We are presented with an adolescent patient who is overweight with pain in the thigh and knee, a length discrepancy of 1 cm and the limb in external rotation. This picture should automatically lead us to mark epiphysiolysis capitis femoris (proximal femoral epiphysiolysis, the fact of reading it in Latin nomina is a bit of a misunderstanding but it should not mislead us). We should think of this one because it is the most frequent and possible (correct answer 2). The other options are not impossible but they are less frequent and they would not ask us this if they wanted us to choose another option. If they were sequelae of hip dysplasia, it would not have this 4-month onset and the age of onset would be earlier. Complications of dysplasia are dislocations and subluxations that may require surgery and avascular necrosis of the head (false answer 5). Perthes disease occurs in younger children (4-9 years) with episodes of limping and pain in the hip and knee (false answer 4). In a child the most typical would be a fracture at the level of the physis, not at the level of the femoral neck, so we discard 3. For us to consider this option we would have to have been presented with a bone cyst, something that would justify a weakness in the femoral neck area. As for juvenile chronic arthritis, it is a rheumatoid option surrounded by trauma options. They do not speak to us of rheumatologic factors in an analytical analysis, nor of a polyarticular picture. Perhaps we could think about this one because they talk about pain in the right knee, but this picture that they present us is limited to the right lower limb, they do not talk about other joints or fever or other accompanying systemic symptoms, so it is not an option to evaluate, especially with the other options presented to us that would be more likely in view of the picture presented to us (option 1 false). In addition, the knee pain in this case refers to a referred pain of the hip, without involvement of the knee.

We are presented with an adolescent patient who is overweight with pain in the thigh and knee, a length discrepancy of 1 cm and the limb in external rotation. This picture should automatically lead us to mark epiphysiolysis capitis femoris (proximal femoral epiphysiolysis, the fact of reading it in Latin nomina is a bit of a misunderstanding but it should not mislead us). We should think of this one because it is the most frequent and possible [HIDDEN]. The other options are not impossible but they are less frequent and they would not ask us this if they wanted us to choose another option. If they were sequelae of hip dysplasia, it would not have this 4-month onset and the age of onset would be earlier. Complications of dysplasia are dislocations and subluxations that may require surgery and avascular necrosis of the head [HIDDEN]. Perthes disease occurs in younger children (4-9 years) with episodes of limping and pain in the hip and knee [HIDDEN]. In a child the most typical would be a fracture at the level of the physis, not at the level of the femoral neck, so we discard [HIDDEN]. For us to consider this option we would have to have been presented with a bone cyst, something that would justify a weakness in the femoral neck area. As for juvenile chronic arthritis, it is a rheumatoid option surrounded by trauma options. They do not speak to us of rheumatologic factors in an analytical analysis, nor of a polyarticular picture. Perhaps we could think about this one because they talk about pain in the right knee, but this picture that they present us is limited to the right lower limb, they do not talk about other joints or fever or other accompanying systemic symptoms, so it is not an option to evaluate, especially with the other options presented to us that would be more likely in view of the picture presented to us [HIDDEN]. In addition, the knee pain in this case refers to a referred pain of the hip, without involvement of the knee.

Obese 12-year-old boy (87 kg). He has been complaining of mechanical pain in the right thigh and knee for 4 months. Clinical examination reveals a 1 cm discrepancy in the length of the lower extremities and an attitude of the right lower extremity in external rotation with loss of internal rotation. We should suspect that he presents:

Fracture of the femoral neck due to overload.

Sequelae of developmental dysplasia of the hip.

[Delayed diagnosis of epiphysiolysis capitis femoris].

The prognosis in epiphysiolysis of the head of the femur (ECF) depends on immediate treatment in the earliest stage of the disease. The reasons for and the extent of delayed diagnosis of slipping of the epiphysis in the hip were analysed in 56 children (72 hips) with ECF. The median total delay was six months with a delay of one month due to the patient and delay of three months due to the doctor. Pain in the lower limbs not related to the hip, including pain in the knee, occurred in 1/3 of the patients and resulted in more extensive delays due to the doctor (median four months). Other reasons for delay due to the doctor were erroneous interpretation of the x-ray films (14 patients). The most characteristic clinical finding was limited internal rotation of the affected hip. Comparison with the literature revealed that delay in the diagnosis of ECF has not been reduced during the past 35 years. Clinical examination of the hips should be undertaken in any child who complains of pain in the knee or thigh. If internal rotation is limited, x-ray examination including Lauenstein's projection should be carried out or the child should be referred to a department of orthopaedic surgery on account of suspected hip disease.

Legg–Calvé–Perthes disease

Signs and symptoms The condition is most commonly found in children between the ages of 4 and 10. Common symptoms include pain in the hip, knee, or ankle (since hip pathology can cause pain to be felt in a normal knee or ankle), or in the groin; this pain is exacerbated by hip or leg movement, especially internal hip rotation (with the knee flexed 90°, twisting the lower leg away from the center of the body). The range of motion is reduced, particularly in abduction and internal rotation, and the patient presents with a limp. Pain is usually mild. Atrophy of thigh muscles may occur from disuse and an inequality of leg length. In some cases, some activity can cause severe irritation or inflammation of the damaged area, including standing, walking, running, kneeling, or stooping repeatedly for an extended period of time. In cases exhibiting severe femoral osteonecrosis, pain is usually a chronic, throbbing sensation exacerbated by activity.

Femoral osteotomy to improve range of motion in residual deformity of perthes disease: A case report.

