Open versus closed reduction and internal fixation in children with femoral neck fractures. Systematic review and meta-analysis of the literature

Background

Femoral neck fractures in children are uncommon, making up little more than 1% of all paediatric fractures. It's not apparent which type of internal fixation-closed or open-is preferable in these situations when it comes to therapeutic options. When treating children with displaced femoral neck fractures, serious problems can arise.

Methods

Five databases were examined: Medline Plus, PubMed, Scopus, Science Direct, and Web of Science. The outcomes that were relevant for the meta-analysis were non-union, coxa vara, and avascular necrosis. Using the RevMan file, we extracted the data and carried out the analysis (Review Manager Version 5.3).

Results

294 patients had ORIF procedures and 266 patients had CRIF procedures in the included trials. Regarding the outcome of avascular necrosis, we discovered that there was no statistically significant difference between the two groups (RR = 0.84, [95% confidence range (CI) = 0.60, 1.18], P = 0.32). There was homogeneity in the data (P = 0.22, I2 = 27%). When it came to coxa vara, there was no statistically significant difference between the two groups (RR = 0.69, [95% CI = 0.30, 1.58], P = 0.38). There was homogeneity in the data (P = 0.22, I2 = 27%). Regarding non-union, the similar outcome was seen (RR = 0.45, [95% CI = 0.16, 1.14], P = 0.12). There was homogeneity in the data (P = 0.49, I2 = 0%).

Conclusion

Regarding reducing the risk of non-union, coxa vara, and avascular necrosis, we did not find any difference between CRIF and ORIF. To validate this outcome, however, additional research on the various variables (fracture type, age, displacement, fixation technique, and duration of surgery) is required. Sorting patients based on the kind of fracture will ensure that the right approach is used for each type.

Short-Term Complications of Relative Femoral Neck Lengthening Combined with Extra-Articular Osteotomies of the Proximal Femur

Purpose

Relative femoral neck lengthening (RNL) is a newer technique to correct coxa breva and coxa vara to relieve a femoro-acetabular impingement and improve hip abductor function without changing the position of the head on the shaft. Proximal femoral osteotomy (PFO) changes the position of the femoral head relative to the shaft. We studied the short-term complications of procedures that combined RNL with PFO.

Methods

All hips that underwent RNL and PFO using a surgical dislocation and extended retinacular flap development were included. Hips that were treated only with intra-articular femoral osteotomies (IAFO) were excluded. Hips that underwent RNL and PFO, with IAFO and/or acetabular procedures were included. Intra-operative evaluation of the femoral head blood flow was performed with the drill hole technique. Clinical evaluation and hip radiographs were obtained at 1 week, 6 weeks, 3 months, 6 months, 12 months and 24 months.

Results

Seventy two patients (31 males, 41 females, 6-52 years of age) underwent 79 combined RNL and PFO. 22 hips underwent additional procedures like head reduction osteotomy, femoral neck osteotomy, and acetabular osteotomies. There were 6 major and 5 minor complications noted. Two hips developed non-unions, both with basicervical varus-producing osteotomies. Four hips developed femoral head ischemia. Two of these hips avoided collapse with early intervention. One hip had persistent abductor weakness requiring hardware removal and three hips, all in boys developed symptomatic widening of the hip on the operated side from varus-producing osteotomy. One hip had asymptomatic trochanteric non-union.

Conclusion

RNL is routinely performed by releasing the short external rotator muscle tendon insertion from the proximal femur to raise the posterior retinacular flap. Though this technique protects the blood supply from direct injury, it seems to stretch the vessels with major corrections in the proximal femur. We recommend evaluating the blood flow intraoperatively and postoperatively and taking necessary steps early to decrease the stretch on the flap. It may be safer to avoid raising the flap for major extra-articular proximal femur corrections.

Significance

The results of this study suggest ways to improve the safety of procedures that combine RNL and PFO.

