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Vink SJC, van Stralen RA, Moerman S, van Bergen CJA. Prophylactic fixation of the unaffected contralateral side in children with slipped capital femoral epiphysis seems favorable: A systematic review. World J Orthop 2022; 13:515-527. [PMID: 35633749 PMCID: PMC9124999 DOI: 10.5312/wjo.v13.i5.515] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 03/21/2022] [Accepted: 04/25/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Slipped capital femoral epiphysis (SCFE) occurs in adolescents and has an incidence of around 10 per 100000 children. Children presenting with a unilateral SCFE are 2335 times more likely to develop a contralateral SCFE than the general population. Prognostic factors that have been suggested to increase the risk of contralateral slip include a younger patient, an underlying endocrine disorder, growth hormone use and a higher radiographic posterior sloping angle. However, there is still much debate on the advantages and disadvantages of prophylactic fixation of the unaffected side in an otherwise healthy patient. AIM To investigate the risk rate of contralateral SCFE and assess the (dis)advantages of prophylactic fixation of the contralateral hip. METHODS A systematic literature search was performed in the Embase, Medline, Web of Science Core Collection and Cochrane databases. Search terms included 'slipped capital femoral epiphysis,' 'fixation,' 'contralateral,' and derivatives. The eligibility of the acquired articles was independently assessed by the authors and additional relevant articles were included through cross-referencing. Publications were considered eligible for inclusion if they presented data about otherwise healthy children with primarily unilateral SCFE and the outcomes of prophylactically pinning their unaffected side, or about the rates of contralateral slips and complications thereof. The study quality of the included articles was assessed independently by the authors by means of the methodological index for non-randomized studies criteria. RESULTS Of 293 identified unique publications, we included 26 studies with a total of 12897 patients. 1762 patients (14%) developed a subsequent symptomatic contralateral slip. In addition, 38% of patients developed a subsequent slip on the contralateral side without experiencing clinical symptoms. The most outspoken advantage of prophylactic fixation of the contralateral hip in the literature is prevention of an (asymptomatic) slip, thus reducing the increased risk of avascular necrosis (AVN), cam morphology and osteoarthritis. Disadvantages include an increased risk of infection, AVN, peri-implant fractures, loss of fixation as well as migration of hardware and morphologic changes as a consequence of growth guidance. These risks, however, appeared to only occur incidentally and were usually mild compared to the risks involved with an actual SCFE. CONCLUSION The advantages of prophylactic pinning of the unaffected side in otherwise healthy patients with unilateral SCFE seem to outweigh the disadvantages. The final decision for treatment remains to be patient-tailored.
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Affiliation(s)
- Steven J C Vink
- Department of Orthopedic Surgery, Erasmus Medical Center, Rotterdam 3015GD, Netherlands
| | - Renée A van Stralen
- Department of Orthopedic Surgery, Erasmus Medical Center, Rotterdam 3015GD, Netherlands
| | - Sophie Moerman
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen 9713GZ, Netherlands
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Fournier A, Monget F, Ternynck C, Fron D, Mezel A, Herbaux B, Canavese F, Nectoux E. Comparison between anterior cuneiform osteotomy and Dunn procedure in the surgical management of unstable severe slipped femoral epiphysis: A case-control study of 41 patients. Orthop Traumatol Surg Res 2022; 108:103167. [PMID: 34871794 DOI: 10.1016/j.otsr.2021.103167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND There is little consensus on the best treatment algorithm for unstable severe slipped capital femoral epiphysis (SCFE). Subcapital osteotomy, which is one of the surgical options, is performed either anteriorly (anterior cuneiform osteotomy, CO) or laterally with trochanteric osteotomy (Dunn procedure, DP). The CO is technically easier and decreases operating time. Moreover, because the DP was the standard in our department before it was replaced by the CO, we had a series of consecutive patients. Therefore, we did a retrospective case-control study in unstable, severe SCFEs treated by CO versus DP, which is to our knowledge the first one aiming to compare: (1) postoperative complications and in particular avascular necrosis, (2) functional outcome, (3) radiologic findings. HYPOTHESIS CO is less or just as likely to cause avascular necrosis and has the same clinical and radiologic findings as DP. METHODS A total of 41 patients (24 girls, i.e. 58.5%) were included between 2005 and 2018: 23 in the CO group and 18 in the DP group. The median age was 12.9 years (range, 11.5-14.9) and the median slip angle 70̊ (range, 62.5̊-80̊) with a median follow-up of 3 years (range, 2-4). Preoperative, intraoperative, and postoperative clinical and radiologic parameters (Southwick and alpha angles, and femoral head-neck offset) were analyzed, and all complications were documented. RESULTS Two (8.7%) cases of avascular necrosis were reported in the CO group and 6 (33.3%) in the DP group (p=.11), with an overall rate of avascular necrosis of 19.5% (8/41). Five out of the 41 patients (12.2%) underwent a total hip arthroplasty: 1/23 (4.3%) in the CO group and 4/18 (22.2%) in the DP group (p=.16). Two (9.5%) patients in the CO group and 7 (38.9%) in the DP group developed postoperative limping before any arthroplasty was performed (p=.055). The alpha angle at follow-up (54±6.1̊ vs. 59.1±7.2̊; p=.027), Oxford hip score at follow-up (17/60 [range, 14-20] vs. 23.5 [range, 19-27]) (p=.021), operating time (132 min [range, 103-166] vs. 199.5 min [range, 142-215]) (p=.011) and intraoperative bleeding (250 mL [range, 100-350] vs. 300 mL [range, 197-450]) (p=.088) were more favorable in the CO group than in the DP group. CONCLUSIONS The CO has similar results to DP in the surgical management of unstable severe SCFE. LEVEL OF EVIDENCE III; retrospective comparative study.
