Slipped capital femoral epiphysis


Scenario
O 13 y.o. male
O Present to clinic with knee pain


Dr. Yousef Khoja
Supervised by
Dr. Aymen Jawadi


What is SCFE
O Misnomer
O A hip disorder, the proximal femoral
metaphysis displaces in relation to the capital
femoral epiphysis.
O The femoral head remains in the acetabulum,
and the neck is displaced anteriorly and rotates
externally


Epidemiology
O Males : females (2:1)
O 12 ± 1.5 years for girls and 13.5 ± 1.7 years
for boys (associated with puberty)
O Left hip is more commonly
O African American or Polynesian
O Obese children
O Unilateral is more common but bilateral
involvement varies 10% to 60%.


Etiology
O Heredity:
O 2nd family Member 7.1 % & close relative 14.1
% (Rennie 1974)
O Mechanical:
O Obesity.
O Minor Trauma
O Femoral retroversion
O Increased physeal obliquity
O Previous radiaotherapy to the femoral head
region


Etiology
O Hormonal
O Puberty: estrogen ↑ & GH ↓  growth plate.
O Endocrinopathies: hypothyroidism,
hypogonadism, panhypopituitarism, growth
hormone abnormalities, systemic diseases such
as renal osteodystropy.
O Younger than 10 years
O Wight < 50th percentile.


History
O Hip, groin, or knee pain, or limping
O 23 - 46% of patients: knee or distal thigh pain
as initial presentation (Carney 1991)
O The diagnosis is missed most often because
patients present with knee pain.
O Weight Bearing
O Younger Patient or < 50th percentile.


Physical Examination
O General
O Gait
O Antalgic or Trendelenburg
O Foot Progression angle  External rotated
O Local
O Look: Position, thigh
O ↓ Internal rotation & flexion
O Obligatory external rotation during passive
flexion of hip


Imaging
O X-ray
O U/S
O Acute
O Chronic
O CT:
O Three-dimensional visualization of femoral
head displacement
O MRI:
O Pre-slip.
O Growth plate widening


X-Ray
O AP & Frog-leg lateral
O Both hips
O Look for
O Epiphysiolysis
O Metaphyseal Blanch Sign of Steel
O Klein's line
O Southwick Slip Angle


Klein's line
O Line drawn along superior border of femoral
neck


Southwick Slip Angle
O Head-shaft angle
O Angle formed by the proximal femoral physis
and femoral shaft on lateral radiographs.


Classification
O Temporal Classification
O Loder Classification
O Radiological Classification:
O Grading
O Southwick Angle Classification


Temporal Classification
O Based on duration of the symptoms
O Acute < 3 weeks
O 10 -15 % of SCFE
O Chronic > 3 weeks
O 85 % of SCFE
O Acute exacerbation of long-standing symptoms


Loder Classification
O 1993, based on SCFE stability:
O Stable: Able to bear weight with or without
crutches
O Un-stable: Unable to ambulate
O Predict osteonecrosis
O Single study, 47 % vs. 0 %


Grading System
O Percentage of epiphyseal displacement relative
to metaphyseal width of femoral neck
O Mild (0% to 33%)
O Moderate (33% to 50%)
O Severe (>50%)


Southwick Angle Classification
O Subtraction of the angle on the normal side
from the angle of the affected hip
O Mild Slip: < 30° difference
O Moderate Slip: 30° - 60° difference
O Severe Slip: > 60° difference


Southwick Angle Classification
O Value
O Determine the severity of the slip
O Planning an osteotomy for post-SCFE
impingement


Treatment
O Goal:
O Prevent further slippage
O Accelerate the fusion
O Avoid the complications


Non-Surgical
O No longer recommended
O Complications:
O Chondrolysis: up to 67%
O Recurrent slip after cast removal: 18%
O Full-thickness pressure ulcers: 16%
O Osteonecrosis: 7%


Surgical
O Considerations:
O Is the slip stable or unstable ?
O Is the slip acute, chronic, or acute-on-chronic ?
O What is the degree of slippage ?
O Is the age of the patient outside of the expected
range (10 to 16 years) ?
O Does the patient have a systemic disorder ?


Surgical Option
O Treatment to prevent further slippage
O Percutaneous in situ fixation
O Open bone bone-peg epiphysiodesis
O Treatment to reduce the degree of slippage
O Corrective osteotomies
O Salvage Procedures


Percutaneous In-situ Fixation
O Reduction of epiphysis ?
O One Vs. Two cannulated screw
O Prophylactic Pinning of Contralateral Hip
O Risk Factors

O Prophylactic Pinning of Contralateral Hip


O Procedure:
O Position:
O Angio vs. Fracture table.
O Proper x-ray
O Skin Markers for the entry point
O The Aim is center-center position of the screws
must be at least 5 mm from subchondral bone
in all views & perpendicular to the physis.
O “APPROACH-WITHDRAW” Technique




O Avoid the blind spot


O Avoid posterosuperior quadrant


O Post OP care
O Educate for contralateral hip
O Follow up every 3 - 4 months until physis
closure, x-rays both hips
O Do not remove screw unless complications
O Rehabilitation Protocol


O Rehabilitation
O stable slip
O weight as tolerated with crutches.
O Return to athletic activity is patient-dependent
and is typically allowed 3 to 6 months
postoperatively
O unstable slip
O 4 - 6 weeks of non-weight bearing
O In the absence of osteonecrosis, the
recommendation to wait 6 months or until
physeal closure before returning to impact
activities.


