The role of trauma mechanism, fracture pattern and fixation technique on clinical outcomes and epiphyseal growth arrest in the surgical treatment of distal tibial epiphysiolysis.

BACKGROUND: Distal tibial epiphyseal fractures damage to epiphyseal growth plate. Epiphyseal growth arrest (EGA), reflex sympathetic dystrophy and ankle joint stiffness may also occur after distal tibial epiphyseal injury. This study aims to evaluate the role of trauma mechanism, fracture pattern and fixation technique on clinical outcomes and EGA in the surgically treated distal tibial epiphyseal fractures. METHODS: Twenty seven patients who underwent surgery for distal tibial epiphyseal fracture between the 2011 and 2017 were evaluated retrospectively. The effects of trauma mechanism, fixation technique, preoperative duration, fracture patterns on the clinical results and EGA were examined. AOFAS (The American Orthopedic Foot and Ankle Score) and MOXFQ (The Manchester-Oxford Foot Questionaire) were used for clinical evaluation. RESULTS: Twenty seven patients (17 male and 10 female) were included in this study. The most important complication of epiphyseal injury was the growth pause in eight patients. No statistically significant difference was observed concerning clinical scores and complications according to trauma mechanism, fixation techniques and fracture patterns (p>0.05). CONCLUSION: Regardless of the trauma mechanism, fracture pattern and the fixation material, an anatomical reduction should be obtained in distal tibial epiphyseal fractures to reduce complications and prevent the EGA.

[Osteonecrosis of the femoral head complicating prophylactic screw fixation for upper femoral epiphyolysis: case report and literature review]. / Ostéonécrose de la tête fémorale compliquant un vissage préventif d'une épiphysiolyse fémorale supérieure: cas clinique et revue de la littérature.

The therapeutic approach for the treatment of children with radiologically "normal" hip presenting with epiphysiolysis of the contralateral upper femur is controversial. We here report the case of a 12-year-old boy with osteonecrosis of radiologically "normal" and asymptomatic left femoral head prophylactically fixed due to acute femoral epiphysiolysis of the contralateral hip. Eight months after first surgery, the patient developed symptoms of avascular osteonecrosis of the femoral head. Specific criteria to be used in evaluating the most effective treatment between preventive screw or simple close monitoring exist. Despite these criteria, the risk of osteonecrosis in the "healthy" hip is not zero.

Traumatic Posterior Hip Dislocation and Epiphysiolysis in a High School Football Player with Successful Outcome at 4 Years Follow-up: A Case Report.

CASE: We describe a case of posterior hip dislocation in a 13-year-old boy after a contact football injury with attempted closed reduction resulting in complete separation of the epiphysis from the femoral neck metaphysis with associated femoral head fracture and posterior dislocation of the femoral head. Treatment was emergently performed with a greater trochanteric osteotomy, open reduction internal fixation using cannulated screws, and additional small diameter drill holes in the femoral head to promote blood flow. The patient did well postoperatively and at over 4 years follow-up had no evidence of avascular necrosis and returned to full athletics participation. CONCLUSION: Particular attention should be taken when reducing hip dislocations in the adolescent population who may be predisposed to epiphysiolysis. Preservation of periosteal soft-tissue attachments and the use of small diameter drill holes to promote femoral head blood flow may have contributed to the excellent outcome.

The unstable slipped capital femoral epiphysis: does the rate of osteonecrosis really depend on the timing of surgery and surgical technique?

The aim of this study was to investigate whether the timing of surgery and surgical technique affect the rate of osteonecrosis in unstable slipped capital femoral epiphysis (SCFE). This is a retrospective review of all unstable slips that were treated at our institution over 8.5 years with a minimum follow-up period of 12 months. Patients with stable slips were excluded from this analysis. Demographic data, time to surgery, and surgical technique were analyzed. Twenty-three unstable slips were included for study after excluding 40 stable slips. There were 17 males and six females, with an average age of 11.9 years; 13 patients had right SCFEs. The average time from diagnosis to surgery was 57.7 h. Nine (39.1%) surgeries were performed within 24 h of admission, whereas 14 (60.9%) surgeries were performed after 24 h. Minimum follow-up was 23 months. Two patients developed osteonecrosis: one underwent surgery within 24 h of admission and the other after 24 h. Both underwent in-situ screw fixation. In the group that did not develop osteonecrosis, 76.2% underwent in-situ screw fixation and 23.8% underwent manipulative reduction. The rate of developing osteonecrosis following screw fixation in unstable SCFE was unrelated to whether surgery was performed before or after 24 h of admission (P = 1.0), or whether in-situ screw fixation or manipulative reduction pre-fixation was performed (P = 0.605). The results of this small series challenge the practice of stabilizing unstable SCFEs emergently and the belief that gentle manipulative reduction pre-fixation is not recommended because it may increase the rate of osteonecrosis. Level of Evidence: Level IV Evidence.

