CC BY-NC-ND 4.0 · Rev Bras Ortop (Sao Paulo) 2022; 57(05): 807-814
DOI: 10.1055/s-0042-1744499
Artigo Original
Oncologia Pediátrica

Avascular Necrosis After Modified Dunn Surgery for the Treatment of Slipped Capital Femoral Epiphysis*

Article in several languages: português | English
1   Departamento de Ortopedia e Traumatologia do Hospital do Trabalhador, Curitiba, PR, Brasil
,
1   Departamento de Ortopedia e Traumatologia do Hospital do Trabalhador, Curitiba, PR, Brasil
,
1   Departamento de Ortopedia e Traumatologia do Hospital do Trabalhador, Curitiba, PR, Brasil
,
1   Departamento de Ortopedia e Traumatologia do Hospital do Trabalhador, Curitiba, PR, Brasil
› Author Affiliations
Financial Support There was no financial support from public, commercial, or non-profits sources.
 

Abstract

Objective The present study analyzed the incidence of epiphyseal avascular necrosis in patients with slipped capital femoral epiphysis (SCFE) treated using a modified Dunn technique. In addition, this study determined the correlation of other variables with this incidence and described treatment complications.

Methods This is a retrospective study with 20 patients treated by the same surgical team from 2009 to 2019 and followed up for 2 to 12 years. The analysis included general features, time from presentation to surgical procedure, classification, and intraoperative blood perfusion of the epiphysis, as well as complications and their treatment.

Results All cases were severe; 65% were acute on chronic, and 55% of the SCFEs were unstable. Our complication rate was 45%, with 5 cases of avascular necrosis, 2 cases of deep infection, 1 case of material failure, and 1 case of joint instability. The statistical analysis revealed that the risk of necrosis was higher when the surgery occurred after a long hospitalization time and there was no intraoperative epiphyseal perfusion. Four necrosis cases happened within the first 5 years, and 1 case in the last 5 years of the study.

Conclusion Our study showed that necrosis was the most common complication. It also revealed that surgery delay and lack of intraoperative epiphysis perfusion potentially predispose to avascular necrosis. Although with no statistical significance, coxofemoral instability occurred in chronic SCFE, and surgical fixation with threaded wires was less effective than fixation with a cannulated screw.

The modified Dunn procedure should be reserved for severe cases in which other techniques are not feasible and performed by an experienced, trained, and qualified team.


#

Introduction

Slipped capital femoral epiphysis (SCFE) is a relatively common condition affecting the hip in adolescents;[1] its incidence is 11 per 100,000 people.[2] Its treatment remains controversial. For mild-to-moderate cases, it consists of traditional in situ fixation. The treatment for severe cases includes the base of the cervix, intertrochanteric, or subcapital osteotomy. Epiphyseal avascular necrosis (AVN) is the most common and feared complication of these procedures, and it often results from intracapsular osteotomies. Recently, some authors described other methods for severe cases. Parsch et al.[3] proposed a gentle, open reduction under monitoring by palpation with the tip of the index finger through a small anterolateral (Watson Jones) access, followed by articular hematoma drainage and subcapital osteotomy to realign the femoral epiphysis in a controlled hip dislocation (modified Dunn procedure).[4] [5]

In situ fixation stabilizes the capital femoral epiphysis, resulting in physeal closure and preventing disease progression. On the other hand, closed or open epiphyseal reduction corrects the deformity by aligning it, potentially minimizing the progression to coxofemoral arthrosis.

The main benefit of the modified Dunn procedure, described in Bern in 1998,[6] [7] is to surgically restore the proximal femur anatomy with the so-called controlled hip dislocation, often by round ligament resection. This approach uses a neck retinaculum flap to spare the femoral epiphysis vascularization, allowing the safe performance of a femoral neck corrective osteotomy.

