"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.

Patients With Symptomatic Sequelae of Slipped Capital Femoral Epiphysis Have Advanced Cartilage Wear at the Time of Surgical Intervention.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a common hip problem in children. The resulting deformity can cause impingement similar to cam-type idiopathic femoroacetabular impingement (FAI). Although there are similarities between FAI and SCFE, deformity patterns, severity, and time of onset of symptoms varies, which may impact management. The purpose of this study was to describe patterns of articular cartilage damage in patients undergoing surgical hip dislocation for sequelae of SCFE in comparison to patients undergoing arthroscopic surgery for primary FAI. METHODS: Patients were identified who underwent surgical treatment for hip pain due to primary FAI (cam type) or sequelae of SCFE. Clinical data and radiographic measurements were recorded. Cartilage was assessed intraoperatively. Severity was classified using the modified Beck classification, while location was classified into 6 sectors. Statistical analysis was performed to test for differences in demographic and radiographic characteristics between the SCFE and FAI patients. χ2 or Fisher exact tests were used to evaluate trends in patterns of acetabular and femoral cartilage wear between SCFE and FAI groups. RESULTS: The SCFE group had 28 hips compared with 304 in the FAI group. SCFE patients were younger (19 vs. 32, P<0.001), had higher body mass index (30±5.9 vs. 24±4.8, P<0.001), and were more often male (61% vs. 27%, P<0.001). Deformity severity based on α-angle was higher in the SCFE group [AP 74 vs. 55 (P=0.001) and Dunn 72 vs. 58 (P<0.001)]. There were no significant differences with regards to lateral center edge angle, anterior center edge angle, or Tonnis angle. In both groups the most common locations for cartilage lesions in both groups were the anterior peripheral and superolateral peripheral regions with fewer but more widely distributed femoral head lesions. The SCFE group had higher rates of femoral head and superolateral central cartilage lesions compared with the FAI group. There was no statistical difference between high-grade femoral or acetabular cartilage lesions between groups. CONCLUSIONS: Patients with SCFE were younger at the time of surgery and presented with more severe deformity based on radiographic α-angle compared to patients with FAI. Our results suggest higher prevalence of femoral head lesions and more diffuse cartilage injury in patients with SCFE. This study can be used to support early surgical intervention in patients with symptomatic sequelae of SCFE due to risk of premature joint damage. LEVEL OF EVIDENCE: Level III-prognostic study.

Musculoskeletal complications following total body irradiation in hematopoietic stem cell transplant patients.

Total body irradiation (TBI) is commonly used in conditioning regimens for allogeneic hematopoietic stem cell transplantation (HSCT) to treat benign and malignant disease. Though life-saving, these therapies place patients at risk for important side effects, including musculoskeletal complications such as short stature, osteonecrosis, slipped capital femoral epiphysis, and the development of benign and malignant bone tumors. With an increasing number of HSCT survivors, there is a growing need for awareness of the musculoskeletal complications of HSCT and TBI.

Pseudohypoparathyroidism type 1B in a patient conceived by in vitro fertilization: another imprinting disorder reported with assisted reproductive technology.

Pseudohypoparathyroidism type 1B (PHP1B) is characterized by renal tubular resistance to parathyroid hormone (PTH) leading to hyperphosphatemia, hypocalcemia, elevated PTH, and hyperparathyroid bone changes. PHP1B is an imprinting disorder that results from loss of methylation at the maternal GNAS gene, which suppresses transcription of the alpha subunit of the stimulatory G protein of the PTH receptor. Emerging evidence supports an association between assisted reproductive technologies (ART) and imprinting disorders; however, there is currently little evidence linking PHP1B and ART. We present a twin boy conceived by ART to parents with no history of subfertility who presented at age 12 with bilateral slipped capital femoral epiphysis and bilateral genu valgum deformity. Clinical and laboratory investigation revealed markedly elevated PTH, low ionized calcium, elevated phosphorus, TSH resistance, and skeletal evidence of hyperparathyroidism, leading to the diagnosis of PHP1B. A partial loss of methylation at the GNAS exon A/B locus was observed. The patient's dizygotic twin sibling was asymptomatic and had normal laboratory evaluation. This is the second reported case of a child with PHP1B conceived by ART, further supporting the possibility that ART may lead to an increased risk for imprinting defects.

