Diagnosis Of Slipped Capital Femoral Epiphysis Research Articles

Сompletely slipped capital femoral epiphysis in an 11 year old girl successfully treated bu DUNN’s open reduction through GANZ’ surgical dislocation of the hip (clinical case)

Slipped capital femoral epiphysis (SCFE) is a hip condition that occurs in teens and preteens who are still growing. Treatment for SCFE involves surgery to stop the head of the femur from slipping any further. Without early detection and proper treatment, SCFE can lead to potentially serious complications, including rapid degeneration of the femoral head and/or painful arthritis in the hip joint. Objective. Our case is presented to familiarize with the technique of safe surgical hip dislocation for the treatment of intraarticular hip pathologies. Case report and Methods. After collision while playing the 11 year old girl developed left hippain still allowing to walk. Imaging documented an acute slipped femoral capital epiphysis with the metaphysis articulating against the acetabulum. The patient was underwent open reduction could be performed using the DUNN procedure modified by GANZ. 6 weeks later prophylactic screw stabilization of the healthy right hip followed. Results. At 9 months follow-up the patient walks painfree with symmetric range of motion. Conclusion. The goal of treatment is to prevent the mildly displaced femoral head from slipping any further. This is always accomplished through surgery. Early diagnosis of SCFE provides the best chance of stabilizing the hip and avoiding complications. When treated early and appropriately, long-term hip function can be expected to be very good. Once SCFE is confirmed, the child will not be allowed to put weight on their hip and will be admitted to the hospital. In most cases, surgery is performed within 24 to 48 hours. In patients with unstable SCFE, the surgeon may first make an open incision in the hip, then gently manipulate (reduce) the head of the femur back into its normal anatomic position. The surgeon will then insert one or two metal screws to hold the bone in place until the growth plate closes. Sometimes surgeon may recommend inserting a screw into the unaffected hip at the same time to reduce the risk of SCFE. Our case demonstrates the value of open reduction of a severely dislocated femoral capital epiphysis in a case otherwise probably needing endoprosthetic hip replacement for restitution of hip function or hip arthrodesis at short-term follow-up

The Effect of Human Growth Hormone Treatment on the Development of Slipped Capital Femoral Epiphysis: A Cohort Analysis With 6 Years of Follow-up.

Slipped capital femoral epiphysis (SCFE) is a common hip disorder in adolescents that can result in substantial complications, impacting the quality of life. Human Growth Hormone (HGH) administration may elevate the risk of SCFE, though the relationship remains unclear. Clarifying this association could enable better monitoring and earlier diagnosis of SCFE in patients receiving HGH. The aim of the study is to investigate the association between HGH administration and the incidence of SCFE. This retrospective cohort study utilized data from the TriNetX research database from January 2003 to December 2022. The study included 2 cohorts: an HGH cohort including 36,791 patients aged below 18 years receiving HGH therapy and a control group consisting of patients who did not receive HGH therapy. A 1:1 propensity score matching technique was employed to ensure comparability between the HGH and no-HGH cohorts. The primary outcome measure was the development of SCFE identified by International Classification of Diseases codes. For comparative analysis, both risk ratios (RR) and hazard ratios were computed to evaluate the association between HGH therapy and the development of SCFE. The HGH cohort had an increased risk of SCFE compared with the no-HGH cohort (RR: 3.5, 95% CI: 2.073, 5.909, P <0.001) and had an increased hazard of developing SCFE (hazard ratio: 2.627, 95% CI: 1.555, 4.437, P <0.001). Patients with higher exposure to HGH (defined as >10 prescriptions) had an RR of 1.914 (95% CI: 1.160, 3.159, P =0.010) when compared with their counterparts with ≤10 prescriptions. In the largest study to date, HGH administration was associated with an elevated risk of SCFE in children in a dose-dependent manner. Level III-therapeutic retrospective cohort study.

Hip Impingement of severe SCFE patients after in situ pinning causes decreased flexion and forced external rotation in flexion on 3D-CT.

