Slipped capital femoral epiphysis (SCFE) is uncommon in India and we routinely look for associated metabolic or endocrine abnormalities. In this study we investigated a possible association between vitamin D deficiency and SCFE. All children presenting with SCFE during the study period had their 25-hydroxyvitamin D levels measured as part of an overall metabolic, renal and endocrine status evaluation, which included measurement of body mass index (BMI). Vitamin D status was compared with age-, gender- and habitat-matched controls with acute trauma or sepsis presenting to our emergency department. A total of 15 children (12 boys and three girls) with a mean age of 13 years (. sd. 1.81; 10 to 16) presented for treatment for SCFE during a two-year period beginning in January 2010. Renal and thyroid function was within the normal range in all cases. The mean BMI was 24.9 kg/m. 2. (17.0 to 33.8), which was significantly higher than that of the controls (p = 0.006). There was a statistically significant difference between the mean values of 25-hydroxyvitamin D in the children with SCFE and the controls (11.78 ng/ml (. sd. 5.4) versus 27.06 ng/ml (. sd. 5.53), respectively; p < 0.001). We concluded that, along with high BMI, there is a significant association of vitamin D deficiency and SCFE in India. Cite this article: Bone Joint J 2013;95-B:851–4

The aim was to examine the descriptive epidemiology of Slipped Capital Femoral Epiphysis, with respect to geography and time. We extracted all children with a diagnosis of Slipped Capital Femoral Epiphysis from the Clinical Practice Research Database between 1990 and 2014 (24 years). CPRD is the world's largest database of primary care, which encompasses 8% of the UK population. CPRD was linked to Hospital Episode Statistics, and a validation algorithm applied to maximise sensitivity and specificity of the cases finding methodology. Poisson confidence intervals were calculated, and poison regression used. 596 cases of SCFE were identified. The internal validation algorithm supported a SCFE diagnosis in 88% cases. The age and sex distribution of cases mirrored that in the literature, offering external validity to the cases identified. There was no significant change in the incidence of SCFE over the 24-year study period, with the overall incidence being 4.8 cases per 100,00 0–16 year olds. There was no significant geographic variation in SCFE within the UK. There was a positive association with rising socioeconomic deprivation (p<0.01). There was no seasonal variation in presentation. This study found no evidence to support the common belief that SCFE incidence is increasing, and for the first time demonstrated an association with socioeconomic deprivation. The results are important for considering the feasibility of intervention studies, and offer insights into the disease aetiology

Purpose. Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in children 9–15 years old. The epidemiology for SCFE in the total population of Sweden has not yet been described. Methods. In a prospective cohort study, we analysed pre- and postoperative radiographs and medical records for all children treated for SCFE in Sweden 2007–2013, and noted demographic data, severity of slip, and surgical procedures performed. Results. We identified 379 Swedish children with primary SCFE 2007–2013; 162 girls, median age 12 (7–15) years, and 217 boys, median age 13 (4–17) years. The cumulative incidence was 45.8/100 000 for girls and 58.2/100 000 for boys. As an initial symptom, 66% of the children had hip/groin pain and 12% knee pain. At first presentation, 7% of the children had bilateral SCFE. Prophylactic fixation was performed in 43% . Of the remaining children, 21% later developed a contralateral slip. Fixation with implants permitting further growth of the femoral neck was used in 90% of the children. Femoral neck osteotomy was performed for 11 hips. Of 34 treating hospitals, only three treated > 3 children with SCFE annually. Conclusions. The cumulative incidence 2007–2013 in the total population in Sweden showed a mild increase for girls. The male-to-female ratio was lower than previously described for Sweden. Prophylactic fixation was performed in 43% of the children. Fixation with an implant that allows further growth was used for 90% of the children. Most hospitals in Sweden treat < 2 children annually

Aim. With the link between obesity and Slipped Upper Femoral Epiphysis (SUFE) well established and a rising number of paediatric orthopaedic patients presenting with vitamin D deficiency, the aim of our study was to establish the incidence of vitamin D deficiency in SUFE patients and whether low vitamin D levels increases the time to proximal femoral physeal fusion post surgical fixation. Method. All paediatric patients presenting to the orthopaedic department at University Hospital Southampton with a SUFE and tested for vitamin D between June 2007 to present day and who were subsequently found to have low levels of vitamin D, were eligible for inclusion in the study. A deficient level of vitamin D (25-(OH)D) was determined as < 52 nmols/L and insufficiency between 52–72 nmols/L. Levels > 72 nmols/L were considered to be normal. The normal time for 50% of physeal fusion on anteroposterior radiograph quoted in the literature is 9 months. Results. This study includes a cohort of 28 patients and 45 hips. All of these patients were treated with pinning insitu. Eighty six per cent were found to be vitamin D deficient. The mean physeal closure for these patients post fixation, including those yet to fuse and which have exceeded 12 months, was 23 months (range 9–64 months). Conclusion. This study has shown a correlation between vitamin D deficiency and prolonged physeal closure in SUFE patients. With an increasing prevalence of vitamin D deficiency, it is recommended that all patients presenting with a SUFE, be tested for low vitamin D levels, so that early treatment with supplementation can be initiated

