Rate Of Avascular Necrosis Research Articles

Developing a sustainable hip service in Cambodia.

Initial report on establishment of a hip service in Phnom Penh, Cambodia at Children's Surgical Centre. We describe indications for total hip replacement (THR) and initial results. A database was established to collect data and track patients for follow up. Initial data collected included; diagnosis, implant used, post-operative complications. As the service developed, pre- and postoperative Harris hip scores were included. High rate of avascular necrosis (AVN) as the initial diagnosis. Five years post initiation of the hip service, 95 patients have received 116 THRs; including 10 revisions, 12 bilateral procedures. Complications/failures requiring revision involved four prosthetic femoral neck fractures, two aseptic acetabular component, two late infections, one instability. One failure, a periprosthetic acetabular fracture, required removal of all prosthetics. Complications not requiring revision, included three post-op foot drops, three superficial wound infections, one Vancouver B1 periprosthetic femur fracture. Average age was 41. Overall implant survival is 85% at three years. AVN was the most common indication for THR: many patients had a history of hip trauma, and/or prolonged steroids from traditional healers for pain. Problems with specific implants were addressed by the company. A different stem is now routinely used, no further fractures have been reported. Acetabular loosening, thought to be due to poor technique, has been addressed by focused training. Infection rate is monitored, and microbiology resources are improving. Developing an affordable hip arthroplasty service in a country like Cambodia is challenging. Developing a local registry has helped to identify complications and modify techniques.

Cannulated Screw Fixation For Femoral Neck Fractures : A 5-year Experience In A Single Institution.

Cannulated screw fixation is a widely accepted surgical method for management of fractures of the neck of femur especially in patients with poor premorbid conditions, minimally displaced fractures and those from a younger age group. A five year retrospective study was carried out in 53 consecutive patients between 2006 to 2010 to determine the pattern of injuries, management, outcomes and the associated predictive factors.All the patients underwent cannulated screw fixation, with 37 (69.8%) having had surgery within 24 hours and the remaining 16 (30.2%) 24 hours after the initial injury. All patients were followed up to union of fractures and complications thereafter if any. Good outcome was observed in 43 (81.1%) patients leaving only 10 (18.9%) patients with a poor outcome, of whom nine developed avascular necrosis (90%) and one non-union (10%). We found no significant relationship between the incidence of avascular necrosis and age of patient, fracture displacement, numbers of cannulated screws used, fracture reduction acceptability and anatomical location of the fracture. The time interval from injury to surgery and the presence of posterior comminution did seem to influence the rate of avascular necrosis but due to the small number of patients, was not statistically significant.We conclude that cannulated screw fixation is a viable option of treatment for fractures of the neck of femur. femoral neck fractures, screw fixation.

Avascular necrosis in proximal humeral fractures in patients treated with operative fixation: a meta-analysis.

BackgroundProximal humeral fractures are common lesions of the elderly, but there are no established treatment guidelines. A surgical treatment for comminuted and displaced fractures of the proximal humerus was developed and is still evolving. The aim of this study was to perform a quantitative review to evaluate the risk of avascular necrosis (AVN) in patients with proximal humeral fractures who were treated by operative fixation compared with conservative treatment.MethodsWe searched the PubMed, MEDLINE, Springer, Elsevier Science Direct, Cochrane Library, Google Scholar, China National Knowledge Infrastructure (in Chinese), and Wanfang database (in Chinese) up to December 2013 to identify studies related to operative fixation and AVN in patients with proximal humeral fractures.ResultsSeven studies with a total of 291 patients (142 operative fixation cases and 149 conservative treatment cases) with proximal humeral fractures were considered in the meta-analysis. The overall meta-analysis showed no significant difference in the incidence of AVN between the two groups [odds ratio (OR) 1.42, 95% confidence interval (CI) 0.33–6.11, p = 0.64]. The subgroup meta-analysis by study design (retrospective/prospective), sample size (≤40/>40), and ethnicity (European/Asian) demonstrated similar results. However, the subgroup analysis by specific operative approach (plate fixation/tension band wiring fixation/others) indicated that plate fixation was associated with a higher rate of AVN than conservative treatment (OR 0.20, 95% CI 0.05–0.76, p = 0.019).ConclusionsPlate fixation was associated with a higher risk of AVN development than conservative treatment in patients with proximal humeral fractures.

