Valgus slipped capital femoral epiphysis: presentation, treatment, and clinical outcomes using patient-reported measurements.

Valgus slipped capital femoral epiphysis (SCFE), is rare. This study describes the diagnosis, treatment and outcome of valgus SCFE in Uruguay. The medical records and radiographs were reviewed in eight consecutive children [mean age 11.9 years (range 9-13; six female)] with valgus SCFE between 1997-2017. In 2018-2019, all patients were reexamined clinically, new radiographs obtained, and patient-reported outcomes completed using the international tool of hip results (iHOT-12). The prevalence of clinical femoroacetabular impingement (FAI), avascular necrosis, and surgical complications were also studied. There were 11 valgus SCFEs in eight patients; two had primary bilateral SCFEs, and one child later developed a valgus SCFE in the contralateral hip. Seven out of eight patients were overweight. All were stable idiopathic SCFEs. The mean femoral head shaft angle on the anteroposterior radiographs for the 11 SCFEs was 145° (range 140-168) and 141° (range 139-145) for the six healthy contralateral hips. Slip severity measured on the Lauenstein projection was mild (<30°) in eight hips and moderate (30°-60°) in three hips. At a mean follow-up of 87 months (range 24-252), there were no cases of avascular necrosis. The mean iHOT12 was 74 (range 13-97). Significant remodeling was detected in both head shaft angle (8°) and alpha angle (10°) in the affected hips. Nine hips (81%) demonstrated clinical signs of FAI. Our study is the first to describe long-term results using both clinical and patient outcome measures (iHOT-12). A majority of patients have residual symptoms, likely associated with FAI.

Patients' delay is the major cause for late diagnosis of slipped capital femoral epiphysis.

Early diagnosis of slipped capital femoral epiphysis (SCFE) is essential in order to reduce slip severity and subsequent risk of sequelae. The aims of this study were to evaluate patients' and doctors' delay in SCFE diagnosis and to identify possible factors leading to delay. We performed a retrospective review of medical charts and a personal interview with 54 consecutive patients admitted with a diagnosis of stable SCFE at three hospitals in Sweden between 2001 and 2009. Data on symptom duration, symptomatology, medical visits and type of medical contacts were retrieved. Slip angle (Southwick head-shaft angle) was measured. Median total delay from onset of symptoms to surgery was 26 weeks (range 1-109). Patients' delay was significantly longer than doctors' delay: 10 weeks (range 1-57) vs. 4 weeks (range 0-57) (P=0.002). Boys had significantly longer patients' delay than girls (13 vs. 6 weeks, P=0.021) but not doctors' delay. Children with dominance of knee pain had significantly longer doctors' delay (14 vs. 4 weeks, P=0.002) but not patients' delay. As expected, the total delay duration correlated with slip severity (R=0.59, P<0.001). Results demonstrate considerable delay in diagnosis of SCFE in Sweden, although the major cause is patients' delay. Boys and children with dominance of knee pain are more likely to be diagnosed late. Efforts to increase the awareness of SCFE directed to both the general society and healthcare providers are necessary to improve future outcomes. Level III. Retrospective comparative study.

Improving musculoskeletal health for children and young people - A 'call to action'.

This chapter describes the musculoskeletal (MSK) context in children and young people as an important contributor to the global non-communicable disease burden. Through selected MSK conditions, we describe the impact on patients, families and communities and highlight the challenges that need to be addressed. We focus on opportunities for better working together and describe exemplar initiatives to raise awareness, workforce capacity building, models of care and research agendas to have a greater global context.

The paediatric global musculoskeletal task force - 'towards better MSK health for all'.

There is increasing concern about the emerging global non-communicable diseases (NCDs) burden. The focus has mainly been on NCDs in adults but it is important that MSK morbidity in both children and adults is included in strategic planning. There have been considerable advances in the understanding and treatment options for children and young people (CYP) and clinical outcomes are improving for those who can access such high quality care. However vast inequity exists and there are many CYP who live in areas of the world with high burden of health care challenges, compounded by paucity of specialist care and limited access to treatments. The Paediatric Global Musculoskeletal Task Force aims to raise awareness about unmet needs for CYP with MSK conditions, promotion of MSK health through lifestyle and the avoidance of injury. We aim to leverage change through 'working together better'.