Purpose. This report compares midterm results of open neck osteoplasty + neck osteotomy vs arthroscopic osteoplasty for severe Slipped Capital Femoral Epiphysis (SCFE). Method. Database from 2006 to 2013 identified 22 patients out of 187 operations for SCFE. 12 underwent Open Neck Osteotomy (ONO) and osteoplasty by Ganz surgical dislocation approach. 10 underwent Arthroscopic Osteoplasty (AO). The mean follow-up for the ONO and AO groups were 59 (46 – 70), 36.1 (33 – 46) months respectively. Results. The unpaired t-test showed that the post-operative corrections were significantly better in the ONO than the AO group. Slip angle (16.7° (1°–28.6°) Vs 47.1° (40.2° – 53.5°) p = .0003), head neck offset correction (5mm (2–13mm) Vs 0mm (0mm – 2mm) p = 0.0003), alpha angle (34.6° (23.2°–45.6°) Vs 61.88° (52.1° – 123°) p= 0.0003), Modified Harris Hip Score (MHHS) (90(86.2–99) Vs 75.5 (58.75 – 96.8) p= 0.003) and internal rotation p= 0.0002. Paired t-test showed significant improvement in corrections within the individual groups compared with their own preoperative values. The results of AO group were oblique plane slip angle (55° (47.7° – 63.2°) Vs 47.1° (40.2° – 53.5°) p= 0.001), alpha angle (90.7° (65° – 131°) Vs 61.88° (52.1° – 123°) p= 0.0001), head neck offset (0mm (−3 mm to 0mm) Vs 0mm (0mm – 2mm) p= 0.001) and MHHS (52.7 (28.7 – 89.1) Vs 75.5 (58.75 – 96.8) p= 0.0005). Complications in ONO group were varus malunion (1) and non-union(1) of the osteotomy. In the arthroscopic group persistent impingement in 3 patients and 5 were not able to return to sports. Conclusion. Our results showed improved hip function following arthroscopic osteoplasty in severe SCFE. Considering the risks of an open surgical dislocation we could find that arthroscopy contributed worthy improvement in hip function in low demand patients

Purpose. We share our experience in management of failed in-situ pinning in severe unstable Slipped Capital Femoral Epiphysis (SCFE) by surgical dislocation approach. Method. A retrospective review of hip database from 2006 to 2013 showed 41 children underwent surgical dislocation for SCFE. We identified seven who had severe slip with failed in-situ pinning. Results. The mean age at presentation was 11.9 years (10–14 years). The average interval between in-situ pinning and surgical dislocation was 10 months (2 to 18 months). The mean follow-up was 50.14 months (25 – 66 months). The mean preoperative slip angle in the oblique plane was 76° (61.1° – 121.5°), the mean preoperative alpha angle was 127.3° (93.1° – 145°), and preoperative head neck offset was −12.7mm (0 – −21.2mm). The mean corrections at latest follow-up were oblique plane slip angle 20.6° (4.2° – 41.8°), alpha angle 51.3° (45.3° – 58°), and head-neck offset 9.5mm (1 – 16.2mm). The mean Modified Harris Hip Score (MHHS) preoperatively was 19.57 (0 – 56) and the mean non-arthritic hip score (NAHS) was 21.07 (5 – 51.5). The mean MHHS at the last visit was 88.97 (71 – 96) and NAHS was 84.28 (69.5 – 91). All patients had gross external rotation deformity at presentation; mean internal rotation of 25° ranging from (0 – 40°) was achieved at follow-up. Four patients had avascular necrosis identified on subtraction MRI scan preoperatively. These four underwent second stage hinged distraction of the hip. Mean duration of hinged distraction was 7.6 months. At follow-up 4 had Tonnis 0, one Tonnis 1 and two Tonnis 2 grade of osteoarthritis. Conclusion. The short-term result of our protocol for management of failed in-situ pinning by staged surgical dislocation and hinged distraction has been encouraging. This could potentially prolong the life of native hip to the third decade of life before definitive salvage procedures could be contemplated

