Aims. The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE). Methods. This was an anonymized comprehensive cohort study, with a nested consented cohort, following the the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) framework. A total of 143 of 144 hospitals treating SCFE in Great Britain participated over an 18-month period. Patients were cross-checked against national administrative data and potential missing patients were identified. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. Results. A total of 486 children (513 hips) were newly affected, with a median of two patients (interquartile range 0 to 4) per hospital. The annual incidence was 3.34 (95% confidence interval (CI) 3.01 to 3.67) per 100,000 six- to 18-year-olds. Time to diagnosis in stable disease was increased in severe deformity. There was considerable variation in surgical strategy among those unable to walk at diagnosis (66 urgent surgery vs 43 surgery after interval delay), those with severe radiological deformity (34 fixation with deformity correction vs 36 without correction) and those with unaffected opposite hips (120 prophylactic fixation vs 286 no fixation). Independent risk factors for avascular necrosis (AVN) were the inability of the child to walk at presentation to hospital (adjusted odds ratio (aOR) 4.4 (95% CI 1.7 to 11.4)) and surgical technique of open reduction and internal fixation (aOR 7.5 (95% CI 2.4 to 23.2)). Overall, 33 unaffected untreated opposite hips (11.5%) were treated for SCFE by two-year follow-up. Age was the only independent risk factor for contralateral SCFE, with age under 12.5 years the optimal cut-off to define ‘at risk’. Of hips treated with prophylactic fixation, none had SCFE, though complications included femoral fracture, AVN, and revision surgery. PROMs demonstrated the marked impact on quality of life on the child because of SCFE. Conclusion. The experience of individual hospitals is limited and mechanisms to consolidate learning may enhance care. Diagnostic delays were common and radiological severity worsened with increasing time to diagnosis. There was unexplained variation in treatment, some of which exposes children to significant risks that should be evaluated through randomized controlled trials. Cite this article: Bone Joint J 2022;104-B(4):519–528

Objectives. The purpose of this study was to evaluate the existing literature from 2005 to 2016 reporting on the efficacy of surgical management of patients with femoroacetabular impingement (FAI) secondary to slipped capital femoral epiphysis (SCFE). Methods. The electronic databases MEDLINE, EMBASE, and PubMed were searched and screened in duplicate. Data such as patient demographics, surgical technique, surgical outcomes and complications were retrieved from eligible studies. Results. Fifteen eligible level IV studies were included in this review comprising 261 patients (266 hips). Treatment groups included arthroscopic osteochondroplasty, surgical hip dislocation, and traditional open osteotomy. The mean alpha angle corrections were 32.14° (standard deviation (. sd). 7.02°), 41.45° (. sd. 10.5°) and 6.0° (. sd. 5.21°), for arthroscopy, surgical hip dislocation, and open osteotomy groups, respectively (p < 0.05). Each group demonstrated satisfactory clinical outcomes across their respective scoring systems. Major complication rates were 1.6%, 10.7%, and 6.7%, for arthroscopy, surgical dislocation and osteotomy treatments, respectively. Conclusion. In the context of SCFE-related FAI, surgical hip dislocation demonstrated improved correction of the alpha angle, albeit at higher complication and revision rates than both arthroscopic and open osteotomy treatments. Further investigation, including high-quality trials with standardised radiological and clinical outcome measures for young patients, is warranted to clarify treatment approaches and safety. Cite this article: K. O. Oduwole, D. de Sa, J. Kay, F. Findakli, A. Duong, N. Simunovic, Y. Yi-Meng, O. R. Ayeni. Surgical treatment of femoroacetabular impingement following slipped capital femoral epiphysis: A systematic review. Bone Joint Res 2017;6:472–480. DOI: 10.1302/2046-3758.68.BJR-2017-0018.R1

