Acute Slipped Capital Femoral Epiphysis Research Articles

Adult case of slipped capital femoral epiphysis initially requiring in situ fixation with revision to total hip arthroplasty after failure of index surgery

Introduction: Slipped capital femoral epiphysis (SCFE) is a disorder classically associated with pediatric patients in which the femoral head is displaced through the physis. In rare cases of metabolic and hormonal disorders, SCFEs can be identified in adult patients as a result of persistent growth plates. Optimal definitive surgical management of these patients is still unknown and more information is needed in order to provide appropriate care for these patients. Case Report: A 31-year-old male with past medical history of hypopituitarism presented with left hip pain after a seizure. He was found to have a left slipped capital femoral epiphysis on initial radiographs for which he was taken to the operating room for open treatment of the left SCFE with in situ screw fixation. Approximately four weeks later he returned to the hospital after a fall with left hip pain and inability to ambulate. Radiographs demonstrated cutout of the cannulated screw in the setting of a SCFE with further displacement. He returned to the operating room for conversion to an uncemented total hip arthroplasty. His post-op course was uneventful and he was discharged home in stable condition. Conclusion: This cases highlights a condition uncommonly identified in adult patients which was further complicated by failure of the initial surgical repair and need for revision surgery. This case is unique in that total hip arthroplasty as a definitive treatment for acute SCFE, rather than treatment for end stage arthritis secondary to chronic SCFE, has not been reported upon this author’s review.

Increased Hip Intracapsular Pressure Decreases Perfusion of the Capital Femoral Epiphysis in a Skeletally Immature Porcine Model.

Increased intracapsular hip pressure is thought to be one of the possible etiologies of femoral head avascular necrosis after intra-articular proximal femoral fractures or acute slipped capital femoral epiphysis. The purpose of this study was to evaluate the relationship between intra-articular hip pressure (IAP) and epiphyseal perfusion pressure (EPP), and its dependency on skeletal maturity using a porcine model. Seven female Yorkshire-hybrid pigs were used to study the direct relationship between IAP and EPP. A needle inserted into the capsule provided both IAP monitoring and saline infiltration until IAP was above mean arterial pressure (MAP). Video simultaneously documented IAP, EPP, MAP. Parameters for all trials in each hip were averaged and compared between the 2 age groups. Significance was P<0.05. Four young hips (in pigs 10.3±1.0 wk, 27.4±2.0 kg) and 5 older hips (21.1±0.1 wk, 89.4±7.1 kg) were studied. There was no significant difference in the MAP (50.0±11.8 and 55.5±7.0 mm Hg respectively, P=0.411) between the 2 age groups. In the older hips, biphasic EPP persisted despite increasing IAP to an average of 177 mm Hg over MAP. In the young pigs, the biphasic EPP waveform ceased with increased IAP to an average of 28 mm Hg over MAP. Biphasic waveforms returned once IAP fell to an average of 5 mm Hg over MAP. Increased IAP resulted in tamponade of epiphyseal perfusion in the young, but not in the older hips. An intact physis may preclude intraosseous metaphyseal vessels from penetrating the epiphysis, leaving it vulnerable to retinacular artery tamponade. The IAP and EPP relationship has direct clinical practice implications. Hip capsulotomy and decompression in young patients with intra-articular proximal femoral fractures and increased intracapsular pressure may decrease avascular necrosis risk.

Relationships Between Severity of Deformity and Impingement in Slipped Capital Femoral Epiphysis.

