“Slipped Capital Femoral Epiphysis”
Current Concepts and Treatment Dr. Donald W. Kucharzyk Clinical Assistant Professor University of Chicago Children’s Hospital The Orthopaedic, Pediatric & Spine Institute
“SCFE: Current Concepts
EpidemiologyEtiologyClinical TypesNatural HistoryTreatment and Treatment GoalsReconstructive ProceduresComplications
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EPIDEMIOLOGY
“SCFE: Current Concepts
Incidence: 2/100,000Male:Female Ratio: 3:1Age of Onset: Male…13-16 years Female..11-14 yearsRace: Black moreso than CaucasianSkeletally and Hormonally ImmatureObeseBilateral: 50-60%
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ETIOLOGY
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Hormonal: Hypothyroidism Hyperthyroidism Hypopituitarism Hypogonadism Hyperparathyroidism Harris W: JBJS 1963 Kelsey JL: Pediatrics 1973
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Trauma: Muscular Joint Reactive Forces Weight-Bearing Forces
Chung SMK: JBJS 1976 Gelberman RH: JBJS 1986 Mickelson MR: JBJS 1977
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Mechanical: Periosteal Thinning and Anteversion Defect in Perichondrial Fibrocartilaginous complex Thinning of Cartilage Bridge Anteversion and Obliquity of Proximal Physis Pritchett JW: J Ped Ortho 1988
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Inflammatory: Synovitis Defect in Synovial and Serum Immunoglobulins Autoimmune Process
Howarth B: Clin Ortho 1966 Ponsetti I: JBJS 1956
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Genetic: Familial Autosomal Dominant with Incomplete Penetrance Jerre T: Acta Orthop Scand 1960
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CLINICAL TYPES
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PRESLIPMild leg, groin, or medial thigh pain with activityLimp, mild decrease in internal rotation
and abduction of involved hipXray reveals widened and irregular
physis with normal head-neck alignment
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ACUTELess than 3 weeks of painSignificant Antalgic gait with inability to
bear weightReduced range of motion: internal rotationExternal Rotation DeformityXray: widened and irregular physis with
variable displacement
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ACUTE ON CHRONICGreater than 3 weeks of low grade
pain with acute sudden exacerbationClinical Findings same as Acute with
coexistent thigh atrophyXray: varying displacement with a
degree of remodeling
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CHRONICPain for longer than 3 weeks
involving groin, thigh or kneeSimilar findings as acuteXray: varying degree of displacement
with rounded contours
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STABILITY CONCEPT CLASSIFICATIONSTABLE: walking and weight-bearing
still possible with or without crutchesUNSTABLE: walking not feasible even
with crutchestime duration not of importance Loder RT: JBJS 1993
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NATURAL HISTORY
“SCFE: Current ConceptsFew studies that evaluate untreated
patientsPrognosis related to the degree of
the Slip and the ability to remodelDegree of the Slip related to the
duration of symptomsAssociation with DJD of the HipChondrolysis seen in untreated hipAVN rare in the untreated hip
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Herndon et al,1963: unrealigned severe slips treated with bone grafting; 25 of 32 hips had good or excellent results.
Boyer et al,1981: severe uncorrected slips; 6 0f 7 had good clinical results but motion was restricted
O’Brien and Fahey,1977: remodeling occurs in the femoral neck and will lend to acceptable results in slips up to 60deg
“SCFE: Current ConceptsFew studies that evaluate untreated
patientsPrognosis related to the degree of
the Slip and the ability to remodelDegree of the Slip related to the
duration of symptomsAssociation with DJD of the HipChondrolysis seen in untreated hipAVN rare in the untreated hip
“SCFE: Current ConceptsWilson et al,1938: a slip up to one-third is
acceptable and will remodelBoyer et al, 1981: remodeling will correct a
slip up to 60degHoworth et al,1965 and Southwick et al,1967:
report that severe slipping and malunion have a poor long term prognosis and debate exists as to the degree of restoration of the normal alignment to prevent osteoarthritis
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TREATMENT GOALSStabalize the epiphyseal-metaphyseal
junction and prevent slippageStimulation of early closureAvoid complications of chondrolysis and
avascular necrosisPreserve hip joint functionAvoid or Delay onset of Degenerative Joint
changes
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TREATMENT TECHNIQUES
Percutaneous Screw FixationOpen Bone Peg EpiphysiodesisRealignment Osteotomies
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TREATMENT PERCUTANEOUS SCREW FIXATIONFluoroscopy and parallel to physis and in the
center of the head; single screwAvoid penetration of screw: transient: without sequlae Zionts JBJS 1991 chronic: chondrolysis Walters & Simon 1980
“SCFE: Current Concepts TREATMENT PERCUTANEOUS SCREW FIXATION“Moseley” Approach-Withdrawl
Technique and rotation of C-ArmUtilizing current technique,
safe,effective,economical with a low complication rate
Aronson DD: JBJS 1992 Ward WT: JBJS 1992
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TREATMENTOPEN BONE GRAFT EPIPHYSIODESISReported advantages: rapid closure of
