Hip arthroscopy in the adolescent and pediatric athlete

Hip arthroscopy is a successful treatment for femoroacetabular impingement in under-16 competitive football players: a prospective study with minimum 2-year follow-up

INTRODUCTION

Femoroacetabular impingement is considered a spectrum disease affecting multiple hip structures and it is especially prevalent in football players. Hip arthroscopy has shown good results in this population. However, little attention has been given to its efficacy in children and adolescent players. The aim of this study is to evaluate the outcomes of hip arthroscopy in under-16 football players.

MATERIALS AND METHODS

Between 2008 and 2019, all under-16 competitive football players who underwent hip arthroscopy for the treatment of femoroacetabular impingement were recruited for this prospective study. Hip pain and function were measured through the VAS, HOS, mHHS and WOMAC scores before the surgery, at 1-year after the surgery and at minimum 2-years after surgery. Preoperative and postoperative scores were compared to  establish the evolution of hip pain and function. Additionally, rate and time to return to play were recorded.

RESULTS

14 subjects were included in the analysis. All subjects attended to the last follow-up, at mean 3.21 years after the surgery (range 2-10). Mean ± SD VAS (0-100) scores were 60.14 ± 15.88 before the surgery, 6.43 ± 5.19 at 1-year follow-up and 5.07 ± 4.05 at final follow-up (p < 0.05). Significant improvements were observed in HOS ADL, HOS SS, mHHS and WOMAC (p < 0.05) between preoperative values and 1-year follow-up. No significant differences were found in knee pain or function between 1-year and final follow-up assessments (p > 0.05). All subjects (100%) were playing football 1-year after the surgery, with a mean ± SD time to return to play of 5.93 ± 2.09 months. 13 subjects (92.86%) were still playing at final follow-up.

CONCLUSIONS

Hip arthroscopy is a safe and effective surgical procedure for the treatment of FAI in under-16 competitive football players, improving hip pain and function with excellent rates to return to play.

Functional Outcomes of Hip Arthroscopy for Pediatric and Adolescent Hip Disorders

Background

There is a paucity of literature on the use of hip arthroscopy for pathologic conditions in skeletally immature patients. Thus, the indications and safety of the procedure are still unclear. The purpose of this study was to investigate the safety and functional outcomes of hip arthroscopy for pediatric and adolescent hip disorders. We further attempted to characterize arthroscopic findings in each disease.

Methods

We retrospectively reviewed 32 children and adolescents with hip disorders who underwent 34 hip arthroscopic procedures at a tertiary care children's hospital from January 2010 to December 2016. We evaluated functional limitations and improvement after operation by using the modified Harris hip score (HHS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), subjective pain assessment with a visual analog scale (VAS), and range of hip motion as well as the complications of hip arthroscopy. Arthroscopic findings in each disease were recorded.

Results

Hip arthroscopy was performed for Legg-Calvé-Perthes disease (n = 6), developmental dysplasia of the hip (n = 6), slipped capital femoral epiphysis (n = 5), idiopathic femoroacetabular impingement (n = 6), sequelae of septic arthritis of the hip (n = 3), hereditary multiple exostosis (n = 2), synovial giant cell tumor (n = 3), idiopathic chondrolysis (n = 2), and posttraumatic osteonecrosis of the femoral head (n = 1). Overall, there was a significant improvement in the modified HHS, WOMAC, VAS, and range of hip motion. Symptom improvement was not observed for more than 18 months in four patients who had dysplastic acetabulum with a labral tear (n = 2) or a recurrent femoral head bump (n = 2). There were no complications except transient perineal numbness in five patients.

Conclusions

Our short-term follow-up evaluation shows that hip arthroscopy for pediatric and adolescent hip disorder is a less invasive and safe procedure. It appears to be effective in improving functional impairment caused by femoroacetabular impingement between the deformed femoral head and acetabulum or intra-articular focal problems in pediatric and adolescent hip disorders.

