Orthopedics

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Case Reports 

Slipped Capital Femoral Epiphysis in an Adult With Panhypopituitarism

Ming-Hsiao Hu, MD; Yu-Ming Jian, MD; Yon-Te Hsueh, MD; Wei-Hsin Lin, MD; Rong-Sen Yang, MD, PhD

Abstract

Slipped capital femoral epiphysis usually occurs in children going through a pubertal growth spurt, possibly because the immature proximal femoral physis is unable to bear the shear stress. It commonly occurs in adolescents between 10 and 16 years. Slipped capital femoral epiphysis in adults is uncommon, with only 10 cases reported in the literature. This article presents a case of a 29-year-old man with craniopharyngioma diagnosed when he was 19. He underwent surgery with subtotal tumor excision and postoperative radiotherapy, but received no further treatment for the panhypopituitarism concomitant with the tumor. He reported sudden onset of left hip pain after riding a bicycle and underwent surgical fixation 5 days later. He also underwent hormone replacement therapy, including prednisolone, thyroxin, desmopressin, and testosterone, and regular clinical follow-up. His hip function recovered with a painless gait. At 18-month follow-up, neither osteonecrosis nor contralateral slipped capital femoral epiphysis was noted. Furthermore, bilateral proximal femoral physes were also closed. For stable slippage as in this case, in situ pinning fixation is a commendable method. A high index of suspicion of endocrinal disorder and proper management are essential for successful treatment of adult slipped capital femoral epiphysis.

Slipped capital femoral epiphysis occurs in children going through a pubertal growth spurt, possibly because the immature proximal femoral physis is unable to bear the shear stress. It commonly occurs in adolescents between ages 10 and 16 years. Slipped capital femoral epiphysis occurs more frequently in obese children with male predominance. The left hip is affected twice as often as the right whereas the bilateral involvement ranges from 25% to 40%.1 Several etiological factors have been suggested for slipped capital femoral epiphysis, such as local trauma,2 obesity,3,4 endocrine disorders (such as hypothyroidism, hypopituitarism, and hyperparathyroidism),5-7 genetic factors,8 etc. Slipped capital femoral epiphysis may also complicate the course of growth hormone therapy.9,10 This article presents a case of a 29-year-old man who had craniopharyngioma associated with panhypopituitarism, including hypogonadotropic hypogonadism and growth hormone deficiency.

A 29-year-old man with abnormal sexual development first presented with negative pubic hair and axillary hair, penis hypodevelopment, and bilateral undescending testes at age 14 years. Blurred vision and bitemporal hemianopia were noted at 19 years. Skull plain radiographs and computed tomography (CT) of the cranium revealed a sellar tumor. He underwent subtotal tumor excision at 19 years. The pathology report showed craniopharyngioma.

Postoperatively, he underwent radiotherapy. The endocrinology studies showed panhypopituitarism, including central diabetes insipidus, hypothyroidism, adrenocorticotropic hormone deficiency, hypogonadotropic hypogonadism, and growth hormone deficiency. He was 165 cm tall, weighed 55 kg, and had a body mass index (BMI) of 20.2 kg/m2. He continued to grow tall in the following 10 years. When he was 29 years old, he was 179 cm tall and weighted 70 kg with a BMI of 21.8 kg/m2. He reported a sudden onset of left hip pain after riding a bicycle. The pain had persisted for 5 days with aggravation.

On physical examination, a shortened and externally rotated right leg with left hip in slight flexion was revealed. He walked into our clinic without crutches or other walking support although he reported left hip pain. Neurovascular status was normal. Further image studies showed open bilateral proximal femoral physes and left femoral head epiphysis slipped posteriorly and medially (Figure 1). The skeletal bone age was 14 years and 6 months, compared to the patient age of 29 years and 7 months.

Intraoperatively, a fracture table was used for traction and slippage reduction was attempted. However, it remained unreduced. The patient then underwent immediate in situ fixation with 1 cannulated screw (7.5 mm in diameter) under fluoroscopy (Figure 2).…

Abstract

Slipped capital femoral epiphysis usually occurs in children going through a pubertal growth spurt, possibly because the immature proximal femoral physis is unable to bear the shear stress. It commonly occurs in adolescents between 10 and 16 years. Slipped capital femoral epiphysis in adults is uncommon, with only 10 cases reported in the literature. This article presents a case of a 29-year-old man with craniopharyngioma diagnosed when he was 19. He underwent surgery with subtotal tumor excision and postoperative radiotherapy, but received no further treatment for the panhypopituitarism concomitant with the tumor. He reported sudden onset of left hip pain after riding a bicycle and underwent surgical fixation 5 days later. He also underwent hormone replacement therapy, including prednisolone, thyroxin, desmopressin, and testosterone, and regular clinical follow-up. His hip function recovered with a painless gait. At 18-month follow-up, neither osteonecrosis nor contralateral slipped capital femoral epiphysis was noted. Furthermore, bilateral proximal femoral physes were also closed. For stable slippage as in this case, in situ pinning fixation is a commendable method. A high index of suspicion of endocrinal disorder and proper management are essential for successful treatment of adult slipped capital femoral epiphysis.

