Specific Indications For Hip Arthroscopy In Children And Adolescents

Developmental Dysplasia of the Hip

Intra-articular pathology is often associated with developmental dysplasia of the hip [1,37,39]. Hip dysplasia may present in adolescence or young adulthood as hip pain from a degenerative labral tear or chondral lesion (Fig. 7). Anterior labral tears may also occur as a result of anterior impingement from a post-slipped capital femoral epiphysis deformity or pistol-grip deformity [36,40-45]. Although favorable results have been reported from the arthroscopic management of intra-articular pathology in dysplastic hips [10], the authors' preferred approach is to address the underlying dysplasia with periacetabular osteotomy, with or without proximal femoral osteotomy [1,37]. After periacetabular osteotomy, some patients may present with increasing hip pain and mechanical symptoms caused by a degenerative labral tear. In the authors' series, we found improvement in symptoms with arthroscopic debridement in six of eight patients; however, the two patients who had full-thickness degenerative joint disease did not improve after arthroscopic debridement, questioning its efficacy in patients who have advanced degenerative joint disease.

Loose Bodies

Loose bodies of the hip may occur from traumatic injury or as a sequelae of hip disorders such as Legg-Perthes disease, spondyloepiphyseal dysplasia (see Fig. 7), chondrocalcinosis, or avascular necrosis. In patients who have Legg-Perthes disease, an unstable osteochondral fragment in the central portion of the femoral head may persist after the healing phase, particularly in patients who have a flattened, aspherical head. Patients may present with pain and mechanical symptoms such as catching or locking. The loose osteochondral lesions may be visible on radiographs, CT scan, or MRI. Arthroscopic excision has yielded

Fig. 7. Loose bodies associated with spondyloepiphyseal dysplasia. (A) Arthroscopic image of intra-articular loose body (arrow) held by grasper. (B) Multiple loose bodies after removal.

excellent results with minimal morbidity [9,14]. In the authors' series, loose bodies were associated with Legg-Perthes disease, spondyloepiphyseal dysplasia, and traumatic osteochondral fracture, and excision typically resulted in resolution of pain and mechanical symptoms during this period of follow-up; however, the longer-term prognosis in patients who have Legg-Perthes disease remains guarded if there is substantial asphericity of the femoral head [1,37].

Inflammatory Arthritis/Septic Arthritis

Arthroscopic synovectomy of the hip in cases of inflammatory arthritis has been suggested to improve pain and function [20]. In the cited series, three patients who had inflammatory arthritis underwent arthroscopic synovectomy for hip pain and dysfunction that was recalcitrant to medical therapy, and all three patients demonstrated improvement.

Arthroscopic irrigation and debridement of septic arthritis of the hip in children has been reported [17-19]. The authors' preference is for open arthro-tomy through a limited anterior approach to the hip, because this allows for capsulectomy, drilling of the femoral neck to rule out associated osteomyelitis, thorough debridement of infected tissue, and placement of a drain.

Other Indications

Femoracetabular impingement is a condition that is being further developed and understood. Cam-type and pincer-type impingement can result in degenerative joint disease. Arthroscopic management of femoracetabular impingement has recently received attention.

Arthroscopy may potentially be used as an adjunct during closed reduction for hip dysplasia in infants. Arthroscopy may allow for the visualization of impediments to reduction, transection of the transverse acetabular ligament, and assessment of reduction.

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