SC FE. Slipped Capital Femoral Epiphysis SPR

Transcription

1 SC FE Slipped Capital Femoral Epiphysis SPR

2 Disclosures Lecture specific-nothing to disclose. Dr. Taragin is a member of the medical advisory board of Carestream Health. SAM Goal SCFE = SCIFI

3 PRESENTATION Decreased Range of Motion/Limp External Rotation with hip flexion Pain with internal rotation Pain referred to knee (15%) Thigh Atrophy (chronic)

4 SCFE Demographics & Risk factors 11/100,00 Obese adolescents (BMI >95th) During growth phase Boys >>> Girls Black: Caucasian 4:1 Prior trauma Prior SCFE 18-63% Endocrinopathies

5 SCFE as an alternate fact SCFE is a fracture through the growth plate which results in the femoral head remaining in place in the acetabulum but the femoral neck and shaft moving antero-laterally and superiorly often causing an apparent varus deformity.

6 Technique: XRAY Findings: XRAY Rotational Shortening with loss of height of the Femoral Head Widened physis Kleins Line 40% sensitivity Blanch Sign Slipping scoop sign

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9 CT PREOP Measurement of variable angles Head Neck Angle Difference 3D modelling POST_OP Painful hip Screw placement issues FAI AVN Metallosis

10 MRI PREOP Excellent at diagnosing SCFE Pre-slip Vascularity Geometry of the displacement POSTOP AVN Chondrolysis Implant Failure Post Repair degenerative disease Bony Abnormalities Labral disease

11 PRE-SLIP

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14 Clinical Severity Classifications Grade Clinical Determinant Length of Symptoms Acute < 3 weeks Acute on Chronic > 3 weeks with acute worsening Chronic > 3 weeks (< AVN) Unstable inability to bear weight >>>Higher risk of eventual AVN

15 Grading of Slipped Capital Femoral Epiphysis Using Frog Lateral Hip Radiographs Wilson method Southwick method (amount of femoral slip angle head displacement) Grade Mild : Less than 1/ Moderate: 1/3 to 1/ Severe: Greater than 1/2 Greater than 60

16 SCIFI staging system

17 Metaphyseal Bone Collapse Mimicking SCFE in Severe RenalOsteodystrophy Masaki T. Et al, Journal J Clin Endocrinol Metab Nov;97(11):3851-6

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19 PREOP Displacement- CT (HNAD) Geometry Vascularity- MRI (subtraction post contrast) Chronicity-CT (callus)

20 Surgical Options Stabilization-Pinning In situ fixation with a single screw in the center of the epiphysis.

21 Surgical options Osteotomy and Realignment Subcapital-Fish/ Dunn 12-35% AVN Basicervical-Kramer and Barmada shortens the femoral neck Intertrochanteric-Southwick -chondrolysis rate 6-50% The risk of necrosis has been described as almost reciprocally proportional to the distance of correction from the physis, a phenomenon that can be explained by the vulnerability of the blood supply to the epiphysis. Capital Realignment for Moderate and Severe SCFE Using a Modified Dunn Procedure Ziebarth, K etal, Clin Orthop Relat Res Mar;467(3):

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23 POST OP Improper placement (plain film, CT) Hardware Failure (plain film, CT) Femoral Acetabular Impingement CAM>>>PINCER (CT,MRI, Arthrogram) AVN (CT/MRI)

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32 18 year old s/p in situ screw fixation for SCFE, s/p osteochondroplasty femoral H/N Courtesy of Sarah Bixby, MD T1 fs T1 map T1 fs T1 maps often demonstrate cartilage thinning better than morphologic sequences T1 map 33

33 First SAM question Who of the following is not SAM? A B C D E

34 FAI VS AVN (or both!!)

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39 Subcapital-Fish/ Dunn Modified Dunn Moderate to severe scfe or unstable SCFE Ganz R, Huff TW, Leunig M. Extended retinacular soft-tissue flap for intraarticular hip surgery: surgical technique, indications, and results of application. In: Azar FM, O Connor MI, eds. Instructional Course Lectures 58. Rosemont, IL: AAOS.

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45 Summary Old News Imaging Xrays CT/MRI if indicated In Situ fixation good Osteotomy Bad AVN and FAI are expected and at times unpreventable New Facts Imaging Xrays CT/MRI may contribute to planning surgical options In Situ fixation sometimes good Osteotomy often better AVN and FAI can be minimized but at times unpreventable

46 FIN