A novel mutation in the proteoglycan 4 gene causing CACP syndrome: two sisters report

BACKGROUND

Camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome, caused by biallelic pathogenic mutations in the proteoglycan 4 (PRG4) gene, is characterized by early-onset camptodactyly, noninflammatory arthropathy, coxa vara deformity, and rarely, pericardial effusion. This syndrome can mimic juvenile idiopathic arthritis. CACP syndrome is caused by mutations in the proteoglycan 4 (PRG4) gene. To date, only 36 pathogenic mutations have been reported in this gene, but none have been reported from Azerbaijan.

CASE PRESENTATION

Herein, we report two siblings presented with chronic polyarthritis, had a prior diagnosis of juvenile idiopathic arthritis, but was subsequently diagnosed as CACP syndrome with novel mutation in the PRG4 gene.

CONCLUSION

Our report expands the knowledge of PRG4 mutations, which will aid in CACP patient counseling.

[A rare case of bilateral femoral neck fracture in a 5-year-old girl with autosomal dominant osteopetrosis type 2]

The rare case of a 5‑year-old girl with autosomal dominant osteopetrosis type 2, who suffered metaphyseal fractures of the femoral neck on both sides within 6 months is described. On the right side, the diagnosis was made 3 months after the onset of symptoms, so that a coxa vara occurred. The treatment was surgically treated through a valgus osteotomy with fixation of the femoral head with K‑wires. Three months after the operation, the girl complained of a painful restriction of movement on her left side. Radiologically, a metaphyseal femoral neck fracture without coxa vara was diagnosed and in situ fixated with 2 K wires. Two months after the second operation, there was a symmetrical free range of motion of the hips with no symptoms. The metaphyseal femoral neck fracture with verticalization of the growth plate is a serious disease in autosomal dominant osteopetrosis due to the development of a coxa vara, which, if diagnosed at an early stage, can be treated well with in situ fixation. If the coxa vara has already developed, a valgus osteotomy should be performed despite the risk of delayed bone healing.

Surgical treatment of femoral deformities in polyostotic fibrous dysplasia and McCune-Albright syndrome: A literature review

BACKGROUND

Surgical correction of femoral deformities in polyostotic fibrous dysplasia (PFD) or McCune-Albright syndrome (MAS), such as coxa vara or shepherd’s crook deformity, is a challenge.

AIM

To evaluate the treatment of patients with femoral deformities caused by PDF or MAS treated by osteotomies and stabilized with different methods, by analyzing the most relevant studies on the topic.

METHODS

A literature search was performed in Medline database (PubMed). Articles were screened for patients affected by PFD or MAS surgically managed by osteotomies and stabilized with different methods.

RESULTS

The initial search produced 184 studies, with 15 fulfilling the eligibility criteria of our study. Selected articles (1987-2019) included 111 patients overall (136 femurs).

CONCLUSION

Based on our results, the preferred method to stabilize corrective osteotomies is intramedullary nailing with neck cross pinning. When the deformity is limited to the proximal part of the femur, a screw or blade plate may be used, although there is a high risk of fracture below the plate. When the femur is entirely involved, a two-stage procedure may be considered.

Retrospective analysis of 35 pediatric femoral neck fractures

OBJECTIVE

Pediatric proximal femur fracture is extremely rare trauma comparing to other fractures. The proximal femur fracture is 1% of all pediatric fractures. The aim of current study is to compare the incidence of early complications and outcomes of pediatric proximal femur fractures regarding fracture types retrospectively.

DESIGN

Our study includes 35 cases which are criticized by Delbet classification system, modalities of treatment, duration of waiting for surgery, duration of follow-up and also complications. Our inclusion criteria are age below 16 years old, proximal femur fractures with no evidence of tumoral, romathologic and methabolic conditions. Age, sex and surgery type (open-closed) were noted, and the data were statistically assessed. Assessment of the final outcome was made at the last follow-up visit using the Ratliff's method.

