Does unstable slipped capital femoral epiphysis require urgent stabilization?

Controversy exists regarding the role of early reduction and stabilization in the management of unstable slipped capital femoral epiphysis. It seems logical that early reduction and stabilization of an unstable slip might preserve the remaining blood supply to the epiphysis and reduce the incidence of avascular necrosis. Some studies have indeed shown lower rates of avascular necrosis following early reduction and stabilization, but others have shown the contrary. To try to resolve this disagreement, we conducted a retrospective review of slipped capital femoral epiphysis treated in Alder Hey Hospital over a 4-year period. We reviewed 117 consecutive slips in 82 children (43 boys and 39 girls, mean age 12 years), treated by internal fixation from 1998 to 2002. Mean follow-up was 18 months (range, 12-48 months). Sixteen cases (19%) were unstable at presentation. Avascular necrosis developed in eight of these, of which all but one were treated between 24 and 72 h after symptom onset. The eight unstable slips that did not develop avascular necrosis were treated either within 24 h (five children) or at 8 days (three children). Avascular necrosis did not develop in any of the stable slips. We recommend immediate stabilization of unstable slips presenting within 24 h. If this is not possible because of delayed presentation, we recommend deferring definitive management until at least a week has elapsed. This study supports the notion that there is a definite period of time during which medical intervention increases the risk of avascular necrosis and should be actively avoided. We term this period 'the unsafe window'.

Arthroscopic stabilization of the shoulder: a prospective randomized study of absorbable versus nonabsorbable suture anchors.

PURPOSE: The aim of this study was to evaluate, prospectively, outcomes following arthroscopic Bankart repair performed with 2 types of suture anchor--the G II (DePuy Mitek, Raynham, MA) nonabsorbable anchor and the Panalok (DePuy Mitek) absorbable anchor. METHODS: Patients with a diagnosis of recurrent traumatic anterior instability of the shoulder who were seen in a single unit between April of 2000 and June of 2003 were considered for inclusion in the study. Patients were assessed preoperatively and postoperatively by means of a subjective, patient-related outcome measurement tool (Oxford Instability Score), a visual analogue scale for pain and instability (VAS Pain and VAS Instability), and a quality-of-life questionnaire (Short Form-12 [SF-12]). Length of follow-up was 1.5 to 5 years (mean, 2.6 y). The incidence of recurrent instability and the level of sporting ability were recorded. Patients were randomized to undergo surgical repair with nonabsorbable or absorbable anchors. RESULTS: A total of 130 patients were included in this study, of whom 6 were lost to follow-up; therefore 124 patients (95%) completed the study. Both types of anchor were highly effective. No differences in rate of recurrence or in any of the scores were noted between the 2 groups. In all, 4 patients in the nonabsorbable group and 3 in the absorbable group experienced additional episodes of dislocation after a traumatic event. Rate of redislocation in the whole series was therefore 6%. In addition, 4 patients, all of them from the absorbable group (4%), described ongoing symptoms of instability but no true dislocations. In all, 85% of the patient group have returned to their previous level of sporting activity. CONCLUSIONS: No differences in outcomes of arthroscopic Bankart repair were seen whether absorbable or nonabsorbable anchors were used. Both are highly effective, with a redislocation rate of 6%. LEVEL OF EVIDENCE: Level I, therapeutic randomized controlled trial.