International
International Orthopaedics (SICOT) (1992) 16: 133-135
Orthopaedics © Springer-Verlag 1992
Intertrochanteric osteotomy for the treatment of chronic slipped capital femoral epiphysis E. C. R. Merchfin, C. M. Na, and L. Munuera Department of Orthopaedic Surgery and Traumatology, "La Paz" Hospital, Madrid, Spain
Summary. Thirty six patients with a chronic slip of the capital femoral epiphysis and a femoral headneck angle of more than 30 degrees, as measured in a lateral radiograph, were treated by intertrochanteric osteotomy. The patients had an abnormal gait, an average age of 14.1 years and symptoms for an average of 14.5 months. The postoperative complications included two patients with avascular necrosis of the femoral head, four with coxa vara and two with loss of position requiring further operation. At an average of 7.5 years after operation 14 were good, 18fair, and 4 poor on clinical assessment, with 13 good, 19fair and 4 poor when judged by radiographs. Patients with complications had only fair or poor results. A postoperative head-neck angle of less than I0 degrees indicated a good result.
R~sum~. Les auteurs pr~sentent les r~sultats de 36 ostdotomies inter-trochant~riennes effectudes pendant une pdriode de 15 arts. Les indications chirurgicales ont ~t~ Ies suivantes: d~placement chronique de la tote f~morale avec un angle tOte-col (ATC), mesurd sur la radiographie de profil, supdrieur g~ 30; associd ~ un signe de Trendelenburg positif et/ou une marche en rotation externe. L'dge moyen des malades au moment de l'op~ration 6tait de 14,1 ans. Le recul moyen des observations est de 7,5 ans. Deux fois l'ostdotomie a du 6tre reprise prdcoc6ment durant la pdriode post-op6ratoire ~ cause d'un red,placement. Les complications les plus importantes ont dtg deux ndcroses de la t6te fdmorale et quatre coxa vara. L'ATC a diminu6 en moyenne de 30 °. Les r6sultats ont 6td dvaluds selon la cotation d'Ireland et Newman: il y a 14 bons, 18 mddiocres et 4 mauvais r6sultats cliniques et 13 bons, 19 rodReprint requests to: E. C. R. MercMn, Capitfin Blanco Argibay 21G, 3°A, 28029-Madrid, Spain
diocres et 4 mauvais rdsultats radiologiques. Les meilleurs r6sultats ont 6td obtenus avec un ATC final de moins de 10 °.
Introduction
Chronic or long standing slip of the femoral capital epiphysis with deformity is usually treated by corrective intertrochanteric osteotomy with internal fixation. Various techniques have been described [1, 2, 3, 5, 6, 7, 8] including osteotomy at the level of the lesser trochanter [9]. We have previously described our results in 21 intertrochanteric osteotomies [4], and have now extended our study to include 36 hips treated over a period of 15 years from January 1974 to December 1988, with an average follow-up of 7.5 years. Materials and methods The patients presented with an average of 14.5 months of symptoms, (range 1 0 - 2 2 months). There were 28 males and eight females, with an average age of 14.1 years (10-16 years). The displacement was measured by the angle between the axis of the head and the neck of the femur as seen on a frog leg lateral radiograph. A first degree, or mild slip was considered to be under 30 °, a second degree, or moderate slip was between 30 and 60 °, and a third degree, or marked slip was over 60 ° [1]. All the patients treated in this series had a second degree or moderate slip of more than 30 °, with a flexion and external rotation deformity and a positive Trendelenburg sign. The capital femoral epiphysis was open in 11 patients and closed in 25 patients. Before operation the angle of slip or displacement was determined in the antero-posterior and lateral planes in order to plan the degree of correction required; resection of 1 mm of bone was required to correct 1° of deformity. A blade plate was inserted horizontally into the greater trochanter, an antero-lateral wedge of bone was removed between the trochanters with an oscillating saw and the femoral shaft was abducted and flexed in neutral or internal rotation to align with the plate and close the wedge. The
134
E.C.R. Merchfinet at.: Intertrochantericosteotomy
Fig. 1 A-D. Sequenceof radiographs showinga case ending with avascular necrosis;the epiphysealplate was fusedwhen operation was performed. A Initial anteroposteriorview; B Frog-leg lateral view at same time; C Sixteen months after the onset of symptoms intertrochanteric osteotomywas carried out; avascular necrosis appeared nine weeks after the osteotomy(AP view at this time); D AP radiograph made 17 months after intertrochanteric osteotomyand one month after removal of the fixationdevice. The capital femoral epiphysishas been destroyedby avascularnecrosis average time to union was 10 weeks with a range from 8 to 12 weeks. Weightbeating was then permitted.