RESULTS

The mean of age of patients in our study is 9.5 ± 5.06 years. The average follow-up was 25.6 ± 13.2 months. 15 patients (42.9%) are type 2 Delbet fracture, 5 patients (14.2%) are Delbet type 3 and 15 patients (42.9%) are Delbet type 4 fracture. Using the Ratliff's method, 25 patients (71.4%) had satisfactory outcomes. Ten patients (28.6%) had unsatisfactory outcomes. The complications as AVN, coxa vara and premature closure of physis, non-union and postoperative infections have been detected in this study. AVN was seen in four (11.4%) patients. In addition, coxa vara was seen in six (17.2%) patients.

CONCLUSION

Pediatric femoral neck fractures are extremely rare fractures and can be treated with low complication rates in cases with early treatment and anatomic reduction.

Statistical shape modeling of the hip and the association with hip osteoarthritis: a systematic review

OBJECTIVE

To summarize available evidence on the association between hip shape as quantified by statistical shape modeling (SSM) and the incidence or progression of hip osteoarthritis.

DESIGN

We conducted a systematic search of five electronic databases, based on a registered protocol (available: PROSPERO CRD42020145411). Articles presenting original data on the longitudinal relationship between radiographic hip shape (quantified by SSM) and hip OA were eligible. Quantitative meta-analysis was precluded because of the use of different SSM models across studies. We used the Newcastle-Ottawa Scale (NOS) for risk of bias assessment.

RESULTS

Nine studies (6,483 hips analyzed with SSM) were included in this review. The SSM models used to describe hip shape ranged from 16 points on the femoral head to 85 points on the proximal femur and hemipelvis. Multiple hip shape features and combinations thereof were associated with incident or progressive hip OA. Shape variants that seemed to be consistently associated with hip OA across studies were acetabular dysplasia, cam morphology, and deviations in acetabular version (either excessive anteversion or retroversion).

CONCLUSIONS

Various radiographic, SSM-defined hip shape features are associated with hip OA. Some hip shape features only seem to increase the risk for hip OA when combined together. The heterogeneity of the used SSM models across studies precludes the estimation of pooled effect sizes. Further studies using the same SSM model and definition of hip OA are needed to allow for the comparison of outcomes across studies, and to validate the found associations.

Bilateral Fracture Neck Femur in Child with Bilateral Delayed Union and Bilateral AVN: A Rare Occurrence and Literature Review

A bilateral neck of femur fracture in children is a rare occurrence with only twelve cases reported till the date. We report a case of a 3-year-old schoolgirl with bilateral Delbet type 2 fracture neck femur after a fall from height. She was managed elsewhere by bilateral closed reduction and screw fixation within 24 h. She presented to us three months after surgery with painful hip movements and inability to walk. Her X-ray showed bilateral Ratliff type three avascular necrosis and bilateral delayed union with visible fracture lines. We placed her in double hip spica for three months. Fortunately, on both sides fractures united well with complete resolution of avascular changes. At one year follow-up, she had no functional limitation, no limb length discrepancy, and an x-ray showed mild coxa vara on left. Bilateral delayed union and avascular necrosis of fracture neck femur has not been reported till date.

Camptodactyly-Arthropathy-Coxa Vara-Pericarditis Syndrome Resembling Juvenile Idiopathic Arthritis: A Single-Center Experience from Southern Turkey

Camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome, caused by biallelic pathogenic mutations in the PRG4 gene, is characterized by early-onset camptodactyly, noninflammatory arthropathy, coxa vara deformity, and rarely, pericardial effusion. Herein, we report 3 patients with CACP syndrome from 2 unrelated families. All patients are female, born to consanguineous parents, and had camptodactyly since the first years of their lives. Two patients had a prior diagnosis of juvenile idiopathic arthritis. Hip changes were present in 2 patients, and 2 of 3 patients had undergone surgery for camptodactyly. Routine echocardiographic evaluations were normal during the 2-year follow-up. This paper represents the third study including CACP patients from Turkey. Clinically, all 3 patients resembled juvenile idiopathic arthritis cases and received unnecessary medication. There is also an ongoing need for improving awareness of CACP and an effective treatment focusing on the lubrication of the joint space in CACP patients.

