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.

Aims. Fixation techniques used in the treatment of slipped capital femoral epiphysis (SCFE) that allow continued growth of the femoral neck, rather than inducing epiphyseal fusion in situ, have the advantage of allowing remodelling of the deformity. The aims of this study were threefold: to assess whether the Free-Gliding (FG) SCFE screw prevents further slip; to establish whether, in practice, it enables lengthening and gliding; and to determine whether the age of the patient influences the extent of glide. Methods. All patients with SCFE who underwent fixation using FG SCFE screws after its introduction at our institution, with minimum three years’ follow-up, were reviewed retrospectively as part of ongoing governance. All pre- and postoperative radiographs were evaluated. The demographics of the patients, the grade of slip, the extent of lengthening of the barrel of the screw and the restoration of Klein’s line were recorded. Subanalysis was performed according to sex and age. Results. A total of 19 hips in 13 patients were included. The mean age of the patients at the time of surgery was 11.5 years (9 to 13) and the mean follow-up was 63 months (45 to 83). A total of 13 FG SCFE screws were used for the fixation of mild or moderate SCFE, with six contralateral prophylactic fixations. No hip with SCFE showed a further slip after fixation and there were no complications. Lengthening occurred in 15 hips (79%), with a mean lengthening of the barrel of 6.8 mm (2.5 to 13.6) at final follow-up. Remodelling occurred in all hips with lengthening of the barrel. There was statistically more lengthening in patients who were aged < 12 years, regardless of sex (p = 0.002). Conclusion. The FG SCFE screw is effective in preventing further slip in patients with SCFE. Lengthening of the barrel occurred in most hips, and thus allowed remodelling. This was most marked in younger children, regardless of sex. Based on this study, this device should be considered for use in patients with SCFE aged < 12 years instead of standard pinning in situ. Cite this article: Bone Joint J 2023;105-B(2):215–219

The Capital Hip implant was a Charnley-based system which included a flanged and a roundback stem, both of which were available in stainless steel and titanium. The system was withdrawn from the market because of its inferior performance. However, all four of the designs did not produce poor rates of survival. Using a simulated-based, finite-element analysis, we have analysed the Capital Hip system. Our aim was to investigate whether our simulation was able to detect differences which could account for the varying survival between the Capital Hip designs, thereby further validating the simulation. We created finite-element models of reconstructions with the flanged and roundback Capital Hips. A loading history was applied representing normal walking and stair-climbing, while we monitored the formation of fatigue cracks in the cement. Corresponding to the clinical findings, our simulation was able to detect the negative effects of the titanium material and the flanged design in the Capital Hip system. Although improvements could be made by including the effect of the roughness of the surface of the stem, our study increased the value of the model as a predictive tool for determining failure of an implant

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

Aims. We aimed to assess the cumulative risk of total hip arthroplasty (THA) from in situ fixation for slipped capital femoral epiphysis (SCFE) after a follow-up of almost 50 years. Methods. In this study, 138 patients with 172 affected hips treated with in situ fixation were evaluated retrospectively. A total of 97 patients (70%) were male and the mean age was 13.6 years (SD 2.1); 35 patients (25%) had a bilateral disease. The median follow-up time was 49 years (interquartile range 43 to 55). Basic demographic, stability, and surgical details were obtained from patient records. Preoperative radiographs (slip angle; SA) were measured, and data on THA was gathered from the Finnish National Arthroplasty Register. Results. The preoperative SA was a mean of 39° (SD 19°). At follow-up, 56 of the patients had undergone THA for a hip previously fixed in situ for SCFE (41%) and 64 of all affected hips had been replaced (37%). Kaplan-Meier analysis gave a median prosthesis-free postoperative survival of 55 years (95% confidence interval (CI) 45 to 64) for the affected hips. In a multivariate analysis, female patients had a two-fold risk for THA (hazard ratio (HR) 2.42 (95% CI 1.16 to 5.07)) and a greater preoperative SA increased the risk of THA (HR 1.03 for every increment of 1° (95% CI 1.01 to 1.05)), while patient age at surgery, slip laterality, stability of slip, or diagnostic delay did not have a statistically significant effect on the risk of THA. Conclusion. SCFE treated primarily with in situ fixation may lead to THA in more than 40% of affected hips at a near 50-year follow-up. This risk is approximately 15-times the reported lifetime risk in the Finnish general population. Female sex and increasing preoperative SA significantly predicted higher risk of THA. Cite this article: Bone Joint J 2023;105-B(12):1321–1326

Conventional treatment of mild slipped capital femoral epiphysis consists of fixation in situ with wires or screws. Recent contributions to the literature suggest that even a mild slip may lead to early damage of the acetabular labrum and adjacent cartilage by abutment of a prominent femoral metaphysis. It has been suggested that the appropriate treatment in mild slipped capital femoral epiphysis should not only prevent further slipping of the epiphysis, but also address potential femoroacetabular impingement by restoring the anatomy of the proximal femur. Between October 1984 and December 1995 we treated 16 patients for unilateral mild slipped capital femoral epiphysis by fixation in situ with Kirschner wires. In this study we have reviewed these patients for clinical and radiological evidence of femoroacetabular impingement. There was little clinical indication of impingement but radiological evaluation assessing the femoral head-neck ratio and measuring the Nötzli α angle on the anteroposterior and cross-table radiographs showed significant alterations in the proximal femur. None of the affected hips had a normal head-neck ratio and the mean α angle was 86° (55° to 99°) and 55° (40° to 94°) on the anteroposterior and lateral cross-table radiographs, respectively. While our clinical data favours conventional treatment, our radiological findings are in support of restoring the anatomy of the proximal femur to avoid or delay the development of femoroacetabular impingement following mild slipped capital femoral epiphysis

Avascular necrosis is a serious complication of slipped capital femoral epiphysis and is difficult to treat. The reported incidence varies from 3% to 47% of patients. The aims of treatment are to maintain the range of movement of the hip and to prevent collapse of the femoral head. At present there are no clear guidelines for the management of this condition and treatment can be difficult and unrewarding. We have used examination under anaesthesia and dynamic arthrography to investigate avascular necrosis and to determine the appropriate method of treatment. We present 20 consecutive cases of avascular necrosis in patients presenting with slipped capital femoral epiphysis and describe the results of treatment with a mean follow-up of over eight years (71 to 121 months). In patients who were suitable for joint preservation (14), we report a ten-year survivorship of the hip joint of 75% and a mean Harris hip score of 82 (44 to 98)

Slipped capital femoral epiphysis may be associated with hypothyroidism and other endocrinopathies. Routine screening for such abnormalities is unlikely to be cost-effective since the overall incidence of these disorders, in association with slipped capital femoral epiphysis, is low. The identification of a presenting characteristic which would predict the chance of an associated endocrinopathy would allow only selected children to be screened. Our aim was to determine if certain characteristics were useful as a screen for patients with an underlying endocrinopathy who presented with slipped capital femoral epiphysis. Between January 1988 and December 1996 we recorded gender, age, height, unilateral or bilateral involvement and an associated diagnosis of endocrinopathy for all patients who were treated for slipped capital femoral epiphysis. Of 166 such patients 13 (7.8%) had an endocrinopathy. Height was the only useful screening characteristic, although bilateral involvement was more likely in those with an endocrinopathy. Most (90.9%) of this latter group were below the tenth percentile for height compared with only 5.4% in those who did not have an endocrinopathy (p < 0.005). The sensitivity and negative predictive value of detecting an underlying endocrinopathy in a patient presenting with a slipped capital femoral epiphysis and short stature (tenth percentile or less) were 90.2% and 98.6%, respectively. Patients who are on or below the tenth percentile for height at the time of presentation should be screened for a possible endocrine abnormality using measurement of thyroid-stimulating hormone and free thyroxine as a preliminary screening test. These hormones are most likely to be abnormal in the presence of endocrine dysfunction

