoperatively. The patient was instructed to toe tip weight-bearing for 6 weeks with limited range of motion to 60° of hip flexion. Eight weeks after surgery, he was free of pain and discomforts. From our experience, the arthroscopic intervention after pediatric hip dislocation associated with intra-articular bony fragments or posterior labral complex injuries, represents to be a preferred minimally invasive method in contrast to open surgical procedures.

Outcomes of intra-articular corticosteroid injections for adolescents with hip pain

Intra-articular injection of corticosteroid and anesthetic (CSI) is a useful diagnostic tool for hip pain secondary to labral tears or femoroacetabular impingement (FAI). However, the effectiveness of CSI as a stand-alone treatment for hip pain in adolescents is unknown. The purpose of this study is to evaluate the use of CSI for the treatment of hip pain and determine factors that may affect outcomes after injection. Retrospective analysis of 18 patients and 19 hips that underwent fluoroscopic guided hip injection for the treatment of pain at a single institution from 2012 to 2015 was carried out in this study. Mean age at the time of injection was 15.1 years (range 13–17) with mean follow-up of 29.4 months. Fifty-two percent (10/19 hips) went on to surgery after the injection. Average time to surgical conversion was 12.8 months after CSI. Cam or pincer morphologies were present in 90% (9/10 hips) of the operative group. Patients with FAI were more likely to need surgery than patients without bony abnormalities (RR= 10, 95% CI 1.6–64.2, P = 0.0001). There was no difference in the presence of labral tears in the operative and non-operative groups (100% versus 89%, P = 0.47). For adolescents without bony abnormalities, 90% improved with CSI alone and did not require further treatment within 2.4 years. Fluoroscopic guided corticosteroid hip injection may have limited efficacy for the treatment of hip pain secondary to FAI in adolescents. However, for patients without osseous deformity, CSI may offer prolonged improvement of symptoms even in the presence of labral tears.

Arthroscopic Treatment of Traumatic Hip Dislocations in Children and Adolescents: A Preliminary Study

INTRODUCTION

Traumatic hip dislocations in children and adolescents require prompt concentric reduction. Incomplete reduction with or without retained osteochondral fragments has traditionally been addressed with open reduction. We report on the use of arthroscopy to remove loose bodies and reduce enfolded soft tissues to obtain concentric reduction in the pediatric and adolescent population. Specific note is made of underlying pathology and arthroscopic intervention.

METHODS

After obtaining Institutional Review Board approval, we performed a retrospective review of patients under the age of 19 who were treated with hip arthroscopy following hip dislocation reduction at a single children's hospital from 2006 to 2013. Clinic notes, operative reports, radiographic images, and arthroscopic photographs were reviewed.

RESULTS

Seven patients were identified (aged 8 to 17) who underwent hip arthroscopy after a posterior hip dislocation. Intra-articular bone fragments were found in 6 of 7 patients and 5 of 7 patients had an incongruent hip joint identified by imaging before surgery. The predominant pathology was avulsion of a small bony fragment attached to the posterior capsular labral soft-tissue complex, which became enfolded and blocked reduction (5 of 7 patients). In all cases, the enfolded soft tissue was reduced without soft tissue or bone repair. Additional loose osteochondral fragments were removed, and in 2 cases an avulsed ligamentum teres was debrided. Average follow-up was 10 months. No avascular necrosis or recurrent instability was identified in any case.

CONCLUSIONS

When incongruent hip joints were arthroscopically evaluated after traumatic dislocation, a consistent pattern of interposition of avulsed posterior bone fragment with attached capsule and labrum was found. Reduction of the capsulolabral complex without repair provided satisfactory short-term outcomes. Arthroscopic treatment of such cases was effective and well tolerated and could lead to considerably less postoperative pain and surgical morbidity than open surgical treatment.

LEVEL OF EVIDENCE

Level IV-case series.

Complications in Hip Arthroscopy

BACKGROUND

Recent developments in hip arthroscopic techniques and technology have made it possible in many cases to avoid open surgical dislocation for treating a variety of pathology in the hip. Although early reports suggest favourable results' using hip arthroscopy and it has been shown to be a relatively safe procedure, complications do exist and can sometimes lead to significant morbidity.

METHODS

This is a review article. The aim of this manuscript is to present the most frequent and/or serious complications that could occur at or following hip arthroscopy and some guidelines to avoid these complications.

CONCLUSION

Most complications of hip arthroscopy are minor or transient but serious complications can occur as well. A lot of complication e.g. acetabular labral puncture go unreported. Appropriate education and training, precise and meticulous surgical technique with correct instrumentation, the right indication in the right patient and adherence to advice from mentors and experienced colleagues are all essential factors for a successful outcome. Level of evidence: V.