In situ pinning is an accepted treatment for stable slipped capital femoral epiphysis. However, residual deformity of severe slipped capital femoral epiphysis can cause femoroacetabular impingement and forced external rotation. The aim of this study was to evaluate the (1) hip external rotation and internal rotation in flexion, (2) hip impingement location, and (3) impingement frequency in early flexion in severe slipped capital femoral epiphysis patients after in situ pinning using three-dimensional computed tomography. A retrospective Institutional Review Board-approved study evaluating 22 patients (26 hips) with severe slipped capital femoral epiphysis (slip angle > 60°) using postoperative three-dimensional computed tomography after in situ pinning was performed. Mean age at slipped capital femoral epiphysis diagnosis was 13 ± 2 years (58% male, four patients bilateral, 23% unstable, 85% chronic). Patients were compared to contralateral asymptomatic hips (15 hips) with unilateral slipped capital femoral epiphysis (control group). Pelvic three-dimensional computed tomography after in situ pinning was used to generate three-dimensional models. Specific software was used to determine range of motion and impingement location (equidistant method). And 22 hips (85%) underwent subsequent surgery. (1) Severe slipped capital femoral epiphysis patients had significantly (p < 0.001) decreased hip flexion (43 ± 40°) and internal rotation in 90° of flexion (-16 ± 21°, IRF-90°) compared to control group (122 ± 9° and 36 ± 11°). (2) Femoral impingement in maximal flexion was located anterior to anterior-superior (27% on 3 o'clock and 27% on 1 o'clock) of severe slipped capital femoral epiphysis patients and located anterior to anterior-inferior (38% on 3 o'clock and 35% on 4 o'clock) in IRF-90°. (3) However, 21 hips (81%) had flexion < 90° and 22 hips (85%) had < 10° of IRF-90° due to hip impingement and 21 hips (81%) had forced external rotation in 90° of flexion (< 0° of IRF-90°). After in situ pinning, patient-specific three-dimensional models showed restricted flexion and IRF-90° and forced external rotation in 90° of flexion due to early hip impingement and residual deformity in most of the severe slipped capital femoral epiphysis patients. This could help to plan subsequent hip preservation surgery, such as hip arthroscopy or femoral (derotation) osteotomy.

Diagnosis of Slipped Capital Femoral Epiphysis: How to Stay out of Trouble?

Slipped capital femoral epiphysis (SCFE) is the most common hip disorder affecting children and adolescents aged between 9 and 16 years, affecting approximately 10 per 100,000 children per year. The diagnosis of SCFE is often delayed, leading to an increased risk of complications. This study aims to provide the latest evidence concerning the causes of diagnostic delay and risk factors for SCFE and to educate general practitioners and paediatricians to help reduce delays in diagnosis and provide earlier therapeutic intervention. A literature search was conducted in the ScienceDirect and PubMed databases according to the PRISMA statement. Suitable studies for this systematic review included 22 articles discussing the aetiology of SCFE, risk factors, and causes of late diagnosis. Causes of delayed diagnosis include underestimation by patients, initial diagnostic approach by a non-orthopaedic professional, inadequate imaging, failure to recognize morphological changes, and variation in symptomatic presentation. The underlying risk factors for SCFE are likely part of a multifactorial process which involves anatomical variations and the metabolism of leptin, growth hormone, insulin, and other metabolic parameters. This review highlights the importance of early recognition and diagnosis of SCFE and proposes an algorithm for physicians to approach children who may have this condition.

