The epidemiology and demographics of slipped capital femoral epiphysis

Pulmonary Embolism in Klippel-Trenaunay-Weber Syndrome With Slipped Capital Femoral Epiphysis

CASE

A 12-year-old boy with Klippel-Trenaunay-Weber syndrome underwent surgery for unstable slipped capital femoral epiphysis who developed pulmonary embolism postoperatively.

CONCLUSION

It is important to be vigilant about pulmonary embolism in children because it is rare but potentially fatal, especially in the presence of risk factors. Early diagnosis and treatment of unstable slipped capital femoral epiphysis are crucial to minimize immobility. Close monitoring of femoral head osteonecrosis is also necessary.

ChatGPT Responses to Common Questions About Slipped Capital Femoral Epiphysis: A Reliable Resource for Parents?

BACKGROUND

We sought to evaluate the ability of ChatGPT, an AI-powered online chatbot, to answer frequently asked questions (FAQs) regarding slipped capital femoral epiphysis (SCFE).

METHODS

Seven FAQs regarding SCFE were presented to ChatGPT. Initial responses were recorded and compared with evidence-based literature and reputable online resources. Responses were subjectively rated as "excellent response requiring no further clarification," "satisfactory response requiring minimal clarification," "satisfactory response requiring moderate clarification," or "unsatisfactory response requiring substantial clarification."

RESULTS

ChatGPT was frequently able to provide satisfactory responses that required only minimal clarification. One response received an excellent rating and required no further clarification, while only 1 response from ChatGPT was rated unsatisfactory and required substantial clarification.

CONCLUSIONS

ChatGPT is able to frequently provide satisfactory responses to FAQs regarding SCFE while appropriately reiterating the importance of always consulting a medical professional.

An articulated shape model to predict paediatric lower limb bone geometry using sparse landmarks

Creating musculoskeletal models in a paediatric population currently involves either creating an image-based model from medical imaging data or a generic model using linear scaling. Image-based models provide a high level of accuracy but are time-consuming and costly to implement, on the other hand, linear scaling of an adult template musculoskeletal model is faster and common practice, but the output errors are significantly higher. An articulated shape model incorporates pose and shape to predict geometry for use in musculoskeletal models based on existing information from a population to provide both a fast and accurate method. From a population of 333 children aged 4-18 years old, we have developed an articulated shape model of paediatric lower limb bones to predict bone geometry from eight bone landmarks commonly used for motion capture. Bone surface root mean squared errors were found to be 2.63 ± 0.90 mm, 1.97 ± 0.61 mm, and 1.72 ± 0.51 mm for the pelvis, femur, and tibia/fibula, respectively. Linear scaling produced bone surface errors of 4.79 ± 1.39 mm, 4.38 ± 0.72 mm, and 4.39 ± 0.86 mm for the pelvis, femur, and tibia/fibula, respectively. Clinical bone measurement errors were low across all bones predicted using the articulated shape model, which outperformed linear scaling for all measurements. However, the model failed to accurately capture torsional measures (femoral anteversion and tibial torsion). Overall, the articulated shape model was shown to be a fast and accurate method to predict lower limb bone geometry in a paediatric population, superior to linear scaling.

Does spinopelvic alignment affect femoral head cartilage and the proximal femoral physis in slipped capital femoral epiphysis? A finite element analysis

BACKGROUND

Slipped capital femoral epiphysis is a prevalent pediatric hip disorder. Recent studies suggest the spine's sagittal profile may influence the proximal femoral growth plate's slippage, an aspect not extensively explored. This study utilizes finite element analysis to investigate how various spinopelvic alignments affect shear stress and growth plate slip.

METHODS

A finite element model was developed from CT scans of a healthy adult male lumbar spine, pelvis, and femurs. The model was subjected to various sagittal alignments through reorientation. Simulations of two-leg stance, one-leg stance, walking heel strike, ascending stairs heel strike, and descending stairs heel strike were conducted. Parameters measured included hip joint contact area, stress, and maximum growth plate Tresca (shear) stress.

FINDINGS

Posterior pelvic tilt cases indicated larger shear stresses compared to the anterior pelvic tilt variants except in two leg stance. Two leg stance resulted in decreases in the posterior tilted pelvi variants hip contact and growth plate Tresca stress compared to anterior tilted pelvi, however a combination of posterior pelvic tilt and high pelvic incidence indicated larger shear stresses on the growth plate. One leg stance and heal strike resulted in higher shear stress on the growth plate in posterior pelvic tilt variants compared to anterior pelvic tilt, with a combination of posterior pelvic tilt and high pelvic incidence resulting in the largest shear.

INTERPRETATION

Our findings suggest that posterior pelvic tilt and high pelvic incidence may lead to increased shear stress at the growth plate. Activities performed in patients with these alignments may predispose to biomechanical loading that shears the growth plate, potentially leading to slip.

Decade-long Trends in Incidence of Slipped Capital Femoral Epiphysis in the United States: A Nationwide Database Analysis of Over 33 Million Patients

PURPOSE

Slipped capital femoral epiphysis (SCFE) is a prevalent pediatric hip disorder linked to severe complications, with childhood obesity as a crucial risk factor. Despite the rising obesity rates, contemporary data on SCFE's epidemiology remain scarce in the United States. This study examined SCFE incidence trends and demographic risk factors in the United States over a decade.

METHODS

A decade-long (2011 to 2020) retrospective cohort study was undertaken using the Healthcare Cost and Utilization Project National Inpatient Sample. Patients aged younger than 18 years were identified and further analyzed if diagnosed with SCFE through ICD-9 or ICD-10 codes. Key metrics included demographics variables, with multivariate regression assessing demographic factors tied to SCFE, and yearly incidence calculated.

RESULTS

Of 33,180,028 pediatric patients, 11,738 (0.04%) were diagnosed with SCFE. The incidence escalated from 2.46 to 5.96 per 10,000 children, from 2011 to 2020, mirroring childhood obesity trends. Lower socioeconomic status children were predominantly affected. Multivariate analysis revealed reduced SCFE risk in female patients, while Black and Hispanic ethnicities, alongside the Western geographic location, had an increased risk.

CONCLUSION

This study underscores a twofold increase in SCFE incidence over the past decade, aligning with childhood obesity upsurge. Moreover, SCFE disproportionately affects lower SES children, with male sex, Black and Hispanic ethnicities amplifying the risk. This calls for targeted interventions to mitigate SCFE's effect, especially amidst the vulnerable populations.

The Effect of Human Growth Hormone Treatment on the Development of Slipped Capital Femoral Epiphysis: A Cohort Analysis With 6 Years of Follow-up

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is a common hip disorder in adolescents that can result in substantial complications, impacting the quality of life. Human Growth Hormone (HGH) administration may elevate the risk of SCFE, though the relationship remains unclear. Clarifying this association could enable better monitoring and earlier diagnosis of SCFE in patients receiving HGH. The aim of the study is to investigate the association between HGH administration and the incidence of SCFE.