The treatment strategies for residual deformity of Perthes disease are not established. This is a case report of a 15-year-old boy. He developed right Perthes disease (lateral pillar classification group B) when he was 10 years old and underwent varus femoral osteotomy of the right side. At 12 years of age, he developed left Perthes disease (lateral pillar classification group B) and underwent varus femoral osteotomy of the left side. Postoperatively, he was treated with partial weight bearing of the left leg with crutches. At 15 years, range of motion (ROM) of his left hip was markedly limited at 30° flexion, 10° abduction, 70° external rotation, and -20° internal rotation, and he was having difficulty maintaining a sitting position. Stulberg group V was noted on plain radiography. Computed tomography (CT) showed collapse of the load-bearing part of the femoral head on the coronal plane, but the ball-shape was maintained in the posterior femoral head on sagittal and transverse sections. Valgus-flexion-internal rotation osteotomy was performed to improve ROM. Left hip ROM improved to 90° flexion, 20° abduction, 50° external rotation, and 40° internal rotation immediately after the surgery. He was able to sit 10 months postoperatively but was left with a limp and limited ROM in the left hip at 60° flexion. Chondroplasty was performed during the plate removal surgery at 10 months postoperatively, which improved hip flexion to 100° immediately after the surgery. The patient was left with limited ROM of 60° flexion of the left hip at the final observation. Femoral osteotomy to improve ROM could be an option for residual deformity of Perthes disease.

Legg-Calve-Perthes Disease -- History and Physical -- Physical Examination

Decreased internal rotation and abduction of the hip Pain on rotation referred to the anteromedial thigh and/or knee Atrophy of thighs and buttocks from pain leading to disuse Afebrile Leg length discrepancy

Intoeing -- Introduction

In coming to understand variational pathologies of the lower limb, it is important to be familiar with the normal growth and development of children’s lower extremities. Neonates are born with about 40 degrees of femoral anteversion or forward rotation of the femoral neck. This increased internal rotation of the hip decreases over time. By about 10 years old, the degree of anteversion decreases by about half. Any deviation from the expected course of limb development and rotation should be recognized and differentiated from the persistence of early angulation, to pathologies preventing normal rotation.

Legg–Calvé–Perthes disease

The first signs are complaints of soreness from the child, which are often dismissed as growing pains, and limping or other guarding of the joint, particularly when tired. The pain is usually in the hip, but can also be felt in the knee (referred pain). In some cases, pain is felt in the unaffected hip and leg, due to the children favoring their injured side and placing the majority of their weight on their "good" leg. It is predominantly a disease of boys (4:1 ratio). Perthes is generally diagnosed between 5 and 12 years of age, although it has been diagnosed as early as 18 months. Typically, the disease is only seen in one hip, but bilateral Perthes is seen in about 10% of children diagnosed. Cause Perthes disease is a childhood hip disorder initiated by a disruption of blood flow to the head of the femur. Due to the lack of blood flow, the bone dies (osteonecrosis or avascular necrosis) and stops growing.

[Perthes disease with onset after nine years of age].

The aim of this study is to evaluate and compare selected clinical and radiological hip joint parameters in Perthes disease with onset before and after 9 years of age. Analysis was based on 261 patients with unilateral Perthes disease. Patient with bilateral changes ware excluded because of earlier onset before 9 years old. The average age of patients at the time of initial symptoms was 7,1 years ( 2,5 - 13 years). The follow-up ranged from 16 to 50 years (average 20, 2 years). The clinical analysis was based on evaluation of age, gender and range of passive abduction. The radiological assessment was based on Catterall and Herring classifications, lateral subluxation, premature physeal closure by Bowen classification, limb length discrepancy, shape of the lateral acetabulum rim, ATD distance and index, center-edge angle, the Mose Classification, epiphyseal index and quotient. Assessments of final results were based on The Mose Classification and the Stulberg Classification. We affirmed that, in children with the onset of disease after 9 years of age, asymmetrical premature physeal closure, major lateralization, grater contour of the head deviation (Mose) and trochanteric overgrowth were more frequent occurred than in children with Perthes disease before 9 years of age. Patients who were over the age of 9 years at the time of onset and have a hip in Catterall 3 group and 4 group together with the lateral pillar B group or C group get a poor outcome. There were not any differences in the outcomes in Catterall 1 and 2 group together with Hering A group depending on age at the time of onset. Both age at the time of onset after 9 and quantity of femoral head necrosis have the most significant impact on the outcome, leading to poor final results. In accordance with our observation we do advise caution in older children's treatment with femoral varus osteotomy.

[Long-Term Outcomes of the Treatment of Pediatric Femoral Shaft Fractures Treated with Bryant's Vertical Traction].