The Peritubercle Lucency Sign is a Common and Early Radiographic Finding in Slipped Capital Femoral Epiphysis.

BACKGROUND: A rotational mechanism of slipped capital femoral epiphysis (SCFE) in which the epiphyseal tubercle acts as a fulcrum has been recently described. However, there is limited radiographic evidence supporting this theory. We aimed to investigate whether a radiographic lucency around the epiphyseal tubercle (peritubercle lucency sign) could be observed before or at the diagnosis of a subsequent slip in patients initially presenting with unilateral SCFE. METHODS: We evaluated 70 patients with unilateral SCFE who were followed until a contralateral slip was diagnosed, and 180 patients with unilateral SCFE who had no contralateral slip until skeletal maturity between 2000 and 2017. We revised anteroposterior and lateral radiographs from the initial presentation, surveillance, and diagnosis of a contralateral SCFE. The presence or absence of the peritubercle lucency sign in the contralateral initially uninvolved hip was recorded for every radiograph. The presence of hip pain, and the presence of classic radiographic parameters for SCFE diagnosis (epiphyseal tilt and Klein's line) were recorded when the peritubercle lucency sign became noticeable. RESULTS: The peritubercle lucency sign was observed in 84% [59/70; 95% confidence interval (CI), 73%-92%] of the patients who developed contralateral slip. Most patients (46/59=78%; 95% CI, 65%-87%; P<0.001) had the peritubercle lucency sign visible within 9 months after the initial diagnosis of unilateral SCFE. The sign preceded the definitive diagnosis of the contralateral slip at a median of 9 weeks (interquartile range, 0 to 10 wk). At the time of first observation of the peritubercle lucency sign, 36% (25/70; 95% CI, 25%-48%) of the patients were asymptomatic and 49% (34/70; 95% CI, 36%-61%) of the hips showed no abnormalities in the tilt angle or the Klein line. Among patients who did not experience a contralateral slip (n=180), the sign was observed in 2 patients (1.1%; 95% CI, 0.2%-4.4%). The sensitivity was 84% and specificity was 99%. CONCLUSIONS: A peritubercle lucency is an early imaging sign, present in >80% of contralateral slips following an initial presentation of unilateral SCFE. The presence of the peritubercle lucency sign may be helpful for contralateral hip surveillance. Future studies are necessary to establish the clinical validity of the peritubercle lucency sign and whether it may serve as a predictor of contralateral involvement. LEVEL OF EVIDENCE: Diagnostic level III.

Treatment of Unstable Slipped Capital Epiphysis Via the Modified Dunn Procedure.

