SUFE
Dr . O. K. A. Samuels
‘when the epiphyses and heads
of the bones are plucked from
the bone whereon they were
placed or fastened; which
unproperly called kind of
luxation, hath place chiefly in
—
the bones of young people.
And it is known by the
importance of the part and by
the noise and grating
together of the crackling
bones when they are handled.’
Ambroise Pare— 1564
INTRODUCTION
Slipped capital femoral epiphysis is a well
known disorder of the hip in adolescents that
is characterized by displacement of the capital
femoral epiphysis from the metaphysis
through the physis.
MISNOMER
INTRODUCTION
The deformity is typically
one of superior migration,
adduction and external
rotation of the femoral
neck.
epiphysis displaces
primarily posterior
relative to the
femoral neck.
Valgus
SUFE
Epidemiology and Demographics
0.2 per 100,000 Japan to 10.2 per 100,000 NE USA
Male predominance 60%
Left 60%
Unilateral 60 %
Average age at diagnosis is 13.5 y M
12.0 y F
Typical range 9- 16 y
Demographics and epidemiology
Majority obese >50% 95th centile weight for age
Presenting age as weight
Relative racial frequency
Whites 1.0
Pacific islanders 4.5
Blacks 2.2
Epidemiology and Demographics
Bilaterality varies 18 – 50 %
Initially 50 % , subsequently 50 %
Higher in blacks ( 34 % )
82% of 2nd slips by 18mths
Younger age
Aetiology
Endocrine or Metabolic ( 5-8 % )
Idiopathic - essentially unknown
multiple theories
Aetiology
Theories - Biomechanical
Biochemical
Final common pathway
-mechanical insufficiency of the proximal
femoral growth plate
physiological load abnormally high loads
across an abnormally across a normal
weak physis physis
Biomechanical Factors
deficiency and abnormality in the
supporting collagenous and
proteoglycan framework of the
physis and perchondral ring
Chondrocyte clustering and
disarray occur in a thickened
hypertrophic zone
proliferative zone demonstrates changes in
proteoglycan and glycoprotein concentrations,
Biomechanical Factors
Obesity
Microtrauma
increased femoral
retroversion
Shear stressess
increased physeal
obliquity
Torsional forces
Deeper acetabulum
Biochemical Factors
Puberty - Hormonal changes (gonadotrophins )
Rapid longitudinal growth
increased physiological activity
widening of the physis
Decreased physeal strength
Aetiology
subtle but as yet
undiagnosable
endocrinopathy may be
present.
A genetic basis for
SUFE has not been
established.
Previous radiation
Aetiology
There have been mixed results implicating an
immunological basis for SUFE.
Some studies have shown increased C3 complement
and immunoglobulins and possibly higher serum IgA
levels.
Aetiology
Hypothyroidism
panhypopituitarism,
Endocrinopathi growth hormone
abnormality
es hypogonadism
6 -8 x more Craniopharyngioma
Hyperparathyroidism (CRF)
80% bilateral MEN II-B
Turner’s syndrome
optic glioma
Presentation and Classification
Preslip
Traditional
Acute
Based on clinical features
Chronic
Acute on chronic
Presentation
Preslip - weakness in the leg
- Limping (painless )
- pain in the groin , thigh or
knee on exertion
-lack of internal rotation
Presentation
Acute Chronic
Symptoms < 3weeks Symptoms > 3 weeks
10 – 15 % 85 %
Inceased risk of AVN in Remissions and
treated cases exacerbations
Presentation
Acute on chronic
- Prodromal symptoms for > 3 weeks
- sudden exacerbation of pain
Examination
Externally rotated attitude
Restriction of flexion, abduction, and internal rotation
Obligatory external rotation on flexion (this is a diagnostic
clue)
Wasting of the thigh in chronic slips
True supratrochanteric shortening (Bryant triangle,
Nélaton line)
Trendelenburg sign and gait possible; antalgic gait in acute
or acute-on-chronic slips
Classification
Stable Unstable
child can walk and bear Unable to walk or bear
weight, with or without weight with or without
crutches crutches
0 % AVN rate
Up to 50% AVN rate
Imaging
Anteriop Frog- lateral (more
sensitive)
osterior
Radiographs
Preslip – essentially a radiographic diagnosis
- widened , irregular, indistinct physis
Radiographs
Metaphysial
Blanch of
Steel
RADIOGRAPHS
Kleins Line
Trethowan’s
Sign
> 2mm
Radiographic Classification
Degree of slip
( Wilson)
percentage of
displacement of the
epiphysis on the width of
the metaphysis
mild, < 33%;
moderate, 33% to 50%;
severe, >50%
Radiographic Classification
Southwicks
epiphyseal /shaft angle
Mild: the head shaft angle
differs by less than 30.
