Contralateral Slip Research Articles

Socioeconomic Deprivation and its Associations With Follow-up Compliance After In Situ Pinning of Slipped Capital Femoral Epiphysis.

Slipped capital femoral epiphysis (SCFE) is a common cause of hip pain in adolescents and is most often treated by in situ screw fixation. Orthopaedic follow-up is critical after treatment for SCFE due to risks of complications and subsequent contralateral slip. Recent studies have shown that socioeconomic deprivation is associated with decreased fracture care compliance, but no studies have explored this relationship with SCFEs. The study aims to determine the relationship between socioeconomic deprivation and SCFE follow-up care compliance. This study included pediatric patients treated with in situ pinning of SCFE between 2011 and 2019 at a single tertiary-care urban children's hospital. Demographic and clinical information were obtained from electronic medical records. The Area Deprivation Index (ADI) was used to quantify the socioeconomic deprivation of each. Outcome variables included patient age and status of physeal closure at the most recent appointment, in addition to the length of follow-up (mo). Statistical relationships were evaluated using nonparametric bivariate analysis and correlation. We identified 247 evaluable patients; 57.1% were male, and the median age was 12.4 years. Most slips were stable (95.1%) and treated with isolated unilateral pinning (55.9%). Median length of follow-up was 11.9 months (interquartile range, 4.95 to 23.1) with median patient age at final visit of 13.6 years (interquartile range, 12.4 to 15.1). Only 37.2% of patients were followed until physeal closure. The mean ADI spread in this sample was similar to the national distribution. However, patients in the most deprived quartile were lost to follow-up significantly earlier (median, 6.5mo) than those in the least deprived quartile (median, 12.5mo; P <0.001). Throughout the entire cohort, there was a significant, inverse relationship between deprivation and follow-up length ( rs (238) = -0.3; P <0.001), with this relationship most pronounced in the most deprived quartile. In this sample, ADI spread was representative of national trends, and the incidence of SCFE was distributed evenly across deprivation quartiles. However, follow-up length does not mirror this relationship; increased socioeconomic deprivation is associated with an earlier loss to follow-up (often well before physeal closure). Level II-retrospective prognostic study.

Which factor is more reliable considering prophylactic pinning of contralateral hip of unilateral SCFE patients?

This study evaluates the radiological parameters of developing subsequent contralateral slips in unilateral slipped capital femoral epiphysis (SCFE) patients at the time of initial presentation. The study group included the review of unilateral SCFE patients treated between June 2007 and August 2018. Age, gen-der, side, stability, posterior slope angle, grade of slip, modified Oxford bone age score (mOBAS), the Risser classification, and the ap-pearance of the triradiate cartilage were evaluated retrospectively. Data were analyzed between two groups: subsequent contralateral SCFE (SCFESC) patients that developed contralateral slip during follow-up and unilateral SCFE (SCFEU) patients that did not develop contralateral slip up to skeletal maturity. Descriptive statistics were used to compare risk factors between groups. This study included 48 patients and 6 patients (12.5%) developed a SCFESC. Only mOBAS was significantly different be-tween groups. The mOBAS scores in SCFESC were 18 in 2 patients (33.3%), 19 in 4 patients (66.7%). The mOBAS scores in SCFEU were 18 in 1 patient (2.4%), 19 in 24 patients (57.1%), and >20 in 17 patients (40.5%). In the SCFESC group, all patients had a Risser score of 0 and all had open triradiate cartilage. Patients with unilateral SCFE are at risk for SCFESC, and the mOBAS is the best predictor of risk assessment. We agree that mOBAS score of 16,17 or 18 patients' contralateral hips can be prophylactically pinned. We also suggest pinning or close screening of mOBAS 19 patients that some carry relatively high risk of subsequent contralateral slip.

The contralateral hip in slipped capital femoral epiphysis: Is there an easy-to-use algorithm to support a decision for prophylactic fixation?

