Severe Severe Slipped Capital Femoral Epiphysis Research Articles

Modified trochanteric triplane osteotomy for chronic moderate to severe slipped capital femoral epiphysis - a preliminary report.

Management of chronic moderate and severe slipped capital femoral epiphysis (SCFE) remains controversial. We propose that the modified trochanteric triplane osteotomy(MTTO) with a 1300 angled blade plate, without removal of bone wedge, is effective for addressing moderate and severe chronic SCFE. A retrospective review was performed on patients who underwent MTTO for moderate to severe chronic SCFE, with at least two years follow-up. Radiological outcomes assessed were osteotomy union, alpha angle, neck shaft angle, mechanical axis deviation and limb length discrepancy(LLD). Functional outcomes were assessed using modified Harris hip score, lower extremity functional scale (LEFS) and SF-36 questionnaire. A total of 11 patients (13 hips) underwent MTTO for chronic SCFE, with a mean age of 12.9 ± 2.1 years. The pre-operative median modified Harris Hip Score was 73. 12 had severe slip and one had moderate slip. All the osteotomies went on to unite by two months. At an average of 37 months follow up, the mean neck shaft angle was 1290, mean alpha angle was 69.70, and mean LLD was 1.05cm. There was significant improvement in the post-operative modified Harris hip score (p < 0.001), the median post-operative modified Harris hip score was 96, and the median LEFS was 78. One case had bone scan evidence of AVN, but did well with bisphosphonate therapy and one case had a superficial infection. MTTO is a safe and effective option for addressing deformities in chronic moderate and severe SCFE. However, a residual proximal femoral Cam deformity persists after this procedure which may need to be treated with a simultaneous or a staged osteochondroplasty.

Do Osteochondroplasty Alone, Intertrochanteric Derotation Osteotomy, and Flexion-Derotation Osteotomy Improve Hip Flexion and Internal Rotation to Normal Range in Hips With Severe SCFE? - A 3D-CT Simulation Study.

Severe slipped capital femoral epiphysis (SCFE) leads to femoroacetabular impingement and restricted hip motion. We investigated the improvement of impingement-free flexion and internal rotation (IR) in 90 degrees of flexion following a simulated osteochondroplasty, a derotation osteotomy, and a combined flexion-derotation osteotomy in severe SCFE patients using 3D-CT-based collision detection software. Preoperative pelvic CT of 18 untreated patients (21 hips) with severe SCFE (slip-angle>60 degrees) was used to generate patient-specific 3D models. The contralateral hips of the 15 patients with unilateral SCFE served as the control group. There were 14 male hips (mean age 13±2y). No treatment was performed before CT. Specific collision detection software was used for the calculation of impingement-free flexion and IR in 90 degrees of flexion and simulation of osteochondroplasty, derotation osteotomy, and combined flexion-derotation osteotomy. Osteochondroplasty alone improved impingement-free motion but compared with the uninvolved contralateral control group, severe SCFE hips had persistently significantly decreased motion (mean flexion 59±32 degrees vs. 122±9 degrees, P <0.001; mean IR in 90 degrees of flexion -5±14 degrees vs. 36±11 degrees, P <0.001). Similarly, the impingement-free motion was improved after derotation osteotomy, and impingement-free flexion after a 30 degrees derotation was equivalent to the control group (113± 42 degrees vs. 122±9 degrees, P =0.052). However, even after the 30 degrees derotation, the impingement-free IR in 90 degrees of flexion persisted lower (13±15 degrees vs. 36±11 degrees, P <0.001). Following the simulation of flexion-derotation osteotomy, mean impingement-free flexion and IR in 90 degrees of flexion increased for combined correction of 20 degrees (20 degrees flexion and 20 degrees derotation) and 30 degrees (30 degrees flexion and 30 degrees derotation). Although mean flexion was equivalent to the control group for both (20 degrees and 30 degrees) combined correction, the mean IR in 90 degrees of flexion persisted decreased, even after the 30 degrees combined flexion-derotation (22±22 degrees vs. 36 degrees±11, P =0.009). Simulation of derotation-osteotomy (30 degrees correction) and flexion-derotation-osteotomy (20 degrees correction) normalized hip flexion for severe SCFE patients, but IR in 90 degrees of flexion persisted slightly lower despite significant improvement. Not all SCFE patients had improved hip motion with the performed simulations; therefore, some patients may need a higher degree of correction or combined treatment with osteotomy and cam-resection, although not directly investigated in this study. Patient-specific 3D-models could help individual preoperative planning for severe SCFE patients to normalize the hip motion. III, case-control study.

