Growth disturbances of the proximal femur after pinning of juvenile slipped capital femoral epiphysis

Premature closure of the capital femoral physis after pin fixation of slipped capital femoral epiphysis (SCFE) in the juvenile population (at least 1 year less than the established mean) can lead to growth disturbances of the proximal femur. A retrospective review of 21 patients (33 hips) who had a pinning of a juvenile SCFE was performed. Growth disturbances including greater trochanteric overgrowth, coxa vara, and coxa breva were noted in 64% of the hips. An 80% incidence of bilateral involvement was noted in the juvenile group. Consideration should be given to prophylactic pinning of the contralateral hip and use of a smooth pin construct to prevent premature closure of the growth plate in children with significant growth remaining.     

Biomechanical analysis of gait in patients with painful osteoarthritis of the hip treated with WISH-type hip brace

Background  A hip brace, the WISH-type S-form brace, improved hip function scores markedly in patients with painful hip osteoarthritis (OA). To evaluate the biomechanical effects of the brace, gait analysis using a force plate was performed. Methods  For the gait of seven patients with this hip brace, characteristic parameters calculated from three-dimensional (i.e., vertical, forward, and medial) components of the floor reaction force were analyzed using a flat force plate. Results  Gait analyses revealed several tendencies: a shorter time for one step, a stronger step, and a shift of the center of gravity of the body to the contralateral side. In particular, stronger vertical reaction force at the first peak in the early stance and earlier switch from backward to forward reaction force vectors were observed as effects of the hip brace, with statistically significant difference. Conclusions  These biomechanical assessments suggest that abnormal gait in hip OA may be closer to normal gait in patients using this brace, although the deceleration and weighing-off effects, which are indicators useful for observing gait recovery, did not reach significance.     

腰大肌面积与股骨转子间骨折后对侧髋部骨折的相关性分析

目的：探讨初次转子间骨折时腰大肌区域面积与再发对侧髋部骨折的关系。方法 ：选取2008年1月至2011年1月股骨转子间骨折患者87例在首次骨折时进行腰椎及髋部CT扫描,根据对侧髋部是否发生骨折分为两组,其中对侧髋部骨折组13例,男5例,女8例,年龄（82.30±5.66）岁;非对侧髋部骨折组74例,男32例,女42例,年龄（79.70±5.84）岁。观察比较两组患者性别,年龄,术前血白蛋白值,骨折侧,体质量指数（body mass index,BMI）,术后1年髋关节Harris评分、术前Barthel指数、术前合并内科疾病,以腰大肌指数（Psoas major index,PMI）比较两组术前CT腰大肌面积,评估初次骨折时腰大肌面积与对侧髋部骨折相关性。结果 ：两组患者术后随访均2年以上,两组的PMI值差异有统计学意义（P<0.05）。患者术前PMI与对侧髋部再次骨折的时间之间存在明显的正相关性（r=0.641,P=0.018）。结论：对侧髋关节骨折患者腰大肌区域面积存在差异,故腰大肌面积可作为对侧髋部骨折的重要危险因素。     

Die Kirschner-Draht-Spickung der Hüftkopfepiphyse bei Epiphyseolysis capitis femoris juvenilis

