Femoral Epiphysis Research Articles

Modified Dunn Procedure for Open Reduction of Chronic Slipped Capital Femoral Epiphysis.

Abnormal femoral head anatomy following moderate-to-severe slipped capital femoral epiphysis (SCFE) can lead to femoroacetabular impingement and premature osteoarthritis4-10. Surgical correction at the deformity site through capital reorientation has the potential to fully ameliorate this but has traditionally been associated with high rates of osteonecrosis11-15. The modified Dunn procedure has the potential to restore anatomy in hips with SCFE while protecting the blood supply to the femoral head. A surgical dislocation of the hip is performed according to the technique described by Ganz et al.16. The remaining posterosuperior portion of the greater trochanter is trimmed to the level of the femoral neck by subperiosteal bone removal performed in an inside-out manner. The periosteum of the femoral neck is gradually elevated. The resulting soft-tissue flap, consisting of the retinaculum and external rotators, holds the blood vessels supplying the epiphysis. The femoral epiphysis is pinned in situ (in unstable cases) with threaded Kirschner wires, the ligamentum teres is transected, and the femoral head is dislocated. With the femoral neck exposed, the epiphysis is gradually mobilized from the metaphysis, allowing exposure of the residual femoral neck and inspection of any posteroinferior callus. To avoid tension on the retinacular vessels during reduction of the epiphysis, the posterior neck callus is completely excised. The remaining physis is removed with use of a burr while holding the epiphysis stable. The epiphysis is gently reduced onto the femoral neck, avoiding tension on the retinacular vessels. If tension is noted, the femoral neck is rechecked for residual callus, which is excised. If no callus is found, the neck may be carefully shortened in order to minimize tension. Epiphyseal fixation is achieved with use of a 3-mm fully threaded wire inserted antegrade through the fovea to the lateral cortex below the greater trochanter. A second wire is inserted retrograde under fluoroscopy. After reducing the hip, the capsule is closed and the greater trochanter is reattached with use of 3.5-mm cortical screws. Alternatives include nonoperative treatment, in situ fixation (e.g., pinning or screw fixation), gentle closed reduction with pinning, and triplanar trochanteric osteotomy (e.g., Imhauser or Southwick osteotomies). In situ pinning of mild-to-moderate, stable SCFE yields good long-term results with low rates of osteonecrosis9. Treatment of higher-grade SCFE without reduction aims to avoid osteonecrosis and assumes that the proximal femoral deformity will remodel; however, the head-neck offset will remain abnormal, risking impingement and early-onset osteoarthritis5,8. The procedure described in the present article allows anatomic reduction of the epiphysis with a low risk of osteonecrosis. Surgical dislocation of the hip16 with development of an extended retinacular soft-tissue flap17 provides extensive subperiosteal exposure of the circumferential femoral neck and preserves the vulnerable blood supply to the epiphysis18. The Dunn subcapital realignment procedure15 with callus removal and slip angle correction allows anatomic restoration of the proximal femur. Reported results of various centers performing the procedure vary greatly with regard to the number of hips treated and the follow-up time. Most studies have been retrospective and have lacked a control group. The reported risk of osteonecrosis ranges from 0% to 25.9%19, with the wide range most likely because of the challenging nature of the technique, the low number of cases per surgeon, and the long learning curve associated with the procedure. In centers with extensive experience in pediatric hip-preserving surgery, the reported rate of osteonecrosis is low3. Studies with mid to long-term follow-up have shown no conversion to total hip arthroplasty3,20,21, but residual deformities can persist, and subsequent surgery is possible. Extensive experience in surgical hip dislocation and retinacular flap development is a prerequisite for successful outcomes and low rates of osteonecrosis.Sufficient callus and physeal remnant resections are needed to avoid tension on the retinacular vessels during epiphyseal reduction.The skin incision should be centered over the greater trochanterThe Gibson interval must be carefully prepared for adequate release and to avoid injury.Tension on the periosteal flap should be avoided to prevent stress on the retinacular vessels. AP = anteroposteriorAVN = avascular necrosis (i.e., osteonecrosis)CI = confidence intervalCT = computed tomographyK-wire = Kirschner wireMRI = magnetic resonance imagingOA = osteoarthritisSHD = surgical hip dislocationTHA = total hip arthroplastyVTE = venous thromboembolism.

