Proximal Femur In Children Research Articles

As simple as it sounds? The treatment of simple bone cysts in the proximal femur in children and adolescents: Retrospective multicenter EPOS study of 74 patients.

Simple bone cysts are among the most prevalent benign cystic tumor-like lesions in children. Proximal femoral simple bone cysts may require specific treatment because of increased fracture risk. With limited literature available on this specific localization, consensus regarding optimal treatment is lacking. We present a large international multicenter retrospective cohort study on proximal femoral simple bone cysts. All consecutive pediatric patients with proximal femoral simple bone cyst from 10 tertiary referral centers for musculoskeletal oncology were included (2000-2021). Demographics, primary treatment, complications, and re-operations were evaluated. Primary outcomes were time until full weight-bearing and failure-free survival. Overall, 74 simple bone cyst patients were included (median age 9 years (range = 2-16), 56 (76%) male). Median follow-up was 2.9 years (range = 0.5-21). Index procedure was watchful waiting (n = 6), percutaneous procedure (n = 12), open procedure (n = 50), or osteosynthesis alone (n = 6). Median time until full weight-bearing was 8 weeks (95% confidence interval = 0.1-15.9) for watchful waiting, 9.5 (95% confidence interval = 3.7-15.3) for percutaneous procedure, 11 (95% confidence interval = -0.7 to 13.7) for open procedure, and 6.5 (95% confidence interval = 5.9-16.1) for osteosynthesis alone (p = 0.58). Failure rates were 33%, 58%, 29%, and 0%, respectively (p = 0.069). Overall failure-free survival at 1, 2, and 5 years was 77.8% (95% confidence interval = 68.2-87.4), 69.5% (95% confidence interval = 58.5-80.5), and 62.0% (95% confidence interval = 47.9-76.1), respectively. A preferred treatment for proximal femoral simple bone cysts remains unclear, with comparable failure rates and times until full weight-bearing. Watchful waiting may be successful in certain cases. If not feasible, osteosynthesis alone can be considered. Treatment goals should be cyst control, minimizing complications and swift return to normal activities. Therefore, an individualized balance should be made between undertreatment, with potentially higher complication risks versus overtreatment, resulting in possible larger interventions and accompanying complications. Level IV, retrospective multicentre study.

Finite Element Analysis of Mechanical Characteristics of Internal Fixation for Treatment of Proximal Femoral Osteolytic Lesions in Children.

Clinically, it is very difficult to prevent pathological fracture caused by high recurrence rate of osteolytic disease of proximal femur in children. At present, there is no consensus in clinical studies of which internal fixation method can significantly reduce the probability of recurrence of pathological fracture. The study aims to research the mechanical properties of different internal fixations in the treatment of osteolytic lesions of proximal femur in children by finite element analysis, and to find out the optimal treatment. Based on finite element analysis, the osteolytic disease models of the femoral neck and intertrochanter in a child (8-year-old, boy) were established respectively, and different internal fixation models (plate and titanium elastic intramedullary nails, TENs) were assembled. For the osteolytic lesion of the femoral neck: model A1 was assembled with a plate; model A2 with two TENs crossing the physis; model A3 with two TENs without crossing the physis. And for pertrochanteric osteolytic lesion: model B1 was assembled with a plate, model B2 with two TENs crossing the physis and model B3 with two TENs without crossing the physis. The Eccentric bearing load, torsional restraintal restraint of calcar femorale and composite load were analyzed for each models. When the yield strain of each model is reached, the stress concentration points are located in the proximal and distal femoral calcar. In the model of femoral neck lesions, the failure load of model A1 and model A2 are the same (1250 N), and the failure load of model A3 (980 N) is significantly lower than that of the former two; in the model of intertrochanteric lesions, the failure load of model B2 is the largest (1350 N), and the failure load of model B1 (1220 N) is lower than that of model B3 (1260 N), but both are smaller than that of model B2. Through finite element analysis, TENs through the epiphyseal plate, is found to be the better internal fixation method for femoral neck lesions and intertrochanteric lesions under two different working conditions. The results of clinical correlation study provide new biomechanical information for orthopedic doctors to consider different treatment options for osteolytic lesions of proximal femur.