Femoral neck shaft angle in relation to the location of femoral stress fracture in young military recruits: femoral head versus femoral neck stress fracture

OBJECTIVE

To evaluate the influences of the femoral neck shaft angle (FNSA) on the location of the femoral stress fracture and to assess the potential differences in FNSA between fractured and normal femurs.

MATERIALS AND METHODS

Thirty-seven patients with femoral stress fractures who underwent both plain hip radiographs and MRI, from January 2016 to September 2019, were retrospectively included. Patients were classified as having either femoral head stress fracture (group A, n = 26) or femoral neck stress fracture (group B, n = 11). The FNSA was measured in anteroposterior (AP) hip radiograph. The Mann-Whitney U testing was used to compare the continuous values between the two groups. A receiver operating characteristic (ROC) analysis was used to evaluate the value of FNSA for predicting the risk of femoral stress fracture.

RESULTS

The FNSA was significantly higher in group A (median 135.9°, range 129.5-138.6°) than group B (median 124.3°, range 119.5-129.0°) (p < 0.001), but there were no significant differences in other clinical factors. Furthermore, the FNSA was significantly higher at the fractured femurs (median 135.9°, range 129.9-138.6°) than contralateral normal femurs (median 127.9°, range 123.8-132.1°) in the patients with unilateral femoral head stress fracture (n = 22) (p < 0.001). The ROC analysis revealed that the area under curve (AUC), sensitivity, and specificity for predicting the risk of femoral head stress fracture were 0.807, 72.7%, and 68.2%, respectively, at a FNSA cutoff of 131.0°.

CONCLUSION

FNSA was associated with the location of the femoral stress fracture. In addition, FNSA could serve as a predictive factor for the risk of femoral head stress fractures.

[Fibrous dysplasia]

Fibrous dysplasia is a benign intraosseous tumor, which can occur as a monostotic or polyostotic disease. As a combination of dermatological and endocrinological features it is known as McCune-Albright syndrome, in conjunction with intramuscular myxoma as Mazabraud's syndrome. Fibrous dysplasia originates from a genetic defect, a postzygotic mutation of the GNAS gene, leading to incorrect regulation of the osteogenesis of the affected area of the bone. The weakening of the bone causes a variety of symptoms ranging from isolated local pain, acute fractures up to severe deformation of the bones. In the latter case the patients may lose the capability of walking. The orthopedic treatment provides suitable methods to set and stabilize fractures, to strengthen weakened bones and to straighten out and stabilize deformed long bones. This can help many patients return to a high level of pain-free mobility and even allow the most badly affected patients to lead a better life with a restricted mobility.

Fractures of the Proximal Femur in Childhood: A Review

BACKGROUND

Femoral neck fractures in children are rare injuries, occurring due to high-energy trauma. Due to the unique anatomy and blood supply of the proximal femur in growing children, these fractures are notorious for high rates of complications despite appropriate management. Classification of these fractures is according to the Delbet system, which not only guides management but also gives prognostic clues. Multiple fixation methods have been described and there is no consensus on what constitutes the best treatment. Osteonecrosis, non-union, coxa vara and premature physeal arrest are the most frequent complications.

PURPOSE

To review the current knowledge, discuss controversial aspects, and provide suggestions for future research.

METHODS

We have reviewed the literature on paediatric proximal femur fractures and have provided an evidence-based guide to the diagnosis and management of these injuries. Common complications have been elaborated and options for their prevention and/or management discussed.

