Obstetrical Fracture-Separation of the Upper Femoral Epiphysis

During the last 15 years we have treated six neonates with obstetrical fracture of the upper epiphysis of the femur. Two other cases have previously been reported by one of us (S.D.T.) in 1958.

A common characteristic was a difficult and traumatic breech delivery, half the babies being “large-for-dates”. The clinical and radiological signs of this injury are described. In two babies there were associated injuries of the same limb whilst two others had congenital dislocation of the contralateral hip.

The prognosis appears to be excellent, in spite of the severity of the injury, and irrespective of treatment.     

Different osteosyntheses for Colles' fracture: A mechanical study in 42 cadaver bones

Background and purpose In recent years several different plate designs for internal fixation of fractures of the distal radius have been developed. However, few biomechanical studies have been performed to compare these new implants. The purpose of this study was to compare the mechanical properties of 5 different commercially available plates (3 volar and 2 dorsal) with standard K-wire fixation using a distal radial cadaver model.Material and methods 42 human radial bones from 26 cadavers were included. The bone mineral density (BMD) was measured by DEXA in all bones, and the radial bones were assigned to 6 equiv alent groups based on bone density and total amount of mineral. A distal radial osteotomy was done and a dorsal 30-degree wedge of bone was removed. 1 K-wire fixation group and 5 plate groups were tested for rigidity, yield load, and maximum load.Results When data from dorsally and volarly applied plates were pooled, we did not find any statistically significant differences between them regarding stiffness, yield load, and maximum load. The K-wire group showed significantly lower yield load than 3 of the plate groups. There were no statistically significant differences in yield load between the 5 plate groups. The K-wire group showed lower rigidity than the plate groups. The K-wire group and 1 plate group failed at a statistically significant lower maximum load than the 4 other plate groups.Interpretation The volar plates had the same mechanical stability as the dorsally applied plates, and they are therefore a good alternative to dorsally applied plates. K-wire osteosynthesis was inferior to plate osteosyntheses regarding all mechanical properties.     

Early results of total hip arthroplasty in patients with slipped upper femoral epiphysis compared with patients with osteoarthritis

We have investigated the results of primary total hip arthroplasty (THA) performed in patients with slipped upper femoral epiphysis (SUFE). Through the New Zealand Joint Registry, we identified all patients with SUFE undergoing primary THA (n = 117) and all patients with primary osteoarthritis (OA) undergoing primary THA (n = 40 589) between January 1, 1999, and December 31, 2008. Baseline information, operative characteristics, and postoperative outcomes were analyzed and compared between the SUFE and the OA groups. There was no significant difference in postoperative Oxford Hip Score or revision rate between the 2 groups. Our results support THA as a successful surgical option in the management of degenerative arthritis in SUFE, with comparable functional outcomes and revision rates to THA performed for primary OA.     

The contralateral hip in slipped capital femoral epiphysis: Is there an easy-to-use algorithm to support a decision for prophylactic fixation?

Purpose:To identify a specific factor that can support the decision for prophylactic fixation in unilateral slipped capital femoral epiphysis.Methods:This retrospective cohort study included a total national population of 379 children diagnosed with slipped capital femoral epiphysis from 2007 to 2013. Regression analysis used information on slip severity, clinical classification of the index hip, age, sex, age-adjusted body mass index, the difference in epiphyseal–diaphyseal angle, and comorbidity to identify any risk factor for the subsequent development of a slip in the contralateral hip. Four observers evaluated the triradiate cartilage following the modified Oxford bone score grade. The occurrence of later development of a contralateral slip in different stage of physeal closure was used to analyze the sensitivity and specificity for this method.Results:This study’s only predictor for a subsequent contralateral slip was chronological age. At age 13 years or older, 1/15 in girls and 3/65 in boys suffered from a slip in the contralateral hip. Thus, when using age <13 years as a test for deciding when to do prophylactic fixation, the sensitivity would be 88% and specificity 51% for preventing contralateral slip. However, the correlation between the four different observers was too low to be considered useful when assessing the triradiate cartilage for skeletal maturity.Conclusion:We would advocate a prophylactic fixation for children <13 years diagnosed with a unilateral slipped capital femoral epiphysis as an easy-to-use algorithm.Level of evidence:level II.     

