[Total hip replacement after slipped capital femoral epiphysis]

BACKGROUND

Total hip replacement (THR) is at present an accepted treatment in patients with severe osteoarthritis of the hip after slipped capital femoral epiphysis. The aim of this paper is to evaluate the results of THR in patients suffering from secondary osteoarthritis, operated from 1987 to 2004 in the Orthopaedic and Traumatologic Department of Poznan University of Medical Sciences.

MATERIAL

Material included 16 patients, 9 females and 7 males, on whom 18 THR were performed, lateral approach was used in all cases. At the time of operation, the age of patients ranged from 32 to 70 years (mean 50). THR was carried out after 33 years afterwards slippage of capital femoral epiphysis. Follow-up ranged from 6 to 23 years (mean 11 years). The operative treatment was a multistage process (during one operation only one joint was replaced). Cemented total hip arthroplasty was used during 5 of the THR, 13 of them were cementless.

METHOD

The patients were clinically and radiologically evaluated preoperatively, postoperatively, and at final examination. The clinical state was evaluated with Harris hip score and WOMAC scale. We based our radiological examination on Hip Society system.

RESULTS

The average preoperative Harris score for the group of patients was 32, WOMAC score 74. After an average of 11-years follow-up all hips were considered excellent, with average Harris score of 91, WOMAC Score of 6. All patients had increased function and decreased pain. The radiograms of all patients revealed that the acetabular and femoral components were correctly positioned with no radiographic evidence of loosening in the last examination. The inclination angle of the acetabular component was 22-49 degrees (mean: 36 degrees) and the acetabular opening angle was 0-10 degrees (mean: 4 degrees). The stem was valgus-oriented in 1 hip, and neutral-oriented in 17 hips. No ectopic ossification concentrations were found.

CONCLUSION

. Clinical and radiological evaluation of our material showed that total hip replacement in the treatment of osteoarthritis secondary to slipped capital femoral epiphysis allows regaining good lower limb function, which helps the patients staying less dependant on the surrounding environment. The results of THR are good regardless of the type of prosthesis and the type of fixation. Importantly, THR was carried out after a quite long time after slippage of capital femoral epiphysis.

In situ pinning with arthroscopic osteoplasty for mild SCFE: A preliminary technical report

BACKGROUND

There is emerging evidence that even mild slipped capital femoral epiphysis leads to early articular damage. Therefore, we have begun treating patients with mild slips and signs of impingement with in situ pinning and immediate arthroscopic osteoplasty. DESCRIPTION OF TECHNIQUES: Surgery was performed using the fracture table. After in situ pinning and diagnostic arthroscopy, peripheral compartment access was obtained and head-neck osteoplasty was completed.

METHODS

Between March 2008 and August 2009, three male patients (age range, 11-15 years; BMI, 22-31 kg/m(2)) presented with slip angles between 15º and 30º. All were ambulatory without assistance but had 2 to 12 weeks of hip and/or knee pain, limited motion and a positive impingement test. Postoperatively, patients were assessed at 6 weeks; 3 and 6 months; then every 6 months for the first two years. Hip motion, epiphyseal-metaphyseal offsets and alpha angles were determined. Patients completed the UCLA activity scale at latest followup that ranged from 6 to 23 months.

RESULTS

Arthroscopic evaluation revealed labral fraying, acetabular chondromalacia, and a prominent metaphyseal ridge. At last followup, each was pain-free and had returned to unrestricted activities. Hip motion improved in all and none demonstrated clinical impingement. Radiographs showed normalized epiphyseal-metaphyseal offsets and alpha angles.

CONCLUSIONS

In situ pinning with arthroscopic osteoplasty can limit impingement after mild slipped capital femoral epiphysis. Due to limited followup, we are unable to say whether this protocol reduces subsequent articular damage. Although we recommend performing these procedures concomitantly, they can be performed in a staged fashion, especially since hip arthroscopy following an epiphyseal slip can be challenging.

MRI morphometry, cartilage damage and impaired function in the follow-up after slipped capital femoral epiphysis

OBJECTIVE

To assess rotation deficits, asphericity of the femoral head and localisation of cartilage damage in the follow-up after slipped capital femoral epiphysis (SCFE).

MATERIALS AND METHODS

Magnetic resonance imaging studies were obtained in adult patients with a history of SCFE. A total of 35 hips after SCFE in 26 patients (mean age 24.1 +/- 6.5, mean follow-up 11.9 +/- 6.1 years) were evaluated. The control group comprised 20 healthy hips from 10 young adults with an average age of 23.9 +/- 3.7 years. The MR protocol included a T1-weighted sequence with a 3D volumetric interpolated breath-hold sequence and a radial 2D proton density-weighted sequence around the femoral neck. Images were evaluated for alpha angle and cartilage damage in five positions around the femoral head. Hip function was evaluated at the time of MRI and correlated with MRI results. Mann-Whitney U test and Spearman's correlation coefficient were used for statistical analysis.

RESULTS

In the hips after SCFE alpha angles were significantly increased in the anterosuperior (74.1 degrees +/- 18.8 degrees ) and superior (72.5 degrees +/- 21.5 degrees ) positions and decreased in the posterior position (25.0 degrees +/- 7.2 degrees ). Cartilage damage was dominant in the anterosuperior and superior positions. Impaired rotation significantly correlated with increased anterosuperior, superior and posterosuperior alpha angles.

CONCLUSION

The data support an anterosuperior and superior cam-type deformity of the femoral head-neck junction in the follow-up after SCFE. MRI after SCFE can be used to assess anterosuperior and superior alpha angles, since the anterior alpha angle by itself may underestimate asphericity and is not associated with rotation deficits.

[Risk factors of osteonecrosis of the femoral head following slipped capital femoral epiphysis]

Osteonecrosis is a serious complication of the treatment of slipped capital femoral epiphysis. The purpose of this study was to identify factors predisposing to the development of this complication. We reviewed retrospectively 127 patients (150 hips) treated for slipped capital femoral epiphysis in our institution between 1980 and 2004. Clinical and radiological data were analyzed before and after treatment, and at consecutive follow-up examination. Osteonecrosis was defined in the basis of radiological criteria. The risk of development of osteonecrosis was correlated with multiple clinical and radiographic parameters.

