Slipped Capital Femoral Epiphysis: Treatment With or Without Hip Dislocation?

Whether you are new to the topic of slipped capital femoral epiphysis (SCFE) or well-acquainted with this condition, the results of this recent study will be of interest to you.

For those just learning about slipped capital femoral epiphysis (SCFE), it is a condition that affects the hip in teenagers between the ages of 12 and 16 most often. Cases have been reported as early as age nine years old. In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thigh bone).

If untreated this can lead to serious problems in the hip joint later in life. Fortunately, the condition can be treated and the complications avoided or reduced if recognized early. But what is the best treatment for this problem? And what evidence do we have to support treatment as “best”? That is the topic of this literature review from two orthopedic surgeons (one from the University of Iowa and another from the University of Indiana).

The goals of treatment are to 1) keep the problem from getting worse, 2) avoid complications, 3) improve hip motion, and 4) delay or prevent the development of degenerative hip disease. With that many different kinds of goals, you can imagine treatment may be varied (different for each child).

One approach is to provide treatment based on whether the condition is stable or unstable. Stable SCFE means the child can put weight on the leg and walk (with or without crutches). Unstable SCFE is defined by the child’s inability to walk with or without crutches due to severe pain. Surgery is usually necessary to stabilize the hip and prevent the situation from getting worse.

In this study, current best evidence is reported on treatment for stable versus unstable SCFE and treatment involving surgical dislocation. As we find out from the results of this systematic review of the literature, there are easily a half dozen ways to treat a stable SCFE. But the consensus is that the best way to treat stable SCFE is with a single, large screw into the epiphysis to hold it in place.

The best treatment for unstable SCFE isn’t as clear. In fact, the treatment for this type of SCFE is quite controversial. The risk of avascular necrosis (AVN; loss of blood to the hip with death of the bone) must be taken into consideration. This complication is the number one reason why patients with SCFE end up with a total hip replacement.

The timing of surgical treatment for unstable SCFE is also hotly debated among and between surgeons from the U.S. and Europe. The risk of necrosis is one reason why some surgeons insist on early treatment. But others think that surgical stabilization can lead to avascular necrosis. Right now, the best evidence suggests that the need for surgery is “urgent” in children with unstable SCFE. This approach has the lowest rates of necrosis.

Then the final decision is whether or not to dislocate the hip during surgery. Hip dislocation is done in order to better realign the epiphysis and therefore improve hip function. But there is concern that surgical dislocation can also increase the rate of avascular necrosis. Surgeons must also weigh other risks that come with surgical dislocation such as damage to the hip cartilage, labrum, joint surface, and/or bone.

According to this review, there is no evidence to support the more aggressive approach of surgical dislocation and epiphyseal realignment for stable SCFE. The single screw fixation method should remain the treatment of choice for these patients. As for surgical dislocation to treat unstable SCFE — caution is advised. This is a newer treatment method that hasn’t stood the test of time. There aren’t enough studies to report on long-term results. For now (and until better evidence is available), gentle surgical reduction with internal fixation is advised.