Despite recent advances in the management of slipped capital femoral epiphysis (SCFE), controversy remains about the treatment of choice for unstable slips. Surgical dislocation and open reduction has the advantage of identifying and preserving the blood supply of femoral head thereby potentially reducing the risk of avascular necrosis, (AVN). There is large variation in the literature from several small series about reported AVN rates ranging from two to 66% for unstable SCFE treated with surgical dislocation. The aim of our study was to analyze our experience with acute open reduction and internal fixation of unstable acute and unstable acute on chronic slips using the technique of surgical dislocation described by Professor Reinhold Ganz. A retrospective review of 11 patients (12 hips) treated by surgical dislocation, reduction and pinning as the primary procedure for unstable acute and unstable acute on chronic SCFE in a tertiary referral children's hospital was undertaken. This represents the entire series treated in this manner from September 2007 to January 2018. These procedures were performed by a team of Orthopaedic surgeons with significant experience performing surgical dislocation of the hip including patients with chronic SCFE, Perthes' disease, impingement and acetabular fractures. Demographic data, intraoperative records, postoperative notes and radiographs including details of subsequent surgery were reviewed. There were seven boys and four girls with mean age of 13.4 years, range 11 to 15 years at the time of surgical dislocation. Out of 12 hips, two had acute unstable slip while the remaining 10 had acute on chronic unstable slip. Six patients had good or excellent results. The remaining six patients developed AVN of which three patients had total hip replacement at six months, 17 months and 18 months following primary procedure. Seven patients required more than one operation. Three patients lost their correction and required re fixation despite surgical dislocation, reduction and fixation being their primary procedure. This series demonstrates a high percentage of AVN (50%) in severe unstable SCFE treated with surgical dislocation despite careful attention to retinacular flap development and intra operative doppler studies. This is in direct contrast to our experience with subcapital reorientation with surgical dislocation in stable slips where excellent results were achieved with a low rate of AVN. Pre-operative imaging with MRI and perfusion studies may identify where ischemia has occurred and might influence operative treatment. Based on our results, we do not recommend routine use of surgical dislocation in unstable SCFE. This technique requires further scrutiny to define the operative indications in unstable SCFE

A group of UK paediatric surgeons (the UK SCFE Study Group) convened to design pertinent trials in slipped capital femoral epiphysis (SCFE), twelve centres across the UK reviewed the demographics and management of children with SCFE. At all contributing centres with digital PACS records, a search for terms relating to SCFE were performed. From the results, radiographs and electronically stored clinic letters were assessed to confirm the diagnosis and ascertain age at presentation, incidence of bilaterality, chronicity, stability, management and complications. A total of 601 SCFEs presented between 2007 and 2012 to the twelve units. The mean age at presentation was 12.5 years. The left hip was nearly twice as commonly involved compared to the right (R: L = 3.3: 5.1), with bilateral presentation in 22% of patients. The most common mode of presentation was acute-on-chronic. Stable slips were over twice as common as unstable. The most common intervention was percutaneous pinning in situ. Open reduction was required in 24% of cases. The commonest complication was osteonecrosis (10.5%). This data concurs with earlier smaller audits and highlights current demographics and contemporary management of SCFE throughout the UK and informs the subject and content of potential future randomized control trials

