Adriana De La Rocha

Preoperative psychological findings in adolescents undergoing hip preservation surgery.

Background: Chronic pain is associated with increased anxiety, depression, and maladaptive behaviors, especially in adolescents. We hypothesized that adolescents with chronic hip pain selected for hip preservation surgery (HPS) would demonstrate increased anxiety and depression compared with same-age peers. We designed a study to assess the psychological state of adolescents before HPS. Methods: We prospectively evaluated 58 patients (23 males, 35 females), average age 16.5 years (range, 11 to 19 y) before HPS. Their diagnoses included: femoroacetabular impingement (n=25), acetabular dysplasia (16), Perthes disease (11), and slipped capital femoral epiphysis (6). Psychological questionnaires included patient-completed and parent-completed Behavioral Assessment System for Children, Second Edition (BASC-2), Beck Youth Inventory, Second Edition (BYI-II), and Resiliency Scales. Self-reported functional questionnaires included the modified Harris hip score (mHHS, max 100) and the UCLA activity score. Psychological scores were compared between diagnoses, procedures performed, and self-reported functional scores with a Student t test and ANOVA. Results: All patients reported pain, 52 (90%) reported pain >6 months with 28 (54%) >1 year. A total of 44 patients (76%) reported moderate or severe pain. All reported decreased function: average UCLA 7.25 (range, 2 to 10), average HHS 65.5 (range, 27.5 to 97.9). At presentation, 10 patients (17.2%) were receiving psychological intervention and 30% had a family history of mental illness. On the basis of the BYI-II scales, 10% and 31% of patients reported at-risk or clinically significant symptoms of anxiety and depression, respectively. Similarly, using the BASC-2 measure, 28% and 14% reported at-risk or clinically significant anxiety and depression, respectively. Resiliency scales demonstrated that 21% to 36% of patients report maladaptive behavior. There were no significant correlations between any psychological score and diagnosis, procedure, or preoperative functional score. Conclusions: Preoperative evaluation identified patients who reported at-risk or clinically significant symptoms of anxiety and/or depression, with up to one third of patients reporting maladaptive behavior that may significantly influence their postoperative outcomes. Preoperative psychological evaluation, with appropriate intervention and follow-up, if needed, should be considered before surgery selection as mental health conditions may be undiagnosed and will likely influence functional outcomes.

Early results of the Bernese periacetabular osteotomy for symptomatic dysplasia in Charcot-Marie-Tooth disease

Introduction Charcot-Marie-Tooth disease (CMTD) is one of the most common inherited neurologic disorders and can be associated with hip dysplasia. Little is known regarding outcomes of the PAO for patients with CMTD. Our purpose is to document the early results and complications of the PAO for hip dysplasia associated with CMTD. Methods A two centre, retrospective clinical and radiographic review was performed. Demographic and surgical data were recorded. Pre- and postoperative lateral centre edge angle (LCEA), acetabular index (AI), ventral centre edge angle (VCEA), and Tönnis osteoarthritis grade were compared. Hips were classified according to Severin. The Harris Hip Score (HHS) and the Western Ontario and McMasters University (WOMAC) index documented self-reported function. Results Nineteen hips in 14 patients underwent PAO, mean age 16.2 (range 11.2–21 years). Thirteen concomitant procedures were performed, including seven proximal femoral osteotomies. Average follow-up was 3.4 years (range 0.9–8.5). Postoperative radiographic measurements significantly improved. Complications included femoral head AVN (1), transient complete bilateral peroneal nerve palsy (1), inferior rami fractures (4), and heterotopic ossification (Brooker stage 3) (1). The HHS significantly improved from a mean 49.6 pre-operatively to 82.2 at final follow-up of four patients. Seven subjects reported a mean postoperative WOMAC score of 94 (range 58.3–100). Conclusions Most patients presented with severe dysplasia in the second decade of life. The PAO successfully corrected the radiographic abnormalities. Complications were common. The majority of patients reported improved outcomes, although seven showed signs of radiographic progression of osteoarthritis.

High-grade SCFE: the role of surgical hip dislocation and reduction.

