Slipped capital femoral epiphysis. A report of 4 cases occurring in one family

A review of slipped capital femoral epiphysis

ABSTRACT

Hip pain in children is common, with causes ranging from the benign to destructive. This article reviews slipped capital femoral epiphysis (SCFE), one of the most common hip pathologies in preadolescents and adolescents, which often is missed or delayed in diagnosis because of its vague, atypical presentation.

Slipped capital femoral epiphysis with hypopituitarism in adults: A case report and literature review

RATIONALE

Slipped capital femoral epiphysis (SCFE) is a common disease in pediatric orthopedics. Most research on SCFE has focused on high-risk groups or the whole population, and studies focusing on adult SCFE patients are rare. In the present study, we report the case of an adult patient with SCFE.

PATIENT CONCERN

A 37-year-old man presented to our clinic with persistent pain that was poorly localized to both hips, groin regions, and thighs for more than 1 year.

DIAGNOSES

A bilateral hip X-ray examination was performed, and the femoral epiphyses were found to be unfused on both sides. Low levels of growth hormone (GH), insulin-like growth factor-1 (IGF-1), triiodothyronine (T3), thyroxine (T4), follicle-stimulating hormone, luteinizing hormone, estradiol, and testosterone, and high levels of thyroid-stimulating hormone, prolactin, and cortisol.

INTERVENTIONS

Hormone-substitution therapies (levothyroxine sodium to treat hypothyroidism and testosterone enanthate to treat hypogonadism) were prescribed. Total hip arthroplasty was performed to treat femoral epiphysis slippage.

OUTCOMES

After 6 months of postoperative follow-up, the patient's gait improved significantly, and bilateral hip pain was relieved.

LESSONS

When treating adults with SCFE, clinicians must be alert to endocrine disorders. Comprehensive imaging evaluation is crucial for the accurate diagnosis and selection of an appropriate treatment.

The Role of Hyperinsulinemia in Slipped Capital Femoral Epiphysis

BACKGROUND

Obesity in the prepuberal stage has been directly associated with slipped capital femoral epiphysis (SCFE). Serum insulin level increases in the prepuberal and adolescence stage, to a greater extent in the obese population. The main objective of this article was to analyze the relationship between insulin levels and SCFE.

METHODS

A case-control study was conducted between January 2018 and April 2019. The study group was formed with patients with SCFE and the control group with patients from the pediatric obesity clinic of our hospital selected during their initial evaluation. None were being treated for obesity. Anthropometric measurements of size, weight, waist circumference, and blood pressure were taken. Body mass index (BMI) and waist-height index of all patients were calculated. According to BMI for age, they were classified as normal, overweight, or obese. Serum determinations of glucose, insulin, glycated hemoglobin, lipid profile, and complete blood count were analyzed. Insulin resistance was diagnosed with Homeostatic Model Assessment (HOMA) >3. Insulin levels >13 U/mL for girls and >17 U/mL for boys were considered as hyperinsulinemia.

RESULTS

We studied 14 patients with SCFE and 23 in the control group. The mean age and BMI in both groups were similar. The elevation of serum insulin was significantly higher in the SCFE group (P=0.001) as was HOMA (P=0.005). Triglycerides and very-low-density lipoprotein were higher in the SCFE group (P=0.037 and 0.009, respectively). Glycemia, glycated hemoglobin, total cholesterol, high-density lipoprotein, low-density lipoprotein, and neutrophils showed no significant difference.

CONCLUSIONS

Patients with SCFE showed elevated levels of insulin, HOMA, triglycerides, and very-low-density lipoprotein, even higher than the control group. Our study demonstrates a significant association between abnormally high serum insulin levels and SCFE. The known effects of insulin on growth cartilage may explain the physeal mechanical insufficiency to support the abnormally high or repetitive loads in accelerated growth stages that lead to SCFE.

LEVEL OF EVIDENCE

Level III-case-control, prognostic study.

[Slipped capital femoral epiphysis-etiology and pathogenesis]

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is the most significant hip disease in adolescence. Because of its typical occurrence at the time of the pubertal growth spurt and some particular clinical symptoms, it has been a topic of special interest in orthopedic research for a long time. A large number of etiological factors have been described, however their meaning in detail is still controversial.

OBJECTIVES

After a short summary of the structure and function of the epiphysis, an overview of concepts in the pathogenesis of SCFE is given.

MATERIALS AND METHODS

A selective review of literature was performed.