Surgical Method for the Treatment of Multiplanar Deformities of the Proximal Femur in Children with Aseptic Necrosis of the Femoral Head

The aim of the study was to evaluate the effectiveness of corrective intertrochanteric osteotomies of the femur in multiplanar deformities of the proximal femur after bloodless reduction of congenital hip dislocation in children.

Intertrochanteric Osteotomies in Children and Adolescents: Principles of Proximal Femoral Deformity Correction.

Intertrochanteric osteotomies are used to correct a variety of congenital and acquired deformities of the proximal femur in children and adolescents. Varus, valgus, flexion, extension, or rotational osteotomies at the intertrochanteric level can be used to restore normal alignment of the proximal femur, increase congruency and stability of the hip joint, facilitate healing or remodeling of the femoral head and neck, redirect the articular surface, and improve functional limb position in the case of soft-tissue contractures. The steps necessary to assess proximal femoral deformity and plan the appropriate osteotomy are described along with indications and long-term considerations.

Patologické zlomeniny proximálního femuru u dětí a dospívajících léčené LCP dětskou kyčelní dlahou

Patologické zlomeniny proximálního femuru u dětí a dospívajících léčené LCP dětskou kyčelní dlahou

X-ray parameters of sagittal balance in children with multiplanar deformities of the proximal femur

BACKGROUND: Multiplanar deformities of the proximal femur in children are often accompanied by a high position of the greater trochanter, causing disturbances in the biomechanics of the hip joint and extra-articular impingement syndrome. Progressive anatomical and biomechanical changes in multiplanar deformities of the proximal femur also lead to changes in the system hip joints, the pelvis, and the lumbosacral spine that mutually burden each other. Currently, the domestic literature has isolated publications on assessing the state of sagittal vertebral-pelvic ratios in children with this pathology.
 AIM: This study assesses the radiological parameters of sagittal balance in children with multiplanar deformities of the proximal femur with a high position of the greater trochanter. It reveals the relationship between the deformity severity of the proximal femur and spinal and pelvic parameter changes in children.
 MATERIALS AND METHODS: The x-ray data of examination of 25 children (25 affected joints) aged from 9 to 15 years with deformities of the proximal femur with a high position of the greater trochanter, in which its apex is located at or above the upper pole of the femoral head, were analyzed. The parameters characterizing the ratio of the femoral head to the greater trochanter in the frontal plane and indicators of the sagittal balance according to lateral skeleton radiographs were evaluated. The obtained data were subjected to statistical processing.
 RESULTS: Children with multiplanar deformities of the proximal femur with a high position of the greater trochanter are characterized by a pronounced increase in global lumbar lordosis, excessive pelvic anteversion, and the pelvic tilt toward the affected limb. A direct relationship was found between the severity of the proximal femur disorders and the degree of change in the sagittal spinal-pelvic ratio indices.
 CONCLUSIONS: The combination and progression of anatomical changes in the hip joints in children with a high position of the greater trochanter cause pathological compensatory changes in the lumbosacral spine with degenerative dystrophic processes development.

Preliminary results of surgical treatment of fibrous dysplasia of proximal femur in children

Objective: To investigate the surgical treatment, clinical effect and revision reasons of children with proximal femoral fibrous dysplasia(FD). Methods: The clinical data of 26 children with polyostotic FD of proximal femur who underwent surgery at Department of Pediatric Orthopaedics, Beijing Jishuitan Hospital from June 2016 to June 2018 were retrospectively analyzed. There were 18 males and 8 females with a mean age of 9.2 years (range:5 to 16 years).One of them was McCune Albright syndrome. Fifteen cases were in first operation and 11 cases were in revision operation. The operation methods and results were reviewed,and the causes of revision were analyzed. Results: Among the 15 children who underwent the first operation,13 cases underwent osteotomy or fracture reduction and interlocking intramedullary nail(IMN) fixation;One case underwent valgus osteotomy and pediatric hip plate(PHP)internal fixation;One case underwent valgus osteotomy+lesion curettage+allogeneic bone graft+PHP fixation. Among the 11 children who underwent revision surgery,9 cases were treated with IMN fixation,1 case with PHP fixation,and 1 case with PHP fixation+allogeneic bone graft. The causes of revision included distal fixation failed in 6 cases,proximal fixation failed in 3 cases,plate fixation failed in 5 cases,and recurrence occurred after curettage and artificial bone graft in 2 cases. Patients were followed up for 1.4 years(range:1.0 to 3.5 years) after recent operation. The osteotomy or fracture healed well with good deformity correction. Postoperative complications included infection in 1 case and local bone partial resorption in 1 case. Conclusions: Osteotomy combined with rigid internal fixation is an effective surgical treatment for fibrous dysplasia of proximal femur in children. Internal fixation should cover the whole length of lesion. Intramedullary nail is the most common choice. Because the growth of height and the progress of the disease itself,this deformity is prone to recur in children,needing closely follow-up after operation.