the physis and sooner return to regular activities
Reported disadvantages: large incision,increased operative time,progression of the slip, graft migration and resorption
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TREATMENTOPEN BONE GRAFT EPIPHYSIODESISComplication rate low in the initial
reported series (Weiner DS: 1989)Higher complication rates reported by
other authors (Ward WT: JPO 1990)
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TREATMENT LONG TERM FOLLOWUP RESULTSExcellent Functional Outcomes reported
with screw fixationIn-Situ fixation preferred given the
increased complication rates with osteotomies (AVN/chondrolysis)
Slip up to 60deg in skeletally immature and 30-40deg in skeletally mature lead to adequate function
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TREATMENT LONG TERM FOLLOWUP RESULTSGrowth plate closure within 16 months with
screw fixation; bone peg epiphysiodesis closure within 15 weeks and full closure at 6 months
Return to sports 3 months with screw and 15 weeks with bone peg
Greatest Motion return within 6 months Sponseller JBJS 1991
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TREATMENT REALIGNMENT OSTEOTOMIESGoals: Realignment of the slip, improved
kinematics of the acetabular and femoral components, and delay onset of DJD
Rationale: Forces resulting from a slip of more than 45deg produces a varus posterior tilting of the head of the femur and altered kinematics with secondary degenerative effects
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TREATMENT REALIGNMENT OSTEOTOMIESIndications: Flexion<90deg; Slip
greater than 45deg; Severe external rotation deformity
Levels of Osteotomies: Subcapital; Base of the Neck; Transtrochanteric; and Intertrochanteric
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SUBCAPITAL WEDGE OSTEOTOMYDunn(1978) and Fish(1984): Open
excision of callous and physeal cartilage with osteotomy of the neck to relax the blood vessel
Advantages: Anatomic ReductionDisadvantages: AVN and Cartilage
Necrosis
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BASE OF THE NECK OSTEOTOMYKramer(intracapsular 1976) and
Abraham(extracapsular 1993)Advantages: Safer than the subcapital and
achieves satisfactory anatomic restorationDisadvantage: Correction limitation:35-55 Shortening of the femoral neck;
Trochanteric osteotomy; AVN
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TRANSTROCHANTERIC OSTEOTOMYSugioka(1980)Advantages: Correction of severe
deformities(>60deg); Direct observation of the correction; No shortening required; Head/Shaft relationship realigned; Preserve abductor mechanism
Disadvantage: AVN and chondrolysis and high complication rate(40%)
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INTERTROCHANTERIC OSTEOTOMYSouthwick Biplane(1967): corrects
posterior tilt, varus, and external rotationAdvantages: Extracapsular; Stimulates
physeal closure; improves hip function; No AVN; Does not affect future surg.
Disadvantages: Chondrolysis and some shortening
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COMPLICATIONS
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Hardware PenetrationHardware BreakageProgression of the SlipAvascular NecrosisDeformity-LateChondrolysisFracture Post Hardware Removal
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HARDWARE PENETRATIONTransient: no relation to chondrolysisPersistant: chondrolysisTreatment: immediate removal and
repostioning
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HARDWARE BREAKAGEDefine whether or not the joint surface
has been compromised and if there is progression of the slip
“Windshield Wiper” loosening due to screw being left to long(Maletis and Bassett JPO 1993)
Treatment: remove broken fragment if joint involved and revise if physis open
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PROGRESSION OF THE SLIPGrowing off a single screwFollowing bone peg epiphysiodesis:
seen in severe slipsTreatment: secure the slip via the
same technique
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AVASCULAR NECROSISReported incidence: mild slip-4%;
moderate-25%; severe-20%; Overall-15%Incidence related to the surgical
procedure: lower in in-situ than in closed or osteotomy
Anatomic Involvement: usually the anterolateral segment but may be total head
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AVASCULAR NECROSISTreatment: Small segmentation
collapse then observe and preserve motion; Larger segmentation collapse then consider a varus flexion osteotomy; Severe collapse, total head involvement, and pain then consider fusion
“SCFE: Current Concepts CHONDROLYSISOverall incidence: 24%(CampbellSeries)Increased incidence in blacks, females, and
in moderate(35%) and severe(45%) slipsLoss of joint space and decreased range of
motion: flexion,abduction,and internal rotation
Etiology: unknown (pin penetration, immunologic,or seen in untreated-5%)
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CHONDROLYSISTreatment: Range of motion exercises Non-weight bearing NSAID Capsulectomy and CPMProtocol reportedly has restored about
50% of the joint motion and an increase of 50% of the joint space on xrays
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FRACTUREPlacement of unnecessary drill holesPossiblity due to thermal necrosisStress fracture of femoral neck due
to reaming (Cummings 1988)Hardware removal (Canale JPO)Treatment: ORIF
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THANK YOU
Dr. Donald W. Kucharzyk