Theddy Slongo

Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee.

The purpose of this new classification compendium is to republish the Orthopaedic Trauma Associations (OTA) classification. The OTA classification was originally published in a compendium of the Journal of Orthopaedic Trauma in 1996. It adopted The Comprehensive Classification of the Long Bones developed by Müller and colleagues and classified the remaining bones. In this compendium, the introductory chapter reviews new scientific information about classifying fractures that has been published in the last 11 years. The classification is presented in a revised format that is easier to follow. The OTA and AO classification will now have a unified alpha-numeric code eliminating the differences that have existed between the 2 codes. The code was significantly revised for the clavicle and scapula, foot and hand, and patella. Dislocations have been expanded on an anatomic basis and for most joints will be coded separately. This publication should stimulate new developments and interest in a unified language to code and classify fractures. Further improvements in classification will result in better patient care and clinical research.

Slipped capital femoral epiphysis : early mechanical damage to the acetabular cartilage by a prominent femoral metaphysis

On the basis of intraoperative observations in 13 consecutive adolescents (14 hips) with slipped capital femoral epiphysis (SCFE), we found that when the anterior femoral metaphysis was level with or extended past the epiphysis, it caused labrum and cartilage damage. As a result of an impingement between the metaphysis and the superomedial acetabular rim, the labrum revealed erosions, scars or tears. Further jamming of the metaphysis into the joint damaged the adjacent acetabular cartilage, varying from a partial- to a full-thickness cartilage loss. In all patients, the femoral head cartilage was intact; no avascular necrosis was present. Our findings suggest that arthrosis in SCFE can be triggered by early mechanical damage of the acetabular cartilage.

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.

Subcapital correction osteotomy in slipped capital femoral epiphysis by means of surgical hip dislocation

