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Slipped capital epiphysis

SCFE

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Slipped capital epiphysis

  1. 1. SLIPPED CAPITAL FEMORAL EPIPHYSIS Presenter - Dr. Prashant Bhavani AIIMS New Delhi
  2. 2. Misnomer Epiphysis “STAYS” Neck and Shaft “DISPLACES” SLIPPED CAPITAL FEMORAL EPIPHYSIS 2
  3. 3. 3
  4. 4. Incidence  0.33/100,000 to 24.58/100,000 4
  5. 5. Race/Ethnicity  RRF, Caucasians at 1.0  5.6 – Polynesians  3.9 – Blacks  2.5 – Hispanics RRF 9.6 - India* 5 *Y. J. Lim, F. Kagda, K. S. Lam et al., “Demographics and clinical presentation of slipped capital femoral epiphysis in Singapore: comparing the East with the West,” Journal of Pediatric Orthopaedics B, vol. 17, no. 6, pp. 289–292, 2008.
  6. 6. Gender & Age  Male predominence, 90% → 60% ↓  Indo-Mediterranean's – 90% male*  Polynesians – M:F equal*  Age- Prepubescence & Early Adolescence  13.5 yrs → 12.0 yrs in boys  12 yrs → 11.2 yrs in Girls  ??????  Early maturation  Obese children present early 6 * R. T. Loder, “The demographics of slipped capital femoral epiphysis: an international multicenter study,” Clinical Orthopaedics and Related Research, no. 322, pp. 8–27, 1996.
  7. 7. Symptom Duration  Stable SCFE (Avg) – 4 to 5 mths  4.5 mths – Boys  3.6 mths – Girls 7 * R. T. Loder, T. Starnes, G. Dikos, and D. D. Aronsson, “Demographic predictors of severity of stable slipped capital femoral epiphyses,” Journal of Bone and Joint Surgery, American, vol. 88, no. 1, pp. 97–105, 2006. Symptom duration as a function of slip severity
  8. 8. Body weight, Obesity, BMI  Majority are Obese ◦ > 50% are > 95th percentile weight for age  Age at Diagnosis - ↓ with ↑ obesity ◦ 12.4 yrs – Obesity (95th percentile) ◦ 14.3 yrs – Others (< 10th percentile)  BMI (Avg) ◦ 25 to 30 kg/m2 or ◦ > 85thpercentile  B/L SCFE (31.1) v/s U/L SCFE (26.8) 8 * R. T. Loder, “The demographics of slipped capital femoral epiphysis: an international multicenter study,” Clinical Orthopaedics and Related Research, no. 322, pp. 8–27, 1996.
  9. 9. Seasonal Variation  Latitude north of 40 ̊- Late Summer & Autumn months 9 N. Maffulli and A. S. Douglas, “Seasonal variation of slipped capital femoral epiphysis,” Journal of Pediatric Orthopaedics B, vol. 11, no. 1, pp. 29–33, 2002.
  10. 10. Bilaterality  Overall – 18 to 50%  M/C Africans (34%) v/s Asians (18%), Hispanics (17%), White (7%)  Rx affect risk of B/L involvement †  36% - In-situ pinning  7% - spica cast  Close attention “MANDATORY”  B/L SCFE *  50% to 60% - Simultaneous SCFE  80% to 90% - Sequential SCFE within 18 mths 10 *R. T. Loder, D. D. Aronson, and M. L. Greenfield, “The epidemiology of bilateral slipped capital femoral epiphysis: a study of children in Michigan,” Journal of Bone and Joint Surgery, American, vol. 75, no. 8, pp. 1141–1147, 1993. † J. M. Hurley, R. R. Betz, R. T. Loder, R. S. Davidson, P. D.nAlburger, and H. H. Steel, “Slipped capital femoral epiphysis: the prevalence of late contralateral slip,” Journal of Bone and Joint Surgery, American, vol. 78, no. 2, pp. 226–230, 1996.
  11. 11. Predictors of risk of B/L involvement  Young age  Modified Oxford Hip bone age < 16  Endocrine cause  Obesity  Tri-radaite cartilage fusion – Risk 4%  ↑ Post slope angle epiphysis (>12) - ↑ Risk 11 T. A. Bidwell and N. S. Stott, “Sequential slipped capital femoral epiphyses: who is at risk for a second slip?” Aus NZ Journal of Surgery, vol. 76, no. 11, pp. 973–976, 2006.
