Systematic Review
Femoroacetabular Impingement in Skeletally Immature Patients: A Systematic Review Examining Indications, Outcomes, and Complications of Open and Arthroscopic Treatment Darren de SA, M.D., Stephanie Cargnelli, M.D. Cand., Michael Catapano, M.D. Cand., Asheesh Bedi, M.D., Nicole Simunovic, M.Sc., Sarah Burrow, M.Sc., M.D., F.R.C.S.C., and Olufemi R. Ayeni, M.D., M.Sc., F.R.C.S.C.
Purpose: Improvements in physical examination and radiographic appreciation of symptomatic femoroacetabular impingement (FAI) has increased the focus on early diagnosis and treatment in an adolescent population. This systematic review aimed to establish specific indications, outcomes, and complications of surgical management of adolescent FAI. Methods: The Medline, Embase, and PubMed online databases were searched from inception until April 21, 2014, for English-language studies that addressed open and/or arthroscopic treatment of FAI in patients aged 10 to 19 years inclusively. The studies were systematically screened and data abstracted in duplicate, with qualitative findings presented. Results: There were 6 eligible case series (4 with arthroscopic and 2 with open technique) and 2 conference abstracts examining 388 patients in total (435 hips), 81% of which were treated with hip arthroscopy. Overall, patients were followed up for a mean of 23.4 months postoperatively (range, 3 to 75 months). The main indication for surgery was a confirmed diagnosis of FAI with persistent pain and impaired function refractory to nonoperative interventions (activity modification, intra-articular injections, and so on). Specific contraindications included Tönnis grade 2, 3, or 4 chondral changes and acetabular dysplasia. All studies reported significant improvements in patient pain, function (e.g., no patients were “abnormally” or “severely abnormally” impaired), and satisfaction rates (84% to 100% with arthroscopic technique v 79% with open technique). Improvements also were observed in range of motion and alpha angle correction, as well as across a variety of patient-reported functional scores, with all but 7 of 388 patients (1.8%) returning to activity/sport. No major complications were reported, with only 13 of 354 hips (3.7%) treated by arthroscopy requiring revision arthroscopy for lysis of adhesions and 1 of 81 open surgical dislocation hips (1%) having asymptomatic heterotopic ossification not requiring additional management. No cases of avascular necrosis, physeal arrest or growth disturbance, or iatrogenic deformity were reported. Conclusions: Both arthroscopic and open surgical dislocation approaches for the treatment of adolescent FAI appear to be safe and effective options for patients with persistent pain and limited function after an appropriate trial of nonoperative therapy. Level of Evidence: Level IV, systematic review of Level IV studies.
From the Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre (D.d.S., S.B., O.R.A.), Department of Clinical Epidemiology and Biostatistics (N.S.), Michael G. DeGroote School of Medicine (S.C., M.C.), McMaster University, Hamilton, Ontario, Canada; and MedSport at Domino’s Farms, MedSport (A.B.), Ann Arbor, Michigan, U.S.A. The authors report the following potential conflict of interest or source of funding: A.B. receives support from Smith & Nephew, A3 Surgical. O.R.A. receives support from Smith & Nephew. Received June 27, 2014; accepted July 24, 2014. Address correspondence to Olufemi R. Ayeni, M.Sc., M.D., McMaster University Medical Centre, 1200 Main St W, 4E15 Hamilton, Ontario L8N 3Z5, Canada. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/14542/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.07.030
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emoroacetabular impingement (FAI) due to abnormal head-neck offset and sphericity and/or acetabular retroversion constitutes an increasingly recognized cause of mechanical hip pain in the young adult.1 In addition to persistent pain and limited function, the natural history and propensity of FAI to accelerate various labral pathology and early hip degenerative changes are of paramount concern in adolescent patients.1,2 As such, there is increased recognition of the condition and attention to hippreservation procedures to restore impingement-free motion at an early age.3 The osseous deformity and chondrolabral pathology of symptomatic FAI may be surgically addressed by an open surgical hip dislocation and osteotomy,4 mini-open
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anterior arthrotomy,5 and/or hip arthroscopic techniques.6 In adults postoperative outcomes are encouraging, and complication rates for both open and arthroscopic approaches are low (1.5%).7,8 Deformity correction in the skeletally immature adolescent with open physes, however, presents unique and additional risks such as (1) avascular necrosis (AVN) with disruption of the posterosuperior ascending vascular supply, (2) acute iatrogenic slipped capital femoral epiphysis (SCFE), or (3) growth arrest of the proximal femur with violation of the perichondrial ring.9,10 With the paucity of literature on the treatment of FAI in skeletally immature patients, results from adult studies are often used as surrogates to guide practice.11,12 Thus this systematic review aims to address 3 fundamental questions when considering operative (open and/or arthroscopic) intervention for FAI in adolescents: (1) What are the indications and contraindications for surgery? (2) What are the important patient-specific outcomes after operative treatment? (3) What are the surgical complications in this population? This review was conducted to help guide surgeon patient selection and decision making and enhance patient care. We hypothesize that, with no unique technical changes applied to adolescents, surgical management for FAI in this demographic will be of similar efficacy and safety to that in adults.
Methods Search Strategy On April 21, 2014, the online databases Embase, Medline, and PubMed were searched from database inception until April 21, 2014, for literature addressing surgical indications and clinical outcomes for FAI management among the adolescent population. The search terms “femoroacetabular impingement,” “skeletally immature,” “adolescent,” “pediatric,” “arthroscopy,” and “osteoplasty” were used (Appendix Table 1). We also searched the abstracts of Orthopaedic Proceedings (a supplement of The Bone & Joint Journal) from the Australian Orthopaedic Association Limited 69th Annual Scientific Meeting, as well as supplemental material from Arthroscopy (June 2014) for additional unpublished data. Finally, the aforementioned search terms were entered into the Google Scholar search engine on June 20, 2014, for any additional unpublished data. Study Screening The titles, abstracts, and full-text articles were screened by 2 reviewers (S.C., M.C.). If, at any stage, one reviewer expressed doubt regarding inclusion/ exclusion of a particular study, it was advanced to the next stage for further review to ensure that all possibly relevant articles and conference abstracts were included. Disagreements at the final stage were addressed by discussion between the 2 reviewers, with a third, senior
reviewer (D.d-S.) to manage unresolved conflicts. The references of the eligible included studies were subsequently searched to capture any additional articles that may have eluded the initial search strategy. Assessment of Study Eligibility The research questions and inclusion/exclusion criteria were determined a priori. Articles included were required to be English-language studies involving human patients. Specifically, included studies must have addressed surgical management of FAI, have been performed open and/or arthroscopically, and have been conducted in patients aged 10 to 19 years inclusively. This age range was based on the World Health Organization definition for an adolescent individual.13 We excluded studies that were review or technical articles; cadaveric studies; studies that solely addressed nonsurgical management of FAI; studies that included adult patients; studies that were case reports or case series of fewer than 5 patients; and/or studies that included patients undergoing surgery for hip dysplasia, SCFE, or any non-FAI etiology. Data Abstraction The 2 reviewers collected data in duplicate and recorded it in a Microsoft Excel spreadsheet (2007 release; Microsoft, Redmond, WA). Data regarding study year of publication, author, location of study, and study design were recorded. Descriptive statistics of the studies, including age, percent female, sample size, level of evidence, and mean follow-up, were recorded. Patient data were recorded regarding history, clinical examination, and radiographic findings. Surgical outcome data, both qualitative and quantitative, were also recorded. Formal quality scoring of included studies was not performed because of the quality of evidence (e.g., case series) resulting from our search. Although 1 included abstract was a casecontrol study in design, the control was a chronologically matched adult (not adolescent) group aged 18 to 50 years, with no full-text data available for quality assessment. Assessment of Agreement A weighted k and 95% confidence intervals (CIs) were calculated for all 3 stages of screening. We determined k values to indicate the level of agreement: k of 0.61 or greater indicates substantial agreement; k greater than 0.20 but less than 0.61 indicates moderate agreement; and k of 0.20 or less indicates slight agreement.14
Results Search Strategy After an initial retrieval of 3,645 studies, 575 duplicates (16%) were removed; the remaining 3,070 studies were systematically searched and yielded 5 full-
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Fig 1. Flow diagram describing systematic review of literature on adolescent FAI.