The use of hip arthroscopy in the management of the pediatric hip

Arthroscopy of the pediatric hip began in 1977 with a publication by Gross. Interest was relatively slow to develop in the 1980s and 1990s. Coupled with the success of hip arthroscopy in the adult, interest heightened in applying the procedure to a variety of pediatric hip disorders, given that the alternative was an open surgical hip dislocation. The success of this initial group of pediatric hip arthroscopist's has further expanded the application of hip arthroscopy as the primary or adjunct procedure for the management of intra-articular problems of the pediatric hip.

Surgical treatment options for septic arthritis of the hip in children

Septic arthritis is the result of bacterial infection of the hip joint and is often found in infants and toddlers. It is the most common septic joint condition during growth and may cause the most devastating complications without prompt and proper treatment. Early diagnosis and intervention are required to avoid irreversible complications. This review documents the systematic approach to diagnosis and management of septic arthritis in children.

Arthroscopic excision of acetabular osteoid osteoma in a 7-year-old patient

The purpose of this study was to present the case report of a 7-year-old patient who was treated with hip arthroscopy for an acetabular osteoid osteoma. A 7-year-old patient was referred to our clinic with hip pain. In the assessment of the patient, an acetabular osteoid osteoma was detected in his right hip; it was adjacent to his triradiate cartilage. An arthroscopic surgery was planned as an alternative to open safe hip dislocation. The osteoid osteoma was completely removed with hip arthroscopy. Postoperative CT scanning and histopathological analysis confirmed the diagnosis. Exposure of the acetabulum can be problematic in paediatric patients due to the potential risks of open safe dislocation. Hip arthroscopy can safely be used for benign hip lesions in paediatric patients. Level of evidence Case report, Level V.

Arthroscopic femoral neck osteoplasty in slipped capital femoral epiphysis

PURPOSE

To investigate the outcomes of arthroscopic femoral neck osteoplasty in patients with slipped capital femoral epiphysis (SCFE)-related impingement.

METHODS

We retrospectively reviewed 37 consecutive patients (40 hips; 19 male and 18 female patients; age range, 10 to 19 years) with SCFE who underwent hip arthroscopy for femoral neck osteoplasty over a 4-year period. Six hips were excluded because of the severity of the slip or conversion to an open procedure. The preoperative and postoperative slip angle, alpha angle, and internal rotation in flexion were compared. Patients were evaluated for pain, functional limitations, and obligatory external rotation deformity (OERD) at each follow-up visit. The mean follow-up period was 22 months (range, 12 to 56 months).

RESULTS

We analyzed the results of 34 hips. Adequate distraction could not be obtained initially in 7 hips. The labral and acetabular cartilage damage appeared to be from crushing and abrasion from the bony prominence of the neck. The goals of complete pain relief and correction of OERD were achieved in 88% of the hips. OERD and pain persisted in 2 hips, and 2 patients had residual pain despite good motion. There was a statistically significant improvement in alpha angle (from 88.22° and 56.91°, P < .0001) and internal rotation in flexion (from -21.53° to 10.28°, P < .0001) with intervention.

CONCLUSIONS

Arthroscopic femoral neck osteoplasty is effective in decreasing pain, the alpha angle, and OERD in mild to moderate SCFE. Morbid obesity, scarring from previous surgery, and the presence of screws in the anterior neck presented challenges to the arthroscopic technique.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

[Arthroscopic therapy of septic hip infections in childhood]

OBJECTIVE

The treatment goal is to rapidly make a diagnosis and establish an effective arthroscopic therapy in order to allow the hip joint to develop normally throughout childhood with respect to anatomical and functional development.

INDICATIONS

Coxarthritis suspected of being septic arthritis

CONTRAINDICATIONS

No experience with arthroscopy, osteomyelitis of the dorsal femoral neck requiring an intervention. Relative contraindication: absence of cannulated systems.

SURGICAL TECHNIQUE

Arthroscopic lavage of the hip joint, including revision of the femoral neck and debridement of osteomyelitis of the femoral neck with placement of an antibiotic carrier if necessary. The arthroscopy is performed using the two portal technique, placing the patient supine on a normal operation table (traction table not required).

POSTOPERATIVE MANAGEMENT

Drain for 2-3 days with mobilization after removal of the drainage. A second look arthroscopy is not normally planned but may become necessary in cases without improvement of the clinical or laboratory test parameters and after follow-up magnetic resonance imaging (MRI).