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.

Clinical and Radiographic Outcomes at 25-30 Years of a Hip Stem Fully Coated With Hydroxylapatite.

BACKGROUND: Little is known about the survival of total hip arthroplasty implants with bioactive coatings beyond the first 20 years. The authors aimed to report survival of a tapered hip stem fully coated with hydroxylapatite (HA) at follow-up of 25-30 years. METHODS: Of the original series of 320 patients (347 hips), 12 patients (12 hips) had stem and cup revisions, 54 patients (55 hips) had cup revisions, 17 patients (17 hips) had liner exchange. A total of 207 patients (225 hips) died with stems in place and 21 patients (24 hips) could not be reached. This left a cohort of 80 patients (86 hips) with their original stem for assessment. Survival was analyzed using the Kaplan-Meier (KM) method and cumulative incidence function (CIF). RESULTS: Considering stem revision as endpoint, the revision risk calculated using the KM method was 6.3%, whereas using the CIF it was 3.7%. Considering any reoperation as endpoint, the revision risk calculated using the KM method was 41.2%, whereas using the CIF it was 25.9%. The Harris Hip Score for 77 patients (18 hips) was 81.6 ± 15.2. Standard x-rays were available for 52 hips (49 patients), and 10 (19.2%) showed radiolucencies <2 mm thick. CONCLUSION: This study is the first to report outcomes of an HA-coated stem beyond 25 years. The survival of stem compares favorably with long-term survival of the Charnley cemented stem, and with shorter-term registry studies. The stem achieved its intended purpose of total osteointegration in the long-term, although the proximolateral region remains susceptible to radiolucencies.

Slipped Capital Femoral Epiphysis: Diagnosis and Management.

Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in adolescents, occurring in 10.8 per 100,000 children. SCFE usually occurs in those eight to 15 years of age and is one of the most commonly missed diagnoses in children. SCFE is classified as stable or unstable based on the stability of the physis. It is associated with obesity, growth spurts, and (occasionally) endocrine abnormalities such as hypothyroidism, growth hormone supplementation, hypogonadism, and panhypopituitarism. Patients with SCFE usually present with limping and poorly localized pain in the hip, groin, thigh, or knee. Diagnosis is confirmed by bilateral hip radiography, which should include anteroposterior and frog-leg views in patients with stable SCFE, and anteroposterior and cross-table lateral views in unstable SCFE. The goals of treatment are to prevent slip progression and avoid complications such as avascular necrosis, chondrolysis, and femoroacetabular impingement. Stable SCFE is usually treated using in situ screw fixation. Treatment of unstable SCFE also usually involves in situ fixation, but there is controversy about timing of surgery and the value of reduction. Postoperative rehabilitation of patients with SCFE may follow a five-phase protocol.

Electrocautery technique for proximal tibial epiphysiodesis in Labrador retriever puppies: experimental study / Técnica de eletrocauterização para epifisiodese proximal da tíbia em cães filhotes da raça Labrador Retriever: estudo experimental

There are few studies about the treatment options for cranial cruciate ligament rupture in growing dogs, especially with epiphysiodesis techniques. The aim of this study was to evaluate the electrocautery technique for proximal tibial epiphysiodesis in Labrador retriever puppies. The novel electrocautery technique was compared with the screw technique regarding the efficacy for tibial plateau leveling in growing dogs. Six healthy Labrador retriever puppies were divided into two groups. The screw technique was used in one group and the electrocautery technique was used in the other group. Both proximal tibial epiphysiodesis techniques for tibial plateau leveling were effective in achieving reduced tibial plateau angle and did not cause significant joint changes. The screw technique was more invasive and caused slightly greater morbidity than the electrocautery technique. The electrocautery technique seems to be a good alternative for proximal tibial epiphysiodesis in young dogs.(AU)

