09- epifizioliza
TRANSCRIPT
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Epifizioliza soldului
= Alunecarea progresiva sau rapida a epifizei femurale superioare
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Epifizioliza
Bascularea vizibila pe RX fata si profil
Normal capul depaseste linia lui Klein
Normal epifizioliza
Basculare in spate
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• Copil mare - adolescent• Morfotip adiposo-genital• 60% baieti• 60% la soldul stang• Mai frecvent vara
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• Biomecanica– Greutate– Oblicitare epifizara– Retroversie relativa
• Biochimie– Hormoni tiroidieni– G.H– H. sexuali
• Placa epifizara slabita• Alunecare
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• Epifizioliza cronica– Durere mecanica, schiopatare, scaderea
mobilitatii
• Epifizioliza acuta– Durere brutala, impotenta functionala totala
• Epifizioliza cronica-acutizata– Tablou acut pe fond dureros
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Tratament
• Brose• Suruburi• Brose cu cap filetat• Osteotomia colului (Dunn)
• Osteotomia bazicervicala (Kramer)• Osteotomie per-trohanteriana• Indepartarea proeminentei anterioare
(Heyman)
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Epifizioliza nedeplasata: osteosinteza cu brose
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Epifizioliza acuta:
Reducere in urgenta si fixare
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Brose percutanate dupa reducere pe masa ortopedica
Reducere blanda
Brose cu capat filetat (fete < 10 ani si baieti < 12 ani)
Suruburi percutanate
Fixare contralaterala sistematica
In caz de esec - operatia Dunn
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Epifizioliza la dreapta. Fixare bilaterala cu suruburi (de partea stanga cu scop preventiv)
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Complicatii
• Necroza epifizara • Coxita laminara• Epifizioliza controlaterala • Artroza• Complicatii iatrogene
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Complicatii post-chirurgicale
• Necroze si coxite
• Infectii
• Inegalitate lungime
• Fracturi col femural dupa ablatia materialului
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Coxite laminare
• Etiologie ?
• Factori favorizanti– Deplasare mare – Gips prelungit– Proeminenta
implantului in articulatie
• Tratament– Osteotomie sub-
trohanteriana
– Proteza totala
Disparitia interliniei+redoare
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Coxita laminara cu redoare in abductie
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Epifizioliza contralaterala
• 25 - 60 % din pacienti
• Survine dupa 18 luni
• Riscul dispare daca se face osteosinteza
Riscurile justifica fixarea contralaterala sistematica
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Sechele: simpla indepartare a proeminentei de pe capul femural
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Sechele: repozitionare
Repozitionarea epifizei pe colul femural dupa reperajul vaselor, scurtare si remodelare
Cale anterioara (Rigault)
Risc sporit de necroza
Repozitionare dupa rezectia colului
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Epifizioliza acuta
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Coxita laminara si necroza dupa reducere si osteosinteza
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Osteotomie si reorientare
Osteotomie subtrohanteriana de flexie
Osteotomie de valgizare si de flexie
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Coxartroza tipica dupa epifizioliza
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Artroza dupa epifizioliza
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Artroza post-epifizioliza rezolvata prin PTS
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Evolutia epifiziolizei
– Artroza este multa vreme suportata bine
– Cel mai frecvent necroza si coxitele sunt complicatii iatrogene
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Epifizioliza acuta Reducere/osteosinteza Artrita acuta
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Secundar: subluxatie + deformare in adductie
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Epifizioliza acuta
Repozitionarea capului
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Necroza dupa repozitionarea capului