CONCLUSION

There is universal agreement that anatomic reduction and stable internal fixation, supplemented by spica immobilization in younger children, are essential to obtain good outcomes. The role of capsular decompression, choice and configuration of implant, and appropriate timing of surgery are aspects that continue to be debated. Multicenter prospective studies are necessary to standardize treatment of these challenging injuries.

A Simple Percutaneous Technique to Reduce Valgus-Impacted Femoral Neck Fractures

The mainstream surgery for valgus-impacted femoral neck fractures (FNFs) is closed reduction and internal fixation under fluoroscopy. However, femoral neck shortening and anterior femoroacetabular impingement are common complications in healed valgus-impacted FNFs after in situ fixation. Some methods have been reported to prevent complications, but these techniques require the use of a transfixing guide wire that passes through the femoral head, which may cause articular cartilage damage. We introduce a simple reduction technique using one Steinmann pin (S-pin) for valgus-impacted FNFs without any interference of the femur head. A S-pin was placed percutaneously at the inferomedial margin of the fracture, and reduction was achieved by applying manual valgus force along the fracture line. By restoring the anatomical alignment, we confirmed the maximum contact area of the fracture and connection of the medial cortical buttress, so the risk of nonunion was also minimized.

Failed Internal Fixation in Bilateral Femoral Neck Stress Fracture Salvaged with Total Hip Arthroplasty: A Report of Two Cases with Literature Review

Bilateral Femoral neck stress fractures (FNSFs) are rare without any underlying metabolic disease or repeated strenuous activities like athletes or military recruits. It constitutes about 5-8% of all stress fractures. Treatment options are still controversial. We report two young women with bilateral simultaneous FNSFs without any metabolic cause, presented to us following failed internal fixation with cancellous screws and neck resorption salvaged with total hip arthroplasty. Compression type stress fracture healed in the final follow-up on the other side.

Novel fibronectin mutations and expansion of the phenotype in spondylometaphyseal dysplasia with "corner fractures"

Heterozygous pathogenic variants in the FN1 gene, encoding fibronectin (FN), have recently been shown to be associated with a skeletal disorder in some individuals affected by spondylometaphyseal dysplasia with "corner fractures" (SMD-CF). The most striking feature characterizing SMD-CF is irregularly shaped metaphyses giving the appearance of "corner fractures". An array of secondary features, including developmental coxa vara, ovoid vertebral bodies and severe scoliosis, may also be present. FN is an important extracellular matrix component for bone and cartilage development. Here we report five patients affected by this subtype of SMD-CF caused by five novel FN1 missense mutations: p.Cys123Tyr, p.Cys169Tyr, p.Cys213Tyr, p.Cys231Trp and p.Cys258Tyr. All individuals shared a substitution of a cysteine residue, disrupting disulfide bonds in the FN type-I assembly domains located in the N-terminal assembly region. The abnormal metaphyseal ossification and "corner fracture" appearances were the most remarkable clinical feature in these patients. In addition, generalized skeletal fragility with low-trauma bilateral femoral fractures was identified in one patient. Interestingly, the distal femoral changes in this patient healed with skeletal maturation. Our report expands the phenotypic and genetic spectrum of the FN1-related SMD-CF and emphasizes the importance of FN in bone formation and possibly also in the maintenance of bone strength.

Surgical correction of coxa vara: Evaluation of neck shaft angle, Hilgenreiner-epiphyseal angle for indication of recurrence

BACKGROUND

Coxa vara is a hip deformity in which the femoral neck-shaft angle decreases below its normal value. Standard surgical treatment for this condition is corrective valgus osteotomy. Appropriate correction of the Hilgenreiner-epiphyseal angle is important to prevent recurrence. The purpose of this study is to: 1) evaluate the recurrence of the deformity at the latest follow up; and 2) find the appropriate angle of correction associated with the lowest recurrence.

