Vascular safe zones for surgical dislocation in children with healed Legg-Calvé-Perthes disease

Latarjet as a primary and revision procedure for anterior shoulder instability - A comparative study of survivorship, complications and functional outcomes in the medium to long-term

BACKGROUND

This retrospective study aims to compare the outcome of the Latarjet procedure when used as a primary or revision procedure for recurrent anterior gleno-humeral instability.

METHODS

One hundred and ninety-seven patients underwent 205 open Latarjet procedures during the period 2006-2015 (mean follow-up 5.6 years). Sixty shoulders had failure of a previous stabilisation requiring revision to the Latarjet procedure. Outcomes were measured using the Western Ontario Shoulder Instability Index and Quick Disabilities of the Arm, Shoulder and Hand score. Survival analyses were performed using Kaplan-Meier curves, and multiple linear regression modelling was utilised to identify predictors of functional outcome (p < 0.05).

RESULTS

Two shoulders had recurrent dislocations in the cohort of 205 (1.0%). Six shoulders underwent further surgery for non-instability complications (2.9%). There were no significant differences in the clinical or functional outcome between patients undergoing a primary Latarjet procedure and those who required revision of a failed soft-tissue stabilisation. Ninety-two per cent of patients were satisfied with their shoulder following surgery. Patient-reported instability and satisfaction was significantly associated with poorer functional scores.

DISCUSSION

The Latarjet procedure successfully prevents recurrent anterior instability and is associated with high levels of satisfaction. Patient-reported outcome measures suggest no difference between primary and revision procedures.

Vascular Supply to the Femoral Head in Patients With Healed Slipped Capital Femoral Epiphysis

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is one of the most common hip disorders. The vascularity of the lateral epiphyseal vessels supplying the femoral head in patients with healed SCFE has not been well defined. The purpose of this study was to characterize the location and number of lateral epiphyseal vessels in young adults with healed SCFE.

METHODS

This was a retrospective study of 17 patients (18 hips) with a diagnosis of SCFE and a matched control group of 17 patients (17 hips) with developmental dysplasia of the hip. All patients underwent high-resolution contrast-enhanced magnetic resonance imaging to visualize the path of the medial femoral circumflex artery and the lateral epiphyseal arterial branches supplying the femoral head.

RESULTS

There were 5 unstable SCFEs and 13 stable SCFEs with an average slip angle of 31 degrees. (All patients had been treated with in situ pinning and screw removal). Average age at time of magnetic resonance imaging was 24.5 years (range, 15 to 34 y). The lateral epiphyseal vessels reliably inserted on the posterior-superior aspect of the femoral neck from the superior-anterior to the superior-posterior position in both the SCFE and control groups. An average of 2 (±0.8) retinacular vessels were identified in the SCFE group compared with 5.2 (±0.7) retinacular vessels in the control group (P<0.001).

CONCLUSIONS

In healed SCFE, the lateral epiphyseal vessels reliably insert in the same anatomic region as patients with hip dysplasia; however, the overall number of vessels is significantly lower.

Skeletal immaturity, rostral sparing, and disparate hip morphologies as biomechanical causes for Legg-Calvé-Perthes' disease

Legg-Calvé-Perthes' (Perthes') disease is a developmental disease of the hip joint that may result in numerous short and long term problems. The etiology of the disease remains largely unknown, but the mechanism is believed to be vascular and/or biomechanical in nature. There are several anatomical characteristics that tend to be prevalent in children with Perthes' disease, namely: skeletal immaturity, reduced height, and rostral sparing. We present an overview of the literature, summarizing the current understanding of the pathogenesis, particularly related to how the formation of the vasculature to the femoral epiphysis places children aged 5-8 at a higher risk for Perthes' disease, how skeletal immaturity and rostral sparing could increase the probability of developing Perthes' disease, and how animal models have aided our understanding of the disease. In doing so, we also explore why Perthes' disease is correlated to latitude, with populations at higher latitudes having higher incidence rates than populations closer to the Equator. Finally, we present five hypotheses detailing how Perthes' disease could have a biomechanical cause. Clin. Anat. 29:759-772, 2016. © 2016 Wiley Periodicals, Inc.

High-grade SCFE: the role of surgical hip dislocation and reduction

The patient with an unstable slipped capital femoral epiphysis poses a challenging problem to the treating physician to improve the position of the displaced epiphysis to avoid femoroacetabular impingement without developing avascular necrosis (AVN)-a potentially devastating complication. Although the standard operative procedure of in situ pinning following an incidental reduction while positioning the patient on the table, has been the mainstay of treatment in North America, other viable options are available including a surgical dislocation approach to the hip followed by a modified Dunn osteotomy with control of the retinacular vessels, reduction of the epiphysis, and internal fixation with pins or screws. Although technically demanding, this approach offers an opportunity to reduce the epiphysis to avoid femoroacetabular impingement, and limit the possibility for the development of AVN. The early results for this procedure are promising with all studies demonstrating excellent reduction of the epiphysis and an overall lower incidence of AVN when compared with in situ pinning.

Application of the surgical dislocation approach to residual hip deformity secondary to Legg-Calvé-Perthes disease

Long-term prognosis after Legg-Calvé-Perthes disease (LCPD) depends on the severity of residual hip deformities including a nonspherical femoral head, a short and wide femoral neck, a high riding greater trochanter, and secondary changes in the acetabulum. Hip deformity after healed LCPD may lead to abnormal hip mechanics including femoroacetabular impingement and hip instability secondary to acetabular dysplasia. The surgical dislocation approach has recently been applied to LCPD hip deformity with encouraging short-term results. This approach allows complete dynamic evaluation of the hip joint, identification, and correction of the most common residual deformities. The purpose of this paper is to describe the application of the surgical hip dislocation approach to LCPD deformity and to evaluate the current available literature on the results of this approach to the healed LCPD hip.

Nonarthroplasty hip surgery for early osteoarthritis

The most favorable mechanical environment for the hip is one that is free of both instability and impingement, creating a concentric articulation with optimum femoral head coverage by the acetabulum. Anatomic variations such as acetabular dysplasia with associated instability, and femoroacetabular impingement with abnormal constraint, will lead to abnormal joint mechanics, articular damage, and osteoarthritis. Surgical techniques such as periacetabular osteotomies, and femoral and acetabular osteoplasties enable correction of anatomic variations that cause mechanical damage to the hip joint, thereby potentially preventing or delaying development of osteoarthritis and subsequent need for joint replacement.

Imaging SCFE: diagnosis, treatment and complications

Slipped capital femoral epiphysis (SCFE) is a common orthopedic disorder in children. It can lead to avascular necrosis, cartilage loss, femoroacetabular impingent (FAI) and early osteoarthritis. The consequences of SCFE are worsened by delays in diagnosis and proper management. Radiography is the primary imaging modality used to evaluate SCFE; however, MR, CT and bone scintigraphy have important roles. Preoperatively, these modalities assist in surgical planning and predicting prognosis; postoperatively, they provide assessment of hardware failure, ischemic necrosis and morphology predisposing to FAI. Emphasizing a multimodality approach, this review addresses the imaging diagnosis of SCFE, the expected postoperative appearances and the findings of immediate and long-term complications.