Orthopedics

Feature Articles 

Bilateral Unstable Slipped Capital Femoral Epiphysis: A Look at Risk Factors

José A. Herrera-Soto, MD; Kelly L. Vanderhav, MD; Eric Gordon, MD; Jorge Fabregas, MD; Jonathan H. Phillips, MD; Perry Schoenecker, MD; Klaus Parsch, MD

Abstract

Unstable slipped capital femoral epiphysis can have disastrous complications including osteonecrosis and chondrolysis. It has been shown that 20% to 80% of patients may develop a contralateral slip =18 months after diagnosis. The purpose of this article is to report and characterize patients who developed bilateral unstable slips. After Institutional Review Board approval, the patients included were only those with bilateral unstable slipped capital femoral epiphyses. A minimum 2-year follow-up was required. Seven patients, all female, were included in the study, with an average age of 11.4 years at the time of their first slips. The interval between slips averaged 127 days (range, 0–245 days). All but 1 patient presented with a severe slip. The second slip was also severe in 3 patients and less severe in 4 patients. The triradiate cartilage was open in 3 patients. Two patients required corrective osteotomies. Chondrolysis developed in 2 patients with no osteonecrosis reported. The incidence of bilateral unstable slips ranged from 4% to 20% of all unstable slipped capital femoral epiphyses based on our findings. Skeletal immaturity was not a risk factor. The surgeon must be vigilant for the possibility of bilateral slips. The family must be instructed on precautions patients must take while recuperating from unstable slipped capital femoral epiphyses. Contralateral fixation of the unaffected side may be warranted in patients with initial severe unstable slipped capital femoral epiphyses to prevent this condition.

Drs Herrera-Soto and Phillips are from Orlando Health, Orlando, Florida; Dr VanderHave is from the Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan; Drs Gordon and Schoenecker are from the Department of Orthopedics, Washington University School of Medicine, St Louis, Missouri; Dr Fabregas is from Children’s Orthopedics of Atlanta, Atlanta Medical Center, Atlanta, Georgia; and Dr Parsch is from the University of Heidelberg, Stuttgart, Germany.

Drs Herrera-Soto, Vanderhave, Gordon, Fabregas, Phillips, Schoenecker, and Parsch have no relevant financial relationships to disclose.

Slipped capital femoral epiphysis is the most common hip disorder in adolescents. 1 This disorder has been classified as stable or unstable according to the ability or inability to bear weight. 2 Patients unable to bear weight, even with crutches, have been defined as unstable. Osteonecrosis of the femoral head is the most dreaded complication after unstable slipped capital femoral epiphysis. It has been estimated that =60% of patients with unstable slipped capital femoral epiphyses will develop osteonecrosis. 3–9

It has been shown that 20% to 80% of patients may develop a contralateral slip =18 months after diagnosis. 8,10–15 Approximately 50% of these patients will show bilateralism at initial presentation. 10,15 Several authors have reported that silent slips were present in =35% of patients with bilateral involvement. 10,16,17 Forty-one percent of these patients were diagnosed at initial presentation. Fixation of the contralateral, unaffected side is accepted for those with metabolic or endocrine disoders. 18,19 Prophylactic fixation in patients without metabolic conditions remains controversial. 11,20–23

The authors have seen several patients with bilateral unstable slipped capital femoral epiphyses. This implies that the chances of a complication developing in these patients doubles, especially osteonecrosis. Some authors propose that prophylactic fixation of the asymptomatic hip is simple and safe in the long run safe. 11,20,21 The purpose of this article is to report and characterize a patient population with an increased risk of devastating complications. This article presents the risk factors associated with unstable slipped capital femoral epiphysis and proposes the best method of treatment.