Magnetic Resonance Imaging in Symptomatic Children With Hereditary Multiple Exostoses of the Hip

BACKGROUND

Magnetic resonance imaging (MRI) is useful in evaluating nontraumatic hip pain. It provides information about associated injuries like labral/chondral tears or ischiofemoral impingement (IFI). However, in hereditary multiple exostoses (HME) there has been no report about MRI findings in symptomatic children with hip involvement.

METHODS

Records of children with HME and hip osteochondromas, who had hip MRI/magnetic resonance arthrography, were reviewed. The presence of chondral lesions and labral tears, as well the presence of IFI, was recorded. IFI was defined as edema or fatty replacement/atrophy in the quadratus femoris muscle or decrease of the space for this muscle between the ischium and the proximal femur. The measurements used to determine the space included the ischiofemoral space, the quadratus femoris space, and the minimum ischiofemoral space (MIFS). All measurements were performed on axial T1-weighted images.

RESULTS

Ten children were included (4 males, 6 females). In 2 patients, MRI was unilateral, therefore a total of 18 hips were analyzed. The indication for MRI was hip pain. Mean age, when MRI was performed, was 11.7 years. Labral tears were found in 44% (8/18) and chondral lesions in 33% (6/18) of the hips. The mean ischiofemoral space was 17.2 mm (SD, 7.3), the mean quadratus femoris space was 14.9 mm (SD, 5.3), and the mean MIFS was of 12.8 mm (SD, 5.9). IFI was seen in 44% (8/18) of hips. Two patients had bilateral IFI. MIFS was <10 mm in all hips with IFI (8/8). Of these hips, 88% (7/8) had edema of the quadratus femoris muscle and 38% (3/8) had fatty replacement/atrophy in the muscle. Osteochondromas were seen in the lesser trochanter in all hips with IFI (8/8) and in the ischium in 50% of them (4/8).

CONCLUSIONS

In symptomatic children with HME of the hip, MRI is helpful in detecting the source of pain. A high percentage of these children have IFI and intra-articular lesions. These findings can play an important role in the indication and planning of the surgical approach.

LEVEL OF EVIDENCE

Level IV-diagnostic study.

Outcomes of Hip Arthroscopy in Adolescents: A Comparison of Acute Versus Chronic Presentation. Two-Year Minimum Follow-up

BACKGROUND

Hip arthroscopy has been shown to be effective in managing various hip pathologies, including labral tears in adolescent patients. The purpose of this study was to ascertain whether outcomes of hip arthroscopy in patients under the age of 18 treated for labral tears differ depending on whether the presentation was acute or chronic. We also present the outcomes of the largest prospectively collected study on hip arthroscopy performed for labral tears in adolescents.

METHODS

Patient reported outcome scores (PROs) for 194 patients undergoing hip arthroscopy for hip pathology, who were 18 or under at the time of surgery were prospectively collected and retrospectively reviewed. Modified Harris hip score (mHHS), Nonarthritic hip score (NAHS), Hip Outcome score-sport specific scale (HOS-SSS) and Visual Analogue Score (VAS) were the PROs collected. The overall cohort was assessed for outcome and a comparison was made between those patients who presented with acute onset of symptoms versus those who presented with insidious onset.

RESULTS

There was significant improvement in all the PROs for the overall cohort, with improvement maintained over an average of 38.5 months. There was no significant difference in outcome scores, between the acute and chronic groups except for change in VAS. Preoperative scores in the acute group were significantly lower, while postoperative scores did not differ. A trend toward more improvement was noted for the acute group. Overall need for revision surgery was 12%, with a higher rate of revision in the acute group.

CONCLUSIONS

Hip arthroscopy in adolescent patients being treated for intra-articular pathology is a safe procedure with favorable outcomes at minimum 2-year follow-up, with no significant difference in final outcomes between patients with acute onset of symptoms as opposed to those with more a more chronic presentation. Reoperation rate may be higher in patients with an acute onset.