PURPOSE OF THE STUDY The paper aimed to evaluate the long-term outcomes of the treatment of diaphyseal femur fractures in children treated with Bryant's vertical traction. Moreover, we also assessed the size of overgrowth in the injured femur. MATERIAL AND METHODS The study included 23 patients with 23 femoral shaft fractures treated with Bryant's vertical traction at our department in 2009-2014. The following parameters were assessed: sex, ïnjured side, weight, age, mechanism of injury, potential abuse, type of fracture, duration of traction, and total length of hospital stay. The healing time of the fracture was the same as the duration of traction. Also assessed was the size of femoral shortening after the removal of traction, the presence of skin complications in the course of treatment and potential development of compartment syndrome. At the mean follow-up of 47.8 months (range 22-85 months) from the date of injury the patients were evaluated clinically and radiologically for: length of limbs, presence of rotational deformity, range of motion of knee and hip joints, potential pain or limping, potential scoliosis of the spine and presence of scars after traction. Finally, through a questionnaire we learned about the opinions of parents as to the treatment method and about the possibility of home traction. RESULTS All the fractures healed. There was a total of 17 injured boys and 6 injured girls. Whereas 12 patients sustained a fracture of the left femur, 11 patients sustained a fracture of the right femur. The mean weight of patients at the time of injury was 13.9 kg (range 5-20 kg). The mean age at the time of traction was 30.8 months (range 1-70 months). The injury most frequently occurred from various falls, altogether in 15 cases (65.2%). Traffic accidents were registered as the cause of injury in 3 cases (13%). No abuse was confirmed. The average duration of traction was 19.8 days (range 8-26 days). The total length of hospital stay took on average 23.6 days (range 9-33 days). Skin excoriation and bullae due to irritation by the traction occurred in 21 children (91.3% cases). All the bullae healed, in 4 (17.4%) patients minor scars of 1x1 cm in size were formed around ankles. Not a single patient developed the compartment syndrome. The average femoral shortening after the removal of traction was 0.8 cm (range 0-2.3 cm). The follow-up examination, performed on average 47.8 months (range 22-85 months) from the date of injury revealed the average discrepancy of spinomalleolar distances in both the lower limps of 0 cm (range -1 to 1 cm). Radiographically measured lengths of both the femurs showed the average difference of 0 cm (range -1.4 to 0.9 cm). The resulting average overgrowth of injured femur was 0.9 cm (range 0.1 to 3.2 cm). Scoliosis of the spine was not reported in any of the patients. In 3 patients femur alignment demonstrated rotation, namely an external rotation of 10° in all the cases. All the children demonstrated full hip and knee joint mobility, identical to the uninjured side. After a heavy load one patient reported pain in the thigh and one walked with limp. The other patients showed no problems whatsoever. Treatment with the use of Bryant's traction was well tolerated by parents. Altogether 15 parents (65.2%) would opt for the same treatment method in case of a recurrent injury. The home traction option would be welcomed by 17 parents (73.9%). DISCUSSION The treatment by Bryant's vertical traction is condemned in Anglo-Saxon countries due to the risk for developing compartment syndrome, described in earlier studies. Neither our cohort, nor more recent studies reported the occurrence of compartment syndrome. The most frequent complication faced in our study was the skin complications underneath the traction, namely in a total of 91.3% of patients. In the literature, the other authors only make references to bullae occurrence, but do not provide any further specifications. Overgrowth after femoral shaft fractures is a very well described phenomenon. The size of femoral overgrowth described in our study was similar to that referred to in the available literature. A method frequently used abroad is the so-called home traction. This method, however, has so far failed to take root in our country, even though this therapeutic technique would be appreciated by parents. CONCLUSIONS The treatment of femoral shaft fractures by Bryant's vertical traction, in children up to the weight of 15 kg, is a simple and safe method with excellent functional outcomes and minimum serious complications. When treating the children with the body weight more than 15 kg, the risk of bullae formation increases, therefore in this weight category treatment shall be decided upon on a case by case basis. The resulting average overgrowth of injured femur was 0.9 cm which corresponds with the findings of other authors. The treatment method using the Bryant's traction is well tolerated by parents, even though most of them would welcome the option of home traction. Key words: traction, femur fracture, overgrowth, children.

High trochanter location: Natural history or complication following treatment of Perthes' disease?

Background. In Perthes' disease femoral head deformities can be accompanied by high location of the greater trochanter and diminished shaft-neck angle, causing decreased joint stability and diminished hip function. The aim of our study was to compare head-trochanter relationships in hips treated for Perthes' disease using surgical and non-surgical methods. Material and methods. The clinical material consisted of 61 children (68 hips) treated in our hospital from 1990 to 1994; 32 hips were treated conservatively, while 36 hips were operated. The mean observation time was 7.7 years. We re-examined X-rays done at onset, after 3-6 months of treatment, and at final follow-up. The projected shaft-neck angle, ATD (Edgren), and degree of head involvement (Catteral and Herring) were evaluated, while the Stulberg classification was used for outcome evaluation. In clinical examination we looked for Trendelenburg sign, limping, and leg length discrepancy. Results. The value of shaft-neck angle and ATD were correlated with age, sex, degree of head containment, and method of treatment. In boys, comparatively low ATD values were found in both treatment groups. In girls the ATD values were considerably lower in operated hips. High trochanter location and diminished shaft-neck angle had no statistical effect on clinical outcome. Conclusion. The natural course of Perthes' disease causes decreased ATD, regardless of treatment type. In our operative technique, containment may be achieved more by extension (anteflexion) osteotomy of the femur than by pure varisation osteotomy. We found no indication for epiphysiodesis of the greater trochanter combined with anteflexion osteotomy of the femur.

Developmental Dysplasia of the Hip -- Differential Diagnosis

Other conditions causing leg length discrepancies: Proximal femoral focal deficiency A femoral neck fracture Coxa vara Residual effects of infective arthritis

Isolated Distal Fibular Stress Fracture after Total Hip Arthroplasty in a Patient with Developmental Dysplasia of the Hip.

Stress fractures following total hip arthroplasty in the lower limbs away from the surgical area are very rare. We report a case of stress fracture in the isolated distal fibula that presented five months after total hip arthroplasty in a patient with developmental dysplasia of the hip. A 67-year-old woman diagnosed with coxarthrosis of the right hip joint, classified as Crowe's group 3, underwent total hip arthroplasty with acetabular reconstruction using a bulk bone graft. The surgery successfully treated the preoperative leg length discrepancy and flexion and external rotation contractures. The alignment of the right lower limbs changed from slight varus to valgus knee following surgery. The postoperative process went well; however, she experienced lateral ankle pain on the affected side five months after surgery. No obvious fracture was observed via radiograph; however, she received a subsequent diagnosis of isolated distal fibula stress fracture. Additionally, she was diagnosed with vitamin D deficiency. Valgus alignment change of the knee joint and vitamin D deficiency were considered the main causes of the stress fracture. Stress fractures should be suspected in patients complaining of unexpected pain following total hip arthroplasty, even in distant areas of the affected limb, especially in osteoporotic patients.

