Early Reversible Ischemia of Femoral Head Epiphysis in Piglets on Gadolinium-enhanced MRI:An experimental study

Summary： The purpose of this study is to demonstrate if Gadolinium-enhanced MRI can detect early reversible ischemia of the femoral head epiphysis caused by hip hyper-abduction in piglets. Between 3 and 6 h consistent hyper-abduction, gadolinium-enhanced MRI was performed in 20 femoral heads of 10 piglets. After completion of MRI scan, the piglets were allowed to ambulate freely for 1 or 7 days and re-imaged. The enhanced-MRI results of epiphyseal and physeal cartilage and the secondary center of ossification were observed. MRI appearances and histological findings were compared. On Gadolinium-enhanced MRI, decreased or absent enhancement was seen in 14 cartilaginous epiphyses of all 20 femoral heads. Reperfusion was completed in 10 of 14 femoral heads after one day of ambulation and in the rest 4 after 7 days of ambulation. Gadolinium-enhanced MR/can identify early ischemia and its reversal of the capital femoral epiphysis induced by hip hyper-abduction.

Controversies in management of slipped capital femoral epiphysis

The traditional treatment of the hip with a slip of the capital femoral epiphysis has been an in situ fixation using a single screw.This has the sanctity of a long term result.Recent literature stresses the outcomes of failure to restore the upper femoral alignment and on the basis of the poor results makes a plea for capital realignment.This being a recent development,it lacks the support of long term follow up and it remains to be seen if this is a better alternative of managing displaced and unstable slipped capital femoral epiphysis.The authors look at some of the available literature on the subject to highlight these controversies and their implications for orthopedic surgeons.Other controversies pertain to contralateral fixation,duration of immobilization and amount of weight bearing after an in situ fixation.

Risk modeling of femoral neck fracture based on geometric parameters of the proximal epiphysis

BACKGROUND Fractures of the proximal femur epiphysis are problematic for state health care because they are associated with severe medical and social problems and high morbidity and mortality rates.AIM To model the potential risk of hip fracture via femur geometric parameters.METHODS Seventy educational cadaveric femurs from people aged 14 to 80 years,10 X-ray images from the records of the Human Anatomy Department and 10 X-ray images from the Department of Traumatology,Orthopedics and Disaster Surgery of Sechenov University,were evaluated.The parameters of the fractured bone were measured using images captured with a Canon d60 camera.The projection values of the proximal epiphysis of the cadaveric femurs and geometric parameters of the bones shown in the X-ray images were measured with Autodesk software(AutoCAD 2018).Analysis of the video frames showing bone rotation reveal that the greater trochanter can be inscribed in a parallelepiped,where one of the faces is parallel to the plane of view in the frontal standard projection and is rectangular.The angle of bone rotation obtained by turning the cube corresponded to the angle measured with the second technique.This reliable method of calculating the rotation of the bone relative to the anterior projection was employed in subsequent calculations.The geometric parameters of the femur were measured using X-ray images according to the proposed method.RESULTS The geometric parameters of 70 femurs were analyzed,and correlation coefficients were calculated.Our measurement results were compared with those reported by other authors.The potential influence of femur geometry on force distribution in the proximal epiphysis of the femur was described,and a 2-dimensional model of the femur epiphysis associated with minimal neck fracture risk was provided.The assessment of the geometric parameters of the femoral epiphysis indicated the greatest risk of a varus fracture of the neck if the angle of the minimal resistance zone(AMRZ)index>24°and the neck-shaft angle(NSA)<127.5°.In contrast,the minimum risk was observed at AMRZ<14°and NSA>128.87°.CONCLUSION The proposed method provides the potential femur neck fracture risk based on geometric parameters.