Staged weaning versus immediate cessation of Pavlik harness treatment for developmental dysplasia of the hip

Outcomes of nonoperative treatment for developmental dysplasia of the hip were compared between two centres. Eighty children in Centre A underwent staged weaning of the Pavlik harness once three consecutive weekly ultrasounds showed Graf Grade I hips, whereas in 48 children in Centre B, the harness was removed immediately. No statistically significant difference was found in the rate of reintervention (repeat harness treatment, closed or open reduction), avascular necrosis or acetabular index between the two methods, although there was a nonsignificant trend towards higher reintervention rate and lower avascular necrosis rate with immediate harness removal. Age at start of treatment significantly impacted upon initial harness success, reinterventions and avascular necrosis.

The incidence of avascular necrosis and the radiographic outcome following medial open reduction in children with developmental dysplasia of the hip

The incidence of clinically significant avascular necrosis (AVN) following medial open reduction of the dislocated hip in children with developmental dysplasia of the hip (DDH) remains unknown. We performed a systematic review of the literature to identify all clinical studies reporting the results of medial open reduction surgery. A total of 14 papers reporting 734 hips met the inclusion criteria. The mean follow-up was 10.9 years (2 to 28). The rate of clinically significant AVN (types 2 to 4) was 20% (149/734). From these papers 221 hips in 174 children had sufficient information to permit more detailed analysis. The rate of AVN increased with the length of follow-up to 24% at skeletal maturity, with type 2 AVN predominating in hips after five years' follow-up. The presence of AVN resulted in a higher incidence of an unsatisfactory outcome at skeletal maturity (55% vs 20% in hips with no AVN; p < 0.001). A higher rate of AVN was identified when surgery was performed in children aged < 12 months, and when hips were immobilised in ≥ 60° of abduction post-operatively. Multivariate analysis showed that younger age at operation, need for further surgery and post-operative hip abduction of ≥ 60° increased the risk of the development of clinically significant AVN.

Analysis of the Development of Avascular Necrosis in Slipped Capital Femoral Epiphysis

Introduction: Slipped capital femoral epiphysis (SCFE) is a common hip disorder in adolescents. The most serious complication is avascular necrosis (AVN), which has lasting sequelae. The objective of this study was to determine the rate of AVN in stable slips. Method: We reviewed retrospectively all the children treated for SCFE between 2004 and 2008 at Princess Margaret Hospital. Results: Of a total of 67 patients, 51 (76%) were stable slips and 16 (24%) unstable. Avascular necrosis developed in 3 patients with stable slip (5.9%) and in 6 with unstable slip (37.5%). There was no statistically significant association found between AVN and age, weight, slip severity, pin position, number of pins used, experience of the surgeon or side affected. Those with stable presentations can develop AVN2, males are more likely and the possibility of developing AVN increases as the time from presentation to operation increased. Conclusion: AVN can occur in stable slips without joint penetration. This combined with male sex and increased time to operation, increases the risk of AVN.