Although this surgery provides an excellent SCFE correction, it is a complex procedure requiring experience and adequate training; it also can result in complications.[8]

The most frequent complications include avascular necrosis (AVN) of the femoral epiphysis, hip instability, infection, osteosynthesis material failure (breakage), and greater trochanter pseudarthrosis.[9] [10]

The main objective of our study was to analyze the incidence of epiphyseal AVN in patients with SCFE treated using a modified Dunn technique. A secondary objective was to determine the correlation of other variables with this incidence and describe treatment complications.


#

Materials and Methods

The research ethics committee approved this study under number CAAE 44899021.6.0000.5225.

This is a retrospective study carried out from 2009 to 2019 in a tertiary hospital and based on the review of medical records from patients with SCFE treated using the modified Dunn technique.

The exclusion criteria were incomplete medical records and a follow-up time lower than 2 years.

Evaluated epidemiological data included gender, age at disease onset, and affected side. Slipped capital femoral epiphysis was classified per severity (mild, moderate, severe) as proposed by Southwick,[11] time of presentation (chronic, acute, and acute on chronic) according to Fahey and O'Brien,[12] and stability (stable or unstable) as proposed by Loder et al.[13]. In addition, we assessed the time from diagnosis (admission) to the surgical procedure and the intraoperative perfusion of the femoral epiphysis (determined by the perforation of the femoral epiphysis with a 1.5-mm Kirschner wire).

A comparison between patients with and without AVN tried to identify the factors influencing AVN occurrence. Analyzed data included age of presentation (younger and older than 12 years old), gender, affected side, time until surgery (less or more than 2 days), disease features (severity, time of presentation, and stability), and the presence or absence of intraoperative perfusion.

Other complications included superficial and deep infection, synthesis material failure, instability (hip dislocation), and greater trochanter pseudarthrosis. We also describe any subsequent procedures performed to treat such complications.

The findings were presented as mean, standard deviation, and median values for quantitative or categorical variables. A Student t-test for independent samples compared groups with and without necrosis per age. A non-parametric Mann-Whitney test analyzed the time from diagnosis to surgery. A Fisher exact test assessed the association between categorical variables and the probability of necrosis. Statistical significance was set at p < 0.05. Data analysis used the Stata/SE software v.14.1 (StataCorp LLC, College Station, TX, USA).


#

Results

Our sample consisted of 20 patients with severe SCFE treated by the same surgical team with the modified Dunn procedure from 2009 to 2019. All patients were followed up after surgery for 2 to 12 years. Eleven patients were male, and the mean age was 12.45 years (8–14 years old). Twelve procedures were performed on the left side, and 12 patients underwent in situ fixation on the contralateral side, either due to bilateral presentation or as a prophylactic procedure. None of the patients had the proposed surgery performed bilaterally. On average, surgery occurred 3 days after disease onset (1–12 days) ([Table 1] and [Figures 1], [2], [3], and [4]).

