ORIGINAL ARTICLE

Open Surgical Treatment of Femoroacetabular Impingement in Adolescent Athletes: Preliminary Report on Improvement of Physical Activity Level Eduardo N. Novais, MD,* Benton E. Heyworth, MD,w Caterina Stamoulis, PhD,z Kristen Sullivan, BSc,w Michael B. Millis, MD,w and Young-Jo Kim, MD, PhDw

Background: The surgical dislocation of the hip (SDH) approach has gained popularity in the treatment of femoroacetabular impingement (FAI) secondary to pediatric hip disorders. However, it has been suggested that SDH may preclude a return to previous levels of function in athletes. The purpose of this study was (1) to determine the level of activity and pain in young athletes before and after open hip surgery through an SDH approach for the treatment of FAI; (2) to investigate how clinical improvement correlates with physical activity; (3) to determine whether articular cartilage injury and the complexity of surgical procedures are associated with improvement in activity level and pain. Methods: SDH was utilized in 29 young athletes treated for symptomatic FAI (20 males 9 females, age range 12.7 to 20.7 years (mean age, 17 y)). Evaluation included sport(s) played, University of California Los Angeles (UCLA) physical activity level, and clinical outcome in terms of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)-Pain scores. Intraoperative articular cartilage status and anteroposterior pelvic and lateral hip radiographs were assessed. Results: All patients had regularly participated in one or more of 13 distinct sports. The median UCLA score increased with marginal significance (P = 0.057) after surgery. Change in the level of pain from preoperatively to postoperatively, as measured by the WOMAC-Pain subscale, was found to be statistically significant (P = 0.0024). A statistically significant correlation between changes in UCLA and WOMAC was estimated (r =  0.61, Pr0.001). No statistically significant correlation was found between change in UCLA and the addition of a second procedure other than femoral head-neck osteochondroplasty. Finally, no statistically significant correlation was found between severity of cartilage injury and change in

From the *Department of Orthopedics Surgery, Children’s Hospital Colorado, Aurora, CO; wThe Adolescent and Young Adult Hip Unit, Department of Orthopedics Surgery, Boston Children’s Hospital; and zDepartment of Radiology, Harvard Medical School, Boston, MA. None of the authors received financial support for this study. The authors declare no conflicts of interest. Reprints: Young-Jo Kim, MD, PhD, The Adolescent and Young Adult Hip Unit, Department of Orthopaedic Surgery, Children’s Hospital Boston. 300 Longwood Avenue, Boston, MA 02115. E-mail: young-jo. [email protected]. Copyright r 2013 by Lippincott Williams & Wilkins

J Pediatr Orthop



Volume 34, Number 3, April/May 2014

UCLA or WOMAC scores. The femoral a-angle improved an average of 22.7 degrees (P < 0.001) after surgery. Conclusions: Pain relief and maintenance or improvement in activity level may be achieved with open FAI surgery through an SDH approach in young athletes. Although this approach is more invasive than hip arthroscopy, it should be considered in the management of adolescents with FAI and complex hip deformities associated with pediatric disorders such as slipped capital femoral epiphysis and Perthes disease. Level of Evidence: Level IV—case series; retrospective. Key Words: femoroacetabular impingement, adolescent athlete, hip surgical dislocation (J Pediatr Orthop 2014;34:287–294)

F

emoroacetabular impingement (FAI) is a mechanical disorder of the hip that involves abnormal contact between the anterior femoral head-neck junction against the acetabular rim.1 A wide range of studies have shown that pediatric hip disorders such as slipped capital femoral epiphysis (SCFE) and Legg-Calve´-Perthes disease (LCPD) may heal with abnormal morphology of the proximal femur that may lead to FAI.2–4 FAI is a recognized cause of hip pain, reduced range of motion, and decreased performance in adult athletes.5 It is becoming increasingly clear that FAI is more prevalent in the athletic population. Furthermore, even in the athletic adolescent population, this condition may lead to pain and disability that may limit athletic performance and activities of daily living. Current treatment options for FAI involve reshaping of the proximal femur and acetabulum through various surgical approaches such as the surgical dislocation of the hip6 (SDH), the mini-open anterior arthrotomy,7 and hip arthroscopy.8 Although hip arthroscopy has been showed to produce improvement in function in adolescents with idiopathic cam deformities causing FAI,9,10 more severe and complex deformities secondary to pediatric hip conditions such SCFE and LCPD may necessitate open treatment. The open treatment of FAI through the SDH approach described by Ganz et al in 20016 has been reported to improve short-term symptoms in adolescents with FAI secondary to those childhood conditions.11–13 There is also evidence that adult athletes may resume athletic activities at previous www.pedorthopaedics.com |

