Slipped Capital Femoral Epiphysis

Shady Mahmoud
Msc otho, MRCS
Assistant lecturer of Orthopaedic at Ain Shams University
 Introduction
• Slipped capital femoral epiphysis (SCFE) is an adolescent hip disorder
where the femoral neck and shaft displace relative to the femoral
epiphysis via the physis.
• Its incidience is 0.2 to 10 per 100.000. The mean age at diagnosis is
13.5 years in boys and 12 years in girls. (1)
• Most of the displacement is in varus (upward, anterior, and external
rotation displacement of the neck) but can occasionally be in valgus
(downward, posterior, and internal rotation displacement of the
neck). (2)
1: Lehmann CL, Arons RR, Loder RT, et al. The epidemiology of slipped capital femoral epiphysis: an update. Journal of Pediatric Orthopaedics, 2006;
26: 286-90.
2: Loder R, Skopelja E. The Epidemiology and Demographics of Slipped Capital Femoral Epiphysis. International Scholarly Research Notices Orthop.
2011; 1-19.
• Its pathogenesis and etiology are still unknown but it is the result of
high load across abnormally weak physis.

• Obesity, endocrine, and chronic systemic diseases are known to be

associated with SCFE.

• Vitamin D deficiency is strongly correlated to SCFE.

SCFE can be classified based on:

Classification

Clinical Radiological
 Clinical Classification
• It can be classified into acute (those with symptoms last less than 3
weeks), chronic (those with symptoms last more than 3 weeks), and
acute on top of chronic (those with chronic symptoms initially with
subsequent development of acute symptoms). (1)
• A more clinically useful classification (Loder et al classification)
depends on physeal stability and predicts the prognosis as regard
avascular necrosis (AVN) of the femoral head. It is classified into:
stable (those who are able to walk with or without crutches) with AVN
< 10%
unstable (those who are unable to walk even with crutches) with AVN
risk as high as 47 %. (2)
1. Loder R, Aronson D, and Greenfield M. The epidemiology of bilateral slipped capital femoral epiphysis: a study of children in Michigan,
Journal of Bone and Joint Surgery, American. 1993, vol. 75, no. 8, pp. 1141–1147.
2. Loder R, Richards B, Shapiro P et al. Acute slipped capital femoral epiphysis: the importance of physeal stability, Journal of Bone and Joint
Surgery, American. 1993, vol. 75, no. 8, pp. 1134–1140.
Radiological classification
• Radiological classification (Southwick), which is based on lateral head
shaft angle, places the slip into mild (< 300), moderate (30-500), and
severe (>500).

Southwick WO. Compression fixation after biplane intertrochanteric osteotomy for slipped capital femoral epiphysis. A technical improve-
ment. Journal of Bone and Joint Surgery, American, 1973; 55(6):1218-1224.
 Presentation
• Pain:
Hip: is the most common.
Knee and thigh: are frequently present.
In an adolescent boy with knee pain, always examine the hips and
consider hip pathology, especially if the knee workup is negative.
Matava et al discusses knee pain as the initial symptom of SCFE. This
retrospective review of 65 patients found that 15 (23%) noted distal
thigh pain, knee pain, or both as the presenting symptom.
Knee and thigh pain resulting from intra-articular hip pathology is a
referred pain phenomenon, and is a common reason for misdiagnosis
of SCFE leading to delay in treatment, possible further displacement,
and worse prognosis.
Matava MJ, Patton CM, Luhmann S, Gordon JE, Schoenecker PL. Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of
initial presentation and treatment. J Pediatr Orthop. 1999 Jul-Aug;19(4):455-60
• Gait:
Antalgic.
Externally rotated.
Waddling or Trendelenburg.
• Range of motion:
obligatory external rotation: during passive flexion of hip (Drehmann
sign)due to a combination of synovitis and impingement of the
displaced anterior-lateral femoral metaphysis on the acetabular rim.
loss of hip internal rotation, abduction, and flexion.
Song et al reviewed 20 unilateral SCFE patients. With increasing slip angles, passive hip flexion, hip
abduction, and internal rotation decreased significantly. (1)

Rab used computer modeling of SCFE patients to determine that posterior epiphyseal displacement
in the plane of the physis is the etiology for the resultant deformities found in SCFE. Additionally,
they found that sitting increases impingement for all slip geometries, requiring proportionately
greater external rotation and accounting for why patients feel better to cross the affected leg while
sitting in a chair. (2)

