Slipped Upper Femoral Epiphysis Research Articles

Slipped Upper Femoral Epiphysis in Adolescents: Evolving Information on Its Mode of Presentation and Management

Background and objective Slipped upper femoral epiphysis (SUFE) is one of the most common hip pathologies in adolescents and pre-adolescents, the diagnosis of which is often missed due to delayed presentations. In this study, we aimed to conduct a retrospective analysis of SUFE cases treated in the hospital during the 15-year period from 2003 to 2018 and examine its bilateral presentation and the need for prophylactic pinning on the unaffected side. Methods This retrospective cohort study involved cases that were treated from 2003 to 2018. The case details were retrieved from the medical records department. Records older than 15 years were excluded owing to their inaccuracy, and 26 cases of SUFE were included in the final analysis. Each case was subjected to physical and radiological examinations of the symptomatic and asymptomatic hips. IBM SPSS Statistics v23 (IBM Corp., Armonk, NY) was used for data analysis. Results In this study, six of the 26 patients had bilateral SUFE and required subsequent surgical pinning. The duration of surgical interventions ranged from two to 22 months, while the mean intervention duration was 10.3 months. Among the cases, 61.5% (p<0.05) were idiopathic in nature upon documentation. However, 19% (p<0.05) of the cases were shown to be associated with an underlying condition or prior symptoms of the condition, whereas 7.6% (p<0.05) had an increased basal metabolic index; 11% (p<0.05) of the cases had an inherited family history of SUFE. A comparison between males and females showed a slightly higher frequency of complications in males (n=14) than in females (n=12) (p=0.556). The age of the patients at the presentation ranged between and 10-15 years, with an average age of 12.5 years. Conclusion Based on our findings, males were affected more than females and most of the cases were idiopathic. There is no significant evidence to support the need for prophylactic pinning of the unaffected hip. We recommend prospective studies with a larger sample of patients to gain more insight into the topic.

Presence and magnitude of anterior physeal separation in slipped upper femoral epiphysis helps identifying those at high risk for avascular necrosis

AimsWe sought to determine if the magnitude of anterior physeal separation (APS) in slipped upper femoral epiphysis was a predictor for the subsequent development of avascular necrosis (AVN). Anterior Physeal Separation (APS) is defined as the distance between the anterior lip of the bony capital epiphysis and the lateral corresponding point of the adjacent bony metaphysis on the Lauenstein radiographic view. It represents hinging of the posterior aspect of the metaphysis with the anterior epiphysis lifting away from its adjacent metaphysis, indicating instability and potential vulnerability of the vessels. Patients and MethodsA retrospective review of all patients treated regionally for slipped upper femoral epiphysis over a 9 year period (2010–2018 inclusive) were identified. Data regarding demographics, radiological parameters and outcomes was recorded. APS was measured on a Launestein radiograph view, with the patient supine, the hip and knee are flexed to 40°, and the hip externally rotated 45°, with film-focus distance of 100 cm. Analysis of the APS was performed to validate a threshold above which AVN occurs. ResultsWe identified 147 hips in 142 patients, of which 5 had bilateral slips at the time of presentation. Average anterior physeal separation was 3.8 ± 1.8 mm, with higher grade slips having significantly greater APS values. Increased APS values were seen with Loder “unstable” slips. Seven hips (4.8%) developed AVN, and in these cases the APS was significantly larger than those who did not (8.5 ± 1.4 Vs 3.9 ± 1.7; p < 0.001). Receiver operator curve analysis demonstrated a critical value of 7.5 mm was associated with a 100% sensitivity and 98.6% specificity for AVN. We identified some grade II/moderate slips with high APS values had similar outcomes to grade III/severe slips, and therefore suggest that APS may serve to alert the surgeon on counselling patients on the risk of developing AVN and to consider strategies to minimise the risk of AVN. ConclusionsAPS is sensitive, specific, accurate and reliable for the association with AVN in SUFE. Its values closely reflect the high AVN rates seen in acute and unstable SUFE. This risk is greatest if the magnitude of APS exceeds the critical value of 7.5 mm.

