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Bavil AY, Eghan-Acquah E, Dastgerdi AK, Diamond LE, Barrett R, Walsh HP, Barzan M, Saxby DJ, Feih S, Carty CP. Simulated effects of surgical corrections on bone-implant micromotion and implant stresses in paediatric proximal femoral osteotomy. Comput Biol Med 2025; 185:109544. [PMID: 39689524 DOI: 10.1016/j.compbiomed.2024.109544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 11/24/2024] [Accepted: 12/05/2024] [Indexed: 12/19/2024]
Abstract
BACKGROUND AND OBJECTIVE Proximal femoral osteotomy (PFO) is a surgical intervention, typically performed on paediatric population, that aims to correct femoral deformities caused by different pathologies (e.g., slipped capital femoral epiphysis). A PFO involves introduction of an implant to fix the proximal and distal sections of femur following the surgical corrections. The femoral neck-shaft angle (NSA) and anteversion angle (AVA) are key geometric parameters that influence PFO outcomes. To date, the effects of NSA and AVA on bone-implant system mechanics in paediatric populations have not been examined. METHODS This study used an established neuromusculoskeletal modelling process paired with finite element analysis to determine the sensitivity of the implanted femur's mechanics to variations in NSA and AVA during the stance phase of walking. Three male patients aged 9-12 years with different pathology (Spastic diplegia, Perthes disease and Slipped Capital Femoral Epiphysis), weight (377, 747, 842 N), height (1.39, 1.55, 1.71 m) and femur lengths (34.1, 39.4, 43.7 cm) and geometries (NSA: 143, 102, 111 deg; AVA: 29, 17, -22 deg) were examined. For each patient, a three-dimensional bone model was created from computed tomography imaging and digital surgical corrections were applied to systematically vary the NSA and AVA. Personalized motion and loading conditions driven from a neuromusculoskeletal modelling process were applied to each model and its associated permutations of NSA and AVA. RESULTS Results indicated significant intra-participant variability in post-PFO bone-implant micromotion and peak von Mises stress on implant. For models with a post-surgery NSA of 135° and AVA of 12°, the averaged micromotion increased by 87 % and the peak von Mises stress decreased by 63% between patient 1 and 2. Between patient 2 and 3, the averaged micromotion decreased by 55% while the peak von Mises stress increased by 84%. CONCLUSIONS Furthermore, post-PFO bone-implant mechanics were sensitive to variation in NSA and AVA in a subject-specific manner. Optimization of PFO planning is recommended based on patient-specific characteristics.
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Affiliation(s)
- Alireza Y Bavil
- Griffith Center of Biomedical and Rehabilitation Engineering (GCORE), Griffith University, Australia; School of Health Sciences and Social Work, Griffith University, Australia; Advanced Design and Prototyping Technologies (ADaPT) Institute, Griffith University, Australia
| | - Emmanuel Eghan-Acquah
- Griffith Center of Biomedical and Rehabilitation Engineering (GCORE), Griffith University, Australia; School of Health Sciences and Social Work, Griffith University, Australia; Advanced Design and Prototyping Technologies (ADaPT) Institute, Griffith University, Australia
| | - Ayda Karimi Dastgerdi
- Griffith Center of Biomedical and Rehabilitation Engineering (GCORE), Griffith University, Australia; School of Health Sciences and Social Work, Griffith University, Australia; Advanced Design and Prototyping Technologies (ADaPT) Institute, Griffith University, Australia
| | - Laura E Diamond
- Griffith Center of Biomedical and Rehabilitation Engineering (GCORE), Griffith University, Australia; School of Health Sciences and Social Work, Griffith University, Australia; Advanced Design and Prototyping Technologies (ADaPT) Institute, Griffith University, Australia
| | - Rod Barrett
- Griffith Center of Biomedical and Rehabilitation Engineering (GCORE), Griffith University, Australia; School of Health Sciences and Social Work, Griffith University, Australia; Advanced Design and Prototyping Technologies (ADaPT) Institute, Griffith University, Australia
| | - Henry Pj Walsh
- Griffith Center of Biomedical and Rehabilitation Engineering (GCORE), Griffith University, Australia; School of Health Sciences and Social Work, Griffith University, Australia; Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, Australia
| | - Martina Barzan
- Griffith Center of Biomedical and Rehabilitation Engineering (GCORE), Griffith University, Australia; School of Health Sciences and Social Work, Griffith University, Australia; Advanced Design and Prototyping Technologies (ADaPT) Institute, Griffith University, Australia
| | - David J Saxby
- Griffith Center of Biomedical and Rehabilitation Engineering (GCORE), Griffith University, Australia; School of Health Sciences and Social Work, Griffith University, Australia; Advanced Design and Prototyping Technologies (ADaPT) Institute, Griffith University, Australia
| | - Stefanie Feih
- Griffith Center of Biomedical and Rehabilitation Engineering (GCORE), Griffith University, Australia; Advanced Design and Prototyping Technologies (ADaPT) Institute, Griffith University, Australia; School of Engineering and Build Environment, Griffith University, Australia
| | - Christopher P Carty
- Griffith Center of Biomedical and Rehabilitation Engineering (GCORE), Griffith University, Australia; School of Medicine and Dentistry, Griffith University, Australia; Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, Australia.
