Inter-observer and intra-observer agreement in the radiographic diagnosis of avascular necrosis of the femoral head following slipped capital femoral epiphysis

Introduction  

Slipped capital femoral epiphysis (SCFE) is a common pediatric hip disorder. Avascular necrosis (AVN) of the femoral head is a devastating complication of SCFE. The frequency of this complication reported in the literature has been variable. It was the objective of this study to estimate the inter- and intra-observer agreement between two experienced pediatric orthopaedic surgeons for the radiographic diagnosis of AVN following SCFE.     

Salvage of failed in-situ pinning in severe unstable slipped capital femoral physis by surgical dislocation and capital realignment

AimsWe describe surgical dislocation with capital realignment as an option for management of failed in-situ pinning in children with severe unstable slipped capital femoral physis.Patients and methodsA retrospective data collection from our hospital hip database retrieved 7 patients with severe unstable slipped capital femoral physis who had failed in-situ pinning with severe deformity and grossly restricted movements. The failure of pinning in-situ was due to slip progression with inadequate screw purchase in four patients, stress fracture of the femoral neck in one patient, and screw head impingement in two patients. All these patients under went open surgical dislocation, removal of the screws, followed by sub-capital realignment and fixation.ResultsThe average age at presentation was 11.9 years (10–14 years). The mean follow-up was 50.14 months (25–66 months). Four patients who had pre-existing avascular necrosis at presentation underwent second stage hinged distraction of the hip joint. Preoperatively, the mean Modified Harris Hip Score (MHHS) was 19.57 (0–56) and the mean Non-Arthritic Hip Score (NAHS) was 21.07 (5–51.5) respectively. The mean MHHS at the last follow-up visit was 88.97 (71–96) and NAHS was 84.28 (69.5–91) respectively.ConclusionAllowing the hip to heal in its anatomical position is the best possible correction we could give for any patient with severe slipped capital femoral epiphysis. We found that surgical dislocation for those with failed in-situ pining proved to be an effective bailout option for restoration of anatomy and function.     

The progressive longitudinal traction reduction of unstable slipped capital femoral epiphysis: preliminary results in 11 patients

Purpose Unstable slipped capital femoral epiphysis is rare, but is frequently associated with avascular necrosis. The rapid and complete reduction of the epiphysis displacement was shown to be responsible for this complication. We present the preliminary results of a progressive reduction technique of epiphysis displacement. Methods A total of 11 patients treated using progressive traction and internal fixation were reviewed retrospectively. Only children who underwent clinical and radiological follow-up for at least 18 months were included in this study to detect avascular necrosis. Results The mean posterior displacement of the femoral head was 67° and mean traction duration was 13 days. Of the patients, 2 had cutaneous problems requiring traction interruption, one on day 5 and the other on day 9. The mean residual slip was 16° and 3 patients had complete or partial avascular necrosis well tolerated at the final follow-up. Conclusion Our experience showed that if traction is supported for more than 2 weeks, a good correction of the epiphysis displacement can be obtained. Our short series does not allow affirmation of the superiority of our therapeutic strategy, especially with regards to avascular necrosis of the femoral head.     

Continued growth of the hip after fixation of slipped capital femoral epiphysis using a single cannulated screw with a proximal threading

Background  

The most commonly used method for unstable slipped capital femoral epiphysis (SCFE) remains in situ fixation. Depending on the surgeon’s preference, screws or Kirschner wires are used for stabilizing the slipped upper femoral epiphysis. The purpose of this study was to evaluate the ability of a single cannulated screw with a proximal threading to ensure stabilization, growth, and remodeling of the slipped epiphysis.     

Bone remodeling of a femoral head after transtrochanteric rotational osteotomy for osteonecrosis associated with slipped capital femoral epiphysis: a case report

A rare case of a 12-year-old boy on whom a joint-preserving operation for osteonecrosis after slipped capital femoral epiphysis (SCFE) was performed, is described. Firstly, in situ pinning was performed for acute-on-chronic SCFE. However, osteonecrosis and collapse of the femoral head occurred at 7 months after surgery. Secondly, transtrochanteric rotational osteotomy (TRO) was performed against progression of the collapse of the femoral head. Eight years of X-ray observation revealed bone remodeling at the osteonecrotic region. No documentation has been reported about the potential of bone remodeling of a femoral head with osteonecrosis after SCFE. This case indicates that a joint-preserving operation such as TRO is capable of promoting bone remodeling in such circumstances.     

