"Slipped capital femoral epiphysis in a 25-year-old hypogonadic man with a large cranial chondroma: causality or coincidence? ".

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a hip disorder frequently occurring in adolescence. In adults it is rare and so far very few cases have been documented. CASE PRESENTATION: This report presents a 25-year-old patient diagnosed with an anterior fossa giant chondroma, hypogonadotropic hypogonadism, and SCFE. The patient underwent surgical and hormonal therapy. His symptoms revealed, and he became a father. CONCLUSIONS: Every patient diagnosed with SCFE in adulthood should undergo endocrinological assessment based on physical examination and laboratory tests.

Pediatric Hip and Pelvis.

The most common pediatric orthopedic conditions of the hip and pelvis involve abnormal architecture of the joint leading to pain and dysfunction. Developmental dysplasia of the hip and femoroacetabular impingement are 2 common and distinct forms of structural pathology in the pediatric hip. The authors also discuss 2 of the more common, and often questioned, pediatric hip disorders-slipped capital femoral epiphysis and Legg-Calvé-Perthes disease. Future investigations are aimed at identifying risk factors to provide pediatric orthopedists tools to risk stratify their patients and understand when conservative approaches such as close observation versus surgical interventions are more appropriate.

Natural History of Slipped Capital Femoral Epiphysis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) occurs at a rate of 1 in 10,000 to 20,000 children. METHODS: A PubMed search was undertaken to evaluate recent SCFE literature. A convenience sample of articles were selected and summarized. RESULTS: Most slips appear well tolerated long-term with ∼5% resulting in total hip arthroplasty (THA) at 20-year follow-up. Classic data reveals poor outcomes following closed reduction for treatment of SCFE. Improvements in intraoperative fluoroscopy and avoidance of pin penetration have reduced the rates of chondrolysis. Unfortunately, avascular necrosis remains a known risk in patients, occurring in 15% to 50% of patients following acute, unstable slips. This is the most common cause of THA in patients with SCFE. Rate of THA due to degenerative arthritis secondary to SCFE is more difficult to determine and occurs at a later age. Although realignment procedures to address anatomic abnormalities from SCFE have increased in popularity, it is unclear if this prevents degenerative arthritis and subsequently reduces the rate of THA. SCFE patients face an increased risk of disability and death due to their underlying medical comorbidities. Interventions for weight loss, blood pressure management, and lifestyle adjustments should be considered at the time of SCFE diagnosis. CONCLUSIONS: SCFE remains a challenging and common condition for pediatric orthopedists. Although innovative techniques have been proposed, long-term outcome data still supports in situ pinning for stable slips, and in situ pinning with capsular decompression for unstable slips to minimize the risk of avascular necrosis.

Avascular necrosis post unstable slipped capital femoral epiphysis: a treatment algorithm with staged hinged hip distraction: mid-term results.

BACKGROUND: Management of avascular necrosis (AVN) of the femoral head in slipped capital femoral epiphysis (SCFE) is difficult. We proposed to ascertain if staged hip distraction could prevent collapse and recover the femoral head. METHODS: A retrospective review of the hip database retrieved 16 children with unstable SCFE and AVN. All underwent capital realignment by surgical dislocation followed by 2nd-stage hinged hip distraction. Patient demographics and radiographic parameters of deformity, AVN and arthritis were collected. The patients scored their hip function both before and after intervention and at follow-up using the modified Harris Hip Score and Nonarthritic Hip score. RESULTS: 7 boys and 9 girls formed the study group (n = 16). The average age at surgery was 12.7 years (9-16 years). 8 rights hips and 8 left hips were involved. The average follow-up was 45 months (33-66 months). Group A (n = 7) had hip distraction only if the follow-up radiographs showed AVN changes and collapse. Based on the observations in Group A, the protocol was changed for Group B. Group B (n = 9) underwent hip distraction at 6 weeks of capital realignment for avascularity of the femoral head. In Group A, all patients had further collapse and advanced arthritis at follow-up. In Group B all patients had hip joint space restored and good hip function without pain at follow-up. CONCLUSIONS: Pre-emptive application of hip distractor for those children with proven lack of blood flow to the femoral head is a potential option to stall the progression of AVN and to help recover useful hip function.