1. Song KM, Halliday S, Reilly C, Keezel W. Gait abnormalities following slipped capital femoral epiphysis.. J Pediatr Orthop. 2004 Mar-Apr;24(2):148-55.
2. Rab GT. The geometry of slipped capital femoral epiphysis: implications for movement, impingement, and corrective osteotomy. J Pediatr Orthop.
1999 Jul-Aug;19(4):419-24.
Imaging
• Radiographs:
AP & frog-leg lateral of both hips.
Look for Kline lines on AP view.
Measure Southwick angle, estimate the hump,
and asses the physis status on the lateal view
• CT
To assess the degree of slippage,
physis status, the degree of alpha
angle of Nötzli, and plan the
osteotomy.
• MRI
can help diagnose a pre-slip condition when
radiographs are negative.
Findings:
• growth plate widening.
• edema in metaphysis.
• decreased signal on T1, increased
signal on T2.
Laboratory
• Serum Ca++ (total and ionized), Phosphorus, and Alkaline
phosphatase.

• 25(OH) D3 .

• Free T3, T4, and TSH.

Treatment options

In situ pinning

Proximal femur osteotomy

Osteochondroplasty
In situ pinning
• Goal: To stabilize the epiphysis from further slippage
and promote closure of the proximal femoral physis.

• Conditions to be fulfilled:
Single screw is sufficient and reduce the risk of
penetration and AVN.

The screw should be started on the anterior surface of the

proximal femur to cross perpendicular to the physis.

Advance until 5 threads across the physis and stop at least

5mm from subchondral bone in all views.

Morrissy RT. Principles of in situ fixation in chronic slipped capital femoral epiphysis. Instr Course Lect. 1989;38:257-62.
 When do you fix the other site?
(Bilateral in situ pinning)
• Remains controversial.
• current indications are high risk patients (contralateral slip ~ 40-80%):
initial slip at young age (< 10 years-old).
open triradiate cartilage.
endocrine disorders (e.g. hypothyroidism).
obese males??

Schultz WR, Weinstein JN, Weinstein SL, Smith BG. Prophylactic pinning of the contralateral hip in slipped capital femoral epiphysis : evaluation
of long-term outcome for the contralateral hip with use of decision analysis. J Bone Joint Surg Am. 2002 Aug;84-A(8):1305-14
 Proximal femur osteotomy
• Indication:
Moderate to severe Slip.

As a golden rule:
The nearer to the physis, the greater
Power of correction, but with
higher risks of AVN.
 Subcapital femoral neck
osteotomy
• Dunn described subcapital femoral neck osteotomy to
correct the deformity where the tension on posterior
flap was reduced by wedge resection. (1) Although it
corrects the deformity completely, the risk of AVN
reported range from 10 – 100 %. (2)
• Ganz et al (3) described a modification to Dunn
procedure where a safe surgical dislocation used to
solve AVN problem, but it is technically demanding
with lack of long term results studies and is used
usually for unstable cases. AVN risk ranges from 0% to
26%. (4)
1.Sucato DJ, De La Rocha A. High-grade SCFE: the role of surgical hip dislocation and reduction. Journal of Pediatric Orthopaedics. 2014; 34 Suppl 1(1):S18-S24.
2.Ganz R, Gill TJ, Gautier E et al. Surgical dislocation of the adult hip. A technique with full access to the femoral neck necrosis. Journal of Bone and Joint Surgery.
1992:1119-1124.
3. Ziebarth K, Zilkens C, Spencer S et al. Capital Realignment for Moderate and Severe SCFE Using a Modified Dunn Procedure. Clinical Orthopedic and Related
Research. 2009:704-716.
4.Madan SS, Cooper AP, Davies AG et al. The treatment of severe slipped capital femoral epiphysis via the Ganz surgical dislocation and anatomical reduction. Journal
of Bone and Joint Surgery. 2013; 95B (3): 424-429.
 Basal neck osteotomy
• Kramer et al (1) described an extra-capsular basal neck osteotomy in
an attempt to decrease the risk of AVN.
• AVN and chondrolysis have still been reported. (2)

1.Kramer W, Craig W, Noel S. Compensating Osteotomy at the Base of the Femoral neck for Slipped Capital Femoral Epiphysis. Journal of
Bone and Joint Surgery, American, 1976: Vol. 58-A, No:6 .
2.El-Mowafi H, El-Adl G, El-Lakkany MR. Extracapsular base of neck osteotomy versus Southwick osteotomy in treatment of moderate to
severe chronic slipped capital femoral epiphysis. Journal of Pediatric Orthopaedic.2005; 25(2):171-177.
 Intertrochanteric osteotomy
• Southwick described an osteotomy at the level of lesser
trochanter which corrects the varus and extension
deformity with no derotation to avoid abductor
weakness.