Double intertrochanteric osteotomy for trochanteric overgrowth and a short femoral neck in adolescents.

To review the outcome of Wagner double intertrochanteric osteotomy for trochanteric overgrowth and a short femoral neck in 7 adolescents. Records of one male and 6 females aged 15 to 20 years who underwent modified Wagner osteotomy for trochanteric overgrowth and a short femoral neck by a single senior surgeon were reviewed. The diagnoses were coxa vara (n=2), developmental dysplasia of the hip (n=3), Leg-Calve-Perthes (n=1), and proximal femoral focal deficiency (n=1). Radiological indication for double intertrochanteric osteotomy included a neck-shaft angle (NSA) <120º or a centre trochanter distance (CTD) <28 mm. Function was evaluated using the Children's Hospıtal Oakland Hip Evaluation Scale (CHOHES). The articulotrochanteric distance (ATD), CTD, NSA, and the distance between the centre of the femoral head and the centre of the acetabulum (MZ) were measured on radiographs. The mean follow-up duration was 61 (range, 28-86) months. The ATD improved from 16±11.5 mm to -6.3±10.2 mm (p=0.018), the CTD from 27.9±3.5 mm to 36.4±7.1 mm (p=0.018), the NSA from 112º±24.4º to 131º±16º (p=0.028), the MZ from 12.7±6.5 mm to 7.7±4.2 mm (p=0.028), and the CHOHES score from 62.1±8.7 to 84±9.6 (p=0.017). One patient had delayed union. Two patients had persistent Trendelenburg gait. Two patients declined second-stage surgery for acetabular dysplasia after solving the femoral side problems at the first stage. One of them developed hip arthrosis. Double intertrochanteric osteotomy is a viable treatment option for adolescents with trochanteric overgrowth and a short femoral neck.

Ipsilateral femoral neck and shaft fracture in children: Two case reports.

Pediatric femoral shaft combined with ipsilateral femoral neck fractures are very rare but challenging injuries fraught with the development of avascular necrosis, coxa vara, and leg length discrepancy. Majority of the previous reports indicated the neck femur fracture was fixed with cannulated screws or/and pins, femoral shaft fracture was stabilized with a plate and screws. However, we used cannulated screws combined with elastic stable intramedullary nails to minimally invasive procedures treat this type of injury and achieved good follow-up results. A 7-year-old boy (Case 1) was hospitalized due to a traffic accident resulting in swelling and deformity of the right thigh accompanied by limited mobility of hip and knee. A 5-year-old male child (Case 2) presented with pain and swelling in the bilateral lower limb after fall from approximately 12 feet. Physical examination, X-ray film, and computed tomography were performed. Both patients were diagnosed with ipsilateral femoral neck and shaft fracture. The fractures were reduced closed by image-intensifier imaging. Two partially threaded cancellous screws were used to fix femoral neck fracture, and elastic intramedullary nails were performed to stable the femoral shaft fracture. Postoperatively, the patients were immobilized in a one-and-a-half hip spica cast for six weeks. The internal fixations were removed after one year. Case one was follow-up at 14 months and the other one was followed up for 3 years. And at the last follow-up showed a normal and painless hip function. No clinical complications were found during follow-up visit, including head penetration, implant failure, fracture nonunion, avascular necrosis and hip varus deformity. Clinician should carefully check and read relevant imaging data to avoid missed diagnosis. And the internal fixation method described in this paper may be more minimally invasive.

Perthes disease: comparison of two surgical options.

Varus intertrochanteric osteotomy (ITO) remains the most popular method to contain the fragmenting femoral head in Perthes disease. However, resultant compromise of hip abductors may result in coxa brevis and acetabular dysplasia, increasing the risk of requiring future surgery. A minimally invasive strategy of tension plating the greater trochanter was developed in effort to avoid these consequences. The objective is to compare greater trochanter-guided growth to ITO for treatment of Perthes disease. This IRB approved, retrospective review compares two series of children with Perthes, one treated with ITO and one with greater trochanter-guided growth (GG). Clinical examination findings and clinical course were recorded via chart review. Weight-bearing pelvic X-rays were analyzed preoperatively and at the last known follow-up prior to other procedures. There were 58 patients: 18 underwent ITO versus 40 GG. The groups matched in age, sex, examination, and radiographic parameters. Average follow-up was 5 years. The change in the center head-trochanteric distance (CTD) was statistically significant (P < 0.05), -0.3 cm in GG versus -1.09 cm in ITO patients. At final follow-up, the ITO group was more likely to have LLD ≥ 2 cm (16.67% vs. 0%; P = 0.03) and 52.5% of GG patients were classified as Stulberg III or greater, versus 72.2% of the ITO group (P < 0.001). Ninety-four percent of ITO patients versus 40% of GG required additional surgery. Containment by ITO reflects exclusive focus upon the femoral head, without considering long-term sequelae. GG addresses the femoral neck issues potentially providing better outcomes. Level of Evidence. This is a level III study providing further understanding of the properties of the proximal femoral physes and an alternative for surgical management of perthes disease.

Perthes Disease in a Child With Osteogenesis Imperfecta From a Rare Genetic Variant: A Case Report.