Prophylactic fixation of the contralateral hip in cases of unilateral slipped capital femoral epiphysis (SCFE) remains contentious. Our senior author reported a 10 year series in 2006 that identified a rate of subsequent contralateral slip of 25percnt; when prophylactic fixation was not performed. This led to a change in local practice and employment of prophylactic fixation as standard. We report the 10 year outcomes following this change in practice. A prospective study of all patients who presented with diagnosis of SCFE between 2004 and 2014 in our region. Intra-operative complication and post-operative complication were the primary outcomes. 31 patients presented during the study period: 16 male patients and 15 female patients. The mean age was 12.16 (8–16, SD 2.07). 25 patients had stable SCFE and 5 had unstable SCFE. Stability was uncertain in 1 patient. 25 patients had unilateral SCFE and 6 had bilateral SCFE. 24 patients who had unilateral SUFE had contralateral pinning performed. 1 unilateral SCFE did not have contralateral pinning performed as there was partial fusion of physis on contralateral side. In the hips fixed prophylactically there was 1 cases of transient intraoperative screw penetration into the joint and 1 case of minor wound dehiscence. There were no cases or chondrolysis or AVN. There were no further contralateral slips. This change in practice has been adopted with minimal complication. The fixation of the contralateral side is not without risk but by adopting this model the risk of subsequent slip has been reduced from 25percnt; to 0percnt;

Despite recent advances in the management of slipped capital femoral epiphysis (SCFE), controversy remains about the treatment of choice for unstable slips. Surgical dislocation and open reduction has the advantage of identifying and preserving the blood supply of femoral head thereby potentially reducing the risk of avascular necrosis, (AVN). There is large variation in the literature from several small series about reported AVN rates ranging from two to 66% for unstable SCFE treated with surgical dislocation. The aim of our study was to analyze our experience with acute open reduction and internal fixation of unstable acute and unstable acute on chronic slips using the technique of surgical dislocation described by Professor Reinhold Ganz. A retrospective review of 11 patients (12 hips) treated by surgical dislocation, reduction and pinning as the primary procedure for unstable acute and unstable acute on chronic SCFE in a tertiary referral children's hospital was undertaken. This represents the entire series treated in this manner from September 2007 to January 2018. These procedures were performed by a team of Orthopaedic surgeons with significant experience performing surgical dislocation of the hip including patients with chronic SCFE, Perthes' disease, impingement and acetabular fractures. Demographic data, intraoperative records, postoperative notes and radiographs including details of subsequent surgery were reviewed. There were seven boys and four girls with mean age of 13.4 years, range 11 to 15 years at the time of surgical dislocation. Out of 12 hips, two had acute unstable slip while the remaining 10 had acute on chronic unstable slip. Six patients had good or excellent results. The remaining six patients developed AVN of which three patients had total hip replacement at six months, 17 months and 18 months following primary procedure. Seven patients required more than one operation. Three patients lost their correction and required re fixation despite surgical dislocation, reduction and fixation being their primary procedure. This series demonstrates a high percentage of AVN (50%) in severe unstable SCFE treated with surgical dislocation despite careful attention to retinacular flap development and intra operative doppler studies. This is in direct contrast to our experience with subcapital reorientation with surgical dislocation in stable slips where excellent results were achieved with a low rate of AVN. Pre-operative imaging with MRI and perfusion studies may identify where ischemia has occurred and might influence operative treatment. Based on our results, we do not recommend routine use of surgical dislocation in unstable SCFE. This technique requires further scrutiny to define the operative indications in unstable SCFE

A one-year-8-month-old girl who received radiotherapy and chemotheraphy after excision of embryonal rhabdomyosarcoma from left labium majus pudendi developed slipped capital femoral epiphysis (SCFE) over right hip when she was 9 years old. After mild limp had been noted for 6 months she was then referred to pediatric orthopedic surgeon and two Knowles pins were used to fix the slipping. The second case was a 17-year-old girl with Turner syndrome. SCFE developed during the growth hormone therapy and it was treated with percutaneous pinning with two cannnulated screws. The possibility of developing SCFE should always be kept in mind when treating and following these particular cases to avoid delay of diagnosis