OBJECTIVE: To stabilize the unstable capital femoral epiphysis to stop further slippage. To prevent imminent epiphyseal dislocation with subsequent articulation disorders of the hip joint and joint degeneration. To prevent additional growth disorders of the proximal femur. INDICATIONS: Epiphyseolysis capitis femoris acuta.Epiphyseolysis capitis femoris lenta. Epiphyseolysis capitis femoris incipiens (incipient epiphyseolysis). Epiphyseolysis capitis femoris imminens (imminent epiphyseolysis of the so-called healthy contralateral side). CONTRAINDICATIONS: None. The diagnosis of slipped capital femoral epiphysis is an absolute indication for surgery unless there is an internal or pediatric disorder that dictates a conservative approach. SURGICAL TECHNIQUE: Three, possibly four, Kirschner wires, at least 2 mm thick, are inserted through a short subtrochanteric approach under image intensification into the femoral neck so that they are seen to be spread uniformly over the cross section of the femoral head when viewed in both planes. The opposite side is transfixed prophylactically. POSTOPERATIVE MANAGEMENT: 3 weeks partial loading at 10 kg, then increased loading after radiologic assessment. Radiologic assessment every 6 months until the end of the growth phase so that migration of the Kirschner wiresout of the femoral head can be identified early. If necessary, renewed Kirschner wire transfixation. Implants are removed after consolidation and closure of the growth plate. RESULTS: 59 therapeutic and 48 prophylactic transfixations of slipped capital femoral epiphysis were performed from 1970 to 1995. The average follow-up period was 4 years (0.1-17.3 years). The most frequent complications were incipient secondary joint degeneration arising in most cases from femoral head necrosis, and postoperative identification of Kirschner wire malalignment. At the time of follow-up 27 patients had an excellent result on the pathologic side according to Southwick's classification, 26 a good, three a moderate, and three a poor result. In particular, a poor result ensued subsequent to femoral head necrosis.     

成人常见髋关节疾病双侧髋关节解剖参数的研究

目的探讨行全髋关节置换术中利用对侧相对正常髋关节的解剖参数作为模板重建患侧髋关节的准确性。 方法选取2019年9月至2020年12月于大连医科大学附属第一医院关节外科行首次单侧全髋关节置换术的患者作为研究对象。纳入标准：患侧诊断为髋关节骨关节炎、股骨头坏死或髋关节发育不良Crowe Ⅰ型；对侧髋关节形态不影响测量。排除标准：患侧髋关节既往手术史；畸形严重影响测量；髋关节发育不良Crowe Ⅱ型及以上。最后共纳入82例患者，其中33例男性，49例女性，年龄范围29~74岁。根据患者X线及CT影像数据，分别测量患者患侧及对侧髋臼前倾角、髋臼外展角、股骨前倾角、颈干角以及股骨偏心距，并计算其各自的联合前倾角。运用t检验、Pearson相关性分析等统计学方法分析双侧髋关节解剖参数的对称性。 结果对股骨头坏死及髋关节骨关节炎患者来说，除双侧股骨偏心距患侧小于对侧外(t＝0.523，P <0.05)，余双侧髋关节解剖参数包括髋臼前倾角、髋臼外展角、股骨前倾角、联合前倾角及颈干角的差异均无统计学意义(均为P>0.05)。Pearson相关性分析显示股骨头坏死及骨关节炎患者股骨偏心距的不对称性与颈干角有相关性(r＝-0.519，P<0.001)，颈干角的不对称性与股骨前倾角(r＝0.303，P＝0.041)以及股骨偏心距有相关性，联合前倾角的不对称性与髋臼外展角(r＝0.311，P＝0.035)、颈干角(r＝0.049，P＝0.032)有相关性。Crowe Ⅰ型髋关节发育不良患者的髋臼前倾角(t＝2.081，P＝0.045)、股骨偏心距(t＝3.934，P<0.001)患侧小于对侧，颈干角患侧大于对侧(t＝3.792，P＝0.001)；而双侧髋臼外展角、股骨前倾角、联合前倾角差异均无统计学意义(均为P>0.05)。Pearson相关性分析发现股骨偏心距的不对称性与颈干角(r＝-0.709，P<0.001)、股骨前倾角(r＝-0.349，P＝0.037)有相关性。Crowe Ⅰ型髋关节发育不良患者的股骨偏心距小于股骨头坏死患者或髋关节骨关节炎患者，而髋臼前倾角、髋臼外展角、颈干角大于后者。 结论对于股骨头坏死患者及髋关节骨关节炎患者来说利用对侧肢体作为模板重建患侧髋关节是可行的。而Crowe Ⅰ型髋关节发育不良患者双侧髋关节解剖形态差异较大，对这类患者的全髋关节置换术需个体化。     

