Nuno Craveiro Lopes
Head
of Orthopedic and Traumatologic Department
Garcia de Orta Hospital, Almada - Portugal
Any comment, suggestion or contact can be done to: [email protected]
CLINICAL CASES PRESENTATION
The effect of transphyseal neck-head tunneling (TNHT) in cases of ischemic disease of the growing hip (IDGH) and Legg-Calvé-Perthes disease (LCPD).
Our experience with TNHT since 30 years ago to present, includes 205 procedures, 88 in IDGH cases with risk of progression to LCPD and 117 cases of LCPD in necrotic stage.
We present some typical cases of the effect of TNHT in IDGH and LCPD.
Indications for the TNHT procedure.
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Stage II of IDGH (Ischemic episode in evolution, with signs of another old ischemic episode) |
Stage III of IDGH (Ischemic episode in evolution, over a earlier ischemic episode). |
Stage I of LCPD (Dense epiphysis, subchondral fracture yet without significant collapse). |
Stage II of LCPD (Collapse yet without significant fragmentation). |
TNHT procedure
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Guide wire centered to the lesion, introduced with a motor drill. |
Tunneling with a 5mm trephine or cannulated drill with a hand drill. |
The trephine or drill must go trough the growth plate till the subchondral zone. |
Biopsy fragment for histological investigation |
TNHT induces a marked increase of epiphyseal micro-vascularisation, due to the passage and anastomosis of small blood vessels between metaphysis and epiphysis, thus preventing new ischemic episodes on a IDGH patient, aborting the evolution to LCPD.
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5 yo patient, presenting a stage III IDGH which was not treated by TNHT. 6 months later the patient developed LCPD.
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04/1995 - Pain and limp at the right hip (left on the image). Widening of the medial space and porotic epphysis, representing a IDGH stage III. |
04/1995 - US scan showing effusion and synovitis on the right hip (left on the image). |
04/1995 - US scan showing thickening of the articular cartilage on the right hip (left on the image). |
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04/1995 - Nuclide bone scan showing a cold spot at the right hip (left on the image) |
04/1995 - MRI showing the typical image of IDGH. Low signal spot near subchondral zone of the right epiphysis, on T1 weighted images (left on the image) |
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10/1995 - Patient was lost from control and returned 6 month later, clinically worst. Then he presented a stage III LCPD (Necrosis with collapse and metaphyseal cysts). |
10/1995 - MRI showing the typical image of LCPD. Extensive zone of low signal at the right epiphysis, on T1 weighted images. (left on the image) |
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10/1999 - Result at 4 years of follow up after Saito acetabuloplasty. Graded as a Stulberg IV end result. |
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Typical long follow up evolution of a 5 yo patient with a IDGH stage II case, treated with a early TNHT procedure.
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Patient with a IDGH stage II, which have undergone an early TNHT procedure. |
Follow up 1 year after TNHT procedure. |
Follow up 5 year after TNHT procedure. |
Follow up 11 year after TNHT procedure. |
Follow up 16 year after TNHT procedure. No sign of growth impairment of the proximal growth plate.. |
6 yo patient presenting a stage III IDGH, where an early TNHT procedure stoped the evolution to LCPD.
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10/1989 - Stage III IDGH. (High risk of evolution to LCPD) Epiphyseal porosis, signs of subchondral fragility |
10/1989 - Nuclide bone scan showing a cold spot on both hips, more extensive at the right hip (left on the image). A stage II IDGH was diagnosed at the left hip (right on the image) |
11/1989 - One month after the bilateral TNHT procedure, showing a fast epiphyseal reconstruction without collapse. |
01/1992 - Nuclide bone scan done 2 years after the bilateral TNHT procedure, showing high uptake of Tecnetium on both hips. |
9/1993 - Follow up 4 years after TNHT. Spherical head, without growth disturbances. Frontal view. |
9/1993 - Follow up 4 years after TNHT. Spherical head, without growth disturbances. Lateral view. |
8 yo patient presenting a stage III IDGH, where an early TNHT procedure stopped the evolution to LCPD.
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06/1989 - Stage III IDGH at the right hip (High risk of evolution to LCPD) and stage II IDGH at the left hip (medium risk of evolution to LCPD). |
08/1989 - Nuclide bone scan showing a cold spot on both hips, more extensive at the right hip (left on the image). |
10/0989 - TNHT procedure done bilaterally. |
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04/1990 - Follow up 6 months after TNHT |
09/1990 - Follow up 1 year after TNHT procedure. Frontal view |
09/1990 - Follow up 1 year after TNHT procedure. Lateral view |
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09/1990 - Nuclide bone scan done 1 year after the bilateral TNHT procedure, showing high uptake of Tecnetium on both hips. |
10/1998 - Follow up 9 years after TNHT procedure, showing a bilateral spherical head, without growth disturbances. |
On LCPD cases where TNHD was done early on the evolution, we found that fragmentation stage was reached in half the usual time ( mean 5 months ) and only 18% needed to be subjected to a surgical containment.
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Above: Evolution without TNHT Bellow. Evolution with TNHT |
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Favorable outcome after TNHT procedure on a 6 yo child presenting a stage I LCPD case.
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Stage I LCPD |
TNHT procedure |
Follow up 2 month after TNHT procedure. Far in front of fragmentation stage. We found that the procedure shortens the evolution of the disease to 1/2 to 1/3. |
Follow up 11 years after the TNHT procedure. Although "head at risk" signs has appeared, patient got a Stulberg III end result without further treatment. |
Favorable outcome after TNHT procedure on a 6 yo child presenting a stage I LCPD case.
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Stage I LCPD at the left hip (right on the image). |
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Nuclide bone scan showing a cold spot at the left hip (right on the image). |
MRI showing the typical image of LCPD. Extensive zone of low signal at the left epyphisis, on T1 weighted images. (right on the image) |
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TNHT procedure on the left hip (right on the image) |
Follow up one month after TNHT procedure. Stage IV LCPD (fragmentation). We found that the procedure shortens the evolution of the disease to 1/2 to 1/3. |
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Follow up 3 years after TNHT. Patient got a Stulberg II end result without further treatment. |
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