<bBackground:</b Although certain genetic components have been reported as contributing factors for Perthes disease, its etiology remains unclear. We present a rare case of Perthes disease in a child with osteogenesis imperfecta (OI) caused by a mutation in the <iCOL1A1</i gene <i(NM_000088):exon25:c.1726C>T, (p.Gln576X)</i. <bCase presentations:</b A 7-year-old boy was initially treated at our medical facility in March 2016 with a history of chronic pain in right hip joint and limping for a year. He was diagnosed as Perthes disease in the right hip joint. He underwent acetabular osteotomy and ipsilateral proximal femoral varus osteotomy for better containment. During the follow-ups, the right hip demonstrated a normal range of motion without pain, and the pelvic X-ray demonstrated Stulberg Type II hip joint with a round femoral head. In the latest admission in 2022, he suffered from a right femoral shaft fracture after petty violence. After reviewing his medical history, he was suspected of having OI. The whole exome sequencing demonstrated a gene mutation in <iCOL1A1</i (OMIM 166200) and confirmed the diagnosis of OI. Telescopic nailing was used to treat the femoral shaft fracture. After the nailing of the right femur, the appearance of the lower extremity seemed normal and symmetrical. <bConclusion:</b This study revealed that there might be an association between OI and Perthes disease. Our case report enriches the phenotypes of osteogenesis imperfecta and provides insight into the pathogenesis of LCPD.

[Painful hip joint with epiphyseal dysplasia (author's transl)].

Among patients who visited our hip clinic, eighteen patients from ten families were diagnosed as mild or atypical cases of spondyloepiphyseal dysplasia or multiple epiphyseal dysplasia. Clinical and X-ray examinations of these patients showed common characteristic features as follows. 1. They usually had short stature but were not dwarfs. Their facial features and body proportions did not suggest hereditary bone dysplasia. 2. Although the disease might be transmitted in an autosomal dominant manner, its occurrence among these families was found to be sporadic. 3. Symptoms of the hip joint mainly resulted from limited range of motion, coxalgia being usually less than expected from X-ray findings. 4. Joints were always affected bilaterally although the degree might be different on each side. 5. In the majority of the cases, the spine, shoulder (in 7 cases), knee (in 6 cases), elbow (in 3 cases), ankle, and wrist joint (in 2 cases) were also affected. 6. Characteristic X-ray findings of the hip joints were as follows. a) Coxa vara, flattening or rectanglar deformity of the femoral head and shortening of the femoral neck. b) The trabecular pattern of the femoral head was irregular and subchondral cysts were often observed. c) Joint space was relatively better restored than expected from the deformity and subchondral bony changes of the femoral head. Spondyloepiphyseal dysplasia and multiple epiphyseal dysplasia are genetic disorders of the epiphyseal and apophyseal cartilage. The hip joint is loading greater mechanical force than any other joint. In both spondyloepiphyseal dysplasia and multiple epiphyseal dysplasia, the hip joint is always affected. As the hip joint is most vulnerable when there is some disorder of the epiphyseal cartilage, it is probably the only detectable abnormal joint. In relatively short period (1972-1978), the diagnosis of mild or atypical spondyloepiphyseal dysplasia was made in 18 patients in our hip clinic. This means that the mild or atypical cases of spondyloepiphyseal dysplasia is not so rare as expected. They might be misdiagnosed as aseptic necrosis, deformity of the femoral head due to Perthes disease or primary osteoarthrosis. An extreme care should be taken when we examine such patients.

Slipped capital femoral epiphysis

SCFEs are most common in adolescents 11–15 years of age, and affects boys more frequently than girls (male 2:1 female). It is strongly linked to obesity, and weight loss may decrease the risk. Other risk factors include: family history, endocrine disorders, radiation / chemotherapy, and mild trauma. The left hip is more often affected than the right. Over half of cases may have involvement on both sides (bilateral). See also Legg–Calvé–Perthes syndrome – another cause of avascular necrosis of the femoral head, seen in younger children than SCFE Hip dysplasia Drehmann sign – Clinical test examining for SCFE References External links Chondropathies Skeletal disorders Rare diseases Medical terminology

Duration of Anti-Programmed Death-1 Therapy in Advanced Melanoma: How Much of a Good Thing Is Enough?

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 53-year-old healthy man presented with recurrent in-transit melanoma of the right lower extremity. Eight years prior he had undergone wide local excision and sentinel lymph node biopsy for invasive melanoma of the anteromedial aspect of the distal right thigh. Pathology revealed an ulcerated melanoma, Breslow depth 3.5 mm, and with one involved micrometastatic inguinal lymph node. Staging studies did not demonstrate distant metastases. Superficial inguinal node dissection was performed and did not identify any additional metastatic nodes of 14 retrieved for a final pathologic staging of T3bN1aM0 (stage IIIB) cutaneous melanoma. He received 12 months of adjuvant high-dose interferon alfa-2b. Two years later, he developed a 1.2-cm subcutaneous focus of in-transit recurrence approximately 4 cm proximal to the original melanoma site in the right thigh, which was treated with surgical resection followed by adjuvant radiotherapy. Over the next 4 years, he underwent six additional surgeries for isolated in-transit recurrences affecting the same limb. He was referred for therapeutic options at the time of his latest in-transit recurrence. Examination revealed three palpable subcutaneous nodules in the right thigh in the setting of lymphedema. A core biopsy confirmed recurrent melanoma (Fig 1). Whole-body fluorodeoxyglucose positron emission tomography imaging revealed at least 17 hypermetabolic cutaneous and subcutaneous nodules in the right thigh, four fluorodeoxyglucose-avid nodules below the right knee, but no distant metastases (Fig 2A). Brain magnetic resonance imaging was normal. His serum chemistry profile, including lactate dehydrogenase, was normal. Molecular analysis demonstrated presence of BRAF V600E mutation in the tumor. After multidisciplinary evaluation, an isolated limb infusion procedure of the right lower extremity was not believed to be feasible, secondary to the proximal extent of the recurrence. Therapy was initiated with pembrolizumab at 2 mg/kg intravenously every 3 weeks.