Moderate: the angle
difference is 30–60.
Severe: the angle
difference is more than 60
Ultrosonographic Classification
Kallio
ultrasound - absence of metaphyseal remodeling and the
presence of an effusion, an acute event is likely to be
unstable.
ultrasound - demonstrate metaphyseal remodeling and the
absence of an effusion, an acute event has not occurred, and
the SCFE is considered stable.
CT
Scan
The later management
if joint penetration has
occurred with fixation devices
exact position of Implants
if the growth plates have closed and
so may help in deciding about
contralateral fixation
3-D images assess residual
deformity of the upper femur when
planning reconstructive osteotomy.
Axial CT scan images also enable
the head–neck angle measurement
Bone Scan and MRI
Limited use
early detection of AVN
Preslip ?
Management
Goals - early detection
- prevention of further slippage
- maintain or regain hip function
- avoidance of complications
Management
Controversies
Management – (Stable/Chronic )
Hip-spica cast immobilization
In situ stabilization with single or multiple pins or
screws
Open epiphysiodesis with autograft or allograft bone
Open reduction with a corrective osteotomy through
the physis and internal fixation with use of multiple
pins
Compensatory basilar neck osteotomy with in situ
stabilization with multiple-pin fixation
Intertrochanteric osteotomy with internal fixation
Hip spica
ADVANTAGES
It avoids the complications
of anesthesia and surgery
It also provides
prophylactic treatment for
the opposite hip
Hip spica
DISADVANTAGES
The hip-spica cast does not
stabilize the SCFE
reported progression of the
slip in 5-10% of patients
chondrolysis rates appears to
be higher than with surgical
treatment.
It is cumbersome, especially if
obese
restricts mobility
It can also cause cast sores.
In situ stabilization
stable or chronic mild and moderate slips (85%)
No formal manipulation
postoperative remodeling occurs
the loss of internal rotation of the hip in most
patients is not clinically relevant (Bellmans JPO
1996)
Key Points
anterior entry site on
the neck, appropriate for
the degree of slip;
no crossing of the
physis until bi-planar
alignment is achieved;
the pin is in the
epiphysis and NOT in
the joint by multiplanar
radiographic evaluation.
Key Points
started on the lateral
entered the epiphysis in
the posterosuperior
quadrant,
which jeopardized the
blood supply to the
femoral head
lateral epiphyseal vessels
Key Points
Ideal screw position.
the central axis of the
screw is located over
the center line of the
femoral head or within a
distance equal to
one-half the diameter of
the screw
Outcome
results of single-screw fixation in patients with SCFE have
been gratifying
rates of slippage and complications are low (Aronson DD,
Loder 1992 , Ward 1992 , Stevens 1996 ,Anand A, Chorney
GS 2007 )
Outcome
CONTROVERSY - multiple vs single screws
the gain in stiffness with a second screw may not offset
the increased risk of complications (Karol JPO 1992)
incidence of pin-related complications was directly
related
the number of pins or screws (Blanco et. al 1992 )
Open Epiphyseodesis with Iliac
Crest or Allogeneic Bone Graft
iliofemoral approach.
rectangular window of bone is
removed from the anterior
aspect of the femoral neck.
A cylindrical tunnel is created
across the physis,
multiple corticocancellous
strips of iliac crest bone graft
are driven into the tunnel
across the proximal femoral
physis
promote early closure of the
physis
Advantages Disadvantages
The risk of damaging the The fixation afforded by
vascularity of the femoral bone graft is not as solid
head is reduced
as that provided by pins.
The risk of joint penetration
A risk of additional
is also reduced.
It avoids the complications of slippage remains.
internal fixation, including The surgery and
unrecognized pin anaesthesia is longer.
penetration and hardware Blood loss is increased.
failure.
It provides rapid, reliable The incision is larger.
closure of the physis. A spica cast is needed.
Unstable SUFE
CONTROVERSAL
UNSTABLE SUFE
many investigators recommend internal fixation
the timing of fixation
the role of preoperative traction
the role of open reduction / surgical hip dislocation
Role of decompression (open vs aspiration )
the number of screws used for fixation
Examine the Evidence
Tomkakova and Stanton (
JBJS 2004 )
Maeda et. al. ( JPO 2001 )
Gordon et. al ( JPO 2002)
Herrera-soto (JPO 2008)
Parsch et. al (JPO 2009 )
Chen et. al (JPO 2009)
Palocaren (JPO 2010)
Examine the evidence
Their good results were attributed to
arthrotomy and decompression of the joint along with
open reduction and internal fixation
within 24 hours of the onset of symptoms.
