Slipped capital femoral epiphysis: a review of management in the hip impingement era

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Abstract

Slipped capital femoral epiphysis (SCFE) remains the most common adolescent hip disorder. Most cases present with stable slips, and in situ fixation is the most commonly adopted treatment worldwide. The introduction of the concept of femoroacetabular impingement and subsequent studies have revealed SCFE-related hip impingement to be a significant pre-arthritic condition, and the previously suggested remodeling of the proximal femur after in situ fixation has been called into question. Complex proximal femoral osteotomies and more recently intra-articular procedures via surgical hip dislocation have been employed. The literature is still lacking a strong evidence to undertake such aggressive procedures. Moreover, the application of a particular procedure regarding the nature of the slip, being stable or unstable, the degree of the slip, and the condition of the physis has not been extensively described in the literature. The purpose of this article is to outline the SCFE-related hip impingement, to review the best evidence for the current treatment options for both stable and unstable slips, and to develop an algorithm for decision making.

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Femoroacetabular impingement: a cause for osteoarthritis of the hip.

Reinhold Ganz, Javad Parvizi, Martin Beck … (2003)

A multitude of factors including biochemical, genetic, and acquired abnormalities may contribute to osteoarthritis of the hip. Although the pathomechanism of degenerative process affecting the dysplastic hip is well understood, the exact pathogenesis for idiopathic osteoarthritis has not been established. Based on clinical experience, with more than 600 surgical dislocations of the hip, allowing in situ inspection of the damage pattern and the dynamic proof of its origin, we propose femoroacetabular impingement as a mechanism for the development of early osteoarthritis for most nondysplastic hips. The concept focuses more on motion than on axial loading of the hip. Distinct clinical, radiographic, and intraoperative parameters can be used to confirm the diagnosis of this entity with timely delivery of treatment. Surgical treatment of femoroacetabular impingement focuses on improving the clearance for hip motion and alleviation of femoral abutment against the acetabular rim. It is proposed that early surgical intervention for treatment of femoroacetabular impingement, besides providing relief of symptoms, may decelerate the progression of the degenerative process for this group of young patients.

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Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis.

R Ganz, T J Gill, E GAUTIER … (2001)

Surgical dislocation of the hip is rarely undertaken. The potential danger to the vascularity of the femoral head has been emphasised, but there is little information as to how this danger can be avoided. We describe a technique for operative dislocation of the hip, based on detailed anatomical studies of the blood supply. It combines aspects of approaches which have been reported previously and consists of an anterior dislocation through a posterior approach with a 'trochanteric flip' osteotomy. The external rotator muscles are not divided and the medial femoral circumflex artery is protected by the intact obturator externus. We report our experience using this approach in 213 hips over a period of seven years and include 19 patients who underwent simultaneous intertrochanteric osteotomy. The perfusion of the femoral head was verified intraoperatively and, to date, none has subsequently developed avascular necrosis. There is little morbidity associated with the technique and it allows the treatment of a variety of conditions, which may not respond well to other methods including arthroscopy. Surgical dislocation gives new insight into the pathogenesis of some hip disorders and the possibility of preserving the hip with techniques such as transplantation of cartilage.

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The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement

H P Nötzli, T. F. Wyss, C H Stoecklin … (2002)

Impingement by prominence at the femoral head-neck junction on the anterior acetabular rim may cause early osteoarthritis. Our aim was to develop a simple method to describe concavity at this junction, and then to test it by its ability to distinguish quantitatively a group of patients with clinical evidence of impingement from asymptomatic individuals who had normal hips on examination. MR scans of 39 patients with groin pain, decreased internal rotation and a positive impingement test were compared with those of 35 asymptomatic control subjects. The waist of the femoral head-neck junction was identified on tilted axial MR scans passing through the centre of the head. The anterior margin of the waist of the femoral neck was defined and measured by an angle (alpha). In addition, the width of the femoral head-neck junction was measured at two sites. Repeated measurements showed good reproducibility among four observers. The angle alpha averaged 74.0 degrees for the patients and 42.0 degrees for the control group (p < 0.001). Significant differences were also found between the patient and control groups for the scaled width of the femoral neck at both sites. Using standardised MRI, the symptomatic hips of patients who have impingement have significantly less concavity at the femoral head-neck junction than do normal hips. This test may be of value in patients with loss of internal rotation for which a cause is not found.

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Author and article information

Journal

Journal ID (nlm-ta): SICOT J

Journal ID (iso-abbrev): SICOT J

Journal ID (publisher-id): sicotj

Title: SICOT-J

Publisher: EDP Sciences

ISSN (Electronic): 2426-8887

Publication date (Electronic, collection): 2017

Publication date (Electronic, pub): 17 May 2017

Volume: 3

Issue: ( publisher-idID: sicotj/2017/01 )

Electronic Location Identifier: 35

Affiliations

[1 ] Division of Paediatric Orthopaedics and Limb Reconstruction Surgery, Department of Orthopaedic Surgery, Faculty of Medicine, Ain-Shams University 38 Abbasia Cairo 11566 Egypt

Author notes

[* ]Corresponding author: mmahran@ 123456med.asu.edu.eg

Article

Publisher ID: sicotj160058 Other ID: 10.1051/sicotj/2017018

DOI: 10.1051/sicotj/2017018

PMC ID: 5434664

PubMed ID: 28513428

SO-VID: 5c04615d-0b3e-4016-b745-02546c17d74d

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 24 June 2016

Date accepted : 07 December 2016

Page count

Figures: 1, Tables: 2, Equations: 0, References: 86, Pages: 11

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