ZusammenfassungOperationszielBehandlungsziel einer Epiphyseolysis capitis femoris ist die anatomisch ausgerichtete und normal durchblutete Epiphyse. Die subkapitale Reorientierung oder Schenkelhalskeilosteotomie ermöglicht ein solches Ergebnis. Mit den bisherigen Vorgehensweisen ist die Gefahr einer avaskulären Nekrose nicht unter optimaler Kontrolle.IndikationenAkute Epiphyseolysen.Chronische Epiphyseolysen, bei denen die Abtragung des metaphysären Überstands bis zur impingementfreien Flexion-Innenrotation weniger als zwei Drittel des Schenkelhalsdurchmessers hinterlassen würde.KontraindikationenAusgeprägte Ankylose des Hüftgelenks.Zerstörung des Hüftkopfs.OperationstechnikMit der chirurgischen Hüftluxation und einem Weichteillappen, der subperiostal aus Retinakulum und Außenrotatoren entwickelt wird, kann die Gefäßversorgung der Epiphyse aus der Arteria circumflexa femoris medialis erhalten werden. Dieser Weichteillappen erlaubt eine Lösung der Epiphyse sowie eine vollständige Kallusresektion vom Schenkelhals ohne Spannung des Retinakulums. Die Luxation des Hüftkopfs dient dessen manueller Sicherung während der Kürettage der Wachstumsfuge und schließlich der anatomischen Reposition unter visueller Kontrolle des Retinakulums. Mit luxiertem Kopf wird eine unerwünschte Manipulation am Bein die Integrität des Retinakulums weniger gefährden, als dies bei in der Pfanne verbliebenem Kopf der Fall wäre.Ergebnisse30 Hüften wurden zwischen 1996 und 2005 bei der Diagnose einer Epiphyseolysis capitis femoris mit der beschriebenen Technik behandelt. Die mittlere Nachuntersuchungszeit lag bei 55 Monaten (24–96 Monate). Es traten keine Hüftkopfnekrosen auf. Es bestand eine ausgeglichene Geschlechtsverteilung. Die Mädchen waren zur Operation im Durchschnitt 12 Jahre, die Jungen 14 Jahre alt. Der dorsale Abrutsch wurde zwischen 30° und 70° bemessen. Bei sechs Hüften bestand ein sog. „acute on chronic“ Abrutsch. Zwei Hüften mussten wegen Schraubenbrüchen revidiert werden, eine Problematik, die mit Verwendung von Vollgewindedrähten entschärft wurde. Eine Hüfte wurde wegen Verbiegung des Vollgewindedrahts revidiert. Alle drei Hüften wiesen eine Verkürzung von maximal 1 cm auf. Bei einem Patienten mit ektoper Ossifikation am ventral-distalen Schenkelhals ist die Innenrotation in Beugung auf die Hälfte reduziert.AbstractObjectiveThe aim of treatment of slipped capital femoral epiphysis is an anatomically aligned epiphysis with normal blood supply. This result can be achieved by open subcapital reorientation of the epiphysis or by a wedge osteotomy of the femoral neck. Other procedures have, so far, not gained optimal control over the risk of avascular necrosis.IndicationsAcute epiphyseolysis.Chronic epiphyseolysis for which trimming of the metaphyseal overhang to permit free flexion and internal rotation without impingement would leave less than two thirds of the femoral neck diameter intact.ContraindicationsAnkylosis of the hip joint at an advanced stage.Destruction of the femoral head.Surgical TechniqueThe blood supply to the epiphysis from the medial femoral circumflex artery can be preserved by surgical hip dislocation and a soft-tissue flap derived subperiosteally from the retinaculum and external rotators. This soft-tissue flap permits not only the detachment of the epiphysis, but also complete callus resection from the femoral neck without causing tension in the retinaculum. Dislocation of the femoral head ensures its manual protection during curettage of the epiphyseal plate and, ultimately, allows anatomic reduction under visual control of the retinaculum. With the head dislocated there is less risk to the integrity of the retinaculum due to unintentional manipulation of the leg than there would be, if the head remained in the socket.ResultsFrom 1996 to 2005, 30 hips with a diagnosis of slipped capital femoral epiphysis were treated according to the technique described. The average follow-up time was 55 months (24–96 months). Femoral head necrosis did not occur. Distribution across sexes was well balanced. Girls were 12 years old at the time of the operation and boys were 14 years old on average. Posterior displacement was measured at 30–70°. In six hips there was a so-called acute on chronic slip. Two hips required revision due to screw failure, a difficulty that was addressed by the introduction of fully threaded wires. One hip had to be revised because the fully threaded wire bent. After reoperation, shortening of maximum 1 cm was seen in these three cases. In one patient with ectopic bone formation at the anteroinferior femoral neck, internal rotation in flexion is reduced by half.

Fracture and Dislocation Classification Compendium for Children: The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)

The AO Pediatric Expert Group and the AO Pediatric Classification Group, in cooperation with the AO Investigation and Documentation Group introduce and present the first comprehensive classification of pediatric long bone fractures. The anatomy is related to the 4 long bones and their 3 segments defined as proximal (1), shaft (2) and distal (3). It is further described by the fracture subsegment recorded as epiphyseal (E), metaphyseal (M) and diaphyseal (D), whereby proximal and distal fractures are classified as E or M and shaft fractures are always D. The distinction between metaphyseal and diaphyseal fractures is achieved by localizing the center of fracture lines with regard to a square drawn over the respective growth plates. The morphology of the fracture is documented by a subsegment-specific child pattern code, a severity code as well as an additional code for displacement of specific fractures such as supracondylar fractures and radial heads. The classification process requires trained observers to read standard radiographic images.

Subkapitale Korrekturosteotomie bei der Epiphyseolysis capitis femoris mittels chirurgischer Hüftluxation

