Case report: bilateral slipped capital femoral epiphyses and hormone replacement

Incidence and Clinical Characteristics of Slipped Capital Femoral Epiphysis in Patients with Endocrinopathy: A Population-Based Cohort Study

BACKGROUND

Endocrinopathy is a risk factor for slipped capital femoral epiphysis (SCFE). We aimed to determine (1) the incidence of endocrinopathy-associated SCFE compared with that of non-endocrinopathy-associated SCFE, (2) whether the incidence of SCFE increases with the number of deficient hormones, and (3) the clinical characteristics of endocrinopathy-associated SCFE.

METHODS

We conducted a population-based cohort study using a nationwide database in South Korea. All new diagnoses of endocrinopathy or SCFE between 2002 and 2019 in children born between 2002 and 2005 were identified. The incidence of SCFE was calculated for each type of endocrinopathy. The trend of the incidence of SCFE relative to the number of deficient hormones was analyzed. The male:female ratio was compared between endocrinopathy-associated SCFE and non-endocrinopathy-associated SCFE. For endocrinopathy-associated SCFE, the time between the diagnoses of SCFE and endocrinopathy was evaluated.

RESULTS

The incidence of SCFE was higher in children with endocrinopathy than in those without endocrinopathy (37.1/100,000 versus 9.0/100,000 children) (relative risk, 4.1 [95% confidence interval, 2.8-6.1]). Among various endocrinopathies, growth hormone deficiency showed the highest incidence of SCFE (583.8/100,000 children). The Cochran-Armitage test showed a linear trend, with an increased number of deficient hormones being associated with a higher incidence of SCFE (p < 0.001). Male sex was dominant in the non-endocrinopathy-associated SCFE group (73%; 117 of 161), whereas female sex was dominant in the endocrinopathy-associated SCFE group (53%; 16 of 30) (p = 0.009). Twenty-two of the 30 cases of endocrinopathy-associated SCFE were diagnosed after the diagnosis of endocrinopathy, with a median time of 3.6 years between the diagnoses. Six (27%) of these 22 children developed SCFE >5 years after the diagnosis of endocrinopathy.

CONCLUSIONS

The incidence of SCFE was approximately 4 times higher in children with endocrinopathy than in those without endocrinopathy. The risk of SCFE increased with an increased number of deficient hormones. Long-term monitoring of SCFE occurrence in children with endocrinopathies is strongly recommended.

LEVEL OF EVIDENCE

Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Slipped capital femoral epiphysis with hypopituitarism in adults: A case report and literature review

RATIONALE

Slipped capital femoral epiphysis (SCFE) is a common disease in pediatric orthopedics. Most research on SCFE has focused on high-risk groups or the whole population, and studies focusing on adult SCFE patients are rare. In the present study, we report the case of an adult patient with SCFE.

PATIENT CONCERN

A 37-year-old man presented to our clinic with persistent pain that was poorly localized to both hips, groin regions, and thighs for more than 1 year.

DIAGNOSES

A bilateral hip X-ray examination was performed, and the femoral epiphyses were found to be unfused on both sides. Low levels of growth hormone (GH), insulin-like growth factor-1 (IGF-1), triiodothyronine (T3), thyroxine (T4), follicle-stimulating hormone, luteinizing hormone, estradiol, and testosterone, and high levels of thyroid-stimulating hormone, prolactin, and cortisol.

INTERVENTIONS

Hormone-substitution therapies (levothyroxine sodium to treat hypothyroidism and testosterone enanthate to treat hypogonadism) were prescribed. Total hip arthroplasty was performed to treat femoral epiphysis slippage.

OUTCOMES

After 6 months of postoperative follow-up, the patient's gait improved significantly, and bilateral hip pain was relieved.

LESSONS

When treating adults with SCFE, clinicians must be alert to endocrine disorders. Comprehensive imaging evaluation is crucial for the accurate diagnosis and selection of an appropriate treatment.

