Case report 511

Acute, unstable slipped capital femoral epiphysis with associated congenital coxa vara Indranil Kusharea, Roger E. Wiltfonga and Kevin E. Klingelea,b Slipped capital femoral epiphysis in patients younger than 10 years is rare and is often associated with some identifiable metabolic or endocrinologic abnormality. We present a case of a 5-year-old girl with an acute, unstable, severe slipped capital femoral epiphysis associated with congenital coxa vara and its surgical management. This association has not been described in previous literature. Surgical treatment is proposed and described. J Pediatr Orthop B 24:511–514 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Introduction Slipped capital femoral epiphysis (SCFE) is a disorder in which a failure through the zone of hypertrophy of the proximal femoral growth plate results in displacement of the proximal femur in relation to the epiphysis [1]. There are very few reported cases of SCFE in children much younger than 10 years [2–4], with most reports describing clinically stable slips. In addition, congenital coxa vara is even more uncommon, with a reported incidence of one in 25 000 live births in the Scandanavian population [5]. Clinical deformity and subsequent mechanical effects on the hip secondary to congenital coxa vara are well described [6]. Varus alignment of the proximal femoral physis may predispose to physeal failure and subsequent slippage. However, SCFE secondary to congenital coxa vara has not yet been reported. This report describes the occurrence and surgical treatment of an acute, unstable SCFE with associated severe, congenital coxa vara deformity in a 5-year-old female. The patient’s parents were informed that data from the case would be submitted for publication and gave written consent.

Case report A 5-year-old, obese girl presented to the emergency room complaining of left hip pain after a low-energy fall. She was unable to ambulate. Her mother reported a 6-month history of a painful left lower-extremity limp and suspected limb length discrepancy. The patient did not have ipsilateral knee or ankle pain and was neurovascular intact. She had no other contributory medical or family history. Examination of the left hip range of motion (ROM) was painful and restricted. The right hip had full pain free ROM. The remainder of the exam was normal, and she 1060-152X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Journal of Pediatric Orthopaedics B 2015, 24:511–514 Keywords: coxa vara, femoral epiphysis, Wagner technique a

Department of Orthopedic Surgery, Nationwide Children’s Hospital and Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA

b

Correspondence to Kevin E. Klingele, MD, Department of Orthopedic Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA Tel: + 1 614 722 3393; fax: + 1 614 355 1395; e-mail: [email protected]

did not show any features of skeletal dysplasia, endocrine or metabolic abnormalities. Radiographs of the hips at presentation showed a markedly displaced left femoral epiphysis, metaphyseal change within the proximal femur with possible preexisiting coxa vara deformity (Fig. 1). Lab analysis revealed normal growth hormone levels, thyroid levels, and chemistry profile. Surgical treatment was recommended per protocol at the treating surgeon’s institution. This protocol includes management of unstable SCFE via a surgical hip dislocation and modified Dunn procedure in an effort to correct deformity and minimize the risk of avascular necrosis (AVN). A modified surgical hip dislocation approach was used via subperiosteal sharp dissection release of the gluteus medius and vastus lateralis. Such dissection precluded the need for a greater trochanteric osteotomy through the proximal trochanteric physis. The femoral epiphysis was displaced and unstable. Provisional Kirschner-wire fixation stabilized the slip, allowing safe, anterior surgical dislocation. Deformity within the femoral neck was noted and a modified subcapital osteotomy was performed to allow anatomic reduction of the femoral epiphysis. The proximal femoral physis was not removed as typically performed with a modified Dunn procedure. Following anatomic reduction, the epiphysis was held with an antegrade smooth Steinmann pin placed through the fovea (Fig. 2). Significant coxa vara was then apparent and a valgus, derotation, intertrochanteric osteotomy was performed and fixed using retrograde smooth Steinmann pins as described by Wagner [7]. Fixation wires were bent to a 145° angle and passed through the femoral neck, across the physis, allowing fixation of both osteotomy sites to the femoral shaft using cerclage wires DOI: 10.1097/BPB.0000000000000209

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512 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 6

Fig. 1

Anteroposterior (a) and lateral (b) views of the left hip showing acute, severely displaced epiphysis with pre-existing proximal femoral deformity.

