Presence and magnitude of anterior physeal separation in slipped upper femoral epiphysis helps identifying those at high risk for avascular necrosis

Abstract

AimsWe sought to determine if the magnitude of anterior physeal separation (APS) in slipped upper femoral epiphysis was a predictor for the subsequent development of avascular necrosis (AVN). Anterior Physeal Separation (APS) is defined as the distance between the anterior lip of the bony capital epiphysis and the lateral corresponding point of the adjacent bony metaphysis on the Lauenstein radiographic view. It represents hinging of the posterior aspect of the metaphysis with the anterior epiphysis lifting away from its adjacent metaphysis, indicating instability and potential vulnerability of the vessels. Patients and MethodsA retrospective review of all patients treated regionally for slipped upper femoral epiphysis over a 9 year period (2010–2018 inclusive) were identified. Data regarding demographics, radiological parameters and outcomes was recorded. APS was measured on a Launestein radiograph view, with the patient supine, the hip and knee are flexed to 40°, and the hip externally rotated 45°, with film-focus distance of 100 cm. Analysis of the APS was performed to validate a threshold above which AVN occurs. ResultsWe identified 147 hips in 142 patients, of which 5 had bilateral slips at the time of presentation. Average anterior physeal separation was 3.8 ± 1.8 mm, with higher grade slips having significantly greater APS values. Increased APS values were seen with Loder “unstable” slips. Seven hips (4.8%) developed AVN, and in these cases the APS was significantly larger than those who did not (8.5 ± 1.4 Vs 3.9 ± 1.7; p < 0.001). Receiver operator curve analysis demonstrated a critical value of 7.5 mm was associated with a 100% sensitivity and 98.6% specificity for AVN. We identified some grade II/moderate slips with high APS values had similar outcomes to grade III/severe slips, and therefore suggest that APS may serve to alert the surgeon on counselling patients on the risk of developing AVN and to consider strategies to minimise the risk of AVN. ConclusionsAPS is sensitive, specific, accurate and reliable for the association with AVN in SUFE. Its values closely reflect the high AVN rates seen in acute and unstable SUFE. This risk is greatest if the magnitude of APS exceeds the critical value of 7.5 mm.