Open bone bone-peg
epiphysiodesis
O Complication:
O Extensive surgical approach
O Longer OR time
O Increased blood loss
O Potential continued slippage
O Need for hip spica immobilization


Corrective Osteotomies
O Indications
O Severe Chronic slips (> 60°)
O Types:
O Subcapital, Femoral Neck, Intertrochanteric, or
Subtrochanteric
O Subcapital and femoral neck levels provide the
most correction but should be avoided because
the osteonecrosis (37% of cases) and future
osteoarthritis (37%)
O Correction consists of flexion, valgus and
derotation


Intertrochanteric Osteotomy


Surgical Hip Dislocation
O First described by Ganz
O Epiphyseal reorientation
O No randomized trials with long-term follow-
up are available

O The mean pre-operative slip angle was 40.2
degrees on the AP view and 50.65 degrees on
the lateral view. Post-operatively, the mean
values were 7,20 degrees on the AP view and
9,45 degrees on the lateral view
O The small number of technical complications
appears favourable considering the surgical
complexity of the procedure, and our
technique offers clear advantages in treating
these complex deformities.


Salvage Procedures
O Hip Arthrodesis


Salvage Procedures
O Hip Arthroplasty
O Not recommended in adolescent with exception
of Bilateral SCFE


Complication
O Recurrent slip
O Osteonecrosis
O Chondrolysis
O Fracture
O Degenerative joint disease
O Contralateral slip


Complication
O Osteonecrosis
O Risk factor
O Stability of the slip
O Placement of screw in the posterior and superior
O Severe SCFE
O Most symptoms within 2 12 mo (up to 18)


Complication
O Chondrolysis
O Definition: joint space reduction of more than
50% compared with the uninvolved side or,
with bilateral disease, a total joint space less
than 3mm
O Risk Factor:
O Unrecognized pin penetration esp. antrosuperior
O Hip spica cast treatment
O Autoimmune destruction
O 5% to 7% of patients with SCFE


Complication
O Recurrent slip
O 1-3 % of cases
O poor pin placement,
O growth of the epiphysis off the implant,
O removal of the implant prior to growth plate
closure


Complication
O Degenerative joint disease
O Pistol-grip deformity of the proximal femur


Q 1
An 12-year-old girl presents with groin pain six months
after treatment of a slipped capital femoral epiphysis.
Preoperative radiographs are seen in Figure A, radiographs
six months after in situ fixation are seen in Figure B.
Which of the following is associated with the radiographic
abnormality seen in Figure B?
O 1. Lack of reduction prior to fixation
O 2. Single screw fixation
O 3. Female sex
O 4. Inability to bear weight preoperatively
O 5. Obesity


Q 2
O Southwick angle (epiphyseal-shaft angle)
serves what purpose in the evaluation of a
slipped capital femoral epiphysis (SCFE)?
O 1. Determine prognosis for AVN
O 2. Determine the severity of the slip
O 3. Determine the presence or absence of a slip
O 4. Determine the etiology of a slip
O 5. Determine the chronicity of the slip


Q 3
O An 11-year-old boy with hypothyroidism
presents with groin pain and the inability to
ambulate. His radiograph is shown in Figure
A. What is the most appropriate treatment?
O 1. Toe-touch weigh tbearing for 3 weeks
O 2. Hip spica cast and non-weight bearing for 4
weeks
O 3. In situ pinning of the right hip
O 4. Open reduction and pinning of the right hip
O 5. In situ pinning of both hips


Q 3
O An 11-year-old boy with hypothyroidism
presents with groin pain and the inability to
ambulate. His radiograph is shown in Figure
A. What is the most appropriate treatment?
O 1. Toe-touch weight bearing for 3 weeks
O 2. Hip spica cast and non-weight bearing for 4
weeks
O 3. In situ pinning of the right hip
O 4. Open reduction and pinning of the right hip
O 5. In situ pinning of both hips


Q 4
O A 14-year-old overweight boy complains of vague left knee
pain which worsens with activity. He has an antalgic gait and
increased external rotation of his foot progression angle
compared to the contralateral side. Knee radiographs,
including stress views, are negative. What is the next step in
management?
O 1. Knee MRI
O 2. Knee CT
O 3. AP pelvis and frog-lateral views
O 4. Diagnostic knee arthroscopy
O 5. Hip MRI

Slipped capital femoral epiphysis

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