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Treatment of adolescent epiphysiolysis with ganz realignment subcapital

osteotomy

Article · January 2018

DOI: 10.7546/CRABS.2018.08.18

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 Доклади на Българската академия на науките
Comptes rendus de l’Académie bulgare des Sciences
Tome 71, No 8, 2018

MEDICINE
Experimental medicine

TREATMENT OF ADOLESCENT EPIPHYSIOLYSIS WITH

GANZ REALIGNMENT SUBCAPITAL OSTEOTOMY

Stefan Tserovsky, Venelin Alexiev, Boyan Hristov

(Submitted by Academician Wl. Ovtscharoff on May 5, 2017)

Abstract

Slipped capital femoral epiphysis is the most common paediatric hip dis-
order in adolescence. All severe slips require surgical treatment. We used oper-
ative techniques with shortening of the femoral neck till 2009 and after – Ganz
subcapital osteotomy with surgical hip dislocation that relatively lengthens the
femoral neck. Without a proper therapy slipped capital femoral epiphysis ends
with a severely deformed femoral head, leading to femoro-acetabular impinge-
ment and early osteoarthritis [1 ].
The aim of the current study is to present our results in the department
of Pediatric Orthopedics at the Medical University of Sofia of this new surgical
technique to restore hip anatomy and function.
For a 5 year and 10 months period (March 2011 – July 2016) we have
operated 19 patients with severe epiphysiolysis by Ganz subcapital osteotomy
with surgical hip dislocation. All cases had a high-grade slip with a posterior
slip angle of 55.84 ± 16.76◦. Thirteen were stable by Loder classification, 6
were unstable. Pre- and postoperatively in all patients on anteroposterior and
lateral (Dunlop) X-ray view were measured Gekeler angle, PTA, alpha angle
and epiphyseal-neck offset. Clinically was accessed Harris Hip Score.
At an average follow-up period of 16.52 ± 8.95 months we measured an
average postoperative Gekeler angle of 141 ± 6.01◦ and postoperative posterior
slip angle 4.36 ± 2.83◦, as well as improvement in all patients of the hip range
of motion. In 31% of the cases there were signs of avascular necrosis, which
coincides with the percentage of unstable slips. In 4 cases we had histological
indications for already existing avascular necrosis preoperatively.

DOI:10.7546/CRABS.2018.08.18

1147
 Ganz subcapital osteotomy is a safe technique after a substantial learning
curve. It restores the proximal femur anatomy by achieving 42.23◦ ±1.5◦ alpha-
angle in our cases with lower avascular necrosis and chondrolysis incidence than
the previously applied techniques.
Key words: slipped capital femoral epiphysiolysis, Ganz subcapital os-
teotomy with surgical hip dislocation, avascular necrosis of femoral head

Introduction. Slipped capital femoral epiphysis (SCFE) is the most com-

mon hip disorder in adolescents [1 ]. The femoral head remains in the acetabular
socket, while the femoral neck and shaft are displaced anteriorly and superiorly
with a high risk for disruption of the blood supply. SCFE can be stable and
unstable. Unstable severe epiphysiolysis has a high percentage of pre- and post-
operative avascular necrosis (AVN), while the stable slips have low AVN, which
basically is iatrogenic [2 ]. Treatment of SCFE is always operative with stabi-
lization of the slip as to stop the inevitable progression due to the remaining
physeal growth. Leaving epiphyseal perfusion intact is crucial in the surgical ap-
proach. The other major complication from undertreated SCFE is developing in
the postoperative years of “cam type” femoro-acetabular impingement (FAI) due
to distortion of the labrum and acetabulum.
There are two different treatment options: fixation in situ or reduction os-
teotomy depending on the severity of the slip. Severe epiphysiolysis requires
intra-articular subcapital osteotomies for realignment. Up to 2008 we applied
the techniques of Fish [3 ], Vladimirov [4 ], Martin [5 ], Dunn [6 ] and others.
These techniques did not offer stability of correction and early ROM. After 2008
we started application of Ganz subcapital osteotomy with surgical dislocation
(SOSHD), introduced in 2001 [1 ] as a modification of Dunn technique. This sur-
gical technique allows direct inspection and preservation of the physeal blood
supply, minimizing the risk of AVN. It also achieves full anatomical restoration of
the proximal femur by complete correction of the slip angle and relative femoral
neck lengthening, thus minimizing chances for FAI.
Our present study reports our early results with Ganz subcapital osteotomy
that confirm its anatomical long term reliability.
Operative technique. The surgical approach uses the original Ganz tech-
nique for hip dislocation with greater trochanter osteotomy and elevation ante-
riorly of the trochanteric fragment with the attached muscles, relative femoral
neck lengthening, Z-shaped capsulotomy, femoral neck offset and dislocation of
the joint. The vessels for the femoral head perfusion (aa. capitis et coli femoris
inferiores et superiores) remain preserved. These vessels are branches of the deep
branch of a. femoris medialis, situated under m. obturatorius externus entering
the capsule at the level of m. gemellus superior. The surgical approach starts with
a greater trochanter osteotomy from posterior to anterior with inside-out remod-
elling of the apophysis and removal of a triangular fragment above the pyriformis
fossa. In this way a new femoral neck with relative lengthening is formed. Then

