Hip Pain In Adolescents Research Articles

Diagnostic Challenges of Osteoid Osteoma of the Femoral Neck in an Adolescent: A Case Report

Non-traumatic hip pain in adolescents presents a significant diagnostic challenge. We report the case of a 19-year-old female patient treated for idiopathic juvenile osteoporosis with zoledronic acid, presenting with chronic inflammatory right hip pain that responded well to NSAIDs, associated with back and buttock pain. The inflammatory markers, including CRP and ESR, were negative. The pelvic radiography was normal, though thoracolumbar spine radiography revealed scoliosis. Consequently, MRI of the sacroiliac joints was performed to search for sacroiliitis but revealed a 5 mm nidus with reactive sclerosis, suggestive of an osteoid osteoma. The natural progression of the patient's pain showed spontaneous regression within one year.

Socioeconomic Deprivation and its Associations With Follow-up Compliance After In Situ Pinning of Slipped Capital Femoral Epiphysis.

Slipped capital femoral epiphysis (SCFE) is a common cause of hip pain in adolescents and is most often treated by in situ screw fixation. Orthopaedic follow-up is critical after treatment for SCFE due to risks of complications and subsequent contralateral slip. Recent studies have shown that socioeconomic deprivation is associated with decreased fracture care compliance, but no studies have explored this relationship with SCFEs. The study aims to determine the relationship between socioeconomic deprivation and SCFE follow-up care compliance. This study included pediatric patients treated with in situ pinning of SCFE between 2011 and 2019 at a single tertiary-care urban children's hospital. Demographic and clinical information were obtained from electronic medical records. The Area Deprivation Index (ADI) was used to quantify the socioeconomic deprivation of each. Outcome variables included patient age and status of physeal closure at the most recent appointment, in addition to the length of follow-up (mo). Statistical relationships were evaluated using nonparametric bivariate analysis and correlation. We identified 247 evaluable patients; 57.1% were male, and the median age was 12.4 years. Most slips were stable (95.1%) and treated with isolated unilateral pinning (55.9%). Median length of follow-up was 11.9 months (interquartile range, 4.95 to 23.1) with median patient age at final visit of 13.6 years (interquartile range, 12.4 to 15.1). Only 37.2% of patients were followed until physeal closure. The mean ADI spread in this sample was similar to the national distribution. However, patients in the most deprived quartile were lost to follow-up significantly earlier (median, 6.5mo) than those in the least deprived quartile (median, 12.5mo; P <0.001). Throughout the entire cohort, there was a significant, inverse relationship between deprivation and follow-up length ( rs (238) = -0.3; P <0.001), with this relationship most pronounced in the most deprived quartile. In this sample, ADI spread was representative of national trends, and the incidence of SCFE was distributed evenly across deprivation quartiles. However, follow-up length does not mirror this relationship; increased socioeconomic deprivation is associated with an earlier loss to follow-up (often well before physeal closure). Level II-retrospective prognostic study.

Hip pain in adolescents with cerebral palsy: a population-based longitudinal study.

AimTo investigate the prevalence, characteristics, and risk factors of hip pain in adolescents with cerebral palsy (CP) and compare the findings with those of the same individuals 5 years earlier.MethodSixty‐seven adolescents (28 females, 39 males; mean age 14y 7mo; SD 1y 5mo; range 12–17y) with bilateral CP, in Gross Motor Function Classification System (GMFCS) levels III to V enrolled in a CP surveillance programme were assessed for hip pain. Their caregivers responded to the questions on the intensity and frequency of hip pain from the Child Health Questionnaire (CHQ) (transformed to CHQ hip pain score; 100 indicates no pain). Interference of hip pain with daily activities and sleep was recorded on numeric rating scales. Hip displacement was measured radiographically by the migration percentage.ResultsTwenty‐eight participants had 44 painful hips. Their mean CHQ hip pain score was 40 (SD 21.4; range 10–80). Independent risk factors for hip pain, low CHQ hip pain score, and interference with sleep were severe hip subluxation (migration percentage 50–89%) and GMFCS level V. A migration percentage of 50% to 89% was the only independent risk factor for interference with daily activities. Over 5 years, the number of participants with hip pain increased from 18 to 28, while the mean migration percentage of the most displaced hip was unchanged.InterpretationOur CP hip surveillance programme did not protect the participants against increasing prevalence of hip pain during adolescence. We suggest that surveillance programmes for CP should include guidelines on the characteristics and management of hip pain.What this paper adds Hip pain prevalence increased in adolescents over a 5‐year period in a cerebral palsy surveillance programme.Risk factors for hip pain were Gross Motor Function Classification System level V and severe hip subluxation.

