Dennis R. Wenger

Impingement and childhood hip disease.

Hip impingement is now recognized as a relatively common cause for hip pain in young adults. The early evolution of impingement begins in childhood in several common hip disorders (slipped capital femoral epiphysis, Perthes, early avascular necrosis due to other causes). Recognition and treatment of childhood impingement may prevent the evolution to early hip arthritis.

Foot Deformities in Infants and Children

Foot deformities may reflect a generalized disorder, especially a neurologic problem; thus, the child should have a brief general examination. Many infantile foot deformities, such as calcaneovalgus, are postural and self-correcting. Metatarsus varus is not referred for treatment until age 2 months and then only if the deformity is moderate or severe. Fixed forefoot equinus and heel varus characterize a clubfoot, which requires immediate treatment. Corrective shoes are not advised as the primary treatment for metatarsus varus or clubfoot but often are prescribed to maintain the corrected position after serial casts. Flexible flatfoot is a manifestation of a constitutional laxity affecting all ligaments and joints. The feet appear abnormal because of weight-bearing stresses. Most children with flatfoot achieve a partial correction spontaneously. Current research does not document that treatment with corrective shoes or inserts produces a result better than the partial correction that occurs naturally.

Three-dimensional characteristics of cartilaginous and bony components of dysplastic hips in children: Three-dimensional computed tomography quantitative analysis

A cartilage-viewing technique was developed to overcome the shortcoming of not seeing the cartilaginous components, believed to play more important role than the osseous components in childrens hips, with computed tomography. This technique was applied to 25 dysplastic hips in children younger than 10 years to evaluate their global and local deficiencies. The findings helped us to understand more about their individual problems. To quantify the three-dimensional (3-D) parameters of acetabular anatomy and femoral head coverage, a measuring technique was developed based on digitization of the 3-D coordinates and fitting of every component of the hip. The improved images and the quantified parameters were expected to aid the planning, formulation, and even simulation of individualized surgical treatment for children with developmental dysplasia of the hip.

Ligamentum teres maintenance and transfer as a stabilizer in open reduction for pediatric hip dislocation: surgical technique and early clinical results

PurposeThe ligamentum teres has primarily been considered as an obstruction to reduction in children with developmental dislocation of the hip (DDH). In the early surgical descriptions of both the medial (Ludloff) approach and the anterior (Salter) approach to the hip, it was generally accepted that the ligamentum teres was an obstruction to reduction and was excised (similar to the discarding of menisci for knee surgery in our orthopedic history). Because of the known propensity for early re-dislocation following open reduction, we developed surgical methods for maintaining the ligamentum teres when performing open reduction for hip dislocation in young children. This study presents the surgical methods developed for ligament maintenance and transfer, and analyzes the early clinical and radiographic results in a study group.MethodsThe techniques for open reduction by both the medial Ludloff approach and the anterior open reduction were developed and refined. Twenty-one children (23 hips) had ligamentum teres shortening and transfer performed as part of either a medial Ludloff or anterior open reduction for hip dislocation. Complete pre-operative and post-operative clinical and radiographic analysis was performed.ResultsAll patients had stable hips at follow-up. The transferred ligamentum teres appeared to provide additional stability to prevent repeat dislocation. We noted no apparent loss of hip motion or other adverse events. One patient had avascular necrosis (AVN).ConclusionsIn this series of 23 hips, in which ligamentum teres transfer/tenodesis was utilized, we found no residual subluxation or dislocation in either the medial Ludloff or the anterior open reduction groups. Based on these early positive results, we recommend the method for children treated with the Ludloff open reduction procedure. Although we have less experience with it, the technique presented for ligamentum maintenance and transfer in anterior open reduction may provide similar added stability. This is an early follow-up study, and long-term follow-up will be required to confirm the ultimate femoral head and acetabular development.