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

Aims. The aims of this study were to evaluate the abductor function in moderate and severe slipped capital femoral epiphysis (SCFE), comparing the results of a corrective osteotomy at the base of the femoral neck and osteoplasty with 1) in situ epiphysiodesis for mild SCFE, 2) contralateral unaffected hips, and 3) hips from healthy individuals. Patients and Methods. A total of 24 patients (mean age 14.9 years (. sd. 1.6); 17 male and seven female patients) with moderate or severe SCFE (28 hips) underwent base of neck osteotomy and osteoplasty between 2012 and 2015. In situ epiphysiodesis was performed in seven contralateral hips with mild slip. A control cohort was composed of 15 healthy individuals (mean age 16.5 years (. sd. 2.5); six male and nine female patients). The abductor function was assessed using isokinetic dynamometry and range of abduction, with a minimum one-year follow-up. Results. We found no differences in mean peak abductor torque between the hips that underwent osteotomy and those that received in situ epiphysiodesis (p = 0.63), but the torque was inferior in comparison with contralateral hips without a slip (p < 0.01) and hips from control individuals (p < 0.001). The abduction strength was positively correlated with the range of hip abduction (R = 0.36; p < 0.001). Conclusion. Although the abductor strength was not restored to normal levels, moderate and severe SCFE treated with osteotomy at the base of the femoral neck and osteoplasty showed abductor function similar to in situ epiphysiodesis in hips with less severe displacement. Cite this article: Bone Joint J 2018;100-B:1524–32

Obesity is thought to be an aetiological factor for slipped capital femoral epiphysis (SCFE). We analysed changes in the incidence of SCFE in Scotland over the last two decades. During this period rates of childhood obesity have risen substantially and evidence for a relationship between these changes and the incidence of SCFE was sought. We found that the incidence of SCFE increased from 3.78 per 100 000 children in 1981 to 9.66 per 100 000 in 2000 (R. 2. = 0.715): a two and a half times increase over two decades. It was seen at a younger age, with a fall in the mean age at diagnosis from 13.4 to 12.6 years for boys (p = 0.007) and 12.2 to 11.6 for girls (p = 0.047). More children under eight years old were seen with SCFE in Scotland in the decade to 2000 than in the previous decade (p = 0.002, R. 2. = 0.346). A close correlation was observed between rising childhood obesity over the last 20 years in Scotland and an increasing incidence of SCFE

Slipped capital femoral epiphysis (SCFE) may lead to symptomatic femoroacetabular impingement (FAI). We report our experience of arthroscopic treatment, including osteochondroplasty, for the sequelae of SCFE. . Data were prospectively collected on patients undergoing arthroscopy of the hip for the sequelae of SCFE between March 2007 and February 2013, including demographic data, radiological assessment of the deformity and other factors that may influence outcome, such as the presence of established avascular necrosis. Patients completed the modified Harris hip score (mHHS) and the non-arthritic hip score (NAHS) before and after surgery. . In total, 18 patients with a mean age of 19 years (13 to 42), were included in the study. All patients presented with pain in the hip and mechanical symptoms, and had evidence of FAI (cam or mixed impingement) on plain radiographs. . The patients underwent arthroscopic osteoplasty of the femoral neck. The mean follow-up was 29 months (23 to 56). . The mean mHHS and NAHS scores improved from 56.2 (27.5 to 100.1) and 52.1 (12.5 to 97.5) pre-operatively to 75.1 (33.8 to 96.8, p = 0.01) and 73.6 (18.8 to 100, p = 0.02) at final follow-up, respectively. Linear regression analysis demonstrated a significant association between poorer outcome scores and increased time to surgery following SCFE (p < 0.05 for all parameters except baseline MHHS). Symptomatic FAI following (SCFE) may be addressed using arthroscopic techniques, and should be treated promptly to minimise progressive functional impairment and chondrolabral degeneration. Take home message: Arthroscopy of the hip can be used to treat femoroacetabular impingement successfully following SCFE. However, this should be performed promptly after presentation in order to prevent irreversible progression and poorer clinical outcomes. Cite this article: Bone Joint J 2016;98-B:21–7

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

Slipped capital femoral epiphysis (SCFE) is relatively common in adolescents and results in a complex deformity of the hip that can lead to femoroacetabular impingement (FAI). FAI may be symptomatic and lead to the premature development of osteoarthritis (OA) of the hip. Current techniques for managing the deformity include arthroscopic femoral neck osteochondroplasty, an arthroscopically assisted limited anterior approach to the hip, surgical dislocation, and proximal femoral osteotomy. Although not a routine procedure to treat FAI secondary to SCFE deformity, peri-acetabular osteotomy has been successfully used to treat FAI caused by acetabular over-coverage. These procedures should be considered for patients with symptoms due to a deformity of the hip secondary to SCFE. Cite this article: Bone Joint J 2013;95-B:445–51

Aims. Several studies have reported the safety and efficacy of subcapital re-alignment for patients with slipped capital femoral epiphysis (SCFE) using surgical dislocation of the hip and an extended retinacular flap. Instability of the hip and dislocation as a consequence of this surgery has only recently gained attention. We discuss this problem with some illustrative cases. Materials and Methods. We explored the literature on the possible pathophysiological causes and surgical steps associated with the risk of post-operative instability and articular damage. In addition, we describe supplementary steps that could be used to avoid these problems. Results. The causes of instability may be divided into three main groups: the first includes causes directly related to SCFE (acetabular labral damage, severe abrasion of the acetabular cartilage, flattening of the acetabular roof and a bell-shaped deformity of the epiphysis); the second, causes not related to the SCFE (acetabular orientation and poor quality of the soft tissues); the third, causes directly related to the surgery (capsulotomy, division of the ligamentum teres, shortening of the femoral neck, pelvi-trochanteric impingement, previous proximal femoral osteotomy and post-operative positioning of the leg). Conclusion. We present examples drawn from our clinical practice, as well as possible ways of reducing the risks of these complications, and of correcting them if they happen. Cite this article: Bone Joint J 2017;99-B:16–21

We reviewed prospectively, after skeletal maturity, a series of 24 patients (25 hips) with severe acute-on-chronic slipped capital femoral epiphysis which had been treated by subcapital cuneiform osteotomy. Patients were followed up for a mean of 8 years, 3 months (2 years, 5 months to 16 years, 4 months). Bedrest with ‘slings and springs’ had been used for a mean of 22 days (19 to 35) in 22 patients, and bedrest alone in two, before definitive surgery. The Iowa hip score, the Harris hip score and Boyer’s radiological classification for degenerative disease were used. The mean Iowa hip score at follow-up was 93.7 (69 to 100) and the mean Harris hip score 95.6 (78 to 100). Degenerative joint changes were graded as 0 in 19 hips, grade 1 in four and grade 2 in two. The rate of avascular necrosis was 12% (3 of 25) and the rate of chondrolysis was 16% (4 of 25). We conclude that after a period of bed rest with slings and springs for three weeks to gain stability, subcapital cuneiform osteotomy for severe acute-on-chronic slipped capital femoral epiphysis is a satisfactory method of treatment with an acceptable rate of complication