Purpose:To identify a specific factor that can support the decision for prophylactic fixation in unilateral slipped capital femoral epiphysis.Methods:This retrospective cohort study included a total national population of 379 children diagnosed with slipped capital femoral epiphysis from 2007 to 2013. Regression analysis used information on slip severity, clinical classification of the index hip, age, sex, age-adjusted body mass index, the difference in epiphyseal–diaphyseal angle, and comorbidity to identify any risk factor for the subsequent development of a slip in the contralateral hip. Four observers evaluated the triradiate cartilage following the modified Oxford bone score grade. The occurrence of later development of a contralateral slip in different stage of physeal closure was used to analyze the sensitivity and specificity for this method.Results:This study’s only predictor for a subsequent contralateral slip was chronological age. At age 13 years or older, 1/15 in girls and 3/65 in boys suffered from a slip in the contralateral hip. Thus, when using age <13 years as a test for deciding when to do prophylactic fixation, the sensitivity would be 88% and specificity 51% for preventing contralateral slip. However, the correlation between the four different observers was too low to be considered useful when assessing the triradiate cartilage for skeletal maturity.Conclusion:We would advocate a prophylactic fixation for children <13 years diagnosed with a unilateral slipped capital femoral epiphysis as an easy-to-use algorithm.Level of evidence:level II.

Prophylactic fixation of the unaffected contralateral side in children with slipped capital femoral epiphysis seems favorable: A systematic review.

BACKGROUNDSlipped capital femoral epiphysis (SCFE) occurs in adolescents and has an incidence of around 10 per 100000 children. Children presenting with a unilateral SCFE are 2335 times more likely to develop a contralateral SCFE than the general population. Prognostic factors that have been suggested to increase the risk of contralateral slip include a younger patient, an underlying endocrine disorder, growth hormone use and a higher radiographic posterior sloping angle. However, there is still much debate on the advantages and disadvantages of prophylactic fixation of the unaffected side in an otherwise healthy patient. AIMTo investigate the risk rate of contralateral SCFE and assess the (dis)advantages of prophylactic fixation of the contralateral hip.METHODSA systematic literature search was performed in the Embase, Medline, Web of Science Core Collection and Cochrane databases. Search terms included ‘slipped capital femoral epiphysis,’ ‘fixation,’ ‘contralateral,’ and derivatives. The eligibility of the acquired articles was independently assessed by the authors and additional relevant articles were included through cross-referencing. Publications were considered eligible for inclusion if they presented data about otherwise healthy children with primarily unilateral SCFE and the outcomes of prophylactically pinning their unaffected side, or about the rates of contralateral slips and complications thereof. The study quality of the included articles was assessed independently by the authors by means of the methodological index for non-randomized studies criteria.RESULTSOf 293 identified unique publications, we included 26 studies with a total of 12897 patients. 1762 patients (14%) developed a subsequent symptomatic contralateral slip. In addition, 38% of patients developed a subsequent slip on the contralateral side without experiencing clinical symptoms. The most outspoken advantage of prophylactic fixation of the contralateral hip in the literature is prevention of an (asymptomatic) slip, thus reducing the increased risk of avascular necrosis (AVN), cam morphology and osteoarthritis. Disadvantages include an increased risk of infection, AVN, peri-implant fractures, loss of fixation as well as migration of hardware and morphologic changes as a consequence of growth guidance. These risks, however, appeared to only occur incidentally and were usually mild compared to the risks involved with an actual SCFE. CONCLUSIONThe advantages of prophylactic pinning of the unaffected side in otherwise healthy patients with unilateral SCFE seem to outweigh the disadvantages. The final decision for treatment remains to be patient-tailored.

Slipped Capital Femoral Epiphysis Associated with Endocrinopathy: A Narrative Review.

Slipped capital femoral epiphysis (SCFE) has a well-documented association with underlying endocrine conditions, including thyroid hormone aberrations and parathyroid dysfunction. Recombinant growth hormone therapy has also been identified as a risk factor for the development of SCFE. Presentation before their 10th birthday or after their 16th birthday along with height of <10th percentile are reliable risk factors for identifying children with an SCFE who are at a heightened risk for an underlying endocrinopathy and can been used to guide selective laboratory testing. Patients with unilateral SCFE presentations with an underlying endocrinopathy are at a heightened risk for contralateral slip development and should be treated with prophylactic fixation.

Can we still use X-rays to predict contralateral slip in primary unilateral slipped capital femoral epiphysis?

