Results following sub-capital and Imh?user-Weber osteotomy in femur head epiphyseolysis

63 slipped capital femoral epiphysis were treated either by a femoral neck osteotomy or by an intertrochanteric osteotomy. In almost all cases a normal anatomical relationship of the proximal capital femoral epiphysis to the neck of the femur was achieved. At an average follow-up of 10 years (2 to 19 years) 90% were rated good to excellent clinically. In 33 hips with a follow-up period of more than 10 years mild degenerative arthritis was present in 36%. Slipping of 60 degrees or less is best treated by an intertrochanteric osteotomy to avoid the higher complication rate in the femoral neck osteotomy.     

Corrective intra-articular surgery in juvenile femur head epiphysiolysis

Treatment of severely slipped capital femoral epiphysis depends on the individual pathoanatomic and pathophysiologic conditions. Since the femoral neck vessels remain intact in chronic slip, they should be preserved whenever possible. Bilateral chondrolysis developed in 1 of our 9 cervical osteotomy patients. Long-term radiologic and clinical findings after a cervical osteotomy do not differ appreciably from those after an Imh?user osteotomy, in some cases, with incomplete realignment of the femoral head-acetabulum relation. Apparently, not only the "quantitative" factor but also the "qualitative" factor plays an important role in epiphyseal separation. By contrast, severe acute slip is a severe irritation of the joint accompanied by intra-articular bleeding and rupture of the femoral neck vessels. Good results are achieved after immediate operative decompression, controlled reduction, and stable fixation of the epiphysis, providing anatomic realignment of the femoral head-acetabulum relation is not forced, but rather carried out only to the limit of tolerance without leverage maneuver and under moderate traction and vision. Epiphyseal necrosis developed after conventional open reduction in 2 of our 16 patients with acute slip. No cases of epiphyseal necrosis have been observed to date in any of our patients (N = 5) treated with this new technique of controlled reduction (i.e., partial reduction in "acute chronic slip").     

Die intertrochantäre Korrekturosteotomie nach Imhäuser

OBJECTIVE: Surgical correction of deformities of the proximal femur caused by epiphyseal displacement by restorative (usually inflection and internal rotation) osteotomy at the intertrochanteric level with the aim of reducing both the offset disorder of the coxal end of the femur that is causing impingement and the prevalence of secondary coxarthrosis. INDICATIONS: Chronic and subacute manifestations of slipped capital femoral epiphysis with an epiphyseal dislocation in the radiographic axial view of 30-60 degrees (ET angle) and DeltaED > 20 degrees (CCD angle minus ED angle) in the anteroposterior view. CONTRAINDICATIONS: Acute phase or course of slipped capital femoral epiphysis. Secondary coxarthrosis (after slipped capital femoral epiphysis). Traumatic epiphyseolysis. SURGICAL TECHNIQUE: Exposure of the proximal femur (anterior femoral neck, intertrochanteric plane, proximal femoral diaphysis) through an anterolateral approach; fixation of the femoral epiphysis with two 3.0-mm Steinmann nails positioned parallel in a posteromedial direction; the seating chisel is hammered in according to the planned, usually inflectional axial correction; intertrochanteric osteotomy by excision of a wedge oriented in accordance with preoperative planning; adaptation of the osteotomy surfaces and osteosynthesis with a 90 degrees AO adolescent plate under interfragmentary compression. POSTOPERATIVE MANAGEMENT: Mobilization on underarm crutches with unloading of the extremity for 2 months postoperatively; gradual increase in loading depending on osseous consolidation of the osteotomy; radiographic assessment 2 and 4 months postoperatively, further clinical and radiologic follow-up until growth is completed (closure of the growth plate); removal of implants at 1 year postoperatively or thereafter. RESULTS: Retrospective follow-up of 51 patients with unilateral, moderate to severe slipped capital femoral epiphysis (indication: epiphyseal displacement angle of 30-60 degrees, average preoperative displacement angle 45 degrees) that was corrected surgically by Imh?user intertrochanteric osteotomy and epiphyseal nailing. After an average observation time of 24 years (range: 20-29 years), 28 (55%) of the 51 hip joints were clinically asymptomatic and radiologically free of degenerative changes; moderate clinical and radiologic changes were recorded for 14 hip joints (28%), and advanced changes for nine (17%). Complications related to surgery were apparent in a total of six hip joints: in one case, the Steinmann nail broke after being damaged by the plate blade; in two cases, revision osteosynthesis of the intertrochanteric osteotomy was necessary due to incorrect implant positioning; partial femoral head necrosis developed in one hip joint; there were two cases of low-grade osteomyelitis that healed after implant removal.     