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Affiliation(s)
- Adrien Fournier
- Service de chirurgie et orthopédie de l'enfant, hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France.
| | - Faustine Monget
- Service de chirurgie et orthopédie de l'enfant, hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France
| | - Camille Ternynck
- Université de Lille, CHRU de Lille, ULR 2694-METRICS: évaluation des technologies de santé et des pratiques médicales, 59000 Lille, France
| | - Damien Fron
- Service de chirurgie et orthopédie de l'enfant, hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France
| | - Aurélie Mezel
- Service de chirurgie et orthopédie de l'enfant, hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France
| | - Bernard Herbaux
- Service de chirurgie et orthopédie de l'enfant, hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France; Université de Lille, faculté de médecine Henri-Warembourg, 2, avenue Eugène-Avinée, 59120 Loos, France
| | - Federico Canavese
- Service de chirurgie et orthopédie de l'enfant, hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France; Université de Lille, faculté de médecine Henri-Warembourg, 2, avenue Eugène-Avinée, 59120 Loos, France
| | - Eric Nectoux
- Service de chirurgie et orthopédie de l'enfant, hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France; Université de Lille, faculté de médecine Henri-Warembourg, 2, avenue Eugène-Avinée, 59120 Loos, France
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Mills H, Flowers MJ, Agrawal Y, Nicolaou N. Outcomes of distally un-threaded screw fixation of slipped capital femoral epiphysis at skeletal maturity: a matched cohort study. J Pediatr Orthop B 2021; 30:540-548. [PMID: 32932415 DOI: 10.1097/bpb.0000000000000800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The most common treatment for slipped capital femoral epiphysis worldwide is in situ fixation with a threaded screw. Un-threaded screws are designed to prevent slip progression without hindering residual growth of the proximal femur. This study aimed to compare growth, remodelling and long-term outcomes after fixation with un-threaded screws and a matched cohort of patients treated with a standard screw. Six patients (nine hips) treated with un-threaded screws and 16 patients (21 hips) treated with standard screws matched for age, skeletal maturity, sex and Southwick angle were recruited. Clinical records were reviewed for patient demographics, medical history and complications. Radiographs were reviewed for residual growth and time to physeal closure. Growth velocity was calculated. Absence of cam deformity signified complete remodelling. Clinical assessment was graded from excellent to poor and patient-reported outcomes were recorded. There was significantly more growth recorded in the un-threaded screw group in femoral neck length (7.6 mm, P = 0.003), articulo-lesser trochanter distance (5.3 mm, P = 0.028), pin-joint ratio (7.439%, P = 0.006) and pin-physis ratio (8.244%, P = 0.001). The probability of revision operations due to ongoing growth was higher in this group (risk ratio: 6.57, P = 0.0008). Time to physeal closure was not significantly different, but growth velocity was significantly higher in the un-threaded group. The lower probability of cam deformity was not significant. Functional and clinical results were not significantly different at average 11.2 years' follow-up. Un-threaded screws allow for significantly more growth than standard threaded screws. The un-threaded screw could not be recommended due to the higher re-operation rates, without any proven benefit.