ZusammenfassungOperationszielBehandlungsziel einer Epiphyseolysis capitis femoris ist die anatomisch ausgerichtete und normal durchblutete Epiphyse. Die subkapitale Reorientierung oder Schenkelhalskeilosteotomie ermöglicht ein solches Ergebnis. Mit den bisherigen Vorgehensweisen ist die Gefahr einer avaskulären Nekrose nicht unter optimaler Kontrolle.IndikationenAkute Epiphyseolysen.Chronische Epiphyseolysen, bei denen die Abtragung des metaphysären Überstands bis zur impingementfreien Flexion-Innenrotation weniger als zwei Drittel des Schenkelhalsdurchmessers hinterlassen würde.KontraindikationenAusgeprägte Ankylose des Hüftgelenks.Zerstörung des Hüftkopfs.OperationstechnikMit der chirurgischen Hüftluxation und einem Weichteillappen, der subperiostal aus Retinakulum und Außenrotatoren entwickelt wird, kann die Gefäßversorgung der Epiphyse aus der Arteria circumflexa femoris medialis erhalten werden. Dieser Weichteillappen erlaubt eine Lösung der Epiphyse sowie eine vollständige Kallusresektion vom Schenkelhals ohne Spannung des Retinakulums. Die Luxation des Hüftkopfs dient dessen manueller Sicherung während der Kürettage der Wachstumsfuge und schließlich der anatomischen Reposition unter visueller Kontrolle des Retinakulums. Mit luxiertem Kopf wird eine unerwünschte Manipulation am Bein die Integrität des Retinakulums weniger gefährden, als dies bei in der Pfanne verbliebenem Kopf der Fall wäre.Ergebnisse30 Hüften wurden zwischen 1996 und 2005 bei der Diagnose einer Epiphyseolysis capitis femoris mit der beschriebenen Technik behandelt. Die mittlere Nachuntersuchungszeit lag bei 55 Monaten (24–96 Monate). Es traten keine Hüftkopfnekrosen auf. Es bestand eine ausgeglichene Geschlechtsverteilung. Die Mädchen waren zur Operation im Durchschnitt 12 Jahre, die Jungen 14 Jahre alt. Der dorsale Abrutsch wurde zwischen 30° und 70° bemessen. Bei sechs Hüften bestand ein sog. „acute on chronic“ Abrutsch. Zwei Hüften mussten wegen Schraubenbrüchen revidiert werden, eine Problematik, die mit Verwendung von Vollgewindedrähten entschärft wurde. Eine Hüfte wurde wegen Verbiegung des Vollgewindedrahts revidiert. Alle drei Hüften wiesen eine Verkürzung von maximal 1 cm auf. Bei einem Patienten mit ektoper Ossifikation am ventral-distalen Schenkelhals ist die Innenrotation in Beugung auf die Hälfte reduziert.AbstractObjectiveThe aim of treatment of slipped capital femoral epiphysis is an anatomically aligned epiphysis with normal blood supply. This result can be achieved by open subcapital reorientation of the epiphysis or by a wedge osteotomy of the femoral neck. Other procedures have, so far, not gained optimal control over the risk of avascular necrosis.IndicationsAcute epiphyseolysis.Chronic epiphyseolysis for which trimming of the metaphyseal overhang to permit free flexion and internal rotation without impingement would leave less than two thirds of the femoral neck diameter intact.ContraindicationsAnkylosis of the hip joint at an advanced stage.Destruction of the femoral head.Surgical TechniqueThe blood supply to the epiphysis from the medial femoral circumflex artery can be preserved by surgical hip dislocation and a soft-tissue flap derived subperiosteally from the retinaculum and external rotators. This soft-tissue flap permits not only the detachment of the epiphysis, but also complete callus resection from the femoral neck without causing tension in the retinaculum. Dislocation of the femoral head ensures its manual protection during curettage of the epiphyseal plate and, ultimately, allows anatomic reduction under visual control of the retinaculum. With the head dislocated there is less risk to the integrity of the retinaculum due to unintentional manipulation of the leg than there would be, if the head remained in the socket.ResultsFrom 1996 to 2005, 30 hips with a diagnosis of slipped capital femoral epiphysis were treated according to the technique described. The average follow-up time was 55 months (24–96 months). Femoral head necrosis did not occur. Distribution across sexes was well balanced. Girls were 12 years old at the time of the operation and boys were 14 years old on average. Posterior displacement was measured at 30–70°. In six hips there was a so-called acute on chronic slip. Two hips required revision due to screw failure, a difficulty that was addressed by the introduction of fully threaded wires. One hip had to be revised because the fully threaded wire bent. After reoperation, shortening of maximum 1 cm was seen in these three cases. In one patient with ectopic bone formation at the anteroinferior femoral neck, internal rotation in flexion is reduced by half.