Poster 278: Low Distal Femoral Epiphysis Height May Be a Risk Factor for Growth Disturbance Following All-inside All-Epiphyseal Anterior Cruciate Ligament Reconstruction

Poster 278: Low Distal Femoral Epiphysis Height May Be a Risk Factor for Growth Disturbance Following All-inside All-Epiphyseal Anterior Cruciate Ligament Reconstruction

Poster 205: Long-Term Outcomes for Patients Undergoing Revision Hip Arthroscopy

Objectives: Previous studies have reported outcomes after revision hip arthroscopy at mid-term follow-up. These studies demonstrate that patients can expect clinical improvement and low rates of reoperation following their revision surgery. However, in comparison to primary hip arthroscopy patients they experience worse outcomes. The purpose of this study was (1) To evaluate long-term outcomes after revision hip arthroscopy and (2) to identify factors that contribute to poorer outcomes. Methods: Patients who underwent revision hip arthroscopy for FAIS between 1/2012-9/2015 were reviewed. Patients were excluded if they underwent revision hip arthroscopy for a reason other than FAIS, underwent staged or prior PAO, had Tönnis grade > 1, had a history of congenital hip disorder (e.g., slipped capital femoral epiphysis), or were missing 8+ year follow-up. Patient-reported outcome (PRO) measures were collected both pre- and post-operatively including Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports Scale (HOS-SS), modified Harris Hip Score (mHHS), and international Hip Outcome Tool (iHOT-12). Minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds were calculated using the distribution and anchor methods, respectively. Rates of MCID and PASS achievement were then evaluated. Rates of reoperation including repeat revision hip arthroscopy and conversion to total hip arthroplasty (THA) were evaluated. Patients were also divided into clinical successes and failures and compared. A clinical failure was defined as failure to achieve MCID or PASS for any PRO or undergoing a reoperation. Results: A total of 43 patients (72% female; age: 30.1 ± 10.3 years; BMI: 25.8 ± 6.0 kg/m2) met criteria for inclusion. Average follow-up was 9.3 years. At last follow-up there were significant improvements across all PROs (p < 0.001, for all). MCID achievement at final follow-up for each PRO was ≥ 56.5%, with achievement of MCID in any PRO occurring in 73.9% of patients. PASS achievement at final follow-up for each PRO was ≥ 29.6%, with achievement of PASS in any PRO occurring in 63.0% of patients. PASS achievement was 75.7% at two years and 75.8% at five years. Incidence of secondary revision hip arthroscopy was 23.3% and THA was 14.0%, occurring at mean 3.9 ± 2.8 years and 4.2 ± 3.0 years following index revision, respectively. 22 patients were considered clinical successes, and 21 patients were determined to be clinical failures. Both groups demonstrated similar age (28.6 ± 8.5 years vs 31.6 ± 11.9, p = 0.351), sex (77.3% female vs 66.7% female, p = 0.438), and BMI (25.7 ± 7.9 vs 25.9 ± 3.6, p = 0.915). Additionally, clinical successes and failures had similar preoperative PROs (p ≥ 0.133, for all). Presence of preoperative pain for over two years occurred more frequently in clinical failures (45.5% vs 76.2%, p = 0.039). Tönnis grade 1 was also present at a higher rate amongst clinical failures (0% vs 23.8%, p = 0.015). Conclusions: Patients undergoing revision hip arthroscopy can see significant clinical improvement, particularly within the first five years following surgery. However, some patients may see clinical decline beyond eight years post-operatively. Revision hip arthroscopy is associated with relatively high reoperation rate. Those with greater Tönnis grade on preoperative radiographs and increased prevalence of chronic preoperative pain were less likely to achieve a clinical success.

Partially Threaded Screws Require More Work During Removal Compared to Fully Threaded Screws in a Bone Simulation Model

