Nuno Craveiro Lopes M.D.

Head of Orthopedic and Traumatologic Department

Garcia de Orta Hospital, Almada - Portugal
Any comment, suggestion or contact can be done to: nuno.lopes@netvisao.pt

PAPER PRESENTATION
The effect of transphyseal neck to head femoral drilling. An experimental model for
a preventive method of Legg-Calvé-Perthes disease.(1993)

We developed an experimental model in the hip of the White New Zealand rabbit, so
that we could study the hemodynamic effect of the transphyseal drilling of the femoral neck
and head and its consequences for the growth of the proximal femur.

Guide and drill developed to perform neck head

drilling on the rabbit experimental model.

We concluded that the drilling induces a marked increase of epiphyseal micro-

vascularisation, due to the passage and anastomosis of small blood vessels between metaphysis
and epiphysis.
We found that to be efficient and get blood vessels crossing the growth plate, it must be
big enough to create a bone bridge. Thin holes are rapidly closed by the growth plate borders.

Arteriographic aspect of increased micro- Anastomosis between the metaphyseal and

vascularisation of the femoral head, after TNHD epiphyseal vascular network, through the growth
at left, comparing with control hip at right. plate.

Oblique cut to the growth plate. A) Growth plate. B) Bone bridge. E) Epiphysis.
M) Metaphysis. Arterial vessels crossing the growth plate (Arrows)
 The perforation of less than 10% of the growth plate area, utilizing a smooth technique,
did not interfere with the normal growth and development of the proximal femur.
We found that, what concerns growth arrest or slowing by the bone bridge, it is a mater
of forces. If the growth force of the remaining growth plate is bigger than the resistance of the
bone bridge, there are no growth arrest or growth slowing. We found on our experimental
work that if the drilled area is less than 10% of the whole area of the growth plate, there are no
growth disturbance. If it is more than 20%, there are growth arrest. In between, there are
some growth slowing.
Those numbers were lately confirmed by the studies about traumatic bone bridges on
distal femur by Peterson.

Drilling less than 10% of the growth plate area of Drilling more than 20% of the growth plate area
the hip at left. At right, control hip. No growth of the hip at left. At right, control hip. Growth
disturbance. arrest.

CLINICAL RELEVANCE: Transphyseal neck to head drilling (TNHD) may have a relevant
importance in the prevention of Legg-Calvé-Perthes disease, if applied in the repetitive
ischemic period that precedes LCPD, called "ischemic disease of the growing hip" (IDGH). It
can have also a favorable application on the early necrotic stage of LCPD, as it increased
micro-vascularisation and blood flow to the necrotic epiphyseal sequestrum, permitting a
faster re-absorption and reconstruction with better vascular conditions.

Nuclide bone scan with a image of IDGH stage T1 weighted MRI bone scan image of the same
III (left) and II (right), on a 6 yo boy case.
 Xr of the IDGH stage III. Note
the epiphyseal porosis that
precedes the sub-chondral
fracture.
One month after TNHD. Xr 6 years after TNHD. No
Epiphyseal ischemic bone was growth disturbance.
remodeled by primary bone
substitution and evolution to
LCPD was aborted

Data from this experimental researsh permitted us to develop a surgical procedure that
can prevent the onset of LCPD, when associated to a screening protocol of IDGH, entity that
precedes LCPD.
The protocol can be seen at http://www.geocities.com/craveiro01/pagedlcp/index.html
The experimental model in which the screening protocol was based can be seen at
http://www.geocities.com/craveiro01/lcpd01.htm

Actually we have done more than 200 TNHD procedures in children aged more than 5
years old, for IDGH and LCPD, half of then as already reached the end of growth, and none
presented growth disturbances. None of the 78 IDGH cases progressed to LCPD and on the 44
LCPD cases where TNHD was done, we found that fragmentation stage was reached in half
the usual time ( mean 5 months ) and only 41% needed to be subjected to a surgical
containment.

Above: Evolution without TNHT Bellow. Evolution with TNHT