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![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]](https://image.slidesharecdn.com/e4ts4riosbgmhusgqem8-signature-4e22566ff3720cbec963c1a4f0885a73e5c642e58ef42c3f1f3449b974bd3a51-poli-191023215951/75/Short-term-outcomes-of-Intertrochanteric-Imhauser-Osteotomy-combined-with-osteochondroplasty-in-slipped-capital-femoral-epiphysis-3-2048.jpg)
![•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](https://image.slidesharecdn.com/e4ts4riosbgmhusgqem8-signature-4e22566ff3720cbec963c1a4f0885a73e5c642e58ef42c3f1f3449b974bd3a51-poli-191023215951/75/Short-term-outcomes-of-Intertrochanteric-Imhauser-Osteotomy-combined-with-osteochondroplasty-in-slipped-capital-femoral-epiphysis-11-2048.jpg)
![• 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](https://image.slidesharecdn.com/e4ts4riosbgmhusgqem8-signature-4e22566ff3720cbec963c1a4f0885a73e5c642e58ef42c3f1f3449b974bd3a51-poli-191023215951/75/Short-term-outcomes-of-Intertrochanteric-Imhauser-Osteotomy-combined-with-osteochondroplasty-in-slipped-capital-femoral-epiphysis-49-2048.jpg)
![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.](https://image.slidesharecdn.com/e4ts4riosbgmhusgqem8-signature-4e22566ff3720cbec963c1a4f0885a73e5c642e58ef42c3f1f3449b974bd3a51-poli-191023215951/75/Short-term-outcomes-of-Intertrochanteric-Imhauser-Osteotomy-combined-with-osteochondroplasty-in-slipped-capital-femoral-epiphysis-50-2048.jpg)
Uploaded byShady Mahmoud
Short term outcomes of Intertrochanteric Imhauser Osteotomy combined with osteochondroplasty in slipped capital femoral epiphysis
The document summarizes a study assessing the short-term outcomes of using intertrochanteric osteotomy combined with osteochondroplasty to treat moderate to severe stable slipped capital femoral epiphysis (SCFE). 20 hips were treated and followed for 12-24 months. Clinical and radiological outcomes improved significantly, with no cases of avascular necrosis or osteoarthritis. The approach was found to provide comparable results to modified Dunn procedure but without the risks of complications like avascular necrosis. It was concluded to be a preferred option for treating chronic stable moderate-severe SCFE.
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Short term outcomes of Intertrochanteric Imhauser Osteotomy combined with osteochondroplasty in slipped capital femoral epiphysis
- 1. Short Term Outcomeof 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.
- 3. Introduction • Slipped CapitalFemoral 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 ofmoderate-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 Preventionof osteoarthritis (OA) prevention of impingement stopping further slippage Prevention of chondrolysis
- 6. Aim of ThisWork • To assess the short-term outcomes of Imhäuser intertrochanteric osteotomy combined with osteochondroplasty in treatment of moderate-severe stable SCFE.
- 7.
- 8. Patients and Methods •Prospectivecase series study. • 20 hips (19 patients) between August 2016 and September 2017. •followed up over 12-24 months.
- 9. Inclusion Criteria • Moderateor severe SCFE. • Stable SCFE. • No or minor hip OA (Grade 1 or less Tönnis classification).
- 10. Exclusion criteria • ValgusSCFE. • Mild SCFE. • Unstable SCFE. • Advanced 2ry osteoarthritis (Grade 2 or more Tönnis classification). • AVN. • Chondrolysis.
- 11. •History [pain andfunction]. •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 • Endocrinopathyfeatures Local • Observational gait analysis. • Trendenleburg sign. • Impingement sign. • Drehmann sign. • Hip ROM. • Staheli rotational profile. • LLD.
- 13.