METHODS

This retrospective cohort study utilized data from the TriNetX research database from January 2003 to December 2022. The study included 2 cohorts: an HGH cohort including 36,791 patients aged below 18 years receiving HGH therapy and a control group consisting of patients who did not receive HGH therapy. A 1:1 propensity score matching technique was employed to ensure comparability between the HGH and no-HGH cohorts. The primary outcome measure was the development of SCFE identified by International Classification of Diseases codes. For comparative analysis, both risk ratios (RR) and hazard ratios were computed to evaluate the association between HGH therapy and the development of SCFE.

RESULTS

The HGH cohort had an increased risk of SCFE compared with the no-HGH cohort (RR: 3.5, 95% CI: 2.073, 5.909, P <0.001) and had an increased hazard of developing SCFE (hazard ratio: 2.627, 95% CI: 1.555, 4.437, P <0.001). Patients with higher exposure to HGH (defined as >10 prescriptions) had an RR of 1.914 (95% CI: 1.160, 3.159, P =0.010) when compared with their counterparts with ≤10 prescriptions.

CONCLUSIONS

In the largest study to date, HGH administration was associated with an elevated risk of SCFE in children in a dose-dependent manner.

LEVEL OF EVIDENCE

Level III-therapeutic retrospective cohort study.

Healthcare segregation in orthopedic surgery: A statewide analysis of American Indian and Alaska Native patients

Significant health disparities have been described for American Indian and Alaska Native (AIAN) patients undergoing various surgical procedures, however, research into healthcare segregation within orthopedic surgery has been limited. In this study, our purpose was to assess if AIAN patients were more likely to be treated by lower-volume surgeons and at lower-volume hospitals. AIAN and White patients who underwent one of four common orthopedic procedures (knee or hip arthroplasty, femur or tibia repair) were identified from a Washington state inpatient database. Demographic, socioeconomic, geographic, and procedure data were surveyed, and volumetric thresholds were established for lower versus higher volume surgeons and hospitals. Adjusted odds ratios were calculated for AIAN patients receiving care from a lower volume surgeon or hospital, including covariates for patient demographics, geographic, and socioeconomic status. AIAN patients were more likely to receive care from a lower-volume surgeon for all procedures except tibial repair. Adjusted odds ratios of 1.53 (95% confidence interval [CI]: 1.22, 1.92) and 1.68 (95% CI: 1.26, 2.21) were found for AIAN patients receiving knee or hip arthroplasty from a lower volume surgeon, respectively. There was no strong evidence of AIAN patients being more likely to receive care at a lower-volume hospital. Finally, AIAN patients having knee arthroplasty at a higher volume hospital were more likely to have their surgery performed by a lower volume surgeon. These data suggest that there may be significant healthcare segregation among AIAN patients across common orthopedic surgical procedures.

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.

Quantifying Risk Factors for Slipped Capital Femoral Epiphysis and Postslip Osteonecrosis

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is a disorder of the proximal femoral physis occurring in late childhood and adolescence. Previously postulated risk factors include obesity and endocrinopathies. The purpose of this investigation was to identify risk factors for developing SCFE, as well as postslip osteonecrosis (ON), among the United States pediatric population.

METHODS

A national database investigation was performed using PearlDiver Technologies, Inc., queried for SCFE and ON using International Classification of Disease codes (2010 to 2020). Regression analyses to determine the risk of developing a SCFE, and ON after a patient has already been diagnosed with a SCFE ("postslip"). Propensity matching between SCFE and control groups generated a pseudo-randomization model to compare the relative risk.

RESULTS

There were 11,465 patients with SCFE available in the database, matched with 134,680 controls. After matching, vitamin D deficiency, obesity, hypothyroidism, and growth hormone use were risk factors for developing SCFE [relative risk ranges from 1.42 (95% CI: 1.21-1.39, vitamin D deficiency) to 3.45 (95% CI: 3.33-3.57, obesity)]. ON risk factors were vitamin D deficiency [1.65 (1.26-2.14)] and hypothyroidism [1.49 (1.10-2.07)].

CONCLUSIONS

This United States national database study quantified risk factors of developing an SCFE and postslip ON. Obesity is the most significant risk factor for the development of a slip, but not ON. Growth hormone use, hypothyroidism, and vitamin D deficiency are also risk factors for SCFE development, whereas only the latter two were associated with ON. These findings demonstrate the public health implications of obesity and comorbid conditions in pediatric hip pathology.

LEVEL OF EVIDENCE

Level III.

In situ fixation of slipped capital femoral epiphysis carries a greater than 40% risk of later total hip arthroplasty during a long-term follow-up

Aims

We aimed to assess the cumulative risk of total hip arthroplasty (THA) from in situ fixation for slipped capital femoral epiphysis (SCFE) after a follow-up of almost 50 years.

Methods

In this study, 138 patients with 172 affected hips treated with in situ fixation were evaluated retrospectively. A total of 97 patients (70%) were male and the mean age was 13.6 years (SD 2.1); 35 patients (25%) had a bilateral disease. The median follow-up time was 49 years (interquartile range 43 to 55). Basic demographic, stability, and surgical details were obtained from patient records. Preoperative radiographs (slip angle; SA) were measured, and data on THA was gathered from the Finnish National Arthroplasty Register.

Results

The preoperative SA was a mean of 39° (SD 19°). At follow-up, 56 of the patients had undergone THA for a hip previously fixed in situ for SCFE (41%) and 64 of all affected hips had been replaced (37%). Kaplan-Meier analysis gave a median prosthesis-free postoperative survival of 55 years (95% confidence interval (CI) 45 to 64) for the affected hips. In a multivariate analysis, female patients had a two-fold risk for THA (hazard ratio (HR) 2.42 (95% CI 1.16 to 5.07)) and a greater preoperative SA increased the risk of THA (HR 1.03 for every increment of 1° (95% CI 1.01 to 1.05)), while patient age at surgery, slip laterality, stability of slip, or diagnostic delay did not have a statistically significant effect on the risk of THA.

Conclusion

SCFE treated primarily with in situ fixation may lead to THA in more than 40% of affected hips at a near 50-year follow-up. This risk is approximately 15-times the reported lifetime risk in the Finnish general population. Female sex and increasing preoperative SA significantly predicted higher risk of THA.

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.

A Narrative Review of Personalized Musculoskeletal Modeling Using the Physiome and Musculoskeletal Atlas Projects

In this narrative review, we explore developments in the field of computational musculoskeletal model personalization using the Physiome and Musculoskeletal Atlas Projects. Model geometry personalization; statistical shape modeling; and its impact on segmentation, classification, and model creation are explored. Examples include the trapeziometacarpal and tibiofemoral joints, Achilles tendon, gastrocnemius muscle, and pediatric lower limb bones. Finally, a more general approach to model personalization is discussed based on the idea of multiscale personalization called scaffolds.