text studies and 2 abstracts with no additional full text available for inclusion. Authors of conference abstracts were contacted to ensure that a full-text article had not been published. Searching the references of these 5 studies produced 1 additional study for inclusion (Fig 1). There was high agreement among reviewers at the title (k ¼ 0.86; 95% CI, 0.89 to 0.82), abstract (k ¼ 0.94; 95% CI, 0.90 to 0.98), and full-text screening stages (k ¼ 1.00; 95% CI, 1.00 to 1.00). Study Characteristics We identified 1 case-control and 5 case series examining hip arthroscopy and 2 case series examining open surgical procedures. Six studies were conducted in the United States and 2 in Australia. Adolescent patients were treated
for FAI with either hip arthroscopy (315 patients, 354 hips) or open surgical dislocation (73 patients, 81 hips). This review includes 2 studies by Philippon et al.15,16 on adolescent patients recruited around the same period. We contacted the authors and confirmed that the patients in each study represented 2 separate populations, reducing duplication. Female patients with similar pathology comprised approximately 54% of the study population, and outcomes were evaluated over a period of a minimum of 3 months postoperatively to a maximum of 75 months (Table 1). Surgical Indications Arthroscopic or open procedures presented in this review encompassed a combination of osteochondroplasty
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Table 1. Participant Demographic Data for Studies Evaluating Surgical Treatment of FAI in Adolescents Study Design, Level of Evidence
Study HIP arthroscopy Fabricant et al.17 Retrospective (2012) case series, Level IV
Sink et al.18 (2013)
Age, yr
%F
Length
17.6 (range, 14.5-19.9)
NR
16 (range, 12-17)
Minimum, 1 yr Mean, 1.5 yr (range, 1-2.5 yr) 54.6 29 mo (range, 12-60 mo)
96/76
57% R and 43% L
17 (range, 13-19)
17/16
NR
65/60
Multicenter prospective longitudinal case series, Level IV
Location
100
Virginia
44.8 19 mo (range, 3-75 mo)
100
NR
Melbourne
15 (range, 11-16)
87.5 1.36 yr (range, 1-2 yr)
100
Boston
55% R and 45% L
15 (range, 11-16)
72
3.5 yr (range, 2-5 yr)
100
41/34
49% R and 51% L
15.7 (range, 11-18)
15
Minimum, 1 yr Mean, 14 mo (range, 1-2 yr)
100
6 wk of nonsteroidal anti-inflammatory drugs, hip joint injections, physical therapy, and/or activity modification 6 mo of conservative treatment (not all patients underwent the same program) NR
Retrospective case series, Level IV
29/29
NR
17 (range, 12.7-20.7)
31.0 1.8 yr (range, 1-3.9 yr)
Retrospective case series, Level IV
52/44
61.5% R 16 (range, and 38.5% L 13-19)
F, female; L, left; NR, not reported; R, right.
84
100
Previous Intervention Minimum of 6 mo nonoperative treatment including activity modification, physical therapy, and steroid injections in hip NR
108/108
43
%
63.1
New York
Boston
4 hips: previous in situ single-screw Colorado fixation for SCFE 5 hips: 3 intertrochanteric osteotomies, 1 shelf procedure, and 1 epiphysiodesis of greater trochanter 1 patient: prior resection of osteochondroma of proximal femur Minimum, 1 yr 100 at 1 yr 6 mo of conservative treatment including Mean, 27 mo 51 at 2 yr activity modification and physical (range, therapy 12-60 mo) 4/52 hips had prior arthroscopic hip surgery without relief of symptoms
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Open hip surgery Novais et al.20 (2014)
27/21
R v L Hip 56% R and 44% L
Gwathemy Prospective case et al.21 (2014) control, (abstract) Level IV Prospective case O’Donnell series, et al.19 (2012) (abstract) Level IV Philippon et al. Retrospective (2008)15 case series, Level IV Philippon et al.16 Therapeutic case (2012) series, Level IV Tran et al.10 (2013)
Follow-up Sample Size (Hips/Patients)
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of the femoral head-neck junction, acetabular rim trimming, labral debridement, and/or suture refixation, with partial psoas tendon release as deemed appropriate by the senior surgeon’s intraoperative assessment. The main indications reported for surgical management in this adolescent population were both clinical and radiographic. Clinical indications were (1) recalcitrant hip pain and mechanical symptoms unresponsive to a minimum of 6 weeks of activity modification, physiotherapy, and intra-articular steroid injections; (2) impaired function in activities of daily living and sport; (3) confirmed diagnosis of FAI through a combination of physical examination (e.g., limited hip internal rotation at 90 of flexion, positive impingement sign); and (4) transient improvement with intra-articular injection. Radiographic indications included (1) decreased femoral head-neck offset and/or (2) increased alpha angle greater than 55 . The most consistently reported contraindications (with definitions or diagnostic criteria not reported) included (1) acetabular dysplasia16-18; (2) global acetabular/femoral retroversion17; (3) Tönnis grade 2, 3, or 4 osteoarthritis17; and (4) other non-FAI diagnoses (e.g., Legg-Calvé-Perthes disease, SCFE, trauma, osteonecrosis).18 Coxa profunda/protrusio deformities were also reported as a contraindication in 1 study19 (Table 2). Outcomes An inconsistent combination of subjective and objective functional outcomes was reported across the studies, limiting a formal meta-analysis. All but 1 open study20 noted subjective improvements with surgical deformity correction to establish impingement-free motion, with 100% of patients treated arthroscopically achieving normal to near normal functional levels17 compared with 79% having fair to excellent results when treated with an open approach.18 Patient satisfaction was greater than 90% in patients treated arthroscopically and was not reported for the open studies. Only 7 of 388 patients (1.8%) treated arthroscopically were unable to return to activities; although all patients treated by open approaches returned to activities, 6 of 73 (8%) did so at a lower level.20 Although statistical improvements in the modified Harris Hip Score; Harris Hip Score; Hip Outcome ScoreeActivities of Daily Living; Hip Outcome ScoreeSport; Short Form 12-Item Survey; range of motion (ROM); University of California, Los Angeles Activity Scale; Western Ontario and McMaster Universities Arthritis Index; and alpha angle were noted across all studies, inconsistent outcomes reporting prevented formal comparisons (Table 3). Whether an adolescent with FAI was treated by hip arthroscopy or open surgical dislocation, the reported complications were low. Across all 388 patients (435 hips) reviewed, there were no reports of postoperative
infection, broken instrumentation, abdominal compartment syndrome, urinary/sexual dysfunction, chondral scuffing, labral penetration, or inadequate deformity correction. There were 2 cases of transient perineal neurapraxia that resolved spontaneously within 2 weeks postoperatively. Specific to the adolescent population, there were no reports of iatrogenic femoral neck fracture, instability/dislocation, acute SCFE, AVN, or premature physeal closure and proximal femoral growth arrest. There was 1 case of asymptomatic heterotopic ossification in a patient treated by an open approach, and 8 patients treated by arthroscopy required a revision procedure for lysis of adhesions; all 8 patients were highly satisfied with their revision outcome.11 Of note, in those patients with concomitant partial psoas tendon release for associated pathology, there were no clinically significant differences in hip flexion (objective or subjective) strength reported at follow-up.17
Discussion Key Findings The results of this review show that both hip arthroscopy and open surgical dislocation are safe and effective means to correct symptomatic FAI deformity in the skeletally immature population. Regarding growth and development of the proximal femur, we know that closure of the physes is initiated at ages 16 to 18 years, with 88% fusion at age 17 to 18 years and 100% fusion at age 20 years.22,23 Given that the mean age of patients in this review is 16.2 years (range, 11 to 20.7 years), essentially every patient reviewed herein possesses open physes. In fact, it was not uncommon for authors to report visualizing open proximal femoral growth plates during femoral osteochondroplasty.10 Thus, to our knowledge, this is the first systematic review addressing surgical management of FAI among the skeletally immature population. Regarding this population, the reported indications and contraindications for surgical management of FAI include a combination of the following: clinical history (e.g., anterior groin pain unresponsive to conservative treatment); physical examination findings (e.g., decreased ROM with flexion and internal rotation, positive impingement sign); radiographic findings (e.g., decreased offset, increased alpha angle, labral tears); and transient response to intra-articular diagnostic injection. The major contraindications include developmental pathology (e.g., SCFE, dysplasia) and/or significant degenerative changes (e.g., Tönnis grade 2, 3, or 4 osteoarthritis; 55
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Table 2. Indications and Contraindications for Surgical Treatment of FAI in Adolescents Diagnostic Injection
NR
NR
NR O’Donnell et al.19 (2012) (abstract)
NR
NR
NR
Persistent pain despite Positive anterior Philippon conservative et al.15 (2008) impingement management (6 wk test of NSAIDs, hip joint Asymmetrical injections, physical FABER test therapy, and/or activity modification) Mechanical symptoms
Plain radiographs showed NR increased femoral headneck offset as measured by alpha angle on cross-table lateral radiograph and presence of crossover sign on AP radiograph MRI of chondral and labral pathology
Contraindications
Pincer lesions were Acetabular dysplasia viewed with inspection Posterior extension of of acetabulum impingement lesions that are Identified type of labral poorly seen arthroscopically disorder Acetabular retroversion with Dynamic assessment of posterior wall deficiency impingement pattern Excessive femoral with hip ROM and retroversion traction released Osteoarthritis greater than Tönnis grade 1
36 cam, 17 pincer, and 69 NR combined lesions 111 labral tears 101 acetabular chondral lesions with 4 microfractures 3 femoral chondral lesions 19 ligamentum teres lesions 7 loose bodies NR Patients with history of developmental dysplasia of hip, Perthes disease, and arthritis were excluded NR NR
(continued)
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NR Gwathemy et al.21 (2014) (abstract)
Intra-articular anesthetic injection with immediate considerable to complete relief of symptoms during immediate postinjection period in all 21 patients, which later proved to be transient NR
