slipped capital femoral epiphysis - by dr. lokesh sharoff

Slipped Capital Femoral Slipped Capital Femoral EpiphysisEpiphysis

Dr. LOKESH SHAROFFOrthopedic surgeon , Mumbai, India

IncidenceIncidence

Annual incidence 2-10 per 100,000Annual incidence 2-10 per 100,000

2.4 M : 1 F2.4 M : 1 FLEFT > RIGHT HIP LEFT > RIGHT HIP

Boys 13-15 yrs (14)Boys 13-15 yrs (14)

Girls 11-13 yrs (12)Girls 11-13 yrs (12)presentation outside these ages consider endocrine or presentation outside these ages consider endocrine or systemic disorder !!systemic disorder !!

IntroductionIntroduction

Obese (50-75% over 95th Obese (50-75% over 95th centile)centile)

Delay in skeletal maturityDelay in skeletal maturity

Bilateral in 17% (50% Bilateral in 17% (50% present-50% sequential)present-50% sequential)

IntroductionIntroduction

femoral neck displace ANTERIORLY AND femoral neck displace ANTERIORLY AND SUPERIORLY with the head in the acetabulum causing an SUPERIORLY with the head in the acetabulum causing an apparent varus deformityapparent varus deformity

AetiologyAetiology

Mechanical factorsMechanical factorsobesityobesity

Increase in femoral retroversionIncrease in femoral retroversion

Vertically oriented physeal plateVertically oriented physeal plate

Thinning of perichondral ringThinning of perichondral ring

AetiologyAetiology

InflammatoryInflammatorysynovial hyperplasiasynovial hyperplasia

increase in IG and C3increase in IG and C3

AetiologyAetiology

EndocrineEndocrineAssociation withAssociation with

Hypothyroidism Primary hyperparathyroidism

Panhypopituitarism Hypogonadal conditions Renal osteodystrophy GH deficiency and therapy

Rubenstein - taybi syndrome Klinefelters syndrome

PathologyPathology

-Periosteum torn anteriorly-Periosteum torn anteriorly-Antero-superior part of neck forms a rounded -Antero-superior part of neck forms a rounded humphump-area between neck and periosteum posteriorly is -area between neck and periosteum posteriorly is filled with osseous tissuefilled with osseous tissue

HistopathologyHistopathology

-PRE SLIP STAGE - widening of physis-PRE SLIP STAGE - widening of physis-DISPLACEMENT - occurs through Proliferative -DISPLACEMENT - occurs through Proliferative and Hypertrophic zonesand Hypertrophic zones-organisation of chondrocytes changes from -organisation of chondrocytes changes from columnar to clumpscolumnar to clumps

Slipped Capital Femoral Slipped Capital Femoral Epiphysis classificationEpiphysis classification

According to duration of symptoms--According to duration of symptoms--

Preslip: synovitisPreslip: synovitis

Acute <3wksAcute <3wks

Chronic >3 wksChronic >3 wks

Acute on Chronic >3 wks with further Acute on Chronic >3 wks with further displacement of epiphysisdisplacement of epiphysis

Slipped Capital Femoral Slipped Capital Femoral Epiphysis PresentationEpiphysis Presentation

Physeal stability– Loder classificationPhyseal stability– Loder classification

Stable: can wt bearStable: can wt bear

Unstable : cannot wt. bear Unstable : cannot wt. bear Acute Slipped Capital Femoral Epiphysis: the Importance of Physeal StabilityAcute Slipped Capital Femoral Epiphysis: the Importance of Physeal Stability

Loder et alLoder et al

JBJS 1993; 75-A:1134-1140JBJS 1993; 75-A:1134-1140

Presentation--chronicPresentation--chronic

-often obese and present with pain in the hip (85%) or knee (15%)-often obese and present with pain in the hip (85%) or knee (15%)—increases in evening or after exertion—increases in evening or after exertion

-Limp-Limp

-thigh atrophy-thigh atrophy-extremity shortening-extremity shortening

Knee Axilla sign: On attempted flexion of the hip, the patients leg Knee Axilla sign: On attempted flexion of the hip, the patients leg goes into external rotationgoes into external rotation

Internal rotation is lost. Internal rotation is lost.

Abduction and extension is also restrictedAbduction and extension is also restricted

Presentation—acute on chronicPresentation—acute on chronic

-sudden onset of pain-sudden onset of pain -unable to move the limb-unable to move the limb

-unable to bear weight-unable to bear weight

-limb in external rotation-limb in external rotation

Presentation --ChondrolysisPresentation --Chondrolysis

-Pain is continous-Pain is continous

-Pain throughout ROM -Pain throughout ROM

-Global restriction of ROM-Global restriction of ROM

-Flexion contracture-Flexion contracture

Slipped Capital Femoral Slipped Capital Femoral Epiphysis RadiologyEpiphysis Radiology

APAPPhyseal wideningPhyseal widening

Steels Metaphyseal Blanch sign (density in neck)Steels Metaphyseal Blanch sign (density in neck)