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Affiliation(s)
- Henry Mills
- Department of Orthopaedic, Sheffield Children's Hospital NHS Trust, Sheffield
| | - Mark J Flowers
- Department of Orthopaedic, Sheffield Children's Hospital NHS Trust, Sheffield
| | | | - Nicolas Nicolaou
- Department of Orthopaedic, Sheffield Children's Hospital NHS Trust, Sheffield
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Zuo B, Zhu JF, Wang XY, Wang CL, Ma F, Chen XD. Outcome of the modified Dunn procedure in severe slipped capital femoral epiphysis. J Orthop Surg Res 2020; 15:506. [PMID: 33143737 PMCID: PMC7641796 DOI: 10.1186/s13018-020-02036-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 10/20/2020] [Indexed: 11/10/2022] Open
Abstract
Background The modified Dunn procedure has rapidly gained popularity as a treatment for slipped capital femoral epiphysis (SCFE) during the past few years. However, there is limited information regarding its safety and efficacy in severe slips with this procedure. The purpose of this study is to present clinical results and incidence of complications associated with the modified Dunn osteotomy in a consecutive series of severe SCFE cohort. Patients and methods We retrospectively assessed the outcomes of all twenty patients who had been treated with the modified Dunn procedure in our tertiary-care institution. According to the Loder and Fahey criteria, all cases were classified as severe slips; nineteen cases were stable, and one case was an unstable slip. All surgical procedures were performed by one senior orthopedic surgeon who had specific training in the modified Dunn procedure. Operative reports, outpatient records, follow-up radiographs, and the intraoperative findings were reviewed to determine the demographic information, type of fixation, final slip angle, presence of avascular necrosis (AVN), and any additional complications. The mean age of the patients was 13.2 ± 1.6 years (range, 10 to 17 years). Twenty patients (twenty-one hips) with a mean of 31.2 ± 14 months (range, 12 to 57 months) follow-up met the inclusion criteria. Pain and function were assessed by the modified Harris score and WOMAC score. Radiographic anatomy was measured using the slip angle and α-angle. The radiographic findings related to the anatomy of the femoral head-neck junction, as well as signs of early-onset of osteoarthritis (OA) and AVN, were evaluated pre- and postoperatively. Results Overall, nineteen patients had excellent clinical and radiographic outcomes with respect to hip function and radiographic parameters. One patient (5%) who developed implant failure at 3 months postoperatively had a poor outcome. The mean preoperative slip angle was corrected from 63.2 ± 8.1° (range, 51 to 84°) to a normal value of 7.5 ± 3.5° (range, 2 to 15°) (p < 0.01). The mean α-angle was improved from an average of 94.5 ± 21.1° (range, 61 to 123°) to postoperative 42 ± 6.4° (range, 25 to 55°) (p < 0.01). The mean modified Harris hip and WOMAC scores postoperatively were 96.7 ± 13.4 (range, 40 to 100) and 95.4 ± 10.6 (range, 38 to 100), respectively. There were no cases of the development of femoroacetabular impingement (FAI) and the progression of OA. We did not record any case of AVN, closure of the growth plate, heterotopic ossification (HO), trochanteric nonunion, or limb length discrepancy that occurred postoperatively either at the most recent follow-up. Conclusions Our series of severe SCFEs treated with the modified Dunn osteotomy demonstrated that the procedure is safe and capable of restoring more normal proximal femoral anatomy by maximum correction of the slip angle, minimizing probability of secondary FAI and early onset of OA. However, despite its lower surgical complication rate compared with alternative treatment described in the literature for SCFE, AVN can and do occur postoperatively which should always be concerned in every hip.
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Affiliation(s)
- Bin Zuo
- Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai JiaoTong University School of Medicine (SJTUSM), Shanghai, China.
| | - Jun Feng Zhu
- Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai JiaoTong University School of Medicine (SJTUSM), Shanghai, China.
| | - Xu Yi Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Cheng Long Wang
- Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai JiaoTong University School of Medicine (SJTUSM), Shanghai, China
| | - Fei Ma
- Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai JiaoTong University School of Medicine (SJTUSM), Shanghai, China.
| | - Xiao Dong Chen
- Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai JiaoTong University School of Medicine (SJTUSM), Shanghai, China.
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Samelis PV, Loukas C, Kantanoleon S, Lalos H, Anoua N, Kolovos P, Georgiou F, Konstantinou AL. Causes of Delayed Diagnosis of Slipped Capital Femoral Epiphysis: The Importance of the Frog Lateral Pelvis Projection. Cureus 2020; 12:e7718. [PMID: 32431996 PMCID: PMC7234041 DOI: 10.7759/cureus.7718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Delayed diagnosis and treatment is a universally reported problem that impairs the prognosis of slipped capital femoral epiphysis (SCFE). Quite frequently, a delayed diagnosis of SCFE is observed in spite of serial admissions and examinations of the limping adolescent. Why do health professionals globally fail to make a definitive diagnosis of SCFE during the first examination of the patient? A retrospective study of 36 adolescents treated for stable SCFE and two adolescents treated for unstable SCFE has been performed. In more than half of the delayed diagnosed stable slips (13/25, 52%), the diagnosis was set after serial examinations of the patient. Health professionals commonly order only the anteroposterior (AP) X-ray view of the pelvis when examining a non-traumatic limping adolescent. The frog lateral (FL) projection is usually spared in an attempt to limit the radiation exposure of the patient, especially in ambulating adolescents with mild symptoms. It is proposed that in the non-traumatic limping adolescent, the FL projection instead of the AP pelvis view should be requested by the health professional in order to timely diagnose a surgical emergency of the adolescent hip such as SCFE.
