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Slipped Capital Femoral Epiphysis Current Concepts and Treatment Dr. Donald W. Kucharzyk Clinical Assistant Professor University of Chicago Childrens Hospital.

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Presentation on theme: "Slipped Capital Femoral Epiphysis Current Concepts and Treatment Dr. Donald W. Kucharzyk Clinical Assistant Professor University of Chicago Childrens Hospital."— Presentation transcript:

1 Slipped Capital Femoral Epiphysis Current Concepts and Treatment Dr. Donald W. Kucharzyk Clinical Assistant Professor University of Chicago Childrens Hospital The Orthopaedic, Pediatric & Spine Institute

2 SCFE: Current Concepts zEpidemiology zEtiology zClinical Types zNatural History zTreatment and Treatment Goals zReconstructive Procedures zComplications

3 SCFE: Current Concepts EPIDEMIOLOGY

4 SCFE: Current Concepts zIncidence: 2/100,000 zMale:Female Ratio: 3:1 zAge of Onset: Male…13-16 years Female years zRace: Black moreso than Caucasian zSkeletally and Hormonally Immature zObese zBilateral: 50-60%

5 SCFE: Current Concepts ETIOLOGY

6 SCFE: Current Concepts zHormonal: Hypothyroidism Hyperthyroidism Hypopituitarism Hypogonadism Hyperparathyroidism Harris W: JBJS 1963 Kelsey JL: Pediatrics 1973

7 SCFE: Current Concepts zTrauma: Muscular Joint Reactive Forces Weight-Bearing Forces Chung SMK: JBJS 1976 Gelberman RH: JBJS 1986 Mickelson MR: JBJS 1977

8 SCFE: Current Concepts zMechanical: 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

9 SCFE: Current Concepts zInflammatory: Synovitis Defect in Synovial and Serum Immunoglobulins Autoimmune Process Howarth B: Clin Ortho 1966 Ponsetti I: JBJS 1956

10 SCFE: Current Concepts zGenetic: Familial Autosomal Dominant with Incomplete Penetrance Jerre T: Acta Orthop Scand 1960

11 SCFE: Current Concepts CLINICAL TYPES

12 SCFE: Current Concepts PRESLIP zMild leg, groin, or medial thigh pain with activity zLimp, mild decrease in internal rotation and abduction of involved hip zXray reveals widened and irregular physis with normal head-neck alignment

13 SCFE: Current Concepts ACUTE zLess than 3 weeks of pain zSignificant Antalgic gait with inability to bear weight zReduced range of motion: internal rotation zExternal Rotation Deformity zXray: widened and irregular physis with variable displacement

14 SCFE: Current Concepts ACUTE ON CHRONIC zGreater than 3 weeks of low grade pain with acute sudden exacerbation zClinical Findings same as Acute with coexistent thigh atrophy zXray: varying displacement with a degree of remodeling

15 SCFE: Current Concepts CHRONIC zPain for longer than 3 weeks involving groin, thigh or knee zSimilar findings as acute zXray: varying degree of displacement with rounded contours

16 SCFE: Current Concepts STABILITY CONCEPT CLASSIFICATION zSTABLE: walking and weight-bearing still possible with or without crutches zUNSTABLE: walking not feasible even with crutches ztime duration not of importance Loder RT: JBJS 1993

17 SCFE: Current Concepts NATURAL HISTORY

18 SCFE: Current Concepts zFew studies that evaluate untreated patients zPrognosis related to the degree of the Slip and the ability to remodel zDegree of the Slip related to the duration of symptoms zAssociation with DJD of the Hip zChondrolysis seen in untreated hip zAVN rare in the untreated hip

19 SCFE: Current Concepts zHerndon et al,1963: unrealigned severe slips treated with bone grafting; 25 of 32 hips had good or excellent results. zBoyer et al,1981: severe uncorrected slips; 6 0f 7 had good clinical results but motion was restricted zOBrien and Fahey,1977: remodeling occurs in the femoral neck and will lend to acceptable results in slips up to 60deg

20 SCFE: Current Concepts zFew studies that evaluate untreated patients zPrognosis related to the degree of the Slip and the ability to remodel zDegree of the Slip related to the duration of symptoms zAssociation with DJD of the Hip zChondrolysis seen in untreated hip zAVN rare in the untreated hip

21 SCFE: Current Concepts zWilson et al,1938: a slip up to one-third is acceptable and will remodel zBoyer et al, 1981: remodeling will correct a slip up to 60deg zHoworth 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

22 SCFE: Current Concepts TREATMENT GOALS zStabalize the epiphyseal-metaphyseal junction and prevent slippage zStimulation of early closure zAvoid complications of chondrolysis and avascular necrosis zPreserve hip joint function zAvoid or Delay onset of Degenerative Joint changes

23 SCFE: Current Concepts TREATMENT TECHNIQUES zPercutaneous Screw Fixation zOpen Bone Peg Epiphysiodesis zRealignment Osteotomies

24 SCFE: Current Concepts TREATMENT PERCUTANEOUS SCREW FIXATION zFluoroscopy and parallel to physis and in the center of the head; single screw zAvoid penetration of screw: transient: without sequlae Zionts JBJS 1991 chronic: chondrolysis Walters & Simon 1980

25 SCFE: Current Concepts TREATMENT PERCUTANEOUS SCREW FIXATION zMoseley Approach-Withdrawl Technique and rotation of C-Arm zUtilizing current technique, safe,effective,economical with a low complication rate Aronson DD: JBJS 1992 Ward WT: JBJS 1992