Aims. The modified Dunn procedure has the potential to restore the anatomy in hips with severe slipped capital femoral epiphyses (SCFE). However, there is a risk of developing avascular necrosis of the femoral head (AVN). In this paper, we report on clinical outcome, radiological outcome, AVN rate and complications, and the cumulative survivorship at long-term follow-up in patients undergoing the modified Dunn procedure for severe SCFE. Patients and Methods. We performed a retrospective analysis involving 46 hips in 46 patients treated with a modified Dunn procedure for severe SCFE (slip angle > 60°) between 1999 and 2016. At nine-year-follow-up, 40 hips were available for clinical and radiological examination. Mean preoperative age was 13 years, and 14 hips (30%) presented with unstable slips. Mean preoperative slip angle was 64°. Kaplan–Meier survivorship was calculated. Results. At the latest follow-up, the mean Merle d’Aubigné and Postel score was 17 points (14 to 18), mean modified Harris Hip Score was 94 points (66 to 100), and mean Hip Disability and Osteoarthritis Outcome Score was 91 points (67 to 100). Postoperative slip angle was 7° (1° to 16°). One hip (2%) had progression of osteoarthritis (OA). Two hips (5%) developed AVN of the femoral head and required further surgery. Three other hips (7%) underwent implant revision due to screw breakage or change of wires. Cumulative survivorship was 86% at ten-year follow-up. Conclusion. The modified Dunn procedure for severe SCFE resulted in a low rate of AVN, low risk of progression to OA, and high functional scores at long-term follow-up. The slip deformities were mainly corrected but secondary impingement deformities can develop in some hips and may require further surgical treatment. Cite this article: Bone Joint J 2019;101-B:403–414

Between June 2001 and November 2008 a modified Dunn osteotomy with a surgical hip dislocation was performed in 30 hips in 28 patients with slipped capital femoral epiphysis. Complications and clinical and radiological outcomes after a mean follow-up of 3.8 years (1.0 to 8.5) were documented. Subjective outcome was assessed using the Harris hip score and the Western Ontario and McMaster Universities osteoarthritis index questionnaire. Anatomical or near-anatomical reduction was achieved in all cases. The epiphysis in one hip showed no perfusion intra-operatively and developed avascular necrosis. There was an excellent outcome in 28 hips. Failure of the implants with a need for revision surgery occurred in four hips. Anatomical reduction can be achieved by this technique, with a low risk of avascular necrosis. Cautious follow-up is necessary in order to avoid implant failure

We found, in a museum collection of skeletons, nine adult hips with untreated slipped capital femoral epiphyses. All the specimens were from men, five black and two white. Their mean age at death was 44 years. Seven of the femora were retroverted beyond neutral and five had true varus deformities. Osteoarthritis was detected in eight of the hips and the most severe degeneration was seen in the most deformed hips. Radiography revealed that cysts which appeared to occupy the femoral head in fact lay in the metaphyseal bone of the femoral neck

In 15 consecutive patients with slipped capital femoral epiphysis we recorded height, weight and skeletal maturity. Sexual maturity was assessed clinically and biochemically, and Harris's hypothesis that there is an increased ratio of serum growth hormone to oestrogen was tested in comparison with 15 age and sex matched controls. We found no difference in skeletal or sexual maturity between the groups, or any overt endocrine abnormality in the patients. However almost half the patients with slipped epiphysis were over the 90th weight percentile, suggesting that mechanical factors such as obesity are more important aetiologically than endocrine abnormalities

We studied radiographs of 125 children (105 boys, 20 girls) with unilateral Legg-Calvé-Perthes’ disease to examine the epiphyseal development of the femoral head in the contralateral (unaffected) hip. The epiphyseal height (EH) and width (EW) of the unaffected hip were measured on the initial anteroposterior pelvic radiograph. In 109 of the patients (87.2%) the EH was below the mean for normal Japanese children and a significantly small EH (below −2 . sd. s) was observed in 23 patients (18.4%). By contrast, the EW of most patients (95.2%) lay within ± 2 SDs of normal values except for six with a significantly small EW. A strong positive linear correlation (R = 0.87) was observed in the EH:EW ratio in the patients. A smaller EH than expected for EW in our series indicated epiphyseal flattening of the femoral head in Legg-Calvé-Perthes’ disease. Our findings support the hypothesis that a delay in endochondral ossification in the proximal capital femoral epiphysis may be associated with the onset of Perthes’ disease

We used ultrasonography to study 26 hips with slipped capital femoral epiphyses. In recently slipped epiphyses the ultrasound image revealed a step at the anterior physeal outline (mean 6.4 mm), diminished distance between the anterior acetabular rim and the femoral metaphysis (mean 4.3 mm) and an effusion. As metaphyseal remodelling progressed the physeal step decreased. The femoral neck appeared straighter in hips which had been symptomatic for longer than three weeks. It was possible to measure posterior epiphyseal displacement without projectional errors and the method was accurate in diagnosing minimal slip and in staging displacement. The suggested criteria are, less than 7 mm for a mild slip, 7 to 11 mm for a moderate slip and more than 11 mm for a severe slip. We recommend ultrasonography for the diagnosis, staging and follow-up management of slipped upper femoral epiphysis

Premature closure of the growth plate of the femoral capital epiphysis associated with limitation of abduction and gluteal insufficiency is described. The indications for trochanteric advancement and the results obtained in the late treatment of Perthes' disease and of congenital dislocation are discussed. Nine hips treated after Perthes' disease had satisfactory results, in that all were improved; but in eight hips with deformity arising from congenital dislocation the outcome was less favourable

We report the case of a 13-year-old obese child presenting with bilateral stable slipped capital femoral epiphyses, which were managed by percutaneous single screw fixation in situ under image intensifier control using arthrography

1. A case is reported of a girl aged fifteen with growth hormone deficiency who developed a slip of the left femoral capital epiphysis at the age of seventeen during human growth hormone therapy. 2. The epiphysiolysis is regarded as iatrogenic

1. Attention is drawn to the danger of avascular necrosis developing in the capital femoral epiphysis as a complication of osteomyelitis in the intertrochanteric region. 2. This necrosis is commonly aseptic. It is believed to be caused by compression or thrombosis of the epiphysial vessels. 3. The situation will be aggravated if infection spreads to involve the joint. 4. We believe that prompt decompression of both the joint and the bone is indicated in order to reduce the incidence and severity of these complications

In an unselected series of 55 cases of slipped capital femoral epiphysis (SCFE) we observed an incidence of 25% of epiphyseal reduction, mostly unintentional. Reduction indicated physeal instability and was associated with an effusion, detected by sonography on admission, and inability to bear weight. The true prevalence of instability may be higher since an effusion was noted in 33 cases (60%) on the initial sonographic assessment. Serial radiographs showed reduction in 12 (22%), with an average change of 15.1 degrees in the head-neck angle. Serial sonography showed reduction in 7 out of 20 cases (35%), with an average change of 3.7 mm in displacement. In two cases reduction was seen on sonography but not on radiography. Of the hips which showed subsequent reduction, 12 had had a bone scan on admission; three showed initial epiphyseal avascularity but only one progressed to symptomatic avascular necrosis. All stable hips had normal epiphyseal vascularity on the initial bone scan. This indicates the importance of injury from the initial displacement in causing avascular necrosis, rather than effusion, vascular compromise or iatrogenic injury from gentle repositioning. Physeal instability in SCFE is common and should be assessed clinically on admission. It is indicated by joint effusion or inability to bear weight. A slip is very unlikely to be unstable in a child able to bear weight and with no sonographic effusion

Fracture separation of the capital femoral epiphysis occurring during attempted closed reduction of a traumatic dislocation of the hip is described in two adolescents. Although this complication is extremely rare, the prognosis of fracture separation with dislocation of the epiphysis is known to be poor. Avascular necrosis subsequently developed in both cases. The importance of gentle manipulative reduction under general anaesthesia with complete muscle relaxation is emphasised

