Bilateral Slipped Capital Femoral Epiphysis in a Young Girl Treated With Chemotherapy: A Case Report.

CASE: A 1-year-old girl was treated with chemotherapy and hematopoietic stem cell transplantation because of CD40 ligand deficiency. Four years later, she presented with pain in her right leg, diagnosed as atypical acute slipped capital femoral epiphysis, without a clear cause, besides chemotherapy possibly. She was treated with fixation of the epiphysis with a cannulated screw. Two years later, the same diagnosis was made for the left hip and the same surgery was applied. After the 2-year follow-up, clinical outcomes were good. CONCLUSION: Chemotherapy may be a risk factor for atypical slipped capital femoral epiphysis, even without the combination with radiotherapy.

Intraoperative Epiphyseal Perfusion Monitoring Does Not Reliably Predict Osteonecrosis Following Treatment of Unstable SCFE.

BACKGROUND: Avascular necrosis (AVN) remains the most dreaded complication of unstable slipped capital femoral epiphysis (SCFE) treatment. Newer closed reduction techniques (with perfusion monitoring) have emerged as a technically straightforward means to address residual SCFE deformity while still minimizing the risk of osteonecrosis. However, limited data exists regarding the reliability of intraoperative epiphyseal perfusion monitoring to predict the development of AVN. The purpose of this study was to evaluate its reliability. METHODS: We retrospectively reviewed all patients with unstable SCFE who underwent closed or open reduction with epiphyseal perfusion monitoring using an intracranial pressure (ICP) probe from 2015 to 2023 at a single institution with a minimum 6-month radiographic follow-up. Demographic, clinical, and radiographic data were recorded, including duration of symptoms, type of reduction, capsulotomy performed, presence of a waveform on ICP monitoring after epiphyseal fixation, and development of AVN on follow-up radiographs. RESULTS: Our cohort included 33 hips (32 patients), of which 60.6% (n=20) were male. The average age was 12.5±1.8 years, with a median follow-up of 15.8 months. Eleven hips were treated with open reduction using the modified Dunn technique (10 hips) or anterior approach (1 hip), and 22 hips were treated with inadvertent (5 hips) or purposeful closed reduction using the Leadbetter technique (17 hips). Overall, 8 of the 33 hips in our series (24.2%) developed AVN, 6 of which (20%) had a pulsatile waveform on intraoperative epiphyseal perfusion monitoring. The overall rate of AVN after closed reductions was 31.8% (7 of 22 hips); the incidence of AVN after closed reduction with a detectable waveform was 30% (6 of 20 hips). There was no significant association between time to surgery ( P =0.416) or type of reduction ( P =0.218) and the incidence of AVN. CONCLUSIONS: In this series, intraoperative epiphyseal perfusion monitoring did not reliably predict the development of osteonecrosis. To our knowledge, this is the first study to report AVN after demonstrable intraoperative epiphyseal perfusion following closed reduction of unstable slips. LEVEL OF EVIDENCE: Level IV: case series-therapeutic study.

Rate and Risk Factors for Contralateral Slippage in Adolescents Treated for Slipped Capital Femoral Epiphysis: A Comprehensive Analysis of 3,528 Cases.