287

J Pediatr Orthop

Novais et al

playing levels and return to professional competitive sports after open surgery through a SDH for treatment of FAI.14,15 Participation in youth sports has become increasingly common in the United States, with estimates of rates of adolescents participating in at least 1 organized competitive sport as high as 60%.16 However, to our knowledge, there is no published report on physical activity outcome after intraarticular hip surgery by a surgical dislocation approach in younger athletes with complex pediatric hip deformities as well as idiopathic FAI. The purpose of this study was 3-fold: (1) to determine the level of athletic activity [as measured by the University of California Los Angeles (UCLA) activity scale]17,18 in young athletes before and after intra-articular hip surgery through a surgical dislocation approach for the treatment of FAI secondary to SCFE, LCPD, and other idiopathic anatomic variants; (2) to investigate symptomatic relief after surgery [as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)-Pain subscale]19 and its correlation with improvement in physical activity; and (3) to determine whether the degree of articular cartilage injury at time surgery (as assessed by the Beck grading system20) and complexity of the surgical procedure is associated with improvement in activity level and pain.

METHODS Following institutional review board approval, a query of our institutional operative hip registry was performed, to identify all patients who underwent an intraarticular hip procedure by a surgical dislocation approach from March 2007 to April 2010. A total of 140 cases were identified. Basic criteria for inclusion in the study were: age of 21 years or younger, regular participation in athletic activity based on chart review, a preoperative UCLA activity score of Z6, complete medical records, and completion of prospectively collected hip questionnaires both preoperatively and at least 1 year postoperatively. Minimum follow-up of 1 year was selected as improvement in function and return to previous level of activity are expected 1 year after surgery. Forty patients with no record of activity level before surgery were excluded. Forty-four patients older than 21 years of age at the time of surgery were also excluded. Therefore, there were 56 patients who could potentially be included in the analysis, however, 10 of these patients did not meet the inclusion criteria (history of athletic activity and UCLA score of >6) and 17 patients were lost to follow-up. A total of 29 patients (63% of the patients that could potentially be included) met all the inclusion and exclusion criteria and were included in this study. No patients were contacted specifically for this retrospective study; all data were obtained from medical records, radiographs, and previously, prospectively collected questionnaires as part of an institutional hip registry.

Activity Level and Clinical Evaluation Level of physical activity and pain were assessed by means of self-administered questionnaires. The UCLA

288 | www.pedorthopaedics.com



Volume 34, Number 3, April/May 2014

activity scale, based on 10 descriptive activity levels, was used to assess the level of physical activity.17,18 To ensure that patients were actively participating in sports in the past 6 months before presentation, only those with UCLA scores level 6 or higher were included, where level 6 corresponds to regular participation in moderate activities such as swimming, level 7 to regular participation in active events such as biking, level 8 to regular participation in very active events such as bowling and golfing, level 9 to sometimes participating in impact sports such as jogging, tennis, skiing, or ballet, and level 10 to regular participation in impact sports. Pain was assessed via the WOMAC19-Pain subscale, an outcome instrument with clinimetric evidence for application in FAI and labral pathology patients.21 Pain over the previous month was rated in 5 areas: (1) walking on a flat surface; (2) climbing up/down stairs; (3) lying on bed at night; (4) sitting or lying; and (5) standing upright. The amount of pain was given a score of 0 (none), 1 (mild), 2 (moderate), 3 (severe), or 4 (extreme). A total pain score was calculated by adding the scores for the 5 different areas, with a maximum score of 20 indicating extreme pain. Additional variables collected from the medical records and analyzed included sex, age at the time of surgery, specific sports participation, previous and subsequent hip surgeries, operative findings, and complications associated with the surgery. Multiple sports were defined as participation in >1 competitive sport year-round. The SDH was performed in all cases by one of the 2 senior authors using the technique previously described by Ganz et al.6 Acetabular cartilage damage was graded according to the system of Beck et al.20