OSTEOTOMY AT THE BASE OF FEMORAL NECK AND OSTEOPLASTY FOR THE TREAMENT OF SCFE.

To compare the clinical outcomes between patients with moderate and severe slipped capital femoral epiphysis (SCFE) treated with osteotomy at the base of neck and osteoplasty and with healthy individuals. Comparative cohort with 12 patients (14 hips) with moderate and severe SCFE who underwent osteotomy at the base of neck and osteoplasty between 2007 and 2014. The mean age at surgery was 13.3 ± 2.5 years and the mean follow-up was 3.8 ± 2.2 years. We assessed the level of hip pain by the visual analog scale (VAS) and anterior impingement test (AIT); the level of function using the Harris Hip Score (HHS) and 12-Item Short Form Health Survey (SF-12), the range of motion (ROM) by goniometry and Drehmann sign, and the hip muscular strength by isokinetic and Trendelenburg sign. The level of pain was slightly higher in the SCFE cohort compared with healthy hips (VAS, 0.8 ± 1.4 vs 0 ± 0, 0.007; AIT, 14% vs 0%, p = 0.06; respectively). No differences were observed between the SCFE and control cohort for the functional scores (HHS, 94 ± 7 vs 100 ± 1, p = 0.135); except for ROM, with increased internal rotation (37.3º ± 9.4º vs 28.7º ± 8.2º, p < 0.001), and strength, with decreased abduction torque (75.5 ± 36.9 Nm/Kg vs 88.5 ± 27.6 Nm/Kg, p = 0.045) in the SCFE cohort. The osteotomy at the base of neck and the osteoplasty restored the hip motion and muscle strength, except for the abductor strength, to near normal levels, representing a viable option for the treatment of moderate and severe SCFE. Level of Evidence III, Ambidirectional Cohort Study.

Comparison between anterior cuneiform osteotomy and Dunn procedure in the surgical management of unstable severe slipped femoral epiphysis: A case-control study of 41 patients

BackgroundThere is little consensus on the best treatment algorithm for unstable severe slipped capital femoral epiphysis (SCFE). Subcapital osteotomy, which is one of the surgical options, is performed either anteriorly (anterior cuneiform osteotomy, CO) or laterally with trochanteric osteotomy (Dunn procedure, DP). The CO is technically easier and decreases operating time. Moreover, because the DP was the standard in our department before it was replaced by the CO, we had a series of consecutive patients. Therefore, we did a retrospective case-control study in unstable, severe SCFEs treated by CO versus DP, which is to our knowledge the first one aiming to compare: (1) postoperative complications and in particular avascular necrosis, (2) functional outcome, (3) radiologic findings. HypothesisCO is less or just as likely to cause avascular necrosis and has the same clinical and radiologic findings as DP. MethodsA total of 41 patients (24 girls, i.e. 58.5%) were included between 2005 and 2018: 23 in the CO group and 18 in the DP group. The median age was 12.9 years (range, 11.5–14.9) and the median slip angle 70̊ (range, 62.5̊–80̊) with a median follow-up of 3 years (range, 2–4). Preoperative, intraoperative, and postoperative clinical and radiologic parameters (Southwick and alpha angles, and femoral head-neck offset) were analyzed, and all complications were documented. ResultsTwo (8.7%) cases of avascular necrosis were reported in the CO group and 6 (33.3%) in the DP group (p=.11), with an overall rate of avascular necrosis of 19.5% (8/41). Five out of the 41 patients (12.2%) underwent a total hip arthroplasty: 1/23 (4.3%) in the CO group and 4/18 (22.2%) in the DP group (p=.16). Two (9.5%) patients in the CO group and 7 (38.9%) in the DP group developed postoperative limping before any arthroplasty was performed (p=.055). The alpha angle at follow-up (54±6.1̊ vs. 59.1±7.2̊; p=.027), Oxford hip score at follow-up (17/60 [range, 14–20] vs. 23.5 [range, 19–27]) (p=.021), operating time (132 min [range, 103–166] vs. 199.5 min [range, 142–215]) (p=.011) and intraoperative bleeding (250 mL [range, 100–350] vs. 300 mL [range, 197–450]) (p=.088) were more favorable in the CO group than in the DP group. ConclusionsThe CO has similar results to DP in the surgical management of unstable severe SCFE. Level of evidenceIII; retrospective comparative study.

