Influence of the modified Dunn procedure on the spine–pelvis relationship in children with severe slipped capital femoral epiphysis

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Abstract

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is one of the most severe hip joint diseases in children. It is characterized by the development of unilateral or bilateral deformity of the proximal femoral epimetaphysis of varying degrees. The pronounced deformity of the femoral component of the affected joint leads to pelvic retroversion, decreased lumbar lordosis, increased thoracic kyphosis (TK), and formation of type I (hypolordotic) vertical posture according to the Roussouly classification, contributing to degenerative and dystrophic processes in the lumbosacral spine. At present, no data in the literature present the effect of surgical treatment on frontal and sagittal spine–pelvis relationships in the patients examined.

AIM: To perform a comparative radiological evaluation of the sagittal spine–pelvis relationship in children with severe SCFE before and after the modified Dunn procedure.

MATERIALS AND METHODS: The study included 30 patients (30 hip joints) aged 14–18 years with severe SCFE characterized by a posterior epiphysis displacement of >60° and downward of no more than 10° in one of the joints and no displacement (preslip stage) in the other. All children underwent the modified Dunn procedure on one side and fixation of the epiphysis of the femoral head with a cannulated screw on the other side. Before and after surgery, the patients underwent clinical and radiologic examinations. Standing radiographs were used to evaluate lumbar lordosis, TK, pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and sagittal vertical axis (SVA). The obtained data were analyzed statistically.

RESULTS: At the examination 3–3.5 years after the abovementioned interventions, a pronounced increase was noted in the mean PI value, which began to correspond to type III (harmonious) of upright posture according to the Roussouly classification. A change was noted in the mean values of positional indices PT (decreased) and SS (increased), and pelvic retroversion disappeared. The mean global lumbar lordosis (GLL) and lumbar lordosis increased, which led to a decrease in TK and the mean value of TK. All clinical observations showed a significant decrease in the mean global sagittal balance index (the sagittal vertical axis (SVA)) and absence of torso imbalance.

CONCLUSIONS: After performing the modified Dunn procedure on the one side and fixation of the epiphysis of the femoral head with a screw on the other side, children with severe SCFE demonstrated improvements in all the studied indices of sagittal spine–pelvis ratios. Consequently, the type of vertical posture according to the Roussouly classification changes from type I (hypolordotic) to type III (harmonious), and the probability of degenerative and dystrophic process development in the lumbosacral spine decreases.

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About the authors

Dmitrii B. Barsukov

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Author for correspondence.
Email: dbbarsukov@gmail.com
ORCID iD: 0000-0002-9084-5634
SPIN-code: 2454-6548

MD, PhD, Cand. Sci. (Med.)

Russian Federation, Saint Petersburg

Pavel I. Bortulev

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: pavel.bortulev@yandex.ru
ORCID iD: 0000-0003-4931-2817
SPIN-code: 9903-6861

MD, PhD, Cand. Sci. (Med.)

Russian Federation, Saint Petersburg

Ivan Yu. Pozdnikin

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: pozdnikin@gmail.com
ORCID iD: 0000-0002-7026-1586
SPIN-code: 3744-8613

MD, PhD, Cand. Sci. (Med.)

Russian Federation, Saint Petersburg

Tamila V. Baskaeva

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: tamila-baskaeva@mail.ru
ORCID iD: 0000-0001-9865-2434
SPIN-code: 5487-4230

MD, orthopedic and trauma surgeon

Russian Federation, Saint Petersburg

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2. Fig. 2. Lateral panoramic radiograph of the spine with femoral heads captured in patient M (14 years 10 months old) as an example of calculating spine–pelvis ratios (see explanations in the text)

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3. Fig. 1. Anteroposterior (a) and Lauenstein (b) radiographs of the hip joints of patient Z. (14 years 6 months old) who had slipped capital femoral epiphysis with a posterior epiphyseal displacement of 71° and downward displacement of 7° on the right and absence of displacement (pre-slip stage) on the left. They were performed 3 years after surgery, i.e., modified Dunn surgery on the right side and fixation of the femoral head epiphysis with a screw on the left side

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4. Fig. 3. Radiographs of the hip joints (anteroposterior and Lauenstein projections) and lateral panoramic radiographs of the spine with femoral heads captured in patient A (16 years 5 months) before surgery (a–c), 6 months after surgery (d, e), and 3 years 3 months after surgery (f) (see explanations in the text)

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5. Fig. 4. Correlations between the main indices of sagittal vertebral–pelvic relationships and posterior epiphyseal displacement: a, immediately before surgery [17]; b, 3–3.5 years after surgery. GLL, global lumbar lordosis; PI, pelvic incidence; PT, pelvic tilt; SS, sacral slope; SSA, spinosacral angle (see explanations in the text)

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6. Fig. 5. Regression analysis results showing the relationship between the main indices of sagittal vertebropelvic relationships and residual posterior epiphyseal displacement: a, between PI and residual posterior epiphyseal displacement; b, between SS and residual posterior epiphyseal displacement; c, between SS and GLL; d, between PI and SS. GLL, global lumbar lordosis; PI, pelvic incidence; SS, sacral slope

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