Southwick WO. Osteotomy through the lesser trochanter for slipped capital femoral
epiphysis. Journal of Bone and Joint Surgery, American, 1967, 49(5):807–835.
 Imhäuser osteotomy
• Imhäuser described an osteotomy proximal to
the lesser trochater which involves valgus,
flexion, and internal rotation. (1)
• Several studies reported the use of Imhäuser
osteotomy with satisfactory outcomes with
clinical and radiological improvement on long
term follow up as long as 39 years and hence
the delay of total hip replacement need. (2)
• As it cannot correct the deformity completely,
being away from the center of deformity, some
admitted the need of additional procedure, as
osteochondroplasty, to deal with the residual
deformity persisted after its use that may
explain the incomplete improvement of some
cases. (3)
1. Kartenbender K, Cordier W, Katthagen B. Long-Term Follow-Up Study After Corrective Imhäuser Osteotomy for Severe Slipped Capital
Femoral Epiphysis. Journal of Pediatric Orthopaedics. 2000:749-756.
2. Saisu T, Kamegaya M, Segawa Y et al. Postoperative improvement of femoroacetabular impingement after intertrochanteric flexion
osteotomy for SCFE hip. Clinical Orthopedic and Related Research. 2013; 471(7):2183-2191.
3. Trisolino G, Pagliazzi G, Gennaro GL Di, Stilli S. Long-term Results of Combined Epiphysiodesis and Imhauser Intertrochanteric
Osteotomy in SCFE : A Retrospective Study on 53 Hips. Journal of Pediatric Orthopaedic. 2015; 00(00):1-7.
 Osteochondroplasty
• It is an adjunct treatment option added to in situ pinning and/or
proximal femur osteotomy.

• Indication: In slips which are impinging as the prominent metaphysis

might cause cam lesion resulting in femoroacetabular impingement
(FAI). (1)

• Goal: Prevent the repetitive mechanical abrasions of the metaphysis

against the acetabular cartilage that trigger osteoarthritis. (2)
1. Abraham E, Gonzalez MH, Pratap S et al. Clinical implications of anatomical wear characteristics in slipped capital femoral epiphysis and primary
osteoarthritis. Journal of Pediatric Orthopaedics. 2007, 27(7):788–795.
2. Leunig M, Casillas MM, Hamlet M et al, Slipped capital femoral epiphysis: early mechanical damage to the acetabular cartilage by a prominent
femoral metaphysis. Acta Orthop Scand. 2000, 71(4):370–375.
• Technique:
Arthroscopic.

Limited anterior arthrotomy (Via Smith Peterson approach).

In combination with intertrochanteric osteotomy (via Watson Jones

approach).

Surgical hip dislocation.

Treatment approach
Factors affect
the decision
making

Open or closed Stable or Degree of

physis unstable slippage
Unstable SCFE
• urgent, gentle reduction, screw fixation, and capsular
decompression.
A recent review by Lykissas and McCarthy confirmed that intraarticular
decompression and performing surgery less than 24 hours from the
onset of symptoms appear to have a positive effect on preventing AVN.
It is the ‘‘gold standard treatment’’ for unstable slips. (1)

• In severe unstable cases, Safe surgical dislocation is an option to do

capital realignment. (2)
1. Lykissas MG, McCarthy JJ. Should all unstable slipped capital femoral epiphysis be treated open? J Pediatr Orthop. 2013; 33(Suppl
1):S92--S98.
2. Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum
without the risk of avascular necrosis. J Bone Joint Surg. 2001; 83(B):1119--1124.
Mild stable SCFE (Southwick angle o
<30 )

No In situ
impingement pinning
In situ pinning +
Impingement Osteochondroplasty
‘arthroscopic or mini open’
Moderate and severe stable SCFE (Southwick
o
angle > 30 )

Closed Intertrochanteric
osteotomy +
physis osteochondroplasty

Open Intertrochanteric
osteotomy +
osteochondroplasty
physis VS modified Dunn
THANK YOU