Epidemiology and demographics of slipped capital femoral epiphysis in Japan: a multicenter study by the Japanese Paediatric Orthopaedic Association

 A nationwide survey of the epidemiology and demographics of slipped capital femoral epiphysis (SCFE) was carried out using questionnaires to investigate the incidence, clinical characteristics, and frequently used treatment procedures in Japan. Inquiries were sent to 2040 of the leading hospitals nationwide. Data were collected for the period between January 1997 and December 1999. Inquiries included onset age, sex, past medical history, type of slip, height, weight, and treatment procedure. Altogether, 314 cases were reported (237 boys, 77 girls) from 131 hospitals. The average annual incidence was estimated to be at least 2.22 for boys and 0.76 for girls for every 100 000 in the age group of 10- to 14-year-olds. These estimations are five times higher than the 1976 statistics from the eastern half of Japan. The average onset age was 11 years 10 months in boys and 11 years 5 months in girls. The most common treatment was surgery including in situ fixation (61.4%), osteotomies (25.9%), fixation after manual reduction (11.9%), and skeletal traction (0.9%). All patients except two were treated surgically. We concluded that SCFE has markedly increased during the last 25 years in Japan, and therefore further study of SCFE is needed to understand this disorder. Received: February 21, 2002 / Accepted: July 3, 2002 Acknowledgments. The authors sincerely thank all of the orthopedic doctors involved in the 131 hospitals who replied to our inquiries concerning SCFE cases. We also thank other members of the Multicenter Study Committee of the Japanese Paediatric Orthopaedic Association, including S. Kokubun, M. Honda, T. Saito, W-C. Kim, K. Hiroshima, and T. Fujii for their valuable discussions and advice. Offprint requests to: Y. Noguchi, Department of Orthopaedic Surgery, Saga Koseikan Hospital, 1-12-9 Mizugae, Saga 840-8571, Japan     

Long-term outcome of slipped capital femoral epiphysis: a 38-year follow-up of 66 patients

Purpose  

The purpose of this retrospective study was to evaluate the long-term outcome of different methods of treatment in slipped capital femoral epiphysis (SCFE), to find risk factors for poor outcome, and to assess whether prophylactic fixation is indicated.     

Avascular necrosis of the femoral head due to malposition in untreated congenital dislocation of the hip

Summary Avascular necrosis of the femoral head is reported as a complication due to malposition in 12 cases of untreated congenital dislocation of the hip (CDH). It occurs after walking has commenced, both in cases of subluxation and in cases of complete dislocation. Two mechanisms are considered responsible. In subluxation or high dislocation, a reduced area of contact between the femoral head and the acetabulum or false acetabulum causes very high loading pressures on weight bearing, leading to pressure necrosis. In unstable dislocation, stretching of the nutrient vessels occurs on weight bearing, leading to vascular obstruction and necrosis of the ossific centre.Concentric reduction of the femoral head eliminates both causes of necrosis. Treatment should be meticulously planned and performed to reduce the risk of yet another, unfortunately common, cause of avascular necrosis associated with CDH, i. e., the iatrogenic one.

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Résumé Une nécrose ischémique de la tête fémorale a été découverte dans 12 cas de luxation congénitale de la hanche avant tout traitement. Elle est apparue à l'âge de la marche, aussi bien dans des luxations vraies que dans des subluxations. Deux mécanismes distincts peuvent être incriminés. Dans les subluxations ou dans les luxations appuyées, la réduction de la surface de contact entre la tête et le cotyle (ou le néo-cotyle) entraîne au cours de la marche une augmentation considérable de la pression unitaire et, de ce fait, la nécrose. Dans les luxations hautes non appuyées, la marche provoque un étirement des vaisseaux nourriciers, aboutissant à leur obstruction et à la nécrose par ischémie.La réduction de la luxation élimine ces deux causes de nécrose. Mais le traitement doit être parfaitement conduit afin de réduire le risque d'une autre cause, malheureusement encore fréquente, la nécrose iatrogène.