Is anterior subcapital shortening osteotomy a reliable and reproducible technique in the treatment of severe slipped capital femoral epiphysis?

IntroductionProximal femoral shortening osteotomies are becoming the treatment of choice for severe slipped capital femoral epiphysis (SCFE) to reduce the risk of femoroacetabular impingement. The reported rates of complication seem reasonable, but these are single-operator series with surgeons highly experienced in this technique. The purpose of this study was to assess how surgeon experience impacted the outcomes of anterior subcapital shortening osteotomy (ASSO) in severe SCFE. HypothesisThe hypothesis was that ASSO is a reproducible technique that is accessible to junior surgeons. Materials and methodsAll ASSOs performed for severe SCFE (slipangle > 40°) between 2015 and 2019 were retrospectively reviewed. All osteotomies were performed by surgeons with less than 4 years’ experience (senior residents), who were trained by a senior surgeon experienced in this technique (Group 1). The incidence of femoral head avascular necrosis (AVN) and complications were analyzed and compared to a historical control cohort (Group 2). ResultsA total of 62 SCFEs (37 unstable and 25 stable) were analyzed. Both groups had similar demographic data and SCFE characteristics. The mean operative times were statistically comparable in both groups. The rates of AVN in unstable SCFEs and in the overall series were comparable in both groups (18.9% vs. 13.3%, p=.55 and 12.9% vs. 9.7%, p=.6). These rates were comparable in the stable forms (4.0% vs. 5.4%; p=1). However, the preoperative MRI in Group 1 showed that 42.8% of unstable hips that developed AVN were already hypoperfused before surgery. The overall rate of complication showed no significant difference between the 2 groups (26% vs. 17%, p=.16). DiscussionAlthough ASSO is a technically demanding procedure, it is reliable and reproducible. The main risk factor for developing AVN remains the unstable nature of SCFE and not the surgeon's experience. It can be performed by trained junior surgeons, but not in an emergency setting, with the possibility of assistance from a more experienced surgeon. Level of evidenceIV; retrospective case study.

Subcapital Shortening Osteotomy for Severe Slipped Capital Femoral Epiphysis: Preliminary Results of the French Multicenter Study.

There is growing evidence that symptomatic femoroacetabular impingement (FAI) can develop after severe slipped capital femoral epiphysis (SCFE) fixed in situ. Realignment procedures have therefore gained popularity, but complication rates remain controversial. Among them, the subcapital shortening osteotomy without hip dislocation has been progressively adopted in France, but results have never been assessed to date. All cases performed in 23 French university hospitals between January 2010 and March 2014 were reviewed to (1) describe the surgical procedure, (2) assess the radiologic and functional outcomes, and (3) report complications and more specifically the avascular necrosis rate (AVN) according to initial stability. Stable and unstable SCFE were distinguished following Loder's definition. Radiologic outcomes were assessed by the 3 authors to determine FAI and osteonecrosis rates. Functional outcomes were evaluated at follow-up and complications were reported. A total of 82 cases (45 unstable and 37 stable), performed in 10 institutions, were included with a mean follow-up of 25 months. No intraoperative complication occurred but 2 patients (2.4%) underwent unplanned early revision. Slip angle was significantly reduced (87%) without loss of correction. Overall AVN rate was 9.7%, reaching 13.3% in unstable slips. However, preoperative magnetic resonance imaging showed that most of the unstable epiphyses (4/6) were already hypoperfused before surgery. The procedure is a reliable option for the treatment of severe SCFE. AVN rates are lower than previously reported in multicenter series of modified Dunn technique, especially in unstable slips. However, the risk of AVN in severe stable SCFE (5.4%) must still be balanced with the functional outcomes of potential future FAI. Level IV-therapeutic study.

