Slipped Capital Femoral Epiphysis Surgery

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Slipped capital femoral epiphysis (SCFE) was first described by Ernst Müller, who called it Schenkelhalsverbiegungen im Jungesalter (“bending of the femoral neck in adolescence”). The term slipped capital femoral epiphysis is actually a misnomer, because the epiphysis is held in the acetabulum by the ligamentum teres; thus, the metaphysis actually moves proximally and anteriorly while the epiphysis remains in the acetabulum. (See the image below.)

In most patients, SCFE appears radiographically as a varus relation between the head and the neck. [1] Occasionally, the slip appears to be in a valgus position, with the epiphysis displaced superiorly in relation to the neck. [2, 3, 4, 5, 6] In the vast majority of cases, the etiology is unknown, though slips may be associated with a known endocrine disorder, with renal failure osteodystrophy, or with previous radiation therapy. [7, 8, 9, 10, 11]

SCFE is not life-threatening. However, untreated and complicated SCFE can lead to deformity and early osteoarthrosis of the hip and thus can cause considerable morbidity. Factors that increase morbidity include avascular necrosis (AVN) of the hip and chondrolysis. Both of these may result in damage severe enough to warrant a salvage procedure, in the form of an arthrodesis or a total hip arthroplasty. Prompt diagnosis is critical to prevent further deformity and AVN. The diagnosis is often subtle, and (eg, groin or knee pain) can be misleading.

SCFE develops as a consequence of increased stresses across a weakened physis, with a combination of both biomechanical and biochemical factors contributing to the development of the slip. Factors affecting the stability of the physis include the following:

Mechanical factors leading to increased stress across the physis [12] include the following:

SCFE is most common in the peripubertal age group; the effect of the following hormones on the physes may contribute to the likelihood of developing a slip [21] :

Even though most children with SCFE do not have an overt endocrinopathy, they may very well have some subtle endocrine disorder. [24, 25, 26, 27, 28] A delay in bone age with respect to chronologic age in some of these children lends further credence to this theory. [22, 23]

Shear stresses across a physis made vulnerable by the biomechanical and biochemical factors outlined above leads to the slip. The displacement is determined by the direction of the deforming force. Posteroinferior displacement of the head (anterosuperior migration of the neck) is the most common pattern, though in rare cases, the head may displace posterosuperiorly, giving rise to an apparent valgus slip (see the image below). [2, 3]

Various causative factors for SCFE have been identified. Factors related to body habitus include the following:

If the patient’s height is below the 10th percentile, the likelihood of an underlying endocrinopathy is high. [30, 31] Endocrinopathies that may be present include the following:

Radiation therapy, especially for childhood leukemias or lymphomas, may be involved in the development of SCFE:

Finally, renal failure is an important factor:

The prevalence of SCFE varies widely even within the continental United States. It has been reported to be 2.13 cases per 100,000 population in the southwestern United States and 10.08 cases per 100,000 population in the northeastern United States [17] ; it is lowest in the mountain and Great Plains states. In Asia, the reported prevalence is quite low, with just 0.2 cases per 100,000 children affected in eastern Japan. [32]

The mean age at diagnosis is 13.5 years in boys (range, 13-15 years) and 12 years in girls (range, 11-13 years). [18]  This corresponds to the period of maximum skeletal growth. Juvenile SCFE (in children <10 years) should raise the suspicion of an underlying cause (eg, an endocrinopathy). Radiation-associated slips tend to occur in young children.

Males are affected more commonly than females are; the male-to-female ratio is 2-5:1.

A race predilection exists for SCFE, as follows [18] :

If the SCFE is mild or moderate in severity and is maintained between the femoral head and the acetabulum, long-term outcome is good, and AVN and chondrolysis do not develop. Hips with a severe SCFE and those with AVN or chondrolysis undergo more rapid deterioration with degenerative changes and ultimately require reconstructive procedures.

