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Schallmo M, Marquez-Lara A, Luo TD, Stone AV, Mannava S, Sharma A, Howse EA, Stubbs AJ. Clinical presentation, imaging findings, and arthroscopic features in skeletally immature and mature adolescent hip patients: a comparative double-cohort retrospective study. J Pediatr Orthop B 2021; 30:316-323. [PMID: 33720073 DOI: 10.1097/bpb.0000000000000746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to evaluate differences in clinical presentation and extent of surgery required based on skeletal maturity between two cohorts of adolescent hip arthroscopy patients. We hypothesized that skeletal immaturity would be associated with a lower frequency of pincer impingement and a decreased need for surgical acetabuloplasty. A database of 1481 hip arthroscopies performed by a single orthopaedic surgeon between 2008 and 2016 was queried. Patients ≤18 years of age with femoroacetabular impingement were divided into two groups based on Risser score: Risser 1-4 (skeletally immature) or Risser 5 (skeletally mature). Groups were compared with respect to presentation, diagnosis, and arthroscopic procedures performed. Eighty-eight skeletally immature and 49 skeletally mature patients were included. Mixed impingement was more common in skeletally mature patients than immature (67.3% vs. 48.9%, P = 0.037). Skeletal maturity was associated with a significantly increased probability of undergoing acetabuloplasty (odds ratio = 4.6, 95% confidence interval 1.4-15.5; P = 0.014). Extent of chondral degeneration was similar between groups. Our findings support the hypothesis that skeletally immature hips undergo acetabuloplasty less frequently and demonstrate similar chondromalacia compared with a skeletally mature cohort. These results suggest that arthroscopic treatment for impingement-associated hip pain may be a reasonable option to consider for symptomatic skeletally immature patients who have completed a structured course of nonoperative treatment. Additional longitudinal outcomes data are needed to clarify the natural history of impingement-associated hip pain in younger populations and whether hip arthroscopy delays progression of osteoarthritis in these patients.
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Affiliation(s)
- Michael Schallmo
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Alejandro Marquez-Lara
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Tianyi David Luo
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Austin V Stone
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Sandeep Mannava
- Department of Orthopaedic Surgery, University of Kentucky Medical Center, Lexington, Kentucky
| | - Aman Sharma
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Elizabeth A Howse
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York
| | - Allston J Stubbs
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
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Saito M, Kuroda Y, Sunil Kumar KH, Khanduja V. Outcomes After Arthroscopic Osteochondroplasty for Femoroacetabular Impingement Secondary to Slipped Capital Femoral Epiphysis: A Systematic Review. Arthroscopy 2021; 37:1973-1982. [PMID: 33359821 DOI: 10.1016/j.arthro.2020.12.213] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the efficacy of arthroscopic osteochondroplasty for patients with femoroacetabular impingement (FAI) secondary to slipped capital femoral epiphysis (SCFE). METHODS A systematic review was performed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using Embase, PubMed (Medline), and Cochrane Library up to November 1, 2019. Data including patient demographics, slip severity according to Southwick, outcomes, and complications were retrieved from eligible studies that reported a minimum 3-month follow-up of arthroscopic osteochondroplasty for FAI secondary to SCFE. Methodological Index for Non-Randomized Studies (MINORS) criteria was used to assess quality of studies. Heterogeneity and quality were evaluated using P values and the I2 statistic. RESULTS Six studies (90 hips) were analyzed. The range of MINORS scores was 8 to 11. Most studies were level of evidence 4 (n = 4, 66.7%), with more men than women (n = 5, 83.3%). The ranges of age, body mass index, and follow-up length after surgery were 10 to 42 years, 17.5 to 32.3 kg/m2, and 3 to 56 months, respectively. The Modified Harris Hip Score (mHHS) was the most commonly used score to report on clinical outcomes (n = 2 studies, 28 hips) with a significant improvement following surgery. Three studies reported an improvement in internal rotation (IR) of the hip with a range of improvement of 17° to 32°, with low heterogeneity (I2 = 0% and P = .531). Five studies reported a significant correction of the α angle, with range of improvement of 19.9° to 37.3°. The range of postoperative α angle was 32° to 67°, and 3 studies achieved appropriate postoperative α angle (40° to 50°), with low heterogeneity (I2 = 8.4% and P = .336). The total number of complications was 8 (1 major complication) and there were 6 revisions, with low heterogeneity. CONCLUSION Arthroscopic osteochondroplasty for FAI secondary to SCFE provides good short- to medium-term outcomes and improves IR of the hip, with the ability to potentially correct the α angle with a low rate of complications and revision. LEVEL OF EVIDENCE IV, systematic review of level II to IV studies.