2 screws VS 1 screw vs smooth pins ?
NWB for 6-8 weeks
Surgical Dislocation
Severe SUFE
Controversial
Severe SUFE
Persistent femoral
retrovertion
Femeroacetabular
impingement
Early osteoarthritis
SEVERE SUFE
In situ pinning can often be very difficult if not
impossible.
An attempt at in situ fixation can be undertaken
accepting that there will be a functional deficit,
depending on the age at presentation, limited
remodelling potential.
SEVERE SUFE
The role of osteotomy in the treatment of SCFE is controversial
regarding indications, timing, and type of osteotomy.
osteotomy should be performed as the initial treatment in SCFE .
an attempt to improve the joint anatomy
and prevent further slippage and later complications.
osteotomies should be considered only after physeal closure and
assessment of the patient’s function and hip rotation
Osteotomies
Anatomically
(A) subcapital (Dunn or
Fish);
(B) basal neck (Kramer
or Barmada et al.);
(C) intertrochanteric
(Southwick or
Imhauser).
Osteotomies
The closer to the epiphysis the osteotomy, the
greater is the risk of AVN,
Frymoyer’s reporting 0% AVN using the
Southwick procedure compared with up to 30% for
subcapital osteotomies.
However, the subcapital osteotomy gives the
highest degree of correction.
Subcapital osteotomy
Technically demanding
Potential complications
(AVN rate )
Avoid posterior neck
Open physis (Dunn )
Basal Neck
compensating closing
wedge
corrects the varus and
retroversion of the slip
theoretically preserving
the blood supply to the
head.
Intertrochanteric Osteotomy
generally used after closure
of the physis.
Southwick - describes a tri-
planar osteotomy
incorporating valgus, flexion
and internal rotation of the
distal segment to restore
proximal femoral alignment
Imhauser - described a bi-
planar osteotomy with
flexion and internal rotation
of the distal portion.
Prophylactic Pinning of Contralateral Hip
commonly accepted In children who have
underlying endocrine or metabolic disorders,
prophylactic fixation of the uninvolved hip
should be strongly considered
Aim to prevent slippage (especially a severe and or
unstable slip)
Prophylactic pinning
two options:
Prophylactic fixation of the opposite hip
observation with close clinical and radiographic
follow-up.
Prophylactic Pinning
advise using sound clinical judgment with respect to
patient
age, sex, and endocrine status
considering the preferences of the patient and family
Prophylactic Pinning
AAOS Annual Meeting 2010
Based on the literature it seems reasonale to pin
the opposite hip when
Absolute - endocrinopathy or metabolic disorder
Relative - chronologic age < 9 girls , <11 boys
- ethnicity
- high physeal slope
Complications
Avascular necrosis
Chondrolysis
Degenerative Joint disease
. Other complications
such as implant failure, growing off the screw, slip
progression, proximal femoral fracture,
femoral neck fracture, and leg length discrepancy.
Avascular Necrosis
FACTORS
an acute unstable SUFE
overreduction of an acute SUFE
attempts at reduction of the chronic
component of an acute-on-chronic SUFE
placement of pins in the superolateral quadrant of the
femoral head
increased if a cuneiform or basilar neck osteotomy is
performed prior to physeal closure.
AVN
Management
non–weight bearing with
crutches, range-of-motion exercises,
and anti-inflammatory medication.
An internal fixation device that protrudes into the
joint should be repositioned in the epiphysis if the
physis is open, or removed if the physis is closed.
Salvage
Re-directional
osteotomies,
vascularised fibular grafting
standard bone grafting procedures have been
attempted in children
there are no convincing outcome studies.
Total hip arthroplasty
Chondrolysis
Acute necrosis of the articular cartilage
Risk factors for chondrolysis are:
1. cast immobilisation
2. unrecognised permanent pin penetration
3. severe slip
4. prolonged symptoms before treatment
Chondrolysis
It usually presents with pain and stiffness
the hip being held in flexion, external rotation and
abduction.
X-rays reveal a loss of joint space,
the criterion for diagnosis being a loss of more than
50% of the joint space compared to the other hip
or an absolute measurement of 3mm or less.
Chrondrolysis
Presentation is usually between 6 weeks and 4 months
after treatment of SUFE.
Progressive joint space narrowing occurs between 6
and 12 months.
Chrondrolysis
Treatment of chondrolysis is largely supportive.
Firstlyinfection must be ruled out.
Secondly, a CT scan of the hip to ensure that penetration of the
jointhas not occurred.
If penetration has occurred then the screw should be removed, or
replaced if the physis has not closed.
Patients who do not recover adequate movement or whohave severe
continued pain may require arthrodesis or arthroplasty.