Comparison between modified Dunn procedure and in situ fixation for severe stable slipped capital femoral epiphysis

Background and purpose — The best treatment option for severe slipped capital femoral epiphysis (SCFE) is still controversial. We compared clinical and radiographic outcomes of modified Dunn procedure (D) and in situ fixation (S) in severe SCFE.Patients and methods — We retrospectively compared D and S, used for severe stable SCFE (posterior sloping angle (PSA) > 50°) in 29 patients (15 D; 14 S). Propensity analysis and inverse probability of treatment weights (IPTW) to adjust for baseline differences were performed. Patients were followed for 2–7 years.Results — Avascular necrosis (AVN) occurred in 3 patients out of 15, after D, causing conversion to total hip replacement (THR) in 2 cases. In S, 1 hip developed chondrolysis, requiring THR 3 years after surgery. 3 symptomatic femoroacetabular impingements (FAI) occurred after S, requiring corrective osteotomy in 1 hip, and osteochondroplasty in another case. The risk of early re-operation was similar between the groups. The slippage was corrected more accurately and reliably by D. The Nonarthritic Hip Score was similar between groups, after adjusting for preoperative and postoperative variables.Interpretation — Although D was superior to S in restoring the proximal femoral anatomy, without increasing the risk of early re-operation, some concern remains regarding the potential risk of AVN in group D.

The Modified Dunn Osteotomy for SCFE: Clinical and Radiographical Results at 3 Years Follow-Up

AbstractThe modified Dunn osteotomy (MDO) gained popularity for the treatment of moderate-to-severe SCFE over the past years, even though both indications and outcomes are currently debated. The aim of this study is to evaluate results and complications of MDO consecutively performed at a single institution for severe slipped capital femoral epiphysis (SCFE) (slip angle ≥ 60°). In this retrospective clinical study, 23 hips (22 patients) were treated with MDO (2009–2015). SCFE was classified according to stability, slip angle, and as chronic/acute. Clinical assessment was performed with clinical examination and nonarthritic hip score (NAHS), modified Harris hip score (mHHS), and short form 12 (SF-12) outcome scores. Residual deformity, avascular necrosis (AVN), and osteoarthrosis (OA) were measured on plain radiographs. The mean slip angle was 70° (range 60–90); 17 of 23(74%) patients had a chronic SCFE, 6 of 23(26%) had acute-on-chronic SCFE, and 1 of 23(4%) had an unstable SCFE. The mean age at surgery was 14 years (range 11–17). At 3 years follow-up (range 1–7), 4 of 23(17%) patients had an AVN or AVN progression, one of these needing a hip arthroplasty. All the cases of AVN or AVN progression were diagnosed within the first year after surgery and there was an association between AVN and operation date (with more AVN among patients operated earlier). Out of 23 patients, 2 (9%) had an implant mobilization or failure and needed a revision surgery without further complications, 1 (4%) developed an asymptomatic heterotopic calcification, and another a partial implant removal without clinical consequence. At follow-up, the slip angle was 9° (range 1–15) and outcome scores were improved. MDO is a demanding technique which allows a near anatomical correction of SCFE and the overall complication rate is not negligible. With actual data, the authors only recommend this procedure for specialized centers, performed by experienced high-volume surgeons, and for severe displaced SCFE (≥50°). The long-term results must be closely monitored and compared with the natural history and other treatment options. This study was a Level IV retrospective study in a case series.

Late correction of neck deformity in healed severe slipped capital femoral epiphysis: short-term clinical outcomes.

