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Scientific Article   |    
Factors Influencing the Development of Osteonecrosis in Patients Treated for Slipped Capital Femoral Epiphysis
Keti P. Tokmakova, MD; Robert P. Stanton, MD; Dan E. Mason, MD
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Investigation performed at the Alfred I. duPont Hospital for Children, Wilmington, Delaware

Keti P. Tokmakova, MD
Department of Orthopaedics and Traumatology, Medical University, 6 May Street, 4000 Plovdiv, Bulgaria

Robert P. Stanton, MD
Department of Orthopaedics, Nemours Children's Clinic, 5153 North 9th Avenue, Pensacola, FL 32504

Dan E. Mason, MD
Department of Orthopaedics, Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803

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.

J Bone Joint Surg Am, 2003 May 01;85(5):798-801
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Abstract

Background: Osteonecrosis is a serious complication of the treatment of slipped capital femoral epiphysis. The purpose of the present study was to identify factors influencing the development of osteonecrosis.

Methods: Two hundred and forty patients who had been treated for slipped capital femoral epiphysis between 1965 and 1999 were retrospectively evaluated. Treatment included stabilization with a spica cast or fixation with one to four pins or screws. Radiographs that had been made at the time of presentation, before and after the operation, and at consecutive follow-up examinations were reviewed. Osteonecrosis was defined retrospectively on the basis of radiographic evidence of sclerosis and collapse of the femoral head. The risk of development of osteonecrosis was correlated with various clinical and radiographic parameters.

Results: All twenty-one patients in whom osteonecrosis developed had presented with an unstable slipped capital femoral epiphysis. None of the 204 patients who had presented with a stable slipped capital femoral epiphysis, regardless of grade, had development of osteonecrosis. In the group of patients who had presented with an unstable slipped capital femoral epiphysis, the risk of development of osteonecrosis increased with the severity (grade) of the slip. Osteonecrosis was more likely to develop in patients who had been treated with multiple pins than in those who had been treated with a single cannulated screw.

Conclusions: Patients who have a stable slipped capital femoral epiphysis are not at risk for the development of osteonecrosis when treated with pinning in situ. Patients who have an unstable slipped capital femoral epiphysis have a decreased risk of osteonecrosis when treated with pinning in situ. Complete or partial reduction of an unstable slipped capital femoral epiphysis increases the risk of development of osteonecrosis. Pinning in situ without reduction with a single cannulated screw is the method of choice for the treatment of a slipped capital femoral epiphysis.

Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    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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    Roderick D D Duncan
    Posted on June 17, 2003
    Physeal Stability and the Loder Classification of SCFE
    Royal Hospital for Sick Children Glasgow

    Sir, The paper by Tokmakova et al (1) is a very valuable contribution to our understanding of slipped capital femoral epiphysis. Two things are clear however - firstly that Loder stable and unstable slips behave very differently. The second thing is that actual stability of the physis is less important than the clinical presentation. Even in Dr Loders original description (2), which remains a landmark paper, the evidence that the clinical presentation relates to physeal stability is far from conclusive. This has been confirmed by others. The terms stable and unstable have become widely accepted in Paediatric Orthopaedic circles, but I suggest these terms are inappropriate. Perhaps Loder Positive SCFE (severe pain that walking is not possible even with crutches) and Loder Negative SCFE (able to bear walk or weight bearstill possible with or without crutches) would be less misleading?

    References: 1. Keti P. et al Factors Influencing the Development of Osteonecrosis in Patients Treated for Slipped Capital Femoral Epiphysis J Bone Joint Surg Am 2003; 85: 798-801 2. Loder et al Acute slipped capital epiphysis: the importance of physeal stability J Bone Joint Surg Am. 1993: 75:1134-1140

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