SLIPPED CAPITAL FEMORAL EPIPHYSIS ACETABULAR ORIENTATION AND SHAPE: A THREE-DIMENSIONAL CT STUDY

Background:Previous studies have analyzed the acetabulum in patients affected by slipped capital femoral epiphysis (SCFE), however controversy remains over how the acetabular shape may be altered in hips experiencing SCFE. In particular, changes in acetabular over-coverage and acetabular version are thought to contribute to SCFE.Hypothesis/Purpose:The purpose of this study was to determine the acetabular morphology in hips with SCFE and compare them to normally developing children.Methods:Images from patients with the diagnosis of SCFE who had a computed tomography (CT) exam of their pelvis were compared to images from an age- and sex-matched cohort of patients with CT exams of the pelvis/abdomen for a non-orthopedic related evaluation (controls). Three dimensional (3D) reconstructions were created from each CT exam (MIMICs software). Custom MATLAB software was used to uniformly align and calculate acetabular parameters from the 3D reconstructions. The acetabular parameters calculated were articular surface area, acetabular tilt, acetabular version, and acetabular coverage angles measured in a radial fashion in 5 out of 8 octants.Results:Two-hundred-ninety-eight hips were evaluated, including 67 hips with SCFE, 39 unaffected contralateral hips in patients with SCFE, and 192 normal controls. The SCFE group consisted of 33 males and 34 females. Acetabular version was similar amongst all SCFE affected hips, unaffected contralateral hips, and normal controls (p=0.575). Control hips had higher acetabular tilt than SCFE affected hips (p=0.001) and unaffected contralateral hips (p=0.012). Acetabular surface area was higher in SCFE affected hips compared to controls (p=0.003)(Table 1). SCFE affected hips had significantly increased acetabular coverage compared to controls in the superior, superior-anterior, and anterior octants (p<0.01). The unaffected contralateral sides had significantly increased acetabular coverage compared to controls in all five regions (p<0.02)(Table 2).Conclusions:Contrary to some previous studies, we did not find the acetabulum to be retroverted in hips with SCFE compared to normal hips. Both the affected and unaffected hips of SCFE patients have decreased acetabular tilt. Acetabular surface area is high in both the affected and unaffected sides in SCFE, suggesting it may be involved in the pathogenesis of the condition. There is increased acetabular coverage in the superior regions of SCFE hips. The shared morphological characteristics of both affected and unaffected sides in SCFE patients suggest that their hip anatomy may predispose them to slips.

Relationship between Treatment Age and Poor Outcome in Slipped Capital Femoral Epiphysis

Aim; Slipped capital femoral epiphysis(SCFE) is an adolescent disease characterized by the slippage of the femoral head epiphysis from the femoral neck. The aim of this study is evaluate the factors affecting clinical outcome the surgical treatment of patients diagnosed with SCFE.Methods; Patients who were admitted to the orthopedic outpatient clinic with the complaint of gait disturbance and underwent surgery with a diagnosis of SCFE and were followed for minimum one year were screened between January 2015 and December 2019. A total of 11 patients, 7 boys and 4 girls, included in the study, were followed mean 27 months (12-47). The degree of deviation was measured with Southwick's method. Both preoperative and postoperative hip clinical evaluation was performed using Heyman and Herndon Classification.Results; The mean age of the patients was 12.45 (10-14). In the perioperative period, the mean BMI of the patients was measured as 26.15 (20.45-32.34) kg/cm2. Lateral radiographs of the affected hips were taken and measured using the Southwick method, and the mean angle was 45,490 (24,30-65,70). Heyman and Herndon classification was evaluated in two main groups clinically. There was no statistically significant difference between the first group and the second group in terms of gender, side, BMI, Southwick value, time between the first symptom and presentation, and the time between presentation and diagnosis. However, the mean age of the first group, whose postoperative Heyman and Herndon classification was evaluated as excellent and good, was statistically lower than the second group (p = 0.016). In addition, while no negative change was observed in the clinical score in any of the treated patients, improvement was observed in 6 patients and it was found that the preoperative score was significantly increased compared to the postoperative evaluation (p = 0.014).Conclusion; In situ fixation with a single cannulated screw and early surgical treatment are two important factors in achieving good clinical results in patients with SCFE. It should be kept in mind that patients diagnosed with SCFE at an older age may also be associated with poor clinical results.