Introduction. We report 3 cases from different centres of infantile tibia vara in which the deformity was due to slippage of the proximal tibial epiphysis on the metaphysis; the aim of this study was to define the features of this previously unreported condition, and their implications for management. Method. Three cases of tibia vara secondary to atraumatic slippage of the upper tibial epiphysis on the metaphysis were identified from three different centres. The case notes and imaging studies were retrospectively reviewed to distinguish common clinical and radiographic features. Results. There were one male and two females, all of non-Caucasian origin, (age 3–7 years). All patients' weights were above the 97th centile for age. In all cases there was an infero-medial subluxation of the tibial epiphysis over a dome shaped proximal tibial metaphysis, with disruption of continuity between their lateral borders. The height of the medial tibial plateau was preserved in all cases. New bone formation suggests this is a chronic process. The evolution of one case indicates that pathogenesis is shared with infantile Blount's disease. A gradual deformity correction was performed in all cases using circular external fixation, with the proximal ring secured to both the proximal epiphysis and metaphysis. Conclusion. Slipped upper tibial epiphysis is an uncommon but distinct cause of tibia vara. The radiological features are completely different from those previously described for infantile tibia vara and not encompassed by the existing classification. The unusual morphology has consequences for treatment. Management is analogous to a slipped upper femoral epiphysis – the physis has to be stabilized to the metaphysis and an osteotomy performed to restore the mechanical axis. We believe this is best achieved with a circular external fixator because this permits multiaxial correction including translation and rotation

Aims

This study analysed the clinical and radiological outcome of anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified Dunn osteotomy) through the surgical approach described by Ganz.

Controversy remains whether the contralateral hip should be fixed in patients presenting with unilateral slipped capital femoral epiphysis (SCFE). This retrospective study compares the outcomes and cost of those patients who had prophylactic fixation with those who did not.

Between January 2000 and December 2010 a total of 50 patients underwent unilateral fixation and 36 had prophylactic fixation of the contralateral hip. There were 54 males and 32 females with a mean age of 12.3 years (9 to 16). The rate of a subsequent slip without prophylactic fixation was 46%. The risk of complications was greater, the generic health measures (Short Form-12 physical (p < 0.001) and mental (p = 0.004) summary scores) were worse. Radiographic cam lesions in patients presenting with unilateral SCFE were only seen in patients who did not have prophylactic fixation. Furthermore, prophylactic fixation of the contralateral hip was found to be a cost-effective procedure, with a cost per quality adjusted life year gained of £1431 at the time of last follow-up.

Prophylactic fixation of the contralateral hip is a cost-effective operation that limits the morbidity from the complications of a further slip, and the diminished functional outcome associated with unilateral fixation.

Cite this article: Bone Joint J 2015;97-B:1428–34.

We describe three cases of infantile tibia vara resulting from an atraumatic slip of the proximal tibial epiphysis upon the metaphysis. There appears to be an association between this condition and severe obesity. Radiologically, the condition is characterised by a dome-shaped metaphysis, an open growth plate and disruption of the continuity between the lateral borders of the epiphysis and metaphysis, with inferomedial translation of the proximal tibial epiphysis. All patients were treated by realignment of the proximal tibia by distraction osteogenesis with an external circulator fixator, and it is suggested that this is the optimal method for correction of this complex deformity. There are differences in the radiological features and management between conventional infantile Blount’s disease and this ‘slipped upper tibial epiphysis’ variant.

Fixation by a single screw is considered the current treatment of choice for a slipped capital femoral epiphysis. This approach promotes premature physeal closure. The use of a modified, standard, single, cannulated screw designed to maintain epiphyseal fixation without causing premature closure of the physis was reviewed in ten patients. The nine boys and one girl aged between 10.6 and 12.6 years with unilateral slipped capital femoral epiphysis (SCFE), were markedly skeletally immature (Tanner stage I, bone age 10 to 12.6 years).

Clinical and radiological review at a mean follow-up of 44.3 months (36 to 76) showed no difference in the time to physeal closure between the involved and uninvolved side. Measurement of epiphyseal and physeal development showed continued growth and remodelling in all patients.

Use of this device provided epiphyseal stability and maintained the capacity for physeal recovery and growth following treatment for both unstable and stable slipped capital femoral epiphysis.

The purpose of this study was to determine the oblique plane deformity in slipped upper femoral epiphysis.

A retrospective radiographic review was undertaken in patients admitted with a slipped upper femoral epiphysis between March 2008 and October 2010. Patients in whom a CT scan had been performed in addition to plain radiographs were assessed further. Angular deformity in the coronal and sagittal planes were measured by the angle formed between the femoral neck and a line perpendicular to the physis on the AP pelvic radiograph and the axial CT scan respectively. The magnitude and direction of the resultant deformity was defined in the oblique plane. Additional demographic data (gender, age, side, procedure and complications) was collected.