  12. 12. Classification  Traditional classification ◦ Based on History, Duration of symptoms, Examination, Radiography Pre-slip Acute slip - < 3wks symptom Chronic slip - > 3 wks symptom Acute on chronic - > 3wks symptom + Acute slip 12
  13. 13. Classification  Kullio et al given a classification ◦ Based on USG findings  Acute Effusion without Metaphyseal remodeling  Chronic No Effusion with Metaphyseal remodeling 13
  14. 14. Classification  Loder`s Classification ◦ Based on ability to bear weight  Stable slip ◦ able to bear weight with or without crutches ◦ No AVN  Unstable slip ◦ unable to bear weight, with or without crutches ◦ 47% incidence of AVN 14
  15. 15. Etiopathogenesis Etiology (unknown) Biomechanical factors ↑ Shear stress across physis Biochemical factors ↓ Resistance to shear Weaken physis FAILURE 15
  16. 16. Biomechanical factors  Obesity  Femoral retroversion  Increased physeal obliquity  Thinning of Perichondrial fibrocartilaginous complex 16
  17. 17. Biochemical factors  Hypogonadism (M/C)  Growth hormone supplementation  Hypothyroidism  Hyperparathyroidism ( Sec to CRF ) 17
  18. 18. Pathology Slipping in hypertrophic Zone of physis Zone of hypertrophy is widened and composed of chondrocytes in disarrayed clusters instead of orderly columns Chondrocytes of the hypertrophied zone at the cleft (C) region are in disordered clusters and irregular columns 18
  19. 19. Watch it in Pre-slip  Weakness in lower extremity  Limping  Exertional pain ◦ Felt as referred pain at groin, thigh or knee  O/E – ◦ ↓ IR (most consistent finding) 19
  20. 20. Acute slip  15% of SCFE patients  Trivial trauma  Prodromal symp < 3 wks  Abrupt displacement  Unable to bear weight  O/E ◦ External rotational deformity ◦ Shortening ◦ Marked limitation of ROM # NOF/typ1physeal Separation Yes Yes Yes 20
  21. 21. Acute slip  15% of SCFE patients  Trivial trauma  Prodromal symp < 3 wks  Abrupt displacement  Unable to bear weight  O/E  External rotational deformity  Shortening  Marked limitation of ROM # NOF/typ1physeal Separation Yes Yes Yes 21
  22. 22. Chronic Slip  M/C type – 85%  Pain in groin, thigh or knee - > 3 wks  Walks with limp  Knee pain delays diagnosis – 46%  O/E –  Antalgic gait  Loss of IR, Abd & flexion  LLD – severe cases  With flexion – spontaneous Abd + ER 22
  23. 23. Acute on chronic slip  Prodromal symptom > 3 wks  Sudden exacerbation of pain  Precludes weight bearing  Imp ????  S/d be differentiated from Acute slip  Attempted reduction - ↑ AVN 23
  24. 24. Radiographic findings Mild slip Klein's line Trethowan's sign 24
  25. 25. Radiographic findings Mild slip Metaphyseal blanch sign of Steel 25
  26. 26. Radiographic findings Mild slip Scham's sign 26
  27. 27. 27
  28. 28. Severity of SCFE 28
  29. 29. Severity of SCFE Frog-leg lateral pelvis radiograph of a patient with a 44° slipped capital femoral epiphysis (moderate), with an epiphyseal-shaft angle of 56° on the right and of 12° on the left (56° – 12° = 44°). 29
  30. 30. Role of CT 30
  31. 31. Role of other investigation  Bone scan Increased Uptake – Chondrolysis Decreased Uptake – AVN  USG Early slips – Effusion + Step b/n neck & epiphysis Severity of slippage  MRI - early AVN 31
  32. 32. Natural History of SCFE All slips STOPS Gradual displacement Physis closure Degree of slip Timing of cessation SHORTTERMCOURSELONGTERMCOURSE Premature 2 ͦ Osteoarthritis α to Severity Resultant deformity 32
  33. 33. What should be our GOALS?  Detect early → Deformity (↓) → 2 ͦ OA (↓) Prevent further slippage → Severity (↓) → 2 ͦ OA (↓) Avoid complications → 2 ͦ OA (↓) 33
  34. 34. How can we detect early ?  Meticulous History taking  Proper Examination  Proper Investigations and their analysis 34
