JBJS | Pseudarthrosis following Slipped Capital Femoral Epiphysis: Treatment with Reduction with Use of Gradual Distraction. A Case Report*

The Journal of Bone & Joint Surgery, Volume 79, Issue 10

Case Reports | October 01, 1997

Pseudarthrosis following Slipped Capital Femoral Epiphysis: Treatment with Reduction with Use of Gradual Distraction. A Case Report*

DROR PALEY, M.D., F.R.C.S.C.†; BERND FINK, M.D.‡; JOHN E. HERZENBERG, M.D., F.R.C.S.C.§, BALTIMORE, MARYLAND

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Investigation performed at Maryland Center for Limb Lengthening and Reconstruction, Baltimore

The Journal of Bone & Joint Surgery. 1997; 79:1552-5

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Introduction

Introduction | Case Report | Discussion | References

Pseudarthrosis is a rare complication of slipped capital femoral epiphysis. Traumatic pseudarthrosis of the femoral neck is treated with bone-grafting, osteotomy, and open reduction with internal fixation or with osteotomy alone. Severe slips are treated with closed pinning, epiphyseodesis with bone-grafting, open reduction, or osteotomy. Open reduction is associated with a high risk of avascular necrosis. We are not aware of any guidelines for the treatment of pseudarthrosis following slipped capital femoral epiphysis. The purposes of this report are to present the case of a patient who had this rare condition and to discuss alternative methods of treatment.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Maryland Center for Limb Lengthening and Reconstruction, The James Lawrence Kernan Hospital, 2200 Kernan Drive, Baltimore, Maryland 21207. The e-mail address for Dr. Paley is dpaley@mcllr.ummc.ab.umd.edu.

‡Orthopaedic Department, University Hospital Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany. E-mail address for Dr. Fink: fink@uke.uni-hamburg.de.

§Division of Orthopaedic Surgery, University of Maryland Medical School, 2200 Kernan Drive, Baltimore, Maryland 21207. E-mail address for Dr. Herzenberg: jherzenberg@mcllr.ummc.ab.umd.edu.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

‡Orthopaedic Department, University Hospital Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany. E-mail address for Dr. Fink: fink@uke.uni-hamburg.de.

§Division of Orthopaedic Surgery, University of Maryland Medical School, 2200 Kernan Drive, Baltimore, Maryland 21207. E-mail address for Dr. Herzenberg: jherzenberg@mcllr.ummc.ab.umd.edu.

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Fig. 1 Preoperative anteroposterior radiograph of the pelvis, showing a severe slip on the right with the femoral head resting on the lesser trochanter. Note the narrowing of the joint space, the foveal osteophyte, and the pseudarthrosis between the femoral head and neck.

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Fig. 2 Anteroposterior radiograph showing the proximal portion of the right femur after distraction of the hip joint with the Orthofix apparatus. The femoral neck has been partially reduced relative to the femoral head. Note the distraction between the femoral head and the roof of the acetabulum.

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Fig. 3 Radiograph showing the proximal portion of the right femur after percutaneous pinning and subtrochanteric osteotomy. The Ilizarov apparatus was used to stabilize the site of the osteotomy.

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Fig. 4 Radiograph showing the realignment of the proximal portion of the right femur. Although the lateral proximal femoral angle was corrected to 87 degrees, the lateral distal femoral angle of 81 degrees was indicative of a pre-existing valgus deformity of the knee.

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Fig. 5 Radiograph of the right hip, made at the latest follow-up examination. There were no signs of avascular necrosis, and the pseudarthrosis and the site of the subtrochanteric osteotomy had healed.

