Original Article With Video Illustration

Arthroscopic Treatment of Mild to Moderate Deformity After Slipped Capital Femoral Epiphysis: Intra-operative Findings and Functional Outcomes James D. Wylie, M.D., James T. Beckmann, M.D., M.S., Travis G. Maak, M.D., and Stephen K. Aoki, M.D.

Purpose: To identify intra-articular pathology during arthroscopic osteochondroplasty for slipped capital femoral epiphysis (SCFE)erelated femoroacetabular impingement and determine functional outcomes after treatment. Methods: Nine hips in 9 patients (6 male and 3 female patients; mean age, 17.5 years; age range, 13.5 to 26.9 years) underwent hip arthroscopy for femoroacetabular impingement after in situ pinning of the SCFE. Medical records, radiographs, and intraoperative images were reviewed to determine the severity of disease and damage to the hip joints. For all patients, we obtained the modified Harris Hip Score and Hip Outcome Score (HOS) preoperatively and at a minimum of 12 months postoperatively, as well as a Likert scale of perceived change in physical activity. Results: All 9 treated patients had some degree of labral or acetabular cartilage injury at the time of arthroscopy, which was a mean of 58.6 months (range, 18 to 169 months) after in situ pinning. The alpha angle improved from 75 preoperatively to 46 postoperatively (P < .001). The mean follow-up period was 28.6 months (range, 12.6 to 55.6 months). The mean modified Harris Hip Score improved from 63.6 preoperatively to 91.4 postoperatively (P ¼ .005). Similarly, the mean HOS activitieseofedaily living scale improved from 70.2 to 93.3 (P ¼ .010), and the HOS sports scale improved from 53.4 to 88.9 (P ¼ .004). Most patients reported significant improvement on a physical-activity Likert scale, with 4 reporting much improved, 3 reporting improved, and 1 reporting slightly improved physical activity. One patient reported an unchanged activity level. No patients reported a worse activity level after surgery. Conclusions: Post-SCFE cartilage and/or labral damage develops in patients with symptomatic mild to moderate SCFE deformity, and arthroscopic treatment improved functional outcomes in a small cohort of patients at short-term follow-up. Level of Evidence: Level IV, therapeutic case series.

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lipped capital femoral epiphysis (SCFE) is a devastating hip problem in the adolescent population that can lead to femoral neck deformity, chondrolysis, and avascular necrosis of the femoral head. SCFE will develop in approximately 11 in 100,000 children.1 The prevalence is hypothesized to be increasing because of the increased rates of obesityd80% of SCFEs occur in patients with a body mass index greater than the 95th percentile.2 Also contributing to this pathology is an

From the Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A. The authors report the following potential conflict of interest or source of funding: S.K.A. receives support from ArthroCare, Pivot Medical, Arthrex, Biomet, Musculoskeletal Transplant Foundation. Received February 5, 2014; accepted August 15, 2014. Address correspondence to Stephen K. Aoki, M.D., Department of Orthopaedic Surgery, University of Utah Orthopedic Center, 590 Wakara Way, Salt Lake City, UT, U.S.A. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/1492/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.08.019

earlier maturation of the population.3 Lower extremity function is commonly compromised after in situ fixation with the potential need for early hip replacement.4 In long-term studies, all degrees of SCFE led to some functional loss, with worse results in the setting of complications and attempted realignment.5 The most common treatment for SCFE is in situ pinning of the slipped epiphysis that, by definition, results in an apex anterosuperior deformity of the femoral head-neck junction.3 Despite the fact that the metaphysis then undergoes some remodeling over time, functional loss results from residual deformity that impinges with the acetabular rim in flexion and internal rotation.6 Similar to other causes of femoroacetabular impingement (FAI), the repetitive trauma from impingement leads to labral tears and injury to the articular cartilage.7 However, the anatomic angle of the physis is distinctly different between the post-SCFE deformity and cam-type FAI, suggesting differing causes of these 2 conditions.8 Three groups have reported that most patients undergoing open surgery for SCFE