In situ pinning, a low-risk treatment for slipped capital femoral epiphysis (SCFE), leaves the slipped femoral head in place and may reduce range of motion (ROM) and cause impingement. It is unclear when a more complex surgery should be considered, because the relationships between severity, slip stability, remodeling, impingement, and ROM are unknown. (1) Do more severe acute SCFE deformities (no bony remodeling) result in a greater loss of flexion ROM?(2) Does the presence or location of impingement on the pelvis vary with severity of acute SCFE deformity? We developed a 3D geometric model of acute SCFE deformity from 1 computed tomography scan of a normal adolescent hip. Ethics board approval was obtained from our institution. Bone models were created from the segmented pelvis, epiphysis, and subphyseal femur.In total, 3721 SCFE deformities were simulated by combining posterior and inferior slips in the axial and coronal planes, respectively. Southwick angles were estimated from a frog-leg lateral projection. Deformities were divided into mild (0 to 30 degrees), moderate (30 to 60 degrees), and severe (≥60 degrees) Southwick groups. Each joint was flexed in combination with internal/external rotation until contact occurred. A total of 121 ROM trials, with different degrees of internal/external rotation (0 to 90 degrees at 1.5-degree steps) were performed for each deformity. In total, 3355 simulated SCFE deformities (363 could not be rotated out of impingement) were analyzed.Increasing slip severity reduced flexion ROM across the range of internal/external rotation. Contact occurred for most mild deformities, and for all moderate and severe deformities in at least 1 ROM trial. Impingement was observed mainly on the anterosuperior aspect of the acetabulum. Increasing slip severity in acute SCFE reduced flexion and increased incidence of impingement, primarily occurring on the anterosuperior aspect of the acetabulum. The impingement patterns observed are consistent with damaged cartilage locations seen in clinical literature. In this experimental model, moderate and severe acute slips in SCFE lead to reduced ROM and impingement with the acetabulum. This suggests that in situ pinning may result in impingement of moderate and severe acute SCFE slips.

It’s Not as Easy as It Looks

Loder et al. first pointed out the importance of physeal instability in predicting the risk of osteonecrosis after acute slipped capital femoral epiphysis, noting a 47% rate of osteonecrosis in their series1. Others have emphasized the importance of reduction of the slip, urgent treatment, and capsular decompression in decreasing the rate of osteonecrosis2,3. In 2009, Parsch et al. reported a 4.7% rate of osteonecrosis after open reduction of sixty-four hips with evidence of instability4. Since the efficacy of the modified Dunn procedure was reported by Ziebarth et al. and echoed by Slongo et al.5,6, substantial interest has been generated in the ability of this procedure to restore anatomy, in an attempt to prevent later problems associated with impingement, and to further reduce the rate of osteonecrosis. Indeed, some have even advocated surgical hip dislocation by means of the modified Dunn procedure as the new gold standard for treatment of unstable slipped capital femoral …

Long-term outcome of slipped capital femoral epiphysis: a 38-year follow-up of 66 patients.

PurposeThe purpose of this retrospective study was to evaluate the long-term outcome of different methods of treatment in slipped capital femoral epiphysis (SCFE), to find risk factors for poor outcome, and to assess whether prophylactic fixation is indicated.MethodsSixty-six patients (76 hips) treated for SCFE with a mean follow-up of 38 years (range 21–57 years) were evaluated. All except seven patients had chronic SCFE. Ten patients (15%) had bilateral affection. Three methods of treatment had been used: screw fixation (35 hips), bone-peg epiphysiodesis (30 hips), and bone-peg epiphysiodesis combined with corrective femoral osteotomy (11 hips). The long-term clinical outcome was classified as good when the patient had not undergone total hip replacement (THR), when the Harris hip score (HHS) was 85 points or above, or the patient had no pain. Good radiographic outcome was defined as no THR or osteoarthritis (OA).ResultsIn 51 patients with chronic slip (mean slip angle 32°) treated with in situ fixation, the clinical outcome was good in 35 patients (69%) and there was no significant difference between screw fixation and bone-peg epiphysiodesis. Eight patients with large chronic slip (mean slip angle 53°) were treated with bone-peg epiphysiodesis and corrective femoral osteotomy, and the clinical outcome was poor in six patients. Seven patients with acute slip had larger mean slip angle (57°) and more complications than those with chronic slip, and the long-term outcome was poor in all. Two hips out of 42 (5%) had OA in the contralateral hip at follow-up.ConclusionIn situ fixation of chronic SCFE gave satisfactory long-term outcome irrespective of the treatment method. Corrective femoral osteotomy did not improve the outcome in hips with large slip angles. Acute SCFE had poor outcome. Prophylactic fixation of the contralateral hip is barely necessary.