Patients’ delay is the major cause for late diagnosis of slipped capital femoral epiphysis

Early diagnosis of slipped capital femoral epiphysis (SCFE) is essential in order to reduce slip severity and subsequent risk of sequelae. The aims of this study were to evaluate patients' and doctors' delay in SCFE diagnosis and to identify possible factors leading to delay. We performed a retrospective review of medical charts and a personal interview with 54 consecutive patients admitted with a diagnosis of stable SCFE at three hospitals in Sweden between 2001 and 2009. Data on symptom duration, symptomatology, medical visits and type of medical contacts were retrieved. Slip angle (Southwick head-shaft angle) was measured. Median total delay from onset of symptoms to surgery was 26 weeks (range 1-109). Patients' delay was significantly longer than doctors' delay: 10 weeks (range 1-57) vs. 4 weeks (range 0-57) (P=0.002). Boys had significantly longer patients' delay than girls (13 vs. 6 weeks, P=0.021) but not doctors' delay. Children with dominance of knee pain had significantly longer doctors' delay (14 vs. 4 weeks, P=0.002) but not patients' delay. As expected, the total delay duration correlated with slip severity (R=0.59, P<0.001). Results demonstrate considerable delay in diagnosis of SCFE in Sweden, although the major cause is patients' delay. Boys and children with dominance of knee pain are more likely to be diagnosed late. Efforts to increase the awareness of SCFE directed to both the general society and healthcare providers are necessary to improve future outcomes. Level III. Retrospective comparative study.

Causes of Delayed Diagnosis of Slipped Capital Femoral Epiphysis: The Importance of the Frog Lateral Pelvis Projection.

Delayed diagnosis and treatment is a universally reported problem that impairs the prognosis of slipped capital femoral epiphysis (SCFE). Quite frequently, a delayed diagnosis of SCFE is observed in spite of serial admissions and examinations of the limping adolescent. Why do health professionals globally fail to make a definitive diagnosis of SCFE during the first examination of the patient? A retrospective study of 36 adolescents treated for stable SCFE and two adolescents treated for unstable SCFE has been performed. In more than half of the delayed diagnosed stable slips (13/25, 52%), the diagnosis was set after serial examinations of the patient. Health professionals commonly order only the anteroposterior (AP) X-ray view of the pelvis when examining a non-traumatic limping adolescent. The frog lateral (FL) projection is usually spared in an attempt to limit the radiation exposure of the patient, especially in ambulating adolescents with mild symptoms. It is proposed that in the non-traumatic limping adolescent, the FL projection instead of the AP pelvis view should be requested by the health professional in order to timely diagnose a surgical emergency of the adolescent hip such as SCFE.

CORR Insights®: What is the Accuracy and Reliability of the Peritubercle Lucency Sign on Radiographs for Early Diagnosis of Slipped Capital Femoral Epiphysis Compared With MRI as the Gold Standard?

BACKGROUND The diagnosis of slipped capital femoral epiphysis (SCFE) often is delayed. Although lack of clinical suspicion is the main cause of delayed diagnosis, typical radiographic changes may not be present during the initial phases of SCFE. The peritubercle lucency sign for follow-up of the contralateral hip in patients with unilateral SCFE may be beneficial in assisting the early diagnosis. However, the accuracy and reliability of this sign in patients with SCFE is unknown. QUESTIONS/PURPOSES (1) What is the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the peritubercle lucency sign on radiographs for the early diagnosis of SCFE compared with MRI as the gold standard? (2) What are the interobserver and intraobserver reliabilities of the peritubercle lucency sign on radiographs? METHODS Between 2000 and 2017, 71 patients underwent MRI for an evaluation of pre-slip or a minimally displaced SCFE. Sixty percent of hips (43 of 71) had confirmed SCFE or pre-slip based on the presence of hip pain and MRI changes, and these patients underwent in situ pinning. Three independent experienced observers reviewed MR images of the 71 hips and agreed on the presence of a juxtaphyseal bright-fluid signal suggesting bone marrow edema in these 43 hips with SCFE, and absence MRI changes in the remaining 28 hips. The same three experienced observers and two inexperienced observers, including a general radiologist and an orthopaedic surgery resident, blindly assessed the radiographs for the presence or absence of the peritubercle lucency sign, without information about the diagnosis. Diagnostic accuracy measures including sensitivity, specificity, PPV, and NPV were evaluated. Intraobserver and interobserver agreements were calculated using kappa statistics. RESULTS The overall accuracy of the peritubercle lucency sign on radiographs was 94% (95% CI 91 to 96), sensitivity was 97% (95% CI 95 to 99), specificity was 89% (95% CI 90 to 96), PPV was 93% (95% CI 90 to 96), and NPV was 95% (95% CI 92 to 99). All accuracy parameters were greater than 85% for the five observers, regardless of experience level. Intraobserver agreement was perfect (kappa 1.0), and interobserver agreement was excellent for the peritubercle lucency sign on radiographs across the five observers (kappa 0.81 [95% CI 0.73 to 0.88]). The reliability was excellent for experienced observers (kappa 0.88 [95% CI 0.74 to 1.00]) and substantial for inexperienced observers (kappa 0.70 [95% CI 0.46 to 0.93]), although no difference was found with the numbers available (p = 0.18). CONCLUSIONS The peritubercle lucency sign on radiographs is accurate and reliable for the early diagnosis of SCFE compared with MRI as the gold standard. Improving the early diagnosis of SCFE may be possible with increased awareness, high clinical suspicion, and a scrutinized evaluation of radiographs including an assessment of the peritubercle lucency sign. LEVEL OF EVIDENCE Level III, diagnostic study.