Management of the young adult hip pathologies is a special entity in orthopaedic surgical practice that needs special emphasis and consideration. A wide range of pathological and traumatic conditions occur in the young adult hip that lead to functional disability and the development of premature osteoarthritis. Proper surgical interference when the hip is still in the pre-arthritic stage restores function to the young hip and protects it from early degenerative changes, and hence the anticipated need for future joint replacement surgery is prevented. Accurate estimation of the biomechanical error combined with careful understanding of the hip joint biology is the cornerstone of success of any hip preservation surgery ever performed to save the young adult hip. Safe surgical hip dislocation approach was adopted as one of the tools in the hands of the hip preservation surgeon to treat a broad spectrum of intra-articular hip pathologies like Perthes disease and severe forms of slipped capital femoral epiphysis (SCFE). Osteo-chondroplasty at the head-neck junction with relative femoral neck lengthening for Perthes disease, and Subcapital re-orientation of severe SCFE based on its retinacular vascular pedicle are often performed via the surgical hip dislocation approach. The approach is also useful with certain types of acetabular fractures that enables fixation of dual-column fractures via single approach with intra-articular visualization for the accuracy of reduction and hardware placement. The 4 cm mini-open direct anterior approach is ideal for the surgical treatment of cases with cam and/or pincer types of femoro-acetabular impingement. Peri-articular osteotomies performed either on the acetabular or the femoral sides of the hip joint are extremely useful in the correction of the biomechanical error that led to an existing hip pathology. Periacetabular osteotomies are commonly performed to treat dysplasia of the young hip. Proximal femoral osteotomies are commonly performed to treat a wide range of hip pathologies including non-unions of femoral neck fractures in the young adult. Correction of the biomechanical error at the proper timing ensures normalization of the hip joint loading conditions and range of motion that leads to reversal of the pathologic process and prevention of osteoarthritis. A hip joint replacement would have an unknown but certainly a finite life, whereas a young hip that has healed after hip preservation surgery would definitely last for a lifetime

Introduction. Hips following in-situ pinning for slipped capital femoral epiphysis (SCFE) have an altered morphology of the proximal femur with cam type deformity. This deformity can result in femoroacetabular impingement and early joint degeneration. The modified Dunn procedure allows to reorientate the slipped epiphysis to restore hip morphology and function. Objectives. To evaluate (1) hip pain and function, (2) 10-year survival rate and (3) subsequent surgeries and complications in hips undergoing modified Dunn procedure for SCFE. Methods. Between April 1998 and December 2005 we performed the modified Dunn procedure for 43 patients (43 hips) with SCFE. Twenty-five hips (58) presented with an acute or acute on chronic slip. The mean slip angle was 43° (range, 15° – 80°). A majority of 53% of procedures were performed in male patients and the mean age at operation was 13 years (10 – 19 years). We could followup all except one hip (followup of 5.5 year) for a minimum of 10 years (mean followup 13 [10 – 18 years]). We used the anterior impingement test to assess pain and the Merle d'Aubigné- ostel score to assess function. Survivorship calculation was performed using the method of Kaplan and Meier and any of the following factors as a definition of failure: radiographic evidence of worsening osteoarthritis (OA), or a Merle d'Aubigné-Postel score less than 15. Results. (1) The prevalence of a positive anterior impingement test decreased from 100% to 16% (p<0.001). The mean Merle d'Aubigné-Postel score improved from 13 (7 – 14) to 17 (14 – 18) at most recent followup (p<0.001). (2) Four hips (9%) showed progression of OA and three hips (7%) had a Merle d'Aubigné-Postel score of less than 15 at most recent followup. This resulted in a 93% survival rate at 10-year followup. (3) No hip developed avascular necrosis. Five hips (12%) had complications with reosteosynthesis due to screw breakage or nonunion. Another nine hips (21%) had subsequent surgeries including acetabular rim trimming / offset creation in 5 hips and screw removal in 4 hips. Conclusion. The modified Dunn procedure is a safe method to correct the morphology of the proximal femur in hips with SCFE. Ninety-free percent of the hips showed no progression of OA and a good clinical result at the 10-year followup. Twelve percent required revision surgery for complications all including screw breakage with nonunion of the greater trochanter