In situ fixation of mild slips of the slipped capital femoral epiphysis (SCFE) is a safe and reliable method of treatment. Hardware failure and fractures are reported at the time of pin retrieval. Difficulty in removing these pins is well reported. Major problems can be expected when arthroplasty is necessary years later, if the pins are still inside the proximal femur. Hence we have come up with a novel technique to remove these pins during Primary Total hip arthroplasty. The hip is exposed through posterior approach, dislocated and the neck is then cut at the usual site. It is then segmented in both sagittal and coronal planes into approximately eight to ten pieces and removed piecemeal. The pins are thus exposed, cleared of any bony debris and hammered retrograde. By using our simple and novel technique to remove these pins we feel it avoids unnecessary trauma to the outer cortex of femur and also reduces the operating time significantly

A group of UK paediatric surgeons (the UK SCFE Study Group) convened to design pertinent trials in slipped capital femoral epiphysis (SCFE), twelve centres across the UK reviewed the demographics and management of children with SCFE. At all contributing centres with digital PACS records, a search for terms relating to SCFE were performed. From the results, radiographs and electronically stored clinic letters were assessed to confirm the diagnosis and ascertain age at presentation, incidence of bilaterality, chronicity, stability, management and complications. A total of 601 SCFEs presented between 2007 and 2012 to the twelve units. The mean age at presentation was 12.5 years. The left hip was nearly twice as commonly involved compared to the right (R: L = 3.3: 5.1), with bilateral presentation in 22% of patients. The most common mode of presentation was acute-on-chronic. Stable slips were over twice as common as unstable. The most common intervention was percutaneous pinning in situ. Open reduction was required in 24% of cases. The commonest complication was osteonecrosis (10.5%). This data concurs with earlier smaller audits and highlights current demographics and contemporary management of SCFE throughout the UK and informs the subject and content of potential future randomized control trials

Controversy remains as to whether the contralateral hip should be fixed in patients presenting with unilateral slipped capital femoral epiphysis (SCFE). This study compares the outcomes of those patients who had prophylactic fixation with those who did not. We identified 90 consecutive patients with a mean age of 12.3 years presenting to the study centre with SCFE from a prospective operative database. The patient's notes and radiographs were retrospectively analysed for post-operative complications, re-presentation with a contralateral slip, and the presence of a cam lesion. The mean length of follow-up was 8 years (range 3 to 13). Fifty patients (56%) underwent unilateral fixation and 40 patients underwent bilateral fixation, of which 4 (4%) patients had simultaneous bilateral SCFE and 36 (40%) had prophylactic fixation of the contralateral hip. Twenty-three patients (46%) that underwent unilateral fixation, went onto have contralateral fixation for a further SCFE. Two patients from this group had symptomatic femoracetabular impingement from cam lesions and one patient required a Southwick osteotomy for a severe slip. Five patients (10%) that had unilateral fixation only demonstrated cam lesions on radiographic analysis, being suggestive of an asymptomatic slip. No post-operative complications were observed for the contralateral hip in patients that had prophylactic screw fixation and no cam lesions were identified on radiographic assessment. This study suggests that the contralateral hip in patients presenting with unilateral SCFE should be routinely offered prophylactic fixation to avoid a further slip, which may be severe, and the morbidity associated with a secondary cam lesion