Surgical treatment of benign lesions and pathologic fractures of the proximal femur in children.

Benign lesions of the proximal femur region, such as simple bone cysts, aneurysmal bone cysts, and fibrous dysplasia, are common in children. Benign lesions may cause pathologic fractures, limb length inequities, and growth disturbances. Differential diagnoses, e.g., malignant bone tumors and osteomyelitis, are sometimes difficult to rule out. We aimed to evaluate outcomes in children with benign lesions of the proximal femur treated with curettage, bone grafting, and plate fixation. In this retrospective study, we included 30 children (median age 10.5years; range 1.1-17.8years) suffering from bone cysts and tumor-like lesions of the proximal femur region treated between 2002 and 2018. We analyzed plain X-ray images and CT scans in all children and obtained MRI scans in a selected group of children (63.3%). We examined histopathologic biopsy results for all bone lesions before initiating treatment. Surgical management comprised tumor curettage with adjuvant high-speed drilling and allogenic bone grafting supplemented by bone graft substitutes before plate fixation. Median follow-up interval was 87months (range 24-156months). We evaluated the healing of lesions according to Capanna's classification and rated functional outcomes according to Merle d'Aubigné and Postel score. Overall, 25 of 30 (83.3%) patients were admitted to hospital because of a pathologic fracture. We diagnosed simple bone cysts in 15 (50.0%) patients, aneurysmal bone cysts in 7 (23.5%) patients, and fibrous dysplasia in 8 (26.5%) patients. Bone consolidation was achieved in 22 of 30 (73.3%) patients after a mean of 5months (range 3-7months). The main complication was recurrence of the lesion in 4 of 30 (13.3%) patients. With respect to the Merle d'Aubigné and Postel scores, 17 of 30 (56.7%) patients obtained an excellent result (18 points), while 12 (40.0%) patients had a good result (15-17 points) and only 1 (3.3%) patient had a fair result (14 points). Surgical treatment of bone cysts and tumor-like lesions of the proximal femur by local resection or destruction of the lesion, followed by filling the defect with bone graft material and internal stabilization represents a safe and effective treatment option in children. Therapeutic, retrospective comparative study-Level III.

An alternative fixation method for femoral varus derotational osteotomy in spastic cerebral palsy: the Rush rod.

The objective of this study is to present the clinical and radiographic data collected from patients who were treated with a varus derotational osteotomy using Rush rod fixation and compare this to published norms of outcomes using blade plate fixation. A retrospective chart and radiograph review was conducted after identifying 44 patients with 61 hips who underwent varus derotational osteotomy with Rush rod fixation at our institution between 2006 and 2016. We identified 44 patients with 61 hips who underwent the procedure. Information from follow-up clinic visits was gathered and any complications were noted. The patients' radiographs were analyzed to measure neck-shaft angle, center-edge angle, and acetabular index. At the time of surgery, 44 patients (61 hips) also had soft tissue releases performed, 44 (61 hips) had an open reduction of the hip, and 39 (55 hips) had Dega acetabular osteotomies performed as well. The average pre-operative neck-shaft angle was measured at 163.0° (range 128-180) with average post-operative neck-shaft angles measuring 111.3° (range 85-167). The acetabular index improved from an average of 33.3° (range 16-60) to 16.4 (range 4-35). Post-operative Center-Edge Angle measured 29.7° (range 5-45). There were no infections or cases of avascular necrosis of the femoral head. We present an alternative fixation method for performing varus derotational osteotomy of the proximal femur in children with cerebral palsy using the Rush rod. In our retrospective analysis of 61 hips undergoing this procedure, we present comparable radiographic outcomes with decreased complication rates. Level of evidence: Retrospective comparative study to previously published results, Level III.

