Introduction: Obligatory external rotation during flexion is well recognised as a cardinal feature of Slipped Upper Femoral Epiphyses (SUFE). We have evaluated the significance of acetabular version in contributing to the external rotational deformity that is seen in otherwise normal hips. We present a small case series focussing on the characteristics of this pathology, highlighting its significance and outlining a treatment strategy.

Method: Five patients (eight hips) presented with disabling hip pain during non-sporting activities. All their hip radiographs had been reported as normal. The rotational profile of both acetabulum and femur in these patients was evaluated by MRI and CT scans.

Results: Clinical examination revealed otherwise normal hips but for an external rotation deformity which got worse on hip flexion. The average external rotation deformity with the hip in extension was 60 degrees, which worsened to 90 degrees during hip flexion. Three of these hips had been previously treated with in situ pinning for SUFE. Other hips were in patients who were either skeletally mature or close to skeletal maturity. We found that all were “profunda hips” with severe acetabular retroversion. The abnormality in acetabular version was best defined on axial imaging.

Conclusions: The femoral head is a spherical conchoid. The concept of version of the hip (both femoral and acetabular) as described by McKibbin, Tonnis and Ganz is reviewed. Femoral retroversion is common in patients with SUFE, but the addition of acetabular retroversion makes these hips disproportionately symptomatic. This deformity causes a combination of pincer and cam impingement, which is responsible for the marked disability. SUFE alone causes cam impingement, whilst a corresponding degree of slip without retroversion and profunda of the acetabulum is not that disabling.

Aim:. Audit of the outcome of subcapital osteotomy for a series of cases of severe unstable slipped capital femoral epiphysis. Method:. 57 cases of unstable severe slipped capital femoral epiphysis were operated on by a single surgeon between 2000 and 2011. The procedure was performed through the anterior abductor sparing approach. Patients have been followed up prospectively and the results are presented at average follow up is 6.4 years with a minimum of 18 month follow to include all risks of avn. Results:. There were 35 males (average age 13.85 years) and 22 females (average age 12.4 years). Three syndromic cases, 2 Trisomy 21 (with no avn) and one pituitary/corpus callosum agenesis (developed avn) were included. 5 patients (8.7%) developed avn, one syndromic, another with noted avn on pre-operative MRI and the third with partially healed growth plate. Excluding these patients the avn rate was 2/54 (3.7%). Re-operations were performed on the avn group including two head neck debridements and valgus osteotomy, one head neck debridement alone and one arthrodesis. One patient is awaiting debridement and valgus osteotomy. One patient developed chondrolysis and has had no intervention 6 years. 2 patients developed asymptomatic heterotopic bone ossification and the incidence of lateral cutaneous nerve symptoms was 35% none requiring intervention. Leg length difference was less than 1 cm in those patients who did not develop avn. Conclusion:. This single surgeon audit shows lower risk of avn than and strengthens the argument for referral to specific centres for such conditions. Level of evidence: IV

Purpose. The decision to undertake prophylactic pinning to prevent contralateral slipped upper femoral epiphysis (SUFE) remains controversial; we hypothesised that the grade of initial SUFE could predict the grade of a second SUFE and risk of poor outcome. Method. We retrospectively reviewed radiographs of all children who presented to Alder Hey with a new diagnosis of SUFE between 2007–2014. Of those who developed a contralateral SUFE, grade of first and second SUFE was determined radio-graphically using % slip and Southwick angle on frog lateral radiograph. Results. 100 patients that presented with a new diagnosis of SUFE were identified. 73 had no contralateral surgery at first presentation. Of these, 56 reached skeletal maturity with no contralateral slip. 17 re-presented acutely with a contralateral slip requiring operative intervention. 4 presented with unilateral symptoms but radiographic evidence of bilateral slips and underwent bilateral surgery at time of first presentation. No cases of severe slip where seen in children with initial mild or moderate slips. 100% of children presented with a contralateral SUFE of the same or less severe grade. In cases of initial severe SUFE, grade of second SUFE was unpredictable; 3 pre-slip, 1 mild, 1 moderate, 2 severe. Conclusion. Grade of initial SUFE may be a useful adjunct to decision making when considering risk- benefit of prophylactic contralateral surgery. In cases of initial mild slip re-presentation with a severe contralateral SUFE is unlikely and a higher threshold for prophylactic intervention may be appropriate

