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

The Epidemiology of Slipped Capital Femoral Epiphysis in Children and Adolescents: A Systematic Review of Risk Factors and Incidence Across Populations

BACKGROUND

Childhood obesity is a growing global health crisis with significant health and orthopedic complications such as slipped capital femoral epiphysis (SCFE), a hip disorder characterized by the displacement of the metaphysis relative to the epiphysis. SCFE always requires surgical intervention to prevent severe outcomes such as avascular necrosis, gait abnormalities, and lifelong disability and deformity. Obesity is a well-established risk factor for SCFE; however, emerging evidence suggests that elevated leptin levels may independently contribute to the development of SCFE, regardless of obesity status. This systematic review synthesizes geographic, socioeconomic, age, and sex-related trends in SCFE incidence among children with obesity.

METHODS

Searches of Embase, OVID Medline, and Emcare databases were performed from inception through October 1, 2024. Observational studies reporting the incidence of SCFE in children and adolescents with obesity (aged ≤18 years) across various geographic populations were included. Studies involving children with other chronic health conditions or animal studies on the physis were excluded. Study quality was evaluated using the methodological index for nonrandomized studies scoring system. Descriptive statistics were presented as absolute frequencies with percentages or as weighted means with corresponding measures of variance where applicable.

RESULTS

Fifteen studies (5,467 patients) from North America, Europe, Asia, and Oceania met inclusion criteria. SCFE patient samples ranged from 55 to 1,630, with some larger cohorts monitoring multiple medical conditions. The mean age was 12.0 years (SD = 0.4), and male-to-female ratios ranged from 1.43:1 to 3.12:1. SCFE incidence varied by region, from 50.5 per 100,000 (Sweden) to 0.33 per 100,000 (South Korea), with a pooled incidence of 9.62 per 100,000. Overweight prevalence was highest in Sweden (66%) and South Korea (67.6%) and lowest in Japan (11.8%). Unilateral SCFE predominated (68.4% to 90.6%). In situ screw fixation was the most common treatment, with 1 study reporting intertrochanteric osteotomy.

CONCLUSION

Geographic variation in SCFE incidence suggests multifactorial influences beyond obesity, including socioeconomic factors, healthcare access, and genetic predisposition. Limited high-quality comparative studies and inconsistent BMI criteria highlight the need for further research to clarify SCFE risk factors.

LEVEL OF EVIDENCE

Level IV, systematic review. See Instructions for Authors for a complete description of levels of evidence.

Slipped capital femoral epiphysis: emphasis on early recognition and potential pitfalls

Slipped capital femoral epiphysis is a shearing injury through the growth plate of the proximal femur and is the most common hip disorder in adolescence. Delays in diagnosis persist across practice settings despite ongoing innovations in imaging. Recent insights into pathomechanics highlight the importance of femoral head surface morphology and rotational microinstability centered at the epiphyseal tubercle in causing early physeal changes, which can be detected on imaging prior to frank slip. Scrutiny of physeal morphology and comparison to the contralateral hip is critical at all stages of disease progression, and improper technique may result in undue diagnostic delay. Selective use of cross-sectional imaging can be helpful for troubleshooting equivocal early slips and can inform operative technique and adjuvant therapy candidacy in more severe cases. This review provides a comprehensive approach to imaging suspected slipped capital femoral epiphysis, with an emphasis on early detection and potential pitfalls.

Physical Examination and Evaluation for Comorbidities in Youth with Obesity

Obesity is a complex and chronic disease that can affect the entire body. The review of systems and physical examination are important components of the evaluation. Laboratory assessment is directed toward known cardiometabolic comorbidities. Regular follow-up visits with repeated review of systems, physical examination, and laboratory testing can facilitate early detection and management of comorbidities of this chronic disease.

Medium-long-term follow-up of slipped capital femoral epiphysis treated with in situ fixation and patient-acceptable symptom state evaluation