Advanced containment methods for Legg-Calvé-Perthes disease: Results of triple pelvic osteotomy

Background Although surgical containment has become a mainstay for the treatment of Legg-Calvé-Perthes (LCP) disease; traditional operations (varus osteotomy of femur, Salter osteotomy) have certain limitations, sometimes resulting in a prolonged limp or inadequate containment. This paper presents the surgical method and results of triple pelvic osteotomy for containment treatment of LCP disease. Methods This retrospective review of 39 children (40 hips; age 5 to 13 y) with LCP disease treated with triple pelvic osteotomy (1995 to 2005) included preoperative lateral pillar assessment and other measurements. Final follow-up films (minimum 3 y, range 3 to 9 y) were assessed using the modified Stulberg classification. Clinical follow-up evaluation assessed limp, limb-length inequality, range of motion, and activity level. Results Twenty-one (53%) hips were graded as lateral pillar B and 19 (48%) were lateral pillar C. Four patients required further treatment before the final follow-up. At final follow-up, 42% had a good outcome (Stulberg I/II), 47% had a fair outcome (Stulberg III), and 11% had a poor outcome. Thus, 89% of patients had satisfactory (good or fair) results. There was a significant difference in outcome based on the preoperative lateral pillar, with B hips more likely to have a good outcome (65%) compared with lateral pillar C hips (12.5%) (P=0.002). There were no lateral pillar B patients with a poor outcome. Seventeen percent of the lateral pillar C patients more than or equal to age 8 had a poor outcome compared with 50% being more than age 8 with a poor outcome. Four patients (3 lateral pillar C, 1 lateral pillar B) required further surgery. Conclusions Triple pelvic osteotomy resulted in maintenance of head shape in lateral pillar B patients of all ages and in younger lateral pillar C patients. Lateral pillar C patients over age 8 were more difficult to treat, however, we still advise containment for these cases because methods are now available to deal with containment failure. Triple pelvic osteotomy is an effective treatment method for LCP patients with lateral pillar B disease and younger patients with lateral pillar C disease. This method provides effective containment, which allows prolonged remodeling while avoiding the limitations of femoral varus osteotomy (limp, short limb) and Salter osteotomy (incomplete containment). Level of Evidence Level IV.

Superior gluteal artery injury secondary to posterior iliac crest bone graft harvesting. A surgical technique to control hemorrhage.

Study Design. This case series and cadaveric dissection illustrates a method of obtaining hemostasis of iatrogenic superior gluteal vessel injury sustained during posterior iliac crest bone graft harvesting. Objectives. To show a simple and effective method of obtaining hemostasis of the iatrogenic superior gluteal vessel injury associated with posterior iliac crest bone graft harvesting. Summary of Background Data. Management of superior gluteal vessel injury has included direct pressure, enlargement of the sciatic notch to allow for exposure of bleeding vessels, retroperitoneal or transperitoneal approaches, and angiographic embolization to obtain hemostasis. The authors present several cases and a cadaveric study to show a simple and effective technique used to control hemorrhage secondary to iatrogenic superior gluteal vessel injury sustained at the time of posterior iliac crest bone graft harvesting. Methods. The management of iatrogenic superior gluteal vessel injury secondary to posterior iliac crest bone graft harvesting involved the extension of the surgical incision, detachment of the origin of the gluteus maximus, lateral retraction of the gluteus maximus along with the tethered superior gluteal vessels, and visualization and ligation of the injured vessels. Results. Hemostasis was achieved quickly with minimal loss of blood. Additional surgery or angiographic embolization was not required. Conclusions. In the cases presented, extension of the posterior iliac bone graft incision, detachment of the origin, and reflection of the gluteus maximus provided excellent exposure and hemostasis of the iatrogenic laceration of the superior gluteal artery. This technique is simple and effective and may prevent the need for transperitoneal and retroperitoneal approaches or angiographic embolization