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had acetabular labral and/or cartilage injury at the time of surgery.9-11 A preliminary report of arthroscopic osteochondroplasty at the time of in situ pinning showed chondrolabral injury and that the 3 patients had a painfree return to full activities after this technique.12 The purpose of the study was to identify intra-articular pathology during arthroscopic osteochondroplasty for SCFE-related FAI and determine functional outcomes after treatment. We hypothesized that patients with a post-SCFE deformity would present with acetabular articular cartilage and labral pathology at the time of arthroscopy. We also hypothesized that patients who underwent arthroscopy with osteochondroplasty for proximal femoral deformity after in situ pinning for SCFE would have significantly decreased pain with increased hip function and improved physical activity compared with preoperatively.

Methods Study Design Patients selected retrospectively for inclusion in this series included both adult and pediatric patients from 2 separate registries that are both approved by the institutional review board at our institution. As part of these registries, all patients fill out a worksheet including the modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS) during their initial patient evaluation. Patients who underwent surgical intervention were asked to complete the mHHS, the HOS, and a Likert scale of activity level at all postoperative visits. Postoperative visits include visits at 1 month, 3 months, 6 months, and 1 year, as well as yearly thereafter. If patients do not return for their yearly visits, then outcomes questionnaires are mailed to them. All patients in this study underwent hip arthroscopy by the principal investigator (S.K.A.) between 2008 and 2013. The principal investigator has performed hip arthroscopy in 1,100 patients. A query of his database for a primary diagnosis for SCFE identified 30 cases, and there were 9 cases in which arthroscopy had been performed more than 1 year earlier. The inclusion criteria included a primary diagnosis of post-SCFE deformity and surgery greater than 1 year ago. The exclusion criteria were the lack of outcome scores at a minimum of 12 months of followup and surgery performed within the past 12 months. Follow-up was obtained for all 9 patients. The mean follow-up period was 28.6 months (minimum, 12.6 months; maximum, 55.6 months). There were no cases of treatment of the original slip by the principal investigator; all patients were referred for treatment of a healed post-SCFE deformity. Patient Evaluation All patients presented with symptoms consistent with hip pathology. They described groin or anterior

thigh pain that was worse with activity or had pain that limited activity. On examination, patients had reproducible pain with deep flexion; in some cases they had obligate external rotation with flexion. Flexioneadductioneinternal rotation impingement testing provoked groin pain. Radiographic imaging showed healed SCFE deformities with lack of femoral head-neck offset. In all patients conservative management including anti-inflammatories and activity modification had failed. The patient’s sex, age, surgical history, and intraoperative findings were obtained from the medical records. Operative reports were reviewed, and intraarticular pathology was recorded and classified as previously described by Beck et al.13 In brief, the acetabular cartilage was defined as follows: normal, malacia, debonding, cleavage, or defect. The acetabular labrum was defined as follows: normal, degeneration, full-thickness tear, detachment, or ossification. The date of in situ pinning was recorded from the medical records, and the time from in situ pinning to hip arthroscopy was determined. Patients also underwent preoperative radiographic analysis with anteroposterior, frog-leg lateral, and false-profile views of the hip. Anteroposterior and false-profile views were completed weight bearing. The radiographic parameters measured were the preoperative alpha angle on the frog-leg lateral film to quantify proximal femoral deformity and the original slip angle on the lateral film to define the severity of the original SCFE. Alpha angles were also measured postoperatively. The radiographs were reviewed and quantified by the authors of the study (J.D.W., J.T.B., S.K.A.). As mentioned previously, patient-reported outcomes including the mHHS and HOS are collected preoperatively and at 3, 6, and 12 months postoperatively and at any visit thereafter. The mHHS is a subjective hip-specific quality-of-life measure that is commonly used in assessing hip outcomes.14-16 On this scale, higher scores represent better hip quality of life. The HOS is another commonly used hipspecific quality-of-life measure; it has 2 subscales, the activitieseofedaily living scale and the sports scale. Scoring for the HOS has been previously described with higher values corresponding to better hip quality of life.17 All patients also filled out a 7-level Likert scale of physical activity with potential answers being much worse, worse, slightly worse, unchanged, slightly improved, improved, and much improved. Surgical Technique and Rehabilitation The patient is placed supine on the traction table (Smith & Nephew, Memphis, TN). The patient is prepared and draped in normal fashion, and access to the hip is obtained as previously described.18 C-arm fluoroscopy is positioned on the opposite side of the table.