50 Years Ago in CORR: Slipping of the Upper Femoral Epiphysis Beckett Howorth MD CORR 1957;10:148–173

This month’s symposium reports various aspects of the diagnosis and treatment of femoroacetabular impingement, a condition recognized for well over a century but only recently emphasized, perhaps owing to the recognition of its occurrence in subtle and common forms. It was perhaps first recognized in 1898 a few years after the introduction of the roentgenogram in association with slipped capital femoral epiphysis [11]. According to Howorth, in the article highlighted here, Poland, in 1898, reported a case in which without reducing the displacement, “the projecting anterosuperior margin of the neck was trimmed away” [5]. He also noted that Whitman in 1909 [17] and Vulpius and Stoffel in 1913 [15] reported similar cases. Howorth suggested the earliest reference to slipped capital femoral epiphysis came from Ambroise Pare, whom he quotes, “The epiphysis of the head of the femur sometimes separates in such a way that the surgeon is misled, thinking there is a dislocation instead of a separation of the epiphysis” [5]. Howorth reviewed the work of many other authors who described slipped capital femoral epiphysis in the preradiographic days, although one wonders how these were identified unless they were observed at surgery (not all that common even in the late 1800s after the advent of general anesthesia) or autopsy. (Interested readers will find a large number of these early citations to slipped capital femoral epiphysis in Howorth’s article.) Howorth stated Poland, in 1898, found 31 cases in the literature and added his own [11]. In the first half of the 20th century the therapeutic emphasis in slipped capital femoral epiphysis was on the acute or chronic slip in adolescents, not the residuals in adults. Campbell, in the first edition of his book (1939) does not mention the treatment of adults with residuals [1]. However, the concept of impingement as a cause of hip pain in adults was certainly known in the 1930s. Smith-Petersen, in the Classic we reproduce in this issue, well described the entity [13]. Howorth only briefly notes a “residual stage,” following the acute slipped capital femoral epiphysis, in which “…some degree of osteoarthritis…may supervene.” In fact, he ventures, “Slipped epiphysis is probably the most common cause of osteoarthritis of the hip, often in the past called by the nonspecific term malum coxae senilis” (a term used in Smith-Peterson’s Classic in this issue). Nearly twenty years later, Stulberg et al. suggested unrecognized childhood diseases (primarily more or less subtle forms of slipped capital femoral epiphysis, developmental dysplasia, and Legg-Calve-Perthes disease) were likely a cause of many cases of presumably idiopathic osteoarthrosis [14]. Ganz and colleagues from Bern believed these conditions and others such as acetabular retroversion and femoral neck fractures caused impingement of the anterosuperior femoral neck against the labrum and acetabulum, resulting in labral and articular cartilage damage [2, 6, 7, 9, 12]. This theme has been recently amplified by Ganz and coworkers, suggesting osteoarthrosis occurs because of subtle forms of impingement not always readily detected on traditional forms of imaging [4, 16]. Many of the deformities of the femoral neck are consistent with mild, unrecognized slipped capital femoral epiphysis. The concepts about femoroacetabular impingement continue to be refined [3, 10], but the recent work of Loder et al. [8] suggests Howorth may be have been correct in surmising that subtle forms of slipped capital femoral epiphysis could be a common cause of osteoarthrosis.