The patient with an unstable slipped capital femoral epiphsyis poses a challenging problem to the treating physician to improve the position of the displaced epiphysis to avoid femoroacetabular impingement without developing avascular necrosis (AVN)—a potentially devastating complication. Although the standard operative procedure of in situ pinning following an incidental reduction while positioning the patient on the table, has been the mainstay of treatment in North America, other viable options are available including a surgical dislocation approach to the hip followed by a modified Dunn osteotomy with control of the retinacular vessels, reduction of the epiphysis, and internal fixation with pins or screws. Although technically demanding, this approach offers an opportunity to reduce the epiphysis to avoid femoroacetabular impingement, and limit the possibility for the development of AVN. The early results for this procedure are promising with all studies demonstrating excellent reduction of the epiphysis and an overall lower incidence of AVN when compared with in situ pinning.

Surgical Hip Dislocation is Safe and Effective Following Acute Traumatic Hip Instability in the Adolescent.

Background: A traumatic hip dislocation in the pediatric patient is a rare but potentially catastrophic injury. The purpose of this study was to review our early clinical results and radiographic morphology of hips treated with a surgical hip dislocation (SHD) approach for intra-articular hip pathology resulting from traumatic instability in pediatric and adolescent patients. Methods: This is a retrospective analysis of a consecutive series of patients presenting with nonconcentric reduction after traumatic hip instability. All patients were treated with a transtrochanteric SHD with concomitant procedures based on intra-articular findings. Radiographic evaluations and Harris Hip Scores were completed at final follow-up. Results: Eleven male patients, mean age of 12.3 years (range, 9.3 to 16.1 y) and mean body mass index 19.6 kg/m2 (range, 15.4 to 28.0 kg/m2). Intraoperative findings included: labral tear (8), femoral cartilage injury (5), acetabular rim fracture (4), acetabular cartilage delamination (3), loose body (2), and femoral head osteochondral fracture (1). Postoperatively, 1 patient developed a transient peroneal nerve palsy. At a mean 24.5 months (range, 12.0 to 48.1 mo) postoperatively, no hips have radiographic evidence of osteonecrosis. The mean lateral center edge angle was 20 degrees (range, 9 to 38 degrees) with 6 hips of <20 degrees; mean acetabular index 9 degrees (range, −2 to 23 degrees) with 5 hips of >10 degrees; mean &agr;-angle 56 degrees (range, 48 to 62 degrees) with 6 hips of >55 degrees; mean acetabular version 12 degrees (range, 8 to 16 degrees) with 8 hips of <15 degrees. At 1-year follow-up, the mean Harris Hip Score was 95.8 (range, 84.7 to 100). Conclusions: Early results suggest that SHD is a safe approach to treat an incomplete reduction following posterior hip instability and is effective for identification and treatment of acute intra-articular pathology. Acetabular dysplasia, relative acetabular retroversion, and/or decreased femoral offset may be risk factors for posterior hip instability in adolescents. Level of Evidence: Level IV.

Patient-Reported Health Outcomes After in Situ Percutaneous Fixation for Slipped Capital Femoral Epiphysis: An Average Twenty-Year Follow-up Study

BACKGROUND Percutaneous in situ fixation is the gold-standard treatment for stable slipped capital femoral epiphysis (SCFE). While numerous studies have documented good to excellent long-term clinical and radiographic outcomes, few have documented long-term patient-reported outcomes of patients with this condition. METHODS This retrospective study was performed to document long-term patient-reported outcomes of a cohort of sixty-four patients with SCFE (ninety-one affected hips) and determine whether the slip angle was associated with poorer health outcomes as measured with the Short Form-12 (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, modified Harris hip score (mHHS), and University of California at Los Angeles (UCLA) Activity Scale. RESULTS The mean age at presentation was 12.6 years, and the mean duration of follow-up was 19.6 years. At the time of follow-up, the cohort reported higher rates of diabetes, obesity, and hypertension than the general U.S. POPULATION The mean body mass index (BMI) had increased by 10.2 kg/m(2), with 72% of the subjects meeting the criteria for obesity (BMI > 30 kg/m(2)) at the time of follow-up. The mean age and sex-adjusted PCS and MCS scores were 49.6 and 50.0, respectively, and the mean mHHS was 84.9. Multivariable general linear modeling revealed no association between the initial slip angle and the PCS, MCS, mHHS, or UCLA Activity Scale score. Male sex and a lower BMI were the only predictors of better long-term PCS, mHHS, and UCLA Activity Scale scores. Subjects with a bilateral slip had outcomes similar to those with unilateral disease. CONCLUSIONS The general self-reported health of this cohort was poor compared with that of the general population. The slip angle on presentation did not correlate with any patient-reported outcome measure collected for this study. Higher BMI was one of the only clinical predictors of patient-reported outcomes.