This study evaluates the Patient Acceptable Symptom State (PASS) in patients with slipped capital femoral epiphysis (SCFE) treated with in situ fixation, focusing on medium to long-term outcomes and quality of life. Its primary goal is to establish a subjective well-being cutoff, using subjective methods and the iHOT33 scale, for assessing patients in future studies. Additionally, it explores functionality differences between mild and moderate-severe SCFE, case series epidemiology and potential complications. A retrospective analysis of 63 patients (73 hips), treated for SCFE between 2000 and 2017 at our facility using in situ fixation, was conducted. These patients underwent clinical, anamnestic, and radiological assessments, with PASS determined based on iHOT33 questionnaire results and statistical analysis. The mean age at surgery was 12.95 years (±1.64, range 9-17), with an average follow-up of 11 years (±4.60, range 5-20). At follow-up, 87% of patients reported achieving PASS, with higher iHOT33 scores correlating to PASS. A cutoff of >68 on the iHOT33 scale showed strong predictive ability for assessing PASS (area under the curve 0.857, 88.89% sensitivity, 79.69% specificity). The findings indicate that 87% of patients achieved PASS at medium to long-term follow-up, with better clinical function than those who did not report PASS. The iHOT33 scale's effectiveness in predicting PASS, especially with a cutoff of >68, suggests this method's efficacy. Given these positive outcomes, including in moderate-severe cases treated with in situ fixation, this approach is considered a viable therapeutic option.

Novelties in slipped capital femoral epiphysis imaging: A narrative review

Rationale and objectives

Imaging plays a key role in Slipped Capital Femoral Epiphysis diagnosis and severity assessment. In the last two decades, signs and measurements emerged in literature showed potential to help in SCFE diagnosis and tailoring treatment. The purpose of this review is to collect and discuss new imaging signs, measurements, and techniques according to investigations published after 2000 to improve SCFE diagnosis.

Material and methods

The PubMed, Scopus, and Science Direct databases were used to search for relevant articles related to imaging in SCFE diagnosis from January 2000 to March 2023. Article selection and review was performed by two board-certified radiologists). Article quality assessment were conducted by authors using QUADAS-2 and SANRA evaluation tools.

Results

The research resulted in a total of 2577 articles. After duplicates removal and abstract analysis, 28 articles were finally selected for full-text analysis. Seventeen articles were focused on Radiographs, 6 on CT, 1 on both Radiographs and CT, 4 on MRI. No study focused on ultrasound was selected.

Conclusions

Use of modified Klein's line and S-sign may improve radiographs accuracy in daily routine. Lucency sign may help in early diagnosis on radiographs. Preoperative CT may be useful in planning a tailored treatment predicting SCFE severity and instability. MRI is the most accurate modality to diagnose SCFE at early stage. Nevertheless, it cannot be used to predict the risk of contralateral SCFE. Risk prediction can be assessed with radiographs, using a new rapid mOBS. Further investigation and validation of these sign is needed.

Epiphysiolysis in a 22-year-old Patient with Congenital Hypogonadotropic Hypogonadism: Case Report

Epiphysiolysis is a relatively common disease in the adolescent population (9-16 years); however, it is rare in the adult population. It is characterized by non-traumatic proximal femur slipping. When it occurs in this population it is associated with some disease that slows sexual development and physis closure, such as endocrine diseases or brain tumors. The aim of the present study is to report a case of epiphysiolysis in a 22-year-old patient with hypogonadotropic hypogonadism. There are only 63 cases reported in the world literature on epiphysiolysis in the adult population.

In situ fixation of slipped capital femoral epiphysis carries a greater than 40% risk of later total hip arthroplasty during a long-term follow-up

Aims

We aimed to assess the cumulative risk of total hip arthroplasty (THA) from in situ fixation for slipped capital femoral epiphysis (SCFE) after a follow-up of almost 50 years.

Methods

In this study, 138 patients with 172 affected hips treated with in situ fixation were evaluated retrospectively. A total of 97 patients (70%) were male and the mean age was 13.6 years (SD 2.1); 35 patients (25%) had a bilateral disease. The median follow-up time was 49 years (interquartile range 43 to 55). Basic demographic, stability, and surgical details were obtained from patient records. Preoperative radiographs (slip angle; SA) were measured, and data on THA was gathered from the Finnish National Arthroplasty Register.

Results

The preoperative SA was a mean of 39° (SD 19°). At follow-up, 56 of the patients had undergone THA for a hip previously fixed in situ for SCFE (41%) and 64 of all affected hips had been replaced (37%). Kaplan-Meier analysis gave a median prosthesis-free postoperative survival of 55 years (95% confidence interval (CI) 45 to 64) for the affected hips. In a multivariate analysis, female patients had a two-fold risk for THA (hazard ratio (HR) 2.42 (95% CI 1.16 to 5.07)) and a greater preoperative SA increased the risk of THA (HR 1.03 for every increment of 1° (95% CI 1.01 to 1.05)), while patient age at surgery, slip laterality, stability of slip, or diagnostic delay did not have a statistically significant effect on the risk of THA.

