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

      1 , * , 1 , 1
      EDP Sciences
      SCFE, Slipped capital femoral epiphysis, Femoroacetabular impingement, Capital realignment, Osteonecrosis

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          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.

          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.

            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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              Etiology of osteoarthritis of the hip.

              More than 90% of patients with so-called primary or idiopathic osteoarthritis of the hips in whom sufficient data were available to make an assessment of the normality of the hip joint at the cessation of growth clearly showed demonstrable abnormalities in the hip joint. The most common are mild acetabular dysplasia and/or pistol grip deformity. This latter deformity is associated with mild slipped capital femoral epiphysis (recognized or unrecognized at the time), Legg-Perthes' disease (recognized or unrecognized at the time), multiple epiphyseal dysplasia, spondyloepiphyseal dysplasia, and/or the presence of an intraacetabular labrum, as well as, in certain instances, acetabular dysplasia. When these abnormalities are taken in conjunction with the detection of other metabolic abnormalities that can lead to osteoarthritis of the hip and which may not be recognized readily, such as hemochromatosis, ochronosis, calcium pyrophosphate disease, and monarticular rheumatoid arthritis, it seems clear that either osteoarthritis of the hip does not exist at all as a primary disease entity or, if it does, is extraordinarily rare.

                Author and article information

                SICOT J
                SICOT J
                EDP Sciences
                17 May 2017
                : 3
                : ( publisher-idID: sicotj/2017/01 )
                : 35
                [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
                sicotj160058 10.1051/sicotj/2017018
                © The Authors, published by EDP Sciences, 2017

                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.

                : 24 June 2016
                : 07 December 2016
                Page count
                Figures: 1, Tables: 2, Equations: 0, References: 86, Pages: 11
                Review Article

                scfe,slipped capital femoral epiphysis,femoroacetabular impingement,capital realignment,osteonecrosis


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