  35. 35. Differential Diagnosis Fractures •Significant trauma •↑ Soft tissue shadow •Displacement any direction •Trivial trauma • No Soft tissue shadow •Displacement post-inf direction Perthes disease •Sclerosis, cyst, collapse of head •MRI - ↑&↓ signal intensity T2 & T1 •Displaced epiphysis •Remodeling changes Osteomyelitis •↑ WBCs, ESR, CRP Fever •MRI - ↑ signal intensity T2 / Intra- osseous/subperiostea l abscess •Normal •No fever •No abscess SlippedCapitalFemoral Epiphysis 35
  36. 36. Cont….. Septic arthritis •X-ray - ↑ joint space •USG - Effusion •Normal/ ↑ joint space •USG – Effusion + step deformity b/n Epiphysis & neck Groin pull/ Adductor muscle strain •Rare •Pain on adduction •Tenderness – groin & adductor tendon •No Ext rotation deformity • No Tenderness – groin & adductor tendon • Ext rotation deformity Stress # MRI - Edema/stress reaction femoral neck Absent SlippedCapitalFemoralEpiphysis 36
  37. 37. How can we prevent further slippage? Stable SCFE (Chronic) Unstable SCFE (Acute) 1.In-situ pinning 2.Epiphysiodesis 3.Femoral Osteotomies without surgical dislocation 4.Surgical dislocation of the hip with modified Dunn osteotomy, reduction, and fixation (5. Urgent reduction, fixation and arthrotomy) 37
  38. 38. In Situ pin or screw fixation • Percutaneous - Acute and chronic slips ◦ Mild ◦ Moderate ◦ Some severe  Open ◦ More severe Acute & ◦ Acute on chronic slip 38
  39. 39. In Situ pin or screw fixation Technical Aspect  Supine position ◦ Fracture table ◦ Radiolucent table top  Entry point ◦ Mark trajectory lines AP & Lateral views 39
  40. 40. In Situ pin or screw fixation Technical Aspect  Intersection of line  Pass guide wire  Pass drill bit over wire  Insert cannulated screw Insertion of Guide wire Measurement & Drilling Insertion of Screw40
  41. 41. Ideal Placement of screw  Entry point ◦ Anterior femoral neck  Extent ◦ 8mm ◦ ⅓ Femoral head radius  No.of screws ◦ 1- Chronic ◦ 2- Acute  Placement ◦ perpendicular to physis ◦ centre of epiphysis  Pin penetration ◦ Rotating fluoroscopic beam Ideal position 41
  42. 42. Osteotomy Closing wedge osteotomy (femoral neck)  Cuneiform osteotomy  Subcapital realignment of epiphysis  Base of neck osteotomy Compensatory osteotomy (Trochanter)  Imhauser/ Southwick osteotomy 42
  43. 43.  Rate of complications α Proximity of the osteotomy ◦ Highest -osteotomies at the apex (intracapsular in the superior neck) ◦ Lowest -osteotomies performed extracapsularly in the intertrochanteric area  Severity of 2 ͦ compensating deformity α Distal the corrective osteotomy 43
  44. 44. Cuneiform osteotomy of the femoral neck (FISH) 44 Exposure & capsule incision Osteotomy Removal of wedge of bone More bone removed Realignment Fixation
  45. 45. Cuneiform osteotomy of the femoral neck (DUNN) 45 Osteotomy of GT Elevation of synovium Removal of callus Osteotomy Line Realignment Fixation
  46. 46. Subcapital realignment of Epiphysis 46
  47. 47. Base-of-Neck Osteotomy 47
  48. 48. Base-of-Neck Osteotomy 48
  49. 49. Intertrochanteric Osteotomy 49
  50. 50. Intertrochanteric Osteotomy 50
  51. 51. Spica Cast  Used as an Adjunct  Also definitive management of slipped epiphysis  Complications Pressure sores Chondrolysis 51
  52. 52. Spica Cast  Little indication - modern management  Reserved for the occasional desperate situation  Very young patients Chronic renal failure 52
  53. 53. Conclusions: A systematic review of the literature recommends on the basis of level of evidence that the best treatment for a stable SCFE is single screw in situ fixation and for unstable SCFEs urgent gentle reduction, decompression, and internal fixation. 53
  54. 54. 54
  55. 55.  Most common complaints are  Excessive external rotation,  Limitation of flexion,  Trendelenburg lurch,  Combination of these Residual Deformity after Closure of the Physis (Femeroacetabular Impingement) 55