- 14. In situ pinning Intertrochanteric ImhauserOsteotomy Osteochondroplasty • Anesthesia: 17 under GA and 3 under spinal anesthesia. • Positioning & approach: supine – Watson-Jones approach • 3 components Surgical Technique
- 15. In situ pinning Requiredin 16 hips 14 via the plate 2 taken independently
- 16. Proximal holes Shaft holes Non-locked Proximalfemoral plate 5
- 17.
- 20.
- 22.
- 23. Postoperative management • calfmassage 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.
- 26. Demographics and baselinedisease 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 • Flexionimproved in every single patient. • The average of improvement was 35.25°.
- 29. Clinical parameters • Abductionimproved in every single patient. • The average of improvement was 15.25°.
- 30. Clinical parameters • IRimproved in every single patient. • The average of improvement was 35°.
- 31. Clinical parameters • LLDimproved 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 gaitand Drehmann sign were present in 85% of the cases preoperatively. • Disappeared in all of them postoperatively. Clinical parameters
- 33. Functional parameters • Averagepreoperative 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 preoperativeWOMAC 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 • Southwickangle decreased in every single patient. • The average decrease was 46.25°.
- 36. Radiological parameters • Alphaangle decreased in every single patient. • The average decrease was 36.68°.
- 37. Radiological parameters • Hilgenreinerepiphyseal angle decreased in every single patient. • The average decrease was 11.35°.
- 38. Radiological parameters • Neckshaft angle improved in every patient. • The average of improvement was 10.74°.
- 39. Radiological parameters • ATDimproved 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.
- 41. Clinical-radiological correlation • Negativecorrelation between preoperative Southwick angle and preoperative HHS. • The more severe the disease, the poorer the scores.
- 42. Clinical-radiological correlation • Anegative correlation between final HHS and patients' age. • The older patients had poorer scores.
- 43. Clinical-radiological correlation • Apositive correlation between final HHS and postoperative ATD. • Those with improved ATD had better outcomes scores.
- 44. Complications • One patientshowed screw breakage. • No sequalae (complete healing).
- 45. Complications • One patienthad screw penetration. • Screw exchange.
- 46.
- 47. Discussion • Moderate-severe stableSCFE 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 Uponreviewing 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 ofimplant 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 theabove, 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 theother 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 aprocedure 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 seriesis 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.
- 56. Case 1 • a14-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.
- 58.
- 59.
- 62.
- 63. Case 2 • A16-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 • Onexamination
- 65.
- 66.
- 67.
- 69.
- 70. Case 3 • A16-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 • Onexamination:
- 72.
- 73.
- 74.
- 75.
- 76.
- 77.
- 78. Conclusion • Despite thatmodified 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 protocolsuggested 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 isrecommended 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.
Editor's Notes
- #2 First of all I would like to express my deepest gratitude and appreciation to Prof. Dr. Tarek Hassan for his generous support and guidance. It was an honor to work under his supervision. Furthermore, I would like to express my gratitude and thanks to Assistant Prof. Ayman Gouda and Assistant Prof. Shady Samir for their kind assistance and support. I am also grateful to Prof. Dr Ali Ibrahim and Prof Dr Bahaa Korna for their great efforts to evaluate the research and to discuss it. Special thanks to Assistant Prof Tamer Fayyad and Dr Ahmed Saeed for their sharing in the surgical procedures And Thanks to my little family, my colleagues, and the audience
- #4 Slipped Capital Femoral Epiphysis incidence is 0.2 to 10 per 100.000. Clinically, it can be classified into acute ,chronic, and acute on top of chronic based on symptoms duration. Loder et al classified it into stable and unstable based on the ambulatory status which predicts the avascular necrosis risk. Radiologically, Southwick used his angle in lateral view to place the slip into mild, moderate, and severe.
- #5 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.
- #6 Generally speaking , the objectives of SCFE treatment are So, the surgical option that is able to fulfill these objectives is the best option
- #7 We aim to assess the short-term outcomes of Imhauser osteotomy combined with osteochondroplasty in treatment of moderate-severe stable SCFE.