Surgical Dislocation in the Management of Pediatric and Adolescent Hip Deformity

The surgical dislocation approach is useful in assessing and treating proximal femoral hip deformities commonly due to pediatric conditions. We sought to demonstrate the efficacy and problems associated with this technique. Diagnoses included slipped capital femoral epiphysis, Perthes disease, developmental dysplasia of the hip, osteonecrosis, and exostoses. Through this approach, femoral head-neck osteoplasty (22), intertrochanteric osteotomy (eight), femoral head-neck osteoplasty plus intertrochanteric osteotomy (15), femoral neck osteotomy (five), open reduction and internal fixation of an acute slipped capital femoral epiphysis with callus resection (five), open reduction and internal fixation of an acetabular fracture (one), trapdoor procedure (one), and acetabular rim osteoplasty (one) were performed. The average patient age was 16 years. The minimum followup was 12 months (average, 41.6 months; range, 12-73 months). Patients with Perthes disease and SCFE had preoperative and postoperative WOMAC scores of 9.6 and 5.1, and 7.9 and 3.5 respectively. In patients with unstable SCFEs, the average postoperative WOMAC score was 1.2. Seven patients underwent THAs and two patients underwent hip fusion. Complications in the 58 procedures included four cases of osteonecrosis: three after femoral neck osteotomy and one after intertrochanteric osteotomy. The surgical dislocation technique can be utilized to effectively treat these deformities and improve short-term symptoms. Although the technique is demanding, we believe surgical dislocation offers sufficient advantages in assessing and treating these complex deformities that it justifies judicious application.

Management Outcome and the Role of Manipulation in Slipped Capital Femoral Epiphysis

To examine and compare treatment outcomes for slipped capital femoral epiphysis (SCFE). 24 patients with acute or acute-on-chronic SCFE underwent preoperative traction, 13 of them followed by in situ screw fixation (group A), and the remaining 11, manipulation with screw fixation (group B). Their treatment outcomes (according to the Aadalen criteria) and complications were compared. There were 2 treatment failures and one poor outcome in patients with acute SCFE (2 had avascular necrosis and one had slight pain with mild limitation of hip movement). The risk of developing avascular necrosis was significantly higher in patients with acute rather than acute-on-chronic or chronic slips. No significant differences were evident between groups A and B with regard to age, sex, ethnicity, outcomes, and preoperative and postoperative changes in the Southwick headshaft angle. Patients with acute or acute-on-chronic SCFE can be safely managed with straight-leg traction for up to 6 days, followed by in situ screw fixation without manipulation. Manipulation is not recommended in such slips, due to a higher avascular necrosis risk.

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

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. 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. 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. 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). 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.

Epiphyseolysis capitis femoris und Übergewicht

The slipped capital femoral epiphysis (SCFE) is defined as a nontraumatic epiphyseal separation and slipping of the proximal femoral epiphysis, which usually occurs during the adolescent growth spurt. Slipping of the upper femoral epiphysis may be classified as acute, chronic, and acute on chronic. The etiology of the disease is still not fully understood but seems to be multifactorial. The typical SCFE during puberty has to be differentiated from the atypical form, which may be associated with an endocrinological disorder or with its therapy. The typical SCFE may be found in male patients, with increased height and weight. It is likely that the growth rate is slightly accelerated before slippage. Obesity is often associated with a decreased femoral anteversion accounting for abnormal mechanical shear forces at the growth plate. SCFE is treated surgically. Surgical methods are administered according to the degree of disease. Because of possible alterations of blood supply to the femoral head, acute SCFE is an emergency. Following SCFE, complications such as chondrolysis and avascular necrosis are feared.

