Scfe Current Concepts

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Slipped Capital Femoral Epiphysis

Current Concepts and Treatment

Dr. Donald W. Kucharzyk

Clinical Assistant ProfessorUniversity of Chicago Childrens Hospital

The Orthopaedic, Pediatric & Spine

Institute


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SCFE: Current Concepts

Epidemiology

Etiology

Clinical Types

Natural History

Treatment and Treatment Goals

Reconstructive Procedures

Complications


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EPIDEMIOLOGY


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Incidence: 2/100,000

Male:Female Ratio: 3:1

Age of Onset: Male13-16 years

Female..11-14 years

Race: Black moreso than Caucasian

Skeletally and Hormonally Immature

Obese

Bilateral: 50-60%


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ETIOLOGY


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Hormonal: Hypothyroidism

Hyperthyroidism

Hypopituitarism

Hypogonadism

Hyperparathyroidism

Harris W: JBJS 1963Kelsey JL: Pediatrics 1973


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Trauma: Muscular Joint Reactive Forces

Weight-Bearing Forces

Chung SMK: JBJS 1976

Gelberman RH: JBJS 1986

Mickelson MR: JBJS 1977


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Mechanical: Periosteal Thinning and

Anteversion

Defect in Perichondrial

Fibrocartilaginous complex

Thinning of Cartilage Bridge

Anteversion and Obliquity ofProximal Physis

Pritchett JW: J Ped Ortho 1988


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Inflammatory: Synovitis

Defect in Synovial and

Serum Immunoglobulins

Autoimmune Process

Howarth B: Clin Ortho 1966

Ponsetti I: JBJS 1956


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Genetic: Familial

Autosomal Dominant with

Incomplete Penetrance

Jerre T: Acta Orthop Scand 1960


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CLINICAL TYPES


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PRESLIP

Mild leg, groin, or medial thigh pain

with activity

Limp, mild decrease in internal rotationand abduction of involved hip

Xray reveals widened and irregular physiswith normal head-neck alignment


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ACUTE

Less than 3 weeks of pain

Significant Antalgic gait with inability tobear weight

Reduced range of motion: internal rotation

External Rotation Deformity Xray: widened and irregular physis withvariable displacement


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ACUTE ON CHRONIC

Greater than 3 weeks of low grade painwith acute sudden exacerbation

Clinical Findings same as Acute withcoexistent thigh atrophy

Xray: varying displacement with a degreeof remodeling


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CHRONIC

Pain for longer than 3 weeks involvinggroin, thigh or knee

Similar findings as acute

Xray: varying degree of displacement with

rounded contours


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STABILITY CONCEPT

CLASSIFICATION

STABLE: walking and weight-bearing stillpossible with or without crutches

UNSTABLE: walking not feasible even with

crutches time duration not of importance

Loder RT: JBJS 1993


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NATURAL HISTORY


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SCFE: Current Concepts Few studies that evaluate untreatedpatients

Prognosis related to the degree of the Slipand the ability to remodel

Degree of the Slip related to the durationof symptoms

Association with DJD of the Hip Chondrolysis seen in untreated hip

AVN rare in the untreated hip


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SCFE: Current Concepts Herndon et al,1963: unrealigned severe slipstreated with bone grafting; 25 of 32 hips had

good or excellent results. Boyer et al,1981: severe uncorrected slips; 60f 7 had good clinical results but motion wasrestricted

OBrien and Fahey,1977: remodeling occurs inthe femoral neck and will lend to acceptableresults in slips up to 60deg


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SCFE: Current Concepts Few studies that evaluate untreatedpatients

Prognosis related to the degree of the Slipand the ability to remodel

Degree of the Slip related to the durationof symptoms

Association with DJD of the Hip Chondrolysis seen in untreated hip

AVN rare in the untreated hip


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SCFE: Current Concepts Wilson et al,1938: a slip up to one-third isacceptable and will remodel

Boyer et al, 1981: remodeling will correct aslip 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 asto the degree of restoration of the normalalignment to prevent osteoarthritis


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SCFE: Current ConceptsTREATMENT GOALS

Stabalize the epiphyseal-metaphyseal

junction and prevent slippage Stimulation of early closure

Avoid complications of chondrolysis andavascular necrosis

Preserve hip joint function

Avoid or Delay onset of Degenerative Jointchanges


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TREATMENT

TECHNIQUES

Percutaneous Screw Fixation

Open Bone Peg Epiphysiodesis

Realignment Osteotomies


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SCFE: Current ConceptsTREATMENT

PERCUTANEOUS SCREW FIXATION

Fluoroscopy and parallel to physis and in thecenter of the head; single screw

Avoid penetration of screw:

transient: without sequlaeZionts JBJS 1991

chronic: chondrolysis

Walters & Simon 1980


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PERCUTANEOUS SCREW FIXATION

Moseley Approach-Withdrawl Techniqueand rotation of C-Arm

Utilizing current technique,safe,effective,economical with a low

complication rateAronson DD: JBJS 1992

Ward WT: JBJS 1992


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TREATMENT

OPEN BONE GRAFT EPIPHYSIODESIS

Reported advantages: rapid closure of thephysis and sooner return to regularactivities