RESULTS

12 hips in 11 patients (8%) had development of osteonecrosis. Ten of them had an unstable slip. From 130 stable hips, regardless of grade, two had development of osteonecrosis. In patients who had presented with an unstable hip, the risk of osteonecrosis increased with the grade of the slip. Osteonecrosis was more likely to develop in hips that had been treated with multiple screws than in those who had been treated with a single screw. In conclusion, partial or complete reduction of an unstable slipped capital femoral epiphysis increases the risk of development of osteonecrosis. Pinning in situ without reduction with a single screw is the method of choice of the treatment of a slipped capital femoral epiphysis.

Delayed-onset slipped capital femoral epiphysis: case report of association with pituitary tumor

Slipped capital femoral epiphysis (SCFE) is an affliction of the hip presenting in adolescent children. There are several theories regarding the pathological cause of SCFE. The hormonal milieu during adolescence, combined with a deficiency in the physeal area of the growth plate, has been postulated as a possible etiology for its specific onset. In atypical circumstances, the early or late onset of SCFE may occur in the setting of unusual hormonal influences. This hormonal imbalance may be secondary to an underlying endocrinopathy-for example, hypothyroidism or hypogonadism. In this case, our patient presented with a clinically and radiographically unstable slip at the age of 22 years. His physical characteristics, along with confirmatory laboratory values and radiographs, indicated that the patient suffered from a disorder of delayed secondary growth. Subsequent thorough work-up revealed a large benign pituitary tumor that was causing severe panhypopituitarism. This article describes the presentation, diagnostic work-up and treatment of our patient with a delayed-onset SCFE in the setting of a pituitary tumor.

Remodelling of the femoral head after proximal femoral osteotomy for avascular necrosis associated with slipped capital femoral epiphysis

Avascular necrosis is the most devastating complication associated with slipped capital femoral epiphysis. In this case report, we present the clinical and radiological outcome of two patients after proximal femoral osteotomy for avascular necrosis associated with slipped capital femoral epiphysis. The Iowa hip score was used to assess the function. Periodic radiographic observations showed no progression of the collapse, and bone remodelling of the necrotic femoral head. Our evaluation of patients who underwent proximal femoral osteotomy for avascular necrosis prior to collapse of the femoral head suggests that its use resulted in acceptable clinical outcome with bone remodelling of the necrotic area (Fig. 4, Ref. 16).

Review of the management outcome of slipped capital femoral epiphysis and the role of prophylactic contra-lateral pinning re-examined

INTRODUCTION

Slipped capital femoral epiphysis is the most common hip problem in the adolescent age group. It can involve both hips, presenting itself bilaterally at first presentation or sequentially. The overall incidence of bilateral disease is variable, but the risk of occurrence is higher when there is underlying endocrinopathy, renal disease and obesity.

MATERIALS AND METHODS

Amongst the 36 cases (44 hips) of slipped capital femoral epiphysis that we had, there were 8 cases of bilateral disease, of which 3 were bilateral sequential slips. A retrospective review of all case records and X-rays was done.

RESULTS

According to Aadalen's criteria, the results were excellent or good in 37 hips, fair in 3 hips, and poor in 2 hips. Two patients were considered as treatment failure because of avascular necrosis. The incidence of bilateral slipped capital femoral epiphysis was 22.2%. The overall average age was 11.4 years. All cases of sequential involvement presented within 15 months of the initial slip. One patient had hypothyroidism (who also had a positive family history for slipped capital femoral epiphysis), while 91.6% were above the 75th percentile for weight. There was no statistically significant difference in age, sex, race, body mass index (BMI) and weight percentile distribution between patients with unilateral and bilateral disease.

CONCLUSION

Satisfactory outcomes can be expected in most patients treated for slipped capital femoral epiphysis. The risk of avascular necrosis is higher in unstable slips. The role of prophylactic contra-lateral pinning should be restricted to patients with hypothalamic-pituitary-ovarian axis disease, especially hypothyroidism.

Avascular necrosis in acute and acute-on-chronic slipped capital femoral epiphysis

This study reviews the factors affecting the development of avascular necrosis (AVN) after slipped capital femoral epiphysis. Seventy-three patients (n=73) with ninety-two (n=92) hips were included in the study. Out of these 92, 16 were acute, 43 acute-on-chronic, 29 chronic, and four were preslips. Postoperative radiographs showed a reduction in 18 (19.5%) slips. The mean preoperative slip angle was 32 degrees (range 9-76) compared with the postoperative slip angle of 29.9 degrees (range 10-75 degrees ) (P=0.004). Four patients developed AVN. Our results showed that intraoperative reduction of the slip (P<0.001) was significantly related to the development of AVN and was also associated with poor functional outcome.

Evaluation of radial-sequence imaging in detecting acetabular labral tears at hip MR arthrography

OBJECTIVE

In recent years, radial imaging has been advocated for improved visualization of the acetabular labrum in magnetic resonance arthrography of the hip. The purpose of this study was to investigate whether radial imaging demonstrates labral tears not visible on standard imaging planes.

METHODS

Fifty-four consecutive magnetic resonance (MR) arthrograms of the hip that included radial imaging over 2 years were retrospectively analyzed by two radiologists. Standard imaging planes and radial imaging were reviewed for identification of labral tears in four specific areas of the labrum: anterosuperior, posterosuperior, anteroinferior, and posteroinferior. The standard imaging sequences include fat-saturated spin-echo T1-weighted images in the coronal and oblique axial planes, non-fat-saturated T1-weighted images in the coronal and sagittal planes, and T2-weighted sequence in the axial plane. Radial imaging was performed as previously described using fat-saturated T1-weighted sequences.