     

Open reduction and internal fixation versus closed reduction and percutaneous fixation in the treatment of Bennett fractures: A systematic review

PurposeOpen reduction and internal fixation (ORIF) of Bennett fractures is increasingly preferred over closed reduction and percutaneous fixation (CRIF) in an attempt to prevent the development of post-traumatic arthrosis. The aim of this systematic review was to determine whether the preference for ORIF is justified based on the available literature regarding functional outcome and complications after surgery.MethodsA systematic review was performed in Medline, Embase, Cochrane CENTRAL, Web of science, and Google scholar. Duplicates were removed and title and abstract were screened after which full text articles were analysed. The reference lists of selected articles were screened for additional relevant studies. Study characteristics were recorded and methodological qualities were assessed after which data was extracted from the included articles. The Eaton-Littler score for post-traumatic arthrosis (primary outcome) on follow-up X-rays was used as primary outcome. Secondary outcomes were Grip strength, Pinch strength, persistent pain, fixation failure, functional impairment, infection and surgery time.ResultsTen studies were included; three retrospective comparative studies and seven retrospective case series. Of the 215 patients in these studies, 138 had been treated using an open technique and 77 by a closed percutaneous technique. The pooled rate of post-traumatic arthrosis was 57.5% (26.6–85.5) in the ORIF group versus 26.1% (3.9–59.0) in the CRIF group. Mean surgical operation time was 71.9 min for ORIF and 30.2 min for percutaneous patients. Fixation failure was significantly more often seen in the ORIF patients, 8.2% (0.7–22.8) vs. 2.9% (0.8–9.1), Risk Ratio 1.132 (0.01–176.745); p = 0.048. Infection was only seen in 5 CRIF patients. Persistent pain was seen in 32.9% (0.6–83.1) in ORIF patients versus 22.3% (8.1–41.1) in the CRIF patients. The pooled means Grip strength was 48.3 kg (95% CI; 39.7–56.9) versus 43.4 kg (95% CI; 22.9–63.8) for ORIF and CRPF, respectively. Functional impairment was similar between the two groups, 1.4% (0.1–4.4) vs 1.8% (0.1–5.7) respectively.ConclusionThe analysed data do not confirm ORIF to prevent post-traumatic arthrosis, secondly more fixation failure and pain was seen in the ORIF group. The pooled data show percutaneous fixation to be preferable over ORIF in the surgical treatment of Bennett fractures.     

Clinical and radiological outcomes following surgical hip dislocation for paediatric hip pathologies,a prospective cohort study

BackgroundSurgical Hip Dislocation (SHD) is a powerful tool in the armamentarium of any surgeon treating conditions affecting the hips of children presenting with sequelae of a number of common conditions including Legg-CalvéPerthes disease (LCPD) and slipped capital femoral epiphysis (SCFE). Risks associated with the procedure are well described. We investigated to assess if SHD is associated with significant surgical risk and if it improved clinical outcomes for patients.MethodsWe conducted a prospective cohort study. We reviewed 18 (11 males and 7 females; mean age 13.7 years (6–17) with symptomatic hip pathology, secondary to femoroacetabular impingement (FAI) between 2017 and 2021. All patients underwent a surgical hip dislocation approach and femoral head-neck osteochondroplasty, Head Split osteotomy or both. Clinical improvement was assessed using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index. The minimum follow-up was 6 months (mean, 22 months; range, 6–42 months).ResultsWOMAC scores improved at final follow-up from 10 to 3 for pain, 33 to 10 for function, and 4 to 2 for the stiffness subscales. All radiographic measures improved significantly of the postoperative X-rays. No patients developed osteonecrosis, implant failure, deep infection, or nonunion.ConclusionSurgical Hip Dislocation, in the short term, we found improvement in WOMAC scores and radiographic indices with a low complication rate.     