LEVEL OF EVIDENCE

Level II.

Does Bony Regrowth Occur After Arthroscopic Femoroplasty in a Group of Young Adolescents?

PURPOSE

To evaluate femoral head-neck bone regrowth and PROs in skeletally immature patients that underwent arthroscopic femoroplasties over a minimum 2-year period.

METHODS

Eleven skeletally immature hips (10 patients) with open femoral head physes underwent femoroplasty between October 2008 and November 2013. Inclusion criteria were minimum 2-year follow-up with patient-reported outcomes (PROs) and radiographs preoperatively, at 2 weeks, and at a minimum of 2 years postoperatively. Exclusion criteria were >16 years of age, preoperative Tönnis grade >1 and previous hip conditions. Preoperative radiographs were used to assess skeletal immaturity, which was indicated by a Risser score ≤4 and femoral head physis >1 mm. Alpha angles were measured preoperatively, at 2 weeks, and at a minimum of 2 years postoperatively. PROs, including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) score, were measured preoperatively and at the latest follow-up.

RESULTS

Mean age at surgery was 14.7 years (range: 13.2-15.9). Mean follow-up was 35.7 months (range: 23.3-61.4). All hips tested positive for anterior impingement preoperatively. The mean preoperative alpha angle was 61.8°, which decreased to 41.5° postoperatively (P < .0001) and was 40.7° at a minimum of 2 years postoperatively. No bony regrowth was documented at the latest follow-up. Mean improvements in scores were as follows: mHHS = 58.5 to 79.8 (P < .0001), NAHS = 56.8 to 87.1 (P = .008), HOS-SSS = 34.3 to 78.3 (P = .004), and VAS score = 7.5 to 1.3 (P < .0001). Mean patient satisfaction was 8.7 ± 1.7. One hip (9.0%) required revision arthroscopy at 31.1 months. No postoperative complications were reported.

CONCLUSIONS

Bony regrowth of the femoral head-neck region did not occur in this study of skeletally immature females who underwent arthroscopic femoroplasty. In this group of patients, hip arthroscopic treatment of FAI and labral tears is a safe and favorable intervention because of its high patient satisfaction and outcome scores and absence of postoperative complications.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Clinical and surgical correlation of hip MR arthrographic findings in adolescents

OBJECTIVE

The purpose of this study was to analyze the utility of MRA-H in adolescents by comparing the results of imaging with surgical findings and/or clinical outcome.

MATERIAL AND METHODS

After obtaining appropriate IRB approval, the Radiologic Information System database was queried for all patients 13-18 years of age who underwent MRA-H from 2004 through 2013. The electronic medical record was reviewed for clinical history, clinical examination findings, and operative notes. MRA-H images were reviewed for soft tissue abnormalities (labral tear, paralabral ganglion, articular cartilage loss, synovitis, ligament tears) and bony abnormalities (cam-type femoroacetabular impingement (FAI), pincer-type FAI, hip dysplasia). MRA-H findings were correlated with surgical findings and with clinical outcomes.

RESULTS

Twenty-six patients with labral tears by MRA-H were included in study and grouped as follows: Group I) patients who underwent surgical management (n=10); group II) patients managed non-surgically (medication, intra-articular injection, physical therapy) (n=9); group III) patients lost to follow up after being advised to have surgery (n=7). With regard to presenting symptomatology, 87.5% of patients with labral tear had groin pain. Of those patients who were diagnosed with a labral tear, 52% were categorized as idiopathic labral tears, 26% as secondary tears (secondary to abnormal bony morphology), and 22% as traumatic labral tears. The labral tears were found to be anterior in 61% and posterior in 22%. Associated articular cartilage lesions were found in 29% of patients. In group I (surgical patients), MRA-H labral findings were confirmed at surgery in 9/10. Seventy percent of labral tears in our study had some form of abnormal bony morphology. Nine of the 12 patients with bone abnormalities were derived from group I patients. Six out of 7 patients with cam-type FAI had a labral tear.