RESULTS

Using standard imaging planes, 50 anterosuperior, 31 posterosuperior, 10 anteroinferior, and 9 posteroinferior labral tears were detected in 54 MR arthrograms of the hip. Using radial sequences alone, 44 anterosuperior, 25 posterosuperior, 9 anteroinferior, and 5 posteroinferior labral tears were detected. In all four areas of the labrum, the radial imaging did not show any labral tear not seen on standard imaging planes.

DISCUSSION

In MR arthrography of the hip, radial imaging did not reveal any additional labral tears. Standard imaging planes sufficiently demonstrate all acetabular labral tears.

[Chondrofibrosis of adolescent hip]

Authors present 420 hips with slipped capital epiphysis treated in the IOHB "Banjica", during the period between 1970 and 2005. Research includes the analysis of incidence, diagnostics and causes which contribute to the genesis of hip chondrofibrosis. Risk factors are shown, as well as the approach to eliminate them. 39 hips in which this complication occured were individually analyzed. Every hip was separately studied with intent to determine the cause of the condition's genesis, it's evolution, treatment and it's final functionality result. Synovia biopsy was performed in 7 cases, as well as the biopsy of the capsule, articular hyaline cartilage and subchondral bone of the femoral head, which enabled detailed description of both microscopic and macroscopic changes that follow this condition. Regardless of still hypothetical comprehension of the inception of chondrofibrosis, authors clearly state all the risky procedures during treatment that can contribute to the development of chondrofibrosis. The importance of early diagnostics and well-timed treatment are highlighted in this article, for they are crucial. Results of treated hip chondrofibrosis presented here give hope for the destiny of the ill joint, which was considered highly uncertain for a long time.

[Results of the treatment of the distal femoral epiphysiolysis]

INTRODUCTION

Distal femoral epiphysiolysis (DFE) is rare. In most of the cases it occures as an open epiphysiolysis. In the past DFE had often resulted in a tissue necrosis and required an amputation. Among complications limb shortening due to premature epiphyseal closure and deviation of the limb axis are evidenced.

AIM

This study was conduced in order to evaluate the results of the treatment of DFE.

MATERIAL

Eight children suffering from DFE who had undergone a treatment between 1990 and 2005 were reviewed. The mean age at the time of injury was 15.3 years. All cases of epiphysiolysis have been classified as Salter-Harris type II. The treatment consisted of reduction and 6 weeks immobilisation in 3 cases. Reduction followed by K-wire stabilization and immobilisation was applied in all other cases.

METHODS

The follow-up evaluation covered a clinical and roentgenographic examination. The angular deformmity of tibia was measured in saggital and frontal plane in comparison to intact side. The range of motion and stability of both knee joints were recorded as well. The comparative X-ray pictures of the femur and knee joint were taken in A-P and lateral positions.

RESULTS

The study revealed a premature closure of the injured distal femoral epiphysis in four children. There was a limb shortening of over 2 cm in 3 cases and over 3cm in one case.

CONCLUSION

The distal femoral epiphysiolysis is a rare type of injury. It often leads to leg length discrepancy.

[Factors influencing the development of avascular necrosis in non-operative treatment of the acute slipped capital femoral epiphysis]

INTRODUCTION

The acute slipped capital femoral epiphysis can result in development of avascular necrosis of the femoral head which is very difficult condition to treat. Orthopedic surgeon can influence the development of avascular necrosis.

OBJECTIVE

The main objective in our study was to identify factors influencing the development of avascular necrosis in nonoperative treated patients for the acute slipped capital femoral epiphysis.

METHOD

A total of 53 patients and 59 hips treated for the acute slipped capital femoral epiphysis at the Institute for Orthopedic Surgery,Banjica" between 1968-2004 were studied. Necessary data were obtained from the accurate medical records.

RESULTS

Avascular necrosis of the femoral head was diagnosed in 8 patients (13.56%). Six of them (75%) were treated by manipulative reduction in general anesthesia and spica cast immobilization. Fischer test, used for statistical data processing, found significant difference between two non-operative methods of treatment (p = 0.0008).

CONCLUSION

Higher-degree epihyseal displacement as well as complete separation of the physis and metaphysis were found to be the risk factors of avascular necrosis. Every manipulation with the affected hip was also associated with higher percentage of avascular necrosis of the femoral head.

Bilateral slipped capital femoral epiphysis: predictive factors for contralateral slip

The primary goal in treatment of slipped capital femoral epiphysis (SCFE) is to prevent further slip by stabilizing the physis. Debate exists concerning prophylactic fixation of the uninvolved hip at presentation. Our goal was to determine predictive factors for a contralateral slip after presentation with a unilateral SCFE. Ninety patients with SCFE and complete radiographs were followed up until the bilateral closure of the proximal femoral physis. Chronological age at presentation, sex, and race were recorded. Open or closed triradiate cartilage was recorded, and a modified Oxford bone age assessment was performed. Twenty patients (22%) had bilateral SCFE at presentation, and 70 patients (78%) were unilateral. Of these 70 patients, 16 (23%) later developed a contralateral SCFE. Analysis revealed that chronological age was the only significant (P = 0.010) predictor for developing a contralateral slip. All girls younger than 10 years and all boys younger than 12 years who presented with unilateral SCFE developed a contralateral slip. Twenty-five percent of girls younger than 12 years and 37% of boys younger than 14 years developed a contralateral slip. No girl older than 13 years and no boy older than 14 years developed a contralateral slip in our series. Surgical complications were infrequent and isolated to the side of the initial SCFE. Chronological age is a predictor for a contralateral slip in patients presenting with a unilateral SCFE. The authors recommend that all girls younger than 10 years and all boys younger than 12 years presenting with unilateral SCFE should undergo strong consideration for prophylactic screw fixation on the contralateral side. In older age groups, prophylactic treatment may be considered on a case-by-case basis.