Purpose. We share our experience in management of failed in-situ pinning in severe unstable Slipped Capital Femoral Epiphysis (SCFE) by surgical dislocation approach. Method. A retrospective review of hip database from 2006 to 2013 showed 41 children underwent surgical dislocation for SCFE. We identified seven who had severe slip with failed in-situ pinning. Results. The mean age at presentation was 11.9 years (10–14 years). The average interval between in-situ pinning and surgical dislocation was 10 months (2 to 18 months). The mean follow-up was 50.14 months (25 – 66 months). The mean preoperative slip angle in the oblique plane was 76° (61.1° – 121.5°), the mean preoperative alpha angle was 127.3° (93.1° – 145°), and preoperative head neck offset was −12.7mm (0 – −21.2mm). The mean corrections at latest follow-up were oblique plane slip angle 20.6° (4.2° – 41.8°), alpha angle 51.3° (45.3° – 58°), and head-neck offset 9.5mm (1 – 16.2mm). The mean Modified Harris Hip Score (MHHS) preoperatively was 19.57 (0 – 56) and the mean non-arthritic hip score (NAHS) was 21.07 (5 – 51.5). The mean MHHS at the last visit was 88.97 (71 – 96) and NAHS was 84.28 (69.5 – 91). All patients had gross external rotation deformity at presentation; mean internal rotation of 25° ranging from (0 – 40°) was achieved at follow-up. Four patients had avascular necrosis identified on subtraction MRI scan preoperatively. These four underwent second stage hinged distraction of the hip. Mean duration of hinged distraction was 7.6 months. At follow-up 4 had Tonnis 0, one Tonnis 1 and two Tonnis 2 grade of osteoarthritis. Conclusion. The short-term result of our protocol for management of failed in-situ pinning by staged surgical dislocation and hinged distraction has been encouraging. This could potentially prolong the life of native hip to the third decade of life before definitive salvage procedures could be contemplated

Introduction. Slipped upper femoral epiphysis (SUFE) predominantly affects males in early adolescence. Severe slips occur with an estimated incidence of 1 per 100,000 children. Controversy exists over optimal treatment of severe slips with debate between in-situ fixation versus corrective surgery. We report on our management of a large series of such patients using a sub-capital cuneiform osteotomy. Patients/Methods. Between 2001–2011, 57 patients (35M: 22F) with an average age of 13.1 years were referred to our tertiary referral institution with a severe slip. This was defined as an epiphyseal-metaphyseal displacement greater than half the width of the femoral neck on a Billing lateral radiograph. The affected limb was rested in slings and springs prior to corrective surgery which was performed via an anterior Smith-Petersen approach. More recently our series has included pre-operative MRI to look for avascular necrosis of the epiphysis. Data was analysed to compare complication rate with time to surgery and surgeon's experience. Results. 50 patients (88%) were complication free at a mean follow up of 7 years and their average Oxford Hip Score was 44 (range: 37–48) and median visual analogue pain score was 0 (out of 10). 6 patients (10.5%) developed AVN requiring further surgery and one patient developed chondrolysis (1.8%) but declined further intervention. Complication rate was closely related to time to surgery with 100% AVN rate for surgery within 1 weeks of symptoms onset or 5–7% thereafter. A learning curve was identified with fewer complications seen as the series progressed. Discussion/Conclusion. This is a technically demanding operation with variable outcomes reported in the literature. We have demonstrated good results but feel it should be reserved for specialist centres exposed to higher volumes of these rare cases