BACKGROUND: The modified Dunn procedure has been shown to be safe and effective in treating unstable slipped capital femoral epiphysis (SCFE). We present a consecutive series of unstable SCFE managed by a single surgeon with a focus on timing of surgical intervention, postoperative complications, and radiographic results. METHODS: Thirty-one consecutive unstable SCFEs were treated. Demographics, presentation time to time of operation, surgical times, and complications were recorded. Bilateral hip radiographs at latest follow-up were utilized to record slip angle, α angle, greater trochanteric height, and femoral neck length. RESULTS: Thirty-one consecutive hips in 30 patients were reviewed: 15 males (50%) and 15 females (50%), average age 12.37 years (range, 8.75 to 14.8 y), 20 left hips (65%) and 11 right hips (35%). Mean follow-up was 27.9 months (range, 1 to 82 mo). Time from presentation to intervention averaged 13.9 hours (range, 2.17 to 23.4 h). Two patients (6%) developed avascular necrosis at average 19 weeks postoperative. Three patients (10%) developed mild heterotopic ossification requiring no treatment. Two patients (6%) required removal of symptomatic hardware. One patient had hardware failure and in no patients was nonunion, delayed union, or postoperative hip subluxation/dislocation seen. Three patients (10%) presented with bilateral, stable SCFE requiring contralateral in situ pinning. Five patients (16%) had sequential SCFE requiring treatment with 1 patient having an acute, unstable SCFE 10 months after the previous realignment. Mean postoperative slip angle measured 2.5 degrees (range, +19 to -9.4 degrees) (SD, 7.2), α angle 47.43 degrees (range, 34 to 64 degrees) (SD, 7.49), greater trochanteric height averaged 3.5 mm below the center of femoral head (-17.5 to +25 mm), and mean femoral neck length difference measured -7.75 mm (range, -1.8 to -18.6 mm). CONCLUSIONS: A single surgeon series of unstable SCFEs treated by a modified Dunn procedure showed a 6% incidence of avascular necrosis and low complication rates at latest follow-up. Radiographs showed restoration of the slip angle, α angle, femoral neck length, and greater trochanteric height. This series reveals the safety and effectiveness of the modified Dunn procedure for unstable SCFE. LEVEL OF EVIDENCE: Level III-retrospective review.

Diagnosis and treatment of slipped capital femoral epiphysis: Recent trends to note.

Slipped capital femoral epiphysis (SCFE) is not frequently encountered during routine practice and diagnosis and treatment are often delayed. It is important to understand symptoms and imaging features to avoid delayed diagnosis. After the diagnosis is made correct classification of the disease is required. The classification should be based on the physeal stability in order to choose safe and effective treatment. However, surgeons should bear in mind that the assessment is challenging and actual physeal stability is not always consistent with the stability predicted by a clinical classification method. TREATMENT OF STABLE SCFE: Closed reduction is not indicated for stable SCFE, where continuity between the epiphysis and metaphysis has not been disrupted. Treatment method(s) is (are) chosen from in-situ fixation, osteotomy and femoroacetabular impingement treatment. A single screw fixation is often used to fix the epiphysis and the dynamic method is considered especially for young patients. Traditional three-dimensional trochanteric osteotomies have been associated with procedural complexity and uncertainty. A simpler osteotomy method using an updated imaging analysis technology should be considered. Modified-Dunn procedure is indicated for a severe stable SCFE. However, caution is required because recent studies have reported a high rate of complications including postoperative femoral head avascular necrosis (AVN) and hip instability when this method is indicated for stable SCFE. TREATMENT OF UNSTABLE SCFE: Treatment of unstable SCFE is difficult and complication rate is high. Most of unstable SCFE patients were previously treated with closed method and it was difficult to predict an occurrence of postoperative AVN. However, treatment of unstable SCFE has gradually changed in recent years and many studies have shown that physeal hemodynamics can be assessed during treatment. Preoperative assessments include contrast-enhanced MRI and bone scintigraphy. Intraoperative assessments include confirmation of bleeding after drilling the femoral head and monitoring the intracranial pressure by laser doppler flowmetry. It is expected that postoperative AVN can be prevented in many cases by performing the treatment while assessing the intraoperative physeal hemodynamics. Open surgeries have begun to be indicated in the treatment of unstable SCFE through either of anterior approach or (modified) Dunn procedure. The authors expect that recent improvements in assessment of physeal hemodynamics and open treatment method provide improved clinical outcomes in the treatment of SCFE.