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Affiliation(s)
- Panagiotis V Samelis
- First Orthopaedic Department, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC.,Orthopaedics, Orthopaedic Research and Education Center, Attikon University Hospital, Athens, GRC
| | - Christos Loukas
- Orthopaedics, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
| | | | - Harris Lalos
- Sports Medicine, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
| | - Nikolaos Anoua
- Orthopaedics, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
| | - Panagiotis Kolovos
- Orthopaedics, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
| | - Flourentzos Georgiou
- Orthopaedics, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
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Daley E, Zaltz I. Strategies to Avoid Osteonecrosis in Unstable Slipped Capital Femoral Epiphysis: A Critical Analysis Review. JBJS Rev 2020; 7:e7. [PMID: 31021894 DOI: 10.2106/jbjs.rvw.18.00129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Erika Daley
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan
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Megaloikonomos PD, Mavrogenis AF, Panagopoulos GN, Igoumenou VG, Giakas G, Zampakides C, Pasparakis D. Similar femoral growth and deformity with one screw versus two smooth pins for slipped capital femoral epiphysis. INTERNATIONAL ORTHOPAEDICS 2018; 43:1627-1634. [PMID: 30039196 DOI: 10.1007/s00264-018-4058-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 07/12/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE To compare longitudinal growth and cam deformity of the proximal femur after treatment for slipped capital femoral epiphysis (SCFE) with one screw versus two smooth pins. METHODS We studied 43 patients (29 males, 14 females; mean age, 12.1 years; range, 9.5-14 years) with idiopathic unilateral SCFE treated with in situ fixation with one cannulated screw (group A, n = 23) or two smooth pins (group B, n = 20). Anteroposterior and frog-leg radiographs of the pelvis were evaluated for each patient at initial presentation, post-operatively and at physeal closure. Longitudinal growth was evaluated using the femoral neck length (FNL), the caput-collum-diaphyseal (CCD) angle, and the articulo-trochanteric distance (ATD). Cam deformity was assessed using the anterior offset α-angle and the head-neck offset ratio (HNOR). The mean follow-up was 5.1 years (range, 4-7 years). RESULTS Postoperatively, the mean CCD angle was 138.3°, the mean α-angle was 66.1° and the mean HNOR was - 0.030. At physeal closure, mean CCD angle significantly decreased to 133.6°, mean α-angle significantly reduced to 52.1°, and mean HNOR significantly improved to + 0.039. CCD, FNL, ATD, α-angle, and HNOR were not different between groups. CONCLUSIONS One screw or two smooth pins result in similar longitudinal growth and deformity of the proximal femur after SCFE. The femoral head-neck junction remarkably improves until physeal closure; however, residual cam deformity is not avoided after in situ pinning. The complication rate with smooth pins is higher.
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Affiliation(s)
- Panayiotis D Megaloikonomos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Str., 15562, Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Str., 15562, Athens, Greece.
| | - Georgios N Panagopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Str., 15562, Athens, Greece
| | - Vasilios G Igoumenou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Str., 15562, Athens, Greece
| | - Giannis Giakas
- Faculty of Physical Education and Sport Sciences, University of Thessaly, Trikala, Greece
| | - Christos Zampakides
- First Department of Orthopaedics, "P. and A. Kyriakou" Children's Hospital, Athens, Greece
| | - Dimitrios Pasparakis
- Second Department Orthopaedics, "P. and A. Kyriakou" Children's Hospital, Athens, Greece
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Magnetic resonance imaging at primary diagnosis cannot predict subsequent contralateral slip in slipped capital femoral epiphysis. Skeletal Radiol 2017; 46:1687-1694. [PMID: 28785827 DOI: 10.1007/s00256-017-2735-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 07/10/2017] [Accepted: 07/18/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Prophylactic fixation of the contralateral hip in slipped capital femoral epiphysis (SCFE) is controversial, and no reliable method has been established to predict subsequent contralateral slip. The main purpose of this study was to evaluate if magnetic resonance imaging (MRI) performed at primary diagnosis could predict future contralateral slip. MATERIALS AND METHODS Twenty-two patients with unilateral SCFE were included, all had MRI of both hips taken before operative fixation. Six different parameters were measured on the MRI: the MRI slip angle, the greatest focal widening of the physis, the global widening of the physis measured at three locations (the midpoint of the physis and 1 cm lateral and medial to the midpoint), periphyseal (epiphyseal and metaphyseal) bone marrow edema, the presence of pathological joint effusion, and the amount of joint effusion measured from the lateral edge of the greater trochanter. Mean follow-up was 33 months (range, 16-63 months). Six patients were treated for contralateral slip during the follow-up time and a comparison of the MRI parameters of the contralateral hip in these six patients and in the 16 patients that remained unilateral was done to see if subsequent contralateral slip was possible to predict at primary diagnosis. RESULTS All MRI parameters were significantly altered in hips with established SCFE compared with the contralateral hips. However, none of the MRI parameters showed any significant difference between patients who had a subsequent contralateral slip and those that remained unilateral. CONCLUSIONS MRI taken at primary diagnosis could not predict future contralateral slip.
