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PubMed1984

Traumatic dislocation of the hip with separation of the proximal femoral epiphysis. Report of two cases and review of the literature.

Traumatic hip dislocation with separation of the proximal femoral epiphysis is a rare injury. Twenty-six observations collected from the literature, together with two further cases presented in this paper, were statistically evaluated. Two types of injury were considered: T1, dislocation with complete separation and displacement of the epiphysis; and T2, dislocation with incomplete separation of the epiphysis. Two main therapeutic protocols had been carried out: restoration of anatomy, supplemented by different means of stabilization; and removal of the epiphysis with or without complementary procedures. Fifteen patients had been followed up for 2 years or more and avascular necrosis had been found in all of them. Leg-length discrepancy also had significant incidence. Eleven patients with T1 injury had been followed up to skeletal maturity: results were fair in four patients and poor in seven. Early surgical restoration of the proximal extremity of the femur, stabilized with Kirschner wires and cast, is the recommended treatment.

Accidents, Traffic↗
PubMed2002

[Radiology and measurement in adolescent slipped capital femoral epiphysis].

Two X-rays taken in two planes perpendicular to each other secure the early diagnosis of adolescent slipped capital femoral epiphysis (SCFE). In imminent SCFE, two radiographic features are considered the most important signs: the broadening and the irregular demarcation of the upper femoral epiphyseal plate. In the beginning of SCFE, the process of dislocation is much better visible in the second radiographic plane (the lateral tangent of the femoral neck builds a smaller secant of the lateral femoral head). In chronic SCFE, the aforementioned radiographic signs including the epiphyseal dislocation are more marked. An additional feature can be various deformities of the femoral neck and duplicate contours of the medial demarcation of the femoral neck. In acute SCFE, there is a complete disruption of continuity between the metaphysis and epiphysis. Beside the marked gap in the epiphyseal plate, there is a severe dislocation between the femoral neck and the epiphysis. There are also partly patchy, partly cystic changes in the metaphyseal part of the femoral neck. The so-called acute on chronic slip, a sudden slip of the upper epiphysis after prolonged chronic slipping, is considered a specific case of SCFE. The long-term result of treated as well as untreated SCFE can be the gradual increase of coxarthrosis, which is typically more marked in the medial direction of the joint. The direction and the degree of the epiphyseal slip play an important role in the development of "epiphyseal" coxarthrosis. The planning of corrective operations as well as the quantitative evaluation of the prearthrotic deformity require the conversion of angles of dislocation that are projected on X-rays into anatomically correct angles. This conversion is done with tables that were created with the aid of computers and requires that the positioning of the femur for taking the X-rays is always done under standardized conditions.Mostly, in minor dislocations in the usual direction (medially and dorsally), the difference between the projected and the real angles is relatively small. Therefore, in these cases of SCFE it might not be necessary for practical and operative needs to convert these angles into real angles. However, this simplification is only then acceptable if the prescribed positioning of the femur for taking the X-rays is strictly adhered to so that additional errors of projection are excluded.

Adolescent↗
PubMed1993

Experimental study on growth of epiphysial plate: free graft in rabbits.

The growth potential of a free graft of an epiphysial plate was investigated in rabbits. Two epiphysial plate grafts were harvested from each iliac crest. One was grafted to the head (onto bone) and the other to the ear (onto cartilage). Both of the epiphysial plates enlarged to a maximum height of 1.4 cm and became similar to iliac crests. Enchondral ossification was observed up till approximately 28 weeks of age. We conclude that an epiphysial plate has growth potential after free heterotopic transplantation.

Animals↗
PubMed2006

[Total knee arthroplasty for recent severe fracture of the proximal tibial epiphysis in the elderly subject].