Development and validation of the AO pediatric comprehensive classification of long-bone fractures by the Pediatric Expert Group of the AO Foundation in collaboration with AO Clinical Investigation and Documentation and the International Association for Pediatric Traumatology

A series of four agreement studies (classification sessions) were conducted to support the development and validation of a comprehensive pediatric long bone fracture classification system. This system follows the principle of the Müller-AO classification for long bones in adults and integrates most relevant existing pediatric classification systems. The diagnosis includes the distinction between epiphyseal (E), metaphyseal (M), or diaphyseal (D) fractures, as well as identification of child-specific features. This article describes the proposed system in some detail. Digital standard preoperative anteroposterior and lateral radiographs from 267 consecutive pediatric patients (<16 years old and open physis) with single fractures of the distal humerus, radius, or tibia were collected at a single university childrens hospital. Fractures were classified independently by five experienced pediatric surgeons. The classification process was assessed for reliability using the kappa coefficient and accuracy using latent class modeling separately for each bone for bone type, and separately for each bone type for child codes. At the last classification session, kappa values for E-M-D and child code classifications were mostly above 0.90, and accuracy estimates were between 75% and 100% for different surgeons, types, and bones. Disagreement and misclassification of fractures were overall very low; hence, experienced and trained surgeons can classify pediatric long bone fractures using the proposed system with high accuracy based on standard radiographic views. The authors encourage wide consultation and further evaluation of this proposed pediatric long bone classification system with a larger number of future users with different training before being used for documentation and clinical studies.

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.

Lateral External Fixation-A New Surgical Technique for Displaced Unreducible Supracondylar Humeral Fractures in Children

BACKGROUND Percutaneous Kirschner wire fixation represents the classic treatment for displaced supracondylar humeral fractures in childhood. This type of treatment first requires satisfactory reduction of the fracture. Failure to achieve a satisfactory reduction or inadequate stabilization can result in instability of the fracture fragments, which can result in either an unsatisfactory cosmetic or functional outcome. In our experience, these problems can be overcome with the use of a small lateral external fixator. METHODS Between 1999 and 2005, thirty-one of 170 Gartland type-III supracondylar humeral fractures were treated with a lateral external fixator. The outcome of treatment was analyzed with regard to limb alignment, elbow movement, cosmetic appearance, and patient satisfaction. RESULTS In twenty-eight of the thirty-one patients, a satisfactory reduction was achieved with closed methods. All children except one had a normal or good range of movement. The cosmetic result was excellent in all cases. All of the children and their parents stated that they would choose this treatment again. CONCLUSIONS The use of a small lateral external fixator seems to be a safe alternative for the treatment of displaced supracondylar fractures of the humerus when a closed reduction appears to be unattainable by means of manipulation alone or when sufficient stability is not achieved with standard methods of Kirschner wire fixation.

The lesser trochanter as a cause of hip impingement: Pathophysiology and treatment options

Impingement of the lesser trochanter on the ischium or the posterior acetabular rim is not a frequent pathology, but has recently received increased recognition. We have seen 14 cases over a period of 14 years, but concentrate on eight hips showing complex deformities revealing similar characteristics. All eight hips had a residual Perthes or a Perthes-like disease with an elliptically deformed femoral head, but a congurent joint a short or absent femoral neck, a high riding greater trochanter, and a reduced vertical distance between the head and the lesser trochanter. Impingement took place between the lesser trochanter and the ischium or the posteroinferior acetabular border, but was hardly recognisable due to the predominant intraarticular impingement of the nonspherical femoral head and the extraarticular impingement of the greater trochanter. In three cases the impingement showed reproducible subluxation of the hip. While in our hips, excision was the preferred treatment for impingement due to an oversized lesser trochanter, distal advancement was used in the hips with the Perthes morphology; the surgical time was not longer. The overall clinical results in this group however were dominated by a substantial increase in the range of motion (ROM), dependent mainly on the achieved contour of the femoral head and the relative lengthening of the neck. Strength of active hip flexion was normal. Recurrent subluxation disappeared and no complications were recorded.