1. The case history of a seven and a half-year-old boy who developed increased radiographic density of the femoral capital epiphysis after traumatic dislocation of the hip is presented. 2. The authors have been able to examine the case reports of thirteen similar cases presented in the literature. 3. The case presented is felt to be of interest because avascular necrosis was diagnosed early, and the radiographic appearance of the hip became normal five months after the injury

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 analysed the incidence of slipped capital femoral epiphysis (SCFE) in South Australia, investigating possible associations between an increased incidence of SCFE, the local indigenous population and the Australian obesity epidemic during the last 20 years. Data including race, age and gender were collected to obtain a profile of the South Australian SCFE patient, and were then compared with epidemiological data for South Australian adolescents. We concluded that the incidence of both obesity and SCFE is increasing. We also noted that the median weight of SCFE patients has increased and the mean age at diagnosis has decreased. Despite weight profiles comparable with those of the general population, we noted that an indigenous child was three times more likely to develop SCFE than a non-indigenous child. As far as we know there is no published literature on the predisposition of Aboriginal Australians to SCFE.

We report the clinical and radiological outcome of subcapital osteotomy of the femoral neck in the management of symptomatic femoroacetabular impingement (FAI) resulting from a healed slipped capital femoral epiphysis (SCFE). We believe this is only the second such study in the literature.

We studied eight patients (eight hips) with symptomatic FAI after a moderate to severe healed SCFE. There were six male and two female patients, with a mean age of 17.8 years (13 to 29).

All patients underwent a subcapital intracapsular osteotomy of the femoral neck after surgical hip dislocation and creation of an extended retinacular soft-tissue flap. The mean follow-up was 41 months (20 to 84). Clinical assessment included measurement of range of movement, Harris Hip Score (HHS) and Western Ontario and McMaster Universities Osteoarthritis score (WOMAC). Radiological assessment included pre- and post-operative calculation of the anterior slip angle (ASA) and lateral slip angle (LSA), the anterior offset angle (AOA) and centre head–trochanteric distance (CTD). The mean HHS at final follow-up was 92.5 (85 to 100), and the mean WOMAC scores for pain, stiffness and function were 1.3 (0 to 4), 1.4 (0 to 6) and 3.6 (0 to 19) respectively. There was a statistically significant improvement in all the radiological measurements post-operatively. The mean ASA improved from 36.6° (29° to 44°) to 10.3° (5° to 17°) (p <  0.01). The mean LSA improved from 36.6° (31° to 43°) to 15.4° (8° to 21°) (p < 0.01). The mean AOA decreased from 64.4° (50° to 78°) 32.0° (25° to 39°) post-operatively (p < 0.01). The mean CTD improved from -8.2 mm (-13.8 to +3.1) to +2.8 mm (-7.6 to +11.0) (p < 0.01). Two patients underwent further surgery for nonunion. No patient suffered avascular necrosis of the femoral head.

Subcapital osteotomy for patients with a healed SCFE is more challenging than subcapital re-orientation in those with an acute or sub-acute SCFE and an open physis. An effective correction of the deformity, however, can be achieved with relief of symptoms related to impingement.

Cite this article: Bone Joint J 2014;96-B:1441–8.

We assessed 70 hips at an average of 7.1 years after pinning for slipped upper femoral epiphysis to determine the frequency of remodelling, what factors influence it and its effect on the clinical outcome. Remodelling was defined by a new classification of the anterior femoral head-neck profile as seen on the lateral radiograph. Remodelling occurred in 50% of hips with a head-shaft angle of 30 degrees or more; the probability of remodelling was significantly less the greater the degree of slip, but was significantly increased if the triradiate cartilage was open at the time of presentation. We found no significant effect for age, sex, weight or length of symptoms. The range of internal rotation was significantly greater in those hips that remodelled. We support the treatment of moderate slips in skeletally immature patients by pinning in situ, since the probability of satisfactory remodelling was 75% for slips of 40 degrees or less.

The reported prevalence of an asymptomatic slip of the contralateral hip in patients operated on for unilateral slipped capital femoral epiphysis (SCFE) is as high as 40%. Based on a population-based cohort of 2072 healthy adolescents (58% women) we report on radiological and clinical findings suggestive of a possible previous SCFE. Common threshold values for Southwick’s lateral head–shaft angle (≥ 13°) and Murray’s tilt index (≥ 1.35) were used. New reference intervals for these measurements at skeletal maturity are also presented.

At follow-up the mean age of the patients was 18.6 years (17.2 to 20.1). All answered two questionnaires, had a clinical examination and two hip radiographs.

There was an association between a high head–shaft angle and clinical findings associated with SCFE, such as reduced internal rotation and increased external rotation. Also, 6.6% of the cohort had Southwick’s lateral head–shaft angle ≥ 13°, suggestive of a possible slip. Murray’s tilt index ≥ 1.35 was demonstrated in 13.1% of the cohort, predominantly in men, in whom this finding was associated with other radiological findings such as pistol-grip deformity or focal prominence of the femoral neck, but no clinical findings suggestive of SCFE.

This study indicates that 6.6% of young adults have radiological findings consistent with a prior SCFE, which seems to be more common than previously reported.

Cite this article: Bone Joint J 2013;95-B:452–8.

We have examined 26 retrieved, failed titanium-alloy femoral stems. The clinical details, radiological appearances and the histology of the surrounding soft tissues in each patient were also investigated.

The stems were predominantly of the flanged design and had a characteristic pattern of wear. A review of the radiographs showed a series of changes, progressive with time. The first was lateral debonding with subsidence of the stem. This was followed by calcar resorption and fragmentation or fracture of the cement. Finally, osteolysis was seen, starting with a radiolucency at the cement-bone interface and progressing to endosteal cavitation.

Three histological appearances were noted: granulomatous, necrobiotic and necrotic. We suggest that an unknown factor, possibly related to the design of the stem, caused it to move early. After this, micromovement at the cement-stem interface led to the generation of particulate debris and fracture of the cement. A soft-tissue reaction to the debris resulted in osteolysis and failure of fixation of the prostheses.

1. Six cases of necrosis of articular cartilage complicating slipping of the upper femoral epiphysis are reviewed: histological examination in one case showed death of the superficial two-thirds of the articular cartilage, with survival of a layer of basal chondrocytes. In all six cases, after severe initial reduction of joint space as seen radiographically, there was gradual return of joint space, suggesting some regeneration of articular cartilage. The prognosis after cartilage necrosis is therefore not always so bad as has been supposed.

2. Various hypotheses concerning the cause of cartilage necrosis complicating slipped epiphysis are reviewed. The precise cause remains unknown, but there is substantial evidence against its being a consequence of ischaemia of the femoral head.