Klein line/Trethowan signKlein line/Trethowan sign

Schams sign Schams sign Break in Shenton’s lineBreak in Shenton’s line

RadiologyRadiology

--Klein's Line:--Klein's Line:– line drawn along superior border of femoral neck should line drawn along superior border of femoral neck should

cross at least a portion of the femoral epiphysiscross at least a portion of the femoral epiphysis– slip must be suspected if a straight line drawn up lateral slip must be suspected if a straight line drawn up lateral

surface of femoral neck does not touch the femoral headsurface of femoral neck does not touch the femoral head

RadiologyRadiology

Metaphyseal blanch sign (STEELS)---Metaphyseal blanch sign (STEELS)---

RadiologyRadiology

SCHAMS sign -- SCHAMS sign -- The posterior acetabular margin normally cuts The posterior acetabular margin normally cuts the medial corner of the metaphysis. In slip the whole metaphysis the medial corner of the metaphysis. In slip the whole metaphysis remains lateral to the acetabular margin.remains lateral to the acetabular margin.

Slipped Capital Femoral Slipped Capital Femoral Epiphysis RadiologyEpiphysis Radiology

LateralLateralShoot-through/Frog legShoot-through/Frog leg

It shows the bending of the femoral neck and the It shows the bending of the femoral neck and the anterior hump of bone growthanterior hump of bone growth

head-shaft angle of SOUTHWICK can be calculatedhead-shaft angle of SOUTHWICK can be calculated

RadiologyRadiology

SOUTHWICK’S SOUTHWICK’S CLASSIFICATIONCLASSIFICATION

calculate the Head-Shaft anglecalculate the Head-Shaft angle<30--mild<30--mild30-60--moderate30-60--moderate>60--severe>60--severe

Slipped Capital Femoral Slipped Capital Femoral Epiphysis RadiologyEpiphysis RadiologyClassification—Classification—

Determined by percentage of displacement of the Determined by percentage of displacement of the EPIPHYSIS in relation to the neck, as follows:EPIPHYSIS in relation to the neck, as follows:

grade I (<33%), grade I (<33%),

grade II (33-50%), grade II (33-50%),

grade III (>50%)grade III (>50%)

Slipped Capital Femoral Slipped Capital Femoral Epiphysis TreatmentEpiphysis Treatment

Prevent further slippagePrevent further slippage

Reduce the degree of slippageReduce the degree of slippage

Salvage treatmentSalvage treatment

CT--SCANCT--SCAN

--To check HEAD – NECK angle --To check HEAD – NECK angle --Neck in ante or retroversion--Neck in ante or retroversion--post-op—whether implant has penetrated into --post-op—whether implant has penetrated into the jointthe joint--closure of physis--closure of physis--compression achieved by screws--compression achieved by screws--residual deformity--residual deformity

ULTRASOUNDULTRASOUND

--to check for joint effusion--to check for joint effusion

--to check for step between femoral neck and --to check for step between femoral neck and epiphysisepiphysis

MRIMRI

--used to asses the pre-slip stage but is expensive--used to asses the pre-slip stage but is expensive

BONE SCANBONE SCAN

--Increased uptake in SCFE--Increased uptake in SCFE--decreased uptake in AVN--decreased uptake in AVN--increased in the joint space in chondrolysis --increased in the joint space in chondrolysis

SCFE Treatment to prevent SCFE Treatment to prevent further slippagefurther slippage

Hip spicaHip spica

Bone peg epiphysiodesisBone peg epiphysiodesis

Pin or screw fixationPin or screw fixation


THEORIESTHEORIES--smooth pins– to allow epiphysial growth--smooth pins– to allow epiphysial growth--threaded pins –to arrest physeal growth--threaded pins –to arrest physeal growth--single cannulated screw—threads placed across --single cannulated screw—threads placed across physis to arrest growthphysis to arrest growth--double screws—for additional rotational stability --double screws—for additional rotational stability in unstable hipsin unstable hips

SCFE Treatment to prevent SCFE Treatment to prevent further slippagefurther slippageIn situ screw or pin fixationIn situ screw or pin fixation

biplane fluoroscopybiplane fluoroscopy

percutaneous techniquepercutaneous technique

Position fixation centrally in headPosition fixation centrally in head


In situ screw or pin fixation--positionIn situ screw or pin fixation--positionpin must be placed perpendicular to plane of the femoral headpin must be placed perpendicular to plane of the femoral head

starting position anterior of the femoral neck and not lateral starting position anterior of the femoral neck and not lateral cortexcortex


In situ screw or pin fixation—to avoidIn situ screw or pin fixation—to avoidavoid superior and anterior quadrant of femoral headavoid superior and anterior quadrant of femoral head

following fixation whilst moving hip to ensure no penetrationfollowing fixation whilst moving hip to ensure no penetration