RESULTS

Etiology of SCFE includes genetic, endocrinologic, histochemical and biomechanical factors. During puberty, obesity together with reduced femoral antetorsion are the main risk factors for the disease. The rarer atypical SCFE is closely related to metabolic disorders or other chronical diseases. The pathogenesis is characterized by the disproportion between the load-bearing capacity of the epiphysis and the acting forces on the proximal femur.

CONCLUSIONS

The concept of the multifactorial etiology of SCFE is convincing. The susceptibility of the femoral epiphysis is explained considering the remarkable biomechanic local forces. The initial damage can be shown on the histological and the histochemical level. Important new aspects refer to the leptin-metabolism. However, in the majority of cases, biomechanical factors seem to be more significant than endocrinological phenomena. A complete understanding has not succeeded to date.

Slipped capital femoral epiphysis in 17 Maine Coon cats

Objectives

From May 2009 to January 2015, 208 Maine Coon cats presented to the Tierklinik Hollabrunn – a small animal referral and first-opinion centre – and 17 (8.17%) cats were diagnosed with a slipped capital femoral epiphysis (SCFE). Over the same time period, 29 (0.67%) of 4348 cats (all breeds) were diagnosed with SCFE.

Methods

Clinical and orthopaedic examinations and diagnostic imaging were performed on all affected Maine Coons. Age at first presentation, sex, body weight, body condition score (BCS), unilateral or bilateral manifestation of the disease, activity level and duration of lameness, age at neutering and known family history of disease were recorded. Sixteen of 17 Maine Coons were surgically treated. Surgically removed femoral tissue samples were histologically examined in 13 cases.

Results

The mean age at first presentation was 21.47 months; male to female ratio was 16:1; mean body weight was 7.5 kg (range 5.3–9.3 kg); and mean BCS was 5.06/9.0. Seven cats were bilaterally affected; the median duration of decreased activity level and lameness was 2 weeks; mean age at neutering was 7.7 months (range 3.0–12.0 months); and four cats were littermates. Fourteen femoral head and neck ostectomies, eight total hip replacements and one primary fixation were performed. All 13 histologically available samples confirmed the diagnosis of SCFE.

Conclusions and relevance

To date, SCFE has been reported only occasionally in Maine Coon cats. However, the results of this study showed that Maine Coons were approximately 12-fold more likely to develop SCFE than the overall population of cats presenting to the Tierklinik Hollabrunn over the same time period. Male sex, neutering, delayed physeal closure and breed-specific high body weight may play an important role in the pathogenesis of SCFE in Maine Coon cats.

The epidemiology and demographics of slipped capital femoral epiphysis

The etiology of slipped capital femoral epiphysis (SCFE) is unknown with many insights coming from epidemiologic/demographic information. A systematic medical literature review regarding SCFE was performed. The incidence is 0.33/100,000 to 24.58/100,000 children 8 to 15 years of age. The relative racial frequency, relative to Caucasians at 1.0, is 5.6 for Polynesians, 3.9 for Blacks, and 2.5 for Hispanics. The average age is 12.0 years for boys and 11.2 years for girls. The physiologic age when SCFE occurs is less variable than the chronologic age. The average symptom duration is 4 to 5 months. Most children are obese: >50% are >95th percentile weight for age with average BMI is 25-30 kg/m(2). The onset of SCFE is in the summer when north of 40°N. Bilaterality ranges from 18 to 50%. In children with bilateral involvement, 50-60% present with simultaneous SCFEs and those who present with a unilateral SCFE and subsequently develop a contralateral SCFE do so within 18 months. The age at presentation is younger for those who present with a unilateral SCFE and later develop a contralateral SCFE. The age-weight, age-height, and height test are useful to differentiate between an idiopathic and atypical SCFE.

Three cases of slipped capital femoral epiphysis in one family

Slipped capital femoral epiphysis is a relatively common disorder of the hip that affects children in late childhood and early adolescence, with an incidence in the United States of approximately 10 per 100,000. Although the diagnosis and treatment of slipped capital femoral epiphysis have been well described, the search for its cause and a method of early identification continues. Recent publications have suggested that there is a familial association among individuals with slipped capital femoral epiphysis, but there is no current genetic marker established for the disorder. This article reports a series of 3 biologically related Caucasian sisters who were athletic; had body mass indices <26 kg/m(2); had no record of any hormonal imbalances or endocrine abnormalities; had good nutrition; and presented with atypical characteristics of slipped capital femoral epiphysis. This is the first report of a series of 3 sisters with slipped capital femoral epiphysis in the United States. Our goals were to document our experience in the identification and treatment of these patients to highlight the complexities of slipped capital femoral epiphysis presentation patterning, to increase the awareness and reporting of familial cases of slipped capital femoral epiphysis by other physicians, and to encourage additional research in this area. As clinicians progress in the ability to diagnose and treat patients with slipped capital femoral epiphysis, they also must be mindful of the varying presentation characteristics.