Evaluation of the Three-Dimensional Translational and Angular Deformity in Slipped Capital Femoral Epiphysis

The purpose of this study was to quantify three-dimensional translational and angular deformity (defined as theta) present at the proximal femoral physis in slipped capital femoral epiphysis (SCFE), and to use theta to differentiate between SCFE hips, contralateral unaffected hips, and normal hips by comparing to the current gold standard measure of the Southwick slip angle (SSA). 3DCT reconstructions of the pelvis and femur in SCFE patients and normal adolescents were obtained and pelvic position was standardized. The center point and direction vector of the femoral epiphysis was determined. The femoral neck axis was defined. The angle between the femoral neck axis and epiphysis vector defined the 3D angle of deformity (theta). The 3D translation of the femoral epiphysis, measured as a percentage of femoral neck diameter, was measured in three planes. The average theta angle was significantly greater in SCFE hips (46.5 ± 24.3°) compared with control (13.7 ± 6.4°) or normal (11.7 ± 3.7°) hips (p < 0.001). There was no significant difference in theta angle between control and normal hips (p = 0.468). Theta angle correlated strongly with SSA (r_s  = 0.737, p < 0.001). Statement of clinical significance: The proximal femoral deformity in patients with slipped capital femoral epiphysis can be defined by measuring displacement of the epiphysis in all three dimensions in relation to the femoral neck axis. This information can be used in epiphyseal reorientation surgery to ensure anatomic reduction. The similarity between control and normal hips may argue against the thought that there is pre-existing deformity in a pre-slip condition of unaffected contralateral hips in SCFE patients. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:1081-1088, 2020.

Slipped Capital Femoral Epiphysis in an Adult Patient With Kabuki Syndrome

Introduction:

Slipped capital femoral epiphysis (SCFE) is a condition which predominantly occurs in adolescents. SCFE is extremely rare in adults, and nearly all previous reported cases have been associated with an endocrine disorder.

Methods:

We present a case of a 19-year-old man with Kabuki syndrome who was diagnosed with an unstable SCFE requiring surgical fixation. A literature search on PubMed and Google Scholar was done looking for all published cases of delayed-onset SCFE. All previous reported cases were reviewed to determine the likely cause of the SCFE.

Results:

No previous cases of SCFE were described in patients with Kabuki syndrome. Literature review revealed 27 articles describing 32 cases of delayed-onset SCFE. Thirty-one of these cases were associated with endocrine disorders or pituitary tumors. Endocrine disorders associated with delayed-onset SCFE included hypothyroidism, hypogonadism, and panhypopituitarism. Pituitary adenomas and craniopharyngiomas were also associated with delayed-onset SCFE.

Discussion:

This is the first reported case of SCFE in a patient with Kabuki syndrome. Kabuki syndrome is a genetic disorder known to cause delayed growth, resulting in delayed physeal closure, placing the patients at risk of SCFE even into adulthood. The literature search revealed that nearly all previously described delayed-onset SCFE cases were associated with endocrine disorders or pituitary tumors. We recommend that all patients diagnosed with delayed-onset SCFE be evaluated for endocrine disorders, pituitary tumors, and/or genetic disorders which can cause delayed skeletal maturation as these disorders can range from severe endocrine disorders to intracranial tumors.

A new compound heterozygous mutation in a female with 17α-hydroxylase/17,20-lyase deficiency, slipped capital femoral epiphysis, and adrenal myelolipoma