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Abstract
BACKGROUND Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in children 9-15 years old. This is a population-based study in Sweden presenting the epidemiology for SCFE. METHODS In a prospective cohort study, we analysed pre- and postoperative radiographs, medical records for all children treated for SCFE in Sweden 2007-2013, demographic data, severity of slip and surgical procedures performed. RESULTS We identified 379 Swedish children with primary SCFE 2007-2013; 162 girls, median age 11.7 (7.2-15.4) years, and 217 boys, median age 13 (3.8-17.7) years. The average annual incidence was 4.4/10000 for girls and 5.7/10000 for boys 9-15 years old. Obesity or overweight was found in 56% of the girls and in 76% of the boys. As an initial symptom, 66% of the children had hip/groin pain and 12% knee pain. At first presentation, 7% of the children had bilateral SCFE. Prophylactic fixation was performed in 43%. Of the remaining children, 21% later developed a contralateral slip. Fixation with implants permitting further growth was used in >90% of the children. Femoral neck osteotomy was performed for 11 hips. CONCLUSIONS The annual average incidence 2007-2013 in Sweden showed a mild increase for girls. The male-to-female ratio was lower than previous regional data from Sweden. Overweight or obesity is one major characteristic for boys with SCFE but to a less extent for girls. Knee pain as initial symptom cause a delay in diagnosis. Most hospitals in Sweden treat <2 children annually.
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Significantly lower femoral neck growth in screw fixation of the asymptomatic contralateral hip in unilateral slipped capital femoral epiphysis. J Pediatr Orthop B 2016; 25:197-201. [PMID: 26919622 DOI: 10.1097/bpb.0000000000000285] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There is an ongoing debate on which fixation technique should be preferred for the prophylactic fixation of the asymptomatic contralateral hip in slipped capital femoral epiphysis (SCFE). In the case of Kirschner-wire (K-wire) fixation, there is a possibility of secondary loss of fixation because of longitudinal growth of the physis, whereas in screw fixation, physeal growth of the femoral neck might be impaired. The aim of this matched-pair study was to compare the longitudinal growth of the femoral neck in screw fixation versus K-wire fixation of the asymptomatic contralateral hip in SCFE. All 18 patients (female:male=3:15), who had undergone screw fixation of the asymptomatic contralateral hip between 9/2001 and 9/2011, were matched according to age, bone age, sex, and time to follow-up to another 18 patients with K-wire fixation. The length of the femoral neck of the contralateral hip was measured in parallel to either screw or K-wire from the apex of the femoral head to the opposite cortical bone. The ratio of the femoral neck length measured directly after surgery and on follow-up was defined as femoral neck growth. There was no significant difference between groups with respect to age, modified Oxford Bone age score, and time to follow-up. We found a significant difference in femoral neck growth between patients with screw fixation (5.5 ± 4.3%) compared with K-wire fixation (8.9 ± 5.7%, P = 0.048 matched Wilcoxon test). The difference in femoral neck growth of patients with K-wire or screw fixation of the contralateral asymptomatic hip in SCFE was small, but statistically significant. Thus, despite high rates of secondary loss of fixation, K-wire fixation should still be considered, especially in very young patients.
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Abstract
Slipped capital femoral epiphysis (SCFE) is a common hip condition that can be disabling. In this review, we provide an orientation on current trends in the clinical management of SCFE including conventional procedures and specialised surgical developments. Different methods of fixation of the epiphysis, risks of complications, and the rationale of addressing deformity, primarily or secondarily, are presented. Although improved understanding of the anatomy, vascularity and implications of residual deformity have changed management strategies, the best modality of treatment that would restore complete vascularity to the femoral head and prevent any residual deformity, impingement and early osteoarthritis remains elusive.
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Faldini C, De Fine M, Di Martino A, Fabbri D, Borghi R, Pungetti C, Traina F. Anterior minimally invasive subcapital osteotomy without hip dislocation for slipped capital femoral epiphysis. INTERNATIONAL ORTHOPAEDICS 2015; 40:1615-1623. [PMID: 26459107 DOI: 10.1007/s00264-015-3015-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/28/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE A minimally invasive anterior approach appears to be an attractive alternative to achieve capital realignment without violating femoral head vascular supply and avoiding hip dislocation in slipped capital femoral epiphysis. The aim of this study was to detail the technical steps of subcapital realignment through a minimally invasive anterior approach and to report the preliminary results of this procedure in a prospective cohort of patients with stable slips. METHODS Nine patients underwent subcapital cuneiform wedge resection through a minimally invasive anterior approach without hip dislocation for moderate or severe stable slips between April 2012 and April 2013. Prophylactic stabilization of the contralateral hip was performed in all cases. A minimum 18 months follow-up was available. Clinical course was assessed using the Harris hip score and the hip range of motion. The degree of slippage as proposed by Southwick, the lateral α angle and the epiphyseal-metaphyseal distance allowed radiographic assessment. RESULTS No patients were lost during follow-up, which was on average 28 months. No intraoperative complications occurred; one postoperative transient apraxia of the femoral cutaneous nerve, which completely recovered in six months, was recorded. Southwick angle, lateral α angle and epiphyseal-metaphyseal distance all improved substantially postoperatively. No cases of avascular necrosis were detected. CONCLUSION Subcapital cuneiform wedge resection through a minimally invasive anterior approach without hip dislocation can be an easier alternative to restore proximal femoral anatomy in moderate to severe stable slips. Prospective case control studies are required to confirm these preliminary results.
