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Gourineni P, Valleri D, Mungalpara N, Watkins S. Hip Joint Instability After Surgery Performed Through the Surgical Dislocation Approach. Indian J Orthop 2023; 57:762-767. [PMID: 37128568 PMCID: PMC10147864 DOI: 10.1007/s43465-023-00844-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/09/2023] [Indexed: 05/03/2023]
Abstract
Background Safe surgical dislocation of the hip is a versatile approach to the hip joint with a low complication rate. Hip joint instability is a devastating complication with poor prognosis. Methods All hips treated surgically through the safe surgical dislocation approach were entered in a database and the complication of hip joint instability was studied prospectively from 2000 to 2021. Instability was diagnosed by intraoperative stress examination and on postoperative radiographs. The initial deformities treated, type of instability, presumed causes, treatment provided, response to the treatment, and final result were recorded as they happened during the course of the treatment. We considered patient's age, sex, body mass index (BMI), and initial diagnosis as risk factors. We evaluated the radiographs for femoral neck shortening, lack of greater trochanteric advancement, acetabular deformity, and incongruity of the hip joint. Anterior hip precautions were initiated in the middle of the study period. Results 22/459 hips developed hip joint instability after surgical dislocation approach performed for hip preservation. Acetabular deficiency, coxa breva, coxa valga, posterior impingement, increased anteversion, lax soft tissues, medial thigh obesity and lack of postoperative precautions seemed to contribute to instability. 50% of the hips became normal. Chondrolysis and residual subluxation were common in the others. Conclusion Surgical dislocation approach disrupts the soft tissue restraints of the hip and joint stability depends on bony morphology, abductor muscle tension, and postoperative precautions. Several risk factors were subjective and speculative, but awareness of all the potential risk factors and prevention and treatment options should decrease this complication. Level of Evidence IV Case series.
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Affiliation(s)
- Prasad Gourineni
- Department of Orthopaedic Surgery, Amara Hospital, Karakambadi, AP 517520 India
| | - Durgaprasad Valleri
- Department of Orthopaedic Surgery, Amara Hospital, Karakambadi, AP 517520 India
| | - Nirav Mungalpara
- Department of Orthopaedic Surgery, Amara Hospital, Karakambadi, AP 517520 India
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Gautier E, Passaplan C, Gautier L. Epiphyseal Angulation and Related Spatial Orientation in Slipped Capital Femoral Epiphysis: Theoretical Model and Biomechanical Explanation of Varus and Valgus Slip. JB JS Open Access 2020; 5:e20.00099. [PMID: 33376931 PMCID: PMC7757839 DOI: 10.2106/jbjs.oa.20.00099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The management of slipped capital femoral epiphysis (SCFE) is controversial. Surgical decision-making is based regularly on the chronicity, stability, and severity of the slip. The purpose of this study was to determine the true angulation and spatial orientation of the epiphysis in hips with SCFE and contralateral hips. METHODS Eighteen hips in 18 patients with SCFE were included in the analysis. Trigonometric calculations, based on angle measurements using 2 conventional radiographs in planes that are perpendicular to each other, were used to determine the angulation of the epiphysis and its orientation in space. RESULTS The mean absolute epiphyseal obliquity of the SCFE hips was 56.2° and the spatial orientation was 36.5°. The mean obliquity of the contralateral side was 34.0°, with a related spatial orientation of 16.8°. The maximum error can reach up to 9.9° (or 41%) when comparing the calculated angles with the angle measurements on radiographs. CONCLUSIONS On standard radiographs, the epiphyseal angulation in SCFE is consistently underestimated. As a consequence, the assigned classification of some patients may be 1 severity group too low, which impacts the value of traditional severity classification for surgical decision-making. The analysis of the spatial orientation of the slip with the concomitant direction of the resultant shear can partially explain varus and valgus slip in SCFE. LEVEL OF EVIDENCE Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Emanuel Gautier
- Department of Orthopaedic Surgery, HFR–Cantonal Hospital, Fribourg, Switzerland
| | - Caroline Passaplan
- Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland
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Femoral neck osteotomy in skeletally mature patients: surgical technique and midterm results. INTERNATIONAL ORTHOPAEDICS 2020; 45:83-94. [PMID: 32997157 DOI: 10.1007/s00264-020-04822-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Using an extended retinacular flap containing the blood supply for the femoral head, proximal femur osteotomies can be performed at the neck level increasing the potential of correction of complex morphologies. The aim of this study was to analyze the safety, clinical, and radiographic results of this intra-articular surgical technique performed in skeletally mature patients with a minimum follow-up of three years. METHODS Fourteen symptomatic adult patients (16 hips) with a mean age of 26 years underwent FNO using surgical hip dislocation and an extended soft tissue flap. Radiographs and radial magnetic resonance imaging (MRI) were obtained before and after surgery to evaluate articular congruency, cartilage damage, and morphologic parameters. Clinical functional evaluation was done using the Nonarthritic Hip Score (NAHS), the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS). RESULTS After surgery, no avascular necrosis was observed, and all the osteotomies healed without complication. The initial neck/shaft angle (range 120 to 150°) improved in all cases to a mean value of 130° ± 4.6 (p < 0.001). In eight of nine valgus hips, the high-positioned fovea capitis changed to a normal position after surgery. The NAHS score improved from a mean of 36.5 ± 14.9 to 82.9 ± 13.9 points after surgery (p < 0.001). After surgery, the mean HOS was 87.1 ± 17.6 points, and the mean mHHS was 78.6 ± 17 points. CONCLUSIONS In this series, femoral neck osteotomy in the adult, although technically more demanding compared with other classic osteotomies, can be considered a safe procedure with considerable potential to correct hip deformities.