Results The results were assessed using the clinical and radiological gradings described by Ireland and Newman [3]. The hips were classed as good if there was no significant pain or limp and hip movements were within 20 ° of normal, fair in the presence of pain or limp but no restriction of activity, with hip flexion to at least 90 ° and other movements within 20 ° of normal, and poor with a limp, restriction of activity, hip flexion of less than 90 ° and fixed deformity. The radiographic appearance was classed as good in the presence of a round femoral head, normal joint space and less than 20 ° of deformity, fair with a less round head, a vacuum sign or a bone nubbin of the femoral neck, and poor when there were degenerative changes in the hip. The clinical gradings showed 14 good, 18 fair and 4 poor; the radiographs showed 13 good, 19 fair, and 4 poor. All but one hip demonstrated good correlation between the clinical and radiographic assessments. The head-neck angle on the lateral radiograph of the femur decreased on average 30 ° with a range from 23 ° to 40 °. A postoperative head-neck angle of less than 10 ° indicated a good result. There were eight complications, with two femoral head necroses (Fig. 1), four residual coxa vara, and in two loss of position requiring further operation (Table 1). Patients with complications had fair or poor overall results.
Discussion Most clinical reviews have shown satisfactory results in moderate chronic slip after intertrochanteric osteotomy. Rao [7] described 23 excellent results out of 27 cases, 85%. Ireland and Newman [3] reported 20 good results out of 35 cases, 60%. We had 14 good results out of 36 patients, 38.8%. Radiographic assessment by Ireland and Newman [3] gave 60% good, 28.5% fair and 11.5% poor results. Our radiographs showed 36.1% good, 52.7% fair, and 11.1% poor. The smaller number of good results in our series is probably related to inadequate correction of the head-neck angle, which should be less than 10 °. This would allow for the difference in good and fair results as indicated by radiographs borne out on clinical assessment. Otherwise the two series have a similar occurrence of poor results. Although we consider it wise to only correct chronic slips with head-neck angle above 30 ° because lesser angles of deformity will remodel, the results in our series suggest that correction by osteomy should be reserved for more than 50 ° of deformity [10]. Removal of more than a 45 ° wedge anteriorly and 50 ° wedge laterally from the femoral osteotomy will make the limb short, and apposition of the fragments difficult. Complications in various series give an incidence of chondrolysis of about 10% [3], although we encountered less than this. Our incidence of avascular necrosis is similar to that observed in other series.
135
E. C. R. Merch~in et al.: Intertrochanteric osteotomy Table 1. Data and results of flais series A
B
C
D
E
F
G
H
I
J
K
L
M
N
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
15 15 14 15 15 14 12 14 16 12 17 12 15 13 11 10 15 13 14 15 15 13 16 14 15 13 15 15 12 14 15 15 13 14 15 15
M M M M M M F M M F M M M M M F M M M M F F M M M M M F M M M M M F F M
R L L L L L L L L L L L L L L R R R R L R L R R R R L R R R L R R L L R
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
L F L L L F L F L F L F L L L F L F F F L L F L F F L L L F L L L F F F
1 2 2 1 2 1 1 1 1 1 2 2 1 2 1 1 2 1 1 1 2 2 1 1 2 2 2 2 1 2 1 2 2 1 1 1
3+4 3+8 15+2 2+7 4+3 5+6 11+2 5+6 10+3 11+5 12+2 12+6 3+9 7+2 9+5 1+9 7+3 4+6 3+2 5 +7 11+3 9+6 7+2 2+5 13+4 9+2 5+6 14+4 3+7 10+2 11+5 5+6 4+3 5+2 7+2 10+6
1 1 1 1 1 1 CV 1 1 1 1 NE 1 CV RI 1 1 1 1 1 NE 1 1 1 CV 1 1 1 RI 1 1 CV 1 1 1 1
Eq/Eq Eq/Eq Eq/Eq -1/Eq Eq/Eq Eq/+l Eq/Eq -1.5/Eq Eq/+l +l/Eq Eq/-1.5 -1/Eq Eq/-2 Eq/-1.5 Eq/Eq -1/Eq Eq/Eq Eq/Eq Eq/Eq Eq/-2 Eq/Eq -1/Eq -1.5/Eq Eq/Eq Eq/-1.5 Eq/Eq Eq/Eq Eq/Eq -1/Eq Eq/Eq -1/Eq Eq/-2 Eq/Eq Eq/Eq -1/Eq Eq/Eq
