Rev. bras. ortop. vol.51 número4

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

Article

Surgical

treatment

of

femoroacetabular

impingement

using

controlled

hip

dislocation

after

occurrence

of

slipped

capital

femoral

epiphysis

夽

Weverley

Rubele

Valenza

∗

_,

_Jamil

_Faissal

_Soni,

_Christiano

_Saliba

_Uliana,

Fernando

Ferraz

Faria,

Gisele

Cristine

Schelle,

Daniel

Sakamoto

Sugisawa

UniversidadeFederaldoParaná,HospitaldoTrabalhador,Curitiba,PR,Brazil

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Articlehistory:

Received21March2015 Accepted5October2015 Availableonline4July2016

Keywords:

Femoroacetabularimpingement Osteochondroplasty

Hipdislocation Hipjoint

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t

Objective:Topresentourexperienceandpreliminaryresultsfromusingcontrolledhip dis-locationtotreatcam-likefemoroacetabularimpingement,inteenagersandyoungadults withsequelaeofslippedcapitalfemoralepiphysis.

Methods:Thiswasaretrospectiveanalysison15patientswhoweretreatedinatertiary-level hospitalbetween2011and2013.Thefollowingdatawerecollectedforanalysisfromthese patients’files:demographic data,surgicalprocedurereports,jointmobilityevaluations, patients’perceptionsregardingclinicalimprovementandwhethertheywouldchooseto undergotheoperationagain,previoushipsurgeryandcomplications.Theexclusioncriteria were:follow-upshorterthansixmonths,thepresenceofanyotherhipdisease,osteotomyof theproximalfemurperformedatthesametimeastheosteochondroplastyandincomplete medicalfileswithregardtotheinformationneededforthepresentstudy.

Results:Fifteenpatients(17hips)whounderwentosteochondroplastytotreat femoroac-etabularimpingementwereevaluated.Nineofthemwerewomen,themeanagewas18 yearsoldandtheminimumfollow-upwastwoyears.Twopatientsunderwent osteochon-droplastybilaterally;eightpatientswereoperatedontheleftsideandfiveontherightside. In14cases,thegreatertrochanterwaslowered(relativelengtheningoftheneck)in asso-ciationwiththeosteochondroplasty.For13patients,theirprevioussurgeryconsistedof fixationofanoccurrenceofslippedcapitalfemoralepiphysis;forsixpatients(eighthips), flexorosteotomywasperformedpreviously;andforonepatient,hiparthroscopywas per-formedpreviously.Fourteenpatientspresentedimprovementofmobilityandhippainrelief, incomparisonwithbeforetheoperation,andtheysaidthattheywouldundergothe opera-tionagain.Twocomplicationswereobserved:oneoflooseningofthefixationofthegreater trochanterandoneofheterotopicossification.

夽

StudyconductedatUniversidadeFederaldoParaná,HospitaldoTrabalhador,Curitiba,PR,Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](W.R.Valenza). http://dx.doi.org/10.1016/j.rboe.2015.10.013

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Conclusion:Thepreliminaryresultsfromthisstudysuggestthatosteochondroplastythrough controlledsurgicalhipdislocationisagoodoptionfortreatingfemoroacetabular impinge-ment.Throughthismethod,thepatientsreportedachievingimprovementofjointmobility andhippain,withfewcomplications.

Tratamento

cirúrgico

do

impacto

femoroacetabular

pós-

epifisiólise

pelo

método

da

luxac¸ão

controlada

do

quadril

Palavras-chave:

Impactofemoroacetabular Osteocondroplastia Luxac¸ãodoquadril Articulac¸ãodoquadril

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Objetivo: Relatarnossaexperiênciaeosresultadospreliminarescomaluxac¸ãocirúrgica controladadoquadrilnotratamentodoimpactofemoroacetabular(I_FA)_tipo_CAM_em ado-lescenteseadultosjovenscomsequeladeepifisiólisefemoralproximal.

Métodos: Análiseretrospectivade15pacientestratadosemhospitalterciário,ondeforam selecionadosprontuáriosdepacientesquefizeramoprocedimentode2011até2013.Os dadoscoletadosparaanáliseforam:dadosdemográficos,descriçãodoprocedimento cirúr-gico,avaliaçãodamobilidadearticular,impressãosubjetivadopacientenoqueserefereà melhoriaclínicaeseoptariamporfazeracirurgianovamente,cirurgiasanterioresnoquadril ecomplicações.Foramexcluídospacientescomseguimentomenordoqueseismeses, por-tadoresdeoutrasdoençasdoquadril,submetidosa osteotomiasdofêmurproximalno mesmomomentodaosteocondroplastiaecujoprontuárioestivesseincompletoquantoàs informaçõesnecessáriasparaopresenteestudo.