Slipped upper femoral epiphysis

Slipped upper femoral epiphysis (SUFE) is a common hip disorder of adolescence, with unknown aetiology. The typical patient presenting with SUFE is an overweight adolescent boy, who reports pain in the groin, thigh or knee, with an associated limp. SUFE is defined as stable when the patient can walk, with or without support. The current treatment of choice for stable SUFE is by fixation in situ with a single screw. This method has a high probability of success, with minimal risk of osteonecrosis or chondrolysis. In those patients presenting with an unstable SUFE, immediate closed reduction and fixation with a single screw provides the best chance of a satisfactory result.     

Slipped upper femoral epiphysis with hemophilia A

A 13-year-old boy who had hemophilia A was reported with pain in the left thigh and hip on walking. He had no history of trauma. Severe hemophilia A is diagnosed with a Factor VIII level of <1 iu/dl. The presumptive diagnosis was that of a spontaneous bleed into the hip joint. Factor VIII mutational analysis revealed a C to G substitution at nucleotide 6683 which results in a cystine change at codon 2194. However, the symptoms persisted and an X-ray demonstrated the presence of an acute on chronic slip of the upper femoral epiphysis. The patient was transferred to the center treating his hemophilia where the hip was pinned in situ under cover with Factor VIII. This case demonstrates the need to be aware of a possible traumatic diagnosis of hip pain in a hemophiliac child with a longstanding history of spontaneous bleeding into joints.     

Vingt ans d'ostéotomie sous-capitale pour épiphysiolyse fémorale supérieure

Résumé De 1945 à 1985, 570 cas d'épiphysiolyse de l'extrémité supérieure du fémur ont été traités à la Clinique Orthopédique de l'Université Justus-Liebig de Giessen. Depuis 20 ans, on réalise une ostéotomie sous-capitale lorsque le déplacement de la calotte de tête femorale est supérieur à 50°. Ce groupe de patients a été soumis à des examens de contrôle. Etant donné les divergences trouvées dans la littérature en ce qui concerne la survenue de nécroses de la tête fémorale après ostéotomie sous-capitale, le critère essentiel des examens de contrôle est l'existence ou non de perturbations vasculaires de la tête fémorale. Le succès d'une ostéotomie sous-capitale dépend, à notre avis, d'une parfaite préparation de l'opération, ainsi que des lignes directrices données par M. E. Müller.

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The indications for and results of subcapital osteotomy for slipped upper femoral epiphysis

Summary Between 1945 and 1985, 570 patients with a slipped upper femoral epiphysis were treated at our hospital. During the last two decades a subcapital osteotomy was performed if the degree of slip exceeded 50°. Twenty two such operations were carried out in 21 patients. In five hips complete avascular necrosis of the epiphysis occurred, and in another hip there was partial necrosis. The success of the operation depends upon careful preoperative planning and a meticulous surgical technique.

     

The oblique plane deformity in slipped capital femoral epiphysis

Background

Slipped capital femoral epiphysis (SCFE) is commonly treated with in situ pinning. However, a severe slip may not be suitable for in situ pinning because the required screw trajectory is such that it risks perforating the posterior cortex and damaging the remaining blood supply to the capital epiphysis. In such cases, an anteriorly placed screw may also cause impingement. It is also possible to underestimate the severity of the slip using conventional radiographs. The aim of this study was to describe and evaluate a novel method for calculating the true deformity in SCFE and to assess the interobserver and intraobserver reliability of this technique.

Methods

We selected 20 patients with varying severity of SCFE who presented to our institution. Cross-sectional imaging [either axial computed tomography (CT) scans or magnetic resonance imaging (MRI) scans] and anteroposterior (AP) pelvis radiographs were assessed by four reviewers with varying levels of experience on two occasions. The degree of slip on the axial image and on the AP pelvis radiographs were measured and, from this, the oblique plane deformity was calculated using the method as popularised by Paley. The intraclass correlation coefficient (ICC) was calculated to determine the interobserver and intraobserver reliabilities between and amongst the raters.