Controversy remains as to whether the contralateral hip should be fixed in patients presenting with unilateral slipped capital femoral epiphysis (SCFE). This study compares the outcomes of those patients who had prophylactic fixation with those who did not. We identified 90 consecutive patients with a mean age of 12.3 years presenting to the study centre with SCFE from a prospective operative database. The patient's notes and radiographs were retrospectively analysed for post-operative complications, re-presentation with a contralateral slip, and the presence of a cam lesion. The mean length of follow-up was 8 years (range 3 to 13). Fifty patients (56%) underwent unilateral fixation and 40 patients underwent bilateral fixation, of which 4 (4%) patients had simultaneous bilateral SCFE and 36 (40%) had prophylactic fixation of the contralateral hip. Twenty-three patients (46%) that underwent unilateral fixation, went onto have contralateral fixation for a further SCFE. Two patients from this group had symptomatic femoracetabular impingement from cam lesions and one patient required a Southwick osteotomy for a severe slip. Five patients (10%) that had unilateral fixation only demonstrated cam lesions on radiographic analysis, being suggestive of an asymptomatic slip. No post-operative complications were observed for the contralateral hip in patients that had prophylactic screw fixation and no cam lesions were identified on radiographic assessment. This study suggests that the contralateral hip in patients presenting with unilateral SCFE should be routinely offered prophylactic fixation to avoid a further slip, which may be severe, and the morbidity associated with a secondary cam lesion

We report our early experience with distracting external fixation used to offload the hip after avascular necrosis (AVN) of the femoral head secondary to severe slipped upper femoral epiphysis (SUFE). A case series of five patients treated in a tertiary centre is reported. Electronic case records and radiographs were reviewed. Data recorded included demographics, initial presentation, timing of head collapse, timing and duration of distraction and outcome including referral to adult arthoplasty services. Mean age at presentation was 12 years (range 12–15). 4 were females. Initial treatment in 4 cases was a delayed cuneiform osteotomy and pinning, one patient underwent serendipitous reduction and percutaneous pinning. Mean duration to initial surgery was 10 days (range 5–16). All patients had femoral head collapse at a mean of 148 days from time of presentation. 2 patients required backing out of screws due to intra-articular protrusion. All patients underwent distraction at a mean 193 days from presentation. Average distraction achieved was 10 mm and duration of application was 125 days (range 91–139). All patients experienced improvement or resolution of pain but persistence of poor function, characterised by fixed adduction and limb length discrepancy. 3 patients were referred to adult arthroplasty services. This may be an effective treatment option for pain associated with AVN post SUFE. However, in our experience normal anatomy and function of the hip is not restored if performed after collapse of the femoral head. Consideration should be given to application of the distractor either at the time of initial fixation or prior to femoral head collapse. Authors believe that timing of the application of the distractor is critical for a successful outcome and recommend a prospective study with large numbers

Aim. (1) To determine whether any difference exists in AVN risk between surgical reduction [Fish] or pinning-in-situ [PIS] of severe slips. (2) To review the different classifications of SUFE in relation to AVN. Materials and Methods. 56 children presented with slipped upper femoral epiphysis (SUFE) from 1998 to 2008; 29 males, 27 females; mean age 12.8 years. The Loder & Southwick classifications were used. All slips were treated surgically. The mild and moderate groups were treated with a single pin-in-situ. The severe group had either surgical reduction [Fish femoral neck osteotomy], alternatively a single pin-in-situ, randomised by day of admission. Avascular necrosis of the femoral head (AVN) was the primary outcome measurement. Results. There were seven cases of AVN (12.5%). 2/41 in the stable group developed AVN compared to 5/15 in the unstable group, statistically significant [Chi-Square P=0.001]. No patient in the mild group, one out of seven in the moderate group, and six out of 22 in the severe group developed AVN. In the severe slip group, the AVN rate in the PIS group was 40%, after Fish osteotomy it was 23.5%. This is not statistically significant, but the trend favours surgical reduction. Conclusion and Significance. (1) Surgical reduction by Fish osteotomy is no riskier for AVN than pinning in situ for severe SUFE. Surgical reduction should therefore be performed to avoid gross deformity in these cases. (2) We have confirmed that the stability and the severity of the slip at presentation are the best indicators for predicting AVN

