Transcript Slipped Capital Femoral Epiphysis”

“Slipped Capital Femoral Epiphysis”
Current Concepts and Treatment
Dr. Donald W. Kucharzyk
Clinical Assistant Professor
University of Chicago Children’s Hospital
The Orthopaedic, Pediatric & Spine
Institute
“SCFE: Current Concepts
Epidemiology
Etiology
Clinical Types
Natural History
Treatment and Treatment Goals
Reconstructive Procedures
Complications
“SCFE: Current Concepts
EPIDEMIOLOGY
“SCFE: Current Concepts
Incidence: 2/100,000
Male:Female Ratio: 3:1
Age of Onset: Male…13-16 years
Female..11-14 years
Race: Black moreso than Caucasian
Skeletally and Hormonally Immature
Obese
Bilateral: 50-60%
“SCFE: Current Concepts
ETIOLOGY
“SCFE: Current Concepts
Hormonal: Hypothyroidism
Hyperthyroidism
Hypopituitarism
Hypogonadism
Hyperparathyroidism
Harris W: JBJS 1963
Kelsey JL: Pediatrics 1973
“SCFE: Current Concepts
Trauma: Muscular Joint Reactive Forces
Weight-Bearing Forces
Chung SMK: JBJS 1976
Gelberman RH: JBJS 1986
Mickelson MR: JBJS 1977
“SCFE: Current Concepts
Mechanical: Periosteal Thinning and
Anteversion
Defect in Perichondrial
Fibrocartilaginous complex
Thinning of Cartilage Bridge
Anteversion and Obliquity of
Proximal Physis
Pritchett JW: J Ped Ortho 1988
“SCFE: Current Concepts
Inflammatory: Synovitis
Defect in Synovial and
Serum Immunoglobulins
Autoimmune Process
Howarth B: Clin Ortho 1966
Ponsetti I: JBJS 1956
“SCFE: Current Concepts
Genetic: Familial
Autosomal Dominant with
Incomplete Penetrance
Jerre T: Acta Orthop Scand 1960
“SCFE: Current Concepts
CLINICAL TYPES
“SCFE: Current Concepts
PRESLIP
Mild leg, groin, or medial thigh pain
with activity
Limp, mild decrease in internal rotation
and abduction of involved hip
Xray reveals widened and irregular physis
with normal head-neck alignment
“SCFE: Current Concepts
ACUTE
Less than 3 weeks of pain
Significant Antalgic gait with inability to
bear weight
Reduced range of motion: internal rotation
External Rotation Deformity
Xray: widened and irregular physis with
variable displacement
“SCFE: Current Concepts
ACUTE ON CHRONIC
Greater than 3 weeks of low grade pain
with acute sudden exacerbation
Clinical Findings same as Acute with
coexistent thigh atrophy
Xray: varying displacement with a degree
of remodeling
“SCFE: Current Concepts
CHRONIC
Pain for longer than 3 weeks involving
groin, thigh or knee
Similar findings as acute
Xray: varying degree of displacement with
rounded contours
“SCFE: Current Concepts
STABILITY CONCEPT
CLASSIFICATION
STABLE: walking and weight-bearing still
possible with or without crutches
UNSTABLE: walking not feasible even with
crutches
time duration not of importance
Loder RT: JBJS 1993
“SCFE: Current Concepts
NATURAL HISTORY
“SCFE: Current Concepts
Few studies that evaluate untreated
patients
Prognosis related to the degree of the Slip
and the ability to remodel
Degree of the Slip related to the duration
of symptoms
Association with DJD of the Hip
Chondrolysis seen in untreated hip
AVN rare in the untreated hip
“SCFE: Current Concepts
Herndon et al,1963: unrealigned severe slips
treated with bone grafting; 25 of 32 hips had
good or excellent results.
Boyer et al,1981: severe uncorrected slips; 6
0f 7 had good clinical results but motion was
restricted
O’Brien and Fahey,1977: remodeling occurs in
the femoral neck and will lend to acceptable
results in slips up to 60deg
“SCFE: Current Concepts
Few studies that evaluate untreated
patients
Prognosis related to the degree of the Slip
and the ability to remodel
Degree of the Slip related to the duration
of symptoms
Association with DJD of the Hip
Chondrolysis seen in untreated hip
AVN rare in the untreated hip
“SCFE: Current Concepts
Wilson et al,1938: a slip up to one-third is
acceptable and will remodel
Boyer et al, 1981: remodeling will correct a
slip up to 60deg
Howorth et al,1965 and Southwick et al,1967:
report that severe slipping and malunion have a
poor long term prognosis and debate exists as
to the degree of restoration of the normal
alignment to prevent osteoarthritis
“SCFE: Current Concepts
TREATMENT GOALS
Stabalize the epiphyseal-metaphyseal
junction and prevent slippage
Stimulation of early closure
Avoid complications of chondrolysis and
avascular necrosis
Preserve hip joint function
Avoid or Delay onset of Degenerative Joint
changes
“SCFE: Current Concepts
TREATMENT
TECHNIQUES
Percutaneous Screw Fixation
Open Bone Peg Epiphysiodesis
Realignment Osteotomies
“SCFE: Current Concepts
TREATMENT
PERCUTANEOUS SCREW FIXATION
Fluoroscopy and parallel to physis and in the
center of the head; single screw
Avoid penetration of screw:
transient: without sequlae
Zionts JBJS 1991
chronic: chondrolysis
Walters & Simon 1980
“SCFE: Current Concepts
TREATMENT
PERCUTANEOUS SCREW FIXATION
“Moseley” Approach-Withdrawl Technique
and rotation of C-Arm
Utilizing current technique,
safe,effective,economical with a low
complication rate
Aronson DD: JBJS 1992
Ward WT: JBJS 1992
“SCFE: Current Concepts
TREATMENT
OPEN BONE GRAFT EPIPHYSIODESIS
