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Slipped Capital Femoral Epiphysis
Current Concepts in Treatment
Eduardo Novais, MD
Assistant Professor of Orthopedic Surgery
Development
Anterior Axial
Mild
< 30o
Moderate
30o – 60o
Severe
> 60o
Severity
Southwick 1969
Stability – Loder Criteria
Loder 1993
Stable Unstable
Osteonecrosis
5-50%
Stable SCFE OA SCFE
Rab 1999
Richold 1999
Wensaas 2012
FAI Cartilage
damage
Ganz 2003
Ganz 2002
Leunig 2000
Sink 2010
SCFE and FAI
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Articular cartilage Damage
SUPERIOR
ANTERIOR
Mild
Pinning
+
Osteoplasty
Arthroscopy
Mini anterior <30o
13 yo male IRF: -30o
In situ pinning + open anterior osteoplasty
-10o IRF 15o IRF
2 year postoperative
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Moderate and Severe Femoral Osteotomy for SCFE
Subcapital
Dunn 1964
Leunig 2007
Neck
Fish 1984
Base of
the neck
Kramer 1976
Barmada 1978
Trochanteric
Imhauser 1957
Southwick 1967
Blood supply to
femoral head
Gautier 2000 Ganz 2009
Extended retinacular
soft tissue flap
0
10
20
30
40
50
60
70
80
90
100
AP alpha angle Lateral alpha angle Southwick angle
In-situ pinning
Modified Dunn
p = 0.0017 P<0.001 P<0.001
Radiographs
Radiographic correction was achieved more reliably in the
modified Dunn group than the in situ pinning group.
Heyman and Herndon scores
good or excellent (p = 0.0343; OR, 5.86; 95% CI, 1.13–40.43)
27% 60% Modified Dunn
In-situ pinning
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Complication N (%) N (%)
Osteonecrosis 1 (7%) 1 (7%)
Slip progression 1 (7%) ---
Pin impingement 2 (13%) ---
Implant failure --- 1 (7%)
Intra-articular pin --- 1 (7%)
p = 0.6588 (OR: 1.6; 95%CI, 0.2–15)
In-situ pinning N = 15
Complications
Modified Dunn N = 15
8X Patients in the in-situ pinning group were more likely to require a
secondary procedure (p = 0.0230; OR, 8.4; 95% CI, 1.32–90.37)
Unplanned reoperations
Moderate and Severe 11 yo female – Severe Stable SCFE
11 yo female – Severe Stable SCFE 2 years postoperative
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Moderate and Severe 14 yo female - FAI 2 y after severe SCFE
SHD flexion valgus rotation ITO – 2 y
Unstable SCFE
12 year-old male
Closed reduction
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In situ
Pinning
Unstable SCFE
Anterior
Arthrotomy
Pinning
Parsh 2009
Modified
Dunn
Ziebarth 2009
0-50%
Necrosis
5%
Necrosis 8%
Necrosis
Lateral Position
Deep exposure
Vastus lateralis Gluteus medius
Piriformis
Gluteus minimus
Hip Capsule
Trochanteric Osteotomy
Modified Dunn is Superior to In-Situ
Pinning for Anatomic Restoration and
Clinical Outcome with Similar
Osteonecrosis Rate in Unstable SCFE
Eduardo N. Novais, MD; Lauryn Kestel, BS; Claire Palmer, MS;
Joao Caetano Abdo, MD; Travis Heare, MD; Ernest Sink, MD
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Variable In situ pinning (n=18) Modified Dunn (n=27) P-value
Gender, No. (%) 0.67
Female 10 (56%) 12 (44%)
Male 8 (44%) 15 (56%)
Age, mean (range) 12.7 (9.9,16.4 ) 12.6 (7.6,17.7) 0.923
BMI, mean (range) 24.6 (17.3,31.1) 26.5 (16.3,38.5) 0.223
Fahey Classification [10] 0.358
Acute on Chronic 12 (67%) 13 (48%)
Acute 6 (33%) 14 (52%)
Time from trauma to surgery 0.1
>24 hours 6 (33%) 17 (63%)
<24 hours 12 (67%) 10 (37%)
Preoperative Southwick angle 64.5 (51.2, 81.3) 66.9 (56.6, 79) 0.808
Follow-up, mean years (range) 5.8 (1,15.9) 2.4 (1,7.96) <0.001
Group characteristics
26% Modified Dunn
28% In-situ Pinning
(p >0.99)
Radiographs
Restoration of proximal femoral head and neck anatomy was superior in the
modified Dunn group compared to the in-situ pinning group
-20
0
20
40
60
80
100
Alpha angle Southwick angle Head-neck offset
Modified Dunn
In-situ Pinning
Heyman and Herndon scores
good or excellent (p = 0.016)
28% 67% Modified Dunn
In-situ pinning
In-situ pinning
(N=18) 33%
Modified Dunn
(N=27) 26%
Single procedure
Removal of implant penetrating the joint 1 (5.5%) SHD with bone graft to the femoral head 1 (3.7%)
SHD with ORIF of femoral head non-union 1 (5.5%) Revision of implant penetrating the joint 1 (3.7%)
SHD with osteochondroplasty 1 (5.5%) THA 1 (3.7%)
Multiple procedures
Revision of implant penetrating the joint 1 (5.5%)
Revision of implant penetrating the joint 2 (7.4%)
SHD with ORIF of femoral head non-union Implant removal after epiphyseal healing
THA followed by revision THA
SHD + osteoplasty aftereosteonecrosis 1 (5.5%)
Revisions of implant penetrating the joint 2 (7.4%)
THA THA
Revision of implant penetrating the joint
1 (5.5%) - - SHD + ORIF of femoral head non-union
THA
Unplanned Procedures (p=0.894) 12 yo female – Acute unstable SCFE
100% displaced
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13 yo male – Acute unstable SCFE 13 yo male – Acute on chronic unstable
100% displaced
Thank you Eduardo Novais, MD
Assistant Professor of Orthopedic Surgery