This was a retrospective study with Institutional Review Board approval. Patients included only those with bilateral unstable slipped capital femoral epiphyses by Loder’s classification. 2 Data were collected from 5 different medical centers.…

Abstract

Unstable slipped capital femoral epiphysis can have disastrous complications including osteonecrosis and chondrolysis. It has been shown that 20% to 80% of patients may develop a contralateral slip =18 months after diagnosis. The purpose of this article is to report and characterize patients who developed bilateral unstable slips. After Institutional Review Board approval, the patients included were only those with bilateral unstable slipped capital femoral epiphyses. A minimum 2-year follow-up was required. Seven patients, all female, were included in the study, with an average age of 11.4 years at the time of their first slips. The interval between slips averaged 127 days (range, 0–245 days). All but 1 patient presented with a severe slip. The second slip was also severe in 3 patients and less severe in 4 patients. The triradiate cartilage was open in 3 patients. Two patients required corrective osteotomies. Chondrolysis developed in 2 patients with no osteonecrosis reported. The incidence of bilateral unstable slips ranged from 4% to 20% of all unstable slipped capital femoral epiphyses based on our findings. Skeletal immaturity was not a risk factor. The surgeon must be vigilant for the possibility of bilateral slips. The family must be instructed on precautions patients must take while recuperating from unstable slipped capital femoral epiphyses. Contralateral fixation of the unaffected side may be warranted in patients with initial severe unstable slipped capital femoral epiphyses to prevent this condition.

Drs Herrera-Soto and Phillips are from Orlando Health, Orlando, Florida; Dr VanderHave is from the Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan; Drs Gordon and Schoenecker are from the Department of Orthopedics, Washington University School of Medicine, St Louis, Missouri; Dr Fabregas is from Children’s Orthopedics of Atlanta, Atlanta Medical Center, Atlanta, Georgia; and Dr Parsch is from the University of Heidelberg, Stuttgart, Germany.

Drs Herrera-Soto, Vanderhave, Gordon, Fabregas, Phillips, Schoenecker, and Parsch have no relevant financial relationships to disclose.

Correspondence should be addressed to: José Herrera-Soto, MD, Orlando Health, 83 W Columbia St, Orlando, FL 32806 (joseher@msn.com).
Posted Online: June 14, 2011

Slipped capital femoral epiphysis is the most common hip disorder in adolescents. 1 This disorder has been classified as stable or unstable according to the ability or inability to bear weight. 2 Patients unable to bear weight, even with crutches, have been defined as unstable. Osteonecrosis of the femoral head is the most dreaded complication after unstable slipped capital femoral epiphysis. It has been estimated that =60% of patients with unstable slipped capital femoral epiphyses will develop osteonecrosis. 3–9

It has been shown that 20% to 80% of patients may develop a contralateral slip =18 months after diagnosis. 8,10–15 Approximately 50% of these patients will show bilateralism at initial presentation. 10,15 Several authors have reported that silent slips were present in =35% of patients with bilateral involvement. 10,16,17 Forty-one percent of these patients were diagnosed at initial presentation. Fixation of the contralateral, unaffected side is accepted for those with metabolic or endocrine disoders. 18,19 Prophylactic fixation in patients without metabolic conditions remains controversial. 11,20–23

The authors have seen several patients with bilateral unstable slipped capital femoral epiphyses. This implies that the chances of a complication developing in these patients doubles, especially osteonecrosis. Some authors propose that prophylactic fixation of the asymptomatic hip is simple and safe in the long run safe. 11,20,21 The purpose of this article is to report and characterize a patient population with an increased risk of devastating complications. This article presents the risk factors associated with unstable slipped capital femoral epiphysis and proposes the best method of treatment.

Materials and Methods

This was a retrospective study with Institutional Review Board approval. Patients included only those with bilateral unstable slipped capital femoral epiphyses by Loder’s classification. 2 Data were collected from 5 different medical centers. Patients with bilateral stable slipped capital femoral epiphyses and bilateral slips that included 1 stable and 1 unstable slip were excluded. We included any type of endocrinopathy or syndrome to verify if it was a risk factor for a bilateral unstable slip.

A chart review evaluated age at the time of surgery, gender, race, weight, and, when available, body mass index. We calculated the time from the first to second slip. Radiographic examination documented the severity of both slips to determine if the severity of the slip in the first hip treated influenced the development of a slip in the contralateral side. We also recorded the status of the triradiate cartilage status. We recorded complications and time to complications from the surgery.

