Upasani Vidyadhar V, Birke Oliver, Klingele Kevin E, Millis Michael B
Rady Children's Hospital San Diego, University of California San Diego, 3030 Children's Way, Suite 410, San Diego, CA, 92123, USA.
The Children's Hospital at Westmead, Westmead, Australia.
Clin Orthop Relat Res. 2017 Apr;475(4):1229-1235. doi: 10.1007/s11999-016-5094-7.
The modified Dunn procedure facilitates femoral capital realignment for slipped capital femoral epiphysis (SCFE) through a surgical hip dislocation approach. Iatrogenic postoperative hip instability after this procedure has not been studied previously; however, we were concerned when we observed several instances of this serious complication, and we wished to study it further.
QUESTIONS/PURPOSES: The purpose of this study was to evaluate the frequency, timing, and clinical presentation (including complications) associated with iatrogenic instability after the modified Dunn procedure for SCFE.
Between 2007 and 2014, eight international institutions performed the modified Dunn procedure through a surgical dislocation approach in 406 patients. During the period in question, indications varied at those sites, but the procedure was used only in a minority of their patients treated surgically for SCFE (31% [406 of 1331]) with the majority treated with in situ fixation. It generally was performed for patients with severe deformity with a slip angle greater than 40°. Institutional databases were searched for all patients with SCFE who developed postoperative hip instability defined as hip subluxation or dislocation of the involved hip during the postoperative period. We reviewed in detail the clinical notes and operative records of those who presented with instability. We obtained demographic information, time from slip to surgery, type of fixation, operative details, and clinical course including the incidence of complications. Followup on those patients with instability was at a mean of 2 years (range, 1-5 years) after the index procedure. Complications were graded according to the modified Dindo-Clavien classification. Radiographic images were reviewed to measure the preoperative slip angle and the presence of osteonecrosis.
A total of 4% of patients treated with the modified Dunn procedure developed postoperative hip instability (17 of 406). Mean age of the patients was 13 years (range, 9-16 years). Instability presented as persistent hip pain in the postoperative period or was incidentally identified radiographically during the postoperative visit and occurred at a median of 3 weeks (range, 1 day to 2 months) after the modified Dunn procedure. Eight patients underwent revision surgery to address the postoperative instability. Fourteen of 17 patients developed femoral head avascular necrosis and three of 17 patients underwent THA during this short-term followup.
Anterolateral hip instability after the modified Dunn procedure for severe, chronic SCFE is an uncommon yet potentially devastating complication. Future studies might evaluate the effectiveness of maintaining anterior hip precautions for several weeks postoperatively in an abduction brace or broomstick cast to prevent this complication.
Level IV, therapeutic study.
改良邓恩手术通过手术性髋关节脱位入路，有助于对股骨头骨骺滑脱（SCFE）进行股骨近端复位。此前尚未对该手术后的医源性髋关节不稳定进行过研究；然而，我们在观察到几例这种严重并发症后感到担忧，希望进一步研究。
问题/目的：本研究的目的是评估改良邓恩手术治疗SCFE后医源性不稳定的发生频率、时间及临床表现（包括并发症）。
2007年至2014年期间，8家国际机构对406例患者采用手术脱位入路实施改良邓恩手术。在此期间，各机构的手术指征有所不同，但该手术仅用于少数接受手术治疗的SCFE患者（占1331例患者中的31%[406例]），多数患者采用原位固定治疗。该手术一般用于滑移角大于40°的严重畸形患者。检索机构数据库，查找所有术后出现髋关节不稳定（定义为术后期间患侧髋关节半脱位或脱位）的SCFE患者。我们详细查阅了出现不稳定患者的临床记录和手术记录。我们获取了人口统计学信息、从滑脱至手术的时间、固定类型、手术细节以及临床病程，包括并发症的发生率。对这些不稳定患者的随访在初次手术后平均2年（范围1至5年）进行。并发症根据改良的丁多 - 克莱维恩分类法进行分级。复查影像学图像以测量术前滑移角及有无骨坏死。
接受改良邓恩手术治疗的患者中，共有4%（406例中的17例）出现术后髋关节不稳定。患者的平均年龄为13岁（范围9至16岁）。不稳定表现为术后持续的髋关节疼痛，或在术后复诊时通过影像学偶然发现，发生在改良邓恩手术后中位时间3周（范围1天至2个月）。8例患者接受了翻修手术以解决术后不稳定问题。在这一短期随访期间，17例患者中有14例发生股骨头缺血性坏死，17例患者中有3例接受了全髋关节置换术。
改良邓恩手术治疗严重、慢性SCFE后的前外侧髋关节不稳定是一种罕见但可能具有毁灭性的并发症。未来的研究可评估术后数周在外展支具或扫帚柄石膏中保持髋关节前侧预防措施以预防该并发症的有效性。
四级，治疗性研究。