Radiographic Evaluation Preoperative and postoperative radiographic evaluation included an anteroposterior pelvic view and a lateral view of the proximal femur. On the anteroposterior pelvis view, the lateral center-edge angle of Wiberg,22 acetabular inclination angle, as described by To¨nnis,23 and minimum joint space were measured. On the lateral view, the contour of the femoral head-neck junction was assessed by measurement of the a-angle.24

Statistical Analysis Data before and after the SDH were examined irrespective of the time of follow-up, that is, ignoring a potential time-effect associated with improved function and/or pain, as by the minimum follow-up time of 1 year, maximum improvement in function and return to physical activity is expected. Differences between preoperative and postoperative UCLA, WOMAC-Pain subscale, aangle, and center-edge angles were assessed using the nonparametric Wilcoxon signed-rank test, given the nonnormal distribution of the data. To assess potential correlations between change in UCLA activity level, change in WOMAC-Pain, and cartilage damage, the Spearman rank correlation coefficient was used. Finally the effect of a second femoral or acetabular surgical procedure (femoral osteotomy, relative femoral neck lengthening, r

2013 Lippincott Williams & Wilkins

J Pediatr Orthop



Volume 34, Number 3, April/May 2014

acetabular rim trimming with labral refixation, or mircrofracture drilling) on changes in the level of activity was investigated using 2  2 contingency tables (0 = no additional procedure, 1 = additional procedure), where significance was assessed using the w2 test.

RESULTS Twenty-nine patients identified as athletes met all inclusion and exclusion criteria. There were 20 male patients and 9 female patients, with a mean age of 17 years (range, 12.7 to 20.7 y) at the time of surgery. Mean duration of follow-up was 1.8 years (range, 1 to 3.9 y). Fourteen (48.2%) patients had FAI secondary to complex pediatric hip deformities and 10 patients had undergone prior surgical interventions. Four hips underwent previous in situ single screw fixation for SCFE (Fig. 1). Five patients with LCPD underwent 3 intertrochanteric osteotomies, 1 shelf procedure, and 1 epiphysiodesis of the greater trochanter, respectively. One patient with multiple hereditary osteochondromatosis had a prior resection of an osteochondroma of the proximal femur. The procedures performed through the surgical hip dislocation approach included osteochondroplasty of the femoral head-neck junction in all patients, acetabular rim trimming and labral refixation in 10 patients (34.5%), a femoral intertrochanteric osteotomy in 3 patients (10.3%), microfracture of the acetabular articular cartilage in 2 patients (6.9%), and a relative femoral neck lengthening to correct the extra-articular FAI caused by a short femoral neck and a high riding greater trochanter secondary to LCPD in 3 patients (10.3%) (Fig. 2). The heterogeneity of the procedures reflect the multiple different etiologies of the femoral and acetabular deformities. Before surgery, physical activity included participation by all patients in one or more of 13 distinct sports (Table 1). There was a marginally significant increase [P = 0.057, median change in UCLA score was 1, confidence interval (CI), [0, 2]] in median postoperative UCLA scores, compared with median preoperative scores (Fig. 3A). Nine patients (31%) had UCLA 10 (maximum score) both before and after surgery with no change in the level of physical activity. However, for 14 patients (48.3%) improvement (at least by 1 point), was measured by a positive change in the UCLA scale. Six patients (20.7%) had decreased levels of activity following SDH (Table 2). There was no apparent correlation between change in the level of activity at most recent follow-up and any particular sport. Improvement in the level of pain from preoperatively to postoperatively, as measured by the WOMAC-Pain subscale, was also found to be statistically significant (P = 0.0024). The median difference in WOMAC between preoperative and postoperative scores was 1.5, (CI, [0.5, 7]) (Fig. 3B). On the basis of the Spearman correlation coefficient, there was a negative linear correlation between the changes in UCLA and WOMAC (r =  0.61, CI, [  0.886,  0.256], P = 0.0004) following surgery, such that symptomatic improvement after intra-articular hip r