A treatment strategy for proximal femoral benign bone lesions in children and recommended surgical procedures: retrospective analysis of 62 patients.

We aimed to develop a surgical treatment strategy for benign bone lesions of the proximal femur based upon retrospective review of our data in 62 children. Sixty-two children [38 male, 24 female; median age 9years (range 5-18years)] with proximal femoral benign bone lesions were surgically treated between 2005 and 2013. Histopathological diagnoses were simple (31) or aneurysmal (27) bone cysts, and nonossifying fibromas (4). The pathological fracture rate was 77.4%. Surgical treatment was determined due to four criteria, including patient's skeletal maturity, localization and initial diagnosis of lesion, and amount of bone loss in the femoral neck and lateral proximal femur. Surgical procedure consisted of biopsy, curettage, bone grafting, and internal fixation when required. The median follow-up was 45months (range 25-89months). Complete clinical recovery was achieved in 56 (90.3%) patients between 4 and 8months postoperatively; full weight-bearing and mobilization, without pain and limping, was possible. The median preoperative and postoperative last follow-up Musculoskeletal Tumor Society (MSTS) scores were 13.3% (range 10-23.3%) and 96.6% (range 90-100%), respectively (p<0.0001). The pathological fractures were healed in 10weeks on average (range 8-12weeks). Fifty-seven (92%) patients demonstrated complete or significant partial radiographic healing between 5 and 7months that maintained throughout follow-up. Local recurrence was not observed, and only 1 (1.6%) patient required reoperation for partial cyst healing. There were 5 (8%) complications, 1 (1.6%) of which required reoperation. This treatment strategy can provide good local control and excellent functional and radiological results in the management of benign bone lesions of the proximal femur in children.

LCP 140° Pediatric Hip Plate for fixation of proximal femoral valgisation osteotomy

PurposeFemoral osteotomy is one of the most widely performed reconstructive operations in pediatric orthopedic surgery. Many implants for fixation have been used, but so far there is no literature about the application and outcome of the LCP 140° Pediatric Hip Plate for proximal femoral valgisation in children.MethodsData of patients with a valgisation of the proximal femur using the LCP 140° Pediatric Hip Plate between February 2011 and July 2012 were retrospectively collected and analyzed.ResultsWe included 10 patients (11 hips) with a mean follow-up of 15.3 ± 6.3 months (range 5.6–23 months). The mean age was 9.6 ± 1.2 years (range 7.3–11.8 years) with a mean hospital stay of 5.2 ± 1.7 days (range 3–9 days). Callus formation was observed in all cases at 6 weeks postoperative control and consolidation was shown after a mean time of 14.1 ± 2.3 weeks (range 12.1–19.1 weeks). There was no delayed union or any case of non-union in our series. The stability of the operative reduction including the corrected neck-shaft angle (mean 19° ± 7.9°; range 10.5°–38.5°) was maintained during the follow-up period. No cases of recurrence (varisation) or complications requiring further treatment or revision were observed.ConclusionsIn our series, the 140° LCP Pediatric Hip Plate was shown to be safe and applicable in the clinical setting with good results. We therefore consider this device to be valuable for the correction of pathologic varus conditions of the proximal femur in children.