Acute slipped femur head epiphysis. Causes--surgical treatment--results

The juvenile slipped capital femoral epiphysis depends on a dysendocrinia during puberal acceleration. The weakening of mechanical stability of the epiphyseal cartilage leads in most of the cases to a slow, only in some cases to an acute dorsocaudal slipping of the capital femoral epiphysis. Representation of our own patients of Orthopedic University Hospital D-Homburg/Saar with altogether 27 acute slipped capital femoral epiphyses during the years 1965-1981. The early operative stabilisation seems to be most important for a good prognosis (danger of development of femoral head necrosis). The opening of the hip joint during the operation by a ventral capsulotomy facilitates the reduction and decompresses the haematoma. In consideration of the mostly slow beginning, in many cases an ideal correction could not be achieved in most of the patients. In contrast to the osteosynthesis by screws the growth in length is less influenced by using a lamellar nail or Kirschner-wires. In cases of an acute slipped capital femoral epiphysis a first conservative treatment with subsequent correction osteotomy does not seem to be justifiable, because the danger of femoral head necrosis raises drastically. In case of opportune operation and correct technique good to fair functional results can be achieved.     

Transtrochanteric anterior rotational osteotomy for slipped capital femoral epiphysis: a report of five cases

We have performed a transtrochanteric anterior rotational osteotomy on five patients with severe chronic slipped capital femoral epiphysis. Four patients were free from clinical symptoms, whereas one patient continued to feel a dull pain in the hip. Radiographic evaluation indicated that the osteotomy was able to correct even a severe slip without any deformity around the trochanteric region. There were complications in two cases: a posteromedial tilt at the osteotomy site and a focal avascular necrosis in the anterolateral epiphysis.     

Should osteotomy after Imh?user be performed immediately or only following setting and healing of epiphysiolysis of the head of the femur? (author's transl)

In slipping of the femoral epiphysis, operative treatment is necessary when slipping exceeds an amount of 30--40 degrees. Therapeutically, the three dimensional intertrochanteric osteotomy, as performed by Imh?user since 1950, has shown good results. According to a follow-up study of 130 cases, it seems to be advantageous first to carry out a fixation of the epiphysis. An intertrochanteric osteotomy should be carried out as a second step (usually after 6 to 12 months), as in the meantime an increase in range of motion can be obtained.     

Surgical treatment for severe slipping of the upper femoral epiphysis

We have used a modified technique of cervical osteotomy to treat a consecutive series of 23 patients with chronic slip of the upper femoral epiphysis. It has been successful in correcting both moderate and severe deformities with a low incidence of avascular necrosis, comparable to that seen after subtrochanteric osteotomies. We describe the operative details and discuss the features which make cervical osteotomy technically superior to intertrochanteric and subtrochanteric procedures.     

Mid-term results of concomitant epiphyseal fixation and trochanteric osteotomy for severe chronic slipped capital femoral epiphysis

The management of severe forms of slipped capital femoral epiphysis (SCFE) has been the subject of intense debate in the literature, and controversy remains as to whether the proximal femoral epiphysis should be realigned by intracapsular or extracapsular osteotomies or just fixated in situ. The aim of this study is to evaluate the late results of treatment of severe unreduced slipped capital femoral epiphyses by combined epiphyseal stabilisation in situ using a single cancellous screw and biplane corrective trochanteric osteotomy. Eighteen hips with severe chronic slipped capital femoral epiphysis before physeal closure were treated by combined epiphyseal fixation in situ using a single cancellous screw, and biplane corrective osteotomy fixed by an angled blade plate. The average follow-up period was 8 years. All patients achieved near-normal hip flexion, internal rotation and abduction, and most were able to bear weight in the early postoperative period. A satisfactory correction of the head-shaft angle was obtained post-operatively on both antero-posterior and frog leg lateral radiographs. There was no instance of chondrolysis, avascular necrosis or early osteoarthrosis. This procedure appears to offer a workable solution to the problem posed by the severely slipped capital femoral epiphysis.     