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Two or three portals are used, with an anterolateral portal and midanterior portal in all cases and a distal anterolateral accessory portal in cases undergoing labral repair. An interportal capsulotomy is performed to connect the anterolateral and midanterior portals. The addition of a T-capsulotomy can be used to improve visualization but was not used in this cohort. If hardware is removed, the hip is placed in deep flexion and the screw is removed under direct visualization with the arthroscope. The cannulated screw or screws are then removed over a guidewire. An acetabuloplasty and labral repair are then performed on a case-by-case basis if overcoverage is present or the labrum is torn. The femoral osteochondroplasty is then performed to reshape the femoral head-neck offset and remove the impingement lesion. Dynamic evaluation under arthroscopy is performed in (1) flexion with internal and external rotation and (2) hip extension and abduction to confirm joint congruence after resection. Fluoroscopic evaluation includes hip extension with internal and external rotation and a 45 Dunn view in neutral rotation, as well as a frog-leg lateral view to confirm the superior, anterolateral, and anterior head-neck shape. A routine capsular repair is performed with 2 to 5 nonabsorbable sutures. The technique is illustrated in Video 1 (available at www. arthroscopyjournal.org). Formal physical therapy is begun at 2 weeks. Patients begin with touch-down weight bearing for 2 weeks, followed by partial weight bearing for 2 additional weeks. Use of crutches is discontinued at 4 weeks. No brace is worn. There is no hyperextension or external rotation of the foot for 6 weeks. Full range of motion is encouraged over the subsequent 6- to 12-week period. Conditioning and strengthening are continued with progression to sporting activities at 4 to 6 months. Naproxen, 500 mg twice daily for 3 weeks, is used for heterotopic ossification prophylaxis.

Statistical Analysis Paired Student t tests were used to determine the significance of patient improvements in outcome scores and changes in alpha angles. Pearson correlation coefficients were calculated to identify relations between continuous variables. P < .05 was considered significant. Calculations were performed using SPSS software, version 17.0 (SPSS, Chicago, IL).

Results Between 2008 and 2013, the principal investigator (S.K.A.) performed 9 hip arthroscopies in patients who had symptoms, examination findings, and imaging findings thought to be consistent with FAI after in situ pinning and healing of the SCFE. The patients’ presenting characteristics are presented in Table 1. All patients had mild to moderate SCFEs according to radiographic criteria; however, severe femoral head cam deformities had developed, as evidenced by their large alpha angles. Preoperative radiographs and arthroscopic images before osteochondroplasty are presented in Figure 1; corresponding postoperative radiographs and post-osteochondroplasty arthroscopic images are presented in Figure 2. All patients had some degree of acetabular cartilage or labral pathology at the time of surgery (Table 1). After femoral osteochondroplasty, the alpha angle measured on frog-leg lateral radiographs improved from a mean of 75 preoperatively to 46 postoperatively (P < .001). Along with femoral osteoplasty, other procedures performed in this series comprised acetabuloplasty for mixed impingement in 5 patients, labral debridement in 2, labral repair in 4, hardware removal in 2, psoas release in 1, and lateral femoral cutaneous nerve decompression in 1 (Table 1). Labral debridement was conservative and did not include any labral excisions. One patient underwent revision surgery for capsular repair after a sporting injury 2 years after arthroscopy (Table 2).