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Affiliation(s)
- Cesare Faldini
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, Bagheria, PA, Italy
| | - Marcello De Fine
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, Bagheria, PA, Italy.
- Department of Orthopaedic Surgery, Istituti Ortopedici Rizzoli, Dipartimento Rizzoli-Sicilia, SS 113, km 246, Bagheria, PA, 90011, Italy.
| | - Alberto Di Martino
- UOC Orthopaedics and Trauma Surgery, University Campus Bio-Medico, Rome, Italy
| | - Daniele Fabbri
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, Bagheria, PA, Italy
| | - Raffele Borghi
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, Bagheria, PA, Italy
| | - Camilla Pungetti
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, Bagheria, PA, Italy
| | - Francesco Traina
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, Bagheria, PA, Italy
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Wensaas A, Gunderson RB, Svenningsen S, Terjesen T. Good long-term outcome of the untreated contralateral hip in unilateral slipped capital femoral epiphysis : Forty hips with a mean follow-up of 41 years. J Child Orthop 2014; 8:367-73. [PMID: 25270941 PMCID: PMC4391051 DOI: 10.1007/s11832-014-0611-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 09/10/2014] [Indexed: 02/03/2023] Open
Abstract
PURPOSE There is no consensus regarding prophylactic fixation of the contralateral hip in slipped capital femoral epiphysis (SCFE). In order to further study this question, we evaluated the long-term natural history of untreated contralateral hips. METHODS Forty patients treated for unilateral SCFE without evidence of subsequent contralateral slip during adolescence were reviewed with a mean follow-up of 36 years (range 21-50 years). The deformity after SCFE may demonstrate radiographic signs of cam-type femoroacetabular impingement. We, therefore, measured α-angles in the contralateral hips on anteroposterior (AP) and frog-leg lateral radiographs. The angles were compared with those of a control group of adults without SCFE. Five years after the radiographic examination, with a mean follow-up of 41 years, all patients were evaluated by telephone interview. As range of motion and deformity could not be examined, a modified Harris hip score (HHS) (maximum score of 91 points) was used. A modified HHS <76 points and/or radiographic osteoarthritis (OA) was classified as a poor long-term outcome. RESULTS The mean value of the AP α-angle was significantly higher in the contralateral hips in SCFE patients than in the control group (55° vs. 46°), while the mean value of the lateral α-angle was not. Abnormally high values for one or both α-angles were found in 16 contralateral hips (40 %), of which five patients had abnormal values for both α-angles and were considered to have had an asymptomatic contralateral slip. Five patients (13 %) had a poor outcome in the contralateral hip, of which three patients (8 %) had OA. There was a significant association between hips with both α-angles that were abnormal and poor outcome. CONCLUSIONS Since the natural history showed good long-term radiographic and clinical outcome in 35 of 40 patients and only three had OA, we conclude that routine prophylactic fixation of the contralateral hip is not indicated.
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Affiliation(s)
- Anders Wensaas
- Department of Orthopaedics, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Ragnhild B. Gunderson
- Department of Radiology, Oslo University Hospital, Rikshospitalet, Postboks 4950, Nydalen, 0424 Oslo, Norway
| | - Svein Svenningsen
- Department of Orthopaedics, Sorlandet Hospital, Postboks 783 Stoa, 4809 Arendal, Norway
| | - Terje Terjesen
- Department of Orthopaedics, Oslo University Hospital, Rikshospitalet, Postboks 4950 Nydalen, 0424 Oslo, Norway
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Abu Amara S, Leroux J, Lechevallier J. Surgery for slipped capital femoral epiphysis in adolescents. Orthop Traumatol Surg Res 2014; 100:S157-67. [PMID: 24397949 DOI: 10.1016/j.otsr.2013.04.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/08/2013] [Accepted: 04/15/2013] [Indexed: 02/02/2023]
Abstract
The treatment of slipped capital femoral epiphysis (SCFE) in adolescents remains controversial. The goal of initial treatment is to prevent further slippage of the epiphysis. In mild forms, both stable and unstable, in situ fixation is widely accepted as the reference treatment. In contrast, several techniques are available for stable moderate-to-severe SCFE. In unstable moderate-to-severe SCFE, emergent reduction with decompression and internal fixation is currently the preferred method. Selection of the surgical technique rests on an appraisal of advantages versus drawbacks. The goal of this review is to discuss the various surgical methods available for SCFE in adolescents.