Idiopathic Slipped Capital Femoral Epiphysis: Demographic Differences and Similarities between Stable, Unstable, and Valgus Types

Idiopathic slipped capital femoral epiphysis (SCFE) is a known disorder in pre/adolescent children with vague hip/knee pain. We wished to study the demographic differences between stable varus, unstable varus, and valgus idiopathic SCFEs using a retrospective review over a 10-year period of SCFE children seen at a tertiary children's hospital. Standard demographic data was collected, and radiographs were measured to determine the Southwick angle and status of the tri-radiate cartilage. There were 190 patients; 138 had stable varus SCFEs, 45 unstable varus SCFEs, and 7 valgus SCFEs. All unstable SCFEs were varus, and all valgus SCFEs were stable. There were significant differences between the three groups by age at diagnosis, sex, race, SCFE severity, weight percentile, and duration of symptoms. The average age at diagnosis was 11.0 ± 1.2, 11.8 ± 1.8, and 12.3 ± 1.7 years for the valgus, unstable varus, and stable varus groups (p = 0.019), and similarly, SCFE severity was 25° ± 15°, 48° ± 18°, and 35° ± 19° (p = 0.0002) for the three same groups. Patients with valgus SCFEs were mostly female (86%) compared to the stable varus (39.9%) and unstable (47%) groups (p = 0.05) and mostly non-White (86%) (0.011). The duration of symptoms was 4.1 ± 4.1, 2.3 ± 5.0, and 4.5 ± 5.0 months for the valgus, unstable varus, and stable varus groups (p = 0.00005). These three types of idiopathic SCFEs demonstrated differences by age at diagnosis, sex, race, weight percentile, and duration of symptoms.

Slipped Capital Femoral Epiphysis in Adolescents: Functional Outcomes and Return to Physical Activity after Surgical Treatment

Background: Slipped capital femoral epiphysis (SCFE) represents a relatively common hip disorder in adolescents. The present retrospective study analyzes the correlation between age, severity of the slip and physeal stability and the functional outcomes, as well as the ability to return to previous physical activity (PA) of patients surgically treated with either pining in situ (PIS) or the modified Dunn (MD) procedure (anatomical reduction of the slipped epiphysis). Methods:The present research is a retrospective observational study of patients surgically treated for SCFE from 2010 to 2015. The sample was divided into two groups: those treated with PIS and those with the MD procedure. Univariate and multivariate logistic regression analyses were performed to determine the relationship between age, Loder classification (stable/unstable), as well as Southwick slip angle (severity of the slip) to return to previous PA. Furthermore, linear regression was used to investigate the association of the above predictor variables to Oxford and Harris hip scores (HHS). Results:A total of 32 patients were identified (16 treated with PIS and 16 with the MD procedure). None of the examined predictor variables (age, Southwick slip angle, Loder classification) had statistically significant effect on the ability to return to previous PA in either the in situ or Dunn group. Univariate analysis showed that higher patients' age at the time of surgery was related to worse HHS and Oxford scores in both the PIS and MD groups. Unstable hips seem to affect unfavorably the HHS. Conclusion:The present study did not reveal any relationship between the age, degree of the Southwick slip angle, the stability of the physis, and the return to PA. Exploration of additional confounding factors are warranted to better understand the physis-related impact on the functional outcomes in both groups.

Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement

Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.

Slipped Capital Femoral Epiphysis Pathogenesis and Its Relation to Obesity—Where Do We Stand? A Narrative Review

Slipped capital femoral epiphysis (SCFE) is the most common adolescent hip disorder in children 9–15 years old with an incidence that ranges from 0.33:100,000 to 24.58:100,000. Idiopathic SCFE is strongly associated with obesity, while atypical SCFE is associated with endocrinopathies, metabolic and renal disease, radiation therapy, and chemotherapy. In this review, we summarized the current data regarding the pathogenesis of SCFE and its association to obesity. In the last years, there have been increasing evidence regarding the implication of obesity in the pathogenesis of SCFE, but no definitive mechanism has been proven. The etiology is probably multifactorial, with both mechanical and metabolic factors contributing to the disease, with the later gaining more ground, especially in obese patients. Understanding what causes the disease will help paediatricians and orthopaedists develop more efficient strategies for treating patients and diminishing complication rates.

Slipped Upper Femoral Epiphysis in Adolescents: Evolving Information on Its Mode of Presentation and Management

Background and objective Slipped upper femoral epiphysis (SUFE) is one of the most common hip pathologies in adolescents and pre-adolescents, the diagnosis of which is often missed due to delayed presentations. In this study, we aimed to conduct a retrospective analysis of SUFE cases treated in the hospital during the 15-year period from 2003 to 2018 and examine its bilateral presentation and the need for prophylactic pinning on the unaffected side. Methods This retrospective cohort study involved cases that were treated from 2003 to 2018. The case details were retrieved from the medical records department. Records older than 15 years were excluded owing to their inaccuracy, and 26 cases of SUFE were included in the final analysis. Each case was subjected to physical and radiological examinations of the symptomatic and asymptomatic hips. IBM SPSS Statistics v23 (IBM Corp., Armonk, NY) was used for data analysis. Results In this study, six of the 26 patients had bilateral SUFE and required subsequent surgical pinning. The duration of surgical interventions ranged from two to 22 months, while the mean intervention duration was 10.3 months. Among the cases, 61.5% (p<0.05) were idiopathic in nature upon documentation. However, 19% (p<0.05) of the cases were shown to be associated with an underlying condition or prior symptoms of the condition, whereas 7.6% (p<0.05) had an increased basal metabolic index; 11% (p<0.05) of the cases had an inherited family history of SUFE. A comparison between males and females showed a slightly higher frequency of complications in males (n=14) than in females (n=12) (p=0.556). The age of the patients at the presentation ranged between and 10-15 years, with an average age of 12.5 years. Conclusion Based on our findings, males were affected more than females and most of the cases were idiopathic. There is no significant evidence to support the need for prophylactic pinning of the unaffected hip. We recommend prospective studies with a larger sample of patients to gain more insight into the topic.

Surgical Hip Dislocation in Pediatric and Adolescent Patients

LEVEL OF EVIDENCE

V, Expert opinion.

Colles' Fracture: An Epidemiological Nationwide Study in Italy from 2001 to 2016

The present study aimed to evaluate the yearly number of Colles' fractures in Italy from 2001 to 2016, based on official information found in hospitalization records. A secondary aim was to estimate the average length of hospitalization for patients with a Colles' fracture. A tertiary aim was to investigate the distribution of the procedures generally performed for Colles' fractures' treatment in Italy. An analysis of the National Hospital Discharge records (SDO) maintained at the Italian Ministry of Health, concerning the 15 years of our study (from 2001 to 2016) was performed. Data are anonymous and include the patient's age, sex, domicile, length of hospital stays (days), primary diagnoses and primary procedures. From 2001 to 2016, 120,932 procedures for Colles' fracture were performed in Italy, which represented an incidence of 14.8 procedures for every 100,000 adult Italian inhabitants. The main number of surgeries was found in the 65-69- and 70-74-year age groups. In the present study, we review the epidemiology of Colles' fractures in the Italian population, the burden of the disease on the national health care system (in terms of length of hospitalization) and the distribution of the main surgical procedures performed for the treatment of the disease.