Conclusion

SCFE treated primarily with in situ fixation may lead to THA in more than 40% of affected hips at a near 50-year follow-up. This risk is approximately 15-times the reported lifetime risk in the Finnish general population. Female sex and increasing preoperative SA significantly predicted higher risk of THA.

The incidence and management of slipped capital femoral epiphysis: a population-based study

We aimed to investigate the national trends in the incidence and management of slipped capital femoral epiphysis (SCFE) and to report the need for reoperations. We included all <19-year-old patients hospitalised for SCFE in 2004-2014 in mainland Finland (n=159). Data from the Finnish Care Register for Health Care, Statistics Finland, and Turku University Hospital patient charts were analyse for the incidence of SCFE in 2004-2012, the length of stay, and the type of surgery with respect to age, gender, study year, and season. The reoperations and rehospitalisations in 2004-2014 for SCFE were analysed for 2-10 years after surgery. In 2004 to 2012, primary surgery for SCFE was performed for 126 children. The average annual incidence of SCFE was 1.06/100 000 (95% confidence interval [CI], 0.81-1.38) in girls and 1.35/100 000 (95% CI 1.07-1.70) in boys. The median age at surgery was lower in girls than in boys (11 and 13 years, respectively, p<0.0001). During the study period, there was no significant change in the incidence of SCFE (p=0.9330), the type of primary procedures performed (p=0.9988), or the length of stay after the primary procedure (p=0.2396). However, the length of stay after percutaneous screw fixation was shorter compared with open reduction and fixation (mean 3.4 and 7.9 days, respectively, p<0.0001). There was no significant difference in the rate of reoperations according to the type of primary surgery. In conclusion, the incidence of SCFE and the proportion of different primary surgeries have recently remained stable in Finland.

Public Insurance and Single-Guardian Households Are Associated with Diagnostic Delay in Slipped Capital Femoral Epiphysis

BACKGROUND

Extensive literature documents the adverse sequelae of delayed diagnosis of slipped capital femoral epiphysis (SCFE), including worsening deformity and surgical complications. Less is known about predictors of delayed diagnosis of SCFE, particularly the effects of social determinants of health. The purpose of this study was to evaluate the impact of insurance type, family structure, and neighborhood-level socioeconomic vulnerability on the delay of SCFE diagnosis.

METHODS

We reviewed medical records of patients who underwent surgical fixation for stable SCFE at a tertiary pediatric hospital from 2002 to 2021. We abstracted data on demographic characteristics, insurance status, family structure, home address, and symptom duration. We measured diagnostic delay in weeks from the date of symptom onset to diagnosis. We then geocoded patient addresses to determine their Census tract-level U.S. Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry (ATSDR) Social Vulnerability Index (SVI), using U.S. Census and American Community Survey data. We performed 3 separate logistic regression models to examine the effects of (1) insurance status, (2) family structure, and (3) SVI on a delay of ≥12 weeks (reference, <12 weeks). We adjusted for age, sex, weight status, number of siblings, and calendar year.

RESULTS

We identified 351 patients with SCFE; 37% (129) had a diagnostic delay of ≥12 weeks. In multivariable logistic regression models, patients with public insurance were more likely to have a delay of ≥12 weeks than patients with private insurance (adjusted odds ratio [OR], 1.83 [95% confidence interval (CI), 1.12 to 2.97]; p = 0.015) and patients from single-guardian households were more likely to have a delay of ≥12 weeks than patients from multiguardian households (adjusted OR, 1.95 [95% CI, 1.11 to 3.45]; p = 0.021). We did not observe a significant increase in the odds of delay among patients in the highest quartile of overall SVI compared with patients from the lower 3 quartiles, in both the U.S. comparison (adjusted OR, 1.43 [95% CI, 0.79 to 2.58]; p = 0.24) and the Massachusetts comparison (adjusted OR, 1.45 [95% CI, 0.79 to 2.66]; p = 0.23).