17α-Hydroxylase/17,20-lyase deficiency (17-OHD) is a rare disease caused by mutations of the CYP17A1 gene. Slipped capital femoral epiphysis (SCFE) rarely occurs in adults. There are occasional reports of adrenal myelolipoma (AML) in 17-OHD. A 27-year-old Chinese female (46, XX) visited the hospital for SCFE and presented with continuous hypokalemia, absent spontaneous puberty, and hypertension. Hypergonadotropic hypogonadism was detected. The laboratory tests were consistent with 17-OHD. AML was considered based on the imaging examinations. A mutation analysis of the CYP17A1 gene identified the following compound heterozygous mutation: a frame-shift mutation, i.e. c.985_987delTACinsAA (p.Tyr329fs), that had been reported to be a common mutation in the Chinese population was found in exon 6. Another new nonsense mutation, i.e. c.1270C > T (p.Gln424*), that causes a premature termination codon was found in exon 8. Treatment with prednisone had poor efficacy. The administration of 0.75 mg dexamethasone and estradiol/dydrogesterone cyclic treatment significantly improved the patient's symptoms. For the first time, we report a 17-OHD case accompanied by SCFE, AML, and a novel mutation site in the CYP17A1 gene. We provide insight into the clinical manifestations, genetic analysis, and treatment options of 17-OHD.

Prepubertal onset of slipped capital femoral epiphysis associated with hypothyroidism: a case report and literature review

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is a common hip disorder characterized by displacement of the capital femoral epiphysis from the metaphysic through the femoral epiphyseal plate. SCFE usually occurs during puberty, with obesity a common risk factor. We experienced a rare case of SCFE associated with hypothyroidism in a prepubescent patient who was not obese.

CASE PRESENTATION

The patient was an 8-year-old boy suffering from bilateral SCFE with hypothyroidism. The patient's growth had started to slow at 4 years of age, and at 8 years he was of short stature. During his evaluation for SCFE management, primary hypothyroidism was diagnosed due to the presence of anti-thyroid peroxidase and anti-thyroglobulin antibodies. After the patient was treated for hypothyroidism, which improved his thyroid function, surgery was performed for bilateral SCFE.

CONCLUSIONS

Among the 42 patients with SCFE associated with hypothyroidism in the literature, most SCFE occurred during puberty or in adults with delayed epiphyseal closure. Only two patients (4.8%), including the present patient, were ≤9 years old. Although being overweight or obese is common for patients with SCFE associated with hypothyroidism (76.0%), it was not observed in the present case. Persistent hypothyroidism, however, may be a risk factor for SCFE even before puberty and without obesity.

Delayed-onset of slipped capital femoral epiphysis

BACKGROUND

Slipped capital femoral epiphysis in adults is uncommon. The purpose of this study was to report our own four cases (six hips) of slipped capital femoral epiphysis (SCFE) in adulthood and to review the cases reported in the literature. The authors attempted to investigate the various causative underlying disorders and clinical characteristics, treatment, outcome, and complications.

METHODS

We searched for all 22 reported cases of SCFE in adults age 18 years and older via MEDLINE and Google Scholar from 1963 to 2012 without any exception. In doing so, we documented our own four cases, along with seven additional reports that we found in the literature but were not reported by Hu et al. in 2011.

RESULTS

All of 22 cases involved causative pathology: panhypopituitary disorders in 11, hypothyroidism in five, Kallmann syndrome in three, postradiation hypoestrogenism in one, hypogonadotropic hypogonadism as sequel of meningitis in one, and Klinefelter syndrome in one. Eight cases (36 %) involved both hips. The most common treatment modality was internal fixation combined with hormonal replacement therapy. Nineteen hips (63 %) healed well without any complications after fixation of the slipped epiphysis. Avascular necrosis of the femoral head developed in one hip after in situ pin fixation.

CONCLUSION

Awareness of the variety of conditions under which SCFE can occur is an important factor in early diagnosis, especially in slippage at atypical ages. In the adults with SCFE, it is very important to look for bilateral involvement as this occurs in 36 % of cases.

The administration of L-thyroxine as soft gel capsule or liquid solution

INTRODUCTION

Levothyroxine (l-T4) is the mainstay of treating hypothyroidism. The tablet is the traditional formulation of l-T4. Tablet l-T4 malabsorption results from either hindered gastric dissolution of the tablet or binding of l-T4 by sequestrants in the intestinal lumen.

AREAS COVERED

This review provides an overview of the pharmacokinetics of l-T4 formulations available in the market: the tablet, the soft gel capsule and the oral solution. We review literature on the new formulations and anticipate the areas of future research.