Mid-term results of subcapital realignment of chronic slipped capital femoral epiphysis using surgical hip dislocation: a prospective case series

BACKGROUND

Slipped capital femoral epiphysis (SCFE) requires surgical treatment when diagnosed. The surgical management of moderate to severe SCFE remains an area of controversy among pediatric orthopedic surgeons. The severity of slippage, the viability of the femoral epiphysis, and the method of surgical management determine the long-term clinical and radiographical outcome. This study sought to evaluate the mid-term results of subcapital realignment of chronic stable slipped femoral epiphysis with open physis using surgical hip dislocation.

MATERIALS AND METHODS

This study was a prospective case series of adolescents with moderate or severe degrees of chronic SCFE who had undergone subcapital osteotomy using the surgical hip dislocation technique. The Harris Hip Score (HHS) was used to assess functional outcomes at 6 years of follow-up. A HHS of ≥ 80 points was considered satisfactory. Postoperative radiological outcomes were evaluated using epiphyseal-shaft angles and alpha angles. Postoperative complications were observed.

RESULTS

This study included 40 patients, 32 (80%) males and 8 (20%) females, with a mean age of 14.1 ± 1.8 years. There was a statistically significant improvement in the mean HHS from 45 ± 12.3 preoperatively to 91.8 ± 11.6 points at 6 years of follow-up. The mean epiphyseal-shaft angle reduced from 60.5 ± 15.3° preoperatively to 10.3 ± 2.4° postoperatively, P < 0.001. The mean alpha angle reduced from 72.5 ± 10.1° preoperatively to 40.4 ± 6.4°, P < 0.001. Four (10%) patients showed femoral head avascular necrosis (AVN).

CONCLUSIONS

Subcapital realignment of chronic SCFE can achieve satisfactory clinical and radiological outcomes, but femoral head AVN remains a risk. Level of evidence Level IV.

A review of slipped capital femoral epiphysis

ABSTRACT

Hip pain in children is common, with causes ranging from the benign to destructive. This article reviews slipped capital femoral epiphysis (SCFE), one of the most common hip pathologies in preadolescents and adolescents, which often is missed or delayed in diagnosis because of its vague, atypical presentation.

Slipped Capital Femoral Epiphysis Managed by Ganz Safe Surgical Dislocation of Hip: A Case Report with 2 Years Follow-up

Introduction

Slipped capital femoral epiphysis (SCFE) is commonly managed by in situ screw fixation. However, higher grades of slips require restoration of normal anatomy of the femoral head without compromising the blood supply.

Case Report

A 16-year-old adolescent male presented with the left hip pain and progressive limping for 4 days with no history of previous trauma. On examination, the patient had severe tenderness and gross restriction of movements. Radiological examination revealed Grade 2 acute on chronic SCFE with unstable slip. Modified Dunn procedure through Ganz surgical hip dislocation facilitated the complete restoration of normal anatomy without avascular necrosis of femoral head changes at 2 years of follow-up.

Conclusion

Ganz safe surgical dislocation of the hip is safe for the femoral head, preserving its blood supply in toto and the modified Dunn procedure facilitated the complete restoration of normal anatomy even in acute on chronic type of SCFE cases.

Development and Validation of SCFE Percutaneous Pinning Surgical Simulation

BACKGROUND

In situ screw fixation with a single percutaneously placed femoral screw remains widely accepted for femoral head fixation in adolescent patients with slipped capital femoral epiphysis (SCFE). Given the potential risks involved with this procedure, a simulation whereby surgical skills could be refined before entering the operating room may be of benefit to orthopaedic trainees.

METHODS

We developed a synthetic model for the simulated treatment of SCFE. Five orthopaedic attendings and twenty trainees were recorded performing an in situ percutaneous fixation on the SCFE model. Time, radiation exposure, and final anteroposterior and lateral radiographs of the SCFE model were recorded. After completion, the attendings and trainees answered a Likert-based questionnaire regarding the realism and utility of the simulation, respectively. Two blinded orthopaedic surgeons rated each participant's skill level based on previously described assessment tools, including a Global Rating Scale (GRS) of technical proficiency and radiographic grading index for screw placement. Performance metrics and survey responses were evaluated for construct validity, face validity, and interrater reliability.

RESULTS

The attendings demonstrated superior technical proficiency compared with trainees in terms of higher GRS scores (27.9±1.9 vs. 14.7±5.0, P<0.001) and better radiographic grading of screw placement on lateral views (P=0.019). Similarly, compared with the trainees, the orthopaedic attendings demonstrated shorter operative times (11.0±4.1 vs. 14.7±6.2 min, P=0.035) and less radiation exposure (3.7±1.7 vs. 9.5±5.7 mGy, P=0.037). The interrater reliability was excellent for both the GRS scoring (intraclass correlation coefficient=0.973) and radiographic grading (weighted κ=1.000). The attendings and trainees rated the realism and teaching utility of the simulation as "very good," respectively.

CONCLUSION

Our surgical simulation for in situ percutaneous fixation of SCFE represents a valid and reliable measure of technical competency and demonstrates much promise for potential use as a formative educational tool for orthopaedic residency programs.

LEVEL OF EVIDENCE

Level II.

Examining delays in diagnosis for slipped capital femoral epiphysis from a health disparities perspective

Slipped Capital Femoral Epiphysis (SCFE) is a skeletal pathology affecting adolescents which requires timely surgery to prevent progression. Delays in diagnosis and treatment of SCFE can negatively affect patient prognosis, and few studies have examined how health disparities and barriers to care may influence these delays. In particular, only a handful of studies have included a Hispanic patient sample, despite this ethnic group’s increased risk for the disease and unique barriers to care. A retrospective chart review was conducted for 124 patients surgically treated for idiopathic SCFE from January 2010 to September 2017. Patient data included age, facility and date of diagnosis, sex, BMI, race and ethnicity, Southwick slip angle, and insurance type. Results indicated that patients with private insurance were more likely to present with a mild slip than patients who were insured by Medicaid or uninsured, while patients without insurance were more likely to have severe slips. Patients without insurance also had a significantly higher mean slip than patients with insurance. The relationship between insurance status and slip angle degree was significant independent of race, even though Hispanic individuals were significantly more likely to have Medicaid or be uninsured. All patients without insurance, and a majority of those with Medicaid, were diagnosed in the emergency department. Time to diagnosis and slip angle were positively correlated, which suggests that longer delays led to increase of the slip angle, consistent with previous findings. Time to diagnosis and BMI were also correlated, which may be tied to socioeconomic factors, but the possibility of weight bias should not be dismissed. These results suggest that socioeconomic status and other factors may have contributed to barriers to care which led to delays in diagnosis and thus more severe slips. Future SCFE research should include health disparities variables to better inform treatment and prognosis.

Slipped Capital Femoral Epiphysis Associated With Athletic Activity

BACKGROUND

Little data exist regarding the association of slipped capital femoral epiphysis (SCFE) and sporting activities.

HYPOTHESIS

There is no association between SCFE and sporting activities.

STUDY DESIGN

Retrospective review of all SCFE cases at our institution from 2010 through March 2021.

LEVEL OF EVIDENCE

Level 3.