São descritos poucos estudos sobre as opções de tratamento para a ruptura do ligamento cruzado cranial em cães na fase de crescimento, especialmente em relação às técnicas de epifisiodese. O objetivo deste estudo foi avaliar a técnica de eletrocauterização para epifisiodese proximal da tíbia em cães filhotes da raça Labrador Retriever. A nova técnica de eletrocauterização foi comparada com a do parafuso em relação à eficácia para nivelamento do platô tibial em cães na fase de crescimento. Seis filhotes saudáveis da raça Labrador foram selecionados e divididos aleatoriamente em dois grupos. A técnica do parafuso foi usada em um grupo, enquanto no outro foi usada a da eletrocauterização. Ambas as técnicas de epifisiodese proximal da tíbia para nivelamento do platô tibial foram eficazes na redução do ângulo do platô tibial e não causaram alterações articulares importantes. A técnica do parafuso foi considerada mais invasiva e causou morbidade um pouco mais acentuada do que a da eletrocauterização. Assim, a técnica da eletrocauterização parece ser uma boa alternativa para a epifisiodese proximal da tíbia em cães jovens.(AU)

Outcome of the unaffected contralateral hip in unilateral slipped capital femoral epiphysis: a report comparing prophylactic fixation with observation.

This was a retrospective review of 80 patients with unilateral slipped capital femoral epiphysis treated with either prophylactic fixation or observation. The unaffected hip of 44 patients (mean age 12.6 years) were subjected to simultaneous prophylactic fixation and 36 patients (mean age 13.4 years) were managed by observation. Fisher's exact test showed a significantly high incidence of sequential slip of unaffected hips in the observation group in comparison with prophylactic fixation (P=0.002). No cases had avascular necrosis or chondrolysis. Prophylactic fixation significantly reduces the incidence of sequential slip. It outweighs the minimal surgical risks compared with its benefit in the prevention of further sequential slip.

Is Assessment of Femoral Head Perfusion During Modified Dunn for Unstable Slipped Capital Femoral Epiphysis an Accurate Indicator of Osteonecrosis?

BACKGROUND: The modified Dunn procedure, which is an open subcapital realignment through a surgical dislocation approach, has gained popularity for the treatment of unstable slipped capital femoral epiphysis (SCFE). Intraoperative monitoring of the femoral head perfusion has been recommended as a method of predicting osteonecrosis; however, the accuracy of this assessment has not been well documented. QUESTIONS/PURPOSES: We asked (1) whether intraoperative assessment of femoral head perfusion would help identify hips at risk of developing osteonecrosis; (2) whether one of the four methods of assessment of femoral head perfusion is more accurate (highest area under the curve) at identifying hips at risk of osteonecrosis; and (3) whether specific clinical features would be associated with osteonecrosis occurrence after a modified Dunn procedure for unstable SCFE. METHODS: Between 2007 and 2014, we performed 29 modified Dunn procedures for unstable SCFE (16 boys, 11 girls; median age, 13 years; range, 8-17 years); two were lost to followup before 1 year. During this period, six patients with unstable SCFE were treated by other procedures. All patients undergoing modified Dunn underwent assessment of epiphyseal perfusion by the presence of active bleeding and/or by intracranial pressure (ICP) monitoring. In the initial five patients perfusion was recorded once, either before dissection of the retinacular flap or after fixation by one of the two methods. In the remaining 22 patients (81%), perfusion was systematically assessed before dissection of the retinacular flap and after fixation by both methods. Minimum followup was 1 year (median, 2.5 years; range, 1-8 years) because osteonecrosis typically develops within the first year after surgery. Patients were assessed for osteonecrosis by the presence of femoral head collapse at radiographs obtained every 3 months during the first year after surgery. Seven (26%) of the 27 patients developed osteonecrosis. Measures of diagnostic accuracy including sensitivity, specificity, and the area under the receiver operating curve (AUC) were estimated. Multiple variable logistic regression analyses were used to test whether the test options were better than random chance (AUC > 0.50) at differentiating between patients who did versus did not develop osteonecrosis. Nonparametric methods were used to test for a difference in AUC across the four methods. A secondary analysis was performed to identify risk factors associated with osteonecrosis. RESULTS: After adjusting for body mass index, which was found to be a confounding variable, assessment of femoral head perfusion with ICP monitoring before retinaculum dissection (adjusted AUC: 0.79; 95% confidence interval [CI], 0.58-0.99; p = 0.006), femoral head perfusion with ICP monitoring after definitive fixation (adjusted AUC: 0.82; 95% CI, 0.65-1.0; p < 0.001), bleeding before retinaculum dissection (adjusted AUC: 0.77; 95% CI, 0.58-0.96; p = 0.006), and bleeding after definitive fixation (adjusted AUC: 0.81; 95% CI, 0.63-0.99; p = 0.001) were found to be helpful at identifying osteonecrosis. We were not able to identify a specific test that had performed best because there was no difference (p = 0.8226) in AUC across the four methods. With the numbers available, we were unable to identify clinical factors predictive of osteonecrosis in our cohort. CONCLUSIONS: Assessments of femoral head blood perfusion by ICP monitoring or by the presence of active bleeding in combination with the patient's body mass index are effective at differentiating between patients who do versus do not develop osteonecrosis after a modified Dunn procedure for unstable SCFE. Additional research is needed to determine whether information gained from assessment of femoral head perfusion during surgery should be used to guide targeted treatment recommendations that may reduce the development of femoral head deformity secondary to osteonecrosis. LEVEL OF EVIDENCE: Level III, diagnostic study.

