Aresh Hashemi-Nejad FRCS(Orth) The Royal National

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Slipped Upper Femoral Epiphysis

• Aresh Hashemi-Nejad FRCS(Orth)
• The Royal National Orthopaedic Hospital

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Slipped Upper Femoral Epiphysis

• Annual incidence 2-10 per 100,000
• 2.4 M 1 F
• Boys 10-16 yrs (13.4)
• Girls 10-14 yrs (11.5)
• presentation outside these ages consider
  endocrine or systemic disorder

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Slipped Capital Femoral Epiphysis

• Obese (50-75 over 95th centile)
• Delay in skeletal maturity
• Bilateral in 25 (50 present-50 sequential)
• Late changes of bilateral SCFE 60-80 of
  unilaterals

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Slipped Capital Femoral Epiphysis

• one of the most common adolescent hip disorders
• Separation through the widened hypertrophic zone
  of the physis

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Slipped Capital Femoral Epiphysis

• femoral neck displace anteriorly with the head in
  the acetabulum causing an apparent varus
  deformity
• hypertrophic zone accounts for 80 of physis due
  to abnormal cartilage maturation and endochondral
  ossification

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Slipped Capital Femoral Epiphysis Aetiology

• Mechanical factors
• obesity
• decrease in normal femoral anteversion/ protrusio
• oblique physeal plate
• weakened perichondral ring

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Slipped Capital Femoral Epiphysis Aetiology

• Inflammatory
• synovial hyperplasia
• increase in IG and C3

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Slipped Capital Femoral Epiphysis Aetiology

• Endocrine
• Girls premenarchal/ Boys longer growth phase
• Association with
• 1 or 2 hypothyroidism
• panhypopituitarism
• hypogonadal conditions
• renal osteodystrophy
• GH therapy

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Slipped Capital Femoral Epiphysis Aetiology

• 5 incidence in family members

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Slipped Capital Femoral Epiphysis Presentation

• Pain groin thigh, knee
• Limp
• Externally rotated limb

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Slipped Capital Femoral Epiphysis Presentation

• Preslip synovitis
• Acute lt3wks
• Chronic
• Acute on Chronic

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Slipped Capital Femoral Epiphysis Presentation

• Physeal stability
• Stable can wt bear
• Unstable
• Acute Slipped Capital Femoral Epiphysis the
  Importance of Physeal Stability
• Loder et al
• JBJS 1993 75-A1134-1140

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Slipped Capital Femoral Epiphysis Radiology

• AP
• physeal widening
• decrease in epiphyseal ht
• Blanch sign (density in neck)
• Klein/Trethowan line
• Capeners sign

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Slipped Capital Femoral Epiphysis Radiology

• AP
• physeal widening
• decrease in epiphyseal ht
• Blanch sign (density in neck)
• Klein/Trethowan line
• Capeners sign

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Slipped Capital Femoral Epiphysis Radiology

• Lateral
• shoot through/Billings
• in acute unstable hips avoid frog lateral
• US
• CT/MRI

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Slipped Capital Femoral Epiphysis Radiology

• Classification
• 1/3, 1/2, gt1/2
• 30, 30-50, .50 (difference to other side)

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Slipped Capital Femoral Epiphysis Natural History

• 30-40 second slip asymptomatic (slow)
• Premature OA (pistol grip deformity 40 primary
  OA)
• Onset of OA directly related to severity of slip

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Natural History

• Carney et al JBJS 1991
• 155 hips in 124 patients, FU 41 years
• Joint deterioration related to the severity of
  the slip and complications of treatment
• Carney and Weinstein Clin Orth 1996
• Untreated mild slips can progress to severe
• 2 joint degeneration corresponded to severity

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Slipped Capital Femoral Epiphysis Treatment

• Prevent further slippage
• Reduce the degree of slippage
• Salvage treatment

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SCFE Treatment to prevent further slippage

• Hip spica
• Bone peg epiphysiodesis
• Pin or screw fixation

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SCFE Treatment to prevent further slippage

• In situ screw fixation
• biplane fluoroscopy
• percutaneous technique
• Position fixation centrally in head and 5mm from
  margin
• single pin substantially reduces pin-related
  complications

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SCFE Treatment to prevent further slippage