Response of the growth plates to tibial osteotomy in rats

The parameters of cellular proliferation and growth in the growth plates of immature rats were measured after unilateral tibial osteotomy and used to calculate growth rates. Distal osteotomy of one tibia was followed by a bilateral increase in the calculated growth rate of the distal growth plates. However, the ipsilateral distal growth plate grew faster than the contralateral between 12 and 18 days after operation, which appeared to be related to increased cell proliferation and height. Proximal osteotomy led to an increase in growth rates proximally which was more marked on the contralateral side. The lesser response of the ipsilateral growth plate may have been due to local impairment of blood supply, or to greater local release of metabolites after bony damage. Distal tibial osteotomy gave similar results to circumferential release of the distal tibial periosteum. Proximal osteotomy, however, produced a relative impairment of growth on the operated side. This may be of importance in the correction of childhood deformities associated with inequality of leg length.     

Dyamic screw fixation for slipped capital femoral epiphysis. Treatment results

Slipped capital femoral epiphysis always requires surgical treatment. The operative technique depends on the degree of dislocation and the type of the slip. The goal of treatment is to achieve physeal stability until the epiphyseal plate closes without harming the further femoral growth. In situ fixation is generally recommended for slipped capital femoral epiphyses of a mild degree. For this purpose the technique of dynamic screw fixation (DSF) is applicable using a long cannulated screw with a short thread.DSF is easy to handle, provides sufficient long-term fixation of the epiphysis, does not promote premature closure of the epiphysis, and engenders few complications. Therefore, this technique is also applicable for the prophylactic treatment of the contralateral unaffected hip, which we always perform. Moreover, DSF can be used following gentle reduction of acute epiphysiolysis, if the amount of eventual residual dislocation does not exceed 30 degrees. We report our results with dynamic screw fixation of 29 slipped capital femoral epiphyses of a mild degree, and the prophylactic dynamic screw fixation of 34 unaffected hips. The fixation technique achieved a reliable stabilization with no visible growth disturbance of the femoral neck in all cases.     

Radiological evaluation of unstable (acute) slipped capital femoral epiphysis treated by pinning with Kirschner wires

Treatment of slipped capital femoral epiphysis is still controversial with regard to the implants used for stabilization and the need for prophylactic treatment of the contralateral, unaffected, side. The objective of this study was to ascertain whether prophylactic transfixation of the epiphysis with Kirschner wires in patients with unstable slipped capital femoral epiphysis resulted in significant disturbance of the growth plate and impairment of further growth of the femoral neck and head. Between 1990 and 1999, 29 patients with unstable slipped capital femoral epiphysis were simultaneously treated with internal fixation of the epiphysis and metaphysis with 3-4 Kirschner wires on the affected and the not (yet) affected side. After a mean follow-up of 3.5 years, we evaluated the hip joints radiologically, analysing different roentgenological parameters (CCD angle, femoral head diameter, length of the femoral neck and sphericity of the femoral head). CCD angle, femoral head diameter and length of the femoral neck showed statistically significant (P<0.001, Student's t-test) differences between the affected and unaffected, but prophylactically pinned, sides. Asphericity of the femoral head was found in six cases only on the affected side, whereas all hips, which were operated prophylactically, showed spherical femoral heads at follow-up (P<0.02, Pearson's chi test). These results indicate that the slip itself may cause impairment of the femoral growth plate in patients with unstable slipped capital femoral epiphysis and not stabilization with Kirschner wires. Compared with other series from the literature using different implants (screws, nails), prophylactic transfixation of the epiphysis and metaphysis with Kirschner wires is less compromising to the growth plate on the not (yet) affected side.     

