Is Subcapital Realignment for Slipped Capital Femoral Epiphysis a Reproducible Technique? Midterm Results.

BACKGROUND: The modified Dunn procedure, which is based on the development of an extended retinacular flap containing the blood supply for the femoral head, allows anatomic reestablishment in patients with moderate to severe slipped capital femoral epiphysis (SCFE). Some controversy exists regarding the short-term to midterm risk of avascular necrosis (AVN) and other complications resulting from the surgical technique. QUESTIONS/PURPOSES: (1) What percentage of patients treated with an extended retinacular flap during the modified Dunn procedure for SCFE with a moderate (slip angle from 30° to 60°) or severe slip (slip angle equal or greater than 60°) develop symptomatic AVN, and what percentage underwent further surgery or had other complications? (2) What femoral head-neck alignment and position parameters relative to the greater trochanter are achieved after surgery? (3) Can we identify radiographic signs of osteoarthritis at a minimum of 4 years after surgery? METHODS: Between January 2006 and December 2018, we treated 61 patients for SCFE. During this time, we generally used the modified Dunn procedure when the slip angle was ≥ 30°. Based on this indication, the modified Dunn procedure was performed in 37 patients (41 hips) during that time period, and those patients were potentially eligible for this retrospective study. Because bilateral hips in the same patient are not statistically independent, for our analyses, we analyzed only the hip with the longer follow-up time. Of those who remained, 11% (4) were lost before the minimum study follow-up of 48 months or had incomplete datasets, leaving 89% (33) for analysis here at a median follow-up of 80 months (range 49 to 208 months). Periacetabular osteotomy or subtrochanteric rotational femoral osteotomy was added under the same anaesthesia time in 33% (11 patients). We added periacetabular osteotomy in 24% (8) when intraoperative anterior instability was present in external rotation. A femoral rotational osteotomy was added in 9% (3) when posterior instability was present in flexion and internal rotation. The mean ± standard deviation age at the time of surgery was 13 ± 1 years, and 33% (11 of 33) of patients were female. The mean slip angle was 51° ± 16º, and 15% (5) of hips had unstable slips, defined as an inability to walk with or without crutches. We documented chronic presentations in 82% (27) of patients, acute and chronic in 12% (4), and acute in 6% (2). The rate of symptomatic AVN was determined by reviewing all radiographs obtained at the latest follow-up interval. Further surgery and other complications were assessed through an electronic medical record review. Radiographic morphologic parameters were measured before surgery and at a minimum follow-up of 4 years by two senior orthopaedic surgeons. Radiographs obtained at the latest follow-up visit were also screened for signs of osteoarthritis by the same surgeons. RESULTS: At the latest follow-up, 3% (1 patient) of patients developed symptomatic AVN and underwent further surgery and 3% (1) underwent revision surgery for screw breakage after a high-energy fall. Postoperatively, the alpha angle was restored to 39º ± 6º, the anterior head-neck offset was restored to 8 ± 3 mm, the neck-shaft angle was 136º ± 6º, and the presence of a positive Klein line decreased from 64% (21 hips) to 0% (0 hips). No patients showed radiographic signs of osteoarthritis at the minimum follow-up of 4 years. CONCLUSION: In this series, the modified Dunn procedure in moderate and severe slips was a reproducible procedure, and few patients developed symptomatic AVN or experienced other complications. Hip morphology was restored, but a longer follow-up duration and a detailed analysis of the results from other centers is warranted to assess the possible long-term risk of progression to AVN or osteoarthritis. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Femoral neck osteotomy in skeletally mature patients: surgical technique and midterm results.

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.

Femoroacetabular Impingement: What the Surgeon Wants to Know.