BackgroundRoutine Slipped Capital Femoral Epiphysis (SCFE) implant removal is controversial. Difficulty with hardware removal is well documented in SCFE patients, however, there is no biomechanical study demonstrating which specific aspect of screw morphology may be responsible for difficult removal. In this study, we compare the removal torques and work energy of fully and partially threaded cannulated SCFE screws from a bone simulation medium. Methods70mm x 6.5 mm partially (20mm threads) and fully threaded stainless-steel screws were tested by reversing them from a cured liquid resin medium. Peak Torque and total work energy were recorded from a load cell apparatus during each trial The mean peak torque and total work energy were compared between the partially threaded and fully threaded screw groups using Student’s t-test. P<0.05 was considered statistically significant. ResultsThe fully threaded screws (n=20) had a mean peak torque of 10.59 Nm (SD=0.95 Nm) which was statistically significantly lower than the mean peak torque of the partially threaded screws (n=23), 11.40 Nm (SD=1.15 Nm) (p=0.014). The fully threaded screws (n=21) had a mean work of 598.7 J (SD=208.3), which was statistically significantly lower than the mean work of the partially threaded screws (n=23), 1737.6 J (SD = 292.4 J) (p<0.0001). ConclusionAlthough our study did not perfectly model the in vivo “stuck screw phenomenon,” our data demonstrate partially threaded screws require more work of removal. Surgeons should consider the use of fully threaded screws if anticipating future hardware removal when selecting implants in the treatment of SCFE. Key concepts(1).SCFE hardware removal can be difficult and construct selection can influence complication rates.(2).Removal torque differences exist between fully and partially threaded screws.(3).Partially threaded screws require greater work energy of removal in comparison to partially threaded screws

Assessment of bone tissue cytoarchitectonics by 2D 1H NMR relaxometry maps

Bone is a complex tissue that fulfills the role of a resistance structure. This quality is most commonly assessed by bone densitometry, but bone strength may not only be related to bone mineral density but also to the preservation of bone cytoarchitectonics. The study included two groups of rats, ovariectomized and non-ovariectomized. Each group was divided into three batches: control, simvastatin-treated, and fenofibrate-treated. In the ovariectomized group, hypolipidemic treatment was instituted at 12 weeks post ovariectomy. One rat from each of the 6 batches was sacrificed 8 weeks after the start of treatment in the group. The experimental study was performed using a Bruker Minispec mq 20 spectrometer operating at a frequency of 20 MHz, subsequently also performed by 1H T2-T2 molecular exchange maps. The results were represented by T2-T2 molecular exchange maps that showed, comparatively, both pore size and their interconnectivity at the level of the femoral epiphysis, being able to evaluate both the effect of estrogen on bone tissue biology and the effect of the lipid-lowering medication, simvastatin, and fenofibrate, in both the presence and absence of estrogen. T2-T2 molecular exchange maps showed that the absence of estrogen results in an increase in bone tissue pore size and interconnectivity. In the presence of estrogen, lipid-lowering medication, both simvastatin and fenofibrate alter bone tissue cytoarchitectonics by reducing pore interconnectivity. In the absence of estrogen, fenofibrate improves bone tissue cytoarchitectonics, the T2-T2 molecular exchange map being similar to that of non-osteoporotic bone tissue.

Barriers to Health Care Communication: Patient Education Resource Readability and Spanish Translation for Slipped Capital Femoral Epiphysis

BackgroundThe American Medical Association (AMA) and the National Institutes of Health (NIH) recommend that patient education resources be written at 6th and 8th grade reading levels, respectively. However, many existing resources are written above this level. In addition, the majority of patient education resources are only available in English, despite the significant Spanish-speaking population in the United States. The purpose of this study was to determine the availability and readability of online patient education resources for Slipped Capital Femoral Epiphysis (SCFE) provided by the top-ranked pediatric orthopaedic hospitals and major pediatric orthopedic professional societies. MethodsWe performed a cross-sectional analysis to determine the availability of English and Spanish language resources for SCFE provided by the top pediatric orthopaedic hospitals and major professional societies. We then assessed the readability of available patient education materials via three measures of readability. Statistical analysis was performed using descriptive, univariate, and correlation analyses. ResultsIn total, 79.6% (39/49) of hospitals and 66.7% (2/3) of professional societies provided English language resources for SCFE. In contrast, Spanish language resources were provided by 34.7% (17/49) and 33% (1/3) hospitals and professional societies. English language resources scored significantly lower than Spanish language resources using the Flesch-Kincaid and Fernandez-Huerta reading ease scales, respectively (60.32 vs. 65.89, p<0.05). There was no difference in grade level calculated by Fry Graph/Gilliam-Peña-Mountain (9.5 vs. 8.5, p>0.05), but English language resources had a significantly higher grade level calculated by SMOG/SOL (11.9 vs. 10.4, p<0.01). There was greater availability of Spanish language resources in states with >20% primary Spanish- speakers (p<0.05). ConclusionThe majority of top-ranked hospitals and professional societies provide online educational materials on SCFE in English; however, only a third provide similar materials in Spanish. Additionally, the average reading level of English and Spanish language resources is above the recommendations from the AMA and NIH. Additional effort and resources should be allocated toward improving SCFE patient education materials to increase accessibility to broader patient and caregiver populations. LEVEL OF EVIDENCELevel III KEY CONCEPTS(1)Online patient education resources for Slipped Capital Femoral Epiphysis (SCFE) are written above the recommended reading grade level for both English and Spanish.(2)There is limited availability of Spanish-language patient education recourses for SCFE, despite a significant Spanish-speaking population in the United States.(3)There is greater availability of Spanish-language resources for SCFE in states with a primary Spanish-speaking population greater than 20%.

