SLIPPED CAPITAL FEMORAL EPIPHYSIS

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SLIPPED CAPITAL FEMORAL EPIPHYSIS

• Joseph E. Burkhardt D.O.
• Garden City Hospital, 1999

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DEFINITION

• SCFE misnomer
• Femoral head held securely in acetabulum, while
  the femoral neck displaces anteriorly
• Retroversion deformity of proximal femur
• Femoral neck ant. sup. ext. rot
• Epiphysis post. inf.

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EPIDEMIOLOGY

• Incidence 2100,000 annually in U.S.
• Low 0.2 100,000 East Japan
• High 10.8100,000 U.S.
• Related to Puberty
• -Males 10-16yrs (AVE 13.5)
• -Females 10-14yrs (AVE 11.5)
  

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EPIDEMIOLOGY

• Children who present outside age range
  endocrine disorder or systemic disorder
• a. Primary hypothyroidism
• b. Secondary hypothyroidism
• c. Panhypopituitarism
• d. Hypogonadal conditions
• e. Renal osteodystrophy

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EPIDEMIOLOGY

• Male predilection 2.41
• Left hip affected twice as often as right
• Increased incidence in African Americans
• Definite association with obesity
• a. wt. for age profiles 49 in 95th -ile
• b. wt. for height profiles 90th percentile
  in 73
• boys and 52 girls affected

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EPIDEMIOLOGY

• 25 bilateral symptomatic involvement
• -50 present with bilateral involvement
• -50 show sequential onset
  
• Second slip generally present 12 mos. 77 pts and
  18 mos in 80 pts
• High incidence males, African-Americans,
  obese pts

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PATHOANATOMY

• Femoral head rotates posteriorly around axis of
  the femoral neck
• Slip known to traverse mainly zone of hypertrophy
• Physeal plate widened (2x normal)
• Hypertrophic zone generally 15-30 width of
  physeal plate, in scfe can be 80 width

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STABILITY OF PHYSIS

• PERICHONDRAL RING
• -Thins during growth
• -decrease in sheer strength
• PHYSEAL PLATE
• -Increase GH gt decrease strength
• -Widened Physis
• HORMONES
• -Estrogen (increase strength)
• -Balance of GH and SH

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ETIOLOGY

• True etiology remains unknown
• Likely result of multiple factors which affect a
  weakened physeal plate
• gt greater than normal shear stresses
• gt trauma usually minor/torsional
• gt changes in bone geometry

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CLINICAL PRESENTATION

• Hip/groin pain, worse with walking
• Knee pain obturator n. sensory distribution
• Loss of IR at the hip, loss of flex. abd. also
  common, abductor lurch
• If stable slip antalgic gait, leg ER
• Unstable slip unable to walk/bear wt. even with
  crutches.
• Howorth sign Flex hip, leg ER abduct

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TRADITIONAL CLASSIFICATION

• 1. Preslip episodic limp, limb weakness,
  
• mild pain with rotation
• 2. Acute slip sudden onset of pain that
• prevents walking
• 3. Chronic slip gradual onset of pain over
• period of greater than three weeks
• 4. Acute-on-chronichx pain gt 3wks with
• sudden exacerbation that precludes
• walking

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CLASSIFICATION LODER

• Slips divided into stable or unstable
• Stable able to walk
• Unstable could not bear wt. Even with crutches
• This classification better correlates with
  prognosis
• gt Loder et al. reported 96 satisfactory
  results with stable hips and 47 unstable

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RADIOGRAPHIIC FEATURES

• AP pelvis, true lateral bilateral hips
• Physeal plate widened
• Irreg. decrease in ephiphyseal height
• Blanch sign of Steel
• Kleins line
• Loss of lateral overhang of epiphysis

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KLEINS LINE
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RADIOGRAPHIC MEASUREMENTS

• Displacement of epiphysis/neck diameter
• - 1/3 slight
• - 1/2 moderate
• - gt 1/2 severe
• Southwick angle
• - lt 30 Mild
• - 30 - 60 Mod.
• - gt 60 severe