• In situ screw fixation
• pin must be placed perpendicular to plane of the
  femoral head
• starting position anterior of the femoral neck
  and not lateral cortex

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SCFE Treatment to prevent further slippage

• In situ screw fixation
• avoid superior and anterior quadrant of femoral
  head
• following fixation screen whilst moving hip to
  ensure no penetration

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Severe Slip - Pin-in-situ
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SCFE Treatment to prevent further slippage

• In situ screw fixation
• cannulated screw
• 5.5 mm screw structural stiffness of two 4.5mm
  screws
• 7.5mm screw stiffness of unslipped epiphysis
• ?need for second screw in unstable hip

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SCFE Treatment to prevent further slippage

• In situ screw fixation
• early closure of physis (13 mths)
• Younger patients ? smooth pins, hook pin
• Complications chondrolysis and osteonecrosis

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SCFE Treatment to Reduce degree of slippage

• Closed manipulation
• Osteotomies
• concurrently with stabilisation or after physeal
  closure

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SCFE Treatment to Reduce degree of slippage

• Closed manipulation
• although after in situ pinning ROM improves this
  is in main due to resolution of synovitis and
  spasm. There is little remodelling
• Closed manipulation gt24hrs significantly
  increases the risk of osteonecrosis
• used in acute on chronic
• MUA v traction

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SCFE Treatment to Reduce degree of slippage

• Osteotomies
• more distal less correction at primary site of
  deformity
• more proximal more risk of osteonecrosis
• used in cases of severe slips

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Intertrochanteric - Southwick

• Compensatory osteotomy, the more distal the less
  correction at primary source of deformity.
• Maximum head-shaft correction is 50.
• Wedge removed therefore shortening.

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SCFE Treatment to Reduce degree of slippage

• Osteotomies
• Intertrochanteric
• single, bi or multiple-plane
• corrects 45
• low incidence of osteonecrosis, but chondrolysis
  rate 6-50
• ?subsequent THR

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SCFE Treatment to Reduce degree of slippage

• Osteotomies
• Cuneiform Osteotmy at femoral physis Fish/ Dunn
• Osteonecrosis 12-35
• Fish 3.5 osteonecrosis and 11 chondrolysis
• RNOH Experience
• JBJS (Br) 2006 88-B 1379-1384
• 88 PATIENTS (22/25 HIPS) EXCELLENT RESULT
• AVN RATE 12
• CHONDROLYSIS RATE 16 (OF WHICH 50 IMPROVED)
• 92 HAD NORMAL JOINT SPACE

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SCFE Treatment to Reduce degree of slippage

• Osteotomies
• Base of neck anterior wedge removed
• corrects 30-50,
• creates coxa breva

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Fish Cuneiform Osteotomy
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SCFE Prophylactic pinning of the contralateral hip

• if all contralateral hips were pinned 50-80
  treated unnecessarily
• FU till skeletal maturity
• Pin if symptoms present
• Pin known metabolic/endocrine disorders
• Pin if FU unreliable

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SCFE Osteonecrosis

• rare in untreated SCFE
• vascular injury, complication of treatment
• increase with severity of slip
• increase in acute, unstable slips
• increases with manipulation, pin placement in
  superior quadrant

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SCFE Osteonecrosis

• remove metal work
• maintain ROM
• realignment
• shelf acetabuloplasty
• arthrodesis/THR

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SCFE Salvage Procedures

• Management of avascular necrosis after Slipped
  upper femoral epiphysisM Mullins, M Sood, A
  Hashemi-Nejad, A CatterallJBJS (Br) 2005 87-B
  1669-74
• Use of Pamidronate to reduce risk of AVN

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SCFE Chondrolysis

• dissolution of articular cartilage with joint
  stiffness and pain
• Cause
• synovial malnutrition, ischaemia, excessive
  pressure
• Autoimmune
• Femalesgtmales

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SCFE Chondrolysis

• incidence 2-20
• higher in females, acute and severe slips
• manipulation, prolonged immobilisation,
  realignment osteotomies
• ? pin penetration
• exclude infection

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SCFE Chondrolysis

• relieved wt bearing, NSAID, ROM
• traction
• in pt therapy
• muscle release
• 3 yr to improve- 64 good outcome deterioration
  with time

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Thank you