Modified Dunn Technique for Unstable Slipped Capital Femoral Epiphysis: A Midterm Single Center Experience.

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.

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%.

Conventional versus locked plates for hip dislocation in cerebral palsy: a matched cohort analysis.

PURPOSE: Bone quality of non-ambulatory patients with cerebral palsy (CP) is a matter of concern for proximal femoral varus derotational osteotomies (VDRO). Locking plates (LCP) have been designed to compensate this biological downfall. Little data exist comparing the LCP with the conventional femoral blade plate. METHODS: We retrospectively studied 32 patients submitted to VDRO (40 hips), operated with blade plates or LCP. Groups were matched, and the minimal follow-up was 36 months. Clinical (age at surgery, sex, GMFCS class, CP patterns) and radiological characteristics (neck shaft angle [NSA], acetabular index [AI], Reimers migration index [MP] and time until bone healing), as well as postoperative complications and the cost of treatment, were evaluated. RESULTS: Preoperative clinical characteristics and radiographic measurements were comparable, except for a higher AI in the BP group (p < 0.01). Mean follow-up was longer in the LCP group (57.35 vs 34.6 months). Mean NSA, AI and MP had comparable correction with surgery (p < 0.01). At final follow-up, dislocation recurrence speed was higher in BP group although not statistically significant (0.56% vs 0.35%/month; p = 0.29). The complication rate was similar in both groups (p > 0.05). Finally, the cost of the treatment was 62% higher in the LCP group (p = 0.01). CONCLUSION: Our cohorts showed LCP or BP equivalence clinically and radiographically in mid-term follow-up, with the former increasing the cost of treatment by a mean of 62%. This may raise a question on the real necessity of locked implants for these operations. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

Acetabular retroversion is prevalent and proportional to the severity of slipped upper femoral epiphysis.

AIMS: Slipped upper femoral epiphysis (SUFE) has well documented biochemical and mechanical risk factors. Femoral and acetabular morphologies seem to be equally important. Acetabular retroversion has a low prevalence in asymptomatic adults. Hips with dysplasia, osteoarthritis, and Perthes' disease, however, have higher rates, ranging from 18% to 48%. The aim of our study was to assess the prevalence of acetabular retroversion in patients presenting with SUFE using both validated radiological signs and tomographical measurements. METHODS: A retrospective review of all SUFE surgical cases presenting to the Royal Children's Hospital, Melbourne, Australia, from 2012 to 2019 were evaluated. Preoperative plain radiographs were assessed for slip angle, validated radiological signs of retroversion, and standardized postoperative CT scans were used to assess cranial and mid-acetabular version. RESULTS: In all, 116 SUFEs presented in 107 patients who underwent surgical intervention; 47 (52%) were male, with a mean age of 12.7 years (7.5 to 16.6). Complete radiological data was available for 91 patients (99 hips) with adequate axial CT imaging of both hips. Overall, 82 patients (82%) underwent pinning in situ (PIS), with subcapital realignment surgery (SRS) performed in 17 patients (18%) (slip angles > 75°). Contralateral prophylactic PIS was performed in 72 patients (87%). On the slip side, 62 patients (68%) had one or more radiological sign of retroversion. Tomographical acetabular retroversion was more pronounced cranially than caudally of the acetabulum on both the affected side and the contralateral side (p < 0.001) as expected in the normal population. Increasing severity of the slip was found to be directly proportional to the degree of reduction in cranial and central acetabular version (p < 0.05) in the SUFE hips. CONCLUSION: Acetabular retroversion is more prevalent in patients with SUFE than previously reported, and have been shown be correlated to the severity of the slip presentation. The presence of radiological signs of acetabular retroversion could be used to justify prophylactic contralateral pinning. Cite this article: Bone Jt Open 2022;3(2):158-164.