METHODS

34 hips in 31 patients who underwent surgery for treatment of coxa vara from 2005 to 2014 were included. Patient-reported outcomes, Hilgenreiner-epiphyseal angle, and neck-shaft angle were assessed preoperatively, postoperatively, and at latest follow-up.

RESULTS

The mean age at surgery was 10.99, with a range of 5-30, years. Preoperative neck-shaft angle ranged from 60 to 100 degrees, and Hilgenreiner-epiphyseal angle ranged from 60 to 90 degrees. At the latest follow up, the neck-shaft angle ranged from 120 to 135 degrees and the Hilgenreiner-epiphyseal angle ranged from 22 to 35 degrees (p < 0.001). The Harris hip score improved from 47.20 (34-66) to 79.68 (60-100) (p < 0.001). There was no recurrence of deformities at the mean follow up of 37.87 months.

CONCLUSION

Surgical correction of coxa vara in various pathologies can be done successfully with the Hilgenreiner-epiphyseal angle corrected to ≤ 35 degrees or the neck shaft angle corrected to > 120 degrees in order to prevent recurrence of the deformity. Majority of the patients were reported improvement of hip function. However, a longer-term follow up is required to determine further outcomes regarding to recurrence of the deformity.

[Modified neck-lengthening osteotomy after Morscher in children and adolescents]

OBJECTIVE

Growth disorders (e. g. caused by congenital hip dislocation, Perthes disease or bacterial coxitis) often lead to an infantile deformity of the proximal femur with a shortened femoral neck and displaced grater trochanter. In 1988, Morscher and Buess described a femoral neck lenghtening osteotomy for treatment of adults. For the first time, we show a modification of this osteotomy for children and adolescents with a locking plate system. The aim is to restore the normal anatomy of the femoral neck and biomechanics of the proximal femur.

INDICATIONS

All symptomatic deformities of the proximal femur with a shortened femoral neck and a proximal displacement of the greater trochanter.

CONTRAINDICATIONS

Bacterial coxitis within the last two years; elevated infections parameters. Acetabular dysplasia with a lack of femoral head containment.

SURGICAL TECHNIQUE

Two osteotomies: one at the level of the greater trochanter to transfer it. The second osteotomy at the level of the distal femoral neck. Stabilization with a locking plate system (LCP Pediatric Hip Plate 130°, Synthes, Oberdorf, Switzerland).

POSTOPERATIVE MANAGEMENT

Full weight bearing to a body weight of 55 kg; partial weight bearing with a body weight >55 kg for 6 weeks.

RESULTS

No intraoperative or postoperative complications were observed in 5 female patients (mean age 11.67 years). After a follow-up of 6-12 weeks, none of the patients presented a Trendelenburg's sign. After 3-6 months, full range of motion was possible.

Fixation of Intertrochanteric Valgus Osteotomy with T Plate in Treatment of Developmental Coxa Vara

BACKGROUND

Although the valgus subtrochanteric osteotomy is considered as a standard surgical treatment for coxa vara, there is no consensus on the optimal method of fixation and osteotomy technique. Fixation of the osteotomy has been achieved by various methods including external fixation and internal fixation with pins and cerclage and a variety of plates. The aim of this study is the evaluation of the results of developmental coxa treated by Y intertrochanteric valgus osteotomy fixed with a T-buttress plate compared with other methods of fixation in the literature.

METHODS

Eighteen corrective valgus intertrochanteric femoral osteotomies were performed in 18 patients (18 hips) for treatment of unilateral developmental coxa vara deformity and fixed with a T plate. There were 12 males and 6 females. The right hip was affected in 10 patients and the left hip in 8 patients. Clinically, patients were evaluated by Larson hip score. Radiographically, anteroposterior view of the pelvis and frog leg lateral views of the affected hip were taken preoperatively and compared with the findings at the final follow-up.