Table 1

Year

Gender

Age

Side

Days until surgery

Severity

Loder classification

Fahey & O'Brien classification

Complication

AVN

Infection

Material failure

Dislocation

2009

Female

12

Left

2

Severe

Unstable

Acute

No

No

No

No

No

2010

Female

13

Right

2

Severe

Stable

Acute on chronic

Yes

No

Yes

No

No

2010

Male

11

Left

3

Severe

Unstable

Acute

Yes

Yes

No

No

No

2010

Male

14

Left

5

Severe

Stable

Chronic

Yes

No

No

No

Yes

2011

Male

14

Left

12

Severe

Stable

Chronic

Yes

Yes

No

No

No

2012

Female

11

Left

3

Severe

Unstable

Acute

Yes

Yes

No

No

No

2012

Female

11

Left

1

Severe

Unstable

Acute

No

No

No

No

No

2012

Female

11

Right

1

Severe

Stable

Acute on chronic

No

No

No

No

No

2013

Male

14

Left

2

Severe

Stable

Acute on chronic

No

No

No

No

No

2014

Female

12

Right

10

Severe

Unstable

Acute on chronic

Yes

Yes

No

No

No

2015

Male

13

Right

3

Severe

Stable

Acute on chronic

No

No

No

No

No

2015

Male

14

Left

2

Severe

Stable

Acute on chronic

Yes

No

No

Yes

No

2015

Female

11

Right

2

Severe

Unstable

Acute

No

No

No

No

No

2016

Male

14

Right

3

Severe

Stable

Acute on chronic

Yes

Yes

No

No

No

2016

Female

13

Right

2

Severe

Stable

Acute on chronic

No

No

No

No

No

2016

Male

14

Right

4

Severe

Stable

Acute on chronic

No

No

No

No

No

2017

Male

13

Left

3

Severe

Stable

Acute on chronic

No

No

No

No

No

2018

Male

14

Left

1

Severe

Unstable

Acute on chronic

No

No

No

No

No

2018

Male

12

Left

1

Severe

Unstable

Acute on chronic

No

No

No

No

No

2019

Female

8

Left

1

Severe

Unstable

Acute on chronic

Yes

No

Yes

No

No

Zoom Image
Fig. 1 Anteroposterior radiograph of a patient with acute, chronic, unstable slipped capital femoral epiphysis.
Zoom Image
Fig. 2 Immediate postoperative anteroposterior radiograph of a case of acute, chronic, unstable slipped capital femoral epiphysis treated using the modified Dunn technique.
Zoom Image
Fig. 3 Anteroposterior radiograph of a patient 8 years after the operation of a slippage of the proximal femoral epiphysis with an acute unstable condition on the left side, treated by the modified Dunn technique and in situ fixation on the contralateral side.
Zoom Image
Fig. 4 Radiograph in Lauestein of the patient 8 years after the operation of slippage of the proximal femoral epiphysis with acute instability on the left side, treated by the modified Dunn technique and in situ fixation on the contralateral side.

The Fahey and O'Brien system classified most of the cases (65%; 13/20) as acute on chronic, followed by acute (25%; 5/20), and chronic (10%; 2/20). Per the Loder classification, 55% (11/20) of the cases were unstable, and the remaining 45% (9/20) were unstable. All SCFE cases were severe, according to the Southwick classification.

The complication rate was 45% (9/20), including 5 (25%) cases of AVN, 2 (10%) cases of deep infection, 1 (5%) case of hip joint dislocation, and 1 (5%) case of synthesis material failure ([Table 2]).

Table 2

Complication

N

Presence

Frequency*

AVN

20

No

Yes

15 (75%)

5 (25%)

Infection

20

No

Yes

18 (90%)

2 (10%)

Material failure

20

No

Yes

19 (95%)

1 (5%)

Dislocation

20

No

Yes

19 (95%)

1 (5%)

When evaluating AVN-related factors, there was no difference regarding age, gender, and affected side. In addition, there was no significant difference in presentation time and SCFE stability. Statistically, the risk of necrosis was lower in patients operated on up to the 2nd day of hospitalization (p < 0.008) or presenting intraoperative epiphyseal perfusion (p < 0.032). Time of presentation (according to the Fahey and O'Brien classification) had no statistically significant influence on the necrosis risk when comparing stable (chronic) versus unstable presentations (acute and acute on chronic) and the 2 unstable presentations.

Subsequent procedures for the five AVN cases included two pelvic support osteotomies, one synthesis material removal with clinical observation, one material removal with neck osteochondroplasty, and one valgus osteotomy with osteochondroplasty ([Table 3] and [Figures 5], [6], and [7]).

Table 3

Variable

Group

N

Necrosis – n (%)

P*

Age group (years-old)

11 or 12

13 or 14

9

11

3 (33.3%)

2 (18.2%)

0.617

Gender

Female

Male

9

11

2 (22.2%)

3 (27.3%)

1

Admission up to surgery (days)

≤ 2

> 2

11

9

0 (0%)

5 (55.6%)

0.0008

Affected side

Left

Right

12

8

3 (25%)

2(25%)

1

Loder classification

Unstable

Stable

9

11

3 (33.3%)

2 (18.2%)

0.617

Fahey & O'Brien classification

Acute

Acute on chronic

Chronic

5

13

2

2 (40%)

2 (15.4%)