Slipped capital femoral epiphysis occurs in children going through a pubertal growth spurt, possibly because the immature proximal femoral physis is unable to bear the shear stress. It commonly occurs in adolescents between ages 10 and 16 years. Slipped capital femoral epiphysis occurs more frequently in obese children with male predominance. The left hip is affected twice as often as the right whereas the bilateral involvement ranges from 25% to 40%.1 Several etiological factors have been suggested for slipped capital femoral epiphysis, such as local trauma,2 obesity,3,4 endocrine disorders (such as hypothyroidism, hypopituitarism, and hyperparathyroidism),5-7 genetic factors,8 etc. Slipped capital femoral epiphysis may also complicate the course of growth hormone therapy.9,10 This article presents a case of a 29-year-old man who had craniopharyngioma associated with panhypopituitarism, including hypogonadotropic hypogonadism and growth hormone deficiency.

Case Report

A 29-year-old man with abnormal sexual development first presented with negative pubic hair and axillary hair, penis hypodevelopment, and bilateral undescending testes at age 14 years. Blurred vision and bitemporal hemianopia were noted at 19 years. Skull plain radiographs and computed tomography (CT) of the cranium revealed a sellar tumor. He underwent subtotal tumor excision at 19 years. The pathology report showed craniopharyngioma.

Postoperatively, he underwent radiotherapy. The endocrinology studies showed panhypopituitarism, including central diabetes insipidus, hypothyroidism, adrenocorticotropic hormone deficiency, hypogonadotropic hypogonadism, and growth hormone deficiency. He was 165 cm tall, weighed 55 kg, and had a body mass index (BMI) of 20.2 kg/m2. He continued to grow tall in the following 10 years. When he was 29 years old, he was 179 cm tall and weighted 70 kg with a BMI of 21.8 kg/m2. He reported a sudden onset of left hip pain after riding a bicycle. The pain had persisted for 5 days with aggravation.

On physical examination, a shortened and externally rotated right leg with left hip in slight flexion was revealed. He walked into our clinic without crutches or other walking support although he reported left hip pain. Neurovascular status was normal. Further image studies showed open bilateral proximal femoral physes and left femoral head epiphysis slipped posteriorly and medially (Figure 1). The skeletal bone age was 14 years and 6 months, compared to the patient age of 29 years and 7 months.

Figure 1A: Slipped capital femoral epiphysis of the left hip Figure 1B: Slipped capital femoral epiphysis of the left hip Figure 1C: Left hip effusion
Figure 1: AP (A) and lateral (B) radiographs showing a slipped capital femoral epiphysis of the left hip with posterior and medial displacement of the femoral head epiphysis. Coronal gradient echo T2-weighted MRI (C). Note the left hip effusion (short white arrow) and the widening of the left growth plate (white dotted arrow).

Intraoperatively, a fracture table was used for traction and slippage reduction was attempted. However, it remained unreduced. The patient then underwent immediate in situ fixation with 1 cannulated screw (7.5 mm in diameter) under fluoroscopy (Figure 2). Neither joint aspiration nor capsulotomy was performed intraoperatively. The patient began ambulating with 2 crutches 3 days postoperatively. He also underwent hormone replacement therapy, including prednisolone, thyroxin, desmopressin, and testosterone, and regular clinical follow-up. His hip function recovered smoothly with a painless gait.

Figure 2A: Immediate in situ fixation Figure 2B: Immediate in situ fixation
Figure 2: AP (A) and lateral (B) radiographs showing immediate in situ fixation with 1 cannulated screw for left femoral head slipped capital epiphysis.

During 18-month follow-up, neither osteonecrosis nor contralateral slipped capital femoral epiphysis was noted. Furthermore, the bilateral proximal femoral physes were also closed on radiographs (Figure 3).

Figure 3A: The left femoral head remodeled well and preserved a good shape Figure 3B: The left femoral head remodeled well and preserved a good shape
Figure 3: AP (A) and lateral (B) radiographs. After 18-month follow-up, the left femoral head remodeled well and preserved a good shape. Neither femoral head osteonecrosis nor contralateral slipped capital femoral epiphysis was noted. Bilateral proximal femoral physes were also closed.