Identification of musculoskeletal problems using pGALS examination in school going boys in Chennai, India.

ABSTRACTBackground and Aim:pGALS (pediatric Gait Arms Legs Spine) is a useful screening tool in identifying musculoskeletal problems in children. Although musculoskeletal problems are common in children, only a small fraction of them have an underlying serious pathology. There is limited data on this subject from north India but none from south India. Our aim was to identify the prevalence of musculoskeletal problems in school going boys in the local community.Methods:We conducted a prospective cross-sectional study among school boys 7–17 years of age from September 2017 to July 2019, in Chennai. The parents or the boys were asked pGALS screening questions and this was followed by the extended pGALS examination including Beighton’s scoring for hypermobility. If abnormalities in the screening tool were found, the subjects were then referred to a pediatric rheumatologist for further evaluation.Results:A total of 1543 boys were included in this study. Of these 37% of the study group were found to be hypermobile. According to our study, the prevalence of growing pains was 4.6%. Of 2 boys with suspected pathology 1 boy had enthesitis-related arthritis and another had slipped upper femoral epiphysis (SUFE). The estimated prevalence of juvenile idiopathic arthritis (JIA) was 65/100000. According to our study 12.3% of the children were obese.Conclusion:pGALS is a useful tool to screen for musculoskeletal problems in school going boys. The estimated prevalence of JIA was 65/100000. Of them, 37% of the children had hypermobility. Obese children were more likely to complain of musculoskeletal pain (P value 0.00).

Preventing Advanced Stages of Disease in Samoa: A Literature Review

Background: Surgeons are scarce in the Pacific Islands, and improvements to public and primary health care services should reduce the burden of avoidable surgical interventions. Three communicable and non-communicable diseases of public health concern in Samoa are filariasis, childhood overweight/obesity, and Helicobacter pylori (H. pylori)-induced gastric cancer. Strengthening existing public and primary health care strategies for these issues should, in turn, reduce the avoidable surgical burden of Hydrocelectomy for filarial hydrocele, in-situ pinning for Slipped Upper Femoral Epiphysis (SUFE), and endoscopic Esophago-Gastro-Duodenoscopy (EGD) for the differential diagnosis of H. pylori-induced gastric pathologies. This study aimed to perform a literature review of these conditions requiring surgical intervention in the Pacific Islands to contribute recommendations to the current public and primary health care activities in Samoa. Method: A literature review was conducted using the PubMed and ScienceDirect databases. The primary search strategy utilized the terms and keywords “Pacific Islands”; “Filarial Hydrocele”; “SUFE”; “H. pylori-induced gastric pathology”; and their relevant synonyms. Inclusion criteria: the study population were Pacific Islanders residing in the Pacific Islands, and the study investigated presentation, etiology, epidemiology, treatment, and/or management for the three diseases of interest. Articles published before 2000 were excluded. Results: There was only one journal article that met the inclusion criteria. There is virtually no research literature on the current state of these preventable surgical conditions among the population residing in the Pacific Islands. Conclusion: Data are needed to inform evidence-based policy formulation and implementation. The surgical voice should positively contribute to public health efforts.