Arthroscopy
Table 2. Continued Study Clinical History Failure of Philippon et al.16 (2012) nonoperative treatment for 6 mo
Tran et al.10 (2013)
Sink et al.18 (2013)
Pain with activity as measured by WOMAC pain subscale
Radiographic Diagnostic Injection AP radiograph used to NR measure center-edge angle: mean, 36 (range, 34 -38 ) Lateral radiograph measured alpha angle >50 MRI without contrast used to evaluate acetabular labrum, ligamentum teres, chondral surfaces, and other soft-tissue structures Positive pain Plain radiographs of hip (AP NR provocation tests pelvis and lateral Dunn (flexion, view) with alpha angle adduction, and >55 Femoral head sphericity internal lost on CT rotation)
NR
Hip pain that affected Positive ADLs At least 6 mo impingement of failed test with pain conservative being provoked treatment similar to their symptoms with hip flexion, slight adduction, and internal rotation Hip flexion and internal rotation at 90
Plain radiographs showing increased alpha angle, abnormal lateral centeredge angle of Wiberg, and abnormal acetabular inclination angle Plain radiographs that meet criteria of FAI MRI evidence of acetabular coverage, retroversion, coxa profunda, or decreased femoral headneck offset
Arthroscopy Contraindications Labral tears visualized Previous hip surgery in all hips Partial Center-edge angle 21 yr No regular participation in athletic activity Preoperative UCLA score 4 cm difference between sides)
ADLs, activities of daily living; AP, anteroposterior; CT, computed tomography; FABER, flexioneabductioneexternal rotation; MRI, magnetic resonance imaging; NR, not reported; NSAIDs, nonsteroidal anti-inflammatory drugs; UCLA, University of California, Los Angeles Activity Scale; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
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Table 3. Clinical Outcomes After Surgical Treatment of Adolescent FAI
Study Hip arthroscopy Fabricant et al.17 (2012)
Gwathemy et al.21 (2014) (abstract) O’Donnell et al.19 (2012) (abstract)
Normal function: 3.7% preoperatively to 37% postoperatively* Nearly normal function: 14.8% preoperatively to 63% postoperatively* Abnormal function: 70.4% preoperatively to 0.0% postoperatively* Severely abnormal function: 11.1% preoperatively to 0.0% postoperatively* NR
84% satisfaction after hip arthroscopy 91% would undergo surgery again Return to sport at previous level of competition: 62% Return to sport at lower level of competition: 32% No return to sport: 5% Mean patient satisfaction score: 9/10 (range, 9-10) All patients able to actively play in their desired sport postoperatively
Philippon et al.16 (2012)
Median satisfaction rating with no revision surgery: 10 (range, 8-10) Median satisfaction rating with revision surgery needed: 10 (mean, 8.8; range, 4-10)
Tran et al.10 (2013)
Satisfied: 88.2% (30/34) 91.2% (31/34) of patients would undergo surgery again Return to full sporting activity: 78.1% (25/34) Return to sport at lower level: 12.5% (4/34) Unable to return to sport: 8.8% (3/34) 2 patients not involved in sports were able to return to full activity
Open hip surgery Novais et al.20 (2014)
NR
Mean Net Improvement in Outcome Score (Mean Change)
Complications
HHS: 21 (range, NR); P < .001* HOS-ADL: 16 (range, NR); P < .001* HOS-Sport: 33 (range, NR); P ¼ .001*
None
mHHS: 23 (preoperatively, 69; postoperatively, 92)
2 patients had transient perineal neurapraxia that resolved within 2 wk 5 reoperations
Significant improvement (P < .01) in mHHS and NAHS
mHHS: 35 (range, NR); P ¼ .005* HOS-ADL: 36 (range, NR); P ¼ .001* HOS-Sport: 56 (range, NR); P ¼ .001* mHHS: 34 (range, NR); P < .001* HOS-ADL: 36 (range, NR); P ¼ .001* HOS-Sport: 44 (range, NR); P < .001* mHHS: 16.76 NAHS: 16.84
WOMAC: 1.5 UCLA: 1 Alpha angle: 22.7
D. DE SA ET AL.
Philippon et al.15 (2008)
Subjective Outcomes
None
8 hips needed repeat procedure at a mean of 26 mo because of persistent pain after surgery due to capsulolabral adhesions
None
6 patients had lower level of activity after surgery (continued)
HHS, Harris Hip Score; HOS-ADL, Hip Outcome ScoreeActivities of Daily Living; HOS-Sport, Hip Outcome ScoreeSport; mHHS, Modified Harris Hip Score; NAHS, Non-Arthritic Hip Score; NR, not reported; UCLA, University of California, Los Angeles Activity Scale; WOMAC, Western Ontario and McMaster Universities Arthritis Index. *Significant finding.
Study Sink et al.18 (2013)
Table 3. Continued
Subjective Outcomes Excellent: 30 hips (58%) (1 preoperatively) Good: 8 hips (15%) (1 preoperatively) Fair: 3 hips (6%) (7 preoperatively) Poor: 11 hips (21%) (36 preoperatively)
Mean Net Improvement in Outcome Score (Mean Change) mHHS: 34.4 (range, 16.5-59.4); P < .001* HOS-ADL: 36 (range, NR); P ¼ .001* HOS-Sport: 44 (range, NR); P < .001*
Complications 1 had grade I complication of asymptomatic heterotopic ossification (Brooker Grade I)
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used were made across all studies reviewed. Thus, with essentially no new indications/contraindications for surgery and without any technical modifications to surgery in this skeletally immature population, it should come as no surprise that the outcomes noteddbe it qualitative or quantitativedwere also consistent with those in adults (e.g., high patient satisfaction, improved patient-reported outcome scores, improved ROM, and high rate of return to activity/ sport). The crux of this review remains in its ability to address complicationsdthe major area of interest concerning surgical treatment of this skeletally immature population. Given the unique anatomy of the developing pediatric/adolescent patientdnamely smaller joint space and differential vascular supplydoperating on skeletally immature hips carries theoretical risks of acute SCFE, AVN, infection, instrument breakage, and premature physeal closure. Because this review reported no such major complications across a total of 388 patients (435 hips), these risks may in fact be simply theoretical. Moreover, there were no additional major complicationsdpreviously reported in adultsdobserved in this patient demographic. That is, none of the following were reported: distraction-type tractionrelated injuries; portal-related complications (e.g., lateral femoral cutaneous nerve injury); vascular injury (e.g., aneurysms, hematoma, hemorrhage); instability/ dislocation; episodes of deep venous thrombosis or fluid extravasation causing abdominal compartment syndrome; or inadequate osseous reshaping.25 The only complications reported were minor and included transient perineal neurapraxia in 2 patients and asymptomatic heterotopic ossification requiring no further intervention in 1 patient; in addition, there were 13 patients with capsulolabral adhesions that responded adequately to revision surgery. The incidence of heterotopic ossification may be attributable to the lack of lavaging the joint after the procedure and/or not administering postoperative nonsteroidal antiinflammatory medications.18,25 We cannot, however, explain the incidence of post-arthroscopy adhesions because both studies reporting this complication had patients immediately start continuous passive motion postoperatively and use the (ideal) stationary bicycle without resistance to improve ROM.25 Nevertheless, this revision/reoperation rate was quite low at 3.0% (13 of 435 hips). It was not possible to stratify these complications by age given the available data. However, an overall minor complication rate of 3.6% (16 of 435 hips) was reported; this finding is consistent with the 0.5% to 6.4% range reported in adults.25 There is inconclusive evidence in the skeletally immature population to suggest any superiority of arthroscopic or open surgical approaches but substantial evidence showing safety with either technique.
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Strengths The use of multiple databases and the use of a duplicate, systemic approach to review the literature are strengths ensuring that this review encompasses the current best-available evidence addressing indications/ contraindications, surgical options, and outcomes/ complications of addressing FAI deformity in patients aged 10 to 19 years inclusively. The improved outcomes, low complication rates, and high follow-up rates from this review support the addition of restoration of FAI-free motion as a surgical indication in the skeletally immature, adolescent population. Future Directions Going forward, efforts in this area should focus on longer-term follow-up for the patients examined in this review to acquire a more accurate understanding of patient outcomes and repercussions, if any, from operating on adolescents. The upper limit for the range of follow-up from this review is 75 months, which is substantial considering the available FAI data. However, there is no established optimal follow-up for patients after FAI correction, and as such, defining an acceptable follow-up period is paramount to ascertaining outcomes and complications. Efforts to conduct a comparative study design appear most feasible to provide additional higher-quality evidence on this topic. Generating a data pool or registry with consistent outcomes reported would further facilitate statistics. Finally, future directions regarding FAI surgery in adolescents should focus on using validated outcomes scores for young, active individuals with hip pathology, such as the International Hip Outcome Tool (iHOT33)26 or Copenhagen Hip and Groin Outcome Score,27 recognizing that these scores still do not capture the demographic that is aged younger than 19 years. Limitations From a methodologic standpoint, the limitations of this review stem from issues well recognized within the FAI literature and include the lack of evidence from high-quality randomized controlled trials or prospective cohort studies, lack of control groups, short-term follow-up, heterogeneous outcomes reporting, and small sample sizes. Specifically, not only were different outcomes reported across the 6 included studies, but the patient-reported scores used (e.g., modified Harris Hip Score, Harris Hip Score, Hip Outcome Score, NonArthritic Hip Score) are not validated in the young population and specifically in those with a diagnosis of FAI.10 A common criticism of the FAI literature surrounds the potential publication bias introduced with a similar cohort of high-volume surgeons with extensive experience contributing the bulk of the current evidence base. This may also introduce an expertise bias because outcomes from these specialized individuals
may not be fully generalizable. They do, however, highlight the fact that in experienced hands, these procedures are both safe and efficacious.
