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Slipped Capital Femoral Epiphysis Surgery

  • Author: Mihir M Thacker, MBBS, MS(Orth), DNB(Orth), FCPS(Orth), D'Ortho; Chief Editor: William L Jaffe, MD  more...
 
Updated: Jan 27, 2015
 

Background

Slipped capital femoral epiphysis (SCFE) was first described by Ernst M ü ller, who called it Schenkelhalsverbiegungen im Jungesalter, meaning "bending of the femoral neck in adolescence." The term slipped capital femoral epiphysis is a misnomer because the epiphysis is held in the acetabulum by the ligamentum teres; thus, the metaphysis actually moves proximally and anteriorly while the epiphysis remains in the acetabulum. (See the image below.)

Bilateral slipped capital femoral epiphysis. One s Bilateral slipped capital femoral epiphysis. One side shows evidence of remodeling of the neck and an anterior bone bump that restricts flexion. The other side demonstrates an acute slip as seen by the absence of any evidence of remodeling.

In most patients, SCFE appears radiographically as a varus relation between the head and the neck. Occasionally, the slip appears to be in a valgus position, with the epiphysis displaced superiorly in relation to the neck.[1, 2, 3, 4, 5] In the vast majority of cases, the etiology is unknown, though atypical slips may be associated with a known endocrine disorder, with renal failure osteodystrophy, or with previous radiation therapy.[6, 7, 8, 9, 10]

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Problem

SCFE is not life-threatening. However, untreated and complicated SCFE can lead to deformity and early osteoarthrosis of the hip and, thus, can cause considerable morbidity. Factors that increase morbidity include avascular necrosis (AVN) of the hip and chondrolysis. Both of these may result in damage severe enough to warrant a salvage procedure, in the form of an arthrodesis or a total hip arthroplasty. Prompt diagnosis is critical to prevent further deformity and AVN. The diagnosis is often subtle, and symptoms (eg, groin or knee pain) can be misleading.

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Epidemiology

Frequency

The prevalence of SCFE varies widely even within the continental United States. It has been reported to be 2.13 cases per 100,000 population in the southwestern United States and 10.08 cases per 100,000 population in the northeastern United States[11] ; it is lowest in the mountain and Great Plains states. In Asia, the reported prevalence is quite low, with just 0.2 cases per 100,000 children affected in eastern Japan.[12]

A race predilection exists for SCFE, as follows[13] :

  • Whites - 1.0
  • Pacific islanders - 4.5
  • Blacks - 2.2
  • American Indians and Hispanic individuals - 1.05
  • Indonesian-Malay peoples (eg, Chinese, Japanese, Thai, Vietnamese) - 0.5
  • Indo-Mediterranean peoples (those of Near East, North African, or Indian subcontinent ancestry) - 0.1

Males are affected more commonly than females are; the male-to-female ratio is 2-5:1.

The mean age at diagnosis is 13.5 years in boys (range, 13-15 years) and 12 years in girls (range, 11-13 years).[13] This corresponds to the period of maximum skeletal growth. Juvenile SCFE (in children < 10 years) should raise the suspicion of an underlying cause (eg, an endocrinopathy). Radiation-associated slips tend to occur in young children.

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Etiology

Various causative factors for SCFE have been identified. Factors related to body habitus include the following:

  • Obesity - At least 50% of patients are above the 95th percentile for weight [14]
  • Excessive tallness, thinness

If the patient's height is below the 10th percentile, the likelihood of an underlying endocrinopathy is high.[15, 16] Endocrinopathies that may be present include the following:

  • Hypothyroidism
  • Acromegaly
  • Hypogonadism (adiposogenital syndrome)
  • Hyperparathyroidism

Radiation therapy, especially for childhood leukemias or lymphomas, may be involved in the development of SCFE:

  • This cause of SCFE tends to occur in young children
  • Affected children are also light and thus tend to have mild slips

Finally, renal failure is an important factor:

  • There is a high incidence of simultaneous bilateral presentations (~87%)
  • The highest incidence of severe slips is in these patients
  • There are two distinct patient subgroups — those whose disease is controlled early (less hyperparathyroidism) tend to have mild slips, and those with poorly controlled disease (significant hyperparathyroidism) tend to have severe slips
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Pathophysiology

SCFE is caused by increased stresses across a weakened physis, with a combination of both biomechanical and biochemical factors contributing to the development of the slip. Factors affecting the stability of the physis include the following:

  • Perichondrium - This is thick in children but progressively thins with age
  • Perichondrial ring - This is a fibrous ring that spans the physeal plate and extends from the metaphysis to the epiphysis; it also thins with age
  • Transphyseal collagen - This weakens because of progressive mineralization; cross-linkage of collagen is affected in osteolathyrism, leading to slippage in these patients
  • Mammillary projections - These assume increasing importance as the perichondrial ring thins
  • Contour of the growth plate - This is normally convex toward the physis with undulations at the periphery, which contribute to its resistance to linear shear and torque forces
  • Growth plate thickness - This is mainly affected by biochemical and endocrine factors

Mechanical factors leading to increased stress across the physis[17] include the following:

  • Relative femoral retroversion [18, 19, 20, 21]
  • Obesity - This is associated with femoral retroversion, which also increases the stress across the physis [11, 13] ; the average femoral version of patients who are not obese was found to be 10.6°, compared with 0.40° in patients who are obese [18]
  • Increased physeal slope - This is an increase in inclination of the physis at the time of rapid skeletal growth around puberty [22] ; patients with SCFE have been shown to have a higher physeal inclination even on the opposite side
  • Deeper acetabula - The mean center-edge angle of Wiberg is higher in children with SCFE than in control subjects; deeper acetabula lead to increased coverage of the femoral heads and increased stress across the physis [23]

SCFE is most common in the peripubertal age group; the effect of the following hormones on the physes may contribute to the likelihood of developing a slip[24] :

  • Growth hormone - This causes widening of the physes and consequent weakening
  • Sex hormones - Increased physeal width and decreased physeal strength result from testosterone, probably accounting for the increased frequency in boys; narrowing of the physis and increased physeal strength result from estrogen, possibly explaining why slips seldom occur in postpubertal females [25, 26]
  • Thyroid hormone - The effect of this hormone is not clear, though it is known that slips can occur in patients with hypothyroidism and those receiving thyroid hormone replacements for hypothyroidism

Even though most children with SCFE do not have an overt endocrinopathy, they may very well have some subtle endocrine disorder.[27, 28, 29, 30, 31] A delay in bone age with respect to chronologic age in some of these children lends further credence to this theory.[25, 26]

Shear stresses across a physis made vulnerable by the biomechanical and biochemical factors outlined above leads to the slip. The displacement is determined by the direction of the deforming force. Posteroinferior displacement of the head (anterosuperior migration of the neck) is the most common pattern, though in rare cases, the head may displace posterosuperiorly, giving rise to an apparent valgus slip (see the image below).[1, 2]

Valgus slip (rare). Valgus slip (rare).
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Presentation

History and physical examination

SCFE must be considered in the differential diagnosis for children presenting with knee pain. Typically, knee examination and radiographic findings are normal in individuals with SCFE. All children with knee pain should have their hips evaluated.

Patients may present with the following symptoms:

  • Pain - The presenting feature is hip (groin) pain in most patients; as many as 46% of patients with chronic slips may present with thigh pain or knee pain (eg, referred pain, obturator nerve)
  • Limp
  • Inability to bear weight in acute slips
  • History of irradiation, renal failure, endocrinopathy (eg, hypothyroidism and treatment thereof, acromegaly, short stature [growth hormone supplementation])

Either side may be affected. The left hip is involved in 60% of unilateral cases. In most studies, 18-50% of cases are bilateral, though some studies have reported the prevalence of bilaterality to be as high as 80%.[32, 33, 34] Bilateral involvement may be evident at the time of initial presentation.[13] Most patients who subsequently develop a contralateral slip do so within 18-24 months of initial symptoms, though slips may occur until physeal closure.[13, 26, 32, 35, 36, 37, 38]

Management of the patient who presents with unilateral involvement is controversial. Significant morbidity can occur if the other side slips and displaces. Early recognition of a preslip on the contralateral side would help determine which patients are at greater risk. A scoring system has been developed to predict the risk of a contralateral slip.[39]

The following physical signs may be present:

  • Externally rotated attitude of the affected lower limb
  • In varus slips, restriction of flexion, abduction, and internal rotation of the affected hip
  • In valgus slips, restriction of flexion, adduction, and internal rotation
  • Obligatory external rotation on flexion (this is a diagnostic clue)
  • In chronic slips, wasting of the thigh
  • True supratrochanteric shortening (Bryant triangle, Nélaton line)
  • Trendelenburg sign and gait possible; antalgic gait in acute or acute-on-chronic slips

