Classic Article: A Treatment Option for SCFE with Good Clinical, Radiographic Outcomes
The treatment focuses on a gentle reduction maneuver with the aid of the surgeon’s finger tip plus Kirschner wire fixation in situ crossing the physis.
Surya N. Mundluru, MD, and Alice Chu, MD
Parsch K, Weller S, Parsch D. Open reduction and smooth Kirschner wire fixation for unstable slipped capital femoral epiphysis. J Pediatr Orthop. 2009;29(1):1–8. doi:10.1097/BPO.0b013e31818f0ea3.
The authors of this article sought to evaluate the outcomes of a gentle reduction maneuver with fixation for unstable acute slipped capital femoral epiphysis (SCFE).
This retrospective, cohort study of acute unstable SCFE at a large tertiary care pediatric hospital in Stuttgart, Germany, included patients who underwent operative reduction and Kirschner wire fixation over a 19-year period starting in 1983.
The study included 20 hips with mild slips (< 20°), 24 hips with moderate slips (31-50°), and 20 hips with severe slips (51-90°). Operative reduction and fixation was indicated if patients’ symptoms were “acute,” described as occurring after a defined stumble or fall; a noted radiographic appearance of a slip; and ultrasound documentation of a joint effusion with an inability to bear weight.
Forty-nine (76.6%) of the 64 patients were seen and operated on within 24 hours after the onset symptoms; intervention was delayed more than 24 hours in 15 patients (23.4%). The operative technique included a Watson Jones approach to the hip joint, anterior arthrotomy with longitudinal capsulotomy, evacuation of joint fluid, gentle reduction maneuver with the aid of the surgeon’s finger tip, and Kirschner wire fixation in situ crossing the physis.
Measured outcomes included short-term follow-up for an unspecified number of visits up to 12 months, with radiographs in the intervening period. Avascular necrosis (AVN) developed in 3 patients (4.7%) within the first 6 months after surgical reduction. One of the 3 patients was treated within the first 24 hours of symptoms, and 2 were treated outside of the first 24 hours. Two of the 3 patients underwent corrective intertrochanteric osteotomies.
In the 64 hips included in the study, an average correction of 32° was achieved, with an average final slip angle of 10.6° (42.6° was the average angle before reduction).
Long-term follow-up was available for 60 patients, with an average of 4.9 years after surgery. These patients were classified using the Iowa hips score, a scoring tool based on clinical features and radiographic changes after SCFE. The Iowa hip score (top score, 100 points) was 94.5 on average for the 60 patients available for follow-up. This included the 3 patients who developed AVN.
The overall incidence for SCFE in the United States is 10.8 cases per 100,000 children. SCFE mainly occurs in children between the ages of 10 to 16 years, with an increased occurrence in African-American children, obese children, and those with endocrine disorders. Complications of SCFE include AVN, chondrolysis, and degenerative joint disease likely related to the residual “pistol grip” deformity of the proximal femur.
Historically, the mainstay of treatment after diagnosis has included simple traction and fixation in situ with acceptance of deformity. This is due to concerns of causing secondary AVN from aggressive attempts at reduction and inadvertent damage to epiphyseal blood supply.
The proposed algorithm for the treatment of unstable SCFE has been shown in this study to correlate with good long-term outcome scores and objective improvement in radiographic slip angles with low rates of AVN.
However, the study has limitations:
- No statistical metrics are described. Pre- and post-reduction slip angles are reported, but the statistical significance of this change is not presented.
- Descriptive population demographics are very limited in this study, as no comment on race or comorbid conditions are provided. The population in the study may not represent the general patient population in other centers.
- The reduction maneuver and fixation was mostly performed by 1 physician (the first author), leading to a bias towards favorable outcome due to this surgeons experience and skill. Successful reproducibility in the orthopaedic surgeon population at large is difficult to determine.
Overall, the use of gentle reduction technique and Kirschner wire fixation seems to lead to both favorable clinical and radiographic outcomes. Future prospective-randomized studies of different management algorithms for SCFE will further clarify its utility.
Surya N. Mundluru, MD, is a resident of orthopaedic surgery at NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York. Alice Chu, MD, is an Assistant Professor of Orthopaedic Surgery, Division of Pediatric Orthopaedics, Department of Orthopaedic Surgery, at NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York.