Management
Aims
1. Prevent further slip by fusing physis - 30% SCFE will worsen untreated
2. Prevent deformity and osteoarthritis
3. Avoid complications
Issue
Residual deformity from moderate and severe hips causes FAI and osteoarthritis
Reduction maneuvers increase risk of AVN
Options
Percutaneous insitu screw fixation
Closed reduction + Percutaneous insitu screw fixation
Open reduction / Parsch technique
Subcapital osteotomy (SCRO)
Percutaneous insitu screw fixation
Indication
Mild to moderate slip
Set up
1. Supine on radiolucent table
- much faster if pinning both sides / reduced set up
- theoretical risk of displacing slip / inadvertant manipulation
- lateral by flexing and full ER of hip / frog legs
2. Traction Table
- easy to get AP and lateral
- need 2 set ups for bilateral pinning
Technique
POSNA insitu pinning technique fracture table PDF
Vumedi insitu pinning technique supine on radiolucent table video
Draw anterior and lateral lines
- intersection of points is incision site
- stab incision
AP view
- centered on femoral neck
- aiming towards center of femoral epiphysis
- more severe slips require more proximal starting points
- aim posterior to SCFE
- avoid starting below lesser trochanter to avoid fracture
Frog leg lateral
- center of femoral epiphysis
Ensure that wire and screw don't penetrate head
- do far and away screening
- see approach / withdraw
- insert fully threaded 6.5 mm / 7.3 mm screw
Postoperative
? CT to ensure no intra-articular screw
Touch weight bear six weeks
Serial xray to ensure no loss of position / physeal fusion
Results
Schlenzka et al, Bone Joint J. 2023
- retrospective review of 172 hips post insitu fixation
- 41% of hips end in THA at 50 year follow up
Closed Reduction
Indications
Severely displaced acute unstable slip
- difficult to pin in situ
- will result in severe functional impairment
Issue
? increased risk of AVN
Results
- 48 unstable SCFE treated with closed reduction and screw fixation
- 26% developed AVN
Open reduction + Percutaneous In Situ Pinning
Parsch technique
- anterior approach
- capsulotomy to decompress hematoma
- controlled reduction of slip
Results
Kaushal et al J Pediatr Orthop 2019
- systematic review of capsulotomy in 450 unstable SCFE
- capsulotomy: AVN 17%
- no capsular decompresion: AVN 27%
Subcapital Realignment Osteotomy (SCRO) / Modified Dunn Procedure
Concept
Open surgical dislocation of hip
Preserve vessels to femoral epiphysis
Reduce epiphysis onto metaphysis
Indication
Moderate and severe slips
- both acute and chronic
- high risk of FAI and subsequent osteoarthritis
Technique
JBJS Essential surgical techniques PDF
Vumedi modified Dunn procedure video
Lateral approach
- trochanteric osteotomy
- Z shaped capsulotomy
- maintain posterior retinacular and medial circumflex vessels
- surgical hip dislocation / release ligamentum teres
- elevate periosteal flap / retinaculum from the femoral neck
- mobilize epiphysis carefully
- remove posterior callus
- open and debride physis
- reduce femoral epiphysis and stabilize
- ORIF greater trochanter osteotomy
Results
Abdelnasser et al BMC Musculoskeletal Disorder 2025
- systematic review of 500 modified Dunn procedures
- AVN 10%
- 54 patients with unstable moderate and severe slips treated with modified Dunn procedure
- AVN 7%
- compared 30 severe SCFE
- half pin in situ, half modified Dunn procedure
- modified Dunn: 9/15 good or excellent outcome
- pin in situ: 4/15 good or excellent outcome
Prophylactic pinning of contralateral hip
Incidence contralateral hip
- 227 unilateral SCFE
- 36% developed contralateral slip
- 1/5 were moderate to severe slips
Risk factors
Swarup et al J Paediatr Orthop 2020
- systematic review of risk factors for contralateral SCFE
- younger patient age
- body mass index ≥95th percentile
- endocrine abnormality,
- higher posterior slope angle (> 15 degrees) of the unaffected hip
Indications
High risk for contralateral slip
- young patient - increased time for a contralateral slip to occus
- high BMI / endocrine issues
- geographical isolation / unreliable parents
- high posterior slope angle > 15 degrees
Issue
Complications such as chondrolysis / AVN / subtrochanteric fracture
- 99 patients with prophylactic pinning contralateral hip
- chondrolysis 0%
- AVN 2%
- periimplant femur fractures 2%
- symptomatic hardware 3%