METHODS

All patients with idiopathic SCFE were reviewed looking for the presence/absence of sporting activities and symptom onset. Also collected were the age, symptom duration, and weight/height of the patient, sex, race, and stable/unstable nature of the SCFE. The severity of the SCFE was measured using the lateral epiphyseal-shaft angle.

RESULTS

There were 193 children (110 boys, 83 girls) with idiopathic SCFEs. The SCFE was stable in 147, unstable in 45, and unknown in 1. The average age was 12.1 ± 1.8 years, average SCFE angle 38° ± 20° and symptom duration 4.0 ± 5.1 months. An association with a sporting activity was present in 64 (33%). The sporting activity was basketball (18), football (11), baseball/softball (10), and others (23). Football, basketball, and soccer predominated in boys, baseball and running sports were equal between boys and girls, and cheerleading/gymnastics/dancing predominated in girls. Differences showed that those involved in sports had a slightly lower body mass index (BMI) (88th percentile vs 95th percentile, P = 0.00). There were no differences between those involved and those not those involved in sporting activities for symptom duration, SCFE severity, sex, race, or stable/unstable SCFE type.

CONCLUSION

Sporting activities are associated with the onset of symptoms in 1 of 3 of patients with SCFE, refuting the null hypothesis.

CLINICAL RELEVANCE

A high level of suspicion for SCFE should be given when any peripubertal athlete presents with hip or knee pain regardless of BMI/obesity status, and appropriate imaging performed.

ETIOLOGY, PATHOGENESIS, DIAGNOSIS AND PRINCIPLES OF TREATMENT OF SLIPPED CAPITAL FEMORAL EPIPHYSIS. LITERATURE REVIEW

Aim: to describe the epidemiology, possible causes and predisposing factors for the development of slipped capital femoral epiphysis. To follow the evo­lution of classifications. Analyze indications for surgical treatment, as well as types of surgical treatment.  

Materials and methods: this review article analyzes the data of Russian and foreign literature on the etiology, pathogenesis, diagnosis and treatment of slipped capital femoral epiphysis.  

Results: in view of the frequent distribution in the population, high risks of disability in pediatric patients, the issue of treatment of slipped capital femoral epiphysis remains very relevant. Many methods of surgical treatment have been proposed depending on the stage of the disease, however, they have their own advantages and disadvantages.  

Conclusions: Conservative treatment in the long term did not show good results, generally accepted, according to most sources of literature, surgical treatment is considered. The gold standard in the surgical treatment of the disease does not exist today, and the methods and tactics of treatment are being improved.

Morphological variation in paediatric lower limb bones

Available methods for generating paediatric musculoskeletal geometry are to scale generic adult geometry, which is widely accessible but can be inaccurate, or to obtain geometry from medical imaging, which is accurate but time-consuming and costly. A population-based shape model is required to generate accurate and accessible musculoskeletal geometry in a paediatric population. The pelvis, femur, and tibia/fibula were segmented from 333 CT scans of children aged 4–18 years. Bone morphology variation was captured using principal component analysis (PCA). Subsequently, a shape model was developed to predict bone geometry from demographic and linear bone measurements and validated using a leave one out analysis. The shape model was compared to linear scaling of adult and paediatric bone geometry. The PCA captured growth-related changes in bone geometry. The shape model predicted bone geometry with root mean squared error (RMSE) of 2.91 ± 0.99 mm in the pelvis, 2.01 ± 0.62 mm in the femur, and 1.85 ± 0.54 mm in the tibia/fibula. Linear scaling of an adult mesh produced RMSE of 4.79 ± 1.39 mm in the pelvis, 4.38 ± 0.72 mm in the femur, and 4.39 ± 0.86 mm in the tibia/fibula. We have developed a method for capturing and predicting lower limb bone shape variation in a paediatric population more accurately than linear scaling without using medical imaging.

Medium-term outcomes of extraarticular corrective osteotomy for slipped capital femoral epiphysis

Despite the diversity of surgical options for slipped capital femoral epiphysis (SCFE), there is an ongoing search for the technique that would ensure a satisfactory outcome, stable fixation of bone fragments and a low rate of complications. The aim of this study was to improve the surgical technique for SCFE in patients with moderate and severe SCFE. The study included 52 children (16 girls and 36 boys) aged 10-15 years (the mean age was 13.2 years) with chronic severe (Krechmar’s stage III) stable (according to Loder’s classification) SCFE. The control group (n = 16) underwent a classic Imhauser procedure; the main group (n = 36) underwent a triplane osteotomy proposed by the authors of the study. The patients were examined prior to surgery and in the late follow-up period (the mean follow-up time was 4.7 years, ranging from 1 to 10 years). The procedure included a clinical examination, history taking, radiography to measure the slip angle and the severity of the slip, and the Harris hip score to assess hip function. After 4.7 years, both groups demonstrated an increase in the range of motion, in comparison with their preoperative results (p ≤ 0.05), good Harris hip scores (94 points in the main group and 81 points in the control group. Postoperative radiographs showed consolidation of the bone, recovery of the proximal femur anatomy. Leg length discrepancy improved significantly in both groups. The proposed technique for extraarticular osteotomy allows recovering the length of the affected leg, the anatomy and physiology of the hip joint, is simple and less traumatic.

Mechanical Failure of 2 Cannulated Screw Fixation for Unstable SCFE: A Case Report

CASE

A 13-year-old obese boy presented with an acute-on-chronic unstable left slipped capital femoral epiphysis (SCFE). He underwent in situ surgical fixation with two 6.5-mm fully threaded cannulated screws. At 6 months, he presented with mechanical failure of both screws. He underwent screw removal, revision in situ fixation, a peritrochanteric flexion and internal rotational osteotomy, and an open femoroplasty. The osteotomy healed at 6 weeks. The femoral physis took an additional year to close.

CONCLUSION

This case highlights an uncommon complication of in situ pinning of SCFE, discusses revision fixation options, and suggests possible prolonged physeal closure in severe slips.

Is a Femoro-Acetabular Impingement Type Cam Predictable after Slipped Capital Femoral Epiphysis?

(1) Background: Previous studies have proven a high incidence of a femoro-acetabular impingement (FAI) type cam in patients sustaining a slipped capital femoral epiphysis (SCFE). Thus, the current study analyzed, if a cam deformity is predictable after SCFE treatment; (2) Methods: 113 cases of SCFE were treated between 1 January 2005 and 31 December 2017. The radiological assessment included the slip angle after surgery (referenced to the femoral neck (epiphyseal tilt) and shaft axis as Southwick angle) and the last available lateral center edge angle (LCEA), the acetabular- and alpha angle. A correlation was performed between these parameters and the last alpha angle to predict a FAI type cam; (3) Results: After a mean follow-up of 4.3 years (±1.9; 2.0-11.2), 48.5% of the patients showed a FAI type cam and 43.2% a dysplasia on the affected side. The correlation between the epiphyseal tilt and alpha angle was statically significant (p = 0.017) with a medium effect size of 0.28; (4) Conclusions: The postoperative posterior epiphyseal tilt was predictive factor to determine the alpha angle. However, the cut-off value of the slip angle was 16.8° for a later occurrence of a FAI type cam indicating a small range of acceptable deviations from the anatomical position for SCFE reconstruction.