Aim: To compare outcomes in patients who suffered a severe slipped upper femoral epiphysis (SUFE) treated by either a modified Dunn or Imhauser Osteotomy. Method: A consecutive group of patients were identified retrospectively from the operative records of a single surgeon at two hospitals since 2003. Patient Notes were used to extract age at presentation, duration of symptoms, stability, and time to surgery. Radiographs were examined to determine: the slip angle; and the degree of correction achieved. Patients were assessed using the Harris and Oxford Hip Scores. Results: Seven patients had a modified Dunn osteotomy and 11 patients an Imhauser osteotomy. Of those only 6 of the Dunn patients and 7 of the Imhauser patients could be recalled for clinical assessment. The average time to clinical assessment from osteotomy was 13.5 months for the Dunn group and 32 months for the Imhauser group. Post-operative lateral radiographs showed a mean angle of deformity correction of 63 degrees in the Dunn and 36 degrees in the Imhauser groups. There were no postoperative complications in either group, specifically no avascular necrosis. In the Dunn group the Harris Hip Score ranged from 78 to 100, mean 92 (excellent) and the Oxford Hip scores from 12 to 21, mean 17. The Harris Hip Score for the Imhauser group ranged from 50 to 98, mean 76 (fair), and the Oxford scores from 13 to 34, mean 25. Range of motion was similar for both groups in all directions. Conclusions: The Dunn and Imhauser osteotomies both give good clinical results in the severe SUFE patient. However the Dunn Osteotomy group had better Harris and Oxford Hip Scores, reflecting improved functional outcome

Purpose: To assess the results of this technique for stabilisation of severe spondylolisthesis. Method: Twelve patients with symptomatic severe spondylolisthesis were treated with this technique. All the patients had significant symptoms, inspite of conservative measures. The mean duration of symptoms was 3.5 years. The fixation technique was purely done through a posterior approach, with extensive posterior decompression. Stabilisation of the slipped L. 5. vertebra was achieved with a trans sacral screw. The point of entry of the screw being the posterior part of the body of S. 1. and it traverses the L. 5. -S. 1. disc space into the L. 5. body. A hollow medullary screw passed over a guide wire helps achieve the fixation. This fixation is supplemented with pedicle screws into L. 5. and S. 1. and posterolateral bone grafting. Thus an anterior and posterior fusion was achieved and the severe slip fixed in-situ. Results: The mean follow-up was 1 year. All but one (8%) patient had improvement in leg pain. 2(16%) patients were aware of the prominent metalwork (pedicle screws). Good 360° fusion was achieved using this technique in all the patients. There was no progression of spondylolisthesis. Conclusion: Thus, anterior and posterior in-situ fusion for severe L. 5. -S. 1. spondylolisthesis can be achieved effectively using a single incision via a transsacral approach

Aims: To find a long-term effect of posterolateral fusion for isthmic spondylolysis and spondylolisthesis on lumbar spine. Methods: A posterolateral fusion was performed on 56 patients (30 females, 26 males) with an average age of 16 (range 11 to 20) years. A clinical and MRI examination was performed on these patients on average 18 years later (range 11 to 25 years). The size of the spinal canal were assessed. Disc space, degeneration and protrusions were evaluated. Bone marrow changes (Modic I & II), facet joint degeneration and the state of the spinal muscles were assessed. Results: In MR images, none of the patients had lumbar spinal stenosis. In contrast, the spinal canal was wide in the level spondylolysis and spondylolisthesis. Narrowing of the neural foramina was noted in 13 (23%) patients. This was associated usually in severe slip (> 50%) and was noted always at the L5-S1 level. Of the studied 332 intervertebral discs 56 (17%) were speckled and 57 (17%) were black and 76 (23%) narrowed. Most commonly speckled/black and narrowed disc was found in the two lowest lumbar levels. Only one patient, 41-year-old female, had prolapse. Modic I and II changes were noted in 7 (2%) and 9 (3%) intervertebral disc levels, respectively. Degenerative-like facet joint hypertrophy was noted in 47 (48%) of the studied levels. Of the patients, seven (12%) had muscular atrophy. Conclusions: Stenosis of neural foramina may be associated to severe spondyolisthesis. Degenerative changes were found most commonly found in the level of the spondylolysis and spondylolisthesis and above fusion level. Bone marrow changes associated with disc degeneration were rare