The use of pediatric locked plates in the paralytic hip: preliminary results of 61 cases / O uso de placas bloqueadas pediátricas no quadril paralítico: resultados preliminares de 61 casos

ABSTRACT Objective: To evaluate the clinical and radiologic results of proximal femoral varus derotational and shortening osteotomy (OVRF) (Port., doesn't match name) with the use of a locked plate in patients with cerebral palsy, classified by the gross motor functional classification system as class IV or V. Methods: A retrospective study of 42 patients (61 hips) with cereFbral palsy, gross motor functional classification system class IV or V, submitted to OVRF. The minimal follow up was 24 months. This study evaluated clinical (age at surgery, gender, Gross Motor Functional Classification System class, anatomical cerebral palsy classification, and motor pattern), pre- and post-operative radiological (neck shaft angle, acetabular index, Reimers migration index and time until bone healing) characteristics, as well as post-operative complications. Results: Mean pre-operative cervicodiaphyseal angle, acetabular index, and Reimers migration index were respectively 121.6°, 22.7°, and 65.4% in uncomplicated cases, and 154.7°, 20.4°, and 81.1% in complicated ones. All parameters were statistically significant difference between pre- and postoperative values (p < 0.05). The patients with postoperative complications had a greater cervicodiaphyseal angle and Reimers migration index (p < 0.0001). There were no differences in clinical characteristics, time of immobilization, or bone healing. Fourteen patients had postoperative complications (33.3%), but only six required surgical treatment. Conclusion: The locked plate is a safe resource, with low complication rates and reproducible technique for OVRF in the cerebral palsy population classified as gross motor functional classification system IV and V. Greater cervicodiaphyseal angles and Reimers migration index are associated with greater chances of postoperative complications, as well as gross motor functional classification system V classification.

RESUMO Objetivo: Avaliar os resultados clínicos e radiológicos da osteotomia varizante, de rotação e encurtamento da extremidade proximal do fêmur (OVRF) com uso de placa bloqueada em pacientes com paralisia cerebral classificados pela escala Gross Motor Functional Classification System como IV e V. Métodos: Estudo retrospectivo de 42 pacientes (61 quadris) com paralisia cerebral, Gross Motor Functional Classification System IV e V, submetidos a OVRF. O seguimento mínimo pós-operatório foi de 24 meses. Foram avaliadas as características clínicas (idade na data da cirurgia, sexo, Gross Motor Functional Classification System, classificação geográfica da paralisia cerebral, padrão de acometimento motor), radiológicas pré e pós-operatórias (ângulo cérvico-diafisário, índice acetabular, índice de Reimers e tempo até a consolidação radiológica) e complicações pós-operatórias. Resultados: O ângulo cérvico-diafisário, índice acetabular e o índice de Reimers médios pré-operatórios foram respectivamente de 121,6 º, 22,7 º e 65,4% nos casos não complicados, vs. 154,7 º, 20,4 º e 81,1% nos que evoluíram com complicações pós-operatórias. Todos os parâmetros apresentaram diferença significativa entre os valores pré e pós-operatórios (p < 0,05). O ângulo cérvico-diafisário e o índice de Reimers foram maiores no grupo com complicações (p < 0,0001). Não houve diferenças nas características clínicas, no tempo de imobilização ou consolidação, exceto em relação ao grau Gross Motor Functional Classification System V (p < 0,0001). Foram observadas complicações pós-operatórias em 14 pacientes (33,3%). Desses, somente seis necessitaram reintervenção cirúrgica. Conclusão: A placa bloqueada é um recurso seguro, com baixa taxa de complicações cirúrgicas e de técnica reprodutível para a OVRF na paralisia cerebral Gross Motor Functional Classification System IV e V. Maiores ângulos cérvico-diafisário, índices de Reimers e graus de Gross Motor Functional Classification System V estão ligados a maiores chances de complicações pós-operatórias.

The use of pediatric locked plates in the paralytic hip: preliminary results of 61 cases.