Long-Term Results of Slipped Capital Femoral Epiphysis Treated with the Modified Dunn Procedure in a Colombian Cohort

Backgroud

Slipped capital femoral epiphysis (SCFE) is a severe and catastrophic disorder that affects the hips of adolescents. Many reports about surgical procedures to treat this condition have been published, but to our knowledge, there are no published results of treatment in Latin American patients. This study describes the clinical and radiological results of the modified Dunn procedure with the surgical approach described by Ganz to treat mild to severe SCFE in a cohort of Colombian pediatric patients.

Methods

We retrospectively analyzed 21 patients (22 hips) with SCFE treated with surgical dislocation of the hip from 2005 to 2017. The same pediatric orthopedic surgeon performed all operations. Clinical outcome was assessed using the range of movement and Merle d'Aubigné score, while radiological measurements and assessment included the slip angle and Tönnis score.

Results

The average duration of follow-up was 29 months (range, 12-72 months). Of all cases, 17 presented with acute-on-chronic symptoms. Preoperatively, all 22 hips were classified as poor according to the Merle d'Aubigné score. Preoperative radiological classification showed compromise grade II or III in 20 hips. Last follow-up Merle d'Aubigné score rated 17 cases as good or excellent (p < 0.05). The postoperative radiological classification was grade I or II in all 22 cases, and the Tönnis score was stage II in 3 cases and stage III in 4 cases.

Conclusions

Our results suggest that the modified Dunn osteotomy performed through the Ganz technique could be safely and effectively used to treat patients with mild to severe SCFE.

Modified Oxford Bone Scores Are Reduced in Patients With Slipped Capital Femoral Epiphysis Compared With Healthy Controls

BACKGROUND

The etiology and pathogenesis of slipped capital femoral epiphysis (SCFE) are attributable to abnormalities of the proximal femoral epiphysis. This study aimed to examine if there is a difference in the bone age of patients diagnosed with SCFE compared with patients without hip pathology.

METHODS

We identified a consecutive series of patients treated for SCFE between December 2012 and December 2019 from a departmental database. Retrospective chart review was performed to collect demographic information and patient medical history. We then obtained a control group of statistically similar patients based on age and sex. These patients did not have hip pathology or medical comorbidities that could alter their bone age. The modified Oxford bone score (mOBS) was calculated for both groups by 3 blinded reviewers. We excluded patients with unstable slips, endocrine disorders, and inadequate imaging.

RESULTS

We identified 60 patients with stable idiopathic SCFE during the study period; 45 met inclusion criteria and were included in the final analysis. There were 27 males and 18 females. The average age of patients with SCFE was higher in males than females (12.6 vs. 11.1, P<0.01). Patients in the comparison cohort did not differ significantly from the SCFE cohort in terms of age (11.6 vs. 12.0, P=0.06) or sex (P=0.52). The comparison group's median mOBS was significantly higher than the SCFE group (22.5 vs. 20.5, P<0.01). The difference in the mOBS between male and female patients in the SCFE group approached significance (20.0 vs. 21.0, P=0.05). The weighted κ coefficient was 0.93.

CONCLUSIONS

Patients with SCFE have a decreased bone age compared with patients without hip pathology. Male patients with SCFE were more likely to be older compared with female patients.

LEVEL OF EVIDENCE

Level IV-retrospective study.

The Genetic Epidemiology of Joint Shape and the Development of Osteoarthritis

Congruent, low-friction relative movement between the articulating elements of a synovial joint is an essential pre-requisite for sustained, efficient, function. Where disorders of joint formation or maintenance exist, mechanical overloading and osteoarthritis (OA) follow. The heritable component of OA accounts for ~ 50% of susceptible risk. Although almost 100 genetic risk loci for OA have now been identified, and the epidemiological relationship between joint development, joint shape and osteoarthritis is well established, we still have only a limited understanding of the contribution that genetic variation makes to joint shape and how this modulates OA risk. In this article, a brief overview of synovial joint development and its genetic regulation is followed by a review of current knowledge on the genetic epidemiology of established joint shape disorders and common shape variation. A summary of current genetic epidemiology of OA is also given, together with current evidence on the genetic overlap between shape variation and OA. Finally, the established genetic risk loci for both joint shape and osteoarthritis are discussed.

A POST-TREATMENT RETROSPECTIVE EVALUATION OF SLIPPED CAPITAL FEMORAL EPIPHYSIS

Objective:

To analyze the cases of slipped capital femoral epiphysis (SCFE) submitted to surgery at the Pediatric Orthopedics Surgery service of the Hospital Risoleta Tolentino Neves (HRTN), Belo Horizonte/MG, between 2016 and 2019.

Methods:

Patients treated for SCFE at the HRTN between January/2016 and January/2019 participated in this study. The following data were collected: gender, age, affected side, procedure performed, and postoperative complications.

Results:

Twenty-one patients were treated at HRTN during the specified period. Among these, most were female (57%) with mean age of 12 years. At the initial diagnosis, about 80% of the patients presented with chronic/acute-on-chronic epiphysis. The left hip was slightly more affected than the right (6:5), with a bilateral rate of 47%, and avascular necrosis was the most frequent complication, occurring in 33% of cases.

Conclusion:

Slipped femoral capital epiphysis is associated with high morbidity; thus, early diagnosis, endocrine disorder investigation, and appropriate surgical treatment are key for improving these patients’ clinical and functional outcome. Level of Evidence II, Retrospective study.

X-linked congenital adrenal hypoplasia: a case presentation

BACKGROUND

Most patients with congenital adrenal hypoplasia (AHC) develop symptoms during infantile and juvenile periods, with varying clinical manifestations. AHC is a disease that is easily misdiagnosed as Addison's disease or congenital adrenal hyperplasia (CAH). There was also a significant time difference between the age at which patients developed symptoms and the age at which they were diagnosed with AHC. Most patients showed early symptoms during infantile and juvenile periods, but were diagnosed with AHC many years later.

CASE PRESENTATION

We are currently reporting a male patient who developed systemic pigmentation at age 2 and was initially diagnosed with Addison's disease. At 22 years of age, he experienced a slipped capital femoral epiphysis (SCFE), a disease mostly seen in adolescents aged 8-15 years, an important cause of which is endocrine disorder. Testes evaluated using color Doppler Ultrasonography suggested microcalcifications. Further genetic testing and auxiliary examinations revealed that the patient had hypogonadotropic hypogonadism (HH) and DAX-1 gene disorders, at which time he was diagnosed with AHC complicated by HH. He was given hormone replacement therapy, followed by regular outpatient review to adjust the medication.

CONCLUSIONS

The typical early symptoms of AHC are hyperpigmentation and ion disturbance during infantile and juvenile periods, while few patients with AHC develop puberty disorders as early symptoms. AHC is prone to being misdiagnosed as Addison's disease, and then gradually develops the symptoms of HH in adolescence. The definitive diagnosis of AHC ultimately is based on the patient's clinical presentation, laboratory results and genetic testing results.