Prepubertal onset of slipped capital femoral epiphysis associated with hypothyroidism: a case report and literature review.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a common hip disorder characterized by displacement of the capital femoral epiphysis from the metaphysic through the femoral epiphyseal plate. SCFE usually occurs during puberty, with obesity a common risk factor. We experienced a rare case of SCFE associated with hypothyroidism in a prepubescent patient who was not obese. CASE PRESENTATION: The patient was an 8-year-old boy suffering from bilateral SCFE with hypothyroidism. The patient's growth had started to slow at 4 years of age, and at 8 years he was of short stature. During his evaluation for SCFE management, primary hypothyroidism was diagnosed due to the presence of anti-thyroid peroxidase and anti-thyroglobulin antibodies. After the patient was treated for hypothyroidism, which improved his thyroid function, surgery was performed for bilateral SCFE. CONCLUSIONS: Among the 42 patients with SCFE associated with hypothyroidism in the literature, most SCFE occurred during puberty or in adults with delayed epiphyseal closure. Only two patients (4.8%), including the present patient, were ≤9 years old. Although being overweight or obese is common for patients with SCFE associated with hypothyroidism (76.0%), it was not observed in the present case. Persistent hypothyroidism, however, may be a risk factor for SCFE even before puberty and without obesity.

Validity and Clinical Consequences of a Rotational Mechanism for Slipped Capital Femoral Epiphysis.

BACKGROUND: Recent anatomic data supports a mechanism for slipped capital femoral epiphysis (SCFE) where the metaphysis rotates on the epiphysis through the eccentrically located epiphyseal tubercle as a pivot. The validity of such a mechanism and its clinical consequences have not been well investigated. METHODS: This cadaveric study defined the normal location of the calcar ridge line in 100 paired femora and compared them with 11 SCFE specimens, and with 25 immature femora where the metaphysis was rotated 30, 60, and 90 degrees on the epiphysis to model progressive SCFE. Coronal, sagittal, and axial plane deformity were measured on the rotational model to define the characteristic deformity caused by rotation, and lateral epiphyseal foramina stretch was measured to quantify the protective effect of an eccentric pivot. RESULTS: The posterior displacement of the fovea with respect to the calcar ridge line was 1±5 mm for the controls, versus 23±10 mm for the SCFE specimens (P<0.0005), and posterior displacement increased with incremental rotation in the rotational model (P<0.0005). The rotational model found minimal varus deformity, but substantial extension and retroversion, with deformities of 0±5, -16±12, and -38±9 degrees, respectively, at 90 degrees of rotation. The eccentric pivot mitigated lateral epiphyseal vessel stretch by 55% to 70%. CONCLUSIONS: This study provides strong anatomic support for a rotational mechanism for stable SCFE. When the metaphysis is rotated on the epiphysis acutely, minimal varus deformity is created, while substantial retroversion occurs. As this rotation occurs the eccentric pivot protects the lateral epiphyseal vessels, and likely accounts for the low rate of avascular necrosis observed in stable SCFE. CLINICAL RELEVANCE: If SCFE is treated in an open manner then the presence of a chronic rotational deformity should be considered. When planning osteotomies for deformity after a stable SCFE, any suspected varus component should be carefully investigated as it may represent retroversion deformity brought into view by external rotation posturing of the leg.

Pelvic Incidence and Acetabular Version in Slipped Capital Femoral Epiphysis.

BACKGROUND: The etiology of slipped capital femoral epiphysis (SCFE) is multifactorial, but the role of sagittal balance of the pelvis as a contributing factor to its development has not been well studied. Our primary purpose was to determine whether a smaller pelvic incidence (PI), a position-independent anatomic parameter that regulates pelvic orientation, could be a factor that increases shear stress in the epiphyseal growth plate and potentially contributes to the development of SCFE. We also set out to determine whether acetabular retroversion was associated with SCFE. METHODS: We obtained 14 cadaveric pelvi from the Hamann-Todd Osteological Collection whose femurs showed evidence of post-SCFE deformity. Two hundred age-matched, sex-matched, and race-matched pelvi were used as controls. PI and acetabular version were measured using standardized lateral photographs and goniometers, respectively. T tests were performed to evaluate for differences in measured parameters between groups. RESULTS: The mean PI was 40.6±6.1 degrees for SCFE specimens and 47.4±9.9 degrees for normal specimens (P=0.01). The mean version of SCFE and normal acetabula was 15±7 and 17±6 degrees, respectively (P=0.39). There was also no significant difference in version between SCFE acetabula and the contralateral, uninvolved acetabular of the same specimen (15±7 vs. 17±8 degrees, P=0.33). CONCLUSIONS: Specimens with SCFE deformity demonstrated a smaller PI than a large cohort of normal control specimens. We found no significant difference between acetabular version of specimens with and without SCFE deformity. Contralateral or unaffected acetabuli of SCFE specimens were not more retroverted than the affected side of the same specimen. CLINICAL RELEVANCE: Sagittal balance of the pelvis, and particularly decreased PI, may play an important role in the development of SCFE. The influence of mechanical factors beyond the hip joint in the development of SCFE should be considered by clinicians.