Long-term functional and degenerative consequences of non treated slipped capital femoral epiphysis (SCFE), have been extensively demonstrated. At present, the treatment of SCFE is well described, however the treatment of the sequelae of SCFE, once osseous consolidation has happened, remains controversial. Our aim is to describe an original technique of cuneiform osteotomy of the femoral neck through surgical hip dislocation for the treatment of sequelae of SCFE. Six hips were operated with sequelae of severe SCFE; average age of 15,2 years, whose consulting motivation was hip pain and severe limp. All of them, with bony consolidation of the femoral physis at the time of the consultation. In all cases, it was performed a cuneiform osteotomy of femoral neck and replacement of the femoral epiphysis, through surgical hip dislocation. It was made a dissection and elevation of cervical periosteum to protect the epiphyseal vessels of the femoral head; then, the cuneiform osteotomy of the femoral neck is made with replacement of the femoral epiphysis to anatomical location and fixed. The mean follow up was 21,2 months. We obtained consolidation in 100% of the cases, did not appear avascular necrosis nor other complications. An improvement was obtained according to Harris Hip Score from 37,6 points to 96,6. Correction of the epiphyseal-shaft angle was obtained from 62° to 12,6°. This technique proposed in patients with sequel of SCFE is a good alternative of treatment, with good anatomical, functional, clinical and radiological results in young patients, without mid-term complications

The aim was to assess contemporary management of slipped capital femoral epiphysis (SCFE) by surveying members of the British Society of Children's Orthopaedic Surgery (BSCOS). A questionnaire with 5 case vignettes was used. Two questions examined the timing of surgery for an acute unstable SCFE in a child presenting at 6 hours and at 48 hours after start of symptoms. Two further questions explored the preferred method of fixation in mild and severe stable SCFE. The final question examined the management of the contralateral normal hip. Responses were entered into an Excel spreadsheet and the data w analysed using a chi-squared test. The response rate was 56% (110/196). 88.2% (97/110) responded that if a child presented with an acute unstable SCFE within 6 hours, they would treat it within 24 hours of presentation, compared with 40.9% (45/110) for one presenting 48 hours after the onset of symptoms (P<0.0001). 52.6% (58/110) of surveyed BSCOS members would offer surgery for an unstable SCFE between 1 and 7 days after onset of symptoms. Single screw fixation in situ was advocated by 96.4% (106/110) and 70.9% (78/110) while corrective osteotomy was preferred by 1.8% (2/110) and 26.4% (29/110) of respondents for the mild and the severe stable slips respectively (P<0.0001). Surgeons preferring osteotomy are more likely to perform an intracapsular technique. Prophylactic fixation of the contralateral normal hip was performed by 27.3% (30/110) of participants. There are significant differences in opinions between BSCOS members as to the optimal management of SCFE in children. This reflects the variable recommendations and quality in the current scientific literature. Further research is therefore required to determine best practice and enable consensus to be reached

Introduction: Avascular necrosis (AVN) is a devastating complication of slipped capital femoral epiphysis (SCFE) and is difficult to treat. The incidence of AVN in this condition varies considerably and is reported to appear in 3–47% of patients. The aims of the treatment of AVN are to maintain range of movement of the hip whilst preventing collapse of the femoral head. Clear treatment guidelines of this condition do not currently exist and the treatment of this condition can be difficult and unrewarding. Method: Dynamic arthrograms were used to assess of cases of AVN in order to determine the method of treatment. We present 20 sequential cases of AVN in patients presenting to our unit with SCFE and report the long-term results of treatment with a mean follow-up in excess of 10 years. Results: In 100 consecutive cases of SUFE there were 20 cases of AVN. There were 18 cases of salvage surgery and one patient refused surgery. Of the 18, there were 2 acetabuloplasty procedures, 12 proximal valgus osteotomies and 4 arthrodeses. At a later date there were 3 proximal femoral osteotomies and 5 total hip replacements. Discussion: There is a good functional result in the majority of cases and a logical approach delays the need of total hip replacement in the majority of cases. The management depends on the radiography, the arthogram and the EUA. If there is early AVN with no collapse the treatment is a shelf procedure. If there is hinge abduction the treatment is a valgus femoral osteotomy. If there is instable movement and the hip is not congruent the treatment is hip arthrodesis

