Pediatric. JBJS. 2016/6. Intraoperative Monitoring of Epiphyseal Perfusion in Slipped Capital Femoral Epiphysis.

 

 

 

BACKGROUND:

The purposes of this study were to validate an innovative, percutaneous method of monitoring femoral head (epiphyseal) perfusion intraoperatively in patients with slipped capital femoral epiphysis (SCFE) and to investigate an association between intraoperative perfusion and the subsequent development of osteonecrosis.

METHODS:

A percutaneous screw fixation technique for SCFE was utilized. A fully threaded, cannulated, stainless-steel 7.0-mm screw was inserted into the epiphysis. The guidewire was removed, and a sterile intracranial pressure (ICP) probe was placed through the screw such that the tip was in the epiphyseal bone past the end of the screw. Intraoperative epiphyseal pressure and waveform were recorded. A prospective analysis of patients undergoing percutaneous screw fixation for unstable or stable SCFE or for prophylactic treatment with the use of this technique to evaluate femoral head perfusion was performed.

RESULTS:

This technique was used in 23 patients (29 hips, including 15 hips with unstable SCFE, 11 with stable SCFE, and 3 treated prophylactically). Three hips (2 with unstable SCFE and 1 treated prophylactically) in 2 patients were eliminated from the analysis because of technical problems with the ICP monitor. All hips with stable SCFE and the prophylactically treated hips had measurable pulsatile flow that was synchronous with the patient's heart rate at the initial time of probe insertion. Seven patients (7 hips) with unstable SCFE had measurable, pulsatile flow with initial insertion of the probe, and 6 patients (6 hips) with unstable SCFE had no measurable flow. We were able to demonstrate perfusion following a percutaneous capsular decompression in the patients with no initial flow. All patients left the operating room with measurable femoral head blood flow. At a mean follow-up of 1.6 years for hips with stable SCFE and 2.0 years for those with unstable SCFE, no hip subsequently developed radiographic evidence of osteonecrosis of the femoral head. No complications from the use of the ICP monitor occurred.

CONCLUSIONS:

Femoral head perfusion in patients with SCFE can be measured intraoperatively using this technique. Demonstrating femoral head perfusion before leaving the operating room was associated with the absence of osteonecrosis postoperatively.

LEVEL OF EVIDENCE:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

 

 

Descriptive statistics were calculated for all variables. Differences in variables between the stable and the unstable group and between the group with intraoperative femoral head blood flow and the group with no flow were evaluated.   Fisher exact test Dichotomous variables were assessed   Wilcoxon rank-sum test continuous variables were assessed.

 

 

 

1. unstable SCFE는 응급. AVN 도 빨리 온다. unstable SCFE 12m f/up 후에 없던 AVN이 생긴 보고는 없다. 1년 버티면 안심.

2. 퇴원할 때 partial weight bearing, crutch 는 6주까지

3. SCFE 뿐만 아니라, ICP로 talar neck, femoral neck, proximal humerus, scaphoid waist 등 cannulated screw와 동시에 쓰면 유용할듯.    

 

 

 

Slipped capital femoral epiphysis (SCFE) is a common adolescent hip disorder, in which the capital femoral epiphysis is displaced posteroinferiorly relative to the metaphysis.

 

If the acute displacement of an unstable SCFE had not reduced with positioning, then a closed manipulation with hip flexion, internal rotation, and traction was performed.

 

 

 

 

 

 

 

 Waveforms with measurable, arterial-like pulsationssynchronouswiththeheartrateofthepatientwerebelievedtorepresent femoral head perfusion. If no perfusion was noted on ICP monitoring, then a hip decompressionwas performed by aspirationwith an 18-gauge needle or by advancing Mayo scissors or a Cobb elevator along the anterior aspect of the femoral neck through the same incision.

 

 

Displacement can occur gradually with the epiphyseal vasculature adapting as the slip progresses or it can occur suddenly after a variable period of prodromal symptoms. 전구 증상의

 

Osteonecrosis of the femoral head is among the most dreaded complications of SCFE. 두려운, 무서운

 

It is hypothesized that disruption of the femoral head blood supply in unstable SCFE develops secondary to increased intracapsular pressure and/or kinking of the lateral epiphyseal vessels. 뒤틀린, 곧지 않고 구부러진

 

Patients were deemed to have an unstable injury if they were not able to bear weight, despite the use of assistive devices.

간주되다. 여기다.

 

Dichotomous variables were assessed using the Fisher exact test. 이분법의, 양자택일의

 

The present study shows that the acute displacement of an unstable SCFE can safely be reduced back to the previous stable position, as long as an adequate capsular decompression is performed. ~이기만 하면, ~하는 한