Long-term follow-up of slipped capital femoral epiphysis

The data on 155 hips in 124 patients who had slipped capital femoral epiphysis were retrospectively reviewed at a mean follow-up of forty-one years after the onset of symptoms. The slips were classified, by the duration of symptoms, as acute, chronic, or acute on chronic. As determined by the head-shaft angle, 42 per cent of the slips were mild; 32 per cent, moderate; and 26 per cent, severe. Reduction was performed in thirty-nine hips, and realignment was done in sixty-five hips. Treatment of chronic slips included symptomatic only in 25 per cent of the hips, a spica cast in 30 per cent, pinning in 24 per cent, and osteotomy in 20 per cent. The Iowa hip-rating and the radiographic classification of degenerative joint disease were determined at follow-up; both worsened with increasing severity of the slip and when reduction or realignment had been done. Osteonecrosis (12 per cent) and chondrolysis (16 per cent) also were more common with increasing severity of the slip and when reduction or realignment had been performed; both led to a poor result. Deterioration over time was most marked with increasing severity of the slip. The natural history of the malunited slip is mild deterioration related to the severity of the slip and complications. Techniques of realignment are associated with a risk of appreciable complications and adversely affect the natural history of the disease. Regardless of the severity of the slip, pinning in situ provided the best long-term function and delay of degenerative arthritis, with a low risk of complications.     

Intertrochanteric corrective osteotomy in slipped capital femoral epiphysis. A long-term follow-up study of 26 patients

The results of intertrochanteric corrective osteotomy in a series of 26 hips with moderate to severe chronic slipped capital femoral epiphysis are reported from follow-up studies in 1976 and 1986. In hips with a slippage of less than 40 degrees (ten hips), arthrosis was present in one hip. In the remaining 16 cases in which slippage exceeded 40 degrees, osteoarthrosis was present in 15, even though correction was adequate. From these observations it can be concluded that intertrochanteric corrective osteotomy does not prevent degeneration in cases with the most severe slip. On the basis of the present observations on treated and untreated cases, the authors advocate treatment by fixation without realignment, accepting the deformity in moderate and severe chronic slips. Rotational osteotomy may be considered in the event of hip joint contracture.     

Follow-up study of slipped capital femoral epiphysis

We studied 50 hips in 46 patients with slipped capital femoral epiphysis (SCFE). Seven patients with acute cases were treated by closed reduction with excellent results and without any known complication. The cases in the remaining 39 patients were of the chronic type. The method of treatment was determined according to the posterior tilting angle: in situ pinning for angles less than 30 degrees, intertrochanteric osteotomy for angles between 30 and 60 degrees, and subcapital wedge osteotomy for angles greater than 60 degrees. Chondrolysis was observed in one case treated with intertrochanteric osteotomy, and chondrolysis and avascular necrosis occurred in one case of subcapital wedge osteotomy.     

Familial slipped capital femoral epiphysis

In 50 consecutive cases of slipped capital femoral epiphysis (SCFE) from 49 families, the heredity was analyzed by radiographic examination of the first-degree relatives and by interview regarding the second-degree relatives. In four of the 49 families, SCFE was obvious in one or more first-degree relatives; and in another 13 families (14 relatives), radiographic signs of SCFE were found besides the primary case.

The familial accumulation was much higher than expected from incidence studies, indicating a hereditary factor in the etiology.     

Valgus slipped capital femoral epiphysis

Abnormally high stresses involving the capital femoral physis were found in a series of valgus slipped capital femoral epiphysis cases. Using a single leg stance model we studied 10 hips in seven patients in which the epiphysis was lateral and posterior in relation to the femoral neck and calculated that shear stresses were high enough to be associated with failure of the physis. Valgus neck shaft angles and lateral tilt of the physes were seen in all cases.     

Valgus slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) is a posteromedial displacement of the epiphysis on the metaphysis. Superolateral displacement of the epiphysis, the valgus SCFE, was first described by Müller, although some authors question its existence. We report 4 additional cases and review the literature regarding valgus SCFE. A retrospective review was performed; the child's sex, race, age, weight and height, symptom duration, type of SCFE (stable/unstable), and slip severity were recorded. There were 105 children (67 boys and 38 girls) with 141 idiopathic SCFEs. Four children were noted to have 7 stable valgus SCFEs. Statistically significant differences between the valgus and varus SCFEs were noted for symptom duration and body mass index, and valgus SCFEs tended to be less severe. When combining the data from the literature and the author's institution, there were 22 children with 30 valgus SCFEs at average age of 12.4 +/- 1.8 years; weight, 69.3 +/- 20.6 kg; height, 155.3 +/- 12.4 cm; and body mass index, 27.l +/- 7.1 kg/cm. The demographics of children with valgus SCFE are similar to children with routine SCFE except for sex: 76% of valgus SCFEs occurred in girls. Awareness of valgus SCFEs is necessary for both diagnosis and treatment. In a "valgus" SCFE, Klein line will always be normal, emphasizing the need for lateral radiographs when evaluating all children for SCFE. Single central screw fixation must be approached with caution because the more medial screw entry point places the screw path in immediate proximity to the femoral neurovascular bundle.     

Familial slipped capital femoral epiphysis

In 50 consecutive cases of slipped capital femoral epiphysis (SCFE) from 49 families, the heredity was analyzed by radiographic examination of the first-degree relatives and by interview regarding the second-degree relatives. In four of the 49 families, SCFE was obvious in one or more first-degree relatives; and in another 13 families (14 relatives), radiographic signs of SCFE were found besides the primary case. The familial accumulation was much higher than expected from incidence studies, indicating a hereditary factor in the etiology.     