1148 S. Tserovsky, V. Alexiev, B. Hristov

follows a Z-capsulotomy and very gentle shaping of a posterior capsulo-periosteal
flap, starting at the posterior-inferior part of the neck. The nourishing femoral
head blood vessels remain intact because they are in this flap and the femoral
head remains attached to them. A positive sign for an intact perfusion of the
femoral head is the bleeding from the epiphyseal spongiosa when a simple drill
hole is made in it. The next step is separation of the epiphysis from the physis
(Fig. 1, 2). In a surgically dislocated hip joint the physeal cartilage is gently re-
moved with a curette by the Fish technique [3, 7 ]. We also remove the pathological
callus, formed as a bump at the posterior-inferior surface of the neck, because it
contributes to capsular distention and blood supply compromise. The epiphysis
is anatomically realigned with a physiological neck-shaft angle and anteversion.
Two 7.3 mm and 4.5 mm cannulated screws are inserted for final fixation. The
hip joint is reduced. The capsuloplasty should be done gently – not too loose
and not too tight, as to create mild compression for preservation of the blood
perfusion. The shaped greater trochanter fragment is fixed with two or three 3.5
mm cannulated screws. The trochanteric tip should match the geometric centre
of the epiphysis. The screw position is controlled with X-Ray in AP and lateral
view.
Postoperative protocol. The postoperative protocol includes passive flex-
ion of the hip joint from the 3rd day up to 30◦ . Flexion of the hip joint up to 90◦
after the 6th postoperative week. Partial weight bearing of the joint with marked
gait starts from the 4th postoperative week. Nonsteroidal anti-inflammatory
drugs are applied in doses of 3 mg/kg for prophylaxis of the reactive synovitis
and ectopic ossification. Physical therapy after 45 days concentrates on abductor
muscles strengthening and hip range of motion improvement. X-Ray controls are
mandatory in the 1st, 3rd, 6th, 12th, and 18th month.
Clinical material. For the period from March 2011 to July 2016 the de-
scribed technique is applied in 19 cases (13 boys and 6 girls) with severe SCFE
with an average age of 11.94 ± 1.64 years. The youngest patient was a 9 years and
6 months old boy. Using Loder classification we divided the cases in 13 stable and
6 unstable SCFE. The diagnosis was confirmed from the data of the orthopaedic
clinical exam, X-Ray in AP and Dunlop projection and or CT. For the evaluation
of the results we used the clinical Heyman Herndon classification, Boyer classi-
fication and Harris Hip Score changes. Criteria for severity of the epiphysiolysis
was an angle of posterior slip > 45◦ . The preoperative Gekeler angle was average
118 ± 15.47◦ . Preoperative posterior slip angle (PTA) was 55.84 ± 16.76◦ . Preop-
erative Harris Hip Score in the study was 51 ± 16.75◦ . In all cases Ganz SOSHD
was the first operative intervention of the hip.
Results. The average follow up of the study was 16.52 ± 8.95 months (min-
imal f/u period of 8 m). The average surgery duration was 139.47 min with an
average intraoperative blood loss of 414.12 ml. The postoperative Gekeler angle
was 141 ± 6.01◦ , postoperative PTA was 4.36 ± 2.83◦ (p < 0.001). In 13 (69%)