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Affiliation(s)
- Masayoshi Saito
- Young Adult Hip Service, Department of Trauma and Orthopaedic Surgery, Addenbrooke's-Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Yuichi Kuroda
- Young Adult Hip Service, Department of Trauma and Orthopaedic Surgery, Addenbrooke's-Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Karadi Hari Sunil Kumar
- Young Adult Hip Service, Department of Trauma and Orthopaedic Surgery, Addenbrooke's-Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Vikas Khanduja
- Young Adult Hip Service, Department of Trauma and Orthopaedic Surgery, Addenbrooke's-Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
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Sutton R, Yacovelli S, Vahedi H, Parvizi J. Does a History of Slipped Capital Femoral Epiphysis in Patients Undergoing Femoroacetabular Osteoplasty for Femoroacetabular Impingement Affect Outcomes Scores or Risk of Reoperation? Clin Orthop Relat Res 2021; 479:1028-1036. [PMID: 33231940 PMCID: PMC8083843 DOI: 10.1097/corr.0000000000001576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 10/22/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Femoroacetabular impingement (FAI) can occur after slipped capital femoral epiphysis (SCFE) regardless of slip severity and even after in situ pinning. These patients represent a rare and unique demographic that is largely unreported on. It is important to further characterize the clinical presentation of these patients, associated treatment modalities, and the efficacy of these treatment modalities. QUESTIONS/PURPOSES (1) How do patients with post-SCFE FAI typically present in terms of radiographic and surgical findings? (2) How do their hip-specific and general-health outcomes scores after mini-open femoroacetabular osteoplasty compare with those obtained in a matched group of patients with FAI caused by other etiologies? (3) How do those groups compare in terms of the proportion who undergo conversion to THA? METHODS Between 2013 and 2017, 20 patients had femoroacetabular osteoplasty for post-SCFE FAI. During that time, general indications for this procedure were symptomatic FAI demonstrated on radiographs and physical exam. Of those, none was lost to follow-up before a minimum of 2 years, leaving all 20 available for matching, and all 20 had suitable matches in our database for patients who underwent femoroacetabular osteoplasty for other diagnoses. Matching was performed by surgeon, patient age, patient gender, and BMI. The matching group was drawn from a large database of patients who had the same procedure during the same period. We matched in a 1:3 ratio to arrive at 60 randomly selected control patients in this retrospective, comparative study. Patient demographics, medical history, clinical presentation, radiographic parameters, and intraoperative findings were compared between the two groups. At a minimum of 2 years of follow-up, the latest clinical functional outcome scores (Hip Disability and Osteoarthritis Outcome Score Jr and SF-12) and proportions of conversion to THA were compared between the groups. RESULTS A greater percentage of patients with a history of SCFE than those without prior SCFE demonstrated full chondral lesions intraoperatively (90% [18 of 20] versus 32% [19 of 60], odds ratio 7 [95% confidence interval 1 to 178]; p < 0.01). A greater percentage of patients with a history of SCFE also demonstrated labral calcifications intraoperatively compared with those without prior SCFE (65% [13 of 20] versus 35% [21 of 60], OR 3 [95% CI 1 to 10]; p = 0.04). Radiographically, patients with SCFE had greater preoperative alpha angles than did patients without SCFE (94° ± 13° versus 72° ± 22°; p = 0.01) as well as lower lateral center-edge angles (25° ± 8° versus 