Murgier et al carried out a single-center, retrospective study assessing clinical and radiographic outcomes of in situ fixation for SCFE in 11 hips followed for a mean of 26 years (range, 10-47 years). [33]  They found that in moderate-to-severe SCFEs, in situ fixation yielded poor functional results, substantial hip osteoarthritis, and potential femoroacetabular impingement, whereas with minor displacement, it yielded satisfactory functional and radiographic results. The cutoff point for considering other treatment options appeared to be about 30° of slippage.

Nectoux et al performed a multicenter retrospective study evaluating the clinical and radiologic evolution of 222 hips treated with in situ fixation and followed for a mean of 11.2 years. [34]  In cases of moderate-to-severe initial epiphyseal displacement, in situ fixation led to hip impingement; however, in cases of lesser displacement, it yielded satisfactory function scores, with no clinical or radiologic evidence of impingement. The threshold seemed to be about 35° of slippage; the authors suggested that beyond this value, other surgical options should be considered.

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Mihir M Thacker, MBBS, MS(Orth), DNB(Orth), FCPS(Orth), D’Ortho Associate Professor of Orthopedic Surgery and Pediatrics, Jefferson Medical College of Thomas Jefferson University; Consulting Staff, Department of Pediatric Orthopedic Surgery, Alfred I duPont Hospital for Children; Orthopedic Oncologist, Helen F Graham Cancer Center and Christiana Care Health Services

Mihir M Thacker, MBBS, MS(Orth), DNB(Orth), FCPS(Orth), D’Ortho is a member of the following medical societies: Children&#8217;s Oncology Group, Medical Council &#111;&#102; India, Musculoskeletal Tumor Society, Pediatric Orthopaedic Society &#111;&#102; North America, Limb Lengthening &#097;&#110;&#100; Reconstruction Society

Disclosure: Nothing to disclose.

Michael S Clarke, MD Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy &#111;&#102; Orthopaedic Surgeons, Arthroscopy Association &#111;&#102; North America, American Academy &#111;&#102; Pediatrics, American Association &#102;&#111;&#114; Hand Surgery, American College &#111;&#102; Surgeons, American Medical Association, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, Missouri State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for . for: Medscape.

James J McCarthy, MD, FAAOS, FAAP Director, Division of Orthopedic Surgery, Cincinnati Children’s Hospital; Professor, Department of Orthopedic Surgery, University of Cincinnati College of Medicine

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: American Academy &#111;&#102; Pediatrics, American Orthopaedic Association, Pennsylvania Medical Society, Philadelphia County Medical Society, Pennsylvania Orthopaedic Society, Pediatric Orthopaedic Society &#111;&#102; North America, Orthopaedics Overseas, Limb Lengthening &#097;&#110;&#100; Reconstruction Society, Alpha Omega Alpha, American Academy &#102;&#111;&#114; Cerebral Palsy &#097;&#110;&#100; Developmental Medicine, American Academy &#111;&#102; Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Orthopediatrics, Phillips Healthcare, POSNA&lt;br/&gt;Serve(d) as a speaker or a member of a speakers bureau for: Synthes&lt;br/&gt;Received research grant from: University of Cincinnati&lt;br/&gt;Received royalty from Lippincott Williams and WIcins for editing textbook; Received none from POSNA for board membership; Received none from LLRS for board membership; Received consulting fee from Synthes for none.

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy &#111;&#102; Orthopaedic Surgeons, American Orthopaedic Association, American College &#111;&#102; Surgeons, Eastern Orthopaedic Association, New York Academy &#111;&#102; Medicine

Disclosure: Received consulting fee from Stryker Orthopaedics for speaking and teaching.

Steven I Rabin, MD Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Musculoskeletal Services, Dreyer Medical Clinic

Steven I Rabin, MD is a member of the following medical societies: American Academy &#111;&#102; Orthopaedic Surgeons, American College &#111;&#102; Forensic Examiners Institute, American College &#111;&#102; Surgeons, American Fracture Association, American Orthopaedic Association, AO Foundation, Chicago Metropolitan Trauma Society, Illinois Association &#111;&#102; Orthopaedic Surgeons, Limb Lengthening &#097;&#110;&#100; Reconstruction Society, Mid-America Orthopaedic Association, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

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