Pediatric Hip Disorders: Slipped Capital Femoral Epiphysis and Legg-Calvé-Perthes Disease

Legg-Calvé-Perthes Disease: Diagnosis, Decision Making, and Outcome

ABSTRACT

Legg-Calvé-Perthes disease (LCPD), or idiopathic avascular necrosis of the proximal capital femoral epiphysis in children, has a variable presentation and can result in significant femoral head deformity that can lead to long-term functional deficits. Plain radiographic imaging is crucial in diagnosing LCPD and guiding treatment. Although the etiology of LCPD remains unknown, the evolution of the disease has been well characterized to include the phases of ischemia, revascularization, and reossification. The mechanical weakening during these phases of healing place the femoral head at high risk of deformity. Treatment of LCPD, therefore, focuses on minimizing deformity through operative and nonoperative strategies to reduce the risk of premature osteoarthritis. Advanced imaging using perfusion MRI may refine surgical decision making in the future, and biological treatments to improve femoral head healing are on the horizon.

Surgeon Preference for Prophylactic Contralateral Fixation in Slipped Capital Femoral Epiphysis (SCFE) Patients: A Nationwide POSNA Survey Study

BACKGROUND

It is estimated that 11% to 60% of unilateral slipped capital femoral epiphysis (SCFE) patients will develop contralateral pathology, usually within 18 months after the first event. Despite this, prophylactic fixation remains controversial, and there is significant variability in surgeon preferences. Thus, this study aimed to determine which factors predict surgeon preferences for prophylactic contralateral pinning in SCFE patients.

METHODS

We designed a survey for pediatric orthopedic surgeons to collect data on (1) surgeon and hospital characteristics, (2) individual preference for contralateral SCFE pinning in three disparate hypothetical scenarios, and (3) personal risk-aversion traits. The questionnaire was distributed across the United States by the POSNA Evidence-Based Orthopaedics Committee. All POSNA members were eligible to respond. We performed analyses to evaluate the role of patient risk factors in hypothetical surgical decision-making and to determine if surgical training, hospital characteristics, and geographic region influenced prophylactic pinning in a surgeon's real-life practice.

RESULTS

A total of 126 POSNA members responded to the survey. In the last year, a median of 6.5 SCFE patients was seen per surgeon (1243 patients total). A median of 10% of those patients underwent prophylactic contralateral fixation. In multiple analyses, surgeons were influenced by body mass index, open triradiate cartilage, patient race, various endocrine abnormalities, and specific radiographic measurements when deciding to fix the contralateral side prophylactically. Moreover, in multivariate regression, more years in practice and a hospital size of 500+ beds predicted fewer prophylactic fixation procedures (all P <0.05). Surgeons practicing in the South Atlantic, New England, and Mountain regions of the United States estimated the highest rate of contralateral pinning.

CONCLUSIONS

This study's findings suggest that multiple factors influence surgeons' decisions to prophylactically fix the contralateral side in SCFE patients. Surgical training, hospital characteristics, and geographical regions played a role in decision-making.

LEVEL OF EVIDENCE

N/A.

Growth-related sports injuries among young male professional football players in the Netherlands: a prospective cohort study concerning injury incidence, severity and burden

OBJECTIVES

To investigate the incidence, type and location of growth-related sports injuries (GRSI) in youth professional football in the Netherlands. Secondary, to gain more knowledge on the injury severity and burden of GRSI.

METHODS

In this prospective, longitudinal cohort study, 813 players aged 10-18 are included. Data collection is performed by instructing the medical staff of six professional football club academies to register GRSI by means of standardized forms. Training and match exposure are registered individually on a weekly basis. Injury incidence was calculated as number of GRSI per 1000 hours, injury severity as the median number of days lost in categories and injury burden as the number of days lost per 1000 hours.

RESULTS

A total of 62 GRSI were documented in the football season 2021-2022. The total incidence of GRSI was 0.62/1000 hours football exposure. Morbus Osgood Schlatter and Morbus Sever were most common types of GRSI, both with incidence rates of 0.22/1000 hours exposure. About 58.3% of the documented GRSI were classified as major (>28 days lost). Within this group, the mean severity was 55 days time-loss to football.

CONCLUSIONS

GRSI are relatively common in youth professional football. The most common types are Morbus Sever and Morbus Osgood Schlatter. Morbus Osgood Schlatter has the highest injury severity and burden compared to other types of GRSI.