The objective of this study was to assess subsequent contralateral slip (SCS) in the unaffected hip in patients with primary unilateral slipped capital femoral epiphysis (SCFE) using three radiographic parameters: posterior sloping angle (PSA), center-edge angle (CEA) and triradiate cartilage (TC) appearance. A total of 152 patients admitted to two pediatric units between 2001 and 2015 were divided into three groups: A - underwent prophylactic fixation of the unaffected hip at the time of index surgery- high clinical risk of SCS; B - no clinical risk factors but SCS occurred; C - no issues regarding the contralateral hip during follow-up. The mean PSA for groups A, B and C were 22°(6-49), 17°(9-24) and 13°(0-27), respectively. PSA was significantly higher in Group A than in Group C ( P < 0.0001). The differences in PSA between groups A and B, but also B and C were insignificant ( P = 0.12 and p=0.21, respectively). The mean CEA in groups A, B and C was 33(25-43), 35(26-42) and 37(17-53), respectively. CEA did not differ significantly between groups A, B and C ( P = 0.25). Assessment of TC did not differ significantly between the groups ( P = 0.66). Observation of TC in groups B and C combined revealed that the cartilage was open in 65% of 77 patients and 14% of them developed SCS; whereas among the 35% of patients with ossified TC only 7% developed SCS (OR=2.0). PSA and CEA alone have no predictive value in determining the risk of contralateral slip. The absence of TC results in a two-fold decrease in the likelihood of developing an SCS. The decision of prophylactic surgical treatment of the contralateral hip in primary unilateral SCFE should not be based solely on radiographic findings.

Is prophylactic fixation preferable to active surveillance of the unaffected contralateral hip in unilateral slipped capital femoral epiphysis?- A Systematic Review

Slipped capital femoral epiphysis is one of the commonest musculoskeletal disorders amongst children. Whilst its management is reasonable well established, the treatment of the unaffected contralateral hip is controversial. The incidence of subsequent contralateral slip has been reported to be between 19 and 63%. The two treatment modalities are prophylactic fixation at initial presentation or active surveillance and fixation on diagnoses of subsequent slip. Both approaches have their merits but there is no clear consensus. Known risk factors include age, sex, young age at initial presentation, endocrine disorders and obesity. Clinical, epidemiological and radiological predictors have been assessed retrospectively but have limited prospective accuracy. We performed a systematic review of the existing literature as per PRISMA guidelines to determine which treatment modality is more effective. Qualitative analysis of the literature also yielded interesting insights into different aspects of the management of the contralateral hip in unilateral SCFE.

Contralateral slip after unilateral slipped capital femoral epiphysis is associated with acetabular retroversion but not increased acetabular depth and overcoverage.

Overcoverage of the femoral head by the acetabulum, increased acetabular depth and retroversion have been associated with the etiology of slipped capital femoral epiphysis (SCFE). However, limited evidence exists about the impact of the acetabular morphology on the development of a contralateral slip following an initial presentation of unilateral SCFE. We aimed to investigate whether acetabular overcoverage as assessed by an increased lateral center-edge angle (LCEA) and low Tönnis angle, increased acetabular depth assessed by the acetabular depth-width ratio (ADR) and the presence of coxa profunda; and acetabular retroversion assessed by the presence of the crossover sign were associated with a contralateral slip in patients presenting with unilateral SCFE. We evaluated 250 patients with initial diagnosis of unilateral SCFE (average age, 12.5 ± 1.7 years), who had not undergone prophylactic fixation on the contralateral hip for a median follow-up of 49 months (interquartile range: 25-76 months). Endpoints were the development of a contralateral slip (70 patients, 28%) or skeletal maturity assessed by complete closure of the proximal femoral growth plate (180 patients, 72%). We measured the LCEA, Tönnis angle, ADR, and the coxa profunda sign on an anteroposterior pelvic radiograph. The crossover sign was assessed in 208 hips who had a secondary ossification center in the posterior acetabular rim. For each additional degree of LCEA, the odds of contralateral slip decreased 8% [odds ratio = 0.92; 95% confidence interval (CI), 0.87-0.98; P = 0.009]. Tönnis angle (P = 0.11), ADR (P = 0.20) and coxa profunda (p = 0.37) had no association with a contralateral slip. The presence of crossover sign increased two and half times the odds for a contralateral slip (odds ratio = 2.5; 95% CI = 1.12-5.64; P = 0.03). Acetabular retroversion, but not acetabular overcoverage or increased acetabular depth, was associated with contralateral SCFE development in patients with unilateral SCFE. Level of evidence: prognostic level II.

Predicting subsequent contralateral slipped capital femoral epiphysis: an evidence-based approach.