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Affiliation(s)
- S Abu Amara
- Clinique chirurgicale infantile, centre hospitalier universitaire de Rouen, 1, rue de Germont, 76031 Rouen, France.
| | - J Leroux
- Clinique chirurgicale infantile, centre hospitalier universitaire de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - J Lechevallier
- Clinique chirurgicale infantile, centre hospitalier universitaire de Rouen, 1, rue de Germont, 76031 Rouen, France
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15
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Lehmann TG, Vetti N, Laborie LB, Engesæter IØ, Engesæter LB, Rosendahl K. Intra- and inter-observer repeatability of radiographic measurements for previously slipped capital femoral epiphysis at skeletal maturity. Acta Radiol 2013; 54:587-91. [PMID: 23436830 DOI: 10.1177/0284185112474918] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Recent studies suggest that even a mild slip of the femoral capital epiphysis may lead to later degenerative changes when undiagnosed. However, little is written on the accuracy of radiographic measurements used to diagnose a slip at skeletal maturity. PURPOSE To assess the accuracy of radiographic measurements commonly used for assessment of previously slipped capital femoral epiphysis (SCFE) at skeletal maturity. MATERIAL AND METHODS All children born at our hospital during 1989 (n = 4006) were invited to participate in a follow-up hip trial at age 18-19 years. Erect pelvic anteroposterior and supine frog leg radiographs were obtained in a standardized fashion. For the purpose of this study, we selected a subset of 100 radiographs. To balance the data-set, we added another 28 radiographs from skeletal mature patients diagnosed and operated for a SCFE. Two observers independently measured Southwick's head-shaft angle, Murray's tilt-index, and the femoral head-neck angle. Intra- and inter-observer variation was assessed using the mean difference, with its 95% limits of agreement. RESULTS A high percentage of the images (40%), particularly for the measurement of the Southwick's head-shaft angle, were judged immeasurable by at least one observer. Mean head-shaft angle was 11.0° (SD = 17.0), head-neck angle was 8.0° (SD = 12.0), and Murray's tilt-index was 1.18 (SD = 0.4). For head-shaft angle, the mean difference between measurements (Observer 2) was 0.8° (SD = 2.7°, 95% limits of agreement -4.5° to 6.1°), while the corresponding figure for the Murray's tilt-index was 0.02 (SD = 0.08, 95% limits of agreement -0.18 to 0.14), and for the head-neck angle 0.9° (SD = 4.0, 95% limits of agreement of -6.9° to 8.7°). Slightly higher variance was seen for Observer 1 and between the two observers. CONCLUSION Common radiographic measurements for the assessment of a previously slipped capital femoral epiphysis are relatively inaccurate in skeletal mature adolescents, in particular between observers (inter-observer), but also for the same observer (intra-observer). Our results underscore the importance of thorough standardization for both image and measurement technique when used in a clinical setting.
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Affiliation(s)
- Trude G Lehmann
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
- Department of Surgical Sciences, University of Bergen, Bergen
| | - Nils Vetti
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Lene B Laborie
- Department of Surgical Sciences, University of Bergen, Bergen
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Ingvild Ø Engesæter
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
- Department of Surgical Sciences, University of Bergen, Bergen
| | - Lars B Engesæter
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
- Department of Surgical Sciences, University of Bergen, Bergen
| | - Karen Rosendahl
- Department of Surgical Sciences, University of Bergen, Bergen
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
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Lehmann TG, Engesæter IØ, Laborie LB, Lie SA, Rosendahl K, Engesæter LB. Radiological findings that may indicate a prior silent slipped capital femoral epiphysis in a cohort of 2072 young adults. Bone Joint J 2013; 95-B:452-8. [PMID: 23539695 DOI: 10.1302/0301-620x.95b4.29910] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The reported prevalence of an asymptomatic slip of the contralateral hip in patients operated on for unilateral slipped capital femoral epiphysis (SCFE) is as high as 40%. Based on a population-based cohort of 2072 healthy adolescents (58% women) we report on radiological and clinical findings suggestive of a possible previous SCFE. Common threshold values for Southwick's lateral head-shaft angle (≥ 13°) and Murray's tilt index (≥ 1.35) were used. New reference intervals for these measurements at skeletal maturity are also presented. At follow-up the mean age of the patients was 18.6 years (17.2 to 20.1). All answered two questionnaires, had a clinical examination and two hip radiographs. There was an association between a high head-shaft angle and clinical findings associated with SCFE, such as reduced internal rotation and increased external rotation. Also, 6.6% of the cohort had Southwick's lateral head-shaft angle ≥ 13°, suggestive of a possible slip. Murray's tilt index ≥ 1.35 was demonstrated in 13.1% of the cohort, predominantly in men, in whom this finding was associated with other radiological findings such as pistol-grip deformity or focal prominence of the femoral neck, but no clinical findings suggestive of SCFE. This study indicates that 6.6% of young adults have radiological findings consistent with a prior SCFE, which seems to be more common than previously reported.