1071 SUFE and the Internet: Are Healthcare Information Websites Accessible to Parents?

Abstract Background Slipped upper femoral epiphysis(SUFE) is an adolescent hip disorder requiring rapid surgical intervention. Faced with the prospect of their child undergoing surgery, many fearful parents will turn to the internet to provide information and reassurance. Previous studies have shown the orthopaedic information can be difficult to comprehend. Objective Assess the readability of healthcare websites regarding SUFE. Method The term Slipped Upper Femoral Epiphysis was searched in Google, Bing and Yahoo and evaluated using readability software with seven specialised readability tests. A Flesich Read Ease Score (FRES) score above 65 and a Reading Grade Level (RGL) of sixth grade and under was considered acceptable. Results 21 unique websites were assessed. The average FRES was 52.5 +/- 15.4. Only 3 websites scored 65 or higher (14%). There was a statistically significant difference between website scores based on affiliation, with physician websites having the overall highest mean(P = 0.004). The average RGL was 8.67 +/- 1.8. Only two websites met the accepted RGL criteria (9.5%) while five websites were marked as extremely difficult to understand (23.8%). Only five websites offered translations (23.8%). There was no statistically significant difference in readability scores between websites which offered translation and those which did not. One-way t-tests showed that both the RGL (p &amp;lt; 0.001; CI: 1.83-3.49) and the FRES (P &amp;lt; 0.001, CI: -19.4 to -5.4) scores were significantly different from the accepted standard. Conclusions Most websites reviewed were deemed inaccessible. Improving readability would enhance the internet’s usability as a healthcare tool for parents.

Total hip arthroplasty in patients with slipped capital femoral epiphysis: a systematic analysis of 915 cases.

There is limited evidence on the outcomes of Total Hip Arthroplasty (THA) in Slipped Capital Femoral Epiphysis (SCFE) patients. This systematic review aims to evaluate the current literature in terms of survival rate, functional outcomes, complications and types of implants of THA in SCFE patients. Following the established methodology of PRISMA guidelines, PubMed, Cochrane library, ScienceDirect and Ovid MEDLINE were systematically searched from inception to September 2018. The search criteria used were: (“total hip arthroplasty’’ OR ‘’total hip replacement’’ OR “hip arthroplasty’’ OR ‘’hip replacement’’) AND (‘’slipped capital femoral epiphysis’’ OR ‘’slipped upper femoral epiphysis’’ OR ‘’femoral epiphysis’’). Ten studies were finally included in the analysis and were qualitatively appraised using the Newcastle-Ottawa tool. Variables were reported differently between studies. The sample size varied from 12 to 374 THAs. A total of 877 patients undergone 915 THAs. The mean reported follow-up ranged from 4.4 to 15.2 years and the mean patients’ age at the time of THA from 26 to 50 years. Four studies specified the type of implants used, with 62% being uncemented, 24% hybrid (uncemented cup/cemented stem) and 14% cemented. All but three studies reported the mean survival of implants that ranged from 64.9% to 94.8%. A limited number of complications were mentioned. There was a tendency for more favorable functional outcomes in modern studies. Modern THA-studies in SCFE patients showed improvement of survivorship, clinical outcomes and patient satisfaction. Future higher-quality studies are necessary to estimate long-term postoperative outcomes better.

Surgical Hip Dislocation for the Treatment of Slipped Upper Femoral Epiphysis Demonstration of Surgical Technique

Surgical hip dislocation for treatment of hip intra-articular pathology has been popularized by the Bernese group over the last few years. This approach provides excellent and safe exposure of the hip joint without compromising the femoral head blood supply. It is, however a very demanding approach and requires surgical experience and attention to detail.

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

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

Are two views of the pelvis routinely required in the assessment of the limping child?

Introduction: Atraumatic hip pain presenting with a limp is a common clinical problem in children. It is considered a diagnostic challenge to the physician. Objectives: Aim of this study was to assess the sensitivity of a single view of the pelvis in radiographic imaging of a limping child. Methodology : Retrospective analysis of all paediatric pelvic radiographs performed in Great North Children’s Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK from 2004 to 2014 was carried out. 143 cases were recruited, in whom both AP and FL views had been performed at presentation, and a cause for hip pain had been identified based on the radiological report. These 286 radiographs were anonymised and randomly shuffled with 100 age-matched controls (50 AP / 50 frog-lateral) selected from normal radiographs within the same period to avoid bias. The images were independently reviewed by three consultant paediatric radiologists. Results: Perthes/Avascular necrosis (AVN) (n=117) was identified with 94.6% sensitivity on the AP view compared to 94.3% on the frog-lateral view. Sensitivity for Slipped Upper Femoral Epiphysis (SUFE) (n=19) was 75.4% on AP and 100% on frog-lateral. Seven cases of other pathologies were identified with sensitivity of 61.9% on AP and 57.2% on frog-lateral. Conclusion: Frog lateral view is superior to AP view in detection of SUFE and comparable in sensitivity for Perthes to the AP view. We suggest only the frog-lateral view is required in the routine assessment of the limping child.