[Complications of slipped capital femoral epiphysis]

Slipped capital femoral epiphysis is well known disorder of the hip in adolescents, which is characterized by displacement of the capital femoral epiphysis from the metaphysis through the physeal plate. The incidence of slipped capital femoral epiphysis is about 5-8 cases per 100,000 adolescents. Etiology of slipped capital femoral epiphysis is still unknown, but this disorder is probably combination of genetic, hormonal and mechanical factors. On the basis of patient's history, physical examination, and radiographs, slipped capital femoral epiphysis can be classified as acute or chronic. Two most severe complications of slipped capital femoral epiphysis are avascular necrosis and chondrolysis. Avascular necrosis is more commonly associated with the acute slips when the lateral epiphyseal vessels are disrupted. In chronic slips, avascular necrosis can occur as a result of treatment. Chondrolysis or cartilage necrosis can occur in untreated slips, but is often associated with spica cast imobilization or penetratation of the internal fixation screws into the joint space. The final outcome of avascular necrosis and chondrolysis is extremly poor for a patient. Therefore, the baseline of management of slipped capital femoral epiphysis is treatment by adequate techniques that have high rate of success with minimal risk of complications.

[The effect of slip grade and chronicity on the development of femur avascular necrosis in surgically treated slipped capital femoral epiphyses]

OBJECTIVES

We investigated the relationship between the grade and chronicity (acute-chronic) of the slip and the development of avascular necrosis (AVN) of the femoral head after surgery for slipped capital femoral epiphysis (SCFE).

METHODS

The study included 424 hips of 269 patients (174 boys, 95 girls; mean age 12 years) who underwent surgery for SCFE and had a minimum follow-up period of one year. The patients were classified according to the severity and chronicity of the slipping using the Southwick classification. The relationship of the slip severity and chronicity with the development of AVN was statistically evaluated.

RESULTS

Involvement was unilateral in 114 patients, and bilateral in 155 patients. The mean follow-up period was 32.9 months. The hips were classified as grade I to II in 267 hips (63%), 120 hips (28.3%), and 37 hips (8.7%), respectively. The symptoms were acute in 130 hips (30.7%), and chronic in 294 hips (69.3%). The incidence of AVN was 4.5% (19 hips; 13 in unilateral cases, 6 in bilateral cases). In logistic regression analysis, a strong correlation was found between the grade of the slip and the development of AVN (odds ratio 10.27; p<0.0001). The acute nature of the slip was also correlated with the development of AVN, but this relation was weaker (odds ratio 0.20, p<0.01).

CONCLUSION

A strong correlation is present between the slipping grade and the development of AVN in SCFE, requiring a closer observation of patients having a high grade slipping in terms of AVN risk. The acute nature of the symptoms represents another risk factor for AVN.

Abductor length alterations in hips with SCFE deformity

Proximal femoral osteotomy may improve clinical outcomes in patients with residual deformity after slipped capital femoral epiphysis. Whether this procedure improves abductor mechanics is not well established. We hypothesized that abductor lengths would be shorter in patients with slipped capital femoral epiphysis compared with normal controls, and a femoral neck base osteotomy would create more normal abductor lengths than an osteotomy performed below the greater trochanter. Abductor muscle lengths were measured in normal, mild, and severe slipped capital femoral epiphyses sawbone models and after two methods of surgical correction. We observed decreases in abductor lengths in patients with slipped capital femoral epiphysis compared with normal controls when positioned in greater than 45 degrees flexion. There were fewer differences in abductor lengths after femoral neck base osteotomies than after subtrochanteric osteotomies. The femoral neck base osteotomy approximated normal abductor lengths more closely than the subtrochanteric osteotomy. The femoral neck base osteotomy restored the hip abductor relationship better than an osteotomy performed below the greater trochanter. We did not address the question of whether this improved relationship directly influenced function.

[Intertrochanteric femoral fractures in children]

Based on two cases and a review of the literature, we describe a rare injury in childhood, intertrochanteric femoral fracture. Because of the insertion and traction of muscles at the proximal femur, conservative treatment is difficult. The hip muscles pull the proximal fragment into flexion, abduction and external rotation. In our opinion, surgical stabilization is the therapy of choice. We use an angular stable, locking compression plate for the stabilization of these fractures. Postoperatively, mobilization with full weight bearing is possible.

Relationship between Body Mass Index and slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) is the most common hip disorder of adolescents and is known to be strongly associated with obesity. The use of Body Mass Index (BMI) as an assessment of obesity has been shown to be a very efficient technique. The Centers for Disease Control & Prevention has recently developed BMI-for-age percentile growth charts that have been shown to effectively evaluate obesity in the pediatric population. In the current study, the investigators provide a retrospective review, looking at the association between SCFE and obesity based on BMI. One hundred six subjects with radiographically diagnosed SCFE were compared with 46 controls without radiographic evidence of SCFE. In the SCFE group, 81.1% of individuals had a BMI above the 95th percentile; for the control group, the corresponding figure was only 41.3% (P < 0.0001). Multiple linear regression analysis controlling both for sex and age confirmed an equally significant difference (P < 0.0001) between SCFE patients and controls with regard to BMI. Based on pediatric obesity criteria designating a weight above the 95th percentile as obese and a weight between the 85th and 95th percentile as "at risk" for obesity, clinicians can use BMI to define obesity, a highly modifiable risk factor for SCFE. Early intervention and lifestyle modifications may reduce the incidence of not only SCFE but other illnesses related to obesity as well.