Continued Growth of the Femoral Neck Leads to Improved Remodeling After In Situ Fixation of Slipped Capital Femoral Epiphysis.

BACKGROUND: Globally, the most common method for in situ fixation of slipped capital femoral epiphysis (SCFE) is a threaded screw, which causes physeal arrest. The standard treatment in Sweden is unthreaded fixation using the Hansson hook-pin, which leads to continued growth of the femoral neck. Our purpose was to study remodeling during the remaining growth after fixation with the Hansson hook-pin. METHODS: We performed a retrospective study of 54 patients with SCFE who were treated with the Hansson hook-pin between 2001 and 2009. The immediate postoperative radiograph and the radiograph taken after physeal closure (mean interval, 34 mo) were analyzed. Three radiographic assessments were used: the head-shaft angle (HSA), the alpha angle (Nötzli), and the displacement from Klein's line. RESULTS: Significant remodeling was detected in all measured parameters. The mean postoperative HSA decreased by 9.0 degrees (P<0.001). The alpha angle improved by a mean of 14.5 degrees (P<0.001). Significant correlations were found between the reduction of the alpha angle and age (P<0.001, R=0.48) and longitudinal growth of the femoral neck (P<0.001, R=0.67). Displacement from Klein's line increased by a mean of 1.6 mm (P=0.006). CONCLUSIONS: Unthreaded fixation of SCFE using the Hansson hook-pin leads to substantial remodeling of the femoral neck. The positive correlation observed between the improvement of the alpha angle and femoral neck growth supports the use of a method that allows continuous growth, to reduce the risk of femoroacetabular impingement. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Unthreaded Fixation of Slipped Capital Femoral Epiphysis Leads to Continued Growth of the Femoral Neck.

BACKGROUND: The optimal treatment for slipped capital femoral epiphysis (SCFE) remains controversial. In Sweden, the standard treatment is unthreaded fixation over the physis, with the purpose to permit continued growth of the femoral neck. The aim of the present study was to verify and quantify longitudinal growth of the femoral neck after in situ pinning with the Hansson hook-pin. METHODS: We performed a retrospective study of 54 patients treated with the Hansson hook-pin for SCFE between 2001 and 2009. The immediate postoperative radiograph and the radiograph after physeal closure (mean interval, 34 mo) were analyzed. Because the smooth Hansson hook-pin only has a grip fixation in the epiphysis, the femoral neck growth was determined as the difference in nail protrusion from the lateral cortex between the 2 radiographs. The femoral neck offset was also measured in all radiographs. RESULTS: Significant longitudinal growth occurred both in the slipped and the prophylactically treated contralateral hip by mean 7.1 mm (P<0.001) and 10.0 mm (P<0.001), respectively. There was no difference in growth between genders and no correlation between the amount of longitudinal growth and slip severity (range, 4.0 to 71,6 degrees; mean 27.3 degrees). Young patients (less than 11 y) grew more than older patients (more than 14 y), 12.1 vs. 4.2 mm, P=0.002. The femoral offset increased by mean 16% from mean 30.0 to 35.2 mm (P<0.001). The longitudinal growth of the femoral neck correlated with the increase in femoral offset (R=0.51, P<0.001). CONCLUSIONS: Unthreaded fixation of SCFE with the Hansson hook-pin allows continued growth of the femoral neck. The remaining growth enables the patient to achieve an almost anatomic offset of the hip. This is essential to optimize the abduction forces that stabilize the pelvis during gait. Future studies need to establish whether the longitudinal growth also results in improved remodelling of the proximal femur. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Vascular evaluation after cervical hip fractures in children: a case series of eight children examined by scintigraphy after surgery for cervical hip fracture and evaluated for development of secondary radiological changes.