Slipped Capital Femoral Epiphysis: A Review for Pediatricians.

Slipped capital femoral epiphysis (SCFE) is one of the most common hip pathologies that occurs during adolescence, and its incidence has been increasing over the past decades. For this reason, pediatricians should be aware of this entity to ensure an early diagnosis and intervene in a timely manner. The typical patient with SCFE is an adolescent who is obese presenting with hip pain, but it can also occur in children who are not obese; therefore, SCFE should be part of the differential diagnosis in any skeletally immature patient presenting with hip or knee pain. This article provides an overview for the clinician of relevant aspects of this disease that can lead to serious long-term consequences if not diagnosed and treated appropriately. [Pediatr Ann. 2018;47(9):e377-e380.].

Pediatric Orthopaedic Consults From Chiropractic Care.

Alternative medicine in pediatrics is expanding, with chiropractic now a common choice for families seeking alternative medical care. Currently, there is sparse information in the literature exploring the role of chiropractic in orthopaedic pathology. The objective of this case series is to present pediatric patients who received treatment from chiropractors and orthopaedic physicians as well as to review the respective existing research. Data collected included chiropractic diagnosis, orthopaedic diagnosis, imaging studies, treatments, and complications. Twenty-three patients were studied. Scoliosis, Legg-Calvé-Perthes disease, developmental dysplasia of the hip, cerebral palsy, skeletal dysplasia, and slipped capital femoral epiphysis were diagnoses included. Children had multiple sessions of chiropractic for management of these conditions. The parents' perception for chiropractic was positive in every case. Delayed referral, misdiagnosis, adverse events from manipulative therapy, and ineffective treatments were observed in the present study. More research is indicated to validate chiropractic in children with orthopaedic pathology. (Journal of Surgical Orthopaedic Advances 27(1):58-63, 2018).

Common paediatric conditions of the lower limb.

Growing children are susceptible to a number of disorders to their lower extremities of varying degrees of severity. The diagnosis and management of these conditions can be challenging. With musculoskeletal symptoms being one of the leading reasons for visits to general practitioners, a working knowledge of the basics of these disorders can help in the appropriate diagnosis, treatment, counselling, and specialist referral. This review covers common disorders affecting the hip, the knee and the foot. The aim is to assist general practitioners in recognising developmental norms and differentiating physiological from pathological conditions and to identify when a specialist referral is necessary.

Treatment for unstable slipped capital femoral epiphysis: Current status and future challenge in Japan.

BACKGROUND: Treatment for unstable slipped capital femoral epiphysis (SCFE) is challenging and controversial. For many years, the debate centered around closed treatments and especially the pros and cons of manual reduction and its concrete procedure. However, recent studies reported on open treatments such as open reduction through an anterior approach and modified Dunn procedure. Being in a period of such transition, we investigated the current status and future challenge of treatment for unstable SCFE. METHODS: A questionnaire survey of medical institutions specializing in pediatric hip disorders across Japan was conducted. Survey items were the accurate diagnosis of physeal stability, the pre- and intra-operative evaluation of epiphyseal hemodynamics, and current treatment strategy. RESULTS: Survey responses returned from 29 out of 40 participant institutions (response rate: 73%) revealed that 55% of the institutions evaluated physeal stability based on clinical findings of ambulation capability in accordance with the Loder classification. Another 38% diagnosed physeal stability comprehensively by combining the Loder classification and imaging findings. Epiphyseal hemodynamics was assessed preoperatively in 18% of the institutions, effectively using angiography, contrast-enhanced magnetic resonance imaging (MRI), and bone scintigraphy. Intraoperative assessment was performed in 13% based on the bleeding through a drilling hole on the articular surface and observation of the cancellous bone color during open surgeries. As a treatment strategy, 52% of the institutions used in-situ fixation, while another 38% used manual reduction and internal fixation. On the other hand, open reduction was used at 3 institutions (the remaining 10%): the modified Dunn procedure at 2 institutions and arthrotomy at 1 institution. CONCLUSION: Treatment for unstable SCFE remains controversial, but closed treatments without hemodynamic monitoring is no longer the center of the controversy. Today, the topic of the discussion is shifting toward how to correlate hemodynamic findings with treatment procedures and the indications for open treatments.