- #9 We conducted a Prospective case series study. on 19 patients between August 2016 and September 2017 and followed up over 12-24 months.
- #10 We included patients with moderate-severe stable SCFE with no or minor hip OA in the study
- #11 And we excluded patients with valgus, mild, or unstable SCFE. Patients with radiological evidence of advanced 2ry osteoarthritis, AVN, or chondrolysis were also excluded
- #12 Preoperative evaluation include -History taking especially pain and function -Clinical examination -Functional outcomes measures which are Harris Hip Score and Western Ontario and McMaster Index score -Radiological imaging in the form of plain x ray and CT -Laboratory investigations that were serum Ca, Po4, and alkaline phosphatase --- serum vitamin D--- thyroid profile --- as well as the routine preoperative labs
- #13 The examination was both general and local General examination involved body mass index and any feature suggestive of endocrinopathy And local examination involved Observational gait analysis. Trendenleburg sign Impingement sign. Drehmann sign. Hip ROM. Staheli rotational profile. And LLD
- #14 Surgical Technique
- #15 Anaesthesia Seventeen hips were performed under general anesthesia and three were performed under spinal anesthesia. Positioning All patients were performed supine utilizing the anterolateral hip approach (Watson-Jones approach) Components The procedure is composed of 3 components: in-situ pinning, Imhäuser osteotomy, and open neck osteochondroplasty.
- #16 In situ pinning was required in 16 hips (as 4 Cases had closed physis). It was Performed through the proximal holes of the plate in 14 cases In 2 cases ,that were severe, in-situ pinning from through the plate was inapplicable and was taken independently.
- #17 The used plate is non-locked proximal femoral plate to allow free orientation of the proximal screws to reach the deformed head with ease. It is formed of proximal holes and shaft holes The proximal hole configuration was inverted triangle and the screw utilized In them are 6.5 mm cancellous screws. The minimum number of shaft holes were five and screws utilized in them are 4.5 mm cortical screws.
- #18 Imhauser osteotomy The level of osteotomy is just above the lower border of the lesser trochanter. The anterolateral femoral border is identified which is considered as the common base of the planned two wedges to be resected, one on the anterior surface of the femur and its apex medial represent the degree of required flexion correction. and the other on the lateral surface and its apex posterior represent the degree of required valgus correction. The level is determined by intraoperative visualization and confirmed by fluoroscopic imaging The first screw is inserted as in situ pinning then the osteotomy is proceeded.
- #19 The osteotomy is proceeded either by an electrical saw or by osteotomes
- #20 But before completing the osteotomy, the second screw is delivered to stabilize the plate in the required degree of flexion. As demonstrated in this model, the angle created between the shaft of femur and the plate in the sagittal view represent the degree of flexion that will be achieved and the angle between the femoral shaft and the plate in the coronal view represent the degree of valgus that will be achieved. This is the clinical appearance of the flexion angle in side view After osteotomy completion, Complete fixation of the plate is followed. And this is the clinical appearance of the resected anterolateral 2 wedges
- #21 For osteochondroplasty, an interval is developed between tensor fascia lata and gluteus medius muscle. Then, the anterior hip capsule is exposed and opened in T-shape fashion to identify The hump.
- #22 The hump is peeled off using curved osteotome or high-speed burr
- #23 Postoperative management
- #24 On day 1, calf massage and static quadriceps exercise are started as well as prophylactic dose of low molecular weight heparin as they considered as high-risk group of DVT according to Cincinnati Children's Hospital Medical Center guidelines.
- #25 from day 3 postoperatively, Sitting is started with passive and assisted active knee ROM On day 5, the patient started to toe touch with aid of crutches At the 6th postoperative week, radiographs were performed to monitor osteotomy healing and the patient was encouraged to start full weight bearing and to commence a physiotherapy regime
- #26 Results
- #27 Demographics and baseline disease characteristics: Are described in the following table It is clear that 80% of the treated cases were severe SCFE And the physeal status at the time of surgery was closing-closed in 75% of the cases Preoperative BMI mean was 29.44 with a range between 20.2 and 33.7 And all but one had vitamin D deficiency preoperatively that was corrected by parentral vitamin D course.