C. R. Acad. Bulg. Sci., 71, No 8, 2018 1149

patients there was an improvement in the range of hip motion for a period of 1–
4 months. Postoperative avascular changes were observed in 6 cases (31%) with
preoperative AVN in 4 (21%) of them. They occurred after the fifth postoperative
month together with a limited ROM due to hip flexion and adductor contracture
with geometric extremity shortening. We had no cases of ectopic ossification or
non union of trochanter major. The postoperative Heyman Herndon classifica-
tion defines 8 excellent, 5 good and 6 bad cases. Boyer classification defines 9
cases of grade 0, 4 cases of grade I and 6 cases of grade III. The postoperative
parameters for FAI are: average alpha angle – 42.23◦ and epiphyseal-neck offset –
13 mm. The average postoperative Harris Hip Score in our study was 92 ± 14.781
points with a statistically significant improvement (p < 0.005) compared to the
preoperative (Fig. 3, 4).
Discussion. Our previous experience with the surgical technique of Vladi-
mirov [4 ] had two major disadvantages that we compensated with the new Ganz
SOSHD: early chondrolysis and high-standing greater trochanter tip postoper-
atively. Vladimirov’s surgical technique did not provide a stable fixation and
required cast immobilization. In the postoperative period no partial weight bear-
ing was allowed in the first 40 postoperative days, raising the risk of chondrolysis.
The greater trochanter fragment was fixed at the initial level, leading to extra ac-
etabular impingement. With Ganz osteotomy we achieve a relative femoral neck
lengthening in contrast to Vladimirov’s technique, avoiding the risk of future FAI.
Hip joint anatomical geometry was restored by the distal transfer of trochanter
major.
In all patients due to the residual growth there is a risk of a slip of the con-
tralateral epiphysis. We pin in situ the contralateral epiphysis after 1 month not
only because of a potential slip, but also to prevent future leg length discrepancy.
Ganz surgical technique preserved the femoral head vessels by forming the
posterior retinacular flap. Femoral head vascularization was tested with Doppler
ultrasound or intraoperative drilling of the femoral head for direct visualization
of the perfusion [8 ]. As the femoral neck osteotomy retards the growth of the
affected proximal femur and leads to leg length discrepancy, contralateral in situ
pining is performed.
In our study preoperative slip angle ranged from 46◦ to 84◦ with a mean of
55.84◦ . Postoperative slip angle ranged from 0◦ to 10◦ with a mean of 4.36◦ and
a mean correction of 51.48◦ . Ziebarth et al. [1 ] reported preoperative slip angle
range from 34◦ to 70◦ with a mean of 45.6◦ , postoperative slip angle ranged from
1◦ to 20◦ with a mean 8.6◦ and a mean correction of 37◦ . In Huber et al. [9 ] study
preoperative slip angle ranged from 19◦ to 77◦ with a mean of 44.9◦ . Postoperative
slip angle ranged from 18◦ to 25◦ with a mean of 5.2◦ and a mean correction of
39.7◦ . In Slongo et al. [10 ] study preoperative slip angle ranged from 39 to 57◦
with a mean of 47.6◦ , postoperative slip angle ranged from 3.5 to 6◦ with a mean
of 4.6◦ and a mean correction of 43◦ . In Novais et al. [11 ] preoperative slip angle

1150 S. Tserovsky, V. Alexiev, B. Hristov

Fig. 1. Intraoperative picture. Isolating the retinacular flap
Fig. 2. Intraoperative picture. Restoring proximal femoral anatomy
 Fig. 3. Clinical case. 12 years old girl. Preoperative PTA – 40◦ . Haris
Hip Score – 43

ranged from 54◦ to 81◦ with a mean of 65◦ , postoperative slip angle ranged from
6◦ to 23◦ with a mean of 16◦ . In Cosma et al. [12 ] preoperative slip angle ranged
from 64◦ to 71.5◦ with a mean of 68◦ , postoperative slip angle ranged from 7.5◦
to 13.5◦ with a mean of 9◦ . In Elmarghany et al. [13 ] preoperative slip angle
ranged 23◦ to 82.1◦ with a mean of 52.5◦ and postoperative slip angle ranged from

C. R. Acad. Bulg. Sci., 71, No 8, 2018 1151

 Fig. 4. Postoperative result. PTA – 6◦ . Haris Hip Score – 98

12.2◦ to 28◦ with a mean of 5.6◦ and a mean correction of 46.85◦ . This shows that
our results of achieved anatomical correction in comparison to the initial severity
grade are fully comprehensive with the others.
The major complication in SCFE treatment is avascular necrosis. Novais et
al. [11 ] recorded one case of AVN (7%). Sankar et al. [14 ] recorded 7 cases of

1152 S. Tserovsky, V. Alexiev, B. Hristov

 AVN – 26%. Cosma et al. [12 ] did not recognize a case of AVN. In our series 6 cases
developed AVN (32%), of which 4 cases were histologically proven intraoperatively
for persistence of AVN before the start of our treatment. The other authors
present better results in terms of AVN. Our high AVN incidence can be explained
with the preoperative existence of AVN in 21% of our cases. In the rest of our
cases we accept AVN was an iatrogenic result of our long learning curve of the
surgical technique. Retrospectively we found that initially we did not address the
postero-inferior bump on the femoral neck, leading to capsular impingement and
distention.
Unlike other authors we do not have any cases of implant failure, deep infec-
tions, delayed subcapital osteotomy and greater trochanter union, hip contrac-
tures with limited range of motion.
The stable fixation with our technique allows early mobilization and reduces
the risk of postoperative chondrolysis in comparison to the previously used os-
teotomies.
The technique is efficient in restoring the anatomy of the proximal femur in
high grade unstable and stable SCFE by avoiding damage to the blood supply
[15 ]. This could be accomplished only after a long learning curve in a specialized
university orthopaedic centre.
For a true evaluation of the Ganz SOSHD technique and all its benefits we
have to do a long term study that estimates the incidence of early hip osteoarthri-
tis as a result of extra articular impingement.

REFERENCES

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[12 ] Cosma D., D. E. Vasilescu, A. Corbu, M. Valeanu, D. Vasilescu (2016)
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Department of Orthopaedics and Traumatology

University Hospital of
Orthopaedics “Prof. B. Boychev”
Medical University of Sofia
56, Nikola Petkov Blvd
1614 Sofia, Bulgaria
e-mail: cerowski stefan@yahoo.com
venelin alexiev@abv.bg

1154 S. Tserovsky, V. Alexiev, B. Hristov

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