PURPOSE OF THE STUDY: Bone comminution, serious cartilage damage, and the poor mechanical quality of osteoporotic bone create a difficult challenge for osteosynthesis of joint fractures in the elderly subject. Poor results with certain hip, elbow and shoulder fractures have lead certain authors to propose emergency arthroplasty in selected cases. We report our experience with four knee arthroplasties implanted for recent severe fracture of the proximal tibial epiphysis in elderly subjects. MATERIAL AND METHODS: Four independent patients aged over 75 years presented a severe comminutive fracture of the proximal epiphysis of the tibia (Three Schatzker 5, one Schatzker 4). After obtaining the patients' informed consent, early knee arthroplasty was performed. A long-stem cemented tibial piece was used on which the epiphysis was reconstructed. Implants providing support for ligament deficits were used in all cases. Immediate weight-bearing was authorized. RESULTS: Follow-up ranged from two to seven years. The IKS function score (15, 60, 100, 100) depended on the patient's general status. The IKS knee score was excellent for three knees (90, 95, 95), and fair in one (45). Re-operations were not needed in any of the patients. All x-rays showed bone healing with correctly aligned limbs (less than 2 degrees deformation). There were no lucent lines at last follow-up. DISCUSSION: Early arthroplasty for complex fractures of the proximal epiphysis of the tibia is a realistic option. Using a cemented long-stem tibial piece ensures primary stability sufficient for early weight-bearing before bone healing. Use of a constrained prosthesis, or better a hinged prosthesis, can be questioned but avoids the difficulty of ligament balance on an osteoporotic knee with a destroyed joint surface. None of the patients required reoperation and the results in terms of pain were excellent. The overall outcome depends on the general status of the patient.

Aged↗
PubMedDate not supplied

[Effects of high-energy shock waves on the structure of the immature epiphysis--a histomorphological study].

AIM: Extracorporeal shock wave treatment of infantile skeleton diseases is theoretical reasonable. The aim of this study was to investigate if extracorporeal shock wave therapy (ESWT) may cause damage to the epiphysis within the energy range of human application doses. METHOD: 18 rabbits were treated with 800 extracorporeal shock waves (Philips lithotripter LDM-E, energy density 0.32 mJ/mm(2)) at the proximal tibia epiphysis. At 72 hours, 14 days and 4 weeks each after shock wave application 6 rabbits were sacrificed. RESULTS: Histological examination showed no damage to the epiphysis in all treated subjects. CONCLUSION: This experimental study demonstrates that, under the conditions used in human shock wave therapy, no damage to the rabbit epiphysis occurs.

Animals↗
PubMedDate not supplied

[Development and growth of the epiphysis].

Most long bones end near the joint in a separate epiphysis which at first consists of cartilage and is later ossified. This epiphysis becomes fused with the shaft of the bone, in most cases only towards the end of puberty. The process is regulated by a number of parallel systemic, cellular and mechanical feedback controls, the complexity of which accounts for its liability to become disordered. The stress acting on the cartilaginous epiphysis is comparable to that in the adult. The relative differences may be attributed to variations in the mechanical relationship and to the hormonal control of the body's growth. The individual epiphyses undergo a characteristic series of events; central calcification, absorption of cartilage and endochondral ossification, the further course of which is definitely determined by the degree of local distortion. This applies to the general shape of the epiphysis as well as to its internal structure. The composition and thickness of the remaining articular cartilage are controlled by these feedback mechanisms throughout the whole of life.

Adolescent↗
PubMed1999

Diagnosis and treatment of slipped capital femoral epiphysis.

Slipped capital femoral epiphysis remains a diagnostic problem despite numerous papers written on the subject. The most important factor in the diagnosis of slipped capital femoral epiphysis is suspicion by the practitioner. The history, physical examination, and radiographic imaging are important in the confirmation of the diagnosis. Imaging is the topic of 1998 with advances in the areas of ultrasound. Ultrasound may be better in experienced hands than plain radiography in the diagnosis of slipped capital femoral epiphysis. Magnetic resonance imaging is used for diagnosis of slipped capital femoral epiphysis and in the assessment of pre-slips. The magnetic resonance image can be oriented to a plane orthoganol to the plane of the physis to assess the width of the physis and to detect edema in the area of the physis.