31° ± 8°; p = 0.04). There was no difference in postoperative follow-up between patients with a history of SCFE and patients without a history of SCFE (4 ± 2 years versus 4 ± 2 years; p = 0.32). There was no difference in the mean postoperative outcome scores between patients with a history of SCFE and patients without (Hip Disability and Osteoarthritis Outcome Score Jr: 75 ± 28 points versus 74 ± 17 points; p = 0.95; SF-12 physical score: 40 ± 11 points versus 39 ± 8 points; p = 0.79). There was no difference with the numbers available in the percentage of patients who underwent conversion to THA (15% [3 of 20] versus 12% [7 of 60], OR 1.36 [95% CI 0 to 6]; p = 0.71). CONCLUSION Patients with FAI after SCFE present with a greater degree of labral and chondral disease than do patients without a history of SCFE. However, at short-term follow-up, the proportion of patients who underwent conversion to THA and patients' postoperative outcome scores did not differ in this small, comparative series between patients with and without SCFE. Further evaluation with long-term follow-up is needed, especially given the more severe chondral damage we observed in patients with SCFE at the time of surgery. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Ryan Sutton
- R. Sutton, S. Yacovelli, H. Vahedi, J. Parvizi, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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Abstract
In situ pinning of slipped capital femoral epiphysis (SCFE) is a safe and effective treatment modality, but often results in residual deformity leading to femoroacetabular impingement, which may limit patient activities and predispose to early onset arthritis. Enhanced understanding of the implications of femoroacetabular impingement and new surgical techniques have prompted interest in treating post-slipped capital femoral epiphysis deformity to both improve current symptoms and delay or prevent hip arthrosis.
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Abstract
Background and purpose - Slipped capital femoral epiphysis (SCFE) results in a more or less pronounced deformity of the proximal femur, sometimes causing impingement and early osteoarthritis. We studied early osteoarthritis after SCFE and the association with deformity and self-reported hip function, pain, and quality of life. Patients and methods - 9 women and 16 men, mean age 32 (21-50) years, 19 with unilateral and 6 with bilateral SCFE, participated. All patients had primarily been operated by pin or screw with no attempt at reposition of the slip. Hips were examined by delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC), which quantifies and locates cartilage degeneration. Plain radiographs were used to measure deformity as determined by the alpha angle. Outcome was assessed by Oxford hip score, Hip Groin Outcome score and EQ-5D-Visual scale. Results - In the 19 unilateral SCFE, on the slip side dGEMRIC mean value was 533 ms (SD 112, range 357-649) versus mean 589 ms (SD 125, range 320-788) on the non-slip side, (p = 0.01). The dGEMRIC correlated negatively to the alpha angle, correlation coefficient (CC) = -0.60, (p = 0.002). Oxford hip score, pain, and EQ-5D-Visual scale correlated to dGEMRIC CC =0.43 (p = 0.03), CC =0.40 (p = 0.05), and CC =0.49 (p = 0.01) respectively. Interpretation - After SCFE, even relatively mild residual hip deformity can be associated with cartilage degeneration. A high alpha angle was associated with worse cartilage status. The Oxford hip score identified symptoms even though our patients had not previously sought medical care after the index operation. Quality of life showed strong inverse correlation with cartilage degeneration. Objective assessment of early cartilage degeneration may be useful for treatment decisions and follow-up.