Anterior minimally invasive subcapital osteotomy without hip dislocation for slipped capital femoral epiphysis.

PURPOSE: A minimally invasive anterior approach appears to be an attractive alternative to achieve capital realignment without violating femoral head vascular supply and avoiding hip dislocation in slipped capital femoral epiphysis. The aim of this study was to detail the technical steps of subcapital realignment through a minimally invasive anterior approach and to report the preliminary results of this procedure in a prospective cohort of patients with stable slips. METHODS: Nine patients underwent subcapital cuneiform wedge resection through a minimally invasive anterior approach without hip dislocation for moderate or severe stable slips between April 2012 and April 2013. Prophylactic stabilization of the contralateral hip was performed in all cases. A minimum 18 months follow-up was available. Clinical course was assessed using the Harris hip score and the hip range of motion. The degree of slippage as proposed by Southwick, the lateral α angle and the epiphyseal-metaphyseal distance allowed radiographic assessment. RESULTS: No patients were lost during follow-up, which was on average 28 months. No intraoperative complications occurred; one postoperative transient apraxia of the femoral cutaneous nerve, which completely recovered in six months, was recorded. Southwick angle, lateral α angle and epiphyseal-metaphyseal distance all improved substantially postoperatively. No cases of avascular necrosis were detected. CONCLUSION: Subcapital cuneiform wedge resection through a minimally invasive anterior approach without hip dislocation can be an easier alternative to restore proximal femoral anatomy in moderate to severe stable slips. Prospective case control studies are required to confirm these preliminary results.

Myth busters: an AOA symposium: AOA critical issues.

One of the goals of the annual American Orthopaedic Association (AOA) meeting is to address controversy, both in leadership and clinical practice. A panel of experts in their respective fields presented the background and literature behind three "myths" in orthopaedic management and made conclusions as to their validity. First, Dr. Kocher took on the myth of prophylactic pinning on the contralateral "normal" side for a patient with a slipped capital femoral epiphysis. Second, Dr. Probe evaluated the myth that all intertrochanteric fractures are best treated with intramedullary devices. Last, Dr. Foster and Dr. Silvestri tackled the myth that autograft is always the best choice for anterior cruciate ligament (ACL) reconstruction. All three of these topics are subjects of current debate. The panel's careful examination of the available data along with their expertise in the management of these problems is presented in this thought-provoking JBJS Critical Issues article.

Approach to the management of slipped capital femoral epiphysis and primary hyperparathyroidism.

CONTEXT: Worldwide, only nine cases of slipped capital femoral epiphysis (SCFE) associated with primary hyperparathyroidism (PHP) have been reported. CASE ILLUSTRATION: This is a report on adolescent subjects with SCFE associated with PHP exhibiting the leading pathogenesis and clinical course. METHODS: Here, we reviewed all known cases and developed an effective approach to the management of SCFE and PHP. RESULTS: In cases of emergency, SCFE fixation is primarily done regardless of any preexistent hypercalcemia due to PHP and is followed by parathyroidectomy as soon as possible. In cases of mild and moderate hypercalcemia, whether SCFE fixation is followed by parathyroidectomy and vice versa or resolved during a single operating session depends on the side effects of hypercalcemia. Severely hypercalcemic patients should undergo urgent parathyroidectomy followed by immediate orthopedic surgery or even as a simultaneous procedure. This is to avoid onset of hypercalcemic side effects or worsening of preexisting side manifestations resulting from hypercalcemia. CONCLUSION: Our report demonstrates that SCFE patients presenting with hypercalcemia, signs of low bone density, or with non-typical age of onset deserve further workup for secondary causes. In addition, the newly developed systematic approach toward achieving an effective, efficient management should help in improving the patients' long-term outcome.