CONCLUSION

Labral tears diagnosed by MRA-H in the adolescent population correlated well with clinical examination and surgical findings. Also, MRA-H contributed by defining bony morphology that was directly applied to surgical management. Non-surgical management of labral tears diagnosed on MRA-H had a generally favorable outcome.

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.

Complications following hip arthroscopy: a systematic review and meta-analysis

PURPOSE

The use of hip arthroscopy to address injuries and conditions about the hip is becoming more widespread. There are several narrative reviews regarding complications of hip arthroscopy but a systematic review is currently lacking. The primary goal of this study is to determine the complication rate associated with hip arthroscopy in the literature.

METHODS

A search of the EMBASE and Ovid Medline databases was performed to identify articles published between 1 January 2000 and 25 November 2011 that reported a complication rate after hip arthroscopy. Appropriate inclusion and exclusion criteria were applied to identify articles, and a meta-analysis was performed to determine an overall complication rate. Complications were divided into major and minor.

RESULTS

A total of 66 papers (n = 6,962 hip arthroscopies) were identified and deemed appropriate for analysis. The overall complication rate was found to be 4.0 % (95 % CI 2.9-5.2 %). Of the 287 complications identified in the literature, 20 were deemed major constituting a rate of 0.3 %.

CONCLUSIONS

Hip arthroscopy appears to be safe. The vast majority of complications are minor in nature. Prospective trials looking at the complications of hip arthroscopy would aid in identifying prognostic factors.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, Level III.

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.

Hip arthroscopy improves symptoms associated with FAI in selected adolescent athletes

BACKGROUND

Femoroacetabular impingement (FAI) is increasingly diagnosed in young and middle-aged patients. Although arthroscopic procedures are becoming frequently used in the treatment of FAI, there are little data regarding rates of complications or the ability of hip arthroscopy to improve hip function specifically in the adolescent athlete population. Because arthroscopic treatment is being used in the treatment of FAI, it is vital to know what, if any, improvements in hip function can be expected and the potential complications.

QUESTIONS/PURPOSES

We asked (1) whether validated measures of hip function improve after arthroscopic treatment of FAI in adolescent athletes, and (2) what complications might be expected during and after arthroscopic treatment of FAI in these patients.

METHODS

We retrospectively reviewed the records of 27 hips in 21 patients 19 years of age or younger who underwent arthroscopic treatment for FAI between 2007 and 2008. From the records we extracted demographic data, operative details, complications, and preoperative and postoperative modified Harris hip scores (HHS) and the Hip Outcome Score (HOS). The minimum followup was 1 year (average, 1.5 years; range, 1-2.5 years).

RESULTS

Modified HHS improved by an average of 21 points, the activities of daily living subset of the HOS improved by an average of 16 points, and the sports outcome subset of the HOS improved by an average of 32 points. All patients' self-reported ability to engage in their preoperative level of athletic competition improved. In 24 hips that underwent cam decompression, the mean alpha-angle improved from 64° ± 16° to 40° ± 5.3° postoperatively.

CONCLUSIONS

We found short-term improvements in HOS and HHS with no complications for arthroscopic treatment of FAI in our cohort of adolescent athletes. We believe arthroscopic treatment of FAI by an experienced hip arthroscopist should be considered in selected patients when treating athletically active adolescents for whom nonoperative management fails.

