A presentation for a newly published paper at JPO B

1. Short Term Outcome of
Intertrochanteric Osteotomy
Combined with Osteochondroplasty in
Slipped Capital Femoral Epiphysis
A Thesis for M.D. degree in Orthopaedic Surgery By
Shady Abdelghaffar Hanafy Mahmoud
Under the Supervision
Professor Tarek Hassan Abdelaziz
Assistant Prof. Ayman Hussein Gouda
Assistant Prof. Shady Samir Elbeshry
Faculty of Medicine
Ain Shams University
2018

2. Introduction

3. Introduction
• Slipped Capital Femoral Epiphysis (SCFE) incidence is
0.2 to 10 per 100.000. [Lehmann et al, 2006]
• Clinically, it can be classified into acute ,chronic, and
acute on top of chronic based on symptoms
duration. [Loder et al, 1993]
• Loder et al classified it into stable and unstable
based on the ambulatory status which predicts the
avascular necrosis (AVN) risk. [Loder et al, 1993]
• Radiologically, Southwick used his angle in lateral
view to place the slip into mild (< 300), moderate
(30-500), and severe (>500). [Southwick, 1973]

4. The treatment of moderate-severe stable SCFE is
highly controversial
Many options are available to manage this issue with
variable outcomes. However, the debate in recent
literatures is between modified Dunn procedure and
Imhäuser osteotomy.

5. Prevention of
AVN
Objectives
of SCFE
treatment
Deformity
correction
Prevention of
osteoarthritis
(OA)
prevention of
impingement
stopping
further
slippage
Prevention of
chondrolysis

6. Aim of This Work
• To assess the short-term outcomes of Imhäuser
intertrochanteric osteotomy combined with
osteochondroplasty in treatment of moderate-severe stable
SCFE.

7. Patients and Methods

8. Patients and Methods
•Prospective case series study.
• 20 hips (19 patients) between August 2016 and September
2017.
•followed up over 12-24 months.

9. Inclusion Criteria
• Moderate or severe SCFE.
• Stable SCFE.
• No or minor hip OA (Grade 1 or less
Tönnis classification).

10. Exclusion criteria
• Valgus SCFE.
• Mild SCFE.
• Unstable SCFE.
• Advanced 2ry osteoarthritis (Grade 2
or more Tönnis classification).
• AVN.
• Chondrolysis.

11. •History [pain and function].
•Examination.
•Functional outcomes scores [HHS and WOMAC scores].
•Radiological Imaging [plain x ray and CT].
•Laboratory investigations:
Serum Ca, Po4, and alkaline phosphatase, serum vitamin
D level, thyroid profile, and routine preoperative labs.
Preoperative Evaluation

12. Examination
General
• BMI
• Endocrinopathy features
Local
• Observational gait analysis.
• Trendenleburg sign.
• Impingement sign.
• Drehmann sign.
• Hip ROM.
• Staheli rotational profile.
• LLD.

13. Surgical Technique

14. In situ pinning
Intertrochanteric
Imhauser Osteotomy
Osteochondroplasty
• Anesthesia: 17 under GA and 3 under spinal anesthesia.
• Positioning & approach: supine – Watson-Jones approach
• 3 components
Surgical Technique

15. In situ pinning
Required in 16
hips
14 via the
plate
2 taken
independently

16. Proximal holes
Shaft holes
Non-locked
Proximal femoral plate
5

17. Imhauser osteotomy

20. Osteochondroplasty

22. Postoperative management

23. Postoperative management
• calf massage and static
quadriceps exercise.
• LMWH.Day 1

24. Postoperative management
• Sitting
• passive and assisted active
knee ROM
Day 3
• Toe touchDay 5
• Radiographs
• Full weight bearing
• Physiotherapy
Week 6

25. Results

26. Demographics and baseline disease characteristics:
Results
Total hip number = 20
Age
Mean ± SD 15.15 ± 1.63
Range 12 – 18
Gender
Female 5 (26.31%)
Male 14 (73.68%)
Follow up
Mean ± SD
Range
14.25 ± 3.10
12-24
Treated
patients
Bilateral
Unilateral
9 (47.36%)
10 (52.63%)
Site
Right
Left
9 (45%)
11 (55%)
Severity
Severe
Moderate
16 (80%)
4 (20%)
Physis
status
Closed
Closing
Open
8 (40.0%)
7 (35.0%)
5 (25.0%)
Previous
operation
Positive
Negative
7 (36.84%)
12 (63.15%)
Operative
time
(minutes)
Mean ± SD 123.50 ± 23.90
Range 90 – 180
Type of
anesthesia
General 17 (85.0%)
Spinal 3 (15.0%)

