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Evidence is presented to support the contention that after slipping of the upper femoral epiphysis there is a potential for the bony epiphysis to grow back to its pre-slipped position. A suggestion is made as to how this recovery may occur.
The frequency of slipping and osteoarthritis of the contralateral hip was recorded in 260 patients with slipped upper femoral epiphysis between 1910 and 1960. Twenty-three of these patients (9%) had primary bilateral slipping, 32 (12%) had a contralateral slip diagnosed later during adolescence and a further 104 (40%) had signs of contralateral slipping at follow-up 16 to 66 years later, giving a total of 159 cases (61%) with bilateral slips. Of the 104 slippings diagnosed at follow-up, 25% showed osteoarthritis. It is concluded that, with a slipped epiphysis, prophylactic contralateral pinning should be performed to avoid slipping and to reduce the risk of osteoarthritis.
In 15 consecutive patients with slipped capital femoral epiphysis we recorded height, weight and skeletal maturity. Sexual maturity was assessed clinically and biochemically, and Harris's hypothesis that there is an increased ratio of serum growth hormone to oestrogen was tested in comparison with 15 age and sex matched controls. We found no difference in skeletal or sexual maturity between the groups, or any overt endocrine abnormality in the patients. However almost half the patients with slipped epiphysis were over the 90th weight percentile, suggesting that mechanical factors such as obesity are more important aetiologically than endocrine abnormalities.
We reviewed the radiological and clinical long-term results after the nailing in situ of slipped upper femoral epiphysis in 59 hips in 43 patients. The displacement of the epiphysis had been measured as the 'slipping angle' before operation and related to the results at follow-up at a mean of 30.9 years (27 to 34). The mean age at follow-up was 44.2 years (39 to 50). Radiographic re-examination of 41 hips with slipping angles of < or =30 degrees at the time of operation showed that eight (20%) had developed mild osteoarthritis and one had severe changes. For 18 hips with slipping angles ranging from 31 to 50 degrees at surgery six (33%) had mild osteoarthritis and three had severe changes. The differences did not quite achieve statistical significance (p = 0.09). Clinical re-examination of the 41 hips with slipping angles of < or =30 degrees showed fair or poor results (Harris hip score <90) in three (7%). In the 18 hips with slipping of 31 to 50 degrees, four had fair or poor results (22%) (p = 0.13). We conclude that nailing in situ for slipping of < or =30 degrees, using one thin nail, can give excellent long-term results. At present we recommend that hips with slips ranging from 31 to 50 degrees should also be nailed in situ, but further long-term studies are required, especially on the choice between nailing in situ and corrective osteotomy for slips in excess of 50 degrees.
We reviewed the management of 100 cases of slipped upper femoral epiphysis treated over a period of 26 years. A total of 14 slips was identified as unstable on admission. These underwent reduction and stabilisation within 24 hours of the onset of severe symptoms. Of the 86 stable slips four progressed to avascular necrosis (AVN), which was not seen in the unstable slips. The literature on slipped upper femoral epiphysis suggests that the acute unstable slip is at higher risk of developing AVN. We recommend reduction and stabilisation of unstable slips within 24 hours of the onset of symptoms in order to reduce the risk of AVN.
Avascular necrosis is a serious complication of slipped capital femoral epiphysis and is difficult to treat. The reported incidence varies from 3% to 47% of patients. The aims of treatment are to maintain the range of movement of the hip and to prevent collapse of the femoral head. At present there are no clear guidelines for the management of this condition and treatment can be difficult and unrewarding. We have used examination under anaesthesia and dynamic arthrography to investigate avascular necrosis and to determine the appropriate method of treatment. We present 20 consecutive cases of avascular necrosis in patients presenting with slipped capital femoral epiphysis and describe the results of treatment with a mean follow-up of over eight years (71 to 121 months). In patients who were suitable for joint preservation (14), we report a ten-year survivorship of the hip joint of 75% and a mean Harris hip score of 82 (44 to 98).
We reviewed prospectively, after skeletal maturity, a series of 24 patients (25 hips) with severe acute-on-chronic slipped capital femoral epiphysis which had been treated by subcapital cuneiform osteotomy. Patients were followed up for a mean of 8 years, 3 months (2 years, 5 months to 16 years, 4 months). Bedrest with 'slings and springs' had been used for a mean of 22 days (19 to 35) in 22 patients, and bedrest alone in two, before definitive surgery. The Iowa hip score, the Harris hip score and Boyer's radiological classification for degenerative disease were used. The mean Iowa hip score at follow-up was 93.7 (69 to 100) and the mean Harris hip score 95.6 (78 to 100). Degenerative joint changes were graded as 0 in 19 hips, grade 1 in four and grade 2 in two. The rate of avascular necrosis was 12% (3 of 25) and the rate of chondrolysis was 16% (4 of 25). We conclude that after a period of bed rest with slings and springs for three weeks to gain stability, subcapital cuneiform osteotomy for severe acute-on-chronic slipped capital femoral epiphysis is a satisfactory method of treatment with an acceptable rate of complication.