RESULTS

The two portal hip joint arthroscopy using an irrigation volume of 6-9 l is an efficient minimally invasive method to safely treat septic arthritis of the hip joint with or without concomitant femoral neck osteomyelitis. It is associated with low morbidity and offers all advantages of an arthroscopic procedure. Out of 23 children 19 could be sufficiently treated by a single arthroscopic lavage of the hip joint. In three patients an additional osseous component required a second intervention. Out of 23 children 22 achieved an excellent Harris hip score, with one girl only achieving a moderate outcome. The 22 children had an unrestricted hip function at follow-up and could return fully to previous activity levels.

Current possibilities for hip arthroplasty

Hip arthroscopy has been popularized over the last decade and, with technical advances regarding imaging diagnostics, understanding of the physiopathology or surgical techniques, several applications have been described. Both arthroscopy for intra-articular conditions and endoscopy for extra-articular procedures can be used in diagnosing or treating different conditions. This updated article has the objective of presenting the various current possibilities for hip arthroscopy.

Clinical and radiographic diagnosis of femoroacetabular impingement

Femoroacetabular impingement (FAI) in the adolescent patient is becoming increasingly recognized. A number of morphologic variants can lead to abnormal abutment of the femoral neck against the acetabular rim. Unrecognized FAI can lead to the development of secondary hip disorders including osteoarthritis. FAI is both a clinical and radiographic diagnosis and requires a thorough and complete understanding to diagnose appropriately. A precise history and comprehensive physical examination is paramount. Radiographs and advanced imaging techniques help to confirm the diagnosis.

The labrum: structure, function, and injury with femoro-acetabular impingement

BACKGROUND

The recognition of the importance of femoro-acetabular impingement (FAI) as a potential cause of hip pain has been stimulated by major efforts to salvage hip joints by reconstruction to prevent or delay the need for replacement. A previous review addressed the nature of FAI, the various types, and how to make the diagnosis. When FAI occurs, the structure between the femur and acetabular rim, the labrum, is initially impinged upon and subsequently injured.

METHOD

Injury to the labrum should be recognized when treating the osseous causes of FAI. Preserving or recovering labral function, enhancing hip stability and protecting the articular surface, is critical to restoring the hip to normal or near-normal mechanical and physiologic function. The present review collected the varied essential information about the labrum in a succinct manner, independent of treatment algorithms.

RESULTS/CONCLUSION

Advanced knowledge of the labrum is presented, including the anatomy, circulation, histology, embryology, and neurology, as well as how the labrum tears, the types of tears, and how to make the diagnosis. The advantages and limitations of diagnostic magnetic resonance techniques are discussed, including magnetic resonance imaging (MRI), indirect magnetic resonance arthrography (i-MRA), and direct magnetic resonance arthrography (d-MRA). The review recognizes the complexity of the labrum and provides a greater understanding of how the labrum is capable of stabilizing the joint and protecting the articular surface of the hip. This information will act as a guide in developing treatment plans when treating FAI.

Outcome of arthroscopic treatment for cam type femoroacetabular impingement in adolescents

BACKGROUND

Hip arthroscopy has become an established procedure in adults with well-published results. These techniques have been extended to the teenage population, but the literature remains limited in regard to indications, efficacy, outcomes and complications specific to the paediatric population.

HYPOTHESIS/PURPOSE

The purpose of this study was to report the short-term outcome of the arthroscopic treatment of cam-type femoroacetabular impingement (FAI) in the skeletally immature adolescent population with open growth plates, with the hypothesis that it is a safe procedure, with good clinical outcomes and low complication rates.

STUDY DESIGN

The study design of this article was a multicentre prospective longitudinal case series.

METHODS

From 2008-2009, 34 consecutive patients who were 18 years or younger at the date of operation (41 hips) with open proximal femoral growth plates had arthroscopic hip surgery for treatment of cam-type FAI and associated lesions by use of the lateral decubitus position by two surgeons. Data were collected prospectively including the modified Harris hip score (MHHS), nonarthritic hip score (NAHS), satisfaction survey and complications. Mean follow-up was 14 months (range 1-2 years).

RESULTS

All hips were available for review. The mean age of patients was 15.7 years with the most common sport activity being Australian Football League, netball and rugby. All patients had cam-type impingement, with the most common associated lesions being acetabular rim lesions (82.9%) and pincer impingement (22%). The labrum underwent debridement in 31.7% of cases, and was repaired in 17.1%. The MHHS and NAHS improved in all patients post-operatively, 77.39-94.15 and 76.34-93.18, respectively. A percentage of 78.1 were able to return to full sporting activity and 88.2% were satisfied with the operation. There were no complications.

