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Editorial Commentary: Femoroacetabular Impingement and Open Physes—To Operate or Not to Operate? Is That the Only Question?

      Abstract

      Our clinical understanding, diagnosis, and treatment of femoroacetabular impingement (FAI) have improved tremendously over the past 2 decades. However, we still have major questions to answer when it comes to the exact etiology of FAI and the role played by intense adolescent athletic activity in the development of FAI. In a society in which there is increasing sports specialization in young people and also rising rates of overuse injuries, the balance between surgical intervention and early preventive measures has yet to be clearly defined. Although we may be able to “safely” treat FAI surgically and provide clinical improvement for these patients, the question remains: Are we addressing with surgery a condition that could be prevented with earlier precautionary measures? It is our responsibility to answer that question for our patients.
      Hip impingement was first conceptualized over 75 years ago.
      • Smith-Petersen M.N.
      The classic: Treatment of malum coxae senilis, old slipped upper femoral epiphysis, intrapelvic protrusion of the acetabulum, and coxa plana by means of acetabuloplasty. 1936.
      In the late 1990s and early 2000s, extensive work by Dr. Reinhold Ganz established the relation between femoral and acetabular impingement and labral injuries. He brought to the forefront the concept of femoroacetabular impingement (FAI).
      • Leunig M.
      • Werlen S.
      • Ungersbock A.
      • Ito K.
      • Ganz R.
      Evaluation of the acetabular labrum by MR arthrography.
      • Beck M.
      • Kalhor M.
      • Leunig M.
      • Ganz R.
      Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip.
      • Ito K.
      • Minka II, M.A.
      • Leunig M.
      • Werlen S.
      • Ganz R.
      Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset.
      An increased recognition as well as diagnosis of FAI has been paralleled by a rising surgical intervention for its treatment.
      • Colvin A.C.
      • Harrast J.
      • Harner C.
      Trends in hip arthroscopy.
      • Montgomery S.R.
      • Ngo S.S.
      • Hobson T.
      • et al.
      Trends and demographics in hip arthroscopy in the United States.
      The adolescent athletic population has been a particular group that has come to prominence because of the increasing incidence of symptomatic FAI in young athletes.
      • Siebenrock K.A.
      • Behning A.
      • Mamisch T.C.
      • Schwab J.M.
      Growth plate alteration precedes cam-type deformity in elite basketball players.
      • Siebenrock K.A.
      • Ferner F.
      • Noble P.C.
      • Santore R.F.
      • Werlen S.
      • Mamisch T.C.
      The cam-type deformity of the proximal femur arises in childhood in response to vigorous sporting activity.
      • Siebenrock K.A.
      • Kaschka I.
      • Frauchiger L.
      • Werlen S.
      • Schwab J.M.
      Prevalence of cam-type deformity and hip pain in elite ice hockey players before and after the end of growth.
      • de Silva V.
      • Swain M.
      • Broderick C.
      • McKay D.
      Does high level youth sports participation increase the risk of femoroacetabular impingement? A review of the current literature.
      It is of great importance that we try to better define the management of these patients. When is surgery needed, and does it have long-term consequences for the patient?
      I read the article by Larson, McGaver, Collette, Giveans, Ross, Bedi, and Nepple
      • Larson, McGaver, Collette
      • et al.
      Arthroscopic surgery for femoroacetabular impingement in skeletally immature athletes: Radiographic and clinical analysis.
      entitled “Arthroscopic Surgery for Femoroacetabular Impingement in Skeletally Immature Athletes: Radiographic and Clinical Analysis” with great interest. This was a retrospective review of a case series of 37 hips in 28 adolescent patients with radiographic and physical examination findings consistent with FAI and open physes. The primary objective was to evaluate the radiographic and clinical outcomes after arthroscopic FAI correction. A secondary objective was to assess whether a non–physeal-sparing arthroscopic approach is safe and effective and does not lead to a clinically relevant complication of growth arrest–related deformity or physeal instability. Although their study is a Level IV study, the authors have provided us valuable clinical information that can help us inform and counsel our young patients and their families about the expected clinical outcomes and the safety of arthroscopic FAI treatment. This current study builds on and reflects findings similar to those of earlier studies, which documented outcome improvement for arthroscopic treatment of FAI in the adolescent population.
      • Philippon M.J.
      • Patterson D.C.
      • Briggs K.K.