BACKGROUND: After a unilateral slipped capital femoral epiphysis (SCFE), the contralateral hip is at risk for a subsequent SCFE. However, further information with regard to risk factors involved in the development of contralateral SCFE must be investigated. The purpose of this study was to report the rate and risk factors for subsequent contralateral SCFE in adolescents treated for unilateral SCFE by exploring a mix of known and potential risk factors. METHODS: A case-control study utilizing aggregated multi-institutional electronic medical record data between January 2003 and March 2023 was conducted. Patients <18 years of age diagnosed with SCFE who underwent surgical management were included. Variables associated with contralateral SCFE were identified using multivariable logistic regression models that adjusted for patient characteristics and time of the surgical procedure, providing adjusted odds ratios (ORs). The false discovery rate was accounted for via the Benjamini-Hochberg method. RESULTS: In this study, 15.3% of patients developed contralateral SCFE at a mean (and standard error) of 296.53 ± 17.23 days and a median of 190 days following the initial SCFE. Increased thyrotropin (OR, 1.43 [95% confidence interval (CI), 1.04 to 1.97]; p = 0.022), diabetes mellitus (OR, 1.67 [95% CI, 1.22 to 2.49]; p = 0.005), severe obesity (OR, 1.81 [95% CI, 1.56 to 2.57]; p < 0.001), history of human growth hormone use (OR, 1.85 [95% CI, 1.10 to 3.38]; p = 0.032), low vitamin D (OR, 5.75 [95% CI, 2.23 to 13.83]; p < 0.001), younger age in boys (under 12 years of age: OR, 1.85 [95% CI, 1.37 to 2.43]; p < 0.001) and in girls (under 11 years of age: OR, 1.47 [95% CI, 1.05 to 2.02]; p = 0.026), and tobacco exposure (OR, 2.43 [95% CI, 1.49 to 3.87]; p < 0.001) were significantly associated with increased odds of developing contralateral SCFE. CONCLUSIONS: In the largest study on this topic, we identified the rate, odds, and risk factors associated with development of contralateral SCFE. We found younger age, hypothyroidism, severe obesity, low vitamin D, diabetes mellitus, and a history of human growth hormone use to be independent risk factors. Our findings can aid clinical decision-making in at-risk patients. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Association of Relative Skeletal Immaturity of the Triradiate Cartilage with Increased Proximal Femoral Deformity in Prophylactic Fixation for Slipped Capital Femoral Epiphysis: A Radiographic Study.

INTRODUCTION: The purpose of this study was to describe proximal femoral deformity after contralateral hip prophylactic fixation of slipped capital femoral epiphysis (SCFE) in patients and the association of relative skeletal immaturity with this deformity. METHODS: A retrospective review of patients presenting with a SCFE was conducted from 2009 to 2015. Inclusion criteria were (1) radiographic evidence of a unilateral SCFE treated with in situ fixation, (2) contralateral prophylactic fixation of an unslipped hip, and (3) at least 3 years of follow-up. Measurements were made on radiographs and included greater trochanter height relative to the center of the femoral head, femoral head-neck offset, and femoral neck length. Skeletal maturity was evaluated by assessing the status of the proximal femoral physis and triradiate cartilage (TRC) of the hip, in addition to the length of time to closure of these physes. Values were compared from initial presentation to final follow-up. Statistical analysis included descriptive statistics and linear regression. RESULTS: Twenty-seven patients were included. Bivariable linear regression demonstrated that an increased relative trochanteric overgrowth was associated with TRC width (ß = 3.048, R = 0.585, P = 0.001) and an open TRC (ß = -11.400, R = 0.227, P = 0.012). Time to proximal femoral physis closure (ß = 1.963, R = 0.444, P = 0.020) and TRC closure (ß = 1.983, R = 0.486, P = 0.010) were predictive of increased deformity. In addition, multivariable elimination linear regression demonstrated that TRC width (ß = 3.048, R = 0.585, P = 0.001) was predictive of an increased relative trochanteric overgrowth. DISCUSSION: Patients with an open TRC and increased TRC width are associated with increased relative trochanteric overgrowth when undergoing prophylactic fixation for a unilateral SCFE. Increased caution should be exercised when considering contralateral hip prophylactic fixation in skeletally immature patients presenting with a unilateral SCFE. LEVEL OF EVIDENCE: Level IV, case series.

Limited angular remodelling after in-situ fixation for slipped capital femoral epiphysis : A study on radiographs from the Swedish pediatric orthopaedic quality registry for SCFE.