Aims. High-quality clinical research in children’s orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children’s orthopaedics. Methods. A modified Delphi technique was used, which involved an initial scoping survey, a two-round Delphi process and an expert panel formed of members of the British Society of Children’s Orthopaedic Surgery. The survey was conducted amongst orthopaedic surgeons treating children in the United Kingdom and Ireland. Results. A total of 86 clinicians contributed to both rounds of the Delphi process, scoring priorities from one (low priority) to five (high priority). Elective topics were ranked higher than those relating to trauma, with the top ten elective research questions scoring higher than the top question for trauma. Ten elective, and five trauma research priorities were identified, with the three highest ranked questions relating to the treatment of slipped capital femoral epiphysis (mean score 4.6/ 5), Perthes’ disease (4.5) and bone infection (4.5). Conclusion. This consensus-based research agenda will guide surgeons, academics and funders to improve the evidence in children’s orthopaedic surgery and encourage the development of multicentre clinical trials. Cite this article: Bone Joint J 2018;100-B:680–4

1 . The arterial pattern and the histological features in the femoral head and neck were studied at necropsy in twenty-five specimens with intracapsular fractures. An improved visual-arteriographic method employing barium sulphate dyed with Prussian blue was used. Twenty-three of the fractures were from a few days to twenty-four weeks old and two were seven and ten years old. Nineteen had been nailed or nail-plated. 2. The results were divided into four groups according to the state of the femoral head. In the first group, four heads were histologically viable and had a normal vascular pattern; in the second group, four showed partial avascular necrosis with part of the head retaining a normal blood supply; in the third group, ten had avascular necrosis in all or most of the head and showed little or no revasculanisation; and in the fourth group, seven showed extensive revascularisation of grossly necrotic heads. Total or subtotal capital necrosis had occurred in 64 per cent and total or partial necrosis in 84 per cent of the specimens. The results indicated that interruption of the retinacular vessels was the cause of gross necrosis; and that in most cases an intact blood supply through the ligamentum teres cannot keep more than a part of the head alive when the other vessels are cut off. Occasionally the ligamentum teres is torn by the nail, or though intact, its blood supply is interrupted. This accounts for completion of avascular necrosis in most cases with total capital necrosis. Viability of the subfoveal area from an intact supply through the ligamentum teres was the main source of revascularisation after capital necrosis. Other sources–from across a uniting fracture line, from growth of soft tissue round the head and neck and from other small viable foci in the head and neck–were much less important and the degree of revascularisation was generally limited. Revascularisation was accompanied by fibrocellular invasion of the marrow, differentiation of cells and the formation of oil cysts whereby the necrotic fat is removed; but bony reconstitution was limited. 3. Six fractures were uniting and another had united by bone making an overall union frequency of 50 per cent considering only the nailed fractures older than two weeks. Four of them (57 per cent) showed total or subtotal capital necrosis. In fractures older than two weeks the frequency of union among the eleven nailed fractures with avascular necrosis was 36 per cent, and it was 100 per cent among the three nailed ones with viable or substantially viable heads. Necrosis of the neck side of the fracture was unrelated to non-union because it soon becomes invaded by fibrovascular tissue and new bone. 4. Fibrosis was the basis of union when the head was dead but examination of older fractures at necropsy is needed to assess the long-term results of revascularisation and union. The clinical desirability or otherwise of capital revascularisation after necrosis also needs to be studied

A series of ten infants is reported, seven of whom showed evidence of osteomyelitis of the upper end of the femur; the remaining three did not, but presented with an acute subluxation of the hip in a febrile illness. Four sequelae among the seven more severe cases were: 1) destruction of the capital epiphysis with dislocation at the hip; 2) destruction of the capital epiphysis, the femoral neck remaining in the acetabulum; 3) destruction of the epiphysial plate with the femoral head, remaining in the acetabulum, connected to the femoral neck by a fibrous union; 4) recovery with coxa magna but no other deformity. The streptococcus plays a greater part in this osteomyelitis of infancy than in osteomyelitis of older children, but various other organisms were identified. The organism should be sought by blood culture as well as from the local lesion. Aspiration of the hip, treatment of the hip in abduction and the use of the appropriate antibiotic are recommended. If there is marked swelling and induration, freer release of the pus is strongly advised. Controlled abduction osteotomy plays a useful part in stabilising the femoral neck in the acetabulum or in stabilising the femoral neck beneath the capital epiphysis, but may usefully be preceded by an arthrograph because late ossification of a detached head sometimes occurs

Aims

We evaluated the national and regional trends from 2013 to 2022, in the prevalence of Perthes’ disease among adolescent males in South Korea.

New brands of joint prosthesis are released for general implantation with limited evidence of their long-term performance in patients. The CUSUM continuous monitoring method is a statistical testing procedure which could be used to provide prospective evaluation of brands as soon as implantation in patients begins and give early warning of poor performance. We describe the CUSUM and illustrate the potential value of this monitoring tool by applying it retrospectively to the 3M Capital Hip experience. The results show that if the clinical data and methodology had been available, the CUSUM would have given an alert to the underperformance of this prosthesis almost four years before the issue of a Hazard Notice by the Medical Devices Agency. This indicates that the CUSUM can be a valuable tool in monitoring joint prostheses, subject to timely and complete collection of data. Regional or national joint registries provide an opportunity for future centralised, continuous monitoring of all hip and knee prostheses using these techniques

In 2017, the British Society for Children’s Orthopaedic Surgery engaged the profession and all relevant stakeholders in two formal research prioritization processes. In this editorial, we describe the impact of this prioritization on funding, and how research in children’s orthopaedics, which was until very recently a largely unfunded and under-investigated area, is now flourishing. Establishing research priorities was a crucial step in this process.

Cite this article: Bone Joint J 2024;106-B(5):422–424.

We undertook a retrospective comparative study of all patients with an unstable slipped capital femoral epiphysis presenting to a single centre between 1998 and 2011. There were 45 patients (46 hips; mean age 12.6 years; 9 to 14); 16 hips underwent intracapsular cuneiform osteotomy and 30 underwent pinning in situ, with varying degrees of serendipitous reduction. No patient in the osteotomy group was lost to follow-up, which was undertaken at a mean of 28 months (11 to 48); four patients in the pinning in situ group were lost to follow-up, which occurred at a mean of 30 months (10 to 50). Avascular necrosis (AVN) occurred in four hips (25%) following osteotomy and in 11 (42%) following pinning in situ. AVN was not seen in five hips for which osteotomy was undertaken > 13 days after presentation. AVN occurred in four of ten (40%) hips undergoing emergency pinning in situ, compared with four of 15 (47%) undergoing non-emergency pinning. The rate of AVN was 67% (four of six) in those undergoing pinning on the second or third day after presentation. Pinning in situ following complete reduction led to AVN in four out of five cases (80%). In comparison, pinning in situ following incomplete reduction led to AVN in 7 of 21 cases (33%). The rate of development of AVN was significantly higher following pinning in situ with complete reduction than following intracapsular osteotomy (p = 0.048). Complete reduction was more frequent in those treated by emergency pinning and was strongly associated with AVN (p = 0.005). Non-emergency intracapsular osteotomy may have a protective effect on the epiphyseal vasculature and should be undertaken with a delay of at least two weeks. The place of emergency pinning in situ in these patients needs to be re-evaluated, possibly in favour of an emergency open procedure or delayed intracapsular osteotomy. Non-emergency pinning in situ should be undertaken after a delay of at least five days, with the greatest risk at two and three days after presentation. Intracapsular osteotomy should be undertaken after a delay of at least 14 days. In our experience, closed epiphyseal reduction is harmful. Cite this article: Bone Joint J 2015;97-B:412–19

Aims

We first sought to compare survival for patients treated surgically for solitary and multiple metastases in the appendicular skeleton, and second, to explore the role of complete and incomplete resection (R0 and R1/R2) in patients with a solitary bony metastasis in the appendicular skeleton.