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Affiliation(s)
| | | | - Ylva Aurell
- Department of Radiology, Mölndal Hospital, Sahlgrenska
| | | | - Johan Kärrholm
- Department of Orthopaedics, Mölndal Hospital, Sahlgrenska, Sweden
| | - Jacques Riad
- Department of Orthopaedics, Skaraborgs Hospital, Skövde,Correspondence:
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Oduwole KO, de Sa D, Kay J, Findakli F, Duong A, Simunovic N, Yi-Meng Y, Ayeni OR. Surgical treatment of femoroacetabular impingement following slipped capital femoral epiphysis: A systematic review. Bone Joint Res 2017; 6:472-480. [PMID: 28790036 PMCID: PMC5579313 DOI: 10.1302/2046-3758.68.bjr-2017-0018.r1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/04/2017] [Indexed: 11/25/2022] Open
Abstract
Objectives The purpose of this study was to evaluate the existing literature from 2005 to 2016 reporting on the efficacy of surgical management of patients with femoroacetabular impingement (FAI) secondary to slipped capital femoral epiphysis (SCFE). Methods The electronic databases MEDLINE, EMBASE, and PubMed were searched and screened in duplicate. Data such as patient demographics, surgical technique, surgical outcomes and complications were retrieved from eligible studies. Results Fifteen eligible level IV studies were included in this review comprising 261 patients (266 hips). Treatment groups included arthroscopic osteochondroplasty, surgical hip dislocation, and traditional open osteotomy. The mean alpha angle corrections were 32.14° (standard deviation (sd) 7.02°), 41.45° (sd 10.5°) and 6.0° (sd 5.21°), for arthroscopy, surgical hip dislocation, and open osteotomy groups, respectively (p < 0.05). Each group demonstrated satisfactory clinical outcomes across their respective scoring systems. Major complication rates were 1.6%, 10.7%, and 6.7%, for arthroscopy, surgical dislocation and osteotomy treatments, respectively. Conclusion In the context of SCFE-related FAI, surgical hip dislocation demonstrated improved correction of the alpha angle, albeit at higher complication and revision rates than both arthroscopic and open osteotomy treatments. Further investigation, including high-quality trials with standardised radiological and clinical outcome measures for young patients, is warranted to clarify treatment approaches and safety. Cite this article: K. O. Oduwole, D. de Sa, J. Kay, F. Findakli, A. Duong, N. Simunovic, Y. Yi-Meng, O. R. Ayeni. Surgical treatment of femoroacetabular impingement following slipped capital femoral epiphysis: A systematic review. Bone Joint Res 2017;6:472–480. DOI: 10.1302/2046-3758.68.BJR-2017-0018.R1.
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Affiliation(s)
- K O Oduwole
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - D de Sa
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - J Kay
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - F Findakli
- Centre for Evidence Based Orthopaedics, McMaster University, Hamilton, Ontario, Canada
| | - A Duong
- Centre for Evidence Based Orthopaedics, McMaster University, Hamilton, Ontario, Canada
| | - N Simunovic
- Centre for Evidence Based Orthopaedics, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Y Yi-Meng
- Division of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - O R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Erickson JB, Samora WP, Klingele KE. Treatment of chronic, stable slipped capital femoral epiphysis via surgical hip dislocation with combined osteochondroplasty and Imhauser osteotomy. J Child Orthop 2017; 11:284-288. [PMID: 28904634 PMCID: PMC5584497 DOI: 10.1302/1863-2548.11.160259] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Treatment of slipped capital femoral epiphysis (SCFE), including the modified Dunn procedure, restores anatomy with significant risk for avascular necrosis (AVN), if performed in the setting of moderate to severe, stable SCFE. The Imhauser osteotomy has been shown to be an effective way to correct residual deformity without the risk of AVN. We sought to evaluate the effectiveness and safety of a combined Imhauser osteotomy and osteochondroplasty, performed via a surgical hip dislocation approach for the acute and delayed treatment of stable SCFE. METHODS A retrospective review was performed on a series of patients who underwent Imhauser osteotomy and osteochondroplasty via surgical hip dislocation for treatment of chronic, stable SCFE. Patients were divided into acute or delayed treatment groups based on whether osteotomy was performed as the initial slip treatment. RESULTS In total 19 patients (15 male, four female, average age 13.7 years) were reviewed. Six osteotomies were performed acutely in combination with in situ pinning, 13 were delayed at least six months after in situ pinning (average 21.7 months). Two hips had labral tears that required repair. The mean follow-up was 61 months (23 to 120) (delayed) and 53 months (27 to 61) (acute). The average improvement in slip angle was 40.7° (delayed) and 50.2° (acute) (p = 0.0916), final post-operative slip angle averaged 15.8° (delayed) and 17.8° (acute) (p = 0.544). Femoral neck length and greater trochanteric height were similar between both groups. Average alpha angle at final follow-up measured 55.8° (delayed) and 60.8° (acute) (p = 0.542). No cases of AVN were identified. CONCLUSION Imhauser osteotomy combined with osteochondroplasty via surgical hip dislocation approach is a safe and effective treatment of moderate to severe, stable SCFE performed in both the acute and delayed setting.
