Modified Dunn Technique for Unstable Slipped Capital Femoral Epiphysis: A Midterm Single Center Experience / Técnica de Dunn modificada no escorregamento da epífise femoral proximal com instabilidade: Experiência unicêntrica de médio prazo

Abstract Objective To evaluate the safety and reproducibility of the surgery for unstable slipped capital femoral epiphysis (SCFE) through the modified Dunn technique in a single center cohort from Brazil. Methods We retrospectively analyzed a cohort of patients submitted to this procedure by a single surgeon who was a hip preservation specialist. Demographic data and radiographic angles were evaluated for the relative risk (RR) of avascular necrosis (AVN) using a log-binomial regression model with simple and random effects. Results Among the 30 patients (30 hips) with a mean age of 11.79 years at the time of the operation, there were 17 boys and 18 left hips, which were operated on in a mean of 11.5 days after the slip. The mean follow-up was of 38 months. The preoperative Southwick angle averaged 60.69° against 4.52° postoperatively (p< 0.001). A larger preoperative slip angle was associated with the development of AVN (RR: 1.05; 95% confidence interval [95%CI]: 1.02-1.07; p< 0.01). The overall AVN rate was of 26.7%. Function was good or excellent in 86% of uncomplicated hips, and poor in 87.5% of the partients who developed AVN, as graded by the Harris Hip Score. There was no statistical relationship between epiphyseal bleeding and AVN development (p= 0.82). Conclusion The modified Dunn technique is associated with restoration of the femoral alignment and function after unstable SCFE, when uncomplicated. Moreover, it was shown to be reproducible in our population, with a rate of 26% of femoral head necrosis.

Resumo Objetivo Avaliar a segurança e a reprodutibilidade da cirurgia para escorregamento da epífise femoral proximal (EEPF) com instabilidade por meio da técnica de Dunn modificada em uma coorte unicêntrica no Brasil. Métodos Analisamos de forma retrospectiva uma coorte de pacientes submetidos a esse procedimento por um único cirurgião especialista em preservação do quadril. Avaliamos os dados demográficos e os ângulos radiográficos quanto ao risco relativo (RR) de necrose avascular (NAV) por meio do modelo de regressão log-binomial com efeitos simples e aleatórios. Resultados Entre os 30 pacientes (30 quadris) com idade média de 11,79 anos no momento da cirurgia, havia 17 meninos e 18 quadris esquerdos. O procedimento ocorreu em média 11,5 dias após o escorregamento. O tempo médio de acompanhamento foi de 38 meses. O ângulo de Southwick pré-operatório foi, em média, de 60,69° contra 4,52° após o procedimento (p< 0,001). O maior ângulo de escorregamento pré-operatório foi associado ao desenvolvimento de NAV (RR: 1,05; intervalo de confiança de 95% [IC95%]: 1,02-1,07; p< 0,01). A frequência geral de NAV foi de 26,7%. De acordo com a Escala de Quadril de Harris (Harris Hip Score), a função foi boa ou excelente em 86% dos quadris sem complicações, e ruim em 87,5% dos casos com NAV. Não houve relação estatística entre sangramento epifisário e desenvolvimento de NAV (p= 0,82). Conclusão A técnica de Dunn modificada restaura o alinhamento femoral e a função articular após o EEPF com instabilidade na ausência de complicações. Além disso, mostrou-se passível de reprodução em nossa população, com frequência de necrose da cabeça femoral de 26%.

Avascular Necrosis After Modified Dunn Surgery for the Treatment of Slipped Capital Femoral Epiphysis* / Necrose avascular pós-cirurgia de Dunn modificada no tratamento do escorregamento da epífise proximal do fêmur*

Abstract Objective The present study analyzed the incidence of epiphyseal avascular necrosis in patients with slipped capital femoral epiphysis (SCFE) treated using a modified Dunn technique. In addition, this study determined the correlation of other variables with this incidence and described treatment complications. Methods This is a retrospective study with 20 patients treated by the same surgical team from 2009 to 2019 and followed up for 2 to 12 years. The analysis included general features, time from presentation to surgical procedure, classification, and intraoperative blood perfusion of the epiphysis, as well as complications and their treatment. Results All cases were severe; 65% were acute on chronic, and 55% of the SCFEs were unstable. Our complication rate was 45%, with 5 cases of avascular necrosis, 2 cases of deep infection, 1 case of material failure, and 1 case of joint instability. The statistical analysis revealed that the risk of necrosis was higher when the surgery occurred after a long hospitalization time and there was no intraoperative epiphyseal perfusion. Four necrosis cases happened within the first 5 years, and 1 case in the last 5 years of the study. Conclusion Our study showed that necrosis was the most common complication. It also revealed that surgery delay and lack of intraoperative epiphysis perfusion potentially predispose to avascular necrosis. Although with no statistical significance, coxofemoral instability occurred in chronic SCFE, and surgical fixation with threaded wires was less effective than fixation with a cannulated screw. The modified Dunn procedure should be reserved for severe cases in which other techniques are not feasible and performed by an experienced, trained, and qualified team.

Resumo Objetivo Analisar a incidência da necrose avascular da epífise no tratamento do escorregamento da epífise proximal do fêmur pela técnica de Dunn modificada, correlacionando-a com outras variáveis. Como objetivo secundário, descrevemos outras complicações encontradas. Métodos Estudo retrospectivo com 20 pacientes tratados entre 2009 e 2019, com seguimento de 2 a 12 anos, tratados pela mesma equipe cirúrgica. A análise incluiu características gerais, tempo entre apresentação e procedimento cirúrgico, classificação, presença de perfusão sanguínea intraoperatória da epífise, avaliação das complicações e seus respectivos tratamentos. Resultados Todos os casos eram graves, 65% crônicos agudizados e 55% dos escorregamentos eram instáveis. Nossa taxa de complicações foi de 45%, sendo 5 casos de necrose avascular, 2 de infecção profunda, uma falha do material e uma instabilidade articular. Pacientes operados com maior tempo após a internação e os sem perfusão intraoperatória da epífise tiveram maior risco de necrose na análise estatística. Considerando o tempo do estudo, tivemos 4 casos de necrose nos primeiros 5 anos e 1 caso nos últimos 5 anos. Conclusão Nosso estudo demonstrou que a necrose foi a complicação mais comum e que o atraso para a realização da cirurgia e a ausência de perfusão da epífise no intraoperatório podem predispor à necrose avascular. Embora não estatisticamente significante, a instabilidade coxofemoral foi observada na forma de apresentação crônica e a fixação cirúrgica com fios rosqueados se mostrou menos eficaz que a fixação com parafuso canulado. Este procedimento deve ser reservado para casos graves nos quais outras técnicas não sejam possíveis e realizado por equipe experiente, treinada e capacitada.