Slipped Capital Femoral Epiphysis as a Complication of Growth Hormone Therapy

Slipped capital femoral epiphysis (SCFE) is a rare complication of growth hormone (GH) therapy. Here, we report three patients who developed SCFE during GH therapy. The first two patients had hypopituitarism and had started GH therapy at the age of 15 years 6 months and 13 years 9 months, respectively. SCFE developed 4 years and 1 year after GH therapy, respectively. The third patient had Prader-Willi syndrome with obesity and hypogonadism and began GH therapy at the age of 12 years and 11 months. SCFE developed 2 months after starting GH therapy. Pain over the hip joints or over the knees is an early sign of SCFE. Despite recommendation, none of the three patients continued GH therapy. A high index of suspicion during GH therapy in patients at high risk of SCFE is important for early diagnosis and appropriate management.

[Slipped capital femoral epiphysis and overweight]

The slipped capital femoral epiphysis (SCFE) is defined as a nontraumatic epiphyseal separation and slipping of the proximal femoral epiphysis, which usually occurs during the adolescent growth spurt. Slipping of the upper femoral epiphysis may be classified as acute, chronic, and acute on chronic. The etiology of the disease is still not fully understood but seems to be multifactorial. The typical SCFE during puberty has to be differentiated from the atypical form, which may be associated with an endocrinological disorder or with its therapy. The typical SCFE may be found in male patients, with increased height and weight. It is likely that the growth rate is slightly accelerated before slippage. Obesity is often associated with a decreased femoral anteversion accounting for abnormal mechanical shear forces at the growth plate. SCFE is treated surgically. Surgical methods are administered according to the degree of disease. Because of possible alterations of blood supply to the femoral head, acute SCFE is an emergency. Following SCFE, complications such as chondrolysis and avascular necrosis are feared.

Idiopathic slipped capital femoral epiphysis in Amish children

BACKGROUND

Of the many studies of slipped capital femoral epiphysis, none have specifically addressed Amish children. The Amish reflect a small gene pool relative to the general white North American population. Additional knowledge of the demographics of this disorder in Amish children may provide genetic insights. The purpose of this study was to review the demographics of slipped capital femoral epiphysis in the Amish population.

METHODS

A retrospective review of the cases of twenty-five Amish children with slipped capital femoral epiphysis treated at two institutions was performed. The child's gender, age, weight, height, and body mass index at the time of the diagnosis; duration of symptoms; laterality of the slip; birth weight; family history; and slip severity were recorded. The slip was classified as stable or unstable. Patients who had been included in a previously published multicenter study served as a control group.

RESULTS

There were seventeen boys and eight girls with a total of thirty-three slipped capital femoral epiphyses; eight of the slips were bilateral. At the time of the diagnosis, the mean age (and standard deviation) was 13.4 +/- 1.6 years, the mean weight and height were 55.6 +/-12.4 kg and 155.5 +/- 10.2 cm, and the mean body mass index was 23.4 +/- 5.4 kg/m(2). The mean duration of symptoms was 6.6 +/-9.0 months. There were thirty-one stable and two unstable slips with a mean slip angle of 38 degrees +/- 20 degrees . Nine (39%) of twenty-three children for whom the information had been recorded had a positive family history of slipped capital femoral epiphysis, a rate that is higher than the 9% and 14.5% rates reported in two other series (p = 0.002). The Amish children were not as heavy as their non-Amish counterparts (55.6 +/- 12.4 kg compared with 66.4 +/- 17.7 kg, p = 0.0036).

CONCLUSIONS

Although the children in this study were moderately heavy, they could not be classified as obese on the basis of weight-for-age or body-mass-index percentiles. The high prevalence of family members with slipped capital femoral epiphysis may reflect either a genetic or environmental component, or an interaction between genetics and environment (for example, work load or common chores requiring particular physical positions) in the Amish population.

Physeal dysplasia with slipped capital femoral epiphysis in 13 cats

Separation of the femoral capital epiphysis is associated with severe trauma in most species. This report describes 13 cats with slipped capital femoral epiphysis characterized by a distinctive lesion in the physeal cartilage. The lesion consists of irregular clusters of chondrocytes separated by abundant matrix on both the epiphyseal and metaphyseal side of the cleavage site. The affected population in this study is 85% male, 90% overweight, 23% Siamese, and 4.5-24 months old. The histopathology and demographics are similar to slipped capital femoral epiphysis in humans, which most often affects overweight adolescent boys.