Birke Oliver, George Justine St, Gibbons Paul J, Little David G
The Children's Hospital at Westmead, Sydney, NSW, Australia.
University of Sydney, Sydney, NSW, Australia.
J Child Orthop. 2021 Oct 1;15(5):479-487. doi: 10.1302/1863-2548.15.210106.
The modified Dunn procedure for slipped capital femoral epiphysis (SCFE) remains controversial. We reviewed our series over ten years to report our learning curve, experience with intraoperative monitoring of femoral head perfusion and its correlation with postoperative Single-photon emission computed tomography (SPECT-CT) bone scan and femoral head collapse in stable and unstable SCFE.
We retrospectively assessed 217 consecutive modified Dunn procedures performed between 2008 and 2018. In all, 178 had a minimum of one-year follow-up (mean 2.7 years (1 to 9.2)) including 107 stable and 71 unstable SCFE. Postoperative viability was assessed with a three-phase Tc99 bone scan and SPECT-CT. From 2011, femoral head perfusion monitoring was performed intraoperatively using a Codman Intracranial Pressure transducer and the capsulotomy was modified.
With intraoperative monitoring, the rate of non-viable femoral heads in stable SCFE decreased from 21.1% to 0% (p < 0.001). In unstable SCFE, the rate remained unchanged from 35.7% to 29.8% (p = 0.669). The positive predictive value (PPV) of pulsatile monitoring for no collapse was 100% in stable and 89.1% in unstable SCFE. Pulsatile monitoring and viable SPECT-CT bone scan gave a 100% PPV for all cases. A non-viable scan defines those hips at risk of collapse since 100% of stable and 68.2% of unstable hips with non-viable bone scans went on to collapse.
Our protocol enables safe performance of this complex procedure in stable SCFE with intraoperative monitoring being a reliable asset. The avascular necrosis rate for unstable SCFE remained unchanged and further research into its best management is required.
Level III.
改良邓恩手术治疗股骨头骨骺滑脱（SCFE）仍存在争议。我们回顾了我们十年来的病例系列，以报告我们的学习曲线、术中监测股骨头灌注的经验及其与术后单光子发射计算机断层扫描（SPECT-CT）骨扫描以及稳定和不稳定型SCFE中股骨头塌陷的相关性。
我们回顾性评估了2008年至2018年间连续进行的217例改良邓恩手术。其中，178例患者进行了至少一年的随访（平均2.7年（1至9.2年）），包括107例稳定型和71例不稳定型SCFE。术后通过三相Tc99骨扫描和SPECT-CT评估股骨头的存活情况。从2011年起，术中使用科德曼颅内压传感器监测股骨头灌注，并对关节囊切开术进行了改良。
通过术中监测，稳定型SCFE中股骨头无活力的发生率从21.1%降至0%（p<0.001）。在不稳定型SCFE中，该发生率从35.7%降至29.8%，保持不变（p=0.669）。稳定型SCFE中，搏动性监测预测无塌陷的阳性预测值（PPV）为100%，不稳定型SCFE中为89.1%。搏动性监测和存活的SPECT-CT骨扫描在所有病例中的PPV均为100%。无活力的扫描定义了那些有塌陷风险的髋关节，因为100%的稳定型和68.2%的不稳定型髋关节在骨扫描无活力后继续塌陷。
我们的方案能够在稳定型SCFE中安全地进行这一复杂手术，术中监测是一项可靠的辅助手段。不稳定型SCFE的缺血性坏死率保持不变，需要进一步研究其最佳治疗方法。
三级。