Osteotomy at the base of femoral neck and osteoplasty for the treament of scfe / Osteotomia na base do colo femoral e osteoplastia para o tratamento da epifisiolistese

ABSTRACT Objective: To compare the clinical outcomes between patients with moderate and severe slipped capital femoral epiphysis (SCFE) treated with osteotomy at the base of neck and osteoplasty and with healthy individuals. Methods: Comparative cohort with 12 patients (14 hips) with moderate and severe SCFE who underwent osteotomy at the base of neck and osteoplasty between 2007 and 2014. The mean age at surgery was 13.3 ± 2.5 years and the mean follow-up was 3.8 ± 2.2 years. We assessed the level of hip pain by the visual analog scale (VAS) and anterior impingement test (AIT); the level of function using the Harris Hip Score (HHS) and 12-Item Short Form Health Survey (SF-12), the range of motion (ROM) by goniometry and Drehmann sign, and the hip muscular strength by isokinetic and Trendelenburg sign. Results: The level of pain was slightly higher in the SCFE cohort compared with healthy hips (VAS, 0.8 ± 1.4 vs 0 ± 0, 0.007; AIT, 14% vs 0%, p = 0.06; respectively). No differences were observed between the SCFE and control cohort for the functional scores (HHS, 94 ± 7 vs 100 ± 1, p = 0.135); except for ROM, with increased internal rotation (37.3º ± 9.4º vs 28.7º ± 8.2º, p < 0.001), and strength, with decreased abduction torque (75.5 ± 36.9 Nm/Kg vs 88.5 ± 27.6 Nm/Kg, p = 0.045) in the SCFE cohort. Conclusion: The osteotomy at the base of neck and the osteoplasty restored the hip motion and muscle strength, except for the abductor strength, to near normal levels, representing a viable option for the treatment of moderate and severe SCFE. Level of Evidence III, Ambidirectional Cohort Study.

RESUMO Objetivo: Comparar resultados clínicos de pacientes com escorregamento epifisário proximal do fêmur (EEPF) moderado e grave tratados com osteotomia basocervical e cervicoplastia com indivíduos saudáveis. Métodos: Coorte comparativa com 12 voluntários saudáveis e 12 pacientes (14 quadris) com EEPF moderado e grave submetidos à osteotomia basocervical e cervicoplastia entre 2007 e 2014. A média de idade na cirurgia foi de 13,3 ± 2,5 anos e o seguimento médio de 3,8 ± 2,2 anos. Avaliou-se nível de dor no quadril utilizando a escala visual analógica (EVA) e o teste de impacto anterior (TIA); nível de função usando o Harris Hip Score (HHS) e o 12-Item Short Form Health Survey (SF-12); amplitude de movimento (ADM) com goniometria e sinal de Drehmann; e força muscular do quadril com dinamômetro isocinético e sinal de Trendelenburg. Resultados: O nível de dor foi ligeiramente maior na coorte de EEPF comparado a quadris saudáveis (EVA, 0,8 ± 1,4 vs 0 ± 0, 0,007; TIA, 14% vs 0%, p = 0,06; respectivamente). Não foram observadas diferenças entre os grupos EEPF e controle para os escores funcionais (HHS, 94 ± 7 vs 100 ± 1, p = 0,135), exceto para ADM, com aumento da rotação interna (37,3º ± 9,4º vs 28,7º ± 8,2º, p < 0,001), e força, com diminuição do torque de abdução (75,5 ± 36,9 Nm/Kg vs 88,5 ± 27,6 Nm/Kg, p = 0,045), para o grupo EEPF. Conclusão: A osteotomia basocervical e a cervicoplastia restauraram o movimento do quadril e a força muscular, com exceção da força abdutora, a níveis próximos do normal, representando uma opção viável para o tratamento de EEPF moderado e grave. Nível de Evidência III, Estudo de Coorte Ambidirecional.

Radiological results of severe scfe treatment at iot-fmusp from 2012 to 2018 / Resultados radiológicos do tratamento de epifisiolistese grave no iot-fmusp entre 2012-2018

ABSTRACT Objective: To assess the complications in patients with severe slipped capital femoral epiphysis treated with the Dunn or modified Dunn procedure from 2012 to 2018 at the Institute of Orthopedics and Traumatology, Medical School, Universidade de São Paulo. Methods: Analysis of medical records, preoperative and postoperative radiographs with at least one year of radiographic follow-up of patients with severe slipped capital femoral epiphysis. Results: We reviewed the complications in 19 operated cases from 2012 to 2018, out of which 36.8% had osteonecrosis of the femoral head, one patient had chondrolysis, and another had postoperative infection. Conclusion: The osteonecrosis rate observed in this series of cases is similar to that described in other orthopedic facilities. We assessed factors that could potentially influence this outcome, including other characteristics of the patient (obesity, endocrine diseases, and history of sports activities) and of the health system. Level of Evidence III, Restropective Case Series.

RESUMO Objetivo: Avaliar as complicações apresentadas nos pacientes com epifisiolistese grave tratados por meio do procedimento de Dunn ou Dunn Modificado entre 2012 e 2018 no IOT-FMUSP. Métodos: Análise de prontuários, radiografias pré-operatórias e radiografias pós-operatórias com pelo menos 1 ano de seguimento radiográfico dos pacientes com epifisiolistese grave. Resultados: Analisou-se a presença de complicações em 19 casos operados de 2012 a 2018. Desses pacientes, 36,8% apresentaram osteonecrose da cabeça femoral, oi observada condrólise em 1 paciente e infecção pós-operatória em 1 paciente. Conclusão: A taxa de osteonecrose observada nesta série de casos está próxima à descrita em outros serviços. Alguns fatores que potencialmente influenciariam neste desfecho poderiam ter sido avaliados, como outras características do paciente (obesidade, doenças endócrinas e atividade esportiva) e do sistema de saúde. Nível de Evidência III, Série Retrospectiva de Casos .

