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Prophylactic Pinning of the Contralateral Hip After Unilateral Slipped Capital Femoral Epiphysis
Mininder S. Kocher, MD, MPH1; Julius A. Bishop, MD2; M. Timothy Hresko, MD1; Michael B. Millis, MD1; Young-Jo Kim, MD1; James R. Kasser, MD1
1 Department of Orthopaedic Surgery, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115. E-mail address for M.S. Kocher: mininder.kocher@tch.harvard.edu
2 Harvard Medical School, 75 Francis Street, Boston, MA 02115
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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.
Investigation performed at the Department of Orthopaedic Surgery, Children's Hospital, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Dec 01;86(12):2658-2665
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Abstract

Background: The management of the contralateral hip after unilateral slipped capital femoral epiphysis is controversial. The purpose of this study was to determine, with use of expected-value decision analysis, the optimal management strategy—prophylactic in situ pinning versus observation—for the contralateral hip.

Methods: Outcome probabilities were determined from a systematic review of the literature. Utility values were obtained from a questionnaire on patient preferences completed with use of a visual analog scale by twenty-five adolescent male patients without slipped capital femoral epiphysis. A decision tree was constructed, fold-back analysis was performed to determine the optimal treatment, and one and two-way sensitivity analyses were performed to determine the effect on decision-making of varying outcome probabilities and utilities.

Results: Observation was the optimal management strategy for the contralateral hip given the outcome probabilities and utilities that we studied (the expected value was 9.5 for observation and 9.2 for prophylactic in situ pinning, with a marginal value of 0.3). Increased rates of a late second slip favored prophylactic in situ pinning (the threshold probability was 27%). Risk-taking patients with a high utility for uncomplicated prophylactic in situ pinning favored prophylaxis (the threshold utility was 9.8).

Conclusions: The iatrogenic risks of treating a healthy patient or an uninvolved body part rarely outweigh the potential benefits unless the probability of the adverse event is likely and the consequences of the adverse event are very severe. In this decision analysis, the optimal decision was observation. In cases where the probability of contralateral slipped capital femoral epiphysis exceeds 27% or in cases where reliable follow-up is not feasible, pinning of the contralateral hip is favored. For a given individual patient, the optimal strategy depends not only on probabilities of the various outcomes but also on personal preference. Thus, we advocate a model of doctor-patient shared decision-making in which both the outcome probabilities and the patient preferences are considered in order to optimize the decision-making process.

Level of Evidence: Economic and decision analysis, Level III-1 (limited alternatives and costs; poor estimates). See Instructions to Authors for a complete description of levels of evidence.

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    References

    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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    Robert Poss, MD
    Posted on April 26, 2005
    Editor's Note
    NULL

    The authors have been invited to respond to the letter by Dr Schultz et al, but to date, have not done so.

    W. Randall Schultz
    Posted on April 11, 2005
    Prophylactic Pinning of the Contralateral Hip in SCFE
    Private Prace

    To the Editor:

    We would like to thank Dr. Kocher for his fine work(1) in response to our decision analysis on prophylactic pinning of slipped capital femoral epiphysis(2). This is an important and controversial topic that warrants thoughtful, scientific debate prior to adopting generalized standards of care.

    Although it may appear that the conclusions of our studies are vastly different, the reality is the treatment options re: observation vs. prophylactic pinning are very nearly equivalent in statistical probability of outcome. In fact this is, in part, why decision modeling is such a powerful tool which allows one to create models for predicting outcome based on multiple probabilities that we otherwise could not compute.

    The major differences in our studies relate to different probability data used in the two studies. The most obvious of these is the probability of late contralateral slip. This is a controversial subject and some authors feel that it is a leading cause of degenerative arthritis of the hip in older patients(3). Hagglund’s data suggest that the rate of unrecognized mild slips is very high(4,5). Anthropometric skeletal studies confirm this finding(3), but it is difficult to say with certainty if the anatomic changes seen are the result of a primary slip or secondary changes of degenerative arthritis.

    We also have concerns about the probabilities of complications. Most of these data were taken from isolated case reports. It is not clear from your paper (1) where the denominator comes from to arrive at these numbers and provide probabilities. In the Greenough paper(6) which was cited as one source of probability data the complications were seen with pins that are no longer in widespread clinical use today or viewed as standard of care(7). In addition, recent studies suggest that avascular necrosis is a phenomenon almost exclusive to unstable slips and not an iatrogenic phenomenon(8). With the advent of computer assisted technology the probabilities for iatrogenic complications related to hardware placement may even be further reduced(9).