Aim. To inform a working group of UK paediatric surgeons (the UK SCFE Study Group) convened to design pertinent trials in slipped capital femoral epiphysis (SCFE), three centres (Bristol, Newcastle and Barts and The London) reviewed the demographics and management of children with SCFE presenting between 2007 and 2012. Method. At all contributing centres with digital PACS records for a minimum of 5 years, a search for the following terms was made of PACS reports: slipped capital femoral epiphysis, slipped upper femoral epiphysis, SCFE and SUFE. From the results, radiographs and electronically stored clinic letters were assessed to confirm the diagnosis and ascertain age at presentation, incidence of bilaterality, chronicity, stability (Loder criteria), management and complications. Results. A total of 134 SCFEs presented between 2007 and 2012 to the three units. The mean age at presentation was 12.8 yrs (range 6–16 yrs). There were 91 males and 43 females. The left hip was nearly twice as commonly involved compared to the right, with bilateral presentation in 26.5% of patients. The most common mode of presentation was acute-on-chronic. Stable slips were over twice as common as unstable. The most common intervention was percutaneous pinning in situ. Open reduction, osteotomy and stabilisation were required in 21% of cases. The most common complications were osteonecrosis (n=17), screw migration/penetration (n=9), leg length discrepancy (n=9) and symptomatic secondary cam with femoroacetabular impingement (n=7). Conclusion. This three-centre UK study gives insight into the demographics and contemporary management of SCFE, acts as a guide to larger audits of current practice throughout the UK and informs the subject and content of potential future randomised clinical trials

Aim. This pilot study aimed to identify the important symptomatic, functional and psychosocial aspects of hip disorders from the perspective of adolescent patients and their families in order to begin developing a patient-focused instrument (Bridging Adolescent Self-Reported Hip – BASH - score). Methods. This was a qualitative patient-centred study at a tertiary paediatric orthopaedic centre involving 50 adolescents aged 13–17 years, composed of five groups of 10 adolescents with slipped capital femoral epiphysis (SCFE), hip dysplasia (DDH), labral tears undergoing arthroscopic treatment, lower limb trauma and a miscellaneous group with conditions including Perthes' disease. A control group of 100 adolescents were also interviewed from a local school. Adolescent and separate concurrent parent groups underwent an ‘open’ phase face-to-face or telephone interview (theme development). This involved agreeing or disagreeing with statements, and open exploration of ideas related to the ‘day in the life’ of an adolescent with hip problems in order to generate and specify themes. This was followed by ranking and finally, scoring and testing. Results. All focus groups consistently and successfully generated themes related to hip problems and the majority of adolescents and parents were able to easily localise their issues to the hip. The ranking activity enabled the final definition of three key themes: a) physical symptoms, b) limitations and restrictions on life activities and situations and c) emotional experiences and self-consciousness which formed the basis of scoring and testing and the test version of the BASH score for adolescents. Scaling was developed with a total of 20 items rated on a five-point scale based on the frequency of effect from 0 (always) to 5 (never) providing a maximum score of 100. Conclusion. The BASH score is the first patient-reported outcome score for adolescent hip disorders developed with adolescents for adolescents