BACKGROUND: In Sweden, most children with slipped capital femoral epiphysis (SCFE) are operated on with a single smooth pin or a short-threaded screw, allowing further growth of the femoral neck. Using the Swedish Pediatric Orthopaedic Quality registry, SPOQ, we investigated whether angular remodelling occurs adjacent to the proximal femoral epiphysis after fixation of SCFE using implants, allowing continued growth of the femoral neck. METHODS: During 2008-2010 a total national population of 155 children were reported to the SPOQ registry. Following our strict inclusion criteria, radiographs of 51 hips were further assessed. The lateral Head Shaft Angle (HSA), the Nötzli 3-point α-angle, the anatomic α-angle, and the Anterior Offset Ratio (AOR) on the first postoperative radiographs and at follow-up were measured to describe the occurrence of remodelling. Slip severity was categorised as mild, moderate or severe according to postoperative HSA. RESULTS: Mean and SD values for the change in HSA were 3,7° (5,0°), for 3-point α-angle 6,8° (8,9°), and anatomic α-angle 13,0° (16,3°). The overall increase in AOR was 0,038 (0.069). There were no significant differences between the slip severity groups. CONCLUSIONS: We found limited angular remodelling after in situ fixation with smooth pins or short threaded screws for SCFE. The angular remodelling and the reduction of the CAM deformity was less than previously described after fixation of SCFE with similar implants. Results about the same magnitude with non-growth sparing techniques suggest that factors other than longitudinal growth of the femoral neck are important for angular remodelling.

The Effects of Residual Femoral Deformity on Computed Contact Mechanics in Patients Treated With In Situ Fixation for Slipped Capital Femoral Epiphysis.

OBJECTIVE: In situ fixation for treatment of slipped capital femoral epiphysis (SCFE) can stabilize the epiphysis and prevent further joint deformation but often leaves residual deformity that may adversely affect intra-articular contact mechanics. The purpose of this study was to investigate the relationship between residual deformity and contact mechanics in the post-SCFE hip. METHODS: Patient-specific hip models were created for 19 patients with SCFE treated with in situ fixation. For each model, discrete element analysis was used to compute cumulative acetabular and femoral contact stress exposure during a walking gait cycle. Slip severity was evaluated for each patient using the two-dimensional Southwick angle and a novel three-dimensional (3D) assessment of multiplanar femoral deformity (3D slip angle). RESULTS: Of the SCFE cases, 2/7 mild (Southwick angle ≤30 degrees) had peak cumulative femoral exposures equivalent to that of severe (Southwick angle ≥60 degrees) cases. Severe SCFE cases had higher peak ( P = 0.015) and mean ( P = 0.028) femoral contact stress exposure and lower cumulative femoral contact area ( P = 0.003) than mild (Southwick angle ≤30 degrees) SCFE cases. Mean femoral contact stress exposure was also higher in severe SCFE cases than in moderate SCFE cases ( P = 0.027). Acetabular and femoral contact mechanics metrics typically demonstrated stronger correlations with 3D slip angle than two-dimensional Southwick angle. CONCLUSIONS: Increased slip severity adversely impacts intra-articular femoral contact mechanics. Contact mechanics metrics demonstrate higher correlations with 3D slip angle, indicating that this novel measurement may better describe global deformity and its relationship to intra-articular mechanics; however, the modest strength of these correlations may also imply that global impingement-generating deformity is not the primary factor driving contact mechanics in the post-SCFE hip. CLINICAL RELEVANCE: Greater slip severity adversely impacts contact mechanics in the post-SCFE hip. However, focal regions of high contact stress were seen even in mild SCFE deformities, suggesting some type of deformity correction should be considered even for mild slips to alleviate secondary impingement, address focal incongruities, and reduce osteoarthritis development/progression.

In situ fixation of slipped capital femoral epiphysis carries a greater than 40% risk of later total hip arthroplasty during a long-term follow-up.