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Rosen M, Wong A, Worts P, Hutchinson H, Harmon K. Slipped Capital Femoral Epiphysis in an Adult with Panhypopituitarism: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00056. [PMID: 34329204 DOI: 10.2106/jbjs.cc.20.00940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Our patient was a 31-year-old woman with previously undiagnosed panhypopituitarism who presented with bilateral slipped capital femoral epiphysis (SCFE). Together with endocrinology, her treatment plan involved medical management of her panhypopituitarism and surgical correction with femoral neck osteotomy. Hormone deficiencies were corrected 6 weeks after replacement therapy began, and the patient was cleared for surgery. By 5 months after osteotomy, examination revealed delayed union and prominent screws bilaterally. Hardware exchange and repeat internal fixation were then performed. At 8 weeks after revision, she presented with avascular necrosis, and the decision was made to proceed with total hip arthroplasty. A 5-year follow-up period was documented. CONCLUSION This case presented a rare look at SCFE in an adult patient with panhypopituitarism. Other systemic illnesses that can contribute to SCFE or other orthopaedic issues include, but are not limited to, multiple endocrine neoplasia syndromes, vitamin D deficiency, renal osteodystrophy, Kallmann syndrome, Klinefelter syndrome, and pathologies affecting the thyroid and pituitary gland.
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Affiliation(s)
- Matthew Rosen
- Department of Clinical Sciences, The Florida State University, Tallahassee, Florida
| | - Andrew Wong
- Department of Clinical Sciences, The Florida State University, Tallahassee, Florida
- Tallahassee Orthopaedic Clinic, Tallahassee, Florida
| | - Phillip Worts
- Tallahassee Orthopaedic Clinic, Tallahassee, Florida
- Department of Nutrition, Food and Exercise Sciences, The Florida State University, Tallahassee, Florida
- FSU Institute of Sports Sciences and Medicine, Tallahassee, Florida
| | - Hank Hutchinson
- Department of Clinical Sciences, The Florida State University, Tallahassee, Florida
- Tallahassee Orthopaedic Clinic, Tallahassee, Florida
| | - Kristin Harmon
- Tallahassee Primary Care Associates, Tallahassee, Florida
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Migliorini F, Liu Y, Eschweiler J, Baroncini A, Tingart M, Maffulli N. Increased range of motion but otherwise similar clinical outcome of arthroscopy over open osteoplasty for femoroacetabular impingement at midterm follow-up: A systematic review. Surgeon 2021; 20:194-208. [PMID: 33731304 DOI: 10.1016/j.surge.2021.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/10/2021] [Accepted: 01/27/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND A systematic review was conducted comparing patient reported outcomes measures (PROMs), functional scores, and the rate of complications between arthroscopic and open treatment for femoroacetabular impingement (FAI) at mid-term follow-up. MATERIAL AND METHODS This systematic review was performed according to the PRISMA guidelines. The literature search was performed in October 2020. All clinical trials treating FAI using open osteoplasty or arthroscopic surgery were considered for inclusion. Only articles reporting >12 months follow-up were included. RESULTS Data from 97 articles (9981 procedures) were collected. At a mean 19.2 months follow-up there was no difference between the two cohorts. At a mean follow-up of 38 months, the external rotation was increased in the arthroscopic group (P < 0.0001). The modified Harris Hip Score scored greater in favour of the open osteoplasty group (P = 0.04), as did the Hip Outcome Score - Activities of Daily Living subscale (P = 0.01). At a mean 45.1 months the arthroscopic group presented greater external rotation (P < 0.0001) and SF-12 Mental (P = 0.04). The modified Harris Hip Score was greater in favour of the open osteoplasty group (P = 0.03), as was the HOS-ADL (P = 0.01). Regarding complications, the arthroscopic group experienced lower rates of subsequent revisions (P < 0.0001). CONCLUSION Based on the significant reduction of revisions-rate and significant increase in range of motion, arthroscopy treatment for the management of FAI may be recommended.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Yu Liu
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Jörg Eschweiler
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Alice Baroncini
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Markus Tingart
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy; School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent, England; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England.
