Hip Arthroscopy In Children And Adolescents

Described originally by Burman in 1931 [2], arthroscopy of the hip has more recently become an established procedure [3-7]. Arthroscopic surgery of the hip may offer potential advantages over traditional open arthrotomy and surgical dislocation in terms of limited invasiveness and diminished morbidity. The most recognized indications for hip arthroscopy are for the management of labral tears [8-13] and loose bodies [9,14]; however, hip arthroscopy has been described for a variety of other hip disorders, including osteoarthritis [9], osteonecrosis [9], osteochondral fracture [15], chondral injury [9], hip dysplasia [16], septic arthritis [17-19], inflammatory arthritis [9,20], synovial chondromatosis [21,22], foreign bodies [23], ligamentum teres tears [24-26], and complications after total joint arthroplasty [27-30].

Most of the experience in hip arthroscopy has been with hip disorders in adults. The indications and results of hip arthroscopy in children and adolescents have been less well-characterized [15,20,31-36]. Pediatric hip conditions include Legg-Perthes disease, slipped capital femoral epiphysis, developmental dysplasia of the hip, septic arthritis, coxa vara, juvenile rheumatoid arthritis, and chondrolysis [1,37]. Gross [33] described his early experience with hip arthroscopy in patients who had congenital dislocation of the hip, Legg-Perthes disease, slipped capital femoral epiphysis, and neuropathic subluxation. Bowen and coworkers [15,34] described arthroscopic chondroplasty of unstable osteo-chondral lesions of the femoral head as sequelae after skeletal maturity in patients who had Legg-Perthes disease as children. Other indications in the pediatric population have included labral tears, loose bodies, chondral lesions, juvenile rheumatoid arthritis, and septic arthritis [20,31,32]. In a review of 24 hip arthroscopies performed in 21 patients ages 11 to 21 years old, Schindler and colleagues [35] concluded that hip arthroscopy was effective for synovial biopsy and loose body removal; however, as a diagnostic procedure, the arthroscopy failed to correlate with the presumptive cause of symptoms in 11 hips (46%).

The authors recently reviewed our results of hip arthroscopy in children and adolescents [37,38]. From January 2001 to March 2004, 164 hip arthroscopies in 129 patients were performed by the first author in the adolescent and young adult hip unit of Children's Hospital in Boston. Of these 164 procedures, 91 procedures were performed in 72 patients who were 18 years old and younger. Of these 91 procedures, 56 procedures in 44 patients had minimum 1-year follow-up. Two of these patients were lost to follow-up (follow-up rate: 95.5%). Thus, the study population included 54 hip arthroscopies in 42 patients.

Data collected included patients' demographics, indications for surgery, complications, and outcomes. Outcome was assessed preoperatively and postoperatively using the modified Harris hip score. The modified Harris hip score is a condition-specific outcome instrument that has been widely used after hip arthroscopy. The score assesses both pain (44 points) and function (47 points). Function is divided into domains of limp (11 points), support (11 points), distance walked (11 points), stairs (4 points), socks/shoes (4 points), sitting (5 points), and public transportation (1 point). The Harris hip score was modi fied from the original by the elimination of the 9 points for range of motion and deformity, because hip arthroscopy is principally indicated for pain and function. Thus, the modified Harris hip score is multiplied by 1.1 to give a total possible score of 100.

Mean patient age was 15.2 years old (range: 5.9-18.9 years old). Twenty eight patients were female (67%) and 14 patients were male (33%). Minimum follow-up was 1 year, with mean 17.4 month follow-up (range: 12.0-26.2 months).