Vitamin D Deficiency in Slipped Upper Femoral Epiphysis: Time to Physeal Fusion.

Slipped upper femoral epiphysis (SUFE) has an incidence of 1 to 7 per 100,000 adolescents in the United Kingdom and its link with obesity is well established. With an increasing number of pediatric orthopaedic patients presenting with vitamin D deficiency, the aim of our study was to establish the prevalence of vitamin D deficiency in SUFE patients presenting to an orthopaedic department in the United Kingdom and whether a low vitamin D level increases the time to proximal femoral physeal fusion after surgical fixation. A total of 27 pediatric patients, with a female to male ratio of 17:10 and a mean age of 11.5 years (SD=1.99), range 8 to 16 years, presented with a SUFE and their vitamin D level was assessed during the study period, June 2007 to July 2012 (inclusive). The majority of these patients (85.2%) were assessed as vitamin D deficient, with a serum 25-(OH)D<52 nmol/L. The time taken for >50% physeal fusion on anteroposterior radiography after surgical fixation reported in the literature is 9.6 months, with no reported vitamin D deficiency or insufficiency. In our study, the median time to physeal fusion in the vitamin D-deficient and vitamin D-insufficient patients was 25 months (interquartile range, 17 to 43 mo; mean of 29 mo, SD=16.8). A negative correlation was also observed between vitamin D level and the time taken for physeal fusion after surgical fixation. We conclude that a high prevalence of vitamin D deficiency has been observed in our SUFE patients. Comparing the time taken for physeal closure of 9.6 months in the literature with vitamin D-deficient patients, this is prolonged. Indeed, a negative correlation has been shown between vitamin D level and time to physeal fusion. This study highlights the need for regular vitamin D status assessment in SUFE patients to allow early implementation of treatment with vitamin D supplementation. The impact of vitamin D screening and supplementation on SUFE outcomes should be investigated further.

Radiographic Femoroacetabular Impingement Is Common in the Contralateral Hip of Patients Presenting with Unilateral Slipped Upper Femoral Epiphysis

Radiographic Femoroacetabular Impingement Is Common in the Contralateral Hip of Patients Presenting with Unilateral Slipped Upper Femoral Epiphysis

Outcomes following subcapital osteotomy for severe slipped upper femoral epiphysis.

Slipped upper femoral epiphysis (SUFE) is the most common hip disorder to affect adolescents. Controversy exists over the optimal treatment of severe slips, with a continuing debate between in situ fixation versus corrective surgery. We present our experience in a series of 57 patients presenting with severe unilateral SUFE (defined > 50°) managed with a subcapital cuneiform osteotomy. Between 2001 and 2011, 57 patients (35 male, 22 female) with a mean age of 13.1 years (9.6 to 20.3, SD 2.3) were referred to our tertiary referral institution with a severe slip. The affected limb was rested in slings and springs before corrective surgery which was performed via an anterior Smith-Petersen approach. Radiographic analysis confirmed an improvement in mean head-shaft slip angle from 53.8(°) (standard deviation (SD) 3.2) pre-operatively to 9.1(°) (SD 3.1) post-operatively, with minimal associated femoral neck shortening. In total 50 (88%) patients were complication free at a mean follow-up of seven years (2.8 to 13.9 years, SD 3). Their mean Oxford hip score was 44 (37 to 48) and median visual analogue pain score was 0 out of 10 (interquartile range 0 to 4). A total of six patients (10.5%) developed avascular necrosis requiring further surgery and one (1.8%) patient developed chondrolysis but declined further intervention. This is a technically demanding operation with variable outcomes reported in the literature. We have demonstrated good results in our tertiary centre.

