Epiphysenlösung

The clinical value of preoperative 3D planning and 3D surgical guides for Imhäuser osteotomy in slipped capital femoral epipysis: a retrospective study

BACKGROUND

Accurate repositioning of the femoral head in patients with Slipped Capital Femoral Epiphysis (SCFE) undergoing Imhäuser osteotomy is very challenging. The objective of this study is to determine if preoperative 3D planning and a 3D-printed surgical guide improve the accuracy of the placement of the femoral head.

METHODS

This retrospective study compared outcome parameters of patients who underwent a classic Imhäuser osteotomy from 2009 to 2013 with those who underwent an Imhäuser osteotomy using 3D preoperative planning and 3D-printed surgical guides from 2014 to 2021. The primary endpoint was improvement in Range of Motion (ROM) of the hip. Secondary outcomes were radiographic improvement (Southwick angle), patient-reported clinical outcomes regarding hip and psychosocial complaints assessed with two questionnaires and duration of surgery.

RESULTS

In the 14 patients of the 3D group radiographic improvement was slightly greater and duration of surgery was slightly shorter than in the 7 patients of the classis Imhäuser group. No difference was found in the ROM, and patient reported clinical outcomes were slightly less favourable.

CONCLUSIONS

Surprisingly we didn't find a significant difference between the two groups. Further research on the use of 3D planning an 3D-printed surgical guides is needed.

TRIAL REGISTRATION

Approval for this study was obtained of the local ethics committees of both hospitals.

[Evaluation of care for slipped capital femoral epiphysis (SCFE) in Germany]

INTRODUCTION

The treatment concept for slipped capital femoral epiphysis is still controversial. According to studies, there is currently no recommendation for a universal approach. Therefore, the aim of this study is to analyze the care reality of children with ECF in Germany.

METHODS

The evaluation of the study is performed based on a questionnaire sent to physicians tending to ECF in 2021. Data is compared to the literature.

RESULTS

36 of 47 questionnaires sent out were included. Overall, no significant difference in ECF care was proven in terms of annual caseload or the size of hospital.

CONCLUSION

A high variance in operative SCFE treatment is reported. According to current literature, the modified Dunn procedure is considered the best therapeutic option to date, especially for patients with severe or chronic ECF. However, compared with alternative care options, this is not feasible in every hospital due to its complicating and challenging nature. Central registration, minimum volume regulation, and expansion of continuing education measures can contribute to optimization.

[Slipped capital femoral epiphysis: clinical presentation, diagnostic procedure and classification]

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is a frequent chronic and often bilateral atraumatic slippage of the epiphysis relative to the femoral neck in adolescence. The success of the treatment depends on the extent of the slippage and possible complications.

OBJECTIVES

Review on current trends in clinical examination and diagnostic imaging protocols. Commonly used imaging techniques, methods of measuring the slippage and treatment-relevant classification schemes are presented.

MATERIALS AND METHODS

An overview on the clinical findings, the diagnostic procedures and the classification of SCFE based on relevant study results and experience gained in our daily clinical practice.

RESULTS

Early diagnosis of SCFE is essential, as a delay in diagnosis regularly leads to an increase in slippage with an increased risk of subsequent damage to the blood vessels, which can lead to irreversible damage of the joint. Symptoms and findings are frequently subtle and nonspecific, often leading to delay in diagnosis and treatment and, consequently, to the manifestation of massive deformities. X‑ray imaging is the primary imaging modality, whereas MRI, computed tomography (CT) and ultrasound are helpful in surgical planning and prognostic evaluation. Postoperatively, they provide information on short and long-term complications.

DISCUSSION

The delay in the diagnosis of SCFE is still present in the literature as well as in our own patient population, indicating that a repeated, consistent training on this topic is essential to prevent harm to patients. Whether patients benefit from advanced imaging techniques such as MRI or CT is questionable and should be screened case by case.

[Early and late complications and their management in slipped capital femoral epiphysis]

BACKGROUND

Slipped capital femoral epiphysis (SCFE) remains a challenge for the treating surgeon. First of all, SCFE should be diagnosed as early as possible. The earlier the diagnosis is made in adolescents, the lower the slip angle will be. Mild slips show more favourable long-term courses than moderate and severe SCFE.

COMPLICATIONS

With increasing slip angle, the risk of complications increases. The complications of SCFE are diverse, the most severe of which are avascular necrosis (AVN) and chondrolysis. AVN is more common in surgically treated than in non-operatively managed patients and unstable SCFE bears the highest risk of AVN.

THERAPY

Adequate treatment of AVN is still controversial. For surgical treatments, variable rates of AVN have been reported. There is a wide spectrum of surgeries for treating AVN, from hip joint-preserving techniques to total hip replacement. In central Europe there is wide consensus in favour of treating the contralateral side, but this is not without complications. Surgical treatment with in-situ pinning must be carried out with great care to take into consideration the morphology of the femoral head and not to perforate it. It should always be ensured that no osteosynthesis material penetrates the hip joint.