Conclusions Both arthroscopic and open surgical dislocation approaches for the treatment of adolescent FAI appear to be safe and effective options for patients with persistent pain and limited function after an appropriate trial of nonoperative therapy.
References 1. 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. 2. Klenke F, Siebenrock K. Pathomorphology and treatment of femoroacetabular impingement. Instr Course Lect 2012;61:263-272. 3. Jayakumar P, Ramachandran M, Youm T, Achan P. Arthroscopy of the hip for paediatric and adolescent disorders: Current concepts. J Bone Joint Surg Br 2012;94:290-296. 4. Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001;83:1119-1124. 5. Clohisy JC, McClure JT. Treatment of anterior femoroacetabular impingement with combined hip arthroscopy and limited anterior decompression. Iowa Orthop J 2005;25:164-171. 6. Philippon MJ, Stubbs AJ, Schenker ML, et al. Arthroscopic management of femoroacetabular impingement: Osteoplasty technique and literature review. Am J Sports Med 2007;35:1571-1580. 7. Clarke MT, Arora A, Villar RN. Hip arthroscopy: Complications in 1054 cases. Clin Orthop Relat Res 2003;406: 84-88. 8. Nötzli HP, Siebenrock KA, Hempfing A, Ramseier LE, Ganz R. Perfusion of the femoral head during surgical dislocation of the hip. Monitoring by laser Doppler flowmetry. J Bone Joint Surg Br 2002;84:300-304. 9. Wenger DR, Kishan S, Pring ME. Impingement and childhood hip disease. J Pediatr Orthop B 2006;15:233-243. 10. Tran P, Pritchard M, O’Donnell J. Outcome of arthroscopic treatment for cam type femoroacetabular impingement in adolescents. ANZ J Surg 2013;83: 382-386. 11. Philippon MJ, Schroder E, Souza BG, Briggs KK. Hip arthroscopy for femoroacetabular impingement in patients aged 50 years or older. Arthroscopy 2012;28:59-65. 12. Boone GR, Pagnotto MR, Walker JA, Trousdale RT, Sierra RJ. Caution should be taken in performing surgical hip dislocation for the treatment of femoroacetabular impingement in patients over the age of 40. HSS J 2012;8: 230-234. 13. World Health Organization. Maternal, newborn, child and adolescent health. Available at http://www.who.int/ maternal_child_adolescent/topics/adolescence/dev/en.
TREATMENT OF ADOLESCENT FAI 14. McGinn T, Wyer PC, Newman TB, et al. Tips for learners of evidence-based medicine: 3 measures of observer variability (kappa statistic). CMAJ 2004;171:1369-1373. 15. Philippon M, Yen Y, Briggs K, Kuppersmith D, Maxwell R. Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient. J Pediatr Orthop 2008;28:705-710. 16. Philippon M, Ejnisman L, Ellis H, Briggs K. Outcomes 2 to 5 years following hip arthroscopy for femoroacetabular impingement in the patient aged 11 to 16 years. Arthroscopy 2012;28:1255-1261. 17. Fabricant PD, Heyworth BE, Kelly BT. Hip arthroscopy improves symptoms associated with FAI in selected adolescent athletes. Clin Orthop Relat Res 2012;470:261-269. 18. Sink EL, Fabricant PD, Pan Z, Dayton MR, Novais E. Results of treatment of femoroacetabular impingement in adolescents with a surgical hip dislocation approach. Clin Orthop Relat Res 2013;471:2563-2569. 19. O’Donnell J, Singh P, Nall A, Pritchard M. The outcome of hip arthroscopy in teenagersdA review of 96 cases. J Bone Joint Surg Br 2012;94:72 (abstr). 20. Novais EN, Heyworth BE, Stamoulis C, Sullivan K, Millis MB, Kim YJ. Open surgical treatment of femoroacetabular impingement in adolescent athletes: Preliminary report on improvement of physical activity level. J Pediatr Orthop 2014;34:287-294.
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21. Gwathemy WF, Byrd JWT, Jones K. Arthroscopic management of femoroacetabular impingement (FAI) in adolescents. Arthroscopy 2014;30:e20-e21 (abstr). 22. Schuenke M, Schulte E, Schumacher U, Ross L, Lampert E. Lower Limb - Bones, Ligaments, and Joints: 1.15 The Development of the Hip Joint. In: General anatomy and musculoskeletal system - Latin nomencl (THIEME atlas of anatomy). New York: Thieme Med Publishers, 2011:388. 23. Scheuer L, Black S. The lower limb. In: The juvenile skeleton. London: Elsevier Academic Press, 2004;351-352. 24. Kelly BT, Williams RJ, Philippon MJ. Hip arthroscopy: Current indications, treatment options, and management issues. Am J Sports Med 2003;31:1020-1037. 25. Papavasiliou A, Bardakos N. Complications of arthroscopic surgery of the hip. Bone Joint Res 2012;7:131-144. 26. Mohtadi NG, Griffin DR, Pedersen ME, et al. The development and validation of a self-administered quality-oflife outcome measure for young, active patients with symptomatic hip disease: The International Hip Outcome Tool (iHOT-33). Arthroscopy 2012;28:595-605. quiz 606610.e1. 27. Thorborg K, Hölmich P, Christensen R, Petersen J, Roos EM. The Copenhagen Hip and Groin Outcome Score (HAGOS): Development and validation according to the COSMIN checklist. Br J Sports Med 2011;45: 478-491.
12
Appendix Table 1. Outline of Search Strategy Used per Database to Retrieve Articles Medline: 483 Studies Strategy 1. Femoroacetabular impingement.mp 2. 3. 4. 5. 6. 7. 8. 9.
Embase: 1,273 Studies No. of Studies 752 703 162 143 5 5 542 240 17
10. limit 9 to (English and humans)
16
11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
skeletally immature.mp limit 11 to (English and humans) labral repair.mp limit 13 to (English and humans) pincer.mp limit 15 to (English and humans) surgery.mp limit 17 to (English and humans) 2 or 4 or 6 or 8 or 10 or 12 or 14 or 16 18 and 19
920 759 124 117 556 324 845,428 543,688 1,995 483
2. 3. 4. 5. 6. 7. 8. 9.
limit 1 to (English and humans) CAM type.mp limit 3 to (English and humans) CAM decompression.mp limit 5 to (English and humans) osteoplasty.mp limit 7 to (English and humans) femoroplasty.mp
10. limit 9 to (English and humans)
11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
skeletally immature.mp limit 11 to (English and humans) labral repair.mp limit 13 to (English and humans) pincer.mp limit 15 to (English and humans) surgery.mp limit 17 to (English and humans) 2 or 4 or 6 or 8 or 10 or 12 or 14 or 16 18 and 19
No. of Studies 1,464 1,312 241 204 7 7 650 310 36
32
1,084 881 205 187 1,002 436 1,587,145 1,042,769 2,805 1,273
Strategy 1. Femoroacetabular impingement[MeSH Terms] 2. CAM type[MeSH Terms] 3. CAM decompression[MeSH Terms] 4. osteoplasty[MeSH Terms] 5. femoroplasty[MeSH Terms] 6. skeletally immature[MeSH Terms] 7. labral repair[MeSH Terms] 8. pincer[MeSH Terms] 9. (((((((femoroacetabular impingement) OR CAM type) OR CAM decompression) OR osteoplasty) OR femoroplasty) OR skeletally immature) OR labral repair) OR pincer 10. ((((((((femoroacetabular impingement) OR CAM type) OR CAM decompression) OR osteoplasty) OR femoroplasty) OR skeletally immature) OR labral repair) OR pincer) AND surgery
No. of Studies 777 2,257 27 238 17 762 307 315 4,326
1,889
D. DE SA ET AL.
limit 1 to (English and humans) CAM type.mp limit 3 to (English and humans) CAM decompression.mp limit 5 to (English and humans) osteoplasty.mp limit 7 to (English and humans) femoroplasty.mp
Strategy 1. Femoroacetabular impingement.mp
PubMed: 1,889 Studies
Femoroacetabular Impingement in Skeletally Immature Patients: A Systematic Review Examining Indications, Outcomes, and Complications of Open and Arthroscopic Treatment Darren de SA, M.D., Stephanie Cargnelli, M.D. Cand., Michael Catapano, M.D. Cand., Asheesh Bedi, M.D., Nicole Simunovic, M.Sc., Sarah Burrow, M.Sc., M.D., F.R.C.S.C., and Olufemi R. Ayeni, M.D., M.Sc., F.R.C.S.C.