A post-treatment retrospective evaluation of slipped capital femoral epiphysis / Avaliação pós-tratamento de epifisiólise proximal do fêmur: estudo retrospectivo

ABSTRACT Objective: To analyze the cases of slipped capital femoral epiphysis (SCFE) submitted to surgery at the Pediatric Orthopedics Surgery service of the Hospital Risoleta Tolentino Neves (HRTN), Belo Horizonte/MG, between 2016 and 2019. Methods: Patients treated for SCFE at the HRTN between January/2016 and January/2019 participated in this study. The following data were collected: gender, age, affected side, procedure performed, and postoperative complications. Results: Twenty-one patients were treated at HRTN during the specified period. Among these, most were female (57%) with mean age of 12 years. At the initial diagnosis, about 80% of the patients presented with chronic/acute-on-chronic epiphysis. The left hip was slightly more affected than the right (6:5), with a bilateral rate of 47%, and avascular necrosis was the most frequent complication, occurring in 33% of cases. Conclusion: Slipped femoral capital epiphysis is associated with high morbidity; thus, early diagnosis, endocrine disorder investigation, and appropriate surgical treatment are key for improving these patients' clinical and functional outcome. Level of Evidence II, Retrospective study.

RESUMO Objetivo: Analisar os casos de epifisiólise do fêmur proximal operados pelo serviço de Ortopedia Pediátrica do Hospital Risoleta Tolentino Neves (HRTN), Belo Horizonte/MG, entre os anos de 2016 e 2019. Métodos: Foram analisados retrospectivamente os pacientes submetidos a tratamento cirúrgico de epifisiólise no Hospital Risoleta Tolentino Neves entre janeiro/2016 a janeiro/2019. Os dados coletados para análise foram: sexo, idade, lado acometido, cirurgia realizada, complicações pós-operatórias. Resultados: De janeiro de 2016 a janeiro de 2019, foram tratados 21 pacientes no HRTN. Houve predomínio do sexo feminino (57%), com média de idade de 12 anos. Cerca de 80% dos pacientes apresentaram quadro de epifisiólise crônica/ crônica-agudizada no primodiagnóstico. O lado esquerdo foi ligeiramente mais acometido em relação ao direito (6:5), com bilateralidade de 47%. A necrose avascular foi a complicação mais frequente, em 33% dos casos. Conclusão: Trata-se de quadro de alta morbidade associada, devendo haver um diagnóstico precoce, investigação de distúrbios endócrinos e tratamento cirúrgico adequado, visando uma melhora do prognóstico clínico e funcional do paciente. Nível de Evidência II, Estudo retrospectivo.

Dolor de cadera en adolescentes: estudio y tratamiento / Hip pain in adolescent: assessment and treatment

En adolescentes que consultan por dolor de cadera o pelvis, es crucial una adecuada historia clínica para orientarnos sobre la etiología del dolor y comprender los mecanismos que lo generan. Es importante conocer y realizar un exhaustivo examen físico, con especial énfasis en la cadera, incluyendo pruebas específicas para diferentes patologías, además de comprender las indicaciones de los diferentes estudios de imágenes, para así lograr un correcto diagnóstico.Entre las causas más frecuentes de coxalgia en adolescentes debemos considerar la epifisiolisis, el pinzamiento femoroacetabular con o sin roturas del labrum, las lesiones avulsivas de la pelvis, la coxa saltans, entre otras. Aunque son poco frecuentes, patologías sistémicas como reumatológicas y oncológicas también deben ser descartadas en adolescentes. Un diagnóstico de certeza nos permitirá realizar una adecuada estrategia de tratamiento, a fin de lograr una rehabilitación precoz y evitar futuras complicaciones.

In adolescents presenting with hip or pelvis pain, an adequate medical history is crucial to guide the etiology and understand the mechanisms that generate it. It is important to know and carry out an exhaustive physical examination, with special attention to the hip, including specific tests for different pathologies, in addition to understand the indications of the different imaging studies, in order to achieve a correct diagnosis. Among the most frequent causes of hip pain in adolescents, we must rule out slipped capital femoral epiphysis, femoroacetabular impingement with or without labral tears, avulsion lesions of the pelvis, snapping hip, among others. Although rare, systemic pathologies such as rheumatologic and oncologic diseases must also be ruled out in adolescents. An accurate diagnosis will allow us to carry out an adequate treatment strategy, in order to achieve early rehabilitation and avoid future complications.

Capital femoral physeal dysplasia in cats submited to ostectomy of the femoral head and neck / Displasia femoral capital em felinos submetidos a ostectomia da cabeça e colo femoral

ABSTRACT: This report described pathological fracture of the femoral head (physeal dysplasia) in four male cats (three mixed breed and one Bengal), with an average age of 16 months, treated by an ostectomy of the femoral head and neck. Three cats were neutered and one entire. All presented with mild intermittent lameness in the pelvic limbs. Displacement of the femoral epiphysis and resorption of the femoral neck were present and excision of the femoral head and remaining neck was performed in all cases. Hstological examination showed mild foci of compaction and trabecular fibrosis with deposition of fibrous connective tissue, permeated by granulation tissues, consistent with the original diagosis. Limb function improved in all patients from 2 to 4 weeks postoperatively. Diagnosis of physeal dysplasia is challenging and treatment is different from acute traumatic fractures. Femoral head and neck excision was considered a good alternative in these patients.

RESUMO: Este trabalho descreve a fratura patológica da cabeça do femur (displasia fiseal) em quatro machos (três raças mistas e um Bengal), com idade média de 16 meses, que foram tratados com ostectomia da cabeça e colo femorais. Três gatos eram castrados e um inteiro. Todos apresentaram leve claudicação intermitente nos membros pélvicos. O deslocamento da epífise femoral e a reabsorção do colo femoral estavam presentes, a excisão da cabeça e colo femoral foi realizada em todos os casos. O exame histológico mostrou focos de compacteção e fibrose trabecular com deposição de tecido conjuntivo fibroso, permeado por tecidos de granulação, consistentes com o suposto diagnóstico. A função dos membros melhorou em todos os paciente entre dois a quatro semanas pós-operatório. O diagnóstico da displasia fiseal pe desafiador e o tratamento é diferente das fraturas traumáticas agudas. A excisão de cabeça e colo femoral é considerada uma boa alternativa nesses pacientes.