Adolescent↗
PubMedDate not supplied

Biomechanical analysis of single screw fixation for slipped capital femoral epiphysis: are more threads across the physis necessary for stability?

PURPOSE: To evaluate single screw fixation stability, in the treatment of slipped capital femoral epiphysis, as a function of screw thread distribution across the physis. STUDY DESIGN: In vitro biomechanical study. METHODS: Thirty porcine proximal femurs were sectioned through the physeal line and stabilized with a cannulated 7.3-mm stainless steel AO screw. The distal 16 mm of each screw was threaded (5 threads). The femurs were randomized into 5 groups (1, 2, 3, 4, or 5 threads across the physis) and biomechanically tested to determine failure load (N) and stiffness (N/mm). RESULTS: Femurs with 2 or 3 threads across the physis had a significantly greater load to failure and stiffness compared with femurs with 1, 4, or 5 threads across the physis (P < 0.05). CONCLUSIONS: Thread distribution across the physis seems to be important. When using screws with a 16-mm thread, greatest strength and stiffness are achieved when 40%-60% of threads engage the epiphysis, with a significant decrease when greater than 80% of threads cross the physis. Too few threads in the epiphysis as well as too few in the metaphysis both lead to decreased stability. CLINICAL RELEVANCE: This study challenges the belief that compression across the physis maximizes slipped capital femoral epiphysis fixation stability. We recommend equal distribution of threads across the physis when using 16-mm thread screws, and we postulate that screws with a greater thread length (32 mm or fully threaded) would increase fixation stability even further. Optimizing purchase may decrease the incidence of slip progression, especially as the prevalence of obesity increases in the adolescent population.

Animals↗
PubMed1996

Bilaterality in slipped capital femoral epiphysis: importance of a reliable radiographic method.

One hundred patients treated for slipped capital femoral epiphysis (SCFE) were reviewed to evaluate the incidence of bilateral slipping of the epiphysis at an average follow-up time of 32 years. When the patients were examined during adolescence, repeat lateral radiographs of the hips had been obtained by the frog lateral view in 33 patients and by the standardized lateral view according to the method of Billing in 67 patients. At re-examination, 59 patients (59%) were judged to have had a previous bilateral SCFE; in 42 of these 59 patients (71%), slipping of the contralateral hip was asymptomatic. In 23 patients (23%), the diagnosis of bilateral slipping was established at primary admission, in 18 (18%) later during adolescence, and in 18 (18%) not until the patients were reexamined as adults and the primary radiographs were reviewed. The incidence of bilateral slipping was higher in patients in whom the Billing standardized lateral view was used (63%) than in patients in whom the frog lateral view was used (52%). We conclude that the incidence of bilateral slipping of the epiphysis in patients with SCFE is approximately 60% in Sweden. If repeat radiographs of the contralateral hip are obtained with the Billing standardized lateral view until physeal closure occurs, even minor slipping of the epiphysis, which is often advisable to treat, will be apparent.

Adolescent↗
PubMed1976

Remodelling by asymmetrical epiphysial growth. An experimental study in dogs.

Spontaneous correction of deformity is produced by bone remodelling during the period of growth. The purpose of this experimental study was to find out in which phase and to what extent asymmetrical epiphysial growth participated in the correction of an experimentally produced deformity. Transverse wedge osteotomy was performed in the legs of twenty growing mongrel dogs, the fragments being fixed with bent AO-plates. From radiographs taken at intervals of two weeks the epiphysial and axial angles were measured. Nine dogs were given tetracycline ten to twenty days before death and the cut surfaces were photographed in reflected ultra-violet light. It was found that epiphysial growth played an important role in the remodelling process. This factor accounted for roughly half of the total correction and averaged 12-5 degrees during the observation time of 160 days. The greatest correction occurred during the first weeks. Correction of the epiphysial angle took place with acceleration of growth.

Animals↗
PubMed1983

Localised immune complexes and slipped upper femoral epiphysis.