CONCLUSIONS

Using hip arthroscopy to treat cam-type impingement and associated lesions in the adolescent population, we confirmed our hypothesis with observed high satisfaction levels, return to sports, significant improvement in post-operative hip scores (MHHS and NAHS) and no complications.

Complications of arthroscopic surgery of the hip

Over recent years hip arthroscopic surgery has evolved into one of the most rapidly expanding fields in orthopaedic surgery. Complications are largely transient and incidences between 0.5% and 6.4% have been reported. However, major complications can and do occur. This article analyses the reported complications and makes recommendations based on the literature review and personal experience on how to minimise them.

Arthroscopy of the hip for paediatric and adolescent disorders

Hip arthroscopy is particularly attractive in children as it confers advantages over arthrotomy or open surgery, such as shorter recovery time and earlier return to activity. Developments in surgical technique and arthroscopic instrumentation have enabled extension of arthroscopy of the hip to this age group. Potential challenges in paediatric and adolescent hip arthroscopy include variability in size, normal developmental change from childhood to adolescence, and conditions specific to children and adolescents and their various consequences. Treatable disorders include the sequelae of traumatic and sports-related hip joint injuries, Legg–Calve–Perthes’ disease and slipped capital femoral epiphysis, and the arthritic and septic hip. Intra-articular abnormalities are rarely isolated and are often associated with underlying morphological changes.

This review presents the current concepts of hip arthroscopy in the paediatric and adolescent patient, covering clinical assessment and investigation, indications and results of the experience to date, as well as technical challenges and future directions.

[Acute traumatic and especially neglected traumatic hip dislocations are very rare in children]

We report about the first hip arthroscopies of extracapsular neglected hip dislocations with concomitant injuries in two children (2 and 4 years old). The major problem of traumatic hip dislocation is avascular necrosis. Further problems are possible concomitant injuries. It is important not to cause further damage by therapeutic procedures. In a 4-year-old child the hip could be reduced under visualization and in a 2-year-old child with epiphyseal fracture the extent of the operation could be reduced. In both children large avulsion injuries of the ligamentum capitis femoris could be resected via hip arthroscopy. Hip arthroscopy can reduce surgical morbidity considerably and can possibly contribute to prevention of the feared avascular necrosis of the femoral head.

Shelf and/or reduction and containment surgery

Hinge abduction occurs early in the fragmentation stage of Legg-Calvé-Perthes disease and should be suspected when abduction and internal rotation are lost. It can be confirmed by an AP radiograph in abduction and internal rotation in which the ossific nucleus is not covered by the acetabulum. An arthrogram can then yield greater information regarding the reversibility of the hinge abduction. Hinge abduction should be considered a contraindication to containment by redirectional pelvic or femoral varus osteotomy. However, good results have been reported with acetabular augmentation via shelf procedures or Chiari osteotomies. Valgus femoral osteotomies have also been beneficial in the treatment of the Legg-Calvé-Perthes hip with hinge abduction.

Trapezoidal bony correction of the femoral neck in the treatment of severe acute-on-chronic slipped capital femoral epiphysis

PURPOSE

To present the first technical description of a modified surgical technique for trapezoidal bony correction of the femoral neck in the treatment of slipped capital femoral epiphysis (SCFE), performed entirely by arthroscopy.

METHODS

From December 2005 to January 2008, 5 patients with severe SCFE underwent trapezoidal femoral neck bone correction through arthroscopy. Their mean age at the time of surgery was 13.2 years. The time for postoperative follow-up ranged from a minimum of 12 months to a maximum of 39 months (mean, 26 months). The study analyzed data regarding the type of slip, degree of correction obtained, clinical and functional outcomes, and complications.

RESULTS

Analysis with the modified Harris Hip Score criteria showed a mean of 17.2 points preoperatively and 86.6 points at the last assessment. The mean epiphyseal deviation ranged from 82° at the initial presentation to 14° postoperatively. There were no intraoperative complications, and there was 1 case of avascular necrosis.

CONCLUSIONS

Arthroscopic treatment of SCFE resulted in correction of the angles of epiphyseal slip (from a mean epiphyseal-diaphyseal angle of 82° before surgery to 14° after surgery), with no immediate complications and 1 case of a late complication (avascular necrosis) in this 5-patient series. Clinical improvement was shown by a mean 69.4-point increase in the modified Harris Hip Score.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.