Is the timing of surgery associated with avascular necrosis after unstable slipped capital femoral epiphysis? A multicenter study

How Urgent Are Stable SCFEs? A Multisite Retrospective Study of Surgical Timing and Complications Among Patients With Stable Slipped Capital Femoral Epiphysis

BACKGROUND

Stable slipped capital femoral epiphysis (SCFE) is often considered semi-urgent, prompting admission for in situ screw fixation (ISF), which may increase the cost/burden of care. Avascular necrosis (AVN) affects 25% to 50% of patients with unstable SCFE, yet it is uncommon after stable SCFE. Among patients presenting with stable SCFE, little is known about the relationship between diagnosis and surgical timing with regard to slip progression or complications.

METHODS

This retrospective observational study included all patients younger than 18 years with stable SCFE at initial diagnosis treated with ISF between 2000 and 2020 at 4 centers. Patients with Loder unstable SCFE at the time of initial SCFE diagnosis were excluded. Timing data included time from (1) symptom onset to diagnosis, (2) symptom onset to surgical team evaluation, (3) symptom onset to surgery, (4) diagnosis to surgical team evaluation, (5) surgical team evaluation to surgery, and (6) diagnosis to surgery. Regression analyses explored relationships between timing and slip progression to unstable, subsequent procedures, and complications as graded by the modified Clavien-Dindo-Sink system.

RESULTS

A total of 298 patients with 362 stable SCFEs were included. The mean time from symptom onset to diagnosis was 134 days, from diagnosis to surgical team evaluation was 3.2 days, and from surgical team evaluation to surgery was 2.1 days. The mean follow-up was 2.4 years. Eighteen percent of hips were affected by a complication. Two patients initially diagnosed with stable SCFE progressed to unstable SCFE, having experienced falls after diagnosis and before orthopaedic evaluation; one of these went on to develop AVN. Time elapsed between symptom onset, diagnosis, surgical team evaluation, and surgery was not associated with the incidence or severity of complications or subsequent procedure.

CONCLUSIONS

The urgency of surgical treatment of stable SCFE does not appear to affect mid-term outcomes. If surgical management of stable SCFE is not performed urgently, it is critical to avoid weight bearing and falls to reduce progression to an unstable SCFE.

LEVEL OF EVIDENCE

Level III, therapeutic.

Age-stratified analysis of delayed fixation outcomes of femoral neck fracture among adults: A retrospective study at a tertiary care trauma center

ObjectiveThis study investigated the delayed fixation outcomes of femoral neck fractures stratified by age and surgical delay in adult patients at a tertiary care trauma center.MethodA retrospective study was conducted involving patients with femoral neck fractures admitted to the orthopedic ward of the Shaheed Mohtarma Benazir Bhutto Institute of Trauma between January 2019 and March 2023. Participants aged 18-60 years who underwent delayed surgery (>48 h) were included. Data on patient demographics, fracture and surgical characteristics, and outcomes were analyzed. This study utilized chi-square or Fisher's exact tests to compare outcomes between patients stratified by surgical delays as well as age.ResultsAmong 108 participants, 63.9% were aged 18-30 years and 36.1% were aged 31-60 years. Avascular necrosis was predominantly observed in older patients who underwent surgery within 7 days (P  = 0.001), whereas other complications such as nonunion and infection were more prevalent in patients aged 18-30 years whose surgery was delayed by >7 days (P  = 0.303). Patients who underwent surgery within 7 days had shorter length of hospital stay and faster return to work in both age groups (P < 0.05), whereas those aged 18-30 years experienced the opposite when surgery was delayed beyond 7 days.ConclusionsSurgical fixation within 7 days leads to better recovery and fewer complications in adults with femoral neck fractures, whereas delayed surgery provides acceptable outcomes. Age-specific protocols are key to optimizing results.

Favourable outcome of severe, unstable grade III slipped capital femoral epiphysis managed by closed reduction percutaneous pinning with mid-term follow up: A case report and literature review

INTRODUCTION AND IMPORTANCE

Slipped capital femoral epiphysis (SCFE) is one of the most common hip pathology in adolescents. Outcome of SCFE management largely depends on the grading of the pathology. Severe, unstable SCFE poses high risk for avascular necrosis (AVN). The objective of this study is to report a good outcome without AVN in an acute, unstable, high grade SCFE managed by closed reduction and percutaneous pinning along with factors that need to be given consideration.