Results

The interobserver reliability for the calculated oblique plane deformity in SCFE ICC was 0.947 [95 % confidence interval (CI) 0.90–0.98] and the intraobserver reliability for the calculated oblique plane deformity of individual raters ranged from 0.81 to 0.94. The deformity in the oblique plane was always greater than the deformity measured in the axial or the coronal plane alone.

Conclusion

This method for calculating the true deformity in SCFE has excellent interobserver and intraobserver reliability and can be used to guide treatment options. This technique is a reliable and reproducible method for assessing the degree of deformity in SCFE. It may help orthopaedic surgeons with varying degrees of experience to identify which hips are suitable for in situ pinning and those which require surgical dislocation and anatomical reduction, given that plain radiographs in a single plane will underestimate the true deformity in the oblique plane.

Level of evidence

Level II diagnostic study.     

Evidence based treatment for unstable slipped upper femoral epiphysis: Systematic review and exploratory patient level analysis

The management of slipped upper femoral epiphysis is controversial and evolving as insight into the condition develops. Loder introduced the concept of slip stability and demonstrated a strong association between poor outcome and instability. Almost half of patients with unstable slip developed femoral head osteonecrosis. This has been influential in surgeons' choice of treatments. Some surgeons have adopted a minimal intervention approach such as pinning in situ or gentle reduction and pinning whereas others advocated an urgent open reduction and stabilisation of slip using various surgical techniques. In this review we analysed the influence of various interventions, timing of surgery and severity of the slip on the outcome of unstable slip.     

Slipped Upper Femoral Epiphysis – A Case of a ‘Dodgem Hip’

A 15 year old male patient of slim habitus presented three times over 3 days to the emergency department. Four weeks prior to the first attendance, he apparently injured his left knee in a sudden jolt whilst going on a ‘bumper car’ (dodgems) at a funfair. Since this incident, he had walked with a limp due to the pain in his left knee. He had sustained a slipped upper femoral epiphysis (SUFE) through this unusual mechanism of injury.     

Slipped capital femoral epiphysis (SCFE) detected in a chiropractic office: a case report

Objective

To report on a case of slipped capital femoral epiphysis (SCFE), which is a somewhat rare condition but one that can present in a chiropractic clinic, particularly one with a musculoskeletal scope of practice.

Case

This is a single case report of a 16-year-old adolescent male patient who presented with an 18-month history of hip pain. Radiographs originally ordered by the patient’s family physician were read by the medical radiologist as “unremarkable.” The family physician diagnosed the patient with tendonitis.

Treatment

After reviewing the radiographs and examining the patient, the chiropractor suspected a SCFE that was confirmed with a repeat radiographic examination. The patient was referred back to his family physician with a diagnosis of SCFE and recommendation for orthopedic surgical consultation. The patient was subsequently treated successfully with surgical reduction by in situ pinning.

Conclusion

The prognosis for the SCFE patient when diagnosed early and managed appropriately is good. The consequences of a delay in the diagnosis of SCFE are an increased risk of further slippage and deformity, increased complications such as avascular necrosis and chondrolysis and increased likelihood of degenerative osteoarthritis of the involved hip later in life. The diagnosis and appropriate management of SCFE is where the chiropractor has an important role to play in the management of this condition.     

The results of downgrading moderate and severe slipped capital femoral epiphysis by an early Imhauser femur osteotomy

Purpose  

Patients with moderate and severe slipped capital femoral epiphysis (SCFE) develop osteoarthritis earlier in life in association with mechanical impingement.     

人工关节置换治疗高龄股骨转子间骨折

2003年1月～2007年6月,我科采用人工关节置换治疗高龄股骨转子间骨折患者30例,取得了较好的疗效,报道如下。     

SEQUENTIAL SLIPPED CAPITAL FEMORAL EPIPHYSES: WHO IS AT RISK FOR A SECOND SLIP?