Introduction: To determine whether there is a correlation between severity of the slip and duration of symptoms in patients presenting with slipped capital femoral epiphysis. Methods: 50 patients with slipped capital femoral epiphysis were identified from the Royal Hospital for Sick Children database from 1998 to 2003. Of these, 47 patients had casenotes and radiographs available. 12 patients had bilateral slips resulting in a total of 59 slipped capital femoral epiphyses studied. On the basis of their history, 16 of these hips were unstable and were excluded leaving 43 stable slips in 35 patients. Case-notes were reviewed and the exact age, weight, symptom duration and treatment were recorded. X-rays were assessed and the slip angle was measured by the technique described by Southwick. Results: The mean age of the patients was 11years 9months (7yrs 5 mths – 16 yrs 5mths). There were 19 males and 16 females. Weights were plotted against age on a centile chart with 85% of patients weighing > 75th centile for age.The mean duration of symptoms was 12.1weeks (2days – 52weeks)The mean slip angle was 22° (5° – 65°)There were 34 mild slips (< 30°), 8 moderate slips (30° – 60°) and 1 severe slip (> 65°). There was no statistical difference in duration of symptoms between these groups. Statistical analysis by ordinal regression analysis showed there was no correlation between slip severity and duration of symptoms. In addition, there was no correlation between slip severity and age or weight. Conclusion: There appears to be no relationship between slip severity and duration of symptoms in patients presenting with stable slipped capital femoral epiphysis

Introduction: The management of severe slipped upper femoral epiphysis (SUFE) is controversial. Many types of operation have been advocated. The cuneiform osteotomy offers the potential to restore normal anatomy and hence reduce the development of osteoarthritis, but it is not without its risks. This aim of this study was to quantify the long-term clinical & radiological results of Fish’s cuneiform osteotomy at skeletal maturity. Method: Twenty-seven patients underwent a cuneiform osteotomy between 1990 – 2003. Two patients were lost to follow-up. Therefore 25 hips in 24 patients were reviewed at a mean follow-up of 8 years and 3 months. The mean slip angle was 77 ± 13 degrees and all were categorized as unstable. Sex distribution was equal and the average age at follow-up was 21.5 years (range 14 – 31 years). The Iowa hip-rating, Harris Hip Score and radiographic classification of degenerative joint disease according to Boyer et al.,. 1. were determined at follow-up. Results: The mean Iowa hip-rating at follow-up was 93.7 ± 7.7 with a mean range of motion score of 8.1 ± 1.8. The Harris Hip Score was 95.6 ± 5.9. Nineteen patients were classified as Grade 0 on Boyer’s radiographic assessment, four Grade 1 and two Grade 2. Correction to neutral ± 10 degrees was achieved in all patients. The rate of avascular necrosis was 12 % and chondrolysis 16 %. Discussion: Cuneiform osteotomy for severe SUFE is a valid treatment option and complication rates were no higher than other operative interventions reported in the literature. Patients enjoyed an excellent range of motion and were extremely satisfied with the outcome. The restoration of anatomy equates to better function and possibly the delay in onset of osteoarthritis

We treated patients with severe slipped capital femoral epiphysisor SCFE with a posterior tilt angle or PTA of greater than or equal to 60 degrees with a Sugioka transtrochanteric rotational osteotomy. We report on the clinical and radiologic results of tis method. The study was performed on 8 cases (including 9 hips) of slipped capital femoral epiphysis, for which transtrochanteric rotational osteotomy of femoral head (Sugioka method) was carried out in author’s department from 1987 to 1996. The age of onset ranged from 9 to 14 years old (average: 11.6 years). There were 4 boys (4 hips) and 4 girls (5 hips). The follow-up period ranged from 2 years to 10 years (average: 4.4 years). Three of the treated hips were classified as chronic and 6 as acute on chronic. Preoperative head-neck angle (HNA) was 64 – 83 degrees (average: 68 degrees). All patients were performed a transtrochanteric rotational osteotomy of the femoral head which is known as the Sugioka method. The rotational angle was from 70 degrees to 90 degrees. The presence of pain, postoperative range of motion, PTA on postoperative X-rays, avascular necrosis and osteoarthritic change were examined as part of the evaluation of the clinical results. Necrosis of femoral head was found in one case, while no pain was noted in the other cases, and the range of motion was generally satisfactory. In the radiologic results, PTA was improved to 10 – 25 degrees (average: 18.5 degrees). Necrosis of femoral head was observed in one hip, but the results were satisfactory in 7 cases (8 hips). These results suggest that this technique is useful for the treatment of severe cases of slipped capital femoral epiphysis