Evaluation of the Southwick Angle in Two Hundred Hips of Asymptomatic Children and Adolescents / Avaliação do ângulo de Southwick em duzentos quadris de crianças e adolescentes assintomáticos

Abstract Objectives To measure the mean value of the Southwick angle using two different methods, the manual (1) and digital (2) methods, and to establish a normality value. Methods A primarily descriptive study with 100 children and adolescents. Individuals with orthopedic complaints regarding the hips and/or knees or gait alterations were excluded. For each patient, an X-ray was performed on the lateral incidence of Lowenstein, totaling 100 radiographs and 200 hips. The Southwick angle was measured in two different ways by the same researcher: the conventional method (1), tracing the lines with pencils and measuring the angle with the use of a goniometer and negatoscope, and through the GNU Image Manipulation Program (GIMP) image editor (open source), version 2.7.0 (2), in which the lines were plotted and the angles of both hips were gauged on each radiograph. Later, we sought to evaluate the correlation between the two methods and to verify the mean Southwick angle by categorically correlating it by gender, age group and body mass index (BMI) in asymptomatic children and adolescents. All radiographs were authorized by the children and adolescents' parents/legal guardians. The study was approved by the ethics committee of the institutions in which the research was conducted. Results The mean of the Southwick angles obtained by the conventional method was of 8.7º (±2.0º), and, by the digital method, it was of 9.9º (±1.8º). The angle obtained by the two methods was statistically significant (p < 0.001). The majority of the studied population (95%) had a body mass index (BMI) > 18.5, and the mean of the angles was within the previously established value (∼ 10º). Conclusion For the first time, using a substantial sample size, a normal value for the Southwick angle measured in asymptomatic individuals was demonstrated. In addition, the image editor proved to be a reliable method to measuring the Southwick angle.

Resumo Objetivos Medir o valor médio do ângulo de Southwick utilizando dois métodos diferentes, manual (1) e digital (2), e estabelecer um valor de normalidade. Métodos Estudo primariamente descritivo, realizado com 100 crianças e adolescentes. Foram excluídos indivíduos que apresentavam queixa ortopédica nos quadris e/ou joelhos, ou alterações de marcha. Para cada paciente, foi realizada uma radiografia na incidência lateral de Lowenstein, totalizando 100 radiografias e 200 quadris. O ângulo de Southwick foi medido de duas formas pelo mesmo pesquisador: pelo método convencional (1), traçando-se as retas com lápis e medindo o ângulo com o uso de goniômetro e negatoscópio, e por meio do editor de imagem GNU Image Manipulation Program (GIMP; código aberto), versão 2.7.0 (2), no qual foram traçadas as linhas e aferidos os ângulos de ambos os quadris em cada radiografia. Posteriormente, buscou-se avaliar a correlação entre os dois métodos e verificar o ângulo médio de Southwick correlacionando-o categoricamente por gênero, faixa etária e índice de massa corpórea (IMC) em adolescentes e crianças assintomáticos. Todas as radiografias foram autorizadas pelos responsáveis. O estudo foi aprovado pelo comitê de ética das instituições em que a pesquisa foi realizada. Resultados A média do ângulo de Southwick obtida pelo método convencional foi de 8,7º (±2,0º), e pelo método digital, foi de 9,9º (±1,8º). O ângulo obtido pelas duas formas teve significância estatística (p < 0,001). A maioria da população estudada (95%) tinha índice de massa corpórea (IMC) > 18,5, e a média dos ângulos esteve dentro do valor previamente estabelecido como normal (∼ 10º). Conclusão Demonstrou-se, pela primeira vez, utilizando uma amostra substanciosa, um valor normal do ângulo de Southwick medido em indivíduos assintomáticos. Além disso, o editor de imagem mostrou ser um método confiável para mensuração do ângulo de Southwick.

Epifisiólisis de fémur proximal: resultados y calidad de vida / Epiphysiolysis of the proximal femur: results and quality of life / Epifisiólise proximal do fémur: Resultados e qualidade de vida

Resumen: Introducción: el impacto sobre la calidad de vida de los pacientes con deslizamientos de epífisis femoral proximal inestables y estables es poco conocido. El objetivo de este estudio fue conocer los resultados terapéuticos utilizando un score de calidad de vida y las complicaciones de la población afectada en un centro de referencia ortopédico. Material y método: estudio de cohorte que incluyó 28 niños tratados en el Centro Hospitalario Pereira Rossell entre 2010 y 2016. Se evaluaron los pacientes clínica y radiológicamente con un mínimo de dos años de seguimiento posoperatorio. Fue utilizado el cuestionario International Hip Outcome Tool (iHOT-12), para medir resultados reportados por el paciente. Se evaluaron las complicaciones necrosis avascular, condrolisis y pinzamiento femoroacetabular. Resultados: se identificaron 38 caderas tratadas por deslizamiento epifisario femoral proximal; 28 clasificadas estables (74%) y 10 inestables (26%). La fijación in situ fue el tratamiento quirúrgico más frecuentemente utilizado. Al final del seguimiento se evaluaron 27 pacientes y el iHOT-12 mostró una diferencia significativa entre deslizamientos estables y deslizamientos inestables 70 (rango 38-95) y 86 (57-100); p=0,017), respectivamente. No se observó necrosis avascular ni condrolisis y el pinzamiento femoroacetabular fue de 19% (n=7 caderas; 6 estables y 1 inestable). Conclusiones: los resultados clínicos de calidad de vida a través de scores reportados por los pacientes (PROM) utilizados eran significativamente mejores en los deslizamientos de la epífisis femoral proximal (DEFP) inestables en comparación con los DEFP estables. La ausencia de necrosis avascular en caderas inestables y la mayor proporción de pinzamiento femoroacetabular en los deslizamientos estables, a pesar de una remodelación femoral notoria luego de fijación in situ, podría explicarnos estos hallazgos inesperados.