Slipped capital femoral epiphysis and its association with endocrine, metabolic and chronic diseases: a systematic review of the literature

Purpose

Puberty, obesity, endocrine and chronic systemic diseases are known to be associated with slipped capital femoral epiphysis (SCFE). The mechanical insufficiency of the physis in SCFE is thought to be the result of an abnormal weakening of the physis. However, the mechanism at the cellular level has not been unravelled up to now.

Methods

To understand the pathophysiology of endocrine and metabolic factors acting on the physis, we performed a systematic review focussing on published studies reporting on hormonal, morphological and cellular abnormalities of the physis in children with SCFE. In addition, we looked for studies of the effects of endocrinopathies on the human physis which can lead to cause SCFE and focussed in detail on hormonal signalling, hormone receptor expression and extracellular matrix (ECM) composition of the physis. We searched in the PubMed, EMBASE.com and The Cochrane Library (via Wiley) databases from inception to 11th September 2012. The search generated a total of 689 references: 382 in PubMed, 232 in EMBASE.com and 75 in The Cochrane Library. After removing duplicate papers, 525 papers remained. Of these, 119 were selected based on titles and abstracts. After excluding 63 papers not related to the human physis, 56 papers were included in this review.

Results

Activation of the gonadal axis and the subsequent augmentation of the activity of the growth hormone–insulin-like growth factor 1 (GH-IGF-1) axis are important for the pubertal growth spurt, as well as for cessation of the physis at the end of puberty. The effects of leptin, thyroid hormone and corticosteroids on linear growth and on the physis are also discussed. Children with chronic diseases suffer from inflammation, acidosis and malnutrition. These consequences of chronic diseases affect the GH-IGF-1 axis, thereby, increasing the risk of the development of SCFE. The risk of SCFE and avascular necrosis in children with chronic renal insufficiency, growth hormone treatment and renal osteodystrophy remains equivocal.

Conclusions

SCFE is most likely the result of a multi-factorial event during adolescence when height and weight increase dramatically and the delicate balance between the various hormonal equilibria can be disturbed. Up to now, there are no screening or diagnostic tests available to predict patients at risk.     

股骨头坏死危险因素病例对照研究

目的研究发生股骨头坏死的危险因素,为该病的预防提供依据。方法采用病例对照研究方法,以临床确诊的股骨头坏死的100例作为病例组,按1∶3比例配对与病例同性别、同一年龄组、同一居住地区的非股骨头坏死者(排除严重的心、肝、肺、肾疾病)作为对照组,对主要疾病史、服药史、吸烟饮酒史以及一些中医症候等因素进行调查研究,并进行统计学分析。结果危险度分析表明,可能与股骨头坏死危险性有关的因素(OR及95%CI)病史有下肢骨折、髋关节炎和类风湿关节炎、高脂血症、糖尿病史;服用糖皮质激素类药物如强的松、地塞米松、氢化可的松;发现面色苍白、畏寒、四肢酸软等肾阳虚症状与股骨头坏死也有联系(P<0.05)。结论下肢骨折、髋关节炎等病史和使用激素类药物可能是股骨头坏死的主要危险因素;肾阳虚症状与股骨头坏死有联系;对股骨头坏死的预防有着重要意义。     

细胞因子治疗股骨头坏死的研究进展

股骨头坏死的骨重建和修复是包括各种细胞在内的复杂过程。十几年来,随着大量的细胞因子不断的被认识、分离和纯化,基础和临床研究发现这些细胞因子在治疗早期股骨头坏死方面有肯定的疗效。本文简要介绍治疗股骨头坏死有关的细胞因子,以期对细胞因子有一个全面的认识并讨论细胞因子在治疗股骨头坏死中作用、现存的问题和前景展望。     