Table 1. Characteristics of Patients Undergoing Hip Arthroscopy for Post-SCFE Deformity Time to Surgery, mo

Alpha Angle,





Other Procedures Performed* Preoperative Postoperative

Slip Angle, Age/sex 15.7 yr/M 36.8 18 18.3 yr/M 81.7 30 15.8 yr/F 35.5 20 17.7 yr/M 23.9 53 18.0 yr/F 68.3 10 14.5 yr/F 18.8 43 19.1 yr/M 51.3 53 26.9 yr/M 168.9 20 15.2 yr/M 42.4 20 Mean age (range) 58.6 (18.8-168.9) 29.7 (10-53) 75.2

97 70 70 86 82 67 74 71 60 (60-97) 46.0

54 58 37 42 51 33 47 49 48 (33-58)

LD LR, Acet LD, LFCN Acet, HWR Acet, LR, PR None HWR Acet, LR Acet, LR

Beck Classification Cartilage

Labrum

Fibrillation Fibrillation Fibrillation Fibrillation Fibrillation Defect Fibrillation Debonded Fibrillation

Detachment Detachment Degeneration Full-thickness tear Full-thickness tear, ossified Normal Degeneration Detachment Full-thickness tear, ossified

Acet, acetabuloplasty; F, female; HWR, hardware removal; LD, labral debridement; LFCN, lateral femoral cutaneous nerve release; LR, labral repair; M, male; PR, psoas release; SCFE, slipped capital femoral epiphysis. *All patients underwent femoral osteoplasty.

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Fig 1. (A) Preoperative anteroposterior pelvis radiograph in a 17-year-old patient showing retained hardware and proximal femoral deformity. (B) Corresponding preoperative frog-leg lateral radiograph. (C) Arthroscopic image of cam deformity (c) interfacing with labrum (L).

All 9 patients had a minimum of 12 months’ followup. Their individual outcomes are reported in Table 2. Among these patients, the mean follow-up period was 28.6 months (range, 12.6 to 55.6 months). The mHHS improved from a mean of 63.6 preoperatively to 91.4 at latest follow-up (P ¼ .005). Similarly, the HOS activitieseofedaily living scale improved from 70.2 to 93.3 at latest follow-up (P ¼ .010), and the HOS sports scale improved from 53.4 to 88.9 at latest follow-up (P ¼ .004) (Fig 3). Regarding physical activity, 8 of the 9 patients reported improvement. The ninth patient reported that the activity level was unchanged. No patients reported worsening of the activity level after arthroscopy (Table 2). There were 4 complications in these 9 patients: 1 patient needed revision surgery for capsular laxity, 1 patient had transient perineal numbness, 1 patient had transient lateral femoral cutaneous nerve numbness, and heterotopic ossification developed in 1 patient (Table 2).

Discussion SCFE treated with in situ pinning, by definition, fixes the femoral neck in a position of deformity even after mild slips. The residual SCFE deformity can cause hip pain, functional impairment, and progression to joint

Fig 2. (A) Postoperative anteroposterior pelvis radiograph in same patient as in Figure 1 showing hardware removal and osteochondroplasty. (B) Corresponding postoperative frog-leg lateral (LAT) radiograph. (C) Arthroscopic image showing osteochondroplasty of cam deformity (c).

degeneration due to impingement of the anterosuperior deformity with the acetabulum. Accordingly, all patients in this study had some degree of acetabular cartilage or labral pathology at the time of surgery. Arthroscopic osteochondroplasty normalized alpha angles and significantly improved outcome scores on average in this series. Acetabular cartilage and labral injury after SCFE have been widely reported both at initial presentation and during deformity correction. Leunig et al.11,12 described universal hip pathology at the time of fixation of the SCFE, through both open surgery and arthroscopy. Similarly, Ziebarth et al.10 found a high incidence of acetabular cartilage and labral lesions visualized on surgical dislocation at the time of index surgery that were not correlated with slip severity. In this case series, the slip angle also was not correlated with acetabular and labral injury severity. Joint damage at the time of presentation could be explained by an average 8-week delay in diagnosis reported in a review of 196 patients by Kocher et al.19 Most patients with unstable SCFEs (88%) have antecedent pain lasting on average 42 days before presentation.20 These delays suggest that joint damage from impingement may be ongoing before the SCFE diagnosis and treatment and presumably continues as long as deformity persists.

