“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 Epidemiology Etiology Clinical Types Natural History Treatment and Treatment Goals Reconstructive Procedures Complications

“SCFE: Current Concepts EPIDEMIOLOGY

“SCFE: Current Concepts Incidence: 2/100,000 Male:Female Ratio: 3:1 Age of Onset: Male…13-16 years Female..11-14 years Race: Black moreso than Caucasian Skeletally and Hormonally Immature Obese Bilateral: 50-60%

“SCFE: Current Concepts ETIOLOGY

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

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

“SCFE: Current Concepts 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

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

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

“SCFE: Current Concepts CLINICAL TYPES

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

“SCFE: Current Concepts ACUTE Less than 3 weeks of pain Significant Antalgic gait with inability to bear weight Reduced range of motion: internal rotation External Rotation Deformity Xray: widened and irregular physis with variable displacement

“SCFE: Current Concepts ACUTE ON CHRONIC Greater than 3 weeks of low grade pain with acute sudden exacerbation Clinical Findings same as Acute with coexistent thigh atrophy Xray: varying displacement with a degree of remodeling

“SCFE: Current Concepts CHRONIC Pain for longer than 3 weeks involving groin, thigh or knee Similar findings as acute Xray: varying degree of displacement with rounded contours

“SCFE: Current Concepts STABILITY CONCEPT CLASSIFICATION STABLE: walking and weight-bearing still possible with or without crutches UNSTABLE: walking not feasible even with crutches time duration not of importance Loder RT: JBJS 1993

“SCFE: Current Concepts NATURAL HISTORY

“SCFE: Current Concepts Few studies that evaluate untreated patients Prognosis related to the degree of the Slip and the ability to remodel Degree of the Slip related to the duration of symptoms Association with DJD of the Hip Chondrolysis seen in untreated hip AVN rare in the untreated hip

“SCFE: Current Concepts 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 Concepts Few studies that evaluate untreated patients Prognosis related to the degree of the Slip and the ability to remodel Degree of the Slip related to the duration of symptoms Association with DJD of the Hip Chondrolysis seen in untreated hip AVN rare in the untreated hip

“SCFE: Current Concepts Wilson et al,1938: a slip up to one-third is acceptable and will remodel Boyer et al, 1981: remodeling will correct a slip up to 60deg Howorth 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

“SCFE: Current Concepts TREATMENT GOALS Stabalize the epiphyseal-metaphyseal junction and prevent slippage Stimulation of early closure Avoid complications of chondrolysis and avascular necrosis Preserve hip joint function Avoid or Delay onset of Degenerative Joint changes

“SCFE: Current Concepts TREATMENT TECHNIQUES Percutaneous Screw Fixation Open Bone Peg Epiphysiodesis Realignment Osteotomies

“SCFE: Current Concepts TREATMENT PERCUTANEOUS SCREW FIXATION Fluoroscopy and parallel to physis and in the center of the head; single screw Avoid 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-Arm Utilizing current technique, safe,effective,economical with a low complication rate Aronson DD: JBJS 1992 Ward WT: JBJS 1992

“SCFE: Current Concepts TREATMENT OPEN BONE GRAFT EPIPHYSIODESIS Reported 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

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

“SCFE: Current Concepts TREATMENT LONG TERM FOLLOWUP RESULTS Excellent Functional Outcomes reported with screw fixation In-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

“SCFE: Current Concepts TREATMENT LONG TERM FOLLOWUP RESULTS Growth 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

“SCFE: Current Concepts TREATMENT REALIGNMENT OSTEOTOMIES Goals: 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

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

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

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

“SCFE: Current Concepts TRANSTROCHANTERIC OSTEOTOMY Sugioka(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%)

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

“SCFE: Current Concepts COMPLICATIONS

“SCFE: Current Concepts Hardware Penetration Hardware Breakage Progression of the Slip Avascular Necrosis Deformity-Late Chondrolysis Fracture Post Hardware Removal

“SCFE: Current Concepts HARDWARE PENETRATION Transient: no relation to chondrolysis Persistant: chondrolysis Treatment: immediate removal and repostioning

“SCFE: Current Concepts HARDWARE BREAKAGE Define 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

“SCFE: Current Concepts PROGRESSION OF THE SLIP Growing off a single screw Following bone peg epiphysiodesis: seen in severe slips Treatment: secure the slip via the same technique

“SCFE: Current Concepts AVASCULAR NECROSIS Reported 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

“SCFE: Current Concepts AVASCULAR NECROSIS Treatment: 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 CHONDROLYSIS Overall incidence: 24%(CampbellSeries) Increased incidence in blacks, females, and in moderate(35%) and severe(45%) slips Loss of joint space and decreased range of motion: flexion,abduction,and internal rotation Etiology: unknown (pin penetration, immunologic,or seen in untreated-5%)

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

“SCFE: Current Concepts FRACTURE Placement of unnecessary drill holes Possiblity due to thermal necrosis Stress fracture of femoral neck due to reaming (Cummings 1988) Hardware removal (Canale JPO) Treatment: ORIF

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