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Wylie JD, McClincy MP, Uppal N, Miller PE, Kim YJ, Millis MB, Yen YM, Novais EN. Surgical treatment of symptomatic post-slipped capital femoral epiphysis deformity: a comparative study between hip arthroscopy and surgical hip dislocation with or without intertrochanteric osteotomy. J Child Orthop 2020; 14:98-105. [PMID: 32351621 PMCID: PMC7184650 DOI: 10.1302/1863-2548.14.190194] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Our primary research question was to investigate the severity of deformity and articular damage as well as outcomes in patients undergoing hip arthroscopy compared with open surgery for the treatment of symptomatic slipped capital femoral epiphysis (SCFE) deformity. METHODS Retrospective review of surgical treatment of symptomatic SCFE deformity with a minimum one-year follow-up. Patients were divided into three groups: the arthroscopic group, surgical hip dislocation(SHD) group and SHD with femoral osteotomy (SHD+ITO) group. Deformity severity was quantified. Hip outcome was assessed by the modified Merle d'Aubigné Postel (MDP) scores. RESULTS There were more severe slips treated by SHD and SHD+ITO. There was more severe deformity in the SHD+ITO group than the arthroscopy group (p < 0.001). There were more full thickness acetabular cartilage defects in the SHD and the SHD+ITO groups (> 40%) compared with the arthroscopy group (11%; p = 0.03). The SHD+ITO and SHD group had lower MDP scores compared with the arthroscopy group both before and after surgery but no difference was detected in the amount of improvement from surgery across groups (p > 0.05). Moderate and severe SCFEs had worse preoperative scores but improvement was not different compared with mild SCFEs (p > 0.05). CONCLUSION Patients undergoing open treatment had more severe SCFE deformity with more extensive articular damage at reconstructive surgery compared with patients undergoing arthroscopy. All groups with SCFE deformity had improved pain and hip function postoperatively. LEVEL OF EVIDENCE III.
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Affiliation(s)
- James D. Wylie
- The Orthopedic Specialty Hospital, Intermountain Healthcare, Murray, Utah, USA
| | - Michael P. McClincy
- Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Young-Jo Kim
- Boston Children’s Hospital, Boston, Massachusetts, USA
| | | | - Yi-Meng Yen
- Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Eduardo N. Novais
- Boston Children’s Hospital, Boston, Massachusetts, USA,Correspondence should be sent to Eduardo N. Novais, Department of Orthopedic Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. E-mail:
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Nanty L, Canovas F, Rodriguez T, Faure P, Dagneaux L. Femoral neck shortening after internal fixation of Garden I fractures increases the risk of femoral head collapse. Orthop Traumatol Surg Res 2019; 105:999-1004. [PMID: 31320235 DOI: 10.1016/j.otsr.2019.05.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 04/12/2019] [Accepted: 05/05/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Arthroplasty has not been proven superior over internal fixation for the treatment of non-displaced femoral neck fractures. However, internal fixation has been followed by high rates of revision for mechanical complications and of femoral neck impaction within the first postoperative year. The objective of this study was to determine whether femoral neck impaction was associated with avascular necrosis (AVN). HYPOTHESIS Fracture healing with femoral neck shortening by impaction after internal fixation of a femoral neck fracture is associated with AVN. MATERIAL AND METHODS A single-centre retrospective study in patients with Garden I fractures managed by screw fixation was performed to compare outcomes in the groups with and without femoral neck impaction. Follow-up radiographs were assessed for evidence of the femoral neck impaction during fracture healing. The occurrence of AVN was the primary evaluation criterion. The secondary evaluation criteria were risk factors for impaction and complications. RESULTS Of the 75 included patients, 9 (12%) experienced AVN. Impaction was significantly associated with AVN (p=0.02; relative risk, 4.38). Significant risk factors for impaction were a higher body mass index (p=0.0003) and valgus-impacted fracture reduction between the radiographs at baseline and immediately after surgery (p=0.0001). DISCUSSION Femoral neck impaction was a significant risk factor for AVN after screw fixation of Garden I fractures. Valgus-impacted fracture reduction must receive careful attention during fixation. We suggest static internal fixation if the impaction is reduced on a traction table and advise caution when using parallel screws. The diagnostic and therapeutic strategy proposed here deserves to be evaluated in a prospective study. LEVEL OF EVIDENCE III, retrospective comparative study.