Chief complaints were pain in 48 hips and catching or locking in 6 hips. All patients reported diminished hip function. Fifteen patients had undergone 17 previous operations, including pelvic osteotomy (n=11), femoral osteotomy (n = 5), and in situ pinning (n = 1). Indications for the 54 hip arthroscopies included isolated labral tears (n=30), Perthes disease (n = 8), developmental dysplasia of the hip following prior periacetabular osteotomy (n = 8) (Fig. 6), inflammatory arthritis (n = 3), spondyloepiphyseal dysplasia (n = 2), avascular necrosis (n = 1), slipped capital femoral epiphysis (n=1), and osteochondral fracture (n=1). Specific procedures included debridement of labral tear (n = 41), chondroplasty of acetabulum or femoral head (n=10), removal of loose bodies (n = 8), synovectomy (n=3), and general debridement for degenerative changes (n = 2). Some hip arthroscopies included multiple specific components. Staged bilateral procedures were performed in 9 patients. Revision procedures were performed in 3 patients who had recurrent labral tears. Concurrent procedures included iliotibial band release at the greater trochanter for snapping (n = 4) and proximal femoral blade plate removal (n=1).

Overall, there was significant improvement in modified Harris hip score (preoperative: 53.1; postoperative: 82.9; P<0.001) (Table 1). For patients who had isolated labral tears (n=30), there was significant improvement in modified Harris hip score (preoperative: 57.6; postoperative: 89.2; P< 0.001), and scores were improved in 26 of 30 procedures (see Table 1). For patients who had Perthes disease (n = 8), there was significant improvement in modified Harris hip

Fig. 6. Full thickness cartilage loss (arrow) of the anterosuperior acetabulum in a patient with hip dysplasia after prior periacetabular osteotomy.

Table 1

Modified Harris hip score results by diagnosis

Table 1

Modified Harris hip score results by diagnosis

Diagnosis

n

Preoperative

Postoperative

P value

Overall

54

53.1 (7.3)

82.9 (8.1)

<0.001

Isolated labral tear

30

57.6 (7.2)

89.2 (8.5)

<0.001

Perthes disease

8

49.5 (7.7)

80.1 (7.9)

<0.001

Developmental dysplasia of the hip (after prior

8

51.8 (8.1)

79.8 (8.9)

<0.001

periacetabular osteotomy)

Inflammatory arthritis

3

54.8 (7.0)

81.3 (8.2)

<0.001

Spondyloepiphyseal dysplasia

2

47.5

82.5

Avascular necrosis

1

55

55

Slipped capital femoral epiphysis

1

62

85

Osteochondral fracture

1

29

96

Values represent mean (standard deviation).

Values represent mean (standard deviation).

score (preoperative: 49.5; postoperative: 80.1; P<0.001), and scores were improved in all eight procedures (see Table 1). For patients who had labral tears with developmental dysplasia of the hip following prior periacetabular osteotomy (n = 8), there was significant improvement in modified Harris hip score (preoperative: 51.8; postoperative: 79.8; P< 0.001) and scores were improved in six of eight procedures (see Table 1). For the 2 patients who had Outerbridge grade 4 degenerative changes (full-thickness chondral loss), scores were not improved. For patients who had inflammatory arthritis (n=3), there was significant improvement in modified Harris hip score (preoperative: 54.8; postoperative: 81.3; P<0.001) and scores were improved in all three procedures (see Table 1). Preoperative and postoperative modified Harris hip scores for patients who had spondyloepiphyseal dysplasia (n = 2), avascular necrosis (n = 1), slipped femoral capital epiphysis (n = 1), and osteochondral fracture (n = 1) are shown in Table 1.

Complications included transient pudendal nerve palsy (n = 3), instrument breakage (n = 1), and recurrent labral tear (n = 3). All three patients who had pudendal nerve palsies had paresthesia in the groin and scrotal/labial region that resolved spontaneously by 3 months postoperative. The case of instrument breakage involved shearing off of a flexible guide wire by a cannulated obturator upon insertion. The broken guide wire was retrieved arthroscopically. Two patients who had isolated labral tears and one patient who had developmental dysplasia of the hip following prior periacetabular osteotomy who had undergone arthroscopic debridement had recurrent labral tears (recurrent labral tear rate: 3/41 = 7.3%). All three patients had demonstrated improvement after their initial arthroscopic debridement, with recurrent symptoms developing 3 to 21 months after their index procedure. All three patients improved after repeat arthroscopy and labral tear debridement.

Thus, in reviewing the authors' results of hip arthroscopy in children and adolescents for a variety of diagnoses, it appears that hip arthroscopy was a safe procedure with few complications, and that it was efficacious in the short term for certain indications.

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