Management of the young adult hip pathologies is a special entity in orthopaedic surgical practice that needs special emphasis and consideration. A wide range of pathological and traumatic conditions occur in the young adult hip that lead to functional disability and the development of premature osteoarthritis. Proper surgical interference when the hip is still in the pre-arthritic stage restores function to the young hip and protects it from early degenerative changes, and hence the anticipated need for future joint replacement surgery is prevented. Accurate estimation of the biomechanical error combined with careful understanding of the hip joint biology is the cornerstone of success of any hip preservation surgery ever performed to save the young adult hip. Safe surgical hip dislocation approach was adopted as one of the tools in the hands of the hip preservation surgeon to treat a broad spectrum of intra-articular hip pathologies like Perthes disease and severe forms of slipped capital femoral epiphysis (SCFE). Osteo-chondroplasty at the head-neck junction with relative femoral neck lengthening for Perthes disease, and Subcapital re-orientation of severe SCFE based on its retinacular vascular pedicle are often performed via the surgical hip dislocation approach. The approach is also useful with certain types of acetabular fractures that enables fixation of dual-column fractures via single approach with intra-articular visualization for the accuracy of reduction and hardware placement. The 4 cm mini-open direct anterior approach is ideal for the surgical treatment of cases with cam and/or pincer types of femoro-acetabular impingement. Peri-articular osteotomies performed either on the acetabular or the femoral sides of the hip joint are extremely useful in the correction of the biomechanical error that led to an existing hip pathology. Periacetabular osteotomies are commonly performed to treat dysplasia of the young hip. Proximal femoral osteotomies are commonly performed to treat a wide range of hip pathologies including non-unions of femoral neck fractures in the young adult. Correction of the biomechanical error at the proper timing ensures normalization of the hip joint loading conditions and range of motion that leads to reversal of the pathologic process and prevention of osteoarthritis. A hip joint replacement would have an unknown but certainly a finite life, whereas a young hip that has healed after hip preservation surgery would definitely last for a lifetime

We have reviewed the complication rate over a ten year period for removal of screws placed for slipped capital femoral epiphysis (SCFE) and have surveyed the views of orthopaedic surgeons with an adult hip practice in Scotland on leaving the metalwork in situ. Whilst screw removal is favoured by many orthopaedic surgeons, a recent review of the literature reported that the complication rate for removal of implants placed for SCFE was 34%. Between 1998 and 2007 84 patients had insertion of screws for SCFE. Of these 54 patients had screws removed, 51 of these records were available. The median duration between insertion and removal of screws was 2 yrs 7 months. Of the 51 children, overall five (9.8%) had complications - three (5.9%) major and two (3.9%) minor. Two screws could not be removed; one patient sustained a fracture after screw removal and two developed an infection. We assessed the attitudes of adult hip surgeons on this topic using an electronic questionnaire which was completed by 29 out of 40 recipients. 78.6% of respondents support routine removal and 21.4% favour leaving the screw permanently in place. 82.2% had needed to remove metalwork from a hip requiring arthroplasty in a patient whose metalwork was inserted during childhood; and described their experience of this including the complications encountered. We have identified a lower complication rate following screw removal inserted for SCFE than in published series. Most adult hip surgeons support routine removal once the physis is closed but studies regarding the long-term outcome of retained orthopaedic implants are needed since even with this lower complication rate the question of routine removal remains unclear

Purpose: In slipped capital femoral epiphysis (SCFE) with increasing slip angle and increasing impingement, pain, stiffness, limping and degenerative change may follow. Currently there are no accepted guidelines to guide management in patients with stable SCFE. The main purpose of this study was to evaluate the proximal femoral geometry in stable SCFE using a postero-anterior radiograph of the hip in the extended position and to determine its use in predicting subsequent surgical management. Methods: Over a 7 year period, we evaluated the proximal femoral geometry in a consecutive series of 31 adolescents with stable SCFE using the prone extension hip radiograph and statistically analysed the relationship between lateral slip angle (LSA), the morphology of the metaphyseal-epiphyseal (ME) junction, pain and hip range of motion. Results: The mean age was 13.5 years and statistical analysis shows that ME anatomy is strongly related to LSA and pain. Linear regression analysis shows a strong significant relationship between LSA and hip range of movements. Conclusions: The prone extension hip x-ray, is capable of accurately predicting the response to a flexion valgus intertrochanteric osteotomy and will clearly demonstrate the degrees of flexion and valgus required to restore the proximal femoral anatomy to allow a more functional range of motion by reducing impingement. The prone extension hip x-ray will also indicate when an additional cheilectomy may be required or alternatively define degrees of proximal femoral deformity which are beyond the scope of intertrochanteric osteotomy and in which a more radical correction at the epiphyseal-metaphyseal junction is required. Significance: We found the prone extension hip radiograph useful in selecting those hips amenable to management by flexion valgus intertrochanteric osteotomy and other surgical Methods:

Purpose: Unstable slipped capital femoral epiphysis (SCFE) can result in a high incidence of avascular necrosis (AVN) and residual deformity leading to femoral acetabular impingement (FAI). Surgical hip dislocation with open reduction and internal fixation (ORIF) has been proposed as a surgical method to avoid or limit these complications. Method: A prospective consecutive series of patients who presented with an unstable SCFE and underwent a surgical hip dislocation/ORIF were reviewed. The procedure entails urgent arrival to the operating room, a surgical dislocation procedure to gain full access to the proximal femur, removal of the posterior and medial callus with necessary shortening of the femoral neck to anatomically reduce the femoral head without tension on the vasculature. Results: There are 15 patients in this series with a minimum of 1 year follow-up. Average age was 12.5 years at the time of presentation, 10 males and 5 females. Surgical dislocation was performed at a mean of 29.1 hours from the traumatic event. The surgical procedure averaged 135.5 minutes, with an average blood loss of 220ccs. Fourteen patients have no evidence of AVN while one patient with AVN was due to a surgical step not performed in the remaining hips. Normal anatomic position of the epiphysis was achieved in 11 of 15 patients while the remaining 4 had mild posterior angulation averaging 6.2 degrees. Average hip flexion was 114°, internal rotation 22°, external rotation 35°. Two patients required reoperation for broken screws (both 4.5mm cannulated screws). Conclusion: Surgical dislocation with removal of medial and posterior callus and shortening of the femoral neck can reduce the femoral head to a near anatomic position to avoid FAI and appears to result in a very low incidence of avascular necrosis. A single patient with AVN was the result of technical issue which can be avoided

Introduction. Hips following in-situ pinning for slipped capital femoral epiphysis (SCFE) have an altered morphology of the proximal femur with cam type deformity. This deformity can result in femoroacetabular impingement and early joint degeneration. The modified Dunn procedure allows to reorientate the slipped epiphysis to restore hip morphology and function. Objectives. To evaluate (1) hip pain and function, (2) 10-year survival rate and (3) subsequent surgeries and complications in hips undergoing modified Dunn procedure for SCFE. Methods. Between April 1998 and December 2005 we performed the modified Dunn procedure for 43 patients (43 hips) with SCFE. Twenty-five hips (58) presented with an acute or acute on chronic slip. The mean slip angle was 43° (range, 15° – 80°). A majority of 53% of procedures were performed in male patients and the mean age at operation was 13 years (10 – 19 years). We could followup all except one hip (followup of 5.5 year) for a minimum of 10 years (mean followup 13 [10 – 18 years]). We used the anterior impingement test to assess pain and the Merle d'Aubigné- ostel score to assess function. Survivorship calculation was performed using the method of Kaplan and Meier and any of the following factors as a definition of failure: radiographic evidence of worsening osteoarthritis (OA), or a Merle d'Aubigné-Postel score less than 15. Results. (1) The prevalence of a positive anterior impingement test decreased from 100% to 16% (p<0.001). The mean Merle d'Aubigné-Postel score improved from 13 (7 – 14) to 17 (14 – 18) at most recent followup (p<0.001). (2) Four hips (9%) showed progression of OA and three hips (7%) had a Merle d'Aubigné-Postel score of less than 15 at most recent followup. This resulted in a 93% survival rate at 10-year followup. (3) No hip developed avascular necrosis. Five hips (12%) had complications with reosteosynthesis due to screw breakage or nonunion. Another nine hips (21%) had subsequent surgeries including acetabular rim trimming / offset creation in 5 hips and screw removal in 4 hips. Conclusion. The modified Dunn procedure is a safe method to correct the morphology of the proximal femur in hips with SCFE. Ninety-free percent of the hips showed no progression of OA and a good clinical result at the 10-year followup. Twelve percent required revision surgery for complications all including screw breakage with nonunion of the greater trochanter

