Hi there, Steve Aoki from the University of Utah. I'm going to be talking about the residual pediatric hip deformities, particularly we're going to concentrate on slipped catephalic femoral epiphysis and Perthes hips. This is my disclosure. So let's start with the skiffy hips. Now obviously, not all skiffies are the same. We've got mild, moderate, severe slips with different slip angles. We can have screw impingement where the screw actually comes up and impinges and hits on the ostabular rim. A lot of different ways that we can deal with these from the standpoint of arthroscopic versus open treatment. I think what we're starting to realize is that what's come back into favor is to do at least a gentle reduction with some of these slips to try to put them in a little bit of a better position because if we can get those slips a little bit less severe, then we can have better options as far as dealing with these from an arthroscopic standpoint. So this is a patient that has a left skiffy. This is his video of his right hip. He's got that internal rotation that is preserved on this side. He's got good range of motion. This is actually a kid that came in with knee pain. And so here's his exam on the left hip. He's got that obligate external rotation. Doesn't internally rotate. And when we try, at least with him, when we try to internally rotate him, he reports that that pain is radiating and it's down more at his knee. Historically, these skiffy deformities, these larger skiffy deformities, have been treated with open techniques. Here's one that was treated with an open surgical dislocation, head reorientation, and osteochondroplasty. There are studies out there looking at the arthroscopic treatment for patients that have had skiffies that have been pinned. Patients that have had skiffies that have been pinned that continue to have pain. All are small, rather small studies, but all show promising results. So this is our study that we published in 2015. It's a small study of only nine hips, but we did show that with arthroscopic treatment of the mild and moderate skiffy with labral repairs, osteochondroplasty, plus or minus hardware removal, that we're able to improve their PROs and Likert scores. So this is a case example. This is a 15-year-old that had an in situ pinning two years prior. Continued right groin pain with walking and sitting. He has obligate external rotation. This is looking down at the head-neck junction. This is one of those lesions that is a little bit more on the aggressive side. If you look at this extra bony deformity on the head-neck junction, it's got this big ledge drop off. Essentially, if you look at it as we start to slightly flex the hip up, you can see how this ledge keys into the rim of the acetabulum and labrum. So this is just some of the intraoperative fluoroscopy showing that large rim on the head-neck junction. For a lot of these hips, that bone is so prominent that in order to get around, because the space is so tight, I just like to debulk the area. I'll take as much of that bone down and just, again, debulk the region so that I can actually get around and start to do some more of my shaping or reshaping. For this hip, I just make a little window. I use fluoroscopy to get down to the head of the screw, and then I'll use my screwdriver. I either go through, usually it's the dollop portal for me, but sometimes it's accessed through the anterior portal with some positioning to get that screw straight with my portal, and then I'll remove it arthroscopically. What's really interesting about these hips is that the position of that screw coming through can be a little bit deceiving. You think it's far down on the neck, and oftentimes it's not. It's really close to that head-neck junction. This is in not such a deep flex position. You can see the screw hole coming up right around the edge of that labrum. Then this is our pre- and post-op films. So let's move on to Perthes. I really find Perthes to be a lot more challenging than the skiffy hip. There are a lot more variability in the involvement and deformity of these hips. And a lot of these Perthes hips have dysplasia or abnormal acetabulum as well. Some of the severe ones, like some of those in the center, you get this kind of incongruently congruent hip where you've got kind of a square head and it's sitting in a square acetabulum. And so it's really challenging to shape these and think that you're going to get adequate clearance or more normal mechanics. These are also, on top of associated with dysplasia, they oftentimes have osseous necrosis or OCD lesions associated with the weight-bearing dome of the head. And they can often have that shortened neck and you can get that really high-riding greater trochanter. And so there's a lot of different deformities that are associated with these types of hips. Although we're here at a arthroscopic meeting, I do want to just mention that there are options out there for the open surgical treatment of these Perthes hips. Now, from my standpoint, when I look at the Perthes hips, they're not my favorite hips to treat arthroscopically, although I do think that if there are individuals that I've identified that I've been able to make better, it's the ones with isolated lesions, particularly like this one, where you can take down the extra bone and get better clearance. They've got maybe a little bit more reasonable acetabular coverage and maybe not so much of that flattened, abnormal-shaped head and abnormal-shaped acetabulum. I think in general, those are the ones that I've done best with. The other ones that I feel like I've done reasonably well with are the ones that have loose bodies inside the joint. If you look at the literature on the arthroscopic treatment of Perthes, all pretty relatively small studies, although they all tend to lean towards showing that there's some improvement with treating these types of hips with arthroscopic treatment. Although again, I'd really have to kind of press and kind of highlight that not all Perthes is the same. There's a lot of different deformities associated with this pathology. If you look at these studies, they all differ in their treatment as well. There's loose body removals, osteochondroplasties, chondrolateral repair, debridement, acetabuloplasty work, microfractures. There's a lot of different ways that these hips were treated. We have to be a little careful with how we interpret this data. My take-home points, I think the way I think of the Skiffy and Perthes hips, they are just not normal joints. The morphology is highly variable, and particularly more so for Perthes than Skiffy. In general, for Skiffy hips, I've been really happy with how these hips have been doing clinically after treating them arthroscopically, particularly the mild and the moderate deformities. They've been the ones that in general have been really happy with being treated through the scope. Perthes, on the other hand, mixed results. I do think that the individuals that I do better with are the ones that have a little bit more of a reasonably round hip with reasonable acetabular coverage. The ones that have the big deformities, the ones that have the square head, the square acetabulum, I have not been able to make those reliably better. I think of these hips as, you know, we can't make them morphologically normal, but hopefully with treating them arthroscopically and picking the right patients, we're able to improve their pain and function and improve their lifestyle. Thanks again for your attention.

slipped capital femoral epiphysis

Perthes hips

arthroscopic treatment

deformities

pediatric hip