Abstract
Aims
We sought to determine if the magnitude of anterior physeal separation (APS) in slipped
upper femoral epiphysis was a predictor for the subsequent development of avascular
necrosis (AVN). Anterior Physeal Separation (APS) is defined as the distance between
the anterior lip of the bony capital epiphysis and the lateral corresponding point
of the adjacent bony metaphysis on the Lauenstein radiographic view. It represents
hinging of the posterior aspect of the metaphysis with the anterior epiphysis lifting
away from its adjacent metaphysis, indicating instability and potential vulnerability
of the vessels.
Patients and Methods
A retrospective review of all patients treated regionally for slipped upper femoral
epiphysis over a 9 year period (2010–2018 inclusive) were identified. Data regarding
demographics, radiological parameters and outcomes was recorded. APS was measured
on a Launestein radiograph view, with the patient supine, the hip and knee are flexed
to 40°, and the hip externally rotated 45°, with film-focus distance of 100 cm. Analysis
of the APS was performed to validate a threshold above which AVN occurs.
Results
We identified 147 hips in 142 patients, of which 5 had bilateral slips at the time
of presentation. Average anterior physeal separation was 3.8 ± 1.8 mm, with higher
grade slips having significantly greater APS values. Increased APS values were seen
with Loder “unstable” slips. Seven hips (4.8%) developed AVN, and in these cases the
APS was significantly larger than those who did not (8.5 ± 1.4 Vs 3.9 ± 1.7; p < 0.001). Receiver operator curve analysis demonstrated a critical value of 7.5 mm
was associated with a 100% sensitivity and 98.6% specificity for AVN. We identified
some grade II/moderate slips with high APS values had similar outcomes to grade III/severe
slips, and therefore suggest that APS may serve to alert the surgeon on counselling
patients on the risk of developing AVN and to consider strategies to minimise the
risk of AVN.
Conclusions
APS is sensitive, specific, accurate and reliable for the association with AVN in
SUFE. Its values closely reflect the high AVN rates seen in acute and unstable SUFE.
This risk is greatest if the magnitude of APS exceeds the critical value of 7.5 mm.
Keywords
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Article info
Publication history
Published online: October 19, 2022
Accepted:
October 17,
2022
Identification
Copyright
© 2022 Elsevier Ltd. All rights reserved.