Pediatric Rheumatology for the Primary Care Clinicians-Recognizing Patterns of Disease

This review presents a diagnostic approach to musculoskeletal and rheumatic diseases in children for primary care clinicians. The focus is on juvenile idiopathic arthritis (JIA) as the major arthritis disease in children. It is necessary to know the personalities of these JIA categories. It is also crucial to be able to recognize the common infectious, orthopedic and mechanical, malignant, genetic, other rheumatic diseases, and other miscellaneous syndromes that can mimic JIA. To do so requires recognition of clinical patterns using a thorough musculoskeletal and rheumatic history and repeated complete physical exams with emphasis on the musculoskeletal exam. It also requires targeted and limited laboratory testing with careful follow-up over time.

The evolution and concepts of joint-preserving surgery of the hip

The use of joint-preserving surgery of the hip has been largely abandoned since the introduction of total hip replacement. However, with the modification of such techniques as pelvic osteotomy, and the introduction of intracapsular procedures such as surgical hip dislocation and arthroscopy, previously unexpected options for the surgical treatment of sequelae of childhood conditions, including developmental dysplasia of the hip, slipped upper femoral epiphysis and Perthes’ disease, have become available. Moreover, femoroacetabular impingement has been identified as a significant aetiological factor in the development of osteoarthritis in many hips previously considered to suffer from primary osteoarthritis.

As mechanical causes of degenerative joint disease are now recognised earlier in the disease process, these techniques may be used to decelerate or even prevent progression to osteoarthritis. We review the recent development of these concepts and the associated surgical techniques.

Cite this article: Bone Joint J 2014;96-B:5–18.

Slipped capital femoral epiphysis: relevant pathophysiological findings with open surgery

BACKGROUND

Traditionally arthrotomy has rarely been performed during surgery for slipped capital femoral epiphysis (SCFE). As a result, most pathophysiological information about the articular surfaces was derived clinically and radiographically. Novel insights regarding deformity-induced damage and epiphyseal perfusion became available with surgical hip dislocation.

QUESTIONS/PURPOSES

We (1) determined the influence of chronicity of prodromal symptoms and severity of SCFE deformity on severity of cartilage damage. (2) In surgically confirmed disconnected epiphyses, we determined the influence of injury and time to surgery on epiphyseal perfusion; and (3) the frequency of new bone at the posterior neck potentially reducing perfusion during epimetaphyseal reduction.

METHODS

We reviewed 116 patients with 119 SCFE and available records treated between 1996 and 2011. Acetabular cartilage damage was graded as +/++/+++ in 109 of the 119 hips. Epiphyseal perfusion was determined with laser-Doppler flowmetry at capsulotomy and after reduction. Information about bone at the posterior neck was retrieved from operative reports.

RESULTS

Ninety-seven of 109 hips (89%) had documented cartilage damage; severity was not associated with higher slip angle or chronicity; disconnected epiphyses had less damage. Temporary or definitive cessation of perfusion in disconnected epiphyses increased with time to surgery; posterior bone resection improved the perfusion. In one necrosis, the retinaculum was ruptured; two were in the group with the longest time interval. Posterior bone formation is frequent in disconnected epiphyses, even without prodromal periods.

CONCLUSIONS

Addressing the cause of cartilage damage (cam impingement) should become an integral part of SCFE surgery. Early surgery for disconnected epiphyses appears to reduce the risk of necrosis. Slip reduction without resection of posterior bone apposition may jeopardize epiphyseal perfusion.

LEVEL OF EVIDENCE

Level IV, retrospective case series. See Guidelines for Authors for a complete description of levels of evidence.

[Coxarthrosis - a radiological approach and guidelines]

CLINICAL/METHODICAL ISSUE

Coxarthrosis is one of the most frequent indications in radiological practice with a prevalence as high as 8%.

STANDARD RADIOLOGICAL METHODS

Radiography, sonography, computed tomography, magnetic resonance imaging.

METHODICAL INNOVATIONS

Magnetic resonance arthrography for detection of early stages of labral and chondral pathologies as well as detection of osteonecrosis at an early stage.

PERFORMANCE

Czerny C, Hofmann S, Neuhold A et al. (1996) Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and staging. Radiology 200(1):225-230. Czerny C, Oschatz E, Neuhold A et al. (2002) [MR arthrography of the hip joint]. Radiologe 42(6):451-456. Kramer J, Breitenseher M, Imhof H et al. (2000) [Diagnostic imaging in femur head necrosis]. Orthopade 29(5):380-388.

ACHIEVEMENTS

Is already established in clinical practice.

PRACTICAL RECOMMENDATIONS

Each modality has relevant indications.

Magnetic resonance imaging of hip joint cartilage and labrum

Hip joint instability and impingement are the most common biomechanical risk factors that put the hip joint at risk to develop premature osteoarthritis. Several surgical procedures like periacetabular osteotomy for hip dysplasia or hip arthroscopy or safe surgical hip dislocation for femoroacetabular impingement aim at restoring the hip anatomy. However, the success of joint preserving surgical procedures is limited by the amount of pre-existing cartilage damage. Biochemically sensitive MRI techniques like delayed Gadolinium Enhanced MRI of Cartilage (dGEMRIC) might help to monitor the effect of surgical or non-surgical procedures in the effort to halt or even reverse joint damage.