--BONE GRAFT EPIPHYSIODESIS--BONE GRAFT EPIPHYSIODESIS

Advantages—rapid epiphysial closure Advantages—rapid epiphysial closure ---no risk of implant penetration into jt. ---no risk of implant penetration into jt. ---no reoperation ---no reoperationDisadvantages---infectionDisadvantages---infection ---chondrolysis ---chondrolysis ---avn ---avnUses --- in failed pinning operationUses --- in failed pinning operation

SCFE Treatment to Reduce SCFE Treatment to Reduce degree of slippagedegree of slippageClosed manipulationClosed manipulation

although after in situ pinning ROM improves this is in although after in situ pinning ROM improves this is in main due to resolution of synovitis and spasm. main due to resolution of synovitis and spasm. There is little remodellingThere is little remodelling

Closed manipulation >24hrs significantly increases the Closed manipulation >24hrs significantly increases the risk of osteonecrosisrisk of osteonecrosis

SCFE Treatment to Reduce SCFE Treatment to Reduce degree of slippagedegree of slippage

OsteotomiesOsteotomies -- to reduce deformity-- to reduce deformity

--to prevent further slipping--to prevent further slipping--to re-orient and stabilise physis--to re-orient and stabilise physis


OsteotomiesOsteotomies1–-dunn’s1–-dunn’s2—kramer2—kramer3—barmada3—barmada4---southwick4---southwick


OsteotomiesOsteotomiesmore distal less correction at primary site of deformitymore distal less correction at primary site of deformity

more proximal more risk of osteonecrosismore proximal more risk of osteonecrosis

used in cases of moderate to severe slipsused in cases of moderate to severe slips


OsteotomiesOsteotomiesCuneiform Osteotmy at femoral Cuneiform Osteotmy at femoral

physis Fish/ Dunnphysis Fish/ Dunn

--done in severe slips in open --done in severe slips in open physisphysis

Osteonecrosis 12-35% Osteonecrosis 12-35%

Fish 3.5% osteonecrosis and 11% Fish 3.5% osteonecrosis and 11% chondrolysischondrolysis

Intertrochanteric - SouthwickIntertrochanteric - Southwick

Compensatory osteotomy, the more distal the less Compensatory osteotomy, the more distal the less correction at primary source of deformity. correction at primary source of deformity.

Maximum head-shaft correction is 50Maximum head-shaft correction is 50°.°.Antero-lateral wedge is removed,so flexion and valgus of Antero-lateral wedge is removed,so flexion and valgus of distal fragment is achieved .distal fragment is achieved .

Wedge removed -- therefore shorteningWedge removed -- therefore shortening..Done in severe slips Done in severe slips


OsteotomiesOsteotomies

IntertrochantericIntertrochantericsingle, bi or multiple-planesingle, bi or multiple-plane

corrects 45’-50’corrects 45’-50’

low incidence of low incidence of osteonecrosis, but osteonecrosis, but chondrolysis rate 6-50%chondrolysis rate 6-50%


OsteotomiesOsteotomiesBase of neck—Base of neck—

KRAMER AND KRAMER AND BARMADABARMADA anterior wedge anterior wedge removedremoved

corrects 30-50corrects 30-50for chronic residual for chronic residual deformitiesdeformitiesmoderate to severe scfemoderate to severe scfe

SCFE Prophylactic pinning of the SCFE Prophylactic pinning of the contralateral hipcontralateral hip

FU till skeletal maturityFU till skeletal maturity

Pin if symptoms presentPin if symptoms present

Pin known Pin known metabolic/endocrine metabolic/endocrine disordersdisorders

Pin if FU unreliablePin if FU unreliable

SCFE OsteonecrosisSCFE Osteonecrosis

vascular injury, complication of treatmentvascular injury, complication of treatment

increase with severity of slipincrease with severity of slip

increase in acute, unstable slipsincrease in acute, unstable slips

increases with manipulation, pin placement in superior quadrantincreases with manipulation, pin placement in superior quadrant

SCFE OsteonecrosisSCFE Osteonecrosis

remove metal workremove metal work

maintain ROMmaintain ROM

shelf acetabuloplastyshelf acetabuloplasty

arthrodesis/THRarthrodesis/THR

SCFE ChondrolysisSCFE Chondrolysis

dissolution of articular cartilage with joint dissolution of articular cartilage with joint stiffness and painstiffness and pain

CauseCausesynovial malnutrition, ischaemia, excessive pressuresynovial malnutrition, ischaemia, excessive pressure

AutoimmuneAutoimmune

Females>malesFemales>males


incidence 2-20%incidence 2-20%higher in females, acute and severe slipshigher in females, acute and severe slips

manipulation, prolonged immobilisation, realignment manipulation, prolonged immobilisation, realignment osteotomiesosteotomies

pin penetrationpin penetration

exclude infectionexclude infection


Non- wt bearing, NSAID, ROMNon- wt bearing, NSAID, ROM

tractiontraction

in pt therapyin pt therapy

Thank youThank you

slipped capital femoral epiphysis - by dr. lokesh sharoff

Health & Medicine