The cross-table lateral radiograph results in a significantly increased effective radiation dose compared with the Dunn and single frog lateral radiographs.

Background: A lateral radiograph of the proximal femur is critical in the evaluation of patients with suspected femoroacetabular impingement. Positioning patients for a cross-table lateral (XTL) image is difficult, which may result in repeat exposures and increased cumulative radiation. Alternatively, the 45-degree Dunn (Dunn) and single frog lateral (SFL) views have been shown to accurately reveal proximal femoral abnormalities in femoroacetabular impingement. The purpose of this study was to compare the effective radiation doses (ERD) for 3 lateral hip projections that provide similar diagnostic information. Methods: Patients presenting to the adolescent hip clinic with indicated examinations were evaluated with a standard anteroposterior (AP) pelvic radiograph and one of 3 lateral hip radiographs: XTL (n=16), Dunn (n=17), or SFL (n=27). Technical exposure parameters and published reference data for an AP pelvic radiograph were used to extrapolate the ERD. A simple Pearson r correlation test determined the relationships between body mass index, age, and ERD. The rate of repeat exposures per study was calculated. Results: Body mass index positively correlated (r=0.34) and age and negatively correlated (r=−0.27) with ERD. ERD was increased for the XTL (0.83±0.98 mSv) over the Dunn (0.37±0.15 mSv) and SFL (0.22±0.11 mSv; P<0.05). Repeat exposures were performed in 10.4%, 4%, and 6% of XTL, Dunn, and SFL studies, respectively. Conclusions: The ERD for a single projection is highest for the XTL, and the examination is more likely to be repeated. The XTL radiograph should be avoided whenever possible and substituted with alternative images providing similar diagnostic information, such as the Dunn or SFL, to minimize lifetime cumulative radiation exposure to the patient. Level of Evidence: Level II.

Increased Body Mass Index Negatively Affects Patient Satisfaction After a Posterior Fusion and Instrumentation for Adolescent Idiopathic Scoliosis

STUDY DESIGN Retrospective. SUMMARY OF BACKGROUND DATA Previous studies have reported the correlation of body mass index (BMI) with non-spine surgical outcomes; however, only a few reviewed the correlation of BMI to outcomes after spine surgery. OBJECTIVES To review the influence of preoperative BMI on the follow-up clinical and functional outcomes after posterior-only fusion (PSF) and instrumentation for adolescent idiopathic scoliosis in a larger patient cohort. METHODS Retrospective review of a consecutive series of patients treated with PSF for adolescent idiopathic scoliosis from 2002 to 2009 at a single institution. There were 3 categories: underweight (UW), normal weight (NML), and overweight (OW). Percent correction of the major curve was collected at 2 years postoperatively and patient outcome scores were analyzed preoperatively and at 2 years postoperatively. Differences between groups were analyzed using analysis of variance, with p < .05. RESULTS A total of 459 patients at an average age of 15.0 years (range, 10.0-21.3 years) treated with PSF instrumentation were included. At 2 years, all groups achieved and maintained equal percent correction with no differences between groups. Regarding preoperative Scoliosis Research Society (SRS) outcome scores, OW patients reported more pain than NML (p = .002) and UW patients (p < .001) despite less reported activity than for the NML (p = .033) and UW groups (p = .005). The total SRS score was also lower in the OW patients compared with NML (p = .009) and UW patients (p = .002). At 2 years, the OW group reported more pain than the UW (p = .031) and NML groups (p = .018), lower mental scores (p = .011) and lower SRS total scores (p = .005) than the NML group. CONCLUSIONS At follow-up, preoperative overweight adolescents reported more pain and lower mental, activity, and appearance domain scores after surgery than UW and NML patients despite equal percent curve correction. This information may help the surgeon with preoperative counseling of OW patients by stressing that their own assessment of outcome is influenced by BMI, which may help promote a healthy weight management program in this patient group.

Perioperative Interdisciplinary Intervention Contributes to Improved Outcomes of Adolescents Treated With Hip Preservation Surgery.