- #28 We used clinical, functional, and radiological measures to assess the outcomes Clinical measures include ROM, LLD, and ER gait and Drehmann sign Functional measures include HHS and WOMAC And radiological measures include Southwick angle, ,Alpha angle, HEA, NSA, ATD, and any Evidence of AVN, OA , or chondrolysis
- #29 Regarding the clinical parameters, the range of flexion improved in every single patient. The average of improvement was 35.25°.
- #30 Similar pattern has been demonstrated regarding abduction range for every case with average improvement at 15.25o
- #31 Similarly, the internal rotation has improved with average improvement at 35o
- #32 Regarding LLD, it improved in 10 patients by an average of 0.7 cm, remained unchanged in 8 patients, and worsened in one patient by one cm because of excessive wedge resection.
- #33 ER gait and Drehmann sign were present in 85% of the cases preoperatively. that Disappeared in all of them postoperatively
- #34 Functionally, the Average Preoperative HHS was at 55.2 that showed marked improvement at one-month postoperative follow up, with average of around 74, then improved at the final follow up reaching an average of 86.8.
- #35 As regard WOMAC, the preoperative index average was at 32.1%, that showed marked improvement at one-month postoperative follow up, with average of 16.2%, then improved at the final follow up, with average of 6.4%.
- #36 Radiologically, Southwick angle decreased in every single patient. The average of decrease was 46.25O.
- #37 The same trend was demonstrated in the alpha angle of Nötzli that showed a reduction in every case with average of reduction at 36.7°.
- #38 Concerning Hilgenreiner epiphyseal angle, there was a reduction in the measures when comparing the preoperative angles to the post-operative ones for every single case. The average of reduction was 11.35°.
- #39 Conversely, NSA improved in every patient. And The average of improvement was 10.74°.
- #40 Regarding ATD, it improved in 16 hips by an average of 4.9 mm, remained unchanged in 2 hips, and worsened in 2 hips by an average of 2.9 mm because of excessive correction
- #41 No radiographic evidence of AVN, chondrolysis, or osteoarthritic changes have been noticed in any patient.
- #42 Clinical-radiological correlation A significant negative correlation between preoperative Southwick angle and the preoperative HHS has been noticed. That indicate the more severe the disease, the poorer the scores.
- #43 In addition, There was a negative correlation between final HHS and patients’ age. The older the patients the poorer the scores
- #44 There was a positive correlation between final HHS and postoperative ATD those with improved ATD had better outcomes scores.
- #45 Complications There was one patient had screw breakage with no sequalae
- #46 . And one patient had screw penetration as seen in the x ray and confirmed with CT that necessitated screw exchange with a shorter one.
- #47 Discussion
- #48 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.
- #49 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 with modified Dunn procedure showed excellent short-term clinical and radiological outcomes. However, the follow up in these studies are short term with an average of 1.8 years, and the reported AVN range is between 3.3% and 47%, with overall incidence at 15%. Moreover, AVN occurrence could not be predicted (as the intraoperative assessment of femoral head perfusion is not reliable). Modified Dunn Procedure also has a Steep learning curve
- #50 There is also a Risk of implant failure (as we fix thin cortical shell of epiphysis). And there is a Considerable risk of reoperation surgeries (for AVN, implant failure, and hip dislocation) we observe that around 40% of the cases , were unstable cases rather than stable ones which reflected the focus of utilization of this technique in the unstable type. That goes with Ziebarth et al belief that the most important indication for modified Dunn procedure is unstable SCFE
- #51 Based on the above, two institutes have modified their practice patterns regarding modified Dunn procedure use in SCFE treatment: Boston Children Hospital recommendations: A high-volume surgeon must be present during each modified Dunn procedure. And this suregry is Restricted to acute severe unstable slippage within 24 hours of the slippage to provide satisfactory results. Javier et al recommendations: The use of modified Dunn procedure in unstable SCFE was abandoned in preference to gentle reduction, open capsulotomy, and in situ pinning. it is Restricted to very selective stable severe cases with open physis. Instead, It is better to choose another option as proximal femoral osteotomy in concomitant with in situ pinning and osteochondroplasty.