Consequences of diagnostic delays in slipped capital femoral epiphysis

Delay in diagnosis of slipped capital femoral epiphysis has important implications with regard to slip severity and long-term hip outcomes. The aims of this review were to identify the incidence of delayed diagnosis of slipped capital femoral epiphysis in the hospital to which the authors are affiliated, and the causes for such delays. A retrospective review was conducted of all patients admitted to the Women's and Children's Hospital in Adelaide between January 1997 and October 2004 with a diagnosis of slipped capital femoral epiphysis. The inpatient and outpatient medical records for each patient were analysed to clarify the history of presentation and identify those patients with a delayed diagnosis. All radiographs were reviewed and the severity of the slip graded according to Southwick's classification. One hundred and two patients were included in this review, of which 20 had a delayed diagnosis and 25 a late presentation. Of the 20 (19.6%) patients who had a delayed diagnosis in this series, a minimum of 2 weeks elapsed between presentation to a health professional and diagnosis of slipped capital femoral epiphysis. Eight patients had seen their local doctor but the diagnosis was not made. The remaining 12 patients with delayed diagnosis had not seen a medical practitioner and had self-referred to a chiropractor or a physiotherapist. All of these patients underwent hip manipulation prior to diagnosis. There was a significant relationship between delay in diagnosis and an increased slip severity, when compared with both the remainder of this series and the late presentation group. Knee or distal thigh pain in slipped capital femoral epiphysis remains the commonest pitfall in diagnosis for local doctors, as well as mild slips being missed on radiograms by inexperienced surgeons or radiologists. An increasing presentation of adolescents with this disorder to allied health professionals for initial management warrants a broader education strategy than has been previously advocated. Slipped capital femoral epiphysis remains an enigmatic disorder; consequently delayed diagnosis of this condition is not likely to disappear. Despite this, the medical community must strive toward early diagnosis through continued education and vigilance.

Transphyseal fracture-separation of the femoral capital epiphysis: a true SCFE of traumatic origin

Acute traumatic transphyseal fracture of the capital femoral epiphysis is a rare but serious injury. The injury is typically inflicted by a severe trauma. Because of the vulnerability and predisposed anatomy of the femoral epiphysis in relation to its blood supply, the fracture has been designated to have poor prognosis with inevitable osteonecrosis and eventual deformity of the hip. We report a case of such fracture in a 13-year-old child in view to highlight some of the anticipated problems in the management of such injury.

Slipped capital femoral epiphysis (SCFE): a 12-year review

Slipped capital femoral epiphysis (SCFE) is a relatively uncommon hip disorder in adolescents and its prevalence in Malaysia has not been studied. This retrospective study is undertaken to provide an overview of a 12-year review of SCFE treated in our institution. Fourteen patients (19 hips) with slipped capital femoral epiphysis (SCFE) admitted to Hospital UKM from 1990 to 2002 were reviewed with respect to demographic profile, functional outcome according to the Iowa Hip Score, and complications. There were ten boys (average age, 12.5 years) and four girls (average age, 12 years). Eight were Malays and six were Indians. The average body mass index was 26.1 verweight). The left hips (11 hips) were affected more than the right hips (eight hips). Five patients had bilateral slips. Thirteen hips were considered stable while the other six hips were unstable. The majority of cases were moderate slips (12 hips), four hips had severe slips while three hips had mild slips. Several methods of treatment were instituted. These include in situ cannulated screw fixation (11 hips), Knowles pin fixation (three hips) and gentle closed manipulative reduction with cannulated screw fixation (three hips). One patient with bilateral slips refused surgical treatment. Based on the Iowa Hip Score, most patients (nine) had satisfactory results (excellent or good), three had fair results while one patient had a poor result. Avascular necrosis developed in five hips while chondrolysis occurred in one hip. In situ cannulated screw fixation is the treatment of choice. SCFE is an uncommon condition in Malaysia.

The management of avascular necrosis after slipped capital femoral epiphysis

Avascular necrosis is a serious complication of slipped capital femoral epiphysis and is difficult to treat. The reported incidence varies from 3% to 47% of patients. The aims of treatment are to maintain the range of movement of the hip and to prevent collapse of the femoral head. At present there are no clear guidelines for the management of this condition and treatment can be difficult and unrewarding.

We have used examination under anaesthesia and dynamic arthrography to investigate avascular necrosis and to determine the appropriate method of treatment. We present 20 consecutive cases of avascular necrosis in patients presenting with slipped capital femoral epiphysis and describe the results of treatment with a mean follow-up of over eight years (71 to 121 months). In patients who were suitable for joint preservation (14), we report a ten-year survivorship of the hip joint of 75% and a mean Harris hip score of 82 (44 to 98).

Unstable slipped capital femoral epiphysis: reduction by gradual distraction with external fixator. A case report

Severe unstable slipped capital femoral epiphysis (SCFE) usually requires some form of reduction before stabilization to avoid loss of motion and to prevent the development of early degenerative arthritis. Gentle manipulation and traction is being used to achieve reduction. The force applied with these techniques is uncontrolled and unpredictable, and may add to the pre-existing risk of avascular necrosis of the femoral head in such cases. The authors report a case of acute on chronic, severe, unstable SCFE in which reduction was satisfactorily achieved by gradual distraction using an external fixator across the hip joint. The patient did not show signs of avascular necrosis or chondrolysis at a follow-up of 38 months. Hip function was excellent with Iowa hip score of 98 at the final follow-up.

Bone remodeling of a femoral head after transtrochanteric rotational osteotomy for osteonecrosis associated with slipped capital femoral epiphysis: a case report

A rare case of a 12-year-old boy on whom a joint-preserving operation for osteonecrosis after slipped capital femoral epiphysis (SCFE) was performed, is described. Firstly, in situ pinning was performed for acute-on-chronic SCFE. However, osteonecrosis and collapse of the femoral head occurred at 7 months after surgery. Secondly, transtrochanteric rotational osteotomy (TRO) was performed against progression of the collapse of the femoral head. Eight years of X-ray observation revealed bone remodeling at the osteonecrotic region. No documentation has been reported about the potential of bone remodeling of a femoral head with osteonecrosis after SCFE. This case indicates that a joint-preserving operation such as TRO is capable of promoting bone remodeling in such circumstances.

Surface arthroplasty in young patients with hip arthritis secondary to childhood disorders

Legg-Calvé-Perthes disease (LCP) and slipped capital femoral epiphysis (SCFE) may result in alterations of the proximal femoral morphology, leading to the development of hip osteoarthritis as a young adult. Hip surface arthroplasty presents special technical challenges in these patients because of the abnormal anatomy of the head and neck. The authors reviewed the radiographic and clinical results of patients with a history of LCP or SCFE who underwent hip resurfacing between 1996 and 2002. Despite the challenges in performing hip resurfacing in this patient population and the inability to completely normalize hip anatomy, biomechanics, and leg length discrepancy, the results to date have been encouraging.

