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Surgical dislocation in the management of pediatric and adolescent hip deformity.

ABSTRACT: The surgical dislocation approach is useful in assessing and treating proximal femoral hip deformities commonly due to pediatric conditions. We sought to demonstrate the efficacy and problems associated with this technique. Diagnoses included slipped capital femoral epiphysis, Perthes disease, developmental dysplasia of the hip, osteonecrosis, and exostoses. Through this approach, femoral head-neck osteoplasty (22), intertrochanteric osteotomy (eight), femoral head-neck osteoplasty plus intertrochanteric osteotomy (15), femoral neck osteotomy (five), open reduction and internal fixation of an acute slipped capital femoral epiphysis with callus resection (five), open reduction and internal fixation of an acetabular fracture (one), trapdoor procedure (one), and acetabular rim osteoplasty (one) were performed. The average patient age was 16 years. The minimum followup was 12 months (average, 41.6 months; range, 12-73 months). Patients with Perthes disease and SCFE had preoperative and postoperative WOMAC scores of 9.6 and 5.1, and 7.9 and 3.5 respectively. In patients with unstable SCFEs, the average postoperative WOMAC score was 1.2. Seven patients underwent THAs and two patients underwent hip fusion. Complications in the 58 procedures included four cases of osteonecrosis: three after femoral neck osteotomy and one after intertrochanteric osteotomy. The surgical dislocation technique can be utilized to effectively treat these deformities and improve short-term symptoms. Although the technique is demanding, we believe surgical dislocation offers sufficient advantages in assessing and treating these complex deformities that it justifies judicious application.

SUBMITTER: Rebello G

PROVIDER: S-EPMC2635463 | biostudies-other | 2009 Mar

REPOSITORIES: biostudies-other

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Project description:PURPOSE:To compare the efficacy and safety of intraocular lens (IOL) repositioning and IOL exchange for the treatment of patients with IOL dislocation. METHODS:We systematically searched for relevant publications in English or Chinese in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, WHO International Clinical Trial Registration Platform, Clinical Trial.gov, China Biology Medicine Database, China National Knowledge Infrastructure Database and grey literature sources. Study quality was assessed using the STROBE template for observational studies and the Cochrane template for randomized controlled trials (RCTs). Data were meta-analyzed using RevMan 5.3. RESULTS:The review included 14 English-language studies reporting 1 RCT and 13 retrospective case series involving 1,082 eyes. Average follow-up time was 13.7 months. Pooled analysis of 10 studies showed that the two procedures had a similarly effect on best corrected visual acuity (MD -0.00, 95%CI: -0.08 to 0.08, P = 0.99). Pooled analysis of nine studies showed no significant difference in incidence of IOL redislocation (RR 2.12, 95%CI 0.85 to 5.30, P = 0.11); pooled analysis of seven studies showed greater extent of incidence of cystoid macular edema in IOL exchange (RR 0.47, 95%CI 0.21 to 1.30, P = 0.06). Pooled analysis of three studies showed greater extent of incidence of anterior vitrectomy in IOL exchange (RR 0.11, 95%CI 0.04 to 0.33, P<0.0001). Pooled analysis of two studies showed greater postoperative spherical equivalents in IOL repositioning (MD 1.02, 95%CI 0.51 to 1.52, P<0.0001). pooled analysis suggested no significant differences between the two procedures in terms of intraocular pressure, endothelial cell density, surgically induced astigmatism, or incidence of retinal detachment, intraocular hemorrhage or pupillary block. CONCLUSION:IOL repositioning and exchange are safe and effective procedures for treating IOL dislocation. Neither procedure significantly affects best corrected visual acuity and IOL redislocation. IOL exchange was superior to repositioning in terms of postoperative SE, but IOL repositioning was associated with lower incidence of anterior vitrectomy, potentially lower incidence of cystoid macular edema.

Project description:BackgroundFemoral head fractures are rare injuries; incongruency and instability are indications for surgical intervention. Anterior, posterior, and transtrochanteric surgical approaches have been proposed, but the exposure is limited with classical approaches. Surgical hip dislocation allows for a 360° view of the head and may facilitate a reduction in selected head fractures, but to our knowledge, few studies have reported on the results with this technique. We therefore report on the (1) quality of fracture reduction; (2) modified Harris hip score at a minimum of 2 years (mean, 6 years, range, 26-122 months); and (3) frequency of complications, including avascular necrosis (AVN), arthritis development, and heterotopic ossification, in a case series of patients with femoral head fractures treated with this approach.Description of techniqueThe procedure involves digastric trochanteric flip osteotomy and safe dislocation of the femoral head, preserving its vessels. Using this technique we are able to reduce all displaced femoral head fractures under direct view. Definitive fixation is performed through this approach with 2.7-mm nonabsorbable screws. The same technique may be used also for Pipkin IV fractures to fix transverse, T-type, posterior wall, or posterior column acetabular fracture.MethodsBetween 2004 and 2011, we used this approach to manage all displaced femoral head fractures in patients younger than 55 years old. A total of 17 patients were thus treated; of those three were lost to followup before 2 years, and one was excluded from study because of severe preoperative neurological impairment, leaving 13 for analysis here. Patient demographic, injury, and surgical variables as well as complications were recorded and retrospectively evaluated. Radiographic outcome was scored according to Matta's criteria on postoperative radiographs. Outcomes were evaluated with the modified Harris hip score. Minimum followup was 24 months (mean, 77 months; SD, 32.8 months).ResultsFracture reduction was anatomic in eight hips and imperfect in five. Mean clinical score was 82 points (SD, 7.7). One patient developed symptomatic femoral head AVN and underwent total hip arthroplasty 4 years after the index procedure; no other patient underwent arthroplasty. Besides this patient, signs of arthritis (Grade I according to Tönnis classification) were found in one patient and heterotopic ossification was recorded in two patients, but neither was symptomatic.ConclusionsOur experience with surgical dislocation shows clinical results comparable to previously reported outcomes in femoral head fractures treated with common approaches; we also present a similar rate of AVN and a lower rate of posttraumatic arthritis, but a higher risk of heterotopic ossification. Further case-control studies are necessary to confirm these statements.Level of evidenceLevel IV, therapeutic study.

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Surgical dislocation in the management of pediatric and adolescent hip deformity.

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