Femoral neck fractures in children and young adults are rare, but have a high risk of avascular necrosis (AVN) and subsequent gradual collapse of the femoral head. In 2006, we initiated the use of scintigraphy for the diagnosis of vascular impairment after a cervical fracture in children. In the present retrospective case study, we evaluated the effect of the remaining postoperative circulation in the femoral head after fracture in terms of the development of AVN and secondary degenerative changes of the hip joint. Eight children, four girls and four boys [mean age 11.5 years (7-16)], had been operated for a cervical or a basocervical hip fracture between 2006 and 2012. The femoral head circulation was evaluated postoperatively with scintigraphy and all children had been followed radiographically for a minimum of 1 year. The Ficat classification was used to stage the AVN and the Stulberg classification was used to stage the sphericity of the femoral head at follow-up. In two patients, the femoral head had normal circulation postoperatively and they also had normal radiographs at follow-up. In two patients, the entire femoral head was avascular postoperatively and at follow-up, one patient had normal radiographs and one had both subchondral sclerosis and flattening. These two patients had been treated with bisphosphonates and prolonged non-weight-bearing. Four patients had postoperatively retained circulation in parts of the femoral head. Three of these four patients had normal radiographs at follow-up. Evaluation of the remaining circulation after surgery may help to predict the outcome and guide the postoperative regime in children with a femoral neck fracture.

In vivo transport of Gd-DTPA(2-) in human knee cartilage assessed by depth-wise dGEMRIC analysis.

PURPOSE: To investigate the transport of Gd-DTPA(2-) in different layers of femoral knee cartilage in vivo. MATERIALS AND METHODS: T(1) measurements (1.5 Tesla) were performed in femoral knee cartilage of 23 healthy volunteers. The weight-bearing central cartilage was analyzed before contrast and at eight time points after an intravenous injection of Gd-DTPA(2-) : 12-60 min (4 volunteers) and 1-4 h (19 volunteers). Three regions of interest were segmented manually: deep, middle, and superficial. RESULTS: Before contrast injection, a depth-wise variation of T(1) was observed with 50% higher values in the superficial region compared with the deep region. In the deep region, the uptake of Gd-DTPA(2-) was not detected until 36 min and the concentration increased until 240 min, whereas in the superficial region, the uptake was seen already at 12 min and the concentration decreased after 180 min (P < 0.01). There was a difference between medial and lateral compartment regarding bulk, but not superficial Gd-DTPA(2-) concentration. The bulk gadolinium concentration was negatively related to the cartilage thickness (r = -0.68; P < 0.01). CONCLUSION: The depth-wise and thickness dependent variations in Gd-DTPA(2) transport influence the interpretation of bulk dGEMRIC analysis in vivo. In thick cartilage, incomplete penetration of Gd-DTPA(2) will yield a falsely too long T(1) .

Hip dGEMRIC in asymptomatic volunteers and patients with early osteoarthritis: the influence of timing after contrast injection.

Eight asymptomatic volunteers and 10 patients with early hip osteoarthritis (OA) were investigated with hip delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) at 30, 65, 100, and 135 min after IV injection with Gd-DTPA(2-). In asymptomatic volunteers there was a decrease in the dGEMRIC index (T(1)(Gd)) between 30 and 100 min. In patients the wash-in of Gd-DTPA(2-) was faster, with a low T(1)(Gd) at 30 min that did not change significantly over time. Therefore, earlier time points showed a larger separation in T(1)(Gd) between asymptomatic and OA hips, with more convenient timing logistics. However, T(1)(Gd) at 30 min had a larger standard deviation (SD) in the OA group, possibly due to variability of the steep slope of wash-in. This sensitivity to the imaging window may be less desirable for longitudinal studies in which reproducibility is a concern. At all time points, T(1)(Gd) was 20-30% lower in patients than in asymptomatic volunteers (P < 0.003), which demonstrates the sensitivity of dGEMRIC to early hip OA.