Slipped capital femoral epiphysis technique of percutaneous in situ fixation

The technique for percutaneous in situ fixation of chronic slipped capital femoral epiphysis (SCFE) is described. It is based on the anatomy of the slip. The technique utilizes a cannulated screw, which obviates the need for an incision and allows variation of the starting point of the screw depending on the degree of slippage.     

Slipped upper femoral epiphysis: Outcome after in situ fixation and capital realignment technique

Background:

Slipped upper femoral epiphysis (SUFE) is the gradually acquired malalignment of the upper femoral epiphysis (capital) and the proximal femoral metaphysis. SUFE is uncommon in India, and there are no previous studies on outcome and clinical characteristics of patients with SUFE from India. This study evaluates the presentation, disease associations and outcome of SUFE from a tertiary care centre in India.

Materials and Methods:

Twenty six consecutive children with SUFE seen over a period of 4 years were reviewed. The clinical presentations, severity of the slip, surgical interventions (n=30) were assessed. Twenty one boys and five girls with a mean age 13.1 years (range 10-16 years) were included in the study. Four children had bilateral involvement. There were 4 rural and 22 urban children from the eastern and southern states of the country. The presentation was acute in 7, acute on chronic in 5, and chronic in 14, with a mean duration of symptoms of 51 days (range 3-120 days). Slips were stable in 16 and unstable in 10 children. Two children had adiposogenital syndrome. Body mass index was high in 12 out of 23 children. Vitamin D levels were low in 20 out of 21 children, with a mean vitamin D level of 12.61 ± 5 ng/ml. Eighteen children underwent in situ pinning. Eight children underwent capital realignment.

Results:

Clinical outcome as assessed by Merle d’ Aubigne score was excellent in 6, good in 10, fair in 6 and poor in 1. Half of the in situ fixation patients underwent osteoplasty procedure for femoroacetabular impingement and 5 more were symptomatic. The head neck offset and α angle after in situ pinning were −1.12 ± 3 mm and 66.05 ± 9.7°, respectively and this improved to 8.7 mm and 49°, respectively, after osteoplasty. One child in the pinning group had chondrolysis. Eight patients with severe slip underwent capital realignment. Mean followup was 20.15 months. The anterior head neck offset and α angle were corrected to 6.8 ± 1.72 mm and 44.6 ± 7.0° mm, respectively. Two children with unstable slip in the capital realignment group had avascular necrosis which was diagnosed at presentation by bone scan.

Conclusion:

High BMI, vitamin D deficiency and endocrine disorders are associated with SUFE in India and should be evaluated as some of these are amenable to prevention and treatment. Most patients treated with in situ pinning developed femoroacetabular impingement. The early results after capital realignment procedure are encouraging and help to avoid a second procedure which is needed in a majority of patients who underwent in situ pinning.     

Slipped capital femoral epiphysis. The case for internal fixation in situ.

The traditional method of treating slipped capital femoral epiphysis by in situ pinning is being challenged. The complication of chondrolysis has been correlated with unrecognized pin penetration into the hip joint. Several studies have shown that black children may be more susceptible to developing chondrolysis. Fifty-five children (89% black) with 80 slipped epiphyses agreed to return for evaluation by the authors at an average of 3.3 years after in situ pinning. The results were classified according to clinical and roentgenographic parameters. The results were excellent or good in 56 (70%) of the 80 slips. Excellent or good results were found in 86% of mild slips, 55% of moderate, and 27% of severe. The complication of chondrolysis developed in three slips (4%) and avascular necrosis in two (3%). Poor pin position could be correlated with the complication in one of the three patients who developed chondrolysis and in both who developed avascular necrosis. Poor pin position was also associated with 12 (60%) of the 20 poor results. The majority of pin problems were secondary to technical problems associated with attempting in situ pinning from the lateral approach. In this study, black children were not more susceptible to chondrolysis than nonblack children.     

Slipped capital femoral epiphysis

SCFE is one of the most potentially damaging conditions of the adolescent hip. The onset may be associated with minor trauma but is often insidious and may present as vague thigh or knee pain. The lateral radiograph is the most sensitive view for detection of a low-grade slip. The contralateral hip must be examined carefully as there may be bilateral disease with the pain and disability of the presenting side masking the symptoms of less involved hip. SCFE is occasionally associated with other metabolic and endocrinologic disease, and these should be screened for in the history and physical examination. Once a slip begins, the hip remains at jeopardy for acute progression until the physeal plate closes. We recommend immediate surgical stabilization and prefer a cannulated screw system. Proper technique is critical to safe and reliable surgery. The most common complications, AVN and chondrolysis, are often related to technical errors and should be minimized with attention to detail.     

Slipped capital femoral epiphysis

Slipped capital femoral epiphysis is a common malady which must be managed by virtually every orthopedic surgeon. While each of us has a "foolproof method" of managing the disease, we also have somewhere in our files a patient with a disastrous outcome. The next several instructional cases will focus on the trials and tribulations of this disorder. Each of the discussants has had to formulate his opinions regarding management at each step in the case presentation, without knowledge of the subsequent outcome. We hope through this process we all will learn from our own and others' mistakes.     