Results

Seven patients comprised our series (). All patients were female; 5 patients were White and 2 were of African-American. Average patient age was 11.4 years at the time of the first slip (range, 6.5–14.1 years). One patient had a history of Down syndrome; when this patient was excluded, the average patient age was 12.3 years. None of the patients presented with a diagnosed endocrine abnormality. The mean interval between slips was 127 days (range, 0–245 days) with 1 hip presenting with bilateral simultaneous unstable slipped capital femoral epiphysis. The average follow-up was 4.3 years (range, 2–9 years). The incidence of bilateral unstable slipped capital femoral epiphysis to unilateral unstable slips was 7% (1/15) at 2 of our centers.

Patient List

Table. Patient List

The treatment was in situ fixation in 3 patients (1 screw only without decompression recorded) and gentle manipulation and fixation in the remaining patients with capsular decompression in 3 patients and 1 patient undergoing gentle manipulation and multiple K-wire fixation without decompression.

The first slip was severe in 6 hips, and moderate in the other. The second hip was less severe in 4 patients (3 mild and 1 moderate), and severe bilaterally in 3. The triradiate cartilages were open in 3 patients (43%). The triradiate cartilage was open in 2 patients at the time of the second slip.

Two patients required bilateral corrective derotation and proximal femoral osteotomies and one is scheduled for an osteotomy for impingement.

Patient 2 developed metachronous slips with subsequent bilateral segmental ischemic changes at 3 months postinjury. She was treated with gentle manipulation, capsulotomy, and 1 screw as fixation per side. In addition, the patient developed chondrolysis and a progressive slip requiring a second screw (Figure ). Computed tomography (CT) scan showed no evidence of screw penetration in the joint. A follow-up single photon emission CT scan revealed normal bilateral perfusion of both femoral heads at 6 months postoperatively. This was also confirmed on radiographs 2 years postinjury. The chondrolysis resolved spontaneously after 6 months of physical therapy. This patient has femoroacetabular impingement but refused a third procedure at this time (Figure ). No patients developed osteonecrosis of the femoral head.

The Right Hip of Patient 2 Demonstrated Changes Consistent with Chondrolysis (A). Six Months After Initializing Physical Therapy the Articular Space Was Improved and the Patient Regained Lost Motion (B).

Figure 1:. The Right Hip of Patient 2 Demonstrated Changes Consistent with Chondrolysis (A). Six Months After Initializing Physical Therapy the Articular Space Was Improved and the Patient Regained Lost Motion (B).

Patient 7 with multiple pinning (3 K-wires per hip) also presented with bilateral chondrolysis. She demonstrated pin penetration to the joint (Figure ). She underwent removal of implants, physical therapy, and bilateral Imhauser osteotomies. Her chondrolysis resolved within 6 months postoperatively. She is doing well 9 years postoperatively (Figure ).

Frog Lateral View of the Hip of Patient Number 7, Who Was Treated with Gentle Reduction and Bilateral Multiple Pinning. Her Hip Demonstrated Joint Penetration by the Kirschner Wires. The Patient Subsequently Developed Chondrolysis.

Figure 2:. Frog Lateral View of the Hip of Patient Number 7, Who Was Treated with Gentle Reduction and Bilateral Multiple Pinning. Her Hip Demonstrated Joint Penetration by the Kirschner Wires. The Patient Subsequently Developed Chondrolysis.

Nine Years Postinjury and Osteotomies, the Patient Demonstrated Excellent Hip Motion (A). Frog Lateral View After Osteotomy and Improvement of the Chondrolysis (B).

Figure 3:. Nine Years Postinjury and Osteotomies, the Patient Demonstrated Excellent Hip Motion (A). Frog Lateral View After Osteotomy and Improvement of the Chondrolysis (B).

Discussion

Unstable slipped capital femoral epiphysis is characterized by a sudden and severe hip pain with inability to bear weight, even with crutches. 2 A history of trauma is the most common reason for instability. 3,24 Early identification and treatment is crucial to prevention of complications. 2,7–9,25 Osteonecrosis of the femoral head is the most concerning complication after unstable slipped capital femoral epiphysis and can have long-term consequences to the patient’s quality of life. 24

Slipped capital femoral epiphysis has been reported to be bilateral in =80% of patients in the literature. 8,10–14,26 Approximately 50% of these occur simultaneously. 8,10–14 The interval between diagnosis of the first and second slip of the 50% that occur sequentially is 1 year (range, 1–5 years). In our patient population, the interval averaged at 127 days, with all occurring within the first year of slipping. Loder et al 10 reported a 71% occurrence of bilaterality within 1 year.