1 (50%)

Time of presentation

Acute/acute on chronic

Chronic

18

2

4 (22.2%)

1 (50%)

0.447

Time of presentation

Acute

Acute on chronic

5

13

2 (40%)

2 (15.4%)

0.533

Intraoperative epiphyseal perfusion

No

Yes

4

16

3 (75%)

2 (12.5%)

0.032

Zoom Image
Fig. 5 Preoperative radiograph of slippage of the proximal femoral epiphysis acutely unstable on the left.
Zoom Image
Fig. 6 Immediate postoperative radiography of acute unstable proximal femoral epiphysis slippage on the left, treated by the modified Dunn technique and prophylactic fixation on the right.
Zoom Image
Fig. 7 Postoperative anteroposterior radiograph of an 8-year-old patient after synthesis material removal and osteochondroplasty using the controlled hip dislocation technique to treat AVN after a modified Dunn surgery.

Considering the time of the study, from 2009 to 2019, 4 of the 5 AVN cases occurred within the first 5 years; these were also the first 10 patients operated on. Only 1 AVN case happened in the last 5 years, comprising the last 10 operated patients ([Table 4]).

Table 4

Year

Days until surgery

Intraoperative perfusion

Proposed treatment

2010

3

None

Pelvic support

2011

12

None

Valgus osteotomy + osteochondroplasty

2012

3

Present

Material removal + osteochondroplasty

2014

10

None

Pelvic support

2016

3

Present

Material removal


#

Discussion

The treatment of SCFE remains a challenge for orthopedic surgeons. The modified Dunn surgery gained popularity to treat moderate and severe cases. This procedure corrects the deformity in situ, preventing a future hip joint degeneration. However, it is technically complex, with a long learning curve for the surgeon and the team, and complications are relatively common.

In 1964, Dunn[14] described a subcapital osteotomy technique by a posterior surgical approach with an AVN rate of only 4%. Later studies did not reproduce this AVN rate, which reached 54%[15] [16] due to posterior retinacular vessels stretching.[7]

Based on the studies of Gautier et al.[17] on femoral vascularization and the description of controlled hip surgical dislocation by Ganz et al.,[18] the Bern group presented the outcomes of a so-called modified Dunn procedure, using this approach to perform a subcapital osteotomy with a surprising AVN rate of 0%.[6] [19] Later, in 2019, Lerch et al.,[20] also from the Bern group, analyzed the long-term outcomes of 40 cases of severe SCFE undergoing the modified Dunn procedure, reporting a 2% incidence of osteoarthrosis, 5% of AVN, and 7% of material failure.

According to the literature, AVN incidence in patients with chronic SCFE not submitted to reduction is close to zero. In unstable acute cases, this incidence ranges from 10 to 60% regardless of treatment.[21] [22] Although there were no AVN cases in the initial study by Zierbath et al.,[23] performed in two institutions and referring to the outcomes of the modified Dunn technique, other series reported incidences from 5 to 47%.[8] [9] [21] [22] [24]

In our sample, the incidence of AVN after the modified Dunn procedure was 25%, consistent with the published literature. Here, one patient presented chronic, stable SFCE, one patient had acute on chronic, stable SFCE, one had acute on chronic, unstable SFCE, and two patients presented acute, unstable SFCE. However, due to the small sample size, we could not establish a statistically significant correlation between presentation time, stability (per the Loder classification), and AVN.

From the 5 AVN cases, the time between admission and surgery was 3 days for 3 patients, 10 days for 1 patient, and 13 days for 1 patient. Time from admission to surgery was statistically relevant for necrosis, which did not occur in patients submitted to the procedure on the first day of admission. Therefore, our current conduct is to perform surgery within the first 24 hours if possible. This data is consistent with reports from Persinger et al.[25] and Herrera-Soto et al.[26]

The intraoperative perfusion of the femoral epiphysis was also statistically significant. Of the five patients with AVN, three had no perfusion when tested. This correlation was not observed by Upasani et al.,[9] but confirmed by Novais et al.[27] and Aprato et al.[28]

Masquijo et al.[8] and Upasani et al.[9] correlate complications with the surgeon's learning curve and experience. Our series had 4 AVN cases among the first 10 patients, operated on within the first 5 years, and a single AVN case during the last 5 years. This data is consistent with previously mentioned studies.