2013 Lippincott Williams & Wilkins

Activity Level After Open Treatment of FAI

surgery via the surgical hip dislocation approach correlated with improvement in physical activity level in this cohort of young athletes (Fig. 4). When the single patient with high positive change in WOMAC was excluded as a statistical outlier, there was still a negative correlation between changes in UCLA and WOMAC (r =  0.35). There was no significant correlation between change in UCLA and the addition of a second procedure other than femoral head-neck osteochondroplasty (P = 0.23). There was also no significant correlation between cartilage injury as graded by Beck et al22 and change in UCLA or WOMAC scores (Fig. 5). Radiographic analysis revealed correction of the femoral cam deformity after surgery, with the a-angle improving an average of 22.7 degrees (from average 64.9 degrees preoperatively to average 42.2 degrees postoperatively; P < 0.0001). There were no significant change in the lateral center-edge angle (P = 0.33), To¨nnis angle (P = 0.46), and minimum joint space (P = 0.18) following surgery, based on comparisons of mean preoperative and postoperative values.

DISCUSSION Recent evidence suggests that FAI can be a significant cause of hip pain in athletes and can limit participation in sports or decrease athletic performance. Pediatric hip disorders such as SCFE and LCPD may heal with abnormal morphology of the proximal femur that may lead to FAI.2–4 While arthroscopic treatment may be an option in many FAI cases,9,10 a subset of adolescent athletes may have substantial enough deformity to make arthroscopic techniques inadequate for the degree of bony resection or the range of procedures required to relieve symptoms and improve the range of motion. In such cases, the technique of SDH may be effective at allowing greater exposure to the joint and for other open acetabular and femoral procedures to be performed concurrently. The current study was designed to investigate the effect of such a technique and its associated procedures on pain, activity level, and functional outcome measures in a young athletic cohort. In this retrospective study of 29 young athletes, a marginally statistically significant improvement in the level of activity and a statistically significant decrease in pain were found at a minimum of 1 year following intraarticular hip surgery via a SDH approach. There was a negative linear correlation between activity scores measured by the UCLA scale and pain scores measured by the WOMAC-Pain subscale. This negative correlation suggests that the intra-articular and extra-articular procedures performed via a SDH allowed for symptomatic improvement that was associated with a significant increase in activity levels. Fifty percent of patients showed improvement in their activity level after surgery. This percentage may be lower than the true number of patients that may benefit from surgery, given that an additional 30% of the patients recorded maximum UCLA activity scores preoperatively and maintained their level of www.pedorthopaedics.com |

289

Novais et al

J Pediatr Orthop



Volume 34, Number 3, April/May 2014

FIGURE 1. A 17-year-old track runner [University of California Los Angeles (UCLA) 10] male with previous in situ fixation of right femur for the treatment of mild slipped capital femoral epiphysis presented with right hip activity related pain. A, Frog lateral radiograph reveals a right femur deformity with loss of the normal concave femoral head-neck offset and increased abnormal a-angle. B, Axial Trufisp magnetic resonance imaging shows abnormal convex femoral head-neck offset and the presence of joint space narrowing and acetabular cyst. C, Postoperative lateral radiograph 2 years after open treatment by surgical dislocation of the hip approach with femoral head-neck osteochondroplasty and acetabular microfracture shows improved femoral head-neck offset and a-angle. Physical activity level and UCLA scores did not change at 1 and 2 years of follow-up (UCLA 10). The arrows indicate (A) location of deformity, (B) location of cysts and joint space narrowing, (C) location of improved femoral head-neck junction.

FIGURE 2. An 18-year-old cheerleader [University of California Los Angeles (UCLA) 6] with a history of right Legg-Calve´-Perthes disease presented with right hip pain. Anteroposterior (A) and lateral (B) radiographs revealed a severe deformity of the proximal femur: high riding greater trochanter with short and thick femoral neck with an enlarged and nonspherical femoral head. Sixteen months after surgical dislocation of the hip, osteochondroplasty of the femoral head and relative femoral neck lengthening anteroposterior (C) and lateral (D) radiographs reveal improvement in the articulotrochanteric distance and femoral head-neck offset. At most recent follow-up she was asymptomatic and had improved her activity level (UCLA 9).