Radiology and measurement in adolescent slipped capital femoral epiphysis

Two X-rays taken in two planes perpendicular to each other secure the early diagnosis of adolescent slipped capital femoral epiphysis (SCFE). In imminent SCFE, two radiographic features are considered the most important signs: the broadening and the irregular demarcation of the upper femoral epiphyseal plate. In the beginning of SCFE, the process of dislocation is much better visible in the second radiographic plane (the lateral tangent of the femoral neck builds a smaller secant of the lateral femoral head). In chronic SCFE, the aforementioned radiographic signs including the epiphyseal dislocation are more marked. An additional feature can be various deformities of the femoral neck and duplicate contours of the medial demarcation of the femoral neck. In acute SCFE, there is a complete disruption of continuity between the metaphysis and epiphysis. Beside the marked gap in the epiphyseal plate, there is a severe dislocation between the femoral neck and the epiphysis. There are also partly patchy, partly cystic changes in the metaphyseal part of the femoral neck. The so-called acute on chronic slip, a sudden slip of the upper epiphysis after prolonged chronic slipping, is considered a specific case of SCFE. The long-term result of treated as well as untreated SCFE can be the gradual increase of coxarthrosis, which is typically more marked in the medial direction of the joint. The direction and the degree of the epiphyseal slip play an important role in the development of "epiphyseal" coxarthrosis. The planning of corrective operations as well as the quantitative evaluation of the prearthrotic deformity require the conversion of angles of dislocation that are projected on X-rays into anatomically correct angles. This conversion is done with tables that were created with the aid of computers and requires that the positioning of the femur for taking the X-rays is always done under standardized conditions.Mostly, in minor dislocations in the usual direction (medially and dorsally), the difference between the projected and the real angles is relatively small. Therefore, in these cases of SCFE it might not be necessary for practical and operative needs to convert these angles into real angles. However, this simplification is only then acceptable if the prescribed positioning of the femur for taking the X-rays is strictly adhered to so that additional errors of projection are excluded.

抜釘に難渋した大腿骨頭すべり症の一例

We report a case of slipped capital femoral epiphysis, for which were uncertain whether removal of titanium canulated cancellous screws was appropriate.A twelve-year-old boy visited our clinic complaining of left coxalgia after a fall. Plain radiography showed left acute slipped capital femoral epiphysis. Internal fixation was performed with canulated cancellous screws made of titanium alloy (Ti-6Al-4V). 22 months after the operation, removal of the screws was attempted. However removal was stopped because of breakage of the screws and instruments for removal. After several days, removal of the screws was attempted again, the bone around the screws was reamed and the screws were removed. Screws made of titanium alloy have good biocompatibility to bone. Failure of the removal after internal fixation of slipped capital femoral epiphysis has been reported. Stainless steel screws have low biocompatibility to bone and should be used in cases like this.

Acute slipped capital femoral epiphysis in the eightieth year of life

Acute slipped capital femoral epiphysis in the eightieth year of life

Acute slipped capital femoral epiphysis: the value and safety of urgent manipulative reduction.

A 40-year experience consisting of 91 cases of acute slipped capital femoral epiphysis (SCFE) was reviewed to assess the safety of manipulative reduction and to determine whether urgent reduction has an effect on the development of avascular necrosis (AVN) of the capital femoral epiphysis. All patients had a history of sudden onset of severe hip pain and were documented to have an unstable (acute) slipped epiphysis. Treatment modalities included manipulative reduction under general anesthesia followed by internal fixation (41 hips), epiphysiodesis and internal fixation (15 hips), epiphysiodesis and cast immobilization (31 hips), and cast immobilization alone (three hips). One case was treated with cast immobilization after reduction by skeletal traction. Patient follow-up averaged 44 months, and ranged from 12 to 216 months. Radiographic review identified 13 (14%) cases of AVN in the series of 91 hips. Of 42 hips reduced in <24 h from presentation, AVN developed in three (7%). Of 49 hips reduced in >24 h from presentation, AVN developed in 10 (20%). Manipulative reduction of the acute SCFE may be accomplished without increased risk of AVN. Time to reduction may be an important risk factor for development of AVN after acute SCFE.

Acute Slipped Capital Femoral Epiphysis: The Value and Safety of Urgent Manipulative Reduction

Acute Slipped Capital Femoral Epiphysis: The Value and Safety of Urgent Manipulative Reduction

Acute slipped capital femoral epiphysis. Review of outcomes and rates of avascular necrosis.