Incidence of Femoroacetabular Impingement and Surgical Management Trends Over Time

Background: Femoroacetabular impingement (FAI) is a well-known cause of hip pain in adolescents and young adults. However, the incidence in the general population has not been clearly defined. Purpose: To (1) define the population-based incidence of diagnosis of FAI in patients with hip pain, (2) report the trends in diagnosis of FAI over time, and (3) determine the changes in the rate and type of surgical management over time. Study Design: Cohort study; Level of evidence, 3. Methods: A geographic database was used to identify patients who were 14 to 50 years old with hip pain between the years 2000 and 2016. Chart and radiographic review was performed to determine which patients had FAI. To be included, patients had to have a triad of clinical symptoms, physical examination signs, and imaging findings consistent with FAI. Medical records were reviewed to obtain demographic information, clinical history, physical examination findings, imaging details, and treatment details. Statistical analysis determined the overall age- and sex-adjusted annual incidence of FAI diagnosis and trends over time. Results: There were 1893 patients evaluated with hip pain, and 716 (38%; 813 hips) had diagnosed FAI. The mean ± SD age was 27.2 ± 8.4 years, and 67% were female. The incidence of FAI diagnosis was 54.4 per 100,000 person-years. Female patients had a higher incidence than male patients (73.2 vs 36.1 per 100,000 person-years; P < .01). Incidence of FAI diagnosis were higher from 2010 to 2016 (72.6 per 100,000 person-years; P < .01) as compared with 2005 to 2009 (45.3) and 2000 to 2004 (40.3). Hip arthroscopy, surgical hip dislocation, and periacetabular osteotomy utilization increased from the 2000-2004 to 2010-2016 periods, respectively: 1 (1%) to 160 (20%; P = .04), 2 (1%) to 37 (5%; P = .01), and 1 (1%) to 22 (3%; P = .58). Conclusion: The overall incidence of FAI diagnosis was 54.4 per 100,000 person-years, and it consistently increased between 2000 and 2016. Female patients had a higher incidence than male patients. The utilization of joint preservation operations, including hip arthroscopy, surgical hip dislocation, and anteverting periacetabular osteotomy, increased over time.

ISCHIOFEMORAL IMPINGEMENT IN ADOLESCENTS: FROM CLINICAL PRESENTATION TO RETURN TO SPORTS

Background: Ischiofemoral impingement is an often unrecognized cause of hip pain in adolescents. It is caused by abnormal contact between the proximal femur and the ischium. The aim of our work is to describe clinical presentation, imaging findings and functional outcomes of ischiofemoral impingement in adolescents. Methods: We performed a retrospective study. Clinical files were reviewed (age, sex, type and duration of symptoms and hip physical examination). Imaging findings were evaluated in pelvis radiographs (presence of coxa profunda, acetabular protrusio, Wiberg angle, femoral neck shaft angle and acetabular retroversion) and in MRI (quadratus femoris edema, measurement of ischiofemoral and quadratus femoris space). Lower extremity functional scale (LEFS) were used to measured response to a physiotherapy protocol. Also relapse and time to sports return were recorded. Results: 24 hips, two bilateral in 20 female patients and 2 male patients, with 13 years-old on average (9-18) were obtained. Main symptom was hip pain with latency to consultant of 9 days on average (2-14). All patients practiced school sports, the most frequent was gymnastics. Positive FADIR test, ischiofemoral impingement test and pain on palpation of the ischium and gluteus medius were found in everyone. The median of Wiberg angle was 37º (25-48), femoral shaft angle 138º (128-144), and coxa profunda was present in 5 hips. MRI showed 13 hips with quadratus femoris edema, one with muscle atrophy, ischiofemoral space was 20 mm on average (16-25) and quadratus femoris space 17 mm on average (13-21). Our physiotherapy protocol was followed for all patients with a median of 18 sessions (10-30). LEFS improved from 56.4% (30-93) to 92% (80-100) (p=0,02). Time to turn asymptomatic was 6 months on average (3-13). With 2 years follow up, 2 hips had recurrence of symptoms. Time to sports return was 5 months on average (3-7). Conclusions: Ischiofemoral impingement is cause of hip pain in active female adolescents. X-rays are inespecific and MRI shows typically quadratus femoris edema. Conservative treatment with physiotherapy is an effective method that allows sports return in few months. This is the first report in the literature regards ischiofemoral impingement in pediatric population including results of treatment and return to sports.