50/15 48/18 45/19 45/ 5 47/16 53/15 50/13 37/ 8 48/14 35/ 9 37/ 6 53/27 50/25 43/15 52/23 38/ 7 43/13 45/17 48/13 46/15 50/20 45/15 46/20 37/ 6 47/ 7 50/25 47/16 45/16 52/15 50/26 50/15 53/30 36/ 9 38/10 50/15 35/10
F F G G F F F G F G G P P F P G F F F F F F G G F G G F F G F G G F P G
F F F G F F F G F G G P P F P G F F F F F F G G F G G F F G F G G F P G
35 30 26 40 31 38 37 29 34 26 31 26 25 28 29 31 30 28 35 31 30 30 26 31 40 25 31 29 37 24 35 23 27 28 35 25
A, Case number; B, Age (years); C, Sex: M = male, F = female; D, Side: R = right, L = left; E, Type of slip: 1 = second degree; F, Range of motion: F = full, L = limited; G, Gait: 1 = moderate external rotation, 2 = severe external rotation; H, Follow-up (years-months); I, Complications: 1 = No, CV = coxa vara, RI = reintervention, NE = femoral head necrosis; J, Leg length discrepancy (Pre/Post); Eq = Equal, + = lengthening, - = shortening; K, Radiographic measurement of femoral head-neck angle on frog-leg lateral view (Preop/Postop), degrees; L, Clinical Result: F = fair, G = good, P = poor; M, Radiographic result: G = good, F = fair, P = poor; N, Head-neck angle decrease at follow-up (on frog-leg lateral radiograph), degrees
We did not encounter any particular complication after o p e r a t i v e c o r r e c t i o n i n t h e p r e s e n c e o f a n o p e n e p i p h y s i s a n d this h a s b e e n n o t e d i n o t h e r s e r i e s [8].
References 1. Fish JB (1984) Cuneiform osteotomy of the femoral neck in the treatment of slipped capital femoral epiphysis. J Bone Jt Surg [Am] 66:1153-1168 2. Griffith MJ (1976) Slipping of the capital femoral epiphysis. Ann Coll Surg Engl 5 8 : 3 4 - 4 2 3. Ireland J, Newman PH (1978) Triplane osteotomy for severely slipped upper femoral epiphysis. J Bone Jt Surg [Br] 6 0 : 3 9 0 - 3 9 3 4. Na CM, Merch~in ECR, Galindo E (1990) Deslizamiento de la epffisis de la cabeza femoral: resultados a largo plazo del tratamiento quirfirgico. Rev Ortop Traum 34 IB, 3:271 - 2 7 6
5. Newman PH (1956) Surgical treatment of slipping of upper femoral epiphysis. J Bone Jt Surg [Br] 3 8 : 7 7 1 - 7 7 2 6. Perkins G (1932) Treatment of adolescent coxa vara. Br Med J 1:55-56 7. Rao JP, Francis AM, Siwek CW (1984) The treatment of chronic slipped capital femoral epiphysis by biplane osteotomy. J Bone Jt Surg [Am] 66:1169-1174 8. Salvati EA, Robinson HJ, O'Dowd TJ (1980) Southwick osteotomy for severe chronic slipped capital femoral epiphysis: results and complications. J Bone Jt Surg [Am] 62: 561-569 9. Southwick WO (1967) Osteotomy through the lesser trochanter for slipped capital femoral epiphysis. J Bone Jt Surg [Br] 4 9 : 8 0 7 - 8 3 5 10. Wong-Chung J, Strong ML (1991) Physeal remodeling after internal fixation of slipped capital femoral epiphysis. J Pediatr Orthop 11: 2 - 5
International Orthopaedics (SICOT) (1992) 16: 133-135
Orthopaedics © Springer-Verlag 1992
Intertrochanteric osteotomy for the treatment of chronic slipped capital femoral epiphysis E. C. R. Merchfin, C. M. Na, and L. Munuera Department of Orthopaedic Surgery and Traumatology, "La Paz" Hospital, Madrid, Spain
Summary. Thirty six patients with a chronic slip of the capital femoral epiphysis and a femoral headneck angle of more than 30 degrees, as measured in a lateral radiograph, were treated by intertrochanteric osteotomy. The patients had an abnormal gait, an average age of 14.1 years and symptoms for an average of 14.5 months. The postoperative complications included two patients with avascular necrosis of the femoral head, four with coxa vara and two with loss of position requiring further operation. At an average of 7.5 years after operation 14 were good, 18fair, and 4 poor on clinical assessment, with 13 good, 19fair and 4 poor when judged by radiographs. Patients with complications had only fair or poor results. A postoperative head-neck angle of less than I0 degrees indicated a good result.