One hundred and forty-nine patients (208 hips) were managed for slipped capital femoral epiphysis at the Hospital for Sick Children in Toronto from 1980 through 1990. We retrospectively reviewed the records of twenty-four patients (twenty-six hips) who had an acute slipped capital femoral epiphysis to evaluate the outcome of treatment and possible risk factors for avascular necrosis associated with this condition. The patients were evaluated with the Iowa hip-scoring system, a physical examination, and anteroposterior and lateral radiographs. The severity of degenerative joint disease was assessed on the radiographs with use of the system described by Boyer et al. Eighteen slips were classified as grade 1; seven, as grade 2; and one, as grade 3, according to the system of Southwick. Twenty-three hips were treated with in situ pinning and three, with reduction and pinning. The mean duration of follow-up was 5.9 years (range, 2.1 to 12.8 years). Poor Iowa hip scores and more severe degenerative changes were related to the development of avascular necrosis and to the severity of the slip. Avascular necrosis developed in four hips (15 per cent), two of which had had a reduction. Multiple logistic regression analysis, which included all 150 slips (both acute and chronic) for which there was adequate follow-up, showed that the rate of avascular necrosis was related to both the severity and the acute nature of the slip.

Acute Slipped Capital Femoral Epiphysis: Treatment Alternatives.

Acute slipped capital femoral epiphysis represents a unique type of proximal femoral epiphyseal instability. The potential for complications and unsatisfactory outcomes is high, especially due to avascular necrosis. A newly proposed classification based on epiphyseal stability provides a rational assessment of this acute physeal fracture. Improvements in imaging and fixation techniques have reduced the morbidity of this condition. Choice of treatment must be based on the surgeon's experience and expertise. Vigilance is particularly required in young patients with underlying endocrine or metabolic conditions that predispose them to bilateral hip involvement.

持続硬膜外ブロック中に生じた細菌性髄膜炎の経験

Bacterial meningitis associated with continuous epidural anesthesia is a rare event. We report a case of a patient who developed a bacterial meningitis during continuous epidural catheterization for management of direct traction for an acute slipped capital femoral epiphysis. The cause of the meningitis is not certain, although cellulitis from the site of the epidural catheter is the best possibility.

Biomechanical comparison of 1-screw and 2-divergent pin internal fixations for treatment of slipped capital femoral epiphysis, using specimens obtained from immature dogs

Summary Biomechanical strength and stiffness of 2 fixation treatments used to repair acute slipped capital femoral epiphysis were evaluated in bone specimens from immature dogs. A servohydraulic testing machine was used to create slipped capital femoral epiphysis in 7 pairs of femurs by shearing the capital femoral epiphysis along the physis in a craniocaudal direction. The slip was reduced and repaired with one 3.5-mm-diameter screw placed in lag fashion or 2 double-pointed, 1.6-mm (0.062 inch)-diameter smooth pins and retested. Strength and stiffness of each intact femur (which served as the control) and repaired femur were compared. Results of the study indicated that the failure strength of 2-pin fixation was significantly (P &lt; 0.05) weaker than its control and the 1-screw fixation. There was no significant difference between failure strength of the 1-screw fixation and its control. The stiffness of 1-screw and 2-pin fixations was not significantly different, compared with each other, but was significantly (P &lt; 0.05) less, compared with their respective controls.

BIOMECHANICAL COMPARISON OF THREE INTERNAL FIXATIONS FOR TREATMENT OF SLIPPED CAPITAL FEMORAL EPIPHYSIS IN IMMATURE DOGS

The biomechanical strength and stiffness of 3 fixation techniques used to repair acute slipped capital femoral epiphysis were evaluated in bone specimens from immature dogs. A servohydraulic testing machine was used to create slipped capital femoral epiphysis in 9 pairs of femurs by shearing the capital femoral epiphysis along the physis in a craniocaudal direction. The slip was reduced and repaired with 1, 2, or 3 double-pointed, 1.6-mm (0.062-inch) smooth pin(s) and retested. The strength and stiffness of each intact femur (which served as the control) and repaired femur were compared. Results of the study indicated that differences among the failure strengths of 1- and 2-pin fixations and their respective controls were not significant; however, the 3-pin fixation was 29% stronger than its control and was 60 and 45% stronger than the 1- and 2-pin fixations, respectively. One- and 2-pin fixations were 34 and 24% less stiff than their respective controls, whereas the stiffness of the 3-pin fixation was similar to its control. The 2- and 3-pin fixations were 48 and 76% stiffer, respectively, than the 1-pin fixation, but were not significantly different, compared with each other.