CONCLUSIONS

The delay in diagnosis of SCFE remains a concern, with 37% of patients with SCFE presenting with delay of ≥12 weeks. Public insurance and single-guardian households emerged as independent risk factors for diagnostic delay. Interventions to reduce delay may consider focusing on publicly insured patients and those from single-guardian households.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Comparing pinning in situ and capital realignment procedures for severe, stable slipped capital femoral epiphysis: a systematic review

In severe, stable slipped capital femoral epiphysis, it is unclear whether pinning in situ (PIS) or capital realignment procedures (CRPs) are superior. Our primary aim was to compare patient-reported outcome measures (PROMs) following each strategy. Secondary aims were to compare rates of femoral head avascular necrosis (AVN) and complications. MEDLINE, Embase and Cochrane databases were searched according to an agreed strategy. Narrative review articles, case reports, letters to the editor and articles not written in English were excluded. The risk of bias was assessed using the Newcastle-Ottawa Scale. Of the 132 citations identified, 127 were excluded following de-duplication and application of the exclusion criteria. Three observational studies comparing PIS with CRP and two case series considering CRP alone were identified. One article was considered fair quality, and four articles were considered poor. In total, 198 hips from five studies were included (66 PIS, 132 CRP). PIS was associated with moderate-good functional outcomes, and CRP with good-high outcomes. Two comparative studies reported significantly better PROMs following CRP. AVN was reported in 1.5% following PIS and 10.6% following CRP. Regarding other complications, chondrolysis occurred in 3.0% following PIS and 2.4% following CRP. Femoroacetabular impingement rates were markedly higher following PIS (60.6% versus 2.3%). Reoperation rates were also greater following PIS (34.5% versus 13.3%). PIS tends to be associated with favourable AVN rates, but CRP with favourable PROMs and complication rates. However, comparisons were drawn from heterogeneous studies lacking long-term follow-up. Further high-quality research is required.

[99m Tc] Tc-MDP bone SPECT/CT diagnosing unstable slipped capital femoral epiphysis with secondary AVN in a patient with misleading knee pain

Bone scan is highly sensitive whole-body imaging with relative low radiation in patients with non-localized skeletal symptoms. Patient is 12-year-old boy with Down syndrome, suffering recent claudication and exacerbated left knee pain unable to walk even with crutches. Three-dimensional Single photon emission computed tomography/Computed tomography (SPECT/CT) detected left slipped capital femoral epiphysis (SCFE) and secondary Avascular necrosis (AVN).

Clinical Diagnosis of Slipped Capital Femoral Epiphysis in a Child With Negative Radiological Findings: A Case Report

Slipped capital femoral epiphyses (SCFE) is considered to be a very common disorder among adolescent age group. Multiple risk factors have been reported such as obesity, endocrine disorders, vitamin D deficiency, and panhypopituitarism. The diagnosis of SCFE is important especially in its early stages as this would prevent complications and delay in surgical intervention. The diagnosis is mainly done by radiological imaging and clinical evaluation. However, clinical evaluation is often overlooked. Herein, we present a case of a seven-year-old with SCFE that was diagnosed late due to negative radiological imaging and received late surgical intervention. Therefore, it is recommended that orthopedic surgeons use their clinical sense and examination skills to diagnose SCFE promptly, in order to maintain a short follow-up window to prevent any delay in surgical management and to observe for any progression, even if the radiological findings are normal.

Mid-term results of subcapital realignment of chronic slipped capital femoral epiphysis using surgical hip dislocation: a prospective case series

BACKGROUND

Slipped capital femoral epiphysis (SCFE) requires surgical treatment when diagnosed. The surgical management of moderate to severe SCFE remains an area of controversy among pediatric orthopedic surgeons. The severity of slippage, the viability of the femoral epiphysis, and the method of surgical management determine the long-term clinical and radiographical outcome. This study sought to evaluate the mid-term results of subcapital realignment of chronic stable slipped femoral epiphysis with open physis using surgical hip dislocation.

MATERIALS AND METHODS

This study was a prospective case series of adolescents with moderate or severe degrees of chronic SCFE who had undergone subcapital osteotomy using the surgical hip dislocation technique. The Harris Hip Score (HHS) was used to assess functional outcomes at 6 years of follow-up. A HHS of ≥ 80 points was considered satisfactory. Postoperative radiological outcomes were evaluated using epiphyseal-shaft angles and alpha angles. Postoperative complications were observed.

RESULTS

This study included 40 patients, 32 (80%) males and 8 (20%) females, with a mean age of 14.1 ± 1.8 years. There was a statistically significant improvement in the mean HHS from 45 ± 12.3 preoperatively to 91.8 ± 11.6 points at 6 years of follow-up. The mean epiphyseal-shaft angle reduced from 60.5 ± 15.3° preoperatively to 10.3 ± 2.4° postoperatively, P < 0.001. The mean alpha angle reduced from 72.5 ± 10.1° preoperatively to 40.4 ± 6.4°, P < 0.001. Four (10%) patients showed femoral head avascular necrosis (AVN).