CASE PRESENTATION

A 13 years old boy was unable to bear weight due to severe pain on right hip after trauma since 2 weeks. Patient was diagnosed with acute, unstable high grade SCFE, patient underwent closed reduction and percutaneous pinning (CRPP) using cannulated screw and K wire augmented with spica cast. At 12 weeks patient was already fully active. At 18 month follow up there was no sign of AVN with full hip range of movement.

CLINICAL DISCUSSION

Treatment for unstable, severe SCFE is still challenging. Unreduced severe slippage will deliver serious impingement and end up with early degenerative arthritis. The magnitude of reduction in a severe, unstable SCFE poses high risk for AVN. While some studies claimed reduction is justified only when it is serendipitous, we successfully and purposely performed CRPP.

CONCLUSION

Even after 2 weeks from onset, an acute and severe slippage can still be reduced closely and fixed percutaneously. The hip regain full range of motion with no sign of AVN on x ray at 18 months follow up.

Subcapital realignment osteotomy for the treatment of moderate and severe slipped upper femoral epiphysis: A retrospective study of 123 hips in a tertiary center

Background

The surgical treatment of moderate and severe slipped capital femoral epiphysis is controversial. Treatment ranges from pinning in situ to open dislocation and reduction of the slipped epiphysis. The modified Dunn procedure has been associated with variable avascular necrosis with rates, ranging between 0% and 67%. The aim of this study was to evaluate the outcomes and complications of patients who have undergone a subcapital realignment osteotomy (SCRO) in our center.

Methods

A retrospective longitudinal study of the osteotomies performed between 2009 and 2019 in a tertiary referral center for Pediatric Orthopedics in Queensland, Australia. Patient demographics, stability, and severity of slip and surgical outcomes were collected.

Results

A total of 123 procedures were performed on 116 patients. The mean age was 12.4 years, 65 (56%) patients were male and the mean posterior sloping angle was 60.10 with 93 (75%) being severe slips. There were 51 (41.5%) Loder's stable and 72 (58%) unstable slipped capital femoral epiphysis. Our overall avascular necrosis rate following SCRO was 17.8%. Time between surgery and diagnosis did not have an effect on avascular necrosis.

Conclusion

The subcapital realignment osteotomy remains a controversial and complex procedure for the management of moderate and severe slipped capital femoral epiphysis. We found that our cohort demonstrated an avascular necrosis rate in keeping with the existing literature. This indicates that when performed in a high-volume center with experienced surgical staff, it can be an effective treatment option for these patients.

Level of evidence

Level IV.

Prevalence of Avascular Necrosis Following Surgical Treatments in Unstable Slipped Capital Femoral Epiphysis (SCFE): A Systematic Review and Meta-Analysis

The choice of treatment for unstable and severely displaced slipped capital femoral epiphysis (SCFE) is controversial. This meta-analysis was conducted to determine the prevalence of femoral head avascular necrosis (AVN) following various treatments for unstable SCFE. Various databases were searched to identify articles published until 4 February 2022. A random-effects model was used to examine prevalence as well as risk ratios with confidence intervals (CIs) of 95%. Thirty-three articles were analyzed in this study. The pooled prevalences of AVN in pinning in situ, pinning following intentional closed reduction, pinning following unintentional closed reduction, and open reduction via the Parsch method, subcapital osteotomy and the modified Dunn procedure were 18.5%, 23.0%, 27.6%, 9.9%, 18.6% and 19.9%, respectively. The risk of developing AVN in pinning following intentional closed reduction was found to be 1.62 times higher than pinning in situ; however, this result was not significant. The prevalence of AVN in open reduction was lowest when performed via the Parsch method; however, this finding should be interpreted with caution, since the majority of slips so-treated are of mild and moderate types as compared with the subcapital osteotomy and modified Dunn procedures, which are predominantly used to treat severely displaced slips. As the risk ratio between intentional closed reduction and the modified Dunn method showed no significant difference, we believe that the modified Dunn method has the advantage of meticulously preserving periosteal blood flow to the epiphysis, thus minimizing AVN risk. In comparison with intentional closed reduction, the modified Dunn method is used predominantly in cases of severe slips.

The British Orthopaedic Surgery Surveillance study: slipped capital femoral epiphysis: the epidemiology and two-year outcomes from a prospective cohort in Great Britain

AIMS

The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE).