Der minimalinvasive Hüftgelenkersatz in Rückenlage mit hochgelagertem kontralateralem Bein

OBJECTIVE: Supine positioning of the patient taking into account - the demands of anesthesia in an emergency requiring intubation, - minimal time for sterile draping, - patient position can be adjusted by the assistants, - easier implant positioning due to the supine position. Reduction of operative trauma with earlier mobilization and shorter rehabilitation time compared with conventional technique. Application of standard instruments and implants. INDICATIONS: Coxarthroses, necroses of the femoral head. CONTRAINDICATIONS: For the "gynecologic position": - hip joint arthrodesis of the contralateral side. - flexion of the contralateral side < 20 degrees . For minimally invasive total hip replacement: - severe anatomic deformities. - revision operations. POSITIONING AND SURGICAL TECHNIQUE: Supine position of the patient with the contralateral leg held at approximately 30 degrees flexion in a gynecologic footrest attached to the operating table. Leg support that can be lowered for the leg being operated on. Minimally invasive anterolateral approach without dissection of muscles or tendons. Resection of the femoral neck and removal of the femoral head. Preparation of the acetabulum and implantation of the cup. Hyperextension of the leg by lowering the leg support with subsequent adduction and external rotation beneath the elevated contralateral leg. Preparation of the femur and implantation of the stem with subsequent repositioning and wound closure. RESULTS: 185 total hip replacements were performed with this positioning and surgical technique from September 2004 to June 2005. The first 108 minimally invasive procedures were compared with 117 conventional procedures. The patients operated in minimally invasive technique generally did better in terms of operating time, blood loss, use of analgesics, rehabilitation time, and functional outcomes. In seven patients, shaft fissures occurred within the first 3 months due to too abrupt intraoperative dislocation of the leg (learning curve!), but were all treated by application of cerclage and healed uneventfully.     

Slipped capital femoral epiphysis

SCFE is one of the most potentially damaging conditions of the adolescent hip. The onset may be associated with minor trauma but is often insidious and may present as vague thigh or knee pain. The lateral radiograph is the most sensitive view for detection of a low-grade slip. The contralateral hip must be examined carefully as there may be bilateral disease with the pain and disability of the presenting side masking the symptoms of less involved hip. SCFE is occasionally associated with other metabolic and endocrinologic disease, and these should be screened for in the history and physical examination. Once a slip begins, the hip remains at jeopardy for acute progression until the physeal plate closes. We recommend immediate surgical stabilization and prefer a cannulated screw system. Proper technique is critical to safe and reliable surgery. The most common complications, AVN and chondrolysis, are often related to technical errors and should be minimized with attention to detail.     

Enhanced computed tomographic techniques for the evaluation of total hip arthroplasty

Computed tomography (CT) has revolutionized the evaluation of musculoskeletal pathology. Until recently, however, CT of the postoperative orthopaedic patient has been severely limited by its inability to provide useful information in the vicinity of acetabular and femoral implants. Typically the hardware produces extensive artifacts that can markedly degrade the whole image. Methods are now available to reduce the metal artifact. Following hip arthroplasty, these methods have been used to plan for revision arthroplasty and to evaluate the contralateral side for avascular necrosis.     

Bone Mineral Density in the Proximal Femur and Contralateral Knee After Total Knee Arthroplasty

Osteoarthrosis (OA) is often associated with pain and disability, which are relieved after total knee arthroplasty (TKA), but the nature of bone changes associated with OA is controversial. We examined preoperative hip and contralateral knee bone mineral density (BMD) in patients requiring TKA and monitored the BMD changes postoperatively. Sixty-nine patients, scheduled to have TKA for osteoarthrotic knees, had both hips and contralateral knee BMD measured by dual-energy X-ray absorptiometry (DXA) at the time of operation (baseline) and at 1 yr after operation. X-rays of the knee joints were also taken to evaluate the severity of OA. Preoperatively, 27% and 38% of the patients had total hip BMD Z-score more than 1 SD in the operated side and contralateral hips, respectively. In all regions of interest (ROI), the mean baseline BMD of the affected side proximal femur was significantly lower than that of the contralateral side (p < 0.0005-0.019). The severity of OA was not associated with BMD. During 1-yr follow-up, the postoperative knee status and the physical activity of the patients (AKS score) improved. However, neither the hip nor the nonoperated knee BMDs increased. Knee OA is associated with significantly lower BMD values in the affected side compared with the contralateral hip, and these levels remained similar or decreased during a 1-yr follow-up. We conclude that improved mobility after TKA does not improve the effects of preoperative disuse-associated bone loss in the short term.     