PurposeThe purpose of this study was to identify risk factors for developing a subsequent contralateral slipped capital femoral epiphysis (SCFE) and provide a prediction score to quantify risk of subsequent slip at the time of initial presentation.MethodsThis retrospective study included patients that presented with a unilateral SCFE between 2006 and 2017. Chart and radiographic review were performed to collect demographic, clinical and radiographic risk factors. Descriptive statistics, univariate analyses and multivariate regression analysis were used to compare risk factors between patients that did or did not develop a subsequent contralateral SCFE.ResultsThis study included 183 patients and 33 patients (18%) developed a subsequent contralateral SCFE. Younger age at time of initial presentation, lower modified Oxford Score and smaller difference in epiphyseal-diaphyseal angle between both sides during index presentation were significant predictors of subsequent contralateral SCFE. Specifically, age ≤ 11 years, modified Oxford Score ≤ 20 and difference in epiphyseal-diaphyseal angle of ≤ 21° between both hips were predictive of a contralateral slip (Area Under the Curve = 0.78; p < 0.05). The presence of each risk factor increased the risk of subsequent contralateral SCFE and having all three risk factors increased the risk to 73%.ConclusionThere is a significant risk of subsequent contralateral SCFE in patients with unilateral SCFE, and predictive risk factors include younger age, lower modified Oxford Score and smaller difference in epiphyseal-diaphyseal angle between the affected and unaffected hips.Level of EvidenceLevel III

Capital Femoral Epiphyseal Cupping and Extension May Be Protective in Slipped Capital Femoral Epiphysis: A Dual-center Matching Cohort Study.

Peripheral cupping of the capital femoral epiphysis over the metaphysis has been reported as a precursor of cam morphology, but may also confer stability of the epiphysis protecting it from slipped capital femoral epiphysis (SCFE). The purpose of this study was to investigate the relationship between a novel morphologic parameter of inherent physeal stability, epiphyseal cupping, and the development of SCFE in a dual-center matched-control cohort study. We performed a dual-center age-matched and sex-matched cohort study comparing 279 subjects with unilateral SCFE and 279 radiographically normal controls from 2 tertiary children's hospitals. All SCFE patients had at least 18 months of radiographic follow-up for contralateral slip surveillance. Anteroposterior and frog lateral pelvis radiographs were utilized to measure the epiphyseal cupping ratio and the current standard measure of inherent physeal stability, the epiphyseal extension ratio. Control hips were found to have greater epiphyseal cupping than the contralateral uninvolved hip of SCFE subjects both superiorly (0.28±0.08 vs. 0.24±0.06; P<0.001) and anteriorly (0.22±0.07 vs. 0.19±0.06; P<0.001). The 58/279 (21%) subjects who went on to develop contralateral slip had decreased epiphyseal cupping superiorly (0.25±0.07 vs. 0.23±0.05; P=0.03) and anteriorly (0.20±0.06 vs. 0.17±0.04; P<0.001). When we compared controls with hips that did not progress to contralateral slip and hips that further developed a contralateral SCFE, 1-way ANOVA demonstrated a stepwise decrease in epiphyseal cupping and epiphyseal extension ratio in the anterior and superior planes from control hips to contralateral hips without subsequent slip to contralateral hips that developed a SCFE (P<0.01 for each). This study provides further evidence that epiphyseal cupping around the metaphysis is associated with decreased likelihood of SCFE and may reflect increased inherent physeal stability. Epiphyseal cupping may represent an adaptive mechanism to stabilize the epiphysis during adolescence at the long-term cost of the eventual development of associated cam-femoroacetabular impingement deformity. Level III-prognostic Study.

The Atypical Patient With Slipped Capital Femoral Epiphyses May Be at Increased Risk for a Missed Contralateral Slip.

Slipped capital femoral epiphysis (SCFE) is a commonly encountered hip disorder. The goal of this study was to describe the incidence of missed contra-lateral SCFE as well as to identify risk factors. The authors hypothesized that contralateral slips are more often missed in patients with severe involvement of the treated side. After institutional review board approval was obtained, a retrospective chart review was performed of all pediatric patients who were treated for sequential and bilateral SCFE at a single institution during an 18-year period. Medical records were reviewed for demographic features and attending surgeon. Radiographs were reviewed for skeletal maturity, Klein's line, and severity of the treated slip. All radiographs were reviewed by 3 pediatric orthopedists. Contralateral SCFE was deemed present when consensus was achieved. Comparisons were made with Fisher's exact test, and P<.05 was considered significant. Of the records that were reviewed, 56 patients met the study criteria. Of these, 19 patients had bilateral involvement and 5 missed slips were identified (8.9%). The patients with missed disease tended to be younger (mean age, 10.8 vs 11.4 years), with a lower body mass index. Fellowship-trained pediatric surgeons were more likely to identify bilateral disease compared with orthopedists without pediatric training (P=.0065). A contralateral slip was more likely to be present in patients who had a positive finding for Klein's line (P<.0001). Severity of the treated slip did not increase the likelihood of missing a contralateral slip. Although Klein's line is a useful tool in the diagnosis of SCFE, a false-negative rate of 40% was observed. The authors recommend increased vigilance when an "atypical" patient with SCFE presents with unilateral disease. [Orthopedics. 2020;43(2):e114-e118.].