Pelvis width associated with bone mass distribution at the proximal femur in children 10–11 years old

Differences in skeletal geometry may generate different patterns of mechanical loading to bone. Impact and muscle loading during physical activity have been shown to influence skeletal geometry. The purpose of this study was to compare geometric measures of the pelvis and proximal femur (PF) of young children and to analyze the contribution and potential interaction of these geometric measures with physical activity on PF bone mass distribution. Participants were 149 girls and 145 boys, aged 10-11years. Total body and left hip DXA scans were used to derive pelvic and PF geometric measures and PF bone mineral density (BMD) at the femoral neck (FN), trochanter (TR), and intertrochanter (IT). These subregions were used to represent bone mass distribution via three BMD ratios: FN:PF, TR:PF, and IT:PF. Physical activity was objectively measured using accelerometry, and maturity was estimated as the years of distance from peak height velocity. When compared to boys, girls had a wider pelvic diameter and greater interacetabular distances (p<0.001), lower BMD at FN, TR, and IT (p<0.05), and higher TR:PF (p<0.001). After controlling for maturity, body height, and lean body mass, the interacetabular distance in girls explained 21.1% (β=0.713, p<0.001) in TR:PF and 2.9% (β=-0.179, p=0.031) in the IT:PF. Neck-shaft angle explained 5.6% (β=-0.265, p=0.001) of the IT:PF and 3.1% (β=0.194, p=0.018) of the FN:PF. In boys, FN axis length explained 2.9% (β=0.195, p=0.040) of TR:PF. There was no main effect of physical activity or interaction effect with pelvic geometry in explaining BMD differences among the subregions of the PF. Even before sexual dimorphism, girls have a wider pelvis than boys, which accounted for proportionally greater BMD of the TR than other subregions of the PF.

Shape of growth plate of proximal femur in children and its significance in the aetiology of slipped capital femoral epiphysis

PurposeThe main objective of the study was to present the influence of the morphological shape of the proximal femoral growth plate in children as one of the risk factors for the incidence of slipped capital femoral epiphysis (SCFE) in adolescents.MethodsThis research is based on the X-ray, computed tomography (CT) and magnetic resonance imaging (MRI) data obtained for 100 children three to 13 years old, all treated at the Children’s Orthopaedic Clinic and Rehabilitation Department and Department of Radiology Medical University of Lublin between 2005 and 2009. We took into account 83 children with healthy hip joints and 17 children with SCFE. We also performed morphological analysis of the shape of the proximal femoral growth plate together with X-ray, CT and MRI examinations of the proximal ends of cadaver femurs for two children aged six and 13.ResultsIn the final findings we present an analysis of the shape of the proximal femoral growth plate in children between the third and 13th years of life and consider a correlation between the shape of the proximal femoral growth plate and its influence on the incidence of SCFE in adolescents.ConclusionsThe change of shape of the proximal femoral growth plate from pleated to more spherical is one of the risk factors for the incidence of SCFE in children ten years old and older.

Unilateral varus osteotomy of the proximal femur in children with cerebral palsy: A five-year follow-up of the development of both hips

Varus osteotomy of the proximal femur (VOPF) is one treatment option to prevent hip dislocation in children with cerebral palsy (CP). It is questioned whether the osteotomy should be performed in the displaced hip only, or if it should be performed bilaterally to prevent later displacement of the contralateral hip. CPUP is a register and healthcare programme for children with CP that was initiated in 1994 in southern Sweden. In the programme, range-of-motion and radiographic examination of the hips is performed regularly. These data have been analysed preoperatively and for 5years postoperatively in children treated with unilateral VOPF. Children with CP living in the counties of Skåne and Blekinge in the south of Sweden, who were treated with unilateral VOPF at least 5years ago, were included in the study. The degree of hip displacement and the range of hip motion were analysed preoperatively and after 5years. Repeat hip operations after the index operation were recorded. Twenty-four children fulfilled the inclusion criteria. Mean age at index operation was 7.6 (2.8-13.2) years. No child died within 5years postoperatively, and no child was lost from follow-up. At follow-up after 5years, 2 of the 24 children had been operated on with VOPF in the contralateral hip. The range of motion in both hips decreased, but the difference between the index hip and the contralateral hip did not change significantly. Children with CP and unilateral hip displacement have a low risk of later contralateral displacement after being operated on with unilateral VOPF. This supports healthcare programmes that advocate unilateral VOPF in children with unilateral hip displacement.

Proximal femoral reconstruction using angle blade plate in aggressive lesions of proximal femur in children: treatment of three cases and review of literature

Purpose To describe three cases of aggressive lesion involving the proximal femur in children presenting with pathological fracture and its treatment in children under 10 years by reconstruction using angle blade plate.