Factors Affecting Outcomes of Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) is a frequent cause of nontraumatic painful hip of the adolescence. It is the result of the separation of the proximal femoral growth cartilage at the level of the hypertrophic cell zone. The femoral neck metaphysis rotates externally and migrates proximally relative to the femoral head epiphysis, which is stably seated in the acetabulum; early diagnosis and in situ stabilization grants the best long term results. Numerous factors affect treatment outcomes. Not all implants have the same effect on the slipped physis. Application of the traditionally used implants, such as non-threaded pins and cannulated screws, is questioned. Modern implants are available, which stabilize the slip without accelerating physis fusion. This allows femoral head and neck growth and remodeling to limit the post-slip sequellae on hip anatomy and function. Femoroacetabular impingement (FAI) complicates almost all slips. It causes progressive labral and articular cartilage damage and leads to early hip osteoarthritis and total hip replacement, approximately ten years earlier compared to the general population. Avascular necrosis of the femoral head is a dramatic complication, seen almost exclusively in unstable slips. It develops within months after the slip and leads to immediate articular joint degeneration and the need for total hip replacement. Another serious complication of SCFE is chondrolysis, which is a rapid progressive articular cartilage degeneration leading to a narrow joint space and restriction of hip motion. Implant-related complications, such as migration and loosening, may lead to the progression of the slip. Though bilateral disease is quite frequent, there is no consensus about the need for preventive surgery on the healthy contralateral hip. Diagnosis of SCFE is frequently missed or delayed, leading to slips of higher severity. Silent slippage of the capital femoral epiphysis is highly suspected as an underlying cause of cam-type FAI and early-onset hip osteoarthritis. There is controversy, whether asymptomatic implants should be removed. Novel surgical techniques, such as the modified Dunn procedure and hip arthroscopy, seem to be effective modalities for the prevention of FAI in SCFE.

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.].

Vascular Supply to the Femoral Head in Patients With Healed Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) is one of the most common hip disorders. The vascularity of the lateral epiphyseal vessels supplying the femoral head in patients with healed SCFE has not been well defined. The purpose of this study was to characterize the location and number of lateral epiphyseal vessels in young adults with healed SCFE. This was a retrospective study of 17 patients (18 hips) with a diagnosis of SCFE and a matched control group of 17 patients (17 hips) with developmental dysplasia of the hip. All patients underwent high-resolution contrast-enhanced magnetic resonance imaging to visualize the path of the medial femoral circumflex artery and the lateral epiphyseal arterial branches supplying the femoral head. There were 5 unstable SCFEs and 13 stable SCFEs with an average slip angle of 31 degrees. (All patients had been treated with in situ pinning and screw removal). Average age at time of magnetic resonance imaging was 24.5 years (range, 15 to 34 y). The lateral epiphyseal vessels reliably inserted on the posterior-superior aspect of the femoral neck from the superior-anterior to the superior-posterior position in both the SCFE and control groups. An average of 2 (±0.8) retinacular vessels were identified in the SCFE group compared with 5.2 (±0.7) retinacular vessels in the control group (P<0.001). In healed SCFE, the lateral epiphyseal vessels reliably insert in the same anatomic region as patients with hip dysplasia; however, the overall number of vessels is significantly lower.