Summary: Introduction: the impact on the quality of life of patients with unstable and stable slipped capital femoral epiphysis is rather unknown. The study aims to learn about therapeutic outcomes in a quality of life score and the complications of the affected population in an orthopedics reference center. Method: this cohort study included 28 children treated at the Pereira Rossell Hospital Center between 2010 and 2016. Patients were assessed both clinically and with x-rays, with a 2-year minimum postoperative follow-up. The "International Hip Outcome Tool" (iHOT-12) questionnaire was used to measure the results reported by patients. Avascular necrosis, chondrolysis and femoroacetabular impingement were the complications evaluated by the study. Results: the study identified 38 hips treated for slipped capital femoral epiphysis. 28 of them were classified as stable (74%) and 10 as unstable (26%). In-situ fixation was the most frequently used surgical treatment. Upon completion of follow-up, 27 patients were assessed and the iHOT12 showed a significant difference between stable and unstable slips (70 (range 38-95) and 86 (57-100); P=0,017) respectively. No avascular necrosis or chondrolysis were observed and femoroacetabular impingement was 19% (n=7 hips; 6 stable and 1 unstable). Conclusions: quality of life clinical results obtained by PROM were significantly better in the unstable slipping epiphysis of the proximal femur than in the stable epiphysis. Absence of avascular necrosis in unstable hips and the greater proportion of femoroacetabular impingements in stable slips despite a noticeable femoral remodeling following in-situ fixation could explain these surprising results.

Resumo: Introdução: o impacto sobre a qualidade de vida dos pacientes com deslizamentos de epífise proximal do fêmur instáveis e estáveis é pouco conhecido. O objetivo deste trabalho foi conhecer os resultados terapêuticos utilizando um indicador de qualidade de vida e as complicações da população afetada em um centro ortopédico de referência. Materiais e métodos: este estudo de coorte incluiu 28 crianças tratadas no Centro Hospitalario Pereira Rossell no período 2010-2016. Foram avaliados os aspectos clínicos e radiológicos com um seguimento pós-operatório mínimo de 2 anos. O questionário International Hip Outcome Tool (iHOT-12) foi utilizado para medir os resultados descritos pelo paciente. Foram avaliadas as complicações por necrose avascular, condrólise e pinçamento femoroacetabular. Resultados: foram identificados 38 quadris tratados por deslizamento epifisário proximal de fêmur. 28 foram classificados como estáveis (74%) e 10 como instáveis (26%). A fixação in situ foi o tratamento cirúrgico mais frequentemente utilizado. No término do seguimento 27 pacientes foram avaliados e o iHOT12 mostrou uma diferença significativa entre deslizamentos estáveis e instáveis (70 (intervalo 38-95) e 86 (57-100); P=0,017) respectivamente. Não foram observadas necrose avascular nem condrólise e o pinzamiento femoroacetabular foi de 19% (n=7 quadris; 6 estáveis e 1 instável). Conclusões: os resultados clínicos de qualidade de vida através do PROM (desfechos medidos pelo paciente) utilizado eram significativamente melhores nos DEFP instáveis comparados com os estáveis. A ausência de necrose avascular nos quadris instáveis e a maior proporção de pinçamento femoroacetabular nos deslizamentos estáveis apesar de uma remodelação femoral notória depois da fixação in situ, poderia explicar estes achados inesperados.

Diagnosis and treatment of slipped capital femoral epiphysis in children / 国际儿科学杂志

Slipped capital femoral epiphysis is a hip disease with an unclear etiology,characterized with displacement and rotation of the femoral neck relative to the femoral epiphysis.Currently,the treatment methods vary according to clinical classification,including non-surgical treatment,in situ fixation,subcapital re-alignment osteotomy,base-of-neck osteotomy and intertrochanteric osteotomy.Postoperative complications such as avascular necrosis of femoral head,instability of hip joint,and chondrolysis are common and extremely challenging to treatment,which seriously affect the quality of life in children.Therefore,it is of great significance to clarify the treatment of different types of slipped capital femoral epiphysis and to reduce complications.At present,arthroscopic adjuvant therapy is mininally invasive and effective.This article reviews the progress of treatment of the slipped capital femoral epiphysis and the reduction of complications in children.

Alpha Angle as a Predictor of Impending Contralateral Slipped Capital Femoral Epiphysis in an Asian Population

BACKGROUND: Prophylactic pinning of the uninvolved side after unilateral slipped capital femoral epiphysis (SCFE) is controversial. The alpha angle, a measurement of femoral head-neck aspherity, was proposed as a predictor of progression of contralateral SCFE with a treatment threshold of greater than 50.5°. The aim of this study was to evaluate its validity in our cohort of patients. METHODS: A retrospective review of a 10-year series of patients who presented with unilateral SCFE was conducted. Minimum follow-up duration to identify contralateral progression was 18 months. Age, sex, ethnicity, and endocrinopathies were noted. Alpha angle measurements of the unaffected hip were performed by two independent observers. The average values of measurements were used for analysis. Univariate and multivariate logistic regression analyses were performed to identify predictors of contralateral progression. A receiver operating characteristic (ROC) curve was generated. RESULTS: There were 43 patients with unilateral SCFE. Seven patients (16.3%) developed contralateral SCFE. There were 31 males (72.1%) and 12 females (27.9%). The mean duration from index surgery to contralateral fixation was 43.9 weeks (range, 16.2 to 77 weeks). The mean alpha angle was significantly higher in the patients with contralateral progression (mean, 50.7°; standard deviation [SD], 5.4°; range, 43.8° to 58.5°) than in the patients without progression (mean, 43.0°; SD, 4.2°; range, 33.0° to 52.5°; p < 0.001). The alpha angle was also identified as a statistically significant predictor of contralateral progression on multivariate analysis (p = 0.02). The intraclass correlation coefficient for interobserver reliability was moderately strong at 0.76 (95% confidence interval, 0.55 to 0.87). The area under the ROC curve was 0.88. The treatment threshold of 50.5° had a sensitivity of 0.43, specificity of 0.94, and number needed to treat (NNT) of 2.7. The ideal treatment threshold derived from the ROC curve was 49.0°, which had a sensitivity of 0.71, specificity of 0.89, and an NNT of 1.7. CONCLUSIONS: Alpha angle is a potential predictor of contralateral hip involvement in children with SCFE who may benefit from prophylactic hip fixation. Results from our series suggest a treatment threshold be 49.0°. However, given the limited sample size and moderately strong interobserver reliability, larger studies are needed to validate our findings.