OBJECTIVE: To evaluate the clinical and radiologic results of proximal femoral varus derotational and shortening osteotomy (OVRF) (Port., doesn't match name) with the use of a locked plate in patients with cerebral palsy, classified by the gross motor functional classification system as class IV or V. METHODS: A retrospective study of 42 patients (61 hips) with cerebral palsy, gross motor functional classification system class IV or V, submitted to OVRF. The minimal follow up was 24 months. This study evaluated clinical (age at surgery, gender, Gross Motor Functional Classification System class, anatomical cerebral palsy classification, and motor pattern), pre- and post-operative radiological (neck shaft angle, acetabular index, Reimers migration index and time until bone healing) characteristics, as well as post-operative complications. RESULTS: Mean pre-operative cervicodiaphyseal angle, acetabular index, and Reimers migration index were respectively 121.6°, 22.7°, and 65.4% in uncomplicated cases, and 154.7°, 20.4°, and 81.1% in complicated ones. All parameters were statistically significant difference between pre- and postoperative values (p < 0.05). The patients with postoperative complications had a greater cervicodiaphyseal angle and Reimers migration index (p < 0.0001). There were no differences in clinical characteristics, time of immobilization, or bone healing. Fourteen patients had postoperative complications (33.3%), but only six required surgical treatment. CONCLUSION: The locked plate is a safe resource, with low complication rates and reproducible technique for OVRF in the cerebral palsy population classified as gross motor functional classification system IV and V. Greater cervicodiaphyseal angles and Reimers migration index are associated with greater chances of postoperative complications, as well as gross motor functional classification system V classification.

OBJETIVO: Avaliar os resultados clínicos e radiológicos da osteotomia varizante, de rotação e encurtamento da extremidade proximal do fêmur (OVRF) com uso de placa bloqueada em pacientes com paralisia cerebral classificados pela escala Gross Motor Functional Classification System como IV e V. MÉTODOS: Estudo retrospectivo de 42 pacientes (61 quadris) com paralisia cerebral, Gross Motor Functional Classification System IV e V, submetidos a OVRF. O seguimento mínimo pós-operatório foi de 24 meses. Foram avaliadas as características clínicas (idade na data da cirurgia, sexo, Gross Motor Functional Classification System, classificação geográfica da paralisia cerebral, padrão de acometimento motor), radiológicas pré e pós-operatórias (ângulo cérvico-diafisário [ACD], índice acetabular [IA], índice de Reimers [MP] e tempo até a consolidação radiológica) e complicações pós-operatórias. RESULTADOS: O ângulo cérvico-diafisário, índice acetabular e o índice de Reimers médios pré-operatórios foram respectivamente de 121,6 o, 22,7 o e 65,4% nos casos não complicados, vs. 154,7 o, 20,4 o e 81,1% nos que evoluíram com complicações pós-operatórias. Todos os parâmetros apresentaram diferença significativa entre os valores pré e pós-operatórios (p < 0,05). O ângulo cérvico-diafisário e o índice de Reimers foram maiores no grupo com complicações (p < 0,0001). Não houve diferenças nas características clínicas, no tempo de imobilização ou consolidação, exceto em relação ao grau Gross Motor Functional Classification System V (p < 0,0001). Foram observadas complicações pós-operatórias em 14 pacientes (33,3%). Desses, somente seis necessitaram reintervenção cirúrgica. CONCLUSÃO: A placa bloqueada é um recurso seguro, com baixa taxa de complicações cirúrgicas e de técnica reprodutível para a OVRF na paralisia cerebral Gross Motor Functional Classification System IV e V. Maiores ângulos cérvico-diafisário, índices de Reimers e graus de Gross Motor Functional Classification System V estão ligados a maiores chances de complicações pós-operatórias.

Atrophic nonunion stromal cells form bone and recreate the bone marrow environment in vivo.

