slipped capital femoral epiphysis current concepts and treatment dr. donald w. kucharzyk clinical...

“Slipped Capital Femoral Epiphysis”

Current Concepts and Treatment Dr. Donald W. Kucharzyk Clinical Assistant Professor University of Chicago Children’s Hospital The Orthopaedic, Pediatric & Spine Institute

“SCFE: Current Concepts

EpidemiologyEtiologyClinical TypesNatural HistoryTreatment and Treatment GoalsReconstructive ProceduresComplications


EPIDEMIOLOGY


Incidence: 2/100,000Male:Female Ratio: 3:1Age of Onset: Male…13-16 years Female..11-14 yearsRace: Black moreso than CaucasianSkeletally and Hormonally ImmatureObeseBilateral: 50-60%


ETIOLOGY


Hormonal: Hypothyroidism Hyperthyroidism Hypopituitarism Hypogonadism Hyperparathyroidism Harris W: JBJS 1963 Kelsey JL: Pediatrics 1973


Trauma: Muscular Joint Reactive Forces Weight-Bearing Forces

Chung SMK: JBJS 1976 Gelberman RH: JBJS 1986 Mickelson MR: JBJS 1977


Mechanical: Periosteal Thinning and Anteversion Defect in Perichondrial Fibrocartilaginous complex Thinning of Cartilage Bridge Anteversion and Obliquity of Proximal Physis Pritchett JW: J Ped Ortho 1988


Inflammatory: Synovitis Defect in Synovial and Serum Immunoglobulins Autoimmune Process

Howarth B: Clin Ortho 1966 Ponsetti I: JBJS 1956


Genetic: Familial Autosomal Dominant with Incomplete Penetrance Jerre T: Acta Orthop Scand 1960


CLINICAL TYPES


PRESLIPMild leg, groin, or medial thigh pain with activityLimp, mild decrease in internal rotation

and abduction of involved hipXray reveals widened and irregular

physis with normal head-neck alignment


ACUTELess than 3 weeks of painSignificant Antalgic gait with inability to

bear weightReduced range of motion: internal rotationExternal Rotation DeformityXray: widened and irregular physis with

variable displacement


ACUTE ON CHRONICGreater than 3 weeks of low grade

pain with acute sudden exacerbationClinical Findings same as Acute with

coexistent thigh atrophyXray: varying displacement with a

degree of remodeling


CHRONICPain for longer than 3 weeks

involving groin, thigh or kneeSimilar findings as acuteXray: varying degree of displacement

with rounded contours


STABILITY CONCEPT CLASSIFICATIONSTABLE: walking and weight-bearing

still possible with or without crutchesUNSTABLE: walking not feasible even

with crutchestime duration not of importance Loder RT: JBJS 1993


NATURAL HISTORY

“SCFE: Current ConceptsFew studies that evaluate untreated

patientsPrognosis related to the degree of

the Slip and the ability to remodelDegree of the Slip related to the

duration of symptomsAssociation with DJD of the HipChondrolysis seen in untreated hipAVN rare in the untreated hip


Herndon et al,1963: unrealigned severe slips treated with bone grafting; 25 of 32 hips had good or excellent results.

Boyer et al,1981: severe uncorrected slips; 6 0f 7 had good clinical results but motion was restricted

O’Brien and Fahey,1977: remodeling occurs in the femoral neck and will lend to acceptable results in slips up to 60deg

“SCFE: Current ConceptsFew studies that evaluate untreated

patientsPrognosis related to the degree of

the Slip and the ability to remodelDegree of the Slip related to the

duration of symptomsAssociation with DJD of the HipChondrolysis seen in untreated hipAVN rare in the untreated hip

“SCFE: Current ConceptsWilson et al,1938: a slip up to one-third is

acceptable and will remodelBoyer et al, 1981: remodeling will correct a

slip up to 60degHoworth et al,1965 and Southwick et al,1967:

report that severe slipping and malunion have a poor long term prognosis and debate exists as to the degree of restoration of the normal alignment to prevent osteoarthritis


TREATMENT GOALSStabalize the epiphyseal-metaphyseal

junction and prevent slippageStimulation of early closureAvoid complications of chondrolysis and

avascular necrosisPreserve hip joint functionAvoid or Delay onset of Degenerative Joint

changes


TREATMENT TECHNIQUES

Percutaneous Screw FixationOpen Bone Peg EpiphysiodesisRealignment Osteotomies


TREATMENT PERCUTANEOUS SCREW FIXATIONFluoroscopy and parallel to physis and in the

center of the head; single screwAvoid penetration of screw: transient: without sequlae Zionts JBJS 1991 chronic: chondrolysis Walters & Simon 1980

“SCFE: Current Concepts TREATMENT PERCUTANEOUS SCREW FIXATION“Moseley” Approach-Withdrawl