Arthroscopic mobilization of the hip joint in children with aseptic necrosis of the femur head

The purpose of the study was to evaluate the ability of arthroscopic mobilization of the hip to improve restricted range of motion after failed conservative therapy (level IV) of patient with aseptic necrosis of the femoral head. We examined 11 patients (eight male, three female). The average age at follow-up was 13 years (8-17 years). All 11 patients suffered from idiopathic femur head necrosis (M. Perthes). A minimum 1-year follow-up revealed an average increase of hip motion of 20 degrees of flexion, 15 degrees of abduction (P=0.007), 30 degrees of adduction (P=0.03), 15 degrees of external rotation, and 20 degrees of internal rotation. Arthroscopic hydraulic hip distension with postoperative physiotherapy in a brace under epidural anesthesia of the hip joint leads to an increased range of motion of the affected hip and allows additional intraarticular assessment of the joint. Whether the arthroscopic findings will alter the treatment and prognosis of future patients has to be established with further studies.

Current concepts in pediatric and adolescent arthroscopy

Arthroscopy continues to grow as a treatment modality for pediatric and adolescent orthopaedic pathologies. In recent years arthroscopic procedures previously reserved for adult patients have become more frequently used in the treatment of younger individuals. Advancements in arthroscopic instrumentation including smaller arthroscopes and tools have made the constraint of smaller joint spaces in the pediatric and adolescent populations less of a limiting factor when addressing surgical options for care. This is valuable considering the consistent increase in pediatric sports- and activity-related injuries, of which many are treatable arthroscopically. Currently, arthroscopy is indicated for the treatment of various chronic and acute injuries of the shoulder, elbow, wrist, hip, knee, and ankle. This review aims to highlight the current literature regarding arthroscopy in this population while also offering treatment algorithms, rehabilitation guidelines, and surgical tips for various pathologies in pediatric and adolescent patients.

Rehabilitation of the hip following sports injury

An athlete often presents to the rehabilitation specialist with either a nonspecific referral, such as "hip pain," or with a diagnosis of a more specific hip pathology. The highly skilled clinician is trained to look at the "linkage" between the trunk and all parts of the lower extremity. Why is the hip not transferring the load well? Where is the breakdown? The gluteus medius, pelvic stability, and supportive muscular slings are of great importance when optimizing the function of the hip. The hip is subjected to forces equal to multiples of the body weight and requires osseous, articular and myofascial integrity for stability. This is the mind set when devising an athlete's rehabilitative program, looking at all influential factors that affect joint movement and integrity.

Acetabular labral tears in patients with sports injury

Background

We wanted to investigate acetabular labral tears and their correlation with femoroacetabular impingement in patients with sports injury.

Methods

Among 111 patients who were diagnosed with the acetabular labral tears after arthroscopic treatment from January 2004 to December 2007, we selected 41 patients with sports injury. There were 12 cases of Taekwondo injury, 5 of golf injury, 4 of soccer injury, 3 of gymnastics injury, 2 of Hapkido injury, 2 of aerobics injury, 2 of rock-climbing injury, 2 of fitness training injury and 9 of other sports injuries. We checked the subtypes of acetabular labral tears and the accompanying femoroacetabular impingement. For the cases with accompanying femoroacetabular impingement, we investigated the subtypes according to the types of sports, gender and age. At last follow-up, we checked the Harris Hip Score (HHS), the Hip Outcome Score (HOS) sports scale and the percentage of patients who returned to their sports activity.

Results

The average age of symptomatic onset was 26 years (range, 12 to 65 years). The ratio of males to females was 29 : 12. An average duration of the hip pain was 17 months (range, 1 to 60 months). The degenerative type of acetabular labral tears was the most prevalent with 32 cases (78%), and there were 9 cases (22%) of the partial tear type. Thirty cases (73%) were accompanied by femoroacetabular impingement. The average age of the 23 cases (56%) of the cam-type was 23 years (range, 12 to 48 years), and it was more likely to occur in men (87%) and for people practicing martial arts such as Taekwondo or Hapkido. An average age of the 5 cases (12%) of the pincer-type was 26 (range, 16 to 43 years), it usually occurred in women (60%) and for non-martial arts such as golf and gymnastics. There were 2 cases of the mixed type (cam + pincer-type). At 27 months follow-up, the HHS was 61 to 92 points, the HOS sports scale increased 43 to 75%, and the rate of returning to sports was 71%.

