Relationships between severity of deformity and impingement in slipped capital femoral epiphysis.

Jones CE, Cooper AP, Doucette J, Buchan LL, Wilson DR, Mulpuri K, d’Entremont AG. Relationships between severity of deformity and impingement in slipped capital femoral epiphysis. J Pediatr Orthop. June 2017. DOI: 10.1097/BPO.0000000000000641

Abstract

Background: 

In situ pinning, a low-risk treatment for slipped capital femoral epiphysis (SCFE), leaves the slipped femoral head in place and may reduce range of motion (ROM) and cause impingement. It is unclear when a more complex surgery should be considered, because the relationships between severity, slip stability, remodeling, impingement, and ROM are unknown. Research questions:

(1) Do more severe acute SCFE deformities (no bony remodeling) result in a greater loss of flexion ROM?

(2) Does the presence or location of impingement on the pelvis vary with severity of acute SCFE deformity?

Methods: 

We developed a 3D geometric model of acute SCFE deformity from 1 computed tomography scan of a normal adolescent hip. Ethics board approval was obtained from our institution. Bone models were created from the segmented pelvis, epiphysis, and subphyseal femur.

In total, 3721 SCFE deformities were simulated by combining posterior and inferior slips in the axial and coronal planes, respectively. Southwick angles were estimated from a frog-leg lateral projection. Deformities were divided into mild (0 to 30 degrees), moderate (30 to 60 degrees), and severe (≥60 degrees) Southwick groups. Each joint was flexed in combination with internal/external rotation until contact occurred. A total of 121 ROM trials, with different degrees of internal/external rotation (0 to 90 degrees at 1.5-degree steps) were performed for each deformity.

Results: 

In total, 3355 simulated SCFE deformities (363 could not be rotated out of impingement) were analyzed.

Increasing slip severity reduced flexion ROM across the range of internal/external rotation. Contact occurred for most mild deformities, and for all moderate and severe deformities in at least 1 ROM trial. Impingement was observed mainly on the anterosuperior aspect of the acetabulum.

Conclusions: 

Increasing slip severity in acute SCFE reduced flexion and increased incidence of impingement, primarily occurring on the anterosuperior aspect of the acetabulum. The impingement patterns observed are consistent with damaged cartilage locations seen in clinical literature.

Clinical Relevance: 

In this experimental model, moderate and severe acute slips in SCFE lead to reduced ROM and impingement with the acetabulum. This suggests that in situ pinning may result in impingement of moderate and severe acute SCFE slips.