Femoroacetabular impingement (FAI) is increasingly recognized as a risk factor for early hip degeneration in young active patients. The diagnosis depends on clinical examination and proper imaging that should be able to identify abnormal and sometimes subtle morphological changes. Labral tears and cartilage lesions rarely occur without underlying bone abnormalities. Surgical approaches to treat FAI are increasing significantly worldwide, even without a clearly defined consensus of what should be accepted as the standard imaging diagnosis for FAI morphology.Hip abnormalities encompass many variations related to the shape, size, and spatial orientation of both sides of the joint and can be difficult to characterize if adequate imaging is not available.This article presents a comprehensive review about the information orthopaedic surgeons need to know from radiologists to plan the most rational approach to a painful hip resulting from a mechanical abnormality.

[Atypical femoral fractures and bisphosphonates treatment: is it a risk factor?]. / Fracturas Femorais Atípicas e o Tratamento com Bifosfonatos: É um Factor de Risco?

INTRODUCTION: Bisphosphonates are effective in preventing osteoporotic fracture, however atypical femoral fractures with a well-defined radiological pattern have been described in association with prolonged treatment with bisphosphonates. Our objectives in this study were to characterize patients ≥ 65 years old with femoral fractures (subtrochanteric/diaphyseal) considered typical and atypical and the relationship between the occurrence of atypical fractures and bisphosphonate use. MATERIAL AND METHODS: We conducted a case-control study with patients admitted in our hospital with subtrochanteric or diaphyseal femur fracture in a period of five and a half years. After applying the exclusion criteria, the 92 fractures (91 patients) were classified as typical or atypical. The determination of prior bisphosphonate treatment was obtained through consultation of the individual medical history. RESULTS: We found 11 atypical fractures (10 patients) and 81 typical fractures (81 patients). The median age of both groups was statistically different (72 years - atypical vs. 80 years - typical, p < 0.01). The reason for the use of bisphosphonates was 0.60 in atypical fractures and 0.01 in typical, and an odds ratio of 101.1 was obtained (p < 0.01). DISCUSSION: Our results are supported and are in agreement with published studies relating to the occurrence of atypical femoral fractures associated with treatment with bisphosphonates. CONCLUSION: Despite the small number of cases it was possible to demonstrate a statistically significant relation between atypical femoral fractures and treatment with bisphosphonates. One should note that these atypical fractures occurred in patients significantly younger than patients with typical fractures.

IntroduçÉo: Os bifosfonatos têm eficácia comprovada na prevençÉo das fracturas osteoporóticas. Contudo, têm sido descritas fracturas femorais atípicas associadas à toma prolongada de bifosfonatos com um padrÉo radiológico bem definido. Os objectivos no nosso estudo foram caracterizar os doentes de idade ≥ 65 anos com fracturas femorais (subtrocantéricas/diafisárias) consideradas típicas e atípicas e avaliar a relaçÉo entre a ocorrência das fracturas atípicas e o uso de bifosfonatos.Material e Métodos: Realizámos um estudo caso-controlo com os doentes admitidos no nosso Hospital por fractura subtrocantérica ou diafisária do fémur, num período de cinco anos e meio. Após aplicaçÉo dos critérios de exclusÉo, as 92 fracturas (91 doentes) foram classificadas como atípicas ou típicas. A determinaçÉo do tratamento prévio com bifosfonatos foi obtida através do historial clínico dos doentes.Resultados: Foram encontradas 11 fracturas atípicas (10 doentes) e 81 fracturas típicas (81 doentes). A idade mediana entre os dois grupos foi estatisticamente diferente (72 anos - atípicas vs 80 anos - típicas, p < 0,01). A razÉo do uso de bifosfonatos foi de 0,60 nas fracturas atípicas e de 0,01 nas típicas, traduzindo um odds ratio de 101,1 (p < 0,01).DiscussÉo: Na generalidade, os nossos resultados sÉo apoiados e estÉo de acordo com os estudos publicados referentes à ocorrência de fracturas femorais atípicas associadas à toma de bifosfonatos.ConclusÉo: Apesar do pequeno número de casos foi possível demonstrar a relaçÉo, estatisticamente, significativa entre as fracturas femorais atípicas e a toma de bifosfonatos. De notar que estas fracturas atípicas ocorreram em doentes, significativamente, mais jovens do que os doentes com fracturas típicas.