Seven girls, average age of 12 (range 10 – 13) and 6 boys, average age of 13 (range 10 – 15) were identified. The slip was bilateral in 2, left sided in 6 and right sided in 5 cases. Two patients were pinned in situ, 8 had surgical dislocation performed to facilitate reduction prior to pinning and 3 patients had secondary procedures performed following in situ pinning. The average angulation in the oblique posteroinferior plane (25 degrees) was less than in the coronal (30 degrees) and the sagittal planes (62 degrees). The average magnitude was 67mm (range 31 – 88).

CT is useful adjunct particularly when a frog legged lateral view is not possible because of pain or the fear of further displacement. Determination of the deformity in the oblique plane may aid in positioning of the screw during in situ pinning and may be helpful in identifying patients in whom pinning maybe difficult.

Aim

Debate remains over the optimal treatment for severe unstable SCFE. AVN is the principle problem; current thinking suggests this can be minimized by emergent reduction and fixation within 24 hours. If emergent treatment is not possible, open osteotomy with a variable delay of 10–21 days has been advocated. We present our experience of delayed intracapsular cuneiform osteotomy (ICO)

Several authors have reported complications from screw removal after treatment of slipped upper femoral epiphysis by single screw fixation, and have attributed these to poor screw design. We have developed a simple and reliable method of screw removal which uses a cannulated 8.0 mm end-threaded cancellous screw (Smith & Nephew Richards Medical, Memphis, Tennessee) and a specially designed cannulated trephine.

The method has been successful, with minimal complications, and a limited surgical exposure.

Purpose

The decision to undertake prophylactic pinning to prevent contralateral slipped upper femoral epiphysis (SUFE) remains controversial; we hypothesised that the grade of initial SUFE could predict the grade of a second SUFE and risk of poor outcome.

This purpose of this study was to investigate whether prophylactic pinning of the contralateral hip in unilateral slipped upper femoral epiphysis affects subsequent femoral morphology.

To determine the effect of prophylactic pinning on growth we compared contralateral hip radiographs of 24 proximal femora prophylactically pinned with 26 cases observed, in a cohort of patients with unilateral SUFE. Validated measurements were used to determine hip morphology; the articulo-trochanteric distance (ATD) and the ratio of the trochanteric-trochanteric distance (TTD) to articulo-trochanteric distance (TTD:ATD) in addition to direct measurement of the femoral neck length. Post-operative radiographs were compared to radiographs taken at a 12–84 months follow-up.

Comparing pinned and unpinned hips the neck length was shorter (mean 5.1 mm vs 11.1 mm) and the ATD was lower (p=0.048). The difference between initial and final radiograph TTD:ATD ratio for each case was calculated. The average was 0.63 in the prophylactically pinned group and 0.25 in the unpinned group (p=0.07).

When hips of the same patient were compared on final radiographs, there was a smaller difference in TTD:ATD between the two sides when the patient had been prophylactically pinned (0.7) as opposed to observed (1.47). This was not statistically significant (p=0.14).

Universal prophylactic pinning of the contralateral hip in slipped upper femoral epiphysis is controversial and alteration of the proximal femoral morphology is one reason for this.

Our results show that prophylactic pinning does not stop growth but does alter subsequent proximal femoral morphology by causing a degree of coxa vara and breva. Some loss of growth in the prophylactically pinned hip contributes to reduction in leg length inequality at skeletal maturity which is advantageous.

No iatrogenic complications were observed with single cannulated screw fixation. Prophylactic pinning prevents the potential catastrophe of a subsequent slip, is safe and the effect on growth is, if anything, beneficial.

Level of evidence: III

We reviewed the long-term results of the treatment of slipped upper femoral epiphysis (SUFE) using realignment procedures in 36 patients (37 hips) at an average follow-up of 33.8 years (26 to 42). There were serious short-term complications in seven of the 22 hips treated by subcapital osteotomy, three of the 11 hips treated by intertrochanteric osteotomy and three of the four hips treated by manipulative reduction.

At re-examination, the clinical and radiological results were excellent or good in 41% of the hips treated by subcapital osteotomy, in 36% treated by intertrochanteric osteotomy and in none treated by manipulative reduction. In all, seven hips (19%) had had arthrodesis or total hip replacement.

The natural history of SUFE was probably not improved by any of the treatments used in our study. We therefore discourage the use of subcapital and intertrochanteric osteotomy as well as manipulative reduction in the primary treatment of chronic SUFE.

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.

Aim:

Audit of the outcome of subcapital osteotomy for a series of cases of severe unstable slipped capital femoral epiphysis.

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.