Resultados:Foramavaliados15pacientese17quadrissubmetidosaosteocondroplastiapara otratamentodoI_FA,_nove_pacientes_eram_do_sexo_feminino,_média_de₁₈_anos_e_seguimento mínimodedoisanos.Quantoàlateralidade,oitopacientesforamoperadosdoladoesquerdo ecincodoladodireito,alémdedoispacientesnosquaisaosteocondroplastiafoifeitade formabilateral.Em14 casos,abaixamentodotrocântermaior(alongamentorelativodo colo)foiassociadoàosteocondroplastia.Trezepacientestinhamcomocirúrgiapréviaa fixaçãodaepifisiólise,emseis(oitoquadris)foifeitaosteotomiaflexorapréviaeumfez umaartroscopiadoquadril.Em14pacienteshouvemelhoriadamobilidadeedadorno quadril,quandocomparadacomopré-operatório.Esses14pacientesrelataramquefariam acirurgianovamente.Foramobservadasduascomplicações,umasolturadafixaçãodo trocântermaioreumaossificaçãoheterotópica.

Conclusões: Osresultadospreliminaresdeste estudosugeremqueaosteocondroplastia pelatécnicadaluxaçãocirúrgicacontroladadoquadriléumaboaopçãonotratamentodo impactofemoroacetabular.Poressemétodoospacientesrelatarammelhoriadamobilidade articularedornoquadriletiverampoucascomplicações.

Introduction

SlippedCapitalFemoralEpiphysis(SCFE)(epiphysiolysis)isa conditionthataffectspre-adolescentsandadolescents with-out a definite cause. In moderate and severe grades, this pathologycauseschangesintheepiphysisand thefemoral neckshape,andcanpredisposefemoroacetabular impinge-ment (FAI). This impingement predisposes biomechanical changes,pain, and deteriorationofthe acetabulararticular cartilage.Inturn,thesefactorsmayincreasetheriskofearly hiposteoarthritis.

Recently, controlled surgical dislocation of the hip was showntobeanappropriatemethodfortreatingFAI,providing

improvementsinhippainandmobility,aswellaspreventing arthrosis.1,2_This_technique,_initially_described_by_Ganz_et_al.,3 isbasedontheanatomicalknowledgeofthepreservationof themedialfemoralcircumflexarterypathway,4_allowing_for anexcellentvisualizationofthefemoralepiphysisand acetab-ulum,andthusminimizingtheriskofavascularnecrosis.It alsoallows,whennecessary,correctionoftheextra-articular impingement,throughfemurosteotomiesanddistaltransfer ofthegreatertrochanter.5

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Material

and

methods

This study retrospectively included patients with FAI sec-ondary to SCFE, in which an osteochondroplasty was performedusingthecontrolledhipdislocationmethod.

Datawerecollectedthroughanalysisofmedicalrecords. Patientswithaminimumfollow-up ofsixmonths,who were previously diagnosed with SCFE and underwent this technique,wereincluded.

Exclusion criteriacomprised patientswith less than six monthsoffollow-up; diagnosis ofFAIcaused byother hip pathologies;patientswhounderwentosteotomyofthe prox-imalfemuratthesametimeofosteochondroplasty;patients withhip osteoarthritis (Tonnis0),as thisis arelative con-traindicationfortheprocedure;andpatientswhosemedical recordswereincompleteorwerelosttofollow-up.

Allsurgerieswereperformedbythesamesurgeon. Surgi-caltechniquecomprisedposterolateralaccess,osteotomyof thegreatertrochanter,preservationoftherotatormusclesand theobturatorinternustendon,anteriorT-shapedcapsulotomy (thisisanalterationinthetechniquedescribedbyGanz,3_who performed a Z-shaped capsulotomy,which does not inter-ferewithfemoralneckexposure,labrum,andacetabulum), anterior dislocationof the hip, complete exposition ofthe epiphysisandfemoralneck, chondrosternoplasty, impinge-mentremoval,andacetabularinspectiontoassesschondral injuryanddamagetotheacetabularlabrum.After osteochon-droplasty,therangeofmotionofthehipwastested;control wasconductedwithanimageintensifiertoassesstheabsence ofimpingement.