Posterior sloping angle of the capital femoral physis in slipped capital femoral epiphysis has poor clinical utility and should not guide treatment on prophylactic fixation

Prophylactic pinning of the uninvolved side after unilateral slipped capital femoral epiphysis (SCFE) is controversial as it balances increased surgical risks against the possibility of protecting a normal hip from initial slip and deformity. A posterior sloping angle (PSA) of greater than 12-14.5° has been proposed by various authors as a treatment threshold to predict for contralateral hip progression and prophylactic pinning. A retrospective review of a 10-year series of patients with the diagnosis of SCFE and follow-up of 18 months was conducted. Patients were divided into two groups, those with Isolated Unilateral Slips and those who subsequently underwent Subsequent Contralateral Progression. PSA measurements were performed by two clinicians and assessed for inter-observer reliability. Data collected included age, sex, ethnicity, Loder class, endocrinopathy, renal impairment, radiation exposure, and PSA. There were no significant differences between the distribution of gender, site of slip, age of onset, Loder class, and presence of medical comorbidities between the Isolated Unilateral Slip and Subsequent Contralateral Progression groups (p > 0.05). The mean PSA value was not significantly higher in the Subsequent Contralateral Progression group (17.9 ± 4.32 (10.5-23.5)) compared to the Isolated Unilateral Slip group (15.8 ± 5.31 (6-26)) (p = 0.32). The receiver operator coefficient-derived ideal treatment threshold of 16.5° gave a sensitivity of 0.71, specificity of 0.64, and number needed to treat of 3. PSA differences between the Subsequent Contralateral Progression and Isolated Unilateral Slip groups were not statistically significant in this series. All proposed treatment thresholds had poor specificity. Prophylactic pinning should not be based on isolated PSA values. III.

Slipped capital femoral epiphysis: clinical presentation, diagnostic procedure and classification

Slipped capital femoral epiphysis (SCFE) is afrequent chronic and often bilateral atraumatic slippage of the epiphysis relative to the femoral neck in adolescence. The success of the treatment depends on the extent of the slippage and possible complications. Review on current trends in clinical examination and diagnostic imaging protocols. Commonly used imaging techniques, methods of measuring the slippage and treatment-relevant classification schemes are presented. An overview on the clinical findings, the diagnostic procedures and the classification of SCFE based on relevant study results and experience gained in our daily clinical practice. Early diagnosis of SCFE is essential, as adelay in diagnosis regularly leads to an increase in slippage with an increased risk of subsequent damage to the blood vessels, which can lead to irreversible damage of the joint. Symptoms and findings are frequently subtle and nonspecific, often leading to delay in diagnosis and treatment and, consequently, to the manifestation of massive deformities. X‑ray imaging is the primary imaging modality, whereas MRI, computed tomography (CT) and ultrasound are helpful in surgical planning and prognostic evaluation. Postoperatively, they provide information on short and long-term complications. The delay in the diagnosis of SCFE is still present in the literature as well as in our own patient population, indicating that arepeated, consistent training on this topic is essential to prevent harm to patients. Whether patients benefit from advanced imaging techniques such as MRI or CT is questionable and should be screened case by case.