Case Report

Introduction | Case Report | Discussion | References

A twenty-seven-year-old man was seen because of progressive pain in the right hip and a limp. Chronic bilateral slipped capital femoral epiphysis had been diagnosed when the patient was fourteen years old, and it had been treated initially with in situ pinning with one pin in each hip. The pin in the right hip was removed because of trochanteric bursitis when the patient was fifteen years old, and the pin in the left hip was removed when he was sixteen and one-half years old. The pain in the right hip and the limp had developed when the patient was seventeen years old. Both of these symptoms became progressively worse; when the patient was first seen by us, he stated that the pain and limp limited his activities of daily living and interfered with his occupation as a housepainter.

The patient was 171 centimeters tall and weighed 109 kilograms at the time of presentation. He walked with a lurch and had a delayed Trendelenburg sign (a positive Trendelenburg sign that is not immediate but that occurs within thirty seconds) on the right. The range of motion of the right hip was 70 degrees of flexion, full extension, 10 degrees of abduction, 15 degrees of adduction, 10 degrees of internal rotation, and 45 degrees of external rotation. Scanograms revealed that the right lower extremity was three centimeters shorter than the left.

Radiographs showed a pseudarthrosis between the right femoral head and the femoral neck (Fig. 1). There was some narrowing of the joint space of the right hip. Both anteroposterior and lateral radiographs revealed that the femoral head had slipped severely from the femoral neck, resulting in a four-centimeter proximal and anterior displacement of the femoral neck relative to the femoral head. The femoral head was tilted into varus angulation in the acetabulum, and an osteophyte was seen to be protruding from the femoral head into the fovea on plain radiographs and on computed tomographic scans. Stress radiographs made with the hip in abduction and adduction showed obvious motion between the femoral head and neck, which indicated a non-union.

We decided to distract the femur from the pelvis gradually in order to reduce the femoral head and neck indirectly. In October 1993, we applied an Orthofix distractor⁶ (Orthofix S.R.L.; Bussolengo, Verona, Italy) to the pelvis and to the middle of the femoral diaphysis. The hip joint was distracted at a rate of 1.5 millimeters per day (0.5 millimeter three times per day). During the period of distraction, the patient was allowed to walk with crutches without weight-bearing on the right side. After two months of distraction, the femoral neck had been reduced to the position that was believed to be that of the original chronic slip—that is, varus extension and external rotation (Fig. 2). In order to maintain the reduction, percutaneous in situ pinning was performed with use of two 6.5-millimeter cannulated cancellous-bone screws. The external fixator attachment then was removed from the pelvis.

In order to facilitate union, a percutaneous subtrochanteric valgus-flexion internal rotation acute opening-wedge osteotomy was performed to reorient the non-union line more perpendicular to the weight-bearing axis (16 degrees to the vertical²⁰); the site of the osteotomy was repositioned and stabilized with the Ilizarov fixator (Smith and Nephew Orthopaedics, Memphis, Tennessee) (Fig. 3). Fixation consisted of two half-pins placed proximal to the site of the osteotomy and two half-pins placed distally in the femoral shaft. A percutaneous adductor tenotomy was performed at the same time in order to increase the range of motion in abduction and to reduce the pressure on the femoral head. Partial weight-bearing on two crutches was permitted during the four months that the external fixator was in place.

The lateral proximal femoral angle, which represents the orientation of the femoral head and the greater trochanter in the frontal plane, was corrected to 87 degrees (normal, 85 to 95 degrees^17,19). When the alignment of the hip was corrected, the knee appeared to be in valgus (Fig. 4). A review of the radiographs revealed that this valgus orientation had been present preoperatively but had been masked by the adducted (varus) position of the hip. The amount of valgus angulation of the knee with the hip corrected was unacceptable to the patient (the mechanical tibiofemoral angle was 12 degrees of valgus [normal, 0 degrees to 5 degrees of valgus¹⁸], and the lateral distal femoral angle was 81 degrees [normal, 85 to 90 degrees^17,19]).

A supracondylar focal dome osteotomy¹⁸, with fixation with a supracondylar nail, was performed to align the distal portion of the femur in July 1994. The alignment was corrected to normal (the mechanical tibiofemoral angle was corrected to 0 degrees and the lateral distal femoral angle, to 89 degrees). The patient returned to full weight-bearing eight weeks later. The only complication during treatment was a superficial infection at the site of a pin; the infection resolved after a ten-day course of oral antibiotic therapy.