Slipped upper femoral epiphysis remains a disease of unknown aetiology. Recent evidence has bolstered speculation that the immune system may play a role in the aetiology or pathogenesis of slipped epiphysis or of one of its complications, chondrolysis. This study reports the finding of immune complexes in the synovial fluid of all but one hip affected with slipped epiphysis in a consecutive series. In seven patients, immune complexes were detected by both the Raji cell assay and C1q-binding assay; in two, by the C1q-assay only; and in one, by the Raji cell assay only. No patients had immune complexes in the serum. Twenty-one patients with synovitis of the knee or hip caused by a variety of disorders served as the control group. Two of these patients had immune complexes in their synovial fluid. It appears that the immune complexes characterise the synovitis found with slipped upper femoral epiphysis as distinct from most other synovitides.

Adolescent↗
PubMed2001

Histopathologic changes in growth-plate cartilage following ischemic necrosis of the capital femoral epiphysis. An experimental investigation in immature pigs.

BACKGROUND: The developing capital femoral epiphysis consists of a secondary center of ossification surrounded by epiphyseal cartilage. Between the epiphyseal cartilage and the secondary center of ossification is a growth plate, which contributes to the circumferential increase in size of the secondary center of ossification during development. The main objective of this study was to describe the histopathologic changes that occur in the growth plate surrounding the secondary center of ossification during the early and reparative phases following the induction of ischemic necrosis of the capital femoral epiphysis in immature pigs. METHODS: Ischemic necrosis of the capital femoral epiphysis was induced in eighteen piglets by placing a nonabsorbable suture ligature around the femoral neck following a capsulotomy and transection of the ligamentum teres. The animals were killed three days to eight weeks following the induction of ischemia, and visual, radiographic, and histologic assessments were performed. RESULTS: Two to four weeks after the induction of ischemic necrosis, the growth plate surrounding the secondary center of ossification became necrotic. The observed histopathologic changes included chondrocyte death, loss of safranin-O staining of the matrix of the necrotic growth-plate cartilage, an absence of vascular invasion of terminal hypertrophic chondrocytes, and a decrease in the amount of primary spongiosa, indicating cessation of endochondral ossification. In the reparative phase, at four to eight weeks postoperatively, chondrocyte clusters and intense safranin-O staining were observed in the epiphyseal cartilage around the necrotic growth-plate cartilage. In the peripheral region of the femoral head, necrotic growth-plate cartilage surrounding the secondary center of ossification was resorbed by a fibrovascular tissue from the marrow space. By six weeks, new accessory centers of ossification with restored endochondral ossification were observed in the peripheral epiphyseal cartilage. New ossification centers contributed to the fragmented radiographic appearance of the secondary center of ossification. The physis appeared essentially normal in most animals, although five of the eighteen piglets showed mild or moderate histopathologic changes. CONCLUSIONS: In this model, ischemic necrosis of the capital femoral epiphysis resulted in necrosis of the growth plate surrounding the secondary center of ossification. Small new ectopic centers of ossification appeared in the epiphyseal cartilage, explaining in part the fragmented radiographic appearance of the secondary center of ossification.

Animals↗
PubMed2006

Atypical and typical (idiopathic) slipped capital femoral epiphysis. Reconfirmation of the age-weight test and description of the height and age-height tests.