27. Measures
Clinical
• ROM
• LLD
• ER gait
• Drehmann sign
Functional
• HHS
• WOMAC
Radiological
• Southwick angle
• Alpha angle
• HEA
• NSA
• ATD
• Evidence of AVN
• Evidence of OA
• Evidence of
chondrolysis

28. Clinical parameters
• Flexion improved in every single patient.
• The average of improvement was 35.25°.

29. Clinical parameters
• Abduction improved in every single patient.
• The average of improvement was 15.25°.

30. Clinical parameters
• IR improved in every single patient.
• The average of improvement was 35°.

31. Clinical parameters
• LLD improved in 10 patients by an average of 0.7 cm.
• Remained unchanged in 8 patients.
• Worsened in one patient by 1 cm (large wedge resection).

32. • ER gait and Drehmann sign were present in 85% of the
cases preoperatively.
• Disappeared in all of them postoperatively.
Clinical parameters

33. Functional parameters
• Average preoperative HHS was 55.21.
• Improved at one-month postoperative follow up, with average of 73.96.
• Improved at the final follow up reaching an average of 86.76.

34. • Average preoperative WOMAC was 32.1%.
• Improved at one-month postoperative follow up, with average of 16.19%.
• Improved at the final follow up reaching an average of 6.4%.
Functional parameters

35. Radiological parameters
• Southwick angle decreased in every single patient.
• The average decrease was 46.25°.

36. Radiological parameters
• Alpha angle decreased in every single patient.
• The average decrease was 36.68°.

37. Radiological parameters
• Hilgenreiner epiphyseal angle decreased in every
single patient.
• The average decrease was 11.35°.

38. Radiological parameters
• Neck shaft angle improved in every patient.
• The average of improvement was 10.74°.

39. Radiological parameters
• ATD improved in 16 patients by an average of 4.9 mm.
• Remained unchanged in 2 hips.
• Worsened in 2 hips by an average of 2.9 mm (Excessive valgus correction).

40. Radiological parameters
NO
AVN
OAChondrolysis

41. Clinical-radiological correlation
• Negative correlation between preoperative Southwick angle and
preoperative HHS.
• The more severe the disease, the poorer the scores.

42. Clinical-radiological correlation
• A negative correlation between final HHS and patients' age.
• The older patients had poorer scores.

43. Clinical-radiological correlation
• A positive correlation between final HHS and postoperative ATD.
• Those with improved ATD had better outcomes scores.

44. Complications
• One patient showed screw breakage.
• No sequalae (complete healing).

45. Complications
• One patient had screw penetration.
• Screw exchange.

46. Discussion

47. Discussion
• Moderate-severe stable SCFE are characterized
by complex proximal femoral deformities which
are difficult to be treated adequately and safely.
• The debate in recent literatures is between
modified Dunn procedure and Imhäuser
osteotomy.

48. Modified Dunn Procedure
Upon reviewing 7 case-series studies assess the use of modified
Dunn procedure in stable SCFE and after excluding the studies
that were solely on unstable cases, we observe that:
• Well treated cases showed excellent short-term clinical and
radiological outcomes.
• Short term follow up with an average of 1.8 years (1-4 years)
• AVN range is between 3.3% and 47%, with overall incidence
at 15%.
• AVN occurrence could not be predicted (intraoperative
assessment of femoral head perfusion is not reliable).
• Steep learning curve.

49. • Risk of implant failure (fixing thin cortical shell of epiphysis).
• Considerable risk of reoperation surgeries (for AVN, implant
failure, and hip dislocation): 18% in Upasani et al study.
• 40% of the cases were unstable cases which reflected the
focus of utilization of this technique in the unstable type.
• The most important indication for modified Dunn procedure
is unstable SCFE [Ziebarth et al, 2009]
Modified Dunn Procedure

50. Based on the above, two institutes have modified their practice
patterns regarding modified Dunn procedure use in SCFE treatment:
 Boston Children Hospital recommendations [Upasani et al, 2014]:
• A high-volume surgeon must be present during each modified Dunn
procedure.
• Restricted to acute severe unstable slippage within 24 hours of the
slippage to provide satisfactory results.
 Javier et al recommendations: [Javier et al, 2017]
• The use of modified Dunn procedure in unstable SCFE was
abandoned in preference to gentle reduction, open capsulotomy,
and in situ pinning within 24 hours (lower AVN risk).
• Restricted its use to very selective stable severe cases with open
physis.
• It is better to choose another option as proximal femoral osteotomy
in concomitant with in situ pinning and osteochondroplasty.

