Juvenile epiphyseolysis of the femoral head: causes, symptoms, diagnosis, treatment

Slipped capital femoral epiphysis is the third most common disease of the hip joint.

Pathogenesis

This endocrine-orthopedic disease is based on a disruption of the correlative relationship between sex hormones and growth hormones - two groups of hormones that play a major role in the vital activity of the cartilaginous epiphyseal plates. Against the background of sex hormone deficiency, a relative predominance of the action of growth hormone is created, reducing the mechanical strength of the proximal growth zone of the femur, which contributes to the emergence of conditions for the displacement of the proximal epiphysis of the femur downwards and backwards. Hormonal imbalance is confirmed by clinical data.

Symptoms of juvenile epiphyseolysis of the femoral head.

Patients with slipped capital femoral epiphysiolysis often show signs of delayed sexual development, metabolic disorders (obesity, latent diabetes mellitus) - 50.5-71% of patients. The disease is characterized by a long asymptomatic course. Symptom complexes gradually form: pain in the knee joint, movements in the hip joint in a vicious position (abduction and external rotation of the hip, Hofmeister's symptom in case of bilateral lesions - crossing of the shins) and lameness.

Stages

• Stage I - pre-displacement. No signs of epiphysis displacement, pronounced structural changes in the proximal growth zone and femoral neck.
• Stage II - displacement of the epiphysis backwards up to 30° and downwards up to 15° against the background of structural changes in the neck and “open” proximal growth zone of the femur.
• Stage III - displacement of the epiphysis backwards by more than 30° and downwards by more than 15° against the background of structural changes in the neck and “open” growth zone of the femur.
• Stage IV - acute displacement of the epiphysis backwards and downwards with inadequate trauma and an “open” growth zone of the femur.
• Stage V - residual deformation of the proximal femur with varying degrees of displacement of the epiphysis and synostosis of the proximal growth zone.

Forms

Flow:

• chronic (stages I-III);
• acute (stage IV).

Degree of joint dysfunction:

• mild (stages I-II);
• moderate and severe (stages III-V).

Degree of posterior displacement of the epiphysis:

• light - up to 30°;
• average - up to 50°;
• heavy - more than 50°.

Diagnostics of juvenile epiphyseolysis of the femoral head.

Radiological signs:

• disruption of the structure of the proximal growth zone and subepiphyseal region of the femoral neck;
• positive segment symptom - Klein's line does not cut off the head segment when the epiphysis is displaced downwards;
• reduction in the height of the pineal gland without damaging its structure;
• double inner contour of the femoral neck;
• reduction of the epiphyseal-diaphyseal and epiphyseal angles against the background of regional osteoporosis.

Treatment of juvenile epiphyseolysis of the femoral head.

Based on the experience of treating patients, a surgical treatment tactic has been developed. The disease always affects both hip joints, so it is necessary to perform surgery on both sides.

Initial stage (I-II). When the epiphysis is displaced backwards by up to 30° and downwards by no more than 15°, bilateral epiphysiodesis is performed simultaneously with Knowles pins and an auto- or allograft after tunneling the neck to stop the displacement of the epiphysis and prevent unilateral shortening of the limb. Transarticular insertion of pins and a graft is unacceptable due to the risk of developing chondrolysis of the hip joint.

Stage III. When the epiphysis is displaced more than 35° backwards and 15° downwards against the background of an "open" growth zone, the goal of the operation is to restore the epiphysis centering in the acetabulum. Two- and three-plane osteotomies of the femur are used to center the femoral head in the acetabulum and to move the anterior superior zone of the femoral neck away from the edge of the acetabulum to eliminate its action as an anterior "brake" even against the background of an "open" proximal growth zone.

Stage IV. In case of acute displacement of the epiphysis, the operation is aimed at closed reposition of the displaced epiphysis and achieving synostosis of the proximal growth zone.

When a patient is admitted to hospital at this stage of the disease, the following is required:

• puncture of the hip joint to evacuate the hematoma and decompress the joint, paraarticular injection of 0.25-0.5% procaine (novocaine) solution;
• insertion of a Kirschner wire for skeletal traction through the supracondylar region in the plane of initial external rotation of the femur above the distal growth plate of the femur.

During the first week, traction is performed along the axis with a gradually increasing load of 5 to 8 kg (depending on the patient's weight). By the end of the second week, abduction of the limb is achieved to 45/135°. When reposition is achieved, epiphysiodesis is performed with pins and a transplant.

Transarticular insertion of pins and graft is not allowed.

Immobilization of the limb in the middle position is carried out with a derotation boot with a stabilizer for 6-8 weeks.

Stage V. In case of posterior displacement of the epiphysis by more than 35° and downward displacement by more than 15° and synostosis of the proximal growth zone, the operation is aimed at restoring the epiphysis centration and eliminating the abnormal position of the limb. If the disease has been going on for no more than 12-18 months and is accompanied by good mobility in the joint, it is usually possible to restore the hip joint ratios approaching normal using detorsion-rotational valgus osteotomy.

In some advanced cases where the disease has been going on for more than 2-2.5 years, it is necessary to limit ourselves to detorsion-abduction osteotomy to correct the malposition and slightly lengthen the limb.

After all operations, immobilization is carried out with a plaster derotation “boot” for 4-6 weeks.

From the first days after the operation, passive movements are performed, and from the 3rd week - active movements in the hip and knee joints against the background of drug therapy: pentoxifylline (trental), xanthinol nicotinate, dipyridamole (curantil), orotic acid (potassium orotate) in age-appropriate dosages.

Physiotherapeutic treatment: electrophoresis of calcium, sulfur, ascorbic acid using a three-pole method, nicotinic acid, humisol, ampli-pulse on the lower back or darsonvalization of the operated limb and lower back 3-4 weeks after surgery.

In the absence of radiographic contraindications (narrowing of the joint space, delayed consolidation, spotted osteoporosis), dosed loading after epiphysiodesis in stages I-II is carried out after 8-10 weeks, after osteotomy - after 4-6 months. Full loading after epiphysiodesis is allowed after 3 months, after osteotomy - after 6-8 months and after epiphysiodesis for acute displacement of the epiphysis - after 10-12 months.

The best results of surgical treatment are obtained in the early stages of the disease (stages I-II).

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