Subsequently, capsule was sutured and the greater trochanterwasfixedwithtwoorthree4.5-mmcorticalscrews. In cases wherethe greater trochanter was raised, causing trochantericimpingement,atransferwasmade,withdistal fixationofthetrochanter(arelativelengtheningofthefemoral neck)(Figs.1–4).

Postoperatively,fullweightsupportonthelimbwasnot allowedforameanofsixweeks,whichistheestimatedtime forconsolidationofthegreatertrochanter.Physicaltherapy wasstartedfromthefirstpostoperativedayaimingtoincrease rangeofmotion.

Thedatacollectedforanalysisweresex(gender),ageat timeofsurgery,theaffectedside,dateofsurgery,description

Fig.1–X-rayinanteroposterorincidenceofapatientwith FAI,afterinsitu_fixation_of_SCFE.

Fig.2–X-rayinprofileofapatientwithFAI,afterinsitu

fixationoftheSCFE.

of the surgical procedure, previous hip surgery, subjective impression of the patient regarding clinical improvement (mobilityandpain)andwhethertheywouldchoosetohave surgeryagain,andcomplicationsrelatedtothisprocedure.

Complications were determined in accordance with the adaptationproposedbySinketal.6_of_the_{classification}_of sur-gicalcomplicationsbyClavien7_and_Dindo_et_al.,8_as_described below:

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Fig.4–X-rayinprofile,sixmonthspostoperatively.

Sinketal.6_{classification:}

GradeI_:_requires_no_change_in_the_{post-operative} manage-ment.

GradeII:requireschangeinthepost-operativemanagement. GradeIII_:_require_surgical_or_radiological_management. GradeIV_:_associated_with_long-term_morbidity. GradeV_:_death.

ThecollecteddatawereevaluatedusinganExcel® spread-sheet.

This study was approved by the Research Ethics Com-mitteeoftheinstitutionunderthefollowingnumber:CAAE: 30485814.4.0000.5225.

Results

FromFebruary2011toDecember2013,15patients(17hips) underwentosteochondroplastytotreatFAI secondarytoSCFE. Minimumfollow-upwasoftwoyearsandmaximumoffour yearsandsixmonthsinthelastclinicalandradiographic eval-uation.

Ninepatientswerefemale.Twopatientsunderwent bilat-eralosteochondroplasty;ineight,ontheleftside;andinfive, ontherightside.Ageatsurgeryrangedfrom14to26years, withameanof18years.In14hips,inadditiontothe osteo-chondroplasty,adistaltransferofthegreatertrochanterwas performed(relativelengtheningofthefemoralneck).Previous surgeriestotreatSCFEwereinsitufixationin13patients(15 hips);insixpatients(eighthips),flexionosteotomy;andone patienthadundergonearthroscopy(Table1).

As a subjective impression of the patients, 14 reported improvementsinjointmobilityandpainwhencomparedwith preoperative period. These same 14 patients reported that theywouldundergosurgeryagain.

ThelastcontrolX-raysofthe15patients–atleasttwoyears aftersurgery–showednosignsofcoxarthrosis.Two complica-tionswereobserved:onelooseningofthegreatertrochanter fixation,whichwasnottreatedandevolvedinto pseudarthro-sis,classifiedastypeIII/IV bythecriteriaofSinketal.6_(type III_,_complication_that_requires_surgical_{intervention,}_and_type

IV_,_long-term_sequelae)._Other_was_one_heterotopic

ossifica-tion,classifiedastypeI _{(complication}_that_does_not_change the postoperativecourse,withoutclinical relevance).Inthe

Table1–Epidemiology,associatedandpriorsurgeries.

Patient Sex Side Ageatsurgery Trochanterlowering Priorsurgery

1-A Female Bilateral–R 19 No insitufix.,flex.ost.

1-B Female Bilateral–L 17 Yes insitufix.,flex.ost.

2-A Male Bilateral–R 26 Yes insitufix.,flex.ost.

2-B Male Bilateral–L 23 No insitufix.,flex.ost.

3 Female Left 14 Yes insitufix.

4 Female Right 25 Yes insitufix.,flex.ost.

6 Male Left 17 Yes No

8 Male Right 19 Yes insitufix.

10 Male Left 16 Yes No

11 Male Left 15 Yes insitufix.,flex.ost.

12 Male Right 16 Yes insitufix.

13 Female Right 20 Yes insitufix.,flex.ost.

14 Female Right 22 No insitufix.,arthro.

15 Female Left 17 Yes insitufix.,flex.ost.

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Table2–Results.