Hip deformity in symptomatic adult Perthes' disease.

Only a limited number of patients that suffered from Legg-Calvé-Perthes' disease (LCPD) develop pain in early adulthood. Classical hinged abduction is well known and is thought to be responsible for secondary lateral insufficiency of the acetabulum, which may become painful. Another possible explanation, which was put forward more recently, is anterior femoroacetabular impingement. We collected information about the exact morphology of the proximal femur and the acetabulum of 15 hips in 15 young adults (mean age: 25.3 years) who had hip surgery consequent to childhood Perthes' disease in our hospital between 1974 and 2001. In addition to the well known lateral bulging of the femoral head, averaging 112% of the functional radius, we found an even larger anterior bulging, averaging 115% of the functional radius. The mean torsion of the femoral head was -3.6 degrees, which in fact corresponds to a retrotorsion. Retroversion of the acetabulum was found in at least 5 of the 15 hips in which the version could be adequately assessed (33%). Since any of the above deformities favours anterior femoroacetabular impingement and thus hinged flexion, this could well be a contributor to the development of the classic sequelae of LCPD and to the later development of osteoarthritis.

A two- stage surgery for severe femoral neck deformity due to fibrous dysplasia: a case report.

Various kinds of surgical treatments have been reported for varus deformity of the proximal femur due to fibrous dysplasia. We report a case of two-stage corrective osteotomy for severe varus-retroversion deformity of the femoral neck due to monostotic fibrous dysplasia. The patient was an 18 year-old man. On initial examination, the spina malleollar distance was 88 cm on the right side and 83 cm on the left. Plain radiography showed prominent varus deformity of his left proximal femur. The morphology was 130 degrees on the right side and 85 degrees on the left. Computed tomography revealed 60 degree retroversion of the femoral neck. A two-stage surgery was performed, consisting of curettage and bone grafting followed by corrective osteotomy 16 months later. A 55 degree valgus osteotomy was performed in the subtrochanteric region. After osteotomy and 40 degree internal rotation of the shaft, a 130 degree angle plate was used for osteosynthesis. Postoperative radiological examination showed a morphology of 140 degrees and computed tomography revealed a 20 degree retroversion of the femoral neck. No recurrence or varus deformity was seen at four years after surgery. Although the leg length discrepancy was 2.5 cm, the patient had no difficulty in one foot standing and no restriction of ADL (activity of daily living). The well-known progressive varus Shepherd's crook deformity in the polyostotic form of fibrous dysphasia is associated with limb shortening, limping, and occasionally chronic fatigue fractures with disabling pain. Various kinds of surgical treatments have been reported for this type of varus deformity. Curettage and bone grafting is one of the most common and simple treatments. However, this method often gives bad results as the grafted bones are absorbed and that the progress of varus deformity van not to be prevented. We report a case of two-stage corrective osteomy forsevere varus-retroversion deformity of the femoral neck due to monostotic fibrous dysplasia.

[Results of the follow-up of varus osteotomy in Perthes disease with reference to the hip value].

A total of 89 patients with 105 hip joints affected by Perthes' disease at Catterall's stages II to IV, which had been treated by varus osteotomy, were re-examined clinically and radiologically between two and ten years after surgery. The clinical and subjective results of treatment were generally good. The best clinical and radiologic results were found in patients who contracted the disease before the age of seven and in whom necrosis was not yet at an advanced stage. The results in children who did not undergo treatment until after the age of eight and those with the disease at Catterall's stage IV were significantly poorer as far as arthrotic deformation of the hip joint was concerned. Radiologic evaluation of the hips examined, with regard to severity of arthrosis, epiphyseal index, and hip value show that the hip value is the best means of distinguishing prearthrotically deformed hip joints from normal findings. For example, at the time of follow-up severe prearthrotic changes were found in 40 of 105 hip joints when the hip values were analyzed. Therefore, in cases of Perthes' disease also, the hip value is of special importance in prognostic counseling of patients as regards the extent to which the hip joint can be subjected to stress either at work or in sports.

Slipped capital femoral epiphysis

SCFE is the most common hip disorder in adolescence. SCFEs usually cause groin pain on the affected side, but sometimes cause knee or thigh pain. One in five cases involves both hips, resulting in pain on both sides of the body. SCFEs occurs slightly more commonly in adolescent males, especially young black males, although it also affects females. Whilst it can occur in any child, the major risk factor is childhood obesity. Symptoms include the gradual, progressive onset of thigh or knee pain with a painful limp. Hip motion will be limited, particularly internal rotation. Running, and other strenuous activity on legs, will also cause the hips to abnormally move due to the condition and can potentially worsen the pain. Stretching is very limited.

Coxa vara

Clinical feature: presents after the child has started walking but before six years of age. Usually associated with a painless hip due to mild abductor weakness and mild limb length discrepancy. If there is a bilateral involvement the child might have a waddling gait or trendelenburg gait with an increased lumbar lordosis. The greater trochanter is usually prominent on palpation and is more proximal. Restricted abduction and internal rotation. X-ray: decreased neck shaft angle, increased cervicofemoral angle, vertical physis, shortened femoral neck decrease in femoral anteversion. HE angle (Hilgenriener epiphyseal angle- angle subtended between a horizontal line connecting the triradiate cartilage and the epiphysis); normal angle is <30 degrees. Treatment: HE angle of 45–60 degrees: observation and periodic follow up. Indication for surgery: HE angle more than 60 degrees, progressive deformity, neckshaft angle <90 degrees, development of Trendelenburg gait

Clinical Case of the Month: A 49 Year-Old Man Who Presents with Left Sided Weakness: An Update on Ischemic Stroke.