RESULTS

The average follow-up was 29 months (range, 24 to 36 months). Clinical results showed improvement of the mean Larson hip score from 57.8 to 97.0 (p < 0.001). Radiological results showed that all osteotomies were completely united in 2.4 months (range, 2 to 3 months) with the achievement of the planned correction angle. The average correction of Hilgenreiner's epiphyseal angle improved from 78.2° to 27.8° (p < 0.001) at the final follow-up. The femoral neck shaft angle was improved from 93.7° to 129.9° (p < 0.001) at the final follow-up. Shortening of the affected limb was corrected from 2.8 cm to 1.3 cm (p < 0.001) at the last follow-up. No major serious complications were recorded in the present study.

CONCLUSIONS

Intertrochanteric valgus osteotomy of the proximal femur fixed with a T plate may be efficient for treatment of developmental coxa vara. With careful planning, it can result in a low complication rate and insignificant or minimal recurrence rate.

Cleidocranial Dysplasia: A Clinico-radiographic Spectrum with Differential Diagnosis

INTRODUCTION

Cleidocranial dysplasia (CCD) is characterized by aplasia or hypoplasia of the clavicles, characteristic craniofacial malformations, and the presence of numerous supernumerary and unerupted teeth. It affects bones derived from both intra-membranous and endochondral ossification. Incidence has been reported as 1 in 10,00,000. It is caused by mutation in the gene encoding transcription factor Core Binding Factor Subunit Alpha l (CBFAl) or Runt related transcription factor 2 (RUNX2).

CASE REPORT

This presentation discusses the clinical and radiographic features of a familial case of cleidocranial dysplasia occurring in a father and a child. All the clinical and radiographic features, except that of the chest x-ray, were more prominent in the child than the father. This supports the fact that CCD is transmitted by an autosomal-dominant mode of inheritance with high penetrance and variable expressivity. It is sporadic in about 40% of cases. Each child of an individual with CCD has a 50% chance of in heriting the mutation.

CONCLUSION

Diagnosis is mostly made on the basis of clinical and radiographic features. Molecular genetic testing such as sequence analysis or deletion analysis can be used in cleidocranial dysplasia. Some cases are diagnosed through incidental findings by physicians, treating patients for unrelated conditions. Treatment of these patients requires a multidisciplinary approach which includes orthopaedic and dental corrections along with management of any complications of cleidocranial dysplasia.

Pertrochanteric osteotomy and distraction femoral neck lengthening for treatment of proximal hip ischemic deformities in children

PURPOSE

Proximal femoral ischemic deformities in the pediatric population is a challenging pathological situation. Many surgical techniques have been proposed to treat this problem, with variable reported results. We believe that a C-shaped pertrochanteric osteotomy plus neck lengthening utilizing distraction osteogenesis principles would restore the femoral anatomical ratios between neck, shaft, and the head, and redress the biomechanics of the proximal femur with resultant sufficient containment of the femoral head within the acetabulum.

METHODS

We reviewed the results of 19 patients divided into two groups with proximal femoral ischemic deformities. Between 2002 and 2009, preoperative and postoperative clinical examination and radiographs were assessed measuring the neck-shaft angle (NSA), neck-epiphyseal angle (NEA), articulo-trochanteric distance (ATD), lateralization of the greater trochanter (LT), the angle of Wiberg (CEA), index of lateral head displacement by Reimers (IM), and lateral angle of displacement (LDA).

RESULTS

All patients were followed prospectively. Clinical outcome was assessed using Colton's criteria, which showed average good improvement in function (58.9 %). Radiological indicators were assessed using Kruczynski's criteria. For group I, the postoperative NSA, NEA, and CEA showed significant change (p < 0.01, p < 0.001, and p < 0.001, respectively). For group II, the postoperative NSA, NEA, and CEA showed significant change (p < 0.001, p < 0.001, and p < 0.001, respectively).

CONCLUSION

The midterm functional results are favorable for the implementation of pertrochanteric osteotomy and distraction osteogenesis to treat proximal femoral ischemic deformities in the pediatric population.