- #52 On the other hand, reviewing 5 case series studies that assess Imhäuser osteotomy alone revealed: Imhäuser osteotomy is much safer than modified Dunn procedure. However, It displayed lower clinical outcomes, but for longer follow up periods with an average of 19.5 years. The reported OA in Imhäuser osteotomy are most probably because of the non-addressed FAI that has a definite relation with OA.
- #53 So, adding a procedure to deal with FAI lesion could be the best option?!
- #54 In 2014, Bali et al described adding an additional procedure, osteochondroplasty, with Imhäuser osteotomy via Watson-Jones approach. They had excellent results evidenced by better Non Arthritic Hip score compared to Imhauser osteotomy alone. There are three studies in which Imhäuser osteotomy and osteochondroplasty were performed through SSD approach (Spencer et al , and Rebello et al , and Erickson et al studies). They have fair results with low WOMAC score outcomes, AVN development, or poor alpha angle correction
- #55 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.
- #56 Case Presentation
- #57 The first case is 14-years-old boy complained of 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 his BMI was 33.2
- #58 On examination, waddling gait and bilateral externally rotated gait were observed positive Drehmann sign, positive impingement sign, and limited ROM with no internal rotation in the right side.
- #59 Preoperative plain x ray revealed rt chronic severe stable SCFE with open physis and lt mild SCFE
- #60 a two-staged procedure was proceeded to deal with the problem. The first stage was targeting the severe side with our protocol and the second one was in situ pinning for the left side 3 weeks after.
- #61 This is the postoperative gait after 1 year follow up And this is the ROM
- #62 This photograph demonstrates the right leg position before and after surgery And this demonstrates the symmetry of internal rotation in prone position
- #63 These are radiological and clinical comparison before and after the surgery
- #64 The second case is16-years-old boy suffered of Bilateral intermittent hip pain and limping for 1.5 years. He was Diagnosed with bilateral SCFE and underwent in situ pinning on Lt side one year before. The condition limited his outdoor activities with HHS at 36.6 and WOMAC at 42.7%
- #65 On examination, waddling gait, antalgic gait and bilateral externally rotated gait were observed positive Drehmann sign and impingement were eminent on the right side and limited ROM in both sides
- #66 Radiographic imaging showed bilateral SCFE: the right side was severe, and the left one was moderate. Southwick angle of right side was 64o and left side was 48o
- #67 Two-staged procedure was performed to tackle the condition. The first stage was our protocol targeting the right side and the second one was Imhäuser osteotomy and osteochondroplasty for the left side 14 months later. Radiographic imaging parameters are improved substantially as seen in the x rays.
- #68 This is the postoperative gait after 1.5 year follow up And this is the ROM, and the abductor function
- #69 No trendenlenburg sign in the right side and left side Full abduction And full IR
- #70 These are radiological and clinical comparison before and after the surgery
- #71 The third one is 16-years-old boy with Right intermittent hip pain and limited motion range for 2 years. He was 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%.
- #72 His examination showed mild limping And positive impingement sign and lost IR
- #73 Plain x ray radiographs showed right severe chronic stable SCFE with closed physis Southwick angle: 58o Preoperative CT delineated the hump more clearly
- #74 Imhäuser osteotomy and osteochondroplasty were performed to treat the deformed hip. Final follow up x rays showed Southwick angle: 4o.
- #75 This is the postoperative gait after 1 year follow up And this is the ROM, and the abductor function
- #76 Good abductor power Full abduction And IR
- #77 These are radiological and clinical comparison before and after the surgery
- #79 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.
- #80 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.
- #81 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.