年龄因素与发育性髋关节脱位保守治疗并发股骨头缺血性坏死的相关性研究

背景：应用保守方法治疗发育性髋关节脱位（developmental dysplasia of the hip,DDH）并发股骨头缺血性坏死（avascularnecrosis of the femoral head,AVN）的风险较高,年龄因素是公认的危险因素。目前国内外均将18个月作为保守治疗与手术切开复位的分界线。目的：研究年龄因素对于应用保守方法治疗DDH并发AVN的影响,讨论DDH保守治疗的年龄选择标准。方法：2005年1月至2010年8月应用保守方法治疗DDH患儿53例（77髋）,分为3个年龄段：（1）12个月龄,25髋;（2）13～15个月龄,20髋;（3）16个月龄,32髋。前3个月每月复诊1次,之后每3个月复诊1次,应用Salter标准评判AVN。总结临床资料及影像学结果,统计分析不同年龄段保守治疗DDH并发AVN率的差异。结果：随访时间为1.1～2.2年,平均1.5年。53例（77髋）中30髋出现AVN（40.0%）,其中12个月以内患儿25髋中3髋发生AVN（12.0%）,13～15个月患儿20髋中12髋发生AVN（60.0%）,16个月以上患儿32髋中15髋发生AVN（46.9%）。结论：脱位程度、股骨头骨化核出现与否等均对保守治疗DDH并发AVN有一定的影响。12个月以上合并Ⅲ度以上脱位的DDH患儿保守治疗并发AVN的风险较高,应根据患儿本身条件制定个性化的治疗方案。     

Significance of preoperative position of the femoral head in failed closed reduction in developmental dislocation of the hip: surgical results

Long-term follow-up results of open reduction for developmental dislocation of 83 hips via the extensive anterolateral approach were retrospectively analyzed. Open reduction was performed in infancy, and the follow-up period ranged from 12 to 24 years. This procedure is a complete circumferential dissection of the joint capsule and produces sufficient concentric reduction of the femoral head in the acetabulum immediately after the surgery. A lateral arthrographic classification of interposed limbus and the preoperative position of the unreduced femoral head is introduced, and is related to operative findings and surgical results, including Severins classification. The results at the final follow-up were: Severins group I in 35 hips, group II in 19 hips, group III in 10 hips, and group IV in four hips. According to the classification of the preoperative position of the femoral head, there were 31 hips of the intracapsular type and 37 hips of the extracapsular type. Thirty-four of the 37 hips of the extracapsular type were classified in Severins group I or II (92%). Twenty of the 31 hips of the intracapsular type were classified in Severins group I or II (65%). A very significantly greater number of hips with good radiological outcome were in the extracapsular type than in the intracapsular type.     

Open reduction and varus-detorsion osteotomy with femoral shortening in treatment of congenital dislocation of the hip

In this study, we clinically and radiographically evaluated open reduction with shortening of the femur in children more than 1 year old with refractory congenital dislocation of the hip. In 19 children (aged 1–4 years), 22 joints were operated on. The patients were followed-up for an average of 8.7 years (range, 2–13 years). Functional results were satisfactory in all joints, and differences in limb length were not significant. Radiographically, good results (grades I and II) were obtained in 16 of the 22 joints, according to Severin's criteria. This surgical procedure may be indispensable for treating refractory congenital dislocation of the hip in children over 1 year old. Received for publication on May 2, 1997; accepted June 3, 1998     

bFGF基因转染促进股骨头坏死修复的实验研究

目的 :为临床治疗股骨头及其它骨缺血性坏死探索新方法。方法 :将碱性成纤维细胞生长因子 (bFGF)真核表达质粒pCD rbFGF与胶原混合植入坏死的兔股骨头内 ,术后RT PCR及免疫组化方法检测bFGF表达情况 ,组织切片及组织形态学分析股骨头内血管生长及新骨形成情况。结果 :术后 2周RT PCR及免疫组化证实转染bFGF基因的股骨头内有bFGF表达。术后 2周股骨头内血管生长与对照组相比 ,术后 8周股骨头内新骨形成与对照组相比 ,差异均有非常显著意义 (P <0 .0 1)。结论 :利用bFGF基因转染可刺激股骨头坏死内血管再生和新骨形成 ,为临床治疗骨缺血性坏死提供了新的研究方向