Two patients from our sample developed surgical site infection, successfully treated with surgical debridement and antibiotic agents. None of them had AVN. Elmarhany et al.[29] reported a 3% incidence of deep infection, which also did not change the procedural outcome.

One patient (5%) presented failure of the synthesis material (bent threaded wires), which was replaced successfully with two cannulated screws. Since this failure, we prefer to perform epiphyseal fixation with two 7.0-mm cannulated screws. Zierbath et al.[30] reported a 7% rate for this complication (3 cases out of 40 patients), whereas Sankar et al.[21] observed a higher figure of 15%.

In a multicentric review, Upasani and the International SCFE Study Group[10] described a 4% rate of coxofemoral instability after a modified Dunn procedure; all cases were severe, chronic, or acute on chronic SCFE. Among these unstable cases, 47% required further surgery, and 82% evolved with AVN, consistent with Upasani et al.[9] findings from 2014 reporting an instability rate of 5%. Our series had 1 patient (5%) with hip joint dislocation during the immediate postoperative period (a severe, chronic SFCE case); treatment with reduction and immobilization with a cast from the pelvis to the foot resulted in instability resolution, with no AVN development. Since this intercurrence, in severe chronic SFCE, when the acetabulum is adapted to the femoral epiphysis deformity, we prefer intertrochanteric flexor osteotomy associated with osteochondroplasty through a controlled surgical dislocation of the hip.

Although the modified Dunn procedure is a complex surgery, its great advantage is to restore hip anatomy by providing function preservation and preventing the onset of osteoarthrosis. On the other hand, its learning curve is long, requiring adequate training to minimize complications.

Currently, we indicate this procedure only for severe, acute on chronic, or unstable cases not amenable to the Parsch et al.[3] technique, that is, more than 48 hours after SCFE onset.

As limitations of our study, we emphasize that this procedure is used in specific situations of severe SCFE, requiring a trained, experienced surgical team. This may partially explain our relatively small sample of 20 cases over 10 years. On the other hand, randomized double-blind studies compared with other surgical options are needed to better assess the incidence of complications correlating with predisposing factors.


#

Conclusion

Our study showed that necrosis was the most common complication. It also revealed a close relationship with surgery delay and lack of intraoperative epiphysis perfusion, that potentially predispose to avascular necrosis. Although there was no statistically significant outcome, coxofemoral instability occurred in chronic SCFE, and surgical fixation with threaded wires was less effective than fixation with a cannulated screw.

The modified Dunn procedure should be reserved for severe cases in which other techniques are not feasible, and performed by an experienced, trained, qualified team.


#
#

* Study developed at the Department of Orthopedics and Traumatology, Hospital do Trabalhador, Curitiba, PR, Brazil.