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Samelis PV, Loukas C, Kantanoleon S, Lalos H, Anoua N, Kolovos P, Georgiou F, Konstantinou AL. Causes of Delayed Diagnosis of Slipped Capital Femoral Epiphysis: The Importance of the Frog Lateral Pelvis Projection. Cureus 2020; 12:e7718. [PMID: 32431996 PMCID: PMC7234041 DOI: 10.7759/cureus.7718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Delayed diagnosis and treatment is a universally reported problem that impairs the prognosis of slipped capital femoral epiphysis (SCFE). Quite frequently, a delayed diagnosis of SCFE is observed in spite of serial admissions and examinations of the limping adolescent. Why do health professionals globally fail to make a definitive diagnosis of SCFE during the first examination of the patient? A retrospective study of 36 adolescents treated for stable SCFE and two adolescents treated for unstable SCFE has been performed. In more than half of the delayed diagnosed stable slips (13/25, 52%), the diagnosis was set after serial examinations of the patient. Health professionals commonly order only the anteroposterior (AP) X-ray view of the pelvis when examining a non-traumatic limping adolescent. The frog lateral (FL) projection is usually spared in an attempt to limit the radiation exposure of the patient, especially in ambulating adolescents with mild symptoms. It is proposed that in the non-traumatic limping adolescent, the FL projection instead of the AP pelvis view should be requested by the health professional in order to timely diagnose a surgical emergency of the adolescent hip such as SCFE.
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Affiliation(s)
- Panagiotis V Samelis
- First Orthopaedic Department, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC.,Orthopaedics, Orthopaedic Research and Education Center, Attikon University Hospital, Athens, GRC
| | - Christos Loukas
- Orthopaedics, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
| | | | - Harris Lalos
- Sports Medicine, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
| | - Nikolaos Anoua
- Orthopaedics, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
| | - Panagiotis Kolovos
- Orthopaedics, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
| | - Flourentzos Georgiou
- Orthopaedics, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
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Samelis PV, Papagrigorakis E, Konstantinou AL, Lalos H, Koulouvaris P. Factors Affecting Outcomes of Slipped Capital Femoral Epiphysis. Cureus 2020; 12:e6883. [PMID: 32190446 PMCID: PMC7058394 DOI: 10.7759/cureus.6883] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Slipped capital femoral epiphysis (SCFE) is a frequent cause of nontraumatic painful hip of the adolescence. It is the result of the separation of the proximal femoral growth cartilage at the level of the hypertrophic cell zone. The femoral neck metaphysis rotates externally and migrates proximally relative to the femoral head epiphysis, which is stably seated in the acetabulum; early diagnosis and in situ stabilization grants the best long term results. Numerous factors affect treatment outcomes. Not all implants have the same effect on the slipped physis. Application of the traditionally used implants, such as non-threaded pins and cannulated screws, is questioned. Modern implants are available, which stabilize the slip without accelerating physis fusion. This allows femoral head and neck growth and remodeling to limit the post-slip sequellae on hip anatomy and function. Femoroacetabular impingement (FAI) complicates almost all slips. It causes progressive labral and articular cartilage damage and leads to early hip osteoarthritis and total hip replacement, approximately ten years earlier compared to the general population. Avascular necrosis of the femoral head is a dramatic complication, seen almost exclusively in unstable slips. It develops within months after the slip and leads to immediate articular joint degeneration and the need for total hip replacement. Another serious complication of SCFE is chondrolysis, which is a rapid progressive articular cartilage degeneration leading to a narrow joint space and restriction of hip motion. Implant-related complications, such as migration and loosening, may lead to the progression of the slip. Though bilateral disease is quite frequent, there is no consensus about the need for preventive surgery on the healthy contralateral hip. Diagnosis of SCFE is frequently missed or delayed, leading to slips of higher severity. Silent slippage of the capital femoral epiphysis is highly suspected as an underlying cause of cam-type FAI and early-onset hip osteoarthritis. There is controversy, whether asymptomatic implants should be removed. Novel surgical techniques, such as the modified Dunn procedure and hip arthroscopy, seem to be effective modalities for the prevention of FAI in SCFE.