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Affiliation(s)
- Léo Nanty
- Département de Chirurgie Orthopédique et Traumatologie, Unité de Chirurgie du membre inférieur et du rachis, Hôpital Lapeyronie, CHRU de Montpellier, 351, avenue Gaston-Giraud, 34295 Montpellier cedex 5, France
| | - François Canovas
- Département de Chirurgie Orthopédique et Traumatologie, Unité de Chirurgie du membre inférieur et du rachis, Hôpital Lapeyronie, CHRU de Montpellier, 351, avenue Gaston-Giraud, 34295 Montpellier cedex 5, France
| | - Thibaut Rodriguez
- Département de Chirurgie Orthopédique et Traumatologie, Unité de Chirurgie du membre inférieur et du rachis, Hôpital Lapeyronie, CHRU de Montpellier, 351, avenue Gaston-Giraud, 34295 Montpellier cedex 5, France
| | - Patrick Faure
- Département de Chirurgie Orthopédique et Traumatologie, Unité de Chirurgie du membre inférieur et du rachis, Hôpital Lapeyronie, CHRU de Montpellier, 351, avenue Gaston-Giraud, 34295 Montpellier cedex 5, France
| | - Louis Dagneaux
- Département de Chirurgie Orthopédique et Traumatologie, Unité de Chirurgie du membre inférieur et du rachis, Hôpital Lapeyronie, CHRU de Montpellier, 351, avenue Gaston-Giraud, 34295 Montpellier cedex 5, France.
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Abstract
The treatment of slipped capital femoral epiphysis (SCFE) in North America has seen a change over the past 15 to 20 years due to a better understanding of the blood flow supplying the femoral head, the ability to monitor the pressure/flow in real time and greater access to the deformity with the development of surgical approaches providing that access. These advances have mainly affected the treatment of the unstable SCFE to mitigate the risk of avascular necrosis but have also been utilized for the stable SCFE when severe deformity remains. This paper will provide a summary of some of the current techniques utilized in North America in the treatment of SCFE and will focus on the studies reported on this condition from this continent. In addition, I wanted this report to reflect the opinions and practices of North American surgeons and so I polled an audience that was representative of the current North American pediatric orthopaedist.
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Kalhor M, Gharanizadeh K, Rego P, Leunig M, Ganz R. Valgus Slipped Capital Femoral Epiphysis: Pathophysiology of Motion and Results of Intracapsular Realignment. J Orthop Trauma 2018; 32 Suppl 1:S5-S11. [PMID: 29373445 DOI: 10.1097/bot.0000000000001085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to report (1) a different but specific pattern of impingement in hips involved with valgus slipped capital femoral epiphysis (valgus SCFE) and (2) the results of surgical treatment using intracapsular realignment techniques. DESIGN Case series. SETTING Multiple academic centers. PATIENTS Six patients with 8 involved hips referred for valgus alignment of proximal femoral epiphysis (valgus SCFE). INTERVENTION Intracapsular realignment osteotomy combined with periacetabular osteotomy if needed. MAIN OUTCOME MEASUREMENT The clinical and radiographical results and pathophysiology of motion. RESULTS Eight hips in 6 patients were treated with subcapital (5 hips) or femoral neck (3 hips) osteotomy for realignment. The medially prominent metaphysis created an inclusive impingement at the anterior acetabular wall, whereas the high coxa valga favored impacting impingement at the posterior head-neck junction. The mean preoperative epiphyseal-shaft angle of 110.5 (range 90-125 degrees) was reduced to 62 degrees (range 55-70 degrees) postoperatively. At the last follow-up, all but 1 hip were pain-free and impingement-free, with normal range of motion. One hip was replaced after repeated attempts of correction. The overall hip functional result using modified Merle d'Aubigne scoring system was excellent in 5 hips (18-16 points), good in 2 hips (16-15 points), and poor in 1 hip (6 points). CONCLUSIONS Impingement in valgus SCFE deformity is specific and complex. Anatomical realignment can lead to favorable results by the restoration of normal morphology and impingement-free range of motion. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Morteza Kalhor
- Department of Orthopaedic Surgery, Firoozgar Medical Center, Iran University of Medical Sciences, Tehran, Iran
| | - Kaveh Gharanizadeh
- Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Paulo Rego
- Department of Orthopaedic Surgery, Hospital da Luz, Lisbon, Portugal
| | - Michael Leunig
- Department of Orthopaedic Surgery, Schulthess Clinic, Zurich, Switzerland
| | - Reinhold Ganz
- Faculty of Medicine, University of Bern, Bern, Switzerland
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Oduwole KO, de Sa D, Kay J, Findakli F, Duong A, Simunovic N, Yi-Meng Y, Ayeni OR. Surgical treatment of femoroacetabular impingement following slipped capital femoral epiphysis: A systematic review. Bone Joint Res 2017; 6:472-480. [PMID: 28790036 PMCID: PMC5579313 DOI: 10.1302/2046-3758.68.bjr-2017-0018.r1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/04/2017] [Indexed: 11/25/2022] Open