Familial slipped capital femoral epiphysis

In 50 consecutive cases of slipped capital femoral epiphysis (SCFE) from 49 families, the heredity was analyzed by radiographic examination of the first-degree relatives and by interview regarding the second-degree relatives. In four of the 49 families, SCFE was obvious in one or more first-degree relatives; and in another 13 families (14 relatives), radiographic signs of SCFE were found besides the primary case.

The familial accumulation was much higher than expected from incidence studies, indicating a hereditary factor in the etiology.     

Controversies in slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) is a common adolescent hip disorder. This article reviews the major controversies in SCFE as of the year 2005. These are (1) treatment of the unstable SCFE, (2) the role of osteotomy in the treatment of SCFE, (3) prophylactic fixation of the contralateral hip in children presenting with unilateral SCFE, and (4) methods of fixation in the very young child with SCFE.     

Chondrolysis of the hip complicating slipped capital femoral epiphysis: long-term follow-up of nine patients

Nine patients with chondrolysis secondary to slipped capital femoral epiphysis of the hip were followed up from a minimum of 7 to a maximum of 19 years (average, 13.7 years) after the onset of the disease. The degree of slipping of the proximal epiphysis of the femur was severe in five patients and moderately severe in four patients. The nine patients were treated with non-weight bearing, antiinflammatory drugs, and physical therapy. The disease had a good resolution, with gradual regression of pain, and radiographs showed restoration of the joint space in an average of 10 months. At follow-up, mild coxalgia after prolonged activity was present in five patients, whereas in the one patient with concomitant avascular necrosis, pain was much more intense. All patients had some limitation of range of motion of the hip. It was most restricted in two patients, one with associated avascular necrosis and one with a severe slip. In all patients, radiographs showed restoration of the joint space. In the group with severe degrees of slipping, there were marginal osteophytes of the femoral head and the acetabulum. Significant arthrosis was present in the patient treated conservatively and in the patient with associated ischemic necrosis. In this long-term study of chondrolysis secondary to slipped capital femoral epiphysis, the overall prognosis was benign and was determined by the degree of slipping of the proximal epiphysis of the femur and concomitant aseptic necrosis. However, the authors believe that the patients with radiographic signs of degenerative joint disease may have a poor long-term prognosis.     

Remodelling in slipped capital femoral epiphysis

In-situ pinning of a slipped capital femoral epiphysis is the most common form of treatment for this problem. To find out if remodelling of the upper femur after pinning occurs often enough to justify this form of treatment and whether secondary osteotomies are required for residual deformity, 82 patients with slipped capital femoral epiphyses were reviewed. X-ray films were studied sequentially, noting remodelling changes in the femoral head and neck. Sixty-eight percent of moderate to severe slips that could be properly assessed showed signs of remodelling. The authors recognized two distinct remodelling processes--one, occurring early, affected the neck adjacent to the growth plate, the second appeared later, more distally along the femoral neck. Very few osteotomies were done for residual deformity. Pinning in situ of a slipped capital femoral epiphysis represents a simple, rapid and effective method of treatment, allowing remodelling even in more severe slips.     

Chondrolysis following slipped capital femoral epiphysis

Medical records and radiographs of 17 known cases of slipped capital femoral epiphysis, treated with in-situ pin fixation and complicated by chondrolysis were reviewed. Fourteen of these 17 hips that developed chondrolysis had definite evidence of pin penetration of the femoral head. One hip had intra-articular pin penetration of the femoral neck. In the remaining two hips, the pins were placed within the anterolateral quadrant of the femoral head and within 2 mm of the articular surface. Overall, this is an 88% incidence of definite intra-articular pin penetration on postoperative radiographs, and a 100% rate if the two probable cases are included. This suggests a correlation between pin penetration and the development of chondrolysis following slipped capital femoral epiphysis.     

Mechanical factors in slipped capital femoral epiphysis

We performed three-dimensional force analyses on the hips of 50 normal patients and 50 patients with slipped capital femoral epiphysis to determine if mechanical factors alone could account for slips. We found that slipped epiphysis patients have reduced resistance to shear because of increased body weight and a decreased neck shaft-plate shaft angle. Slipped epiphysis patients have relative retroversion, and this generates increased sagittal plane shear stress at the proximal femoral growth plate. We suggest that, during running, these mechanical factors cause shear failure of the growth plate in obese adolescents.     

Maturation factors in slipped capital femoral epiphysis

Several maturation factors relative to growth and epiphyseal development were reviewed retrospectively in 191 patients with slipped capital femoral epiphysis, including bone age, height and weight, thyroid functions, sex hormone levels, and growth hormone levels. Seventy-one percent of 138 patients had weights above the 80th percentile. Active thyroid (T3) was significantly low in 25% of 80 patients studied. Testosterone levels were markedly depressed in 76% of 64 patients tested. In this same group, 87% had low growth hormone levels. The consistently low testosterone and growth hormone levels, along with a tendency toward hypothyroidism, lend support to the biochemical theory of a delicate hormonal imbalance in slipped capital femoral epiphysis.     

Articulotrochanteric distance in slipped capital femoral epiphysis

Summary The difference in altitude between the proximal limit of the femoral head and the tip of the greater trochanter — the articulotrochanteric distance (ATD) —was recorded in 312 patients with slipped capital femoral epiphysis and compared with that in normal hips. The ATD was markedly reduced after severe slipping, independent of the method of treatment. In mild or moderate slippings, the ATD differed with the method of treatment. The shortest ATD was seen after osteosynthesis with AO screws. Nonoperative treatment and osteosynthesis with the Johansson nail or Nyström pin caused a slight reduction of the ATD, while no reduction was seen after hook-pinning. These differences probably reflect various degrees of damage to the subcapital growth plate, which may result in leg length difference and abduction insufficiency.