R~sum~. Les auteurs pr~sentent les r~sultats de 36 ostdotomies inter-trochant~riennes effectudes pendant une pdriode de 15 arts. Les indications chirurgicales ont ~t~ Ies suivantes: d~placement chronique de la tote f~morale avec un angle tOte-col (ATC), mesurd sur la radiographie de profil, supdrieur g~ 30; associd ~ un signe de Trendelenburg positif et/ou une marche en rotation externe. L'dge moyen des malades au moment de l'op~ration 6tait de 14,1 ans. Le recul moyen des observations est de 7,5 ans. Deux fois l'ostdotomie a du 6tre reprise prdcoc6ment durant la pdriode post-op6ratoire ~ cause d'un red,placement. Les complications les plus importantes ont dtg deux ndcroses de la t6te fdmorale et quatre coxa vara. L'ATC a diminu6 en moyenne de 30 °. Les r6sultats ont 6td dvaluds selon la cotation d'Ireland et Newman: il y a 14 bons, 18 mddiocres et 4 mauvais r6sultats cliniques et 13 bons, 19 rodReprint requests to: E. C. R. MercMn, Capitfin Blanco Argibay 21G, 3°A, 28029-Madrid, Spain
diocres et 4 mauvais rdsultats radiologiques. Les meilleurs r6sultats ont 6td obtenus avec un ATC final de moins de 10 °.
Introduction
Chronic or long standing slip of the femoral capital epiphysis with deformity is usually treated by corrective intertrochanteric osteotomy with internal fixation. Various techniques have been described [1, 2, 3, 5, 6, 7, 8] including osteotomy at the level of the lesser trochanter [9]. We have previously described our results in 21 intertrochanteric osteotomies [4], and have now extended our study to include 36 hips treated over a period of 15 years from January 1974 to December 1988, with an average follow-up of 7.5 years. Materials and methods The patients presented with an average of 14.5 months of symptoms, (range 1 0 - 2 2 months). There were 28 males and eight females, with an average age of 14.1 years (10-16 years). The displacement was measured by the angle between the axis of the head and the neck of the femur as seen on a frog leg lateral radiograph. A first degree, or mild slip was considered to be under 30 °, a second degree, or moderate slip was between 30 and 60 °, and a third degree, or marked slip was over 60 ° [1]. All the patients treated in this series had a second degree or moderate slip of more than 30 °, with a flexion and external rotation deformity and a positive Trendelenburg sign. The capital femoral epiphysis was open in 11 patients and closed in 25 patients. Before operation the angle of slip or displacement was determined in the antero-posterior and lateral planes in order to plan the degree of correction required; resection of 1 mm of bone was required to correct 1° of deformity. A blade plate was inserted horizontally into the greater trochanter, an antero-lateral wedge of bone was removed between the trochanters with an oscillating saw and the femoral shaft was abducted and flexed in neutral or internal rotation to align with the plate and close the wedge. The
134
E.C.R. Merchfinet at.: Intertrochantericosteotomy
Fig. 1 A-D. Sequenceof radiographs showinga case ending with avascular necrosis;the epiphysealplate was fusedwhen operation was performed. A Initial anteroposteriorview; B Frog-leg lateral view at same time; C Sixteen months after the onset of symptoms intertrochanteric osteotomywas carried out; avascular necrosis appeared nine weeks after the osteotomy(AP view at this time); D AP radiograph made 17 months after intertrochanteric osteotomyand one month after removal of the fixationdevice. The capital femoral epiphysishas been destroyedby avascularnecrosis average time to union was 10 weeks with a range from 8 to 12 weeks. Weightbeating was then permitted.