CONCLUSIONS

Subcapital realignment of chronic SCFE can achieve satisfactory clinical and radiological outcomes, but femoral head AVN remains a risk. Level of evidence Level IV.

Slipped capital femoral epiphysis: Diagnostic pitfalls and therapeutic options

One of the most prevalent hip pathologies that develops during adolescence is Slipped Capital Femoral Epiphysis (SCFE), and over the past few decades, its incidence has been rising. To ensure an early diagnosis and prompt intervention, orthopedic surgeons should be aware of this entity. Review of recent developments in clinical examination and imaging diagnostic procedures. The presentation includes commonly used imaging methods, slippage measurement techniques, and classification schemes that are pertinent to treatment. An overview of SCFE surgery based on pertinent study findings and knowledge gained from ongoing clinical practice. The gold standard treatment for stable SCFE cases— those in which the continuity of the metaphysis and epiphysis is preserved—is pinning in situ using a single cannulated screw without reduction. However, there are disagreements over the best course of action for stable moderate/severe SCFE. On the best surgical strategy for unstable epiphysiolysis, no universal agreement has been reached. Finding the surgical procedure that will improve the long-term outcomes of a slipped capital femoral epiphysis is the question at hand.

Short-Term Clinical and Radiographic Outcome after Stabilization of Femoral Capital Physeal Fractures with Cortical Positional Screws in 39 Cats

OBJECTIVE

 The aim of this study was to report the short-term clinical and radiographic outcome for the treatment of femoral capital physeal fractures with cortical positional screws in cats.

STUDY DESIGN

 Medical records and radiographs of cats with femoral capital physeal fractures stabilized with cortical positional screws were retrospectively reviewed. Signalment, bodyweight, femoral head affected, fracture classification, fracture reduction, implants, concurrent orthopaedic injuries, osteoarthritis, femoral neck osteolysis, complications and 6-week follow-up clinical results were recorded. A short- to long-term follow-up was performed by telephone questionnaire with the owners.

RESULTS

 Forty-six fractures in 39 cats met the inclusion criteria. In 45/46 fractures, radiographic signs of bone healing were present and 35/39 cats were assessed as walking normally by a veterinarian at 6-week follow-up. There was a significant increase in radiographic signs of osteoarthritis (p=0.037) and femoral neck osteolysis (p=0.001) on 6-week follow-up radiographs. Pre- and postoperative osteoarthritis and femoral neck osteolysis were not associated with clinical outcome. The mean follow-up period for the telephone questionnaire was 48 months (range, 5-147 months). Seven out of 25 owners reported a gait abnormality in the short- to long-term.

CONCLUSION

 Femoral capital physeal fractures in cats can be treated successfully with the use of cortical positional screws. This technique may be considered as an alternative to other primary fixation techniques and salvage procedures for the treatment of femoral capital physeal injuries in cats. This technique seemed successful in cats with a low-grade preoperative femoral neck osteolysis.

Advantages of Telescopic Screw in Slipped Capital Femoral Epiphysis Treatment: A Retrospective Study and Review of the Literature

Background: Slipped capital femoral epiphysis is due to proximal femur physis failure in adolescent patients. Early iatrogenic closure of proximal growth cartilage in children with significant residual growth potential causes complications such as coxa breva, coxa vara, and lower limb length inequalities. The Free-Gliding SCFE Screw System is a self-extending cannulated screw used in Slipped Capital Femoral Epiphysis (SCFE) fixation and femoral neck fractures. Materials and Method: We conducted a retrospective study on 16 patients. All patients under 11 years old were treated by telescopic cannulated screws fixation. The youngest patient was 7 years old. Results: Out of the 22 operated hips, 2 screws have failed, thus resulting in a lack of telescoping of the screw. We discovered an average lengthening of approximately 10 mm at 24 months postoperative check-up in 20 hips in which lengthening took place. According to the Notzli method, none of the patients had an alpha angle value greater than 48 degrees. Conclusion: Fixation with telescopic screw for SCFE in patients less than 11 years old, with mild to moderate slippage, allows the continuous growth and remodeling of the proximal femur, thus avoiding deformities such as coxa breva, coxa vara, FAI, AVN, limb length discrepancies and also allows good range of motion.