Contemporary methods for the management of neck deformity following a healed severe slipped capital femoral epiphysis (SCFE) include subcapital neck osteotomy. 18 patients with chronic severe SCFE in the oblique plane (mean slip angle = 70°) constituted the study group. 6 patients with an open physis underwent modified Dunn capital realignment and 12 patients with a closed physis underwent surgical dislocation with a corrective neck osteotomy. 10 patients already had an in-situ pinning. The mean follow-up was 4.5 years (3-6 years). The mean preoperative modified Harris Hip Score (mHHS) and nonarthritic hip score (NAHS) were 24 and 40 respectively, followed by a score of 89 and 92 respectively at the last follow-up (p = 0.0002). Radiologically, all the parameters showed a significant correction. The mean pre- and postoperative values of alpha angle were 79.8 and 34.5 respectively (p = 0.0002); AP slip angle being 36.7 and 14.8 (p = 0.002); lateral slip angle being 54.2 and 13.6 (p = 0.0002); oblique plane slip angle being 70.7 and 20.8 (p = 0.0002) and centre trochanter distance being -6.9 and 1.2 (p = 0.002). The major complications seen were nonunion of the neck osteotomy (n = 1/12) and chondrolysis (n = 1/6) in the modified Dunn's group. The overall complication rate was 11%. There was no statistically significant difference in outcome between the 2 groups clinically and radiologically. Femoral neck osteotomy is a potentially rewarding technique to correct severe neck deformities and restoring hip function in the short term.

Severe slipped capital femoral epiphysis: A French multicenter study of 186 cases performed by the SoFOP

IntroductionThe treatment of severe slipped capital femoral epiphysis (SCFE) remains controversial. Despite numerous treatments being available, the outcome of published studies has been variable. Recent studies emphasize that poor reduction of the severe SCFE is responsible for the appearance of joint cartilage lesions and progression towards early osteoarthritis. But surgical reduction of severe SCFE also results in a significant rate of necrosis. ObjectiveEvaluate the results of various treatment strategies for severe SCFE and identify the optimal course of action. Material and methodsThis was a French multicenter retrospective study of severe SCFE cases (>45° displacement) evaluated a minimum of 12months after treatment. The stability of the slipped epiphysis, type of the treatment, delay before treatment, early and short-term complications, Harris and WOMAC functional scores and radiological signs of femoroacetabular impingement (FAI) at the last review were evaluated. A total of 186 cases of severe SCFE in 182 patients were included. One hundred and seven (58.7%) of these were male. The average age was 13years. The average follow-up was 23months. The average displacement was 60°. The SCFE was considered stable in 94 cases (50.5%) and unstable in 92 cases (49.5%). The main surgical treatments used by the various centers were in situ fixation (ISF), lateral Dunn, anterior Dunn and reduction using traction or under anesthesia (for unstable forms). ResultsIn the stable SCFE cases, there were 6 cases of necrosis (6.4%), all of which occurred after reduction by osteotomy; there were 32 cases of radiological FAI (34%), 30 of which occurred after ISF. The necrosis rate in the unstable SCFE cases was 21.7%: one (11%) after ISF, seven (19%) after anterior Dunn, eight (21%) after preoperative reduction and three (43%) after lateral Dunn. ConclusionsThe results of this study confirm the diverse nature of SCFE treatments available and the variability of their results. When selecting a treatment for severe SCFE, the goal is to stop the slip and also to prevent osteoarthritis by correcting the hip deformities. The “anterior” Dunn procedure was able to achieve these two goals, while having a lower complication rate than the other reduction techniques. Level of evidenceIV.

Results of surgical treatment for moderate or severe slipped capital femoral epiphysis through the approach of surgical hip dislocation