INTRODUCTION: Nonunion is a challenging condition in orthopaedics as its etiology is not fully understood. Clinical interventions currently aim to stimulate both the biological and mechanical aspects of the bone healing process by using bone autografts and surgical fixation. However, recent observations showed that atrophic nonunion tissues contain putative osteoprogenitors, raising the hypothesis that its reactivation could be explored to achieve bone repair. METHODS: Here we characterized atrophic nonunion stromal cells (NUSC) in vitro, using bone marrow stromal cells (BMSC) and osteoblasts as controls cells of the osteoblastic lineage, and evaluated its ability to form bone in vivo. RESULTS: NUSC had proliferative and senescence rates comparable to BMSC and osteoblasts, and homogeneously expressed the osteolineage markers CD90 and CD73. Regarding CD105 and CD146 expression, NUSC were closely related to osteoblasts, both with an inferior percentage of CD105+/CD146+ cells as compared to BMSC. Despite this, NUSC differentiated along the osteogenic and adipogenic lineages in vitro; and when transplanted subcutaneously into immunocompromised mice, new bone formation and hematopoietic marrow were established. CONCLUSIONS: This study demonstrates that NUSC are osteogenically competent, supporting the hypothesis that their endogenous reactivation could be a strategy to stimulate the bone formation while reducing the amount of bone autograft requirements.

Surgical treatment for unstable pelvic fractures in skeletally immature patients.

OBJECTIVE: To present the results and conclusions of our study on surgical treatment for unstable pelvic fractures in children subjected to surgical reduction and stabilisation. METHODS: We analysed the cases of fourteen skeletally immature patients with unstable pelvic fractures who underwent surgery for this condition between March 2004 and January 2011. The surgical technique used was based on the principle of surgical reduction and stabilisation of anterior and posterior lesions of the pelvic ring. This was a retrospective study, based on clinical assessment and X-ray analyses. RESULTS: The mean age of patients at the time of the condition was 9.4 years (range 2-13 years). Eight patients were female and six were male. The cause of the trauma was being hit by a car in ten cases, falls in three cases and an accident involving a motorcycle in one case. Five patients presented with other associated injuries, including fracture of the clavicle, femur shaft, proximal humerus, tibial shaft or olecranon, and bladder damage. All the patients assessed showed excellent clinical progress. Pelvic asymmetry prior to surgery varied from 1.1 to 2.9 cm (mean 1.5 cm) and dropped to a range of 0.2 to 0.9 cm (mean 0.4 cm) after reduction. In none of the cases was there a change between the pelvic asymmetry measured immediately after surgery and at the end of the follow-up period. CONCLUSION: Pelvic fracture in skeletally immature patients is rare and surgery is not normally indicated. Various authors have questioned this conservative type of treatment due to complications encountered. Bone remodelling does not seem to be sufficient to ensure an improvement in pelvic asymmetry, which justifies opting for surgery to reduce and correct deformities in the pelvic ring.

Os acromiale sintomático

O os acromiale representa a falha de fusão da apósife anterior do acrômio, que se desenvolve a partir de quatro centros de ossificação. Sua incidência é de até 8 por cento, com bilateralidade de 60 por cento, sendo o mais comum em negros e homens

Alongamento Femoral Convencional versus Alongamento sobre Haste Intramedular: Comparação de Resultados / Convencional Femoral Lengthening With an External Fixator Over an Intramedullary nail are Compared

Com base em critérios clínicos e radiológicos, foram alcançados três resultados excelentes no grupo do alongamento sobre haste contra um no grupo controle, quatro resultados bons contra quatro, três moderados contra três e nenhum mau contra dois no grupo controle. As vantagens do alongamento sobre haste incluem a redução no tempo de uso do fixador externo, na incidência de complicações, principalmente nas fraturas do regenerado, e no tempo de reabilitação

Osteonecrose e Pseudartrose após Osteossíntese de Fraturas do Colo Femoral em Adultos

Fraturas do colo femoral são cada vez mais prevalentes na população geral, devido principalmente ao envelhecimento da população e ao aumento da energia cinética envolvida nos acidentes automobilísticos. O tratamento com osteossíntese após redução da fratura é de escolha, principalmente em pacientes mais jovens e de maior demanda funcional