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Other Congenital & Developmental Hip Disorders 이대목동병원 윤여헌 Other children’s hip disorders Idiopathic Slipped capital femoral epiphysis (SCFE, 대퇴골 두 골단 분리) Transient synovitis of the hip (TSH, 일과성 고관절 활액막염) Idiopathic chondrolysis of the hip (특발성 고관절 연골 용해증) Congenital & developmental Developmental coxa vara (발달성 내반 고) Proximal femoral focal deficiency (PFFD, 근위 대퇴골 부분 결손) SCFE Most common hip disorder in adolescence Pathology in proximal femoral physis Neck displaced - anterolateral Head (epiphysis) displaced - posteromedial Apparent varus (Pistol grip deformity) Valgus SCFE (rare) SCFE (epidemiology) During growth spurt Male 10-16Y, Female 9-15Y Bilateral in 25 (18~63)% Younger children (< 10Y) 5~10% Mostly bilateral Endocrine/systemic disorder Hypothyroidism Panhypopituitarism Hypogonadism Hyperparathyroidism Renal osteodystrophy Tumor, radiation… Obesity (adioposo-genital syndrome) SCFE (pathoanatomy) In preslip stage Physeal widening Hypertrophic zone Synovial congestion Slip cleft Joint fluid collection Metaphysis – decalcification Posteromedial (anterolateral) displacement of femoral head (neck) Apparent varus SCFE (classification) By clinical presentation Preslip Acute (< 3 wks) Chronic Acute on chronic By stability Stable Unstable Unable to ambulate, remodelling (-), effusion AVN 50% “cold bone scan” – AVN in 80~100% SCFE (classification) By displacement Mild: slip<1/3, HSA<30 Moderate: 1/3~1/2, 30~60 Severe: >1/2, >60 SCFE (clinical finding) Overweight teenager Pain – hip, groin, thigh, knee Limited IR of hip Most consistent physical finding passive flexion steers abductionexternal rotaton (obligate ER of hip) ER gait Leg length discrepancy SCFE (radiography) Early X-ray findings (AP) Physis: widening, irregularity Epiphysis: decreased ht. Blanch sign of Steel (crescent sign) Kline’s line Chronic or AOC SCFE Remodelling on femoral metaphysis (superior and anterior) New bone on epi-metaphyseal junction (inferior and posterior) SCFE (radiography) Lateral Better defines posterior displacement Head-shaft angle SCFE (treatment) Goals Prevention of further slip Avoid osteonecrosis / chondrolysis Treatment modalities Stable SCFE In situ fixation with a single central screw Corrective osteotomy – subcapital (physeal), basilar neck, intertrochanteric Obsolete Bone peg epiphyseodesis, Cast, IF with multiple pins Unstable SCFE Prophylactic fixation of the contralat. hip Stable SCFE (in situ fixation) Currently gold standard for stable SCFE Metaphyseal remodelling Surgical technique Percutaneous single screw Center of epiphysis, perpendicular to physis 6.5~7.3mm, cannulated, stainless steel Avoid posterosuperior quadrant of femoral head Avoid violation of posterior retinacular art. Anterior intertroch line >5 threads in epiphysis Check the screw tip >5mm from subchondral bone Approach-withdraw maneuver Stable SCFE (treatment) Osteotomy Severe chronic slip Proximal realignment Subcapital (physeal) AVN 21~35% Base of neck Intertrochanteric Valgus-flexion closing wedge osteotomy Unstable SCFE Controversies Urgent (8 hours) > emergent > elective Gentle closed (complete) reduction < incidental reduction Joint decompression < not One > two screws POSNA study (JPO, 2005) Prophylactic fixation of the contralateral hip Indications Younger patient (<10Y) with metabolic-endocrine disease Reliable follow-up is not feasible SCFE (complications) Progression of slip 2. Osteonecrosis 3. Chondrolysis 1. SCFE (complications) Osteonecrosis acute, unstable slip iatrogenic ill-advised reduction violation of posterior cortex of neck posterosuperior quadrant of epiphysis osteotomy SCFE (complications) Chondrolysis Persistent pin penetration Manipulative reduction Prolonged immobilization Corrective osteotomy Transient Synovitis of the Hip Acute nonspecific inflammatory disease of hip 3~8 year old Healthy child Etiology unknown URI etc. 70% Acute monarticular hip pain Limping, antalgic gait LOM (abduction, IR) TSH Normal x-ray Joint effusion in 71% (ultrasound) TSH Gradual but complete recovery Association with LCP (1.5%?) Treatment Bed rest full relief from weight bearing for 2 weeks Oral NSAID: sometimes Useless Traction Antibiotics Steroid Aspiration Idiopathic Chondrolysis of the Hip Idiopathic progressive destruction of articular cartilage from acetabulum & femoral head Joint space narrowing Stiffness Adolescent age Insidious onset Autoimmune disease? Radiology Joint space <3mm Osteopenia Blurring subchondral Enlarged fovea capitis femori Mild coxa magna Idiopathic Chondrolysis Premature closure of proximal physis & trochanteric apophysis (bone scan) Dry joint (aspiration) Two clinical stage Acute (6-16M) Chronic (Years) Nl basal layer & subchon. bone Subsequent regeneration Partial-complete recovery in 50-60% Developmental Coxa Vara Developmental coxa vara Not at birth, but in early childhood Progressive Primary ossification defect in the inferior femoral neck: shearing – fatigue failure Congenital coxa vara At birth Not progressive Assoc. PFFD, cong. short femur Aquired coxa vara Fracture, tumor, fibrous dysplasia, rickets Coxa Vara Physical findings Abductor weakness Trendelenburg (+) LLD or waddling gait LOM Abduction (decreased NSA) IR (decreased F. anteversion) Radiography Vertical physis Triangular metaphyseal fragment Hilgenreiner angle: 40~70 (N<25) Inverted radiolucent Y pattern Decreased F. anteversion Coxa Vara Treatment Recovery if H-angle < 45 Op indications NSA < 90 or progressing H angle > 45 Trendelenburg (+) Valgus derotational osteotomy Goals NSA > 160 H angle < 30-40 경청해주셔서 감사합니다
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