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TREATMENT GOALS

• Most important first do no harm
• Priorities
• 1. Avoid avascular necrosis
• 2. Avoid chonrolysis
• 3. Prevent further slip
• 4. Correct deformity
• Progressive gradual slip is the rule

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BLOOD SUPPLY TO FEMORAL HEAD

• Ligamentum teres (centrally)
• Inferior metaphyseal (ant.inf)
• Lateral epiphyseal vessels (post.sup)
• Lateral epiphyseal gt outer 2/3 of the fem. head
• Crucial to avoid pin placement in postsup quad

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NATURAL HISTORY

• DJD develops in hips with displaced slipped
  capital femoral epiphysis
• AVN is very rare
• Untreated SCFE can progress to a severe degree,
  progression of the slip is the rule
• Natural history is favorable provided
  displacement is minimal and remains so.

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TREATMENT OPTIONS

• NONOPERATIVE
• -Bucks traction, spica cast 12 weeks
• -Associated with AVN
• OPERATIVE
• -Pinning in situ
• -Open epiphysiodesis
• -Osteotomy (after 6 months)

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SCFE TREATMENT STABLE/UNSTABLE

• STABLE - PIN IN SITU
• -One screw, center of head on AP/Lat.
• -Reduction not recommended
• UNSTABLE
• -Timing lt 24 hrs vs gt24 hrs
• -Gentle reduction by positioning extremity
• -one screw center of head on AP/Lat.
• -Some recommend two screws
• -NWB with crutches until painless ROM

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SCFE - ACUTE

• Pin in situ, one screw
• Timing lt 24 hrs,
• Gentle positioning/manipulation of slip
• Some recommend two screws, inc. strength of
  fixation

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CHRONIC SCFE

• Pin in situ
• -regardless of slip degree
• Never attempt reduction
• One screw
• Greater degree of slip, more anterior starting
  point needed

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ACUTE ON CHRONIC

• Pin in situ
• Gentle manipulation of acute portion of slip
• One screw fixation
• Avoid over manipulation
• gt tenting of epiphyseal vessels

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TECHNIQUE

• Fx table, C-arm
• intersecting lines
• Cannulated screw
• Ant. starting point
• One screw across physis

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SINGLE SCREW FIXATIONIN SITU

• High success rate
• Low incidence of further slippage
• Minimal complications if screw properly placed
• Ideal position central area or neutral zone
• Avoid postsup. quad

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MULTIPLE PIN/SCREW FIXATION

• Historically traditional treatment method
• Inc. fixation stiffness
• High rate of pin penetration into joint
• gt chondrolysis
• Increased avn
• Increase pin number complications inc.

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BONE-GRAFT EPIPHYSIODESIS

• Iliac crest bone graft driven across proximal
  femoral physis
• Less risk of damage to blood supply, graft not
  inserted as deep as pins
• Disadvantages epiphysis not well stabilized
• Graft can resorb, move or fracture
• Blood loss, operative time and scar greater

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RECONSTRUCTIVE OSTEOTOMIES

• Delays OA
• Improvement of motion
• Significant. Complication rates
• Recommend waiting 6 mos minimum prior to
  osteotomy

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OSTEOTOMY LEVELS

• SUBCAPITAL (cuneiform)
• -high incidence of AVN
• BASE OF NECK (Kramer)
• -less AVN , limited degree of correction
• INTERTROCHANTERIC (Southwick)
• - safest, less AVN, biplane
• - higher incidence of chondrolysis

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JBJS 1991 Long-term follow-up of slipped
capital femoral epiphysis Loder

• 155 hips, 124pts reviewed retrospectively
• Mean f/u 41 yrs
• Ave. Iowa hip scores
• -89 mild slip
• -81 moderate slip
• -73 severe slip
• AVN and chondrolysis lowest in mild slips
• Reduction and realignment gt poor outcome
• Pinning in situ regardless of slip best outcome

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SUMMARY

• Natural history DJD relative to severity of slip
• Substantial complications with reduction or
  realignment procedures
• Best results with pinning in situ regardless of
  slip degree
• Prophylactic pinning not recommended
• Do not perform forced reduction maneuvers
• Risk of AVN, chondrolysis inc. number of pins