Prophylactic pinning should be considered in patients at risk for slipped capital femoral epiphysis / Journal of Rural Medicine

Background: The use of prophylactic contralateral pinning for slipped capital femoral epiphysis (SCFE) remains controversial. This study evaluated the outcome of SCFE treatment and examined the use of prophylactic pinning.Methods: The study included 44 patients (33 men, 11 women; 54 hips [right, 31; left, 23]), with mean age of 12.9 (7.3–29) years, who underwent treatment between 1986 and 2017, with follow-up for more than 6 months. Patients were divided into 3 groups: group 1 had bilateral SCFE at first presentation, group 2 developed contralateral side SCFE during follow-up, and group 3 had unilateral SCFE until final follow-up. Three patients who received prophylactic pinning were excluded. Univariate and multivariate logistic analyses were performed.Results: Overall, 93% (50/54) of hips underwent positional reduction and in situ fixation and 7.4% (4/54) underwent open reduction. Mean follow-up period was 4.8 (0.5–25) years. Groups 1, 2, and 3 had 7, 3, and 31 cases, respectively. Sex, age, and follow-up period showed no significant differences among the groups. The Rohrer index was significantly higher in group 1, the affected side posterior sloping angle (PSA) was significantly higher in group 3, and the contralateral side PSA and percentage with endocrinopathy were significantly higher in group 2. In multivariate logistic analysis, age, sex, Rohrer index, affected side PSA, and endocrinopathy were significantly correlated with bilateral SCFE.Conclusion: We recommend prophylactic contralateral side pinning in patients with risk factors of obesity, high PSA before slipping, and endocrinopathy. Careful observation until growth plate closure is required in patients without risk factors.

Caso Clínico: Luxación Controlada de Cadera. Epifisiólisis de Cabeza Femoral / Case Report: Controlled Hip Dislocation. Slipped Capital Femoral Epiphysis

INTRODUCCIÓN: La epifisiólisis de la cabeza femoral es el desplazamiento de la epífisis con respecto a la metáfisis, en dirección anterosuperior; su etiología es desconocida, frecuente en adolescentes, periodo peripuberal, y con índice de masa corporal elevado, edad promedio entre 12 y 18 años. Su incidencia es variable, 0.2 (Japón) a 10 (Estados Unidos) por 100 000 habitantes. Se caracteriza por dolor progresivo en cadera, con irradiación a la ingle o rodilla, se asocia a cojera; con la detección precoz se puede instaurar un tratamiento adecuado, el más aceptado es la fijación in situ con tornillos centrales. CASO CLÍNICO: Paciente de sexo femenino 14 años de edad sin antecedentes patológicos, acudió al servicio de ortopedia infantil por presentar dolor lancinante crónico de cadera derecha de nueve meses de evolución que aumenta con la deambulación, diagnosticada por clínica y exámenes complementarios de imagen de epifisiólisis de cabeza femoral. Se realizó luxación quirúrgica de la cadera y reducción abierta anatómica con colocación de tornillos esponjosos. EVOLUCIÓN: Al tercer día de la cirugía, se decide alta hospitalaria; deambulación con muletas y sin apoyo durante un mes posquirúrgico. La osteosíntesis permaneció durante un año con controles mensuales y fisioterapia correspondiente; se ha evidenciado evolución favorable; arcos de movilidad de cadera conservados, deambulación normal, sin complicaciones. CONCLUSIÓN: El tratamiento inicial de un paciente con epifisiólisis de cabeza femoral estable depende del tiempo de evolución y se realiza fijando con tornillos o agujas mediante la luxación anatómica de la cadera y osteoplastia de remodelación del cuello femoral. La mayoría de los pacientes no desarrollan necrosis ni condrolisis y los resultados a largo plazo con la fijación in situ suelen ser excelentes, a diferencia de los pacientes con diagnóstico tardío.

BACKGROUND: The epiphysiolysis of the femoral head is the displacement of the epiphysis with respect to the metaphysis, in anterosuperior direction; it is etiology is unknown, frequent in adolescents, peripubertal period, and with high body mass index, average age between 12 and 18 years. It is incidence is variable, 0.2 (Japan) to 10 (United States) per 100 000 inhabitants. It is characterized by progressive pain in the hip, with irradiation to the groin or knee, is associated with lameness; with the early detection, an adequate treatment can be established, the most accepted one is the in situ fixation with central screws. CASE REPORT: A 14-year-old female patient with no pathological history attended the Children's Orthopedic Service due to the chronic lancinating pain of the right hip, which increases with walking, it is diagnosed by clinical examination and complementary exams of femoral head epiphysiolysis. Surgical dislocation of the hip and anatomical open reduction with placement of spongy screws was performed. EVOLUTION: On the third day of surgery, hospital discharge is decided; walking with crutches and without support during a postoperative month. The osteosynthesis remained for a year with monthly controls and corresponding physiotherapy; it has been evidenced favorable evolution; hip mobility arches preserved, normal ambulation, without complications CONCLUSIONS: The initial treatment of a patient with epiphysiolysis of stable femoral head depends on the evolution time and is done by fixing with screws or needles with of anatomical dislocation of the hip and osteoplasty of femoral neck remodeling. Most patients do not develop necrosis or chondro- lysis and long-term results with in situ fixation are usually excellent, unlike patients with late diagnosis.