Osteosynthese zentraler Talusfrakturen

Anatomic reduction of talar neck and body fractures with axial realignment and restoration of the articular surfaces of the talus. Displaced talar neck and body fractures. High perioperative risk, soft tissue infection, neurogenic osteoarthropathy. Reduction of the axial alignment of the talus and its joints via bilateral approaches according to the preoperative CT-based planning. A medial malleolar osteotomy may be necessary to approach the talar dome. The blood supply via the deltoid ligament and the sinus tarsi has to be respected. Manipulation of the main fragments with K-wires introduced temporarily; a mini-distractor is helpful in restoring the length. Internal fixation is tailored to the individual fracture pattern, including conventional and headless screws, bioresorbable pins, lost K-wires, and/or minifragment plates. Joint transfixation for 6 weeks to ensure ligamentous healing if instability persists after internal fixation. With severe soft tissue damage, temporary tibiometatarsal external fixation is applied until soft tissue consolidation. Range of motion exercises of the ankle and subtalar joints starting postoperative day 2 except for cases with joint transfixation. Partial weight bearing of 20 kg for 10-12 weeks. Use of a cast or walker for 6 weeks followed by intensive active and passive range of motion exercises of the ankle and subtalar joints. Over 8 years 79 fractures of the talar neck and body were treated. In all, 43 patients with 45 talar neck (n = 30) and body (n = 15) fractures were re-examined clinically and radiologically (mean follow-up 3 years). Definite treatment consisted of open reduction and screw fixation of the talus in 41 cases and small plate fixation in 2 cases supplemented by temporary external fixation for 1-3 weeks in 12 cases. At follow-up, the Maryland Foot Score averaged 86.1 and the AOFAS Ankle/Hindfoot Score averaged 78.9. The Hawkins classification was of prognostic value in talar neck fractures. The functional results and the rate of avascular necrosis (AVN) were unaffected by the time to definite internal fixation. AVN was observed in 11 cases (24%); with only partial AVN involving less than one third of the talar body in 8 of these patients. Due to complete AVN with collapse of the talar dome, 3 patients (6.7%) required fusion. Signs of posttraumatic arthritis of the tibiotalar or subtalar joint were seen in 21 cases (47%). The rate of symptomatic posttraumatic arthritis correlated with the occurrence of total AVN, but not with partial AVN.

What Is the Cause of Avascular Necrosis in Unstable Slipped Capital Femoral Epiphysis and What Can Be Done to Lower the Rate?

An unstable slipped capital femoral epiphysis (SCFE) is associated with a high rate of avascular necrosis (AVN). Etiology of the AVN is not completely known and likely multifactorial. Potential causes are a tear/anatomic disruption of the retinacular vessels to the epiphysis, kinking of the retinacular vessels, or vascular tamponade due to increased intracapsular pressure. A review of the recent literature of unstable SCFE was performed to abstract various potential causes of AVN. The overall rate of AVN was 21% (88 of 417). Kinking of the retinacular vessels was demonstrated angiographically in 5 unstable SCFEs where the vessels did not fill in 3; in 1 the vascularity returned after reduction. Intracapsular joint pressure was measured in 13 unstable SCFEs with an average of 48 mm Hg on the unstable side compared with 23 mm Hg in the opposite normal hip. After manipulative reduction the pressures increased to 75 mm Hg, and dropped markedly to 17 mm Hg after capsulotomy and decompression. Although a complete tear of the vessels is another possibility, there are no described cases in the literature. Means to lower AVN depends upon its etiology. In 28 unstable SCFEs urgent reduction, internal fixation and decompressive arthrotomy resulted in a rate of 14% (4 of 28). Urgent open reduction through an anterior approach with smooth Kirschner wire fixation resulted in a rate of 5% (3 of 64). The modified Dunn procedure using a surgical dislocation resulted in a rate of 8% (2 of 26). Larger and combined series will be needed to determine the best treatment to minimize the rate of AVN in the unstable SCFE. With today's present techniques, AVN in the unstable SCFE will never be a "never" event.