Differential diagnosis

Conditions to be considered in the differential diagnosis include the following:

  • Knee injury
  • "Groin pull"
  • Trauma - Hemarthrosis or fracture may manifest similarly to an acute slip
  • Infections - Septic arthritis and acute osteomyelitis must be excluded in acute cases
  • Legg-Calvé-Perthes disease - This disease usually affects children aged 4-9 years
  • Juvenile rheumatoid arthritis - This condition may manifest with hip involvement and minimal systemic manifestations
  • Transient synovitis
  • Benign or malignant tumors
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Contributor Information and Disclosures
Author

Mihir M Thacker, MBBS, MS(Orth), DNB(Orth), FCPS(Orth), D'Ortho Associate Professor of Orthopedic Surgery and Pediatrics, Jefferson Medical College of Thomas Jefferson University; Consulting Staff, Department of Pediatric Orthopedic Surgery, Alfred I duPont Hospital for Children; Orthopedic Oncologist, Helen F Graham Cancer Center and Christiana Care Health Services

Mihir M Thacker, MBBS, MS(Orth), DNB(Orth), FCPS(Orth), D'Ortho is a member of the following medical societies: Children's Oncology Group, Medical Council of India, Musculoskeletal Tumor Society, Pediatric Orthopaedic Society of North America, Limb Lengthening and Reconstruction Society

Disclosure: Nothing to disclose.

Coauthor(s)

Michael S Clarke, MD Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, Missouri State Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

James J McCarthy, MD, FAAOS, FAAP Director, Division of Orthopedic Surgery, Cincinnati Children's Hospital; Professor, Department of Orthopedic Surgery, University of Cincinnati College of Medicine

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Orthopaedic Association, Pennsylvania Medical Society, Philadelphia County Medical Society, Pennsylvania Orthopaedic Society, Pediatric Orthopaedic Society of North America, Orthopaedics Overseas, Limb Lengthening and Reconstruction Society, Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Orthopediatrics, Phillips Healthcare, POSNA<br/>Serve(d) as a speaker or a member of a speakers bureau for: Synthes<br/>Received research grant from: University of Cincinnati<br/>Received royalty from Lippincott Williams and WIcins for editing textbook; Received none from POSNA for board membership; Received none from LLRS for board membership; Received consulting fee from Synthes for none.

Chief Editor

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American College of Surgeons, Eastern Orthopaedic Association, New York Academy of Medicine

Disclosure: Received consulting fee from Stryker Orthopaedics for speaking and teaching.

Additional Contributors

Steven I Rabin, MD Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Orthopedic Surgery, Podiatry, Rheumatology, Sports Medicine, and Pain Management, Dreyer Medical Clinic; Chairman, Department of Surgery, Provena Mercy Medical Center

Steven I Rabin, MD is a member of the following medical societies: AO Foundation, American Academy of Orthopaedic Surgeons, American Fracture Association, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

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Valgus slip (rare).
Frog-leg (Lauenstein) lateral view, showing a mild slip that can easily be missed on an anteroposterior view.
Klein line (line drawn along the superior border of the neck intersects less of the capital epiphysis than on the unaffected side).
Southwick head-shaft angle (angle between the metaphyseal surface of the physis and the shaft of the femur on a frog leg lateral view). Difference from the opposite side is used to grade the severity of the slip.
Bilateral slipped capital femoral epiphysis. One side shows evidence of remodeling of the neck and an anterior bone bump that restricts flexion. The other side demonstrates an acute slip as seen by the absence of any evidence of remodeling.
Chronic slipped capital femoral epiphysis showing the extent of remodeling along the anterior neck (arrow).
Pin placement (anteroposterior view). A: The entry point must be at or above the level of the lesser trochanter to avoid the risk of subtrochanteric fracture. B: The pin (screw) should be in the center of the epiphysis. C: At least 2.5 threads engaging the epiphysis should be used for a secure hold.
Pin placement (lateral view). Arrow shows entry point in the anterolateral cortex.
Osteotomies in slipped capital femoral epiphysis (SCFE). A: Subcapital osteotomy. B: Base of the neck compensatory osteotomy. C: Intertrochanteric compensatory osteotomy. Note that the amount of correction increases from subcapital to intertrochanteric osteotomies.
Principle of the Dunn osteotomy. Reduction of the slip after shortening the neck to avoid stretch on the vessels and decrease the risk of avascular necrosis.
 
 
 
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