The purpose of this study was to determine as to which of the children who present to our unit with a unilateral slipped capital femoral epiphysis (SCFE) are most at risk of presenting with a subsequent contralateral SCFE. Between 1988 and 2000, 171 patients presented with unilateral SCFE to our unit, whereas 40 presented with bilateral SCFE. At a minimum of 3 years follow up, 56 of the 171 patients had re-presented with a contralateral SCFE (31%). Age less than 12 years at the time of the first SCFE (odds ratio (OR) = 3.809, 95% confidence interval (CI) = 1.631-8.891, P < 0.002) and New Zealand European ethnicity (OR = 3.989, 95%CI = 1.824 to 8.720, P < 0.001) were significantly predictive of a second SCFE. Sex (OR = 0.722, 95%CI = 0.326-1.601, P = 0.4) and stability of the first slip (OR = 1.558, 95%CI = 0.582-4.172, P = 0.38) were not significantly associated with an increased probability of a second SCFE.     

全髋关节置换术治疗高龄患者股骨颈骨折

目的探讨高龄患者股骨颈骨折全髋关节置换术(THA)的疗效。方法采用THA治疗58例高龄患者股骨颈骨折,分析其疗效及并发症。结果 经2．5～6年(平均4．3年)随访,按Harris评分标准：优良率93．1％(54／58);术后并发症主要为深静脉栓主塞6例(10．3％),异位骨化3例。结论THA适应证取决于患者手术耐受性、患者的预期寿命及社会生活需求,年龄不宜作为影响手术选择的决定性因素。     

全髋与半髋关节置换术治疗股骨颈骨折

2015年3月~2016年2月,我科行全髋与半髋关节置换术治疗36例股骨颈骨折患者,临床效果满意,报道如下。1材料与方法1.1病例资料本组共36例,男19例,女17例,年龄62~78(68.46±3.69)岁。全髋置换20例,半髋置换16例。骨折Garden分型:Ⅲ型29例,Ⅳ型7例。受伤至手术时间2~5 d。1.2治疗方法硬膜外麻醉下手术。患者侧卧位。按髋关节后外侧切口入路,切开皮肤及阔筋膜,离断部分臀中肌和外旋肌群,充分暴露股骨颈后进行不同术式的髋关节置换。1.2.1半髋关节置换术电摆锯在股骨颈处截骨,保留股骨小转子上沿1.5 cm长度的股骨颈,将股骨头取出后测量最大直径,选用配套股骨头假体备用。扩髓器对股骨端进行扩髓,冲洗髓腔,放置股骨远端塞至假体柄远端2 cm处,调制骨水泥至拉丝状,打入股骨髓腔后装配股骨柄假体,至骨水泥完全硬化后安上股骨柄双极头假体,复位髋关节后未见松动及脱位,放置引流管后逐层关闭切口。术后1 d拔除引流管。     

Mid-term results after in situ pinning and hip arthroscopy for mild slipped capital femoral epiphysis: a minimum five-year follow-up

Purpose In situ pinning of mild slipped capital femoral epiphysis (SCFE) results in an aspherical head–neck junction and arthroscopic osteochondroplasty can successfully correct the head–neck junction. However, whether the correction stays stable over at least five years remains unknown.MethodsIn a retrospective and consecutive series, 11 patients with a mean age of 12 years (range, 10 years to 15 years) were included. All patients were treated for mild SCFE with in situ pinning and staged hip arthroscopy correcting the head–neck junction. All patients were assessed clinically and radiographically (radiograph and magnetic resonance imaging (MRI)) pre-operatively, 12 weeks and at least five years’ post-operatively.ResultsThe mean range of motion (ROM) for flexion and internal rotation was stable over time with 100° (sd 4) and 21° (sd 6), respectively at the last follow-up. The mean alpha angle decreased from pre-operative 64° (range 61° to 68°) to 12 weeks post-operative 49° (range 46° to 52°; p = 0.001) and stayed stable over time. New superficial cartilage damage on either the acetabular or femoral side was seen in each three patients. Progressive labral degeneration was present in two patients.Conclusion In situ pinning and staged hip arthroscopy for the correction of mild SCFE is safe, restores normal alpha angles and reveals stable morphological correction at mid-term follow-up. Furthermore, the clinical results were excellent with almost normalized internal hip rotation at mid-term follow-up in patients who had reached adulthood. However, there was some joint deterioration, but without negative impact on subjective and clinical outcome after at least five years.Level of evidenceIV