  56. 56. TREATMENT Osteoplasty of the femoral neck May be done in conjunction with fixation of the epiphysis (usually epiphysiodesis) or independently, after closure of the physis 56
  57. 57. TREATMENT Intertrochanteric repositioning osteotomy performed for complaints of restricted flexion and internal rotation after in situ fusion. A, Before intertrochanteric osteotomy. B, After intertrochanteric osteotomy. The patient was pleased with the more functional position of the hip arc of motion, with increased flexion and internal rotation. Intertrochanteric repositioning osteotomy 57
  58. 58. Complications of SCFE  Chondrolysis  AVN 58
  59. 59. Chondrolysis Epidemiology  Incidence - 1.5% after In-situ pinning - 50% with spica cast Rx Girls > Boys Black patients Spontaneously/After treatment 59
  60. 60. Etiology  Unknown, but theories says…….  Loss of synovial fluid - ↓ Nutrition  Autoimmunity - ↑ IgM & C₃  Metallic Implant penetration  Impingement of labrum & acetabulum (“Pistol grip deformity”) 60
  61. 61. Clinical features  Persistent pain – groin/upper thigh  Flexion, Abduction & ER  ROM- painful/decreased in all planes  Walking/activities-adversely affected  Radiography  Loss of joint space > 50%  Joint space of 3mm/less  Bone scan  Increased uptake-seldom necessary 61
  62. 62. Natural History  Pain + Restriction ROM + ↓ joint space  6 wks to 4 mths – after treatment  6 to 12 mths – max ↓ joint space  Reconstitute (variable extent) – 3 yrs 62
  63. 63. Treatment  Non-specific & supportive Rule out Infection – Hip aspiration Implant penetration – CT scan  Supportive care Modification of activities Use of crutches Gentle ROM Ex Anti-inflammatory medications 63
  64. 64. AVN  Severe complication  Occur with/without Rx  M/C occur Closed/open reduction of unstable slips Osteotomy of the femoral neck  Less Open epiphysiodesis In situ pinning of stable slips 64
  65. 65. How it occurs?  Unstable slips- tearing of the periosteum →lateral epiphyseal arterial system damage  Forcible reduction → tear the posterior periosteum  During surgery→ direct injury to the periosteum  Intra-articular tamponade by traumatic effusion 65
  66. 66. How they present?  Can occur – few wks/ 1yr/ 18mths  Increasing pain + deformity + loss of motion  Develop progressive deformity and restriction of motion  Radiography- Two patterns of distribution  Total head necrosis  Partial (or segmental) necrosis 66
  67. 67. TREATMENT  Prevention - ↓ surgeon's control  How? ◦ Open reduction ◦ Femoral neck osteotomies ◦ Manipulation of stable slips ◦ Forcible manipulation of unstable slips 67
  68. 68. TREATMENT  Educate the patient - potential outcome  Ascertain metallic implants 2 ͦ encroachment  Remove the implant  Physis not fused – Manipulate/Reinsert  Intertrochanteric osteotomy - little pain + deformity + poor functional position  Arthroplasty or Hip fusion - Debilitating pain with progressive radiographic changes 68
  69. 69. Contralateral Slips  B/L Slips ◦ Simultaneous – 50% to 60% ◦ Subsequent – 80% to 90%  Castro et al – 2335 times risk  Rx controversial  Indication ◦ Age ◦ Endocrine cause ◦ Follow up not feasible ◦ Posterior slope angle >12 deg ◦ Young obese children
  70. 70. Conclusion  SCFE is not an uncommon disease  Most commonly occurs in Adolescent obese male, involving left hip  Take meticulous history, do proper examination, get proper investigations  Detect early, intervene early and avoid complications  In-situ fixation gold standard surgical option stable SCFE  Surgical dislocation with modified Dunn osteotomy provides promising result by reducing the Incidence of AVN 70
  71. 71. THANK YOU

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