Análise do risco do escorregamento epifisário femoral proximal contralateral pelo escore de Oxford modificado / Analysis on the risk of contralateral proximal femoral epiphyseal slippage using the modified Oxford score

Objetivo: Determinar a aplicacão do escore de Oxford modificado em pacientes com escorre gamento epifisário femoral proximal (EEFP) no auxílio da indicacão do tratamento cirúrgico profilático dos quadris contralaterais. Métodos: Análise retrospectiva dos prontuários dos pacientes atendidos na instituicão na qual os autores trabalham. Foram selecionados aqueles com um tempo de seguimento mínimo de dois anos, atendidos de 2008 até 2011, que apresentaram EEPF unilateral. Os cri térios de exclusão foram pacientes com doenca endócrina ou metabólica, síndrome de Down e aqueles com radiografias inadequadas para determinar a pontuacão no escore de Oxford modificado. As radiografias iniciais receberam uma pontuacão que varia de 16 a 26. A aná lise estatística foi usada para determinar se a pontuacão foi preditiva do desenvolvimento futuro de deslizamento contralateral. Resultados: Dos 15 pacientes selecionados com EEFP unilateral, cinco (33,3%) evoluíram para o escorregamento contralateral. Os pacientes foram divididos em dois grupos, qua tro pacientes foram considerados de risco e desses três desenvolveram o escorregamento contralateral. No grupo sem risco havia 11 pacientes, dois evoluíram para o escorregamento contralateral. Nota-se assim uma tendência de que pacientes do grupo que desenvolveu a doenca difiram do grupo que não desenvolveu em relacão à classificacão de risco. Conclusão: Apesar de na nossa amostra a aplicacão do escore de Oxford modificado não ter sido estatisticamente significativa, notamos uma tendência para o escorregamento contra lateral nos quadris com escore baixo.

OBJECTIVE: To determine the application of the modified Oxford score among patients with proximal femoral epiphyseal slippage (PFES) as an aid to indicating prophylactic surgical treatment on the contralateral hip. METHODS: Retrospective analysis on the medical files of patients attended at the institution where the authors work. From these, patients attended between 2008 and 2011 who presented unilateral PFES and were followed up for a minimum of two years were selected. Patients were excluded if they presented endocrine disease, metabolic disease, Down syndrome or radiographs that were inadequate for determining the modified Oxford score. The initial radiographs received scores ranging from 16 to 26. Statistical analysis was used to determine whether the scoring was predictive of future development of contralateral slippage. RESULTS: Among the 15 patients with unilateral PFES that were selected, five (33.3%) evolved with contralateral slippage. The patients were divided into two groups. Four patients were considered to present risk and three of them developed contralateral slippage. In the group that was considered not to present risk, there were 11 patients and two of these evolved with contralateral slippage. Thus, there was a tendency for the patients in the group that developed the disease to differ from the group that did not develop it, in relation to the risk classification. CONCLUSION: Although application of the modified Oxford score was not statistically significant in our sample, we noted a tendency toward contralateral slippage among hips with low scores.

Digital Chondrolysis and Epiphysiolysis Associated With Snakebite: A Report of 2 Cases.