Background: Adolescent hip preservation surgery (HPS) candidates typically present with chronic pain, which can negatively affect psychological function and surgical outcomes. A previous study demonstrated high rates of psychological symptoms and maladaptive behaviors in this population. This study quantified psychological and functional improvements in these patients from preoperative presentation to postoperative follow-up. An integrated interdisciplinary approach is also described. Methods: A total of 67 patients undergoing HPS were evaluated preoperatively and postoperatively at 1 year by staff psychologists. Perioperative psychological intervention consisted of education, counseling, and administration of self-report measures. Self-report measure scores were compared preoperatively and postoperatively, grouped by orthopaedic diagnoses. Frequency analysis, correlational analysis, and analysis of variance were conducted. Results: Psychological function improved significantly at follow-up: decreased emotional symptomatology (46.1 to 43.6, P=0.013), anxiety (49.6 to 45.8, P<0.001), school problems (46.6 to 44.7, P=0.035), internalizing problems (46.3 to 44.1, P=0.015), social stress (44.5 to 42.3, P=0.024), sense of inadequacy (49.0 to 46.0, P=0.004), and increased self-concept (51.1 to 54.1, P=0.003). Resiliency factors also significantly improved: increased mastery (50.3 to 52.9, P=0.001) and resourcefulness (49.7 to 52.0, P=0.046), decreased emotional reactivity (46.3 to 42.9, P=0.001), and vulnerability (47.7 to 44.7, P=0.011). Physical function and return to activity also significantly improved (University of California—Los Angeles: 7.1 to 8.7, P=0.017; modified Harris Hip Score: 67.3 to 83.8, P<0.001). Return to activity positively correlated with optimism and self-efficacy (P=0.041). Femoroacetabular impingement and hip dysplasia patients consistently reported feeling less depressed (P=0.036), having fewer somatic complaints (P=0.023), fewer internalized problems (P=0.037), and exhibiting fewer atypical behaviors (P=0.036) at follow-up. Slipped capital femoral epiphysis patients did not demonstrate improvements in psychological functioning postoperatively. Conclusions: Perioperative psychological education and counseling, in combination with HPS, improved postoperative psychological and physical function. Patients reported reduced anxiety, school problems, and social stress, with marked increase in resilience. Increased mobility and return to activity significantly correlated with improved optimism and self-efficacy. Level of Evidence: Level II—therapeutic studies—investigating the results of treatment.

Improved functional outcome with no decrease in hip strength 2 years following Ganz periacetabular osteotomies for adolescent hip dysplasia

To analyze outcomes of adolescents treated with a periacetabular osteotomies (PAO) with a minimum of 2 years of follow-up. Patients undergoing a PAO for adolescent hip dysplasia were analyzed preoperatively, 1 and 2 years postoperatively. In 32 dysplastic hips significant improvement was seen in all radiographic parameters. Gait speed, hip flexion pull-off power, and hip abductor moment impulse were unchanged postoperatively, whereas strength was maintained in 85% (abduction) and 95% (flexion). The Harris Hip Score increased from 67.1 to 77.9 to 81.3 at 1 and 2 years, respectively. Ganz PAO is effective in correcting dysplasia in adolescents radiographically and functionally.

Precocious appearance of the capital femoral ossific nucleus in Larsen syndrome.

BACKGROUND Larsen syndrome is associated with multiple complications, including spinal deformities and recalcitrant joint dislocations. We noted capital femoral ossific nuclei on ultrasonographic images that were made for two infants with Larsen syndrome who were less than two weeks of age. We sought to confirm that this finding is common in patients with Larsen syndrome and unusual in patients with normal hips or idiopathic developmental dysplasia of the hip. METHODS We identified eight patients with Larsen syndrome who had undergone ultrasonographic or radiographic evaluation of the hips before the age of three months. We compared the findings for these eight patients with those for forty consecutive patients from a prospective study of infants with developmental dysplasia of the hip who had ultrasonographic evaluation of the hips at approximately three months of age, including twenty patients who had normal clinical and ultrasonographic findings and twenty who had clinical instability of one or both hips. RESULTS All eight patients with Larsen syndrome had radiographic or ultrasonographic evidence of an ossific nucleus at an average age of forty days (range, six to 115 days); four of these patients had evidence of an ossific nucleus at six to ten days of age. In comparison, only two of twenty normal infants (three of forty hips) and one of twenty infants (two of forty hips) with developmental dysplasia of the hip had ultrasonographic evidence of an ossific nucleus at an average age of eighty-four days (range, seventy-six to ninety-four days) (p < 0.0001, Fisher exact test). CONCLUSIONS In this small group of patients with clinically documented Larsen syndrome, the capital femoral ossific nucleus was evident on ultrasonography of the hip as early as six days of age and was unusual in normal patients or those with idiopathic developmental dysplasia of the hip. The detection of precocious development of a capital femoral ossific nucleus in infants being screened for skeletal anomalies may warrant further evaluation for the possibility of the presence of Larsen syndrome.