Many events occur concurrently during the initiation of the secondary ossification center in the cartilaginous epiphyses of long bones. We have investigated the chronology of interactions between the vascular system and epiphyseal chondrocytes by culturing explanted heads of femurs and humeri from pre- and neonatal rabbits on the chorioallantoic membrane (CAM) of growing chick embryos. We confirmed that, on the whole, the epiphyseal cartilage was resistant to vascular invasion, whereas the physeal growth plate was resorbed. However, new CAM-derived cartilage canals occasionally penetrated through the articular surface. This caused death of those chondrocytes in the immediate vicinity of the canal but no further reaction. If explants already contained a bony epiphysis and were halved prior to culture, CAM-derived vessels were attracted to the spongiosa. From there they pushed into the uncalcified cartilage, indicating that calcification was not a prerequisite for vascular invasion. Where at least two vessels were in apposition, a new pseudo-ossification center was initiated: chondrocytes became hypertrophic and the matrix calcified. This suggests that cumulative release of diffusible factors from more than one vessel was the trigger for chondrocyte hypertrophy, which, in turn, led to the initiation of the bony epiphysis. CAM cultures thus provide an experimental model for both the quiescent angiogenesis of cartilage canal formation and the reactionary angiogenesis associated with chondrocyte hypertrophy. By exploiting the different anatomy of CAM-derived vascularity, events that occur concurrently in vivo can be specially separated in CAM culture.
Slipped capital femoral epiphysis (SCFE) mainly occurs in pubertal children and is associated with delayed skeletal maturation, obesity, high growth velocity and tall stature. Furthermore, SCFE often coincides with endocrine disorders. This is the first report of a possible relationship between SCFE and GnRH agonist treatment: four patients developed SCFE during or shortly after treatment with GnRH agonists was stopped. We compared the clinical aspects of these patients with patients described in the literature who developed SCFE. Puberty started at the age of 3.3, 9.6, 0.0 and 5.6 years respectively. One patient developed sequential SCFE of both hips. SCFE occurred at the age of 11.9 (patient 1), 12.7 (patient 2), 14.3 (patient 2), 11.3 (patient 3) and 11.3 (patient 4) years. Of the five incidences of SCFE, one occurred during GnRH agonist treatment and four shortly after treatment was stopped. None of our patients met the typical criteria seen in SCFE and no 'regular' characteristics of patients with SCFE could be designated. Probably the hormonal changes during and shortly after treatment with GnRH agonists make the epiphysis more prone to slip. Considering our observations and by reviewing the literature, GnRH agonist treatment might present a risk factor for the occurrence of SCFE.
One hundred and forty-nine patients (208 hips) were managed for slipped capital femoral epiphysis at the Hospital for Sick Children in Toronto from 1980 through 1990. We retrospectively reviewed the records of twenty-four patients (twenty-six hips) who had an acute slipped capital femoral epiphysis to evaluate the outcome of treatment and possible risk factors for avascular necrosis associated with this condition. The patients were evaluated with the Iowa hip-scoring system, a physical examination, and anteroposterior and lateral radiographs. The severity of degenerative joint disease was assessed on the radiographs with use of the system described by Boyer et al. Eighteen slips were classified as grade 1; seven, as grade 2; and one, as grade 3, according to the system of Southwick. Twenty-three hips were treated with in situ pinning and three, with reduction and pinning. The mean duration of follow-up was 5.9 years (range, 2.1 to 12.8 years). Poor Iowa hip scores and more severe degenerative changes were related to the development of avascular necrosis and to the severity of the slip. Avascular necrosis developed in four hips (15 per cent), two of which had had a reduction. Multiple logistic regression analysis, which included all 150 slips (both acute and chronic) for which there was adequate follow-up, showed that the rate of avascular necrosis was related to both the severity and the acute nature of the slip.
BACKGROUND: The risk of a contralateral slip in patients who are first seen with a unilateral slipped capital femoral epiphysis has been reported to be 2335 times higher than the risk of an initial slip. The overall prevalence of bilaterality varies widely throughout the literature, with some reports indicating rates as high as 80%. This finding has led many authors to recommend prophylactic pinning of the contralateral asymptomatic hip in patients presenting with a unilateral slipped capital femoral epiphysis. METHODS: A decision analysis model with probabilities for the occurrence of contralateral slip and for the severity of slip at different intervals of follow-up was used in the present study. These probabilities were compared with those for various outcomes when the contralateral hip is prophylactically pinned. Scores representing long-term outcome, according to the Iowa hip-rating system, were used in the model as a measure of utility. The probabilities of contralateral slip and the rates of slip severity were taken from large retrospective series. All meaningful clinical scenarios with regard to long-term outcome for the hip were considered in the model. Variables of uncertainty were subjected to sensitivity analyses in order to explore the effect on outcome over the range of plausible values for variables of interest. RESULTS: The results showed a benefit in the long-term outcome for patients who had prophylactic pinning of the contralateral hip. The threshold level at which a benefit is obtained with prophylactic pinning is expressed according to the rates of sequential slip, rates of slips overlooked at follow-up, and complications associated with prophylactic pinning of the contralateral hip. CONCLUSIONS: The decision model shows that, when pooled data are used to predict probabilities of sequential slip, treatment of the contralateral hip with prophylactic pinning is beneficial to the long-term outcome for that hip. When considering prophylactic pinning of the contralateral hip, the clinician should use sound clinical judgment with respect to the age, sex, and endocrine status of the patient. Long-term follow-up studies are needed to establish the efficacy of prophylactic pinning, but the predictions in the present study, which are based on findings in the literature, support the safety of this procedure.