Higher BMI, Higher Risk of Slipped Capital Femoral Epiphysis

Research Article| February 01 2019 Higher BMI, Higher Risk of Slipped Capital Femoral Epiphysis AAP Grand Rounds (2019) 41 (2): 20. https://doi.org/10.1542/gr.41-2-20 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Higher BMI, Higher Risk of Slipped Capital Femoral Epiphysis. AAP Grand Rounds February 2019; 41 (2): 20. https://doi.org/10.1542/gr.41-2-20 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: body mass index procedure, epiphyses, slipped, obesity Source: Perry DC, Metcalfe D, Lane S, et al. Childhood obesity and slipped capital femoral epiphysis. Pediatrics. 2018; 142(5): e20181067; doi: https://doi.org/10.1542/peds.2018-1067Google Scholar Investigators from multiple UK institutions conducted a cohort study to assess the strength of association between childhood obesity and slipped capital femoral epiphysis (SCFE). The cohort was identified using a nationwide child health surveillance program in Scotland, as well as a data set that included 10% of the Scottish population. In both data sets, child demographics, height, and weight were routinely recorded at school entry (5–6 years old) by school nurses. Height and weight among a subgroup of cohort children at 11–12 years old were recorded in a third data set. The primary exposure was BMI, categorized as underweight (<5%), normal weight (5%–85%), overweight (≥85%–94%), mild/moderate obesity (≥95%–99%), or severe obesity (≥99%). The primary outcome was SCFE diagnosed between the ages of 6 and 18 years, as determined by ICD-10 codes in the Scottish Morbidity Record, a registry of patients discharged from all Scottish hospitals. Cohort children contributed to follow-up until they reached 18 years, received a diagnosis of SCFE, or the study period ended. Investigators calculated the incidence of SCFE by BMI category among children 5–6 years old and 11–12 years old. The risk of SCFE attributable to BMI was also calculated. There were 597,017 children 5–6 years old and 39,468 children 11–12 years old included in the analysis, with a total follow-up time of 4.26 million child-years. Among children 5–6 years old, 11.9% were overweight, and 9.2% were obese. Of those obese at 5–6 years old, 75% remained obese at 11–12 years old. There were 209 children diagnosed with SCFE. The incidence of SCFE in children 5–6 years old was 4.7 per 100,000 child-years of risk (95% CI, 4.1–5.4). Compared to children of normal weight at 5–6 years old, those who had severe obesity, had mild/moderate obesity, or were overweight had 5.9 (95% CI, 3.9–9.0), 3.8 (95% CI, 2.6–5.8), and 1.5 (95% CI, 0.9–2.3) times greater risk of developing SCFE, respectively. The risk of SCFE attributable to BMI at 5–6 years old was 78% among children with obesity and 31% among children who were overweight. The incidence of SCFE in children 11–12 years old was 23.8 per 100,000 child-years of risk (95% CI, 14.8–36.4), with a 17 times greater risk of developing SCFE (95% CI, 5.9–49.0) in those with severe obesity (vs normal BMI) at 11–12 years. The investigators conclude that childhood BMI is strongly associated with SCFE. Dr Hennrikus has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Childhood obesity is a global health problem.1 SCFE is a disease that causes lifelong disability due to arthritis, pain, and leg length inequality.2,3 SCFE occurs through the histologic zone of hypertrophy in the open growth plate.4 The peak age for SCFE is around puberty.... You do not currently have access to this content.

A Pilot Study on Resident and Pediatrician Knowledge and Confidence in the Diagnosis of Slipped Capital Femoral Epiphysis.

Introduction. The purpose of this study was to identify deficiencies in pediatric residents’ and pediatricians’ knowledge and confidence in diagnosing slipped capital femoral epiphysis (SCFE). Methods. Pediatricians and residents at our institution answered an anonymous 12-question survey on knowledge and confidence in SCFE diagnosis. Results. Twenty pediatricians and 30 pediatric residents participated in the survey. Of 30 residents, 22 (77%) reported low confidence ordering radiographs evaluating for SCFE in patients with hip pain. Four of 20 pediatricians (20%) reported low confidence ordering radiographs for patients with hip pain. Forty percent (8/20) of pediatricians did not feel comfortable diagnosing a SCFE based on radiographs, which was significantly different from 80% (24/30) of residents who did not feel comfortable diagnosing a SCFE based on radiographs (P = .004). There was a significant difference between residents and pediatricians in comfort ordering and diagnosing radiographs (P < .01). There was no significance between pediatrician and resident scores for knowledge-based questions (P = .50). Discussion. Despite scoring well on knowledge-based questions, more than half of pediatricians and pediatric residents felt uncomfortable ordering radiographs to evaluate for SCFE in patients with hip or knee pain. This may be one factor contributing to the continued delay in SCFE diagnosis.

Seasonal Variation in Slipped Capital Femoral Epiphysis: New Findings Using a National Children's Hospital Database.