Surgical outcomes of proximal femoral bone cysts in pediatric patients: a retrospective study of 41 cases.

The aim of this study was to evaluate the surgical outcomes of proximal femoral bone cysts in pediatric patients. We retrospectively analyzed 41 pediatric patients (31 males and 10 females, mean age 7.47 ± 2.67 years, range 2.03-14.67 years) diagnosed with proximal femoral bone cysts treated at a single institute between March 2009 and November 2021. Data included demographics, preoperative details, intraoperative conditions, surgical techniques, postoperative outcomes, recurrence, and complications. Of the participants, 68% presented with simple bone cysts and 32% with aneurysmal bone cysts. Prior to surgery, 32% exhibited pathological fractures. Surgical methods included lesion curettage, defect filling using allograft bone and Minimally-Invasive Injectable Graft ×3, and varied fixation techniques. Postoperative recurrence (17%) was associated with cyst location between the capital femoral epiphysis and the linea intertrochanterica (P = 0.010). At the final assessment (mean follow-up: 26.51 ± 18.99 months), all showed radiological bony union with 93% rated as "good" and 7% as 'fair' based on Ratliff hip scores. Complications arose in 20% of patients, significantly correlated with prior pathological fractures (P = 0.007) and their association with the linea intertrochanterica (P = 0.004). Those with fractures reported higher intraoperative blood loss (P = 0.015) and longer surgery durations (P = 0.012) compared to those without. Treating pediatric proximal femoral bone cysts using techniques such as lesion curettage, defect filling, and selective internal fixation yields favorable outcomes. The presence of pathological fractures can prolong surgical time, increase intraoperative blood loss, and elevate postoperative complication risks. Hence, early surgical intervention for these cysts is recommended to prevent fractures.

LGG-19. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE): A RARE ADVERSE EVENT ASSOCIATED WITH FGFR TYROSINE KINASE INHIBITOR THERAPY IN A CHILD

Abstract BACKGROUND FGFR tyrosine kinase inhibitors (FGFR-TKIs) are being increasingly used off-label in children with hard-to-treat tumors harboring specific FGFR alterations. We report a case of Slipped Capital Femoral Epiphysis (SCFE), an on target skeletal toxicity of a pan-FGFR TKI inhibitor, erdafitinib. METHODS Data was extracted from chart review of the patient and literature search for the use of FGFR-TKIs in children and their side effects. RESULTS A 13-year-old boy was diagnosed to have a optic pathway/ hypothalamic glioma with signs of increased intracranial pressure and obstructive hydrocephalus requiring placement of ventriculo-peritoneal (VP) shunt. Sequencing of the tumor showed FGFR1-Tyrosine kinase domain internal tandem duplication (FGFR1-KD-ITD) and was negative for BRAF mutation/ fusion. Two weeks later, he was treated for a VP shunt infection (surgical revision and 6 weeks antibiotics). He developed hypothalamic obesity with rapid weight gain and BMI &amp;gt;30. After a four-month delay from the initial diagnosis, he was started on erdafitinib a pan-FGFR1-4 inhibitor, through a special access program. At 12 weeks of treatment, he developed persistent knee pain. X-ray of the hips showed slipped capital femoral epiphysis (SCFE) of the right hip. Erdafitinib was discontinued and he underwent surgery with in-situ pinning of the right hip and prophylactic pinning of the left hip. MRI at the time of stopping the medication showed a 30% decrease in the size of the tumor, which has remained stable at 6 months follow up. CONCLUSIONS Based on our experience and literature review of pediatric patients who are treated with pan-FGFR TKIs, we recommend: a) monitoring both rate of weight gain/ BMI for obesity and growth velocity while on therapy and b) update the drug toxicity profile of FGFR TKIs to include skeletal toxicities and inform parents/ patients of these toxicities at the time of consent for therapy.