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Affiliation(s)
- J. B. Erickson
- Department of Orthopedic Surgery, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - W. P. Samora
- Department of Orthopedic Surgery, Nationwide Children’s Hospital, and Department of Orthopedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - K. E. Klingele
- Department of Orthopedic Surgery, Nationwide Children’s Hospital, and Department of Orthopedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA,Correspondence should be sent to: Dr K. E. Klingele, Department of Orthopedic Surgery, Nationwide Children’s Hospital, 700 Children’s Drive Suite, A2630 Columbus, Ohio 43205-2696, USA. E-mail:
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Abstract
UNLABELLED Slipped capital femoral epiphysis (SCFE) may lead to symptomatic femoroacetabular impingement (FAI). We report our experience of arthroscopic treatment, including osteochondroplasty, for the sequelae of SCFE. Data were prospectively collected on patients undergoing arthroscopy of the hip for the sequelae of SCFE between March 2007 and February 2013, including demographic data, radiological assessment of the deformity and other factors that may influence outcome, such as the presence of established avascular necrosis. Patients completed the modified Harris hip score (mHHS) and the non-arthritic hip score (NAHS) before and after surgery. In total, 18 patients with a mean age of 19 years (13 to 42), were included in the study. All patients presented with pain in the hip and mechanical symptoms, and had evidence of FAI (cam or mixed impingement) on plain radiographs. The patients underwent arthroscopic osteoplasty of the femoral neck. The mean follow-up was 29 months (23 to 56). The mean mHHS and NAHS scores improved from 56.2 (27.5 to 100.1) and 52.1 (12.5 to 97.5) pre-operatively to 75.1 (33.8 to 96.8, p = 0.01) and 73.6 (18.8 to 100, p = 0.02) at final follow-up, respectively. Linear regression analysis demonstrated a significant association between poorer outcome scores and increased time to surgery following SCFE (p < 0.05 for all parameters except baseline MHHS). Symptomatic FAI following (SCFE) may be addressed using arthroscopic techniques, and should be treated promptly to minimise progressive functional impairment and chondrolabral degeneration. TAKE HOME MESSAGE Arthroscopy of the hip can be used to treat femoroacetabular impingement successfully following SCFE. However, this should be performed promptly after presentation in order to prevent irreversible progression and poorer clinical outcomes.
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Affiliation(s)
| | - A P Cooper
- University of British Columbia, Vancouver, Canada
| | | | - B Balakumar
- Sheffield Children's Hospital, Sheffield, UK
| | - S Madan
- Sheffield Children's Hospital and Doncaster Royal Infirmary, Sheffield, UK
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Tscholl PM, Zingg PO, Dora C, Frey E, Dierauer S, Ramseier LE. Arthroscopic osteochondroplasty in patients with mild slipped capital femoral epiphysis after in situ fixation. J Child Orthop 2016; 10:25-30. [PMID: 26586587 PMCID: PMC4763150 DOI: 10.1007/s11832-015-0707-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 11/06/2015] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Mild slipped capital femoral epiphyses (SCFE) nevertheless show significant femoral head-neck deformities which may put cartilage and acetabular labrum at risk. Whether this deformity can be restored to normal has not yet been described in the literature. METHODS In a prospective follow-up study, 14 patients with mild SCFE underwent in situ fixation with a single 6.5-mm cancellous, partially threaded screw. In 14 patients arthroscopic osteochondroplasty was performed, and in 13 patients pre- and postoperative measurements of the α-angle were made using antero-superior radial magnetic resonance imaging. RESULTS After arthroscopic osteochondroplasty, the mean α-angle decreased from 57° (range 50°-74°) to 37° (range 32°-47°; p < 0.001). Six patients showed beginning degenerative intra-articular changes (four antero-superior cartilage and three antero-superior labrum lesions) at the time of hip arthroscopy. No intra-operative complications occurred. In one patient, arthroscopic debridement was necessary due to arthrofibrosis and persistent pain. CONCLUSION Arthroscopic osteochondroplasty can successfully correct the antero-superior α-angle in patients with mild SCFE to normal values. Clinical randomized controlled studies with long-term follow-up are required to find evidence of improved functional and radiographic mid- and long-term outcome compared to in situ fixation alone.
