Flexion Intertrochanteric Osteotomy for Severe Slipped Capital Femoral Epiphysis



Flexion Intertrochanteric Osteotomy for Severe Slipped Capital Femoral Epiphysis


Young-Jo Kim





PATHOGENESIS



  • The true etiology of SCFE is unclear. However, because it occurs mainly in adolescent boys (80%), hormonal factors are thought to be involved.


  • Additionally, the orientation of the growth plate becomes more vertical in adolescents compared to the juvenile hip, leading to increased shear stress across the physis.


  • The transition from juvenile to adolescent is a period of rapid weight gain, leading to the stereotypical obese body habitus in the SCFE patient.


NATURAL HISTORY



  • Undetected SCFEs can lead to hip arthrosis. Murray4 suggests that up to 40% of hips with degenerative arthritis have a “tilt deformity” or other deformities that may be due to an undetected subclinical SCFE or other developmental problems.


  • A review by Aronson1 found that 15% to 20% of patients with SCFE had painful osteoarthritis by age 50 years. Additionally, 11% of patients with end-stage osteoarthritis had an SCFE.


PATIENT HISTORY AND PHYSICAL FINDINGS



  • Patients will complain of insidious-onset groin or knee pain that may have previously been diagnosed as a sprain.



    • They may walk with a limp, but typically they walk with an externally rotated foot progression angle, which may indicate chronic SCFE or femoral retroversion.


    • Pain is elicited with hip flexion, adduction, and internal rotation stress (impingement test).


    • The physical examination should include flexion and internal rotation range-of-motion tests. Normal, physiologic hip flexion needed for activities of daily living is at least 90 degrees.


    • Patients with a chronic SCFE and anterior impingement will have less than 90 degrees of true hip flexion.


    • Patients with impingement secondary to SCFE will have less internal rotation in flexion than extension and may have a compensatory external rotation of the hip as it is flexed (obligate external rotation).


IMAGING AND OTHER DIAGNOSTIC STUDIES



  • Plain radiographs include an anteroposterior (AP) and frog-leg lateral views of the pelvis or the involved hip (FIG 1A,B).


  • Computed tomography (CT) scans with two- and three-dimensional reconstructions are helpful for preoperative planning (FIG 1C,D).






    FIG 1 • Preoperative AP (A) and frog-leg lateral (B) radiographs of the left hip demonstrate a chronic, stable severe SCFE with greater than 70 degrees of posterior slippage. (continued)







    FIG 1(continued) Preoperative two-dimensional (C) and three-dimensional (D) CT reconstructions further define the severity of the deformity.




NONOPERATIVE MANAGEMENT



  • Nonoperative management includes cessation of aggravating activities and symptomatic treatment using nonsteroidal anti-inflammatories.


  • Physical therapy to strengthen the hip musculature does not address the mechanical impingement associated with an SCFE.


  • All SCFE should be stabilized surgically. Nonoperative management if for impingement symptoms.


SURGICAL MANAGEMENT



  • A chronic slip may be pinned in situ to prevent continued slippage. Remodeling of the SCFE deformity has been described in long-term follow-up studies.


  • Corrective osteotomies have been described through the femoral neck at the growth plate (cuneiform), at the base of the femoral neck, or intertrochantic or subtrochanteric.6


Preoperative Planning

Jul 22, 2016 | Posted by in ORTHOPEDIC | Comments Off on Flexion Intertrochanteric Osteotomy for Severe Slipped Capital Femoral Epiphysis
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