Reported advantages: rapid closure of the
physis and sooner return to regular
activities
Reported disadvantages: large
incision,increased operative
time,progression of the slip, graft
migration and resorption
“SCFE: Current Concepts
TREATMENT
OPEN BONE GRAFT EPIPHYSIODESIS
Complication rate low in the initial
reported series (Weiner DS: 1989)
Higher complication rates reported by
other authors (Ward WT: JPO 1990)
“SCFE: Current Concepts
TREATMENT
LONG TERM FOLLOWUP RESULTS
Excellent Functional Outcomes reported
with screw fixation
In-Situ fixation preferred given the
increased complication rates with
osteotomies (AVN/chondrolysis)
Slip up to 60deg in skeletally immature and
30-40deg in skeletally mature lead to
adequate function
“SCFE: Current Concepts
TREATMENT
LONG TERM FOLLOWUP RESULTS
Growth plate closure within 16 months with
screw fixation; bone peg epiphysiodesis
closure within 15 weeks and full closure at
6 months
Return to sports 3 months with screw and
15 weeks with bone peg
Greatest Motion return within 6 months
Sponseller JBJS 1991
“SCFE: Current Concepts
TREATMENT
REALIGNMENT OSTEOTOMIES
Goals: Realignment of the slip, improved
kinematics of the acetabular and femoral
components, and delay onset of DJD
Rationale: Forces resulting from a slip of
more than 45deg produces a varus posterior
tilting of the head of the femur and altered
kinematics with secondary degenerative
effects
“SCFE: Current Concepts
TREATMENT
REALIGNMENT OSTEOTOMIES
Indications: Flexion<90deg; Slip greater
than 45deg; Severe external rotation
deformity
Levels of Osteotomies: Subcapital; Base of
the Neck; Transtrochanteric; and
Intertrochanteric
“SCFE: Current Concepts
SUBCAPITAL WEDGE OSTEOTOMY
Dunn(1978) and Fish(1984): Open excision
of callous and physeal cartilage with
osteotomy of the neck to relax the blood
vessel
Advantages: Anatomic Reduction
Disadvantages: AVN and Cartilage
Necrosis
“SCFE: Current Concepts
BASE OF THE NECK OSTEOTOMY
Kramer(intracapsular 1976) and
Abraham(extracapsular 1993)
Advantages: Safer than the subcapital and
achieves satisfactory anatomic restoration
Disadvantage: Correction limitation:35-55
Shortening of the femoral neck; Trochanteric
osteotomy; AVN
“SCFE: Current Concepts
TRANSTROCHANTERIC OSTEOTOMY
Sugioka(1980)
Advantages: Correction of severe
deformities(>60deg); Direct observation of
the correction; No shortening required;
Head/Shaft relationship realigned;
Preserve abductor mechanism
Disadvantage: AVN and chondrolysis and
high complication rate(40%)
“SCFE: Current Concepts
INTERTROCHANTERIC OSTEOTOMY
Southwick Biplane(1967): corrects posterior
tilt, varus, and external rotation
Advantages: Extracapsular; Stimulates
physeal closure; improves hip function; No
AVN; Does not affect future surg.
Disadvantages: Chondrolysis and some
shortening
“SCFE: Current Concepts
COMPLICATIONS
“SCFE: Current Concepts
Hardware Penetration
Hardware Breakage
Progression of the Slip
Avascular Necrosis
Deformity-Late
Chondrolysis
Fracture Post Hardware Removal
“SCFE: Current Concepts
HARDWARE PENETRATION
Transient: no relation to chondrolysis
Persistant: chondrolysis
Treatment: immediate removal and
repostioning
“SCFE: Current Concepts
HARDWARE BREAKAGE
Define whether or not the joint surface
has been compromised and if there is
progression of the slip
“Windshield Wiper” loosening due to screw
being left to long(Maletis and Bassett JPO
1993)
Treatment: remove broken fragment if
joint involved and revise if physis open
“SCFE: Current Concepts
PROGRESSION OF THE SLIP
Growing off a single screw
Following bone peg epiphysiodesis: seen in
severe slips
Treatment: secure the slip via the same
technique
“SCFE: Current Concepts
AVASCULAR NECROSIS
Reported incidence: mild slip-4%;
moderate-25%; severe-20%; Overall-15%
Incidence related to the surgical
procedure: lower in in-situ than in closed
or osteotomy
Anatomic Involvement: usually the
anterolateral segment but may be total
head
“SCFE: Current Concepts
AVASCULAR NECROSIS
Treatment: Small segmentation collapse
then observe and preserve motion; Larger
segmentation collapse then consider a varus
flexion osteotomy; Severe collapse, total
head involvement, and pain then consider
fusion
“SCFE: Current Concepts
CHONDROLYSIS
Overall incidence: 24%(CampbellSeries)
Increased incidence in blacks, females, and in
moderate(35%) and severe(45%) slips
Loss of joint space and decreased range of
motion: flexion,abduction,and internal rotation
Etiology: unknown (pin penetration,
immunologic,or seen in untreated-5%)
“SCFE: Current Concepts
CHONDROLYSIS
Treatment: Range of motion exercises
Non-weight bearing
NSAID
Capsulectomy and CPM
Protocol reportedly has restored about
50% of the joint motion and an increase of
50% of the joint space on xrays
“SCFE: Current Concepts
FRACTURE
Placement of unnecessary drill holes
Possiblity due to thermal necrosis
Stress fracture of femoral neck due to
reaming (Cummings 1988)
Hardware removal (Canale JPO)
Treatment: ORIF
“SCFE: Current Concepts
THANK YOU
Dr. Donald W. Kucharzyk