Temporal changes in slipped upper femoral epiphysis at a regional level: a declining incidence and literature review.

PurposeSlipped upper femoral epiphysis (SUFE) is one of the most common adolescent hip pathologies in children with potential for life-long morbidity secondary to avascular necrosis (AVN). The primary aim is to determine an up-to-date demographic of SUFE, as well as current trends in presentation and radiological characteristics. Secondary aims are to quantify prophylactic fixation and subsequent contralateral SUFE.MethodsBetween 01 January 2013 and 31 December 2015, all cases of SUFE were identified in Northern Ireland. Patient demographics, slip characteristics and outcomes are presented and the incidence rates were calculated using census data. Temporal changes in incidence, compared with a previous cohort, are demonstrated.ResultsA total of 56 patients (80 hips) were identified. Based on census data, SUFE incidence has declined from 7.14 to 4.69/100,000 population aged < 16 years. Male cases predominated by > 2:1 ratio, and tended to be older than female cases. Approximately 75% of patients were above the 75th centile for age-sex adjusted body weight. Knee pain as a presenting symptom led to a delay in diagnosis. Prophylactic fixation was performed in 25.9%, with contralateral slips occurring in 27.5%. AVN occurred in 7.4% and remained static.ConclusionThe incidence of SUFE has declined ~34% in our region. When SUFE occurs, knee pain often results in a delay in definitive diagnosis, and commands clinical vigilance to avoid delays in diagnosis. Patients in our region should be aware of a 1-in-4 contralateral slip rate. Overall, AVN rates remain static and are acceptable, despite the declining incidence of SUFE.Level of evidenceLevel III - Retrospective Cohort Study

COMPARISON OF PROPHYLACTIC IN-SITU SCREW FIXATION VERSUS OBSERVATION OF THE ASYMPTOMATIC CONTRALATERAL HIP IN SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

BACKGROUND: Prophylactic fixation of the asymptomatic, radiographically-normal contralateral hip after unilateral (SCFE) is controversial. Children with unilateral SCFE whose contralateral hip is observed are at risk for having a contralateral slip and associated complications such as avascular necrosis (AVN). On the other hand, prophylactic pinning may be an unnecessary surgery that may also result in substantial complications. A comparison of the two treatment options has not been performed. This study seeks to compare the outcomes and nature of complications of patients whose contralateral hip was observed with those whose hip underwent prophylactic in-situ screw fixation. METHODS: We retrospectively reviewed 197 patients treated for a unilateral SCFE over 20 years between the 1997 and 2017 at two hospitals. Medical records and x-rays were reviewed, and variables of interest included age, sex, body mass index (BMI), Modified Oxford Bone Age Score (MOBA) at presentation, length of operation, estimated blood loss (EBL), and length of hospitalization. Additionally, postoperative complications/outcomes such as reoperation in the unaffected hip, pain in the unaffected hip, AVN, chondrolysis, infection. abnormal gait (limp), reslipped epiphysis (growth off of the implanted screw), degenerative joint disease, and development of a limb length discrepancy were recorded. RESULTS: Of the 197 total patients (mean age 11.8) treated for unilateral SCFE, 100 (51%) received prophylactic fixation of their unaffected, contralateral hip and 97 (49%) were observed. Average follow up was 24.5 months. A statistically significant difference was found between groups for age, MOBA Score, EBL, and operative time. No difference was found between groups for BMI, BMI %ile, and length of hospitalization. The unilateral group was older (p&lt;0.001) and had a greater MOBA Score (p=0.006) compared to the prophylactic group (Table 1). Patients in the prophylactic group had greater EBL during surgery (p=0.004) and longer operative time (p&lt;0.001) compared to the unilateral group. In those patients whose contralateral hip was observed, 19% developed a contralateral SCFE which required later in-situ fixation. Amongst those, 2/19 (10%) developed AVN or chondrolysis of the contralateral hip (2% overall). For the contralateral hip, 17/97 (17%) developed hip pain, 10/97 (10%) developed a leg length difference and 24/97 (24%) developed a limp. In those patients who had prophylactic fixation, for the contralateral hip 2/100 (2%) developed AVN, (3/100) 3% required reoperation, 1/100 (1%) developed an infection, 10/100 (10%) developed contralateral hip pain, 4/100 (4%) developed a LLD, and 26/100 (26%) developed a limp. CONCLUSIONS: Surgeons and patients should be able to compare outcomes when deciding whether or not to prophylactically fix the asymptomatic contralateral hip in SCFE. For patients with unilateral SCFE, there are similar rates of AVN (2%) of the asymptomatic contralateral hip whether the hip is prophylactically pinned or observed. Between the two treatment options, there are similar outcomes for length of hospital stay, EBL, rate of infection and development of a limp. There is a higher rate of a LLD and the need for another operation in patients whose contralateral asymptomatic hip is observed, rather than prophylactically pinned. [Table: see text]