Hallux valgus (HV) presents as a common forefoot deformity that causes problems with pain, mobility, footwear, and quality of life. The most common open correction used in the UK is the Scarf and Akin osteotomy, which has good clinical and radiological outcomes and high levels of patient satisfaction when used to treat a varying degrees of deformity. However, there are concerns regarding recurrence rates and long-term outcomes. Minimally invasive or percutaneous surgery (MIS) has gained popularity, offering the potential for similar clinical and radiological outcomes with reduced postoperative pain and smaller scars. Despite this, MIS techniques vary widely, hindering comparison and standardization. This review evaluates the evidence for both open Scarf and Akin osteotomy and newer-generation MIS techniques. Fourth-generation MIS emphasizes multiplanar rotational deformity correction through stable fixation. While MIS techniques show promise, their evidence mainly comprises single-surgeon case series. Comparative studies between open and MIS techniques suggest similar clinical and radiological outcomes, although MIS may offer advantages in scar length and less early postoperative pain. MIS may afford superior correction in severe deformity and lower recurrence rates due to correcting the bony deformity rather than soft-tissue correction. Recurrence remains a challenge in HV surgery, necessitating long-term follow-up and standardized outcome measures for assessment. Any comparison between the techniques requires comparative studies. Surgeons must weigh the advantages and risks of both open and MIS approaches in collaboration with patients to determine the most suitable treatment.

Cite this article: Bone Joint J 2025;107-B(1):10–18.

We present our experience of the modified Dunn procedure in combination with a Ganz surgical dislocation of the hip to treat patients with severe slipped capital femoral epiphysis (SCFE). The aim was to prospectively investigate whether this technique is safe and reproducible. We assessed the degree of reduction, functional outcome, rate of complications, radiological changes and range of movement in the hip. There were 28 patients with a mean follow-up of 38.6 months (24 to 84). The lateral slip angle was corrected by a mean of 50.9° (95% confidence interval 44.3 to 57.5). The mean modified Harris hip score at the final follow-up was 89.1 (. sd. 9.0) and the mean Non-Arthritic Hip score was 91.3 (. sd. 9.0). Two patients had proven pre-existing avascular necrosis and two developed the condition post-operatively. There were no cases of nonunion, implant failure, infection, deep-vein thrombosis or heterotopic ossification. The range of movement at final follow-up was nearly normal. This study adds to the evidence that the technique of surgical dislocation and anatomical reduction is safe and reliable in patients with SCFE. Cite this article: Bone Joint J 2013;95-B:424–9

Hip arthroscopy is particularly attractive in children as it confers advantages over arthrotomy or open surgery, such as shorter recovery time and earlier return to activity. Developments in surgical technique and arthroscopic instrumentation have enabled extension of arthroscopy of the hip to this age group. Potential challenges in paediatric and adolescent hip arthroscopy include variability in size, normal developmental change from childhood to adolescence, and conditions specific to children and adolescents and their various consequences. Treatable disorders include the sequelae of traumatic and sports-related hip joint injuries, Legg–Calve–Perthes’ disease and slipped capital femoral epiphysis, and the arthritic and septic hip. Intra-articular abnormalities are rarely isolated and are often associated with underlying morphological changes. This review presents the current concepts of hip arthroscopy in the paediatric and adolescent patient, covering clinical assessment and investigation, indications and results of the experience to date, as well as technical challenges and future directions

A study of 78 children (110 hips) was undertaken in an attempt to assess the risk of avascular necrosis (AVN) after slipped capital femoral epiphysis based on the radiological appearances of the hip at the time of presentation. Physeal separation, which was defined as the amount of separation of the anterior lip of the epiphysis from the metaphysis on the frog lateral view, was assessed. Of the eight hips which developed AVN, seven had anterior physeal separation. We conclude that anterior physeal separation is associated with a high incidence of subsequent AVN after slipped capital femoral epiphysis and that screw fixation may not be appropriate in these patients

The nuclide bone-scan will reliably diagnose Perthes' disease with a sensitivity of 0.98 and a specificity of 0.95. The comparable figures for radiographic sensitivity and specificity are respectively 0.92 and 0.78. In addition, it is possible on the scan to recognise the onset of revascularisation of the femoral capital epiphysis some months before there are radiographic signs of new bone formation. Scintigraphy also suggests that in some cases of transient synovitis there may bae a period of reversible ischaemia of the capital epiphysis, which may have relevance to the pathogenesis of Perthes' disease

1. The long-term results in a consecutive series of 323 healed subcapital fractures of the femur show that, with few exceptions, the capital fragment maintains its integrity when the fragments are aligned within the narrow limits of good reduction, but undergoes superior segmental collapse when reduction is poor. 2. The effect of malreduction on the congruity of the hip joint is examined, and a remodelling response to malalignment of the aspherical femoral head in the imperfectly round acetabulum is proposed as an alternative interpretation of the radiological changes now considered to be the result of capital ischaemia

The importance of registries has been brought into focus by recent UK national reports focusing on implant (Cumberlege) and surgeon (Paterson) performance. National arthroplasty registries provide real-time, real-world information about implant, hospital, and surgeon performance and allow case identification in the event of product recall or adverse surgical outcomes. They are a valuable resource for research and service improvement given the volume of data recorded and the longitunidal nature of data collection. This review discusses the current value of registry data as it relates to both clinical practice and research.

Cite this article: Bone Joint J 2023;105-B(4):356–360.

Telehealth has the potential to change the way we approach patient care. From virtual consenting to reducing carbon emissions, costs, and waiting times, it is a powerful tool in our clinical armamentarium. There is mounting evidence that remote diagnostic evaluation and decision-making have reached an acceptable level of accuracy and can safely be adopted in orthopaedic surgery. Furthermore, patients’ and surgeons’ satisfaction with virtual appointments are comparable to in-person consultations. Challenges to the widespread use of telehealth should, however, be acknowledged and include the cost of installation, training, maintenance, and accessibility. It is also vital that clinicians are conscious of the medicolegal and ethical considerations surrounding the medium and adhere strictly to the relevant data protection legislation and storage framework. It remains to be seen how organizations harness the full spectrum of the technology to facilitate effective patient care.

Cite this article: Bone Joint J 2023;105-B(8):843–849.

Aims

The aim of this study was to produce clinical consensus recommendations about the non-surgical treatment of children with Perthes’ disease. The recommendations are intended to support clinical practice in a condition for which there is no robust evidence to guide optimal care.

Aims

Dislocation is a major concern following total hip arthroplasty (THA) for osteoarthritis (OA). Both dual-mobility components and standard acetabular components with large femoral heads are used to reduce the risk of dislocation. We investigated whether dual-mobility components are superior to standard components in reducing the two-year dislocation and revision risk in a propensity-matched sample from the Danish Hip Arthroplasty Register (DHR).

Aims

The aim of this study was to characterize the influence of social deprivation on the rate of complications, readmissions, and revisions following primary total shoulder arthroplasty (TSA), using the Social Deprivation Index (SDI). The SDI is a composite measurement, in percentages, of seven demographic characteristics: living in poverty, with < 12 years of education, single-parent households, living in rented or overcrowded housing, households without a car, and unemployed adults aged < 65 years.

Aims

The aim of this trial was to assess the cost-effectiveness of a soft bandage and immediate discharge, compared with rigid immobilization, in children aged four to 15 years with a torus fracture of the distal radius.