      Hip arthroscopy and femoroacetabular impingement in the pediatric patient.
      • Fabricant P.D.
      • Heyworth B.E.
      • Kelly B.T.
      Hip arthroscopy improves symptoms associated with FAI in selected adolescent athletes.
      • Philippon M.J.
      • Yen Y.M.
      • Briggs K.K.
      • Kuppersmith D.A.
      • Maxwell R.B.
      Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: A preliminary report.
      Nwachukwu et al.
      • Nwachukwu B.U.
      • Chang B.
      • Kahlenberg C.A.
      • et al.
      Arthroscopic treatment of femoroacetabular impingement in adolescents provides clinically significant outcome improvement.
      most recently reported on defining the minimal clinically important difference and the substantial clinical benefit for adolescents undergoing arthroscopic FAI surgery. In their study, a review of a prospective institutional hip preservation registry found that adolescents undergoing arthroscopic FAI surgery achieved clinically significant outcome improvement. Although the minimal clinically important difference was achieved by most patients, a considerable improvement in postoperative outcome scores was needed for patients to perceive a substantial clinical benefit. In my opinion, this finding reinforces the importance of extensive nonoperative management prior to any consideration of surgical intervention in this age group (my preferred course of treatment). The patients who respond best to surgery are those in whom all nonsurgical options have been exhausted. They will, in turn, perceive significant improvement from their presurgical state.
      Although Larson et al.
      • Larson, McGaver, Collette
      • et al.
      Arthroscopic surgery for femoroacetabular impingement in skeletally immature athletes: Radiographic and clinical analysis.
      presented the safety profile of non–physeal-sparing arthroscopic surgery as a secondary objective of the study, it is, in my view, the most valuable finding of the study. Kocher et al.
      • Kocher M.S.
      • Kim Y.J.
      • Millis M.B.
      • et al.
      Hip arthroscopy in children and adolescents.
      and Nwachukwu et al.
      • Nwachukwu B.U.
      • McFeely E.D.
      • Nasreddine A.Y.
      • Krcik J.A.
      • Frank J.
      • Kocher M.S.
      Complications of hip arthroscopy in children and adolescents.
      had previously brought attention to the risk profile of arthroscopic FAI surgery in the adolescent. In my experience, a major concern for adolescent patients and their families regarding FAI is the risk of long-term problems or complications from arthroscopic surgical intervention. The study by Larson et al. does provide reassuring support for families and patients about the risk of surgery, but I am concerned about the minimal 1-year follow-up they used. The secondary effects of any surgical intervention could take longer than a year to appear.
      A major question that is not answered in this study: Are there any preventive measures that we, as surgeons, should be instituting? A common question from patients and their families is why and how FAI developed. I am left having to explain that the etiology is not completely clear. We have seen in past studies an increased prevalence of FAI in patients who were athletically active during skeletal development.
      • Siebenrock K.A.
      • Behning A.
      • Mamisch T.C.
      • Schwab J.M.
      Growth plate alteration precedes cam-type deformity in elite basketball players.
      • Siebenrock K.A.
      • Ferner F.
      • Noble P.C.
      • Santore R.F.
      • Werlen S.
      • Mamisch T.C.
      The cam-type deformity of the proximal femur arises in childhood in response to vigorous sporting activity.
      • Siebenrock K.A.
      • Kaschka I.
      • Frauchiger L.
      • Werlen S.
      • Schwab J.M.
      Prevalence of cam-type deformity and hip pain in elite ice hockey players before and after the end of growth.
      One theory was that it might be due to a subclinical slipped capital femoral epiphysis; however, this has not been shown to necessarily be the case.
      • Beaule P.E.
      • Zaragoza E.
      • Motamedi K.
      • Copelan N.
      • Dorey F.J.
      Three-dimensional computed tomography of the hip in the assessment of femoroacetabular impingement.
      • Siebenrock K.A.
      • Schwab J.M.
      The cam-type deformity—What is it: SCFE, osteophyte, or a new disease?.
      It also has been reported that there is a genetic component that contributes to FAI development.
      • Pollard T.C.
      • Villar R.N.
      • Norton M.R.
      • et al.
      Genetic influences in the aetiology of femoroacetabular impingement: A sibling study.
      Asking adolescent athletes not to participate in sports is not a realistic solution. I think more effort at understanding the etiology of FAI in adolescents and the study of possible preventive measures are two goals to work toward.

      Supplementary Data

      References

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