Aims: We aimed to assess the cumulative risk of total hip arthroplasty (THA) from in situ fixation for slipped capital femoral epiphysis (SCFE) after a follow-up of almost 50 years. Methods: In this study, 138 patients with 172 affected hips treated with in situ fixation were evaluated retrospectively. A total of 97 patients (70%) were male and the mean age was 13.6 years (SD 2.1); 35 patients (25%) had a bilateral disease. The median follow-up time was 49 years (interquartile range 43 to 55). Basic demographic, stability, and surgical details were obtained from patient records. Preoperative radiographs (slip angle; SA) were measured, and data on THA was gathered from the Finnish National Arthroplasty Register. Results: The preoperative SA was a mean of 39° (SD 19°). At follow-up, 56 of the patients had undergone THA for a hip previously fixed in situ for SCFE (41%) and 64 of all affected hips had been replaced (37%). Kaplan-Meier analysis gave a median prosthesis-free postoperative survival of 55 years (95% confidence interval (CI) 45 to 64) for the affected hips. In a multivariate analysis, female patients had a two-fold risk for THA (hazard ratio (HR) 2.42 (95% CI 1.16 to 5.07)) and a greater preoperative SA increased the risk of THA (HR 1.03 for every increment of 1° (95% CI 1.01 to 1.05)), while patient age at surgery, slip laterality, stability of slip, or diagnostic delay did not have a statistically significant effect on the risk of THA. Conclusion: SCFE treated primarily with in situ fixation may lead to THA in more than 40% of affected hips at a near 50-year follow-up. This risk is approximately 15-times the reported lifetime risk in the Finnish general population. Female sex and increasing preoperative SA significantly predicted higher risk of THA.

3D printed patient-specific fixation plates for the treatment of slipped capital femoral epiphysis: Topology optimization vs. conventional design.

Orthopedic plates are commonly used after osteotomies for temporary fixation of bones. Patient-specific plates have recently emerged as a promising fixation device. However, it is unclear how various strategies used for the design of such plates perform in comparison with each other. Here, we compare the biomechanical performance of 3D printed patient-specific bone plates designed using conventional computer-aided design (CAD) techniques with those designed with the help of topology optimization (TO) algorithms, focusing on cases involving slipped capital femoral epiphysis (SCFE). We established a biomechanical testing protocol to experimentally assess the performance of the designed plates while measuring the full-field strain using digital image correlation. We also created an experimentally validated finite element model to analyze the performance of the plates under physiologically relevant loading conditions. The results indicated that the TO construct exhibited higher ultimate load and biomechanical performance as compared to the CAD construct, suggesting that TO is a viable approach for the design of such patient-specific bone plates. The TO plate also distributed stress more evenly over the screws, likely resulting in more durable constructs and improved anatomical conformity while reducing the risk of screw and plate failure during cyclic loading. Although differences existed between finite element analysis and experimental testing, this study demonstrated that finite element modelling can be used as a reliable method for evaluating and optimizing plates for SCFE patients. In addition to enhancing the mechanical performance of patient-specific fixation plates, the utilization of TO in plate design may also improve the surgical outcome and decrease the recovery time by reducing the plate and incision sizes.

Public Insurance and Single-Guardian Households Are Associated with Diagnostic Delay in Slipped Capital Femoral Epiphysis.