Abstract
Objectives The purpose of this study was to evaluate the existing literature from 2005 to 2016 reporting on the efficacy of surgical management of patients with femoroacetabular impingement (FAI) secondary to slipped capital femoral epiphysis (SCFE). Methods The electronic databases MEDLINE, EMBASE, and PubMed were searched and screened in duplicate. Data such as patient demographics, surgical technique, surgical outcomes and complications were retrieved from eligible studies. Results Fifteen eligible level IV studies were included in this review comprising 261 patients (266 hips). Treatment groups included arthroscopic osteochondroplasty, surgical hip dislocation, and traditional open osteotomy. The mean alpha angle corrections were 32.14° (standard deviation (sd) 7.02°), 41.45° (sd 10.5°) and 6.0° (sd 5.21°), for arthroscopy, surgical hip dislocation, and open osteotomy groups, respectively (p < 0.05). Each group demonstrated satisfactory clinical outcomes across their respective scoring systems. Major complication rates were 1.6%, 10.7%, and 6.7%, for arthroscopy, surgical dislocation and osteotomy treatments, respectively. Conclusion In the context of SCFE-related FAI, surgical hip dislocation demonstrated improved correction of the alpha angle, albeit at higher complication and revision rates than both arthroscopic and open osteotomy treatments. Further investigation, including high-quality trials with standardised radiological and clinical outcome measures for young patients, is warranted to clarify treatment approaches and safety. Cite this article: K. O. Oduwole, D. de Sa, J. Kay, F. Findakli, A. Duong, N. Simunovic, Y. Yi-Meng, O. R. Ayeni. Surgical treatment of femoroacetabular impingement following slipped capital femoral epiphysis: A systematic review. Bone Joint Res 2017;6:472–480. DOI: 10.1302/2046-3758.68.BJR-2017-0018.R1.
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Affiliation(s)
- K O Oduwole
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - D de Sa
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - J Kay
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - F Findakli
- Centre for Evidence Based Orthopaedics, McMaster University, Hamilton, Ontario, Canada
| | - A Duong
- Centre for Evidence Based Orthopaedics, McMaster University, Hamilton, Ontario, Canada
| | - N Simunovic
- Centre for Evidence Based Orthopaedics, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Y Yi-Meng
- Division of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - O R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Stevens PM, Anderson L, MacWilliams BA. Femoral shaft osteotomy for obligate outward rotation due to SCFE. Strategies Trauma Limb Reconstr 2017; 12:27-33. [PMID: 28229355 PMCID: PMC5360675 DOI: 10.1007/s11751-017-0276-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 01/30/2017] [Indexed: 11/29/2022] Open
Abstract
Slipped capital femoral epiphysis (SCFE) is an adolescent disease that leads to retroversion of the femoral neck and shaft, relative to the head. Observing that patients with SCFE must walk with an outward foot progression angle and externally rotate the leg in order to flex the hip, we have been performing a femoral shaft rotational osteotomy wherein we rotate the lower femur 45° inward, relative to the upper femur. By correcting retroversion, our goal is to improve functional hip and knee motion, thereby mitigating the effects of SCFE impingement. This is a retrospective review of five hips in four patients (two boys and two girls), average age 14.7 years (range 11 + 7–18 years) who underwent femoral midshaft rotational osteotomy for correction of acquired retroversion of the femur secondary to severe SCFE. We compared clinical findings at the outset to those at an average follow-up of 46 months (range 24–74 months). Pre- and post-gait analysis was performed in three patients. Two of the patients underwent elective arthroscopic osteochondroplasty to alleviate residual FAI: contralateral arthroscopy is pending in one. The first patient in this series received a hip arthroplasty, 62 months after his osteotomy, at age 23. Following midshaft osteotomy, all patients experienced improvement in comfort, gait and activities of daily living. With the patella neutral, they had improved range of hip flexion from an average preoperative flexion of <25° to a postoperative flexion of >90°. Two patients (both male) had delayed union and some loss of correction, secondary to broken interlocking screws; each healed with reamed, exchange nailing. The interlocking screws have since been redesigned and enlarged. Femoral shaft rotational osteotomy restores the functional range of hip motion, while correcting obligate out-toeing and improving knee kinematics. This procedure is technically straightforward, permitting progressive weight bearing, while avoiding the risk of AVN. Osteochondroplasty for residual FAI can be deferred, pending the outcome. Level of evidence III: retrospective series—no controls.