    Dr. Kocher is absolutely correct in his explanation of decision analysis. We chose to perform what is more appropriately termed an “expected value analysis” for several reasons. First, utility analysis is a challenging and difficult task in the adult population and virtually impossible in the pediatric population. A true utility is not obtained from a visual analogue scale because there is no relative quantification of the value of a particular health state. Standard gamble and time trade off methods are required to obtain true utility values. Both methods require abstract thought, usually beyond the facility of the subjects studied in this model.

    We chose, instead, to assume the perspective of a person at middle age that would have experienced the long-term outcomes of a slipped epiphysis. We believe this is essential to the reasoning behind performing these operations in children - for long-term gain. To bring short-term complications into the model distorts the results of the model. Many of these short-term complications are reversible and do not result in long-term disability.

    If short-term complications are to be considered then one must perform Markhov modeling(10) within the decision analysis. This allows time in a particular health state to be considered. One cannot compare utilities for temporary health states such as superficial infections or even fracture with utilities for long-term health states such as degenerative arthritis of the hip. In a perfect model we would be able to calculate the utility associated with short-term and long-term disabilities and the different treatment options would accumulate utility based on time spent in that particular health state – essentially Quality Adjusted Life Years(QALY’s).

    This type of model is achievable and may provide us with the most accurate assessment of the benefits associated with each treatment option but the major obstacle will remain the assessment of utility in the pediatric population using traditional utility assessment tools (time trade off or standard gamble).

    It is still our opinion that long-term disability remains the overriding concern when treating children with Slipped Capitol Femoral Epiphysis and we stand by our assertion that prophylactic pinning provides superior probability of better hip function over the long term.

    Sincerely,

    W. Randall Schultz MD, MS

    James N. Weinstein, DO, MS

    Stuart L. Weinstein, MD

    Brian G. Smith, MD

    References:

    1. Kocher, M. S.; Bishop, J. A.; Hresko, M. T.; Millis, M. B.; Kim, Y. J.; and Kasser, J. R.: Prophylactic pinning of the contralateral hip after unilateral slipped capital femoral epiphysis. J Bone Joint Surg Am, 86-A(12): 2658-65, 2004.

    2. Schultz, W. R.; Weinstein, J. N.; Weinstein, S. L.; and Smith, B. G.: 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. J Bone Joint Surg Am, 84-A(8): 1305-14, 2002.

    3. Goodman, D. A.; Feighan, J. E.; Smith, A. D.; Latimer, B.; Buly, R. L.; and Cooperman, D. R.: Subclinical slipped capital femoral epiphysis. Relationship to osteoarthrosis of the hip. J Bone Joint Surg Am, 79(10): 1489-97., 1997.

    4. Hagglund, G.; Hannson, L. I.; and Sandstrom, S.: Slipped capital femoral epiphysis in southern Sweden. Long-term results after nailing/pinning. Clin Orthop, (217): 190-200., 1987.

    5. Hagglund, G.; Hansson, L. I.; Ordeberg, G.; and Sandstrom, S.: Bilaterality in slipped upper femoral epiphysis. J Bone Joint Surg Br, 70(2): 179-81., 1988.

    6. Greenough, C. G.; Bromage, J. D.; and Jackson, A. M.: Pinning of the slipped upper femoral epiphysis--a trouble-free procedure? J Pediatr Orthop, 5(6): 657-60., 1985.

    7. Kenny, P.; Higgins, T.; Sedhom, M.; Dowling, F.; Moore, D. P.; and Fogarty, E. E.: Slipped upper femoral epiphysis. A retrospective, clinical and radiological study of fixation with a single screw. J Pediatr Orthop B, 12(2): 97-9, 2003.

    8. Tokmakova, K. P.; Stanton, R. P.; and Mason, D. E.: Factors influencing the development of osteonecrosis in patients treated for slipped capital femoral epiphysis. J Bone Joint Surg Am, 85-A(5): 798-801, 2003.

    9. Perlick, L.; Tingart, M.; Wiech, O.; Beckmann, J.; and Bathis, H.: Computer-assisted cannulated screw fixation for slipped capital femoral epiphysis. J Pediatr Orthop, 25(2): 167-70, 2005.

    10. Weinstein, M. C.: Clinical decision analysis. Edited, xiv, 351 p., Philadelphia, Saunders, 1980.

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