Aims

Slipped upper femoral epiphysis (SUFE) has well documented biochemical and mechanical risk factors. Femoral and acetabular morphologies seem to be equally important. Acetabular retroversion has a low prevalence in asymptomatic adults. Hips with dysplasia, osteoarthritis, and Perthes’ disease, however, have higher rates, ranging from 18% to 48%. The aim of our study was to assess the prevalence of acetabular retroversion in patients presenting with SUFE using both validated radiological signs and tomographical measurements.

The initial management of slipped upper femoral epiphysis (SUFE) can determine the occurrence of longterm disability due to complications. Previous surveys have concentrated on orthopaedic surgeons with a specialist paediatric interest. In many units in Scotland, the initial responsibility for management may be an admitting trauma surgeon with a different subspecialty interest. All Orthopaedic surgeons in Scotland participating in acute admitting were invited to complete a web based survey to ascertain current practice in the initial management of adolescents presenting with SUFE. 92/144 (64%) of surgeons approached responded. When faced with a severe stable slip, 53% of respondents were happy to pin in situ, whilst 47% would refer either to a colleague or specialist paediatric unit. With an unstable slip of similar magnitude, 38% would self-treat, 18% refer to a colleague and 44% refer to a paediatric orthopaedic unit. Of those treating, 58% stated their treatment was selected irrespective of timing of presentation. 79% of respondents had treated 5 or less cases in the preceding 5 years with 7% more than 10 cases. Universal prophylactic pinning was supported in 29%, selective in 62% and never in 9%. The responses obtained confirm the variance in management of SUFE that exists amidst acute admitting units in Scotland. Management of a stable slip is uncontroversial except possibly in severe cases. This contrasts with the acute unstable slip, in which various factors are thought to influence the outcome, such as instability and the issue of timing, which are not universally appreciated

Aims

Our retrospective analysis reports the outcome of patients operated for slipped capital femoral epiphysis using the modified Dunn procedure. Results, complications, and the need for revision surgery are compared with the recent literature.

Introduction: Avascular necrosis (AVN) is a serious complication affecting the femoral head following an unstable slipped capital femoral epiphysis (SCFE) particularly if the slip is severe. The incidence of AVN may be as high as 47%. Purpose: To determine whether or not the avascular insult associated with a massive unstable SCFE is a temporary event and whether this may resolve in the second week post injury. Methods: 6 patients (4 male:2 females), mean age 14.9 yrs (13.2–17.5yrs) with acute severe unstable SCFE were reviewed. The mean Southwick slip angle was 51.20 deg (40.1 – 66.60). 5 of 6 cases were severe. All cases underwent a subcapital cuneiform femoral neck osteotomy at a mean 14 days (7–24 days) after the acute event. Pre-operatively, the hip/limb was rested in ‘slings and springs’. No hip underwent a manipulative procedure. All hips underwent an MRI scan at a mean 8.6 days post injury (range 4–15 days) to determine the viability of the femoral head. Results: In all 6 cases, the femoral head was reported to be viable. All femoral heads showed signs of bone oedema and other features indicative of a blood supply. Following the cuneiform osteotomy, patients were mobilized partial weight bearing for 8 weeks. At a mean 12 month follow up, radiographs confirmed that all oste-otomies had united and no hip showed evidence of AVN. Conclusion: If the acute severe unstable slip is associated with an avascular insult to the femoral head, this may be a temporary phenomenon and assuming the hip is not subjected to any immediate secondary trauma such as operative reduction, then there may be a spontaneous recovery in the blood supply as evidenced by the viable femoral head seen on MRI. Significance: Our study suggests that there may be a time period during which the slipped femoral head may be vulnerable to a second insult and hence AVN. The timing of any surgical intervention designed at reducing the slip should take this into account and be performed carefully to ensure that the blood vessels on the posterior aspect of the femoral neck are not disrupted. When the presentation of an acute unstable and severe SCFE is delayed beyond 24 hours, we favour delaying subsequent operative correction for a further 2–3 weeks to maximize the chance of a viable femoral head