Unstable slipped capital femoral epiphysis (SCFE) has an increased incidence of avascular necrosis (AVN). The purpose of this study was to determine if early identification and intervention for AVN may help preserve the femoral head. We retrospectively reviewed 48 patients (50 hips) with unstable SCFE managed between 2000 and 2014. Based on two different protocols during the same time period, 17 patients (17 hips) had a scheduled MRI between 1 and 6 months from initial surgery, with closed bone graft epiphysiodesis (CBGE) or free vascularised fibular graft (FVFG) if AVN was diagnosed. Thirty-one patients (33 hips) were evaluated by plain radiographs. Outcomes analysed were Steinberg classification and subsequent surgical intervention. We defined Steinberg class IVC as failure in treatment because all of the patients referred for osteotomy, arthoplasty, or arthrodesis in our study were grade IVC or higher. Overall, 13 hips (26%) with unstable SCFE developed AVN. MRI revealed AVN in 7 of 17 hips (41%) at a mean of 2.5 months postoperatively (range, 1.0 to 5.2 months). Six hips diagnosed by MRI received surgical intervention (4 CBGE, 1 FVFG, and 1 repinning due to screw cutout) at a mean of 4.1 months (range, 1.3 to 7.2 months) postoperatively. None of the 4 patients treated with CBGE within two months postoperatively progressed to stage IVC AVN. The two patients treated after four months postoperatively both progressed to stage VC AVN. Radiographically diagnosed AVN occurred in 6 of 33 hips (18%) at a mean of 6.8 months postoperatively (range, 2.1 to 21.1 months). One patient diagnosed with stage IVB AVN at 2.4 months had screw cutout and received CBGE at 2.5 months from initial pinning. The remaining 5 were not offered surgical intervention. Five of the 6 radiographically diagnosed AVN, including the one treated with CBGE, progressed to stage IVC AVN or greater. None of the 4 patients with unstable SCFE treated with CBGE within 2 months post pinning developed grade IVC AVN, while all patients treated with other procedures after 2 months developed IVC or greater AVN. Early detection and treatment of AVN after SCFE may alter the clinical and radiographic progression

Purpose: To evaluate the vascularisation of the femoral head in children with slipped capital femoral epiphysis (SCFE) before and after surgery with use of contrast-enhanced MRI. Methods and Materials: 20 consecutive children, 13 boys and 7 girls, aged 9–15 years, with slipped capital femoral epiphysis, were included into the study. The classification of SCFE was performed traditionally due to the patient’s history, physical examination and findings of the radiographs. There were no pre-slips, 9 children had acute, 5 children had acute-on-chronic and 6 children had chronic SCFE. The MRI-examinations were performed in a 1.5 Tesla MR-scanner with use of the body coil and all postoperative MR-examinations were carried out within 4 weeks after surgery. The examination protocol included a coronal fat-suppressed STIR-sequence, a coronal contrast-enhanced T1-weighted spin-echo sequence and a sagittal 3D-gradient-echo (FFE) sequence. Morphology, signal intensities and contrast-enhancement of the femoral head were assessed retrospectively by two experienced radiologists in consensus. Results: Morphologic distortion of the physis, bone marrow edema in the metaphysis and epiphysis and joint effusion were the preoperative MRI-findings of slipped capital femoral epiphysis in each child. In 17 children, who underwent in situ-fixation with a single screw, and in one child, who underwent open reduction of the epiphysis, the vascularisation of the femoral head before and after surgery was normal. An avascular zone in the posterior-lateral aspect of the epiphysis was visible preoperatively in one child, which completely revascularized after open reduction and internal fixation of the epiphysis with two screws. One child with severe SCFE developed avascular necrosis of the femoral head after open reduction and corrective osteotomy through the physis. Conclusion: MRI allows for accurate evaluation of the femoral head vascularisation before and after surgery in children with slipped capital femoral epiphysis