Purpose: Improvements in physical examination and radiographic appreciation of symptomatic femoroacetabular impingement (FAI) has increased the focus on early diagnosis and treatment in an adolescent population. This systematic review aimed to establish specific indications, outcomes, and complications of surgical management of adolescent FAI. Methods: The Medline, Embase, and PubMed online databases were searched from inception until April 21, 2014, for English-language studies that addressed open and/or arthroscopic treatment of FAI in patients aged 10 to 19 years inclusively. The studies were systematically screened and data abstracted in duplicate, with qualitative findings presented. Results: There were 6 eligible case series (4 with arthroscopic and 2 with open technique) and 2 conference abstracts examining 388 patients in total (435 hips), 81% of which were treated with hip arthroscopy. Overall, patients were followed up for a mean of 23.4 months postoperatively (range, 3 to 75 months). The main indication for surgery was a confirmed diagnosis of FAI with persistent pain and impaired function refractory to nonoperative interventions (activity modification, intra-articular injections, and so on). Specific contraindications included Tönnis grade 2, 3, or 4 chondral changes and acetabular dysplasia. All studies reported significant improvements in patient pain, function (e.g., no patients were “abnormally” or “severely abnormally” impaired), and satisfaction rates (84% to 100% with arthroscopic technique v 79% with open technique). Improvements also were observed in range of motion and alpha angle correction, as well as across a variety of patient-reported functional scores, with all but 7 of 388 patients (1.8%) returning to activity/sport. No major complications were reported, with only 13 of 354 hips (3.7%) treated by arthroscopy requiring revision arthroscopy for lysis of adhesions and 1 of 81 open surgical dislocation hips (1%) having asymptomatic heterotopic ossification not requiring additional management. No cases of avascular necrosis, physeal arrest or growth disturbance, or iatrogenic deformity were reported. Conclusions: Both arthroscopic and open surgical dislocation approaches for the treatment of adolescent FAI appear to be safe and effective options for patients with persistent pain and limited function after an appropriate trial of nonoperative therapy. Level of Evidence: Level IV, systematic review of Level IV studies.
From the Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre (D.d.S., S.B., O.R.A.), Department of Clinical Epidemiology and Biostatistics (N.S.), Michael G. DeGroote School of Medicine (S.C., M.C.), McMaster University, Hamilton, Ontario, Canada; and MedSport at Domino’s Farms, MedSport (A.B.), Ann Arbor, Michigan, U.S.A. The authors report the following potential conflict of interest or source of funding: A.B. receives support from Smith & Nephew, A3 Surgical. O.R.A. receives support from Smith & Nephew. Received June 27, 2014; accepted July 24, 2014. Address correspondence to Olufemi R. Ayeni, M.Sc., M.D., McMaster University Medical Centre, 1200 Main St W, 4E15 Hamilton, Ontario L8N 3Z5, Canada. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/14542/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.07.030
F
emoroacetabular impingement (FAI) due to abnormal head-neck offset and sphericity and/or acetabular retroversion constitutes an increasingly recognized cause of mechanical hip pain in the young adult.1 In addition to persistent pain and limited function, the natural history and propensity of FAI to accelerate various labral pathology and early hip degenerative changes are of paramount concern in adolescent patients.1,2 As such, there is increased recognition of the condition and attention to hippreservation procedures to restore impingement-free motion at an early age.3 The osseous deformity and chondrolabral pathology of symptomatic FAI may be surgically addressed by an open surgical hip dislocation and osteotomy,4 mini-open
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anterior arthrotomy,5 and/or hip arthroscopic techniques.6 In adults postoperative outcomes are encouraging, and complication rates for both open and arthroscopic approaches are low (1.5%).7,8 Deformity correction in the skeletally immature adolescent with open physes, however, presents unique and additional risks such as (1) avascular necrosis (AVN) with disruption of the posterosuperior ascending vascular supply, (2) acute iatrogenic slipped capital femoral epiphysis (SCFE), or (3) growth arrest of the proximal femur with violation of the perichondrial ring.9,10 With the paucity of literature on the treatment of FAI in skeletally immature patients, results from adult studies are often used as surrogates to guide practice.11,12 Thus this systematic review aims to address 3 fundamental questions when considering operative (open and/or arthroscopic) intervention for FAI in adolescents: (1) What are the indications and contraindications for surgery? (2) What are the important patient-specific outcomes after operative treatment? (3) What are the surgical complications in this population? This review was conducted to help guide surgeon patient selection and decision making and enhance patient care. We hypothesize that, with no unique technical changes applied to adolescents, surgical management for FAI in this demographic will be of similar efficacy and safety to that in adults.
Methods Search Strategy On April 21, 2014, the online databases Embase, Medline, and PubMed were searched from database inception until April 21, 2014, for literature addressing surgical indications and clinical outcomes for FAI management among the adolescent population. The search terms “femoroacetabular impingement,” “skeletally immature,” “adolescent,” “pediatric,” “arthroscopy,” and “osteoplasty” were used (Appendix Table 1). We also searched the abstracts of Orthopaedic Proceedings (a supplement of The Bone & Joint Journal) from the Australian Orthopaedic Association Limited 69th Annual Scientific Meeting, as well as supplemental material from Arthroscopy (June 2014) for additional unpublished data. Finally, the aforementioned search terms were entered into the Google Scholar search engine on June 20, 2014, for any additional unpublished data. Study Screening The titles, abstracts, and full-text articles were screened by 2 reviewers (S.C., M.C.). If, at any stage, one reviewer expressed doubt regarding inclusion/ exclusion of a particular study, it was advanced to the next stage for further review to ensure that all possibly relevant articles and conference abstracts were included. Disagreements at the final stage were addressed by discussion between the 2 reviewers, with a third, senior
reviewer (D.d-S.) to manage unresolved conflicts. The references of the eligible included studies were subsequently searched to capture any additional articles that may have eluded the initial search strategy. Assessment of Study Eligibility The research questions and inclusion/exclusion criteria were determined a priori. Articles included were required to be English-language studies involving human patients. Specifically, included studies must have addressed surgical management of FAI, have been performed open and/or arthroscopically, and have been conducted in patients aged 10 to 19 years inclusively. This age range was based on the World Health Organization definition for an adolescent individual.13 We excluded studies that were review or technical articles; cadaveric studies; studies that solely addressed nonsurgical management of FAI; studies that included adult patients; studies that were case reports or case series of fewer than 5 patients; and/or studies that included patients undergoing surgery for hip dysplasia, SCFE, or any non-FAI etiology. Data Abstraction The 2 reviewers collected data in duplicate and recorded it in a Microsoft Excel spreadsheet (2007 release; Microsoft, Redmond, WA). Data regarding study year of publication, author, location of study, and study design were recorded. Descriptive statistics of the studies, including age, percent female, sample size, level of evidence, and mean follow-up, were recorded. Patient data were recorded regarding history, clinical examination, and radiographic findings. Surgical outcome data, both qualitative and quantitative, were also recorded. Formal quality scoring of included studies was not performed because of the quality of evidence (e.g., case series) resulting from our search. Although 1 included abstract was a casecontrol study in design, the control was a chronologically matched adult (not adolescent) group aged 18 to 50 years, with no full-text data available for quality assessment. Assessment of Agreement A weighted k and 95% confidence intervals (CIs) were calculated for all 3 stages of screening. We determined k values to indicate the level of agreement: k of 0.61 or greater indicates substantial agreement; k greater than 0.20 but less than 0.61 indicates moderate agreement; and k of 0.20 or less indicates slight agreement.14
Results Search Strategy After an initial retrieval of 3,645 studies, 575 duplicates (16%) were removed; the remaining 3,070 studies were systematically searched and yielded 5 full-
TREATMENT OF ADOLESCENT FAI
3
Fig 1. Flow diagram describing systematic review of literature on adolescent FAI.
