Management of slipped capital femoral epiphysis: Results of a survey of the members of the European Paediatric Orthopaedic Society

Abstract

AimTo determine current practice recommendations for the treatment of slipped capital femoral epiphysis (SCFE) among members of the European Paediatric Orthopaedic Society (EPOS).Materials and methodsA questionnaire with 4 case vignettes of a 12-year-old boy presenting with a stable and unstable SCFE. Each, stable and unstable slips, was of mild (20° epiphyseal-shaft angle) and of severe (60° epiphyseal-shaft angle) degree was sent to all members of EPOS in 2009 in order to ascertain their views on the best management of SCFE. Specifically, respondents were asked about the role of reduction, methods of fixation, prophylactic fixation of the non-affected hip, postoperative management and their view on the anticipated need for secondary surgery.ResultsThe response rate was 25% (72/287). The participating surgeons’ average workload was 76% in paediatric orthopaedics, with mean 16 years of experience. Surgeons were most consistent in their advice for stable slips, where around 90% of the respondents did not recommend a reduction of the slip regardless of severity of slip. Seventy per cent of the respondents recommended the use of only one screw for fixation of a stable slip and for mild unstable slips. For severe unstable slips, 46% of surgeons recommended reduction only by positioning of the hip on the fracture table, 35% by manipulation and 11% advised open reduction. Responders were less consistent in their advice on the anticipated need for secondary osteotomies (in mild slips about 40% and about 60% in severe slips would advise an osteotomy) and on treatment of the contralateral hip (with 32% of surgeons recommending prophylactic fixation of the contralateral hip).ConclusionWithin members of EPOS, there is controversy on several aspects of the management of SCFE particularly on aspects of the treatment of unstable SCFE.SignificanceMembers of EPOS predominantly use traditional means of treatment for patients with SCFE. In contrast, the more modern treatment concepts, such as open reduction via surgical dislocation, are rarely used.

A consensus exercise identifying priorities for research into clinical effectiveness among children’s orthopaedic surgeons in the United Kingdom

“…[1][2][3][4][5] This is often due to differences in opinion, which surgeons frequently accept because much of the literature underpinning practice is contradictory. 6 Another determinant is the poor quality of the evidence, which until recently almost universally involved observational case series.…”

The treatment of an unstable slipped capital femoral epiphysis by either intracapsular cuneiform osteotomy or pinningin situ

“…Only 8% of members indicated that they would deliberately avoid epiphyseal reduction. 3 An equivalent survey was conducted in America in 2005, with similar findings, although 27% of respondents did not routinely use the stable/unstable concept. 4 There are several studies (Table I) 5,6 documenting variable rates of AVN for unstable SCFEs treated by pinning in situ.…”

“…Closed reduction and pinning in situ has been shown to be favoured in Europe as recently as 2011. 3 Our experience raises questions regarding this practice. We suggest that imaging of an unstable SCFE represents a snapshot of a dynamic process.…”

“…Pinning in situ remains the popular approach for unstable SCFE, presumably due to the perceived lower incidence of AVN and shorter operating time. 3,4 Both in theory and with some evidence from Biring et al, 24 intracapsular osteotomy offers the potential to restore the anatomical relationships of the proximal femur towards normality, which may theoretically reduce the incidence of FAI and subsequent degenerative change. There is little evidence concerning both methods of treatment; in particular, there is no comparative evidence to ascertain whether the perceived high risk of AVN after intracapsular osteotomy is a reality.…”

Relationships Between Severity of Deformity and Impingement in Slipped Capital Femoral Epiphysis

“…3,4 SCFE can result in premature hip osteoarthritis (OA), 5 hip pain associated with loss of flexion and internal rotation, 6 and disability. 7 Premature OA, pain, and loss of hip range of motion (ROM) have been attributed to abnormal femoroacetabular geometry and mechanics 6 including that caused by SCFE.…”