Abstract
Aim
Debate remains over the optimal treatment for severe unstable SCFE. AVN is the principle problem; current thinking suggests this can be minimized by emergent reduction and fixation within 24 hours. If emergent treatment is not possible, open osteotomy with a variable delay of 10–21 days has been advocated. We present our experience of delayed intracapsular cuneiform osteotomy (ICO)
Methods
SCFE cases were identified through ICD-10 coding and theatre records. Unstable slips were identified and reviewed retrospectively. When ICO was performed, the hip was accessed via anterior approach without hip dislocation. A cuneiform shortening osteotomy of the neck with physeal excision was undertaken. The epiphysis was carefully reduced and stabilized with a single screw.
Results
46 unstable slips were treated during the study period. 16 hips underwent ICO, while the remaining cases were treated by closed pinning in situ (PIS) without capsulotomy. The rate of AVN following ICO in 16 hips was 25% in comparison to the PIS group, in which 40% developed AVN. AVN was not seen in those cases treated with ICO with a delay of at least 14 days. In contrast, AVN occurred regardless of the timing of PIS, including a rate of 33% in those treated emergently. Sub analysis of the PIS group revealed that AVN occurred more frequently (66.7% vs. 33.3%) when complete epiphyseal reduction occurred during patient positioning. While these results are not statistically significant, they are striking. Patients who developed AVN had a poor outcome in both groups, with 75% requiring further surgical intervention. There were 2 cases of heterotrophic ossification and meralgia paraesthetica respectively. Hardware failure occurred once.
Conclusion
Timing and method of treatment for unstable SCFE remains controversial. This series suggests delayed intracapsular cuneiform osteotomy may result in a lower rate of AVN than closed reduction and pinning within 24 hours.