Predicting Risk of Contralateral Slip in Unilateral Slipped Capital Femoral Epiphysis

Femoral morphology may influence the etiology of slipped capital femoral epiphysis (SCFE). We investigated whether radiographic parameters of femoral head-neck morphology are associated with a subsequent contralateral slip in patients presenting with unilateral SCFE. We evaluated 318 patients treated for unilateral SCFE between 2000 and 2017. There were 145 males (46%), and the mean age in the series was 12.4 ± 1.7 years. The patients were followed for a minimum of 18 months or until the development of a contralateral slip (70 patients, 22%). We measured the epiphyseal tilt, epiphyseal extension ratio, alpha angle, and epiphyseal angle of the uninvolved, contralateral hip at initial presentation. Multivariable logistic regression analysis was used to assess whether femoral measurements were associated with the occurrence of a contralateral slip. Receiver operating characteristic (ROC) curves were used to determine optimal thresholds of radiographic measures to determine an increased risk of a contralateral slip. A number-needed-to-treat (NNT) analysis was conducted to evaluate the effectiveness of the femoral measurement thresholds in preventing a contralateral slip. Multivariable analysis, controlling for triradiate cartilage status, identified the lateral tilt angle and the superior epiphyseal extension ratio as independent factors associated with the likelihood of a contralateral slip. For each additional degree of posterior tilt, the odds of a contralateral slip increase by 8% (odds ratio [OR] = 1.08; 95% confidence interval [CI] = 1.02 to 1.14; p = 0.008), and for each 0.01 increase in the superior epiphyseal extension ratio, the odds of a contralateral slip decrease by 6% (OR = 0.94; 95% CI = 0.88 to 0.99; p = 0.03). A threshold for the epiphyseal tilt of 10° corresponded to a predicted probability of a contralateral slip of 54% in patients with open triradiate cartilage and an NNT of 3.3. In patients presenting with unilateral SCFE, a higher posterior tilt of the epiphysis increases the risk while an increased superior extension of the epiphysis reduces the risk of a contralateral slip. Our findings may assist the discussion about contralateral prophylactic pinning in patients with unilateral SCFE. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Gait abnormalities following slipped capital femoral epiphysis

Aim: The aim of this study was to compare the gait function following slipped capital femoral epiphysis (SCFE) with the healthy controls.Material and Methods: We included 31 of 76 SCFE patients who were treated with in situ pinning between 2005 and 2013. We excluded patients with radiographic or clinical evidence of a contralateral slip, less than 2-years follow-up, incomplete epiphyseal closure, musculoskeletal abnormalities that can affect gait, avascular necrosis or chondrolysis and needed revision surgery. To measure the patients’ quality of life and physical function Harris hip score and the Pediatric Outcomes Data Collection Instruments (PODCI) scores were used. All patients and control group were underwent whole-body motion analysis.Results: The mean age of patients when gait analyses were performed was 16.5 ± 2.5 years, and mean body mass index (BMI) was 27.78 ± 5.6 kg/m2. A control group was formed from volunteers whose mean age was 17.84 ± 1.47 years that ranged between 16 and 20 years, with a mean BMI of 27.72 ± 2.61 kg/m2. Significant gait deviations were detected in SCFE patients such as (SCFE versus control group); Pelvis tilt range of motion (ROM) (3.5±1.5 - 2.3±0.5, p=0.01), Hip flexion ROM (35.1±3.7 - 39.8±4.6, p0.01), Pelvis obliquity ROM (5.5±2.3 - 9.5±2.8, p0.01), Hip abduction ROM (10.8±2.9 - 12.9±3.4, p=0.02), Knee Abduction ROM (15.2±6.1 - 10.7±6.9, p=0.01), Mean FPA (-11.1±7.7 - -5.2±6.5, p=0.01), Ankle rotation ROM (31.2±1.7 - 22.9±6.7, p=0.01), Mean thorax tilt (5.6±5.4 - 1.4±4.4, p0.01), Spine tilt ROM (5.1±3.3 - 7.8±3.4, p=0.02). Conclusion: Significant gait deviations were identified in patients with unilateral-SCFE in comparison with age and BMI matched healthy controls. Three-dimensional gait analysis can be used as an objective method for evaluation of functional outcomes of SCFE.