[Primary hyperparathyroidism associated to slipped capital femoral epiphysis in a teenager]

Primary hyperparathyroidism (PHP) is an uncommon disease in children and adolescents. The association between PHP and slipped capital femoral epiphysis is rare, and so far only four cases have been reported in the literature. Herein, we report a case of PHP due to a parathyroid adenoma, with several painful skeletal deformities and associated with slipped capital femoral epiphysis in an 18-year-old male patient. Laboratory evaluation showed: calcium of 13.6 mg/dL, parathyroid hormone of 1,524 pg/mL and alkaline phosphatase of 3,449 U/L. Deformities were caused by late diagnosis during the growth spurt, and this association is the result of combinations between metabolic and mechanical factors. The patient underwent parathyroidectomy and, in agreement with the literature, since the removal of the adenoma is followed by prompt resolution of the slipped capital femoral epiphysis we decided for a conservative approach. We observed improvement of the pain and normalization of calcium and parathyroid hormone levels.

Slipped capital femoral epiphysis in down syndrome

Slipped capital femoral epiphysis (SCFE) and Down syndrome are both uncommon in the population at large, and rarely are both conditions present in a single individual. Institutional records were searched for both Down syndrome and SCFE. At least 2 years of follow-up was required. Eight patients were identified. At presentation four patients could not walk due to pain and four could walk. Six of eight hips presented with grade III SCFE. Four hips were treated with internal fixation in situ and four were manipulatively reduced in the operating room at the time of fixation with percutaneous screws or pins. Three hips healed uneventfully. Five hips developed aseptic necrosis (three partial, two whole head). This small retrospective study suggests an extremely high rate of complications in adolescents with Down syndrome and SCFE.

[Long-term results of pinning for slipped capital femoral epiphysis]

Clinical and radiological analysis of 39 hips in 32 patients treated with in situ pinning for light and non-severe (up to 78 degrees) slipped capital femoral epiphysis. The population of 21 boys and 11 girls aged 10-16 (av. 13.1) was observed in 4-27 (av. 21) years. The observation showed 18.8% very good, 18.8% good, 46.8% satisfactory, 12.5% bad results and 3.1% (1 patient) of unsuccessful treatment, according to Heyman & Herndon clinical evaluation scale. Radiological evaluation of secondary coxarthritis acc. to Boyer: 0 - 35.,8%, I - 23.1%, II - 33.4%, III - 7.7%. Slipped upper femoral epiphysis causes secondary coxarthritis. Kirschner wire pinning is good method for non-severe cases.

[Reduction of epiphyseal displacement and fixation in the treatment of unstable slipped capital femoral epiphysis]

Reduction of epiphyseal displacement by manipulation in the treatment of unstable slipped capital femoral epiphysis (scfe) can lead to very severe complications as avascular necrosis or acute necrosis of cartilage. The aim of this study is to analyze the results of treatment of unstable scfe with open reduction and fixation. Material consists of 14 patients (10 boys and 4 girls) with 15 hips treated surgically because of unstable scfe with an average follow up of 10 years and 6 months (ranged from 2 to 26 yrs). The age of the patients ranged from 9 to 17 yrs (mean 13). There was 14 cases of acute-on-chronic slips and 1 acute slip. The slip angle measured on anteroposterior radiographs ranged from 27 degrees to 57 degrees (mean 39 degrees) and on frog lateral radiographs ranged from 52 degrees to 81 degrees (mean 67 degrees). In all of the cases manipulated reduction and internal fixation was done. The mean amount of correction was 30 degrees measured on anteroposterior radiographs (from 7 degrees to 55 degrees) and 37 degrees on frog lateral radiographs (from 8 degrees to 82 degrees). An end results were classified according to Hall and Southwick classification with Szypryt modification.

RESULTS

Excellent result was achieved in 6 hips (40%), good in 4 hips (27%), fair in 3 (20%) and poor in 2 (13%). Avascular necrosis developed in 2 hips. There was no cases with acute necrosis of cartilage.

CONCLUSION

Reduction of epiphyseal displacement and fixation is a save procedure in the treatment of unstable slipped capital femoral epiphysis. Severe under-correction as well as over-reduction can lead to unsatisfactory results.

[Juvenile unstable severe slip of the proximal femoral epiphysis: case report and review of treatment options]

The authors present the case of a severe unstable slip of the proximal femoral epiphysis in a 14-year-old boy. A serious metabolic disorder diagnosed in the boy led to postponement of necessary surgical intervention. The primary development of necrosis of the proximal femoral epiphysis during the 6 months following the slip is reported here. A good outcome was eventually achieved by three-plane valgus, flexion and derotational osteotomy of the femur at second-stage surgery. The authors emphasize the prognostic importance of stability assessment in the displaced epiphysis.

Apophyseal avulsion fracture of the greater trochanter after slipped capital femoral epiphysis: a case report

A 13-year-old boy sustained an avulsion fracture of the left greater trochanter eight months after surgical stabilisation of a slipped capital femoral epiphysis on the same side. In this specific case, avulsion of the greater trochanter after slipping of the capital femoral epiphysis may have been facilitated by weakening of the trochanteric physis.

Slipped capital femoral epiphysis: an analysis of treatment outcome according to physeal stability

INTRODUCTION

Slipped capital femoral epiphysis (SCFE) is a common hip disorder in adolescents. Treatment can be associated with serious complications, mainly avascular necrosis (AVN). The objective of this study was to evaluate treatment outcomes and complications based on physeal stability at presentation.

METHODS

We reviewed retrospectively all children treated for SCFE from 1990 through 2000 at the Children's Hospital of Eastern Ontario, Ottawa.