Cam deformity and hip degeneration are common after fixation of a slipped capital femoral epiphysis.

BACKGROUND AND PURPOSE: Slipped capital femoral epiphysis is thought to result in cam deformity and femoroacetabular impingement. We examined: (1) cam-type deformity, (2) labral degeneration, chondrolabral damage, and osteoarthritic development, and (3) the clinical and patient-reported outcome after fixation of slipped capital femoral epiphysis (SCFE). METHODS: We identified 28 patients who were treated with fixation of SCFE from 1991 to 1998. 17 patients with 24 affected hips were willing to participate and were evaluated 10-17 years postoperatively. Median age at surgery was 12 (10-14) years. Clinical examination, WOMAC, SF-36 measuring physical and mental function, a structured interview, radiography, and MRI examination were conducted at follow-up. RESULTS: Median preoperative Southwick angle was 22o (IQR: 12-27). Follow-up radiographs showed cam deformity in 14 of the 24 affected hips and a Tönnis grade>1 in 1 affected hip. MRI showed pathological alpha angles in 15 affected hips, labral degeneration in 13, and chondrolabral damage in 4. Median SF-36 physical score was 54 (IQR: 49-56) and median mental score was 56 (IQR: 54-58). These scores were comparable to those of a Danish population-based cohort of similar age and sex distribution. Median WOMAC score was 100 (IQR: 84-100). INTERPRETATION: In 17 patients (24 affected hips), we found signs of cam deformity in 18 hips and early stages of joint degeneration in 10 hips. Our observations support the emerging consensus that SCFE is a precursor of cam deformity, FAI, and joint degeneration. Neither clinical examination nor SF-36 or WOMAC scores indicated physical compromise.

Symptomatic femoroacetabular impingement: does the offset decrease correlate with cartilage damage? A pilot study.

BACKGROUND: Current measures of the reduced head-neck offset such as residual deformity of slipped capital femoral epiphysis (SCFE) including the alpha angle, which measures the femoral head-neck sphericity but does not account for acetabular abnormalities, do not represent the true magnitude of the deformity and the mechanical consequences. The beta angle (angle between the femoral head-neck junction and acetabular rim) accounts for the morphology of both the acetabulum and femur and, thus, may be the more appropriate parameter for assessing SCFE deformity. QUESTIONS/PURPOSES: We determined (1) whether the beta angle could be reliably measured on MRI; and (2) whether the beta angle correlates with the cartilage status. METHODS: We recruited 10 adult patients (mean age, 28 years) with symptomatic cam femoroacetabular impingement and 15 asymptomatic volunteers (mean age, 24 years) to have three-dimensional MRI including delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) for cartilage status assessment. Corresponding alpha angles, beta angles, and acetabular dGEMRIC indices were obtained in seven radial reformats to assess the hip in seven regions (anterior to superior and posterior). RESULTS: We noted high reproducibility for both alpha and beta angle measurements. The dGEMRIC indices correlated with beta angles in the superoinferior and superior regions but not the alpha angles. CONCLUSIONS: Beta angle measurement in radial MR images is reproducible and appears to correspond to cartilage damage in the superior regions of the hip. The beta angle may be a useful parameter to assess hip deformity in the followup of SCFE although further confirmation is warranted.

Slipped capital femoral epiphysis: relevant pathophysiological findings with open surgery.