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Affiliation(s)
- Philippe M. Tscholl
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Patrick O. Zingg
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Claudio Dora
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Eric Frey
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Stefan Dierauer
- Orthopaedic Division, Department of Surgery, University Children’s Hospital, University Hospital of Zurich, Zurich, Switzerland
| | - Leonhard E. Ramseier
- Orthopaedic Division, Department of Surgery, University Children’s Hospital, University Hospital of Zurich, Zurich, Switzerland
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10
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Abstract
PURPOSE OF REVIEW The present review discusses the etiology, clinical presentation, and management of femoroacetabular impingement (FAI) in the pediatric population, including etiologic and diagnostic controversies, management options, and outcomes. RECENT FINDINGS New evidence demonstrates conflicting results regarding how and when primary FAI develops in relation to skeletal maturity. Recent studies also discuss the effects of sex, race, and sports on FAI development and radiographic considerations in the pediatric population. Recent literature demonstrates good to excellent outcomes in the operative management of FAI in children and adolescents. SUMMARY FAI is a source of pediatric hip pain and can occur primarily or secondarily. It is characterized by anterior hip pain, made worse with flexion activities, decreased hip internal rotation, and a positive impingement sign. Pathologic values for radiographic measures of FAI are not clearly defined in the pediatric population. As FAI is a risk factor for osteoarthritis, early intervention in specific patients may be indicated. Hip arthroscopy, surgical hip dislocation, or combined mini-open and arthroscopic approaches are utilized, with good to excellent short, and mid-term functional results. Further study is required in the pediatric population to identify potential preventive strategies, to delineate the pathologic radiographic values of FAI, to define specific indications for operative management, and to examine long-term outcomes to determine optimal management.
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Abstract
While hip arthroscopy grows in popularity, there are still many circumstances under which open hip preservation is the most appropriately indicated. This article specifically reviews open hip preservation procedures for a variety of hip conditions. Femoral acetabular impingement may be corrected using an open surgical hip dislocation. Acetabular dysplasia may be corrected using a periacetabular osteotomy. Acetabular protrusio may require surgical hip dislocation with rim trimming and a possible valgus intertrochanteric osteotomy. Legg-Calve-Perthes disease produces complex deformities that may be better served with osteotomies of the proximal femur and/or acetabulum. Chronic slipped capital femoral epiphysis may also benefit from a surgical hip dislocation and/or proximal femoral osteotomy.
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Affiliation(s)
- David M Levy
- Department of Orthopedic Surgery, Hip Preservation Center, Rush University Medical Center , Chicago, IL , USA
| | - Michael D Hellman
- Department of Orthopedic Surgery, Hip Preservation Center, Rush University Medical Center , Chicago, IL , USA
| | - Bryan Haughom
- Department of Orthopedic Surgery, Hip Preservation Center, Rush University Medical Center , Chicago, IL , USA
| | - Michael D Stover
- Department of Orthopedic Surgery, Northwestern Memorial Hospital , Chicago, IL , USA
| | - Shane J Nho
- Department of Orthopedic Surgery, Hip Preservation Center, Rush University Medical Center , Chicago, IL , USA
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Abstract
We report the clinical and radiological outcome of subcapital osteotomy of the femoral neck in the management of symptomatic femoroacetabular impingement (FAI) resulting from a healed slipped capital femoral epiphysis (SCFE). We believe this is only the second such study in the literature. We studied eight patients (eight hips) with symptomatic FAI after a moderate to severe healed SCFE. There were six male and two female patients, with a mean age of 17.8 years (13 to 29). All patients underwent a subcapital intracapsular osteotomy of the femoral neck after surgical hip dislocation and creation of an extended retinacular soft-tissue flap. The mean follow-up was 41 months (20 to 84). Clinical assessment included measurement of range of movement, Harris Hip Score (HHS) and Western Ontario and McMaster Universities Osteoarthritis score (WOMAC). Radiological assessment included pre- and post-operative calculation of the anterior slip angle (ASA) and lateral slip angle (LSA), the anterior offset angle (AOA) and centre head–trochanteric distance (CTD). The mean HHS at final follow-up was 92.5 (85 to 100), and the mean WOMAC scores for pain, stiffness and function were 1.3 (0 to 4), 1.4 (0 to 6) and 3.6 (0 to 19) respectively. There was a statistically significant improvement in all the radiological measurements post-operatively. The mean ASA improved from 36.6° (29° to 44°) to 10.3° (5° to 17°) (p < 0.01). The mean LSA improved from 36.6° (31° to 43°) to 15.4° (8° to 21°) (p < 0.01). The mean AOA decreased from 64.4° (50° to 78°) 32.0° (25° to 39°) post-operatively (p < 0.01). The mean CTD improved from -8.2 mm (-13.8 to +3.1) to +2.8 mm (-7.6 to +11.0) (p < 0.01). Two patients underwent further surgery for nonunion. No patient suffered avascular necrosis of the femoral head. Subcapital osteotomy for patients with a healed SCFE is more challenging than subcapital re-orientation in those with an acute or sub-acute SCFE and an open physis. An effective correction of the deformity, however, can be achieved with relief of symptoms related to impingement. Cite this article: Bone Joint J 2014;96-B:1441–8.