Surgeon Recommendations for Physical Activity in Patients With Pediatric Hip Conditions.

While physical activity (PA) is important during youth, it is unclear if children and adolescents with developmental dysplasia of the hip (DDH), Legg-Calvé-Perthes disease (LCPD), or slipped capital femoral epiphysis (SCFE) are expected or encouraged to return to PA once they have healed. This study examines the orthopaedic surgeons' role in advising pediatric hip patients on the PA they should engage in, assessing their practice, opinions, and consensus when making recommendations. Orthopaedic surgeons were invited from member lists of 4 hip study groups. The survey included demographics, opinions regarding PA, and 10 case scenarios that queried respondents on the duration and intensity of PA as well as the restrictions on activity type that they would recommend for DDH, LCPD, or SCFE patients. Consensus was evaluated on a scale ranging from 0 to 1, with a value of 0 indicating no agreement among respondents and a value of 1 indicating complete agreement. A total of 51 orthopaedic surgeons responded. While 94% agreed that it is important for school-aged hip patients to return to PA after they have healed, 53% believed that PA may compromise the hip and contribute to the development of osteoarthritis. Average standardized consensus was 0.92 for suggesting the patient engage in some amount of PA, 0.44 for suggesting the recommended daily minimum of 60 minutes of moderate-to-vigorous physical activity (MVPA), and 0.33 for suggesting restrictions on activity type. The most frequently selected restrictions included avoiding impact activities (93%, 235/254) and contact activities (58%, 147/254), followed by weight-bearing activities (24%, 62/254). Respondents were not aware of existing PA guidelines, although 57% expressed interest in following guidelines and 39% were uncertain. While there is consensus among orthopaedic surgeons that children with chronic hip conditions should engage in PA, there is considerable variation when recommending the recommended daily MVPA minimum and placing restrictions on activity type. This study suggests interest among orthopaedic surgeons in developing PA guidelines that optimize outcomes for pediatric hip patients. Level II-Survey study.

Children’s orthopaedics

The June 2024 Children’s orthopaedics Roundup360 looks at: Proximal femoral unicameral bone cysts: is ESIN the answer?; Hybrid-mesh casts in the conservative management of paediatric supracondylar humeral fractures: a randomized controlled trial; Rate and risk factors for contralateral slippage in adolescents treated for slipped capital femoral epiphysis; CRP predicts the need to escalate care after initial debridement for musculoskeletal infection; Genu valgum in paediatric patients presenting with patellofemoral instability; Nusinersen therapy changed the natural course of spinal muscular atrophy type 1: what about spine and hip?; The necessity of ulnar nerve exploration and translocation in open reduction of medial humeral epicondyle fractures in children.

Radiological and clinical femoroacetabular impingement after slipped capital femoral epiphysis treated by in situ fixation.

The treatment of slipped capital femoral epiphysis (SCFE) is always surgical. In situ fixation (ISF) is widely accepted to stop the epiphysis slipping. Femoroacetabular impingement (FAI) is recognized as a complication after ISF and is one of the major causes of early hip osteoarthritis. The aim of this study was to characterize the relation between clinical and radiological signs of FAI. A monocentric study that included all consecutive children treated for SCFE by ISF between 2006 and 2017 was performed. Clinical examination consisted in range of motion (ROM) measurement for both hips, impingements tests and functional scores (Harris Hip Score (HHS) and Womac score). Radiological analysis was based on signs of impingement (alpha angle, anterior head neck offset (OS), anterior head neck offset ratio (HNOR). 36 hips were included. At follow-up, the difference between the mean hip ROM on the SCFE side and the healthy side were statistically significant in abduction and in internal rotation. Ten (28%) hips presented at least one clinical test positive for FAI (FADDIR and/or FABER). All the patients presented a good or excellent functional score. Eight patients (22%) presented all radiological signs of impingement; among these, 3 had a clinical sign of FAI. Twenty-eight hips (78%) presented at least one radiological sign of FAI; among these, 10 had clinical signs of FAI. Despite a high rate of radiological FAI, less than one-third of patients have clinical signs of FAI after ISF for SCEFE. III: retrospective study.

