Factors Affecting Outcomes of Slipped Capital Femoral Epiphysis

Analysis of risk factors for difficult implant removal in children with slipped capital femoral epiphysis treated by cannulated screws

Introduction

Cannulated screws are widely used in the treatment of slipped capital femoral epiphysis, which can be removed after physeal closure on patient's request. This study aimed to analysis the potential risk factors for difficult removal in children with slipped capital femoral epiphysis treated by cannulated screws.

Patients and methods

This study enrolled 32 hips that had undergone removal of cannulated screws after treatment of slipped capital femoral epiphysis at our department. The primary outcomes were the difficult screw removal. The secondary outcomes were functional outcome assessed by using a modified Harris Hip Score and complications of fractures and surgical site infection. Related risk factors for difficult removal were recorded and analyzed by multivariable logistic regression.

Results

In total, 32 hips were evaluated, with a mean age of 14.9 ± 1.3 years old (range, 13-19 years). Six (18.8%) hips presented with difficult removal, including 4 cases of screws' slip and 2 breakages. The average implantation time in the difficult removal group (5.7 ± 1.0) was also significantly longer than that in the easily removed group (3.8 ± 0.9, p = 0.001). The mean surgical time in patients with difficult removal was 66.3 ± 11.6 min, which was also significantly longer than that (54.8 ± 8.3) in the other patients (p = 0.008). The duration of screw implantation was an independent risk factor for difficult removal.

Conclusions

Prolonged screw duration was a predictor for difficult removal in children with slipped capital femoral epiphysis treated by cannulated screws. An early surgery after physeal closure might benefit those with a request for screw removal.

Management of chondral and osteochondral lesions of the hip : A comprehensive review

Chondral and osteochondral lesions encompass several acute or chronic defects of the articular cartilage and/or subchondral bone. These lesions can result from several different diseases and injuries, including osteochondritis dissecans, osteochondral defects, osteochondral fractures, subchondral bone osteonecrosis, and insufficiency fractures. As the cartilage has a low capacity for regeneration and self-repair, these lesions can progress to osteoarthritis. This study provides a comprehensive overview of the subject matter that it covers. PubMed, Scopus and Google Scholar were accessed using the following keywords: "chondral lesions/defects of the femoral head", "chondral/cartilage lesions/defects of the acetabulum", "chondral/cartilage lesions/defects of the hip", "osteochondral lesions of the femoral head", "osteochondral lesions of the acetabulum", "osteochondral lesions of the hip", "osteochondritis dissecans," "early osteoarthritis of the hip," and "early stage avascular necrosis". Hip osteochondral injuries can cause significant damage to the articular surface and diminish the quality of life. It can be difficult to treat such injuries, especially in patients who are young and active. Several methods are used to treat chondral and osteochondral injuries of the hip, such as mesenchymal stem cells and cell-based treatment, surgical repair, and microfractures. Realignment of bony anatomy may also be necessary for optimal outcomes. Despite several treatments being successful, there is a lack of head-to-head comparisons and large sample size studies in the current literature. Additional research will be required to provide appropriate clinical recommendations for treating chondral/osteochondral injuries of the hip joint.

How Safe and Technical Is Modified Dunn Osteotomy in the Management of Patients with SCFE: A Clinical Trial with Short-Term Follow-Up

Objective

Over the last decade, modified Dunn osteotomy has been widely used in the management of slipped capital femoral epiphysis (SCFE) with varying degrees of complications. Different conclusions have been adopted. Our study represented our experience in using such a technique in stable and unstable SCFE and tried to determine its safety and applicability for routine practice.

Methods

Our study adopted an interventional prospective design performed on 24 hips divided evenly between both sexes with a mean age of 13.25. On the Southwick classification, the cases were distributed between moderate and severe, which constituted 41.7% and 58.33%, respectively. Three quarters of the study subjects were stable according to the Loder classification. Each underwent modified Dunn osteotomy after a safe surgical hip dislocation.

Results

Over the period of about 1-year follow-up, clinical evaluation was performed by examining the surgical site and assessing the legs' length, range of hip movement, Harris hip score, and iHOT-12 score. Radiological assessment was performed by calculation of slip angle from the frog lateral view, assessment of union, and occurrence of any complications. The study showed that there was significant improvement in patients in terms of radiological and clinical outcomes, with the occurrence of AVN in 16.7% of cases (4 out of 24). All cases of AVN occurred in unstable hips.

Conclusion

Despite the complication of AVN, we believe the results of this study add to the current literature which suggests that modified Dunn osteotomy is an effective and safe technique for the management of moderate and severe SCFE. This trial is registered with PACTR202312819351504.

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.

Subacute Bacterial Infection Mimicking a Slipped Capital Femoral Epiphysis in an Obese Adolescent Male - A Case Report and Review of Literature

Introduction

Atypical and subacute presentations of pediatric bacterial septic arthritis are difficult to diagnose due to lack of systemic manifestations and inadequate laboratory data. Furthermore, they may mimic certain well-documented pediatric disorders to confound the diagnosis and management.