Trends in hospitalization for pediatric hip arthroplasty: an epidemiological Nationwide study in Italy from 2001 to 2015

Background

The epidemiology of Pediatric Hip Arthroplasty (PHA) is unclear. Prevalence of PHA in Europe was reported in Scandinavian registries, but data on this procedure are not described in other countries. Therefore, it is challenging to redact a complete and valid epidemiological report on PHA in Europe. Nevertheless, national health statistics for PHA are helpful for an international audience, as different treatments are reported between countries. Moreover, sharing national statistics and correlating those to other countries’ protocols could be helpful to compare outcomes for different procedures internationally. The principal purpose is to evaluate the yearly hospital admission for PHA in Italy.

Methods

Data of this study were collected from the National Hospital Discharge Reports (SDO) reported at the Italian Ministry of Health.

Results

From 2001 to 2015, 770 PHA hospitalizations were performed in Italy, with an incidence of 0.5 procedures for every 100,000 pediatric Italian inhabitants. The average age of patients was 15.2 ± 4.6 years. The mean length of days of hospitalization was 10.9 ± 8.6 days. The majority of patients were male of 15–19 years old age group. A progressive decrease in days of hospitalizations was found during the years of the study.

Conclusions

In Europe, the incidence of hospital admission for PHA is not fully described. There is a lack of consensus on the best type of surgery to perform on young patients. Epidemiological studies are helpful to understand the national variation of a specific surgical procedure and compare them with other countries.

Slipped capital femoral epiphysis in a healed Perthes hip

Perthes disease and slipped capital femoral epiphysis (SCFE) in the same child is a rare occurrence. A 7-year-old boy with the left hip Perthes' disease was managed with femur osteotomy. The femur head healed with a spherical congruent hip. After 3 years, he developed right tibia vara which was treated with growth modulation. The deformity was corrected after one and a half years. At age of 15 years, he presented with left side painful limp and typical features of SCFE. The left hip was managed with modified Dunn's osteotomy. The hip range of movements was painless and near-normal range at final follow-up. Though this is the first case of ipsilateral SCFE following healed Perthes in a non-syndromic child, one must always consider SCFE in adolescents with hip or knee pain or altered gait, even if they have had other conditions like Perthes disease in the past.

Slipped capital femoral epiphysis: an epidemiological Nationwide study in Italy from 2001 to 2015

BACKGROUND

Slipped capital femoral epiphysis (epiphysiolysis of the femoral head, SCFE) is the most common pediatric hip disease in 10-14 years old children. The most used procedure to correct a stable form of SCFE is in situ pinning. Instead, the proper treatment for unstable forms is controversial. The first purpose of this study was to estimate annual admissions for SCFE in Italian patients from 2001 to 2015, basing on the hospitalization reports. The second aim was to assess the difference between regions regarding SCFE procedures. Lastly, a statistical prediction of the volume of SCFE procedures performed in Italy based on data from 2001 to 2015 was performed.

METHODS

Data of this study were collected from the National Hospital Discharge Reports (SDO) reported at the Italian Ministry of Health regarding the years of this paper. The yearly number of hospital admission for SCFE, the percentage of males and females, the average age, days of hospitalization, primary diagnoses and primary procedures in the whole Italian population were calculated using descriptive statistical analyses.

RESULTS

From 2001 to 2015, 4893 hospitalizations for SCFE were recorded in Italy, with a mean incidence of 2.9 (cases/100.000 inhabitants). The majority of patients treated by SCFE were males (70.6%).

CONCLUSION

National health statistics for SCFE are attractive for an international audience, as different approaches to screening are reported between countries. These differences allow comparing outcomes internationally. Moreover, sharing national statistics and correlating those to other countries protocols, could be helpful to compare outcomes for different procedures internationally. However, further studies are required to understand the specific reasons for regional variation for SCFE procedures in Italy.

LEVEL OF EVIDENCE

III.