Results The results were assessed using the clinical and radiological gradings described by Ireland and Newman [3]. The hips were classed as good if there was no significant pain or limp and hip movements were within 20 ° of normal, fair in the presence of pain or limp but no restriction of activity, with hip flexion to at least 90 ° and other movements within 20 ° of normal, and poor with a limp, restriction of activity, hip flexion of less than 90 ° and fixed deformity. The radiographic appearance was classed as good in the presence of a round femoral head, normal joint space and less than 20 ° of deformity, fair with a less round head, a vacuum sign or a bone nubbin of the femoral neck, and poor when there were degenerative changes in the hip. The clinical gradings showed 14 good, 18 fair and 4 poor; the radiographs showed 13 good, 19 fair, and 4 poor. All but one hip demonstrated good correlation between the clinical and radiographic assessments. The head-neck angle on the lateral radiograph of the femur decreased on average 30 ° with a range from 23 ° to 40 °. A postoperative head-neck angle of less than 10 ° indicated a good result. There were eight complications, with two femoral head necroses (Fig. 1), four residual coxa vara, and in two loss of position requiring further operation (Table 1). Patients with complications had fair or poor overall results.
Discussion Most clinical reviews have shown satisfactory results in moderate chronic slip after intertrochanteric osteotomy. Rao [7] described 23 excellent results out of 27 cases, 85%. Ireland and Newman [3] reported 20 good results out of 35 cases, 60%. We had 14 good results out of 36 patients, 38.8%. Radiographic assessment by Ireland and Newman [3] gave 60% good, 28.5% fair and 11.5% poor results. Our radiographs showed 36.1% good, 52.7% fair, and 11.1% poor. The smaller number of good results in our series is probably related to inadequate correction of the head-neck angle, which should be less than 10 °. This would allow for the difference in good and fair results as indicated by radiographs borne out on clinical assessment. Otherwise the two series have a similar occurrence of poor results. Although we consider it wise to only correct chronic slips with head-neck angle above 30 ° because lesser angles of deformity will remodel, the results in our series suggest that correction by osteomy should be reserved for more than 50 ° of deformity [10]. Removal of more than a 45 ° wedge anteriorly and 50 ° wedge laterally from the femoral osteotomy will make the limb short, and apposition of the fragments difficult. Complications in various series give an incidence of chondrolysis of about 10% [3], although we encountered less than this. Our incidence of avascular necrosis is similar to that observed in other series.
135
E. C. R. Merch~in et al.: Intertrochanteric osteotomy Table 1. Data and results of flais series A
B
C
D
E
F
G
H
I
J
K
L
M
N
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
15 15 14 15 15 14 12 14 16 12 17 12 15 13 11 10 15 13 14 15 15 13 16 14 15 13 15 15 12 14 15 15 13 14 15 15
M M M M M M F M M F M M M M M F M M M M F F M M M M M F M M M M M F F M
R L L L L L L L L L L L L L L R R R R L R L R R R R L R R R L R R L L R
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
L F L L L F L F L F L F L L L F L F F F L L F L F F L L L F L L L F F F