At the most recent follow-up examination, the patient had no pain in either hip. The range of motion of the right hip was 100 degrees of flexion, full extension, 30 degrees of abduction, 5 degrees of adduction, 15 degrees of internal rotation, and 15 degrees of external rotation. The range of motion of the knee was 125 degrees of flexion and full extension on the right compared with 135 degrees of flexion and full extension on the left. The patient had returned to full-time work as a housepainter. The Harris hip score had improved from 68 points preoperatively to 91 points postoperatively. The mild narrowing of the joint space that had been present preoperatively was unchanged, but the non-union of the slipped capital femoral epiphysis appeared to be healed radiographically (Fig. 5). The osteophyte of the femoral head could no longer be seen.

Discussion

Introduction | Case Report | Discussion | References

Premature fusion of the involved physis is the goal of in situ pinning^23,24. Removal of the pins or screws has been recommended for a variety of reasons, including trochanteric bursitis⁸, fracture from the stress-riser effect²², and the risk of neoplasia from the corrosion of metal implants². Removal of the hardware while the physis is still open, however, can lead to a recurrent slip^5,8. Therefore, such removal should be done only after closure of the growth plate.

Realignment of the femoral head and shaft is desirable in instances of severe chronic slipped capital femoral epiphysis. Such realignment not only improves the gait and the arc of motion of the hip but also prevents impingement and early degenerative changes in the joint^10,21. Subcapital osteotomy with open reduction restores the anatomical relationship of the epiphysis with the femoral neck as well as the alignment of the femoral head and shaft because the osteotomy is performed at the location of the deformity^{4,10,11,15,16}. The greatest risk of this procedure is avascular necrosis¹². An unacceptably high rate of avascular necrosis has been reported in previous studies: Gage et al., for example, reported this complication in twenty-two (29 per cent) of seventy-seven hips, and Loder reported it in fourteen (47 per cent) of thirty unstable hips. Carney et al. reported avascular necrosis and chondrolysis in twelve (31 per cent) and eleven (28 per cent) of thirty-nine hips that had been treated with reduction of a slipped capital femoral epiphysis compared with seven (6 per cent) and fourteen (12 per cent) of 116 hips that had been treated without reduction for a slip of comparable severity. Both Carney et al. and Boyer et al. also showed that, among hips that had been reduced, the rates of avascular necrosis and chondrolysis increased with the severity of the slip. The prevalence of avascular necrosis of the femoral head decreases as the level of osteotomy proceeds distally because the risk of disturbing the blood supply of the femoral head during the operation is lower^9,15. However, the amount of possible correction of the varus angulation and posterior tilt of the femoral head is more limited when the osteotomy is performed more distally^1,9,21.

Other treatment options that might have been offered to our patient include arthrodesis of the hip and valgus-flexion derotation osteotomy with in situ pinning, or internal fixation and osteotomy. We decided against open reduction because of the high risks of avascular necrosis and chondrolysis. An open reduction would have necessitated an acute lengthening of the femur and a simultaneous closing-wedge osteotomy in the femoral neck because of the chronic deformity at that site. This choice of procedures would have further shortened the already short femoral neck.

The advantages of gradual distraction with external fixation are its minimum invasiveness, the low risk of damage to the blood supply of the femoral head, and the correction of limb-length discrepancy and alignment of the hip. Although we do not normally advocate gradual reduction by means of articular distraction with use of an external fixator as treatment for acute or chronic slipped capital femoral epiphysis, we believe that it was preferable to open reduction in this instance because of the high risk of avascular necrosis. As the reduction is closed and gradual, this method may have a role in the treatment of severe acute slipped capital femoral epiphysis for the reasons just cited.

References

Introduction | Case Report | Discussion | References

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