Association of Slipped Capital Femoral Epiphysis With Panhypopituitarism Due to Pituitary Macroadenoma: A Case Report

Slipped capital femoral epiphysis (SCFE) commonly occurs in overweight or obese adolescents, but can also be associated with endocrine disorders including hypothyroidism, pituitary tumors, and growth hormone deficiency. In this article, we present a case of panhypopituitarism that initially presented with SCFE. A 16-year-old male presented with right SCFE. After a right hip open reduction and percutaneous pinning procedure, findings of skeletal maturity that lagged behind his chronologic age and a delayed Tanner stage resulted in a referral to an endocrine specialist. Endocrine laboratory evaluation identified elevated prolactin levels (1493 ng/mL), hypogonadotropic hypogonadism, and central adrenal insufficiency as evidenced by low morning cortisol level of 1.0 µg/dL. Magnetic resonance imaging revealed a large pituitary T2 isointense mass measuring 1.8 × 2.7 × 2.3 cm. The patient was diagnosed with panhypopituitarism due to a pituitary macroadenoma. Multidisciplinary collaboration for treatment of this patient consisted of oral cabergoline, oral levothyroxine, oral hydrocortisone therapy, intramuscular testosterone therapy, and a prophylactic closed reduction percutaneous pinning of the left hip due to high risk of also developing SCFE of the left hip. Panhypopituitarism should be considered as a diagnosis after atypical presentations of SCFE. In our case, an astute clinical assessment resulted in prompt endocrine referral and management of panhypopituitarism. Our report highlights the importance of multidisciplinary collaborations to guarantee early detection of endocrinopathies in patients with SCFE undergoing surgical interventions in order to avoid potential complications, such as adrenal crisis during surgery.

The diagnosis and management of common childhood orthopedic disorders: An update

Musculoskeletal illness represents a significant portion of office visits to primary and urgent care clinicians. Despite this, little emphasis is placed on learning pediatric orthopaedics during medical school or residency. The focus of this paper is to provide a systematic approach to this general musculoskeletal physical exam and to assist in the recognition of what conditions are normal development and what conditions require observation, workup and referral to an experienced pediatric orthopaedist.

Imaging of osteochondrosis

Osteochondrosis is an abnormality of the epiphyses or epiphyseal equivalents (round bones and apophyses) during later stages of endochondral ossification. This process of abnormal endochondral ossification can occur at various locations throughout the body. The pathogenesis of osteochondrosis is under active investigation. In humans, the process of abnormal endochondral ossification has been attributed to a combination of vascular insult and trauma. Although the proposed etiology of osteochondrosis varies based on body part affected, the overall process is defined by necrosis, revascularization and repair. As such, common radiologic findings include those of osseous destruction and associated inflammation. The purpose of this review is to discuss the current understanding of osteochondroses as a disease entity and explore imaging features of osteochondroses throughout the body.

Diagnostic and Therapeutic Challenges of a Slipped Capital Femoral Epiphysis in a Low and Middle Income Country: A Case Report and Literature Review

Background:

Slipped Capital Femoral Epiphysis (SCFE) is an incapacitating orthopedic disease, particularly affecting older children and adolescents and caused by the sliding of the proximal femoral epiphysis on the metaphysis. SCFE has a clinical polymorphism, compounded with a certain diagnostic variability among health practitioners and the relatively high cost of its surgical management contribute to the diagnostic delay observed in most developed countries as well as developing ones. Herein, we report the case of SCFE in an adolescent Cameroonian, with emphasis on its diagnostic and therapeutic challenges in Low and Middle-Income Countries (LMICs), in a bit to improve on timely recognition and management by clinicians in these settings.

Case Presentation:

A 10-year-old girl has presented with unilateral right thigh pain of more than one year duration associated with a limping gait and no fever. Before the referral to our health facility, she consulted several general practitioners in rural areas and pediatricians in the city with no definite diagnosis. On the basis of the clinical and the imaging studies, the diagnosis of stable right SCFE with moderate displacement was made. Under general anesthesia, the patient underwent open reduction and internal fixation with three pins under c-arm fluoroscopy. Clinical and radiological follow-up till one year after surgical intervention were satisfactory. The pins were removed after one year of fixation confirming a good bone fusion in plain x-ray. Her clinical examination and radiological follow-up three years after removal of the pins were satisfactory.

Conclusion:

The case report illustrates that SCFE often a missed diagnosis in LMICs. This is worrisome because delayed diagnosis may lead to long-term complications such as avascular necrosis and early degenerative joint disease. Although the above case was missed by several clinicians and finally diagnose late, the present case highlights the need for a high index of clinical suspicion in order to timely diagnose and timely manage SCFE to avert potential long-term physical disabilities and psychological trauma in children.