  • Referências

  • 1 Lehmann CL, Arons RR, Loder RT, Vitale MG. The epidemiology of slipped capital femoral epiphysis: an update. J Pediatr Orthop 2006; 26 (03) 286-290
  • 2 Aronsson DD, Loder RT, Breur GJ, Weinstein SL. Slipped capital femoral epiphysis: current concepts. J Am Acad Orthop Surg 2006; 14 (12) 666-679
  • 3 Parsch K, Weller S, Parsch D. Open reduction and smooth Kirschner wire fixation for unstable slipped capital femoral epiphysis. J Pediatr Orthop 2009; 29 (01) 1-8
  • 4 Slongo T, Kakaty D, Krause F, Ziebarth K. Treatment of slipped capital femoral epiphysis with a modified Dunn procedure. J Bone Joint Surg Am 2010; 92 (18) 2898-2908
  • 5 Soni JF, Valenza WR, Uliana CS. Surgical treatment of femoroacetabular impingement after slipped capital femoral epiphysis. Curr Opin Pediatr 2018; 30 (01) 93-99
  • 6 Leunig M, Slongo T, Kleinschmidt M, Ganz R. Subcapital correction osteotomy in slipped capital femoral epiphysis by means of surgical hip dislocation. Oper Orthop Traumatol 2007; 19 (04) 389-410
  • 7 Tannast M, Jost LM, Lerch TD, Schmaranzer F, Ziebarth K, Siebenrock KA. The modified Dunn procedure for slipped capital femoral epiphysis: the Bernese experience. J Child Orthop 2017; 11 (02) 138-146
  • 8 Masquijo JJ, Allende V, D'Elia M, Miranda G, Fernández CA. Treatment of Slipped Capital Femoral Epiphysis With the Modified Dunn Procedure: A Multicenter Study. J Pediatr Orthop 2019; 39 (02) 71-75
  • 9 Upasani VV, Matheney TH, Spencer SA, Kim YJ, Millis MB, Kasser JR. Complications after modified Dunn osteotomy for the treatment of adolescent slipped capital femoral epiphysis. J Pediatr Orthop 2014; 34 (07) 661-667
  • 10 Upasani VV, Birke O, Klingele KE, Millis MB. International SCFE Study Group. Iatrogenic Hip Instability Is a Devastating Complication After the Modified Dunn Procedure for Severe Slipped Capital Femoral Epiphysis. Clin Orthop Relat Res 2017; 475 (04) 1229-1235
  • 11 Southwick WO. Osteotomy through the lesser trochanter for slipped capital femoral epiphysis. J Bone Joint Surg Am 1967; 49 (05) 807-835
  • 12 Fahey JJ, O'Brien ET. Acute slipped capital femoral epiphysis: review of the literature and report of ten cases. J Bone Joint Surg Am 1965; 47: 1105-1127
  • 13 Loder RT, Richards BS, Shapiro PS, Reznick LR, Aronson DD. Acute slipped capital femoral epiphysis: the importance of physeal stability. J Bone Joint Surg Am 1993; 75 (08) 1134-1140
  • 14 Dunn DM. The treatment of adolescent slipping of the upper femoral epiphysis. J Bone Joint Surg Br 1964; 46: 621-629
  • 15 Hall JE. The results of treatment of slipped femoral epiphysis. J Bone Joint Surg Br 1957; 39-B (04) 659-673