Peterson et al 8 presented a series of 91 acute slips. Four of 87 patients had bilateral acute slips (4.3%). All were male patients. The average age of these patients and the status of their triradiate cartilage were not reported. Three were White and 1 was African-American. The incidence of complications in these specific patients was not documented in this report. Rao et al 27 studied 43 patients who underwent bone peg epiphysiodesis for the treatment of slipped capital femoral epiphysis. Twenty-two patients had bilateral slips and 15 patients had unstable slipped capital femoral epiphyses. Eight of 22 bilateral epiphyses had at least 1 unstable hip (36%). Three patients presented with bilateral unstable slips (20% with unstable slipped capital femoral epiphyses). The average patient age was 13.1 years (all male). Two of the patients had open triradiate cartilage on each diagnosed slip.

Eight additional patients exist in the literature with this type of condition. 8,9,27 These reports mention age, race, and maturity level of the specific patients, but the patients were not fully characterized. We have identified 6 new patients from our institutions (plus patient 2 who was previously reported). 9 The incidence of bilateral unstable slips ranges from 4% to 20% of all unstable slipped capital femoral epiphyses based on our findings and those of Peterson et al 8 and Rao et al. 27 The incidence of patients with unstable slips is approximately 5% to 17% of all slipped capital femoral epiphyses. Therefore, =3.5% of patients with slips may develop bilateral unstable slips.

It is unknown if the presence of bilateral unstable slipped capital femoral epiphysis increases the likelihood of osteonecrosis or if it has a worse prognosis than unilateral unstable slipped capital femoral epiphysis. Two of our patients developed chondrolysis, and 1 developed transient photopenia. Two patients required bilateral corrective osteotomies and 1 is pending osteotomy for impingement. However, none of these patients developed osteonecrosis.

The increased awareness of the prevalence of bilaterality has made prophylactic fixation an option. However, prophylactic fixation of an unaffected hip remains controversial due to fears of iatrogenic osteonecrosis, chondrolysis, or other complications. 13,18–21,28–31 Other possible complications include wound infection, screw irritation that requires a second procedure, and scar formation. 22,32 Concern remains about which patients may benefit from prophylactic treatment of the healthy side. 13,21,22,28 In patients where the probability of contralateral slipped capital femoral epiphysis is >27% or in those children where follow-up may be impossible, fixation of the contralateral hip may be warranted. 22 In 1 of the series evaluating prophylactic treatment, no patients had perioperative or significant postoperative complications or problems with subsequent normal growth of the prophylactically treated physis. 21 The authors supported the prophylactic treatment of the asymptomatic hip. Prophylactic treatment is recommended in girls younger than 10 years and boys younger than 12 years, and in those with endocrine or renal anomalies. 11,18,33

The authors recommend prophylactic fixation in any patient presenting with an unstable slip to decrease the chances of another unstable or stable slip. The literature suggests that the chance of a contralateral slip is >50%. Because of the difficulty persuading patients to report contralateral symptoms immediately, the possibility of a silent slip, and the devastating consequences of a contralateral unstable slip, we recommend prophylactic contralateral fixation for patients with an unstable slipped capital femoral epiphysis.

However, a contralateral slip may not be preventable in patients who present with simultaneous bilateral slips. 8,14,15 This was the case for 1 of our patients who presented with a synchronous unstable slipped capital femoral epiphysis. In retrospect, 2 other patients sustained the injury within 1 month of the first slip while convalescing from the initial slip. Prophylactic fixation may have avoided this situation. But it has been shown that slips may progress despite fixation of acute injuries, even in those fixed with two screws. 34 This was the case in 1 of our patients whose slip progressed when she fell and developed a second unstable slipped capital femoral epiphysis. Both were African-American girls, who have a risk factor for bilateralism. 10