MRI in idiopathic, stable, slipped capital femoral epiphysis: evaluation of contralateral pre-slip.

:PurposeEarly diagnosis and treatment of slipped capital femoral epiphysis (SCFE) is important to prevent slip progression and avoid complications. We sought to determine if MRI findings in patients with unilateral SCFE could indicate ‘pre-slip’ or predict future SCFE in the contralateral hip.MethodsA prospective study evaluated patients with unilateral SCFE over a two-year period. MRI of the asymptomatic hip was performed within the perioperative period. Patients were followed with radiographs until a contralateral slip occurred or until physeal closure. Demographics, clinical stability, severity, posterior slope angle (PSA), modified Oxford Bone Score (mOBS) and patency of the triradiate cartilage were recorded and statistical analysis performed.ResultsIn all, 33 of 54 patients with unilateral SCFE were enrolled into the study. In all, 29 (87.8%) had complete follow-up. Five of the enrolled patients (15.2%) developed a sequential slip requiring in situ pinning. Six of 33 (18.2%) patients had positive MRI findings: four of which proceeded to sequential SCFE and two which did not. One sequential slip had a negative MRI. PSA predicted 1/11 sequential slips (sensitivity 9.09%, specificity 81.4%, positive predictive value (PPV) 11.1%, negative predictive value (NPV) 77.8%) and mOBS predicted 5/11 sequential slips (sensitivity 45.5%, specificity 93%, PPV 62.5%, NPV 87%). An open triradiate cartilage was present in 8/11 patients with sequential slips (sensitivity 72.7%, specificity 81.4%, PPV 50%, NPV 92.1%).ConclusionMRI findings consistent with ‘pre-slip’ were present in 66.7% of patients who developed a sequential SCFE. Further study on the utility/sensitivity of MRI in predicting sequential SCFE is warranted.Level of EvidenceII, diagnostic

The Peritubercle Lucency Sign is a Common and Early Radiographic Finding in Slipped Capital Femoral Epiphysis.

A rotational mechanism of slipped capital femoral epiphysis (SCFE) in which the epiphyseal tubercle acts as a fulcrum has been recently described. However, there is limited radiographic evidence supporting this theory. We aimed to investigate whether a radiographic lucency around the epiphyseal tubercle (peritubercle lucency sign) could be observed before or at the diagnosis of a subsequent slip in patients initially presenting with unilateral SCFE. We evaluated 70 patients with unilateral SCFE who were followed until a contralateral slip was diagnosed, and 180 patients with unilateral SCFE who had no contralateral slip until skeletal maturity between 2000 and 2017. We revised anteroposterior and lateral radiographs from the initial presentation, surveillance, and diagnosis of a contralateral SCFE. The presence or absence of the peritubercle lucency sign in the contralateral initially uninvolved hip was recorded for every radiograph. The presence of hip pain, and the presence of classic radiographic parameters for SCFE diagnosis (epiphyseal tilt and Klein's line) were recorded when the peritubercle lucency sign became noticeable. The peritubercle lucency sign was observed in 84% [59/70; 95% confidence interval (CI), 73%-92%] of the patients who developed contralateral slip. Most patients (46/59=78%; 95% CI, 65%-87%; P<0.001) had the peritubercle lucency sign visible within 9 months after the initial diagnosis of unilateral SCFE. The sign preceded the definitive diagnosis of the contralateral slip at a median of 9 weeks (interquartile range, 0 to 10 wk). At the time of first observation of the peritubercle lucency sign, 36% (25/70; 95% CI, 25%-48%) of the patients were asymptomatic and 49% (34/70; 95% CI, 36%-61%) of the hips showed no abnormalities in the tilt angle or the Klein line. Among patients who did not experience a contralateral slip (n=180), the sign was observed in 2 patients (1.1%; 95% CI, 0.2%-4.4%). The sensitivity was 84% and specificity was 99%. A peritubercle lucency is an early imaging sign, present in >80% of contralateral slips following an initial presentation of unilateral SCFE. The presence of the peritubercle lucency sign may be helpful for contralateral hip surveillance. Future studies are necessary to establish the clinical validity of the peritubercle lucency sign and whether it may serve as a predictor of contralateral involvement. Diagnostic level III.