  • 16 Hiertonn T. Wedge osteotomy in advanced femoral epiphysiolysis. Acta Orthop Scand 1955; 25 (01) 44-62
  • 17 Gautier E, Ganz K, Krügel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br 2000; 82 (05) 679-683
  • 18 Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001; 83 (08) 1119-1124
  • 19 Leunig M, Slongo T, Ganz R. Subcapital realignment in slipped capital femoral epiphysis: surgical hip dislocation and trimming of the stable trochanter to protect the perfusion of the epiphysis. Instr Course Lect 2008; 57: 499-507
  • 20 Lerch TD, Vuilleumier S, Schmaranzer F. et al. Patients with severe slipped capital femoral epiphysis treated by the modified Dunn procedure have low rates of avascular necrosis, good outcomes, and little osteoarthritis at long-term follow-up. Bone Joint J 2019; 101-B (04) 403-414
  • 21 Sankar WN, Vanderhave KL, Matheney T, Herrera-Soto JA, Karlen JW. The modified Dunn procedure for unstable slipped capital femoral epiphysis: a multicenter perspective. J Bone Joint Surg Am 2013; 95 (07) 585-591
  • 22 Zaltz I, Baca G, Clohisy JC. Unstable SCFE: review of treatment modalities and prevalence of osteonecrosis. Clin Orthop Relat Res 2013; 471 (07) 2192-2198
  • 23 Ziebarth K, Zilkens C, Spencer S, Leunig M, Ganz R, Kim YJ. Capital realignment for moderate and severe SCFE using a modified Dunn procedure. Clin Orthop Relat Res 2009; 467 (03) 704-716
  • 24 Huber H, Dora C, Ramseier LE, Buck F, Dierauer S. Adolescent slipped capital femoral epiphysis treated by a modified Dunn osteotomy with surgical hip dislocation. J Bone Joint Surg Br 2011; 93 (06) 833-838
  • 25 Persinger F, Davis II RL, Samora WP, Klingele KE. Treatment of Unstable Slipped Capital Epiphysis Via the Modified Dunn Procedure. J Pediatr Orthop 2018; 38 (01) 3-8
  • 26 Herrera-Soto JA, Duffy MF, Birnbaum MA, Vander Have KL. Increased intracapsular pressures after unstable slipped capital femoral epiphysis. J Pediatr Orthop 2008; 28 (07) 723-728
  • 27 Novais EN, Sink EL, Kestel LA, Carry PM, Abdo JCM, Heare TC. Is Assessment of Femoral Head Perfusion During Modified Dunn for Unstable Slipped Capital Femoral Epiphysis an Accurate Indicator of Osteonecrosis?. Clin Orthop Relat Res 2016; 474 (08) 1837-1844
  • 28 Aprato A, Bonani A, Giachino M, Favuto M, Atzori F, Masse A. Can we predict femoral head vitality during surgical hip dislocation?. J Hip Preserv Surg 2014; 1 (02) 77-81
  • 29 Elmarghany M, Abd El-Ghaffar TM, Seddik M. et al. Surgical hip dislocation in treatment of slipped capital femoral epiphysis. SICOT J 2017; 3: 10
  • 30 Ziebarth K, Steppacher SD, Siebenrock KA. Die modifizierte Dunn-Operation zur Behandlung der schweren Epiphyseolysis capitis femoris. Orthopade 2019; 48 (08) 668-676