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Affiliation(s)
- T G Lehmann
- University of Bergen, Department of Surgical Sciences, Haukeland University Hospital, Bergen, Norway.
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Lehmann TG, Engesaeter IØ, Laborie LB, Lie SA, Rosendahl K, Engesaeter LB. Total hip arthroplasty in young adults, with focus on Perthes' disease and slipped capital femoral epiphysis: follow-up of 540 subjects reported to the Norwegian Arthroplasty Register during 1987-2007. Acta Orthop 2012; 83:159-64. [PMID: 22112152 PMCID: PMC3339530 DOI: 10.3109/17453674.2011.641105] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Pediatric hip diseases account for 9% of all primary hip arthroplasties in the Norwegian Arthroplasty Register. We wanted to validate the diagnosis as reported to the register and to assess the quality of life of these patients after hip replacement. PATIENTS AND METHODS 540 patients accepted to participate in this follow-up study (634 hips). All were less than 40 years of age and had been reported to the Norwegian Arthroplasty Register as having undergone a primary total hip arthroplasty (THA) between 1987 and 2007. The underlying diagnosis, age at diagnosis, and type of treatment given prior to the hip replacement were recorded from the original hospital notes. RESULTS The diagnoses reported to the Norwegian Arthroplasty Register were confirmed to be correct in 91% of all cases (538/592). For the 94 hips that had been treated due to Perthes' disease or slipped capital femoral epiphysis (SCFE), the diagnosis was verified in 95% of cases (89/94). The corresponding proportion for inflammatory hip disease was 98% (137/140) and it was only 61% for primary osteoarthritis (19/31). The self reported quality of life (EQ-5D) was poorer for these young patients with THA than for persons in age-matched cohorts from Great Britain and Sweden, except for those with an underlying SCFE. INTERPRETATION The diagnoses reported to the Norwegian Arthroplasty Register as the underlying cause of THA were correct in 91% of cases. Individuals who undergo THA before the age of 40 have a reduced quality of life, except for those requiring a hip replacement because of SCFE.
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Affiliation(s)
- Trude G Lehmann
- Department of Orthopaedic Surgery, Haukeland University Hospital, Norway.
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Westhoff B, Ruhe K, Weimann-Stahlschmidt K, Zilkens C, Willers R, Krauspe R. The gait function of slipped capital femoral epiphysis in patients after growth arrest and its correlation with the clinical outcome. INTERNATIONAL ORTHOPAEDICS 2011; 36:1031-8. [PMID: 22113736 DOI: 10.1007/s00264-011-1409-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2011] [Accepted: 10/28/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE Slipped capital femoral epiphysis (SCFE) represents the preliminary stage of osteoarthritis. Reliable tools for outcome evaluation should be developed to prevent persisting defects. The functional outcome of SCFE-patients after growth arrest is analysed by instrumented 3D-gait analysis (GA). The results are matched to the clinical examination findings. METHODS A total of 39 SCFE patients after growth arrest (18.8 years; BMI 26.5 kg/m²) with unilateral affection were included. The clinical results were classified according to Harris hip and clinical Heyman Herndon scores. 3D-GA-parameters were evaluated and compared to the sound side and a group of 40 healthy adults (28.0 years; 21.9 kg/m²). The subgroup analysis was performed according to clinical results. RESULTS The clinical examination revealed very good results. GA could detect even small alterations. Some parameters indicated sustained functional impairments: Compared to the control group patients' walking speed (p = 0.022), step frequency (p < 0.001) and single support of the slip side (p < 0.001) decreased, while step width (p = 0.014), double support (p = 0.004) and stance time of sound side increased (p = 0.001). For kinematics patients, the sagittal range of motion (ROM) of pelvis (p < 0.001) and the external rotation of the ankle on both sides increased (p = 0.011) and sagittal ROM of hip (p = 0.002) and knee flexion of slip side (p < 0.001) decreased. The sagittal ROM of the ankle on the slip side decreased compared to the sound side (p = 0.003). Subgroup analysis revealed a positive correlation between clinically unsatisfying results and GA parameters. CONCLUSIONS Functional impairments in SCFE-patients can be found even after growth arrest. Alterations are explained partly by the disease and partly by patients' constitution. BMI-matched controls and long-term follow-up are needed.
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Affiliation(s)
- Bettina Westhoff
- Medical Faculty, Department of Orthopaedics, University of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
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