Endocrinopathy and Slipped Capital Femoral Epiphysis

Endocrinopathy and Slipped Capital Femoral Epiphysis

Case report: Slipped capital femoral epiphysis: a rare adverse event associated with FGFR tyrosine kinase inhibitor therapy in a child

We report a case of slipped capital femoral epiphysis (SCFE), an on target skeletal toxicity of a pan-FGFR TKI inhibitor, erdafitinib. A 13-year-old boy was diagnosed to have an optic pathway/hypothalamic glioma with signs of increased intracranial pressure and obstructive hydrocephalus requiring placement of ventriculo-peritoneal (VP) shunt. Sequencing of the tumor showed FGFR1-tyrosine kinase domain internal tandem duplication (FGFR1-KD-ITD). He developed hypothalamic obesity with rapid weight gain and BMI &amp;gt;30. At 12 weeks of treatment with erdafitinib, he developed persistent knee pain. X-ray of the right hip showed SCFE. Erdafitinib was discontinued, and he underwent surgical pinning of the right hip. MRI at discontinuation of erdafitinib showed a 30% decrease in the size of the tumor, which has remained stable at 6 months follow-up. Our experience and literature review suggest that pediatric patients who are treated with pan-FGFR TKIs should be regularly monitored for skeletal side effects.

Analysis of risk factors for difficult implant removal in children with slipped capital femoral epiphysis treated by cannulated screws.

Cannulated screws are widely used in the treatment of slipped capital femoral epiphysis, which can be removed after physeal closure on patient's request. This study aimed to analysis the potential risk factors for difficult removal in children with slipped capital femoral epiphysis treated by cannulated screws. This study enrolled 32 hips that had undergone removal of cannulated screws after treatment of slipped capital femoral epiphysis at our department. The primary outcomes were the difficult screw removal. The secondary outcomes were functional outcome assessed by using a modified Harris Hip Score and complications of fractures and surgical site infection. Related risk factors for difficult removal were recorded and analyzed by multivariable logistic regression. In total, 32 hips were evaluated, with a mean age of 14.9 ± 1.3 years old (range, 13-19 years). Six (18.8%) hips presented with difficult removal, including 4 cases of screws' slip and 2 breakages. The average implantation time in the difficult removal group (5.7 ± 1.0) was also significantly longer than that in the easily removed group (3.8 ± 0.9, p = 0.001). The mean surgical time in patients with difficult removal was 66.3 ± 11.6 min, which was also significantly longer than that (54.8 ± 8.3) in the other patients (p = 0.008). The duration of screw implantation was an independent risk factor for difficult removal. Prolonged screw duration was a predictor for difficult removal in children with slipped capital femoral epiphysis treated by cannulated screws. An early surgery after physeal closure might benefit those with a request for screw removal.

Does spinopelvic alignment affect femoral head cartilage and the proximal femoral physis in slipped capital femoral epiphysis? A finite element analysis

BackgroundSlipped capital femoral epiphysis is a prevalent pediatric hip disorder. Recent studies suggest the spine's sagittal profile may influence the proximal femoral growth plate's slippage, an aspect not extensively explored. This study utilizes finite element analysis to investigate how various spinopelvic alignments affect shear stress and growth plate slip. MethodsA finite element model was developed from CT scans of a healthy adult male lumbar spine, pelvis, and femurs. The model was subjected to various sagittal alignments through reorientation. Simulations of two-leg stance, one-leg stance, walking heel strike, ascending stairs heel strike, and descending stairs heel strike were conducted. Parameters measured included hip joint contact area, stress, and maximum growth plate Tresca (shear) stress. FindingsPosterior pelvic tilt cases indicated larger shear stresses compared to the anterior pelvic tilt variants except in two leg stance. Two leg stance resulted in decreases in the posterior tilted pelvi variants hip contact and growth plate Tresca stress compared to anterior tilted pelvi, however a combination of posterior pelvic tilt and high pelvic incidence indicated larger shear stresses on the growth plate. One leg stance and heal strike resulted in higher shear stress on the growth plate in posterior pelvic tilt variants compared to anterior pelvic tilt, with a combination of posterior pelvic tilt and high pelvic incidence resulting in the largest shear. InterpretationOur findings suggest that posterior pelvic tilt and high pelvic incidence may lead to increased shear stress at the growth plate. Activities performed in patients with these alignments may predispose to biomechanical loading that shears the growth plate, potentially leading to slip.