BACKGROUND: Femoral head deformity is the most serious sequela of ischemic necrosis of the immature femoral head. The purpose of this study was to determine if a highly potent antiresorptive agent, ibandronate, can inhibit bone resorption during the repair of the infarcted femoral head and thus alter the repair process. We hypothesized that preservation of the trabecular framework by inhibiting osteoclastic bone resorption would minimize the development of deformity in a piglet model of ischemic necrosis. The effect of ibandronate on long-bone growth was also assessed. METHODS: Ischemic necrosis of the right femoral head was produced in twenty-four piglets by placing a ligature tightly around the femoral neck. The animals were divided into three groups according to whether they received saline solution, prophylactic treatment, or post-ischemia treatment. The contralateral, untreated femoral heads from the animals that had received saline solution served as the normal control group. At eight weeks, the femoral heads were assessed for deformity with radiography and for trabecular bone indices with histomorphometry. Also, the length of femur from the untreated side was measured on the radiographs and compared among the groups. RESULTS: Radiographic assessment showed that the epiphyseal quotient, determined by dividing the maximum height of the osseous epiphysis by the maximum diameter, was better preserved in the prophylactic (p < 0.001) and post-ischemia (p = 0.02) treatment groups than in the group treated with saline solution. Histomorphometric assessment also showed that the trabecular bone indices were better preserved in the prophylactic and the post-ischemia treatment groups than in the group treated with saline solution (p < 0.01). The mean femoral length on the untreated side of the animals treated with ibandronate was reduced compared with the length on the untreated side of the animals that had received saline solution (p </= 0.01). CONCLUSIONS: Ibandronate preserves the trabecular structure of the osseous epiphysis and prevents femoral head deformity during the early phase of repair of ischemic necrosis in the piglet model.
The site of injury to the distal tibial epiphysis in the younger individual depends on the relation of the ligaments to the epiphysis, the type of injury, and the maturity and degree of closure of the growth plate. A characteristic radiographic pattern of injury occurs as a result of each particular injuring force, which in turn requires a specific mode of fracture reduction. One hundred and ninety-four cases of epiphyseal injuries were reviewed, and the incidence and diagnostic characteristics of the various types are presented. The Salter-Harris classification of lesions reveal the type II is the most common (46.4%), followed by type III (25.2%), type IV (10.3%), and type I (5.7%). The triplane fracture constituted 9.8%, and miscellaneous injuries, which could not be classified, were 2.6%.
A girl with growth hormone deficiency developed a necrosis of the femoral capital epiphysis 6 months after the start of human growth hormone treatment. The compensatory growth spurt is believed to have caused an insufficient blood supply to the epiphysis, resulting in necrosis.
A case of osteomyelitis of the proximal radial epiphysis in a 6-year-old boy is presented. The effect on the cartilaginous tissues and the potential for growth of the epiphysis must be considered.
Penetration of the joint by metal pins can occur when treating slipped capital femoral epiphysis. Predisposing factors are present in the usual surgical methods. These include x-ray detail loss secondary to the pelvic projection and failure to obtain specific x-ray orientation to the axis of the capital epiphysis. One operative strategy to reduce these predispositions is presented. A probable mechanism of how chondrolysis can occur without joint penetration following extra capsular osteotomy is described with a theoretical remedy. Computer disease modeling and treatment simulation are the basis of this study. The computer model, which closely simulates all degrees of the disease, suggests that SCFE deformation is caused by hip extension against anterior hip capsule contracture. The latter is also the proposed cause of chondrolysis following realignment procedures.
This study compared cannulated 4.5-mm bioabsorbable screws made of self-reinforced poly-levolactic acid to cannulated 4.5-mm steel and titanium screws for resistance to shear stress and ability to generate compression in a polyurethane foam model of slipped capital femoral epiphysis fixation. The maximum shear stress resisted by the three screw types was similar (self-reinforced poly-levolactic acid 371 +/- 146 MPa, steel 442 +/- 43 MPa, and titanium 470 +/- 91 MPa). The maximum compression generated by both the self-reinforced poly-levolactic acid screw (68.5 +/- 3.3 N) and the steel screw (63.3 +/- 5.9 N) was greater than that for the titanium screw (3 +/- 1.4 N, P <.05). These data suggest cannulated self-reinforced poly-levolactic acid screws can be used in the treatment of slipped capital femoral epiphysis because of their sufficient biomechanical strength.
One case of a bilateral idiopathic slipped capital femoral epiphysis--"slipped epiphysis"--in a cat is described. The similarities and the differences between the cases in human and small animal medicine concerning the incidence, the hypotheses of the pathogenesis and the treatment options are discussed.