Prophylactic fixation of the unaffected contralateral side in children with slipped capital femoral epiphysis seems favorable:A systematic review

BACKGROUND Slipped capital femoral epiphysis(SCFE)occurs in adolescents and has an incidence of around 10 per 100000 children.Children presenting with a unilateral SCFE are 2335 times more likely to develop a contralateral SCFE than the general population.Prognostic factors that have been suggested to increase the risk of contralateral slip include a younger patient,an underlying endocrine disorder,growth hormone use and a higher radiographic posterior sloping angle.However,there is still much debate on the advantages and disadvantages of prophylactic fixation of the unaffected side in an otherwise healthy patient.AIM To investigate the risk rate of contralateral SCFE and assess the(dis)advantages of prophylactic fixation of the contralateral hip.METHODS A systematic literature search was performed in the Embase,Medline,Web of Science Core Collection and Cochrane databases.Search terms included‘slipped capital femoral epiphysis,’‘fixation,’‘contralateral,’and derivatives.The eligibility of the acquired articles was independently assessed by the authors and additional relevant articles were included through cross-referencing.Publications were considered eligible for inclusion if they presented data about otherwise healthy children with primarily unilateral SCFE and the outcomes of prophylactically pinning their unaffected side,or about the rates of contralateral slips and complications thereof.The study quality of the included articles was assessed independently by the authors by means of the methodological index for non-randomized studies criteria.RESULTS Of 293 identified unique publications,we included 26 studies with a total of 12897 patients.1762 patients(14%)developed a subsequent symptomatic contralateral slip.In addition,38%of patients developed a subsequent slip on the contralateral side without experiencing clinical symptoms.The most outspoken advantage of prophylactic fixation of the contralateral hip in the literature is prevention of an(asymptomatic)slip,thus reducing the increased risk of avascular necrosis(AVN),cam morphology and osteoarthritis.Disadvantages include an increased risk of infection,AVN,peri-implant fractures,loss of fixation as well as migration of hardware and morphologic changes as a consequence of growth guidance.These risks,however,appeared to only occur incidentally and were usually mild compared to the risks involved with an actual SCFE.CONCLUSION The advantages of prophylactic pinning of the unaffected side in otherwise healthy patients with unilateral SCFE seem to outweigh the disadvantages.The final decision for treatment remains to be patient-tailored.

Comparing complications of outpatient management of slipped capital femoral epiphysis and Blount’s disease:A database study

BACKGROUND Currents trends in pediatric orthopaedics has seen an increase in surgeries being successfully completed in an outpatient setting.Two recent examples include slipped capital femoral epiphysis(SCFE)and Blount’s disease.Surgical indications are well-studied for each pathology,but to our knowledge,there is an absence in literature analyzing safety and efficacy of inpatient vs outpatient management of either condition.We believed there would be no increase in adverse outcomes associated with outpatient treatment of either conditions.AIM To investigate whether outpatient surgery for SCFE and Blount’s disease is associated with increased risk of adverse outcomes.METHODS The 2015-2017 American College of Surgeons National Surgical Quality Improvement Program Pediatric Registries were used to compare patient characteristics,rates of complications,and readmissions between outpatient and inpatient surgery for SCFE and Blount’s disease.RESULTS Total 1788 SCFE database entries were included,30%were performed in an outpatient setting.In situ pinning was used in 98.5%of outpatient surgeries and 87.8%of inpatient surgeries(P<0.0001).Inpatients had a greater percent of total complications than outpatients 2.57%and 1.65%respectively.Regarding Blount’s disease,outpatient surgeries constituted 41.2%of the 189 procedures included in our study.The majority of inpatients were treated with a tibial osteotomy,while the majority of outpatients had a physeal arrest(P<0.0001).Complications were encountered in 7.4%of patients,with superficial surgical site infections and wound dehiscence being the most common.1.6%of patients had a readmission.No differences in complication and readmission risks were found between inpatients and outpatients.CONCLUSION The current trend is shifting towards earlier discharges and performing procedures in an outpatient setting.This can be safely performed for a large portion of children with SCFE and Blount’s disease without increasing the risk of complications or readmissions.Osteotomies are more commonly performed in an inpatient setting where monitoring is available.

Pseudomyogenic Hemangioendothelioma of Bone Initially Managed as Slipped Capital Femoral Epiphysis: A Case Report

Pseudomyogenic hemangioendothelioma is a rare, recently described neoplasm that usually presents as multifocal lesions in a single extremity. The disease has demonstrated a high propensity for infiltrative growth and local recurrence but limited metastatic potential. Variations of histological appearance and immunohistochemical signatures have been described, but typically involve spindle or polygonal cells with nuclear atypia and neutrophilic infiltration. Here we present a case report of an 8-year-old female who presented with hip pain that was initially diagnosed and managed as a slipped capital femoral epiphysis (SCFE). Subsequent evaluation led to the diagnosis of pseudomyogenic hemangioendothelioma of bone. Due to the degree of osseous destruction, described patterns of local recurrence, and metastatic potential of this neoplasm, a wide resection with endoprosthetic reconstruction of the proximal femur was performed. This case highlights the importance of due diligence in the diagnoses of SCFE and bone tumors in young patients with abnormalities of the proximal femur, including consideration of the need for biopsy.