Subcapital realignment osteotomy for the treatment of moderate and severe slipped upper femoral epiphysis: A retrospective study of 123 hips in a tertiary center.

The surgical treatment of moderate and severe slipped capital femoral epiphysis is controversial. Treatment ranges from pinning in situ to open dislocation and reduction of the slipped epiphysis. The modified Dunn procedure has been associated with variable avascular necrosis with rates, ranging between 0% and 67%. The aim of this study was to evaluate the outcomes and complications of patients who have undergone a subcapital realignment osteotomy (SCRO) in our center. A retrospective longitudinal study of the osteotomies performed between 2009 and 2019 in a tertiary referral center for Pediatric Orthopedics in Queensland, Australia. Patient demographics, stability, and severity of slip and surgical outcomes were collected. A total of 123 procedures were performed on 116 patients. The mean age was 12.4 years, 65 (56%) patients were male and the mean posterior sloping angle was 60.10 with 93 (75%) being severe slips. There were 51 (41.5%) Loder's stable and 72 (58%) unstable slipped capital femoral epiphysis. Our overall avascular necrosis rate following SCRO was 17.8%. Time between surgery and diagnosis did not have an effect on avascular necrosis. The subcapital realignment osteotomy remains a controversial and complex procedure for the management of moderate and severe slipped capital femoral epiphysis. We found that our cohort demonstrated an avascular necrosis rate in keeping with the existing literature. This indicates that when performed in a high-volume center with experienced surgical staff, it can be an effective treatment option for these patients. Level IV.

Implants removal in children: results of a survey among Italian orthopaedic surgeons.

In the treatment of paediatric limb disorders, the use of metal implants has been increasing over the last decades. Recent studies have addressed the decision of orthopaedic surgeons regarding the removal of implants after the treatment of fracture, and there is a growing consensus within the scientific community supporting the choice of not removing implants in children. This survey aimed to investigate the rationale behind the Italian orthopaedic community's decision regarding metal implant removal in paediatric patients. An electronic questionnaire was sent to all members of the Italian Paediatric Orthopaedic and Traumatology Society, Italian Orthopaedic and Traumatology Society, Italian Club of Osteosynthesis, and South Italy Society of Orthopaedic and Traumatology. The survey comprised 34 questions about hardware removal after the treatment of long bone fractures, epiphyseal growth plate injuries, slipped capital femoral epiphysis (SCFE), and flat foot. Of the 3500 orthopaedic surgeons who received the questionnaire, 5.5% responded. The leading indications for implant removal were the patient's intolerance, pain, ROM limitations, and hardware breakage. Removal of elastic nails for long bone fractures, cannulated screws for growth plate injuries, and SCFE and screws for arthroereisis for flat foot correction were analysed in detail. The consensus among Italian Orthopaedic Surgeons is to remove elastic nails and cannulated screws in cases of pain, intolerance, or breakage and to reduce further risks during patient growth. An increasing number of physicians, however, are endorsing and advocating the growing trend in the literature of not routinely removing the hardware.

Low Rate of AVN and Complications in Unstable SCFE With Epiphyseal-metaphyseal Discontinuity After Treatment With a Modified Dunn Procedure.