Reported disadvantages: largeincision,increased operativetime,progression of the slip, graftmigration and resorption


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TREATMENT

OPEN BONE GRAFT EPIPHYSIODESIS

Complication rate low in the initial reportedseries (Weiner DS: 1989)

Higher complication rates reported by

other authors (Ward WT: JPO 1990)


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LONG TERM FOLLOWUP RESULTS

Excellent Functional Outcomes reportedwith screw fixation

In-Situ fixation preferred given theincreased complication rates with

osteotomies (AVN/chondrolysis) Slip up to 60deg in skeletally immature and30-40deg in skeletally mature lead to

ade uate function


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LONG TERM FOLLOWUP RESULTS

Growth plate closure within 16 months withscrew fixation; bone peg epiphysiodesisclosure within 15 weeks and full closure at6 months

Return to sports 3 months with screw and15 weeks with bone peg

Greatest Motion return within 6 months

S onseller JBJS 1991


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REALIGNMENT OSTEOTOMIES

Goals: Realignment of the slip, improvedkinematics of the acetabular and femoralcomponents, and delay onset of DJD

Rationale: Forces resulting from a slip ofmore than 45deg produces a varus posteriortilting of the head of the femur and alteredkinematics with secondary degenerative

effects


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TREATMENT

REALIGNMENT OSTEOTOMIES

Indications: Flexion


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SUBCAPITAL WEDGE OSTEOTOMY

Dunn(1978) and Fish(1984): Open excisionof callous and physeal cartilage withosteotomy of the neck to relax the bloodvessel

Advantages: Anatomic Reduction Disadvantages: AVN and Cartilage Necrosis


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SCFE: Current ConceptsBASE OF THE NECK OSTEOTOMY

Kramer(intracapsular 1976) and

Abraham(extracapsular 1993) Advantages: Safer than the subcapital andachieves satisfactory anatomic restoration

Disadvantage: Correction limitation:35-55Shortening of the femoral neck; Trochantericosteotomy; AVN


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SCFE: Current ConceptsTRANSTROCHANTERIC OSTEOTOMY

Sugioka(1980)

Advantages: Correction of severedeformities(>60deg); Direct observation ofthe correction; No shortening required;Head/Shaft relationship realigned;

Preserve abductor mechanism Disadvantage: AVN and chondrolysis andhigh complication rate(40%)


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INTERTROCHANTERIC OSTEOTOMY

Southwick Biplane(1967): corrects posteriortilt, varus, and external rotation

Advantages: Extracapsular; Stimulatesphyseal closure; improves hip function; No

AVN; Does not affect future surg. Disadvantages: Chondrolysis and someshortening


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SCFE: Current Concepts Hardware Penetration

Hardware Breakage

Progression of the Slip

Avascular Necrosis

Deformity-Late

Chondrolysis Fracture Post Hardware Removal


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SCFE: Current ConceptsHARDWARE PENETRATION

Transient: no relation to chondrolysis

Persistant: chondrolysis

Treatment: immediate removal andrepostioning


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SCFE: Current ConceptsHARDWARE BREAKAGE

Define whether or not the joint surface

has been compromised and if there isprogression of the slip

Windshield Wiper loosening due to screwbeing left to long(Maletis and Bassett JPO

1993) Treatment: remove broken fragment ifjoint involved and revise if physis open


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SCFE: Current ConceptsPROGRESSION OF THE SLIP

Growing off a single screw

Following bone peg epiphysiodesis: seen insevere slips

Treatment: secure the slip via the same

technique


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SCFE: Current ConceptsAVASCULAR NECROSIS

Reported incidence: mild slip-4%;

moderate-25%; severe-20%; Overall-15% Incidence related to the surgicalprocedure: lower in in-situ than in closedor osteotomy

Anatomic Involvement: usually theanterolateral segment but may be totalhead


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SCFE: Current ConceptsAVASCULAR NECROSIS

Treatment: Small segmentation collapse

then observe and preserve motion; Largersegmentation collapse then consider a varusflexion osteotomy; Severe collapse, totalhead involvement, and pain then considerfusion


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SCFE: Current ConceptsCHONDROLYSIS

Overall incidence: 24%(CampbellSeries)

Increased incidence in blacks, females, and inmoderate(35%) and severe(45%) slips

Loss of joint space and decreased range ofmotion: flexion,abduction,and internal rotation

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


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SCFE: Current ConceptsCHONDROLYSIS

Treatment: Range of motion exercises

Non-weight bearingNSAID

Capsulectomy and CPM

Protocol reportedly has restored about50% of the joint motion and an increase of50% of the joint space on xrays


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SCFE: Current ConceptsFRACTURE

Placement of unnecessary drill holes

Possiblity due to thermal necrosis

Stress fracture of femoral neck due toreaming (Cummings 1988)

Hardware removal (Canale JPO) Treatment: ORIF


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THANK YOU

Dr. Donald W. Kucharzyk

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