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Affiliation(s)
- Peter M Stevens
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, 84113, USA.
| | - Lucas Anderson
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, 84113, USA
| | - Bruce A MacWilliams
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, 84113, USA
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Late correction of neck deformity in healed severe slipped capital femoral epiphysis: short-term clinical outcomes. Hip Int 2016; 26:344-9. [PMID: 27229167 DOI: 10.5301/hipint.5000347] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Contemporary methods for the management of neck deformity following a healed severe slipped capital femoral epiphysis (SCFE) include subcapital neck osteotomy. METHODS 18 patients with chronic severe SCFE in the oblique plane (mean slip angle = 70°) constituted the study group. 6 patients with an open physis underwent modified Dunn capital realignment and 12 patients with a closed physis underwent surgical dislocation with a corrective neck osteotomy. 10 patients already had an in-situ pinning. RESULTS The mean follow-up was 4.5 years (3-6 years). The mean preoperative modified Harris Hip Score (mHHS) and nonarthritic hip score (NAHS) were 24 and 40 respectively, followed by a score of 89 and 92 respectively at the last follow-up (p = 0.0002). Radiologically, all the parameters showed a significant correction. The mean pre- and postoperative values of alpha angle were 79.8 and 34.5 respectively (p = 0.0002); AP slip angle being 36.7 and 14.8 (p = 0.002); lateral slip angle being 54.2 and 13.6 (p = 0.0002); oblique plane slip angle being 70.7 and 20.8 (p = 0.0002) and centre trochanter distance being -6.9 and 1.2 (p = 0.002). The major complications seen were nonunion of the neck osteotomy (n = 1/12) and chondrolysis (n = 1/6) in the modified Dunn's group. The overall complication rate was 11%. There was no statistically significant difference in outcome between the 2 groups clinically and radiologically. CONCLUSIONS Femoral neck osteotomy is a potentially rewarding technique to correct severe neck deformities and restoring hip function in the short term.
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Johari AN, Pandey RA. Controversies in management of slipped capital femoral epiphysis. World J Orthop 2016; 7:78-81. [PMID: 26925378 PMCID: PMC4757661 DOI: 10.5312/wjo.v7.i2.78] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 09/13/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023] Open
Abstract
The traditional treatment of the hip with a slip of the capital femoral epiphysis has been an in situ fixation using a single screw. This has the sanctity of a long term result. Recent literature stresses the outcomes of failure to restore the upper femoral alignment and on the basis of the poor results makes a plea for capital realignment. This being a recent development, it lacks the support of long term follow up and it remains to be seen if this is a better alternative of managing displaced and unstable slipped capital femoral epiphysis. The authors look at some of the available literature on the subject to highlight these controversies and their implications for orthopedic surgeons. Other controversies pertain to contralateral fixation, duration of immobilization and amount of weight bearing after an in situ fixation.
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Abstract
Slipped capital femoral epiphysis (SCFE) is a common hip condition that can be disabling. In this review, we provide an orientation on current trends in the clinical management of SCFE including conventional procedures and specialised surgical developments. Different methods of fixation of the epiphysis, risks of complications, and the rationale of addressing deformity, primarily or secondarily, are presented. Although improved understanding of the anatomy, vascularity and implications of residual deformity have changed management strategies, the best modality of treatment that would restore complete vascularity to the femoral head and prevent any residual deformity, impingement and early osteoarthritis remains elusive.
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Levy DM, Hellman MD, Haughom B, Stover MD, Nho SJ. Techniques and Results for Open Hip Preservation. Front Surg 2015; 2:64. [PMID: 26649292 PMCID: PMC4664697 DOI: 10.3389/fsurg.2015.00064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/13/2015] [Indexed: 11/13/2022] Open
Abstract
While hip arthroscopy grows in popularity, there are still many circumstances under which open hip preservation is the most appropriately indicated. This article specifically reviews open hip preservation procedures for a variety of hip conditions. Femoral acetabular impingement may be corrected using an open surgical hip dislocation. Acetabular dysplasia may be corrected using a periacetabular osteotomy. Acetabular protrusio may require surgical hip dislocation with rim trimming and a possible valgus intertrochanteric osteotomy. Legg-Calve-Perthes disease produces complex deformities that may be better served with osteotomies of the proximal femur and/or acetabulum. Chronic slipped capital femoral epiphysis may also benefit from a surgical hip dislocation and/or proximal femoral osteotomy.