BACKGROUND: Here, we present 2 cases of the unusual sequelae of a venomous bite to the finger in children resulting in chondrolysis and physeal loss. There have been few isolated case reports documenting this phenomenon. Currently, there is no preventative treatment, and patients should be warned of this possible complication of envenomation. METHODS: Two patients with chondrolysis and physeal loss have been seen in our practice. RESULTS: Chondrolysis and epiphysiolysis occurred in 2 patients. One patient was treated with proximal interphalangeal joint fusion and one is being managed conservatively. CONCLUSION: The toxic action of snake venom may cause loss of the growth plate and chondrolysis in the pediatric hand. LEVEL OF EVIDENCE: Level IV.

Myth busters: an AOA symposium: AOA critical issues.

One of the goals of the annual American Orthopaedic Association (AOA) meeting is to address controversy, both in leadership and clinical practice. A panel of experts in their respective fields presented the background and literature behind three "myths" in orthopaedic management and made conclusions as to their validity. First, Dr. Kocher took on the myth of prophylactic pinning on the contralateral "normal" side for a patient with a slipped capital femoral epiphysis. Second, Dr. Probe evaluated the myth that all intertrochanteric fractures are best treated with intramedullary devices. Last, Dr. Foster and Dr. Silvestri tackled the myth that autograft is always the best choice for anterior cruciate ligament (ACL) reconstruction. All three of these topics are subjects of current debate. The panel's careful examination of the available data along with their expertise in the management of these problems is presented in this thought-provoking JBJS Critical Issues article.

Surgery for slipped capital femoral epiphysis in adolescents.

The treatment of slipped capital femoral epiphysis (SCFE) in adolescents remains controversial. The goal of initial treatment is to prevent further slippage of the epiphysis. In mild forms, both stable and unstable, in situ fixation is widely accepted as the reference treatment. In contrast, several techniques are available for stable moderate-to-severe SCFE. In unstable moderate-to-severe SCFE, emergent reduction with decompression and internal fixation is currently the preferred method. Selection of the surgical technique rests on an appraisal of advantages versus drawbacks. The goal of this review is to discuss the various surgical methods available for SCFE in adolescents.

Epiphyseal separation of the proximal humerus after birth trauma.

The purpose of this study was to report a new entity of epiphyseal slipping, which is a slipping of the upper humeral epiphysis in neonates due to birth trauma, and reporting the results of their management. Eight neonates presented with pseudo-paralysis with associated shoulder swelling and pain on passive movements of the upper limb; the radiographs revealed slipping of the proximal humeral epiphyses in six cases and associated shoulder dislocations in the other 2 cases. Failed attempts of closed reduction were done for all cases; they were managed through open reduction of the slipping and relocation of the glenohumeral joint when dislocated. The deltopectoral approach was used for management, and the slipping was fixed with k-wires through the skin. A full painless range of motion of the shoulder was achieved in all patients; no limb-length discrepancy or deformity was detected and no recurrent shoulder dislocation. In the last follow-up, all radiographs showed an anatomic reduction of the epiphyses, and all the epiphyseal plates were open. All cases showed normally growing well-formed epiphyses with no evidence of a vascular necrosis or collapse. A new entity of epiphyseal slipping was reported in this study; slipping of the upper humeral epiphysis in neonates due to birth trauma whether it is associated with shoulder dislocation or not is a benign injury with excellent results with open reduction.

Deslizamientos epifisarios femorales proximales >30º. Procedimiento de Dunn modificado: evaluación anatómica y funcional en una cohorte retrospectiva / Sliped capital femoral epiphysis >30º. Modified Dunn procedure: anatomical and functional evaluation in a retrospective cohort