Conclusions

In spite of the early expression of symptoms and the short duration of the acetabular labral tears, the high rate of degenerative acetabular labral tears in sports patients is likely associated with repetitive injury after the expression of symptoms. Femoroacetabular impingement in sports patients is seemed to be a cause of the early occurrence of acetabular labral tears. Because the possibility of acetabular labral tears is high in femoroacetabular impingement, sports patients may need to undergo early screening for the diagnosis and care of femoroacetabular impingement.

Arthroscopy of the hip in children and adolescents

Intra-articular abnormalities of the hip, such as labral tears, loose bodies, chondral lesions, ligamentum teres tears and femoral acetabular impingement are increasingly being recognized in the pediatric age group. Evaluation for these abnormalities starts with a good history and physical exam. Radiographic imaging with plain films and magnetic resonance imaging help confirm the clinical impression. Arthroscopy of the hip can be utilized to diagnose and treat these abnormalities. Arthroscopy of the hip is a challenging procedure with a learning curve that requires a thorough knowledge of the anatomy of the hip. The hip is a deeply recessed joint that has a large muscular envelope, thick joint capsule and convex and concave surfaces of the femoral head and acetabulum, respectively. The normal anatomy may be distorted due to childhood developmental disorders such as hip dysplasia, Legg-Calve-Perthes Disease and Slipped Capital Femoral Epiphysis that adds additional challenges to the arthroscopist. Isolated intra-articular abnormalities occur rarely and an underlying morphologic abnormality should be identified which also requires management. Complications can be minimized with attention to detail.

Bilateral symptomatic hypertrophic ligamentum teres of the hip in a young athlete

We report the case of a 14-year-old female gymnast who presents with bilateral hip pain and mechanical symptoms with extremes of range of motion. The patient failed conservative management and had worsening symptoms, including pain at rest. Diagnostic imaging failed to provide any definitive diagnosis and the patient underwent staged bilateral hip arthroscopies with debridement of inflamed, hypertrophic ligamentum teres. The patient did well postoperatively and has returned to athletic activities.

The management of labral tears and femoroacetabular impingement of the hip in the young, active patient

PURPOSE

The purpose of this systematic review was to determine (1) the quality of the literature assessing outcomes after surgical treatment of labral tears and femoroacetabular impingement (FAI), (2) patient satisfaction after open or arthroscopic intervention, and (3) differences in outcome with open or arthroscopic approaches.

METHODS

Computerized literature databases were searched to identify relevant articles from January 1980 to May 2008. Studies were eligible for inclusion if they had a level I, II, III, or IV study design and if the patient population had a labral tear and/or FAI as the major diagnosis. Patients with severe pre-existing osteoarthritis or acetabular dysplasia were excluded.

RESULTS

Of the 19 articles with reported outcomes after surgery, none used a prospective study design and only 1 met the criteria for level III basis of evidence. Open surgical dislocation with labral debridement and osteoplasty is successful, with a good correlation between patient satisfaction and favorable outcome scores. The studies reviewed support that 65% to 85% of patients will be satisfied with their outcome at a mean of 40 months after surgery. A common finding in all series, however, was an increased incidence of failure among patients with substantial pre-existing osteoarthritis. Arthroscopic treatment of labral tears is also effective, with 67% to 100% of patients being satisfied with their outcomes.

CONCLUSIONS

The quality of literature reporting outcomes of surgical intervention for labral tears and FAI is limited. Although open surgical dislocation with osteoplasty is the historical gold standard, the scientific data do not show that open techniques have outcomes superior to arthroscopic techniques.

LEVEL OF EVIDENCE

Level IV, systematic review.