Slipped capital femoral epiphysis (SCFE) demonstrates seasonal variation in certain latitudes but not others. Is such variation influenced by temperature differences, sunlight exposure and subsequent vitamin D production, or other climate variables? It was the purpose of this study to further investigate the seasonal variation in month of presentation for SCFE. Data for this study originated from the Pediatric Hospital Information System for all children with a diagnosis of SCFE from January 1, 2004 through December 31, 2014. From this database the patient's sex, ethnicity, hospital location, and month of presentation was determined. Only those patients treated primarily for SCFE were included. Geographic and climate data [latitude, average annual temperature, precipitation, climate type (Köppen-Geiger and Liss), horticultural plant zone hardiness, and sunlight exposure] for each of the 49 Pediatric Hospital Information System hospitals was determined. Seasonal variation was analyzed using cosinor analysis. A P<0.05 was considered statistically significant. There were 10,350 cases of SCFE with an overall peak presentation in mid August. For those living at a latitude of >35-degree N there was single peak, a less prominent double peak for those 31- to 35-degree N, and no variation for those <31-degree N. As the average annual temperature increased there was less seasonal variability. Humid, temperate and cold winter climates demonstrated seasonal variation, whereas other climate types did not. Those living in areas having <2500 hours of sunlight per year demonstrated seasonal variation. Further, areas having a photovoltaic solar production potential <5.0 kWh/m/d also demonstrated seasonal variation. We discovered new seasonal variation findings regarding SCFE. These are a double peak pattern for those between 31- and 35-degree N latitude; less variability as the average annual temperature increases; and sunlight exposure correlates with seasonal variability. Potential explanations are a rachitic state due to seasonal variation in vitamin D production, and seasonal variation in physeal growth and strength. These new findings will require further investigation. Level III.

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.

Diagnosing slipped capital femoral epiphysis amongst various medical specialists.

PurposeTo evaluate sensitivity, specificity and accuracy of a radiographic slipped capital femoral epiphysis (SCFE)-diagnosis among medical specialists.MethodsThree paediatricians, three paediatric radiologists and three paediatric orthopaedic surgeons completed two rounds of a survey of anteroposterior and frog-leg lateral radiographs of patients with a diagnosis of SCFE (25), femoroacetabular impingement (four), Legg-Calvé-Perthes (11) or no hip pathology (ten). Intra- and interobserver agreement among specialties regarding the diagnosis of a SCFE were assessed using Cohen’s kappa coefficient (κ). Diagnostic accuracy of SCFE relative to the benchmark, a combination of the radiographic diagnosis based on Klein’s line, clinical symptoms and surgical treatment, was assessed computing sensitivity, specificity and accuracy.ResultsIntraobserver agreement between the surveys was moderate among paediatricians (κ-range, 0.44 to 0.52), moderate to almost perfect among orthopaedic surgeons (κ-range, 0.79 to 0.88) and almost perfect among paediatric radiologists (κ-range, 0.83 to 1.00). Interobserver agreement for survey 1 and 2 was slight among paediatricians (mean κ, 0.19), substantial among orthopaedic surgeons (mean κ, 0.77) and almost perfect among paediatric radiologists (mean κ, 0.86). Sensitivity of SCFE-diagnosis was high among radiologists and orthopaedic surgeons (88% to 100% for both specialties), but lower for paediatricians (24% to 76%). Specificity was high among radiologists and orthopaedic surgeons (72% to 84%), however, variable among paediatricians (56% to 80%). Accuracy of a SCFE-diagnosis was highest in radiologists (84% to 92%), followed by orthopaedic surgeons (80% to 88%) and paediatricians (48% to 78%).ConclusionSCFE can be detected on radiographs by different medical specialties. Intra- and interobserver agreement, specificity, sensitivity and accuracy for radiographic SCFE-diagnosis amongst paediatric radiologists and orthopaedic surgeons are better than that of general paediatricians.Level of EvidenceII

A nationwide cohort study of slipped capital femoral epiphysis

ObjectivesTo describe the epidemiology of slipped capital femoral epiphysis (SCFE), to examine associations with childhood obesity and socioeconomic deprivation, and to explore factors associated with diagnostic delays.DesignHistoric cohort study using...