Aresh Hashemi-Nejad FRCS(Orth) The Royal National - PowerPoint PPT Presentation

1 / 42
About This Presentation
Title:

Aresh Hashemi-Nejad FRCS(Orth) The Royal National

Description:

Aresh Hashemi-Nejad FRCS(Orth) The Royal National Orthopaedic Hospital Fish Cuneiform Osteotomy SCFE Prophylactic pinning of the contralateral hip if all ... – PowerPoint PPT presentation

Number of Views:241
Avg rating:3.0/5.0
Slides: 43
Provided by: bartsandth
Category:

less

Transcript and Presenter's Notes

Title: Aresh Hashemi-Nejad FRCS(Orth) The Royal National


1
Slipped Upper Femoral Epiphysis
  • Aresh Hashemi-Nejad FRCS(Orth)
  • The Royal National Orthopaedic Hospital

2
Slipped Upper Femoral Epiphysis
  • Annual incidence 2-10 per 100,000
  • 2.4 M 1 F
  • Boys 10-16 yrs (13.4)
  • Girls 10-14 yrs (11.5)
  • presentation outside these ages consider
    endocrine or systemic disorder

3
Slipped Capital Femoral Epiphysis
  • Obese (50-75 over 95th centile)
  • Delay in skeletal maturity
  • Bilateral in 25 (50 present-50 sequential)
  • Late changes of bilateral SCFE 60-80 of
    unilaterals

4
Slipped Capital Femoral Epiphysis
  • one of the most common adolescent hip disorders
  • Separation through the widened hypertrophic zone
    of the physis

5
Slipped Capital Femoral Epiphysis
  • femoral neck displace anteriorly with the head in
    the acetabulum causing an apparent varus
    deformity
  • hypertrophic zone accounts for 80 of physis due
    to abnormal cartilage maturation and endochondral
    ossification

6
Slipped Capital Femoral Epiphysis Aetiology
  • Mechanical factors
  • obesity
  • decrease in normal femoral anteversion/ protrusio
  • oblique physeal plate
  • weakened perichondral ring

7
Slipped Capital Femoral Epiphysis Aetiology
  • Inflammatory
  • synovial hyperplasia
  • increase in IG and C3

8
Slipped Capital Femoral Epiphysis Aetiology
  • Endocrine
  • Girls premenarchal/ Boys longer growth phase
  • Association with
  • 1 or 2 hypothyroidism
  • panhypopituitarism
  • hypogonadal conditions
  • renal osteodystrophy
  • GH therapy

9
Slipped Capital Femoral Epiphysis Aetiology
  • 5 incidence in family members

10
Slipped Capital Femoral Epiphysis Presentation
  • Pain groin thigh, knee
  • Limp
  • Externally rotated limb

11
Slipped Capital Femoral Epiphysis Presentation
  • Preslip synovitis
  • Acute lt3wks
  • Chronic
  • Acute on Chronic

12
Slipped Capital Femoral Epiphysis Presentation
  • Physeal stability
  • Stable can wt bear
  • Unstable
  • Acute Slipped Capital Femoral Epiphysis the
    Importance of Physeal Stability
  • Loder et al
  • JBJS 1993 75-A1134-1140

13
Slipped Capital Femoral Epiphysis Radiology
  • AP
  • physeal widening
  • decrease in epiphyseal ht
  • Blanch sign (density in neck)
  • Klein/Trethowan line
  • Capeners sign

14
Slipped Capital Femoral Epiphysis Radiology
  • AP
  • physeal widening
  • decrease in epiphyseal ht
  • Blanch sign (density in neck)
  • Klein/Trethowan line
  • Capeners sign

15
Slipped Capital Femoral Epiphysis Radiology
  • Lateral
  • shoot through/Billings
  • in acute unstable hips avoid frog lateral
  • US
  • CT/MRI

16
Slipped Capital Femoral Epiphysis Radiology
  • Classification
  • 1/3, 1/2, gt1/2
  • 30, 30-50, .50 (difference to other side)

17
Slipped Capital Femoral Epiphysis Natural History
  • 30-40 second slip asymptomatic (slow)
  • Premature OA (pistol grip deformity 40 primary
    OA)
  • Onset of OA directly related to severity of slip

18
Natural History
  • Carney et al JBJS 1991
  • 155 hips in 124 patients, FU 41 years
  • Joint deterioration related to the severity of
    the slip and complications of treatment
  • Carney and Weinstein Clin Orth 1996
  • Untreated mild slips can progress to severe
  • 2 joint degeneration corresponded to severity

19
Slipped Capital Femoral Epiphysis Treatment
  • Prevent further slippage
  • Reduce the degree of slippage
  • Salvage treatment