290 | www.pedorthopaedics.com

r

2013 Lippincott Williams & Wilkins

J Pediatr Orthop



Volume 34, Number 3, April/May 2014

TABLE 1. Sports Participation and FAI-related Diagnosis in 29 Adolescent Athletes N (%) Athletic activity Football Baseball Ballet/dance Hockey Basketball Cheerleading Cross country running Equestrian Lacrosse Soccer Skiing Track Multiple sports Diagnosis Primary cam Primary pincer Primary mixed FAI (cam+pincer) SCFE LCPD MHO OCD Inflammatory arthritis

4 3 3 3 2 2 2 2 1 1 1 1 4

(13.8) (10.4) (10.4) (10.4) (6.9) (6.9) (6.9) (6.9) (3.4) (3.4) (3.4) (3.4) (13.8)

7 2 5 7 5 1 1 1

(22.6) (6.9) (17.2) (22.6) (17.2) (3.4) (3.4) (3.4)

FAI indicates femoroacetabular impingement; LCPD, Legg-Calve´-Perthes disease; MHO, multiple hereditary osteochondromatosis; OCD, osteochondritis dissecans of the femoral head; SCFE, slipped capital femoral epiphysis.

activity (maximum score) after surgery, suggesting a potential ceiling effect of the UCLA scale. Therefore, 80% of the young athletes in this study either improved their athletic activity level or maintained it at the maximum possible level after SDH. Our study is consistent with previous reports on the outcome of SDH for the treatment of FAI that showed significant improvement in pain and overall quality of life in adult patients25 as well as in adolescents.11–13,26,27 Beaule et al25 analyzed 34 patients from 19 to 54 years old who underwent open treatment of FAI using the surgical hip dislocation approach. The authors used the WOMAC score and UCLA as their outcome measures. The mean UCLA activity score improved from 4.8 ± 1.9 to 7.5 ± 2.4 points (P = 0.001). Naal et al28 also evaluated the physical activity level in patients undergoing open treatment of FAI using the surgical hip dislocation approach. Their study population had an average age of 30 years (14 to 55 y) and at an average follow-up of 60.7 months the mean UCLA activity level was 7.7 ± 1.9. In this series, 6 patients had lower level of activity after surgery, 3 of whom only decreased by 1 point, but maintained a UCLA score Z8 (regular participation in very active events). The other 3 patients had a severe decrease in their level of activity, 2 of whom were found to have Beck grade V20 (full-thickness defect) acetabular cartilage damage. Notably, preexisting articular cartilage damage has been shown to increase the risk for failure after FAI surgery. For example, in a previous report from our institution, adolescents with FAI secondary to healed SCFE who were noted to have chondral flaps intraoperatively showed a trend r

2013 Lippincott Williams & Wilkins

Activity Level After Open Treatment of FAI

toward less pain relief and poorer function postoperatively.13 In a series of 16 athletic adolescent patients who underwent arthroscopic FAI treatment, Philippon et al10 also observed a trend toward lower outcomes in adolescent athletes who required chondroplasty of either the acetabular rim or the femoral head. Interestingly, in the current study the severity of cartilage injury as classified by Beck et al20 did not correlate with change in UCLA scores. In addition, the complexity of the intra-articular hip surgery performed through the SDH approach (as defined by adding an additional procedures performed, such as femoral osteotomy, relative femoral neck lengthening, or acetabular rim trimming with labral refixation) was not correlated to the change in UCLA scores. Despite promising findings, there are several limitations of this study. First, the sample size is small, which limits the interpretation and generalization of our findings, as well as the development of statistical models to assess the relationship between potential predictors of the surgical outcome in the presence of confounders, such as type of athletic activity, cartilage status, and previous surgical interventions. Therefore, in this study it was not possible to analyze the influence of specific sport type or level on change of activity level after surgery. For patients with lower scores after surgery, we were not able to identify specific reasons for their lower level of activity. However, serial UCLA activity levels were prospectively assessed before and after surgery, allowing for comparative analyses. One limitation of the UCLA score is that it has not been validated in children and adolescents, although the majority of the cohort was older teenagers (mean patient cohort age was 17 y and in the range 12.7 to 20.7 y) who likely have adequate understanding of the questionnaire components, when compared with adults. Although the UCLA may not truly reflect the whole spectrum of activities that adolescents do; the data were prospectively collected and are quantitative data. As a gross measure of level of activity we feel it is still useful and better than retrospectively collected data. We showed a marginally significant increase (P = 0.057, median change in UCLA score was 1, CI, [0, 2]) in median postoperative UCLA scores, compared with median preoperative scores. Thirty percent of our patients did not change the UCLA score because they scored 10 (maximum) before surgery— this is a ceiling effect inherent for the UCLA. The WOMAC scale has been shown to have clinimetric evidence for application in FAI and labral pathology patients.21 In addition, the heterogeneity of the sample, in terms of comorbidities to include hip deformities, and prior surgeries, as well as cartilage status, and type of athletic activity pursued by each patient, may also confound the results. However, these effects were difficult to decouple in this study. We believe that including patients with previous LCPD and SCFE is one of the strengths of our study and it indeed reflects the nature of a pediatric orthopedic hip preservation practice. In these patients hip arthroscopy may have a limited role and we sought to investigate whether an adolescent athlete with hip pain and deformity leading to FAI could resume the www.pedorthopaedics.com |