1 2 2 1 2 1 1 1 1 1 2 2 1 2 1 1 2 1 1 1 2 2 1 1 2 2 2 2 1 2 1 2 2 1 1 1
3+4 3+8 15+2 2+7 4+3 5+6 11+2 5+6 10+3 11+5 12+2 12+6 3+9 7+2 9+5 1+9 7+3 4+6 3+2 5 +7 11+3 9+6 7+2 2+5 13+4 9+2 5+6 14+4 3+7 10+2 11+5 5+6 4+3 5+2 7+2 10+6
1 1 1 1 1 1 CV 1 1 1 1 NE 1 CV RI 1 1 1 1 1 NE 1 1 1 CV 1 1 1 RI 1 1 CV 1 1 1 1
Eq/Eq Eq/Eq Eq/Eq -1/Eq Eq/Eq Eq/+l Eq/Eq -1.5/Eq Eq/+l +l/Eq Eq/-1.5 -1/Eq Eq/-2 Eq/-1.5 Eq/Eq -1/Eq Eq/Eq Eq/Eq Eq/Eq Eq/-2 Eq/Eq -1/Eq -1.5/Eq Eq/Eq Eq/-1.5 Eq/Eq Eq/Eq Eq/Eq -1/Eq Eq/Eq -1/Eq Eq/-2 Eq/Eq Eq/Eq -1/Eq Eq/Eq
50/15 48/18 45/19 45/ 5 47/16 53/15 50/13 37/ 8 48/14 35/ 9 37/ 6 53/27 50/25 43/15 52/23 38/ 7 43/13 45/17 48/13 46/15 50/20 45/15 46/20 37/ 6 47/ 7 50/25 47/16 45/16 52/15 50/26 50/15 53/30 36/ 9 38/10 50/15 35/10
F F G G F F F G F G G P P F P G F F F F F F G G F G G F F G F G G F P G
F F F G F F F G F G G P P F P G F F F F F F G G F G G F F G F G G F P G
35 30 26 40 31 38 37 29 34 26 31 26 25 28 29 31 30 28 35 31 30 30 26 31 40 25 31 29 37 24 35 23 27 28 35 25
A, Case number; B, Age (years); C, Sex: M = male, F = female; D, Side: R = right, L = left; E, Type of slip: 1 = second degree; F, Range of motion: F = full, L = limited; G, Gait: 1 = moderate external rotation, 2 = severe external rotation; H, Follow-up (years-months); I, Complications: 1 = No, CV = coxa vara, RI = reintervention, NE = femoral head necrosis; J, Leg length discrepancy (Pre/Post); Eq = Equal, + = lengthening, - = shortening; K, Radiographic measurement of femoral head-neck angle on frog-leg lateral view (Preop/Postop), degrees; L, Clinical Result: F = fair, G = good, P = poor; M, Radiographic result: G = good, F = fair, P = poor; N, Head-neck angle decrease at follow-up (on frog-leg lateral radiograph), degrees
We did not encounter any particular complication after o p e r a t i v e c o r r e c t i o n i n t h e p r e s e n c e o f a n o p e n e p i p h y s i s a n d this h a s b e e n n o t e d i n o t h e r s e r i e s [8].
References 1. Fish JB (1984) Cuneiform osteotomy of the femoral neck in the treatment of slipped capital femoral epiphysis. J Bone Jt Surg [Am] 66:1153-1168 2. Griffith MJ (1976) Slipping of the capital femoral epiphysis. Ann Coll Surg Engl 5 8 : 3 4 - 4 2 3. Ireland J, Newman PH (1978) Triplane osteotomy for severely slipped upper femoral epiphysis. J Bone Jt Surg [Br] 6 0 : 3 9 0 - 3 9 3 4. Na CM, Merch~in ECR, Galindo E (1990) Deslizamiento de la epffisis de la cabeza femoral: resultados a largo plazo del tratamiento quirfirgico. Rev Ortop Traum 34 IB, 3:271 - 2 7 6
5. Newman PH (1956) Surgical treatment of slipping of upper femoral epiphysis. J Bone Jt Surg [Br] 3 8 : 7 7 1 - 7 7 2 6. Perkins G (1932) Treatment of adolescent coxa vara. Br Med J 1:55-56 7. Rao JP, Francis AM, Siwek CW (1984) The treatment of chronic slipped capital femoral epiphysis by biplane osteotomy. J Bone Jt Surg [Am] 66:1169-1174 8. Salvati EA, Robinson HJ, O'Dowd TJ (1980) Southwick osteotomy for severe chronic slipped capital femoral epiphysis: results and complications. J Bone Jt Surg [Am] 62: 561-569 9. Southwick WO (1967) Osteotomy through the lesser trochanter for slipped capital femoral epiphysis. J Bone Jt Surg [Br] 4 9 : 8 0 7 - 8 3 5 10. Wong-Chung J, Strong ML (1991) Physeal remodeling after internal fixation of slipped capital femoral epiphysis. J Pediatr Orthop 11: 2 - 5
