Kai Ziebarth

Treatment of slipped capital femoral epiphysis with a modified Dunn procedure.

BACKGROUND Surgical procedures with use of traditional techniques to reposition the proximal femoral epiphysis in the treatment of slipped capital femoral epiphysis are associated with a high rate of femoral head osteonecrosis. Therefore, most surgeons advocate in situ fixation of the slipped epiphysis with acceptance of any persistent deformity in the proximal part of the femur. This residual deformity can lead to secondary osteoarthritis resulting from femoroacetabular cam impingement. METHODS We retrospectively assessed the cases of twenty-three patients with slipped capital femoral epiphysis after surgical correction with a modified Dunn procedure, an approach that included surgical hip dislocation. The study reviewed the clinical status and radiographs made at the time of surgery, as well as the intraoperative findings. At a minimum follow-up of twenty-four months after surgery, the motion of the treated hip was compared with the motion of the contralateral hip, and the radiographic findings related to the anatomy of the femoral head-neck junction, as well as signs of early osteoarthritis or osteonecrosis, were evaluated. RESULTS Twenty-one patients had excellent clinical and radiographic outcomes with respect to hip function and radiographic parameters. Two patients who developed severe osteoarthritis and osteonecrosis had a poor outcome. The mean slip angle of the femoral head of 47.6° preoperatively was corrected to a normal value of 4.6° (p < 0.0001). The mean flexion and internal rotation postoperatively were 107.3° and 37.8°, respectively. The mean range of motion of the treated hips was not significantly different (p > 0.05) from that of the normal, contralateral hips. Of the eight hips that were considered unstable in the intraoperative clinical assessment, six had been considered stable preoperatively. CONCLUSIONS The treatment of slipped capital femoral epiphysis with the modified Dunn procedure allows the restoration of more normal proximal femoral anatomy by complete correction of the slip angle, such that probability of secondary osteoarthritis and femoroacetabular cam impingement may be minimized. The complication rate from this procedure in our series was low, even in the treatment of unstable slipped capital femoral epiphysis, compared with alternative procedures described in the literature for fixation of slipped capital femoral epiphysis.

Femoroacetabular cam-type impingement: Diagnostic sensitivity and specificity of radiographic views compared to radial MRI

PURPOSE To retrospectively assess the diagnostic sensitivity of 45° Dunn view and cross-table lateral radiographs for the assessment of cam deformity by comparison with radial MRI. MATERIALS AND METHODS 60 cases with radiographs (38 a-p and 45° Dunn views, 22 a-p and cross-table lateral views) and radial MRI were assessed. Alpha angle measurements were obtained both for radiographs and radial MRI. Statistics included frequency analysis, bivariate linear correlation analyses of MRI and radiograph measurements and cross-table analyses testing for the sensitivity and specificity of radiographs for the detection of an alpha angle larger than 55°. RESULTS 53.3% had the maximum alpha angle in the superior-anterior aspect of the femoral head-neck junction. Cam deformity was found in 45/60 cases (75%) in radial MRI. Pearson correlation demonstrated the Dunn view was most accurate for the superior-anterior aspect (.772, P<.001). The cross-table lateral views were best suited for the anterior-superior aspect (.511, P<.05). The sensitivity for cam deformity in the Dunn view was 96.4% vs. 70.6% in the cross-table lateral view. CONCLUSION The 45° Dunn view can improve the first line of impingement diagnostics. Radial MRI however remains indispensable for pre-operative planning and the evaluation of symptomatic cases without obvious deformity.

Mid-term results of transphyseal anterior cruciate ligament reconstruction in children and adolescents

BACKGROUND Optimal therapy for anterior cruciate ligament (ACL) rupture in the paediatric population still provokes controversy. Although conservative and operative treatments are both applied, operative therapy is slightly favored. Among available surgical techniques are physeal-sparing reconstruction and transphyseal graft fixation. The aim of this study was to present our mid-term results after transphyseal ACL reconstruction. METHODS Fifteen young patients (mean age=12.8±2.6, range=6.2-15.8 years, Tanner stage=2-4) with open physis and traumatic anterior cruciate rupture who had undergone transphyseal ACL reconstruction with unilateral quadriceps tendon graft were prospectively analyzed. All children were submitted to radiological evaluation to determine the presence of clearly open growth plates in both the distal femur and proximal tibia. Postoperatively, all patients were treated according to a standardized rehabilitation protocol and evaluated by radiographic analysis and the Lysholm-Gillquist and IKDC 2000 scores. Their health-related quality of life was measured using the SF-12 PCS (physical component summary) and MCS (mental component summary) questionnaires. RESULTS Mean postoperative follow-up was 4.1 years. Mean Lysholm-Gillquist score was 94.0. Thirteen of the 15 knees were considered nearly normal on the IKDC 2000 score. The mean SF-12 questionnaire score was 54.0±4.8 for SF-12 PCS and 59.1±3.7 for SF-12 MCS. No reruptures were observed. Radiological analysis detected one knee with valgus deformity. All patients had a normal gait pattern without restrictions. CONCLUSION Transphyseal reconstruction of the anterior cruciate ligament shows satisfactory mid-term results in the immature patient.