The readability of online patient education materials for slipped capital femoral epiphysis

Given the long-term complications of undiagnosed slipped capital femoral epiphysis (SCFE) and the importance of readable health information materials on positive, equitable health outcomes, the objective of this study was to determine if the online patient education materials regarding SCFE are written at or below accepted recommendations. The secondary objective was to determine whether the readability of these materials varied when stratified by the type of website. 'Slipped capital femoral epiphysis', 'SCFE', and 'slipped femoral head' were used as search queries in three common search engines. The readability of each website was evaluated using five established metrics, and the scores were compared by website type and by the complexity of the search query. In this study of 53 unique websites about SCFE, we demonstrated that only one of the web pages was written at the recommended sixth-grade level, and the mean reading level of the online material was above the 10th-grade level. Post hoc testing showed that only websites associated with pediatric academic institutions were written at a significantly lower grade level than general health websites [P < 0.05 for all, range (0.003, 0.04)]. The materials about SCFE that are available to patients and their families continue to be written at an inappropriate level. To increase accessibility and allow for equitable long-term health outcomes, physicians, universities, hospitals and medical societies must ensure that they produce readable education to increase patients' understanding of SCFE, its symptoms and available treatment options. Future studies evaluating progress regarding these metrics are warranted.

RADIOLOGICAL RESULTS OF SEVERE SCFE TREATMENT AT IOT-FMUSP FROM 2012 TO 2018

ABSTRACT Objective: To assess the complications in patients with severe slipped capital femoral epiphysis treated with the Dunn or modified Dunn procedure from 2012 to 2018 at the Institute of Orthopedics and Traumatology, Medical School, Universidade de São Paulo. Methods: Analysis of medical records, preoperative and postoperative radiographs with at least one year of radiographic follow-up of patients with severe slipped capital femoral epiphysis. Results: We reviewed the complications in 19 operated cases from 2012 to 2018, out of which 36.8% had osteonecrosis of the femoral head, one patient had chondrolysis, and another had postoperative infection. Conclusion: The osteonecrosis rate observed in this series of cases is similar to that described in other orthopedic facilities. We assessed factors that could potentially influence this outcome, including other characteristics of the patient (obesity, endocrine diseases, and history of sports activities) and of the health system. Level of Evidence III, Restropective Case Series.

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.

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.

Slipped capital femoral epiphysis: an epidemiological Nationwide study in Italy from 2001 to 2015

BACKGROUND

Slipped capital femoral epiphysis (epiphysiolysis of the femoral head, SCFE) is the most common pediatric hip disease in 10-14 years old children. The most used procedure to correct a stable form of SCFE is in situ pinning. Instead, the proper treatment for unstable forms is controversial. The first purpose of this study was to estimate annual admissions for SCFE in Italian patients from 2001 to 2015, basing on the hospitalization reports. The second aim was to assess the difference between regions regarding SCFE procedures. Lastly, a statistical prediction of the volume of SCFE procedures performed in Italy based on data from 2001 to 2015 was performed.

METHODS

Data of this study were collected from the National Hospital Discharge Reports (SDO) reported at the Italian Ministry of Health regarding the years of this paper. The yearly number of hospital admission for SCFE, the percentage of males and females, the average age, days of hospitalization, primary diagnoses and primary procedures in the whole Italian population were calculated using descriptive statistical analyses.

RESULTS

From 2001 to 2015, 4893 hospitalizations for SCFE were recorded in Italy, with a mean incidence of 2.9 (cases/100.000 inhabitants). The majority of patients treated by SCFE were males (70.6%).

CONCLUSION

National health statistics for SCFE are attractive for an international audience, as different approaches to screening are reported between countries. These differences allow comparing outcomes internationally. Moreover, sharing national statistics and correlating those to other countries protocols, could be helpful to compare outcomes for different procedures internationally. However, further studies are required to understand the specific reasons for regional variation for SCFE procedures in Italy.

LEVEL OF EVIDENCE

III.

Does a History of Slipped Capital Femoral Epiphysis in Patients Undergoing Femoroacetabular Osteoplasty for Femoroacetabular Impingement Affect Outcomes Scores or Risk of Reoperation?

BACKGROUND

Femoroacetabular impingement (FAI) can occur after slipped capital femoral epiphysis (SCFE) regardless of slip severity and even after in situ pinning. These patients represent a rare and unique demographic that is largely unreported on. It is important to further characterize the clinical presentation of these patients, associated treatment modalities, and the efficacy of these treatment modalities.