EXPERT OPINION

Failure of l-T4 treatment to reach target serum thyroid-stimulating hormone levels generally prompts the physicians to increase l-T4 daily dose. In vitro studies have shown that the soft gel capsule releases the active ingredient more consistently at varying pH than the tablet. In addition, in vivo studies have confirmed the in vitro data and have demonstrated that both the soft gel capsule and the liquid formulation are capable to solve tablet l-T4 malabsorption caused by certain drugs, bariatric surgery or coffee. These new formulations may be attractive also for patients who cannot/do not want to change their (improper) habits of l-T4 ingestion. Finally, the oral solution l-T4 could be suitable for patients who cannot swallow the solid formulations.

The effects of hypothyroidism on the proximal femoral physis in miniature swine

As a potential means of comparing hypothyroidism in humans, this work intended to establish a defined hypothyroid state in immature miniature swine and evaluate specific molecular, cellular, and extracellular responses of their growth plates. Two male, 11-week-old Sinclair miniature swine were given 6-propyl-2-thiouracil (PTU) in their water and two other like animals (controls) were provided water without PTU. Blood levels of thyroid stimulating hormone (TSH), triiodothyronine (T3), and thyroxin (T4) were monitored weekly. At 25 weeks of age, the hind limb proximal femoral physes were harvested and divided into portions for histology and reverse transcription-quantitative polymerase chain reaction (RT-qPCR) analysis. Compared to controls, swine administered PTU exhibited increased TSH and decreased T3 and T4 serum levels during the study period, features consistent with a hypothyroid state. Compared to controls, hypothyroid swine exhibited structurally altered physes and demonstrated significantly decreased gene expression of aggrecan (p < 0.05) and type X collagen (p ≤ 0.1). This is the first hypothyroid model established in miniature swine and represents a potentially important advance for understanding the condition in humans, in which, like this swine model, there are changes critical to growth plate molecular biology, biochemistry and structure.

Slipped capital femoral epiphysis in an adult with panhypopituitarism

Slipped capital femoral epiphysis usually occurs in children going through a pubertal growth spurt, possibly because the immature proximal femoral physis is unable to bear the shear stress. It commonly occurs in adolescents between 10 and 16 years. Slipped capital femoral epiphysis in adults is uncommon, with only 10 cases reported in the literature. This article presents a case of a 29-year-old man with craniopharyngioma diagnosed when he was 19. He underwent surgery with subtotal tumor excision and postoperative radiotherapy, but received no further treatment for the panhypopituitarism concomitant with the tumor. He reported sudden onset of left hip pain after riding a bicycle and underwent surgical fixation 5 days later. He also underwent hormone replacement therapy, including prednisolone, thyroxin, desmopressin, and testosterone, and regular clinical follow-up. His hip function recovered with a painless gait. At 18-month follow-up, neither osteonecrosis nor contralateral slipped capital femoral epiphysis was noted. Furthermore, bilateral proximal femoral physes were also closed. For stable slippage as in this case, in situ pinning fixation is a commendable method. A high index of suspicion of endocrinal disorder and proper management are essential for successful treatment of adult slipped capital femoral epiphysis.

Slipped upper femoral epiphysis in Hashimoto’s thyroiditis in a 29-year-old man

Slipped upper femoral epiphysis (SUFE) with an open physis is rare in an adult and the condition may present without prior diagnosis of an underlying medical condition. We have treated a 29-year-old man with bilateral SUFE associated with autoimmune hypothyroidism. The management was delayed and complicated by co-existing autoimmune chronic active hepatitis. He underwent thyroxine therapy and bilateral pinning in situ with a single ASNIS screw. Closure of the physis occurred after five months on the right side. The left side required a further corrective intertrochanteric osteotomy, and it was only after 13 months that complete fusion of this physis was seen. The case highlights the need to consider endocrine and metabolic conditions in atypical presentation of SUFE.