BACKGROUND: Extensive literature documents the adverse sequelae of delayed diagnosis of slipped capital femoral epiphysis (SCFE), including worsening deformity and surgical complications. Less is known about predictors of delayed diagnosis of SCFE, particularly the effects of social determinants of health. The purpose of this study was to evaluate the impact of insurance type, family structure, and neighborhood-level socioeconomic vulnerability on the delay of SCFE diagnosis. METHODS: We reviewed medical records of patients who underwent surgical fixation for stable SCFE at a tertiary pediatric hospital from 2002 to 2021. We abstracted data on demographic characteristics, insurance status, family structure, home address, and symptom duration. We measured diagnostic delay in weeks from the date of symptom onset to diagnosis. We then geocoded patient addresses to determine their Census tract-level U.S. Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry (ATSDR) Social Vulnerability Index (SVI), using U.S. Census and American Community Survey data. We performed 3 separate logistic regression models to examine the effects of (1) insurance status, (2) family structure, and (3) SVI on a delay of ≥12 weeks (reference, <12 weeks). We adjusted for age, sex, weight status, number of siblings, and calendar year. RESULTS: We identified 351 patients with SCFE; 37% (129) had a diagnostic delay of ≥12 weeks. In multivariable logistic regression models, patients with public insurance were more likely to have a delay of ≥12 weeks than patients with private insurance (adjusted odds ratio [OR], 1.83 [95% confidence interval (CI), 1.12 to 2.97]; p = 0.015) and patients from single-guardian households were more likely to have a delay of ≥12 weeks than patients from multiguardian households (adjusted OR, 1.95 [95% CI, 1.11 to 3.45]; p = 0.021). We did not observe a significant increase in the odds of delay among patients in the highest quartile of overall SVI compared with patients from the lower 3 quartiles, in both the U.S. comparison (adjusted OR, 1.43 [95% CI, 0.79 to 2.58]; p = 0.24) and the Massachusetts comparison (adjusted OR, 1.45 [95% CI, 0.79 to 2.66]; p = 0.23). CONCLUSIONS: The delay in diagnosis of SCFE remains a concern, with 37% of patients with SCFE presenting with delay of ≥12 weeks. Public insurance and single-guardian households emerged as independent risk factors for diagnostic delay. Interventions to reduce delay may consider focusing on publicly insured patients and those from single-guardian households. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Surgeon Preference for Prophylactic Contralateral Fixation in Slipped Capital Femoral Epiphysis (SCFE) Patients: A Nationwide POSNA Survey Study.

BACKGROUND: It is estimated that 11% to 60% of unilateral slipped capital femoral epiphysis (SCFE) patients will develop contralateral pathology, usually within 18 months after the first event. Despite this, prophylactic fixation remains controversial, and there is significant variability in surgeon preferences. Thus, this study aimed to determine which factors predict surgeon preferences for prophylactic contralateral pinning in SCFE patients. METHODS: We designed a survey for pediatric orthopedic surgeons to collect data on (1) surgeon and hospital characteristics, (2) individual preference for contralateral SCFE pinning in three disparate hypothetical scenarios, and (3) personal risk-aversion traits. The questionnaire was distributed across the United States by the POSNA Evidence-Based Orthopaedics Committee. All POSNA members were eligible to respond. We performed analyses to evaluate the role of patient risk factors in hypothetical surgical decision-making and to determine if surgical training, hospital characteristics, and geographic region influenced prophylactic pinning in a surgeon's real-life practice. RESULTS: A total of 126 POSNA members responded to the survey. In the last year, a median of 6.5 SCFE patients was seen per surgeon (1243 patients total). A median of 10% of those patients underwent prophylactic contralateral fixation. In multiple analyses, surgeons were influenced by body mass index, open triradiate cartilage, patient race, various endocrine abnormalities, and specific radiographic measurements when deciding to fix the contralateral side prophylactically. Moreover, in multivariate regression, more years in practice and a hospital size of 500+ beds predicted fewer prophylactic fixation procedures (all P <0.05). Surgeons practicing in the South Atlantic, New England, and Mountain regions of the United States estimated the highest rate of contralateral pinning. CONCLUSIONS: This study's findings suggest that multiple factors influence surgeons' decisions to prophylactically fix the contralateral side in SCFE patients. Surgical training, hospital characteristics, and geographical regions played a role in decision-making. LEVEL OF EVIDENCE: N/A.

Which factor is more reliable considering prophylactic pinning of contralateral hip of unilateral SCFE patients?