The risk of developing avascular necrosis (AVN) in the setting of an unstable slipped capital femoral epiphysis (SCFE) that is undergoing treatment with the modified Dunn procedure is not well understood. In addition, since the Loder classification of unstable is reportedly different than actual intraoperatively observed instability (that is, discontinuity between the femoral head epiphysis and proximal femoral metaphysis), the overall risk of developing AVN, as well as the potential complications of treatment of these patients with the modified Dunn procedure, are unknown. To evaluate the modified Dunn procedure for the treatment of patients with epiphyseal-metaphyseal discontinuity, we asked: (1) What was the survivorship free from AVN at 10 years? (2) What was the survivorship free from subsequent surgery and/or complications at 10 years? (3) What were the clinical and patient-reported outcome scores? In a retrospective analysis, we identified 159 patients (159 hips) treated with a modified Dunn procedure for SCFE between 1998 and 2020, of whom 97% (155 of 159) had documentation about intraoperatively observed epiphyseal-metaphyseal stability. Of those, 37% (58 of 155) of patients were documented to have intraoperatively observed epiphyseal-metaphyseal discontinuity and were considered eligible for inclusion, whereas 63% (97 of 155) had documented epiphyseal-metaphyseal stability and were excluded. No patients were lost to follow-up before the 2-year minimum. All patients were assessed for survival, but 7% (4 of 58) did not fill out our outcomes score questionnaire. This resulted in 93% (54 of 58) of patients who were available for outcome score assessment. Additionally, 50% (29 of 58) of patients had not been seen within the last 5 years; they are included, but we note that there is uncertainty about their status. The median (range) age at surgery was 13 years (10 to 16), and the sex ratio was 60% (35 of 58) male and 40% (23 of 58) female patients. Sixty-four percent (37 of 58) of patients were classified as acute-on-chronic, and 17% (10 of 58) of patients were classified as acute. Forty-seven percent (27 of 58) of patients presented with severe slips and 43% (25 of 58) of patients with moderate slips based on radiographic classification. All patients underwent surgical hip dislocation with the modified Dunn procedure to correct the slip deformity and provide stabilization. Complications and reoperations were assessed from a review of electronic medical records, and a Kaplan-Meier estimator was used to estimate survivorship free from complications and reoperations at 10 years. Clinical examination results and questionnaire responses were evaluated at minimum 2-year follow-up. Kaplan-Meier survivorship free from AVN was 93% (95% CI 87% to 100%) at 10 years. Survivorship free from any reoperation was 75% (95% CI 64% to 88%) at 10 years. In addition, survivorship free from complications, defined as development of AVN, reoperation, or a Sink Grade II complication or higher, was 57% (95% CI 45% to 73%) at 10 years. The median (range) Merle D'Aubigne Postel score was 18 (14 to 18) for the patients who did not develop AVN, and 12 (6 to 16) for the four patients who developed AVN (p < 0.001). The median modified Harris hip score was 100 (74 to 100) in the non-AVN cohort and 65 (37 to 82) in the AVN cohort (p = 0.001). Median HOOS total score was 95 (50 to 100) in the non-AVN cohort and 53 (40 to 82) in the AVN cohort (p = 0.002). Although the modified Dunn procedure is technically challenging, this study shows that in experienced hands, patients with who have demonstrated epiphyseal-metaphyseal discontinuity can be treated with a low risk of AVN and subsequent surgery. Referral of these patients to specialists who have substantial expertise in this procedure is recommended to improve patient outcomes. Prospective, long-term observational studies will help us identify these high-risk patients preoperatively and determine the long-term success of this procedure. Level IV, therapeutic study.

The shadow side of growth: understanding growth hormone therapy’s role in slipped capital femoral epiphysis

The shadow side of growth: understanding growth hormone therapy’s role in slipped capital femoral epiphysis

Decade-long Trends in Incidence of Slipped Capital Femoral Epiphysis in the United States: A Nationwide Database Analysis of Over 33 Million Patients.

Slipped capital femoral epiphysis (SCFE) is a prevalent pediatric hip disorder linked to severe complications, with childhood obesity as a crucial risk factor. Despite the rising obesity rates, contemporary data on SCFE's epidemiology remain scarce in the United States. This study examined SCFE incidence trends and demographic risk factors in the United States over a decade. A decade-long (2011 to 2020) retrospective cohort study was undertaken using the Healthcare Cost and Utilization Project National Inpatient Sample. Patients aged younger than 18 years were identified and further analyzed if diagnosed with SCFE through ICD-9 or ICD-10 codes. Key metrics included demographics variables, with multivariate regression assessing demographic factors tied to SCFE, and yearly incidence calculated. Of 33,180,028 pediatric patients, 11,738 (0.04%) were diagnosed with SCFE. The incidence escalated from 2.46 to 5.96 per 10,000 children, from 2011 to 2020, mirroring childhood obesity trends. Lower socioeconomic status children were predominantly affected. Multivariate analysis revealed reduced SCFE risk in female patients, while Black and Hispanic ethnicities, alongside the Western geographic location, had an increased risk. This study underscores a twofold increase in SCFE incidence over the past decade, aligning with childhood obesity upsurge. Moreover, SCFE disproportionately affects lower SES children, with male sex, Black and Hispanic ethnicities amplifying the risk. This calls for targeted interventions to mitigate SCFE's effect, especially amidst the vulnerable populations.