BACKGROUND: The age-weight test was described to aid the clinician in defining demographic predictors of an atypical slipped capital femoral epiphysis. We wished to retest the accuracy and applicability of the age-weight test and height differences in children with atypical and typical slipped capital femoral epiphyses. METHODS: A retrospective review of the records for all children with slipped capital femoral epiphysis from 1998 through 2003 was performed. Gender, race, chronological age, weight, height, the duration of symptoms, and the laterality of the slip were recorded. The slip angle was classified as mild (< 30 degrees), moderate (30 to 50 degrees), or severe (> 50 degrees). Statistical analyses were performed. RESULTS: The study included 105 children (thirty-eight girls and sixty-seven boys) with 141 slipped capital femoral epiphyses; ten children had fifteen atypical slipped capital femoral epiphyses, and ninety-five children had 126 typical slipped capital femoral epiphyses. Sixty-nine children had unilateral involvement, and thirty-six had bilateral involvement. The average age at the time of presentation for the first slipped capital femoral epiphysis was 12.1 +/- 2.0 years. The average duration of symptoms was 3.7 +/- 5.5 months. In the group of 128 slipped capital femoral epiphyses for which the slip angle was known, there were ninety-three mild, twenty-seven moderate, and eight severe slips. The average slip angle was 24 degrees +/- 18 degrees. The age-weight test demonstrated a sensitivity of 50%, a specificity of 89%, a positive predictive value of 33%, and a negative predictive value of 94%. The age-height test, involving the same definition as the age-weight test except that the percentiles apply to height and not weight, demonstrated a sensitivity of 88%, a specificity of 73%, a positive predictive value of 30%, and a negative predictive value of 98%. The height test, which was defined as positive if the child's height was at or below the tenth percentile for age and as negative if it was above the tenth percentile, demonstrated a sensitivity of 75%, a specificity of 97%, a positive predictive value of 75%, and a negative predictive value of 97%. CONCLUSIONS: The present study reaffirmed the accuracy and applicability of the age-weight test for differentiating between typical and atypical slipped capital femoral epiphyses, and it further defined the age-height and height tests. If the height of a child can be obtained, the height test is likely to be most useful for differentiating between typical and atypical slipped capital femoral epiphysis. When height is not known, the age-weight test will result in a similar negative predictive value but with a lower sensitivity, specificity, and positive predictive value. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions to Authors for a complete description of levels of evidence.

Adolescent↗
PubMed1999

Chondrolysis of the hip complicating slipped capital femoral epiphysis: long-term follow-up of nine patients.

Nine patients with chondrolysis secondary to slipped capital femoral epiphysis of the hip were followed up from a minimum of 7 to a maximum of 19 years (average, 13.7 years) after the onset of the disease. The degree of slipping of the proximal epiphysis of the femur was severe in five patients and moderately severe in four patients. The nine patients were treated with non-weight bearing, antiinflammatory drugs, and physical therapy. The disease had a good resolution, with gradual regression of pain, and radiographs showed restoration of the joint space in an average of 10 months. At follow-up, mild coxalgia after prolonged activity was present in five patients, whereas in the one patient with concomitant avascular necrosis, pain was much more intense. All patients had some limitation of range of motion of the hip. It was most restricted in two patients, one with associated avascular necrosis and one with a severe slip. In all patients, radiographs showed restoration of the joint space. In the group with severe degrees of slipping, there were marginal osteophytes of the femoral head and the acetabulum. Significant arthrosis was present in the patient treated conservatively and in the patient with associated ischemic necrosis. In this long-term study of chondrolysis secondary to slipped capital femoral epiphysis, the overall prognosis was benign and was determined by the degree of slipping of the proximal epiphysis of the femur and concomitant aseptic necrosis. However, the authors believe that the patients with radiographic signs of degenerative joint disease may have a poor long-term prognosis.

Adolescent↗
PubMed2005

[Axial and derotational traction before surgery for slipped femoral capital epiphysis].

18 cases of slipped femoral capital epiphysis were prepared for surgery by axial and derotational traction lasting 1 to 5 (av. 2,9) weeks. In all cases significant pain relief was achieved, partially the range of passive motion in the hip was improved. No reduction of slipped epiphysis was recorded. Best results occurred in medium and severe (> 60 degrees) cases. The traction before surgery for slipped femoral epiphysis is considered to improve range of motion, bring good pain relief, but not reduce the slipped epiphysis.

Adolescent↗
PubMed2005

[Regulation of differentiation and proliferation of epiphysis stem cells by Notch1 signaling system].