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Affiliation(s)
- Panagiotis V Samelis
- Orthopaedics, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
| | | | | | - Harris Lalos
- Sports Medicine, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
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Leunig M, Fickert S, Ganz R. Findings and Management of the Rare Caput Flexum Deformity of the Hip: A Case Report. JBJS Case Connect 2019; 9:e0321. [PMID: 31441832 DOI: 10.2106/jbjs.cc.18.00321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 10-year-old girl presented after possible occult hip trauma, with shortening of the leg being the initial clinical symptom, followed by motion-dependent pain. She had limited external rotation in extension with anterior apprehension. Radiographically, the deformity was an anterior tilt of the epiphysis with coxa vara. Surgery included surgical dislocation using a retinacular flap for the anterior open wedge femoral neck osteotomy for extension and posterior translation, with an excellent 4.5-year clinical outcome. CONCLUSIONS Caput flexum is a rare deformity with localized premature closure of the anterior growth plate of the hip. To avoid secondary impingement, an osteotomy was successfully placed close to the deformity.
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Affiliation(s)
- M Leunig
- Department of Orthopedics, Schulthess Clinic, Zurich, Switzerland
| | - S Fickert
- Hüftchirurgie, Sportorthopaedicum Straubing, Straubing, Germany.,Department of Orthopedics, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - R Ganz
- Faculty of Medicine, University of Bern, Bern, Switzerland
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Maranho DA, Davila-Parrilla A, Miller PE, Kim YJ, Novais EN, Millis MB. Acetabular morphology in slipped capital femoral epiphysis: comparison at treatment onset and skeletal maturity. J Child Orthop 2018; 12:444-453. [PMID: 30294368 PMCID: PMC6169558 DOI: 10.1302/1863-2548.12.180057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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 To investigate changes in acetabular morphology during the follow-up of slipped capital femoral epiphysis (SCFE) and search for factors associated with acetabular dysplasia at skeletal maturity. METHODS We evaluated 108 patients with unilateral SCFE (mean age at slip, 12.3 years sd 1.7) to skeletal maturity, with a minimum follow-up of two years (median 4.5 years; interquartile range 3.2 to 6.2). Acetabular parameters obtained from initial and most recent radiographs included the lateral centre-edge angle (LCEA), Tönnis angle (TA) and acetabular depth-width ratio (ADR). Acetabular dysplasia was considered for LCEA < 20° or TA > 10°. Femoral parameters consisted of the most recent head diameter, neck-shaft angle, neck length, articulotrochanteric distance and alpha angle. RESULTS At SCFE onset, the affected hip showed a slightly lower LCEA (26.4° sd 6.1° versus 27.3° sd 5.7°; p = 0.01) and ADR (330 sd 30 versus 340 sd 30; p < 0.001) compared with the uninvolved hip. At final follow-up, the affected hip showed lower LCEA (24.5° sd 7.6° versus 28.8°sd 6.6°; p < 0.001) and ADR (330 sd 40 versus 350 sd 40; p < 0.001), and TA was larger (5.5° sd 5.4° versus 2.3° sd 4.2°; p < 0.001) compared with the uninvolved hip. Acetabular dysplasia was observed in 27 (25%) of 108 hips with SCFE. Femoral head overgrowth, age at slip and SCFE severity were independent factors associated with acetabular dysplasia (p < 0.05). CONCLUSION Acetabular coverage and depth are not increased in SCFE, and the acetabular coverage tends to decrease up to skeletal maturity. A potential disturbance in the acetabular growth and remodelling exists mainly for young children with severe SCFE, and a potential for acetabular insufficiency may be observed at the diagnosis and follow-up of SCFE. LEVEL OF EVIDENCE Prognostic Level IV.
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Affiliation(s)
- D. A. Maranho
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, USA,Department of Biomechanics, Medicine and Rehabilitation of the Locomotor System, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - A. Davila-Parrilla
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, USA
| | - P. E. Miller
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, USA
| | - Y.-J. Kim
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, USA
| | - E. N. Novais
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, USA
| | - M. B. Millis
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, USA, Correspondence should be sent to M. B. Millis, Department of Orthopedic Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Hunnewell Building, Boston, Massachusetts 02115, United States. E-mail:
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CORR Insights®: Morphologic Features of the Contralateral Femur in Patients With Unilateral Slipped Capital Femoral Epiphysis Resembles Mild Slip Deformity: A Matched Cohort Study. Clin Orthop Relat Res 2018; 476:900-901. [PMID: 29481357 PMCID: PMC6260066 DOI: 10.1007/s11999.0000000000000213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Abstract
Up-date on the pathogenesis, epidemiology, pathology, histopathology, clinical findings, diagnosis & classification, imaging modalities and all treatment options in slipped capital femoral epiphysis. This symposium issue of JCO is based on lectures presented at the Pre-Course at the 35th Annual Congress of the European Paediatric Orthopaedic Society (EPOS) in 2016.
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Affiliation(s)
- R. Krauspe
- Orthopaedic Department, University Hospital, Dusseldorf, Germany,Correspondence should be sent to Dr R. Krauspe, Orthopaedic Department, University Hospital, Dusseldorf, Germany. E-mail:
| | - S. Weinstein
- Orthopaedic Department, University of Iowa, Iowa, USA
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