Patient Improvedmobility Wouldundergosurgeryagain Complications

1 Yes Yes No

2 Yes Yes No

3 Yes Yes No

4 Yes Yes No

5 Yes Yes No

6 Yes Yes No

7 Yes Yes No

8 Yes Yes No

9 Yes Yes No

10 Yes Yes No

11 Yes Yes No

12 Yes Yes No

13 Yes Yes Heterotopicossification

14 Yes Yes No

15 No No Looseningofthegreatertrochanter

presentstudy,nocasesofavascularnecrosis,femoralneck fractures,andsciaticnerveinjurywereobserved(Table2).

Discussion

FAI hasbeen described as a series ofanatomical changes in the hip, which may be located in the femoral epiph-ysis(CAM),intheacetabulum(PINCER),orcombined.These deformities cause damage to the acetabular labrum and acetabularcartilage,thereforeleadingtohipdegeneration.9,10 Astheseabnormalitiesprogress,theycausepainanddecrease hipfunction.Inthemedicalliterature,severalstudies have demonstratedthatFAI _is_one_of_the_main_causes_of_secondary hiposteoarthrosis.9–14

Hipswithsequelaefromchildhoodandadolescence dis-eases,suchasLegg-Calve-PerthesdiseaseandSCFE,develop seriousandcomplexdeformities;theirresolutionwithlimited accessorhiparthroscopyisdifficult.Inthesecases,surgical dislocationprovidesawideaccesstothefemoralepiphysis,to thetransitionfromthenecktothefemoralhead,andtothe acetabulum,allowingforthetreatmentoflabraltear, osteo-chondroplasty,redirectionalosteotomy,anddistaltransferof the greater trochanter (relative lengtheningof the femoral neck).15

Anotheroptioninthisapproach,oftenmentionedinthe literature, is femoral intra- or extracapsular osteotomies. However,long-term studiesthat assessedintertrochanteric osteotomyforthetreatmentofSCFEsequelaewithoutfemoral neckosteochondroplastywerenotsuccessfulintheirattempt tochangethenaturalcourseofcoxarthrosis.15,16

Inthepresentstudy,ninefemalepatientswereincluded; theliteratureindicatesahigherincidenceofSCFEinmales. Thiscanbeexplainedbythefactthatthepresentstudydidnot showtheincidenceofepiphysiolysis,butratherthepatients intheclinicwhohadSCFEandFAIcomplaints.

Inthepresentstudy,osteochondroplastieswereperformed using the controlled surgical hip dislocation technique in patientswithproximalfemoralepiphysiolysissequelae. Thir-teenhipshadbeenfixedwithcannulatedscrewstoprevent theprogressionoftheslip;eighthipshadundergoneflexion andderotationalintertrochantericosteotomyinanattempt

to improve mobility; and one patient had undergone an arthroscopyinordertotreattheCAM.

Prior to surgical treatment of FAI_, _these _patients com-plained oflimitations inhip mobility. Thephysical exami-nationshowedapositiveimpingementtest(painonflexion, adduction,andinternalhiprotation)andX-raysalsoshowed signs of hip impingement; no hips had coxarthrosis sig-nals. Thus, osteochondroplasty withcontrolled dislocation wasindicated,withorwithoutdistaltransferofthegreater trochanter on the principle of femoral neck lengthening, whichwouldimprovetheabductormechanism.

Resultsobtainedwereimprovementinpainandespecially inmobility.Inthesubjectiveassessment,14patientswere sat-isfiedandreportedthattheywouldundergosurgeryagain.The contralateralsideprocedurewasperformedintwopatients, andonlyonepatientreporteddissatisfactionwiththeresult of the surgical procedure and would not undergo surgery again.

Thepresentresultsreflectthetrendindicatedinthe lit-erature,whichshowsasignificantimprovementinpainand mobilitywithosteochondroplastyusingthe described tech-niqueforFAI.6,10,15,17

However, althoughthesestudies showed good improve-mentintheshort-andmedium-term,thissurgicalprocedure andhiparthroscopyarerelativelyrecent;therefore,alonger follow-uptimeisnecessarytodeterminewhethertheychange thenaturalcourseofcoxarthrosis.5,10,17,18

Themostprevalentcomplicationsreportedinthis proce-dure are heterotopic ossification, avascular necrosisof the femoral head, sciatic nerve injury, pseudarthrosis of the greatertrochanter,femoralneckfractures,and thromboem-bolicdiseases(TEP,DV_T);_most_of_these_were_described_in_the multicenterstudybySinketal.6

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Asaclinical inference, it isreasonableto estimatethat longerfollow-up ofthepresent sampleisneededtoassess changeintheinstallationofhiparthrosis,aswellastoanalyze long-termresults.