Introducción: La deformidad residual resultante de un deslizamiento epifisario femoral proximal moderado o grave conduce a osteoartritis prematura debida al choque femoroacetabular. Los objetivos del trabajo fueron evaluar la mejoría de la anatomía del fémur proximal y evaluar la función de la cadera en pacientes con deslizamiento epifisario femoral proximal >30 grados tratados con el procedimiento de Dunn modificado, a corto plazo. Materiales y Métodos: Cohorte retrospectiva de pacientes con deslizamiento epifisario femoral proximal >30 grados, tratados con luxación controlada de cadera y el procedimiento de Dunn modificado. Se evaluaron mediciones clínicas y radiológicas preoperatorias y posoperatorias, hallazgos intraoperatorios y funcionalidad con los puntajes de Harris y de D'Aubigne-Postel. Resultados: Trece casos, mediana de edad 12 años y mediana de seguimiento 14 meses. El ángulo de deslizamiento de Southwick preoperatorio (75 grados, RI 67-85) y posoperatorio (10 grados, RI 5-17) mostró una disminución estadísticamente significativa (p <0,001). El offset radio cabeza-cuello preoperatorio (-0,13) versus el posoperatorio (0,12) obtuvo una mejoría significativa (p 0,002). El 69,2 por ciento de los pacientes presentó daño de alguna estructura intraarticular. Los puntajes promedio de funcionalidad fueron 14,6 (muy buena mejoría) y 83,4 (bueno). Complicaciones: necrosis avascular 15,3 por ciento y condrólisis 15,3 por ciento. Conclusiones: Esta técnica restaura la anatomía del fémur proximal y la funcionalidad de la cadera a corto plazo. Aunque no disponemos de resultados a largo plazo, al menos en teoría, serían buenos. Sin embargo, la luxación controlada con Dunn modificado no está exenta de complicaciones y el riesgo de necrosis avascular y condrólisis persiste. Nivel de evidencia: Estudios terapéuticos - III.

Background: The residual deformity resulting from a moderate and/or severe proximal femoral epiphysis slipping (SCFE) leads to premature osteoarthritis due to impingement. The objectives were to assess improvement in the anatomy of the proximal femur and to evaluate hip function in patients with SCFE >30° treated with the modified Dunn procedure. Methods: A retrospective cohort of patients with SCFE >30° treated with hip dislocation control and modified Dunn procedure. Preoperative and postoperative clinical and radiographic measurements, intra-operative findings and functionality using Harris and D'Aubigne & Postel scores were evaluated. Results: Thirteen cases, median age 12 years, median follow-up 14 months. Southwick slip angle showed a statistically significant decrease (preoperative: 75, IR 67-85; postoperative: 10, IR 5-17) (p <0.001). The head-neck offset radius obtained a significant improvement (preoperative -0.13; postoperative: 0.12) (p 0.002). The 69.2% of patients presented intraarticular damage. The average scores for functionality were 14.6 (excellent improvement) and 83.4 (good). Complications: avascular necrosis 15.3% and chondrolysis 15.3%. Conclusions: This technique restores the anatomy of the proximal femur and hip functionality in the short term. Although we do not have long-term results, at least in theory they would be good. However, the dislocation controlled with modified Dunn procedure is not free of complications and the risk of avascular necrosis and chondrolysis persists. Level of evidence: Therapeutic studies - III.

Persisting growth after prophylactic single-screw epiphysiodesis in upper femoral epiphysis.

BACKGROUND: Prophylactic fixation of the contralateral hip in cases of slipped upper femoral epiphysis is controversial. Therefore, using a single-cannulated screw has been widely accepted. However, differing reports exist on the occurrence of persisting growth after prophylactic epiphysiodesis. The aim of this retrospective study was to evaluate the presence of persisting growth of the upper femoral epiphysis after prophylactic fixation. METHODS: From 2006 until 2009, 11 children underwent prophylactic pinning using a single-cannulated 6.5-mm cancellous screw. Time to fusion, persisting growth, and overgrowing of the screw were measured on plain radiographs taken postoperatively and at least after the growth plate was fused. RESULTS: All patients except 1 (91%) showed a persisting growth of the epiphysis, and in 2 cases a hardware replacement was necessary. The mean increase of the femoral neck length was 8.2% (SEM 1.46%). Mean follow-up was 37 months (range, 12 to 49 mo). All patients had a Risser sign grade 0 at the time of surgery, and equal or less than grade 3, when the growth plate was fused. CONCLUSIONS: Despite previous reports that a prophylactic fixation using a single-cannulated cancellous screw is unproblematic and safe, we showed that in our series growth persistence was the rule and in some cases the physeal overgrowth necessitates a hardware replacement. Careful follow-up until fusion of the growth plate should be recommended.

Frequency of radiographic signs of slipped capital femoral epiphysiolysis sequelae in hip arthroplasty candidates for coxarthrosis.