Three cases of slipped capital femoral epiphysis in one family.

Slipped capital femoral epiphysis is a relatively common disorder of the hip that affects children in late childhood and early adolescence, with an incidence in the United States of approximately 10 per 100,000. Although the diagnosis and treatment of slipped capital femoral epiphysis have been well described, the search for its cause and a method of early identification continues. Recent publications have suggested that there is a familial association among individuals with slipped capital femoral epiphysis, but there is no current genetic marker established for the disorder. This article reports a series of 3 biologically related Caucasian sisters who were athletic; had body mass indices <26 kg/m(2); had no record of any hormonal imbalances or endocrine abnormalities; had good nutrition; and presented with atypical characteristics of slipped capital femoral epiphysis. This is the first report of a series of 3 sisters with slipped capital femoral epiphysis in the United States. Our goals were to document our experience in the identification and treatment of these patients to highlight the complexities of slipped capital femoral epiphysis presentation patterning, to increase the awareness and reporting of familial cases of slipped capital femoral epiphysis by other physicians, and to encourage additional research in this area. As clinicians progress in the ability to diagnose and treat patients with slipped capital femoral epiphysis, they also must be mindful of the varying presentation characteristics.

Nonoperative treatment of slipped capital femoral epiphysis: a scientific study.

BACKGROUND: Treatment of the Slipped Capital Femoral Epiphysis remains a cause of concern due to the fact that the true knowledge of the etiopathogeny is unknown, as well as one of its major complications: chondrolysis. The conservative treatment remains controversial; it has been overlooked in the studies and subjected to intense criticism. The purpose of this study is to investigate the results of treatment on the hip of patients displaying slipped capital femoral epiphysis, using the plaster cast immobilization method and its link to chondrolysis. METHODS: The research was performed based on the study of the following variables: symptomatology, and the degree of slipping. A hip spica cast and bilateral short/long leg casts in abduction, internal rotation with anti-rotational bars were used for immobilizing the patient's hip for twelve weeks. Statistical analysis was accomplished by Wilcoxon's marked position test and by the Fisher accuracy test at a 5% level. RESULTS: A satisfactory result was obtained in the acute group, 70.5%; 94%; in the chronic group (chronic + acute on chronic). Regarding the degree of the slipping, a satisfactory result was obtained in 90.5% of hips tested with a mild slip; in 76% with moderate slip and 73% in the severe slip. The statistical result revealed that a significant improvement was found for flexion (p = 0.0001), abduction (p = 0.0001), internal rotation (p = 0.0001) and external rotation (p = 0.02). Chondrolysis was present in 11.3% of the hips tested. One case of pseudoarthrosis with aseptic capital necrosis was presented. There was no significant variation between age and chondrolysis (p = 1.00).Significant variation between gender/non-white patients versus chondrolysis (p = 0.031) and (p = 0.037), respectively was verified. No causal association between plaster cast and chondrolysis was observed (p = 0.60). In regard to the symptomatology group and the slip degree versus chondrolysis, the p value was not statistically significant in both analyses, p = 0.61 and p = 0.085 respectively. CONCLUSIONS: After analyzing the nonoperative treatment of slipped capital femoral epiphysis and chondrolysis, we conclude that employment of the treatment revealed that the method was functional, efficient, valid, and reproducible; it also can be used as an alternative therapeutic procedure regarding to this specific disease.