METHODS

This was an anonymized comprehensive cohort study, with a nested consented cohort, following the the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) framework. A total of 143 of 144 hospitals treating SCFE in Great Britain participated over an 18-month period. Patients were cross-checked against national administrative data and potential missing patients were identified. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants.

RESULTS

A total of 486 children (513 hips) were newly affected, with a median of two patients (interquartile range 0 to 4) per hospital. The annual incidence was 3.34 (95% confidence interval (CI) 3.01 to 3.67) per 100,000 six- to 18-year-olds. Time to diagnosis in stable disease was increased in severe deformity. There was considerable variation in surgical strategy among those unable to walk at diagnosis (66 urgent surgery vs 43 surgery after interval delay), those with severe radiological deformity (34 fixation with deformity correction vs 36 without correction) and those with unaffected opposite hips (120 prophylactic fixation vs 286 no fixation). Independent risk factors for avascular necrosis (AVN) were the inability of the child to walk at presentation to hospital (adjusted odds ratio (aOR) 4.4 (95% CI 1.7 to 11.4)) and surgical technique of open reduction and internal fixation (aOR 7.5 (95% CI 2.4 to 23.2)). Overall, 33 unaffected untreated opposite hips (11.5%) were treated for SCFE by two-year follow-up. Age was the only independent risk factor for contralateral SCFE, with age under 12.5 years the optimal cut-off to define 'at risk'. Of hips treated with prophylactic fixation, none had SCFE, though complications included femoral fracture, AVN, and revision surgery. PROMs demonstrated the marked impact on quality of life on the child because of SCFE.

CONCLUSION

The experience of individual hospitals is limited and mechanisms to consolidate learning may enhance care. Diagnostic delays were common and radiological severity worsened with increasing time to diagnosis. There was unexplained variation in treatment, some of which exposes children to significant risks that should be evaluated through randomized controlled trials. Cite this article: Bone Joint J 2022;104-B(4):519-528.

Controversies in the Management of Unstable Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) involves anterior-superior displacement of the proximal metaphysis relative to the epiphysis of the proximal femur. It is the most common hip disorder affecting the pediatric population. SCFE has a higher incidence in adolescent males in addition to racial and regional predilections. Despite being described over 500 years ago, there remains controversy surrounding the topic. This article examines current concepts in SCFE, with a spotlight on treatment. An evidence-based discussion of treatment controversies regarding reduction method, fixation construct, supplemental procedures and surgical timing is included.

The modified Dunn procedure can be performed safely in stable slipped capital femoral epiphysis but does not alter avascular necrosis rates in unstable cases: a large single-centre cohort study

PURPOSE

The modified Dunn procedure for slipped capital femoral epiphysis (SCFE) remains controversial. We reviewed our series over ten years to report our learning curve, experience with intraoperative monitoring of femoral head perfusion and its correlation with postoperative Single-photon emission computed tomography (SPECT-CT) bone scan and femoral head collapse in stable and unstable SCFE.

METHODS

We retrospectively assessed 217 consecutive modified Dunn procedures performed between 2008 and 2018. In all, 178 had a minimum of one-year follow-up (mean 2.7 years (1 to 9.2)) including 107 stable and 71 unstable SCFE. Postoperative viability was assessed with a three-phase Tc99 bone scan and SPECT-CT. From 2011, femoral head perfusion monitoring was performed intraoperatively using a Codman Intracranial Pressure transducer and the capsulotomy was modified.

RESULTS

With intraoperative monitoring, the rate of non-viable femoral heads in stable SCFE decreased from 21.1% to 0% (p < 0.001). In unstable SCFE, the rate remained unchanged from 35.7% to 29.8% (p = 0.669). The positive predictive value (PPV) of pulsatile monitoring for no collapse was 100% in stable and 89.1% in unstable SCFE. Pulsatile monitoring and viable SPECT-CT bone scan gave a 100% PPV for all cases. A non-viable scan defines those hips at risk of collapse since 100% of stable and 68.2% of unstable hips with non-viable bone scans went on to collapse.

CONCLUSION

Our protocol enables safe performance of this complex procedure in stable SCFE with intraoperative monitoring being a reliable asset. The avascular necrosis rate for unstable SCFE remained unchanged and further research into its best management is required.

LEVEL OF EVIDENCE

Level III.