BACKGROUND: This study evaluates the radiological parameters of developing subsequent contralateral slips in unilateral slipped capital femoral epiphysis (SCFE) patients at the time of initial presentation. METHODS: The study group included the review of unilateral SCFE patients treated between June 2007 and August 2018. Age, gen-der, side, stability, posterior slope angle, grade of slip, modified Oxford bone age score (mOBAS), the Risser classification, and the ap-pearance of the triradiate cartilage were evaluated retrospectively. Data were analyzed between two groups: subsequent contralateral SCFE (SCFESC) patients that developed contralateral slip during follow-up and unilateral SCFE (SCFEU) patients that did not develop contralateral slip up to skeletal maturity. Descriptive statistics were used to compare risk factors between groups. RESULTS: This study included 48 patients and 6 patients (12.5%) developed a SCFESC. Only mOBAS was significantly different be-tween groups. The mOBAS scores in SCFESC were 18 in 2 patients (33.3%), 19 in 4 patients (66.7%). The mOBAS scores in SCFEU were 18 in 1 patient (2.4%), 19 in 24 patients (57.1%), and >20 in 17 patients (40.5%). In the SCFESC group, all patients had a Risser score of 0 and all had open triradiate cartilage. CONCLUSION: Patients with unilateral SCFE are at risk for SCFESC, and the mOBAS is the best predictor of risk assessment. We agree that mOBAS score of 16,17 or 18 patients' contralateral hips can be prophylactically pinned. We also suggest pinning or close screening of mOBAS 19 patients that some carry relatively high risk of subsequent contralateral slip.

[Slipped capital femoral epiphysis]. / Epiphyseolysis capitis femoris.

BACKGROUND: In slipped capital femoral epiphysis (SCFE), the femoral head slides in an anterosuperior direction along the growth plate. The femoral head remains in the acetabulum. The pathogenesis of SCFE is multifactorial. An important predisposing factor is obesity. PROBLEM: Epiphysiolysis can compromise the blood supply to the epiphysis and osteonecrosis of the femoral head may result. DIAGNOSTICS AND PROGNOSIS: Conventional radiography represents the first diagnostic step. The long-term prognosis of the disease depends on the residual deformity of the femoral head and in the worst case may result in early osteoarthritis of the hip joint.

Prolonged Length of Stay and Readmissions Following In Situ Pinning of Slipped Capital Femoral Epiphysis An Analysis of Incidence and Predictive Factors.

BACKGROUND: In situ pinning is one of the primary treat-ments for slipped capital femoral epiphysis (SCFE) in pedi-atric patients, many of whom have multiple comorbidities. Despite the fact that SCFE pinning is a frequently performed procedure in the United States, little is known regarding sub-optimal postoperative outcomes in this patient population. The purpose of this study was thus to identify the incidence, perioperative predictors, and specific causes of prolonged hospital length of stay (LOS) and readmissions following fixation. METHODS: The 2016-2017 National Surgical Quality Im-provement Program database was employed to identify all patients undergoing in situ pinning of a SCFE. Significant variables, such as demographics, preoperative comor-bidities, birth history, operative characteristics (length of surgery and inpatient and outpatient procedure), and postop-erative complications were collected. The primary outcomes of interest were prolonged LOS (defined as exceeding the 90th percentile, or 2 days) and readmission within 30 days following the procedure. The specific reason for readmission was recorded for each patient. Bivariate statistics followed by binary logistic regression modeling were employed to explore the relationship between perioperative variables and prolonged LOS and readmissions. RESULTS: A total of 1,697 patients underwent pinning, with a mean age of 12.4 years. Of these, 110 (6.5%) experienced a prolonged LOS and 16 (0.9%) were readmitted within 30 days. The most common causes of readmission related to the initial treatment were hip pain (n = 3) followed by postop-erative fracture (n = 2). Surgery on an inpatient basis (OR = 3.64; 95% CI: 1.99-6.67; p < 0.001), history of seizure disorder (OR = 6.79; 95% CI: 1.55-29.7; p = 0.01), and longer operative time (OR = 1.03; 95% CI: 1.02-1.03; p < 0.001) were significantly associated with prolonged LOS. CONCLUSIONS: The majority of readmissions following SCFE pinning were due to postoperative pain or fracture. Patients presenting with medical comorbidities and un-dergoing pinning as an inpatient were at increased risk of experiencing a prolonged LOS.

