Scientific Article   |    
Prophylactic Pinning of the Contralateral Hip in Slipped Capital Femoral Epiphysis Evaluation of Long-Term Outcome for the Contralateral Hip with Use of Decision Analysis
W. Randall Schultz, MD, MS; James N. Weinstein, DO, MS; Stuart L. Weinstein, MD; Brian G. Smith, MD
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Investigation performed at the Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Orthopedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; Department of Orthopedic Surgery, Connecticut Children's Medical Center, Hartford, Connecticut; and the Center for Evaluative Clinical Sciences at Dartmouth College, Hanover, New Hampshire

W. Randall Schultz, MD, MS
James N. Weinstein, DO, MS
Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756

Stuart L. Weinstein, MD
Department of Orthopedic Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242

Brian G. Smith, MD
Department of Orthopedic Surgery, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

J Bone Joint Surg Am, 2002 Aug 01;84(8):1305-1314
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Background: The risk of a contralateral slip in patients who are first seen with a unilateral slipped capital femoral epiphysis has been reported to be 2335 times higher than the risk of an initial slip. The overall prevalence of bilaterality varies widely throughout the literature, with some reports indicating rates as high as 80%. This finding has led many authors to recommend prophylactic pinning of the contralateral asymptomatic hip in patients presenting with a unilateral slipped capital femoral epiphysis.

Methods: A decision analysis model with probabilities for the occurrence of contralateral slip and for the severity of slip at different intervals of follow-up was used in the present study. These probabilities were compared with those for various outcomes when the contralateral hip is prophylactically pinned. Scores representing long-term outcome, according to the Iowa hip-rating system, were used in the model as a measure of utility. The probabilities of contralateral slip and the rates of slip severity were taken from large retrospective series. All meaningful clinical scenarios with regard to long-term outcome for the hip were considered in the model. Variables of uncertainty were subjected to sensitivity analyses in order to explore the effect on outcome over the range of plausible values for variables of interest.

Results: The results showed a benefit in the long-term outcome for patients who had prophylactic pinning of the contralateral hip. The threshold level at which a benefit is obtained with prophylactic pinning is expressed according to the rates of sequential slip, rates of slips overlooked at follow-up, and complications associated with prophylactic pinning of the contralateral hip.

Conclusions: The decision model shows that, when pooled data are used to predict probabilities of sequential slip, treatment of the contralateral hip with prophylactic pinning is beneficial to the long-term outcome for that hip. When considering prophylactic pinning of the contralateral hip, the clinician should use sound clinical judgment with respect to the age, sex, and endocrine status of the patient. Long-term follow-up studies are needed to establish the efficacy of prophylactic pinning, but the predictions in the present study, which are based on findings in the literature, support the safety of this procedure.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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