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Slipped Capital Femoral Epiphysis

Current Concepts in Treatment

Eduardo Novais, MD

Assistant Professor of Orthopedic Surgery

Development

Anterior Axial

Mild

< 30o

Moderate

30o – 60o

Severe

> 60o

Severity

Southwick 1969

Stability – Loder Criteria

Loder 1993

Stable Unstable

Osteonecrosis

5-50%

Stable SCFE OA SCFE

Rab 1999

Richold 1999

Wensaas 2012

FAI Cartilage

damage

Ganz 2003

Ganz 2002

Leunig 2000

Sink 2010

SCFE and FAI

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Articular cartilage Damage

SUPERIOR

ANTERIOR

Mild

Pinning

+

Osteoplasty

Arthroscopy

Mini anterior <30o

13 yo male IRF: -30o

In situ pinning + open anterior osteoplasty

-10o IRF 15o IRF

2 year postoperative

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Moderate and Severe Femoral Osteotomy for SCFE

Subcapital

Dunn 1964

Leunig 2007

Neck

Fish 1984

Base of

the neck

Kramer 1976

Barmada 1978

Trochanteric

Imhauser 1957

Southwick 1967

Blood supply to

femoral head

Gautier 2000 Ganz 2009

Extended retinacular

soft tissue flap

0

10

20

30

40

50

60

70

80

90

100

AP alpha angle Lateral alpha angle Southwick angle

In-situ pinning

Modified Dunn

p = 0.0017 P<0.001 P<0.001

Radiographs

Radiographic correction was achieved more reliably in the

modified Dunn group than the in situ pinning group.

Heyman and Herndon scores

good or excellent (p = 0.0343; OR, 5.86; 95% CI, 1.13–40.43)

27% 60% Modified Dunn

In-situ pinning

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Complication N (%) N (%)

Osteonecrosis 1 (7%) 1 (7%)

Slip progression 1 (7%) ---

Pin impingement 2 (13%) ---

Implant failure --- 1 (7%)

Intra-articular pin --- 1 (7%)

p = 0.6588 (OR: 1.6; 95%CI, 0.2–15)

In-situ pinning N = 15

Complications

Modified Dunn N = 15

8X Patients in the in-situ pinning group were more likely to require a

secondary procedure (p = 0.0230; OR, 8.4; 95% CI, 1.32–90.37)

Unplanned reoperations

Moderate and Severe 11 yo female – Severe Stable SCFE

11 yo female – Severe Stable SCFE 2 years postoperative

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Moderate and Severe 14 yo female - FAI 2 y after severe SCFE

SHD flexion valgus rotation ITO – 2 y

Unstable SCFE

12 year-old male

Closed reduction

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In situ

Pinning

Unstable SCFE

Anterior

Arthrotomy

Pinning

Parsh 2009

Modified

Dunn

Ziebarth 2009

0-50%

Necrosis

5%

Necrosis 8%

Necrosis

Lateral Position

Deep exposure

Vastus lateralis Gluteus medius

Piriformis

Gluteus minimus

Hip Capsule

Trochanteric Osteotomy

Modified Dunn is Superior to In-Situ

Pinning for Anatomic Restoration and

Clinical Outcome with Similar

Osteonecrosis Rate in Unstable SCFE

Eduardo N. Novais, MD; Lauryn Kestel, BS; Claire Palmer, MS;

Joao Caetano Abdo, MD; Travis Heare, MD; Ernest Sink, MD

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Variable In situ pinning (n=18) Modified Dunn (n=27) P-value

Gender, No. (%) 0.67

Female 10 (56%) 12 (44%)

Male 8 (44%) 15 (56%)

Age, mean (range) 12.7 (9.9,16.4 ) 12.6 (7.6,17.7) 0.923

BMI, mean (range) 24.6 (17.3,31.1) 26.5 (16.3,38.5) 0.223

Fahey Classification [10] 0.358

Acute on Chronic 12 (67%) 13 (48%)

Acute 6 (33%) 14 (52%)

Time from trauma to surgery 0.1

>24 hours 6 (33%) 17 (63%)

<24 hours 12 (67%) 10 (37%)

Preoperative Southwick angle 64.5 (51.2, 81.3) 66.9 (56.6, 79) 0.808

Follow-up, mean years (range) 5.8 (1,15.9) 2.4 (1,7.96) <0.001

Group characteristics

26% Modified Dunn

28% In-situ Pinning

(p >0.99)

Radiographs

Restoration of proximal femoral head and neck anatomy was superior in the

modified Dunn group compared to the in-situ pinning group

-20

0

20

40

60

80

100

Alpha angle Southwick angle Head-neck offset

Modified Dunn

In-situ Pinning

Heyman and Herndon scores

good or excellent (p = 0.016)

28% 67% Modified Dunn

In-situ pinning

In-situ pinning

(N=18) 33%

Modified Dunn

(N=27) 26%

Single procedure

Removal of implant penetrating the joint 1 (5.5%) SHD with bone graft to the femoral head 1 (3.7%)

SHD with ORIF of femoral head non-union 1 (5.5%) Revision of implant penetrating the joint 1 (3.7%)

SHD with osteochondroplasty 1 (5.5%) THA 1 (3.7%)

Multiple procedures

Revision of implant penetrating the joint 1 (5.5%)

Revision of implant penetrating the joint 2 (7.4%)

SHD with ORIF of femoral head non-union Implant removal after epiphyseal healing

THA followed by revision THA

SHD + osteoplasty aftereosteonecrosis 1 (5.5%)

Revisions of implant penetrating the joint 2 (7.4%)

THA THA

Revision of implant penetrating the joint

1 (5.5%) - - SHD + ORIF of femoral head non-union

THA

Unplanned Procedures (p=0.894) 12 yo female – Acute unstable SCFE

100% displaced

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13 yo male – Acute unstable SCFE 13 yo male – Acute on chronic unstable

100% displaced

Thank you Eduardo Novais, MD

Assistant Professor of Orthopedic Surgery