Bilateral slipped capital femoral epiphysis: predictive factors for contralateral slip

The primary goal in treatment of slipped capital femoral epiphysis (SCFE) is to prevent further slip by stabilizing the physis. Debate exists concerning prophylactic fixation of the uninvolved hip at presentation. Our goal was to determine predictive factors for a contralateral slip after presentation with a unilateral SCFE.Ninety patients with SCFE and complete radiographs were followed up until the bilateral closure of the proximal femoral physis. Chronological age at presentation, sex, and race were recorded. Open or closed triradiate cartilage was recorded, and a modified Oxford bone age assessment was performed. Twenty patients (22%) had bilateral SCFE at presentation, and 70 patients (78%) were unilateral. Of these 70 patients, 16 (23%) later developed a contralateral SCFE. Analysis revealed that chronological age was the only significant (P = 0.010) predictor for developing a contralateral slip. All girls younger than 10 years and all boys younger than 12 years who presented with unilateral SCFE developed a contralateral slip. Twenty-five percent of girls younger than 12 years and 37% of boys younger than 14 years developed a contralateral slip. No girl older than 13 years and no boy older than 14 years developed a contralateral slip in our series. Surgical complications were infrequent and isolated to the side of the initial SCFE.Chronological age is a predictor for a contralateral slip in patients presenting with a unilateral SCFE. The authors recommend that all girls younger than 10 years and all boys younger than 12 years presenting with unilateral SCFE should undergo strong consideration for prophylactic screw fixation on the contralateral side. In older age groups, prophylactic treatment may be considered on a case-by-case basis.     

Osteosynthesis with the Hook-Pin in Slipped Capital Femoral Epiphysis

Osteosynthetic materials, such as metallic nails, screws, pins, and bone pegs, used in the surgical treatment of slipped capital femoral epiphysis, have caused peroperative problems because of increased displacement of the femoral head and postoperative problems because of bone resorption and growth of the femoral neck, resulting in loosening of the osteosynthetic material and reslipping of the femoral head. Premature closure of the growth plate and shortening of the femoral neck have also been registered.

In order to avoid these problems, a hook-pin was developed. This device has now been in use for a period of 6 years and has been applied in 38 cases, the pin being placed in a drilled channel with the hook in the femoral head. The operation has been performed on the slipped side with or without reduction of displacement and on the asymptomatic side. Seventy-five hips have been operated on.

The advantages of the hook-pin and of the operative technique are presented. No avascular necrosis has been noted in 74 hips pinned in situ or after closed reduction. Avascular necrosis occurred in one hip after femoral neck osteotomy. All 28 asymptomatic hips and 27 out of 37 hips with slipped epiphyses showed no tendency toward premature closure during a postoperative observation period of 1-6 years. The growth in length of the femoral neck was found to be up to 15 mm, almost the same on the slipped side as on the asymptomatic side.

Only one of the 75 hips required reoperation because of resorption around the hook-pin.

After the end of the growth period the hook-pin was extracted in 19 hips without problems.     

Premature closure of the triradiate cartilage. A case report and animal experiment

Traumatic premature fusion of the triradiate cartilage is a rare complication of fractures of the pelvis in children. Only five cases were reported, leading eventually to subluxation of the hip. A case of premature closure of the triradiate cartilage where the injury occurred at the age of four years is reported. Severe hip subluxation with marked shallow acetabulum and widening of its medial wall was noted at the age of 15 years. Intrapelvic epiphysiodesis of the triradiate cartilage, without disturbing the hip joint, was performed in young rabbits, leading to thickening of the acetabular medial wall and subluxation of the hip. Fusion of the triradiate cartilage in young age leaves the growth plate inside the acetabulum intact, it continues to grow, displacing the acetabulum laterally. As the acetabulum becomes more shallow, the hip progresses to subluxation.     