Intraoperative assessment of femoral head perfusion during surgical hip dislocation for slipped capital femoral epiphysis

Avascular necrosis is the most devastating complication of slipped capital femoral epiphysis, leading to collapse of the femoral head, increased risk of osteoarthritis and the requirement of early total hip arthroplasty. It is believed that intraoperative femoral head perfusion assessment may be an accurate predictor of post-operative avascular necrosis (radiographic collapse). At our institution, femoral head perfusion is assessed intraoperatively during all sub-capital realignment procedures. We hypothesize that our method is accurate in predicting the risk of developing post-operative avascular necrosis. In this retrospective study, we collected data from all patients that had intraoperative blood flow measurements during sub-capital realignment procedures. We correlated this with long-term radiographs looking for radiographic collapse. The intraoperative femoral head perfusion assessments during sub-capital realignment procedures for slipped capital femoral epiphysis at our institution, between January 2015 and March 2020 inclusive were assessed for reliability. In total, 26 of 35 patients had intraoperative femoral head perfusion present. Only 2 (8%) of these patients developed radiographic collapse. In contrast, 7 (78%) of the 9 patients who did not have femoral head perfusion present intraoperatively developed radiographic collapse, indicating that our method may be reliable in predicting a patient’s post-operative risk of developing avascular necrosis.

Patients' delay is the major cause for late diagnosis of slipped capital femoral epiphysis

Early diagnosis of slipped capital femoral epiphysis (SCFE) is essential in order to reduce slip severity and subsequent risk of sequelae. The aims of this study were to evaluate patients' and doctors' delay in SCFE diagnosis and to identify possible factors leading to delay. We performed a retrospective review of medical charts and a personal interview with 54 consecutive patients admitted with a diagnosis of stable SCFE at three hospitals in Sweden between 2001 and 2009. Data on symptom duration, symptomatology, medical visits and type of medical contacts were retrieved. Slip angle (Southwick head-shaft angle) was measured. Median total delay from onset of symptoms to surgery was 26 weeks (range 1-109). Patients' delay was significantly longer than doctors' delay: 10 weeks (range 1-57) vs. 4 weeks (range 0-57) (P=0.002). Boys had significantly longer patients' delay than girls (13 vs. 6 weeks, P=0.021) but not doctors' delay. Children with dominance of knee pain had significantly longer doctors' delay (14 vs. 4 weeks, P=0.002) but not patients' delay. As expected, the total delay duration correlated with slip severity (R=0.59, P<0.001). Results demonstrate considerable delay in diagnosis of SCFE in Sweden, although the major cause is patients' delay. Boys and children with dominance of knee pain are more likely to be diagnosed late. Efforts to increase the awareness of SCFE directed to both the general society and healthcare providers are necessary to improve future outcomes. Level III. Retrospective comparative study.

Total hip arthroplasty in patients with slipped capital femoral epiphysis: a systematic analysis of 915 cases

There is limited evidence on the outcomes of Total Hip Arthroplasty (THA) in Slipped Capital Femoral Epiphysis (SCFE) patients. This systematic review aims to evaluate the current literature in terms of survival rate, functional outcomes, complications and types of implants of THA in SCFE patients. Following the established methodology of PRISMA guidelines, PubMed, Cochrane library, ScienceDirect and Ovid MEDLINE were systematically searched from inception to September 2018. The search criteria used were: (“total hip arthroplasty’’ OR ‘’total hip replacement’’ OR “hip arthroplasty’’ OR ‘’hip replacement’’) AND (‘’slipped capital femoral epiphysis’’ OR ‘’slipped upper femoral epiphysis’’ OR ‘’femoral epiphysis’’). Ten studies were finally included in the analysis and were qualitatively appraised using the Newcastle-Ottawa tool. Variables were reported differently between studies. The sample size varied from 12 to 374 THAs. A total of 877 patients undergone 915 THAs. The mean reported follow-up ranged from 4.4 to 15.2 years and the mean patients’ age at the time of THA from 26 to 50 years. Four studies specified the type of implants used, with 62% being uncemented, 24% hybrid (uncemented cup/cemented stem) and 14% cemented. All but three studies reported the mean survival of implants that ranged from 64.9% to 94.8%. A limited number of complications were mentioned. There was a tendency for more favorable functional outcomes in modern studies. Modern THA-studies in SCFE patients showed improvement of survivorship, clinical outcomes and patient satisfaction. Future higher-quality studies are necessary to estimate long-term postoperative outcomes better.

Long-term follow-up of patients undergoing the modified Dunn procedure for slipped capital femoral epiphysis

Aims

Our retrospective analysis reports the outcome of patients operated for slipped capital femoral epiphysis using the modified Dunn procedure. Results, complications, and the need for revision surgery are compared with the recent literature.

Methods

We retrospectively evaluated 17 patients (18 hips) who underwent the modified Dunn procedure for the treatment of slipped capital femoral epiphysis. Outcome measurement included standardized scores. Clinical assessment included ambulation, leg length discrepancy, and hip mobility. Radiographically, the quality of epiphyseal reduction was evaluated using the Southwick and Alpha-angles. Avascular necrosis, heterotopic ossifications, and osteoarthritis were documented at follow-up.

Results

At a mean follow-up of more than nine years, the mean modified Harris Hip score was 88.7 points, the Hip Disability and Osteoarthritis Outcome Score (HOOS) 87.4 , the Merle d’Aubigné Score 16.5 points, and the UCLA Activity Score 8.4. One patient developed a partial avascular necrosis of the femoral head, and one patient already had an avascular necrosis at the time of delayed diagnosis. Two hips developed osteoarthritic signs at 14 and 16 years after the index operation. Six patients needed a total of nine revision surgeries. One operation was needed for postoperative hip subluxation, one for secondary displacement and implant failure, two for late femoroacetabular impingement, one for femoroacetabular impingement of the opposite hip, and four for implant removal.

Conclusion

Our series shows good results and is comparable to previous published studies. The modified Dunn procedure allows the anatomic repositioning of the slipped epiphysis. Long-term results with subjective and objective hip function are superior, avascular necrosis and development of osteoarthritis inferior to other reported treatment modalities. Nevertheless, the procedure is technically demanding and revision surgery for secondary femoroacetabular impingement and implant removal are frequent.

Cite this article: 2020;1-4:80–87.

Slipped Capital Femoral Epiphysis: A Review of the New Zealand Literature

BACKGROUND

The New Zealand Māori and Pacific ethnicities have the highest burden of slipped capital femoral epiphysis (SCFE) worldwide. Therefore, New Zealand provides a rich and unique therapeutic and research environment for this devastating hip condition.

METHODS

A systematic literature review was performed using MEDLINE, PubMed, and Google Scholar from January 1, 1900, to December 31, 2019, with the following keywords: New Zealand, SCFE, slipped capital femoral epiphysis, SUFE, and slipped upper femoral epiphysis. The references were also screened.