ADL, activities of daily living; F, female; HOS, Hip Outcome Score; LFCN, lateral femoral cutaneous nerve release; M, male; mHHS, modified Harris Hip Score; SCFE, slipped capital femoral epiphysis. *The patient underwent revision surgery for capsular repair because of perceived anterior capsular instability after a sporting injury postoperatively.

Much improved Unchanged Improved 94.4 100 100 88.9 (47.2-100) 38.9 94.4 63.8 53.4 (25.0-94.4) 98.5 100 98.5 93.3 (57.4-100) 66.2 97.0 72.0 70.2 (42.6-97.0) 100 95.7 84.7 91.4 (61.6-100) 64.9 95.7 61.6 63.6 (33.0-95.7) 20.2 15.0 12.6 28.6 (12.6-55.6) 19.1 yr/M 26.9 yr/M 15.2 yr/M Mean age (range)

Improved Much improved Improved 88.9 94.4 83.3 25.0 44.4 77.8 94.1 100 91.2 63.2 42.6 79.4 84.7 100 95.7 21.5 24.7 22.6 17.7 yr/M 18.0 yr/F 14.5 yr/F

67.1 64.9 68.2

34.8 15.8 yr/F*

63.8

61.6

72.1

57.4

50.0

47.2

Slightly improved

None Perineal numbness, resolved by 6-wk follow-up Capsular instability requiring revision None None LFCN numbness, resolved by 3-mo follow-up none none Heterotopic ossification Much improved Much improved 97.2 94.4 27.8 58.3 100 100 70.6 69.1 100 100 52.8 33.0 55.6 50.3

Likert Activity Level Postoperative

HOS-Sports

Preoperative Postoperative

HOS-ADL

Preoperative Postoperative

mHHS

Preoperative Follow-up, mo

Table 2. Outcomes of Patients Undergoing Hip Arthroscopy for Post-SCFE Deformity

Age/sex 15.7 yr/M 18.3 yr/M

Complications

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Joint injury has also been found ubiquitously during delayed deformity correction. Three groups have reported that all patients undergoing a surgical dislocation to treat a post-SCFE deformity had some degree of articular cartilage or labral injury.9-11 Interestingly, the absence of hip pain may not preclude the possibility of articular damage. A recent case report of 5 asymptomatic patients with mild SCFE deformity showed that all patients had acetabular damage within 18 months of in situ pinning.21 Similarly, gadolinium-enhanced magnetic resonance imaging of hips after in situ fixation of SCFE showed cartilage abnormalities in postSCFE hips that did not correlate with subjective symptoms.22 These studies suggest that SCFE deformity commonly results in early articular damage that persists after in situ pinning, can be present even in the absence of symptoms, and may lead to early total hip arthroplasty in this population.3 In our cohort all 9 patients had acetabular and/or labral pathology visualized at a mean of 52.8 months after in situ pinning during arthroscopic osteochondroplasty. Pathology was primarily located in the anterosuperior region of the joint and the corresponding labral tissue, as has been primarily described with cam-type FAI.7 Treatment of the residual SCFE deformity is performed to reduce pain, improve function, and reduce progression of joint degeneration.12 It is difficult to determine whether the timing of deformity correction plays a role in joint degeneration; however, several reports have raised the concern that premature arthritis may develop from FAI associated with even minor slips.23 Consequently, reduction of the SCFE acutely or reorientation of the proximal femur after healing in situ has been advised in an attempt to prevent long-term sequelae including early hip arthritis.24 Retrospective data support a possible link between residual SCFE deformity and premature hip arthritis. A recent study found subclinical SCFE morphology in over 60% of cases of early hip arthritis.25 The potential for future development of hip arthritis after SCFE in our series is concerning because joint injury was found in all patients at the time of treatment that did not seem to be dependent on the time from pinning to arthroscopy. We were unable to determine whether time to osteochondroplasty was associated with worsened hip pathology; however, without correction of the SCFE deformity, the possibility of repetitive impingement is likely. Resultant joint degradation from post-SCFE impingement could justify aggressive correction to hopefully prevent compounded articular injury and preserve the hip joint. However, in the setting of traditional cam, pincer, or mixed FAI, there is no evidence to suggest that prophylactic surgery to preserve the hip joint is indicated.26 Arthroscopic osteochondroplasty is a low-morbidity procedure that may be capable of correcting post-