51. Imhauser Osteotomy
On the other hand, reviewing 5 case series studies
that assess Imhäuser osteotomy alone revealed:
• Imhäuser osteotomy is much safer than modified
Dunn procedure.
• It displayed lower clinical outcomes, but for
longer follow up periods with an average of
19.48 years (5-24 years).
• The reported OA in Imhäuser osteotomy are
most probably because of the non-addressed FAI
that has a definite relation with OA.

52. So, adding a procedure
to deal with FAI lesion
could be
the best option?!

53. Imhäuser osteotomy and
osteochondroplasty
• In 2014, Bali et al described adding osteochondroplasty to
Imhäuser osteotomy (modified Imhäuser osteotomy) via
Watson-Jones approach.
• They had excellent results evidenced by better NAHS score
compared to Imhauser osteotomy alone.
• There are three studies in which Imhäuser osteotomy and
osteochondroplasty were performed through safe surgical
dislocation approach (Spencer et al , Rebello et al , and
Erickson et al studies).
• They have fair results with low WOMAC score outcomes,
AVN development, or poor alpha angle correction

54. • Our series is the second one conducting modified Imhäuser
osteotomy via Watson-Jones approach and the largest ever
case series study.
• It comprises a lot of clinical and radiological parameters to
quantify the outcomes accurately and to lessen the bias.
• The clinical outcomes were comparable with modified
Dunn procedure studies.
• Compared to modified Imhäuser osteotomy using SSD
approach, our study showed better postoperative WOMAC
(6.4%) with no AVN reported.
• Our results are in line with Bali et al conclusion that
adding osteochondroplasty provide better results.
Imhäuser osteotomy and
osteochondroplasty

55. Case Presentation

56. Case 1
• a 14-year-old boy.
•RT hip pain and limping for 5 months.
• The hip problem was interfering with his daily routine, a
figure that was evident in both HHS and WOMAC with values
of 57.23 and 29%, respectively.
• No history of trauma or previous surgery and his BMI was
33.2

57. On examination:
Case 1

58. Case 1

59. Case 1

62. Post-operativePre-operative

63. Case 2
• A 16-year-old boy.
•Bilateral intermittent hip pain
and limping for 1.5 years.
•Diagnosed with bilateral SCFE
and underwent in situ pinning on Lt side one year before.
•He suffered of limited outdoor activities with HHS at 36.6 and
WOMAC at 42.7%

64. Case 2
• On examination

65. Case 2

66. Case 2

67. Case 2

69. Post-operativePre-operative

70. Case 3
• A 16-year-old boy.
•Right intermittent hip pain and
limited motion range for 2 years.
•Diagnosed with SCFE and
underwent in situ pinning 18 months before his presentation to us.
• His HHS was at 58.7 and WOMAC at 26.04%.

71. Case 3
• On examination:

72. Case 3

73. Case 3

74. Case 3

75. Case 3

76. Post-operativePre-operative

77. Conclusion

78. Conclusion
• Despite that modified Dunn procedure provides the best
available correction for SCFE deformity, the possible
hazardous complications, the high surgical demands, and the
lack of long term follow up are drawbacks that should be
considered in the decision making.
• On the other hand, Imhäuser osteotomy is a safer procedure;
however, it provides lower correction power with lower
clinical satisfaction and showed fair OA end results on the
long-term.

79. Conclusion
• The protocol suggested in this study offers comparable
clinical outcomes with modified Dunn procedure
without its possible irreversible complication of AVN.
• It maintains the safety displayed by Imhäuser
osteotomy and abolishes the trigger of OA which is FAI
lesions.
• It can be considered to be the best option for the
treatment of chronic stable moderate-severe SCFE.

80. Conclusion
• It is recommended to combine the osteotomy and
osteochondroplasty with in situ pinning at an early age
once the diagnosis has been established as there is a
negative correlation between patients' age and the
functional outcomes evidenced by the study results.
• It is also advocated to fix the physis (in-situ pinning) by
only one screw to lessen the possible risk of pin
penetration.
• We thus believe that Imhäuser osteotomy combined
with osteochondroplasty is the preferred option in
the treatment of chronic stable moderate-severe SCFE
with open or closing-closed physis.