A 49 year-old man with a past medical history significant for essential hypertension, hyperlipidemia, and coronary artery disease status post percutaneous coronary intervention and stent placement in the right coronary artery in 2010 presented for evaluation of left hemiplegia. He was feeling well until three hours prior to presentation, at which time he fell while walking from his bedroom into the kitchen. After falling, he noticed that his left upper and lower extremities felt weak. He denied any symptoms preceding the fall or any loss of consciousness. On initial exam, the temperature was 99°F, the pulse was 93 beats per minute, the blood pressure was 191/100 mmHg, the respiratory rate was 22 breaths per minute, and the oxygen saturation was 100% while breathing room air. His neurological exam revealed diminished strength in the left upper extremity: 4/5 arm abduction and adduction of the left shoulder; 4/5 elbow and wrist extension and flexion; and 4/5 extension, abduction, and adduction of the digits. The patient also exhibited slight left upper extremity pronator drift. The strength was also diminished in the left lower extremity: 2/5 hip flexion, extension, and rotation; 3/5 knee flexion and extension; and 3/5 ankle dorsiflexion and plantar flexion. Initial NIH stroke scale score was 5, otherwise, there were no focal neurological deficits and the remainder of his exam was unremarkable. Initial computed tomography (CT) of the head was negative for any acute intracranial hemorrhage or infarct. A subsequent CT cerebral perfusion scan (Figure 1) was notable for areas of ischemia in the right cingulate gyrus as well as the medial frontal and parietal lobes. CT angiogram of the neck revealed bilateral atherosclerotic plaque in the carotid arteries; however, there was no evidence of any flow-limiting stenosis.

[Long-term development of primary osteochondritis of the hip (Legg-Perthes-Calvé). Apropos of 60 hips with a follow-up of more than 30 years].

This study concerns 60 hips in 57 patients aged between 33 and 56 years with a follow-up of 30 to 44 years since the onset of the disease. The progress of the condition was assessed by objective and subjective clinical criteria and radiographic criteria including roundness of the head, head height, head cover, abnormal head shape and the presence of arthrosis. The main prognostic feature was found to be the eventual shape of the femoral head. Normal heads (7 cases) and round heads with some flattening (20 cases) had few problems at the time of follow-up. Irregular heads (7 cases) and, most of all, very irregular heads (20 cases) progressed badly. Pain was common, often severe and the patients were disabled. Fourteen of them had consulted a doctor and seven had already been treated surgically. Arthrosis as a consequence of osteochondritis seemed to be due to joint incongruence. We consider that the prognosis can be made at the end of the progressive phase of the disease, since remodelling plays no part in the roundness of the head. These findings indicate the need for care in recommending treatment in the residual phase of the disease and suggest that it is difficult to determine what surgical treatment should be considered in adult life.

Hip pain

Figure 1. X-ray in pediatrics X-ray of infants should be obtained with the pelvis in neutral position with the lower limbs held in neutral rotation and slight flexion. Hip dysplasia Despite the widespread of ultrasound, pelvis X-ray is still frequently used to diagnose and/or monitor hip dysplasia or for assessing other congenital conditions or bone tumors. The most useful lines and angles that can be drawn in the pediatric pelvis assessing DDH are as follows: Joint effusion Legg-Calvé-Perthes disease (LCPD) Most cases of Legg-Calvé-Perthes disease (LCPD) develop between the ages of 4 and 10 years (Figure 3). Classification of its severity can be assessed by radiographs. Herring or lateral pillar classifications and the patient’s age strongly correlate with the outcome.

SubcapitalNeck of Femur Fracture in a Case of Osteonecrosis of Femoral Head - Rare Presentation.

Osteonecrosis of femoral head is a common debilitating condition affecting young males most commonly. It is endpoint of a series of events leading to disturbance in the blood supply of femoral head. Rarely, these cases present with acute pain following trivial trauma due to pathological fracture in the neck of femur. We present a rare case of pathological subcapital neck of femur fracture in a case of osteonecrosis of femoral head. These cases should not be confused with post-traumatic neck of femur fracture. A 28-year-old male student presented with history of acute pain in right hip and inability to walk after a squatting event. He was diagnosed to have osteonecrosis of bilateral femoral head 1 year back, for which he denied further treatment. On clinical examination, right hip examination was painful with flexion, adduction, and external rotation deformity. Radiological examination revealed fracture at subcapital region in neck of right femur with osteonecrosis of femoral head. After discussing treatment options with the patient, we performed total hip arthroplasty (THA). Harris hip scores improved from 17.1 to 83.5. The presentation of osteonecrosis of femoral head with pathological fractures is rare. Furthermore, it is not included in the commonly used classifications. Osteosynthesis of pathological fracture of neck of femur with osteonecrosis of femoral head rarely has good results.THAcan be a good option in these cases with good functional results.

[Legg-Calvé-Perthes disease--diagnostics and contemporary treatment].

