Description regarding SCFE & their osteotomies involved

1. SCFE & OSTEOTOMIES
INVOLVED
DR PARTH PATEL
PG 3RD YEAR

2. What is SCFE?
• SLIPPED CAPITAL FEMORAL EPIPHYSIS
• Adolescent coxa vara ; Epiphyseal coxa vara ;Epiphysiolisthesis
• It’s misnomer because epiphysis maintain it’s position but femoral
neck and shaft displaces
• So the deformity consist of anterior-superior-lateral displacement of
femoral neck , which present as posterior-inferior of femoral head
epiphysis in relative to femoral neck

3. DISPLACEMENT:
The patient’s left hip (arrow) shows that a slight shift of the head of the
femur has occurred through the growth plate

4. Epidemiology
• Incidence: 2 per 1 lakh population
• M:F – 2:1 (Testosterone reduce physeal strength)
• Race: indo-Mediterranean , Polynesian
• Age: 12-14 year in male
11-13 year in female (rare after menarche because of oestrogen
strengthen the physis)
• Left hip > right hip
• B/L hip: 20-40% (in most of the patients second slip occurs within 18
months of 1st presentation)

5. ETIOLOGY
(A)BIOMECHANICAL FACTORS:
• Trauma
• Obesity
• Thinning of Perichondral fibrocartilaginous complex /
ring with maturation
• Increased physeal obliquity { change in inclination of
proximal physis}
• Retroversion of femoral neck

6. (B)Endocrine factors:
•Hypothyroidism –most common
•Hypogonadism
•Hyperparathyroidism
•Panhypopituitarism
•GH administration: stimulate the growth of physis

7. PATHOLOGY

9. (B) HISTOLOGICAL CHANGES:
• Slips occurs in hypertrophic zone of epiphysis which
shows,
• Widening with composed of chondrocytes in
disarranged clusters instead of orderly column

10. CLASSIFICATION
(A)Based on onset:
(1) Pre-slip : restriction of internal rotation
(2) Acute slip: <3 wks symptoms (Effusion without
metaphysis remodeling) + fixed external rotation deformity
with shortening
(3) Chronic slip: >3 wks symptoms ( No effusion with
metaphysis remodeling) + most common
(4) Acute on chronic slip: >3 wks symptoms + Acute slip

11. (B) Morphogenic classification : Based on extent of slip
Head shaft angle of Southwick : 145 normally
(1)Mild slip: different in head shaft angle <30
(2) Moderate slip: different in head shaft angle 30-60 degree
(3)Severe slip:>60 degree different
(c) Loader’s classification: Based on ability to weight bear
(1) Stable slip: able to weight bear with or without crutches
No AVN
(2) Unstable slip: Unable to bear weight with or without crutches
50% chances of AVN

14. Clinical features:
(A)Stable-Chronic SCFE:
• Pain in groin radiating to thigh and knee &thigh muscles wasting
• Antalgic gait with limb in external rotation & shortening
• Should not ask for running, squatting, jumping as they may cause
acute slip
• Limited internal rotation ,abduction and flexion
• The presence of hip flexion contracture points towards the
possibility of “Chondrolysis”.
• Knee-Axilla sign –On attempting knee flexion, limb goes in
external rotation
• Decreased: Flexion / Internal rotation / Abduction

16. • Real shortening due to upward displacement of femur ,while
Apparent shortening due to adduction.
• As the hip flexed ,external rotation deformity increased.
• When slipping is extreme, the gluteus medius function
inadequate as a result TENDELENBURG test positive.
• Bilateral sever slipping gait cased “Waddeling gait”

17. (B) Unstable- Acute & Acute on chronic:
• Sudden onset severe pain in hip with minor trauma or twisting
injury
• Unable to bear weight
• Antalgic gait
• Painful restriction of movement
• Triple deformity seen on SCFE:
AdEER: Adduction + Extension + External rotation
No FFD in SCFE
• The grater the amount of slip, the greater is the restriction of
motion.

18. RADIOLOGY INVESTIGATION:
ON X-RAYS : (AP view) Frog-leg lateral view
• Trethowan’s sign (Kleins line)
• Steeel metaphyseal blanch sign
• Capner’s sign
• Widening of growth plate
• Decrease epiphyseal height
CT SCAN
MRI SCAN

19. Widening of growth plate

24. COMPLICATION
• AVN
• Chondrolysis
• Osteoarthritis
• Coxa vara (angle between the head and shaft of femur reduced to less
than 120 degree)
• Slipping of opposite hip- 60 to 80% of cases

25. MANAGEMENT
1. Conservative management: rest and traction or hip spica
cast
2. Closed manipulative reduction
3. Operative management
• In situ pinning
• ORIF
• BONE PEG Epiphysiodesis
• Osteotomy
• Reconstruction by- Arthroplasty / Arthrodesis / Cheilectomy

26. Goals in treatment
1)To prevent further displacement of the epiphysis
2)To promote closure of the physeal plate.
Long-term goals of treatment include
1)Restoration of a functional range of motion
2)Freedom from pain
3) Avoidance of aseptic necrosis and chondrolysis

27. IN SITU PIN OR SCREW FIXATION
• Single
• Central pin- the screw in the center of the femoral head
DISADVANTAGE
• Persistent pin penetration
AFTER TREATMENT
• Range-of-motion exercises - begun the day.
• Unstable slips- partial weight bearing 6 to 8 weeks.
• sports and other activities forbidden until physes have closed.
• The screws removed after physeal closure

29. • A portion of the residual physis is removed and a dowel or
“peg” of autologous bone graft (ipsilateral iliac crest) is
inserted into the epiphysis.
• In unstable slips, supplementary internal fixation,
postoperative traction, or spica cast immobilization for 3 to 8
weeks until early stabilization has occurred

30. Disadvantages
1)Graft insufficiency
2)Increase in severity of slip
3)Failure of physeal fusion
4)longer operating time, increased blood loss, longer
hospitalization, and longer rehabilitation.
AFTER TREATMENT
• In acute slips - spica cast for 6 weeks
• In chronic slips weight bearing started at approximately 10
weeks.