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compared with open hip surgery and has been shown to be equivalent to open surgery for similar procedures including the treatment of FAI.28,29 In this series the alpha angle was corrected, on average, from 75 preoperatively to 46 postoperatively, showing the technical feasibility of arthroscopic osteochondroplasty to restore a more normal femoral anatomy. This report shows that hip arthroscopy with femoral osteochondroplasty is a viable option to treat symptomatic SCFE patients previously treated with in situ pinning at the time of the slip. This study is the first to report functional outcomes in this cohort of patients.

Fig 3. Improvement at mean of 28.6 months postoperatively in modified Harris Hip Score (mHHS), Hip Outcome Score activitieseofedaily living scale (HOS ADL), and Hip Outcome Score sports scale (HOS Sports) after arthroscopy for poste slipped capital femoral epiphysis deformity. The asterisks indicate P < .05.

Limitations There are limitations to this study. It included a small number of patients with limited follow-up, and there was no control group of patients who underwent conservative or open treatment. There was no a priori power analysis performed. Larger groups of patients with longer follow-up periods will be needed to understand the durability of hip arthroscopy for SCFE deformity. Comparisons with open treatment will need to be made to understand how best to care for these patients. However, this study does show the described technique to be effective at least in the short-term for symptomatic deformity after SCFE. Further studies are needed to determine whether this procedure preserves the hip joint and prevents degenerative change over time.

Conclusions SCFE deformity. Historically, staged intertrochanteric osteotomy was performed after in situ SCFE pinning, with good long-term outcomes reported.27 More recently, some authors have advocated techniques that address the SCFE deformity concomitantly with treatment of the acute slip. Open surgical dislocation of the hip while monitoring blood flow to the femoral head has been described for reduction of the acute slip with concomitant osteochondroplasty for correction of residual femoral neck deformity.24,27 A recent report showed good short-term outcomes in 3 patients who underwent hip arthroscopy with osteochondroplasty at the time of in situ fixation for SCFE.12 These patients were reported to have no pain and a return to full activities at final follow-up; however, there were no functional outcomes reported. Our study found that patients who underwent arthroscopic osteochondroplasty also had improved pain and function at a minimum 1-year follow-up. Although comparison among procedures is difficult because this is the first study to report preoperative and postoperative validated outcome measures after arthroscopy, functional improvements were observed to be statistically significant in all outcome scores in this series. Hip arthroscopy has the added advantage of less morbidity when

Cartilage and/or labral damage caused by SCFE develops in patients with symptomatic mild to moderate SCFE deformity and that arthroscopic treatment improved functional outcomes and physical activity levels in a small cohort of patients at short-term follow-up.