Legg-Calvé-Perthes disease represents avascular necrosis of the femoral head in a growing child. It commonly affects children aged 2-14 years, mostly boys, and has familiar pattern. The etiology of this disease is unknown. It is based on avascular necrosis due to variations of the femoral head vascular supply, trauma, coagulation of endocrine disturbances. The disease presents with limping and pain localized in the hip with projection to thigh and knee, frequently accompanied by the limitation of abduction and internal rotation, as well as slight limitation in flexion of about 20 degrees. Plain radiography is most informative additional diagnostic procedure, enabling assessment of the stage of disease, containment of the femoral head within the acetabulum, acetabular coverage and the extent of disease. Main treatment goal is obtaining the spherical congruity of the hip joint. This can be achieved by abduction bracing, varization femoral osteotomies and various innominate osteotomies (sometimes combined with femoral osteotomies). Children younger than four years of age, with minimal femoral head involvement, do not need any treatment. These children with a larger involvement, older than four years of age, with possible containment in hip abducion, should be treated by one of the following procedures: Salter innominate osteotomy, Salter innominate osteotomy with femoral shortening, or triple pelvic osteotomy. The patients with containment of the hip is not possible in abduction (related to subluxation and femoral head crush), should be treated by Chiari pelvic osteotomy.

Proximal Femoral Rotational Osteotomy for Symptomatic Femoral Retroversion : A Case Report.

The Rotational osteotomy for femoral retroversion has been extremely rare despite the known association between femoral neck retroversion, hip pain, and osteoarthritis. Here, we describe a case of femoral neck retroversion for which proximal femoral rotation osteotomy. A 16-year-old boy with a past history of developmental dysplasia of the both hip treated conservatively presented with a complaint of pain in left hips. On physical examination, flexion of the left hip was limited to 90° with terminal pain. Internal rotation was also limited to 10°. Computed tomography (CT) showed -7.1° anteversion of the left femur. We performed rotational osteotomy to increase femoral anteversion because conservative treatment was not effective. The postoperative course was uneventful. At 12 postoperative months, his left hip pain was completely disappeared and femoral anteversion was 34° on CT scans. Retroversion of the femur is a distinct dynamic factor that should be considered in the evaluation of mechanical causes of hip pain. Restoring the normal rotational alignment of the hip resulted in cure of the impingement due to femoral retroversion. J. Med. Invest. 67 : 214-216, February, 2020.

Unilateral hip osteoarthritis: can we predict the outcome of the other hip?

The objective of this study was to define, in unilateral hip osteoarthritis (OA), factors predicting the outcome of the other hip. We examined the anteroposterior radiographs of the pelvis of 95 white patients with unilateral idiopathic (56 patients) or secondary to congenital hip diseases (39 patients) OA. The other hip was free from symptoms (pain or limping) at the initial examination and without radiographic evidence of OA; it was what we call a "normal" hip. Two parameters were evaluated: (1) the type of osteoarthritis of the involved hip and (2) the range of four radiographic indices of the contralateral hip: the sourcil inclination (weight-bearing surface), the acetabular angle, the Wiberg's center-edge angle, and the neck-shaft angle. Follow-up radiographs for the hips that remained OA-free were available for 10 to 35 years and for those that developed OA, at the time of initial symptoms, range 2 to 31 years. Logistic regression analysis showed that the presence of idiopathic OA in one hip had a statistically significant effect on the development of OA on the other hip (p < 0.001). Minor deviations of radiographic indices of the contralateral hip is not a predictive factor for its outcome. When the radiographic indices are examined together with the pathology of the involved hip, only WBS was shown to have a significant effect to the development of OA and its type (p < 0.001). The following conclusions can be drawn from this study: 1. Patient with idiopathic OA of one hip is at increased risk of developing OA in the other hip. 2. The outcome of the other hip cannot be predicted only on the basis of the evaluation of its radiographic indices. 3. Among the different indices, WBS seems to have a strong influence toward the development of OA.

External rotational positioning of the leg after intertrochanteric combined varus-derotational osteotomy in Perthes' disease.

A 13-year-old boy underwent an intertrochanteric combined varus derotational osteotomy (VDO) for Perthes' disease of his right hip. After surgery he walked with his right leg externally rotated. Computed tomography scans of both knees and hips were obtained with the legs in their spontaneous position to evaluate rotation and anteversion. The femoral condyles were in 28 degrees of external rotation on the operated side compared with 2 degrees on the non-operated side. The angle between the femoral neck and the horizontal plane was 32 degrees on both sides. We conclude that there may be a risk that a derotational osteotomy may produce an external rotational position of the leg instead of altering the angle between the femoral neck and the horizontal plane.

[A case of proximal-type Hirayama disease associated with neck axial rotation].

Hirayama disease is characterized by juvenile onset of unilateral muscular atrophy of a distal upper extremity. The pathogenic mechanism of Hirayama disease is cervical cord compression by the posterior dura with forward displacement in the neck flexion position. A few cases of 'proximal-type Hirayama disease' have been described as showing muscular weakness and atrophy of the proximal upper extremities caused by the pathogenic mechanism similar to that of Hirayama disease. We report herein the case of a 16-year-old boy with proximal-type Hirayama disease, who developed symptoms after he began kyudo (Japanese traditional archery). Neurological examination revealed bilateral weakness of the muscles innervated by C5 and C6 segments (the deltoid, biceps brachii, brachioradialis), bilateral mild sensory disturbance in the radial side of the forearm, absent tendon reflexes of the biceps brachii and brachioradialis with preserved triceps reflex, pyramidal signs of the bilateral lower extremities (pathologically brisk reflexes of lower extremities, Babinski's signs). MR images in the neck flexion position showing expansion of the posterior extradural space and forward displacement of the spinal cord at the C3/4, C4/5, C5/6 and C6/7 disk levels. CT myelogram revealed spinal cord compression not only in neck flexion but also in neck left axial rotation. His symptoms improved after the restriction of neck flexion and axial rotation. Weakness of the upper extremities improved after 2 months. Pyramidal signs of the lower extremities disappeared after 18 months. The pathogenic mechanism in this case may be associated with not only neck flexion but also neck axial rotation.