A Three-View Radiographic Approach to Femoroacetabular Impingement.

Femoroacetabular impingement (FAI) is an abnormality of the hip joint that is increasingly being recognized as a cause of athletic disability and early degenerative hip disease. Despite significant advances in the knowledge of FAI, it remains a frequently unrecognized cause of hip pain in adolescents and young adults among orthopedic providers. The purpose of this article is to present a simple 3-view radiographic approach to young adults with hip pain. The radiographs include a standing anteroposterior view of the pelvis, a cross-table lateral view, and a false profile view. Good quality radiographs showing the common sites of potential impingement combined with a basic understanding of certain radiographic parameters may allow faster diagnosis, eliminate unnecessary studies, and allow earlier referral and management.

Outcomes of intra-articular corticosteroid injections for adolescents with hip pain.

ABSTRACTIntra-articular injection of corticosteroid and anesthetic (CSI) is a useful diagnostic tool for hip pain secondary to labral tears or femoroacetabular impingement (FAI). However, the effectiveness of CSI as a stand-alone treatment for hip pain in adolescents is unknown. The purpose of this study is to evaluate the use of CSI for the treatment of hip pain and determine factors that may affect outcomes after injection. Retrospective analysis of 18 patients and 19 hips that underwent fluoroscopic guided hip injection for the treatment of pain at a single institution from 2012 to 2015 was carried out in this study. Mean age at the time of injection was 15.1 years (range 13–17) with mean follow-up of 29.4 months. Fifty-two percent (10/19 hips) went on to surgery after the injection. Average time to surgical conversion was 12.8 months after CSI. Cam or pincer morphologies were present in 90% (9/10 hips) of the operative group. Patients with FAI were more likely to need surgery than patients without bony abnormalities (RR= 10, 95% CI 1.6–64.2, P = 0.0001). There was no difference in the presence of labral tears in the operative and non-operative groups (100% versus 89%, P = 0.47). For adolescents without bony abnormalities, 90% improved with CSI alone and did not require further treatment within 2.4 years. Fluoroscopic guided corticosteroid hip injection may have limited efficacy for the treatment of hip pain secondary to FAI in adolescents. However, for patients without osseous deformity, CSI may offer prolonged improvement of symptoms even in the presence of labral tears.

Simultaneous Bilateral Hip Arthroscopy in Adolescent Athletes With Symptomatic Femoroacetabular Impingement.

Femoroacetabular impingement represents a common cause of hip pain in adolescents. The purpose of the present study was to evaluate the safety and efficacy of simultaneous bilateral hip arthroscopy for bilateral symptomatic femoroacetabular impingement in adolescent athletes. Clinical data were collected in a prospective database on patients who underwent unilateral or simultaneous bilateral hip arthroscopy and included complications, reoperation rate, and return to play time. Differences in International Hip Outcome Tool (iHOT)-12 scores according to hip side and postoperative follow-up time (preoperative, 1.5, 3, 6, 12, and 24 mo) were evaluated using a 2×6 repeated-measures analysis of variance with post hoc repeated-measures 1-way analysis of variance and Bonferroni-corrected paired t tests. In total, 24 patients (36 hips) were studied, of whom 12 underwent simultaneous bilateral hip arthroscopy (24 hips) and a case-matched control group of 12 patients underwent unilateral hip arthroscopy. There were 5 males in each group (41.7%). Average age was 15.7 and 16.5 years in the bilateral and unilateral groups, respectively. No patients were lost to follow-up. In the bilateral group, a significant increase in mean iHOT-12 score was observed between 1.5- and 3-month follow-up (61.8 vs. 82.8, respectively; P=0.003), and 6-, 12-, and 24-month follow-up (91.4, 95.1, and 96.6, respectively, P=0.004). At all follow-up times, there were no significant differences in mean iHOT-12 scores or other outcome measures between bilateral and unilateral cohorts. Time to return to preinjury level of activity was similar between the bilateral and unilateral groups (4.7 vs. 4.9 mo, respectively; P=0.40). One transient lateral femoral cutaneous nerve palsy occurred in each group, though no other complications were documented. No patients required revision surgery by latest follow-up. Bilateral simultaneous hip arthroscopy is safe and reproducible in adolescent athletes, achieving equivalent outcomes, and similar rehabilitation time when compared with unilateral surgery. Level II-therapeutic study.

