Avascular Necrosis After Modified Dunn Surgery for the Treatment of Slipped Capital Femoral Epiphysis*

Valenza, Weverley; Soni, Jamil; Przysiada, Laís; Faggion, Heloísa

doi:10.1055/s-0042-1744499

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Original Article • Rev. bras. ortop. 57 (05) • Sep-Oct 2022 • https://doi.org/10.1055/s-0042-1744499 copy

Avascular Necrosis After Modified Dunn Surgery for the Treatment of Slipped Capital Femoral Epiphysis*

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

The present study analyzed the incidence of epiphyseal avascular necrosis in patients with slipped capital femoral epiphysis (SCFE) treated using a modified Dunn technique. In addition, this study determined the correlation of other variables with this incidence and described treatment complications.

Methods

This is a retrospective study with 20 patients treated by the same surgical team from 2009 to 2019 and followed up for 2 to 12 years. The analysis included general features, time from presentation to surgical procedure, classification, and intraoperative blood perfusion of the epiphysis, as well as complications and their treatment.

Results

All cases were severe; 65% were acute on chronic, and 55% of the SCFEs were unstable. Our complication rate was 45%, with 5 cases of avascular necrosis, 2 cases of deep infection, 1 case of material failure, and 1 case of joint instability. The statistical analysis revealed that the risk of necrosis was higher when the surgery occurred after a long hospitalization time and there was no intraoperative epiphyseal perfusion. Four necrosis cases happened within the first 5 years, and 1 case in the last 5 years of the study.

Conclusion

Our study showed that necrosis was the most common complication. It also revealed that surgery delay and lack of intraoperative epiphysis perfusion potentially predispose to avascular necrosis. Although with no statistical significance, coxofemoral instability occurred in chronic SCFE, and surgical fixation with threaded wires was less effective than fixation with a cannulated screw.

The modified Dunn procedure should be reserved for severe cases in which other techniques are not feasible and performed by an experienced, trained, and qualified team.

Keywords
slipped capital femoral epiphyses/complications; femur head necrosis; osteotomy

Year	Gender	Age	Side	Days until surgery	Severity	Loder classification	Fahey & O'Brien classification	Complication	AVN	Infection	Material failure	Dislocation
2009	Female	12	Left	2	Severe	Unstable	Acute	No	No	No	No	No
2010	Female	13	Right	2	Severe	Stable	Acute on chronic	Yes	No	Yes	No	No
2010	Male	11	Left	3	Severe	Unstable	Acute	Yes	Yes	No	No	No
2010	Male	14	Left	5	Severe	Stable	Chronic	Yes	No	No	No	Yes
2011	Male	14	Left	12	Severe	Stable	Chronic	Yes	Yes	No	No	No
2012	Female	11	Left	3	Severe	Unstable	Acute	Yes	Yes	No	No	No
2012	Female	11	Left	1	Severe	Unstable	Acute	No	No	No	No	No
2012	Female	11	Right	1	Severe	Stable	Acute on chronic	No	No	No	No	No
2013	Male	14	Left	2	Severe	Stable	Acute on chronic	No	No	No	No	No
2014	Female	12	Right	10	Severe	Unstable	Acute on chronic	Yes	Yes	No	No	No
2015	Male	13	Right	3	Severe	Stable	Acute on chronic	No	No	No	No	No
2015	Male	14	Left	2	Severe	Stable	Acute on chronic	Yes	No	No	Yes	No
2015	Female	11	Right	2	Severe	Unstable	Acute	No	No	No	No	No
2016	Male	14	Right	3	Severe	Stable	Acute on chronic	Yes	Yes	No	No	No
2016	Female	13	Right	2	Severe	Stable	Acute on chronic	No	No	No	No	No
2016	Male	14	Right	4	Severe	Stable	Acute on chronic	No	No	No	No	No
2017	Male	13	Left	3	Severe	Stable	Acute on chronic	No	No	No	No	No
2018	Male	14	Left	1	Severe	Unstable	Acute on chronic	No	No	No	No	No
2018	Male	12	Left	1	Severe	Unstable	Acute on chronic	No	No	No	No	No
2019	Female	8	Left	1	Severe	Unstable	Acute on chronic	Yes	No	Yes	No	No

Complication	N	Presence	Frequency*
AVN	20	No Yes	15 (75%) 5 (25%)
Infection	20	No Yes	18 (90%) 2 (10%)
Material failure	20	No Yes	19 (95%) 1 (5%)
Dislocation	20	No Yes	19 (95%) 1 (5%)

Variable	Group	N	Necrosis – n (%)	P*
Age group (years-old)	11 or 12 13 or 14	9 11	3 (33.3%) 2 (18.2%)	0.617
Gender	Female Male	9 11	2 (22.2%) 3 (27.3%)	1
Admission up to surgery (days)	≤ 2 > 2	11 9	0 (0%) 5 (55.6%)	0.0008
Affected side	Left Right	12 8	3 (25%) 2(25%)	1
Loder classification	Unstable Stable	9 11	3 (33.3%) 2 (18.2%)	0.617
Fahey & O'Brien classification	Acute Acute on chronic Chronic	5 13 2	2 (40%) 2 (15.4%) 1 (50%)	–
Time of presentation	Acute/acute on chronic Chronic	18 2	4 (22.2%) 1 (50%)	0.447
Time of presentation	Acute Acute on chronic	5 13	2 (40%) 2 (15.4%)	0.533
Intraoperative epiphyseal perfusion	No Yes	4 16	3 (75%) 2 (12.5%)	0.032

Year	Days until surgery	Intraoperative perfusion	Proposed treatment
2010	3	None	Pelvic support
2011	12	None	Valgus osteotomy + osteochondroplasty
2012	3	Present	Material removal + osteochondroplasty
2014	10	None	Pelvic support
2016	3	Present	Material removal

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[1] Address for correspondence Heloisa Zimmermann Faggion, Rua Quintino Bocaiuva, 280, Cabral, Curitiba, Paraná, 80030310, Brazil (e-mail: heloisafaggion@gmail.com).