291

J Pediatr Orthop

Novais et al



Volume 34, Number 3, April/May 2014

FIGURE 3. A, Distribution of the change in the activity level after intra-articular hip surgery through a surgical dislocation approach, as measured by the difference between postoperative and preoperative University of California Los Angeles (UCLA) scores. B, Distribution of the difference between postoperative and preoperative pain scores using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)-Pain subscale. SDH indicates surgical dislocation of the hip.

activity level after surgery, independent of the etiology of the hip deformity. Finally, although >50% of patients (16 of 29) had follow-ups at approximately 1 year following surgery, the remaining patients had longer followup times, of at least 2 years. Nevertheless, this difference in follow-up is not expected to affect the results significantly, as the improvement in function between 1 and 2 years following surgery, and consequently the parameters used to assess it, are not expected to vary significantly.

Only a few previous studies9–13,29 have analyzed the outcomes of surgical treatment of FAI in adolescents. Most of these studies have evaluated adolescents without stratifying for athletic participation or activity level. In addition, although previous reports have investigated the effects of surgical treatment of FAI utilizing validated instruments of hip pain and function, such as the WOMAC19 and the Harris Hip Score,30 most have not directly assessed the level of physical activity or sports participation, and none have done so for open surgery

TABLE 2. Patients With Decrease in Activity Level After FAI Treatment Preoperative

Postoperative

Age

Sex

Follow-up (y)

Sports

Diagnosis

Surgery

UCLA

WOMAC

UCLA

WOMAC

17.7 20.6 16.3 12.7 16.6 15.5

M M F M F F

2.6 1.1 1.3 2.5 1.0 1.2

Multiple Basketball Cross country Soccer Cheerleader Ballet

SCFE-AVN FAI FAI SCFE-AVN FAI OCD

FHNO+ITO+AMF FHNO+ARTLR FHNO+ARTLR FHNO+ITO FHNO+ARTLR FHNO+FHD

10 9 9 9 9 10

1 11 5 8 3 2

3 5 7 8 8 9

11 8 5 7 1 0

AMF indicates acetabular microfracture; ARTLR, acetabular rim trimming with labral refixation; AVN, avascular necrosis of the femoral head; FAI, femoroacetabular impingement; FHNO, femoral head-neck osteochondroplasty; ITO, intertrochanteric femoral osteotomy; OCD, osteochondritis dissecans of the femoral head; SCFE, slipped capital femoral epiphysis; UCLA, University of California Los Angeles; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

292 | www.pedorthopaedics.com

r

2013 Lippincott Williams & Wilkins

J Pediatr Orthop



Volume 34, Number 3, April/May 2014

Activity Level After Open Treatment of FAI

FIGURE 4. Correlation between changes in University of California Los Angeles (UCLA) activity scores and changes in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)-Pain subscale. There was a linear negative correlation between UCLA and WOMAC (r =  0.61, CI, [ 0.886, 0.256], P = 0.0004).