Clinical stability of slipped capital femoral epiphysis does not correlate with intraoperative stability

BackgroundThe most important objective of clinical classifications of slipped capital femoral epiphysis (SCFE) is to identify hips associated with a high risk of avascular necrosis (AVN) — so-called unstable or acute slips; however, closed surgery makes confirmation of physeal stability difficult. Performing the capital realignment procedure in SCFE treatment we observed that clinical estimation of physeal stability did not always correlate with intraoperative findings at open surgery. This motivated us to perform a systematic comparison of the clinical classification systems with the intraoperative observations.Questions/purposesWe asked: (1) Is the classification of an acute versus chronic slip based on the duration of symptoms sensitive and specific in detecting intraoperative disrupted physes in patients with SCFE? (2) Is the stable/unstable classification system based on clinical symptoms sensitive and specific in detecting intraoperative disrupted physes in patients with SCFE?MethodsWe retrospectively reviewed 82 patients with SCFE treated by open surgery between 1996 and 2009. We classified the clinical stability of all hips using the classifications based on onset of symptoms and on function. We classified intraoperative stability as intact or disrupted. We determined the sensitivity and specificity of two classification systems to determine intraoperative stability.ResultsComplete physeal disruption at open surgery was seen in 28 of the 82 hips (34%). With classification as acute, acute-on-chronic, and chronic, the sensitivity for disrupted physes was 82% and the specificity was 44%. With the classification of Loder et al., the values were 39% and 76%, respectively.ConclusionCurrent clinical classification systems are limited in accurately diagnosing the physeal stability in SCFE.Level of EvidenceLevel III, retrospective diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

The Locking Compression Paediatric Hip Plate™: technical guide and critical analysis

PurposeOsteotomies of the proximal femur and stable fixation of displaced femoral neck fractures are demanding operations. An LCP Paediatric Hip Plate™ was developed to make these operations safer and less demanding. The article focuses on the surgical technique and critically analyses the device.MethodsBetween 2006 and 2008, 30 hips in 22 patients underwent surgery. Patients’ demographics, perioperative details, postoperative outcome and complications were retrospectively collected and analysed.ResultsPatients’ diagnoses included persistent congenital hip dysplasia (n = 4), neuropathic hip dysplasia (n = 9), idiopathic ante/retroversion (n = 8), femoral neck fracture (n = 3), Perthes’ disease (n = 2), deformity after slipped capital femoral epiphysis (SCFE), congenital femoral neck pseudarthrosis, deformity after pelvic tumour resection and malunion following proximal femoral fracture (one each). In 21 of 22 patients, the postoperative radiographs showed corrections as planned. Two cases had to be revised for screw loosening. Intraoperative handling using the plate was excellent in all cases.ConclusionsIn our case series of 30 hip operations, the LCP Paediatric Hip Plate™ was shown to be safe and applicable in the clinical setting with excellent results and a low complication rate. We consider that the LCP Paediatric Hip Plate™ is a valuable device for correction of pathological conditions of the proximal femur and for fixation of displaced femoral neck fractures in children. Larger studies should be carried out to better quantify the risk of clinically relevant complications.

Anterior cruciate ligament injuries in children and adolescents: A review of the recent literature

In contrast to the treatment of avulsion lesions of the anterior cruciate ligament (ACL) the management of intrasubstance ACL tears in the skeletally immature patient remains controversial. Prospective studies could show that conservative treatment results in severe instability with concomitant intraarticular damage and poor function of the knee. Reconstruction of a torn ACL always carries the risk of damaging the open growth plates; with consecutively affecting the longitudinal or axial growth of the lower extremity either on the femoral or the tibial side. Thus, several surgical procedures are available to prevent adverse events mentioned above. The purpose of this study is to review the recent literature regarding the treatment algorithm for ACL injuries in skeletally immature patients. This review will (1) investigate the indications for ACL surgery in children; (2) determine if a surgical procedure is clinically superior in skeletally immature patients; and (3) correlate the adverse events with the surgical technique.