Technique and rotation of C-ArmUtilizing current technique,

safe,effective,economical with a low complication rate

Aronson DD: JBJS 1992 Ward WT: JBJS 1992


TREATMENTOPEN BONE GRAFT EPIPHYSIODESISReported advantages: rapid closure of

the physis and sooner return to regular activities

Reported disadvantages: large incision,increased operative time,progression of the slip, graft migration and resorption


TREATMENTOPEN BONE GRAFT EPIPHYSIODESISComplication rate low in the initial

reported series (Weiner DS: 1989)Higher complication rates reported by

other authors (Ward WT: JPO 1990)


TREATMENT LONG TERM FOLLOWUP RESULTSExcellent Functional Outcomes reported

with screw fixationIn-Situ fixation preferred given the

increased complication rates with osteotomies (AVN/chondrolysis)

Slip up to 60deg in skeletally immature and 30-40deg in skeletally mature lead to adequate function


TREATMENT LONG TERM FOLLOWUP RESULTSGrowth plate closure within 16 months with

screw fixation; bone peg epiphysiodesis closure within 15 weeks and full closure at 6 months

Return to sports 3 months with screw and 15 weeks with bone peg

Greatest Motion return within 6 months Sponseller JBJS 1991


TREATMENT REALIGNMENT OSTEOTOMIESGoals: Realignment of the slip, improved

kinematics of the acetabular and femoral components, and delay onset of DJD

Rationale: Forces resulting from a slip of more than 45deg produces a varus posterior tilting of the head of the femur and altered kinematics with secondary degenerative effects


TREATMENT REALIGNMENT OSTEOTOMIESIndications: Flexion<90deg; Slip

greater than 45deg; Severe external rotation deformity

Levels of Osteotomies: Subcapital; Base of the Neck; Transtrochanteric; and Intertrochanteric


SUBCAPITAL WEDGE OSTEOTOMYDunn(1978) and Fish(1984): Open

excision of callous and physeal cartilage with osteotomy of the neck to relax the blood vessel

Advantages: Anatomic ReductionDisadvantages: AVN and Cartilage

Necrosis


BASE OF THE NECK OSTEOTOMYKramer(intracapsular 1976) and

Abraham(extracapsular 1993)Advantages: Safer than the subcapital and

achieves satisfactory anatomic restorationDisadvantage: Correction limitation:35-55 Shortening of the femoral neck;

Trochanteric osteotomy; AVN


TRANSTROCHANTERIC OSTEOTOMYSugioka(1980)Advantages: Correction of severe

deformities(>60deg); Direct observation of the correction; No shortening required; Head/Shaft relationship realigned; Preserve abductor mechanism

Disadvantage: AVN and chondrolysis and high complication rate(40%)


INTERTROCHANTERIC OSTEOTOMYSouthwick Biplane(1967): corrects

posterior tilt, varus, and external rotationAdvantages: Extracapsular; Stimulates

physeal closure; improves hip function; No AVN; Does not affect future surg.

Disadvantages: Chondrolysis and some shortening


COMPLICATIONS


Hardware PenetrationHardware BreakageProgression of the SlipAvascular NecrosisDeformity-LateChondrolysisFracture Post Hardware Removal


HARDWARE PENETRATIONTransient: no relation to chondrolysisPersistant: chondrolysisTreatment: immediate removal and

repostioning


HARDWARE BREAKAGEDefine whether or not the joint surface

has been compromised and if there is progression of the slip

“Windshield Wiper” loosening due to screw being left to long(Maletis and Bassett JPO 1993)

Treatment: remove broken fragment if joint involved and revise if physis open


PROGRESSION OF THE SLIPGrowing off a single screwFollowing bone peg epiphysiodesis:

seen in severe slipsTreatment: secure the slip via the

same technique


AVASCULAR NECROSISReported incidence: mild slip-4%;

moderate-25%; severe-20%; Overall-15%Incidence related to the surgical

procedure: lower in in-situ than in closed or osteotomy

Anatomic Involvement: usually the anterolateral segment but may be total head


AVASCULAR NECROSISTreatment: Small segmentation

collapse then observe and preserve motion; Larger segmentation collapse then consider a varus flexion osteotomy; Severe collapse, total head involvement, and pain then consider fusion

“SCFE: Current Concepts CHONDROLYSISOverall incidence: 24%(CampbellSeries)Increased incidence in blacks, females, and

in moderate(35%) and severe(45%) slipsLoss of joint space and decreased range of

motion: flexion,abduction,and internal rotation

Etiology: unknown (pin penetration, immunologic,or seen in untreated-5%)


CHONDROLYSISTreatment: Range of motion exercises Non-weight bearing NSAID Capsulectomy and CPMProtocol reportedly has restored about

50% of the joint motion and an increase of 50% of the joint space on xrays


FRACTUREPlacement of unnecessary drill holesPossiblity due to thermal necrosisStress fracture of femoral neck due

to reaming (Cummings 1988)Hardware removal (Canale JPO)Treatment: ORIF


THANK YOU

Dr. Donald W. Kucharzyk

slipped capital femoral epiphysis current concepts and treatment dr. donald w. kucharzyk clinical...

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