Analysis of the Development of Avascular Necrosis in Slipped Capital Femoral Epiphysis

Introduction: Slipped capital femoral epiphysis (SCFE) is a common hip disorder in adolescents. The most serious complication is avascular necrosis (AVN), which has lasting sequelae. The objective of this study was to determine the rate of AVN in stable slips. Method: We reviewed retrospectively all the children treated for SCFE between 2004 and 2008 at Princess Margaret Hospital. Results: Of a total of 67 patients, 51 (76%) were stable slips and 16 (24%) unstable. Avascular necrosis developed in 3 patients with stable slip (5.9%) and in 6 with unstable slip (37.5%). There was no statistically significant association found between AVN and age, weight, slip severity, pin position, number of pins used, experience of the surgeon or side affected. Those with stable presentations can develop AVN2, males are more likely and the possibility of developing AVN increases as the time from presentation to operation increased. Conclusion: AVN can occur in stable slips without joint penetration. This combined with male sex and increased time to operation, increases the risk of AVN.

Long-term effect of intrathecal baclofen treatment on bone health and body composition after spinal cord injury:A case matched report

BACKGROUND Severe spasticity may negatively impact functionality and quality of life after spinal cord injury(SCI).Intrathecal baclofen treatment(IBT)is effectively used to manage severe spasticity and reduce comorbidities.However,long-term IBT may have a negative effect on bone mineral content(BMC),bone mineral density(BMD)and body composition(such as percentage fat mass and lean body mass).We demonstrated the negative effects of long-term IBT use in a single case compared with two non-IBT users.CASE SUMMARY A 46-year old Caucasian male Veteran(case)with a 21 year history of complete tetraplegia(complete C6 SCI)was implanted with IBT for 20 years.The case was matched to two participants with different time since injuries[2(match 1)and 13(match 2)years]without IBT.Knee BMC and BMD at the epiphysis and metaphysis of the distal femur and proximal tibia were evaluated using dual knee and the dual femur modules of GE Lunar iDXA software.Total and leg body composition assessments were also conducted for the three participants.Potential effect of long-term IBT was demonstrated by changes in BMD,consistent with bone demineralization,at the distal femur and proximal tibia and changes in percentage fat mass and lean mass of legs.The case showed 113%lower BMD at the distal femur,and 78.1%lower at the proximal tibia compared to match 1,moreover the case showed 45%lower BMD at the distal femur,and no observed changes at the proximal tibia compared to match 2.The case had 27.1%and 16.5%greater leg%fat mass compared to match 1 and match 2,respectively.Furthermore,the case had 17.4%and 11.8%lower%leg lean mass compared to match 1 and match 2,respectively.CONCLUSION Long-term IBT may impact bone health and body composition parameters in persons with complete SCI.It may be prudent to encourage regular screening of individuals on long-term IBT considering the prevalence of osteoporosis related fractures,cardiovascular diseases,and metabolic disorders in this population.

EDM1： a novel point mutation in cartilage oligomeric matrix protein gene in a Chinese family with multiple epiphyseal dysplasia

Background Multiple epiphysis dysplasia （MED） is a common skeletal dysplasia with a significant locus heterogeneity. In the majority of clinically defined.cases, mutations have been identified in the gene encoding cartilage algometric matrix protein （ COMP）. Methods Five patients were included in the study. Linkage analysis and mutation analysis of the COMP gene were conducted in the patients and their family members. Results We have identified a novel mutation in axon 14 of COMP gene in the family. Conclusions This mutation produced a severe MED phenotype with marked short stature, early onset osteoarthritis, and remarkable radiographic changes. Our results extended the range of disease-causing mutations in COMP gene and contributed more information about relationship between mutations and phenotype.