Endereço para correspondência

Heloisa Zimmermann Faggion
Rua Quintino Bocaiuva, 280, Cabral
Curitiba, Paraná, 80030310
Brasil   

Publication History

Received: 04 August 2021

Accepted: 20 January 2022

Article published online:
06 July 2022

© 2022. Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • Referências

  • 1 Lehmann CL, Arons RR, Loder RT, Vitale MG. The epidemiology of slipped capital femoral epiphysis: an update. J Pediatr Orthop 2006; 26 (03) 286-290
  • 2 Aronsson DD, Loder RT, Breur GJ, Weinstein SL. Slipped capital femoral epiphysis: current concepts. J Am Acad Orthop Surg 2006; 14 (12) 666-679
  • 3 Parsch K, Weller S, Parsch D. Open reduction and smooth Kirschner wire fixation for unstable slipped capital femoral epiphysis. J Pediatr Orthop 2009; 29 (01) 1-8
  • 4 Slongo T, Kakaty D, Krause F, Ziebarth K. Treatment of slipped capital femoral epiphysis with a modified Dunn procedure. J Bone Joint Surg Am 2010; 92 (18) 2898-2908
  • 5 Soni JF, Valenza WR, Uliana CS. Surgical treatment of femoroacetabular impingement after slipped capital femoral epiphysis. Curr Opin Pediatr 2018; 30 (01) 93-99
  • 6 Leunig M, Slongo T, Kleinschmidt M, Ganz R. Subcapital correction osteotomy in slipped capital femoral epiphysis by means of surgical hip dislocation. Oper Orthop Traumatol 2007; 19 (04) 389-410
  • 7 Tannast M, Jost LM, Lerch TD, Schmaranzer F, Ziebarth K, Siebenrock KA. The modified Dunn procedure for slipped capital femoral epiphysis: the Bernese experience. J Child Orthop 2017; 11 (02) 138-146
  • 8 Masquijo JJ, Allende V, D'Elia M, Miranda G, Fernández CA. Treatment of Slipped Capital Femoral Epiphysis With the Modified Dunn Procedure: A Multicenter Study. J Pediatr Orthop 2019; 39 (02) 71-75
  • 9 Upasani VV, Matheney TH, Spencer SA, Kim YJ, Millis MB, Kasser JR. Complications after modified Dunn osteotomy for the treatment of adolescent slipped capital femoral epiphysis. J Pediatr Orthop 2014; 34 (07) 661-667
  • 10 Upasani VV, Birke O, Klingele KE, Millis MB. International SCFE Study Group. Iatrogenic Hip Instability Is a Devastating Complication After the Modified Dunn Procedure for Severe Slipped Capital Femoral Epiphysis. Clin Orthop Relat Res 2017; 475 (04) 1229-1235
  • 11 Southwick WO. Osteotomy through the lesser trochanter for slipped capital femoral epiphysis. J Bone Joint Surg Am 1967; 49 (05) 807-835
  • 12 Fahey JJ, O'Brien ET. Acute slipped capital femoral epiphysis: review of the literature and report of ten cases. J Bone Joint Surg Am 1965; 47: 1105-1127
  • 13 Loder RT, Richards BS, Shapiro PS, Reznick LR, Aronson DD. Acute slipped capital femoral epiphysis: the importance of physeal stability. J Bone Joint Surg Am 1993; 75 (08) 1134-1140
  • 14 Dunn DM. The treatment of adolescent slipping of the upper femoral epiphysis. J Bone Joint Surg Br 1964; 46: 621-629
  • 15 Hall JE. The results of treatment of slipped femoral epiphysis. J Bone Joint Surg Br 1957; 39-B (04) 659-673
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Fig. 1 Radiografia em anteroposterior de um paciente com escorregamento da epífise proximal do fêmur crônica agudizada instável.
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Fig. 2 Radiografia em anteroposterior do pós-operatório imediato de escorregamento da epífise proximal do fêmur crônica agudizada instável, tratada pela técnica de Dunn modificada.
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Fig. 3 Radiografia em anteroposterior do paciente com 8 anos de pós-operatório de escorregamento da epífise proximal do fêmur crônica agudizada instável no lado esquerdo, tratada pela técnica de Dunn modificada e fixação in situ do lado contralateral.
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Fig. 4 Radiografia em lauestein do paciente com 8 anos de pós-operatório de escorregamento da epífise proximal do fêmur crônica agudizada instável no lado esquerdo, tratada pela técnica de Dunn modificada e fixação in situ do lado contralateral.
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Fig. 5 Radiografia no pré operatório de escorregamento da epífise proximal do fêmur aguda instável a esquerda.
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Fig. 6 Radiografia no pós-operatório imediato de escorregamento da epífise proximal do fêmur aguda instável a esquerda, tratada pela técnica de Dunn modificada e fixação profilática a direita.
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Fig. 7 Radiografia em anteroposterior do paciente com 8 anos de pós-operatório de retirada do material de síntese e osteocondroplastia pela técnica da luxação controlada do quadril para tratar necrose avascular pós cirurgia de Dunn modificada.
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Fig. 1 Anteroposterior radiograph of a patient with acute, chronic, unstable slipped capital femoral epiphysis.
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Fig. 2 Immediate postoperative anteroposterior radiograph of a case of acute, chronic, unstable slipped capital femoral epiphysis treated using the modified Dunn technique.
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Fig. 3 Anteroposterior radiograph of a patient 8 years after the operation of a slippage of the proximal femoral epiphysis with an acute unstable condition on the left side, treated by the modified Dunn technique and in situ fixation on the contralateral side.
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Fig. 4 Radiograph in Lauestein of the patient 8 years after the operation of slippage of the proximal femoral epiphysis with acute instability on the left side, treated by the modified Dunn technique and in situ fixation on the contralateral side.
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Fig. 5 Preoperative radiograph of slippage of the proximal femoral epiphysis acutely unstable on the left.
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Fig. 6 Immediate postoperative radiography of acute unstable proximal femoral epiphysis slippage on the left, treated by the modified Dunn technique and prophylactic fixation on the right.
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Fig. 7 Postoperative anteroposterior radiograph of an 8-year-old patient after synthesis material removal and osteochondroplasty using the controlled hip dislocation technique to treat AVN after a modified Dunn surgery.