The Relative Contribution to Small Finger Abduction of the Ulnar Versus Radial Slip of the EDM: Implications for Tendon Transfers.

The extensor digiti minimi (EDM) tendon is commonly divided into a radial slip (EDM-R) and an ulnar slip (EDM-U). To our knowledge, the degree to which each EDM slip concomitantly abducts the small finger with active extension has not been formally tested. This study sought to characterize the comparative contributions of finger abduction inherent to each slip of the EDM to observe the sequelae of active small finger extension following transfer of the contralateral slip. Eighteen fresh-frozen cadaveric hands were used in this study. Starting with the hand in resting position, a controlled traction of 10 N was applied to each slip of the EDM tendon. The range of small finger abduction with respect to the fixed ring finger was recorded utilizing infrared reflective markers tracked through the range of motion using a digital video camera. The mean abduction of the small finger when the radial slip of the EDM tendon was tested was 13.33° (95% confidence interval [CI]: 10.10°-16.55°), which was significantly different ( P ≤ .001) than small finger abduction produced by the ulnar slip of the EDM, with a mean of 23.72° (95% CI: 19.40°-28.04°). Given the fact that the ulnar slip of the EDM tendon is shown to be the major contributor of aberrant abduction with active small finger extension, as traction on this slip produces almost twice as much abduction as the radial slip, the EDM-U is the ideal donor graft with respect to tendon transfers of the EDM.

Magnetic resonance imaging at primary diagnosis cannot predict subsequent contralateral slip in slipped capital femoral epiphysis.

Prophylactic fixation of the contralateral hip in slipped capital femoral epiphysis (SCFE) is controversial, and no reliable method has been established to predict subsequent contralateral slip. The main purpose of this study was to evaluate if magnetic resonance imaging (MRI) performed at primary diagnosis could predict future contralateral slip. Twenty-two patients with unilateral SCFE were included, all had MRI of both hips taken before operative fixation. Six different parameters were measured on the MRI: the MRI slip angle, the greatest focal widening of the physis, the global widening of the physis measured at three locations (the midpoint of the physis and 1cm lateral and medial to the midpoint), periphyseal (epiphyseal and metaphyseal) bone marrow edema, the presence of pathological joint effusion, and the amount of joint effusion measured from the lateral edge of the greater trochanter. Mean follow-up was 33months (range, 16-63months). Six patients were treated for contralateral slip during the follow-up time and a comparison of the MRI parameters of the contralateral hip in these six patients and in the 16 patients that remained unilateral was done to see if subsequent contralateral slip was possible to predict at primary diagnosis. All MRI parameters were significantly altered in hips with established SCFE compared with the contralateral hips. However, none of the MRI parameters showed any significant difference between patients who had a subsequent contralateral slip and those that remained unilateral. MRI taken at primary diagnosis could not predict future contralateral slip.

Pinning the slipped and contralateral hips in the treatment of slipped capital femoral epiphysis.

PurposeTo describe and comment on the treatment of the slipped capital femoral epiphysis (SCFE) with pinning and to present the pros and cons of prophylactic pinning of the contralateral hip.SummaryPinning the SCFE aims to fix the epiphysis and prevent further slipping. Some devices allow for further growth and remodeling of the femoral neck post-operatively. This results in maintained femoral offset and probably reduced risk of femoroacetabular impingement. There are currently no long-term follow-up studies showing less complications or better function than after in situ fixation.The contralateral hip can be managed by prophylactic pinning or close follow-up with repeated radiographic examinations. Which of the methods is best is still controversial due to different opinions on the risk of bilateral SCFE, the consequences of a later contralateral slip and the risks of prophylactic pinning. Although research supports prophylactic pinning the child and the family’s preference is crucial.