Hip impingement in slipped capital femoral epiphysis: a changing perspective

BackgroundFemoroacetabular impingement (FAI) as a result of slipped capital femoral epiphysis (SCFE) has recently gained significant attention. Seen as an intermediate step toward the development of early osteoarthritis, symptomatic FAI develops in SCFE patients who have residual hip deformity characterized by relative posterior and medial displacement of the capital femoral epiphysis, leading to an anterolateral prominence of the metaphysis which abuts on the acetabular rim. This results in a decreased range of hip motion as well as progressive labral damage and articular cartilage injury, which cause symptoms of FAI. All degrees of slips from mild to severe can develop impingement.MethodsThe existing literature on the subject was thoroughly reviewed and all levels of studies that have made any meaningful changes to clinical practice were considered.ResultsBased on the literature review, current practice trends, and our own institutional practice pattern, all treatment options for SCFE in the impingement era have been presented with an open discussion regarding potential benefits and limitations.ConclusionsSeveral surgical options exist for the SCFE patient who develops FAI. These are largely determined by the degree of deformity present and severity of the initial slip. Extraarticular (intertrochanteric, base of the neck) as well as subcapital osteotomies can be utilized with a goal of restoring proximal femoral anatomy in order to minimize the effect of the anterolateral prominence in more severe deformities. Patients with milder deformities can undergo osteochondroplasty of the femoral head and neck to remove impinging structures via either an open or arthroscopic approach. Also, proximal femoral osteotomy and open head–neck recontouring can be combined. Finally, patients who develop pain very early after in situ pinning must also be examined for potential iatrogenic screw-head impingement as a source of their pain and decreased hip motion, in addition to abnormalities in the proximal femoral anatomy. There are many centers that are approaching acute unstable SCFE patients as well as the more displaced stable cases with open reduction techniques that seem to be demonstrating good mid-term results. The goal of treatment is to improve patient function, alleviate hip pain, and to delay or prevent the development of early degenerative changes in adolescents and young adults. Prospective multi-center studies will be necessary so as to determine what methods work best in treatment and delay the onset and progression of osteoarthritis.Level of evidenceV.

Intramalleolar triplane fractures of the distal tibial epiphysis

The intramalleolar triplane fracture of the distal tibial epiphysis is a relatively rare injury in children. We studied five children with intramalleolar triplane fractures. Four of the five children were competitive athletes. Each child underwent computerized tomography with three-dimensional reconstruction. Delineation of the intramalleolar fracture pattern with computerized tomography with three-dimensional reconstruction demonstrated three distinct types of intramalleolar triplane fractures: I. intraarticular and within the weight-bearing zone, II. intraarticular and outside the weight-bearing zone, and III. extraarticular. Computerized tomography with three-dimensional reconstruction delineated the fracture pattern and allowed selection of the optimal treatment method. A classification scheme of the three types of intramalleolar triplane fracture is proposed.

Biomechanical stability of single-screw versus two-screw fixation of an unstable slipped capital femoral epiphysis model: Effect of screw position in the femoral neck

Purpose: To biomechanically evaluate single screw and varying 2 screw fixations for an unstable slipped capital femoral epiphysis (SCFE) model using physiologically relevant loading. Study Design: In vitro biomechanical study. Methods: Twenty-four immature porcine proximal femurs were prepared to simulate a mild-to-moderate unstable SCFE. The femurs were randomized into 4 fixation groups: single screw, 2 screws horizontally placed, 2 screws vertically placed, and 2 oblique screws. Biomechanical testing determined maximum load to failure (N), load (N) at 2, 4, 6, and 8 mm of femoral head displacement, and stiffness (newtons per millimeter) for each group. Results: No significant differences were found among the 3 different 2 screw configurations. The 2 screw constructs were 66% stiffer and 66% stronger than the single screw construct. In addition, whereas there was no difference at 2 mm of femoral head displacement, each subsequent displacement (4, 6, and 8 mm) demonstrated significantly higher failure loads when 2 screws were used for stabilization. Conclusions: Slipped capital femoral epiphysis stabilization with 2 screws leads to increased stability over single screw fixation; however, none of the 3 configurations/placement patterns of the 2 screw constructs seemed to be superior in fixation stability. Clinical Relevance: These data support the use of a 2 screw construct in acute/unstable SCFE fixation. The biomechanical benefit of 2 screws needs to be considered in the face of greater potential for inadvertent penetration into the joint with an increased number of screws.

Principles of Treating the Sequelae of Perthes Disease

Despite early treatment efforts, many patients with Perthes disease are left with residual femoral head deformity, which can be symptomatic with a residual limp and poor hip motion. Many such patients can be treated using an extra-articular femoral osteotomy. Selecting treatment methods for patients with symptomatic Perthes disease with healed but deformed femoral heads has always been difficult but is now even more complex because of the new possibilities of femoral head-neck recontouring and femoral head reduction surgery. Occasionally, patients develop osteochondritis dissecans when there is little femoral head deformity. The primary objective of management is to establish the exact cause of pain and address that cause specifically. This article outlines an approach to these patients.