Oblique Percutaneous In-Situ Cannulated Screw Fixation Of Stable Slipped Capital Femoral Epiphysis- Our Surgical Experience

Introduction: The percutaneous in-situ pinning perpendicular to the physis has been described as the standard technique for fixing mild to moderate stable Slipped capital femoral epiphysis. In this study we are going to discuss about our results using an alternative anterolateral oblique pinning technique for SCFE. Methods: We treated 10 patients by this technique from June 2015 to May 2017. The average age of the patients was 12 years with the range between 10 to 15 years. Only mild to moderate slips as measured by Southwick angle of less than 60 degrees in frog leg lateral view were included in this study. Results: None of the patients developed complications like screw penetration, AVN, chondrolysis, slip progression or breakage of screw. There was restriction of terminal 10 degrees abduction in 6 patients and obligatory external rotation on hip flexion in 3 patients. Conclusion: To conclude anterolaterally based insitu oblique screw fixation is a relatively easier technique providing better stability without risk of complications.

A comparison study of radiographic and computerized tomographic angles in slipped capital femoral epiphysis / Estudo comparativo dos ângulos radiográficos e tomográficos na epifisiolistese do fêmur proximal

ABSTRACT Objective: To compare proximal femur radiologic angles in patients with slipped capital femoral epiphysis and to analyze whether computerized tomography may modify the treatment. Methods: Cross-sectional study comparing and analyzing the similarity between angles and radiologic classification of interest in slipped capital femoral epiphysis (SCFE) . Results: It was observed that the therapeutic management in slipped capital femoral epiphysis might be modified depending on the classification and radiologic acquisition method adopted. Conclusion: Multiplanar assessment of proximal femoral deformity in patients with slipped capital femoral epiphysis is a viable option, with the potential to modify the disease classification and, consequently, the therapeutic management.

RESUMO Objetivo: Comparar ângulos radiológicos do fêmur proximal em pacientes com escorregamento proximal da cabeça do fêmur (EPCF) e analisar se a avaliação por tomografia computadorizada pode modificar a conduta. Método: Estudo transversal que comparou e analisou a concordância entre ângulos e classificações radiológicas de interesse no escorregamento proximal da cabeça do fêmur (EPCF). Resultado: Observou-se que a conduta terapêutica na EPCF pode ser modificada a depender da classificação adotada e do método de aquisição de imagens radiológicas. Conclusão: A avaliação multiplanar da deformidade do fêmur proximal em pacientes com escorregamento proximal da cabeça do fêmur é uma opção viável e com potencial de modificar a classificação da doença nos pacientes e, por conseguinte, a modalidade terapêutica.

Measurement of reference value of maximum epiphyseal width lateral to Klein's line and modification of Klein's line in 2 800 hips of 1 400 normal children / 国际儿科学杂志

Objective To investigate the maximum epiphyseal width lateral to Klein' s line (MEWLKL) and modification of Klein's Line (namely difference value of bilateral MEWLKL) on hip plain radiographs of normal children, and to investigate the relationship between MEWLKL and modification of Klein's Line and gender and body side, respectively.Methods Anteroposterior (AP) view pelvic plain radiographs of fourteen thousand eight hundred and thirty-seven cases aged from zero to fourteen years old in Shengjing Hospital of China Medical University from 2005 January to 2014 December were reviewed.Seven thousand one hundred and forty-seven normal AP pelvic plain radiographs were included in the present study.Fourteen groups based on the age from one years old to fourteen years old were divided.One hundred cases in each age group, including fifty males and fifty females, were randomly selected.Fourteen hundred AP view pelvic plain radiographs including twenty eight hundred hips were measured.The reference value of MEWLKL and modification of Klein's line were measured using AutoCAD2007 software.the Normal distribution test were performed using Excel and SPSS19.0 software.The relationship curve between MEWLKL and modification of Klein's Line and age were drawed.The intra-group difference between MEWLKL and gender and body side were performed using t-test in normal children.The inter-group difference between modification of Klein's line and average MEWLKL were performed using one-way analysis of variance in normal children.Results The reference value of MEWLKL and modification of Klein's Line were both normal distribution.Average reference value of MEWLKL were (5.20 ± 1.92) mm, (5.04 ± 1.88) mm in male, and (5.36 ± 1.94) mm in female (P =0.000), (5.06 ± 1.87) mm on the left side, and (5.33 ± 1.96) mm on the right side (P =0.000).The curve of reference value of MEWLKL in fourteen general groups were similar to those of fourteen male groups and fourteen female groups, and reference value of MEWLKL increased with age.It was in the trough at the age of five [general groups: (3.77 ± 1.00) mm;male groups: (3.53 ± 1.00) mm;female groups: (4.01 ±0.94) mm], and it was at the peak at the age of thirteen [general groups: (7.49 ± 1.43)mm;female group: (7.84 ± 1.42) mm].It was at the peak at the age of fourteen in male groups, and the value was (7.24 ± 1.46) mm.The reference value of MEWLKL in fourteen groups and in female groups both fell slightly after the age of fourteen.There were second trough, (6.44 ± 1.86) mm to (6.38 ± 1.15) mm,at age eleven to twelve in female groups.The curves of reference value of MEWLKL on bilateral sides was very similar, and they increased with age.They were in the trough at the age of five [(3.54 ± 0.84) mm in left side and (4.00 ± 1.10) mm in right side], and they were at the peak at the age of thirteen [(7.25 ± 1.57)mm in left side and (7.72 ± 1.24) mm in right side].The curves both fell slightly after the age of fourteen.The general reference value of modification of Klein's line was (0.93 ±0.82) mm.The average value of each age group waved in the level of 1.0 mm.Statistical significance were found in comparison of two intergroups, age eight versus age seven (P =0.011), and age eleven versus age ten (P =0.04).The maximum value of modification of Klein's line in four of fourteen groups were greater than 2.0 mm, including 2.02 mm in age ten, 2.05 mm in age eleven, 2.3 mm in age thirteen, and 2.17 mm in age fourteen, respectively.Conclusion The value of modification of Klein's line in normal children can be more than 2.0 mm, and the average value waved in the level of 1.0 mm.It is not reliable to determine slipped capital femoral epiphysis using modification of Klein's line.

Case series – Slipped capital femoral epiphysis in three members of same family as an unusual presentation.