Slipped capital femoral epiphysis. Treatment by pinning in situ

This paper retrospectively reviews 46 hips in 33 patients treated for slipped capital femoral epiphyses (SCFE) between December 1964 and January 1983. The average clinical and roentgenogram follow-up evaluation was seven years. Twenty-nine patients had in-situ pinning and four had primary Southwick osteotomies. Eighty-nine percent of the patients treated had acceptable results. Unacceptable results were directly related to preoperative manipulation and/or pin penetration on x-ray. These results were not dependent on the degree of the slip, which ranged from 7 degrees-94 degrees.     

Slipped capital femoral epiphysis: current concepts

Slipped capital femoral epiphysis is a common hip disorder in adolescents, with an incidence of 0.2 (Japan) to 10 (United States) per 100,000. The etiology is unknown, but biomechanical and biochemical factors play an important role. Symptoms at presentation include pain in the groin, thigh, or knee. Ambulatory patients also may present with a limp. Nonambulatory patients present with excruciating pain. The slipped capital femoral epiphysis is classified as stable when the patient can walk and unstable when the patient cannot walk, even with the aid of crutches. Because the epiphysis slips posteriorly, it is best seen on lateral radiographs. The treatment of choice for stable slipped capital femoral epiphysis is single-screw fixation in situ. This method has a high probability of long-term success, with minimal risk of complications. In the patient with unstable slipped capital femoral epiphysis, urgent hip joint aspiration followed by closed reduction and single- or double-screw fixation provides the best environment for a satisfactory result, while minimizing the risk of complications.     

Slipped capital femoral epiphysis: long-term results of an abandoned technique

Sixty-two (11 women and 51 men) of 76 consecutive patients treated between January 1960 and December 1979 with percutaneous pinning, traction, and ambulation in Thomas splints for slipped capital femoral epiphyses (physiolysis colli femoris; PCF) were re-examined radiologically and clinically to evaluate long-term results of an abandoned technique. Median follow-up time was 21 years (range: 8 to 28). The average age at symptom start was 14 years (range: 9 to 17). Fourteen patients were operated bilaterally, while 15 were operated on the right side only and 33 on the left side only. No additional hip surgery for coxarthrosis as adults had been performed. At the clinical examination the mean hip-movement-sum was 220 degrees (range: 30 degrees to 300 degrees). Pain occurred in 31 hips. A limp was found in 23 patients, and 56 had no impairment of working ability. At radiologic examination, 30 patients showed sequelae of PCF, and 30 (48%) had bilateral signs of PCF at follow up.     

Slipped capital femoral epiphysis: a prospective study of dynamic screw fixation

Twenty-five consecutive children (29 hips) who had slipped capital femoral epiphysis of a mild degree (slip angle less than 30 degrees) were treated with dynamic screw fixation. The goal of dynamic screw fixation is to achieve physeal stability to prevent additional slippage and to avoid premature physeal closure. Seventeen boys and eight girls were followed up for an average of 7 years (range, 4-13 years). There were 25 chronic slips, three acute slips, and one preslip. The average age at the time of surgery was 11.7 years for the girls (range, 11.1-12.9 years) and 13.9 years for the boys (range, 9.4-16.1 years). The average time to physeal closure was almost the same in both genders (boys, 3.0 years; girls, 3.2 years), ranging from 1.1 years to 6.3 years. No increase in the degree of slippage occurred; there were no perioperative complications, and avascular necrosis and chondrolysis were not apparent. In all 29 hips, no growth disturbance, including greater trochanteric overgrowth, coxa brevis, or coxa vara, was seen. According to the clinical criteria of Heyman and Herndon, 26 hips were rated either excellent or good, and two were rated fair. One was rated poor because of the presence of slight pain after strenuous exercise. The technique of dynamic screw fixation provides sufficient immediate and long-term fixation, does not promote premature physeal closure, and permits normal hip development.     

Slipped capital femoral epiphysis following radiotherapy

Two children with rhabdomyosarcoma who developed slipped capital femoral epiphyses following pelvic irradiation are described. Previous case reports are summarised, and the relevant orthopedic implications of the disorder discussed.     

Slipped capital femoral epiphysis: physeal histologic features before and after fixation

Physeal histopathologic changes following slipped capital femoral epiphysis (SCFE) are usually considered permanent. This assumption may not be correct, since radiographic signs of proximal femoral neck growth and remodeling are commonly seen after fixation. This work analyzed the physeal histologic features of chondroepiphyseal biopsies before and after SCFE surgical fixation but before complete physiologic epiphysiodesis. Eighteen patients, nine with unstable and nine with stable SCFE of varying severity, had pretreatment biopsies. Three patients had postfixation biopsies prior to total physiologic proximal femoral epiphysiodesis. Pretreatment biopsies showed varied degrees of histoarchitectural changes ranging from almost normal arrangement to markedly deranged physeal morphology. Postfixation biopsies showed improved physeal organization in a case of moderate unstable SCFE. In one severe unstable case and one severe stable case, nearly normal physeal architecture was seen. Physeal histopathologic changes appear to improve after fixation. Progressive modulation of the recovering physis after fixation helps explain the remodeling and growth changes seen radiographically after chondroepiphyseal fixation.     

Slipped capital femoral epiphysis in three generations

A male, his son, and grandson all had a slipped capital femoral epiphysis (physiolysis colli femoris - PCF). The importance of inheritance in PCF is discussed.     

Slipped capital femoral epiphysis in three generations

A male, his son, and grandson all had a slipped capital femoral epiphysis (physiolysis colli femoris--PCF). The importance of inheritance in PCF is discussed.