32. Primary Upper Femoral Osteotomy:
1)Cuneiform osteotomy through the fracture callus or femoral
neck (DUNN OSTEOTMY)
2)Closing wedge osteotomy at the base of femoral neck
a) Intracapsular ( Kramar osteotomy)
b) Extracapsular ( Barmada and Coworkers)
3)Intertrochanteric osteotomy (Southwick and Imhauser)
• Dunn and intracapsular osteotomy has highest complication

33. INDICATION
• To restore the normal relationship of the femoral head and
neck
• Delay the onset of degenerative joint disease.
• Prevent further slippage
• Correct preexisting deformity.

34. The goal of preventing further slippage is
achieved
1)Curetting the physis and securing the capital epiphysis to the neck
2) Fixing the capital epiphysis with a bone graft epiphysiodesis or
metallic implant
3) Inducing fusion by reorienting the plane of the capital physis into a
more horizontal position

35. 1) Dunn Procedure
• Trapezoidal osteotomy of the femoral neck
• Referred as “an open replacement of the displaced femoral
head”
• should not be done if the physis is closed.
• Reduce the capital femoral epiphysis on the femoral neck by
resecting a portion of the superior femoral neck.
• Advantage - the deformity itself is corrected
• Results- High risk of complications, AVN and chondrolysis.

37. 2)Base-of-Neck Osteotomy (Kramer and
Barmada Procedures)
• Indicated to correct residual deformity after closure of the
physis.
• corrects the varus and retroversion components of moderate
or severe chronic SCFE.
• Pose less risk to interruption of the blood supply to the femoral
head than the Dunn procedure
• Osteotomy held with threaded Steinmann pins, which
extended into the capital epiphysis if the physis is still open

38. Barmada's group
• Extracapsular base-of-neck osteotomy performed slightly
more distally
• Recommended for moderate to severe chronic SCFE with a
greater than 30-degree head–shaft angle on lateral
radiographs.

40. 3)Intertrochanteric osteotomy (Southwick and
Imhauser)
• Preferable method to correct deformity associated with SCFE.
Southwick osteotomy –
• chronic or healed slips with head–shaft deformities between 30 and 70 degrees
• Biplane osteotomy
• Performed at the level of the lesser trochanter.
Imhauser's procedure –Intertrochanteric
COMPLICATIONS
I)Chondrolysis
2)Post operative narrowing of joint space

42. Prophylactic Pinning of Contralateral Slips
• Not performed routinely.
• Symptomatic slipping of the contralateral slip after unilateral
treatment - 12.5% .
• Asymptomatic slipping of the contralateral hip has - 40%.

43. Indications
• High-risk
• Noncompliant patients
• Epiphysiolysis from irradiation therapy
• Metabolic or endocrinopathy
• Renal failure.
• Children younger than 10 years at the time of presentation

44. COMPLICATIONS
1)CHONDROLYSIS
• Occasionally referred to as “acute cartilage necrosis”
• NATURAL HISTORY
• Symptoms develop between 6 weeks and 4 months after treatment,
• Progressive joint space narrowing occurs, maximum reduction - 6 to
12 months of onset of symptoms.

46. ETIOLOGY
• Etiology is not known various theories
1) Lack of synovial fluid production- failure of nutrition of
articular cartilage
2) Autoimmune - Produce an antigen
3) Metallic implant penetration
4) Impingement - labrum and acetabulum by anterior “pistol
grip” deformity of the femoral neck

47. TRETMENT
• 1)CT of the hip to confirm that no implant encroachment is present.
• 2) Aspiration of the hip to rule out a low-grade infection.
• 3)If pin penetration has occurred, the implant must be removed or
replaced if the physis is not fused.
• 4)Supportive care
• 5) Muscle releases or capsulotomy.
• 6) Arthrodesis or total joint arthroplasty.

48. AVASCULAR NECROSIS
• Axhausen in 1924 used the term aseptic necrosis
Without treatment
• Acute displacement (unstable slip).
• Closed or open reduction of unstable slips
• Osteotomy of the femoral neck.
• Intertrochanteric osteotomy.
• lowest open epiphysiodesis or in situ pinning of stable slips

49. CAUSES
• The blood supply to the femoral head is interrupted,
• The lateral epiphyseal arterial system may be damaged
RADIOGRAPHIC & CLINICAL FINDING:
• Two patterns of distribution are typically seen:
Total head necrosis
Partial (or segmental) necrosis
• Affected epiphysis first fails to become osteopenic
• Resorption of the necrotic bone
• collapse of the affected portion of the epiphysis.

50. TREATMENT
• 1)prevention.
• 2)Implant removal
• 3) Joint arthroplasty (total or partial) or hip fusion
• 4)Hip arthrodesis

51. (3)OSTEONECROSIS
• 10% to 15% of patients with SCFE
• Osteonecrosis is rare in untreated patients
• Results from interruption of the retrograde blood supply by
the original injury (superior retinacular artery of the medial
circumfl ex femoral)
1) unstable (acute) slips,
2) 2) forceful repetitive manipulations
3) 3) open reduction, or
4) 4) osteotomy of the femoral neck.
5) 5) Superolateral placement of pins

52. This Photo by Unknown Author is licensed under CC BY-SA