Options for correction of post-traumatic length discrepancies in forearm bones in children (case reports)

Correction of radius length after a premature complete or partial closure of the distal epiphyseal plate is important for both the correction of radial deviation of the hand and the restoration of normal function of the radiocarpal articulation. This study comprised four patients. Two children with complete closure of the epiphyseal plate of the distal radius underwent callotaxis. One patient was treated for atrophic pseudoarthrosis of the distal radial metaphysis by external fixation and subsequent spongioplasty. One patient with partial closure of the epiphyseal plate was treated by physeal distraction. In each patient an Ilizarov's external fixator was applied. The full correction of radius length was achieved in all cases. No complications were recorded with the exception of tissue irritation around Kirchner's wires, which occurred mainly on the volar side. In the therapy of injuries suffered during adolescent growth acceleration, it is necessary to perform a certain overdistraction of the radius. An alternative method includes epiphyseodesis of the distal ulna. Key words: post-traumatic closure of the epiphyseal plate, callotaxis, physeal distraction, chondrodiatasis.     

Fixation of Subtrochanteric Fractures in Two Patients with Osteopetrosis Using a Distal Femoral Locking Compression Plate of the Contralateral Side

Osteopetrosis or Albers-Sch?nberg disease is a rare inherited skeletal disorder characterized by increased osteodensity and modeling defects. The fragility of such dense bone may lead to an increased incidence of fractures, especially on the hip and proximal femur. These fractures can pose problems during surgery, as the bones are hard and no medullary cavity is available for intramedullary nailing. Here we report our experience of two sisters who both presented with a subtrochanteric fracture that was fixed using a distal femoral locking compression plate (DF-LCP; Synthes, Obedors, Switzerland) of the contralateral side.     

Prediction of the strength and fracture location of the femoral neck by CT-based finite-element method: a preliminary study on patients with hip fracture

The purpose of this study was to predict fracture load and fracture location of the femora by means of the originally developed CT-based finite-element method (FEM). The femora of ten patients with contralateral hip fracture were analyzed to estimate fracture strength and to investigate whether the predicted fracture locations were similar to those of contralateral hip fractures. FEM has been utilized to determine the stress or strain distribution in bones under a certain load. FEM analyses of the strength of the femora in cadavers and patients have been reported, but those of hip fracture patients have not been analyzed. The femora of ten patients with contralateral hip fracture and those of three volunteers were analyzed based on the axial CT images of the whole femora. Prediction of hip fracture load and failure locations was made using CT-based finite-element analysis software. The predicted strength of the patients was less than half that of volunteers, and the predicted fracture lines existed at the proximal femur in all patients. It can be concluded that the FEM analyses adopted in this study are able to predict the fracture locations and load of the femora in patients with hip fracture.     

Bilateral synovitis in symptomatic unilateral transient synovitis of the hip: An ultrasonographic study in 56 children

56 children with a clinical diagnosis of unilateral transient synovitis of the hip underwent bilateral sonographic assessment. On the anterior scan, the distance between the femoral neck and the fibrous joint capsule was measured. This distance, which we call the synovial capsular complex distance, was compared with age-dependent normal values. An in-creased distance was found in all 56 symptomatic hips (mean 10 mm, SD 1.8). This distance was also increased in 14 hips on the contralateral side (mean 8 mm, SD 1.6). An effusion was demonstrated in 53 symptomatic hips and in 8 hips on the contralateral side. These findings indicate that in one quarter of children with symptoms of unilateral transient synovitis the contralateral hip may have an increased synovial capsular complex distance due to synovial swelling or joint effusion, suggesting an asymptomatic synovitis. We therefore recommend a comparison of the synovial capsular complex distance on the symptomatic side with age-related normal values, in addition to a comparison with the asymptomatic hip.