Discussion

Slipped capital femoral epiphysis occurs during young adolescence, especially during the growth spurt. The combination of reduced growth plate stability at this age and rapid increasing mechanical overload on the physis due to body weight gain is considered the etiology of slipped capital femoral epiphysis. Overweight children during pubertal growth spurt (between age 9 and 16 years) are generally considered to be most at risk.11,12 Obese children usually have reduced femoral anteversion that can result in increased mechanical shear stress on the upper femoral epiphysis. In addition, growth plates can have physiological weakness during this rapid growth period. The exact mechanism is unknown. However, bone remodeling during rapid turnover may reduce the skeleton strength. Since bone strength is determined by bone quantity and bone quality, another possibility of weak bone strength may be related to suboptimal bone quality associated with the endocrine disorders, as in this patient. Some investigators believe that hormone imbalances such as hypothyroidism, hyperparathyroidism, or hypogonadism all contribute to weak bone.3,5-7

Bone mass index-related mechanical load seems to play another important factor in slipped capital femoral epiphysis patients. Patients presenting with slipped capital femoral epiphysis have higher than average body mass indexes with values in the overweight or obese range. Patients with bilateral slipped capital femoral epiphysis have a significantly greater mean body mass index than children with unilateral slipped capital femoral epiphysis.3 A combination of these factors predisposes overweight adolescents to develop slipped capital femoral epiphysis.

Craniopharyngiomas are the most common hypothalamic-pituitary tumors in children (80%), accounting for 6% to 9% of pediatric brain tumors. They also occur in adults.13 The absence of a pituitary stimulus to testicular maturation hinders the pubertal development of secondary sexual characteristics as our patient presented. However, the secreted growth hormone is usually sufficient so the patient continued to grow for a longer-than-normal period. The closure of the growth plates usually does not occur until the third decade of life in untreated cases.14

Slipped capital femoral epiphysis in adults is limited and commonly associated with endocrinal disturbances. In a search of the literature from 1960 to 2009, 10 cases of slipped capital femoral epiphysis in adults older than 20 years were reported. The associated endocrinopathies were also recorded. Five sustained panhypopuitary disorders consisting of 2 craniopharyngiomas,5,12 one pituitary microadenoma,15 one histiocytosis,5 and 1 hemosiderosis.16 Four sustained hypothyroidism17-20 and the other post-irradiation hypoestrogenism.16 According to the literature mentioned above, hormone replacement therapy and definite surgical management are indicated and effective in adult slipped capital femoral epiphysis. For stable slippage, meaning the patient can walk dependently or independently, in situ pinning fixation is a commendable method. A high index of suspicion toward endocrinal disorder and proper management are essential in successful treatment of adult slipped capital femoral epiphysis.

Prophylactic pinning or other fixation procedures for an asymptomatic hip in slipped capital femoral epiphysis remain controversial. Many authors stay in a low threshold for prophylactic operations on pathologic slipped capital femoral epiphysis related to endocrinopathy or renal disease. However, there is a lack of evidence of hip slippage predictions.21 Prophylactic operations on the asymptomatic hips would elicit possible complications of fixation (eg, chondrolysis, avascular necrosis, and infection).22 Close follow-up and protected weightbearing are sufficient for prevention of neglected contralateral hip slippage.

References

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  16. McAfee PC, Cady RB. Endocrinologic and metabolic factors in atypical presentations of slipped capital femoral epiphysis. Report of four cases and review of the literature. Clin Orthop Relat Res. 1983; (180):188-197.
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  19. Al-Aswad BI, Weinger JM, Schneider AB. Slipped capital femoral epiphysis in a 35-year-old man. Clin Orthop Relat Res. 1978; (134):131-134.
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Authors

Drs Hu and Hsueh are from the Department of Orthopedic Surgery, National Taiwan University Hospital, Yun-lin Branch, Douliou City, Drs Jian and Yang are from the Department of Orthopedics, College of Medicine, National Taiwan University Hospital, Taipei, and Dr Lin is from the Department of Orthopedics, Hsin Chu General Hospital, Department of Health, Executive Yuan, Taiwan.

Dr Hu, Jian, Hsueh, Lin, and Yang have no relevant financial relationships to disclose.

Correspondence should be addressed to: Rong-Sen Yang, MD, PhD, Department of Orthopedics, National Taiwan University Hospital, No 7, Chung-Shan South Rd, Taipei, Taiwan (yang@ha.mc.ntu.edu.tw).

doi: 10.3928/01477447-20110124-27

10.3928/01477447-20110124-27

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