Konrad Seller

Risk-benefit analysis of prophylactic pinning in slipped capital femoral epiphysis.

There is a broad and controversial discussion about the surgical procedure and the type of hardware for internal transfixation of the epiphysis and metaphysis in slipped capital femoral epiphysis (SCFE). Prophylactic pinning is even more controversial. One hundred and nine patients showing SCFE underwent a one-stage bilateral fixation of the epiphysis with three or four Kirschner wires (pins). From these 109 patients (69 male and 40 female), 94 had an unilateral slip and were operated prophylactically on the contralateral side. There were no complications such as avascular necrosis of the femoral head, chondrolysis, bone fracture, failure of metal implant, osteomyelitis or deep wound infection either at the time of surgery or at the minimum follow-up of 1 year with prophylactic pinning in SCFE. Therefore, we consider pinning allows for efficient stabilization, reliably preventing any progression of SCFE on the affected side and, furthermore, prevents the incidence of a secondary slip on the primarily nondisplaced contralateral side. The transfixation of epiphysis and metaphysis with Kirschner wires (pins) shows good subjective and objective long-term results compared with other surgical methods and implants. There is only a low morbidity rate with this method, because reoperations may only become necessary in the younger age group owing to normal growth of the femoral neck, compared with a high benefit from prophylactic surgical treatment of the nonaffected opposite side at the time of unilateral onset of the disease. The pins may no longer catch the epiphysis but further growth will allow for remodeling of the femoral head and for an optimal neck/shaft ratio. In case of further growth and relative shortening of the pins, refixation may become necessary. Therefore, we like to recommend the Kirschner-wire transfixation (pinning) of the epiphysis and metaphysis in patients with SCFE for primary treatment of SCFE as well as for prophylactic pinning of the contralateral side in one sitting.

Correction of length discrepancies and angular deformities of the leg by Blount's epiphyseal stapling

Abstract. The management of leg length difference (LLD) and angular deformities of the leg remains controversial. Numerous treatment options have been proposed over the past years depending on the patients general condition, skeletal age, function, and degree and configuration of the deformity. Our retrospective study consisted of 48 patients with 58 legs treated between 1970 and 1991 by Blounts epiphyseal stapling to equalise length or correct angular deformity. After an average follow-up of 16.5 years, all patients with idiopathic bow-legs or knock-knees (n=12) and 71% of LLD caused by overgrowth (e.g. Klippel-Trenaunay syndrome) showed good and excellent results at skeletal maturity, whereas the results of the treatment of LLD with undergrowth of the leg and angular deformities due to trauma, infection or general dysplasia and malformation were fair to poor because of the difficulty in prediction of growth development and growth potential, allowing only for partial correction of the deformity. Besides the restriction of the stapling procedure due to the aetiology of the deformity, the age of the patients at the time of surgery is important, as it determines the complication rate of this technique (loosening or dislocation of staples). Thus Blounts epiphyseodesis should not be performed before the age of 9 years in girls and 11 years in boys. Conclusion: Blounts epiphyseal stapling can be recommended as a safe procedure with predictably good results in idiopathic angular deformities of the leg and leg length difference caused by overgrowth.

Radiological evaluation of unstable (acute) slipped capital femoral epiphysis treated by pinning with Kirschner wires.

Treatment of slipped capital femoral epiphysis is still controversial with regard to the implants used for stabilization and the need for prophylactic treatment of the contralateral, unaffected, side. The objective of this study was to ascertain whether prophylactic transfixation of the epiphysis with Kirschner wires in patients with unstable slipped capital femoral epiphysis resulted in significant disturbance of the growth plate and impairment of further growth of the femoral neck and head. Between 1990 and 1999, 29 patients with unstable slipped capital femoral epiphysis were simultaneously treated with internal fixation of the epiphysis and metaphysis with 3–4 Kirschner wires on the affected and the not (yet) affected side. After a mean follow-up of 3.5 years, we evaluated the hip joints radiologically, analysing different roentgenological parameters (CCD angle, femoral head diameter, length of the femoral neck and sphericity of the femoral head). CCD angle, femoral head diameter and length of the femoral neck showed statistically significant (P<0.001, Students t-test) differences between the affected and unaffected, but prophylactically pinned, sides. Asphericity of the femoral head was found in six cases only on the affected side, whereas all hips, which were operated prophylactically, showed spherical femoral heads at follow-up (P<0.02, Pearsons χ2 test). These results indicate that the slip itself may cause impairment of the femoral growth plate in patients with unstable slipped capital femoral epiphysis and not stabilization with Kirschner wires. Compared with other series from the literature using different implants (screws, nails), prophylactic transfixation of the epiphysis and metaphysis with Kirschner wires is less compromising to the growth plate on the not (yet) affected side.