Purposeful Closed Reduction and Pinning in Unstable Slipped Capital Femoral Epiphysis Results in a Rate of Avascular Necrosis Comparable to the Literature Mean

Medium-long-term follow-up of slipped capital femoral epiphysis treated with in situ fixation and patient-acceptable symptom state evaluation

This study evaluates the Patient Acceptable Symptom State (PASS) in patients with slipped capital femoral epiphysis (SCFE) treated with in situ fixation, focusing on medium to long-term outcomes and quality of life. Its primary goal is to establish a subjective well-being cutoff, using subjective methods and the iHOT33 scale, for assessing patients in future studies. Additionally, it explores functionality differences between mild and moderate-severe SCFE, case series epidemiology and potential complications. A retrospective analysis of 63 patients (73 hips), treated for SCFE between 2000 and 2017 at our facility using in situ fixation, was conducted. These patients underwent clinical, anamnestic, and radiological assessments, with PASS determined based on iHOT33 questionnaire results and statistical analysis. The mean age at surgery was 12.95 years (±1.64, range 9-17), with an average follow-up of 11 years (±4.60, range 5-20). At follow-up, 87% of patients reported achieving PASS, with higher iHOT33 scores correlating to PASS. A cutoff of >68 on the iHOT33 scale showed strong predictive ability for assessing PASS (area under the curve 0.857, 88.89% sensitivity, 79.69% specificity). The findings indicate that 87% of patients achieved PASS at medium to long-term follow-up, with better clinical function than those who did not report PASS. The iHOT33 scale's effectiveness in predicting PASS, especially with a cutoff of >68, suggests this method's efficacy. Given these positive outcomes, including in moderate-severe cases treated with in situ fixation, this approach is considered a viable therapeutic option.

Subcapital realignment osteotomy for the treatment of moderate and severe slipped upper femoral epiphysis: A retrospective study of 123 hips in a tertiary center

Background

The surgical treatment of moderate and severe slipped capital femoral epiphysis is controversial. Treatment ranges from pinning in situ to open dislocation and reduction of the slipped epiphysis. The modified Dunn procedure has been associated with variable avascular necrosis with rates, ranging between 0% and 67%. The aim of this study was to evaluate the outcomes and complications of patients who have undergone a subcapital realignment osteotomy (SCRO) in our center.

Methods

A retrospective longitudinal study of the osteotomies performed between 2009 and 2019 in a tertiary referral center for Pediatric Orthopedics in Queensland, Australia. Patient demographics, stability, and severity of slip and surgical outcomes were collected.

Results

A total of 123 procedures were performed on 116 patients. The mean age was 12.4 years, 65 (56%) patients were male and the mean posterior sloping angle was 60.10 with 93 (75%) being severe slips. There were 51 (41.5%) Loder's stable and 72 (58%) unstable slipped capital femoral epiphysis. Our overall avascular necrosis rate following SCRO was 17.8%. Time between surgery and diagnosis did not have an effect on avascular necrosis.

Conclusion

The subcapital realignment osteotomy remains a controversial and complex procedure for the management of moderate and severe slipped capital femoral epiphysis. We found that our cohort demonstrated an avascular necrosis rate in keeping with the existing literature. This indicates that when performed in a high-volume center with experienced surgical staff, it can be an effective treatment option for these patients.

Level of evidence

Level IV.

A Delphi consensus study on the treatment of slipped capital femoral epiphysis: Considerable consensus in mild and moderate slips and limited consensus in severe slips

Purpose

The aim of this expert consensus study was to establish consensus on the treatment of different types of slipped capital femoral epiphysis and on the use of prophylactic screw fixation of the contralateral unaffected side.

Methods

In this study, a four-round Delphi method was used. Questionnaires including all possible theoretical slip scenarios were sent online to 14 participants, experienced in the field of children's orthopedics and in the treatment of hip disorders in children.

Results

In-situ fixation was considered to be the first treatment choice in all types of mild slip scenarios and in moderate, stable ones. Performing in-situ fixation was not favored in moderate, unstable, and in all severe slip scenarios. In moderate to severe, unstable slip scenarios, there was consensus on the use of gentle closed or open reduction and internal fixation. Any consensus was not established in the optimal treatment of severe, stable slips. There was also consensus on the use of prophylactic screw fixation of the contralateral side in case of co-existing endocrine disorder and younger age.

Conclusions

The establishment of consensus on the treatment of all types of slipped capital femoral epiphysis even among the experienced surgeons does not seem to be possible. The severity of the slip and stability of the slip are the primary and secondary determinants of the surgeons' treatment choices, respectively. In-situ fixation is still the preferred treatment option in several slip types. Gentle capital realignment by closed or open means is recommended in displaced, unstable slips. Prophylactic screw fixation of the contralateral side is indicated under certain circumstances.

Level of evidence

level V.