INTRODUCTION: The rate of osteoarthritis of the hip secondary to slipped capital femoral epiphysis (SCFE) is a subject of debate, and its frequency is underestimated in particular because of subclinical forms that may not be diagnosed during childhood. HYPOTHESIS: The frequency of radiographic anomalies subsequent to SCFE in adults requiring hip arthroplasty is higher than that reported in recent studies (6% to 15%). MATERIALS AND METHODS: A prospective single-center epidemiological radiography study was performed by one observer. Hip X-rays of patients who were being treated by arthroplasty for advanced hip osteoarthritis between January 2010 and May 2012 were analyzed. The etiology of osteoarthritis was classified in each patient according to the data obtained (primary, SCFE, dysplasia, protrusio acetabuli, other). The lateral view head-neck index (LVHNI) was used to quantify posterior translation of the femoral head, and identify SCFE sequelae. RESULTS: One hundred and eighty-six hips were included. Osteoarthritis was considered primary in 51 patients (27.4%), secondary to dysplasia in 42 (22.5%), protrusio acetabuli in 38 (20.5%) or another disease in nine (4.9%) while 46 hips (24.7%) presented a radiographic image suggesting SCFE past history. SCFE type deformities were the primary etiology of osteoarthritis in patients less than 60years old (30/84 or 35.7%). The mean age of patients in the SCFE group was 56.2years old (26-80) compared to 66 (54-91) for the primary osteoarthritis group (P<0.0001). The mean LVHNI was 13% (9-24%) in the SFCE group, the mean body mass index was 27.1kg/m(2) (±3.5; 18.2-35.4) in the SFCE group and the male to female ratio was 7.3/1. CONCLUSION: Our study identified a population with a morphological SCFE type anomaly of the coxofemoral joint (LVHNI>9%), which results in the development of earlier osteoarthritis than that found in the rest of the population. SCFE is more common than reported in the literature because it is the first etiology of osteoarthritis of the hip in subjects less than 60years old. LEVEL OF EVIDENCE: Level III. Diagnostic prospective study with a control group.

The modified Dunn procedure for unstable slipped capital femoral epiphysis: a multicenter perspective.

BACKGROUND: The modified Dunn procedure has rapidly gained popularity as a treatment for unstable slipped capital femoral epiphysis (SCFE), but limited data exist regarding its safety and efficacy. The purpose of this study was to present results and complications following this procedure in a large multicenter series. METHODS: We reviewed the outcomes of all patients who had been treated with the modified Dunn procedure by five surgeons from separate tertiary-care institutions. All slipped capital femoral epiphyses were defined as unstable according to the Loder criteria. Patients with less than one year of follow-up and those with an underlying endocrinopathy or syndrome were excluded. All surgical procedures were performed by pediatric orthopaedic surgeons who had specific training in the modified Dunn procedure. Operative reports, outpatient records, and follow-up radiographs were used to determine the demographic information, type of fixation, final slip angle, presence of osteonecrosis, and any additional complications. Standardized surveys were administered to determine the pain level (0 to 10 scale), satisfaction (0 to 100 scale), function (modified Harris hip score, 0 to 91 scale), and activity level (UCLA [University of California Los Angeles] activity score, 0 to 10 scale) at time of the most recent follow-up. RESULTS: Twenty-seven patients (twenty-seven hips) with a mean of 22.3 months (range, twelve to forty-eight months) of follow-up met the inclusion criteria. Four patients (15%) had broken implants at three to eighteen weeks after surgery and required revision fixation. Seven patients (26%) developed osteonecrosis at a mean of 21.4 weeks (range, ten to thirty-nine weeks), with each surgeon having at least one case of osteonecrosis. The mean slip angle at the time of the most recent follow-up was 6° (95% confidence interval, 2° to 11°). Patients who did not develop osteonecrosis had significantly better clinical results compared with those who developed osteonecrosis, as demonstrated by a lower mean pain score (0.3 compared with 3.1, p = 0.002), higher level of satisfaction (97.1 compared with 65.8, p = 0.001), higher modified Harris hip score (88.0 compared with 60.0, p = 0.001), and higher UCLA activity score (9.3 compared with 5.9, p = 0.031). CONCLUSIONS: This largest reported series of unstable slipped capital femoral epiphyses treated with the modified Dunn procedure demonstrated that the procedure is capable of restoring anatomy and preserving function after a slip but that implant complications and osteonecrosis can and do occur postoperatively.