Long-term outcome of medial open reduction in developmental dysplasia of hip

Long-term outcome of medial open reduction (MOR) was examined. We aimed to evaluate the effects of MOR on hip development in developmental dysplasia of hip (DDH). One hundred and ten hips of 74 patients that admitted to our clinic were evaluated. 15 (20.27%) were male, 59 (79.73%) were female. The mean age at the time of MOR was 17.71±7.71months (range 6-48months). The mean duration of follow-up was 13.97±4.89years (range 5-24years). Radiological results were Severin 1 and 2 in 86.37% of the hips, Severin 3 in 10.0% of the hips and Severin 4 in 3.63% of the hips. Functional results were excellent (94.55%) or good (5.45%) according to modified McKay's criteria. When we excluded the hips that underwent additional operations, radiological results were Severin 1 and 2 in 82.05% of the hips, and Severin 3 and 4 in 17.95% of the hips. Acetabular angles and ACM, CE, Sharp angles were evaluated at last follow-up. Acetabular development was better in patients that were treated before the age of 18months. Additional operations were performed to 32 hips (29.09%). No additional operation was performed to the patients that were treated with MOR before the age of 12months. The patients that were treated with MOR between 19 and 24months of age had a higher proportion (47.61%) for additional operations. Avascular necrosis rate was 17.27%. Avascular necrosis rate was decreased to 6.3% when type 1 differences were excluded. Avascular necrosis rate was 12.82% when the hips that underwent additional operations were excluded. Medial open reduction is effective and safe treatment method in DDH. Early concentric stable reduction with MOR improved results.

Emergent Surgical Reduction and Fixation for Pipkin Type I Femoral Fractures

The purpose of this study was to assess the effect of timing of large fragment fixation in patients with Pipkin type-I fractures. Patients with Pipkin type-I fractures from the authors' trauma center were prospectively observed between July 2007 and July 2010. Fragments that constituted more than one-fourth of the femoral head were included. Thirty-six patients were equally randomized to undergo emergent surgical reduction and fixation or secondary operative fixation after emergent closed reduction. No significant differences existed between the 2 groups with regard to the baseline characteristics, operating time, and blood loss (P>.05). However, the emergent surgical reduction and fixation group had a shorter hospital stay (P<.05). The results after more than 2-year follow-up showed that the complication and avascular necrosis rates were higher in the secondary operative fixation after emergent closed reduction group compared with the emergent surgical reduction and fixation group (P<.05). It was difficult to achieve an anatomically reduced femoral head when the fragments constituted more than one-fourth of the femoral head. Patients who underwent secondary operative fixation after emergent closed reduction had a high avascular necrosis rate and a relatively poor outcome. Emergent surgical reduction and fixation should be performed shortly after injury to enhance the treatment outcome.

Assessment of time factor in managing femoral neck fractures by internal fixation in patients above 55 years of age

Background Intracapsular hip fractures account for approximately half of all hip fractures. Present treatment of an intracapsular fracture entails either replacement arthroplasty or preservation of the femoral head. In old age patients, the decision between fixation and arthroplasty becomes an issue: Although fixation is a biological solution for this fracture treatment, it has a high nonunion rate with a long postoperative recumbency period and its known complications; in contrast, arthroplasty has its advantage in early mobilization of the patient but has its well-known complications, starting with infection and ending with loosening and the need for revisions. Evidence from the literature on the effect of timing of fixation on outcomes after femoral neck fractures is conflicting. The purpose of this study was to analyze the effect of timing of surgery on the incidence of nonunion and avascular necrosis (AVN) after internal fixation of femoral neck fractures in patients above the age of 55 years. Patients and methods This study included 30 patients (13 men and 17 women) between 56–77 years of age (average 65.1 years) with femoral neck fractures who were treated by closed reduction and internal fixation and were followed up for a minimum of period of 2 years. Nineteen patients (63.33%) had displaced fractures. The average time lag between injury and surgery was 37.5 h (6–144). The patients were divided into two groups: 12 patients (40%) were treated within 12 h after injury (early fixation group) and 18 (60%) were treated more than 12 h after injury (late fixation group). All patients were treated by closed reduction and multiple screw fixation. Results The average age of the patients in the early fixation group (12 patients) was 61.9 years and that of patients in the late fixation group (18 patients) was 67.7 years. There were seven women in the early fixation group and 10 in the late fixation group. There were eight cases of displaced fractures (66.67%) in the early fixation group and 11 cases (61.1%) of the same in the late fixation group. The average time lag between injury and fixation was 10.5 h in the early fixation group and 54.78 h in the late fixation group. All fractures united within an average period of 86.8 days (range 60–128). The final results were satisfactory in 22 hips (73.33%) and unsatisfactory in eight hips (26.67%). No statistically significant difference was found in the duration of fracture union and AVN with regard to sex distribution and mechanism of injury. Variables affecting the final results of treatment were: the time factor, age at surgery and type of fracture. Conclusion Closed reduction and internal fixation is a valid contribution to the treatment of femoral neck fractures in patients above 55 years of age (56–65). The rate of nonunion and AVN was affected by a delay of more than 12 h before fixation for femoral neck fractures in this age group. The incidence of failure was significantly higher in patients aged 65 years or above and in cases of displaced fractures.