RESULTS

Eight original scientific research articles that had been published in peer-reviewed journals were identified, as well as 4 published abstracts from conference proceedings; we summarized the key findings. The New Zealand Māori and Pacific ethnicities have the highest reported burden of SCFE, with 4.2 and 5.6 times the prevalence, respectively, when compared with New Zealand European (Caucasian). Māori children are younger at presentation (p = 0.002) and more frequently present with bilateral SCFE (p = 0.05), and there is a strong link with childhood obesity. A contralateral posterior sloping angle (PSA) of ≥14° may be used as an adjunct threshold for decision-making regarding prophylactic pinning. A PSA of ≥40° was found to correlate with a higher likelihood of unsatisfactory functional outcome following SCFE pinning in situ. When conversion to total hip arthroplasty is eventually required due to SCFE, early functional outcomes are similar to those of patients with primary osteoarthritis, and revision rates and mortality rates are not significantly different.

CONCLUSIONS

Landmark literature from New Zealand has been published on SCFE management, and there is a promising future of quality, impactful research.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Age- and sex-specific morphologic changes in the metaphyseal fossa adjacent to epiphyseal tubercle in children and adolescents without hip disorders

The epiphyseal tubercle plays an important role in epiphyseal stabilization. While the majority of studies have focused on tubercle morphology, there is a paucity of information on the morphological features of the metaphyseal fossa, where the tubercle sits on the metaphysis. The goal of this study was to determine the developmental changes in the capital femoral metaphyseal fossa. Computed tomography of the pelvis from 80 children and adolescents 8-15 years old were used to create three-dimensional models of the proximal femur. Depth, width, length, and surface area of the metaphyseal fossa were measured and the impact of age and sex on fossa morphology was assessed using the linear regression and two-way analysis of variance, respectively. The metaphyseal fossa was located in the posterosuperior quadrant of the metaphysis without any variations in the location with increasing age (P > .1). However, with increasing age, there was a reduction in all metaphyseal fossa measurements including the depth, length, width, and surface area (P < .01). No significant differences were noted for the metaphyseal fossa measurements between males and females (P > .1). The metaphyseal fossa reduces in size from 8 to 15 years of age in a similar fashion in males and females. As the metaphyseal fossa adjacent to the tubercle matches the area where a focal radiolucency has been observed in early slipped capital femoral epiphysis (SCFE), further studies should clarify the mechanisms by which the interlocking interaction of the epiphyseal tubercle and its fossa contributes to or is affected by SCFE.

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.

Effect of seasonal variation on the peak presentation of slipped capital femoral epiphysis. A comparison of children in Johannesburg, South Africa and London, UK

Variation exists in the peak presentation of slipped capital femoral epiphysis (SCFE). The objective of this study was to compare two cohorts of children (South Africa and the UK) and explore similarities and differences regarding demographic and epidemiological features, incidence and seasonal variation in peak presentation. Patients presenting with SCFE at one of two hospitals were included in the study. A retrospective cohort was collected from hospital records. The following factors were recorded: duration of symptoms, chronicity, stability, seasonality, severity and prophylactic pinning. A total of 137 patients were included in the study - 70 patients (80 hips) from South Africa and 67 patients (73 hips) from the UK. Both sites recorded more than 50% incidence of a chronic slip. There was higher delay to presentation in the UK compared with South Africa (90 vs 60 days, P = 0.0262). The UK population were more skeletally mature (32.8% open triradiate cartilage) compared with the South Africa population (64.9% open triradiate cartilage). In both populations, the most common season of symptom onset was summer. In the UK, the most common season of symptom presentation was in autumn compared with summer in South Africa. This study found significant differences in the two countries, including a more skeletally mature population in the UK. Both cohorts showed seasonal variation in peak incidence, but there was more seasonal variation in peak incidence in the UK - in the summer for onset of symptoms and autumn months for time of presentation.

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.

Predicting subsequent contralateral slipped capital femoral epiphysis: an evidence-based approach

PURPOSE

The purpose of this study was to identify risk factors for developing a subsequent contralateral slipped capital femoral epiphysis (SCFE) and provide a prediction score to quantify risk of subsequent slip at the time of initial presentation.

METHODS

This retrospective study included patients that presented with a unilateral SCFE between 2006 and 2017. Chart and radiographic review were performed to collect demographic, clinical and radiographic risk factors. Descriptive statistics, univariate analyses and multivariate regression analysis were used to compare risk factors between patients that did or did not develop a subsequent contralateral SCFE.

RESULTS

This study included 183 patients and 33 patients (18%) developed a subsequent contralateral SCFE. Younger age at time of initial presentation, lower modified Oxford Score and smaller difference in epiphyseal-diaphyseal angle between both sides during index presentation were significant predictors of subsequent contralateral SCFE. Specifically, age ≤ 11 years, modified Oxford Score ≤ 20 and difference in epiphyseal-diaphyseal angle of ≤ 21° between both hips were predictive of a contralateral slip (Area Under the Curve = 0.78; p < 0.05). The presence of each risk factor increased the risk of subsequent contralateral SCFE and having all three risk factors increased the risk to 73%.

CONCLUSION

There is a significant risk of subsequent contralateral SCFE in patients with unilateral SCFE, and predictive risk factors include younger age, lower modified Oxford Score and smaller difference in epiphyseal-diaphyseal angle between the affected and unaffected hips.

LEVEL OF EVIDENCE

Level III.

Slipped Capital Femoral Epiphysis in Children without Obesity

OBJECTIVE

To evaluate rates and characteristics of slipped capital femoral epiphysis (SCFE) in children who are not obese to prevent missed diagnoses and subsequent complications.

STUDY DESIGN

A multicenter, retrospective review identified all patients with SCFE from January 1, 2003 to December 31, 2012. Patients were excluded if they received previous surgery at an outside institution, had no recorded height and weight, or had medical co-morbidity associated with increased risk of SCFE. Body mass index (BMI) percentile for age was calculated and categorized for each patient (patients without obesity vs with obesity).

RESULTS

In total, 275 patients met inclusion criteria. Average BMI was 91.2 percentile (range: 8.4-99.7). Thirteen percent (34 patients) were considered "normal weight" (BMI 5%-85%), 17% (48 patients) were considered "overweight" (BMI 85%- 95%), and 70% (193 patients) were considered "obese" (BMI >95%). Average BMI percentile was higher in male than female patients (93.2 ± 12.7 vs 88.5 ± 21.4, P = .034). Patients without obesity were older compared with patients with obesity (12.2 ± 1.7 vs 11.7 ± 1.6 years, P = .015). Fewer patients without obesity were seen at the hospital in the southwest. The southwest had fewer patients without obesity than the northeast (18.3% vs 36.1%, P = .002). Patients without obesity were more likely to present with a severe slip as graded by Wilson percent displacement (27.2% vs 11.4%, P = .007) and an unstable slip (32.9% vs 14.7%, P = .001).

CONCLUSION

Rates of nonobese SCFE in this study are higher than reported in the previous literature. Normal weight patients with SCFE are more likely to be older, female, and present with a severe and unstable SCFE.