QUESTIONS/PURPOSES

(1) How do patients with post-SCFE FAI typically present in terms of radiographic and surgical findings? (2) How do their hip-specific and general-health outcomes scores after mini-open femoroacetabular osteoplasty compare with those obtained in a matched group of patients with FAI caused by other etiologies? (3) How do those groups compare in terms of the proportion who undergo conversion to THA?

METHODS

Between 2013 and 2017, 20 patients had femoroacetabular osteoplasty for post-SCFE FAI. During that time, general indications for this procedure were symptomatic FAI demonstrated on radiographs and physical exam. Of those, none was lost to follow-up before a minimum of 2 years, leaving all 20 available for matching, and all 20 had suitable matches in our database for patients who underwent femoroacetabular osteoplasty for other diagnoses. Matching was performed by surgeon, patient age, patient gender, and BMI. The matching group was drawn from a large database of patients who had the same procedure during the same period. We matched in a 1:3 ratio to arrive at 60 randomly selected control patients in this retrospective, comparative study. Patient demographics, medical history, clinical presentation, radiographic parameters, and intraoperative findings were compared between the two groups. At a minimum of 2 years of follow-up, the latest clinical functional outcome scores (Hip Disability and Osteoarthritis Outcome Score Jr and SF-12) and proportions of conversion to THA were compared between the groups.

RESULTS

A greater percentage of patients with a history of SCFE than those without prior SCFE demonstrated full chondral lesions intraoperatively (90% [18 of 20] versus 32% [19 of 60], odds ratio 7 [95% confidence interval 1 to 178]; p < 0.01). A greater percentage of patients with a history of SCFE also demonstrated labral calcifications intraoperatively compared with those without prior SCFE (65% [13 of 20] versus 35% [21 of 60], OR 3 [95% CI 1 to 10]; p = 0.04). Radiographically, patients with SCFE had greater preoperative alpha angles than did patients without SCFE (94° ± 13° versus 72° ± 22°; p = 0.01) as well as lower lateral center-edge angles (25° ± 8° versus 31° ± 8°; p = 0.04). There was no difference in postoperative follow-up between patients with a history of SCFE and patients without a history of SCFE (4 ± 2 years versus 4 ± 2 years; p = 0.32). There was no difference in the mean postoperative outcome scores between patients with a history of SCFE and patients without (Hip Disability and Osteoarthritis Outcome Score Jr: 75 ± 28 points versus 74 ± 17 points; p = 0.95; SF-12 physical score: 40 ± 11 points versus 39 ± 8 points; p = 0.79). There was no difference with the numbers available in the percentage of patients who underwent conversion to THA (15% [3 of 20] versus 12% [7 of 60], OR 1.36 [95% CI 0 to 6]; p = 0.71).

CONCLUSION

Patients with FAI after SCFE present with a greater degree of labral and chondral disease than do patients without a history of SCFE. However, at short-term follow-up, the proportion of patients who underwent conversion to THA and patients' postoperative outcome scores did not differ in this small, comparative series between patients with and without SCFE. Further evaluation with long-term follow-up is needed, especially given the more severe chondral damage we observed in patients with SCFE at the time of surgery.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Intraoperative assessment of femoral head perfusion during surgical hip dislocation for slipped capital femoral epiphysis

Avascular necrosis is the most devastating complication of slipped capital femoral epiphysis, leading to collapse of the femoral head, increased risk of osteoarthritis and the requirement of early total hip arthroplasty. It is believed that intraoperative femoral head perfusion assessment may be an accurate predictor of post-operative avascular necrosis (radiographic collapse). At our institution, femoral head perfusion is assessed intraoperatively during all sub-capital realignment procedures. We hypothesize that our method is accurate in predicting the risk of developing post-operative avascular necrosis. In this retrospective study, we collected data from all patients that had intraoperative blood flow measurements during sub-capital realignment procedures. We correlated this with long-term radiographs looking for radiographic collapse. The intraoperative femoral head perfusion assessments during sub-capital realignment procedures for slipped capital femoral epiphysis at our institution, between January 2015 and March 2020 inclusive were assessed for reliability. In total, 26 of 35 patients had intraoperative femoral head perfusion present. Only 2 (8%) of these patients developed radiographic collapse. In contrast, 7 (78%) of the 9 patients who did not have femoral head perfusion present intraoperatively developed radiographic collapse, indicating that our method may be reliable in predicting a patient’s post-operative risk of developing avascular necrosis.