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Affiliation(s)
- David M Levy
- Department of Orthopedic Surgery, Hip Preservation Center, Rush University Medical Center , Chicago, IL , USA
| | - Michael D Hellman
- Department of Orthopedic Surgery, Hip Preservation Center, Rush University Medical Center , Chicago, IL , USA
| | - Bryan Haughom
- Department of Orthopedic Surgery, Hip Preservation Center, Rush University Medical Center , Chicago, IL , USA
| | - Michael D Stover
- Department of Orthopedic Surgery, Northwestern Memorial Hospital , Chicago, IL , USA
| | - Shane J Nho
- Department of Orthopedic Surgery, Hip Preservation Center, Rush University Medical Center , Chicago, IL , USA
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14
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Modified Dunn Procedure is Superior to In Situ Pinning for Short-term Clinical and Radiographic Improvement in Severe Stable SCFE. Clin Orthop Relat Res 2015; 473:2108-17. [PMID: 25502479 PMCID: PMC4419009 DOI: 10.1007/s11999-014-4100-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 12/04/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND In situ pinning is the conventional treatment for a stable slipped capital femoral epiphysis (SCFE). However, with a severe stable SCFE the residual deformity may lead to femoroacetabular impingement and articular cartilage damage. A modified Dunn subcapital realignment procedure has been developed to allow for correction at the level of the deformity while preserving the blood supply to the femoral head. QUESTIONS/PURPOSES We compared children with severe stable SCFE treated with the modified Dunn procedure or in situ pinning in terms of (1) proximal femoral radiographic deformity; (2) Heyman and Herndon clinical outcome; (3) complication rate; and (4) number of reoperations performed after the initial procedure. METHODS In this nonmatched retrospective study, 15 patients treated with the modified Dunn procedure (between 2007 and 2012) and 15 treated with in situ pinning (between 2001 and 2009) for severe but stable SCFE were followed for a mean of 2.5 years (range, 1-6 years). During the period in question, the decision regarding which procedure to use was based on the on-call surgeon's discretion; six surgeons performed in situ pinning and three surgeons performed the modified Dunn procedure. A total of 15 other patients were treated for the same diagnosis during the study period but were lost to followup before 1 year; of those, 12 were in the in situ pinning group. Radiographs were reviewed to measure the AP and lateral alpha angles, femoral head-neck offset, and Southwick angle preoperatively and at the latest clinical visit. The Heyman and Herndon clinical outcome, complications, and subsequent hip surgeries were recorded. RESULTS At latest followup, the median AP alpha angle (52°, range 41°-59° versus 76°, interquartile range [IQR]: 68°-88°; p = 0.0017), median lateral alpha angle (44°, IQR: 40°-51° versus 87°, IQR: 74°-96°; p < 0.001), median head-neck offset (7 mm, IQR: 5-9 mm versus -5, IQR: -11 to -4 mm; p < 0.001), and median Southwick angle (16°, IQR: 6°-23° versus 58°, IQR: 47°-66°; p < 0.001) revealed better deformity correction with the modified Dunn procedure compared with in situ pinning. Nine patients had good or excellent results in the modified Dunn group compared with four of 15 in the in situ pinning group (p = 0.0343; odds ratio, 5.86; 95% CI, 1.13-40.43). With the numbers available, there were no differences in the numbers of complications in each group (five versus three complications in the in situ and modified Dunn groups, respectively; p = 0.66), but there were more reoperations in the in situ pinning group (three versus seven; p = 0.0230). CONCLUSIONS The modified Dunn procedure results in better morphologic features of the femur, a higher rate of good and excellent Heyman and Herndon clinical outcome, a lower reoperation rate, and a similar occurrence of complications when compared with in situ pinning for treatment of severe stable SCFE. LEVEL OF EVIDENCE Level III, therapeutic study.