Evaluation of valgus intertrochanteric osteotomy in neglected fracture neck femur in young adults.

Femoral neck fractures in young adults have always presented a difficult problem with high rates of non-union and avascular necrosis. At our centre we have been using the traditional Pauwels intertrochanteric osteotomy for neglected un-united femoral neck fractures in young adults. We have made certain modifications in this procedure to suit our resources and so we evaluated the outcome of this procedure at our institute. The study included fifty consecutive cases of neglected femoral neck fractures treated at our centre between February 1996 and October 2012. Patients in whom internalfixation had failed were excluded. The average age of the patients was 37 years (range: 17-55 years). Eleven of the patients were female & Thirty-nine were male. Fifteen patients belonged to Pauwels grade 1, Twenty-six patients belonged to grade 2, and nine belonged to grade 3. The interval between the injury and operation ranged from 1 to 12months (average: 4.3 months). The cases were operated on a normal table using a Watson Jones Approach. The fracture ends were freshened and fixed using a 6.5mm screw followed by a valgus osteotomy which was fixed by a double angle (120 degree) blade plate. A fracture union rate of 90% (45 cases) was achieved. Two of the healed cases developed avascular necrosis. Results were graded using Askin and Bryan's criteria. Overall, an excellent result was seen in 35 patients, good in 5, fair in 5 and poor in 5. Of the five patients having poor result (3 non-union, 1 implant breakage, 1 implant cut out), two refused revision surgery. In remaining three, one underwent total hip arthroplasty and in two revision osteotomy was performed. We believe that intertrochanteric osteotomy provides a good outcome for neglected femoral neck fractures. Performing the procedure on a routine table, with Watson Jones approach and fixing with double angle blade plate is a good option.

Femoral fractures in children

Femoral fractures in children are the commonest children's fracture requiring hospitalization. They consume disproportionate amounts of healthcare resource. Advances in operative management have resulted in improved clinical and health economic outcomes. This article describes 21st-century management of femoral fractures concentrating on recent advances. There is a clear trend to increased operative management in all femoral fractures with improved outcomes in the proximal femur and shaft. Crucially, advances in the treatment of both have led to a reduction in the rate of avascular necrosis of the femoral head. Units treating paediatric fractures need access to specialist surgeons and equipment to treat the full range of femoral fractures and improve outcomes.

Factors affecting the outcome of fractures of the femoral neck in children and adolescents

Fractures of the femoral neck in children are rare, high-energy injuries with high complication rates. Their treatment has become more interventional but evidence of the efficacy of such measures is limited. We performed a systematic review of studies examining different types of treatment and their outcomes, including avascular necrosis (AVN), nonunion, coxa vara, premature physeal closure (PPC), and Ratliff's clinical criteria. A total of 30 studies were included, comprising 935 patients. Operative treatment and open reduction were associated with higher rates of AVN. Delbet types I and II fractures were most likely to undergo open reduction and internal fixation. Coxa vara was reduced in the operative group, whereas nonunion and PPC were not related to surgical intervention. Nonunion and coxa vara were unaffected by the method of reduction. Capsular decompression had no effect on AVN. Although surgery allows a more anatomical union, it is uncertain whether operative treatment or the type of reduction affects the rate of AVN, nonunion or PPC, because more severe fractures were operated upon more frequently. A delay in treatment beyond 24 hours was associated with a higher incidence of AVN.