The place of threaded pin fixation in the treatment of slipped upper femoral epiphysis

Pin fixation in the treatment of slipped upper femoral epiphysis was evaluated in 60 patients admitted to the authors' hospital in Melbourne between 1970 and 1978. Forty-three cases were reviewed at an average of eight years following initial treatment. For chronic slips, in situ fixation with pins prevented further slip and promoted growth plate closure. The complication rate was low. Best results were achieved with two or three threaded pins placed into the posteroinferior segment of the femoral head to avoid avascular necrosis. Early upper femoral osteotomy was not required, as considerable bone remodeling occurred even after growth plate closure. In contrast, avascular necrosis was common following treatment of acute, severe slips, even with gentle internal rotation of the leg to reduce the acute component of the slip and pinning.     

Late results of subcapital linear osteotomy in epiphysiolysis capitis femoris juvenilis (author's transl)

107 patients with separation of the head of the femoral epiphysis were treated surgically at the Marburg Orthopaedic University Hospital during the 1955--1975 period. Followup examinations were performed in 69 patients. 34 of these had been subjected to subcapital linear osteotomy. On the average the operation had been performed 7.64 years ago. Early results were good. In most cases it was possible to correct the malposition caused by the slipping. Necroses of the femoral head were not seen more frequently than with most other methods. Necrosis of the femoral head occurred four times after 35 linear osteotomies in 34 patients. Definite roentgenological signs of arthrosis were seen about 2--3 years after the opration. These changes increased with increasing interval between operation and examination. Subcapital linear osteotomy cannot prevent the development of early arthrosis in cases where separation of the head of the femoral epiphysis exceeds 30 degrees. Despite this limitation, the patients examined during the followup study revealed a clinically favourable picture with good functioning and very considerable freedom from symptoms; it must be borne in mind in this connection that all patients were still under 35 years of age.     

Coxa vara in spina bifida

In spina bifida the femoral neck can develop either the well-known coxa valga or the hitherto unreported coxa vara. Twenty-three cases of coxa vara in spina bifida are reported. These result from spontaneous separation of the upper femoral epiphysis (10 cases), spontaneous fracture of the femoral neck (three cases) and iatrogenic avascular necrosis of the upper femoral epiphysis (10 cases).     

Sugioka's Modified Hungria-Kramer intertrochanteric osteotomy in the treatment of severe slipped capital femoral epiphysis

From May 1990 to November 1997, 24 cases of severe slipped capital femoral epiphysis were treated by an osteotomy that is a modification of the Hungria-Kramer intertrochanteric osteotomy proposed by Sugioka (Hungria-Kramer-Sugioka osteotomy or HKS osteotomy). The degree of displacement as seen on the frog-leg lateral radiograph of the proximal femur was measured according to the deviation of the longitudinal axis of the epiphysis from the center line of the neck (Fish classification). All hips were considered as grade III and underwent HKS osteotomy. Sugioka's radiographic study (true AP view with the limb internally rotated until the patella is perpendicular to the x-ray beam, and lateral view with the hip in 90 degrees flexion and 45 degrees abduction) was performed before surgery to show that the real direction of the slip was posterior in relation to the neck. Clinical results were assessed according to Merle-D'Aubigné and Postel system modified by Charnley (hip score system that takes into consideration pain, gait, and joint motion). Roentgenographic results were considered good if none of the following was present: joint space decreased by more than 2 mm (chondrolysis), avascular necrosis of the femoral head, neck-shaft angle of less than 120 degrees, nonunion at the osteotomy site, and a epiphyseal plate still open. Follow-up varied from 31 to 120 months (average 65.1 months).     

Cuneiform osteotomy of the femoral neck in the treatment of slipped capital femoral epiphysis

I reviewed the cases of eighty-two patients (106 hips) with slipped capital femoral epiphysis who were treated during a twenty-four-year period. Of these, forty-two hips had a sufficiently severe displacement to require surgical correction by means of a cuneiform osteotomy of the neck of the femur just distal to the physis. The purpose was to restore the normal anatomical relationship of the proximal capital femoral epiphysis to the neck of the femur. Follow-up of these patients ranged from two to twenty-two years, with an average of nine years and nine months. Aseptic necrosis developed in one femoral head and osteoarthritis developed in one hip. The remaining forty hips were graded as having an excellent result.     

Die subkapitale Schenkelhalsosteotomie ohne operative Hüftgelenkluxation bei Epiphyseolysis capitis femoris lenta mit hochgradigem Abrutsch

THE PROBLEM: Severe displacement in the lenta form of slipped capital femoral epiphysis leads to distinct joint incongruence with subsequent severe deformity, limitations of function and walking ability as well as early joint degeneration. THE SOLUTION: Subcapital femoral neck osteotomy restores the congruence of the hip joint as far as possible. This procedure is a so-called secondary prophylactic intervention. SURGICAL TECHNIQUE: Disimpaction of the slipped epiphysis in several planes by wedge-shaped osteotomy in the subcapital region of the femoral neck (slippage is in a posterior and caudal direction). Careful preservation of the nutrient vessels to the femoral head within the posterior capsule. Stabilization of the osteotomy with cannulated screws with a short thread. RESULTS: The data reported in the literature vary greatly with regard to frequency and extent of femoral head necrosis. The present author holds the opinion that this risk is minimal, if the surgeon proceeds with care. Nevertheless, the indications for this procedure should be chosen with great reservation.     

