What is the role of surgery in the treatment of slipped capital femoral epiphysis (SCFE)?

Updated: Dec 03, 2018
  • Author: Kevin D Walter, MD, FAAP; Chief Editor: Craig C Young, MD  more...
  • Print

At this time, immediate internal fixation in-situ using a single cannulated screw is the treatment of choice of SCFE. Fixation allows early stabilization of the slippage, enhancement of physeal closure, prevention of further slippage, and amelioration of symptoms with minimal morbidity. [31, 32] Unstable or grade III slips may require gentle repositioning to improve alignment. Revision of the screw fixation may be needed if the child "outgrows" the screw, placing the child at risk for a repeat slip.

Prophylactic fixation of the unaffected hip in unilateral SCFE remains controversial. [3, 33] Each case should be approached individually. However, stronger consideration for the prophylactic fixation should be given to patients with endocrinologic or metabolic comorbidities, or patients who fall outside of the usual age range (10-16 y).

Wensaas et al evaluated the long-term natural history of untreated contralateral hips to see if there is a consensus regarding prophylactic fixation of the contralateral hip in SCFE. 40 patients treated for unilateral SCFE without evidence of subsequent contralateral slip during adolescence were reviewed with a mean follow-up of 36 years (range 21-50 years). The authors concluded that since the natural history showed good long-term radiographic and clinical outcome in 35 of 40 patients, that routine prophylactic fixation of the contralateral hip is not indicated. [34]

Evidence suggests that if surgical intervention occurs within 24 hours of SCFE onset, significantly fewer complications occur (7% AVN). However, if surgical intervention occurs between 24 and 48 hours, the AVN rate dramatically increases (87.5%). This risk decreases to 32% if the procedure is performed after 48 hours. True cause and effect among onset, diagnosis, and intervention cannot be truly ascertained; thus, urgency with surgical intervention is still the unquestioned rule. A study by Kohno et al found that patients with unstable slipped capital femoral epiphysis who underwent a closed reduction and pinning procedure between 24 hours to 7 days after the onset of symptoms were at significantly higher risk for AVN. [35]

Osteotomy of the proximal femur is not indicated as the primary procedure for SCFE. However, it may be needed as a secondary procedure for repositioning of the femoral head to improve functional range of motion, or as a primary procedure for patients with severe morphologic displacement.

Bone-graft epiphysiodesis in combination with internal fixation or casting is advocated by some surgeons, but the procedure is associated with a high learning curve, a high prevalence of AVN and chondrolysis, poor initial fixation, prolonged operative time, increased intraoperative blood loss, and loss of epiphyseal position. [34]

Historically, spica casts were used [36] ; however, because of the high morbidity (eg, AVN, chondrolysis) and difficulty in applying and maintaining these casts, especially in patients who are obese, spica casts have fallen out of favor.

Two techniques to correct moderate and/or severe SCFE have been evaluated [37, 24] :

Witbreuk et al performed epiphysiodesis combined with early Imhauser intertrochanteric osteotomy in 28 patients (32 hips) to downgrade moderate and severe SCFE to diminish mechanical impingement and prevent osteoarthritis. [37] At a median follow-up of 8 years (range, 2-25 y), the patients were performing well clinically, functionally, and socially. In addition, there were no radiologic signs of chondrolysis or avascular necrosis, and greater than 80% of the patients did not have signs of osteoarthritis. [37]

Lawane et al retrospectively evaluated the Dunn procedure in adolescents aged 10-15 years with severe SCFE (epiphyseal slippage of 60-90 degrees) with regard to avascular necrosis of the femoral head. [24] Of the 25 cases, 15 achieved good clinical and radiologic results, but 10 had immediate or late complications, for a 40% complication rate. Of the 8 immediate complications (32%), 4 were necroses (16%), 2 of which resulted in arthritis; 3 were chondrolyses, all of which progressed to arthritis; and 1 was mechanical. [24] Before 10-year follow-up, 2 arthrodeses and 3 hip replacements were performed. At long-term follow-up, an additional 2 late deteriorations occurred despite initial favorable clinical and radiologic outcomes.

The investigators concluded that although the Dunn procedure limits the vascular risk of surgical correction of the SCFE displacement, there are issues of concern, including "tricky" technical aspects of the procedure and the risk of necrotic complication, at rates up to 17% in other reported series. [24] Lawane et al reported a necrosis rate of 16%, which they found unacceptable in view of the immediate loss of joint function in the adolescent patients. Their preferred approach to severe SCFE is arthrotomy followed by a direct approach to the displacement with associated anterior cuneiform neck resection. [24]

A multicenter study of 186 cases of SCFE that evaluated the results of various treatment strategies for severe SCFE reported favorable results with the "anterior" Dunn procedure with regards to stopping the slip and preventing osteoarthritis while having a relatively low complication rate. [25]

Did this answer your question?
Additional feedback? (Optional)
Thank you for your feedback!