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
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to InjuryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Incidence and gender differences of slipped capital femoral epiphysis in the Netherlands from 1998 to 2010 combined with a review of the literature on epidemiology of SCFE.J Child Orthop. 2013; 7: 99-105
- The epidemiology of slipped capital femoral epiphysis: an update.J Pediatr Ortho. 2006; 26: 286-290
- Slipped capital femoral epiphysis.Inst Course Lect. 2001; 50: 555-570
- The demographic of slipped capital femoral epiphysis: an international multicentre study.CORR. 1996; 322: 8-27
- Atypical and typical (idiopathic) slipped capital femoral epiphysis.JBJS. 2006; 88: 1574-1581
- Slipped capital femoral epiphysis: a prospective study of fixation with a single screw.JBJS. 1992; (74-A:810-9)
- Management of unstable/acute slipped capital femoral epiphysis: results of a survey of the POSNA membership.J Pediatr Orthop. 2005; 25: 162-166
- Anterior Physeal Separation: a sign indicating a high risk for avascular necrosis after slipped capital femoral epiphysis.JBJS. 2002; (84-B:1176-9)
- The most important risk factors for avascular necrosis and chondrolysis in patients with slipped capital femoral epiphysis.J Med Assoc Thai. 2014; 97: S133-S138
- Fixation of intracapsular fractures f the femoral neck in young patients: risk factors for failure.J Bone Joint Surg. 2011; (93-B:811-816)
- A concordance correlation coefficient to evaluate reproducibility.Biometrics. 1989; 45: 255-268
- A note on the concordance correlation coefficient.Biometrics. 2000; 48: 599-604
McBride G.B.: National Institute of Water and Atmospheric Research Ltd (NIWA): client Report 2005: a proposal for strength-of-agreement criteria for Lins Corcordance Correlation Coefficient - HAM 2005-062. Available online at http://www.medcalc.org/download/pdf/McBride2005.pdf [Last Accessed 2nd January 2020]
- Acute slipped capital femoral epiphysis: the importance of physeal stability.JBJS. 1993; 75: 1134-1140
- The role of capital realignment versus in situ stabilization for the treatment of slipped capital femoral epiphysis.J Paediatr Orthop. 2014; 34: 791-798
- Does the upper femoral epiphysis slip or rotate?.JBJS(Br). 2007; 89: 1402-1406
- The modified Dunn procedure for slipped capital femoral epiphysis: the Bernese experience.J Child Orthop. 2017; 11: 138-146
- Vascular supply to slipped capital femoral epiphysis.J Paediatr Orthop B. 2001; 21: 664-667
- Imaging modalities in patients with slipped capital femoral epiphysis.J Child Orthop. 2017; 11: 99-106
- The role of pre-treatment MRI in established cases of slipped capital femoral epiphysis.Eur J radiol. 2009; 70: 570-578
- Magnetic resonance perfusion and diffusion imaging charatceristics of transient bone marrow edema, avascular necoris sna d subchondral insufficiency fractures of the proximal femur.Eur J Radiol. 2014; 83: 1862-1869
- The treatment of severe slipped capital femoral epiphysis via the Ganz surgical dislocation and anatomical reduction: a prospective study.Bone Joint J. 2013; 95-B: 424-429
- Surgical hip dislocation for anatomic reorientation of slipped capital femoral epiphysis: preliminary results.Hip Int. 2012; 22: 137-144
- Complication after modified Dunn Osteotomy for the treatment of adolescent slipped capital femoral epiphysis.J Paediatr Orthop. 2014; 34: 561-567
- The modified Dunn procedure for untable slipped capital femoral epiphysis: a multicentre perspective.JBJS. 2013; 96: 585-591
- open reduction and smooth Kirschner wire fixation for unstable slipped capital femoral epiphysis.J Paediatr Ortho. 2009; 29: 1-8
- Restoration of blood flow to the proximal femoral epiphysis in unstable slipped capital femoral epiphysis by modified Dunn procedure: a preliminary angiogrpahoc and intracranial pressure monitoring study.J Paediatr Ortho. 2018; 38: 94-99
- Intraoperative monitoring of epiphyseal perfusion in slipped capital femoral epiphsyis.JBJS. 2016; 98: 1030-1040
- Intraoperative monitoring of epiphyseal perfusion in slipped capital femoral epiphysis – surgical technique.JBJS Essential Surg tech. 2017; 7: e2
- Is assessment of femoral head perfusion during modified Dunn for unstable slipped capital femoral epiphysis an accurate indicator of osteonecrosis?.CORR. 2016; 474: 1837-1844
NICE Guidelines IPG511: Open reduction of slipped capital femoral epiphysis. Available at https://www.nice.org.uk/guidance/ipg511/chapter/2-Indications-and-current-treatments [Last accessed 27th December 2018]
- Is it worth the risk and cost not to offer prophylactic fixation of the contralateral hip?.Bone Joint J. 2015; 97-B: 1428-1434
- gabos PG: bilateral slipped capital femoral epiphysis: predictive factors for contralateral slip.J Paediatr Orthop. 2007; 27: 411-414
- Prediction fo contralateral slipped capital femoral epiphysis using the modified Oxford bone age score.J Paediatr Orthop. 2012; 32: 290-294
- Chondrolysis, osteonecrosis and slip severity in patients with subsequent contralateral slipped capital femoral epiphysis.JBJS. 2008; 90: 485-492
- Severity of asynchronous slipped capital femoral epiphysis in skeletally immature versus more skeletally mature patients.J Paediatr Orthop. 2017; 37: e23-e27
- slipped capital femoral epiphysis: the European Perspective.J Paediatr Orthop. 2018; 38: S1-S4
- Management of slipped capital femoral epiphysis: results of a survey of the members of the European Paediatric Orthopaedic Society.J Child Orthop. 2011; 5: 433-438
- Current practice in the management of acute/unstable slipped capital femoral epiphyses in the United Kingdom and the Netherlands: results of a survey of the membership of the British Society of Children's Orthopaedic Surgery and the Werkgroep Kinder Orthopaedie.J Pediatr Orthop B. 2007; 16: 79-83
Article Info
Publication History
Published online: October 19, 2022
Accepted:
October 17,
2022
Identification
Copyright
© 2022 Elsevier Ltd. All rights reserved.