Juvenile unstable severe slip of the proximal femoral epiphysis: case report and review of treatment options

The authors present the case of a severe unstable slip of the proximal femoral epiphysis in a 14-year-old boy. A serious metabolic disorder diagnosed in the boy led to postponement of necessary surgical intervention. The primary development of necrosis of the proximal femoral epiphysis during the 6 months following the slip is reported here. A good outcome was eventually achieved by three-plane valgus, flexion and derotational osteotomy of the femur at second-stage surgery. The authors emphasize the prognostic importance of stability assessment in the displaced epiphysis.     

大转子股骨头互换术治疗股骨头骺早闭

作者于1990年10月至1994年10月,利用股骨转子下截骨大转子股骨头互换术,治疗股骨头骨骺早闭、大转子相对过长的髋关节病废患者5例,经随访观察,效果满意.文中讨论了本病的病理特点及其手术治疗原理和适应证.     

Intertrochanteric versus subcapital osteotomy in slipped capital femoral epiphysis

We reviewed 15 flexion intertrochanteric osteotomies and 11 subcapital osteotomies done for chronic, severe, stable slipped capital femoral epiphysis at one institution with a minimum 2 years followup. The goal was to determine which procedure achieved better deformity correction and which procedure was safer. Radiographically, the two groups were equivalent in compensating for epiphyseal slip. Flexion intertrochanteric osteotomy was more effective in restoring proximal femoral anatomy, as determined by articulotrochanteric distance and trochanter-center of head distance. The incidence of complications, including osteonecrosis and chondrolysis, was low for both groups, but the reoperation rate was greater in the subcapital osteotomy group than in the flexion intertrochanteric group. Flexion intertrochanteric osteotomy seems to be an effective, safe, and reproducible realignment osteotomy for treatment of chronic, severe, stable slipped capital femoral epiphysis.     

Follow-up study of slipped capital femoral epiphysis

We studied 50 hips in 46 patients with slipped capital femoral epiphysis (SCFE). Seven patients with acute cases were treated by closed reduction with excellent results and without any known complication. The cases in the remaining 39 patients were of the chronic type. The method of treatment was determined according to the posterior tilting angle: in situ pinning for angles less than 30 degrees, intertrochanteric osteotomy for angles between 30 and 60 degrees, and subcapital wedge osteotomy for angles greater than 60 degrees. Chondrolysis was observed in one case treated with intertrochanteric osteotomy, and chondrolysis and avascular necrosis occurred in one case of subcapital wedge osteotomy.     

Preoperative assessment for intertrochanteric femoral osteotomies in severe chronic slipped capital femoral epiphysis using computed tomography

We propose here to focus on preoperative assessment for intertrochanteric femoral osteotomies in severe slipped capital femoral epiphysis (SCFE) using computed tomography. This intertrochanteric osteotomy was preoperatively customized for each chronic SCFE patient treated, and has been performed on 22 patients with an average posterior slip angle of 55 degrees. The osteotomy is planned with images from computed tomography as follows. The angle between a provisional axis on one image and the axis of the lateral aspect of the femur on the other image is defined as alpha. When the alpha angle varies from 20 to 30 degrees, a simple flexion osteotomy is selected for correction along the axis of the lateral femur; when the alpha angle is more than 30 degrees, a flexion osteotomy along with some valgus correction should be considered; when the alpha angle is less than 20 degrees, varus correction should be added. The postoperative posterior slip angle, head-shaft angle (P < 0.05) and epiphyseal height ratio (P < 0.005) in the group using our method were superior to the Southwick group. Postoperative hip motion was nearly the same as the unaffected side. The average leg length discrepancy was 0.9 cm (range, from 0 to 2.0 cm). Reduced blood loss (P < 0.001) and shorter operation time (P < 0.001) were also noted, compared with the Southwick group. We concluded that the intertrochanteric femoral osteotomy based on this strategy minimizes the surgical complexity, resulting in a more anatomic reduction of the capital femoral epiphysis.