The seasonality of slipped upper femoral epiphysis--meta-analysis: a possible association with vitamin D.

We performed a meta-analysis of studies evaluating the seasonality of slipped upper femoral epiphysis (SUFE). In addition we compared the monthly incidences of SUFE at latitudes greater than 40° with the established serum 25-hydroxyvitamin levels for children resident at a comparative latitude. In total 11 relevant studies were identified, involving 7451 cases of SUFE. There was significant variation in the month of onset of SUFE. The degree of variability increased with increasing latitude. The modal month of symptomatic onset was dependent upon latitude. At latitudes greater than 40°, the most common month of onset was August. At latitudes between 20° and 40°, this was earlier in the calendar year, around April. The seasonal variability was statistically significant (p<0.0001 and p<0.005 for latitudes >40° and 20°-40° respectively). The pattern of monthly fluctuation in onset of SUFE very closely mirrored the monthly pattern of variation for serum 25-hydroxyvitamin D3. There was a very strong positive correlation (Spearman rank rho = + 0.8, p = 0.001). There is a monthly variation in incidence of SUFE. The degree of variability increases with increasing latitude. There may be an association with vitamin D. We hypothesise that elevated serum 25-hydroxyvitamin D3 accelerates growth thus rendering the growth plate vulnerable to slippage in analogous manner to the pubertal growth spurt.

Slipped upper femoral epiphysis: a rare clinical manifestation of MEN2: a case report

Slipped upper femoral epiphysis: a rare clinical manifestation of MEN2: a case report

The child with joint pain in primary care.

Joint pains are a common reason for children to present to primary care. The differential diagnosis is large including some diseases that do not primarily affect the musculoskeletal system. Although the cause for many patients will be benign and self-resolving, in rare cases the diagnosis is associated with long-term morbidity and mortality if not detected early and appropriately treated. These include primary and secondary malignancies, septic arthritis, osteomyelitis, inflammatory arthritis, slipped upper femoral epiphysis (SUFE) and non-accidental injury. We highlight the importance of a thorough history and directed yet comprehensive examination. A diagnostic algorithm is provided to direct primary care physicians' clinical assessment and investigation with the evidence base where available. In many cases, tests are not required, but if there is suspicion of malignancy, infection or inflammatory conditions, laboratory tests including full blood count, blood film, erythrocyte sedimentation rate, C-reactive protein and lactate dehydrogenase help to support or exclude the diagnosis. Autoimmune tests, such as antinuclear antibodies and rheumatoid factor, have no diagnostic role in juvenile idiopathic arthritis; therefore, we advise against any form of 'rheumatological/autoimmune disease screen' in primary care. Imaging does have a place in the diagnosis of joint pains in children, with plain radiographs being most appropriate for suspected fractures and SUFE, whilst ultrasound is better for the detection of inflammatory or infective effusions. The appropriate referral of children to paediatric rheumatologists, oncologists, orthopaedic surgeons and the emergency department are discussed.

Slipped upper femoral epiphysis: Outcome after in situ fixation and capital realignment technique

Slipped upper femoral epiphysis: Outcome after in situ fixation and capital realignment technique

Reslip of a Previously Fixed Slipped Upper Femoral Epiphysis with an Associated Vitamin D Deficiency

Slipped upper femoral epiphysis (SUFE) is a relatively common adolescent hip disorder that represents a biomechanical instability of the proximal femoral growth plate. A link between vitamin D deficiency and SUFE has emerged in recent years; however, we present a unique case of a 10-year-old girl who presented with a reslip of a previously fixed SUFE with an associated vitamin D deficiency.

Hardware complications related to the surgical fixation of slipped capital femoral epiphyses.