RESULTS

Of a total of 87 patients (56 male) identified, 73 had slips classed as stable and 14, unstable; 42 involved the left side, 34 the right, and 19 were bilateral. Avascular necrosis (AVN) developed in 1 patient with a stable slip (morbidity 1.4%) and in 3 with unstable slips (21.4%; p = 0.001). Manipulative anatomical reduction was done in 11 cases (78.5%), all unstable slips. All slips complicated by AVN had been classified according to the traditional system as acute-on-chronic. Complication rates differed significantly between unstable slips (36%) and stable (20%). No statistically significant association was found between AVN and slip severity, time to fixation or use of reduction.

CONCLUSIONS

The treatment of stable slips exhibits a lower incidence of AVN. These results nevertheless suggest that gentle reduction of unstable slips is safe and unaccompanied by an increase in complications.

Gait abnormalities following slipped capital femoral epiphysis

The authors evaluated 30 subjects with treated unilateral slipped capital femoral epiphysis and a range of severity from mild to severe to characterize gait and strength abnormalities using instrumented three-dimensional gait analysis and isokinetic muscle testing. For slip angles less than 30 degrees, kinematic, kinetic, and strength variables were not significantly different from age- and weight-matched controls. For moderate to severe slips, as slip angle increased, passive hip flexion, hip abduction, and internal rotation in the flexed and extended positions decreased significantly. Persistent pelvic obliquity, medial lateral trunk sway, and trunk obliquity in stance increased, as did extension, adduction, and external rotation during gait. Gait velocity and step length decreased with increased amount of time spent in double limb stance. Hip abductor moment, hip extension moment, knee flexion moment, and ankle dorsiflexion moment were all decreased on the involved side. Hip and knee strength also decreased with increasing slip severity. All of these changes were present on the affected and to a lesser degree the unaffected side. Body center of mass translation or pelvic obliquity in mid-stance greater than one standard deviation above normal correlated well with the impression of compensated or uncompensated Trendelenburg gait.

Delay in diagnosis of slipped capital femoral epiphysis

OBJECTIVE

Delay in diagnosis of slipped capital femoral epiphysis (SCFE) has important implications in terms of slip severity and long-term hip outcome. The purpose of this study was to identify predictors of delay in the diagnosis of SCFE.

METHODS

A review of 196 patients with SCFE was performed. The primary outcome measure was delay from onset of symptoms to diagnosis. Covariates included age, gender, side, weight, pain location, insurance status, family income, slip severity, and slip stability. Delay in diagnosis was not normal in distribution; therefore, nonparametric univariate and multivariate analyses were performed.

RESULTS

The median delay in diagnosis was 8.0 weeks. There was a significant relationship between delay in diagnosis and slip severity (<30 degrees : 10.0 weeks; 30 degrees to 50 degrees : 14.4 weeks; >50 degrees : 20.6 weeks). There were no significant associations between delay in diagnosis and covariates of age, gender, side, and weight. There were significant associations between longer delay in diagnosis and covariates of knee/distal-thigh pain versus hip/proximal-thigh pain (6.0 vs 15.0 weeks), Medicaid coverage versus private insurance (12.0 vs 7.5 weeks), lower family income, and stable slips versus unstable slips (8.0 vs 6.5 weeks). Controlling for the other covariates, knee/distal-thigh pain, Medicaid insurance, and stable slips remained significant independent multivariate predictors of delay in diagnosis.

CONCLUSIONS

Patients who present with primarily knee or distal-thigh pain, patients with Medicaid coverage, and patients with stable slips have longer delays in diagnosis of SCFE. Focused intervention programs to reduce the delay in diagnosis of SCFE should emphasize patients with knee/thigh pain and patients with Medicaid coverage.

Slipped capital femoral epiphysis in a child with sickle cell disease

Slipped capital femoral epiphysis in a child with sickle cell disease has not been reported previously. The diagnostic challenges, role of imaging techniques, and the medical treatment of this patient are discussed. The presentation of acute hip or leg pain in a child with sickle cell disease should alert the treating physician to the possibility of a vaso-occlusive crisis as the likely source of the child's pain. The goal of the current case report is to emphasize the need to maintain a high index of suspicion for other potential causes of hip, thigh, or knee pain such as slipped capital femoral epiphysis in an adolescent. Preoperative and postoperative care for a child with sickle cell disease needs to be modified to minimize the risks of vaso-occlusive complications.

[Clinical outcome and assessment of spontaneous remodeling of slipping angle in SCFE]

38 patients, and 45 hips has undergone treatment for slipped capital femoral epiphysis between 1995 and 2000. On the basis of the measurement of the head shaft angle on X-ray examination done preoperatively, hips were classified to one of the three groups--mild, moderate, and severe slippage. All patients had undergone pinning in situ as a primary treatment. All were checked out periodically, clinically and radiologically. On the last X-ray before physeal plate closure the head shaft angle was evaluated again. Retrospectively the head neck angle was measured as well. After the average 2.5 years long observation there was stated, that according to Southwick clinical and radiological classification 73% of good and very good outcomes were among moderate and severe slippages. On X-ray assessment 38% of initial and final projection were estimated to be comparable. Amount was inversely proportional to escalation of the slippage. On the comparable projections remodeling of the proximal femur occurred in 27% of the head-shaft angle cases, and 39% on the head-neck angle cases. Remodeling often concerned younger patients and greater slippages. Primary in situ stabilization in treatment SCFE is a correct therapy. Because of spontaneous remodeling occurring in a large amount of hips after stabilization making, a decision of realignment procedures should be rescheduled until remodeling is over after physeal plate closure. Conventional X-rays examination is a method of qualitative, not quantitative monitoring of a treatment of SCFE.