Socioeconomic Deprivation and its Associations With Follow-up Compliance After In Situ Pinning of Slipped Capital Femoral Epiphysis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a common cause of hip pain in adolescents and is most often treated by in situ screw fixation. Orthopaedic follow-up is critical after treatment for SCFE due to risks of complications and subsequent contralateral slip. Recent studies have shown that socioeconomic deprivation is associated with decreased fracture care compliance, but no studies have explored this relationship with SCFEs. The study aims to determine the relationship between socioeconomic deprivation and SCFE follow-up care compliance. METHODS: This study included pediatric patients treated with in situ pinning of SCFE between 2011 and 2019 at a single tertiary-care urban children's hospital. Demographic and clinical information were obtained from electronic medical records. The Area Deprivation Index (ADI) was used to quantify the socioeconomic deprivation of each. Outcome variables included patient age and status of physeal closure at the most recent appointment, in addition to the length of follow-up (mo). Statistical relationships were evaluated using nonparametric bivariate analysis and correlation. RESULTS: We identified 247 evaluable patients; 57.1% were male, and the median age was 12.4 years. Most slips were stable (95.1%) and treated with isolated unilateral pinning (55.9%). Median length of follow-up was 11.9 months (interquartile range, 4.95 to 23.1) with median patient age at final visit of 13.6 years (interquartile range, 12.4 to 15.1). Only 37.2% of patients were followed until physeal closure. The mean ADI spread in this sample was similar to the national distribution. However, patients in the most deprived quartile were lost to follow-up significantly earlier (median, 6.5 mo) than those in the least deprived quartile (median, 12.5 mo; P <0.001). Throughout the entire cohort, there was a significant, inverse relationship between deprivation and follow-up length ( rs (238) = -0.3; P <0.001), with this relationship most pronounced in the most deprived quartile. CONCLUSIONS: In this sample, ADI spread was representative of national trends, and the incidence of SCFE was distributed evenly across deprivation quartiles. However, follow-up length does not mirror this relationship; increased socioeconomic deprivation is associated with an earlier loss to follow-up (often well before physeal closure). LEVEL OF EVIDENCE: Level II-retrospective prognostic study.

Epidemiology and demographics of slipped capital femoral epiphysis in South Korea: A nationwide cohort study.

BACKGROUND: This study investigated the epidemiology and demographics of slipped capital femoral epiphysis (SCFE) in South Korea using a nationwide population-based database. METHODS: Information on sex, age at onset, endocrine comorbidities, history of growth hormone therapy, history of radiation therapy, surgical methods, and complications in patients with SCFE aged younger than 18 years between 2007 and 2019 was retrieved from the Korean Health Insurance Review and Assessment Service database. RESULTS: Data were available for 586 children (429 boys, 157 girls). The average age at onset was 11.1 ± 1.8 years (boys, 11.3 ± 1.9; girls, 10.6 ± 1.5). Five hundred and twenty-nine (90.3%) patients were aged 9-14 years; the incidence rate in this age group was 6.0/100,000 (95% confidence interval, 5.5-6.6) and significantly higher in boys (8.4 vs 3.5, p<0.001). There was a significant increase in the annual incidence rate from 0.96/100,000 in 2009 to 2.05/100,000 in 2019 (p = 0.006). Ninety-five patients (16.2%) had endocrine comorbidities or a history of hormone/radiation therapy. Osteotomy and internal fixation were performed in 59 patients and in situ pinning in 527. Seventy-six patients developed postoperative complications. CONCLUSION: The annual incidence rate of SCFE in South Korea has increased since 2009.

Free-gliding screw fixation in slipped capital femoral epiphysis: potentially growing im-plants for symptomatic and prophylactic pinning.