Slipped capital femoral epiphysis is a disorder of the hip that affects children in late childhood and early adolescence, characterized by medial and posterior displacement of the proximal femoral epiphysis on the metaphysis. Although the diagnosis and treatment of slipped capital femoral epiphysis have been well described, the search for its cause and a method of early identification continues. We have reported here an interesting case of a bilateral slipped capital femoral epiphysis as an unusual presentation in one family -father and two siblings, had no record of any hormonal imbalances or endocrine abnormalities; had good nutrition; and presented with atypical characteristics of slipped capital femoral epiphysis. epiphysis have been well described, the search for its cause and a method of early identification continues. We have reported here an interesting case of a bilateral slipped capital femoral epiphysis as an unusual presentation in one family-father and two siblings, had no record of any hormonal imbalances or endocrine abnormalities; had good nutrition; and presented with atypical characteristics of slipped capital femoral epiphysis.

Panhypopituitarism due to craniopharyngioma with bilateral slipped capital femoral epiphysis / 영남의대학술지

Craniopharyngiomas are rare primary intracranial tumors. Despite their benign histological appearance, they are often associated with an unfavorable prognosis. The typical manifestations upon diagnosis are headache, visual impairment, polyuria/polydypsia, growth retardation, disturbance of pubertal development, and significant weight gain. The treatment options include radical surgery or radiotherapy, or a combination of these modalities. Slipped capital femoral epiphysis (SCFE) is the most common adolescent hip disorder. SCFE occurs when the capital femoral epiphysis displaces posteriorly on the femoral neck at the level of the physis. The etiology of SCFE is thought to be multifactorial and may include obesity, growth surges, and less common endocrine disorders. The related endocrine disorders include hypothyroidism, growth hormone supplementation, hypogonadism, and panhypopituitarism. Reported herein is a case of panhypopituitarism caused by craniopharyngioma combined with SCFE.

Remodelación y deterioro en epifisiolisis de cadera después de la fijación in situ. Resultados preliminares / Slipped capital femoral epiphysis remodeling and deterioration after in situ fixation. Preliminary results

Introducción: Una vez detenida la progresion del deslizamiento, las caderas experimentan un fenomeno complejo de remodelacion. Mientras tanto, el choque femoro-acetabular provoca daño irreversible del cartilago articular. El proposito del trabajo es determinar si la remodelacion es suficiente para impedir el deterioro articular en el corto plazo. Materiales y Métodos: Se diseñó un estudio de cohorte retrospectivo de pacientes con deslizamientos moderados y graves, que recibieron como tratamiento la fijacion in situ. Se evaluó la capacidad de remodelación con el ángulo de Southwick y el ángulo alfa. El deterioro funcional se evaluó con el puntaje de Harris y el radiologico, con la escala de Tonnis. Seguimiento minimo: 4 años. Resultados: Diecisiete pacientes, mediana de seguimiento: 63 meses (Ri 55-81). El angulo de Southwick prequirurgico 57o (Ri 50-72) versus el posquirurgico 48o (Ri 45-74) disminuyó significativamente (p 0,023). lo mismo ocurrio con el angulo alfa complementario. El deterioro radiologico evaluado con la escala de Tonnis fue estadisticamente significativo (p 0,012). los resultados funcionales, cuantificados con el puntaje de Harris no mostraron diferencias estadisticamente significativas (p 0,49). Conclusiones: En esta serie, las epifisiolisis moderadas y graves fijadas in situ presentaron deterioro radiologico en 63 meses de seguimiento promedio. Sin embargo, la funcionalidad no se deterioro con la misma rapidez. Nivel de Evidencia: IV.

Background: After stopping the slip progression, hips undergo a remodeling complex phenomenon. Meanwhile femoro-acetabular shock causes irreversible joint cartilage damage. The purpose of the study is to determine if remodeling is sufficient to prevent joint deterioration in the short-term. Methods: a retrospective cohort study of patients with moderate and severe landslides, treated with in situ fixation was designed. Remodeling capacity was evaluated with Southwick angle and alpha angle. Functional and radiological impairment was evaluated with the Hip Harris Score and Tonnis scale, respectively. Minimum follow-up: 4 years. Results: Seventeen patients, median follow-up 63 months (iR 55-81). The pre-surgical Southwick angle 57o (iR 50-72) versus the postoperative one 48o (iR 45-74) significantly decreased (p 0.023). The same happened with the complementary angle alpha. The radiological deterioration was statistically significant (p 0.012). Functional results showed no statistically significant differences (p 0.49). Conclusions: in this series, moderate and severe slipped capital femoral epiphysis fixed in situ showed radiological deterioration during a 63-month follow-up. However, the functionality is not deteriorating as quickly. Level of Evidence: IV.

Epifisiolistesis capital femoral: consecuencias del diagnóstico tardío: reporte de un caso y revisión de la literatura / Slipped capital femoral epiphysis: consequences of late diagnosis: a case report and literature review

La epifisiolistesis capital femoral es la pérdida de la relación anatómica entre la epífisis y la metáfisis del extremo proximal del fémur, producida por un desplazamiento a través del cartílago de crecimiento. Es la patología de cadera más frecuente de la adolescencia y su origen es multifactorial. El diagnóstico es clínico y se confirma radiológicamente. Es una urgencia traumatológica y su tratamiento debe ser precoz y quirúrgico. Es una lesión que requiere un alto índice de sospecha por parte del médico examinador y no realizar su diagnóstico a tiempo puede tener consecuencias devastadoras. Presentamos el caso de un adolescente, femenino de 12 años, quien sufrió una epifisiolistesis capital femoral, con 6 meses de evolución, no diagnosticada en su fase aguda; mostramos su evolución desde el inicio y su resolución mediante osteotomía de Dunn. El diagnóstico oportuno es la primera y única forma de evitar complicaciones a mediano y largo plazo(AU)

The slipped capital femoral epiphysis syndrome is the loss of the anatomical relationship between the epiphysis and metaphysis of the proximal end of the femoral head caused by a movement across the growth cartilage. Hip is the most common pathology of adolescence and its origin is multifactorial. Diagnosis is clinical and confirmed radiologically. It's an emergency trauma and its treatment should be early and surgical. It is an injury that requires a high index of suspicion by the examining physician and diagnose it early can have devastating consequences. We report the case of a female teenager aged 12, who presented a capital femoral epiphyseal, 6 months of evolution, which was not diagnosed in its acute phase. Introducing its evolution from the beginning and its resolution by Dunn osteotomy. Early diagnosis is the first and only way to avoid complications in the medium and long term(AU)