[Remodeling after in situ pinning for slipped capital femoral epiphysis]

We reviewed 61 hips in 50 children (33 boys and 17 girls) with slipped capital femoral epiphysis (SCFE), all treated by in situ pinning. Average age of our patients was 11.8 years (range, from 8 to 15 years). The average clinical and radiographic follow-up was 7.4 years. By studying the changes in physeal-shalt angle on radiographs in Lauenstein (frog) position, we found evidence of physeal remodeling in three (8%) of 38 mild and seven (30%) of 23 moderate slips. Remodeling of the proximal femoral metaphysis occurred in 92% of hips with a head-shaft angle less than 30 degrees and in 52% of hips between 30 degrees and 60 degrees. A process of local resorption and apposition of bone seems to be essential to final remodeling. The probability of remodeling was significantly less the greater the degree of slip, but was significantly increased among children 11 years old or younger and if the triradiate cartilage was open at the time of presentation. The range of internal rotation was significantly greater in those hips that remodeled. Pinning in situ of a slipped capital femoral epiphysis represents a simple, quick and effective method of treatment, allowing remodeling in mild and moderate slips.

[Slipped capital femoral epiphysis associated with hyperparathyroidism. A case report]

Slippage of the upper femoral epiphysis can occur in association with multiple endocrine imbalances. A case of slipped femoral epiphysis with primary hyperparathyroidism is reported. The patient was an adolescent, 16 Years of age, who presented bilateral slipped epiphysis. Investigation showed that he had hypercalcemia (3.1 mmol/l) related to primary hyperparathyroidism. A parathyroid adenoma was removed. Outcome was favorable and the slipped femoral epiphyses did not require a specific treatment.

Pinning in slipped capital femoral epiphysis: long-term follow-up study

This long-term follow-up study was aimed at evaluating patients with hip epiphysiolysis treated by pinning and previously controlled by short-term follow-up, in order to evaluate both clinical and radiographic evolution. The case series included 36 patients (17 female and 19 male) for overall 48 hips (21 right, 27 left). The epiphysiolysis was bilateral in 12 patients. Median follow-up was 17.9 years (range 8.8-29.2). Clinical results were evaluated according to Harris, radiographic results according to Boyer. The patients were divided into three groups according to slipping degree calculated following Southwick (0-30 degrees, 30-60 degrees, >60 degrees ). Slipping degree was found to be directly correlated with worsening of results. Reduction manoeuvres on chronic epiphysiolysis proved to lead to even poorer results. Our review, even though carried out on a limited number of cases, showed that (1) hips with arthrosis at first control resulted in worsening in the majority of cases; (2) slipping degree was proportional to the result obtained; (3) reduction manoeuvres performed on chronic epiphysiolysis had a negative influence on results; (4) the presence of chondrolysis or epiphyseal necrosis always led to early hip arthrosis; (5) in the absence of major complications, evolution towards arthrosis can be slow and adulthood or even old age can be reached without resorting to total hip replacement.

Nonunion of femoral neck fracture and trochanteric osteotomy after a pinned, slipped capital femoral epiphysis: a case report

Femoral neck fracture as a complication of slipped capital femoral epiphysis (SCFE) is rare. Even rarer is a femoral neck nonunion as an additional complication. This is the first case reported in the literature of a failed valgus osteotomy for a femoral neck nonunion. A salvage operation involving a step-cut valgus/flexion/internal rotation osteotomy, open reduction and internal fixation, with a blade plate and cannulated screw, placement of an allograft femoral strut, and allograft bone grafting was successfully performed. Femoral neck fractures following SCFE fixation are more difficult to treat because of abnormal femoral neck configuration. Therefore a valgus, flexion, and internal rotation producing osteotomy may need to be initially performed to prevent a femoral neck nonunion.

[Closed reduction and pinning for acute slipped capital femoral epiphysis]

Acute slipped capital femoral epiphysis is a rare adolescent hip disorder, which may be a problem for orthopedic surgeon. No series to date has demonstrated the superiority of any treatment method. The purpose of the study was to evaluate the outcome of treatment and to assess the risk factors of avascular necrosis associated with this condition. Fourteen cases of acute slipped capital femoral epiphysis were treated with closed reduction and pinning. There were 9 boys and 5 girls. The average age at presentation was 11.8 years (range 9.1-15.3). Eight children were treated 4-10 days and six within 48 hours of the onset of their acute symptoms. The severity of the slip was classified according to the system of Southwick. Presence of chondrolysis and avascular necrosis was estimated. The clinical results were graded with the use of the criteria of Aadelen et al. Four slips were classified as mild, seven as moderate and three as severe. Average follow up was 5.2 years (range from 2.4 to 14.3). In two hips with severe slip AVN developed. One of these cases was treated within 48 hours and one after 7 days. Chondrolysis developed in one hip and was associated with presence of intra-articular fixation. Twelve of the fourteen hips had good and vary good results and remaining 2 with AVN had poor. Closed reduction and pinning in acute slipped capital femoral epiphysis is an effective and giving satisfactory outcome method of treatment. Early reduction is not associated with a high rate of AVN and should be performed as soon as possible. More severe slips were noted to have an increased risk of AVN.

Anterior physeal separation. A sign indicating a high risk for avascular necrosis after slipped capital femoral epiphysis

A study of 78 children (110 hips) was undertaken in an attempt to assess the risk of avascular necrosis (AVN) after slipped capital femoral epiphysis based on the radiological appearances of the hip at the time of presentation. Physeal separation, which was defined as the amount of separation of the anterior lip of the epiphysis from the metaphysis on the frog lateral view, was assessed. Of the eight hips which developed AVN, seven had anterior physeal separation. We conclude that anterior physeal separation is associated with a high incidence of subsequent AVN after slipped capital femoral epiphysis and that screw fixation may not be appropriate in these patients.

Improved percutaneous slipped capital femoral epiphysis treatment: continuous biplanar fluoroscopy and proper guide wire selection

In 1990, a report was published outlining a technique of percutaneous fixation of slipped capital femoral epiphyses dramatically diminishing the morbidity associated with the open technique. Technical difficulties are still encountered with the morbidly obese child and the percutaneous technique. Two fluoroscopic units used continuously during the technique facilitate placement of the guide wire in a more acceptable anatomic location. Guide wire stiffness was also measured and used in preoperative planning. Ten hips were treated with this technique, and a prospective analysis of the surgical time and fluoroscopy time was done. Using the new technique, we found a significant reduction in surgical and fluoroscopic times.