Diagnosis and Management of Unstable Slipped Capital Femoral Epiphysis: A Critical Analysis Review

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An unstable slipped capital femoral epiphysis (SCFE) is characterized by the inability to walk and is associated with a high risk of osteonecrosis.

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An unstable SCFE is less common than a stable SCFE; however, the demographics are similar in both groups of patients with SCFE.

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The diagnosis of an unstable SCFE is characterized by a history of antecedent pain and the inability to walk on examination, and it is confirmed by radiographic assessment.

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Management of an unstable SCFE includes closed reduction, open reduction, and capital realignment, which have all been noted to have lower rates of osteonecrosis than reported in historic reports.

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All management approaches have certain advantages and disadvantages, and comparative studies are needed to guide clinical decision-making.

[Fixation techniques for slipped capital femoral epiphysis : Principles, surgical techniques, and complications]

The purpose of this review is to present the pros and cons as well as the surgical techniques of conventional implants used for fixation of slipped capital femoral epiphysis (SCFE). Worth mentioning are K‑wires, Hansson pins, transfixing screws, and gliding screws. We searched PubMed for "ECF" and "SCFE" in combination with "in situ fixation," "pin," "wire," "screw," and "nail." We considered Johansson nail, Knowles pin, and Nyström nail to be obsolete and of historical interest only. We noticed a trend from absolute stability towards some form of dynamic fixation over time, likely related to considerations of growth disturbance of the proximal femur and also the inherent potential for remodeling with time.

Patterns of Pain in Adolescents with Slipped Capital Femoral Epiphysis

OBJECTIVE

To prospectively characterize pain locations in slipped capital femoral epiphysis (SCFE) and evaluate pain locations as predictors of a delay in diagnosis.

STUDY DESIGN

This was an institutional review board approved prospective study of 110 children who underwent surgery for SCFE at a tertiary children's hospital between 2009 and 2015. Standardized pain diagrams were completed by 107 children. Pain zones were designated via a composite diagram. Hips without hip pain were categorized as atypical; hips with hip pain were typical.

RESULTS

In total, 122 hips were eligible for pain zone analysis. Seventy hips (57.4%) had hip pain. Atypical pain was present in 52 hips (42.6%), which included groin pain in 17 hips (13.9%), thigh/leg pain in 43 (35.2%), knee pain in 32 (26.2%), and posterolateral pain of the hip and leg in 13 (10.7%). A combination of pain zones was present in 48 hips (39.3%). Forty-nine percent of patients had more than 1 visit until diagnosis. The three most common pain locations for typical hips were hip, hip/thigh, and hip/knee pain (77.2% of typical hips). The 3 most common pain locations for atypical hips were isolated thigh, knee, and groin (65.4% of atypical hips). The least common pain presentations had a longer duration of symptoms (P = .04) and more healthcare visits before diagnosis (P = .04).

CONCLUSIONS

A combination of pain locations is common in SCFE. Less frequent pain presentations may delay diagnosis. Delays in diagnosis continue despite education efforts.

Outcomes after slipped capital femoral epiphysis: a population-based study with three-year follow-up

PURPOSE

To evaluate outcomes three years after treatment for slipped capital femoral epiphysis (SCFE): development of avascular necrosis (AVN), subsequent surgery, hip function and the contralateral hip.

METHODS

This prospective cohort study included a total national population of 379 children treated for SCFE between 2007 and 2013. A total of 449 hips treated for SCFE and 151 hips treated with a prophylactic fixation were identified. The Barnhöft questionnaire, a valid patient-reported outcome measure (PROM), was used.

RESULTS

In all, 90 hips had a severe slip, 61 of these were clinically unstable. AVN developed in 25 of the 449 hips. Six of 15 hips treated with capital realignment developed AVN. A peri-implant femur fracture occurred in three slipped hips and in two prophylactically pinned hips. In three of these five hips technical difficulties during surgery was identified. In 43 of 201 hips scheduled for regular follow-up a subsequent SCFE developed in the contralateral hip. Implant extraction after physeal closure was performed in 156 of 449 hips treated for SCFE and in 51 of 151 prophylactically fixed hips. Children with impaired hip function could be identified using the Barnhöft questionnaire.