To evaluate the results of surgical treatment for moderate or severe slipped capital femoral epiphysis (SCFE) using modified Dunn procedure through the approach of surgical hip dislocation at the interval of minimum 12 months follow-up. From November 2011 to June 2013, 6 patients (7 hips) with SCFE were treated in department of pediatric orthopedics, Hospital Affiliated to Shanghai Jiaotong University School of Medicine, they all had trauma history. The patients were aged from 10-15 years, mean 13.6 years. The duration of symptoms ranged from 4 to 35 days, average 14.2 days. The degree of slip was averagely 45% (25%-55%). In 6 patients (except right side of 1 case was treated in situ with cannulated screws) were surgically treated using modified Dunn procedure through the approach of surgical hip dislocation. Postoperatively the brace was used for immobilizing the hip for 4 weeks, then 4 weeks of bed traction combined with rehabilitation program of hip joint activity. Eight weeks later, the gradual touchdown weight bearing was being allowed. The follow-up time ranged from 12 to 30 months, average 23.8 months. Six patients have been able to walk without crutches, no obvious limp. X-ray film showed femoral epiphysis line on the bit of good recovery, no appearance of avascular necrosis of the femoral head, joint space was normal. The Harris score of hip evaluation was 94.7 averagely, ranging 85-100, at the time of last follow-up. Application of surgical treatment for moderate or severe SCFE with open reduction through the approach of surgical hip dislocation is a valid alternative method. The femoral head epiphysis can be capable of restoring anatomy, at present no case occurred avascular necrosis, and patients are satisfied with the function of the hip joint.

Extracapsular Base of Neck Osteotomy Versus Southwick Osteotomy in Treatment of Moderate to Severe Chronic Slipped Capital Femoral Epiphysis

The aim of this study was to evaluate the results of extracapsular base of neck osteotomy and Southwick osteotomy from clinical and radiologic points of view. This retrospective study included 35 hips in 33 patients who presented with moderate to severe slipped capital femoral epiphysis (SCFE) between 1995 and 2001. These patients were divided into two groups according to the type of osteotomy: group A patients (n = 15) were treated by extracapsular base of neck osteotomy and group B patients (n = 18) were treated by modified Southwick osteotomy. Follow-up averaged 3.5 years (range 1-6 years). Clinical and radiologic evaluations were done before and after surgery. All patients were finally evaluated according to the modified Southwick criteria. Group A had 86.7% satisfactory results; group B had 90% satisfactory results. There was no statistically significant difference between the type of osteotomy and the final outcome. The authors believe that both types of osteotomy are equally safe and effective procedures, with minimal risks of avascular necrosis and chondrolysis, in the treatment of moderate to severe chronic SCFE.

Role of osteotomy in the treatment of slipped capital femoral epiphysis.

The treatment of severe slipped capital femoral epiphysis (SCFE) remains problematic. Treatment of most mild and moderate cases has been simplified, not by our increasing knowledge of physiology or molecular genetics, but by the advances in radiographic imaging, metallurgy, and the development of cannulated screw technology. Most centers agree that the placement of a single pin or screw across the center of the epiphysis, stabilizing the unreduced epiphysis and keeping the implant out of the joint space until physeal closure is achieved, is the most efficient and effective method for the majority of slips. Despite this knowledge and improvement in early results, the problems of avascular necrosis and chondrolysis have not been eliminated. Of more concern for patients whose severe unreduced SCFE has been pinned in situ is the secondary problem of the altered biomechanics of the lower extremity, leaving the hip in extension, the limb externally rotated and shortened. Most series show poor long-term results of realignment osteotomies; however, most series also show poor long-term results of severe slips treated by any means. These population groups are historically the same. Current radiographic imaging and implant design may eliminate most of the technical problems encountered with the accuracy and stability of realignment osteotomies, thereby allowing earlier motion, which may improve our results. The current status of realignment osteotomies is reviewed.

Anterolateral approach for moderate to severe slipped capital femoral epiphysis.

The efficacy of the anterolateral pinning of moderate and severe slipped capital femoral epiphysis (SCFE) was studied both mechanically and clinically. The mechanical stability of anterolateral pinning was equivalent to that of conventional lateral pinning as shown by study in 16 immature porcine hips. The clinical results in the group pinned from the anterolateral approach were superior in that fewer complications occurred as compared with the traditional lateral approach. The group with anterolateral pinning had 2 complications in 13 hips, whereas lateral pinnings resulted in 8 complications in 28 hips. We recommend the anterolateral approach rather than the conventional lateral approach in pinning of moderate and severe SCFE.