Slipped upper femoral epiphysis is a disabling condition with an annual incidence of 2-13 per 100,000. In situ surgical fixation is the preferred initial treatment for both stable and unstable slipped capital femoral epiphysis (SCFE) cases. The main aim is to avoid further slippage and complications such as osteonecrosis and chondrolysis. The choice of medical implants in managing this condition has changed along the years from large nail-like devices to cannulated screws. The biomechanical properties of different fixation techniques have been studied. All implants have been associated with complications that can occur intraoperatively as well as in the early and late postoperative periods. This report examines a number of different implants used and identifies complications and ways on how to avoid such complications. It also looks at the complications directly related to medical implants in the management of SCFE. We looked at published literature in peer-reviewed journals describing the use of the different medical implants and the documented complications. We also examined literature that suggests ways on how to avoid and manage these complications. A review of the current literature is presented in this text.

Gait kinematics and radiographic deformity following slipped upper femoral epiphysis

Introduction: Slipped upper femoral epiphysis (SUFE) results in hip deformity and femoro-acetabular impingement (FAI). FAI affects hip motion and impacts on gait. The purpose of this study was to quantify the effects of moderate to severe SUFE on 3D gait kinematics and to determine if there were correlations between gait deviations and slip severity. Patients/materials andmethods: Patients referred to the Royal Children’s Hospital for a 3D gait analysis (3DGA) between 2000 and 2009 after pinning in situ of a stable SUFE were studied retrospectively. Inclusion criteria were unilateral SUFE, Southwick Lateral Slip Angle (LSA)≥30◦, [1], no surgical complications, appropriate hip and pelvis radiology and 3DGA. 3DGA was performed with a Vicon motion system (OMG, UK) and followed the Plug in Gait (VICON, UK) protocol. Gait variable score (GVS) and Gait profile score (GPS) [2], were calculated on the study cohort for both the sound and slipped side, compared to 38 paediatric subjects with no gait pathology (NGP), using t-test with unequal variances ( =0.05) in Minitab (Minitab, Inc., USA). Results:30Patients (17Male, 13 Female),with an average age at pinning of 13.3 years (±1.9 years) were included. The average LSA, Klein’s line offset and alpha angle of Noztli were 45.3◦ (±13.0◦), −6.4mm (±8.0mm) and 113.6◦(±13.1◦) respectively. The GPS and all GVS, except pelvic tilt (sound and slip side) and foot progression (sound side), were significantly different compared to the NGP group. Hip rotation and foot progression GVSs as well as GPS were significantly different between the slipped and sound sides. However, no significant correlations were found between GVSs and the radiological measurements.

Correlation of radiological outcome and gait function of SCFE patients after growth arrest

Introduction: Slipped upper femoral epiphysis (SUFE) results in hip deformity and femoro-acetabular impingement (FAI). FAI affects hip motion and impacts on gait. The purpose of this study was to quantify the effects of moderate to severe SUFE on 3D gait kinematics and to determine if there were correlations between gait deviations and slip severity. Patients/materials andmethods: Patients referred to the Royal Children’s Hospital for a 3D gait analysis (3DGA) between 2000 and 2009 after pinning in situ of a stable SUFE were studied retrospectively. Inclusion criteria were unilateral SUFE, Southwick Lateral Slip Angle (LSA)≥30◦, [1], no surgical complications, appropriate hip and pelvis radiology and 3DGA. 3DGA was performed with a Vicon motion system (OMG, UK) and followed the Plug in Gait (VICON, UK) protocol. Gait variable score (GVS) and Gait profile score (GPS) [2], were calculated on the study cohort for both the sound and slipped side, compared to 38 paediatric subjects with no gait pathology (NGP), using t-test with unequal variances ( =0.05) in Minitab (Minitab, Inc., USA). Results:30Patients (17Male, 13 Female),with an average age at pinning of 13.3 years (±1.9 years) were included. The average LSA, Klein’s line offset and alpha angle of Noztli were 45.3◦ (±13.0◦), −6.4mm (±8.0mm) and 113.6◦(±13.1◦) respectively. The GPS and all GVS, except pelvic tilt (sound and slip side) and foot progression (sound side), were significantly different compared to the NGP group. Hip rotation and foot progression GVSs as well as GPS were significantly different between the slipped and sound sides. However, no significant correlations were found between GVSs and the radiological measurements.