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Affiliation(s)
- K. Bali
- University of Calgary, Department
of Orthopedics, 3134 Hospital Drive North West Calgary, Alberta, T2N
5A1, Canada
| | - P. Railton
- University of Calgary, Department
of Orthopedics, 3134 Hospital Drive North West Calgary, Alberta, T2N
5A1, Canada
| | - G. N. Kiefer
- Alberta Children’s Hospital., Shaganappi
Trail North West, Calgary, Alberta, T3B
6A8, Canada
| | - J. N. Powell
- University of Calgary, Department
of Orthopedics, 3134 Hospital Drive North West Calgary, Alberta, T2N
5A1, Canada
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Murgier J, de Gauzy JS, Jabbour FC, Iniguez XB, Cavaignac E, Pailhé R, Accadbled F. Long-term Evolution of Slipped Capital Femoral Epiphysis Treated by in Situ Fixation: A 26 Years Follow-up of 11 Hips. Orthop Rev (Pavia) 2014; 6:5335. [PMID: 25002939 PMCID: PMC4083312 DOI: 10.4081/or.2014.5335] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 04/18/2014] [Indexed: 01/30/2023] Open
Abstract
Slipped capital femoral epiphysis (SFCE) may lead to femoro acetabular impingement and long-term function impairment, depending on initial displacement and treatment. There are several therapeutic options which include in situ fixation (ISF). The objective of this study was to evaluate long-term functional and radiographic outcomes of patients with SFCE treated with ISF. We conducted a single-center, retrospective study evaluating the clinical and radiographic outcomes of SCFE in situ fixation with a mean follow-up of 26 years (10-47). Analysis of preoperative and last follow up radiographs was performed. The functional status of the hip was evaluated according to the Oxford hip score-12 and the radiographic osteoarthritis stage was rated according to Tönnis classification. Signs of femoro acetabular impingement were sought. Ten patients (11 hips) were included. The average initial slip was 33.5° (10-62). At final follow up, the average Oxford hip score was 19.3 (12-37), it was good for groups who had a small initial slip (16.7) or moderate (17) and fair for the severe group (27). Average Tönnis grade was 1.3 (0-3). The average alpha angle was 65.3° (50-80°). Femoro acetabular impingement was likely in 100% of patients with severe slip, in 50% of patients with moderate slip and in 33% of patients with a slight slip. In situ fixation generated poor functional results, substantial hip osteoarthritis and potential femoro acetabular impingement in moderate to severe SCFE's. However, in cases with minor displacement, functional and radiographic results are satisfactory. The cut off seems to be around 30° slip angle, above which other treatment options should be considered.