Screw Osteosynthesis of Proximal Femur Fractures in Children

Optimal reposition and stable fixation of M/1 and M/2 fractures are necessary. Careful operation and urgent surgery prevent complications. M/1 and M/2 fractures of the proximal femur in children > 4 years. E/1 fractures are fixed with Kirschner wires. M/3 fractures are fixed with elastic stable intramedullary nailing. Fractures up to the age of 4 are fixed with Kirschner wires. Surgical approach via a lateral incision. Anatomic fixation of the fracture with two to three cannulated screws. No weight bearing during the first 4-6 weeks. Physiotherapy is optional. Magnetic resonance imaging at least 1 year after the fracture or immediately in case of problems to control the vascular situation of the femoral head. Due to the rarity of these fractures, only few results from large series have been published. M/1 fractures show a higher complication rate than M/2 fractures. The risk of avascular necrosis has to be estimated at up to 40%.

Proximal femoral geometry in cerebral palsy

There is much debate about the nature and extent of deformities in the proximal femur in children with cerebral palsy. Most authorities accept that increased femoral anteversion is common, but its incidence, severity and clinical significance are less clear. Coxa valga is more controversial and many authorities state that it is a radiological artefact rather than a true deformity. We measured femoral anteversion clinically and the neck-shaft angle radiologically in 292 children with cerebral palsy. This represented 78% of a large, population-based cohort of children with cerebral palsy which included all motor types, topographical distributions and functional levels as determined by the gross motor function classification system. The mean femoral neck anteversion was 36.5 degrees (11 degrees to 67.5 degrees) and the mean neck-shaft angle 147.5 degrees (130 degrees to 178 degrees). These were both increased compared with values in normally developing children. The mean femoral neck anteversion was 30.4 degrees (11 degrees to 50 degrees) at gross motor function classification system level I, 35.5 degrees (8 degrees to 65 degrees ) at level II and then plateaued at approximately 40.0 degrees (25 degrees to 67.5 degrees) at levels III, IV and V. The mean neck-shaft angle increased in a step-wise manner from 135.9 degrees (130 degrees to 145 degrees) at gross motor function classification system level I to 163.0 degrees (151 degrees to 178 degrees) at level V. The migration percentage increased in a similar pattern and was closely related to femoral deformity. Based on these findings we believe that displacement of the hip in patients with cerebral palsy can be explained mainly by the abnormal shape of the proximal femur, as a result of delayed walking, limited walking or inability to walk. This has clinical implications for the management of hip displacement in children with cerebral palsy.

Long-term outcome of a child with a proximal femur fracture after high-energy trauma

Fractures of the proximal femur in children are less common than in adults and account for fewer than 1% of all children's fractures. Complications after these fractures, however, are quite common and tend to be more severe in children than in adults. Language: en

Pathologic Morphology of the Dislocated Proximal Femur in Children with Cerebral Palsy

We describe the gross and microscopic anatomic changes in the hip that result from the deforming forces in children with neuromuscular imbalance. Twelve dislocated proximal femora that had been resected from children with spastic diplegia or tetraplegia were evaluated with respect to their gross, microscopic, and radiographic structure. The epiphyses were wedge shaped with deformation of the femoral head apparent in all cases. In addition to a severe loss of articular cartilage, a furrowed erosion of epiphyseal bone suggested a sustained, blunt, band-like force across the surface of the hip where it opposed the acetabular labrum. The underlying physis of the capital femur was irregular with aberrant histologic structure, whereas that of the lesser trochanter was hypertrophic and angulated in a superior and anterior direction. A significant degree of valgus was not noticeable in most specimens. In summary, the spastic adductor and iliopsoas, responsible for the changes in the lesser trochanter, work in conjunction with the hip flexor and internal rotator muscles to subluxate the proximal femur. In the process, the superior rim of the acetabulum and capsule causes focal deformation of the superolateral femoral head, creating a fulcrum upon which the hip then progressively subluxates. The indentation locks the femoral head at the lateral acetabular margin, preventing complete dislocation, but leading to bone pain consequent to cartilage erosion.

Fractures of the Proximal Femur in Children and Adolescents

Fractures of the Proximal Femur in Children and Adolescents