Coxa valga may sometimes occur as a complication of varus osteotomy for congenital dislocation of the hip. Six such cases are described with a minimum follow-up of nine years. In three cases the varus osteotomy had been performed on only one side; in one case it was done on both sides and coxa valga developed bilaterally; and in two further bilateral cases coxa valga developed on one side only. In each case the coxa valga was sub-capital. Detailed radiographic analysis included measurements of neck-shaft angle, acetabular angle and C.E. angle. The epiphysis-shaft angle is described; it is an index of the constant tendency of the capital epiphysis to assume a horizontal position. The cause remains unknown, but damage to the trochanteric growth plate or to the lateral part of the capital growth plate could not be identified as aetiological factors. Poor acetabular cover was considered a possible factor. All the patients in this series had functionally excellent hips, but the long-term prognosis of the hips with partly uncovered femoral heads is doubtful

The radiographs of 153 children suffering from Perthes' disease of one hip were studied to examine the bony outline of the femoral capital epiphysis in the unaffected hip. In 48.4 per cent of patients irregularity of the surface, flattening or dimpling, were noted; in the majority of instances (37.2 per cent) these changes were present in the initial anteroposterior radiograph. By contrast, these changes were present in only 10.4 per cent of a control series of 153 children in whom intravenous urography was being performed, these children being matched for age and sex with the children with Perthes' disease. A second unmatched control series of 49 children whose pelves were being radiographed after injury showed a 6.1 per cent incidence of contour irregularities in 98 femoral capital epiphyses. In the patients with Perthes' disease and in the control series obtained at urography the incidence of changes was inversely related to age. The possible cause and significance of contour irregularities in normal children and in those with Perthes' disease is disscussed

1. A family is described of which several members in four generations suffered epiphysial growth disturbances of an unusual kind in the capital epiphyses of the femur, with shortness of stature. 2. This disorder forms one of a group of epiphysial growth disturbances which embraces several recognised disorders, whose effects on the epiphyses vary in severity. They may occur sporadically or they may be inherited as recessive or dominant characters. 3. Differentiation depends on the behaviour of the joint line–in other words, whether the epiphysis starts to show defects through inability to sustain the stress of weight bearing. In the most serious cases the picture is that of Morquio-Brailsford's disease; when the changes are less severe the appearance may be that of bilateral Perthes' disease. Differential diagnosis is no longer possible in later life, because the ultimate condition of the defective femoral heads is the same. Only in the hereditary cases is one able, by studying the capital epiphyses of the hip in childhood, to differentiate between the changes like those of Perthes' disease on the one hand, and micro-epiphysial dysplasia without necrosis on the other

Aims

This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection.

Aims

To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child.

Aims

The aim of this study was to evaluate the epidemiology and treatment of Perthes’ disease of the hip.

A. R. Nguyen, J. Ling, B. Gomes, G. Antoniou, L. M. Sutherland, P. J. Cundy. Slipped capital femoral epiphysis: rising rates with obesity and aboriginality in South Australia. J Bone Joint Surg Br 2011 93-B: 1416-1423

The aim of this study was to determine whether an osteoplasty of the femoral neck performed at the same time as an intertrochanteric Imhäuser osteotomy led to an improved functional outcome or increased morbidity. A total of 20 hips in 19 patients (12 left, 8 right, 13 male, 6 female), who underwent an Imhäuser intertrochanteric osteotomy following a slipped capital femoral epiphysis were assessed over an eight-year period. A total of 13 hips in 13 patients had an osteoplasty of the femoral neck at the same time. The remaining six patients (seven hips) had intertrochanteric osteotomy alone. The mean age was 15.3 years (13 to 20) with a mean follow-up of 57.8 months (15 to 117); 19 of the slips were severe (Southwick grade III) and one was moderate (grade II), with a mean slip angle of 65.3° (50° to 80°); 17 of the slips were stable and three unstable at initial presentation. The mean Non-Arthritic Hip Scores (NAHS) in patients who underwent osteoplasty was 91.7 (76.3 to 100) and the mean NAHS in patients who did not undergo osteoplasty was 76.6 (41.3 to 100) (p = 0.056). Two patients required a subsequent arthroplasty and neither of these patients had an osteoplasty. No hips developed osteonecrosis or chondrolysis, and there was no increase in complications related to the osteoplasty. We recommend that for patients with a slipped upper femoral epiphysis undergoing an intertrochanteric osteotomy, the addition of an osteoplasty of the femoral neck should be considered. Cite this article: Bone Joint J 2014;96-B:1119–23

Aims

Knee arthroplasty surgery is a highly effective treatment for arthritis and disorders of the knee. There are a wide variety of implant brands and types of knee arthroplasty available to surgeons. As a result of a number of highly publicized failures, arthroplasty surgery is highly regulated in the UK and many other countries through national registries, introduced to monitor implant performance, surgeons, and hospitals. With time, the options available within many brand portfolios have grown, with alternative tibial or femoral components, tibial insert materials, or shapes and patella resurfacings. In this study we have investigated the effect of the expansion of implant brand portfolios and where there may be a lack of transparency around a brand name. We also aimed to establish the potential numbers of compatible implant construct combinations.

We report a 45-year follow-up of a patient with Engelmann’s disease previously described in 1950, showing progression of the disease with unique involvement of the femoral capital epiphyses. The case is compared with others to add some information about the later stages of a disease which is not fully understood

We describe a 15-year-old boy with a posterior dislocation of the hip, fracture of the posterior column of the acetabulum and separation of the femoral capital epiphysis. To our knowledge no previous case in a child has been reported. Such high-energy injuries are extremely rare, and a poor outcome is expected. We advocate early referral to a specialised tertiary centre, and the use of a modification of Delbet’s classification to reflect the complexity and displacement which may occur with this injury

We have reviewed 82 children with congenital dislocation of the hip, after treatment by anterior open reduction followed by derotation femoral osteotomy. The clinical and radiological results were significantly better in the group that had open reduction before the appearance of the capital femoral epiphysis; this group also had a lower incidence of avascular necrosis. We conclude that, when it is clearly indicated, the earlier an open reduction is carried out the better the results

The case illustrated substantiates the explanation of the rare epiphysial separation of the head of the radius with 90 degrees backward tilting referred to above as Group 2. It suggests also that the initial fall on the hand may loosen the capital epiphysis. The undesirability of reducing dislocations of the elbow merely by pulling on the hand of the injured limb is emphasised. The dislocation should be reduced by gentle traction accompanied by pressure with the thumbs on the front of the displaced olecranon

Aims

The diagnosis of developmental dysplasia of the hip (DDH) is challenging owing to extensive variation in paediatric pelvic anatomy. Artificial intelligence (AI) may represent an effective diagnostic tool for DDH. Here, we aimed to develop an anteroposterior pelvic radiograph deep learning system for diagnosing DDH in children and analyze the feasibility of its application.

Computerised tomography is useful in the diagnosis of abnormalities of the hip in children, particularly in assessing the size and shape of the acetabulum, the position and congruity of the femoral head relative to the acetabulum, and the degree of femoral anteversion or retroversion. It is most useful when limited hip movement and previous operations preclude adequate clinical examination and assessment by routine radiographic techniques. It is not recommended for routine use in screening congenital dislocation of the hip or in diagnosis or follow-up of Perthes' disease or slipped capital femoral epiphysis

Six boys were examined during the second year of life, each with symptoms in one hip. The affected femoral capital epiphysis was smaller or more irregular (or both) than that of the unaffected hip but was neither subluxed nor dislocated. The subsequent radiographs revealed changes similar to those in severe Perthes' disease. Nevertheless, we give reasons for believing that this disorder in boys under two years of age should be distinguished from Perthes' disease

There are differences of opinion about the pathogenesis of Perthes' disease. All are agreed that it is due to ischaemia, but the cause of this and the size and number of infarctions are in dispute. Through the generosity of the contributors six whole femoral heads and core biopsies of five other cases have been studied radiographically and histologically. The findings ranged from an ischaemic arrest of ossification in the capital articular cartilage without infarction to multiple complete infarctions of the epiphysial bone. The ensuing reparative process contributes to the pathology, which is of a range to warrant grading or grouping

