Chomiak J, Ošťádal M, Dungl P
Ortopedická klinika 1. lékařské fakulty Univerzity Karlovy, IPVZ a Fakultní nemocnice Bulovka, Praha.
Acta Chir Orthop Traumatol Cech. 2024;91(4):199-206. doi: 10.55095/achot2024/025.
The study aimed to evaluate the results of closed reduction and epiphyseodesis of unstable slips of the proximal femoral epiphysis. The hypothesis was that the clinical and radiological results of this method and incidence of avascular necrosis are comparable to the results of closed reduction and open reduction using surgical hip dislocation reported by literature.
In the period 2013-2023, 20 patients were treated for unstable slips in one institution. Whereas the boys were older (mean age of 13.4 years) than girls (mean age of 11.6 years), the gender distribution was equal. Acute on chronic slips prevailed over the acute slips (ratio 3:1). The slips were treated using the closed reduction, transphyseal fixation and capsular decompression at 6 to 240 hours after slip (81 hours on average). All patients were treated concurrently on the contralateral side as the prevention of the slip or to treat the grade I slips (two patients). The follow-up ranged from 7 months to 7 years. Clinical results were evaluated according to two scores: 1) own score (Bulovka University Hopspital score) based on the reduction of ROM, shortening of extremity and limitations of activities; 2) D'Aubigne-Postel score. In the radiological evaluation, correction of slip angle, alpha-angle, avascular necrosis (AVN) and the prominence of the anterior margin of the femoral neck on axial radiographs were evaluated.
According to the Bulovka University Hospital score, there were 10 excellent results (50%) with no limitation of activity, including sport, in tree cases the results were very good (15%) and in five cases good (25%), respectively, with some limitation of activity, and two results were unsatisfactory (10%) with severe limitation of activity due to the AVN. According to the D'Aubigne-Postel score, there were 14 excellent results (70%), four good results (20%), and two unsatisfactory results (10%). The slip reduction was as follows: under 20 deg. in five patients; under 30 deg. in 10 patients, and over 30 deg. in five patients, respectively. Alfa-angle was greater than 63 degrees (range 45-88 deg.) on average. Prominence of the off-set epiphysis-femoral neck and femoroacetabular impingement (FAI) were observed in six patients. Remodelling of this prominence was seen in one patient four years after surgery. Shortening of the femoral neck over 1 cm was reported in two patients. Complete AVN with severe deformity of the hip was noted in two patients.
Our hypothesis was confirmed because the results of treatment of the unstable slips by closed reduction are comparable with the published results of the same method and with surgical hip dislocation. The results correspond with those of large published cohorts of patients concerning the correction as well as rate of complications.
According to our results, urgent gentle closed reduction, transphyseal fixation and capsular decompression represent efficient and relatively safe methods of treatment of unstable slips with low incidence of complication. Residual deformity of the off-set epiphysis-femoral neck and FAI represent limitations of this method.
slipped proximal femoral epiphysis, unstable slips, closed reduction, transphyseal fixation.
本研究旨在评估股骨近端骨骺不稳定滑脱的闭合复位及骨骺阻滞术的效果。假设该方法的临床和放射学结果以及无血管坏死的发生率与文献报道的使用手术性髋关节脱位进行闭合复位和切开复位的结果相当。
2013年至2023年期间，一家机构对20例不稳定滑脱患者进行了治疗。男孩（平均年龄13.4岁）比女孩（平均年龄11.6岁）年龄大，性别分布均等。慢性急性滑脱多于急性滑脱（比例为3:1）。在滑脱后6至240小时（平均81小时）采用闭合复位、经骨骺固定和关节囊减压治疗滑脱。所有患者均同时对侧治疗以预防滑脱或治疗I级滑脱（2例患者）。随访时间为7个月至7年。临床结果根据两个评分进行评估：1）基于活动范围减小、肢体缩短和活动受限的自身评分（布洛夫卡大学医院评分）；2）达布尼-波斯特尔评分。在放射学评估中，评估了滑脱角、α角的矫正、无血管坏死（AVN）以及股骨颈前缘在轴位X线片上的突出情况。
根据布洛夫卡大学医院评分，10例结果为优（50%），活动无受限，包括运动，3例结果为良（15%），5例结果为可（25%），活动有一定受限，2例结果不满意（10%），因AVN导致活动严重受限。根据达布尼-波斯特尔评分，14例结果为优（70%），4例结果为良（20%），2例结果不满意（10%）。滑脱矫正情况如下：5例患者小于20度；10例患者小于30度，5例患者大于30度。α角平均大于63度（范围45 - 88度）。6例患者观察到骨骺-股骨颈偏移突出和股骨髋臼撞击（FAI）。1例患者术后4年这种突出有重塑。2例患者报告股骨颈缩短超过1厘米。2例患者出现完全性AVN且髋关节严重畸形。
我们的假设得到证实，因为闭合复位治疗不稳定滑脱的结果与相同方法以及手术性髋关节脱位的已发表结果相当。结果与已发表的大量患者队列在矫正以及并发症发生率方面的结果一致。
根据我们的结果，紧急轻柔闭合复位、经骨骺固定和关节囊减压是治疗不稳定滑脱的有效且相对安全的方法，并发症发生率低。骨骺-股骨颈偏移的残留畸形和FAI是该方法的局限性。
股骨近端骨骺滑脱、不稳定滑脱、闭合复位、经骨骺固定