Results of medial open reduction of developmental dysplasia of the hip with regard to walking age

This study aimed to evaluate the outcome of medial open reduction for developmental dysplasia of the hip (DDH) in patients before and after walking age. A minimum 5-year radiographic and clinical follow-up compared 29 patients (group 1) before walking age with 38 patients (group 2) after walking age for DDH. The correction ratio of acetabular index was similar in both groups postoperatively (41.8% for group 1 and 44.9% for group 2), and it was statistically not significant (P>0.05). The Kalamchi-MacEwen classification showed no correlation between operative age and the rate of avascular necrosis (P>0.05). This report presents similar complication rates as that of the Severin criteria for medial open reduction of the hip and challenges the conventional belief that a medial open reduction for the treatment of DDH in a walking-age child at short-term to mid-term follow-up has comparable results.

Slipped Capital Femoral Epiphysis: Prevalence, Pathogenesis, and Natural History

Obesity is a risk factor for developing slipped capital femoral epiphysis (SCFE). The long-term outcome after SCFE treatment depends on the severity of residual hip deformity and the occurrence of complications, mainly avascular necrosis (AVN). Femoroacetabular impingement (FAI) is associated with SCFE-related deformity and dysfunction in both short and long term. We examined obesity prevention, early diagnosis, reducing AVN and hip deformity as strategies to reduce SCFE prevalence, and the long-term outcomes after treatment. A search of the literature using the PubMed database for the key concepts SCFE and treatment, natural history, obesity, and prevalence identified 218, 15, 26, and 49 abstracts, respectively. WHERE ARE WE NOW?: A correlation between rising childhood obesity and increasing incidence of SCFE has been recently reported. Residual abnormal morphology of the proximal femur is currently believed to be the mechanical cause of FAI and early articular cartilage damage in SCFE. WHERE DO WE NEED TO GO?: Reducing the increasing prevalence rate of SCFE is important. Treatment of SCFE should aim to reduce AVN rates and residual deformities that lead to FAI to improve the long-term functional and clinical outcomes. HOW DO WE GET THERE?: Implementing public health policies to reduce childhood obesity should allow for SCFE prevalence to drop. Clinical trials will evaluate whether restoring the femoral head-neck offset to avoid FAI along with SCFE fixation allows for cartilage damage prevention and lower rates of osteoarthritis. The recently described surgical hip dislocation approach is a promising technique that allows anatomic reduction with potential lower AVN rates in the treatment of SCFE.

A prospective analysis of the functional and radiological outcomes of minimally invasive plating in proximal humerus fractures

BackgroundLocking-plate osteosynthesis is a well-established treatment option for proximal humerus fractures. The standard approach is delta-pectoral, but few data using the minimally invasive antero-lateral delta-split approach exist.The aim of the study was to prospectively evaluate shoulder function and radiological outcome after a minimally invasive antero-lateral delta-split approach. Materials and methodsFrom December 2007 to October 2010, 124 patients with proximal humerus fractures were treated with locking-plate osteosynthesis using a minimally invasive antero-lateral delta-split approach. Complete prospective clinical and radiographic data were available for 97 patients for a minimum 1-year follow-up period. ResultsAfter a follow-up period of 18±6months, the patients achieved a mean absolute Constant score of the injured shoulder of 75±11, equalling 91% of the contralateral shoulder Constant score (p<0.01).Implant-related complications (e.g., screw perforation) were observed in seven patients (7.2%), and avascular necrosis occurred in eight patients (8.2%). Damage to the ventral branch of the axillary nerve was recorded in four cases (4%) without any clinical consequences. The mean delay between trauma and surgery was 0.5days. The procedures were performed by a total of 16 surgeons who required an average of 73±27min of OR time and 108±121s of fluoroscopy time. ConclusionsMinimally invasive osteosynthesis using angle-stable implants for proximal humerus fractures demonstrated good functional results. Compared to the literature, this minimally invasive procedure resulted in a shorter operation time and may have reduced the avascular necrosis rate. Level of evidenceLevel IIb, monocentric prospective cohort study.