Case Report

The authors present a case of an adolescent obese male with features suggestive of a slipped capital femoral epiphysis (SCFE). Further investigations revealed bacterial septic arthritis which may have contributed to the slip. He was treated with an initial debridement followed by a definitive pelvic support osteotomy (PSO) with a compensatory distal femoral varus osteotomy. At 12 months, he had a satisfactory clinical and radiological outcome.

Conclusion

Clinicians should have a high degree of suspicion for infection in patients presenting with atypical clinical or radiological signs of SCFE. A thorough investigation in such cases is a must, to aid in correct management. PSO is an effective salvage procedure in adolescents with septic hip sequelae.

Advantages of Telescopic Screw in Slipped Capital Femoral Epiphysis Treatment: A Retrospective Study and Review of the Literature

Background: Slipped capital femoral epiphysis is due to proximal femur physis failure in adolescent patients. Early iatrogenic closure of proximal growth cartilage in children with significant residual growth potential causes complications such as coxa breva, coxa vara, and lower limb length inequalities. The Free-Gliding SCFE Screw System is a self-extending cannulated screw used in Slipped Capital Femoral Epiphysis (SCFE) fixation and femoral neck fractures. Materials and Method: We conducted a retrospective study on 16 patients. All patients under 11 years old were treated by telescopic cannulated screws fixation. The youngest patient was 7 years old. Results: Out of the 22 operated hips, 2 screws have failed, thus resulting in a lack of telescoping of the screw. We discovered an average lengthening of approximately 10 mm at 24 months postoperative check-up in 20 hips in which lengthening took place. According to the Notzli method, none of the patients had an alpha angle value greater than 48 degrees. Conclusion: Fixation with telescopic screw for SCFE in patients less than 11 years old, with mild to moderate slippage, allows the continuous growth and remodeling of the proximal femur, thus avoiding deformities such as coxa breva, coxa vara, FAI, AVN, limb length discrepancies and also allows good range of motion.

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.

Femoral Head-Neck Translation Ratio Is a Measurement of the True Deformity of Slipped Capital Femoral Epiphysis

A new method to quantify proximal femoral head-neck deformity in slipped capital femoral epiphysis (SCFE) is presented. In SCFE the femoral head slips posteriorly and inferiorly relative to the femoral neck. The distance of the femoral head center from the femoral neck axis (center-axis distance, CAD) represents the severity of the post-slip deformity. CAD is calculated on the anteroposterior and the frog-lateral pelvis views. It is shown that CAD is only a function of the femoral head-neck offset difference on both sides of the femoral neck. The percentage of CAD relative to the diameter of femoral neck is the femoral head-neck translation ratio (FHNTR) on the respective x-ray projection. Measurements on radiographs of 37 patients with history of unilateral SCFE were performed. The asymptomatic contralateral hips were used as controls. On the anteroposterior pelvis view, mean FHNTR was -12.2% and -4.3% for the affected and asymptomatic contralateral hips, respectively (paired t-test, p < .01), indicating inferior translation of the femoral head relative to the femoral neck. On the frog-lateral view, mean FHNTR was -21.1% and -6.5% for the affected and the contralateral hips, respectively (paired t-test, p < .01), indicating posterior translation of the femoral head relative to the femoral neck. There is a moderate inverse correlation between FHNTR on the frog-lateral pelvis view and Southwick's slip angle (Pearson correlation coefficient r = -0.679, p < .001). FHNTR on two radiological planes (anteroposterior and frog-lateral) is a simple measurement of the posteroinferior translation of the femoral head relative to the femoral neck in SCFE. It is a measurement of the true deformity of the proximal femur in SCFE. Calculation of FHNTR may be applicable to classify SCFE, to monitor femoral head-neck remodeling after slip stabilization, to describe the femoral head-neck relation in healthy individuals, and to monitor femoral head-neck changes secondary to other hip pathology, such as Perthes disease or developmental dysplasia of the hip.

Causes of Delayed Diagnosis of Slipped Capital Femoral Epiphysis: The Importance of the Frog Lateral Pelvis Projection

Delayed diagnosis and treatment is a universally reported problem that impairs the prognosis of slipped capital femoral epiphysis (SCFE). Quite frequently, a delayed diagnosis of SCFE is observed in spite of serial admissions and examinations of the limping adolescent. Why do health professionals globally fail to make a definitive diagnosis of SCFE during the first examination of the patient? A retrospective study of 36 adolescents treated for stable SCFE and two adolescents treated for unstable SCFE has been performed. In more than half of the delayed diagnosed stable slips (13/25, 52%), the diagnosis was set after serial examinations of the patient. Health professionals commonly order only the anteroposterior (AP) X-ray view of the pelvis when examining a non-traumatic limping adolescent. The frog lateral (FL) projection is usually spared in an attempt to limit the radiation exposure of the patient, especially in ambulating adolescents with mild symptoms. It is proposed that in the non-traumatic limping adolescent, the FL projection instead of the AP pelvis view should be requested by the health professional in order to timely diagnose a surgical emergency of the adolescent hip such as SCFE.