Unstable slipped capital femoral epiphysis (SCFE) has an increased incidence of avascular necrosis (AVN). The purpose of this study was to determine if early identification and intervention for AVN may help preserve the femoral head. We retrospectively reviewed 48 patients (50 hips) with unstable SCFE managed between 2000 and 2014. Based on two different protocols during the same time period, 17 patients (17 hips) had a scheduled MRI between 1 and 6 months from initial surgery, with closed bone graft epiphysiodesis (CBGE) or free vascularised fibular graft (FVFG) if AVN was diagnosed. Thirty-one patients (33 hips) were evaluated by plain radiographs. Outcomes analysed were Steinberg classification and subsequent surgical intervention. We defined Steinberg class IVC as failure in treatment because all of the patients referred for osteotomy, arthoplasty, or arthrodesis in our study were grade IVC or higher. Overall, 13 hips (26%) with unstable SCFE developed AVN. MRI revealed AVN in 7 of 17 hips (41%) at a mean of 2.5 months postoperatively (range, 1.0 to 5.2 months). Six hips diagnosed by MRI received surgical intervention (4 CBGE, 1 FVFG, and 1 repinning due to screw cutout) at a mean of 4.1 months (range, 1.3 to 7.2 months) postoperatively. None of the 4 patients treated with CBGE within two months postoperatively progressed to stage IVC AVN. The two patients treated after four months postoperatively both progressed to stage VC AVN. Radiographically diagnosed AVN occurred in 6 of 33 hips (18%) at a mean of 6.8 months postoperatively (range, 2.1 to 21.1 months). One patient diagnosed with stage IVB AVN at 2.4 months had screw cutout and received CBGE at 2.5 months from initial pinning. The remaining 5 were not offered surgical intervention. Five of the 6 radiographically diagnosed AVN, including the one treated with CBGE, progressed to stage IVC AVN or greater. None of the 4 patients with unstable SCFE treated with CBGE within 2 months post pinning developed grade IVC AVN, while all patients treated with other procedures after 2 months developed IVC or greater AVN. Early detection and treatment of AVN after SCFE may alter the clinical and radiographic progression

INTRODUCTION. Childhood diseases involving the proximal femoral epiphysis often cause abnormalities that can lead to end-stage arthritis at a relatively young age and the need for total hip arthroplasty (THA). The young age of these patients makes hip resurfacing arthroplasty (HRA) an alternative and favorable option due to the ability to preserve femoral bone. Patients presenting with end-stage hip arthritis as sequelae of childhood diseases such as Legg-Calves-Perthes (LCP) and slipped capital femoral epiphysis (SCFE) pose altered femoral anatomy, making HRA more technically complicated. LCP patients can result in coxa magna, coxa plana and coxa breva causing altered femoral head-to-neck ratio. There can also be acetabular dysplasia along with the proximal femoral abnormalities. SCFE patients have altered femoral head alignment. In particular, the femoral head is rotated medially and posteriorly, reducing the anterior and lateral offset. Additionally, many of these patients have retained hardware, making resurfacing more complicated. We report findings of a cohort of patients, with history of either LCP or SCPE who underwent HRA to treat end-stage arthritis. METHODS. Data was retrospectively collected for patients who had HRA for hip arthritis as a result of either LCP (n=67) or SCFE (n=21) between 2004 and 2014 performed by two surgeons. Demographic information, clinical examination and improvement was collected pre and postoperatively. Improvement was determined using Harris Hip Scores (HHS) and UCLA activity scores. Anteroposterior radiographs were measured pre and postoperatively to determine leg length discrepancy. Radiographs were inspected postoperatively for radiolucent lines, implant loosening and osteolysis. Kaplan-Meier survivorship for freedom from reoperation for any reason was calculated. Paired student t-tests were used to compare groups. RESULTS. The average age at the time of surgery was 44 years (11.8–68), with an average follow-up of 3.7 years (.22–11.2). Retained hardware was present in a total of 5 patients, 1 LCP and 4 SCFE. Preoperative HHS was 58.3 (33–83), which increased significantly to 94.9 (55–100) at the most recent postoperative timepoint (p<.0001). The most recent UCLA activity score was 7 (1–10). Average leg length discrepancy preoperatively was 7.5mm (0–20), which significantly improved to 0.6mm (0–7.5) postoperatively (p<.0001). At most recent follow-up, metal ion testing revealed median chromium level of 2.3 parts per billion (ppb, 1–7.7) and median cobalt level of 1.5 (0–9.2). There were three failures in the group with 1 LCP due to instability at 2.7 years, and 2 SCFE due to femoral neck fracture at 1 month in one and clinical failure due to unexplained pain at 5.5 years in one. Revision surgery was done in 2 patients, 1 LCP and 1 SCFE. Radiographic examination of all non-failure HRA patients revealed implants to be in good alignment with no indication of implant loosening at the most recent postoperative timepoint. Kaplan-Meier survivorship for freedom from revision was 96.2 at 5 years. CONCLUSION. The findings demonstrated increase in functional outcomes in patients who underwent HRA for osteoarthritis associated with LCP and SCFE. There was no increase in complications including femoral neck fracture or implant loosening despite technical challenges of the procedure