Arthroscopic chondral cyst excision in a stiff Perthes' hip

Persistent hip stiffness in Perthes' disease indicates a poor prognosis and is a therapeutic challenge. We report a case of a 13-year-old boy with a stiff Perthes' hip that was nonresponsive to prolonged nonsurgical treatment. Imaging revealed Catterall group IV Perthes' disease in an advanced reossification stage, with a focal defect in the weight-bearing area of the capital femoral epiphysis. A focal, compressible chondral elevation was detected on hip arthroscopy; on incision, flocculent fluid was released. After the cyst was excised, microfracture revascularization of the chondral defect was undertaken. Postoperatively, the patient had immediate pain relief, correction of deformity, and restoration of painless range of motion; this has continued for 4 years since surgery was performed. Persistence of an unhealed necrotic segment in Perthes' disease has traditionally been associated with osteochondritis dissecans; however, in this case, the unhealed and nonossified segment produced an elevated painful chondral cyst that caused spasm and stiffness of the hip. Although 2 distinct types of chondral lesions have been described in Perthes' disease, stiffness arising because of these lesions has not been reported. Patients with this unusual third type of chondral lesion of the capital femoral epiphysis, which causes persistent stiffness in Perthes' hip, may be identified and successfully treated with the use of arthroscopic techniques.

Arthroscopic management of labral tears in the hip: a systematic review of the literature

Arthroscopic management of labral problems in the hip has become an accepted therapeutic modality in appropriately selected patients. We performed a systematic review of the literature to determine the rate of patient satisfaction that can be expected following acetabular labral débridement. Computerized literature databases were searched from January 1980 to September 2005 to identify relevant articles that met inclusion criteria and had at least 2 years followup. We included patients with symptomatic acetabular labral tears who failed conservative management, were not claiming workers' compensation, and did not have severe arthritis or severe acetabular dysplasia. Following labral débridement this patient population can expect: (1) a patient satisfaction rate of approximately 67% at 3.5 years follow-up; (2) good results by a modified Harris Hip Score in patients who are subjectively satisfied with their outcome; and (3) a complete resolution of mechanical symptoms in nearly 50% of patients with this complaint. Although limited, the current literature supports non workers' compensation patients with isolated labral tears, who lack associated intraarticular abnormality, can receive both symptomatic and functional improvement following arthroscopic labral débridement.

Nontraumatic osteonecrosis of the femoral head: ten years later

The etiology of osteonecrosis of the hip may have a genetic basis. The interaction between certain risk factors and a genetic predisposition may determine whether this disease will develop in a particular individual. The rationale for use of joint-sparing procedures in the treatment of this disease is based on radiographic measurements and findings with other imaging modalities. Early diagnosis and intervention prior to collapse of the femoral head is key to a successful outcome of joint-preserving procedures. The results of joint-preserving procedures are less satisfactory than the results of total hip arthroplasty for femoral heads that have already collapsed. New pharmacological measures as well as the use of growth and differentiation factors for the prevention and treatment of this disease may eventually alter our treatment approach, but it is necessary to await results of clinical research with long-term follow-up of these patients.

Pediatric Athlete Hip Disorders

Injuries of the hip and pelvis in pediatric athletes are receiving increased attention. The majority of injuries are soft tissue injuries or apophyseal injuries that heal with nonoperative supportive treatment. Unique injury patterns can be seen in patients who have underlying pediatric hip disorders such as slipped capital femoral epiphysis, and Legg-Perthes disease. With the advent of hip arthroscopy and the development of more advanced imaging of the hip through MR arthrography, internal derangements of the hip such as labral tears, loose bodies, and chondral injuries are being diagnosed and treated with increased frequency. This article reviews the more common injuries of the hip and pelvis in pediatric athletes.

Hip arthroscopy in children and adolescents

Hip arthroscopy has become an established procedure for certain indications in adults; however, experience in children and adolescents has been more limited. This article reviews the technique, indications, and results of hip arthroscopy in children and adolescents.