OBJECTIVE: To investigate the regulation of differentiation and proliferation of epiphysis stem cells by Notch1 signaling system. METHODS: Costocostal cartilage was taken from a SD rat. Epiphysis stem cells were isolated and cultured. Recombinant human nuclear factor-kappaB (rhNF-kappaB), an activator of the Notch signaling system, and gamma-secretase inhibitor (MW167), an inhibitor of the Notch signaling system, were added into the culture medium respectively. The cells cultured in the medium added with phosphate-buffered saline were used as control group. Then the cultured cells were collected. The expression of the homologous Notch receptors and homologous Notch ligands was detected by RT-PCR. Immunohistochemistry was used to detect the levels of collagen II, collagen X, and proliferating cell nuclear antigen (PCNA). MTT method was used to calculate the growth curve. The cell phase was examined by flow cytometry. The level of alkaline phosphatase (AP) was measured. Western blotting was used to detect the protein expression of collagen II, collagen X, and stathmin, a signaling protein of proliferation. RESULTS: Only 2 the expression of the receptor Notch1 and the ligand Jagged1 was found. The expression of PCNA was stronger in the rhNF-kappaB group than in the other 2 groups. rhNF-kappaB remarkably promoted the expression of collagen II and inhibited the expression of collagen X and MW167 remarkably promoted the expression of collagen X and did not remarkably influence the expression of collagen II. MTT method showed that rhNF-kappaB significantly promote the proliferation of the cells (P = 0.027), and MW167 did not significantly promote the cell proliferation (P > 0.05). The percentage of cells at S phase of the rhNF-kappaB group was 26.54%, significantly higher than those of the MW167 group and control group (8.22% and 6.15%). AP was significantly expressed in the MW167 group, and less expressed in the other groups. Western blotting showed a significantly increased expression of collagen X protein and decreased expression of collagen II protein and stathmin. CONCLUSION: When the Notch signaling system is activated the epiphysis stem cells proliferate, and when the Notch signaling system is suppressed the epiphysis stem cells differentiate.

Animals↗
PubMedDate not supplied

[Clinical and radiologic study of hereditary diseases of the femoral epiphysis].

The diseases that involve the proximal femoral epiphysis are an heterogeneous group with similar clinical characteristics, so it is important to establish a differential diagnosis to bring suitable management and genetic counseling. The present study includes 33 patients: eleven with multiple epiphyseal dysplasia (MED), five with spondylo-epiphyseal dysplasia (SED), twelve with unilateral Perthes disease (PD uni) and five with bilateral Perthes disease (PD bi). The clinical study showed that affected relatives and associated clinical manifestations were more frequent in the dysplastic patients. The somatometric profile of the 17 PD patients was within two standard deviations of the average, whereas the dysplastic patients showed short stature. In the radiological study all patients had one or both proximal femoral epiphysis affected. All the dysplastic patients had other irregular or flattened epiphysis, but only half of those with PD showed mild flattening or distal femoral epiphysis. Eight of 29 patients had a delay in bone maturity, and all patients had mild flattened vertebras. We think this study shows the importance of having sufficient clinic and radiologic criteria to establish the differential diagnosis in view of the heterogeneity of these entities.

Adolescent↗
PubMedDate not supplied

Endocrine dysfunction and slipped captial femoral epiphysis.

Five patients with concomitant endocrinopathy and slipped capital femoral epiphysis were studied in detail. One had diabetes and hypothyroidism, one had hypothyroidism, one had hypergonadotropic hypogonadism and two had a craniopharyngioma (one of whom had severe panhypopituitarism post-operatively). An additional seven patients with cranio-pharyngioma revealed marked delay in closure of epiphyses and an additional undiagnosed case of slipped capital femoral epiphysis. Of the six patients with slipped capital femoral epiphysis, three had bilateral and three unilateral involvement. Of the five patients undergoing surgical stabilization, there was significant delay of epiphyseodesis, prompting us to recommend concomitant bone grafting. Histological examination of the femoral head from a three year old child with panhypopituitarism showed marked irregularity of the growth plate and loss of columnar integrity, which may be a predisposing factor to slipping in older children with endocrinopathies. The effects of various hormones on the physis are specifically discussed, especially as they relate to the possible etiology of slipped capital femoral epiphysis.

Adolescent↗