Cemented titanium stems in hip arthroplasty are associated with proximal cement-stem debonding and early failure. This was well publicised with the 3M Capital hip. However, corrosion in this setting has been reported with only one stem design and is less widely accepted. We present a series of 12 cemented titanium Furlong Straight Stems which required revision at a mean of 78 months for thigh pain. At revision the stems were severely corroded in a pattern which was typical of crevice corrosion. Symptoms were eliminated after revision to an all-stainless steel femoral prosthesis of the same design. We discuss the likely causes for the corrosion. The combination of a titanium stem and cement appears to facilitate crevice corrosion

A prospective survey was carried out on all cases of irritable hip presenting at the Royal Liverpool Children's Hospital over a period of one year. All children had a radioisotope scan of the hips and were then followed for one year by serial radiography. Five of the 50 children seen during the one year had areas of ischaemia in the capital femoral epiphysis demonstrated on the scan. all five developed radiological signs of Perthes' disease within sic months. The remaining 45 had radiographically normal hips at one year

We have studied aseptic loosening of the femoral component in 76 patients with primary total hip replacement using the Capital prosthesis. The mean follow-up was 26 months (10 to 37). Twelve femoral components (16%) were definitely and eight (10%) were possibly loose. They were characterised by a thin cement mantle (p < 0.001) and excessive residual cancellous bone in the proximomedial region (p < 0.01). We recommend that the cement mantle around the prosthesis should be 2 to 3 mm and that further long-term studies are needed to evaluate the wear properties of titanium-nitride-coated titanium femoral heads

We present the long-term results of simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head. We followed 26 hips in 20 patients, with a mean age at the time of surgery of 36 years, for a mean of 12.5 years. The mean varus angulation was 23°. The outcome in 19 of the hips (73%) was good or excellent; seven (27%) had a fair or poor result, with four needing some form of prosthetic arthroplasty. Simple varus intertrochanteric osteotomy is indicated, even if the extent of the capital infarct comprises more than 50% of the diameter of maximum radial distance from the circumference, provided that after operation the medial necrotic lesion measures less than two-thirds of the weight-bearing area, and the superolateral bone is normal

We compared 63 hips (Catterall Groups 3 and 4) contained by femoral osteotomy with 85 untreated hips and found that 50.7 per cent of treated patients developed congruous spherical femoral heads in contrast to 14.1 per cent of those untreated. We have also considered certain other features relevant to the outcome. We suggest that the indications should not be modified on the grounds of early age of onset. Relief from weight-bearing does not appear to improve the results of containment. We have assessed the shortening which follows femoral osteotomy and conclude that this is only significant when there is growth disturbance at the capital epiphysis. These changes are at least as frequent in untreated patients

Aims

While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty.

We reviewed 14 patients (16 hips) treated by open reduction and upper femoral derotation osteotomy for congenital dislocation of the hip. Nine patients with 11 treated hips had growth deformities of the proximal femur; in all of them the top screw of the fixation plate lay within the cartilaginous precursor of the greater trochanter. In the five control hips the top screw was more distal. In the nine patients (mean follow-up 10.8 years) there was an increase of 14 degrees in the neck-shaft angle (p = 0.01) and of 18 degrees in the angle between the capital femoral physis and the shaft (p = 0.01) compared to the control group. This indicates that growth disturbance of the greater trochanteric apophysis as a result of plate fixation leads to long-term deformity

Aims

Highly cross-linked polyethylene (HXLPE) has greatly improved the durability of total hip arthroplasty (THA) in young patients because of its improved wear characteristics. Few studies have followed this population into the second decade, and therefore the purpose of this investigation was to evaluate the clinical outcome for THA patients 50 years of age and younger at a minimum of 15 years postoperatively. The second purpose was to evaluate the radiological findings secondary to wear or mechanical failure of the implant.

Aims

Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants.

The pathogenesis of Perthes' disease has been related to increased intra-articular pressure secondary to a joint effusion. The pressure within the hip in different positions was measured in eight children with transient synovitis and four with the synovial stage of Perthes' disease. In the position of comfort for the hip this pressure was always less than the arteriolar blood pressure and in a supine position it did not exceed the systolic blood pressure. However, in extension with medial rotation the intra-articular pressure always became several times the systolic blood pressure. This high pressure was also recorded in the stable lateral position which occurs normally during sleep. It is concluded that in the presence of a synovial effusion in the hip, a position of extension and medial rotation causes an increase in intra-articular pressure which may compromise the blood supply to the capital epiphysis of the femur

1. Synovitis was induced in the hip joints of fifty-six rabbits by the intra-articular injection of surgical talc. The opposite hip joint and eleven suitable"sham" operations served as controls. 2. The results in the hips injected with talc were as follows. Widening of the medial joint space and sometimes acetabular changes were seen; enlargement of the femoral head and neck in two planes was found, with, in most cases, flattening of the superior aspect of the head; there was thickening of the joint cartilage and sometimes deformity of the capital epiphysis; thickening of the cartilage was the main cause of the coxa magna, cervix magna and ischium magnum. 3. The embryology, micro-anatomy and development of the hip joint is reviewed and attention is drawn to the configuration of the layers of germinal cartilage cells. The effect of an induced synovitis in producing hyperplasia of the joint cartilage, incongruity of the articulating surfaces and subsequent subluxation is discussed

Children who present late with hip dislocation may require femoral osteotomy after reduction, to correct valgus and anteversion deformity of the femoral neck. After these procedures proximal femoral growth is unpredictable. We have studied proximal femoral growth in 40 children who had been treated by femoral osteotomy. Preoperatively, the mean femoral neck-shaft angle was 5° greater on the affected side than on the contralateral side. Postoperatively, it was 28° less. There was progressive recorrection; after five years the angle was not significantly different from that on the contralateral side. In our series 70% of the capital epiphyses became abnormally shaped, taking the appearance of a ‘jockey’s cap’. All the growth plates became angulated but this corrected with time. Correction of the neck-shaft angle probably results from the more normal mechanical environment provided by reduction. The abnormal radiographic appearance of the epiphysis and growth plate is probably due to the rotation produced by the osteotomy

1. Two cases of an unrecognised congenital defect of the humeral head are described and the cause is discussed. 2. Only six cases with similar radiographic appearances could be collected from the literature. In most of these cases other skeletal deformities were present, whereas in those now reported only the shoulder was affected. 3. Examination of radiographs suggests that the main deformity consists of lack of development of the capital epiphysis of the humerus. 4. Consideration of the cases, together with experimental data from the studies of Fell and Canti, suggests that the time in development at which the fault occurred was the presumptive joint stage, just when the articular rudiments had separated. 5. A "nociferous agent," acting only for a limited period, and only on certain tissues, is postulated. 6. It is suggested that the defects recorded should be recognised as a group of congenital deformities of the shoulder joint

Aims

Adverse local tissue reactions associated with abnormal wear considerably slowed down the general use of metal-on-metal (MoM) hip resurfacing arthroplasty (HRA), now limited to a few specialized centres. In this study, we provide the clinical results of 400 consecutive MoM HRAs implanted more than 20 years ago in one such centre.

Aims

Robotic-assisted total knee arthroplasty (RA-TKA) is theoretically more accurate for component positioning than TKA performed with mechanical instruments (M-TKA). Furthermore, the ability to incorporate soft-tissue laxity data into the plan prior to bone resection should reduce variability between the planned polyethylene thickness and the final implanted polyethylene. The purpose of this study was to compare accuracy to plan for component positioning and precision, as demonstrated by deviation from plan for polyethylene insert thickness in measured-resection RA-TKA versus M-TKA.