CONCLUSION

Fixation in situ is justified to remain as the primary treatment of choice in SCFE. Overweight is more common in children with SCFE than in the average population. Prophylactic fixation is a safe procedure when performed using a correct technique. The number of patients who developed AVN after capital realignment is of concern. We recommend rigorous follow-up of both hips, including PROM evaluation, until physeal closure.

LEVEL OF EVIDENCE

II - prospective cohort study.

Diagnosis and treatment of slipped capital femoral epiphysis: Recent trends to note

Slipped capital femoral epiphysis (SCFE) is not frequently encountered during routine practice and diagnosis and treatment are often delayed. It is important to understand symptoms and imaging features to avoid delayed diagnosis. After the diagnosis is made correct classification of the disease is required. The classification should be based on the physeal stability in order to choose safe and effective treatment. However, surgeons should bear in mind that the assessment is challenging and actual physeal stability is not always consistent with the stability predicted by a clinical classification method.

TREATMENT OF STABLE SCFE

Closed reduction is not indicated for stable SCFE, where continuity between the epiphysis and metaphysis has not been disrupted. Treatment method(s) is (are) chosen from in-situ fixation, osteotomy and femoroacetabular impingement treatment. A single screw fixation is often used to fix the epiphysis and the dynamic method is considered especially for young patients. Traditional three-dimensional trochanteric osteotomies have been associated with procedural complexity and uncertainty. A simpler osteotomy method using an updated imaging analysis technology should be considered. Modified-Dunn procedure is indicated for a severe stable SCFE. However, caution is required because recent studies have reported a high rate of complications including postoperative femoral head avascular necrosis (AVN) and hip instability when this method is indicated for stable SCFE.

TREATMENT OF UNSTABLE SCFE

Treatment of unstable SCFE is difficult and complication rate is high. Most of unstable SCFE patients were previously treated with closed method and it was difficult to predict an occurrence of postoperative AVN. However, treatment of unstable SCFE has gradually changed in recent years and many studies have shown that physeal hemodynamics can be assessed during treatment. Preoperative assessments include contrast-enhanced MRI and bone scintigraphy. Intraoperative assessments include confirmation of bleeding after drilling the femoral head and monitoring the intracranial pressure by laser doppler flowmetry. It is expected that postoperative AVN can be prevented in many cases by performing the treatment while assessing the intraoperative physeal hemodynamics. Open surgeries have begun to be indicated in the treatment of unstable SCFE through either of anterior approach or (modified) Dunn procedure. The authors expect that recent improvements in assessment of physeal hemodynamics and open treatment method provide improved clinical outcomes in the treatment of SCFE.

Percutaneous pinning after prolonged skeletal traction with the hip in a flexed position for unstable slipped capital femoral epiphysis: A case series of 11 patients

BACKGROUND

Unstable slipped capital femoral epiphysis (SCFE) has a relatively high risk of avascular necrosis of the femoral head. Standard treatment for unstable SCFE is still controversial. We reviewed unstable SCFE case series treated with the standardized protocol, which consisted of percutaneous pinning after prolonged skeletal traction.

METHODS

Our treatment regimen for unstable SCFE patients included 1 week or more of skeletal traction with the hip in a flexed position of 45 degrees, and subsequent percutaneous pinning after unintentional reduction. Eleven patients were treated in our institution and an affiliated hospital between 2003 and 2013. Sex, age at surgery, body mass index, the presence of hormonal abnormality, duration between onset and surgery, head shaft angle, posterior tilting angle, and modified Harris hip score were investigated from the medical records and radiographs.

RESULTS

There were 8 male and 3 female with an average age of 11.7 years and an average body mass index of 24.5 kg/mm. No patients had hormonal abnormalities. The duration between onset and surgery ranged from 8 to 16 days. The average preoperative and postoperative head shaft angles were 126 and 141 degrees, respectively. Postoperative posterior tilting angle was averaged of 30.7 degrees, which decreased to 21.5 degrees during follow-up period. One patient showed mild avascular necrosis only confirmed by magnetic resonance imaging, but he was uneventfully treated without additional procedures. As a result, all patients had a perfect modified Harris hip score of 91 points.

CONCLUSIONS

Prolonged traction with the hip in a flexed position may not only provide gradual reduction of posteriorly displaced epiphysis but also decrease intra-articular pressure before surgery. Although percutaneous pinning after unintentional reduction leaves mild displacement of the femoral epiphysis, remodeling could be expected during remaining growth period.