using the SDH approach, to our knowledge. Philippon et al10 reported the results of 16 athletes (aged 11 to 16 y) treated with arthroscopic approach (mean follow-up, 1.36 y). All patients had idiopathic FAI, with no reported cases representing sequellae of pediatric hip disease. In their series, postoperative Hip Outcome Score (HOS) sports subscales increased by 56 points and all patients were able to return to their sport. Fabricant et al9 recently reported on 21 adolescent athletes with a mean age of 17.6 years (range, 14.5 to 19.9 y) who underwent arthroscopic decompression for FAI not associated with pediatric hip disorders. There was an overall clinical and functional improvement measured by 21 points in the modified Harris hip score, 16 points on the activities of daily living subset of the HOS and by 32 points on the sports outcome subset of the HOS. By comparison, although half of the patients in the current series had FAI secondary to pediatric hip diseases such as SCFE and LCPD, our results are comparable with those presented in the arthroscopically treated cohorts.9,10 In the adult athletic population, hip arthroscopy has been showed to produce improvement in symptoms and performance in the treatment of FAI.5,31 Some authors have suggested that use of surgical dislocation techniques may interfere with a complete return to high-level participation in sports.8,32 However, we are not aware of any studies investigating the effect of arthroscopy on return to play or activity level in athletes with FAI that is secondary to pediatric hip disorders such as SCFE or LCPD. The improvement in activity level reported in the current series is also consistent with previous studies involving the SDH approach utilized for adult athletes. For example, Bizzini et al14 reported on 5 professional ice hockey players who underwent SDH and were able to return to r

2013 Lippincott Williams & Wilkins

FIGURE 5. Effect of cartilage injury on physical activity. There was no significant correlation between cartilage injury and change in University of California Los Angeles (UCLA) activity scale and in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)-Pain subscale.

unrestricted high-level ice hockey play by a mean of 6.7 months. Naal et al15 reported that FAI treatment using a SDH allowed 96% of 22 professional male athletes to remain playing at a professional level at a mean follow-up of 3.8 years. In summary, this study investigated 29 adolescent athletes undergoing intra-articular hip surgery through a surgical dislocation approach for the treatment of FAI related to pediatric hip disorders and anatomic variants. Our data demonstrated that adolescent athletes can resume their level of athletic activities after open treatment of FAI using the SDH approach. A lower level of pain, as assessed by the WOMAC index, correlated to a higher level of activity at the most recent follow-up. Successful short-term outcomes, including pain relief and maintenance or improvement in activity level, may therefore be achieved with open FAI surgery through a surgical www.pedorthopaedics.com |

293

Novais et al

J Pediatr Orthop

dislocation approach in adolescent athletes. Although this approach is, without question, more invasive than hip arthroscopy, it should be considered in the management of adolescents with FAI and complex hip deformities associated with pediatric disorders such as SCFE and LCPD. The data presented here may be useful in counseling the adolescent athlete with FAI regarding the improvement of level of activity they may expect after surgical hip dislocation.