The younger the patient, the higher the risk of developing a bilateral slip. 10 Bilaterality has been shown to occur in 7% of patients with closed triradiate cartilage and 23% in those with open triraidate cartilage. 35 Others have not found age or the status of triradiate cartilage to be a factor. 33,36,37 This was not true for our patients, where 43% had open triradiate cartilage. We cannot fully explain why this phenomenon occurred primarily in mature rather than skeletally immature patients. But it may have been caused by the rapid growth phase seen in the early teen years, which debilitate the growth plate stability and may predispose it to slipping. 38 Kumm et al 21 found that patients younger than 12 years were at a significant risk of developing a second slip. Fifty-seven percent of our patients were younger than 12 years. Two of the oldest patients at the time of the initial slip took the longest to develop a contralateral involvement. In reports by Loder et al 10 and Dreghorn et al, 39 patients with bilateral involvement were an average of 1 year younger than those who developed no bilateral involvement (12 vs 13 years). We agree with this finding of a younger age (an average of 11.4 years in our series).

Yildirim et al 12 evaluated 498 patients with slipped capital femoral epiphyses. One hundred eighty-nine patients (38%) had bilateral slips and 82 others (16%) developed them during the study at a 54% incidence of bilaterality. They found that patients with unilateral slips were on average 2 years older than those who developed bilateral slips (13 vs 11 years). Twenty-five percent of patients who developed a unilateral slip were acute and 5% were acute on chronic slip. Twenty-eight percent of those with bilateral slips presented on the index slip with an acute slip and 7% with an acute on chronic slip (35% potentially unstable slips). On the contralateral slip, 76% were acute and 4% were acute on chronic. At the moment of injury in most of the patients, the Loder et al 2 classification was not available. No difference in the chronicity of the first slip existed in patients with bilateral involvement and unilateral slips.

Reports by Loder et al 10 and Hagglund et al 28 showed silent slipped capital femoral epiphysis to be present in =35% of patients with bilateral involvement, 41% of which were diagnosed at initial presentation. Furthermore, several studies have shown that the prevalence of bilateral slips increases with aging to at least double of that seen in adolescence. 28,40–42

Chondrolysis and implant-related fractures are other possible complications associated with fixation of a slipped capital femoral epiphysis. 12,43 The overall incidence of chondrolysis is 7%. 43 The causes of chondrolysis are controversial. 43 It appears to be an autoimmune reaction in predisposed individuals. Chondrolysis has also been attributed to persistent screw penetration into the joint as seen in 1 of our patients (Figure ). 26 It is more prevalent in females and those of African American descent. 10 Despite this, the incidence of chondrolysis has decreased as the type of fixation has changed from multiple pinning to 1 or 2 screws and good quality image intensification has become available. 44 Therefore, it appears that the risk of chondrolysis is mainly from the patient’s own reaction to the exposed growth plate and not to the fixation. Based on the low potential for chondrolysis and osteonecrosis on the contralateral, nonaffected side, prophylactic pinning seems to be reasonable and safer than observation. 28,45 This is particularly true of the disastrous complications possible in patients with bilateral unstable slipped capital femoral epiphyses.

The other long-term complication is the development of osteoarthritis. It has been shown to occur in approximately 25% to 50% of patients with slipped capital femoral epiphyses. 28,41,46,47 Carney et al 47 and Hagglund 29 have found that all of the patients with moderate to severe slips will develop degenerative changes. Another report found that 23% of patients had poor outcome in subsequent slips. 12

The surgeon must be vigilant of this rare complication. Families must be instructed on the precautions to be taken while a patient recuperates from an unstable slipped capital femoral epiphysis to avoid injury to the other side. Contralateral fixation of the unaffected side may be warranted in all patients with initial severe unstable slipped capital femoral epiphyses to prevent this condition.

References

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Patient List

Patient Race Southwick Age Injury 1 Age injury 2 Interval, days TRC Status Complications
1 AA Moderate/mild 13.1 13.1 9 Closed None
2 AA Severe/moderate 10.5 10.5 20 Open/Open Chondrolysis right hip, transient photopenia
3 White Severe×2 6.5 7.0 179 Open/open None
4 White Severe×2 12.6 12.6 0 Closed None
5 White Severe/mild 14.1 14.7 245 Closed None
6 White Severe/mild 12.7 13.5 284 Closed None
7 White Severe×2 10.4 10.8 150 Open/closed Bilateral chondrolysis
Average 11.4 11.7 126.7

10.3928/01477447-20110427-04

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