BACKGROUND: Traditionally arthrotomy has rarely been performed during surgery for slipped capital femoral epiphysis (SCFE). As a result, most pathophysiological information about the articular surfaces was derived clinically and radiographically. Novel insights regarding deformity-induced damage and epiphyseal perfusion became available with surgical hip dislocation. QUESTIONS/PURPOSES: We (1) determined the influence of chronicity of prodromal symptoms and severity of SCFE deformity on severity of cartilage damage. (2) In surgically confirmed disconnected epiphyses, we determined the influence of injury and time to surgery on epiphyseal perfusion; and (3) the frequency of new bone at the posterior neck potentially reducing perfusion during epimetaphyseal reduction. METHODS: We reviewed 116 patients with 119 SCFE and available records treated between 1996 and 2011. Acetabular cartilage damage was graded as +/++/+++ in 109 of the 119 hips. Epiphyseal perfusion was determined with laser-Doppler flowmetry at capsulotomy and after reduction. Information about bone at the posterior neck was retrieved from operative reports. RESULTS: Ninety-seven of 109 hips (89%) had documented cartilage damage; severity was not associated with higher slip angle or chronicity; disconnected epiphyses had less damage. Temporary or definitive cessation of perfusion in disconnected epiphyses increased with time to surgery; posterior bone resection improved the perfusion. In one necrosis, the retinaculum was ruptured; two were in the group with the longest time interval. Posterior bone formation is frequent in disconnected epiphyses, even without prodromal periods. CONCLUSIONS: Addressing the cause of cartilage damage (cam impingement) should become an integral part of SCFE surgery. Early surgery for disconnected epiphyses appears to reduce the risk of necrosis. Slip reduction without resection of posterior bone apposition may jeopardize epiphyseal perfusion. LEVEL OF EVIDENCE: Level IV, retrospective case series. See Guidelines for Authors for a complete description of levels of evidence.

A treatment algorithm for stable slipped capital femoral epiphysis deformity.

The authors' current experience in the surgical treatment strategy of stable slipped capital femoral epiphysis deformities was reviewed. From this, a treatment algorithm was developed that could be utilized as a guide in the evaluation and treatment of future patients with slipped capital femoral epiphysis. The clinical parameters of patients' histories of symptoms, physical examinations, and radiographic assessments of slip severity were used in formulating the algorithm. The intent was to prepare a comprehensive algorithm providing necessary alternate treatment pathways for the variable slip deformity in accordance with the surgical experience/expertise of the treating surgeon.

Risks and benefits of the modified Dunn approach for treatment of moderate or severe slipped capital femoral epiphysis.

In North America, in situ pinning is the most common treatment for a stable slipped capital femoral epiphysis (SCFE), with generally good results and relatively low risk of avascular necrosis. Since the recognition that even a mild SCFE can cause femoroacetabular impingement, there has been a reconsideration of the goals of treatment, particularly for moderate, severe, or unstable slips. The modified Dunn approach for moderate or severe SCFE involves a surgical hip dislocation, creation of a retinacular flap, controlled open reduction of the epiphysis, and internal fixation of the slip. It has the advantage of correcting the pathoanatomy at the site of the deformity and at the time of diagnosis, minimizing secondary chondrolabral damage. The short-term results are generally good to excellent with few complications. The modified Dunn technique is, however, technically complex and more invasive than in situ pinning, with some inherent risk of avascular necrosis because of the proximity to the lateral retinacular vessels. When performed by experienced surgeons, the modified Dunn technique is an ideal technique for the treatment of moderate to severe SCFE. Because of the technically challenging nature of the procedure, it is recommended that it be performed in tertiary care centers by surgeons with experience in this technique.