INTRODUCTION: In situ fixation is the gold standard for mild and moderate slipped capital femoral epiphysis (SCFE) cases. The condition is associated with a low percentage of avascular necrosis and chondrolysis.[1] The present study examines the postoperative femoral neck remodelling and implant elongation in cases of therapeutic and prophylactic in situ fixation using the free-gliding screw system. AIM: The aim of our study was to assess the postoperative femoral neck growth and evaluate the biomechanical evolution and complication's rate for 19 therapeutic and 11 prophylactic in situ fixations with a free-gliding screw. MATERIALS AND METHODS: We measured the preoperative and postoperative articulo-trochanteric distance (ATD), alpha angle (α angle) and screw elongation in symptomatic hips and in contralateral hips with prophylactic fixation. We compared the radiographic param-eters of 30 hips. RESULTS: ATD remains approximately the same for symptomatic cases, whereas it increases for prophylactic fixated hip. Screw elongates in both group with statistically higher value for the prophylactic group. The alpha angle remains pathological in these cases with a mean value of 67.12±4.62°, but decreases for group II. Screw elongates by a mean value of 3.14±2.74 mm for group I and 6.78±8.81 mm for group II. CONCLUSIONS: Prophylactic in situ fixation with free-gliding screws does not affect the proximal femoral growth (ATD), and does not decrease the alpha angle significantly. Screw elongates statistically in both groups, but more significantly for group II. For symptomatic hips, the in situ fixation allows the femoral neck to grow with ATD preserved, but significantly less than in group II. The alpha angle decreases but remains pathological.

Who Benefits From Allowing the Physis to Grow in Slipped Capital Femoral Epiphysis?

BACKGROUND: The globally acknowledged treatment for mild to moderate slipped capital femoral epiphysis (SCFE) is single screw in situ fixation, also used for prophylactic contralateral fixation. The Free-Gliding Screw (FG; Pega Medical) is a 2-part free-extending screw system designed to allow the growth of the proximal femur. We aimed to analyze the relationship between skeletal maturity and potential growth of the proximal physis and remodeling of the femoral neck using this implant. MATERIALS AND METHODS: Females below 12 years and males below 14 years undergoing in situ fixation for stable SCFE or prophylactic fixation were treated using the implant. Three elements of the modified Oxford Bone (mOB 3 ) score were used to measure maturity (triradiate cartilage, head of the femur, and greater trochanter). Radiographs were analyzed immediately postoperatively and at a minimum of 2 years for a change in screw length, posterior-sloping angle, articulotrochanteric distance, α angle, and head-neck offset. RESULTS: The study group comprised 30 (F:M=12:18) of 39 hips treated with SCFE and 22 (F:M=13:9) of 29 hips managed prophylactically using the free-Gliding screw. In the therapeutic group, chronologic age was a less valuable predictor of future screw lengthening than mOB 3 . An mOB 3 of ≤13 predicted future growth of >6 mm but did not reach statistical significance ( P =0.07). Patients with open triradiates showed a mean screw lengthening of 6.6 mm compared with those with closed triradiates (4.0 mm), but this did not reach significance ( P =0.12). In those with mOB 3 ≤13, the α angle reduced significantly ( P <0.01) and the head-neck offset increased significantly, suggesting remodeling. There was no change in these parameters when mOB 3 ≥14. In the prophylactic group, change in screw length was significant with mOB 3 of ≤13 (mean=8.0 mm, P <0.05), as was the presence of an open triradiate cartilage (mean=7.7 mm, P <0.05). In both cohorts, posterior-sloping angle and articulotrochanteric distance did not change, indicating no slip progression in either treatment or prophylactic groups and minimal effect on the proximal physeal growth relative to the greater trochanter. CONCLUSIONS: Growing screw constructs can halt slip progression while allowing proximal femoral growth in young patients with SCFE. Ongoing growth is better when the implant is used for prophylactic fixation. The results in treated SCFE need to be expanded to demonstrate a clinically meaningful cut-off for significant growth, but SCFE patients with an open triradiate remodel significantly more than those where it is closed. LEVEL OF EVIDENCE: Level III-retrospective comparative study.