after open surgical decompression of the hip. Am J Sports Med. 2007;35:1955–1959. Naal FD, Miozzari HH, Wyss TF, et al. Surgical hip dislocation for the treatment of femoroacetabular impingement in high-level athletes. Am J Sports Med. 2011;39:544–550. Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance—United States, 2009. MMWR Surveill Summ. 2010; 59:1–142. Amstutz HC, Thomas BJ, Jinnah R, et al. Treatment of primary osteoarthritis of the hip. A comparison of total joint and surface replacement arthroplasty. J Bone Joint Surg Am. 1984;66:228–241. Zahiri CA, Schmalzried TP, Szuszczewicz ES, et al. Assessing activity in joint replacement patients. J Arthroplasty. 1998;13:890–895. Bellamy N, Buchanan WW, Goldsmith CH, et al. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:1833–1840. Beck M, Leunig M, Parvizi J, et al. Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Clin Orthop Relat Res. 2004;418:67–73. Lodhia P, Slobogean GP, Noonan VK, et al. Patient-reported outcome instruments for femoroacetabular impingement and hip labral pathology: a systematic review of the clinimetric evidence. Arthroscopy. 2011;27:279–286. Wiberg G. Studies on dysplastic acetabula and congenital subluxation of the hip joint. With special reference to the complication of osteoarthritis. Acta Chir Scand. 1939;83(suppl 58):28–38. Tonnis D. Normal values of the hip joint for the evaluation of X-rays in children and adults. Clin Orthop Relat Res. 1976;119:39–47. Notzli HP, Wyss TF, Stoecklin CH, et al. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84:556–560. Beaule PE, Le Duff MJ, Zaragoza E. Quality of life following femoral head-neck osteochondroplasty for femoroacetabular impingement. J Bone Joint Surg Am. 2007;89:773–779. Anderson LA, Erickson JA, Severson EP, et al. Sequelae of Perthes disease: treatment with surgical hip dislocation and relative femoral neck lengthening. J Pediatr Orthop. 2010;30:758–766. Sink EL, Zaltz I, Heare T, et al. Acetabular cartilage and labral damage observed during surgical hip dislocation for stable slipped capital femoral epiphysis. J Pediatr Orthop. 2010;30:26–30. Naal FD, Miozzari HH, Schar M, et al. Midterm results of surgical hip dislocation for the treatment of femoroacetabular impingement. Am J Sports Med. 2012;40:1501–1510. Friend L, Kelly BT. Femoroacetabular impingement and labral tears in the adolescent hip: diagnosis and surgical advances. Curr Opin Pediatr. 2009;21:71–76. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737–755. Byrd JW, Jones KS. Hip arthroscopy in athletes: 10-year follow-up. Am J Sports Med. 2009;37:2140–2143. Brunner A, Horisberger M, Herzog RF. Sports and recreation activity of patients with femoroacetabular impingement before and after arthroscopic osteoplasty. Am J Sports Med. 2009;37:917–922.

15. 16. 17. 18.

REFERENCES 1. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;417: 112–120. 2. Kim YJ, Novais EN. Diagnosis and treatment of femoroacetabular impingement in Legg-Calve-Perthes disease. J Pediatr Orthop. 2011;31(suppl 2):S235–S240. 3. Millis MB, Novais EN. In situ fixation for slipped capital femoral epiphysis: perspectives in 2011. J Bone Joint Surg Am. 2011;93 (suppl 2):46–51. 4. Novais EN, Clohisy J, Siebenrock K, et al. Treatment of the symptomatic healed Perthes hip. Orthop Clin North Am. 2011;42: 401–417, viii. 5. Philippon MJ, Schenker ML. Arthroscopy for the treatment of femoroacetabular impingement in the athlete. Clin Sports Med. 2006;25:299–308, ix. 6. 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. 7. Clohisy JC, McClure JT. Treatment of anterior femoroacetabular impingement with combined hip arthroscopy and limited anterior decompression. Iowa Orthop J. 2005;25:164–171. 8. 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. 9. 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. 10. Philippon MJ, Yen YM, Briggs KK, et al. Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report. J Pediatr Orthop. 2008;28: 705–710. 11. Rebello G, Spencer S, Millis MB, et al. Surgical dislocation in the management of pediatric and adolescent hip deformity. Clin Orthop Relat Res. 2009;467:724–731. 12. Shore BJ, Novais EN, Millis MB, et al. Low early failure rates using a surgical dislocation approach in healed Legg-Calve-Perthes Disease. Clin Orthop Relat Res. 2012;470:2441–2449. 13. Spencer S, Millis MB, Kim YJ. Early results of treatment of hip impingement syndrome in slipped capital femoral epiphysis and pistol grip deformity of the femoral head-neck junction using the surgical dislocation technique. J Pediatr Orthop. 2006;26:281–285. 14. Bizzini M, Notzli HP, Maffiuletti NA. Femoroacetabular impingement in professional ice hockey players: a case series of 5 athletes

294 | www.pedorthopaedics.com

19.

20. 21.

22. 23. 24. 25. 26. 27. 28. 29. 30.

31. 32.



Volume 34, Number 3, April/May 2014

r

2013 Lippincott Williams & Wilkins

Open surgical treatment of femoroacetabular impingement in adolescent athletes: preliminary report on improvement of physical activity level.

The surgical dislocation of the hip (SDH) approach has gained popularity in the treatment of femoroacetabular impingement (FAI) secondary to pediatric...
280KB Sizes 0 Downloads 0 Views