text studies and 2 abstracts with no additional full text available for inclusion. Authors of conference abstracts were contacted to ensure that a full-text article had not been published. Searching the references of these 5 studies produced 1 additional study for inclusion (Fig 1). There was high agreement among reviewers at the title (k ¼ 0.86; 95% CI, 0.89 to 0.82), abstract (k ¼ 0.94; 95% CI, 0.90 to 0.98), and full-text screening stages (k ¼ 1.00; 95% CI, 1.00 to 1.00). Study Characteristics We identified 1 case-control and 5 case series examining hip arthroscopy and 2 case series examining open surgical procedures. Six studies were conducted in the United States and 2 in Australia. Adolescent patients were treated
for FAI with either hip arthroscopy (315 patients, 354 hips) or open surgical dislocation (73 patients, 81 hips). This review includes 2 studies by Philippon et al.15,16 on adolescent patients recruited around the same period. We contacted the authors and confirmed that the patients in each study represented 2 separate populations, reducing duplication. Female patients with similar pathology comprised approximately 54% of the study population, and outcomes were evaluated over a period of a minimum of 3 months postoperatively to a maximum of 75 months (Table 1). Surgical Indications Arthroscopic or open procedures presented in this review encompassed a combination of osteochondroplasty
4
Table 1. Participant Demographic Data for Studies Evaluating Surgical Treatment of FAI in Adolescents Study Design, Level of Evidence
Study HIP arthroscopy Fabricant et al.17 Retrospective (2012) case series, Level IV
Sink et al.18 (2013)
Age, yr
%F
Length
17.6 (range, 14.5-19.9)
NR
16 (range, 12-17)
Minimum, 1 yr Mean, 1.5 yr (range, 1-2.5 yr) 54.6 29 mo (range, 12-60 mo)
96/76
57% R and 43% L
17 (range, 13-19)
17/16
NR
65/60
Multicenter prospective longitudinal case series, Level IV
Location
100
Virginia
44.8 19 mo (range, 3-75 mo)
100
NR
Melbourne
15 (range, 11-16)
87.5 1.36 yr (range, 1-2 yr)
100
Boston
55% R and 45% L
15 (range, 11-16)
72
3.5 yr (range, 2-5 yr)
100
41/34
49% R and 51% L
15.7 (range, 11-18)
15
Minimum, 1 yr Mean, 14 mo (range, 1-2 yr)
100
6 wk of nonsteroidal anti-inflammatory drugs, hip joint injections, physical therapy, and/or activity modification 6 mo of conservative treatment (not all patients underwent the same program) NR
Retrospective case series, Level IV
29/29
NR
17 (range, 12.7-20.7)
31.0 1.8 yr (range, 1-3.9 yr)
Retrospective case series, Level IV
52/44
61.5% R 16 (range, and 38.5% L 13-19)
F, female; L, left; NR, not reported; R, right.
84
100
Previous Intervention Minimum of 6 mo nonoperative treatment including activity modification, physical therapy, and steroid injections in hip NR
108/108
43
%
63.1
New York
Boston
4 hips: previous in situ single-screw Colorado fixation for SCFE 5 hips: 3 intertrochanteric osteotomies, 1 shelf procedure, and 1 epiphysiodesis of greater trochanter 1 patient: prior resection of osteochondroma of proximal femur Minimum, 1 yr 100 at 1 yr 6 mo of conservative treatment including Mean, 27 mo 51 at 2 yr activity modification and physical (range, therapy 12-60 mo) 4/52 hips had prior arthroscopic hip surgery without relief of symptoms
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Open hip surgery Novais et al.20 (2014)
27/21
R v L Hip 56% R and 44% L
Gwathemy Prospective case et al.21 (2014) control, (abstract) Level IV Prospective case O’Donnell series, et al.19 (2012) (abstract) Level IV Philippon et al. Retrospective (2008)15 case series, Level IV Philippon et al.16 Therapeutic case (2012) series, Level IV Tran et al.10 (2013)
Follow-up Sample Size (Hips/Patients)
5
TREATMENT OF ADOLESCENT FAI
of the femoral head-neck junction, acetabular rim trimming, labral debridement, and/or suture refixation, with partial psoas tendon release as deemed appropriate by the senior surgeon’s intraoperative assessment. The main indications reported for surgical management in this adolescent population were both clinical and radiographic. Clinical indications were (1) recalcitrant hip pain and mechanical symptoms unresponsive to a minimum of 6 weeks of activity modification, physiotherapy, and intra-articular steroid injections; (2) impaired function in activities of daily living and sport; (3) confirmed diagnosis of FAI through a combination of physical examination (e.g., limited hip internal rotation at 90 of flexion, positive impingement sign); and (4) transient improvement with intra-articular injection. Radiographic indications included (1) decreased femoral head-neck offset and/or (2) increased alpha angle greater than 55 . The most consistently reported contraindications (with definitions or diagnostic criteria not reported) included (1) acetabular dysplasia16-18; (2) global acetabular/femoral retroversion17; (3) Tönnis grade 2, 3, or 4 osteoarthritis17; and (4) other non-FAI diagnoses (e.g., Legg-Calvé-Perthes disease, SCFE, trauma, osteonecrosis).18 Coxa profunda/protrusio deformities were also reported as a contraindication in 1 study19 (Table 2). Outcomes An inconsistent combination of subjective and objective functional outcomes was reported across the studies, limiting a formal meta-analysis. All but 1 open study20 noted subjective improvements with surgical deformity correction to establish impingement-free motion, with 100% of patients treated arthroscopically achieving normal to near normal functional levels17 compared with 79% having fair to excellent results when treated with an open approach.18 Patient satisfaction was greater than 90% in patients treated arthroscopically and was not reported for the open studies. Only 7 of 388 patients (1.8%) treated arthroscopically were unable to return to activities; although all patients treated by open approaches returned to activities, 6 of 73 (8%) did so at a lower level.20 Although statistical improvements in the modified Harris Hip Score; Harris Hip Score; Hip Outcome ScoreeActivities of Daily Living; Hip Outcome ScoreeSport; Short Form 12-Item Survey; range of motion (ROM); University of California, Los Angeles Activity Scale; Western Ontario and McMaster Universities Arthritis Index; and alpha angle were noted across all studies, inconsistent outcomes reporting prevented formal comparisons (Table 3). Whether an adolescent with FAI was treated by hip arthroscopy or open surgical dislocation, the reported complications were low. Across all 388 patients (435 hips) reviewed, there were no reports of postoperative
infection, broken instrumentation, abdominal compartment syndrome, urinary/sexual dysfunction, chondral scuffing, labral penetration, or inadequate deformity correction. There were 2 cases of transient perineal neurapraxia that resolved spontaneously within 2 weeks postoperatively. Specific to the adolescent population, there were no reports of iatrogenic femoral neck fracture, instability/dislocation, acute SCFE, AVN, or premature physeal closure and proximal femoral growth arrest. There was 1 case of asymptomatic heterotopic ossification in a patient treated by an open approach, and 8 patients treated by arthroscopy required a revision procedure for lysis of adhesions; all 8 patients were highly satisfied with their revision outcome.11 Of note, in those patients with concomitant partial psoas tendon release for associated pathology, there were no clinically significant differences in hip flexion (objective or subjective) strength reported at follow-up.17
Discussion Key Findings The results of this review show that both hip arthroscopy and open surgical dislocation are safe and effective means to correct symptomatic FAI deformity in the skeletally immature population. Regarding growth and development of the proximal femur, we know that closure of the physes is initiated at ages 16 to 18 years, with 88% fusion at age 17 to 18 years and 100% fusion at age 20 years.22,23 Given that the mean age of patients in this review is 16.2 years (range, 11 to 20.7 years), essentially every patient reviewed herein possesses open physes. In fact, it was not uncommon for authors to report visualizing open proximal femoral growth plates during femoral osteochondroplasty.10 Thus, to our knowledge, this is the first systematic review addressing surgical management of FAI among the skeletally immature population. Regarding this population, the reported indications and contraindications for surgical management of FAI include a combination of the following: clinical history (e.g., anterior groin pain unresponsive to conservative treatment); physical examination findings (e.g., decreased ROM with flexion and internal rotation, positive impingement sign); radiographic findings (e.g., decreased offset, increased alpha angle, labral tears); and transient response to intra-articular diagnostic injection. The major contraindications include developmental pathology (e.g., SCFE, dysplasia) and/or significant degenerative changes (e.g., Tönnis grade 2, 3, or 4 osteoarthritis; 55
6
Table 2. Indications and Contraindications for Surgical Treatment of FAI in Adolescents Diagnostic Injection
NR
NR
NR O’Donnell et al.19 (2012) (abstract)
NR
NR
NR
Persistent pain despite Positive anterior Philippon conservative et al.15 (2008) impingement management (6 wk test of NSAIDs, hip joint Asymmetrical injections, physical FABER test therapy, and/or activity modification) Mechanical symptoms
Plain radiographs showed NR increased femoral headneck offset as measured by alpha angle on cross-table lateral radiograph and presence of crossover sign on AP radiograph MRI of chondral and labral pathology
Contraindications
Pincer lesions were Acetabular dysplasia viewed with inspection Posterior extension of of acetabulum impingement lesions that are Identified type of labral poorly seen arthroscopically disorder Acetabular retroversion with Dynamic assessment of posterior wall deficiency impingement pattern Excessive femoral with hip ROM and retroversion traction released Osteoarthritis greater than Tönnis grade 1
36 cam, 17 pincer, and 69 NR combined lesions 111 labral tears 101 acetabular chondral lesions with 4 microfractures 3 femoral chondral lesions 19 ligamentum teres lesions 7 loose bodies NR Patients with history of developmental dysplasia of hip, Perthes disease, and arthritis were excluded NR NR
(continued)