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range of motion in slipped capital femoral epiphysis. Clin Orthop Relat Res 2009;467:692-698. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003;(417):112-120. Monazzam S, Bomar JD, Pennock AT. Idiopathic cam morphology is not caused by subclinical slipped capital femoral epiphysis. An MRI and CT study. Orthop J Sports Med 2013;1:1-6. Sink EL, Zaltz I, Heare T, Dayton M. Acetabular cartilage and labral damage observed during surgical hip dislocation for stable slipped capital femoral epiphysis. J Pediatr Orthop 2010;30:26-30. Ziebarth K, Leunig M, Slongo T, Kim YJ, Ganz R. Slipped capital femoral epiphysis: Relevant pathophysiological findings with open surgery. Clin Orthop Relat Res 2013;471: 2156-2162. Leunig M, Casillas MM, Hamlet M, et al. Slipped capital femoral epiphysis: Early mechanical damage to the acetabular cartilage by a prominent femoral metaphysis. Acta Orthop Scand 2000;71:370-375. Leunig M, Horowitz K, Manner H, Ganz R. In situ pinning with arthroscopic osteoplasty for mild SCFE: A preliminary technical report. Clin Orthop Relat Res 2010;468: 3160-3167. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br 2005;87: 1012-1018. Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy 2000;16: 578-587. Byrd JW, Jones KS. Primary repair of the acetabular labrum: Outcomes with 2 years’ follow-up. Arthroscopy 2014;30:588-592. Larsen CM, Giveans MR, Samuelson KM, Stone RM, Bedi A. Arthroscopic hip revision surgery for residual femoroacetabular impingement (FAI): Surgical outcomes compared with a matched cohort after primary arthroscopic FAI correction. Am J Sports Med 2014;42: 1785-1790. Martin RL, Philippon MJ. Evidence of validity for the hip outcome score in hip arthroscopy. Arthroscopy 2007;23: 822-826.

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18. Aoki SK, Beckmann JT, Wylie JD. Hip arthroscopy and the anterolateral portal: Avoiding labral penetration and femoral articular injuries. Arthrosc Tech 2012;1:e155-e160. 19. Kocher MS, Bishop JA, Weed B, et al. Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics 2004;113: e322-e325. 20. McPartland TG, Sankar WN, Kim YJ, Millis MB. Patients with unstable slipped capital femoral epiphysis have antecedent symptoms. Clin Orthop Relat Res 2013;471: 2132-2136. 21. Lee CB, Matheney T, Yen YM. Case reports: Acetabular damage after mild slipped capital femoral epiphysis. Clin Orthop Relat Res 2013;471:2163-2172. 22. Zilkens C, Miese F, Bittersohl B, et al. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC), after slipped capital femoral epiphysis. Eur J Radiol 2011;79:400-406. 23. Fraitzl CR, Kafer W, Nelitz M, Reichel H. Radiological evidence of femoroacetabular impingement in mild slipped capital femoral epiphysis: A mean follow-up of 14.4 years after pinning in situ. J Bone Joint Surg Br 2007;89: 1592-1596. 24. Kuzyk PR, Kim YJ, Millis MB. Surgical management of healed slipped capital femoral epiphysis. J Am Acad Orthop Surg 2011;19:667-677. 25. Giles AE, Corneman NA, Bhachu S, et al. Shared morphology of slipped capital femoral epiphysis and femoroacetabular impingement in early-onset arthritis. Orthopedics 2013;36:e1365-e1370. 26. Collins JA, Ward JP, Youm T. Is prophylactic surgery for femoroacetabular impingement indicated?: A systematic review. Am J Sports Med in press, available online 21 August, 2013. doi: 10.1177/0363546513499227. 27. Masse A, Aprato A, Grappiolo G, Turchetto L, Campacci A, Ganz R. Surgical hip dislocation for anatomic reorientation of slipped capital femoral epiphysis: Preliminary results. Hip Int 2012;22:137-144. 28. Botser IB, Smith TW Jr, Nasser R, Domb BG. Open surgical dislocation versus arthroscopy for femoroacetabular impingement: A comparison of clinical outcomes. Arthroscopy 2011;27:270-278. 29. Domb BG, Stake CE, Botser IB, Jackson TJ. Surgical dislocation of the hip versus arthroscopic treatment of femoroacetabular impingement: A prospective matchedpair study with average 2-year follow-up. Arthroscopy 2013;29:1506-1513.

Arthroscopic treatment of mild to moderate deformity after slipped capital femoral epiphysis: intra-operative findings and functional outcomes.

To identify intra-articular pathology during arthroscopic osteochondroplasty for slipped capital femoral epiphysis (SCFE)-related femoroacetabular imp...
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