An unusual cause of paralysis of the peroneal nerve: a report of 3 cases

We present 3 cases of a 12-year-old boy, an 8-year-old girl, and a 9-year-old boy with progressive paresis of the peroneal nerve. Peroneal intraneural ganglia are a rare cause of paralysis of the lower limb in children; more often these symptoms occur because of exostosis. Ultrasound imaging in both patients showed a cystic mass near the fibular neck. Magnetic resonance imaging examination revealed that the ganglion is communicating with the proximal tibiofibular joint. Surgical exploration in these patients confirmed a cystic formation involving the common peroneal nerve. The ganglion originates from the articular nerve branch to the proximal tibiofibular joint. Total recovery of nerve function was seen 2 years later for the first patient, whereas the other 2 showed immediate postoperative improvement of peroneal nerve function and complete recovery within 6 to 8 weeks. On the other hand, patients with exostosis showed varying outcomes. In children with symptoms suspicious of nerve compression, fast diagnosis and immediate treatment are necessary to ensure the best possible recovery.

Fractures in Children and Adolescents

Fractures of the growing bone require fixation techniques, which preclude any injury to the growth plate regions. This requirement is met by Elastic Stable Intramedullary Nails (ESIN) which are positioned between both metaphyseal regions. Pronounced malposition and/or shortening, open fractures and fractures with impending skin perforation are indications for clavicle nailing in adolescents. Retrograde nailing with two elastic nails, inserted from lateral, is the method of choice for stabilization of humerus fractures. In radial neck fractures with severe tilting of the radial head, a retrograde nail may reduce and fix the head. In Monteggia lesions, the ulna fracture is reduced and fixed with an antegrade nail. Forearm fractures with unacceptable axial deviation are reduced and fixed with one antegrade nail in the ulna and a retrograde nail in the radius. Ascending elastic nailing is done for femur shaft and proximal femur fractures. The medial and lateral entry sites are located above the distal physis. End caps are used to prevent shortening in spiral and multiple segment fractures. Fractures of the distal third of the femur are nailed in a descending technique. The entry sites of two nails are located on the lateral cortex below the greater trochanter. Combined tibia and fibula fractures, open fractures and unstable fracture types such as spiral and multifragmental tibia fractures are good indications for ESIN. Descending nailing is the method of choice. The nail entry points are medially and laterally distal to the apophysis of the proximal tibia. Thorough knowledge of each fracture type, fracture location and age specific healing pattern is necessary for safe and effective treatment of pediatric fractures.

Four years follow-up after clavicle reconstruction in a child: A case report

Clavicle reconstruction is a rare operation. In most cases a mid-shaft defect of the clavicle is bridged by using different grafting techniques or musculo-osteous flaps. In some clinical situations where reconstruction is not a suitable option claviculectomy as a salvation procedure has proven to be an acceptable solution. In the paediatric population the challenge of both the cosmetic and the functional result attempting reconstruction of large bone defects is of higher demand. To our knowledge, this is the first case of a successful clavicle reconstruction with a sufficient follow-up using a free vascularised fibula graft in a child. This case provides a technique description, considerations in the paediatric population, an overview of other techniques used, and a long-term follow-up.

The modified Dunn procedure for slipped capital femoral epiphysis: the Bernese experience

Abstract Purpose Based on previous investigations on the vascular blood supply to the femoral head, a technique for anatomical reduction after slipped capital femoral epiphysis was developed. This technique is a modification of the original technique by Dunn using a retinacular soft-tissue flap. This allows the visual control of the epiphyseal vascular blood supply. We report the experience at the inventor’s institution with a critical discussion of the available literature. Methods Using a trochanteric osteotomy for surgical dislocation of the hip, a retinacular soft tissue flap is created containing the deep branch of the medial femoral circumflex artery, the external rotators and the capsule. The femoral epiphysis can be mobilised safely and reduced on the femoral neck after resection of the almost constantly present reactive metaphyseal callus. Results In our institution, the rate of avascular necrosis with 2% is comparably low to Dunn’s original results. It is only present in cases where no bleeding was already evident before reduction of the epiphysis. The ten-year long-term results are favorable in these cases with a good functional result and only little progression of osteoarthritis. However, other authors have reported higher rates of avascular necrosis up to 24% in their initial experience. Conclusions In experienced hands using the correct meticulous surgical technique, the results are favorable regarding the rates of avascular necrosis, the functional outcome and the development of radiographic osteoarthritis – even in acute and severe cases. Avascular necrosis is rare but can be observed if there is no evidence of intra-operative femoral head perfusion before and after reduction of the epiphysis.