(Fig. 3). The patient was then placed in a left hip spica cast for 6 weeks.

Fig. 2

At 1-year follow-up, the patient was back to full activity with no pain. Hip ROM was 65° of symmetric internal rotation, 35° of symmetric external rotation, and 45° of symmetric abduction. Scanogram revealed a 2 cm limb length discrepancy, left shorter than right (1.9 cm was accounted for by the femur). Radiographs (Fig. 4) show good remodeling of the proximal femur and no evidence of AVN.

Discussion SCFE in children younger than 10 years is rare and is often associated with endocrine disorders such as hypothyroidism, metabolic processes such as renal osteodystrophy, or a history of radiation therapy [2–4]. The youngest reported patient with idiopathic SCFE is a 5-year, 9-month-old female who was treated with spica casting [4]. In this case report, we present a 5-year-old female with an acute, unstable, left SCFE associated with pre-existing congenital coxa vara and its surgical management. Status postanatomic reduction of proximal femoral epiphysis and antegrade, transfoveal pin placement; reduction confirmed pre-existing coxa vara deformity.

The patient in our report was obese but had none of the classic risk factors associated with developing SCFE at a very young age – endocrinopathy, renal disease and

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SCFE with coxa vara Kushare et al. 513

Fig. 3

Anteroposterior (a) and lateral (b) views of the left hip following modified Dunn procedure and proximal femoral valgus derotational osteotomy and fixation via the Wagner technique.

Fig. 4

Anteroposterior (a) and frog (b) views of the hips showing good healing of the osteotomy and remodeling of the proximal femur at 1-year follow-up.

growth factor deficiency, or history of radiation therapy. The varus alignment and associated decreased anteversion of the femoral neck seen with congenital coxa vara possibly predisposed to the uncommon anterior slip of the femoral epiphysis.

Some reports are emerging which suggest that more invasive procedures are necessary in the treatment of acute SCFE given that the risk of osteonecrosis may be as high as 60% [8–11]. Sankar et al. [12] published a multicenter study of 27 unstable SCFEs treated with the

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514 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 6

modified Dunn procedure showing a AVN rate of 26%, with cases of AVN affecting all treating surgeons. A single surgeon experience recently revealed a 6.9% AVN rate for 31 consecutive unstable SCFE treated with a modified Dunn procedure. Low complication rates and restoration of proximal femoral anatomy, including little change in greater trochanteric height and femoral neck length, was documented within this series [13].

femoral intertrochanteric osteotomy. The Wagner technique of fixation allowed excellent healing and result at 1-year follow-up.

Choice of fixation for this patient was a unique problem due to the associated coxa vara. Smooth pins across the physis have been shown to be safe in terms of physeal damage [10,14]. Very young patients with SCFE can be fixed with nonthreaded hardware to increase the possibility of future remodeling and longitudinal growth [2]. In 1978, Heinz Wagner described a technique for fixation of the valgus producing intertrochanteric osteotomy for correction of coxa vara in children. In 2001, Widmann and colleagues published a case series in Journal of Pediatric Orthopaedics reporting the results of 17 Wagner osteotomies. Both series showed a reproducible technique with stable fixation and maintained correction [7].

References

Such a technique utilizes an intertrochanteric osteotomy held with multiple, transphyseal Kirschner wires which are then bent and cerclaged to the proximal femoral shaft to create a high-angle blade plate type construct. To our knowledge, the Wagner fixation technique has not been described to simultaneously fix an acute slip of the proximal, femoral epiphysis as well as a valgus producing intertrochanteric osteotomy for correction of developmental coxa vara.

Acknowledgements Conflicts of interest

There are no conflicts of interest.

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Conclusion

This case report presents a 5-year-old female with an unstable, severe left SCFE with pre-existing coxa vara deformity. Treatment included a modified surgical hip dislocation technique and modified Dunn procedure, followed by a valgus producing, derotational proximal

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Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

Acute, unstable slipped capital femoral epiphysis with associated congenital coxa vara.

Slipped capital femoral epiphysis in patients younger than 10 years is rare and is often associated with some identifiable metabolic or endocrinologic...
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