Hip arthroscopy in children and adolescents

Hip arthroscopy has become an established procedure for certain indications in adults, but experience in children and adolescents has been more limited. The purpose of this study is to report the early-term results of hip arthroscopy in children and adolescents. A consecutive case series of 54 hip arthroscopies in 42 patients 18 years old and younger over a 3-year period at a tertiary-care children's hospital with a minimum of 1 year of follow-up was reviewed. Patients were assessed with the modified Harris hip score (HHS) before and after surgery. Overall results and results by common diagnoses were analyzed. Indications for surgery included isolated labral tear (n = 30), Perthes disease (n = 8), hip dysplasia with labral tear after prior periacetabular osteotomy (n = 8), inflammatory arthritis (n = 3), spondyloepiphyseal dysplasia (n = 2), avascular necrosis (n = 1), slipped capital femoral epiphysis (n = 1), and osteochondral fracture (n = 1). Overall, there was a significant improvement in HHS from 53.1 to 82.9 (P < 0.001), with 83% of patients improved. By diagnosis, significant improvement in HHS was seen for patients with isolated labral tears undergoing labral debridement (before surgery 57.6; after surgery 89.2; P < 0.001), for patients with Perthes disease undergoing chondroplasty and loose body excision (before surgery 49.5; after surgery 80.1; P < 0.001), and for patients with hip dysplasia after prior periacetabular osteotomy undergoing labral debridement (before surgery 51.8; after surgery 79.8; P < 0.001). Complications included transient pudendal nerve palsy (n = 3), instrument breakage (n = 1), and recurrent labral tear (n = 3). Hip arthroscopy in children and adolescents appears to be safe and efficacious for certain indications in the short term.

Pediatric femoral avascular necrosis after pyarthrosis: use of free vascularized fibular grafting

Pyarthrosis of a child's hip can lead to osteonecrosis of the femoral head. Symptomatic treatment options for this condition are limited. We supposed that free vascularized fibula autografting would improve range of motion, decrease pain, and increase function in patients with symptomatic osteonecrosis of the pediatric femoral head secondary to pyarthrosis. We prospectively evaluated seven consecutive patients who presented with Stages IV and V osteonecrosis of the femoral head. All patients were treated with free vascularized fibular autografting to the femoral head. Postoperative evaluations of range of motion, pain symptoms, and functional activity showed improvements in all patients. Range of motion of the hip was significantly improved in the arcs of flexion (+23 degrees) and external rotation (+22 degrees). Harris hip scores significantly increased from an average preoperative score of 68 to an average postoperative score of 96. No patients needed revision surgery to hip arthrodesis or arthroplasty within the 3-year 11-month followup.

The young adult with hip pain: diagnosis and medical treatment, circa 2004

Hip pain in young adults (18-35 years old) often is characterized by nonspecific symptoms, normal imaging studies, and vague findings from the history and physical examination. In younger patients, pain is more likely to be caused by congenital hip dysplasia, athletic injuries, trauma, spondyloarthropathy, and by conditions that first appear during this stage of life, such as rheumatoid arthritis, osteoarthritis, intravenous drug use, alcoholism, or corticosteroid use. The history and physical examination may narrow the diagnosis to intraarticular, extraarticular, or referred sources of pain. Plain radiography and magnetic resonance imaging are the preferred initial imaging procedures. Analyses of the blood, urine, and synovial fluid can be helpful in diagnosing inflammation, infection, and systematic rheumatic disease. Fractures, infection, and ischemic necrosis should be ruled out early because they require immediate treatment to prevent damage to the joint. Hip trauma at a young age increases the risk of osteoarthritis with advancing age, and, unlike most older adults, young adults receiving total hip replacement can expect revision surgery. Medical treatment often involves patient education, physical therapy, and pharmacotherapy. Acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids for pain and antibiotics for infection are the most often prescribed drugs for this population.