Subcapital correction osteotomy for malunited slipped capital femoral epiphysis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE), causing posterior and inferior displacement and retroversion of the femoral head, is a well-recognized etiology for femoroacetabular impingement and can lead to premature arthritis in the young adult. The treatment of malunited SCFE remains controversial. Surgical dislocation and subcapital correction osteotomy (SCO) has been described as a powerful method to correct the proximal femoral deformity. METHODS: Between January 2003 and January 2010, 11 patients (12 hips) with closed femoral physes and symptomatic femoroacetabular impingement from malunited SCFE were treated with surgical dislocation and SCO. We performed a retrospective review of patient histories, physical examinations, operative findings, and preoperative and postoperative anteroposterior (AP) and groin-lateral (GLat) radiographs. Mean follow-up was 61 months. RESULTS: There were 4 female and 7 male patients with an average age of 15 years at the time of SCO. On the AP radiograph, the mean inferior femoral head displacement (AP epiphyseal-neck angle) was significantly improved (-26 to -6 degrees, P<0.001). On the GLat radiograph, the mean posterior femoral head displacement (lateral epiphyseal-neck angle) was significantly improved (-45 to -3 degrees, P<0.001). The mean α-angle was also significantly improved on both views (AP: 85 to 56 degrees, P<0.001; GLat: 85 to 46 degrees, P<0.001). Operative findings included 1 femoral osteochondral defect, 8 Outerbridge grade 3 to 4 acetabular cartilage lesions, and 10 labral lesions. Significant improvement of the mean Harris Hip Score was seen at latest follow-up (54 to 77, P=0.016). Complications occurred in 4 of the 12 cases with avascular necrosis in 2 patients, a worse postoperative Harris Hip Score in 1 patient, and failure of fixation treated successfully with revision open reduction internal fixation in 1 patient. CONCLUSIONS: SCO as an adjunct to surgical dislocation and osteochondroplasty can be used to correct the deformity of the proximal femur associated with malunited SCFE. Normalization of proximal femoral anatomy may postpone progression to severe osteoarthritis and thus delay the need for arthroplasty in this young patient population. However, surgeons and patients should be aware that the risks of this procedure in this population are significant. LEVEL OF EVIDENCE: Level IV-therapeutic study.

The cam-type deformity--what is it: SCFE, osteophyte, or a new disease?

Cam-type deformity of the proximal femur is a risk factor for the development of cam-type femoroacetabular impingement and a prearthrotic condition of the hip. The etiology of cam-type deformity remains unclear. There are a number of causes of cam-type deformity including sequellae of slipped capital femoral epiphysis, Legg-Calvé-Perthes disease or Perthes-like deformities, postinfectious, and traumatic. However, the majority of cam-type deformities arise without any apparent preexisting hip disease. These "idiopathic" cam-type deformities likely represent a majority of cases, and show clear racial and sex differences, as well as developmental and genetic influences. Idiopathic cam-type deformity also seems to be a distinct entity from residual or silent slipped capital femoral epiphysis, as well as osteoarthritis-induced osteophytes. In this paper we examine the different pathogenetic aspects of the proximal femur that contribute to cam-type deformity and/or symptomatic cam-type femoroacetabular impingement.

Total hip arthroplasty in the young: special emphasis on post-SCFE patients.

Slipped capital femoral epiphysis (SCFE) is a hip disorder of adolescence, which has the potential for profound implications into adulthood. SCFE patients are at risk of early joint degeneration and subsequent need for arthroplasty. The rate at which arthroplasty is required is not precisely known, but is estimated to be approximately 45% by 50 years after a slip. The femoral neck and shaft displace anteriorly and rotate externally relative to the femoral epiphysis, which remains fixed in the acetabulum. Stabilization of the physis is the goal of acute management. Despite such efforts, accelerated joint degeneration may occur over time. This progression is due to avascular necrosis, chondrolysis, or following years of femoroacetabular impingement. Total hip arthroplasty (THA) and total hip resurfacing (THR) are options for end-stage hip arthritis due to SCFE. THR is technically more challenging, with very limited ability to address deformity-related issues of impingement, decreased hip offset, and trochanteric malposition. THR, as in any metal on metal arthroplasty, may be associated with local metal sensitivity or systemic metal toxicity. Given the limited utility and potential risks, THR is currently not recommended in the majority of cases. THA, although historically demonstrating poor long-term implant performance in the young patient, has become a more reliable option recently. The potential benefits of THA are considerable, even for the young patient with end-stage hip degeneration. Certain cemented and many cementless stem designs show good long-term survival, as do current cementless cups. Advances in bearing surfaces promise to minimize wear and extend implant longevity. Ceramic on ceramic, metal on highly cross-linked polyethylene, and ceramic on highly cross-linked polyethylene bearing couples offer promise.