Arterial supply of the tendinous rotator cuff insertions: an anatomical study

Confirming the presence of arteries crossing the osteotendinous junctions (OTJs) of the rotator cuff may explain why rates of avascular necrosis (AVN) of the humeral head vary between three- and four-part proximal humeral fractures. It is hypothesized that the humeral head remains better vascularized in three-part fractures because one tuberosity with its inserting rotator cuff tendons is still attached to the articular fragment and supplying it with blood. Eighty rotator cuff tendons from 20 shoulder girdles of cadavers aged 68-94 years were studied. In six shoulder girdles, the anterior circumflex humeral artery and posterior circumflex humeral artery (PCHA) were injected with ink, and the extra- and intraosseous courses of the vasculature were dissected until the OTJs of the rotator cuff. The rotator cuff insertions received an arterial supply across their OTJs in 50% of cases (75% in supraspinatus, 67% in subscapularis, 33% in infraspinatus and 20% in teres minor). Supraspinatus and subscapularis insertions were vascularized by the arcuate artery, while the insertions of infraspinatus and teres minor were supplied by an unnamed terminal branch of the PCHA. This was named 'posterolateral artery'. The presence of arteries crossing the OTJs of the rotator cuff, as well as the differences in the frequency arteries crossed the OTJs of individual rotator cuff tendons, may help explain why there is a lower rate of AVN of the humeral head in thee-part, compared with four-part proximal humeral fractures.

Open reduction and internal fixation of unstable slipped capital femoral epiphysis by means of surgical dislocation does not decrease the rate of avascular necrosis: A preliminary study

The treatment of unstable slipped capital femoral epiphysis (SCFE) remains controversial. Surgical dislocation and open reduction has the potential to significantly reduce the rate of avascular necrosis (AVN) by allowing direct preservation of the femoral head blood supply. The purpose of this study was to determine if open reduction of the unstable SCFE by means of surgical hip dislocation reduced the risk of AVN compared with closed reduction and percutaneous pinning. We reviewed the medical records and radiographs of patients treated at our institution between the years 2000 and 2008. Sex, age, side of slip, precipitating event, pre- and post-operative anterior physeal separation (APS) and slip angle, slip severity, time between inciting event and surgical treatment, number of screws used, development of AVN, and need for subsequent surgery were evaluated. Statistical analysis was performed to compare risk factors and occurrence of AVN. From 2004 to 2008, we treated 12 patients with unstable SCFEs: six had closed reduction and percutaneous pinning and six underwent open reduction by means of surgical hip dislocation. There were no statistically significant differences between the two groups regarding sex, age, slip angle, APS, time to surgery, and AVN rate. At follow-up, 4 (66.7%) patients had AVN in the group which had open reduction, while 2 (33.3%) patients had AVN in the group which underwent closed reduction. (p=0.57). Open reduction of the unstable SCFE by means of surgical dislocation of the hip does not decrease the rate of AVN when compared to closed reduction.

Evaluation of Surgical Treatment of Developmental Dysplasia of Hip for Avascular Necrosis of Femoral Head in Children

Developmental Dysplasia of the Hip (DDH) is a common congenital malformation. Avascular necrosis of femoral head is the major complication of both close and open reduction of the dislocated joint. Aim of this study was to determine the incidence and influencing factors in different types of a vascular necrosis of femoral head, following surgical treatment of developmental dysplasia of hip in 1-7 years patients. In this study, 120 patients aged from 1 to 7 years old with DDH who had been undergone open surgery, entered to the study. All of these patients followed up for at least 1 year. Surgery procedures divided to 4 groups: open reduction, open reduction+salter osteotomy, open reduction+femur shortening and open reduction+salter osteotomy+femur shortening. The presence of Avascular Necrosis (AVN) had been appraised. 27.5% of surgeries performed on male and 72.5 on female patients. 35.0% of DDH cases were unilateral and remaining was bilateral. 36 patients (30%) shows radiologic findings of AVN, although all of them placed at group I of Bucholz-Ogden classification. 40% of group A patients, 25% of group B, 14.3% of group C and 36.4% of group D patients developed this findings. Open reduction of DDH in older children is effective in the management of DDH and if all of the contrivance considered in the surgery, the rate of AVN would be low and mild (at least in short term follow ups).