Causes of Delayed Diagnosis of Slipped Capital Femoral Epiphysis: The Importance of the Frog Lateral Pelvis Projection

Delayed diagnosis and treatment is a universally reported problem that impairs the prognosis of slipped capital femoral epiphysis (SCFE). Quite frequently, a delayed diagnosis of SCFE is observed in spite of serial admissions and examinations of the limping adolescent. Why do health professionals globally fail to make a definitive diagnosis of SCFE during the first examination of the patient? A retrospective study of 36 adolescents treated for stable SCFE and two adolescents treated for unstable SCFE has been performed. In more than half of the delayed diagnosed stable slips (13/25, 52%), the diagnosis was set after serial examinations of the patient. Health professionals commonly order only the anteroposterior (AP) X-ray view of the pelvis when examining a non-traumatic limping adolescent. The frog lateral (FL) projection is usually spared in an attempt to limit the radiation exposure of the patient, especially in ambulating adolescents with mild symptoms. It is proposed that in the non-traumatic limping adolescent, the FL projection instead of the AP pelvis view should be requested by the health professional in order to timely diagnose a surgical emergency of the adolescent hip such as SCFE.

Predicting epiphyseal stability of slipped capital femoral epiphysis with preoperative CT imaging

BACKGROUND

We analyzed preoperative CT scans of hips with slipped capital femoral epiphysis (SCFE) for characteristics that could be predictive of intraoperative epiphyseal stability and developed a set of imaging criteria for stable and unstable SCFE. We then compared this grading system with the Loder classification.

METHODS

We reviewed preoperative CT imaging to develop a SCFE stability classification system. Three orthopaedic surgeons used the classification system to grade stability on a series of SCFE hips. Kappa was used to evaluate intra- and interobserver reliability among the observers. A series of SCFE hips treated with open procedures in which intraoperative stability was determined under direct visualization was evaluated. Intraoperative stability was compared with stability ratings as determined by the CT classification system and the Loder classification system.

RESULTS

Interobserver reliability among our three observers was κ = 0.823 (95% confidence interval (CI) 0.414 to 1.0; p < 0.001). Intraobserver reliability was κ = 0.901 (95% CI 0.492 to 1.31; p < 0.001). In all, 27 hips were used in the comparison of intraoperative stability with the Loder and CT classification systems. CT-predicted stability exhibited 78% concordance with intraoperative stability. The sensitivity and specificity of CT-predicted stability was 75% and 82%, respectively, versus Loder sensitivity of 69% and specificity of 91%.

CONCLUSION

The CT evaluation method provided is easy to use and can help to improve the accuracy in determining preoperative epiphyseal stability, which may lead to improved treatment outcomes for this population.

LEVEL OF EVIDENCE

III.

Non-traumatic Infantile Slipped Capital Femoral Epiphysis following an Epileptic Seizure - A Case Report

Introduction:

Slipped capital femoral epiphysis (SCFE) is a rather uncommon fracture, occurring usually in adolescence, during a period of rapid growth. Various pathogenetic risk factors contributing to its development have been identified. We present the case of a 10-month-old male infant who developed SCFE in his left hip following an epileptic seizure. To the best of our knowledge, this is the first such case report in the English literature.

Case Report:

A 10-month-old male infant, with a known medical history of epileptic encephalopathy, was referred to the accident and emergency department of our hospital. The parents of the youngster reported inability of the child to move his left lower limb and inconsolable crying following several epileptic seizures. A radiograph revealed the existence of SCFE in the left hip. The fracture was reduced (with gentle closed traction under general anesthesia) and a hip spicacast was applied. It was removed at 8 weeks. Physical examination at this stage revealed a painless hip with a full range of motion. Painless hip range of motion was retained during all follow-up visits throughout the next 22 months. Amagnetic resonance imaging scan at 2 years post-reduction showed normal shape and size of the affected femoral head, with no signs of physeal arrest and/or avascular necrosis.

Conclusion:

This unique case of a 10-month-old infant who developed SCFE following an epileptic seizure shows that this rare fracture may occur even in very young children. Although it is not currently indicated for the treatment of the vast majority of patients with SCFE, closed reduction and immobilization in a hip spicacast may be considered as an alternative treatment option in carefully selected patients.