Femoroacetabular impingement following an osteotomy for acetabular dysplasia: a commentary on a recently published study

Acetabular dysplasia (AD) is a common cause of hip pain in adolescents. Furthermore, compared to a normally shaped acetabulum, AD results in increased contact stresses due to the smaller weight bearing surface (1). These increased contact stresses are thought to contribute to damage to the labrum and cartilage, thus, increasing the chance of developing osteoarthritis later in life (1-3). In order to prevent this long term sequela, osteotomies have been used to treat AD (4). Two of these osteotomies include the Salter (5) innominate osteotomy and the Pemberton (6) pericapsular osteotomy (7,8). The salter osteotomy consists of stabilizing the reduced hip in the position of function by averting the acetabulum, whereas, the pericapsular osteotomy involves reshaping the dysplastic acetabulum. These two procedures have demonstrated good long-term results (8); however, there is the potential for overcorrection leading to iatrogenic pincer femoroacetabular impingement (FAI). With the development of FAI, some have proposed that this will lead to compression and shear stresses between the labrum and the cartilage, eventually also leading to articular degeneration and ultimately global hip OA (1). This question outlines the importance in publishing mid to long-term results following osteotomies to treat AD.

Arthroscopic management of large-size cam-type femoroacetabular impingement

Background Ganz and colleagues have popularized that femoroacetabular impingement (FAI) is a cause of hip pain in adolescents and young adults, and it can eventually lead to osteoarthritis of the hip. FAI is the result of abnormal contact between the proximal femur and the acetabulum. A size and shape mismatch within the hip joint causes collision events that lead to labral and cartilage degeneration. The principle of treatment is based on providing an adequate clearance during terminal range of movement of the hip, thereby avoiding abutment of the proximal femur on the acetabular rim. Objective The aim of our study was to report the results of arthroscopic femoroplasty in cases with large-size cam-type FAI. Patients and methods Twenty patients (11 male and nine female) with a mean age of 33 years (range: 22–48 years), with a large cam-type FAI underwent arthroscopic femoroplasty. The duration of symptoms before surgical intervention averaged 14 months. The patients were assessed preoperatively and 3 months and 1 year postoperatively using the modified Harris hip score (MHHS). The patients were excluded if the disease state was too advanced to reasonably benefit from arthroscopic intervention, with bone-on-bone contact an absolute contraindication. Results The mean MHHS increased more than 20 points from 52 preoperatively to 72 postoperatively after 3 months and to 75 after 1 year. The mean abduction improved from 22° preoperatively to 28° at 12 months postoperatively. The mean internal rotation improved from 16° preoperatively to 23° at 12 months postoperatively. The mean pain score in MHHS increased from 25.8 preoperatively to 41 at 12 months postoperatively. The mean duration of arthroscopic femoroplasty was 120 min (range: 90–180 min). Conclusion With the advancement in hip arthroscopy techniques, it is now possible to address large cam-type FAI arthroscopically with results comparable to open surgical dislocation and femoroplasty with the advantage of low morbidity and early rehabilitation.

Children’s orthopaedics

The June 2015 Children’s orthopaedics Roundup360 looks at: ACL reconstruction in paediatric knees; Hips, slips and cams; The adolescent clavicle; 3D fluoroscopy in DDH?; The psychiatric aspects of hip pain in adolescents; Adolescent bunions: dealer’s choice?; Medial epicondylar fractures revisited

Slipped Capital Femoral Epiphysis: Preventing and Managing Complications.

In nonmedical English parlance, a “slip” is a relatively benign event. But the term “slipped” in orthopaedics often describes a potentially serious condition, as in a slipped capital femoral epiphysis (SCFE). This usually backward slippage of the femur’s proximal epiphysis through the hypertrophic zone of the growth plate is one of the most common causes of hip pain in adolescents. Early detection and treatment of SCFE (typically with in situ screw fixation) is crucial because complications of the untreated condition are serious; they include osteonecrosis, chondrolysis, degenerative joint disease, chronic pain, and gait abnormalities. Bone destruction from SCFE is largely the result of blood-supply restrictions to the epiphysis, with subsequent articular cartilage damage occurring because of femoral head deformity. A case in the February 26 edition of JBJS Case Connector suggests that optimal treatment of osteonecrosis associated with SCFE may include hinged distraction after fixation. Madan and Maheshwari report on a ten-year-old girl who twisted her right leg while playing rugby. She continued to be weight-bearing on the leg for a few days, but then presented unable to bear weight. Radiographs revealed a severe SCFE, and she underwent an in situ single screw fixation within twenty-four hours of presentation, approximately one week after the onset of the initial symptoms. A postoperative radiograph revealed that the posteriorly positioned screw had exited the femoral neck and had penetrated the femoral head, putting the posterior retinacular vessels at risk. The authors first saw the patient at six weeks postinjury; three-phase computed tomography of both hips showed photopenia around the right femoral head …

Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a recognized cause of hip pain in adolescents and is an etiologic factor in progressive hip osteoarthritis (OA). Optimum care includes early and accurate diagnosis to impede cartilage delamination and progression to OA. Here, we present the current perspectives and spectrum of data pertaining to the association of hip deformity and OA. Management of FAI is reviewed, and the need for efficacy studies is underscored. Further, this paper considers existing (short-term to mid-term) study results and highlights the importance of strengthening data quality and developing a standardized method of reporting outcomes data in surgical treatment for FAI. For the purposes of illustration, outcomes of surgical dislocation of the hip and arthroscopic technique are taken into account; results of surgical management of FAI in athletes are also explored. Through numerous examples from the literature, we demonstrate that current outcome studies of surgical correction for FAI are variable in their description and measurement of disease characteristics, type of surgical procedure, and documentation of complications. A standardized method of data collection and reporting is a fundamental step toward understanding the effects of surgical intervention on the natural history of FAI. Together with a future diagnostic standard and long-term study data, we will be better equipped to provide first-rate operative care for this population of patients.

Femoroacetabular Impingement in Adolescents and Young Adults

Femoroacetabular impingement (FAI) is a recently described hip disorder resulting from an abnormal morphology between the proximal femur and acetabulum (socket). It is now recognized as a cause of hip pain in adolescents and young adults, and research has shown that it may also lead to early degenerative changes and osteoarthritis. Femoroacetabular impingement as a cause of precocious hip arthrosis was originally described by Ganz et al. in 2001, and a quick literature search on this topic will confirm that it has become a topic of cutting edge research within the orthopaedic community. The abnormal morphology in FAI results in increased hip contact forces with hip motion, especially flexion. This results in abnormal contact that can lead to acetabular labral tears and cartilaginous injury. Early diagnosis and treatment may possibly delay the future onset of hip arthritis. Although the precise cause of FAI is not well understood, the condition has become increasingly recognized as a cause of hip pain in active adolescents and young adults. The purpose of this article is to outline the history, physical examination and radiographic findings, and current conservative and surgical treatment modalities for FAI.

Hip pain in adolescents: Results of a cross‐sectional study in German pupils and a review of the literature

To determine the prevalence of hip pain (HP) in adolescents in East Germany and to evaluate the potential factors associated with HP. Cross-sectional epidemiological study of a total of 2368 pupils (1137 males, 1231 females; age 14.5+/-0.65, range 13-18 y). Demographic data and information on sports activity and consumption of soft legal drugs were obtained using a questionnaire. Physical examination was carried out by school doctors. Odds ratio (OR [95% confidence interval]) was calculated for common factors associated with HP. The prevalence of adolescents suffering from HP was 6.5% (n=151). Pain episodes were reported as occasional in 3.0%. A total of 69 subjects (2.9%) suffered from permanent pain during physical activity. Permanent pain when at rest was reported in 0.5% (n=12). Female subjects, students attending high school, smoking adolescents and adolescents with a consumption of alcoholic beverages had a significantly higher prevalence of HP. HP was associated with a significantly higher prevalence of low back pain and knee pain. The prevalence of pathological findings of the hip was 2.5% (n=60). Factors significantly associated with HP were: female gender (1.9-fold), attending high school (2.1-fold) and consumption of tobacco (1.6-fold). HP in adolescents seems to be mostly caused by functional disorders. There is a possible association between HP and psychological stress or consumption of legal drugs. Prophylactic measures are necessary in this age group in future.

Arthroscopic findings of the hip in new onset hip pain in adolescents with previous Legg–Calvé–Perthes disease

Nine adolescent patients with new onset hip pain and previous Legg-Calve-Perthes disease (LCPD) were evaluated by hip arthroscopy. Eight of the nine patients had previous hip surgery for their LCPD and a pain-free interval averaging over 5 years. Hip arthroscopy was performed in the supine position on a fracture table using a distention distraction technique. Eight of the nine hips had intra-articular abnormalities including; four tears of the ligamentum teres, three femoral head osteochondritis dissecans, two labral tears, two hips with significant synovitis and three hips with other femoral head abnormalities. Seven of the eight hips improved following their arthroscopic treatment and the patients returned to their before-pain activities including sports. Three patients have required subsequent surgery. The abnormal mechanics from residual femoral head deformity may increase the risk of developing a variety of painful lesions. Hip arthroscopy is a safe way to evaluate and treat these intra-articular abnormalities.