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Affiliation(s)
- Jérôme Murgier
- Department of Orthopedics and Trauma Surgery, Musculoskeletal Institute, Pierre Paul Riquet Hospital , Toulouse, France
| | | | - Fouad C Jabbour
- Department of Orthopedics, Saint George University Hospital, University of Balamand , Beirut, Lebanon
| | - Xavier Bayle Iniguez
- Department of Orthopedics and Trauma Surgery, Musculoskeletal Institute, Pierre Paul Riquet Hospital , Toulouse, France
| | - Etienne Cavaignac
- Department of Orthopedics and Trauma Surgery, Musculoskeletal Institute, Pierre Paul Riquet Hospital , Toulouse, France
| | - Régis Pailhé
- Department of Orthopedics and Trauma Surgery, Musculoskeletal Institute, Pierre Paul Riquet Hospital , Toulouse, France
| | - Franck Accadbled
- Department of Pediatric Orthopedics, Hôpital des Enfants , Toulouse, France
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Murgier J, Reina N, Cavaignac E, Espié A, Bayle-Iniguez X, Chiron P. The frequency of sequelae of slipped upper femoral epiphysis in cam-type femoroacetabular impingement. Bone Joint J 2014; 96-B:724-9. [DOI: 10.1302/0301-620x.96b6.33000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Slipped upper femoral epiphysis (SUFE) is one of the known causes of cam-type femoroacetabular impingement (FAI). The aim of this study was to determine the proportion of FAI cases considered to be secondary to SUFE-like deformities. We performed a case–control study on 96 hips (75 patients: mean age 38 years (15.4 to 63.5)) that had been surgically treated for FAI between July 2005 and May 2011. Three independent observers measured the lateral view head–neck index (LVHNI) to detect any SUFE-like deformity on lateral hip radiographs taken in 45° flexion, 45° abduction and 30° external rotation. A control group of 108 healthy hips in 54 patients was included for comparison (mean age 36.5 years (24.3 to 53.9). The impingement group had a mean LVHNI of 7.6% (16.7% to -2%) versus 3.2% in the control group (10.8% to -3%) (p < 0.001). A total of 42 hips (43.7%) had an index value > 9% in the impingement group versus only six hips (5.5%) in the control group (p < 0.001). The impingement group had a mean α angle of 73.9° (96.2° to 53.4°) versus 48.2° (65° to 37°) in the control group (p < 0.001). Our results suggest that SUFE is one of the primary aetiological factors for cam-type FAI. Cite this article: Bone Joint J 2014; 96-B:724–9.
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Affiliation(s)
- J. Murgier
- Pierre Paul Riquet Hospita, Orthopaedics
and Trauma Surgery, Musculoskeletal Institute, 308
avenue de Grande Bretagne, 31059, Toulouse, France
| | - N. Reina
- Pierre Paul Riquet Hospita, Orthopaedics
and Trauma Surgery, Musculoskeletal Institute, 308
avenue de Grande Bretagne, 31059, Toulouse, France
| | - E. Cavaignac
- Pierre Paul Riquet Hospita, Orthopaedics
and Trauma Surgery, Musculoskeletal Institute, 308
avenue de Grande Bretagne, 31059, Toulouse, France
| | - A. Espié
- Pierre Paul Riquet Hospita, Orthopaedics
and Trauma Surgery, Musculoskeletal Institute, 308
avenue de Grande Bretagne, 31059, Toulouse, France
| | - X. Bayle-Iniguez
- Pierre Paul Riquet Hospita, Orthopaedics
and Trauma Surgery, Musculoskeletal Institute, 308
avenue de Grande Bretagne, 31059, Toulouse, France
| | - P. Chiron
- Pierre Paul Riquet Hospita, Orthopaedics
and Trauma Surgery, Musculoskeletal Institute, 308
avenue de Grande Bretagne, 31059, Toulouse, France
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15
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Abstract
Femoroacetabular Impingement (FAI) is characterized by abnormal contact of the hip joint. Many etiologies cause this painful condition, which leads to early osteoarthritis. While hip arthroscopy has become the most prevalent way to surgically correct a hip, some presentations of FAI require open surgical hip preservation techniques to fully address the pathology at hand. Certain head neck deformities may require open surgical hip dislocation utilizing a trochanteric slide osteotomy. A retroverted acetabulum may require an open periacetabular osteotomy to gain anteversion and eliminate impingement in the hip joint. Acetabular protrusio may require surgical hip dislocation with rim trimming and a possible valgus intertrochanter osteotomy. The sequelae of Legg-Calvé-Perthes disease causes complex abnormalities about the hip joint, which may require open surgery to address both the intra-articular pathology and the extra-articular pathology. Osteotomies of the proximal femur and acetabulum may all be necessary to restore a hip back to normal morphology. Chronic slipped capital femoral epiphysis (SCFE) may also require open surgical hip dislocations and complex intertrochanter osteotomies to recreate normal morphology.
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Affiliation(s)
- Michael D Hellman
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA,
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