Conclusions

The preliminary results of this study indicate that osteo-chondroplasty using the technique of controlled surgical hip dislocation isan option to treatFAI. Patients reported improvementsin hip mobility and pain. Thefew reported complicationsmayberelatedtothesteeplearningcurvefor thissurgicaltechnique.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1. BediA,KellyBT.Femoroacetabularimpingement.JBoneJoint SurgAm.2013;95(1):82–92.

2. LeunigM,BeauléPE,GanzR.Theconceptof

femoroacetabularimpingement:currentstatusandfuture perspectives.ClinOrthopRelatRes.2009;467(3):616–22. 3. GanzR,GillTJ,GautierE,GanzK,KrügelN,BerlemannU.

Surgicaldislocationoftheadulthipatechniquewithfull accesstothefemoralheadandacetabulumwithouttherisk ofavascularnecrosis.JBoneJointSurgBr.2001;83(8): 1119–24.

4. GautierE,GanzK,KrügelN,GillT,GanzR.Anatomyofthe medialfemoralcircumflexarteryanditssurgical

implications.JBoneJointSurgBr.2000;82(5):679–83.

5. TiborLM,SinkEL.Prosandconsofsurgicalhipdislocationfor thetreatmentoffemoroacetabularimpingement.JPediatr Orthop.2013;33Suppl.1:S131–6.

6.SinkEL,BeauléPE,SucatoD,KimYJ,MillisMB,DaytonM, etal.Multicenterstudyofcomplicationsfollowingsurgical dislocationofthehip.JBoneJointSurgAm.

2011;93(12):1132–6.

7.ClavienPA,StrasbergSM.Severitygradingofsurgical complications.AnnSurg.2009;250(2):197–8.

8.DindoD,DemartinesN,ClavienPA.Classificationofsurgical complications:anewproposalwithevaluationinacohortof 6336patientsandresultsofasurvey.AnnSurg.

2004;240(2):205–13.

9.GanzR,ParviziJ,BeckM,LeunigM,NötzliH,SiebenrockKA. Femoroacetabularimpingement:acauseforosteoarthritisof thehip.ClinOrthopRelatRes.2003;(417):112–20.

10.ClohisyJC,StJohnLC,SchutzAL.Surgicaltreatmentof femoroacetabularimpingement:asystematicreviewofthe literature.ClinOrthopRelatRes.2010;468(2):555–64.

11.AronsonJ.Osteoarthritisoftheyoungadulthip:etiologyand treatment.InstrCourseLect.1986;35:119–28.

12.BeckM,KalhorM,LeunigM,GanzR.Hipmorphology influencesthepatternofdamagetotheacetabularcartilage: femoroacetabularimpingementasacauseofearly

osteoarthritisofthehip.JBoneJointSurgBr. 2005;87(7):1012–8.

13.BeckM,LeunigM,ParviziJ,BoutierV,WyssD,GanzR. Anteriorfemoroacetabularimpingement:partII.Midterm resultsofsurgicaltreatment.ClinOrthopRelatRes. 2004;(418):67–73.

14.GanzR,LeunigM,Leunig-GanzK,HarrisWH.Theetiologyof osteoarthritisofthehip:anintegratedmechanicalconcept. ClinOrthopRelatRes.2008;466(2):264–72.

15.RebelloG,SpencerS,MillisMB,KimYJ.Surgicaldislocationin themanagementofpediatricandadolescenthipdeformity. ClinOrthopRelatRes.2009;467(3):724–31.

16.SchaiPA,ExnerGU,HänschO.Preventionofsecondary coxarthrosisinslippedcapitalfemoralepiphysis:along-term follow-upstudyaftercorrectiveintertrochantericosteotomy.J PediatrOrthopB.1996;5(3):135–43.

17.SinkEL,KimYJ.Femoroacetabularimpingement:current clinicalevidence.JPediatrOrthop.2012;32Suppl.2:S166–71. 18.PhilipponMJ,PattersonDC,BriggsKK.Hiparthroscopyand