26 SCFE: Current Concepts TREATMENT OPEN BONE GRAFT EPIPHYSIODESIS zReported advantages: rapid closure of the physis and sooner return to regular activities zReported disadvantages: large incision,increased operative time,progression of the slip, graft migration and resorption

27 SCFE: Current Concepts TREATMENT OPEN BONE GRAFT EPIPHYSIODESIS zComplication rate low in the initial reported series (Weiner DS: 1989) zHigher complication rates reported by other authors (Ward WT: JPO 1990)

28 SCFE: Current Concepts TREATMENT LONG TERM FOLLOWUP RESULTS zExcellent Functional Outcomes reported with screw fixation zIn-Situ fixation preferred given the increased complication rates with osteotomies (AVN/chondrolysis) zSlip up to 60deg in skeletally immature and 30-40deg in skeletally mature lead to adequate function

29 SCFE: Current Concepts TREATMENT LONG TERM FOLLOWUP RESULTS zGrowth plate closure within 16 months with screw fixation; bone peg epiphysiodesis closure within 15 weeks and full closure at 6 months zReturn to sports 3 months with screw and 15 weeks with bone peg zGreatest Motion return within 6 months Sponseller JBJS 1991

30 SCFE: Current Concepts TREATMENT REALIGNMENT OSTEOTOMIES zGoals: Realignment of the slip, improved kinematics of the acetabular and femoral components, and delay onset of DJD zRationale: 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

31 SCFE: Current Concepts TREATMENT REALIGNMENT OSTEOTOMIES zIndications: Flexion<90deg; Slip greater than 45deg; Severe external rotation deformity zLevels of Osteotomies: Subcapital; Base of the Neck; Transtrochanteric; and Intertrochanteric

32 SCFE: Current Concepts SUBCAPITAL WEDGE OSTEOTOMY zDunn(1978) and Fish(1984): Open excision of callous and physeal cartilage with osteotomy of the neck to relax the blood vessel zAdvantages: Anatomic Reduction zDisadvantages: AVN and Cartilage Necrosis

33 SCFE: Current Concepts BASE OF THE NECK OSTEOTOMY zKramer(intracapsular 1976) and Abraham(extracapsular 1993) zAdvantages: Safer than the subcapital and achieves satisfactory anatomic restoration zDisadvantage: Correction limitation:35-55 Shortening of the femoral neck; Trochanteric osteotomy; AVN

34 SCFE: Current Concepts TRANSTROCHANTERIC OSTEOTOMY zSugioka(1980) zAdvantages: Correction of severe deformities(>60deg); Direct observation of the correction; No shortening required; Head/Shaft relationship realigned; Preserve abductor mechanism zDisadvantage: AVN and chondrolysis and high complication rate(40%)

35 SCFE: Current Concepts INTERTROCHANTERIC OSTEOTOMY zSouthwick Biplane(1967): corrects posterior tilt, varus, and external rotation zAdvantages: Extracapsular; Stimulates physeal closure; improves hip function; No AVN; Does not affect future surg. zDisadvantages: Chondrolysis and some shortening

36 SCFE: Current Concepts COMPLICATIONS

37 SCFE: Current Concepts zHardware Penetration zHardware Breakage zProgression of the Slip zAvascular Necrosis zDeformity-Late zChondrolysis zFracture Post Hardware Removal

38 SCFE: Current Concepts HARDWARE PENETRATION zTransient: no relation to chondrolysis zPersistant: chondrolysis zTreatment: immediate removal and repostioning

39 SCFE: Current Concepts HARDWARE BREAKAGE zDefine whether or not the joint surface has been compromised and if there is progression of the slip zWindshield Wiper loosening due to screw being left to long(Maletis and Bassett JPO 1993) zTreatment: remove broken fragment if joint involved and revise if physis open

40 SCFE: Current Concepts PROGRESSION OF THE SLIP zGrowing off a single screw zFollowing bone peg epiphysiodesis: seen in severe slips zTreatment: secure the slip via the same technique

41 SCFE: Current Concepts AVASCULAR NECROSIS zReported incidence: mild slip-4%; moderate-25%; severe-20%; Overall-15% zIncidence related to the surgical procedure: lower in in-situ than in closed or osteotomy zAnatomic Involvement: usually the anterolateral segment but may be total head

42 SCFE: Current Concepts AVASCULAR NECROSIS zTreatment: 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

43 SCFE: Current Concepts CHONDROLYSIS zOverall incidence: 24%(CampbellSeries) zIncreased incidence in blacks, females, and in moderate(35%) and severe(45%) slips zLoss of joint space and decreased range of motion: flexion,abduction,and internal rotation zEtiology: unknown (pin penetration, immunologic,or seen in untreated-5%)

44 SCFE: Current Concepts CHONDROLYSIS zTreatment: Range of motion exercises Non-weight bearing NSAID Capsulectomy and CPM zProtocol reportedly has restored about 50% of the joint motion and an increase of 50% of the joint space on xrays

45 SCFE: Current Concepts FRACTURE zPlacement of unnecessary drill holes zPossiblity due to thermal necrosis zStress fracture of femoral neck due to reaming (Cummings 1988) zHardware removal (Canale JPO) zTreatment: ORIF

46 SCFE: Current Concepts THANK YOU Dr. Donald W. Kucharzyk


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