D. DE SA ET AL.
NR Gwathemy et al.21 (2014) (abstract)
Intra-articular anesthetic injection with immediate considerable to complete relief of symptoms during immediate postinjection period in all 21 patients, which later proved to be transient NR
Arthroscopy
Table 2. Continued Study Clinical History Failure of Philippon et al.16 (2012) nonoperative treatment for 6 mo
Tran et al.10 (2013)
Sink et al.18 (2013)
Pain with activity as measured by WOMAC pain subscale
Radiographic Diagnostic Injection AP radiograph used to NR measure center-edge angle: mean, 36 (range, 34 -38 ) Lateral radiograph measured alpha angle >50 MRI without contrast used to evaluate acetabular labrum, ligamentum teres, chondral surfaces, and other soft-tissue structures Positive pain Plain radiographs of hip (AP NR provocation tests pelvis and lateral Dunn (flexion, view) with alpha angle adduction, and >55 Femoral head sphericity internal lost on CT rotation)
NR
Hip pain that affected Positive ADLs At least 6 mo impingement of failed test with pain conservative being provoked treatment similar to their symptoms with hip flexion, slight adduction, and internal rotation Hip flexion and internal rotation at 90
Plain radiographs showing increased alpha angle, abnormal lateral centeredge angle of Wiberg, and abnormal acetabular inclination angle Plain radiographs that meet criteria of FAI MRI evidence of acetabular coverage, retroversion, coxa profunda, or decreased femoral headneck offset
Arthroscopy Contraindications Labral tears visualized Previous hip surgery in all hips Partial Center-edge angle 21 yr No regular participation in athletic activity Preoperative UCLA score 4 cm difference between sides)
ADLs, activities of daily living; AP, anteroposterior; CT, computed tomography; FABER, flexioneabductioneexternal rotation; MRI, magnetic resonance imaging; NR, not reported; NSAIDs, nonsteroidal anti-inflammatory drugs; UCLA, University of California, Los Angeles Activity Scale; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
7
8
Table 3. Clinical Outcomes After Surgical Treatment of Adolescent FAI
Study Hip arthroscopy Fabricant et al.17 (2012)
Gwathemy et al.21 (2014) (abstract) O’Donnell et al.19 (2012) (abstract)
Normal function: 3.7% preoperatively to 37% postoperatively* Nearly normal function: 14.8% preoperatively to 63% postoperatively* Abnormal function: 70.4% preoperatively to 0.0% postoperatively* Severely abnormal function: 11.1% preoperatively to 0.0% postoperatively* NR
84% satisfaction after hip arthroscopy 91% would undergo surgery again Return to sport at previous level of competition: 62% Return to sport at lower level of competition: 32% No return to sport: 5% Mean patient satisfaction score: 9/10 (range, 9-10) All patients able to actively play in their desired sport postoperatively
Philippon et al.16 (2012)
Median satisfaction rating with no revision surgery: 10 (range, 8-10) Median satisfaction rating with revision surgery needed: 10 (mean, 8.8; range, 4-10)
Tran et al.10 (2013)
Satisfied: 88.2% (30/34) 91.2% (31/34) of patients would undergo surgery again Return to full sporting activity: 78.1% (25/34) Return to sport at lower level: 12.5% (4/34) Unable to return to sport: 8.8% (3/34) 2 patients not involved in sports were able to return to full activity
Open hip surgery Novais et al.20 (2014)
NR
Mean Net Improvement in Outcome Score (Mean Change)
Complications
HHS: 21 (range, NR); P < .001* HOS-ADL: 16 (range, NR); P < .001* HOS-Sport: 33 (range, NR); P ¼ .001*
None
mHHS: 23 (preoperatively, 69; postoperatively, 92)
2 patients had transient perineal neurapraxia that resolved within 2 wk 5 reoperations
Significant improvement (P < .01) in mHHS and NAHS
mHHS: 35 (range, NR); P ¼ .005* HOS-ADL: 36 (range, NR); P ¼ .001* HOS-Sport: 56 (range, NR); P ¼ .001* mHHS: 34 (range, NR); P < .001* HOS-ADL: 36 (range, NR); P ¼ .001* HOS-Sport: 44 (range, NR); P < .001* mHHS: 16.76 NAHS: 16.84
WOMAC: 1.5 UCLA: 1 Alpha angle: 22.7
D. DE SA ET AL.
Philippon et al.15 (2008)
Subjective Outcomes
None
8 hips needed repeat procedure at a mean of 26 mo because of persistent pain after surgery due to capsulolabral adhesions
None
6 patients had lower level of activity after surgery (continued)
HHS, Harris Hip Score; HOS-ADL, Hip Outcome ScoreeActivities of Daily Living; HOS-Sport, Hip Outcome ScoreeSport; mHHS, Modified Harris Hip Score; NAHS, Non-Arthritic Hip Score; NR, not reported; UCLA, University of California, Los Angeles Activity Scale; WOMAC, Western Ontario and McMaster Universities Arthritis Index. *Significant finding.
Study Sink et al.18 (2013)
Table 3. Continued
Subjective Outcomes Excellent: 30 hips (58%) (1 preoperatively) Good: 8 hips (15%) (1 preoperatively) Fair: 3 hips (6%) (7 preoperatively) Poor: 11 hips (21%) (36 preoperatively)
Mean Net Improvement in Outcome Score (Mean Change) mHHS: 34.4 (range, 16.5-59.4); P < .001* HOS-ADL: 36 (range, NR); P ¼ .001* HOS-Sport: 44 (range, NR); P < .001*
Complications 1 had grade I complication of asymptomatic heterotopic ossification (Brooker Grade I)
TREATMENT OF ADOLESCENT FAI
9
used were made across all studies reviewed. Thus, with essentially no new indications/contraindications for surgery and without any technical modifications to surgery in this skeletally immature population, it should come as no surprise that the outcomes noteddbe it qualitative or quantitativedwere also consistent with those in adults (e.g., high patient satisfaction, improved patient-reported outcome scores, improved ROM, and high rate of return to activity/ sport). The crux of this review remains in its ability to address complicationsdthe major area of interest concerning surgical treatment of this skeletally immature population. Given the unique anatomy of the developing pediatric/adolescent patientdnamely smaller joint space and differential vascular supplydoperating on skeletally immature hips carries theoretical risks of acute SCFE, AVN, infection, instrument breakage, and premature physeal closure. Because this review reported no such major complications across a total of 388 patients (435 hips), these risks may in fact be simply theoretical. Moreover, there were no additional major complicationsdpreviously reported in adultsdobserved in this patient demographic. That is, none of the following were reported: distraction-type tractionrelated injuries; portal-related complications (e.g., lateral femoral cutaneous nerve injury); vascular injury (e.g., aneurysms, hematoma, hemorrhage); instability/ dislocation; episodes of deep venous thrombosis or fluid extravasation causing abdominal compartment syndrome; or inadequate osseous reshaping.25 The only complications reported were minor and included transient perineal neurapraxia in 2 patients and asymptomatic heterotopic ossification requiring no further intervention in 1 patient; in addition, there were 13 patients with capsulolabral adhesions that responded adequately to revision surgery. The incidence of heterotopic ossification may be attributable to the lack of lavaging the joint after the procedure and/or not administering postoperative nonsteroidal antiinflammatory medications.18,25 We cannot, however, explain the incidence of post-arthroscopy adhesions because both studies reporting this complication had patients immediately start continuous passive motion postoperatively and use the (ideal) stationary bicycle without resistance to improve ROM.25 Nevertheless, this revision/reoperation rate was quite low at 3.0% (13 of 435 hips). It was not possible to stratify these complications by age given the available data. However, an overall minor complication rate of 3.6% (16 of 435 hips) was reported; this finding is consistent with the 0.5% to 6.4% range reported in adults.25 There is inconclusive evidence in the skeletally immature population to suggest any superiority of arthroscopic or open surgical approaches but substantial evidence showing safety with either technique.
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D. DE SA ET AL.
Strengths The use of multiple databases and the use of a duplicate, systemic approach to review the literature are strengths ensuring that this review encompasses the current best-available evidence addressing indications/ contraindications, surgical options, and outcomes/ complications of addressing FAI deformity in patients aged 10 to 19 years inclusively. The improved outcomes, low complication rates, and high follow-up rates from this review support the addition of restoration of FAI-free motion as a surgical indication in the skeletally immature, adolescent population. Future Directions Going forward, efforts in this area should focus on longer-term follow-up for the patients examined in this review to acquire a more accurate understanding of patient outcomes and repercussions, if any, from operating on adolescents. The upper limit for the range of follow-up from this review is 75 months, which is substantial considering the available FAI data. However, there is no established optimal follow-up for patients after FAI correction, and as such, defining an acceptable follow-up period is paramount to ascertaining outcomes and complications. Efforts to conduct a comparative study design appear most feasible to provide additional higher-quality evidence on this topic. Generating a data pool or registry with consistent outcomes reported would further facilitate statistics. Finally, future directions regarding FAI surgery in adolescents should focus on using validated outcomes scores for young, active individuals with hip pathology, such as the International Hip Outcome Tool (iHOT33)26 or Copenhagen Hip and Groin Outcome Score,27 recognizing that these scores still do not capture the demographic that is aged younger than 19 years. Limitations From a methodologic standpoint, the limitations of this review stem from issues well recognized within the FAI literature and include the lack of evidence from high-quality randomized controlled trials or prospective cohort studies, lack of control groups, short-term follow-up, heterogeneous outcomes reporting, and small sample sizes. Specifically, not only were different outcomes reported across the 6 included studies, but the patient-reported scores used (e.g., modified Harris Hip Score, Harris Hip Score, Hip Outcome Score, NonArthritic Hip Score) are not validated in the young population and specifically in those with a diagnosis of FAI.10 A common criticism of the FAI literature surrounds the potential publication bias introduced with a similar cohort of high-volume surgeons with extensive experience contributing the bulk of the current evidence base. This may also introduce an expertise bias because outcomes from these specialized individuals
may not be fully generalizable. They do, however, highlight the fact that in experienced hands, these procedures are both safe and efficacious.