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15
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Bali K, Railton P, Kiefer GN, Powell JN. Subcapital osteotomy of the femoral neck for patients with healed slipped capital femoral epiphysis. Bone Joint J 2014; 96-B:1441-8. [PMID: 25371454 DOI: 10.1302/0301-620x.96b11.33519] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the clinical and radiological outcome of subcapital osteotomy of the femoral neck in the management of symptomatic femoroacetabular impingement (FAI) resulting from a healed slipped capital femoral epiphysis (SCFE). We believe this is only the second such study in the literature. We studied eight patients (eight hips) with symptomatic FAI after a moderate to severe healed SCFE. There were six male and two female patients, with a mean age of 17.8 years (13 to 29). All patients underwent a subcapital intracapsular osteotomy of the femoral neck after surgical hip dislocation and creation of an extended retinacular soft-tissue flap. The mean follow-up was 41 months (20 to 84). Clinical assessment included measurement of range of movement, Harris Hip Score (HHS) and Western Ontario and McMaster Universities Osteoarthritis score (WOMAC). Radiological assessment included pre- and post-operative calculation of the anterior slip angle (ASA) and lateral slip angle (LSA), the anterior offset angle (AOA) and centre head–trochanteric distance (CTD). The mean HHS at final follow-up was 92.5 (85 to 100), and the mean WOMAC scores for pain, stiffness and function were 1.3 (0 to 4), 1.4 (0 to 6) and 3.6 (0 to 19) respectively. There was a statistically significant improvement in all the radiological measurements post-operatively. The mean ASA improved from 36.6° (29° to 44°) to 10.3° (5° to 17°) (p < 0.01). The mean LSA improved from 36.6° (31° to 43°) to 15.4° (8° to 21°) (p < 0.01). The mean AOA decreased from 64.4° (50° to 78°) 32.0° (25° to 39°) post-operatively (p < 0.01). The mean CTD improved from -8.2 mm (-13.8 to +3.1) to +2.8 mm (-7.6 to +11.0) (p < 0.01). Two patients underwent further surgery for nonunion. No patient suffered avascular necrosis of the femoral head. Subcapital osteotomy for patients with a healed SCFE is more challenging than subcapital re-orientation in those with an acute or sub-acute SCFE and an open physis. An effective correction of the deformity, however, can be achieved with relief of symptoms related to impingement. Cite this article: Bone Joint J 2014;96-B:1441–8.
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Affiliation(s)
- K. Bali
- University of Calgary, Department
of Orthopedics, 3134 Hospital Drive North West Calgary, Alberta, T2N
5A1, Canada
| | - P. Railton
- University of Calgary, Department
of Orthopedics, 3134 Hospital Drive North West Calgary, Alberta, T2N
5A1, Canada
| | - G. N. Kiefer
- Alberta Children’s Hospital., Shaganappi
Trail North West, Calgary, Alberta, T3B
6A8, Canada
| | - J. N. Powell
- University of Calgary, Department
of Orthopedics, 3134 Hospital Drive North West Calgary, Alberta, T2N
5A1, Canada
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16
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Bali NS, Harrison JO, Bache CE. A modified Imhäuser osteotomy: an assessment of the addition of an open femoral neck osteoplasty. Bone Joint J 2014; 96-B:1119-23. [PMID: 25086130 DOI: 10.1302/0301-620x.96b8.33927] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to determine whether an osteoplasty of the femoral neck performed at the same time as an intertrochanteric Imhäuser osteotomy led to an improved functional outcome or increased morbidity. A total of 20 hips in 19 patients (12 left, 8 right, 13 male, 6 female), who underwent an Imhäuser intertrochanteric osteotomy following a slipped capital femoral epiphysis were assessed over an eight-year period. A total of 13 hips in 13 patients had an osteoplasty of the femoral neck at the same time. The remaining six patients (seven hips) had intertrochanteric osteotomy alone. The mean age was 15.3 years (13 to 20) with a mean follow-up of 57.8 months (15 to 117); 19 of the slips were severe (Southwick grade III) and one was moderate (grade II), with a mean slip angle of 65.3° (50° to 80°); 17 of the slips were stable and three unstable at initial presentation. The mean Non-Arthritic Hip Scores (NAHS) in patients who underwent osteoplasty was 91.7 (76.3 to 100) and the mean NAHS in patients who did not undergo osteoplasty was 76.6 (41.3 to 100) (p = 0.056). Two patients required a subsequent arthroplasty and neither of these patients had an osteoplasty. No hips developed osteonecrosis or chondrolysis, and there was no increase in complications related to the osteoplasty. We recommend that for patients with a slipped upper femoral epiphysis undergoing an intertrochanteric osteotomy, the addition of an osteoplasty of the femoral neck should be considered.
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Affiliation(s)
- N S Bali
- Royal Orthopaedic Hospital, Bristol Road, Birmingham, West Midlands, B31 2AP, UK
| | - J O Harrison
- University Hospital Birmingham, Queen Elizabeth Medical Centre, Birmingham B15 2TH, UK
| | - C E Bache
- Royal Orthopaedic Hospital, Bristol Road, Birmingham, West Midlands, B31 2AP, UK
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