Smaller epiphyseal tubercle in hips with slipped capital femoral epiphysis compared to the uninvolved contralateral hip.

Recent investigations suggest that physeal morphologic features have a major role in the capital femoral epiphysis stability and slipped capital femoral epiphysis (SCFE) pathology, with a smaller epiphyseal tubercle and larger peripheral cupping of the femoral epiphysis being present in hips with progressive SCFE compared to healthy controls. Yet, little is known on the causal versus remodeling nature of these associations. This study aimed to use preoperative magnetic resonance imaging (MRI) of patients with unilateral SCFE to perform a comparison of the morphology of the epiphyseal tubercle, metaphyseal fossa, and peripheral cupping in hips with SCFE versus the contralateral uninvolved hips. Preoperative MRIs from 22 unilateral SCFE patients were used to quantify the morphological features of the epiphyseal tubercle (height, width, and length), metaphyseal fossa (depth, width, and length), and peripheral cupping height in three dimension. The quantified anatomical features were compared between hips with SCFE and the contralateral uninvolved side across the whole cohort and within SCFE severity subgroups using paired t-test. We found significantly smaller epiphyseal tubercle heights (p < 0.001) across all severities of SCFE when compared to their uninvolved contralateral side. There was a marginally smaller metaphyseal fossa length (p = 0.05) in SCFE hips compared to their contralateral uninvolved hips, with mild SCFE hips specifically having smaller fossa and epiphyseal lengths (p < 0.05) than their contralateral uninvolved side. There were no side-to-side differences in any other features of the epiphyseal tubercle, metaphyseal fossa and peripheral cupping across all severities (p > 0.05). These findings suggest a potential causal role of epiphyseal tubercle in SCFE pathogenesis.

Clinical stability of slipped capital femoral epiphysis does not correlate with intraoperative stability.

BACKGROUND: The most important objective of clinical classifications of slipped capital femoral epiphysis (SCFE) is to identify hips associated with a high risk of avascular necrosis (AVN)--so-called unstable or acute slips; however, closed surgery makes confirmation of physeal stability difficult. Performing the capital realignment procedure in SCFE treatment we observed that clinical estimation of physeal stability did not always correlate with intraoperative findings at open surgery. This motivated us to perform a systematic comparison of the clinical classification systems with the intraoperative observations. QUESTIONS/PURPOSES: We asked: (1) Is the classification of an acute versus chronic slip based on the duration of symptoms sensitive and specific in detecting intraoperative disrupted physes in patients with SCFE? (2) Is the stable/unstable classification system based on clinical symptoms sensitive and specific in detecting intraoperative disrupted physes in patients with SCFE? METHODS: We retrospectively reviewed 82 patients with SCFE treated by open surgery between 1996 and 2009. We classified the clinical stability of all hips using the classifications based on onset of symptoms and on function. We classified intraoperative stability as intact or disrupted. We determined the sensitivity and specificity of two classification systems to determine intraoperative stability. RESULTS: Complete physeal disruption at open surgery was seen in 28 of the 82 hips (34%). With classification as acute, acute-on-chronic, and chronic, the sensitivity for disrupted physes was 82% and the specificity was 44%. With the classification of Loder et al., the values were 39% and 76%, respectively. CONCLUSION: Current clinical classification systems are limited in accurately diagnosing the physeal stability in SCFE. LEVEL OF EVIDENCE: Level III, retrospective diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.