Conclusions Both arthroscopic and open surgical dislocation approaches for the treatment of adolescent FAI appear to be safe and effective options for patients with persistent pain and limited function after an appropriate trial of nonoperative therapy.
References 1. 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. 2. Klenke F, Siebenrock K. Pathomorphology and treatment of femoroacetabular impingement. Instr Course Lect 2012;61:263-272. 3. Jayakumar P, Ramachandran M, Youm T, Achan P. Arthroscopy of the hip for paediatric and adolescent disorders: Current concepts. J Bone Joint Surg Br 2012;94:290-296. 4. Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001;83:1119-1124. 5. Clohisy JC, McClure JT. Treatment of anterior femoroacetabular impingement with combined hip arthroscopy and limited anterior decompression. Iowa Orthop J 2005;25:164-171. 6. Philippon MJ, Stubbs AJ, Schenker ML, et al. Arthroscopic management of femoroacetabular impingement: Osteoplasty technique and literature review. Am J Sports Med 2007;35:1571-1580. 7. Clarke MT, Arora A, Villar RN. Hip arthroscopy: Complications in 1054 cases. Clin Orthop Relat Res 2003;406: 84-88. 8. Nötzli HP, Siebenrock KA, Hempfing A, Ramseier LE, Ganz R. Perfusion of the femoral head during surgical dislocation of the hip. Monitoring by laser Doppler flowmetry. J Bone Joint Surg Br 2002;84:300-304. 9. Wenger DR, Kishan S, Pring ME. Impingement and childhood hip disease. J Pediatr Orthop B 2006;15:233-243. 10. Tran P, Pritchard M, O’Donnell J. Outcome of arthroscopic treatment for cam type femoroacetabular impingement in adolescents. ANZ J Surg 2013;83: 382-386. 11. Philippon MJ, Schroder E, Souza BG, Briggs KK. Hip arthroscopy for femoroacetabular impingement in patients aged 50 years or older. Arthroscopy 2012;28:59-65. 12. Boone GR, Pagnotto MR, Walker JA, Trousdale RT, Sierra RJ. Caution should be taken in performing surgical hip dislocation for the treatment of femoroacetabular impingement in patients over the age of 40. HSS J 2012;8: 230-234. 13. World Health Organization. Maternal, newborn, child and adolescent health. Available at http://www.who.int/ maternal_child_adolescent/topics/adolescence/dev/en.
TREATMENT OF ADOLESCENT FAI 14. McGinn T, Wyer PC, Newman TB, et al. Tips for learners of evidence-based medicine: 3 measures of observer variability (kappa statistic). CMAJ 2004;171:1369-1373. 15. Philippon M, Yen Y, Briggs K, Kuppersmith D, Maxwell R. Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient. J Pediatr Orthop 2008;28:705-710. 16. Philippon M, Ejnisman L, Ellis H, Briggs K. Outcomes 2 to 5 years following hip arthroscopy for femoroacetabular impingement in the patient aged 11 to 16 years. Arthroscopy 2012;28:1255-1261. 17. Fabricant PD, Heyworth BE, Kelly BT. Hip arthroscopy improves symptoms associated with FAI in selected adolescent athletes. Clin Orthop Relat Res 2012;470:261-269. 18. Sink EL, Fabricant PD, Pan Z, Dayton MR, Novais E. Results of treatment of femoroacetabular impingement in adolescents with a surgical hip dislocation approach. Clin Orthop Relat Res 2013;471:2563-2569. 19. O’Donnell J, Singh P, Nall A, Pritchard M. The outcome of hip arthroscopy in teenagersdA review of 96 cases. J Bone Joint Surg Br 2012;94:72 (abstr). 20. Novais EN, Heyworth BE, Stamoulis C, Sullivan K, Millis MB, Kim YJ. Open surgical treatment of femoroacetabular impingement in adolescent athletes: Preliminary report on improvement of physical activity level. J Pediatr Orthop 2014;34:287-294.
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21. Gwathemy WF, Byrd JWT, Jones K. Arthroscopic management of femoroacetabular impingement (FAI) in adolescents. Arthroscopy 2014;30:e20-e21 (abstr). 22. Schuenke M, Schulte E, Schumacher U, Ross L, Lampert E. Lower Limb - Bones, Ligaments, and Joints: 1.15 The Development of the Hip Joint. In: General anatomy and musculoskeletal system - Latin nomencl (THIEME atlas of anatomy). New York: Thieme Med Publishers, 2011:388. 23. Scheuer L, Black S. The lower limb. In: The juvenile skeleton. London: Elsevier Academic Press, 2004;351-352. 24. Kelly BT, Williams RJ, Philippon MJ. Hip arthroscopy: Current indications, treatment options, and management issues. Am J Sports Med 2003;31:1020-1037. 25. Papavasiliou A, Bardakos N. Complications of arthroscopic surgery of the hip. Bone Joint Res 2012;7:131-144. 26. Mohtadi NG, Griffin DR, Pedersen ME, et al. The development and validation of a self-administered quality-oflife outcome measure for young, active patients with symptomatic hip disease: The International Hip Outcome Tool (iHOT-33). Arthroscopy 2012;28:595-605. quiz 606610.e1. 27. Thorborg K, Hölmich P, Christensen R, Petersen J, Roos EM. The Copenhagen Hip and Groin Outcome Score (HAGOS): Development and validation according to the COSMIN checklist. Br J Sports Med 2011;45: 478-491.
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Appendix Table 1. Outline of Search Strategy Used per Database to Retrieve Articles Medline: 483 Studies Strategy 1. Femoroacetabular impingement.mp 2. 3. 4. 5. 6. 7. 8. 9.
Embase: 1,273 Studies No. of Studies 752 703 162 143 5 5 542 240 17
10. limit 9 to (English and humans)
16
11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
skeletally immature.mp limit 11 to (English and humans) labral repair.mp limit 13 to (English and humans) pincer.mp limit 15 to (English and humans) surgery.mp limit 17 to (English and humans) 2 or 4 or 6 or 8 or 10 or 12 or 14 or 16 18 and 19
920 759 124 117 556 324 845,428 543,688 1,995 483
2. 3. 4. 5. 6. 7. 8. 9.
limit 1 to (English and humans) CAM type.mp limit 3 to (English and humans) CAM decompression.mp limit 5 to (English and humans) osteoplasty.mp limit 7 to (English and humans) femoroplasty.mp
10. limit 9 to (English and humans)
11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
skeletally immature.mp limit 11 to (English and humans) labral repair.mp limit 13 to (English and humans) pincer.mp limit 15 to (English and humans) surgery.mp limit 17 to (English and humans) 2 or 4 or 6 or 8 or 10 or 12 or 14 or 16 18 and 19
No. of Studies 1,464 1,312 241 204 7 7 650 310 36
32
1,084 881 205 187 1,002 436 1,587,145 1,042,769 2,805 1,273
Strategy 1. Femoroacetabular impingement[MeSH Terms] 2. CAM type[MeSH Terms] 3. CAM decompression[MeSH Terms] 4. osteoplasty[MeSH Terms] 5. femoroplasty[MeSH Terms] 6. skeletally immature[MeSH Terms] 7. labral repair[MeSH Terms] 8. pincer[MeSH Terms] 9. (((((((femoroacetabular impingement) OR CAM type) OR CAM decompression) OR osteoplasty) OR femoroplasty) OR skeletally immature) OR labral repair) OR pincer 10. ((((((((femoroacetabular impingement) OR CAM type) OR CAM decompression) OR osteoplasty) OR femoroplasty) OR skeletally immature) OR labral repair) OR pincer) AND surgery
No. of Studies 777 2,257 27 238 17 762 307 315 4,326
1,889
D. DE SA ET AL.
limit 1 to (English and humans) CAM type.mp limit 3 to (English and humans) CAM decompression.mp limit 5 to (English and humans) osteoplasty.mp limit 7 to (English and humans) femoroplasty.mp
Strategy 1. Femoroacetabular impingement.mp
PubMed: 1,889 Studies