20
SCFE Treatment to prevent further slippage
  • Hip spica
  • Bone peg epiphysiodesis
  • Pin or screw fixation

21
SCFE Treatment to prevent further slippage
  • In situ screw fixation
  • biplane fluoroscopy
  • percutaneous technique
  • Position fixation centrally in head and 5mm from
    margin
  • single pin substantially reduces pin-related
    complications

22
SCFE Treatment to prevent further slippage
  • In situ screw fixation
  • pin must be placed perpendicular to plane of the
    femoral head
  • starting position anterior of the femoral neck
    and not lateral cortex

23
SCFE Treatment to prevent further slippage
  • In situ screw fixation
  • avoid superior and anterior quadrant of femoral
    head
  • following fixation screen whilst moving hip to
    ensure no penetration

24
Severe Slip - Pin-in-situ
25
SCFE Treatment to prevent further slippage
  • In situ screw fixation
  • cannulated screw
  • 5.5 mm screw structural stiffness of two 4.5mm
    screws
  • 7.5mm screw stiffness of unslipped epiphysis
  • ?need for second screw in unstable hip

26
SCFE Treatment to prevent further slippage
  • In situ screw fixation
  • early closure of physis (13 mths)
  • Younger patients ? smooth pins, hook pin
  • Complications chondrolysis and osteonecrosis

27
SCFE Treatment to Reduce degree of slippage
  • Closed manipulation
  • Osteotomies
  • concurrently with stabilisation or after physeal
    closure

28
SCFE Treatment to Reduce degree of slippage
  • Closed manipulation
  • although after in situ pinning ROM improves this
    is in main due to resolution of synovitis and
    spasm. There is little remodelling
  • Closed manipulation gt24hrs significantly
    increases the risk of osteonecrosis
  • used in acute on chronic
  • MUA v traction

29
SCFE Treatment to Reduce degree of slippage
  • Osteotomies
  • more distal less correction at primary site of
    deformity
  • more proximal more risk of osteonecrosis
  • used in cases of severe slips

30
Intertrochanteric - Southwick
  • Compensatory osteotomy, the more distal the less
    correction at primary source of deformity.
  • Maximum head-shaft correction is 50.
  • Wedge removed therefore shortening.

31
SCFE Treatment to Reduce degree of slippage
  • Osteotomies
  • Intertrochanteric
  • single, bi or multiple-plane
  • corrects 45
  • low incidence of osteonecrosis, but chondrolysis
    rate 6-50
  • ?subsequent THR

32
SCFE Treatment to Reduce degree of slippage
  • Osteotomies
  • Cuneiform Osteotmy at femoral physis Fish/ Dunn
  • Osteonecrosis 12-35
  • Fish 3.5 osteonecrosis and 11 chondrolysis
  • RNOH Experience
  • JBJS (Br) 2006 88-B 1379-1384
  • 88 PATIENTS (22/25 HIPS) EXCELLENT RESULT
  • AVN RATE 12
  • CHONDROLYSIS RATE 16 (OF WHICH 50 IMPROVED)
  • 92 HAD NORMAL JOINT SPACE

33
SCFE Treatment to Reduce degree of slippage
  • Osteotomies
  • Base of neck anterior wedge removed
  • corrects 30-50,
  • creates coxa breva

34
Fish Cuneiform Osteotomy
35
SCFE Prophylactic pinning of the contralateral hip
  • if all contralateral hips were pinned 50-80
    treated unnecessarily
  • FU till skeletal maturity
  • Pin if symptoms present
  • Pin known metabolic/endocrine disorders
  • Pin if FU unreliable

36
SCFE Osteonecrosis
  • rare in untreated SCFE
  • vascular injury, complication of treatment
  • increase with severity of slip
  • increase in acute, unstable slips
  • increases with manipulation, pin placement in
    superior quadrant

37
SCFE Osteonecrosis
  • remove metal work
  • maintain ROM
  • realignment
  • shelf acetabuloplasty
  • arthrodesis/THR

38
SCFE Salvage Procedures
  • Management of avascular necrosis after Slipped
    upper femoral epiphysisM Mullins, M Sood, A
    Hashemi-Nejad, A CatterallJBJS (Br) 2005 87-B
    1669-74
  • Use of Pamidronate to reduce risk of AVN

39
SCFE Chondrolysis
  • dissolution of articular cartilage with joint
    stiffness and pain
  • Cause
  • synovial malnutrition, ischaemia, excessive
    pressure
  • Autoimmune
  • Femalesgtmales

40
SCFE Chondrolysis
  • incidence 2-20
  • higher in females, acute and severe slips
  • manipulation, prolonged immobilisation,
    realignment osteotomies
  • ? pin penetration
  • exclude infection

41
SCFE Chondrolysis
  • relieved wt bearing, NSAID, ROM
  • traction
  • in pt therapy
  • muscle release
  • 3 yr to improve- 64 good outcome deterioration
    with time

42
Thank you
Write a Comment
User Comments (0)
About PowerShow.com