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

Abstract

We undertook a retrospective comparative study of all patients with an unstable slipped capital femoral epiphysis presenting to a single centre between 1998 and 2011. There were 45 patients (46 hips; mean age 12.6 years; 9 to 14); 16 hips underwent intracapsular cuneiform osteotomy and 30 underwent pinning in situ, with varying degrees of serendipitous reduction. No patient in the osteotomy group was lost to follow-up, which was undertaken at a mean of 28 months (11 to 48); four patients in the pinning in situ group were lost to follow-up, which occurred at a mean of 30 months (10 to 50). Avascular necrosis (AVN) occurred in four hips (25%) following osteotomy and in 11 (42%) following pinning in situ. AVN was not seen in five hips for which osteotomy was undertaken > 13 days after presentation. AVN occurred in four of ten (40%) hips undergoing emergency pinning in situ, compared with four of 15 (47%) undergoing non-emergency pinning. The rate of AVN was 67% (four of six) in those undergoing pinning on the second or third day after presentation. Pinning in situ following complete reduction led to AVN in four out of five cases (80%). In comparison, pinning in situ following incomplete reduction led to AVN in 7 of 21 cases (33%). The rate of development of AVN was significantly higher following pinning in situ with complete reduction than following intracapsular osteotomy (p = 0.048). Complete reduction was more frequent in those treated by emergency pinning and was strongly associated with AVN (p = 0.005). Non-emergency intracapsular osteotomy may have a protective effect on the epiphyseal vasculature and should be undertaken with a delay of at least two weeks. The place of emergency pinning in situ in these patients needs to be re-evaluated, possibly in favour of an emergency open procedure or delayed intracapsular osteotomy. Non-emergency pinning in situ should be undertaken after a delay of at least five days, with the greatest risk at two and three days after presentation. Intracapsular osteotomy should be undertaken after a delay of at least 14 days. In our experience, closed epiphyseal reduction is harmful. Cite this article: Bone Joint J 2015;97-B:412-19.

Strategies to Avoid Osteonecrosis in Unstable Slipped Capital Femoral Epiphysis

“…Particularly, the Parsch technique 2 of capsulotomy, controlled gentle reduction, and pinning with smooth Kirschner wires for unstable slips has a reported osteonecrosis rate of only 4.7%. However, multiple studies 3,11,35,37,[39][40][41] have also demonstrated an increased rate of osteonecrosis following reduction of an unstable SCFE. These studies have found that, in reduced slips, there is a higher rate of osteonecrosis when higher initial slip angles are present 35 and higher degrees of reduction are achieved 37,41 .…”

The British Orthopaedic Surgery Surveillance study: slipped capital femoral epiphysis

“… 26 Among unstable hips, a particular difference in practice was that some surgeons enforced a period of ‘bed rest’ prior to surgery, in the belief that there is a time window (between 24 hours and one to two weeks) during which surgery heightens the risk of AVN. 27 , 28 Among those patients with severe deformity, surgeons are generally divided on whether to perform open reduction to normalize the anatomy, albeit risking AVN, or to accept deformity and the symptoms and potential sequelae associated with it. A review by the UK National Institute for Health and Care Excellence noted the safety risk related to AVN, and concluded that the procedure should only be undertaken with special arrangements for governance, consent, audit, and research.…”

A Retrospective Study of Risk Factors and Outcomes in the Surgical Management of Slipped Capital Femoral Epiphysis

“…29,30 MDP involves a surgical hip dislocation, creation of a retinacular flap, open reduction of the epiphysis, and internal fixation of the slip to surgically correct the pathoanatomy, avoiding future cartilage damage. 23,25,27 Recent studies have shown that MDP leads to better clinical and radiographic improvement than ISP when treating stable SCFE. 34,38 A 2015 study by Novais et al showed that MDP led to better deformity correction, higher rates of good and excellent Heyman and Herndon clinical outcome, and a lower revision surgery rate compared with ISP for treatment for severe stable SCFE.…”